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Bleil C, Vitulli F, Mirza AB, Boardman TM, Al Banna Q, AlFaiadh W, Zebian B. Ventriculosubgaleal shunts in the management of neonatal post-haemorrhagic hydrocephalus: technical note. Childs Nerv Syst 2023; 39:3263-3271. [PMID: 37584741 DOI: 10.1007/s00381-023-06125-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 08/09/2023] [Indexed: 08/17/2023]
Abstract
INTRODUCTION Germinal matrix / intraventricular haemorrhage (GMIVH) remains a significant complication of prematurity. The more severe grades are associated with parenchymal haemorrhagic infarction (PHI) and hydrocephalus. A temporising procedure is usually the first line in management of neonatal post-haemorrhagic hydrocephalus (nPHH) as the risk of failure of a permanent cerebrospinal fluid (CSF) diversion is higher in the early stage. Our choice of temporising procedure is a ventriculosubgaleal shunt (VSGS). In this technical note, we describe a modification in technique whereby the pocket of the VSGS is fashioned away from the surgical wound. This resulted in lower CSF leak and subsequent infection rates in our centre. METHODS We conducted a retrospective analysis of all patients who underwent insertion of a VSGS between September 2014 and February 2023. RESULTS Twenty children were included in our study with a mean gestational age of 31 weeks + 4 days. Post-operatively, 10% of patients did not need a tap, and 10%, 20%, 15%, 25% and 20% respectively had 1, 2, 3, 4 and 5 taps. Two patients experienced CSF leak from their wounds. In both these patients, the pocket was deemed too close to the wound. None of the patients without suspected pre-existing CNS infection at the time of insertion of VSGS had a subsequent VSGS-related infection. VSGS conversion to permanent ventriculoperitoneal shunts (VPS) was required in 15 (75%) of the patients with an average interval duration of 72 days. On reviewing the literature, the infection rate following VSGS is quoted up to 13.5%. In our own centre, 13 patients had undergone VSGS insertion between 2005 and 2013 with a 30.8% infection rate which seemed related to increased leak rates. CONCLUSION Our modified surgical approach seems to be effective in reducing the risk of infection, which we postulate is a direct result of reduction in the risk of leak from the surgical wound.
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Affiliation(s)
- Cristina Bleil
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Francesca Vitulli
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK.
- Department of Neurosciences and Reproductive and Dental Sciences, Division of Neurosurgery, Federico II" University of Naples, Via Sergio Pansini n.5, 80131, Naples, Italy.
| | - Asfand Baig Mirza
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | | | - Qusai Al Banna
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Wisam AlFaiadh
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
| | - Bassel Zebian
- Department of Neurosurgery, King's College Hospital NHS Foundation Trust, Denmark Hill, London, UK
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Paez-Gonzalez P, Lopez-de-San-Sebastian J, Ceron-Funez R, Jimenez AJ, Rodríguez-Perez LM. Therapeutic strategies to recover ependymal barrier after inflammatory damage: relevance for recovering neurogenesis during development. Front Neurosci 2023; 17:1204197. [PMID: 37397456 PMCID: PMC10308384 DOI: 10.3389/fnins.2023.1204197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 05/22/2023] [Indexed: 07/04/2023] Open
Abstract
The epithelium covering the surfaces of the cerebral ventricular system is known as the ependyma, and is essential for maintaining the physical and functional integrity of the central nervous system. Additionally, the ependyma plays an essential role in neurogenesis, neuroinflammatory modulation and neurodegenerative diseases. Ependyma barrier is severely affected by perinatal hemorrhages and infections that cross the blood brain barrier. The recovery and regeneration of ependyma after damage are key to stabilizing neuroinflammatory and neurodegenerative processes that are critical during early postnatal ages. Unfortunately, there are no effective therapies to regenerate this tissue in human patients. Here, the roles of the ependymal barrier in the context of neurogenesis and homeostasis are reviewed, and future research lines for development of actual therapeutic strategies are discussed.
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Affiliation(s)
- Patricia Paez-Gonzalez
- Department of Cell Biology, Genetics and Physiology, University of Malaga, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
| | | | - Raquel Ceron-Funez
- Department of Cell Biology, Genetics and Physiology, University of Malaga, Málaga, Spain
| | - Antonio J. Jimenez
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
| | - Luis Manuel Rodríguez-Perez
- Department of Cell Biology, Genetics and Physiology, University of Malaga, Málaga, Spain
- Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina-IBIMA Plataforma BIONAND, Málaga, Spain
- Department of Human Physiology, Human Histology, Pathological Anatomy and Sports, University of Malaga, Málaga, Spain
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3
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Lu VM, Wang S, Niazi TN, Ragheb J. Impact of intraventricular hemorrhage symmetry on endoscopic third ventriculostomy with choroid plexus cauterization for posthemorrhagic hydrocephalus: an institutional experience of 50 cases. J Neurosurg Pediatr 2023; 31:245-251. [PMID: 36585872 DOI: 10.3171/2022.12.peds22492] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 12/05/2022] [Indexed: 12/31/2022]
Abstract
OBJECTIVE The success rate of endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in the management of posthemorrhagic hydrocephalus (PHH) following intraventricular hemorrhage (IVH) in infants is not well defined. Furthermore, parameters of IVH at initial presentation have not been tested for predictive associations of ETV/CPC success in this setting. The authors sought to summarize their institutional outcomes to identify possible predictors of ETV/CPC success within this niche. METHODS A retrospective review was conducted of all ETV/CPC procedures performed at the authors' institution for PHH between 2011 and 2021. Patients were screened against a set of selection criteria including follow-up time of at least 6 months. Associations with ETV/CPC failure were evaluated using regression and Kaplan-Meier analyses. RESULTS A total of 50 patients satisfied all criteria. There were 32 (64%) male and 18 (36%) female patients with a mean gestational birth age of 26 weeks. The presenting IVH was symmetric in 30 (60%) and asymmetric in 20 (40%) patients, and the maximum IVH grade was IV in 30 (60%) patients overall. Six months after the procedure, ETV/CPC success was seen in 18 (36%) patients and failure in 32 (64%) patients. The median overall follow-up was 42 months, at which point ETV/CPC success was observed in 11 (22%) patients and ETV/CPC failure in 39 (78%) patients. Regression analyses indicated that radiological IVH symmetry was a statistically significant predictor of ETV/CPC failure at 6 months (OR 3.46, p = 0.04) and overall (OR 5.33, p = 0.03). Overall rates of failure were 89% versus 62% (p = 0.02) when comparing symmetric versus asymmetric IVH patients, and time to failure occurred at median times of 1.4 versus 6.5 months (p = 0.03) after the initial procedure. Higher maximum IVH grade and younger age at initial ETV/CPC only trended toward increased failure rates. When the etiology component of the ETV Success Score was adjusted such that symmetric IVH was scored 0, the area under the curve for failure at 6 months increased from 0.58 to 0.69. CONCLUSIONS Overall, approximately 1 in 5 infants with PHH can expect to not require further intervention following ETV/CPC. The authors demonstrate that IVH symmetry is statistically predictive of ETV/CPC failure in this setting independent of all other parameters, where PHH infants with symmetric IVH are more likely to experience failure, and sooner, than PHH infants with asymmetric IVH. When discussing possible success rates of ETV/CPC for PHH, IVH symmetry should be considered.
