Incidence of hydrocephalus and the need to ventriculoperitoneal shunting in premature infants with intraventricular hemorrhage: risk factors and outcome

Current Status and Associated Factors of Post-Hemorrhagic Hydrocephalus in Infants of 22 to 28 Weeks Gestation With Severe Intraventricular Hemorrhage in Korea: A Nationwide Cohort Study

BACKGROUND

Post-hemorrhagic hydrocephalus (PHH), a common complication of severe intraventricular hemorrhage (IVH) in very low birth weight (BW) infants, is associated with significant morbidity and poor neurological outcomes. The objective of this study was to assess the current status of PHH and analyze the risk factors associated with the necessity of treatment for PHH in infants born between 22 and 28 weeks of gestation, specifically those with severe IVH (grade 3 or 4).

METHODS

The analysis was conducted on 1,097 infants who were born between 22-28 gestational weeks and diagnosed with severe IVH, using data from the Korean Neonatal Network. We observed that the prevalence of PHH requiring treatment was 46.3% in infants with severe IVH.

RESULTS

Higher rates of mortality, transfer during admission, cerebral palsy, and ventriculoperitoneal shunt after discharge were higher in infants with PHH than in those without PHH. PHH in severe IVH was associated with a higher rate of pulmonary hemorrhage, seizures, and IVH grade 4 in the entire cohort. In addition, it was associated with a lower rate of small for gestational age and chorioamnionitis. In the subgroup analysis, high BW, outborn status, pulmonary hemorrhage, seizure, sepsis, and IVH grade 4 were associated with a higher incidence of PHH between 22 and 25 gestational weeks (GW). In infants born between 26 and 28 GW, a higher incidence of PHH was associated with seizures and IVH grade 4.

CONCLUSION

It is necessary to maintain meticulous monitoring and neurological intervention for infants with PHH not only during admission but also after discharge. In addition, identifying the clinical factors that increase the likelihood of developing PHH from severe IVH is crucial.

Intraventricular hemorrhage in term infants: a single institutional experience between 2016 and 2020

PURPOSE

Intraventricular hemorrhage (IVH) of prematurity is a known complication of preterm birth. Intraventricular hemorrhage in term infants is much less commonly encountered. To address the lack of information in the current literature concerning this demographic, we offer demographic and image findings that demonstrate etiology and predict the need for permanent cerebrospinal fluid (CSF) diversion.

METHODS

A prospectively maintained database was queried for all patients with intraventricular hemorrhage from 2016 to 2020 treated at our institution. Demographic data and etiology were collected, along with need for and timing of surgical intervention.

RESULTS

A total of 150 IVH patients were identified. Of these patients, 138 were excluded due to prematurity. Twelve patients were born at term with IVH. All patients were followed for at least 8 months. Seven patients (58.3%) underwent ventriculoperitoneal (VP) shunt placement, performed between 4 days and 4 months of age. Superficial siderosis detected by MRI during in-patient stay or follow-up showed a sensitivity of 100% and specificity of 60% for the future development of post-hemorrhagic hydrocephalus (PHH) (p < 0.05). All full-term infants who developed PHH (n = 7, 58.3%) obtained a VP shunt.

CONCLUSION

IVH in term infants occurs infrequently when compared to IVH of prematurity. Etiology of IVH in term infants remains difficult to ascertain, but the majority of patients did demonstrate risk factors. The presence of superficial siderosis on MRI significantly predicted the development of PHH and eventual need for CSF diversion.

A single center experience of adjusting valve pressure ventriculoperitoneal shunts for the treatment of hydrocephalus in infants under 6 months old

INTRODUCTION

Ventriculoperitoneal shunt (VPS) with adjustable differential pressure valves are commonly used to treat infants with hydrocephalus avoiding shunt related under- or overdrainage. The aim of this study was to analyse the influence of VPS adjustable differential pressure valve on the head circumference (HC) and ventricular size (VS) stabilization in infants with post intraventricular haemorrhage, acquired and congenital hydrocephali.

METHODS

Forty-three hydrocephalic infants under 6 months old were prospectively included between 2014 and 2018. All patients were treated using a VPS with adjustable differential pressure valve. HC and transfontanelle ultrasonographic VS measurements were regularly performed and pressure valve modifications were done aiming HC and VS percentiles between the 25th and 75th. The patients were divided into two groups: infants with hydrocephalus due to an intraventricular haemorrhage (IVH-H), and infants with hydrocephalus due to other aetiologies (OAE-H).

RESULTS

The mean of pressure valve modification was 3.7 per patient in the IVH-H group, versus 2.95 in the OAE-H group. The median of last pressure valve value was higher at 8.5 cm H2O in the IVH-H group comparing to 5 cm H2O in the OAE-H group (p = 0.013).

CONCLUSION

Optimal VPS pressure valve values could be extremely difficult to settle in order to gain normalisation of the HC and VS in infants. However, after long term follow up (mean of 18 months) and several pressure valve modifications, this normalisation is possible and shows that infants with IVH-H need a higher pressure valve value comparing to infants with OAE-H.

