Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study

Comparison of endoscopic third ventriculostomy versus cerebrospinal fluid shunt procedures for the treatment of pediatric hydrocephalus in Taiwan

PURPOSE

Pediatric hydrocephalus is the most common cause of surgically treatable neurological disease in children. Controversies exist whether endoscopic third ventriculostomy (ETV) or cerebrospinal fluid (CSF) shunt placement is the most appropriate treatment for pediatric hydrocephalus. This study aimed to compare the risk of re-operation and death between the two procedures.

METHODS

We performed a retrospective population-based cohort study and included patients younger than 20-years-old who underwent CSF shunt or ETV for hydrocephalus from the Taiwan National Health Insurance Research Database.

RESULTS

A total of 3,555 pediatric patients from 2004 to 2017 were selected, including 2,340 (65.8%) patients that received CSF shunt placement and 1215 (34.2%) patients that underwent ETV. The incidence of all-cause death was 3.31 per 100 person-year for CSF shunt group and 2.52 per 100 person-year for ETV group, with an adjusted hazard ratio (HR) of 0.79 (95% confidence interval [CI] = 0.66-0.94, p = 0.009). The cumulative incidence competing risk for reoperation was 31.2% for the CSF shunt group and 26.4% for the ETV group, with an adjusted subdistribution HR of 0.82 (95% CI = 0.70-0.96, p = 0.015). Subgroup analysis showed that ETV was beneficial for hydrocephalus coexisting with brain or spinal tumor, central nervous system infection, and intracranial hemorrhage.

CONCLUSION

Our data indicates ETV is a better operative procedure for pediatric hydrocephalus when advanced surgical techniques and instruments are available.

Ventriculoperitoneal shunt failures at Red Cross War Memorial Children's Hospital

INTRODUCTION

Ventriculoperitoneal shunt (VP shunt) insertion is one of the mainstays of treatment of hydrocephalus and although very effective, a high rate of shunt failure persists globally. The purpose of the study was to quantify the ventriculoperitoneal shunt failure rate at Red Cross War Memorial Children's Hospital (RCWMCH) and assess potential factors contributing to shunt failures.

METHODS

A retrospective review of VP shunts done at RCWMCH between August 2015 through December 2019 was performed. Operative notes, discharge summaries and patient folders were reviewed to collect information about patient age, aetiology of hydrocephalus, index vs revision shunt, shunt system and other noticeable variables. Overall shunt failure was recorded. Univariate and multivariate models were used to determine causal relationship.

RESULTS

Four hundred and ninety-four VP shunt operations were performed on 340 patients with 48.8% being index shunts and 51.2% revision shunts. The average patient age was 3.4 months. The total VP shunt failure rate over the study period was 31.2%, with a 7.3% infection rate, 13.6% blockage and 3.6% disconnection rate. The most common aetiologies were post-infectious hydrocephalus 29.4%, myelomeningocele 19.7% and premature intraventricular haemorrhage 14.1%. Orbis-sigma II (OSVII), distal slit valves and antibiotic-impregnated catheters were used most frequently. Failure rates were highest in the revision group, 34.7% compared to 27.3% in index shunts. Sixty-five percent (65%) of the head circumferences measured were above the + 3 Z score (> 90th centile).

CONCLUSION

VP shunt failure occurs most commonly in revision surgery, and care should be taken at the index operation to reduce failure risk. Surgeon level, duration of surgery, aetiology of hydrocephalus and shunt system used did not influence overall failure rates. A closer look at larger head circumferences, their effect on shunt systems and the socio-economic factors behind late presentations should be investigated further in the future.

Neurosurgical management of Myelomeningocele in premature infants: a case series

INTRODUCTION

Myelomeningocele (MMC) is the most common neural tube defect, but rarely seen in premature infants. Most centers advocate for closure of MMC within 24 h of birth. However, this is not always possible in severely premature infants. Given the rarity of this patient population, we aimed to share our institutional experience and outcomes of severely premature infants with MMC.

METHODS

We performed a retrospective, observational review of premature infants (≤ 32 weeks gestational age) identified through our multidisciplinary spina bifida clinic (1995-2021) and surgical logs. Descriptive statistics were compiled about this sample including timing of MMC closure and incidence of adverse events such as sepsis, CSF diversion, meningitis, and death.

RESULTS

Eight patients were identified (50% male) with MMC who were born ≤ 32 weeks gestational age. Mean gestational age of the population was 27.3 weeks (SD 3.5). Median time to MMC closure was 1.5 days (IQR = 1-80.8). Five patients were taken for surgery within the recommended 48 h of birth; 2 patients underwent significantly delayed closure (107 and 139 days); and one patient's defect epithelized without surgical intervention. Six of eight patients required permanent cerebrospinal fluid (CSF) diversion (2 patients were treated with ventriculoperitoneal shunting (VPS), three were treated with endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) and 1 patient treated with ETV; mean of 3 years after birth, ranging from 1 day to 16 years). Two patients required more than one permanent CSF diversion procedure. Two patients developed sepsis (defined as meeting at least 2/4 SIRS criteria). In both cases of sepsis, patients developed signs and symptoms more than 72 h after birth. Notably, both instances of sepsis occurred unrelated to operative intervention as they occurred before permanent MMC closure. Two patients had intraventricular hemorrhage (both grade III). No patients developed meningitis (defined as positive CSF cultures) prior to MMC closure. Median follow up duration was 9.7 years. During this time epoch, 3 patients died: Two before 2 years of age of causes unrelated to surgical intervention. One of the two patients with grade III IVH died within 24 h of MMC closure.

CONCLUSIONS

In our institutional experience with premature infants with MMC, some patients underwent delayed MMC closure. The overall rate of meningitis, sepsis, and mortality for preterm children with MMC was similar to MMC patients born at term.

Complement Inhibition Reduces Early Erythrolysis, Attenuates Brain Injury, Hydrocephalus, and Iron Accumulation after Intraventricular Hemorrhage in Aged Rats

Blood components released by erythrolysis play an important role in secondary brain injury and posthemorrhagic hydrocephalus (PHH) after intraventricular hemorrhage (IVH). The current study examined the impact of N-acetylheparin (NAH), a complement inhibitor, on early erythrolysis, PHH and iron accumulation in aged rats following IVH. This study, on 18-months-old male Fischer 344 rats, was in 3 parts. First, rats had an intracerebroventricular injection of autologous blood (IVH) mixed with NAH or saline, or saline alone. After MRI at four hours, Western blot and immunohistochemistry examined complement activation and electron microscopy choroid plexus and periventricular damage. Second, rats had an IVH with NAH or vehicle, or saline. Rats underwent serial MRI at 4 h and 1 day to assess ventricular volume and erythrolysis. Immunohistochemistry and H&E staining examined secondary brain injury. Third, rats had an IVH with NAH or vehicle. Serial MRIs on day 1 and 28 assessed ventricular volume and iron accumulation. H&E staining and immunofluorescence evaluated choroid plexus phagocytes. Complement activation was found 4 h after IVH, and co-injection of NAH inhibited that activation. NAH administration attenuated erythrolysis, reduced ventricular volume, alleviated periventricular and choroid plexus injury at 4 h and 1 day after IVH. NAH decreased iron accumulation, the number of choroid plexus phagocytes, and attenuated hydrocephalus at 28 days after IVH. Inhibiting complement can reduce early erythrolysis, attenuates hydrocephalus and iron accumulation after IVH in aged animals.

Paediatric hydrocephalus

Hydrocephalus is classically considered as a failure of cerebrospinal fluid (CSF) homeostasis that results in the active expansion of the cerebral ventricles. Infants with hydrocephalus can present with progressive increases in head circumference whereas older children often present with signs and symptoms of elevated intracranial pressure. Congenital hydrocephalus is present at or near birth and some cases have been linked to gene mutations that disrupt brain morphogenesis and alter the biomechanics of the CSF-brain interface. Acquired hydrocephalus can develop at any time after birth, is often caused by central nervous system infection or haemorrhage and has been associated with blockage of CSF pathways and inflammation-dependent dysregulation of CSF secretion and clearance. Treatments for hydrocephalus mainly include surgical CSF shunting or endoscopic third ventriculostomy with or without choroid plexus cauterization. In utero treatment of fetal hydrocephalus is possible via surgical closure of associated neural tube defects. Long-term outcomes for children with hydrocephalus vary widely and depend on intrinsic (genetic) and extrinsic factors. Advances in genomics, brain imaging and other technologies are beginning to refine the definition of hydrocephalus, increase precision of prognostication and identify nonsurgical treatment strategies.

Postoperative shunt failure following hemispherectomy in pediatric patients with pre-existing hydrocephalus

OBJECTIVE

The risk of hydrocephalus following hemispherectomy for drug resistant epilepsy (DRE) remains high. Patients with pre-existing hydrocephalus pose a postoperative challenge, as maintaining existing shunt patency is necessary but lacks a clearly defined strategy. This study examines the incidence and predictors of shunt failure in pediatric hemispherectomy patients with pre-existing ventricular shunts.