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Affiliation(s)
- Victor M Lu
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - Shelly Wang
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - Toba N Niazi
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
| | - John Ragheb
- 1Department of Neurological Surgery, University of Miami, Jackson Memorial Hospital, Miami; and
- 2Department of Neurological Surgery, Nicklaus Children's Hospital, Miami, Florida
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Liu G, Nie C. Ultrasonic Diagnosis and Management of Posthemorrhagic Ventricular Dilatation in Premature Infants: A Narrative Review. J Clin Med 2022; 11:jcm11247468. [PMID: 36556084 PMCID: PMC9784170 DOI: 10.3390/jcm11247468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/08/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
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.
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Affiliation(s)
- Gengying Liu
- Neonatology Department, Guangdong Women and Children Hospital, Guangzhou 510010, China
- Guangdong Neonatal ICU Medical Quality Control Center, Guangzhou 510010, China
| | - Chuan Nie
- Neonatology Department, Guangdong Women and Children Hospital, Guangzhou 510010, China
- Guangdong Neonatal ICU Medical Quality Control Center, Guangzhou 510010, China
- Correspondence:
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Raghuram H, Looi T, Pichardo S, Waspe AC, Drake JM. A robotic MR-guided high-intensity focused ultrasound platform for intraventricular hemorrhage: assessment of clot lysis efficacy in a brain phantom. J Neurosurg Pediatr 2022; 30:586-594. [PMID: 36115058 DOI: 10.3171/2022.8.peds22144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 08/05/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intraventricular hemorrhage (IVH) is a neurovascular complication due to premature birth that results in blood clots forming within the ventricles. Magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) has been investigated as a noninvasive treatment to lyse clots. The authors designed and constructed a robotic MRgHIFU platform to treat the neonatal brain that facilitates ergonomic patient positioning. The clot lysis efficacy of the platform is quantified using a brain phantom and clinical MRI system. METHODS A thermosensitive brain-mimicking phantom with ventricular cavities was developed to test the clot lysis efficacy of the robotic MRgHIFU platform. Whole porcine blood was clotted within the phantom's cavities. Using the MRgHIFU platform and a boiling histotripsy treatment procedure (500 W, 10-msec pulse duration, 1.0% duty cycle, and 40-second duration), the clots were lysed inside the phantom. The contents of the cavities were vacuum filtered, and the remaining mass of the solid clot particles was used to quantify the percentage of clot lysis. The interior of the phantom's cavities was inspected for any collateral damage during treatment. RESULTS A total of 9 phantoms were sonicated, yielding an average (± SD) clot lysis of 97.0% ± 2.57%. Treatment resulted in substantial clot lysis within the brain-mimicking phantoms that were apparent on postsonication T2-weighted MR images. No apparent collateral damage was observed within the phantom after treatment. The results from the study showed the MRgHIFU platform was successful at lysing more than 90% of a blood clot at a statistically significant level. CONCLUSIONS The robotic MRgHIFU platform was shown to lyse a large percentage of a blood clot with no observable collateral damage. These results demonstrate the platform's ability to induce clot lysis when targeting through simulated brain matter and show promise toward the final application in neonatal patients.
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Affiliation(s)
- Hrishikesh Raghuram
- 1Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario
- 2The Institute of Biomedical Engineering, University of Toronto, Ontario
| | - Thomas Looi
- 1Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario
- 4Mechanical Engineering, and
| | - Samuel Pichardo
- 5Radiology and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Alberta; and
- 6Hotchkiss Brain Institute, University of Calgary, Alberta, Canada
| | - Adam C Waspe
- 1Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario
- Departments of3Medical Imaging
| | - James M Drake
- 1Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario
- 2The Institute of Biomedical Engineering, University of Toronto, Ontario
- 4Mechanical Engineering, and
- 7Neurosurgery, University of Toronto, Ontario
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6
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Afifi J, Shah PS, Ye XY, Shah V, Piedboeuf B, Barrington K, Kelly E, El-Naggar W. Epidemiology of post-hemorrhagic ventricular dilatation in very preterm infants. J Perinatol 2022; 42:1392-1399. [PMID: 35945347 DOI: 10.1038/s41372-022-01483-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Revised: 06/22/2022] [Accepted: 07/26/2022] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To describe the incidence, trends, management's variability and short-term outcomes of preterm infants with severe post-hemorrhagic ventricular dilatation (sPHVD). METHODS We reviewed infants <33 weeks' gestation who had PHVD and were admitted to the Canadian Neonatal Network between 2010 and 2018. We compared perinatal characteristics and short-term outcomes between those with sPHVD and those with mild/moderate PHVD and those with and without ventriculo-peritoneal (VP) shunt. RESULTS Of 29,417 infants, 2439 (8%) had PHVD; rate increased from 7.3% in 2010 to 9.6% in 2018 (P = 0.005). Among infants with PHVD, sPHVD (19%) and VP shunt (29%) rates varied significantly across Canadian centers and between geographic regions (P < 0.01 and P = 0.0002). On multivariable analysis, sPHVD was associated with greater mortality, seizures and meningitis compared to mild/moderate PHVD. CONCLUSIONS Significant variability in sPHVD and VP shunt rates exists between centers and regions in Canada. sPHVD was associated with increased mortality and morbidities.
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Affiliation(s)
- Jehier Afifi
- Department of Pediatrics, IWK Health Centre and Dalhousie University, Halifax, NS, Canada.
| | - Prakesh S Shah
- Maternal-infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada.,Departments of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, ON, Canada
| | - Xiang Y Ye
- Maternal-infant Care Research Centre, Mount Sinai Hospital, Toronto, ON, Canada
| | - Vibhuti Shah
- Departments of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, ON, Canada
| | - Bruno Piedboeuf
- Department of Pediatrics, CHU de Québec-Université Laval, Québec, QC, Canada
| | - Keith Barrington
- Department of Pediatrics, CHU Sainte Justine, Québec, QC, Canada
| | - Edmond Kelly
- Departments of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, ON, Canada
| | - Walid El-Naggar
- Department of Pediatrics, IWK Health Centre and Dalhousie University, Halifax, NS, Canada
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Park YS. Treatment Strategies and Challenges to Avoid Cerebrospinal Fluid Shunting for Pediatric Hydrocephalus. Neurol Med Chir (Tokyo) 2022; 62:416-430. [PMID: 36031350 PMCID: PMC9534569 DOI: 10.2176/jns-nmc.2022-0100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
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.
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Affiliation(s)
- Young-Soo Park
- Department of Neurosurgery and Children's Medical Center, Nara Medical University
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8
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Pindrik J, Schulz L, Drapeau A. Diagnosis and Surgical Management of Neonatal Hydrocephalus. Semin Pediatr Neurol 2022; 42:100969. [PMID: 35868728 DOI: 10.1016/j.spen.2022.100969] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 03/30/2022] [Accepted: 04/01/2022] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Jonathan Pindrik
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH; Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, OH.