Revision rates of flow- versus pressure-regulated ventricular shunt valves for the treatment of hydrocephalus in neonates following germinal matrix haemorrhage-a retrospective review

PURPOSE

Neonates with ventricular shunts inserted for hydrocephalus following germinal matrix haemorrhage (GMH) have high rates of shunt revision. The shunt valve plays a key role in regulating the function of the shunt. In this study, we aim to determine if the choice of flow-regulated or pressure-regulated valve used in the initial implantation of a shunt affects the rate of shunt revision.

METHODS

A retrospective cohort comparison study was performed on 34 neonates with hydrocephalus following GMH who underwent placement of a ventricular shunt at the Queensland Children's Hospital from November 2014 to June 2020. The primary outcome examined was the need for revision or replacement of the ventricular shunt after successful initial placement within 2 years of implantation. The secondary outcome examined was the survival time of the shunt.

RESULTS

16 patients had placement of a flow-regulated valve, and 18 patients had placement of a pressure-regulated valve. 14 (87.5%) patients with flow-regulated valves required replacement during the follow-up period. 2 (18.18%) patients with a fixed pressure regulated underwent revision, while 2 (28.57%) programmable pressure-regulated shunts required revision. Patients that had a flow-regulated valve had a statistically significant higher rate of revision compared to those who had a pressure-regulated valve, (87.5% flow vs 22.22% pressure) with a P-value of < 0.001. Valve obstruction was also more common in patients with flow-regulated valves than pressure-regulated valves (4 vs 0) with a P-value of 0.010. Overall mean median survival time was 22.06 months, shunts with flow-regulated valves had a shorter median survival time of 3.19 months compared with over 24 months for pressure-regulated valves with a P-value of < 0.001.

CONCLUSION

Our study suggests that the initial implantation of flow-regulated valves may carry an increased total rate of shunt revision and valve obstruction within the first 2 years following implantation compared to pressure-regulated valves in patients with hydrocephalus following GMH.

Ultrasonic Diagnosis and Management of Posthemorrhagic Ventricular Dilatation in Premature Infants: A Narrative Review

The survival rate of preterm infants is increasing as a result of technological advances. The incidence of intraventricular hemorrhages (IVH) in preterm infants ranges from 25% to 30%, of which 30% to 50% are severe IVH (Volpe III-IV, Volpe III is defined as intraventricular bleeding occupying more than 50% of the ventricular width and acute lateral ventricle dilatation, Volpe IV is defined as intraventricular hemorrhage combined with venous infarction) and probably lead to posthemorrhagic ventricular dilatation (PHVD). Severe IVH and subsequent PHVD have become the leading causes of brain injury and neurodevelopmental dysplasia in preterm infants. This review aims to review the literature on the diagnosis and therapeutic strategies for PHVD and provide some recommendations for management to improve the neurological outcomes.

Antibiotic-impregnated external ventricular drainage for the management of post-hemorrhagic hydrocephalus in low birth weight premature infants following intraventricular hemorrhage

PURPOSE

This study aims to evaluate the infection rates and catheterization duration of applying antibiotic-impregnated external ventricular drain (EVD) for the treatment of post-hemorrhagic hydrocephalus (PHH) in low birth weight infants (LBWI).

METHODS

This retrospective cohort study included 13 preterm LBWI with PHH. Data were collected from the patient's medical charts and included gender, gestational age, birth weight, intraventricular hemorrhage grade, ventriculostomy-associated infection (VAI), and the duration of catheterization. All patients were followed up for at least 6 months after EVD surgery.

RESULTS

The mean gestational age at birth was 27 ± 2.5 weeks, and the mean birth weight was 907 ± 220 g. Among all patients with IVH, two (6.7%) had grade 2 IVH, five (38.5%) had grade 3 IVH, and six (46.2%) had grade 4 IVH. EVD surgery was conducted once for six patients, twice for five patients, and three times for two patients. One patient (7.7%) had VAI post-EVD surgery at 14 days. Three patients (23%) expired due to sepsis, shock, and chylous ascites. Seven patients (53.8%) had hydrocephalus and needed a ventriculoperitoneal shunt over the following course. The longest EVD catheterization period was 57 days without sustained VAI.

CONCLUSIONS

Antibiotic-impregnated EVD has a similar infection rate with the ventricular access device and ventriculosubgaleal shunt. The risk of VAI was not increased even with the EVD catheterization day approaching 2 months. Our study supports the evidence that antibiotic-impregnated EVD is safe and effective for the management of PHH in LBWI. However, this research has a small sample sized and a retrospective design.

Development of an integrated risk scale for prediction of shunt placement after neonatal intraventricular hemorrhage

OBJECTIVE

Neonatal intraventricular hemorrhage (IVH) is a major cause of mortality and morbidity, particularly following premature birth. Even after the acute phase, posthemorrhagic hydrocephalus is a long-term complication, frequently requiring permanent ventriculoperitoneal shunt (VPS) placement. Currently, there are no risk classification methods integrating the constellation of clinical data to predict short- and long-term prognosis in neonatal IVH. To address this need, the authors developed a two-part machine learning approach for predicting short- and long-term outcomes after diagnosis of neonatal IVH. Integrating both maternal and neonatal characteristics, they developed a binary classifier to predict short-term mortality risk and a clinical scale to predict the long-term risk of VPS placement.