METHODS

We performed a retrospective chart review at our center to identify pediatric patients diagnosed with DRE who were treated with ventricular shunt prior to their first hemispherectomy surgery. Demographic and perioperative data were obtained including shunt history, hydrocephalus etiology, epilepsy duration, surgical technique, and postoperative outcomes. Univariate analysis was performed using Fisher's exact test and Pearson correlation, with Bonferroni correction to a = 0.00625 and a = 0.01, respectively.

RESULTS

Five of nineteen (26.3%) patients identified with ventriculoperitoneal shunting prior to hemispherectomy experienced postoperative shunt malfunction. All 5 of these patients underwent at least 1 shunt revision prior to hemispherectomy, with a significant association between pre- and post-hemispherectomy shunt revisions. There was no significant association between post-hemispherectomy shunt failure and valve type, intraoperative shunt alteration, postoperative external ventricular drain placement, hemispherectomy revision, lateralization of shunt relative to resection, postoperative complications, or postoperative aseptic meningitis. There was no significant correlation between number of post-hemispherectomy shunt revisions and age at shunt placement, age at hemispherectomy, epilepsy duration, or shunt duration prior to hemispherectomy.

CONCLUSIONS

Earlier shunt revision surgery may portend a subsequent need for shunt revision following hemispherectomy. These findings may guide neurosurgeons in counseling patients with pre-existing ventricular shunts prior to hemispherectomy surgery.

Low surgical weight associated with ETV failure in pediatric hydrocephalus patients

The use of endoscopic third ventriculostomy (ETV) for treatment of pediatric hydrocephalus has higher failure rates in younger patients. Here we investigate the impact of select perioperative variables, specifically gestational age, chronological age, birth weight, and surgical weight, on ETV failure rates. A retrospective review was performed on patients treated with ETV - with or without choroid plexus cauterization (CPC) - from 2010 to 2021 at a large academic center. Analyses included Cox regression for independent predictors and Kaplan-Meier survival curves for time to-event outcomes. In total, 47 patients were treated with ETV; of these, 31 received adjunctive CPC. Overall, 66% of the cohort experienced ETV failure with a median failure of 36 days postoperatively. Patients aged < 6 months at time of surgery experienced 80% failure rate, and those > 6 months at time of surgery experienced a 41% failure rate. Univariate Cox regression analysis showed weight at the time of ETV surgery was significantly inversely associated with ETV failure with a hazard ratio of 0.92 (95% CI 0.82, 0.99). Multivariate analysis redemonstrated the inverse association of weight at time of surgery with ETV failure with hazard ratio of 0.76 (95% CI 0.60, 0.92), and sensitivity analysis showed < 4.9 kg as the optimal cutoff predicting ETV/CPC failure. Neither chronologic age nor gestational age were found to be significantly associated with ETV failure.In this study, younger patients experienced higher ETV failure rates, but multivariate regression found that weight was a more robust predictor of ETV failure than chronologic age or gestational age, with an optimal cutoff of 4.9 kg in our small cohort. Given the limited sample size, further study is needed to elucidate the independent role of weight as a peri-operative variable in determining ETV candidacy in young infants. Previous presentations: Poster Presentation, Congress of Neurological Surgeons.

Neurosurgical Management of Myelomeningocele in Premature Infants: A Case Series

Introduction

Myelomeningocele (MMC) is the most common neural tube defect, but rarely seen in premature infants. Most centers advocate for closure of MMC within 24 hours of birth. However, this is not always possible in severely premature infants. Given the rarity of this patient population, we aimed to share our institutional experience and outcomes of severely premature infants with MMC.

Methods

We performed a retrospective, observational review of premature infants (≤ 32 weeks gestational age) identified through our multidisciplinary spina bifida clinic (1995-2021) and surgical logs. Descriptive statistics were compiled about this sample including timing of MMC closure and incidence of adverse events such as sepsis, CSF diversion, meningitis, and death.

Results

Eight patients were identified (50% male) with MMC who were born ≤ 32 weeks gestational age. Mean gestational age of the population was 27.3 weeks (SD 3.5). Median time to MMC closure was 1.5 days (IQR = 1 -80.8). Five patients were taken for surgery within the recommended 48 hours of birth; 2 patients underwent significantly delayed closure (107 and 139 days); and one patient's defect epithelized without surgical intervention. Six of eight patients required permanent cerebrospinal fluid (CSF) diversion (2 patients were treated with ventriculoperitoneal shunting (VPS), three were treated with endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) and 1 patient treated with ETV; mean of 3 years after birth, ranging from 1 day to 16 years). Two patients required more than one permanent CSF diversion procedure. Two patients developed sepsis (defined as meeting at least 2/4 SIRS criteria), and 2 patients had intraventricular hemorrhage (both grade III). No patients developed meningitis (defined as positive CSF cultures) prior to MMC closure. Median follow up duration was 9.7 years. During this time epoch, 3 patients died: Two before 2 years of age of causes unrelated to surgical intervention. One of the two patients with grade III IVH died within 24 hours of MMC closure.

Conclusions

In our institutional experience with premature infants with MMC, some patients underwent delayed MMC closure. The overall rate of meningitis, sepsis, and mortality for preterm children with MMC was similar to MMC patients born at term.

Optimization of number and range of shunt valve performance levels in infant hydrocephalus: a machine learning analysis

Shunt surgery is the main treatment modality for hydrocephalus, the leading cause of brain surgery in children. The efficacy of shunt surgery, particularly in infant hydrocephalus, continues to present serious challenges in achieving improved outcomes. The crucial role of correct adjustments of valve performance levels in shunt outcomes has been underscored. However, there are discrepancies in the performance levels of valves from different companies. This study aims to address this concern by optimizing both the number and range of valve performance levels for infant hydrocephalus, aiming for improved shunt surgery outcomes. We conducted a single-center cohort study encompassing infant hydrocephalus cases that underwent initial shunt surgery without subsequent failure or unimproved outcomes. An unsupervised hierarchical machine learning method was utilized for clustering and reporting the valve drainage pressure values for all patients within each identified cluster. The optimal number of clusters corresponds to the number of valve performance levels, with the valve drainage pressure ranges within each cluster indicating the pressure range for each performance level. Comparisons based on the Silhouette coefficient between 3-7 clusters revealed that this coefficient for the 4-cluster (4-performance level) was at least 28.3% higher than that of other cluster formations in terms of intra-cluster similarity. The Davies-Bouldin index for the 4-performance level was at least 37.2% lower than that of other configurations in terms of inter-cluster dissimilarity. Cluster stability, indicated by a Jaccard index of 71% for the 4-performance level valve, validated the robustness, reliability, and repeatability of our findings. Our suggested optimized drainage pressure ranges for each performance level (1.5-5.0, 5.0-9.0, 9.0-15.0, and 15.0-18.0 cm H2O) may potentially assist neurosurgeons in improving clinical outcomes for patients with shunted infantile hydrocephalus.

Techniques to Reduce the Rate of Infection in Surgeries for Cerebrospinal Fluid Shunting in Adults

OBJECTIVE

Cerebrospinal fluid shunt placement is associated with high rates of infection. Multiple standardized protocols, particularly in pediatric populations, have been proposed to mitigate this infection rate. We sought to determine the effectiveness of a standardized shunt infection protocol in a large adult population.

METHODS

A retrospective cohort study of adults presenting for primary cerebrospinal fluid shunt placement from 2012 to 2022. The primary outcome of interest was shunt infection. The primary exposure of interest was implementation of the shunt protocol (began October 2015). Secondary exposures of interest included use and type of perioperative antibiotics and total operating room time.

RESULTS

In total, 820 patients were included, 140 before protocol implementation and 680 after protocol implementation. The overall number of infections over the study period was 15 (1.8% infection rate), with 8 infections preprotocol (5.7%) and 7 infections during the protocol period (1.0%). The infection protocol was associated with a decreased infection rate (odds rato [OR] 0.18, 95% confidence interval [CI] 0.05-0.58, P = 0.002). Total operating room time (OR 1.38 per 30-minute increase, 95% CI 1.05-1.81, P = 0.021) was associated with increased infection rate. Patients who received antibiotics with primarily gram-positive coverage (cefazolin or equivalent) did not have significantly different odds of shunt infection as patients who received broad-spectrum coverage (OR 2.10, 95% CI 0.56-7.88, P = 0.274).

CONCLUSIONS

The implementation of an evidence-based perioperative shunt infection protocol is an effective method to decrease shunt infections. Broad-spectrum perioperative antibiotics may not have greater efficacy than gram-positive only coverage, but more research is required.

Endoscopic third ventriculostomy (ETV) or ventriculoperitoneal shunt (VPS) for paediatric hydrocephalus due to primary aqueductal stenosis

PURPOSE

The purpose of this study was to compare outcomes of endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in children with symptomatic triventricular hydrocephalus due to primary aqueductal stenosis.

METHOD

This is a retrospective analytical study. Patients who underwent either ETV or VPS as the first procedure for hydrocephalus due to primary aqueductal stenosis were included in the study.