| | - Lauren Schulz
- Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, OH
| | - Annie Drapeau
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH; Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, OH
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Raghuram H, Keunen B, Soucier N, Looi T, Pichardo S, Waspe AC, Drake JM. A robotic magnetic resonance-guided high-intensity focused ultrasound platform for neonatal neurosurgery: Assessment of targeting accuracy and precision in a brain phantom. Med Phys 2022; 49:2120-2135. [PMID: 35174892 DOI: 10.1002/mp.15540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 02/07/2022] [Accepted: 02/07/2022] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Intraventricular Hemorrhage (IVH) is one of the most serious neurovascular complications resulting from premature birth. It can result in clotting of blood within the ventricles, which causes a buildup of cerebrospinal fluid that can lead to posthemorrhagic ventricular dilation and posthemorrhagic hydrocephalus. Currently, there are no direct treatments for these blood clots as the standard of care is invasive surgery to insert a shunt. Magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) has been investigated as a non-invasive treatment to lyse blood clots. However, current MRgHIFU systems are not suitable in the context of treating IVH in neonates. PURPOSE We have developed a robotic MRgHIFU neurosurgical platform designed to treat the neonatal brain. This platform facilitates ergonomic patient positioning and directs treatment through their open anterior fontanelle while providing a larger treatment volume. The platform is based on an MR-compatible robot developed by our group. Further development of the platform has warranted investigation of its targeting ability to assess its feasibility in the neonatal brain. This study aimed to quantify the platform's targeting accuracy, precision, and repeatability using a brain phantom and clinical MRI system. METHODS A thermosensitive brain-mimicking phantom was developed to test the platform's targeting accuracy. Rectangular grid patterns were created with HIFU thermal energy "lesions" in the phantoms by targeting specific coordinate points. The intended target locations were demarcated by inserting carbon fibre rods through a targeting assessment template. Coordinates for the intended and actual targets were derived from T2-weighted MRI scans and the centroid distance between them was measured. Subsequently, the platform's targeting accuracy was quantified according to equations derived from ISO Standard 9283:1998. RESULTS HIFU ablation resulted in distinct thermal lesions within the thermosensitive phantoms, which appeared as discrete hypointense regions in T2-weighted MR scans. A total of 127 target points were included in the data analysis, which yielded a targeting accuracy of 0.6mm and targeting precision of 1.2mm. CONCLUSIONS The robotic MRgHIFU platform was shown to have a high degree of accuracy, precision, and repeatability. The results demonstrate the platform's functionality when targeting through simulated brain matter. These results serve as an initial verification of the platform targeting ability and showed promise towards the final application in a neonatal brain. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Hrishikesh Raghuram
- Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario, M5G 1 × 8, Canada.,The Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, M5G 3G9, Canada
| | - Benjamin Keunen
- The Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, M5G 3G9, Canada
| | - Nathan Soucier
- Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario, M5G 1 × 8, Canada.,The Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, M5G 3G9, Canada
| | - Thomas Looi
- Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario, M5G 1 × 8, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, M5T 1W7, Canada
| | - Samuel Pichardo
- Radiology and Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, T2N 1N4, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, T2N 1N4, Canada
| | - Adam C Waspe
- Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario, M5G 1 × 8, Canada.,Department of Medical Imaging, University of Toronto, Toronto, Ontario, M5T 1W7, Canada
| | - James M Drake
- Posluns Centre for Image Guided Innovation and Therapeutic Intervention, Hospital for Sick Children, Toronto, Ontario, M5G 1 × 8, Canada.,The Institute of Biomedical Engineering, University of Toronto, Toronto, Ontario, M5G 3G9, Canada.,Department of Neurosurgery, University of Toronto, Toronto, Ontario, M5S 1A1, Canada
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10
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Neuroendoscopic lavage for the management of neonatal post-haemorrhagic hydrocephalus: a retrospective series. Childs Nerv Syst 2022; 38:115-121. [PMID: 34757453 DOI: 10.1007/s00381-021-05373-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 09/20/2021] [Indexed: 10/19/2022]
Abstract
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.
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Dawes W. Secondary Brain Injury Following Neonatal Intraventricular Hemorrhage: The Role of the Ciliated Ependyma. Front Pediatr 2022; 10:887606. [PMID: 35844746 PMCID: PMC9280684 DOI: 10.3389/fped.2022.887606] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 06/07/2022] [Indexed: 11/15/2022] Open
Abstract
Intraventricular hemorrhage is recognized as a leading cause of hydrocephalus in the developed world and a key determinant of neurodevelopmental outcome following premature birth. Even in the absence of haemorrhagic infarction or posthaemorrhagic hydrocephalus, there is increasing evidence of neuropsychiatric and neurodevelopmental sequelae. The pathophysiology underlying this injury is thought to be due to a primary destructive and secondary developmental insult, but the exact mechanisms remain elusive and this has resulted in a paucity of therapeutic interventions. The presence of blood within the cerebrospinal fluid results in the loss of the delicate neurohumoral gradient within the developing brain, adversely impacting on the tightly regulated temporal and spatial control of cell proliferation and migration of the neural stem progenitor cells within the subventricular zone. In addition, haemolysis of the erythrocytes, associated with the release of clotting factors and leucocytes into the cerebrospinal (CSF), results in a toxic and inflammatory CSF microenvironment which is harmful to the periventricular tissues, resulting in damage and denudation of the multiciliated ependymal cells which line the choroid plexus and ventricular system. The ependyma plays a critical role in the developing brain and beyond, acting as both a protector and gatekeeper to the underlying parenchyma, controlling influx and efflux across the CSF to brain interstitial fluid interface. In this review I explore the hypothesis that damage and denudation of the ependymal layer at this critical juncture in the developing brain, seen following IVH, may adversely impact on the brain microenvironment, exposing the underlying periventricular tissues to toxic and inflammatory CSF, further exacerbating disordered activity within the subventricular zone (SVZ). By understanding the impact that intraventricular hemorrhage has on the microenvironment within the CSF, and the consequences that this has on the multiciliated ependymal cells which line the neuraxis, we can begin to develop and test novel therapeutic interventions to mitigate damage and reduce the associated morbidity.
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Affiliation(s)
- William Dawes
- Alder Hey Children's Hospital, Liverpool, United Kingdom.,NIHR Great Ormond Street Hospital BRC, London, United Kingdom
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Deger J, Goethe EA, LoPresti MA, Lam S. Intraventricular Hemorrhage in Premature Infants: A Historical Review. World Neurosurg 2021; 153:21-25. [PMID: 34144164 DOI: 10.1016/j.wneu.2021.06.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
Intraventricular hemorrhage (IVH) is common in premature newborns and poses a high risk for morbidity with lifelong disability. We searched the available literature for original and secondary literature regarding the epidemiology, pathogenesis, and treatment of IVH in order to trace changes in the management of this disease over time. We examined IVH pathogenesis and epidemiology and reviewed the history of medical and surgical treatment for intraventricular hemorrhage in preterm children. Initial medical management strategies aimed at correcting coagulopathy and eventually targeted mediators of perinatal instability including respiratory distress. Surgical management centered around cerebrospinal fluid diversion, initially through serial lumbar punctures, progressing to ventriculoperitoneal shunting, with more recent interventions addressing intraventricular clot burden. We provide a historical review of the evolution of treatment for IVH in newborns. While the management of IVH has grown significantly over time, IVH remains a common neurosurgical disease that continues to affect patient and caregiver quality of life and health care costs. Despite advances in treatment over more than a century, IVH remains a significant cause of morbidity and mortality in premature infants, and an understanding of past approaches may inform the development of new treatments.
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Affiliation(s)
- Jennifer Deger
- Department of Neurosurgery, Baylor College of Medicine, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Eric A Goethe
- Department of Neurosurgery, Baylor College of Medicine, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Melissa A LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Sandi Lam
- Department of Neurosurgery, Northwestern University School of Medicine, Division of Neurosurgery, Lurie Children's Hospital, Chicago, Illinois, USA.