METHODS

Neonates with IVH were identified from the Optum Clinformatics Data Mart administrative claims database. Matched maternal and childbirth characteristics were obtained for all patients. The primary endpoints of interest were short-term (30 day) mortality and long-term VPS placement. Classification of short-term mortality risk was evaluated using 5 different machine learning approaches and the best-performing method was validated using a withheld validation subset. Prediction of long-term shunt risk was performed using a multivariable Cox regression model with stepwise variable selection, which was subsequently converted to an easily applied integer risk scale.

RESULTS

A total of 5926 neonates with IVH were identified. Most patients were born before 32 weeks' gestation (67.2%) and with low birth weight (81.2%). Empirical 30-day mortality risk was 10.9% across all IVH grades and highest among grade IV IVH (34.3%). Among the neonates who survived > 30 days, actuarial 12-month postdiagnosis risk of shunt placement was 5.4% across all IVH grades and 31.3% for grade IV IVH. The optimal short-term risk classifier was a random forest model achieving an area under the receiver operating characteristic curve of 0.882 with important predictors ranging from gestational age to diverse comorbid medical conditions. Selected features for long-term shunt risk stratification were IVH grade, respiratory distress syndrome, disseminated intravascular coagulation, and maternal preeclampsia or eclampsia. An integer risk scale, termed the Shunt Prediction After IVH in Neonates (SPAIN) scale, was developed from these 4 features, which, evaluated on withheld cases, demonstrated improved risk stratification compared with IVH grade alone (Harrell's concordance index 0.869 vs 0.852).

CONCLUSIONS

In a large cohort of neonates with IVH, the authors developed a two-pronged, integrated, risk classification approach to anticipate short-term mortality and long-term shunt risk. The application of such approaches may improve the prognostication of outcomes and identification of higher-risk individuals who warrant careful surveillance and early intervention.

Brain Network Connectivity and Executive Function in Children with Previous Infantile Hydrocephalus

INTRODUCTION

Infantile hydrocephalus is a condition in which there is an abnormal build-up of cerebrospinal fluid in the ventricles within the first few months of life, which puts pressure on surrounding brain tissues. Compression of the developing brain increases the risk of secondary brain injury and cognitive disabilities.

METHODS

In this study, we used diffusion-weighted imaging and resting-state functional MRI to investigate the effects of ventricle dilatation on structural and functional brain networks in children with shunted infantile hydrocephalus and examined how these brain changes may impact executive function.

RESULTS

We found that children with hydrocephalus have altered structural and functional connectivity between and within large-scale networks. Moreover, hyperconnectivity between the ventral attention and default mode network in children with hydrocephalus correlated with reduced executive function scores. Compared to typically developing age-matched control participants, our patient population also had lower fractional anisotropy in posterior white matter.

DISCUSSION

Overall, these findings suggest that infantile hydrocephalus has long-term effects on brain network connectivity, white matter development, and executive function in children at school-age. Future work will examine the relationship between ventricular volumes prior to shunt placement in infancy and brain network development throughout childhood.

Development of machine learning-based predictor algorithm for conversion of an Ommaya reservoir to a permanent cerebrospinal fluid shunt in preterm posthemorrhagic hydrocephalus

BACKGROUND

Ommaya reservoir can be used to treat posthemorrhagic hydrocephalus secondary to intraventricular hemorrhage of prematurity until an acceptable weight can be obtained to place a permanent shunt. Identifying newborns at higher risk of developing shunt conversion may improve the management of these patients.

OBJECTIVE

Develop a predictive algorithm for the conversion of an Ommaya reservoir to a permanent shunt using artificial intelligence techniques and "classical" statistics.

METHODS

Database of 43 preterm patients weighing ≤ 1500g with posthemorrhagic hydrocephalus (Papile Grades III and IV with Levene index > 4 mm above the 97th percentile) managed with Ommaya reservoir at our institution between 2002 and 2017 was used to train a KNN algorithm. Validation of results with cross validation technique. Three scenarios were calculated. 1: considering all features regardless whether or not they are correlated with the output variable. 2: consider the features as predictors if they have a correlation greater than a 30% with the output variable. 3: consider the output of the previous analysis.

RESULTS

Results show that when considering the outputs of a previous multivariate analysis the algorithm reaches an 86% of cross validation accuracy.

CONCLUSION

The use of machine learning-based algorithms can help in the early identification of patients with permanent need of shunt. We present the development of a predictive algorithm for permanent shunt with an accuracy of 86%, accuracy of the algorithm can be improved with larger volume of data and previous analysis.

Risk factors associated with conversion of an Ommaya reservoir to a permanent cerebrospinal fluid shunt in preterm posthemorrhagic hydrocephalus

OBJECTIVE

A considerable percentage of preterm infants with posthemorrhagic hydrocephalus initially managed with an Ommaya reservoir require a permanent CSF shunt. The objective of the study was to analyze possible risk factors associated with the need for converting an Ommaya reservoir to a permanent shunt.

METHODS

The authors retrospectively reviewed the clinical records of premature infants weighing 1500 g or less with posthemorrhagic hydrocephalus (Papile grades III and IV) managed with an Ommaya reservoir at their institution between 2002 and 2017.