RESULT

A total of 89 children were included in the study for analysis. The mean age was 8.4 years. Forty-four (49.4%) had their first surgery as ETV and 45 (50.6%) had their first surgery as VPS. Overall, 34 (38.2%) patients required a second surgery (either ETV or VPS) for persistent or recurrent hydrocephalus. The mean follow-up duration was 832.9 days. The overall complication rate was 13.5%. The mean timing of the second surgery after index surgery was 601.35 days. Factors associated with a second surgery were the presence of complications, high protein in cerebrospinal fluid, the relative change of frontal-occipital horn ratio (FOHR) and Evans' index. The survival of the first surgery was superior in ETV (751.55 days) compared to VPS (454.49 days), p = 0.013. The relative change of fronto-occipital horn index ratio (FOIR) was high in the VPS (mean 7.28%) group compared to the ETV (mean 4.40%), p = 0.001 group.

CONCLUSION

Overall procedural survival was better after ETV than VPS for hydrocephalus due to aqueductal stenosis. VPS causes more reduction in linear indices of ventricles as compared to ETV, however, is not associated with the success or complication of the procedure.

The Relationship Between Procedural Volume, Hospital Quality, and Postoperative Mortality in Pediatric Neurosurgery: Review of the Literature

BACKGROUND

Studies of neurosurgical pediatric patients associate treatment at low-volume hospitals and by low-volume surgeons with increased odds of adverse outcomes. Although these associations suggest that increased centralization of care could be considered, we evaluate whether confounding endogenous factors mitigate against the proposed outcome benefits.

METHODS

Literature review of English language articles from 1999 to 2021. We included articles that assessed volume-outcome effects in pediatric neurosurgical patients.

RESULTS

Twelve papers were included from 1999 to 2021. Primary outcomes included mortality (9), length of stay (LOS) (6), complications (4), and shunt revision/failure rates (3). Volume was measured at the hospital level (8) and at the surgeon level (6). Four papers found that higher volume hospitals had lower odds of mortality. Two papers found that hospitals with higher volume had fewer complications. Two papers found that higher volume surgeons had decreased mortality (odds ratio [OR] 0.09-0.3). One paper found that high-volume surgeons had fewer complications (-2.4%; P = 0.006). After controlling for hospital factors (HF), two out of 7 analyses remained significant. Five analyses did not control for HF.

CONCLUSIONS

The literature consistently demonstrates a relationship between higher hospital and surgeon volume and better outcomes for pediatric neurosurgical patients. Of the 7 articles that assessed HF, only 2 analyses found that surgical volume remained associated with better outcomes. No reports assessed the degree of centralization already present. The call for centralization of pediatric care should be tempered until variables such as hospital factors, distribution of cases, and clinical thresholds can be defined and studied.

The Shunt Valve Recession Technique as a Neuroplastic Surgery Adjunct in Complex and High-Risk Shunt Revisions: Technical Note and Case Series

BACKGROUND AND OBJECTIVES

Ventricular shunting is one of the most common procedures in neurosurgery. However, complications and revisions are frequent. Patients requiring multiple revisions often suffer secondary issues with scalp healing over hardware. Many common ventricular shunt valves have an obligate thickness that creates a visible protrusion and can potentially cause local tissue ischemia and breakdown in the setting of repeated surgery. The authors present a simple technique for recessing the shunt valve into the underlying bone to alleviate protrusion in high-risk cases. Three example cases utilizing this technique are presented.

METHODS

The skull directly underlying the planned valve site is uniformly recessed with a cutting burr several millimeters as desired while maintaining the inner cortical bone layer. The valve is fixed with standard cranial plating hardware.

EXPECTED OUTCOMES

Three patients are reported who underwent shunt valve recession as an adjunct to their shunt revision with neuroplastic surgery assistance. All patients had undergone multiple prior surgeries that had resulted in thin and high-risk fragile scalp. In 1 patient, the prior valve was eroding through the scalp before the described revision. All patients had satisfactory cosmetic outcomes, and there were no revisions in the 2-month follow-up period.

DISCUSSION

Complex and high-risk ventricular shunt patients should be considered for shunt valve recession into the bone to reduce wound-related complications and enhance healing. This is a technically simple, safe, and effective technique to include as a neuroplastic adjunct.

Iron homeostasis and post-hemorrhagic hydrocephalus: a review

Iron physiology is regulated by a complex interplay of extracellular transport systems, coordinated transcriptional responses, and iron efflux mechanisms. Dysregulation of iron metabolism can result in defects in myelination, neurotransmitter synthesis, and neuronal maturation. In neonates, germinal matrix-intraventricular hemorrhage (GMH-IVH) causes iron overload as a result of blood breakdown in the ventricles and brain parenchyma which can lead to post-hemorrhagic hydrocephalus (PHH). However, the precise mechanisms by which GMH-IVH results in PHH remain elusive. Understanding the molecular determinants of iron homeostasis in the developing brain may lead to improved therapies. This manuscript reviews the various roles iron has in brain development, characterizes our understanding of iron transport in the developing brain, and describes potential mechanisms by which iron overload may cause PHH and brain injury. We also review novel preclinical treatments for IVH that specifically target iron. Understanding iron handling within the brain and central nervous system may provide a basis for preventative, targeted treatments for iron-mediated pathogenesis of GMH-IVH and PHH.

Myelomeningocele: Long-Term Neurosurgical Management

Open spina bifida, also known as myelomeningocele (MMC), is the most challenging and severe birth defect of the central nervous system compatible with life and it is due to a failure in the dorsal fusion of the nascent neural tube during embryonic development. MMC is often accompanied by a constellation of collateral conditions, including hydrocephalus, Arnold - Chiari II malformation, brainstem disfunction, hydrosyringomyelia, tethered cord syndrome and scoliosis. Beyond early surgical repair of the dorsal defect, MMC requires lifelong cares. Several additional surgical procedures are generally necessary to improve the long-term outcomes of patients affected by MMC and multidisciplinary evaluations are crucial for early identification and management of the various medical condition that can accompany this pathology. In this chapter, the most common pathological entities associated with MMC are illustrated, focusing on clinical manifestations, treatment strategies and follow up recommendations.

Programmable (proSA®) vs. fixed (SHUNTASSISTANT®) gravitational valves in pediatric patients with hydrocephalus: a 16-year retrospective single-center comparative study with biomechanical analysis

PURPOSE

In pediatric hydrocephalus (HC) treatment, programmable gravitational valves offer greater flexibility to manage overdrainage during children's growth. However, it remains unclear whether these devices provide better outcomes rather than their precursors. The study assessed the benefit from programmability of gravitational valve, i.e., programmable-SHUNTASSISTANT (proSA®) vs. SHUNTASSISTANT® (SA®).

METHODS

Clinical records and imaging of pediatric patients with hydrocephalus of non-tumoral etiology treated with fixed (SA®) or programmable (proSA®) gravitational valves between January 2006 and January 2022 were analyzed in a retrospective single-center study. Valve survival was compared in relation to age and etiology. Lately explanted valves received biomechanical analysis.

RESULTS

A total of 391 gravitational valves (254 SA® and 137 proSA®) were inserted in 244 patients (n = 134 males). One hundred thirty-three SA® (52.4%) and 67 proSA® (48.9%) were explanted during a follow-up of 81.1 ± 46.3 months. Valve survival rate at 1 and 5 years with proSA® was 87.6% and 60.6% compared to 81.9% and 58.7% with SA®, with mean survival time 56.4 ± 35.01 and 51.4 ± 43.0 months, respectively (P = 0.245). Age < 2 years at implantation correlated with significantly lower valve survival rates (P < 0.001), while HC etiology showed no significant impact. Overdrainage alone accounted for more SA® revisions (39.8% vs. 3.1%, P < 0.001), while dysfunctions of the adjustment system represented the first cause of valve replacement in proSA® cohort (45.3%). The biomechanical analysis performed on 41 proSA® and 31 SA® showed deposits on the valve's internal surface in 97.6% and 90.3% of cases.

CONCLUSION

Our comparative study between proSA® and SA® valves in pediatric HC demonstrated that both valves showed similar survival rates, regardless of etiology but only with young age at implantation. The programmability may be beneficial in preventing sequelae of chronic overdrainage but does not reduce need for valve revision and proSA® valve should be considered in selected cases in growing children older than 2 years.

Disparities in Postoperative Communication Patterns Among Spanish-speaking Pediatric Patients with Hydrocephalus

OBJECTIVE

To determine if differences exist in postoperative communication patterns or healthcare use among English-speaking patients (ESPs) and Spanish-speaking patients (SSPs) with childhood hydrocephalus.

STUDY DESIGN

A single-institution, retrospective cohort study was conducted. Through simple random sampling, 50 ESPs and 50 SSPs (<18 years old) who underwent a ventriculoperitoneal shunt or endoscopic third ventriculostomy were identified. Demographics, communication with clinic (eg, number of calls or messages postoperatively), and healthcare use were collected. Multiple linear regressions assessed the significance of predictors on communication frequency and use.