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Lakomkin N, Hadjipanayis CG. The Role of Prophylactic Intraventricular Antibiotics in Reducing the Incidence of Infection and Revision Surgery in Pediatric Patients Undergoing Shunt Placement. Neurosurgery 2021; 88:301-305. [PMID: 32985657 DOI: 10.1093/neuros/nyaa413] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2019] [Accepted: 07/05/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Ventriculoperitoneal shunt placement remains the primary treatment modality for children with hydrocephalus. However, morbidity and revision surgery secondary to infection remains high, even while using antibiotic-impregnated shunts. OBJECTIVE To determine whether intraoperative injection of antibiotics is independently associated with reduced rates of infection and revision surgery in children undergoing shunt placement. METHODS This is an analysis of a prospectively collected, multicenter, shunt-specific neurosurgical registry consisting of data from over 100 hospitals collected between 2016 and 2017. All patients under 18 yr of age undergoing first-time shunt placement for the definitive treatment of hydrocephalus were included. The primary exposure of interest was injection of intraventricular antibiotics into the shunt catheter following shunt placement and prior to closure. The use of additional surgical adjuncts, such as antibiotic-impregnated shunts, stereotactic guidance, and endoscopy was collected. The primary outcome metric was the need for additional intervention because of an infection. RESULTS A total of 2007 pediatric patients undergoing shunt placement for hydrocephalus were identified. Postoperatively, 97 (4.8%) patients had additional intervention secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, and placement of an antibiotic-impregnated shunt, injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (odds ratio = 0.29, 95% CI: 0.04-0.89, P = .038). Of those receiving intraventricular antibiotics, only 2 (0.38%) went on to undergo re-intervention due to infection. CONCLUSION These data suggest that for this select group of patients, use of intraventricular antibiotics was associated with decreased rates of re-intervention secondary to infection.
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Affiliation(s)
- Nikita Lakomkin
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York.,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, New York
| | - Constantinos G Hadjipanayis
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, New York, New York.,Department of Neurosurgery, Icahn School of Medicine, Mount Sinai Beth Israel, Mount Sinai Health System, New York, New York
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14
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Li D, Romanski K, Kilgallon M, Speck S, Bowman R, DiPatri A, Alden T, Tomita T, Lam S, Saratsis AM. Safety of Ventricular Reservoir Sampling in Pediatric Posthemorrhagic Hydrocephalus Patients: Institutional Experience and Review of the Literature. J Neurosci Nurs 2021; 53:11-17. [PMID: 33395155 DOI: 10.1097/jnn.0000000000000566] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
ABSTRACT INTRODUCTION: Posthemorrhagic hydrocephalus (PHH) is a common disease process encountered in neonates. Management often includes cerebrospinal fluid (CSF) aspiration through ventricular access devices (VADs). However, a common concern surrounding serial access of implanted subcutaneous reservoirs includes introduction of infection. In addition, there is great variability in aseptic technique. Therefore, the authors sought to evaluate the incidence of VAD access-associated infections in the literature and compare them with the rate of infection found at our institution. We also highlight the use of a preassembled VAD access kit and standardized access protocol, as well as the role of provider education, in maintaining safety and sterility during serial VAD access. METHODS: A single-institution retrospective review was performed for PHH patients younger than 1 year old undergoing serial CSF aspirations via implanted VADs (2009-2019). Patients were excluded if they had a ventriculoperitoneal shunt placed as primary intervention. MEDLINE search for reports of serial VAD access in PHH was also performed. Reports were excluded if they did not include full-text articles in the English literature. RESULTS: At our institution, subcutaneous reservoirs were placed in 37 neonates with PHH for serial CSF aspiration. No infections occurred after a total of 630 taps (average, 17 taps per reservoir; range, 0-83) and 10 420 collective reservoir days (average, 282 per patient; range, 6-3700). Only 2 reservoirs required revision for malfunction. Serial VAD taps for PHH were described in 14 articles in the medical literature, with 7.9% (n = 47/592) of patients reported with tap-related infectious complications. CONCLUSION: A standardized VAD access kit, along with stringent adherence to access protocol, can significantly minimize risk of infection associated with serial VAD access. These principles can be generalized to percutaneous aspiration of CSF from subcutaneous reservoirs placed for other indications to promote safety and sterility of this common procedure.
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Neuroendoscopic surgery in neonates - indication and results over a 10-year practice. Childs Nerv Syst 2021; 37:3541-3548. [PMID: 34216233 PMCID: PMC8578165 DOI: 10.1007/s00381-021-05272-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 06/18/2021] [Indexed: 11/17/2022]
Abstract
PURPOSE Neuroendoscopic procedures for treatment of term and preterm newborn infants, such as endoscopic lavage for posthemorrhagic hydrocephalus, are gaining popularity despite sparse data. This single-institution report compiles all neuroendoscopic surgical procedures performed in neonates during a 10-year period. METHODS Charts and electronic records were reviewed of all consecutive newborns who underwent a neuroendoscopic procedure before reaching a postmenstrual age of 44 weeks between 09/2010 and 09/2020. Available documentation was reviewed regarding the performed neuroendoscopic procedure, course of disease, complications, and all re-operations throughout the first year of life. RESULTS During the 10-year study period, 116 infants (median gestational age at birth: 29 1/7 weeks) underwent a total of 153 neuroendoscopic procedures (median postmenstrual age at surgery: 35 0/7 weeks). The most common indication at the time of the neuroendoscopic procedures (n = 153) was intraventricular hemorrhage (IVH, n = 119), intraventricular infection (n = 15), congenital malformation (n = 8), isolated 4th ventricle (n = 7), multiloculated hydrocephalus (n = 3), and tumor (n = 1). Thirty-eight of 116 children (32.8%) underwent 43 operative revisions after 153 neuroendoscopic procedure (28.1%). Observed complications requiring surgical revision were secondary infection (n = 11), CSF fistula (n = 9), shunt dysfunction (n = 8), failure of ETV (n = 6), among others. 72 children (62%) of 116 children required permanent CSF diversion via a shunt. The respective shunt rates per diagnosis were 47 of 80 (58.8%) for previously untreated IVH, 11 of 13 (84.6%) for intraventricular infection. Shunt survival rate for the first year of life was 74% for the whole cohort. CONCLUSION The experience with this large cohort of neonates demonstrates the feasibility of neuroendoscopic technique for the treatment of posthemorrhagic or postinfectious hydrocephalus. Rate and type of complications after neuroendoscopic procedures were within the expected range. Assessing the potential long-term benefits of neuroendoscopic techniques has to await results of ongoing studies.
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Efficacy and safety of intraventricular fibrinolytic therapy for post-intraventricular hemorrhagic hydrocephalus in extreme low birth weight infants: a preliminary clinical study. Childs Nerv Syst 2021; 37:69-79. [PMID: 32661643 DOI: 10.1007/s00381-020-04766-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 06/22/2020] [Indexed: 01/25/2023]
Abstract
PURPOSE To evaluate the efficacy and safety of our unique therapy for treating post-intraventricular hemorrhagic hydrocephalus (PIVHH) in low birth weight infants (LBWls) through an early stage fibrinolytic therapeutic strategy involving urokinase (UK) injection into the lateral ventricle, called the "Ventricular Lavage (VL) therapy." METHODS Overall, 43 consecutive infants with PIVHH were included. Most were extremely LBWIs (n = 39). Other cases included very LBWIs (n = 2) and full-term infants (n = 2). VL therapy involved continuous external ventricular drainage (EVD) management using a very fine catheter and intermittent slow injection of 6000 IU of UK every 3-6 h to actively dissolve hematomas. RESULTS Early EVD management (within 3 weeks of IVH onset) was performed in 25 infants, with combination VL therapy in 21 infants. Five initiated late EVD management (≥ 3 weeks after IVH onset); the remaining 13 were treated conservatively for several weeks, delaying surgical intervention. Eighteen of 21 (86%) infants who received VL therapy did not require permanent shunt surgery. There were no serious complications, including the absence of secondary hemorrhage and infection. Two-thirds of the infants treated in the late stages required permanent shunt, and various shunt-related complications frequently occurred. A good outcome occurred in 13/17 infants in the early treatment group, despite most subjects having an IVH grade IV, and in 6/15 in the late treatment group. CONCLUSIONS Permanent shunt surgery needs were dramatically reduced following early VL therapy, and functional outcomes were favorable. VL therapy might be a promising strategy that could lead to the development of new treatments for PIVHH.