RESULTS

Forty-six patients received an Ommaya reservoir. Five patients (10.9%) were excluded due to intraventricular infection during management with an Ommaya reservoir. Average gestational age and weight for the remaining 41 patients was 27 ± 1.8 weeks and 987 ± 209 grams, respectively. Thirty patients required a permanent shunt and 11 patients did not require a permanent shunt. The conversion rate from an Ommaya reservoir to a permanent shunt was 76.1%. Symptomatic persistent ductus arteriosus (PDA) was more frequent in the nonpermanent shunt group than in the shunt group (88.9% vs 50%, p = 0.04). The need for extraction of more than 10 ml/kg per day of CSF through the Ommaya reservoir was lower in the nonpermanent shunt group than in the shunt group (9.1% vs 51.7%, p = 0.015). CSF lactate was lower in the nonpermanent group than in the shunt group (mean 2.48 mg/dl vs 3.19 mg/dl; p = 0.004). A cutoff value of ≥ 2.8 mg/dl CSF lactate predicted the need for a permanent shunt with sensitivity and specificity of 82.4% and 80%, respectively. There were no significant differences in gestational age, sex, weight, Papile grade, ventricular index, or other biochemical markers. After the multivariate analysis, only CSF lactate ≥ 2.8 mg/dl was associated with a higher conversion rate to a permanent shunt.

CONCLUSIONS

This study showed that a high level of CSF lactate, absence of symptomatic PDA, and a higher CSF extraction requirement were associated with a higher likelihood of implanting a permanent CSF shunt. The authors believe these findings should be considered in future studies.

Endoscopic third ventriculostomy inpatient failure rates compared with shunting in post-hemorrhagic hydrocephalus of prematurity

PURPOSE

Endoscopic third ventriculostomy (ETV) has gained traction as a method for treating post-hemorrhagic hydrocephalus of prematurity (PHHP) in an effort to obviate lifelong shunt dependence in neonates. However, data remains limited regarding inpatient failures.

METHODS

A retrospective analysis of the NIS between 1998 and 2014 was performed. Discharges with age < 1 year and ICD-9-CM codes indicating intraventricular hemorrhage of prematurity (772.1x) and ETV/shunt (02.22 and 02.3x) were included. Patients with ICD-9-CM codes for ventricular drain/reservoir (02.21) were excluded to prevent confounding. Time trend series plots were created. Yearly trends were quantified using logarithmic regression analysis. Kaplan-Meier curves were utilized to analyze time to treatment failure. Time to failure for each treatment was compared using log-rank.

RESULTS

A total of 11,017 discharges were identified. ETV was more likely to be utilized at < 29 weeks gestational age (p = 0.0039) and birth weight < 1000 g (p = 0.0039). Shunts were less likely to fail in older and heavier newborns (OR 0.836 p = 0.00456, OR 0.828 p = 0.0001, respectively). Those initially shunted had lower failure rates compared with ETV (OR 0.44, p < 0.0001) but time to failure was longer with ETV (p = 0.04562). 79.5% of ETVs that failed were shunted after the first failure. Shunts were much less likely to undergo ETV if they failed (OR 0.21, p < 0.0001). Higher grade IVH was predictive of shunt failure but not ETV (OR 2.36, p = 0.0129).

CONCLUSIONS

Although ETV can be effective in PHHP, it has a much higher initial failure rate than shunting and should thus be chosen based on a multifactorial approach.

The Complication for Ventricular Shunt Based on Different Etiologies: A Prospective Study in Tehran, Iran

Objectives:

The purpose of this study was to evaluate and compare complications caused by VP shunt (based on imaging changes, clinical and laboratory findings) in children with congenital (intrauterine) infections, referred to as TORCH, in contrast to other causes of Shunt insertion in children.

Materials and Methods:

In this cross-sectional, observational and descriptive study, 68 hospitalized patients in Rasool-Akram Hospital were selected using convenience method during 2 years from 2013 to August, 2016. Clinical examination and organ involvement were determined. Blood sampling, serological and complementary tests were performed to determine the type of infection, cause and duration of shunt insertion, mechanical and infectious complications (meningitis and peritonitis), the course of the disease and finally, mortality and morbidity. All data were collected in questionnaires. Statistical analysis was performed using SPSS-24 version software. The comparison was carried out between two groups of infectious and noninfectious causes. P-value less than 5.5 was considered significant.

Results:

From total 68 children with VP shunt, 13 patients died (including 8 males and 5 females with a mean age of 69.41 ± 81.57 months-old). The main cause of shunt insertion was infection in 4 patients and tumor, cerebral hemorrhage and myelomeningocele in 9 other children. Shunt-induced meningitis and peritonitis were detected in 92% and 7.7% respectively. The leading causes of shunt insertion In remaining 47 live children (including 27 males and 19 females with a mean age of 63 +83 months) were infectious in 28% and noninfectious in the rest of cases. The shunt mechanical complications were reported in 8.7% (4 patients). Fever was detected in 33% of patients. Positive blood culture and cerebrospinal fluid were reported in 6.8% and 8.5% of patients in that order, but meningitis was detected in 26% (12 cases) and peritonitis in 10.9% (5 cases). Although, there were no significant differences between two groups in terms of mechanical complications such as shunt obstruction, cerebral hemorrhage ;but, a considerable difference was reported in death rate due to shunt insertion between two groups with infectious and noninfectious origin. The risk of shunt-induced meningitis was clearly higher in group with infectious origin. (P-value = 0.05). But peritonitis risk was not different.