RESULTS

SSPs were more likely to have a comorbidity and ventriculoperitoneal shunt than ESPs. SSPs had longer median postoperative length of stay (P < .01) and 30-day readmission rate (P < .01) than ESPs. Only 18% of SSPs communicated with clinic; 11 total calls or messages were from SSPs vs 57 from ESPs (P < .01). The most common reason for outreach among both cohorts was a new symptom. ESP outreach most frequently resulted in reassurance or medical course changes on an outpatient basis (30% ESPs vs 0% SSPs; P = .04), whereas SSP outreach most frequently resulted in guidance to present to the emergency department (3% ESPs vs 36% SSPs; P < .01). Language remained a significant predictor for number of calls or messages, even after adjusting for comorbidity, operation type, and insurance (P < .01).

CONCLUSIONS

Despite having more complex disease, only 18% of SSPs communicated with the neurosurgical team postoperatively and were more frequently sent to the emergency department for management. Future research will explore communication barriers and preferences to ensure postoperative care is timely and patient centered.

Current status and challenges of neurosurgical procedures for patients with myelomeningocele in real-world Japan

BACKGROUND

Little is known about the real-world status of neurosurgical treatment of myelomeningocele patients.

OBJECTIVE

To investigate the real-world status of neurosurgical treatment of myelomeningocele patients, medical claims data provided by the Japan Medical Data Center (JMDC) were analyzed.

METHODS

The health claims data of 556 patients with myelomeningoceles from January 2005 to March 2020 were examined. The number of neurosurgical procedures, including myelomeningocele repair, tethered cord release, cerebrospinal fluid (CSF) shunt, CSF drainage, and endoscopic third ventriculostomy (ETV), was determined.

RESULTS

A total of 313 neurosurgical procedures were performed for 135 patients in 74 institutions during the study period. The shunt survival rate was most affected by shunts that were revised when the patient was less than 1 year old, which had a significantly lower survival rate than all of the initial shunts performed when the patient was less than on1 year old; the 1-year shunt survival rate was 35 vs 64% (P = 0.0102). The survival rate was significantly lower in patients younger than 1 year who had CSF drainage before shunting compared to those younger than 1 year who did not have CSF drainage before shunting; the 1-year shunt survival rate was 27 vs 59% (P = 0.0196), and 81% of patients remained free of tethered cord release 10 years later.

CONCLUSIONS

In this study, a revised shunt of less than 1 year of age and CSF drainage before shunting were the factors that lowered the shunt survival rate in the real world for CSF shunts for hydrocephalus associated with myelomeningocele.

Life on the Frontlines: Caregiver Experience of Pediatric Cerebrospinal Shunt Malfunction

BACKGROUND

We aimed to characterize the caregiver experience in the detection and evaluation of pediatric cerebrospinal shunt malfunction.

METHODS

In this descriptive qualitative study, we recruited English-speaking caregivers of children aged five years or less in collaboration with a stakeholder organization. Semistructured interviews were completed; content targeted the caregiver experience of shunt malfunction. Interviews were audio-recorded, transcribed, and deidentified. Qualitative data were analyzed using a conventional content analysis approach.

RESULTS

We enrolled 20 caregivers (n = 20 mothers). The median child age at the time of the interview was 2.8 years; about half (n = 11) were born prematurely and the majority (n = 15) had shunts placed at age less than six months. Caregiver experiences of shunt malfunction were grouped into three major themes: (1) my error could be life or death: the high stakes of shunt malfunction and the ambiguity of malfunction symptoms exacerbated baseline caregiver vigilance; (2) finding and engaging people who can help: hurdles during malfunction evaluation included locating trusted clinicians and advocating for parental intuition; and (3) how the shunt defines our family: caregivers described evolving expertise and modifications made to everyday life due to the threat of malfunction.

CONCLUSIONS

In this study, caregivers highlighted the challenges associated with recognizing shunt malfunction, accessing necessary treatment, and the impact of their child's shunt on family life. Future work should leverage these findings to inform counseling about shunt malfunction, develop interventions to better support families in shunt malfunction identification, and educate medical providers.

Serial Neuroendoscopic Lavage for the Treatment of Elevated Cerebrospinal Fluid Protein Levels in Infants with Gram-Negative Rod Ventriculitis

INTRODUCTION

Gram-negative rod (GNR) bacterial ventriculitis is a rare complication of shunt-dependent hydrocephalus, often requiring an extended and invasive treatment course. Accumulation of purulent material, as well as empyema and septation formation, limits circulation of antibiotics and infection clearance. Supplementation of standard care with neuroendoscopic-guided intraventricular lavage with lactated Ringer solution and fenestration of septations may facilitate infection clearance and simplify the eventual shunt construct required. Here, the utility of serial lavage for ventriculitis is described in a population of shunt-dependent neonates and infants at high risk for morbidity and mortality.

METHODS

Five infants with shunt-dependent hydrocephalus and subsequent GNR ventriculitis were treated with standard care measures with the addition of serial neuroendoscopic lavage. A retrospective chart review was performed to collect patient characteristics, shunt dependency, and shunt revisions within a year of ventriculitis resolution.

RESULTS

Patients demonstrated a mean 74% decrease in cerebrospinal fluid (CSF) protein following each neuroendoscopic lavage and trended toward a shorter time to infection clearance in comparison to previously published literature. Patients required 0-2 shunt revisions at 1-year follow-up following hospitalization for shunt-related ventriculitis (mean 0.8 +/- 0.8).

CONCLUSIONS

Serial neuroendoscopic lavage is an effective technique, used alone or in combination with fenestration of septations, to reduce the CSF protein and bacterial load in the treatment of ventriculitis, decreasing time until eradication of infection. Serial lavage may reduce the risk of future shunt malfunction, simplify the future shunt construct, and decrease duration of infection.

Initial Clinical Experience and Biomechanical Analysis of a Novel Gravity Unit-Assisted Valve (M.blue) in Pediatric Patients With Hydrocephalus: A Retrospective Study With Two Years of Follow-up

BACKGROUND

Overdrainage is a widely reported complication representing common indication for shunt revision. Despite recent advances in valve design, repeated shunt revisions represent burden on healthcare systems.

OBJECTIVE

To investigate the efficiency of a novel gravity unit-assisted programmable valve "M.blue" in pediatric hydrocephalus using clinical and biomechanical analyses.

METHODS

Thisretrospective single-center study included pediatric patients who received M.blue valve between April 2019 and 2021. Several clinical and biomechanical parameters were documented including complications and revision rates. Flow rate, functional assessment in vertical and horizontal positions, and extent of depositions inside valve were analyzed in explanted valves.

RESULTS

Thirty-seven M.blue valves in 34 pediatric patients with hydrocephalus (mean age 2.82 ± 3.91 years) were included. Twelve valves (32.4%) were explanted during a follow-up period of 27.3 ± 7.9 months. One-year survival rate of 89% and overall survival rate of 67.6% with a valve survival average of 23.8 ± 9.7 months were observed. Patients with explanted valves (n = 12) were significantly younger, with 0.91 ± 0.54 years of age in average ( P = .004), and showed significantly more adjustments difficulties ( P = .009 ). 58.3% of explanted valves showed deposits in more than 75% of the valve surface despite normal cerebrospinal fluid findings and were associated with dysfunctional flow rate in vertical, horizontal, or both positions.

CONCLUSION

The novel M.blue valve with integrated gravity unit is efficient in pediatric hydrocephalus with comparable survival rate. Deposits inside valves could affect its flow rate in different body positions and might lead to dysfunction or difficulties in valve adjustments.

Retrospective comparison of long-term functionality and revision rate of two different shunt valves in pediatric and adult patients

PURPOSE

The most frequent therapy of hydrocephalus is implantation of ventriculoperitoneal shunts for diverting cerebrospinal into the peritoneal cavity. We compared two adjustable valves, proGAV and proGAV 2.0, for complications resulting in revision surgery.

METHODS

Four hundred patients undergoing primary shunt implantation between 2014 and 2020 were analyzed for overall revision rate, 1-year revision rate, and revision-free survival observing patient age, sex, etiology of hydrocephalus, implantation site, prior diversion of cerebrospinal fluid, and cause of revision.

RESULTS

All data were available of all 400 patients (female/male 208/192). Overall, 99 patients underwent revision surgery after primary implantation. proGAV valve was implanted in 283 patients, and proGAV 2.0 valves were implanted in 117 patients. There was no significant difference between the two shunt valves concerning revision rate (p = 0.8069), 1-year revision rate (p = 0.9077), revision-free survival (p = 0.6921), and overall survival (p = 0.3232). Regarding 1-year revision rate, we observed no significant difference between the two shunt valves in pediatric patients (40.7% vs 27.6%; p = 0.2247). Revision operation had to be performed more frequently in pediatric patients (46.6% vs 24.8%; p = 0.0093) with a significant higher number of total revisions with proGAV than proGAV 2.0 (33 of 59 implanted shunts [55.9%] vs. 8 of 29 implanted shunts [27.6%]; p = 0.0110) most likely due to longer follow-up in the proGAV-group. For this reason, we clearly put emphasis on analyzing results regarding 1-year revision rate.

CONCLUSION

According to the target variables we analyzed, aside from lifetime revision rate in pediatric patients, there is no significant difference between the two shunt valves.