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A comparison between flow-regulated and adjustable valves used in hydrocephalus during infancy. Childs Nerv Syst 2020; 36:2013-2019. [PMID: 32152667 DOI: 10.1007/s00381-020-04552-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2019] [Accepted: 02/24/2020] [Indexed: 10/24/2022]
Abstract
INTRODUCTION Ventriculoperitoneal shunt insertion during the neonatal period and early infancy is associated with a high rate of shunt failure when compared to the adult population. Furthermore, the function of flow-regulated valves and differential pressure valves may be different in neonatal hydrocephalus. METHODS A retrospective case series of all primary shunt procedures carried out during or immediately following the neonatal period, from August 2011 to February 2018 at Sheffield Children's Hospital. The total sample size was 55. This included 34 patients with adjustable valves (Miethke ProGav) and 21 with flow-regulated valves (Orbis-Sigma); however, only 53 had adequate follow-up. RESULTS The overall 1 year shunt survival was 34% (18/53), and there was no significant difference depending on which shunt valve was implanted. The primary shunt infection rate was 11% (6/53) with S. aureus being the most common causative organism. During the first year of life, clinical signs of shunt overdrainage were seen more frequently in patients with adjustable valves than in those with flow-regulated valves (59% [19/32] versus 24% [5/21], p = 0.02). Furthermore, 2 patients in the adjustable valve group developed sagittal craniosynostosis secondary to shunt overdrainage. CONCLUSION Shunt failure is high when inserted during or immediately following the neonatal period. Overdrainage may be less common in patients with flow-regulated valves. However, if overdrainage is observed, adjusting the setting of a differential pressure valve can effectively treat the overdrainage without the need for invasive shunt revision surgery.
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van Lindert EJ, Liem KD, Geerlings M, Delye H. Bedside placement of ventricular access devices under local anaesthesia in neonates with posthaemorrhagic hydrocephalus: preliminary experience. Childs Nerv Syst 2019; 35:2307-2312. [PMID: 31506779 DOI: 10.1007/s00381-019-04361-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 08/30/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE Posthaemorrhagic ventricular dilatation in preterm infants is primarily treated using temporising measures, of which the placement of a ventricular access device (VAD) is one option. Permanent shunt dependency rates are high, though vary widely. In order to improve the treatment burden and lower shunt dependency rates, we implemented several changes over the years. One of these changes involves the setting of the surgery from general anaesthesia in the OR to local anaesthesia in bed at the neonatal intensive care unit (NICU), which may seem counterintuitive to many. In this article, we describe our surgical technique and present the results of this regimen and compare it to our previous techniques. METHODS Retrospective study of a consecutive series of 37 neonates with posthaemorrhagic ventricular dilatation (PHVD) treated using a VAD, with a cohort I (n = 13) treated from 2004 to 2008 under general anaesthesia in the OR, cohort II (n = 11) treated from 2009 to 2013 under general anaesthesia in the NICU and cohort III (n = 13) treated from December 2013 to December 2017 under local anaesthesia on the NICU. RESULTS The overall infection rate was 14%; the VAD revision rate was 22% and did not differ significantly between the cohorts. Procedures under local anaesthesia never required conversion to general anaesthesia and were well tolerated. After an average of 33 tapping days, 38% of the neonates received a permanent ventriculoperitoneal (VP) shunt. The permanent VP shunt rate was 9% with VAD placement under local anaesthesia and 52% when performed under general anaesthesia (p = 0.02). CONCLUSION Bedside placement of VADs for PHVD under local anaesthesia in neonates is a low-risk, well-tolerated procedure that results in at least equal results to surgery performed under general anaesthesia and/or performed in an OR.
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Affiliation(s)
- Erik J van Lindert
- Department of Neurosurgery, Radboud University Medical Center, Geert Groteplein-Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands.
| | - K Djien Liem
- Department of Paediatrics-Neonatology, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Martin Geerlings
- Department of Neurosurgery, Radboud University Medical Center, Geert Groteplein-Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
| | - Hans Delye
- Department of Neurosurgery, Radboud University Medical Center, Geert Groteplein-Zuid 10, P.O. Box 9101, 6500 HB, Nijmegen, The Netherlands
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19
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Valdez Sandoval P, Hernández Rosales P, Quiñones Hernández DG, Chavana Naranjo EA, García Navarro V. Intraventricular hemorrhage and posthemorrhagic hydrocephalus in preterm infants: diagnosis, classification, and treatment options. Childs Nerv Syst 2019; 35:917-927. [PMID: 30953157 DOI: 10.1007/s00381-019-04127-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Accepted: 03/15/2019] [Indexed: 11/30/2022]
Abstract
PURPOSE Intraventricular hemorrhage is the most important adverse neurologic event for preterm and very low weight birth infants in the neonatal period. This pathology can lead to various delays in motor, language, and cognition development. The aim of this article is to give an overview of the knowledge in diagnosis, classification, and treatment options of this pathology. METHOD A systematic review has been made. RESULTS The cranial ultrasound can be used to identify the hemorrhage and grade it according to the modified Papile grading system. There is no standardized protocol of intervention as there are controversial results on which of the temporizing neurosurgical procedures is best and about the appropriate parameters to consider a conversion to ventriculoperitoneal shunt. However, it has been established that the most important prognosis factor is the involvement and damage of the white matter. CONCLUSION More evidence is required to create a standardized protocol that can ensure the best possible outcome for these patients.
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Affiliation(s)
- Paola Valdez Sandoval
- Department of Clinical Sciences, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, Avenida General Ramón Corona 2514, Guadalajara, 45138, Mexico
| | - Paola Hernández Rosales
- Department of Clinical Sciences, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, Avenida General Ramón Corona 2514, Guadalajara, 45138, Mexico
| | - Deyanira Gabriela Quiñones Hernández
- Department of Clinical Sciences, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, Avenida General Ramón Corona 2514, Guadalajara, 45138, Mexico
| | | | - Victor García Navarro
- Department of Clinical Sciences, Tecnológico de Monterrey, Escuela de Medicina y Ciencias de la Salud, Campus Guadalajara, Avenida General Ramón Corona 2514, Guadalajara, 45138, Mexico. .,Neurosurgery Department, Nuevo Hospital Civil de Guadalajara, Juan I. Menchaca, Guadalajara, 44340, Mexico.