Conclusion:

VP shunt complications were observed in one-quarter of children, but mechanical complications of VP shunt were uncommon (8% in live patients). VP shunt mortality was relatively high (13 patients from total 68), and occurred more often in patients with non-infectious causes of VP shunt, mainly due to meningitis. Shunt meningitis was very common In patients with infectious origin. Shunt infection in patients (meningitis, bacteremia and peritonitis) was common and could increase mortality if not controlled. Prescribing antibiotics is not recommended without initial diagnostic measures (such as spinal fluid puncture, ascites, and proper imaging) because it will result in incomplete and improper treatments.

Evaluation of factors for poor outcome in preterm newborns with posthemorrhagic hydrocephalus associated with late-onset neonatal sepsis

Purpose

Preterm newborns, due to many factors, are at increased risk for poor neural development, intraventricular hemorrhages, infections, and higher rate of mortality. The aim of this study was to evaluate the risk factors associated with poor outcome in preterm neonates with late-onset neonatal sepsis (LONS) who had posthemorrhagic hydrocephalus and underwent neurosurgical procedures for treatment of the hydrocephalus.

Patients and methods

Preterm neonates who had undergone insertion of ventriculoperitoneal shunt or Ommaya reservoir, during the 10-year period at University Children's Hospital, were retrospectively analyzed. According to the presence or absence of LONS, patients were divided into LONS group and non-LONS group. In both groups, we analyzed demographic and clinical data as well as nondependent factors. Additionally, we evaluated the patients who had lethal outcome in respect to all the analyzed factors.

Results

A total of 74 patients were included in the study, 35 in LONS group and 39 in control group. Patients in LONS group were born significantly earlier with lower birth weight, needed significantly higher O₂ inspiratory concentration, and had longer duration of mechanical ventilation when compared to the nonseptic group. Five patients in LONS group had lethal outcome, and for these patients we identified a grade American Society of Anaesthesiologists score of 4 (P=0.000), ductus arteriosus persistens (P=0.000), bronchopulmonary dysplasia (P=0.003), and pneumothorax (P=0.003) as independent preoperative risk factors for lethal outcome.

Conclusion

Neurosurgical procedures are relatively safe in neonates with posthemorrhagic hydrocephalus without LONS after birth. However, if LONS is present, various conditions such as preoperative high grade American Society of Anaesthesiologists score, ductus arteriosus persistens, bronchopulmonary dysplasia, and pneumothorax markedly increase the risk for a lethal outcome after the operation.

Post hemorrhagic hydrocephalus and neurodevelopmental outcomes in a context of neonatal intraventricular hemorrhage: an institutional experience in 122 preterm children

BACKGROUND

Intraventricular hemorrhage (IVH) is a frequent complication in extreme and very preterm births. Despite a high risk of death and impaired neurodevelopment, the precise prognosis of infants with IVH remains unclear. The objective of this study was to evaluate the rate and predictive factors of evolution to post hemorrhagic hydrocephalus (PHH) requiring a shunt, in newborns with IVH and to report their neurodevelopmental outcomes at 2 years of age.

METHODS

Among all preterm newborns admitted to the department of neonatalogy at Rouen University Hospital, France between January 2000 and December 2013, 122 had an IVH and were included in the study. Newborns with grade 1 IVH according to the Papile classification were excluded.

RESULTS

At 2-year, 18% (n = 22) of our IVH cohort required permanent cerebro spinal fluid (CSF) derivation. High IVH grade, low gestational age at birth and increased head circumference were risk factors for PHH. The rate of death of IVH was 36.9% (n = 45). The rate of cerebral palsy was 55.9% (n = 43) in the 77 surviving patients (49.4%). Risk factors for impaired neurodevelopment were high grade IVH and increased head circumference.

CONCLUSION

High IVH grade was strongly correlated with death and neurodevelopmental outcome. The impact of an increased head circumference highlights the need for early management. CSF biomarkers and new medical treatments such as antenatal magnesium sulfate have emerged and could predict and improve the prognosis of these newborns with PHH.

The Neuroimaging Studies in Children with Ventriculoperitoneal Shunt Complications: A 10 Years Descriptive Sudy in Tehran

Background

Any mismatch between the production and absorption of CSF results in hydrocephalus. In most cases, the selected choice of treatment is the ventriculoperitoneal shunt insertion. Although, the surgery could have complications such as infection, shunt malfunction, subdural hematoma, seizure and Shunt immigration; so, the early and proper detection of these complications could result in better prognosis. The aim of this study was to evaluate and compare the efficacy of CT scan, CSF analysis and X-ray radiography in detection of shunt complications and problems in shunt placement and further follow-up in hospitalized children.

Methods

The medical records of children in Rasul Akram hospital in Tehran were reviewed retrospectively in the last 10 years, from 2006 to 2016. All data were recorded in the prepared form including the age, sex, shunt complication, CT scan and CSF characteristics.