Open versus laparoscopic ventriculoperitoneal shunt placement in children: a systematic review and meta-analysis

BACKGROUND

Ventriculoperitoneal shunt (VPS) surgery is the traditional method for treating hydrocephalus, remaining one of the most regularly used procedures in pediatric neurosurgery. The reported revision rate of VPS can reach up to 80% and significantly reduces the quality of life in the affected children and has a high socioeconomic burden. Traditionally, distal VPS placement has been achieved open via a small laparotomy. However, in adults several studies have shown a lower rate of distal dysfunction using laparoscopic insertion. As the data in children are scarce, the aim of this systematic review and meta-analysis was to compare open and laparoscopic VPS placement in children regarding complications.

METHODS

PubMed and Embase databases were searched using a systematic search strategy to identify studies comparing open and laparoscopic VPS placement up to July 2022. Two independent researchers assessed the studies for inclusion and quality. Primary outcome measure was distal revision rate. A fixed effects model was used if low heterogeneity (I2 < 50%) was present, otherwise a random effects model was applied.

RESULTS

Out of 115 screened studies we included 8 studies in our qualitative assessment and three of them in our quantitative meta-analysis. All studies were retrospective cohort studies with 590 analyzed children, of which 231 children (39.2%) received laparoscopic, and 359 children (60.8%) open shunt placement. Similar distal revision rates were observed between the laparoscopic and open group (3.75% vs. 4.3%, RR 1.16, [ 95% CI 0.48 to 2.79], I2 = 50%, z = 0.32, p = 0.74). There was no significant difference in postoperative infection rate between the two groups (laparoscopic 5.6% vs. open 7.5%, RR 0.99, (95% CI [0.53 to 1.85]), I2=0%, z = -0.03, p= 0.97). The meta-analysis showed a significantly shorter surgery time in the laparoscopic group (49.22 (±21.46) vs. 64.13 (±8.99) minutes, SMD-3.6, [95% CI -6.9 to -0.28], I2=99%m z= -2.12, p= 0.03) compared to open distal VPS placement.

CONCLUSION

Few studies are available comparing open and laparoscopic shunt placement in children. Our meta-analysis showed no difference in distal revision rate between laparoscopic and open shunt insertion; however, laparoscopic placement was associated with a significantly shorter surgery time. Further prospective trials are needed to assess possible superiority of one of the techniques.

Developing Predictive Models to Anticipate Shunt Complications in 33,248 Pediatric Patients with Shunted Hydrocephalus Utilizing Machine Learning

INTRODUCTION

Hydrocephalus is a common pediatric neurosurgical pathology, typically treated with a ventricular shunt, yet approximately 30% of patients experience shunt failure within the first year after surgery. As a result, the objective of the present study was to validate a predictive model of pediatric shunt complications with data retrieved from the Healthcare Cost and Utilization Project (HCUP) National Readmissions Database (NRD).

METHODS

The HCUP NRD was queried from 2016 to 2017 for pediatric patients undergoing shunt placement using ICD-10 codes. Comorbidities present upon initial admission resulting in shunt placement, Johns Hopkins Adjusted Clinical Groups (JHACG) frailty-defining criteria, and Major Diagnostic Category (MDC) at admission classifications were obtained. The database was divided into training (n = 19,948), validation (n = 6,650), and testing (n = 6,650) datasets. Multivariable analysis was performed to identify significant predictors of shunt complications which were used to develop logistic regression models. Post hoc receiver operating characteristic (ROC) curves were created.

RESULTS

A total of 33,248 pediatric patients aged 6.9 ± 5.7 years were included. Number of diagnoses during primary admission (OR: 1.05, 95% CI: 1.04-1.07) and initial neurological admission diagnoses (OR: 3.83, 95% CI: 3.33-4.42) positively correlated with shunt complications. Female sex (OR: 0.87, 95% CI: 0.76-0.99) and elective admissions (OR: 0.62, 95% CI: 0.53-0.72) negatively correlated with shunt complications. ROC curve for the regression model utilizing all significant predictors of readmission demonstrated area under the curve of 0.733, suggesting these factors are possible predictors of shunt complications in pediatric hydrocephalus.

CONCLUSION

Efficacious and safe treatment of pediatric hydrocephalus is of paramount importance. Our machine learning algorithm delineated possible variables predictive of shunt complications with good predictive value.

Characterization of cerebrospinal fluid (CSF) microbiota at the time of initial surgical intervention for children with hydrocephalus

OBJECTIVE

To characterize the microbiota of the cerebrospinal fluid (CSF) from children with hydrocephalus at the time of initial surgical intervention.

STUDY DESIGN

CSF was obtained at initial surgical intervention. One aliquot was stored in skim milk-tryptone-glucose-glycerol (STGG) medium and the second was unprocessed; both were then stored at -70°C. Bacterial growth for CSF samples stored in STGG were subsequently characterized using aerobic and anaerobic culture on blood agar and MALDI-TOF sequencing. All unprocessed CSF samples underwent 16S quantitative polymerase chain reaction (qPCR) sequencing, and a subset underwent standard clinical microbiological culture. CSF with culture growth (either after storage in STGG or standard clinical) were further analyzed using whole-genome amplification sequencing (WGAS).

RESULTS

11/66 (17%) samples stored in STGG and 1/36 (3%) that underwent standard clinical microbiological culture demonstrated bacterial growth. Of the organisms present, 8 were common skin flora and 4 were potential pathogens; only 1 was also qPCR positive. WGAS findings and STGG culture findings were concordant for only 1 sample, identifying Staphylococcus epidermidis. No significant difference in time to second surgical intervention was observed between the STGG culture-positive and negative groups.

CONCLUSION(S)

Using high sensitivity methods, we detected the presence of bacteria in a subset of CSF samples at the time of first surgery. Therefore, the true presence of bacteria in CSF of children with hydrocephalus cannot be ruled out, though our findings may suggest these bacteria are contaminants or false positives of the detection methods. Regardless of origin, the detection of microbiota in the CSF of these children may not have any clinical significance.

First reports of fetal SMARCC1 related hydrocephalus

The SMARCC1 gene has been involved in congenital ventriculomegaly with aqueduct stenosis but only a few patients have been reported so far, with no antenatal cases, and it is currently not annotated as a morbid gene in OMIM nor in the Human Phenotype Ontology. Most of the reported variants are loss of function (LoF) and are often inherited from unaffected parents. SMARCC1 encodes a subunit of the mSWI/SNF complex and affects the chromatin structure and expression of several genes. Here, we report the two first antenatal cases of SMARCC1 LoF variants detected by Whole Genome Sequencing (WGS). Ventriculomegaly is the common feature in those fetuses. Both identified variants are inherited from a healthy parent, which supports the reported incomplete penetrance of this gene. This makes the identification of this condition in WGS as well as the genetic counseling challenging.

The survival time of the ventriculo-peritoneal-shunt in children with hydrocephalus is dependent on the type of valve implanted

PURPOSE

Despite constantly improving developments in ventriculo-peritoneal shunt systems, most patients with hydrocephalus require revision or replacement at some point of time. Therefore, this study aimed to analyse parameters that are associated with shunt dysfunction.

METHODS

In this retrospective study, we included 81 patients aged 0-17 who were treated at our institution. Demographic data, etiology of the hydrocephalus, type of valve implanted, reason for any revision procedures, any complications and survival time of the ventriculo-peritoneal shunts were detected. Statistical analysis was performed using SPSS. The significance level was set at p ≤ 0.05.

RESULTS

Over a mean study period of 18 years, we analyzed 226 valves subjected to 146 revision operations in 81 patients. The etiology of the hydrocephalus (p = 0.874) and the age of the child at the time of VP shunt implantation (p = 0.308) did not have any impact on the shunt survival time. However, the type of the valve significantly changed the survival time of the shunt (p = 0.030). Pressure differential valves presented a longer survival time than gravitational valves.

CONCLUSION

The majority of patients in this study needed at least one replacement of the initial shunt system. Pressure differential valves may be beneficial for the survival time of the shunt system.

Distal shunt placement in pediatric ventriculoperitoneal shunt surgery: an international survey of practice

OBJECTIVE

Ventriculoperitoneal shunt (VPS) surgery is a common treatment for hydrocephalus in children and adults, making it one of the most common procedures in neurosurgery. Children being treated with a VPS often require several revisions during their lifetime with a lifetime revision rate of up to 80%. Several different techniques exist for inserting the distal catheter, while mini-laparotomy, trocar, or laparoscopy is traditionally used. As opposed to adults, only few studies exist, comparing the outcome of the different distal catheter placement techniques in children. This international survey aims to investigate the current daily practice concerning distal shunt placement techniques in children.

MATERIAL AND METHODS

An online questionnaire investigating the different techniques used to place the distal catheter in pediatric VPS surgery was distributed internationally. All results were analyzed using descriptive and comparative statistics.

RESULTS

A total of 139 responses were obtained. Mini-laparotomy was reported to be the most frequently used technique (n = 104, 74.8%) for distal shunt placement in children, while laparoscopic or trocar-assisted placements were only used by 3.6% (n = 5) and 21.6% (n = 30) of all respondents, respectively. Over half (n = 75, 54.0%) of all respondents do not believe that laparoscopic placement improves the outcome.