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First clinical experience with the new noninvasive transfontanelle ICP monitoring device in management of children with premature IVH. Neurosurg Rev 2019; 43:681-685. [PMID: 31079320 DOI: 10.1007/s10143-019-01105-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2019] [Revised: 02/28/2019] [Accepted: 04/10/2019] [Indexed: 10/26/2022]
Abstract
We previously introduced a novel noninvasive technique of intracranial pressure (ICP) monitoring in children with open fontanelles. Within this study, we describe the first clinical implementation and results of this new technique in management of children with hydrocephalus caused by intraventricular hemorrhage (IVH). In neonates with posthemorrhagic hydrocephalus (PHH), an Ommaya reservoir was implanted for initial treatment of hydrocephalus. The ICP obtained noninvasively with our new device was measured before and after CSF removal and correlated to cranial ultra-sonographies. Six children with a mean age of 27.3 weeks and mean weight of 1082.3 g suffering from PHH were included in this study. We performed an overall of 30 aspirations due to ventricular enlargement. Before CSF removal, the mean ICP was 15.3 mmHg and after removal of CSF the mean ICP measured noninvasively decreased to 3.4 mmHg, p = 0.0001. The anterior horn width (AHW), which reflects early expansion of the ventricles, was before and after CSF removal 15.1 mm and 5.5 mm, respectively, p < 0.0006. There was a strong correlation between noninvasively measured ICP values and sonographically obtained AHW, r = 0.81. Ultimately, all children underwent ventriculoperitoneal shunt procedures. This is the first study providing proof for a noninvasively ICP-based approach for management of posthemorrhagic hydrocephalus in newborn children.
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Thomale UW, Cinalli G, Kulkarni AV, Al-Hakim S, Roth J, Schaumann A, Bührer C, Cavalheiro S, Sgouros S, Constantini S, Bock HC. TROPHY registry study design: a prospective, international multicenter study for the surgical treatment of posthemorrhagic hydrocephalus in neonates. Childs Nerv Syst 2019; 35:613-619. [PMID: 30726526 DOI: 10.1007/s00381-019-04077-4] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 01/27/2019] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Among children with hydrocephalus, neonates with intraventricular hemorrhage (IVH) and posthemorrhagic hydrocephalus (PH) are considered a group with one of the highest complication rates of treatment. Despite continued progress in neonatal care, a standardized and reliable guideline for surgical management is missing for this challenging condition. Thus, further research is warranted to compare common methods of surgical treatment. The introduction of neuroendoscopic lavage has precipitated the establishment of an international registry aimed at elaborating key elements of a standardized surgical treatment. METHODS The registry is designed as a multicenter, international, prospective data collection for neonates aged 41 weeks gestation, with an indication for surgical treatment for IVH with ventricular dilatation and progressive hydrocephalus. The following initial temporizing surgical interventions, each used as standard treatment at participating centers, will be compared: external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). Type of surgery, perioperative data including complications and mortality, subsequent shunt surgeries, ventricular size, and neurological outcome will be recorded at 6, 12, 36, and 60 months. RESULTS An online, password-protected website will be used to collect the prospective data in a synchronized manner. As a prospective registry, data collection will be ongoing, with no prespecified endpoint. A prespecified analysis will take place after a total of 100 patients in the NEL group have been entered. Analyses will be performed for safety (6 months), shunt dependency (12, 24 months), and neurological outcome (60 months). CONCLUSION The design and online platform of the TROPHY registry will enable the collection of prospective data on different surgical procedures for investigation of safety, efficacy, and neurodevelopmental outcome of neonates with IVH and hydrocephalus. The long-term goal is to provide valid data on NEL that is prospective, international, and multicenter. With the comparison of different surgical treatment modalities, we hope to develop better therapy guidelines for this complex neurosurgical condition.
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Affiliation(s)
- Ulrich-Wilhelm Thomale
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany.
| | - Giuseppe Cinalli
- Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Sara Al-Hakim
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Jonathan Roth
- Pediatric Neurosurgery, Dana Children's Hospital, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Andreas Schaumann
- Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Christoph Bührer
- Department of Neonatology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Spyros Sgouros
- Pediatric Neurosurgery, Mitera Children's Hospital, School of Medicine, Athens, Greece
| | - Shlomi Constantini
- Pediatric Neurosurgery, Dana Children's Hospital, Sourasky Medical Center, Tel Aviv University, Tel Aviv, Israel
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Dewan MC, Rattani A, Mekary R, Glancz LJ, Yunusa I, Baticulon RE, Fieggen G, Wellons JC, Park KB, Warf BC. Global hydrocephalus epidemiology and incidence: systematic review and meta-analysis. J Neurosurg 2019; 130:1065-1079. [PMID: 29701543 DOI: 10.3171/2017.10.jns17439] [Citation(s) in RCA: 130] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2017] [Accepted: 10/18/2017] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Hydrocephalus is one of the most common brain disorders, yet a reliable assessment of the global burden of disease is lacking. The authors sought a reliable estimate of the prevalence and annual incidence of hydrocephalus worldwide. METHODS The authors performed a systematic literature review and meta-analysis to estimate the incidence of congenital hydrocephalus by WHO region and World Bank income level using the MEDLINE/PubMed and Cochrane Database of Systematic Reviews databases. A global estimate of pediatric hydrocephalus was obtained by adding acquired forms of childhood hydrocephalus to the baseline congenital figures using neural tube defect (NTD) registry data and known proportions of posthemorrhagic and postinfectious cases. Adult forms of hydrocephalus were also examined qualitatively. RESULTS Seventy-eight articles were included from the systematic review, representative of all WHO regions and each income level. The pooled incidence of congenital hydrocephalus was highest in Africa and Latin America (145 and 316 per 100,000 births, respectively) and lowest in the United States/Canada (68 per 100,000 births) (p for interaction < 0.1). The incidence was higher in low- and middle-income countries (123 per 100,000 births; 95% CI 98-152 births) than in high-income countries (79 per 100,000 births; 95% CI 68-90 births) (p for interaction < 0.01). While likely representing an underestimate, this model predicts that each year, nearly 400,000 new cases of pediatric hydrocephalus will develop worldwide. The greatest burden of disease falls on the African, Latin American, and Southeast Asian regions, accounting for three-quarters of the total volume of new cases. The high crude birth rate, greater proportion of patients with postinfectious etiology, and higher incidence of NTDs all contribute to a case volume in low- and middle-income countries that outweighs that in high-income countries by more than 20-fold. Global estimates of adult and other forms of acquired hydrocephalus are lacking. CONCLUSIONS For the first time in a global model, the annual incidence of pediatric hydrocephalus is estimated. Low- and middle-income countries incur the greatest burden of disease, particularly those within the African and Latin American regions. Reliable incidence and burden figures for adult forms of hydrocephalus are absent in the literature and warrant specific investigation. A global effort to address hydrocephalus in regions with the greatest demand is imperative to reduce disease incidence, morbidity, mortality, and disparities of access to treatment.