Results

The total number of 95 patients were interfered in this study including 56 males (58.9%) and 39 females (41.1%). The mean age at the onset of complications were 2.8±2.2 years-old. The shunt obstruction (60%) and infection (25.3%) were the most common complications. The CT scan was able to detect 36.5% of shunt complications. The CT scan had the sensitivity and specificity of 50 and 87%, respectively in detection of shunt obstruction. The all cases of brain hematoma and hemorrhage were revealed by CT scan. On the other hand, the CT scan had 20% of sensitivity and 60% of specificity in the detection of shunt infection. The CSF evaluation in shunt infection revealed 92% hypoglycemia, 87.5% pleocytosis, and 62.5% positive CSF culture. CSF had the sensitivity, specificity, positive predictive value and negative predictive value of 92, 82, 63 and 97%, respectively. The patient's symptoms and signs were helpful in obtaining higher test accuracy.

Conclusion

The CT scan was not a good sensitive and specific study in the detection of shunt obstruction and infection, but it was very accurate in detection of hemorrhage and hematoma. On the other hand, CSF evaluation was a reliable test in shunt infection disclosure.

Long-term mortality rates in pediatric hydrocephalus-a retrospective single-center study

PURPOSE

Very long-term follow-up and outcome are rare for pediatric patients with hydrocephalus and shunt operations. The aim of this study was to determine the long-term mortality rates in these patients.

METHODS

Pediatric patients with first shunt operation between 1982 and 1992 were included. For each patient, time and cause of death were determined. Further, patients with first operation from 1982 to 1987 were compared to those first operated from 1988 to 1992.

RESULTS

One-hundred thirty-seven patients were included. Etiologies of hydrocephalus were intraventricular hemorrhage (31.4 %), meningomyelocele (25.5 %), postinfectious (11.7 %), congenital (10.2 %), posterior fossa cyst (8.8 %), aqueductal stenosis (8 %), and others (4.4 %). Overall, 53 patients (38.7 %) died. The percentage of patients surviving 1, 2, 10, and 20 years after first operation were 82.6, 73.6, 69.4, and 65.3 %, respectively. In 23 patients, the cause of death was related to shunt treatment: shunt infection was diagnosed in 18 and acute shunt dysfunction in 5 patients. Mortality was considerably higher for patients with their first operation in time period 1982-1987 compared to time period 1988-1992 (51 versus 25 %). The reduction of mortality was mainly due to an increased survival after shunt infection. Eighty-seven patients survived more than 20 years after initial shunt operation. Of those long-term survivors, three (3.4 %) patients died 22-24 years after first operation.

CONCLUSION

Mortality in hydrocephalic pediatric patients is high especially in the first postoperative years but is even significant in adult patients with pediatric hydrocephalus. As deaths occur even after 20 years, routine follow-up of long-term survivors remains necessary.

Intraventricular Hemorrhage and Post Hemorrhagic Hydrocephalus among Very-Low-Birth-Weight Infants in Korea

Here, we aimed to evaluate the incidence and mortality of intraventricular hemorrhage (IVH) and post-hemorrhagic hydrocephalus (PHH) among very-low-birth-weight (VLBW) infants in Korea and assess the associated factors of PHH. This cohort study used prospectively collected data from the Korean Neonatal Network (KNN). Among 2,386 VLBW infants in the KNN database born between January 2013 and June 2014, 63 infants who died without brain ultrasonography results were excluded. Maternal demographics and neonatal clinical characteristics were assessed. The overall incidence of IVH in all the VLBW infants was 42.2% (987 of 2,323), while those of IVH grade 1, 2, 3, and 4 were 25.1%, 7.0%, 4.8%, and 5.5%, respectively. The incidence and severity of IVH showed a negatively correlating trend with gestational age and birth weight. PHH developed in 0%, 3.5%, 36.1%, and 63.8% of the surviving infants with IVH grades 1, 2, 3, and 4, respectively. Overall, in the VLBW infants, the IVH-associated mortality rate was 1.0% (24/2,323). Only IVH grade severity was proven to be an associated with PHH development in infants with IVH grades 3-4. This is the first Korean national report of IVH and PHH incidences in VLBW infants. Further risk factor analyses or quality improvement studies to reduce IVH are warranted.

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 2: Management of posthemorrhagic hydrocephalus in premature infants

OBJECT

The objective of this systematic review and analysis was to answer the following question: What are the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants?

METHODS

Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to PHH. Two hundred thirteen abstracts were reviewed, after which 98 full-text publications that met inclusion criteria that had been determined a priori were selected and reviewed.

RESULTS

Following a review process and an evidentiary analysis, 68 full-text articles were accepted for the evidentiary table and 30 publications were rejected. The evidentiary table was assembled linking recommendations to strength of evidence (Classes I-III).

CONCLUSIONS

There are 7 recommendations for the management of PHH in infants. Three recommendations reached Level I strength, which represents the highest degree of clinical certainty. There were two Level II and two Level III recommendations for the management of PHH. Recommendation Concerning Surgical Temporizing Measures: I. Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of PHH. Clinical judgment is required.