CONCLUSION

This international survey shows that mini-laparotomy is the most frequently used technique for distal VPS placement in children all over the world. Further randomized trials are needed to elucidate this matter.

Factors affecting ventriculoperitoneal shunt revision: a post hoc analysis of the British Antibiotic and Silver Impregnated Catheter Shunt multicenter randomized controlled trial

OBJECTIVE

The British Antibiotic and Silver Impregnated Catheter Shunt (BASICS) trial established level I evidence of the superiority of antibiotic-impregnated catheters in the prevention of infection of newly implanted ventriculoperitoneal shunts (VPSs). A wealth of patient, shunt, and surgery-specific data were collected from trial participants beyond that of the prespecified trial objectives.

METHODS

This post hoc analysis of the BASICS survival data explores the impact of patient age, hydrocephalus etiology, catheter type, valve type, and previous external ventricular drain on the risk of infection or mechanical failure. Time to failure was analyzed using Fine and Gray survival regression models for competing risk.

RESULTS

Among 1594 participants, 75 patients underwent revision for infection and 323 for mechanical failure. Multivariable analysis demonstrated an increased risk of shunt infection associated with patient ages < 1 month (subdistribution hazard ratio [sHR] 4.48, 95% CI 2.06-9.72; p < 0.001) and 1 month to < 1 year (sHR 2.67, 95% CI 1.27-5.59; p = 0.009), as well as for adults with posthemorrhagic hydrocephalus (sHR 2.75, 95% CI 1.21-6.26; p = 0.016). Age ≥ 65 years was found to be independently associated with reduced infection risk (sHR 0.26, 95% CI 0.10-0.69; p = 0.007). Antibiotic-impregnated catheter use was also associated with reduced infection risk (sHR 0.43, 95% CI 0.22-0.84; p = 0.014). Independent risk factors predisposing to mechanical failure were age < 1 month (sHR 1.51, 95% CI 1.03-2.21; p = 0.032) and 1 month to < 1 year (sHR 1.31, 95% CI 0.95-1.81; p = 0.046). Age ≥ 65 years was demonstrated to be the only independent protective factor against mechanical failure risk (sHR 0.64, 95% CI 0.40-0.94; p = 0.024).

CONCLUSIONS

Age is the predominant risk for VPS revision for infection and/or mechanical failure, with neonates and infants being the most vulnerable.

Outcomes of the 2019 hydrocephalus association workshop, "Driving common pathways: extending insights from posthemorrhagic hydrocephalus"

The Hydrocephalus Association (HA) workshop, Driving Common Pathways: Extending Insights from Posthemorrhagic Hydrocephalus, was held on November 4 and 5, 2019 at Washington University in St. Louis. The workshop brought together a diverse group of basic, translational, and clinical scientists conducting research on multiple hydrocephalus etiologies with select outside researchers. The main goals of the workshop were to explore areas of potential overlap between hydrocephalus etiologies and identify drug targets that could positively impact various forms of hydrocephalus. This report details the major themes of the workshop and the research presented on three cell types that are targets for new hydrocephalus interventions: choroid plexus epithelial cells, ventricular ependymal cells, and immune cells (macrophages and microglia).

Mortality and complications 1 year after treatment of hydrocephalus with endoscopic third ventriculostomy and ventriculoperitoneal shunt in children at Queen Elizabeth Central Hospital, Malawi

BACKGROUND

Over the past two decades, the management of hydrocephalus has witnessed the addition of endoscopic third ventriculostomy with or without choroid plexus cauterization (ETV ± CPC) to the traditional methods including ventriculoperitoneal shunt insertion (VPSI). We conducted this study to assess mortality and complications with surgical implications associated with the two procedures in children with hydrocephalus.

METHODS

We reviewed our operating theater registry to identify children below 17 years old who underwent hydrocephalus surgery for the first time in 2016. The patients were followed for up to 1 year from the date of the initial operation. Their vital status was confirmed by follow-up visits by a community nurse. Descriptive analyses were used to describe the characteristics of the patients and evaluate the study outcomes (i.e., mortality and complications).

RESULTS

One hundred fifty-three patients were eligible for the study; 56% were males and 73.2% had primary ETV ± CPC. Complete 1-year follow-up data was available for 79 patients, and 73.4% of these had ETV ± CPC. One-year success (event-free) rates for ETV and VPSI were similar at 67.4% and 66.7%, respectively. ETVs in infants under 6 months performed poorly; failing in half the infants, who were subsequently converted to VPS. Shunt sepsis was very high, 21.4% (95% CI 10.3-36.8). The majority of surgical complications (81.8%) occurred within 3 months of surgery.

CONCLUSION

ETV ± CPC and VPSI carry a similar frequency of mortality and complications in our setting, and therefore, both should be considered as a treatment option for patients with hydrocephalus. As VP shunt is still used for managing most of the patients, there is still a need to prioritize measures to reduce shunt infections.

Symptoms of Cerebrospinal Shunt Malfunction in Young Children: A National Caregiver Survey

Objective: This study aimed to describe shunt malfunction symptoms in children ≤5 years old. Results: In a national survey of 228 caregivers, vomiting (23.1%), irritability (20.8%), and sleepiness (17.2%) were the most frequent symptoms of malfunction. These symptoms also occurred in over 1/3 of "false alarms" experienced by 75% of respondents. Compared with malfunctions, irritability (OR = 1.39, 95% CI [1.05, 1.85], p = 0.022) and fever (OR = 2.22, 95% CI [1.44, 3.44], p < 0.001) were more likely false alarms. Caregivers counseled about "most" symptoms were more confident detecting malfunctions than those informed of "some" (p = 0.036). The majority of caregivers (85%) first contacted a neurosurgeon with concerns about malfunction, followed by neurologists (22%) and family/friends (19%). Most (85%) struggled to differentiate malfunction from regular development. Conclusions: Vomiting, irritability, and sleepiness were the most common symptoms of shunt malfunction and false alarms for children ≤5 years. Most caregivers reported challenges differentiating malfunctions from their child's development.

Time to shunt failure in children with myelomeningocele: an analysis of the National Spina Bifida Patient Registry

OBJECTIVE

Hydrocephalus is common among children with myelomeningocele and is most frequently treated with a ventriculoperitoneal shunt (VPS). Although much is known about factors related to first shunt failure, relatively less data are available about shunt failures after the first one. The purpose of this study was to use a large data set to explore time from initial VPS placement to first shunt failure in children with myelomeningocele and to explore factors related to multiple shunt failures.

METHODS

Data were obtained from the National Spina Bifida Patient Registry. Children with myelomeningocele who were enrolled within the first 5 years of life and had all lifetime shunt operations recorded in the registry were included. Kaplan-Meier survival curves were constructed to evaluate time from initial shunt placement to first shunt failure. The total number of children who experienced at least 2 shunt failures was calculated. A proportional means model was performed to calculate adjusted hazard ratios (HRs) for shunt failure on the basis of sex, race/ethnicity, lesion level, and insurance status.

RESULTS

In total, 1691 children met the inclusion criteria. The median length of follow-up was 5.0 years. Fifty-five percent of patients (938 of 1691) experienced at least 1 shunt failure. The estimated median time from initial shunt placement to first failure was 2.34 years (95% confidence interval [CI] 1.91-3.08 years). Twenty-six percent of patients had at least 2 shunt failures, and 14% of patients had at least 3. Male children had higher likelihood of shunt revision (HR 1.25, 95% CI 1.09-1.44). Children of minority race/ethnicity had a lower likelihood of all shunt revisions (non-Hispanic Black children HR 0.74, 95% CI 0.55-0.98; Hispanic children HR 0.74, 95% CI 0.62-0.88; children of other ethnicities HR 0.80, 95% CI 0.62-1.03).

CONCLUSIONS

Among the children with myelomeningocele, the estimated median time to shunt failure was 2.34 years. Forty-five percent of children never had shunt failure. The observed higher likelihood of shunt revisions among males and lower likelihood among children of minority race/ethnicity illustrate a possible disparity in hydrocephalus care that warrants additional study. Overall, these results provide important information that can be used to counsel parents of children with myelomeningocele about the expected course of shunted hydrocephalus.

Pattern of neurosurgical cases and procedures in Gilgit Baltistan: two-year experience at a newly established neurosurgical department

BACKGROUND

In Pakistan, there are a total of 160 neurosurgeons that constitute a ratio of one neurosurgeon for a 5.5 million population. Gilgit Baltistan being a backward region does not have a single tertiary care facility. A new department of neurosurgery was established at Regional Headquarter City Hospital (RHQ) Gilgit with only one neurosurgeon. This study aimed to determine which neurosurgical diagnoses are common and which surgical interventions were performed at RHQ.

METHODS

This is a retrospective cross-sectional study conducted at Regional Headquarter Hospital (RHQ) Gilgit in which data of patients operated for neurosurgical diseases between January 2020 and January 2022 was collected from patient record books.