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Affiliation(s)
- Michael C Dewan
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- 2Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Abbas Rattani
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- 3Meharry Medical College, School of Medicine, Nashville, Tennessee
| | - Rania Mekary
- 4Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts
- 5Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Laurence J Glancz
- 6Department of Neurosurgery, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom
| | - Ismaeel Yunusa
- 4Department of Pharmaceutical Business and Administrative Sciences, School of Pharmacy, MCPHS University, Boston, Massachusetts
- 5Department of Neurosurgery, Cushing Neurosurgical Outcomes Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Ronnie E Baticulon
- 7University of the Philippines College of Medicine-Philippine General Hospital, Manila, Philippines
| | - Graham Fieggen
- 8Departments of Surgery and Neurosurgery, University of Cape Town, South Africa
| | - John C Wellons
- 2Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Kee B Park
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
| | - Benjamin C Warf
- 1Global Neurosurgery Initiative, Program in Global Surgery and Social Change, Department of Global Health and Social Medicine, Harvard Medical School, Boston, Massachusetts
- 9Department of Neurological Surgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts; and
- 10CURE Children's Hospital of Uganda, Mbale, Uganda
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Kestle JRW, Riva-Cambrin J. Prospective multicenter studies in pediatric hydrocephalus. J Neurosurg Pediatr 2019; 23:135-141. [PMID: 30717034 DOI: 10.3171/2018.10.peds18328] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Accepted: 10/09/2018] [Indexed: 11/06/2022]
Abstract
Prospective multicenter clinical research studies in pediatric hydrocephalus are relatively rare. They cover a broad spectrum of hydrocephalus topics, including management of intraventricular hemorrhage in premature infants, shunt techniques and equipment, shunt outcomes, endoscopic treatment of hydrocephalus, and prevention and treatment of infection. The research methodologies include randomized trials, cohort studies, and registry-based studies. This review describes prospective multicenter studies in pediatric hydrocephalus since 1990. Many studies have included all forms of hydrocephalus and used device or procedure failure as the primary outcome. Although such studies have yielded useful findings, they might miss important treatment effects in specific subgroups. As multicenter study networks grow, larger patient numbers will allow studies with more focused entry criteria based on known and evolving prognostic factors. In addition, increased use of patient-centered outcomes such as neurodevelopmental assessment and quality of life should be measured and emphasized in study results. Well-planned multicenter clinical studies can significantly affect the care of children with hydrocephalus and will continue to have an important role in improving care for these children and their families.
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Affiliation(s)
- John R W Kestle
- 1Department of Neurosurgery, Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah; and
| | - Jay Riva-Cambrin
- 2Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
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Preterm neuroimaging and neurodevelopmental outcome: a focus on intraventricular hemorrhage, post-hemorrhagic hydrocephalus, and associated brain injury. J Perinatol 2018; 38:1431-1443. [PMID: 30166622 PMCID: PMC6215507 DOI: 10.1038/s41372-018-0209-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/23/2018] [Accepted: 08/06/2018] [Indexed: 12/29/2022]
Abstract
Intraventricular hemorrhage in the setting of prematurity remains the most common cause of acquired hydrocephalus. Neonates with progressive post-hemorrhagic hydrocephalus are at risk for adverse neurodevelopmental outcomes. The goal of this review is to describe the distinct and often overlapping types of brain injury in the preterm neonate, with a focus on neonatal hydrocephalus, and to connect injury on imaging to neurodevelopmental outcome risk. Head ultrasound and magnetic resonance imaging findings are described separately. The current state of the literature is imprecise and we end the review with recommendations for future radiologic and neurodevelopmental research.
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Predictors of mortality for preterm infants with intraventricular hemorrhage: a population-based study. Childs Nerv Syst 2018; 34:2203-2213. [PMID: 29987373 PMCID: PMC6326904 DOI: 10.1007/s00381-018-3897-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2018] [Accepted: 06/29/2018] [Indexed: 02/07/2023]
Abstract
PURPOSE The goal of this longitudinal, population-level study was to examine factors affecting mortality in preterm infants with intraventricular hemorrhage (IVH). METHODS The study examined patients who were born at 36 weeks estimated gestational age (EGA) or less with a diagnosis of IVH between the years 2005 and 2014 using data from the New York and Nebraska State Inpatient Databases. Potential predictors for mortality were investigated with multivariable survival analysis. RESULTS The cohort included 7437 preterm infants with IVH. All-cause inpatient mortality occurred in 746 (10.0%). The majority of deaths were in infants born at less than 25 weeks EGA (378 or 50.7%) and with birthweight less than 750 g (459 or 61.5%). Mortality was highest for children with grade IV IVH (306/848 or 36.1%), followed by grades III (203/955 or 21.3%), II (103/1328 or 7.8%), and I (134/4306 or 3.1%). Hydrocephalus was diagnosed within 6 months in 627 (8.4%) patients, with cerebrospinal fluid shunts required in 237 (3.2%). Shunts were eventually revised in 122 (51.5% of shunts), and 43 (18.1%) had infections. Multivariable Cox survival analyses found male sex (HR 1.3 [95% CI 1.1-1.5]), Asian race (HR 1.5 [1.1-2.2]), lower EGA (HR 9.9 [6.3-15.5] for < 25 weeks), higher IVH grade (HR 6.1 [4.9-7.6] for grade IV), gastrostomy (HR 4.0 [2.0-7.7]), tracheostomy (HR 3.5 [1.7-7.1]), and shunt infection (HR 3.2 [1.0-9.9]) to be independently associated with increased mortality risk. CONCLUSIONS This database is the first of its kind assembled for population-based investigations of long-term neurosurgical outcomes in preterm infants with IVH.
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An MR-based quantitative intraventricular hemorrhage porcine model for MR-guided focused ultrasound thrombolysis. Childs Nerv Syst 2018; 34:1643-1650. [PMID: 29796753 DOI: 10.1007/s00381-018-3816-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 04/25/2018] [Indexed: 10/16/2022]
Abstract
PURPOSE Intraventricular hemorrhage (IVH) affects approximately 50% of premature births where 50% further develop post-hemorrhagic ventricular dilation (PHVD). Patients face significant impact to long-term development if PHVD is not managed. Unfortunately, there is no accepted treatment to remove the thrombus caused by IVH. This paper describes an acute and chronic IVH model for use with magnetic resonance-guided focused ultrasound (MRgFUS) thrombolysis. METHODS A total of 12 pigs (~ 1 month in age) were used in the model (eight acute and four chronic). A pre-operative brain MRI was obtained for ventricular targeting. 1.25 cm3/kg of autologous blood was injected through a burr hole lateral to the midline and anterior of the coronal suture at a rate of 0.6 cm3/min. A craniotomy was performed to simulate a "fontanelle". Post-operative MRI was used to calculate the clot volume. Chronic piglets were recovered, monitored daily with a neurological scoring system (NSS), and MRI scanned for 21 days. RESULTS The clot injection was well tolerated. The average clot size was 3987 mm3 (median = 4330 mm, standard deviation = 739 mm3). Postmortem examination validated the presence of the clot. In the chronic animals, there was an increase in ventricular volume of 30%. Transient neurological impairment immediately followed clot injection and with onset of hydrocephalus in the chronic animals. CONCLUSIONS This model establishes a measurable and targetable IVH clot in an MRI-based neonatal porcine model. The progressive post-hemorrhagic ventricular dilation in the chronic model is a potential alterable outcome from MRgFUS thrombolysis.
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Gilard V, Chadie A, Ferracci FX, Brasseur-Daudruy M, Proust F, Marret S, Curey S. Post hemorrhagic hydrocephalus and neurodevelopmental outcomes in a context of neonatal intraventricular hemorrhage: an institutional experience in 122 preterm children. BMC Pediatr 2018; 18:288. [PMID: 30170570 PMCID: PMC6119335 DOI: 10.1186/s12887-018-1249-x] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2018] [Accepted: 08/08/2018] [Indexed: 11/10/2022] Open
Abstract
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.
