Management of posthemorrhagic hydrocephalus in the low-birth-weight preterm neonate

Timing of Temporizing Neurosurgical Treatment in Relation to Shunting and Neurodevelopmental Outcomes in Posthemorrhagic Ventricular Dilatation of Prematurity: A Meta-analysis

OBJECTIVE

To determine the relationship between timing of initiation of temporizing neurosurgical treatment and rates of ventriculoperitoneal shunt (VPS) and neurodevelopmental impairment in premature infants with post-hemorrhagic ventricular dilatation (PHVD).

STUDY DESIGN

We searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Database of Systematic Reviews, and the Cochrane Center Register of Controlled Trials for studies that reported on premature infants with PHVD who underwent a temporizing neurosurgical procedure. The timing of the temporizing neurosurgical procedure, gestational age, birth weight, outcomes of conversion to VPS, moderate-to-severe neurodevelopmental impairment, infection, temporizing neurosurgical procedure revision, and death at discharge were extracted.

RESULTS

Sixty-two full-length articles and 6 conference abstracts (n = 2533 patients) published through November 2020 were included. Pooled rate for conversion to VPS was 60.5% (95% CI, 54.9-65.8), moderate-severe neurodevelopmental impairment 34.8% (95% CI, 27.4-42.9), infection 8.2% (95% CI, 6.7-10.1), revision 14.6% (95% CI, 10.4-20.1), and death 12.9% (95% CI, 10.2-16.4). The average age at temporizing neurosurgical procedure was 24.2 ± 11.3 days. On meta-regression, older age at temporizing neurosurgical procedure was a predictor of conversion to VPS (P < .001) and neurodevelopmental impairment (P < .01). Later year of publication predicted increased survival (P < .01) and external ventricular drains were associated with more revisions (P = .001). Tests for heterogeneity reached significance for all outcomes and a qualitative review showed heterogeneity in the study inclusion and diagnosis criteria for PHVD and initiation of temporizing neurosurgical procedure.

CONCLUSIONS

Later timing of temporizing neurosurgical procedure predicted higher rates of conversion to VPS and moderate-severe neurodevelopmental impairment. Outcomes were often reported relative to the number of patients who underwent a temporizing neurosurgical procedure and the criteria for study inclusion and the initiation of temporizing neurosurgical procedure varied across institutions. There is need for more comprehensive outcome reporting that includes all infants with PHVD regardless of treatment.

Pharmacological Preventions of Brain Injury Following Experimental Germinal Matrix Hemorrhage: an Up-to-Date Review

Germinal matrix hemorrhage (GMH) is defined as the rupture of immature blood vessels in the subependymal zone of premature infants with significant mortality and morbidity. Considering the notable social and ecological stress brought by GMH-induced brain injury and sequelae, safe and efficient pharmacological preventions are badly needed. Currently, several appropriate animal models are available to mimic the clinical outcomes of GMH in human patients. In the long run, hemorrhagic strokes are the research target. Previously, we found that minocycline was efficient to alleviate GMH-induced brain edema and posthemorrhagic hydrocephalus (PHH) in rats, which may be closely related to the activation of cannabinoid receptor 2 (CB2R). However, how the two molecules correlate and the underlined molecular pathway remain unknown. To extensively understand current experimental GMH treatment, this literature review critically evaluates existing therapeutic strategies, potential treatments, and potentially involved molecular mechanisms. Each strategy has its own advantages and disadvantages. Some of the mechanisms are still controversial, requiring an increasing number of animal experiments before the therapeutic strategy would be widely accepted.

Treatment of posthemorrhagic ventricular dilation in preterm infants: a systematic review and meta-analysis of outcomes and complications

OBJECT The optimal clinical management of intraventricular hemorrhage (IVH) and posthemorrhagic ventricular dilation (PHVD)/posthemorrhagic hydrocephalus (PHH) in premature infants remains unclear. A common approach involves temporary treatment of hydrocephalus in these patients with a ventriculosubgaleal shunt (VSGS), ventricular access device (VAD), or external ventricular drain (EVD) until it becomes evident that the patient needs and can tolerate permanent CSF diversion (i.e., ventriculoperitoneal shunt). The present systematic review and meta-analysis aimed to provide a robust and comprehensive summary of the published literature regarding the clinical outcomes and complications of these 3 techniques as temporizing measures in the management of prematurity-related PHVD/PHH. METHODS The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library for studies published through December 2013 on the use of VSGSs, VADs, and/or EVDs as temporizing devices for the treatment of hydrocephalus following IVH in the premature neonate. Data pertaining to patient demographic data, study methods, interventions, and outcomes were extracted from eligible articles. For each of the 3 types of temporizing device, the authors performed meta-analyses examining 6 outcomes of interest, which were rates of 1) obstruction; 2) infection; 3) arrest of hydrocephalus (i.e., permanent shunt independence); 4) mortality; 5) good neurodevelopmental outcome; and 6) revision. RESULTS Thirty-nine studies, representing 1502 patients, met eligibility criteria. All of the included articles were observational studies; 36 were retrospective and 3 were prospective designs. Nine studies (n = 295) examined VSGSs, 24 (n = 962) VADs, and 9 (n = 245) EVDs. Pooled rates of outcome for VSGS, VAD, and EVD, respectively, were 9.6%, 7.3%, and 6.8% for obstruction; 9.2%, 9.5%, and 6.7% for infection; 12.2%, 10.8%, and 47.3% for revision; 13.9%, 17.5%, and 31.8% for arrest of hydrocephalus; 12.1%, 15.3%, and 19.1% for death; and 58.7%, 50.1%, and 56.1% for good neurodevelopmental outcome. CONCLUSIONS This study provides robust estimates of outcomes for the most common temporizing treatments for IVH in premature infants. With few exceptions, the range of outcomes was similar for VSGS, VAD, and EVD.

Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants

OBJECT

Intraventricular hemorrhage in premature infants often leads to progressive ventricular dilation and the need for ventricular reservoir placement. Unfortunately, these reservoirs have a higher rate of infection than ventriculoperitoneal shunts in premature babies. The authors analyzed the risk factors for infection in this population and studied whether the implementation of an institutional protocol for shunt placement had a corollary effect on ventricular access device (VAD) infection rates in premature neonates with intraventricular hemorrhage.

METHODS

The authors conducted a retrospective cohort review of consecutive premature neonates in whom VADs were inserted in the operating room at Primary Children's Hospital between June 2003 and June 2011 to identify risk factors for infection. Medical records were reviewed for information on infection (culture proven or eroded hardware at 90 days), gestational age at birth, weight, gestational age at surgery, intrathecal antibiotics, hemorrhage, death, and surgeon. The institution used a pilot protocol for shunt infection reduction in 2006-2007, and then the full Hydrocephalus Clinical Research Network protocol from June 2007 to 2011, and the rates of infection during these periods were analyzed. Confounding factors such as sepsis, necrotizing enterocolitis, and a history of meningitis were also analyzed.

RESULTS

The overall infection rate was 10.5% (11 patients) in the 105 patients identified. Gestational age at procedure was a significant risk factor for infection (p=0.05). Meningitis was significantly associated with infection, with 63% of the infected group having had prior meningitis compared with 7% for the noninfected group (p<0.001). Concurrent with the implementation of the protocol to reduce shunt infection, the VAD infection rate decreased from 14.7% to 5.4% (p=0.2).

CONCLUSIONS

Gestational age at procedure and previous meningitis were significant risk factors for VAD infections. In addition, the implementation of an institutional standardized shunt protocol for ventriculoperitoneal shunts may have altered the operating room team's behavior, indicated by a nonmandated use of intrathecal antibiotics in VAD surgeries, contributing to a reduced VAD infection rate. Although the observed difference was not statistically significant with the small sample size, the authors believe that these findings deserve further study.

Ventricular access device infection rate: a retrospective study and review of the literature

PURPOSE

Ventricular access devices (VAD) are often used for treatment of posthemorrhagic hydrocephalus (PHH) in preterm infants. The reported rates of infection have varied and range from 0 to 22 %. The objective of our study is to present our VAD associated infection at our institution.

METHODS

The charts for patients that had VADs inserted between May 1, 2009 and October 31, 2013 at a single institution (Children's Healthcare of Atlanta) were retrospectively reviewed. The number of VAD infections, defined as either cerebrospinal fluid (CSF)-positive cultures or wound complication, was recorded. Of patients that survived, the number of VAD to shunt conversions was also examined. The data from 15 previously published studies were pooled to determine overall VAD infection and VAD to shunt conversion rates.

RESULTS

A total of 142 VADs were placed. There were 13 infections (9.2 %), 11 of which had CSF-positive cultures (7.7 %). There were two wound complications with negative CSF cultures. Six patients died after VAD placement for reasons unrelated to their VAD surgeries (4.2 %). In the remaining patients, there were 113 VAD to shunt conversions (83.1 %). Fifteen studies that reported VAD infections were analyzed; an overall infection rate of 7.0 % and VAD to shunt conversion rate of 79 % were calculated.

CONCLUSIONS

While VAD is a valuable tool to treat PHH, it remains a procedure with an infection rate between 7.0 and 8.0 %. Close follow-up is needed to capture these adverse events as early as possible. Approximately 80 % of patients with PHH will require permanent CSF diversion.

Neonatal posthemorrhagic hydrocephalus from prematurity: pathophysiology and current treatment concepts

OBJECT

Preterm infants are at risk for perinatal complications, including germinal matrix-intraventricular hemorrhage (IVH) and subsequent posthemorrhagic hydrocephalus (PHH). This review summarizes the current understanding of the epidemiology, pathophysiology, management, and outcomes of IVH and PHH in preterm infants.