RESULTS

Of total of 223 patients, 148 (66.3%) were males and 75 (33.6%) were females. 92(41.2%) belonged to the pediatric age group. The top most diagnosis included Neurotrauma (46.6%), NTDs (13.9%) and CSDH (10.3%) while the most routinely performed procedures were craniotomy & hematoma evacuation (22.9%), debridement & elevation of DSF (20.6%), and burrhole evacuation (13.9%). In the pediatric age group, the top diagnosis was Neurotrauma (43.5%), NTDs (32.6%), and Hydrocephalus (19.6%) while in adults, neurotrauma (48.9%) was the leading diagnosis followed by CSDH (17.6%). In the pediatric age group, repair of NTDs (32.6%) was the most frequently performed procedure.

CONCLUSION

This study shows different kinds of neurosurgical cases but because of a lack of diagnostic and therapeutic facilities, very limited operations were performed and many cases were referred to metropolitan cities. The hospitals in the region need further up-gradation to cater to the presenting burden.

Treatment Strategies and Challenges to Avoid Cerebrospinal Fluid Shunting for Pediatric Hydrocephalus

Treatment for pediatric hydrocephalus aims not only to shrink the enlarged ventricle morphologically but also to create an intracranial environment that provides the best neurocognitive development and to deal with various treatment-related problems over a long period of time. Although the primary diseases that cause hydrocephalus are diverse, the ventricular peritoneal shunt has been introduced as the standard treatment for several decades. Nevertheless, complications such as shunt infection and shunt malfunction are unavoidable; the prognosis of neurological function is severely affected by such factors, especially in newborns and infants.

In recent years, treatment concepts have been attempted to avoid shunting, mainly in the context of pediatric cases. In this review, the current role of neuroendoscopic third ventriculostomy for noncommunicating hydrocephalus is discussed and a new therapeutic concept for post intraventricular hemorrhagic hydrocephalus in preterm infants is documented. To avoid shunt placement and achieve good neurodevelopmental outcomes for pediatric hydrocephalus, treatment modalities must be developed.

Pathogenesis of posthemorrhagic hydrocephalus of prematurity: New horizons

Posthemorrhagic hydrocephalus of prematurity (PHHP) remains a vexing problem for patients, their families, and the healthcare system. The complexity of the pathogenesis of PHHP also presents a unique challenge within the fields of neonatology, neurology and neurosurgery. Here we focus on pathogenesis of PHHP and its impact on the development of CSF dynamics including choroid plexus, ependymal motile cilia and glymphatic system. PHHP is contrasted with infantile hydrocephalus from other etiologies, and with other types of posthemorrhagic hydrocephalus that occur later in life. The important concept that distinguishing ventricular volume from brain health and function is highlighted. The influence of the pathogenesis of PHHP on current interventions is reviewed, with particular emphasis on how the unique pathogenesis of PHHP contributes to the high rate of failure of current existing interventions. Finally, we discuss emerging interventions. A thorough understanding of the pathogenesis of PHHP is essential to developing effective non-surgical therapeutics to prevent the transformation from severe IVH to PHHP.

The Construction of a Predictive Composite Index for Decision-Making of CSF Diversion Surgery in Pediatric Patients following Prenatal Myelomeningocele Repair

BACKGROUND AND PURPOSE

There is a wide range of clinical and radiographic factors affecting individual surgeons' ultimate decision for CSF diversion for pediatric patients following prenatal myelomeningocele repair. Our aim was to construct a composite index (CSF diversion surgery index) that integrates conventional clinical measures and neuroimaging biomarkers to predict CSF diversion surgery in these pediatric patients.

MATERIALS AND METHODS

This was a secondary retrospective analysis of data from 33 patients with prenatal myelomeningocele repair (including 14 who ultimately required CSF diversion surgery). Potential independent variables, including the Management of Myelomeningocele Study Index (a dichotomized variable based on the shunt-placement criteria from the Management of Myelomeningocele Study), postnatal DTI measures (fractional anisotropy and mean diffusivity in the genu of the corpus callosum and the posterior limb of internal capsule), fronto-occipital horn ratio at the time of DTI, gestational ages, and sex, were evaluated using stepwise logistic regression analysis to identify the most important predictors.

RESULTS

The CSF diversion surgery index model showed that the Management of Myelomeningocele Study Index and fractional anisotropy in the genu of the corpus callosum were significant predictors (P < .05) of CSF diversion surgery. The predictive value of the CSF diversion surgery index was also affected by fractional anisotropy in the posterior limb of the internal capsule and sex with marginal effect (.05<P < .10), but not by the fronto-occipital horn ratio (P > .10). The overall CSF diversion surgery index model fit the data well with statistical significance (eg, likelihood ratio: P < .001), with the performance (sensitivity = 78.6%; specificity = 86.5%, overall accuracy = 84.8%) superior to all individual indices in sensitivity and overall accuracy, and most of the individual indices in specificity.

CONCLUSIONS

The CSF diversion surgery index model outperformed all single predictor models and, with additional validation, may potentially be developed and incorporated into a sensitive and robust clinical tool to assist clinicians in hydrocephalus management.

Endoscopic third ventriculostomy revision after failure of initial endoscopic third ventriculostomy and choroid plexus cauterization

OBJECTIVE

Primary treatment of hydrocephalus with endoscopic third ventriculostomy (ETV) and choroid plexus cauterization (CPC) is well described in the neurosurgical literature, with wide reported ranges of success and complication rates. The purpose of this study was to describe the safety and efficacy of ETV revision after initial ETV+CPC failure.

METHODS

Prospectively collected data in the Hydrocephalus Clinical Research Network Core Data Project registry were reviewed. Children who underwent ETV+CPC as the initial treatment for hydrocephalus between 2013 and 2019 and in whom the initial ETV+CPC was completed (i.e., not abandoned) were included. Log-rank survival analysis (the primary analysis) was used to compare time to failure (defined as any other surgical treatment for hydrocephalus or death related to hydrocephalus) of initial ETV+CPC versus that of ETV revision by using random-effects modeling to account for the inclusion of patients in both the initial and revision groups. Secondary analysis compared ETV revision to shunt placement after failure of initial ETV+CPC by using the log-rank test, as well as shunt failure after ETV+CPC to that after ETV revision. Cox regression analysis was used to identify predictors of failure among children treated with ETV revision.

RESULTS

The authors identified 521 ETV+CPC procedures that met their inclusion criteria. Ninety-one children underwent ETV revision after ETV+CPC failure. ETV revision had a lower 1-year success rate than initial ETV+CPC (29.5% vs 45%, p < 0.001). ETV revision after initial ETV+CPC failure had a lower success rate than shunting (29.5% vs 77.8%, p < 0.001). Shunt survival after initial ETV+CPC failure was not significantly different from shunt survival after ETV revision failure (p = 0.963). Complication rates were similar for all examined surgical procedures (initial ETV+CPC, ETV revision, ventriculoperitoneal shunt [VPS] placement after ETV+CPC, and VPS placement after ETV revision). Only young age was predictive of ETV revision failure (p = 0.02).

CONCLUSIONS

ETV revision had a significantly lower 1-year success rate than initial ETV+CPC and VPS placement after ETV+CPC. Complication rates were similar for all studied procedures. Younger age, but not time since initial ETV+CPC, was a risk factor for ETV revision failure.

Diagnosis and Surgical Management of Neonatal Hydrocephalus

Neonatal hydrocephalus represents an important pathological condition with significant impact on medical care and neurocognitive development. This condition requires early recognition, appropriate medical and surgical management, and long-term surveillance by clinicians and pediatric neurosurgeons. Common etiologies of neonatal and infant hydrocephalus include intraventricular hemorrhage related to prematurity with subsequent post-hemorrhagic hydrocephalus, myelomeningocele, and obstructive hydrocephalus due to aqueductal stenosis. Clinical markers of elevated intracranial pressure include rapid increases in head circumference across percentiles, elevation and firmness of the anterior fontanelle, splitting or splaying of cranial sutures, upgaze palsy, lethargy, frequent emesis, or episodic bradycardia (unrelated to other comorbidities). Complementing these clinical markers, imaging modalities used for the diagnosis of neonatal hydrocephalus include head ultrasonography, brain magnetic resonance imaging, and head computed tomography in urgent or emergent situations. Following diagnosis, temporizing measures may be employed prior to definitive treatment and include ventricular access device or ventriculo-subgaleal shunt insertion. Definitive surgical management involves permanent cerebrospinal fluid (CSF) diversion via CSF shunt insertion, or endoscopic third ventriculostomy with or without choroid plexus cauterization. Surgical decision-making and approaches vary based on patient age, hydrocephalus etiology, neuroanatomy, imaging findings, and medical comorbidities. Indications, surgical techniques, and clinical outcomes of these procedures continue to evolve and elicit significant attention in the research environment. In this review we describe the epidemiology, pathophysiology, clinical markers, imaging findings, early management, definitive surgical management, and clinical outcomes of pediatric patients with neonatal hydrocephalus.