STRENGTH OF RECOMMENDATION

Level II, moderate degree of clinical certainty. Recommendation Concerning Surgical Temporizing Measures: II. The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs.

STRENGTH OF RECOMMENDATION

Level II, moderate degree of clinical certainty. Recommendation Concerning Routine Use of Serial Lumbar Puncture: The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents: I. Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents. II. Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH.

STRENGTH OF RECOMMENDATION

Level I, high clinical certainty. Recommendation Concerning Timing of Shunt Placement: There is insufficient evidence to recommend a specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Clinical judgment is required.

STRENGTH OF RECOMMENDATION

Level III, unclear clinical certainty. Recommendation Concerning Endoscopic Third Ventriculostomy: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with posthemorrhagic hydrocephalus.

STRENGTH OF RECOMMENDATION

Level III, unclear clinical certainty.

Long-term neurodevelopmental outcomes after preterm birth

CONTEXT

All over the the world, preterm birth is a major cause of death and important neurodevelopmental disorders. Approximately 9.6% (12.9 million) births worldwide are preterm.

EVIDENCE ACQUISITION

In this review, databases such as PubMed, EMBASE, ISI, Scopus, Google Scholar and Iranian databases including Iranmedex, and SID were researched to review relevant literature. A comprehensive search was performed using combinations of various keywords.

RESULTS

Cerebral palsy especially spastic diplegia, intellectual disability, visual (retinopathy of prematurity) and hearing impairments are the main neurodevelopmental disorders associated with prematurity.

CONCLUSIONS

The increased survival of preterm infants was not associated with lower complications. There is now increasing evidence of sustained adverse outcomes into school age and adolescence, for preterm infants.

Neuroendoscopic lavage for the treatment of intraventricular hemorrhage and hydrocephalus in neonates

Object Neonatal intraventricular hemorrhage (IVH) may evolve into posthemorrhagic hydrocephalus and cause neurodevelopmental impairment. In this study, an endoscopic surgical approach directed toward the removal of intraventricular hematoma was evaluated for its safety and efficacy. Methods Between August 2010 and December 2012 (29 months), 19 neonates with posthemorrhagic hydrocephalus underwent neuro endoscopic lavage for removal of intraventricular blood remnants. During a similar length of time (29 months) from March 2008 to July 2010, 10 neonates were treated conventionally, initially using temporary CSF diversion via lumbar punctures, a ventricular access device, or an external ventricular drain. Complications and shunt dependency rates were evaluated retrospectively. Results The patient groups did not differ regarding gestational age and birth weight. In the endoscopy group, no relevant procedure-related complications were observed. After the endoscopic lavage, 11 (58%) of 19 patients required a later shunt insertion, as compared with 100% of infants treated conventionally (p < 0.05). Endoscopic lavage was associated with fewer numbers of overall necessary procedures (median 2 vs 3.5 per patient, respectively; p = 0.08), significantly fewer infections (2 vs 5 patients, respectively; p < 0.05), and supratentorial multiloculated hydrocephalus (0 vs 4 patients, respectively; p < 0.01) [corrected].Conclusions Within the presented setup the authors could demonstrate the feasibility and safety of neuro endoscopic lavage for the treatment of posthemorrhagic hydrocephalus in neonates with IVH. The nominally improved results warrant further verification in a multicenter, prospective study.

Early and late complications of germinal matrix-intraventricular haemorrhage in the preterm infant: what is new?

Germinal matrix-intraventricular haemorrhage (GMH-IVH) remains a serious problem in the very and extremely preterm infant. This article reviews current methods of diagnosis, treatment and neurodevelopmental outcome in preterm infants with low-grade and severe GMH-IVH. We conclude that there is still no consensus on timing of intervention and treatment of infants with GMH-IVH, whether or not complicated by post-haemorrhagic ventricular dilatation. The discrepancies between the studies underline the need for international collaboration to define the optimal strategy for these infants.

Treatment of neonatal progressive ventricular dilatation: a single-centre experience

OBJECTIVE

To describe our experience with a cohort of 295 infants with progressive ventricular dilatation occurring in the antenatal or neonatal period.

METHODS

A search was performed in our cranial ultrasound database. All records and images of infants in whom an imaging diagnosis of progressive ventricular dilatation had been made were retrieved. In addition, modes of treatment were analysed.

RESULTS

Between February 1991 and March 2012, 295 neonates were admitted to our level 3 neonatal intensive care unit (NICU), and developed progressive ventricular dilatation for which they required intervention. In the majority of these infants, progressive ventricular dilatation developed following IVH grade III or IV (240/295; 81%) of whom 214/240 (89%) were preterms. Temporary treatment with lumbar punctures and punctures from ventricular reservoirs was sufficient for the majority of the preterms. A ventricular reservoir was inserted in 216/295 infants (73%). The overall infection rate was low (6%). A ventriculoperitoneal shunt (VP shunt) was inserted in 32% of the whole cohort, revision within 3 months was necessary in 20%, and shunt-related infection occurred in 12%.

CONCLUSIONS

This large, single-centre cohort study reports the management of progressive ventricular dilatation in newborn infants. We have shown that with our approach, complications stay within acceptable limits.