METHODS

The MEDLINE database was systematically searched using terms related to IVH, PHH, and relevant neurosurgical procedures to identify publications in the English medical literature. To complement information from the systematic search, pertinent articles were selected from the references of articles identified in the initial search.

RESULTS

This review summarizes the current knowledge regarding the epidemiology and pathophysiology of IVH and PHH, primarily using evidence-based studies. Advances in obstetrics and neonatology over the past few decades have contributed to a marked improvement in the survival of preterm infants, and neurological morbidity is also starting to decrease. The incidence of IVH is declining, and the incidence of PHH will likely follow. Currently, approximately 15% of preterm infants who suffer severe IVH will require permanent CSF diversion. The clinical presentation and surgical management of symptomatic PHH with temporary ventricular reservoirs (ventricular access devices) and ventriculosubgaleal shunts and permanent ventriculoperitoneal shunts are discussed. Preterm infants who develop PHH that requires surgical treatment remain at high risk for other related neurological problems, including cerebral palsy, epilepsy, and cognitive and behavioral delay. This review highlights numerous opportunities for further study to improve the care of these children.

CONCLUSIONS

A better grasp of the pathophysiology of IVH is beginning to impact the incidence of IVH and PHH. Neonatologists conduct rigorous Class I and II studies to advance the outcomes of preterm infants. The need for well-designed multicenter trials is essential because of the declining incidence of IVH and PHH, variations in referral patterns, and neonatal ICU and neurosurgical management. Well-designed multicenter trials will eventually produce evidence to enable neurosurgeons to provide their smallest, most vulnerable patients with the best practices to minimize perioperative complications and permanent shunt dependence, and most importantly, optimize long-term neurodevelopmental outcomes.

Hydrocephalus

Hydrocephalus is not an exotic condition in general pediatric practice. A general pediatrician might expect to serve two to five children with CSF shunts. This article reviews posthemorrhagic hydrocephalus in detail.

Necrotizing enterocolitis complicating the management of posthemorrhagic hydrocephalus

The case notes of all newborn infants with posthemorrhagic hydrocephalus (PHH) operated over the past 10 years at our institution were reviewed to establish the incidence and the effect of necrotizing enterocolitis (NEC) on morbidity and mortality following cerebrospinal fluid (CSF) shunting. Thirteen neonates had both PHH and NEC (group A); 7 of these patients were initially treated by ventriculoatrial (VA) shunt and six by ventriculoperitoneal (VP) shunt. Seventy-five patients had PHH alone (group B); all were treated by VP shunt. Eight patients in group A required an abdominal operation for NEC. The two groups were comparable for birth weight, gestational age, and other complications of prematurity. Episodes of shunt malfunction (infection and/or obstruction) and deaths occurring within 12 months from shunt insertion, in the two groups were compared. Shunt malfunction was more frequent in group A (72%) than in group B (27%) (P < .001). Shunt infection was observed in 39% of group A patients versus 14% in group B (P = .03). Distal shunt obstructions occurred in 28% of group A patients and only 3% of group B patients (P = .001). There were more deaths in group A (62% v 9%; P < .001). Thirty-one percent of group A patients and 4% of group B patients died following shunt complications (P = .006). In group A, there was no significant difference in mortality and shunt malfunction between patients with VA or VP shunts. The method of treatment and the stage of NEC did not influence morbidity and mortality after internal drainage for PHH.(ABSTRACT TRUNCATED AT 250 WORDS)

Neurological outcome following neonatal post-haemorrhagic hydrocephalus: the effects of maximum raised intracranial pressure and ventriculo-peritoneal shunting

The neuromotor outcome of 33 survivors of grade 3 or 4 neonatal post-haemorrhagic hydrocephalus born between 1975 and 1988 was assessed at a mean age of 4.7 years (9 months to 13 years). Two outcomes were determined: 12 patients were either normal (10 or had neurological signs without functional impairments (2), while 21/33 were moderately (16), severely (2), or profoundly impaired (3). Intracranial pressure (ICP) was measured in 26/33 patients (4-40 mm Hg): 2 had normal pressures (< 5.6 mm Hg) and were normal. Raised ICP was not significantly different between outcome groups. Twenty-seven children were shunted; 10/27 had five or more operations (up to 14) and all of these had abnormal neurological outcomes, whereas the number of children with 1-4 shunt procedures was equal in both outcome groups. The rise in morbidity after the fourth shunt procedure may be associated with the ventriculitis suffered by 9 of the 10 patients with more than four shunts (P < 0.01): this compares with 4/14 cases of ventriculitis in the children with 2-4 shunts and no cases of infection in the 3/27 who were shunted once. Outcome was independent of antenatal and perinatal factors including the age at or mode of presentation, and was unrelated to grade of intraventricular haemorrhage or parenchymal changes on ultrasound or CT scanning.

CONCLUSION

for these small numbers, adverse outcome is statistically related to more than four shunt procedures and ventriculitis but independent of maximum ICP or other perinatal factors.