Mechanisms of neuroinflammation in hydrocephalus after intraventricular hemorrhage: a review

Intraventricular hemorrhage (IVH) is a significant cause of morbidity and mortality in both neonatal and adult populations. IVH not only causes immediate damage to surrounding structures by way of mass effect and elevated intracranial pressure; the subsequent inflammation causes additional brain injury and edema. Of those neonates who experience severe IVH, 25-30% will go on to develop post-hemorrhagic hydrocephalus (PHH). PHH places neonates and adults at risk for white matter injury, seizures, and death. Unfortunately, the molecular determinants of PHH are not well understood. Within the past decade an emphasis has been placed on neuroinflammation in IVH and PHH. More information has come to light regarding inflammation-induced fibrosis and cerebrospinal fluid hypersecretion in response to IVH. The aim of this review is to discuss the role of neuroinflammation involving clot-derived neuroinflammatory factors including hemoglobin/iron, peroxiredoxin-2 and thrombin, as well as macrophages/microglia, cytokines and complement in the development of PHH. Understanding the mechanisms of neuroinflammation after IVH may highlight potential novel therapeutic targets for PHH.

Treatment of Posthemorrhagic Hydrocephalus

The incidence of intraventricular hemorrhage (IVH) has overall declined to 15% to 20% of preterm infants with birth weight less than 1500 g. One of the major complications of severe IVH is posthemorrhagic ventricular dilation (PHVD). Nearly 10% of all infants with IVH and 20% of infants with severe IVH will develop progressive PHVD requiring surgical intervention to prevent parenchymal damage in the developing brain. This review focuses on the controversies regarding posthemorrhagic hydrocephalus interventions with a focus on how to interpret recent data from trials that some have seen as heralding a call toward more aggressive intervention.

Transcutaneous ventriculo-peritoneal shunt catheter extrusion with silent bowel perforation following digestive surgery: a case report

This case report provides an account of transcutaneous ventriculo-peritoneal (VP) shunt extrusion with silent bowel perforation occurring 2 years post digestive surgery. A 22-year-old man treated since childhood for post-infectious hydrocephalus was referred to our neurosurgery department for an inflammatory wound to the right hypochondrium caused by an abandoned calcified VP shunt. This VP shunt was surgically removed without complications. The perforated bowel required no direct repair. Progress is favorable at 1 year follow-up.

A comparison of Adult and Pediatric Hydrocephalus

Hydrocephalus is a common clinical problem encountered in neurosurgical practice. With greater subspecialisation, pediatric neurosurgery has emerged as a special discipline in several countries. However, in the developing world, which inhabits a large pediatric population, a limited number of neurosurgeons manage all types of hydrocephalus across all ages. There are some essential differences in pediatric and adult hydrocephalus. The spectrum of hydrocephalus of dysgenetic origin in a neonate and that of normal pressure hydrocephalus of the old age has a completely different strategy of management. Endoscopic third ventriculostomy outcomes are known to be closely associated with age at presentation and surgery. Efficacy of alternative pathways of CSF absorption also differs according to age. Managing this disease in various age groups is challenging because of these differences in etiopathology, tempo of the disease, modalities of investigations and various treatment protocols as well as prognosis.

Variables Associated With Shunt Failure in Children With Cerebrospinal Fluid Diverting Shunts

OBJECTIVES

We sought to identify clinical characteristics that would negatively predict shunt failure, thus potentially obviating the need for further diagnostic workup or extended periods of observation. We hypothesized that viral symptoms and a patient history of epilepsy or chronic headaches would be negative predictors of shunt failure.

METHODS

Data were retrospectively collected for children 19 years or younger with a cerebrospinal fluid diverting shunt in their medical history or problem list who underwent neuroimaging during an ED visit from March 2008 to September 2016. Patients were defined as having shunt failure if they required surgical exploration for shunt revision within 7 days of the ED visit. Descriptive statistics were used for patient demographics, current symptoms, and historical features. We conducted a logistic regression analysis to determine which characteristics were associated with the odds of shunt failure and used binary recursive partitioning to determine if there were features or a combination of features that were able to accurately classify patients without shunt failure.

RESULTS

There were 606 visits by 277 patients during this interval, 34% of whom were experiencing shunt failure. Variables found to be significantly predictive of shunt failure were revision within the prior 6 months, vomiting, personality changes, family opinion of shunt failure, and cranial nerve palsies. Viral symptoms and a history of epilepsy or chronic headaches were not predictive of shunt failure. Binary recursive partitioning identified family opinion and personality changes as predictive of shunt failure, with a sensitivity of 72.2% (95% confidence interval, 65.5%-78.2%) and specificity of 46.6% (95% confidence interval, 41.7%-51.7%).

CONCLUSIONS

Although certain clinical and historical features have modest predictive value in children with shunted hydrocephalus, these factors are insufficiently sensitive to exclude shunt failure, arguing for liberal neuroimaging and extended observation.

Neuroendoscopic lavage for the management of neonatal post-haemorrhagic hydrocephalus: a retrospective series

INTRODUCTION

Intraventricular haemorrhage (IVH) is a common complication of preterm birth, and optimal treatment remains uncertain. Neuroendoscopic lavage (NEL) has gained interest as a method for removal of intraventricular haematoma, with outcomes suggesting it to be safe and potentially effective.

METHODS

A retrospective review was carried identifying infants who underwent NEL for post-IVH hydrocephalus at our institution. Data was extracted on patient baseline demographics, comorbidities, complications, re-operation requirement, and neurodevelopmental outcomes.

RESULTS

Twenty-six patients (17 male) were identified, who underwent NEL at a mean age of 39 weeks and 4 days. Eighteen patients underwent simultaneous endoscopic third ventriculostomy (ETV). Mean patient follow-up was 57.7 months ± 11.8 months. A total of 17/26 patients went on to require a ventriculoperitoneal shunt (VPS). Nine patients did not require further surgical management of hydrocephalus; all had been managed with NEL + ETV. The relative risk of requiring VPS with NEL + ETV compared with NEL alone was 0.500 (CI: 0.315-0.794; p = 0.0033). The 24-month survival rate of VPS inserted following NEL was 64.7%. Exactly 5/26 (19.2%) had post-procedure complications: 2 CSF leaks (7.7%), 2 infections (7.7%), and 1 rebleed within 72 h of NEL (3.8%). On long-term follow-up, 22/25 patients achieved good motor outcome, either walking independently or with mobility aids. A total of 8/15 children attended mainstream schooling with adaption.

DISCUSSION

NEL is safe and potentially efficacious treatment for neonatal IVH. The procedure may reduce shunt dependence and, for those who require CSF diversion, improve shunt survival. Neurodevelopmentally, good motor and cognitive outcome can be achieved.

Factors associated with early shunt revision within 30 days: analyses from the National Surgical Quality Improvement Program

OBJECTIVE

CSF shunt insertion is the most commonly performed neurosurgical procedure for pediatric patients with hydrocephalus, and complications including infections and catheter obstruction are common. The rate of readmission in the first 30 days after surgery has been used across surgical disciplines to determine healthcare quality. In the current study, the authors sought to assess factors associated with early shunt revision within 30 days using real-world data.

METHODS

Targeted shunt data set participant user files of the National Surgical Quality Improvement Program (NSQIP) from 2016 to 2019 were queried for patients undergoing a shunt procedure. A multivariable logistic regression model was performed to assess the impact of demographics, etiologies, comorbidities, congenital malformations, and shunt adjuncts on shunt revision within 30 days, as well as shunt revision due to infection within 30 days.

RESULTS

A total of 3919 primary pediatric shunt insertions were identified in the NSQIP database, with a mean (± SD) patient age of 26.3 ± 51.6 months. There were a total of 285 (7.3%) unplanned shunt revisions within 30 days, with a mean duration of 14.9 ± 8.5 days to first intervention. The most common reason for intervention was mechanical shunt failure (32.6% of revision, 2.4% overall, n = 93), followed by infection (31.2% of all interventions, 2.3% overall, n = 89) and wound disruption or CSF leak (22.1% of all interventions, 1.6% overall, n = 63). Patients younger than 6 months of age had the highest overall unplanned 30-day revision rate (8.5%, 203/2402) as well as the highest 30-day shunt infection rate (3%, 72/2402). Patients who required a revision were also more likely to have a cardiac risk factor (34.7%, n = 99, vs 29.2%, n = 1061; p = 0.048). Multivariable logistic regression revealed that compared to patients 9-18 years old, those aged 2-9 years had significantly lower odds of repeat shunt intervention (p = 0.047), while certain etiologies including congenital hydrocephalus (p = 0.0127), intraventricular hemorrhage (IVH) of prematurity (p = 0.0173), neoplasm (p = 0.0005), infection (p = 0.0004), and syndromic etiology (p = 0.0136), as well as presence of ostomy (p = 0.0095), were associated with higher odds of repeat intervention. For shunt infection, IVH of prematurity was found to be associated with significantly higher odds (p = 0.0427) of shunt infection within 30 days, while use of intraventricular antibiotics was associated with significantly lower odds (p = 0.0085).

CONCLUSIONS

In this study of outcomes after pediatric shunt placement using a nationally derived cohort, early shunt failure and infection within 30 days were found to remain as considerable risks. The analysis of this national surgical quality registry confirms that, in accordance with other multicenter studies, hydrocephalus etiology, age, and presence of ostomy are important predictors of the need for early shunt revision. IVH of prematurity is associated with early infections while intraventricular antibiotics may be protective. These findings could be used for benchmarking in hospital efforts to improve quality of care for pediatric patients with hydrocephalus.