Ventriculoperitoneal shunt failure: an institutional review of 2-year survival rates

PURPOSE

Prior research has examined predictors of shunt failure in children with hydrocephalus and concluded that the majority of shunts do not survive long-term. However, risk factors such as etiology, birth weight, and gestational age may vary across institutions and populations. We sought to identify the social, clinical, and neonatal factors associated with initial ventriculoperitoneal (VP) shunt failure in the intraventricular hemorrhage (IVH) patient population and the patient population with an etiology other than IVH (non-IVH).

METHODS

A retrospective review of patients, born during 2000-2005 diagnosed and treated for hydrocephalus at Children's of Alabama was conducted. Survival analysis identified factors associated with time to shunt failure.

RESULTS

Analyses were done separately for the IVH and non-IVH cohorts. Age and weight at initial VP shunt insertion were found to be associated with shunt failure in the non-IVH group (p < .05). Of the 238 patients in the non-IVH cohort, 108 failed within 2 years of their initial insertion. Fifty of those shunt failures occurred within 3 months of initial shunt placement. In the IVH cohort, 56 out of 100 failed within 2 years; 36 of those failed within 3 months post initial shunt insertion. When controlling for type of shunt failure, age at initial shunt placement was associated with time to shunt failure (p = .0004).

CONCLUSION

This study confirms previously published studies on the IVH population. A prospective cohort study and standardized clinical decision making are necessary to further assess the impact that shunting has on this patient population.

Effect of delayed intermittent ventricular drainage on ventriculomegaly and neurological deficits in experimental neonatal hydrocephalus

PURPOSE

Evidence-based guidelines do not indicate when ventricular reservoirs should be placed in children with neonatal hydrocephalus, and delayed intervention is common. We hypothesize that delayed ventricular drainage has adverse effects on structural development and functional outcomes.

METHODS

Using a well-established animal model of kaolin-induced obstructive hydrocephalus, we evaluated neurologic deficit after early (~1 week post-kaolin) or late (~2 weeks post-kaolin) placement of ventricular reservoirs which were tapped according to strict neurologic criteria.

RESULTS

Progressive ventriculomegaly was similar in early- and late-reservoir implantation groups. The average neurologic deficit scores (NDSs) over the experimental period were 0 (n=6), 2.74 (n=5), and 2.01 (n=3) for the control, early-, and late-reservoir groups, respectively. At reservoir placement, early-group animals displayed enlarged ventricles without neurologic deficits (mean NDS=0.17), while the late group displayed ventriculomegaly with clinical signs of hydrocephalus (mean NDS=3.13). The correlation between ventriculomegaly severity and NDS in the early group was strongly positive in the acute (before surgery to 3 weeks post-reservoir placement) (R(2)=0.65) and chronic (6 to 12 weeks post-reservoir placement) (R(2)=0.65) phases, while the late group was less correlated (acute R(2)=0.51; chronic R(2)=0.19).

CONCLUSIONS

Current practice favors delaying reservoir implantation until signs of elevated intracranial pressure and neurologic deficit appear. Our results demonstrate that animals in early and late groups undergo the same course of ventriculomegaly. The findings also show that tapping reservoirs in these neonatal hydrocephalic animals based on neurologic deficit does not halt progressive ventricular enlargement and that neurologic deficit correlates strongly with ventricular enlargement.

Electromagnetic-guided neuronavigation for safe placement of intraventricular catheters in pediatric neurosurgery

OBJECT

Ventricular catheter shunt malfunction is the most common reason for shunt revision. Optimal ventricular catheter placement can be exceedingly difficult in patients with small ventricles or abnormal ventricular anatomy. Particularly in children and in premature infants with small head size, satisfactory positioning of the ventricular catheter can be a challenge. Navigation with electromagnetic tracking technology is an attractive and innovative therapeutic option. In this study, the authors demonstrate the advantages of using this technology for shunt placement in children.

METHODS

Twenty-six children ranging in age from 4 days to 14 years (mean 3.8 years) with hydrocephalus and difficult ventricular anatomy or slit ventricles underwent electromagnetic-guided neuronavigated intraventricular catheter placement in a total of 29 procedures.

RESULTS

The single-coil technology allows one to use flexible instruments, in this case the ventricular catheter stylet, to be tracked at the tip. Head movement during the operative procedure is possible without loss of navigation precision. The intraoperative catheter placement documented by screenshots correlated exactly with the position on the postoperative CT scan. There was no need for repeated ventricular punctures. There were no operative complications. Postoperatively, all children had accurate shunt placement. The overall shunt failure rate in our group was 15%, including 3 shunt infections (after 1 month, 5 months, and 10 months) requiring operative revision and 1 distal shunt failure. There were no proximal shunt malfunctions during follow-up (mean 23.5 months).

CONCLUSIONS

The electromagnetic-guided neuronavigation system enables safe and optimal catheter placement, especially in children and premature infants, alleviating the need for repeated cannulation attempts for ventricular puncture. In contrast to stereotactic techniques and conventional neuronavigation, there is no need for sharp head fixation using a Mayfield clamp. This technique may present the possibility of reducing proximal shunt failure rates and costs for hydrocephalus treatment in this age cohort.