Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network

Hydrocephalus surveillance following CSF diversion: a modified Delphi study

OBJECTIVE

Long-term follow-up is often recommended for patients with hydrocephalus, but the frequency of clinical follow-up, timing and modality of imaging, and duration of surveillance have not been clearly defined. Here, the authors used the modified Delphi method to identify areas of consensus regarding the modality, frequency, and duration of hydrocephalus surveillance following surgical treatment.

METHODS

Pediatric neurosurgeons serving as institutional liaisons to the Hydrocephalus Clinical Research Network (HCRN), or its implementation/quality improvement arm (HCRNq), were invited to participate in this modified Delphi study. Thirty-seven consensus statements were generated and distributed via an anonymous electronic survey, with responses structured as a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A subsequent, virtual meeting offered the opportunity for open discussion and modification of the statements in an effort to reach consensus (defined as ≥ 80% agreement or disagreement).

RESULTS

Nineteen pediatric neurosurgeons participated in the first round, after which 15 statements reached consensus. During the second round, 14 participants met virtually for review and discussion. Some statements were modified and 2 statements were combined, resulting in a total of 36 statements. At the conclusion of the session, consensus was achieved for 17 statements regarding the following: 1) the role of standardization; 2) preferred imaging modalities; 3) postoperative follow-up after shunt surgery (subdivided into immediate postoperative imaging, delayed postoperative imaging, routine clinical surveillance, and routine radiological surveillance); and 4) postoperative follow-up after an endoscopic third ventriculostomy. Consensus could not be achieved for 19 statements.

CONCLUSIONS

Using the modified Delphi method, 17 consensus statements were developed with respect to both clinical and radiological follow-up after a shunt or endoscopic third ventriculostomy. The frequency, modality, and duration of surveillance were addressed, highlighting areas in which no clear data exist to guide clinical practice. Although further studies are needed to evaluate the clinical utility and cost-effectiveness of hydrocephalus surveillance, the current study provides a framework to guide future efforts to develop standardized clinical protocols for the postoperative surveillance of patients with hydrocephalus. Ultimately, the standardization of hydrocephalus surveillance has the potential to improve patient care as well as optimize the use of healthcare resources.

The effect of image-guided ventricular catheter placement on shunt failure: a systematic review and meta-analysis

INTRODUCTION

Cerebrospinal fluid (CSF) diversion for the treatment of hydrocephalus is one of the most common neurosurgical procedures. Over the years, the development of the neuronavigation system has allowed the surgeon to be guided in real time during the procedures. Nevertheless, to date, the revision rate remains as high as 30-40%. The aim of this study was to investigate the role of intraoperative image guidance in the prevention of shunt failure. We herein report the first literature meta-analysis of image guidance and shunt revision rate in the pediatric population.

METHODS

Principal online databases were searched for English-language articles published between January, 1980, and December, 2021. Analysis was limited to articles that included patients younger than 18 years of age at the time of primary V-P shunt. Articles reporting combined results of free-hand and image-guided placement of ventricular catheter (VC) were included. The main outcome measure of the study was the revision rate in relation to the intraoperative tools. Secondary variables collected were the age of the patient and ventricle size. Statistical analyses and meta-analysis plots were done via R and RStudio. Heterogeneity was formally assessed using Q, I², and τ² statistics. To examine publication bias was performed a funnel plot analysis.

RESULT

A total of 9 studies involving 2017 pediatric patients were included in the meta-analysis. 55.9% of procedures were carried out with the aid of intraoperative tools, while 44.1% procedures were conducted free hand. The intraoperative tools used were ultrasound (9.1%), electromagnetic neuronavigation (21.07%), endoscope (67.32%), and combined images (2.4%).The image-guided placement of VC was not statistically associated with a lower revision rate. The pooled OR was 0.97 [CI 95% 0.88-1.07] with an I² statistics of 34%, t² of 0.018 and a p-value of 0.15 at heterogeneity analysis.

CONCLUSION

Our analysis suggest images guidance during VC shunt placement does not statistically affect shunt survival. Nevertheless, intraoperative tools can support the surgeon especially in patients with difficult anatomy, slit ventricles or complex loculated hydrocephalus.

Ventilation and respiratory outcome in extremely preterm infants: trends in the new millennium

Ventilation and respiratory care have substantially changed over the last decades in extremely premature neonates but the impact on respiratory health remains largely unclear. To determine changes in respiratory care and disease frequency in extremely premature infants, a retrospective single-centre cohort study of extremely preterm infants was performed. All infants born alive between 24 + 0 and 27 + 6 weeks of gestation in 2000-2001 (Epoch 1), 2009-2010 (Epoch 2), and 2018-2019 (Epoch 3) were included. The primary outcome of this study was the incidence of bronchopulmonary dysplasia (BPD, diagnosed according to three different criteria) or death. Secondary outcomes included the usage of different ventilation modes, changes in pharmacotherapy, and the incidence of significant extra-pulmonary morbidities. A total of 184 neonates were included of whom 151 survived until 36 weeks of corrected GA (cGA). Oxygen or positive pressure dependence increased over time (26.1%, 41.7%, and 56.1% respectively), with higher adjusted odds in Epoch 3 for the composite outcome "BPD or death" (adjusted odds ratio: 2.55 [95%CI 1.19-5.61]). Severity-based definitions showed increasing trends in survivors only. Time spent on invasive mechanical ventilation was similar throughout the years, but the use of non-invasive ventilation significantly increased in Epoch 3 (32.0 [95%CI 25.0-37.0] vs 27.0 [95%CI 26.0-32.0] vs 53.0 [95%CI 46.0-58.0] days). Moreover, mortality-adjusted rates of severe IVH, NEC, or intestinal perforation and multiple sepsis tended to decrease.   Conclusion: In spite of significant clinical advancements and adherence to novel treatment guidelines in our neonatal intensive care unit, the incidence of BPD increased over time. What is Known: • Rates of BPD are stable or increase in population-based studies. • Extremely preterm infants are particularly susceptible to developing BPD. What is New: • Despite increased use of evidence-based corticosteroid administration and early initiation of caffeine, the incidence of BPD has not decreased over the past decade.  • Increased usage of non-invasive ventilation is associated with an increase of BPD incidence.