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Affiliation(s)
- Vianney Gilard
- Neurosurgery Department, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France.
| | - Alexandra Chadie
- Paediatrics Department, Rouen University Hospital, 76000, Rouen, France
| | | | | | - François Proust
- Neurosurgery Department, Strasbourg University Hospital, 67000, Strasbourg, France
| | - Stéphane Marret
- Paediatrics Department, Rouen University Hospital, 76000, Rouen, France
| | - Sophie Curey
- Neurosurgery Department, Rouen University Hospital, 1 rue de Germont, 76000, Rouen, France
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d’Arcangues C, Schulz M, Bührer C, Thome U, Krause M, Thomale UW. Extended Experience with Neuroendoscopic Lavage for Posthemorrhagic Hydrocephalus in Neonates. World Neurosurg 2018; 116:e217-e224. [DOI: 10.1016/j.wneu.2018.04.169] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/21/2018] [Accepted: 04/23/2018] [Indexed: 11/24/2022]
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Kutty RK, Sreemathyamma SB, Korde P, Prabhakar RB, Peethambaran A, Libu GK. Outcome of Ventriculosubgaleal Shunt in the Management of Infectious and Non-infectious Hydrocephalus in Pre-term Infants. J Pediatr Neurosci 2018; 13:322-328. [PMID: 30271465 PMCID: PMC6144600 DOI: 10.4103/jpn.jpn_41_18] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Background: Hydrocephalus in premature infants is an onerous disease. In such situations, choosing the best option for cerebrospinal fluid (CSF) diversion is difficult. Ventriculosubgaleal shunt is an effective method of temporary CSF diversion in such situations. In this retrospective study, we compare the outcome of ventriculosubgaleal shunt in premature infants with hydrocephalus of infectious and noninfectious etiology. Materials and Methods: All premature children with hydrocephalus secondary to various etiologies who underwent ventriculosubgaleal shunt were studied. The participants were grouped into two depending upon the etiology of hydrocephalus: Group 1 (infectious) and Group 2 (non-infectious). The primary outcome was a successful conversion to ventriculoperitoneal shunt (VPS) and the secondary outcome was mortality. Data were entered into statistical software SPSS version 16 and appropriate statistical analysis was performed to conclude any statistical significance between groups. Results: The study included 16 infants among whom 9 were in the infectious group and 7 in the non-infectious group. Primary end point of conversion to VPS was achieved in 55.5% of patients in group 1 and 85.7% in group 2. The secondary end point, i.e., mortality was observed in 44.4% of patients in group 1 and 14.2% in group 2. The average duration during which this was achieved was 40 days (range 20–60 days) in group 1 and 25 days (range 20–30 days) in group 2. Conclusion: Ventriculosubgaleal shunt is a safe and effective procedure in infants awaiting definitive VPS for hydrocephalus of infectious as well as noninfectious origin. There was no statistical difference in the rate of successful conversion to a permanent VPS from ventriculosubgaleal shunt in hydrocephalus of either etiologies. Complications and time for successful conversion were more in postmeningitic hydrocephalus.
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Affiliation(s)
- Raja K Kutty
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | | | - Paresh Korde
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Rajmohan B Prabhakar
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Anilkumar Peethambaran
- Department of Neurosurgery, Government Medical College, Thiruvananthapuram, Kerala, India
| | - Gnanaseelan K Libu
- Department of Preventive Medicine, Government Medical College, Thiruvananthapuram, Kerala, India
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Diwakar K, Hader WJ, Soraisham A, Amin H, Tang S, Bullivant K, Kamaluddeen M, Lodha A. Long-Term Neurodevelopmental and Growth Outcomes of Premature Infants Born at <29 week Gestational Age with Post-Hemorrhagic Hydrocephalus Treated with Ventriculo-Peritoneal Shunt. Indian J Pediatr 2017; 84:662-669. [PMID: 28367615 DOI: 10.1007/s12098-017-2319-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2016] [Accepted: 02/10/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare long-term neurodevelopmental and growth (NDG) outcomes at 3 y corrected gestational age (GA) in premature infants with grade ≥ III intraventricular hemorrhage (IVH) and post-hemorrhagic hydrocephalus who were treated with ventriculo-peritoneal shunt with those who were not treated with shunt. METHODS In a retrospective cohort study, NDG outcomes were compared between preterm infants of <29 wk GA with IVH treated with shunt (IVHS) and IVH with no shunt (IVHNS). This was a single centre study. The primary outcome was moderate to severe cerebral palsy (CP). RESULTS Of 1762 preterm infants who survived to discharge, 90 had grade ≥ III IVH. Infants in IVHS group had more grade IV IVH than IVHNS (p < 0.05). Seventy percent of the patients in IVHNS groups had no hydrocephalus. IVHS group had increased CP (76% vs. 30%; p 0.003), and higher odds of CP after controlling for GA and IVH grade [odds ratio (OR); 4.23 (1.38 to 13.00)]. Growth delay was not different between groups. CONCLUSIONS Infants with IVHS are at increased risk of CP but not growth delay.
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Affiliation(s)
- K Diwakar
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Walter J Hader
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
- Section of Pediatric Neurosurgery, Department of Surgery, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Calgary, Alberta, Canada
| | - A Soraisham
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Calgary, Alberta, Canada
| | - Harish Amin
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Calgary, Alberta, Canada
| | - Selphee Tang
- Alberta Health Services, Calgary, Alberta, Canada
| | - Kelly Bullivant
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Calgary, Alberta, Canada
| | - Majeeda Kamaluddeen
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Calgary, Alberta, Canada
| | - Abhay Lodha
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada.
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.
- Alberta Children's Hospital, University of Calgary, Calgary, Alberta, Canada.
- Alberta Health Services, Calgary, Alberta, Canada.
- Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada.
- Department of Pediatrics, Cumming School of Medicine, Foothills Medical Centre, C211-1403 29 St NW, Calgary, AB,, T2N2T9, Canada.
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Melo JRT, Passos RK, Carvalho MLCMD. Cerebrospinal fluid drainage options for posthemorrhagic hydrocephalus in premature neonates. ARQUIVOS DE NEURO-PSIQUIATRIA 2017; 75:433-438. [PMID: 28746429 DOI: 10.1590/0004-282x20170060] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/20/2016] [Accepted: 03/14/2017] [Indexed: 11/22/2022]
Abstract
Objective The literature describes various cerebrospinal fluid (CSF) drainage techniques to alleviate posthemorrhagic hydrocephalus in preterm newborns; however, consensus has not been reached. The scope of this study was describing a case series of premature neonates with posthemorrhagic hydrocephalus and assessing the outcomes of different approaches used for CSF diversion. Methods A consecutive review of the medical records of neonates with posthemorrhagic hydrocephalus treated with CSF drainage was conducted. Results Forty premature neonates were included. Serial lumbar puncture, ventriculosubgaleal shunt, and ventriculoperitoneal shunt were the treatments of choice in 25%, 37.5% and 37.5% of the cases, respectively. Conclusion Cerebrospinal fluid diversion should be tailored to each case with preference given to temporary CSF drainage in neonates with lower age and lower birth-weight, while the permanent ventriculoperitoneal shunt should be considered in healthier, higher birth-weight neonates born closer to term.
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Affiliation(s)
- José Roberto Tude Melo
- Hospital Pediátrico Martagão Gesteira, Unidade de Neurocirurgia Pediátrica, Salvador BA, Brasil
| | - Rosane Klein Passos
- Hospital Pediátrico Martagão Gesteira, Unidade de Radiologia, Salvador BA, Brasil
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Wellons JC, Shannon CN, Holubkov R, Riva-Cambrin J, Kulkarni AV, Limbrick DD, Whitehead W, Browd S, Rozzelle C, Simon TD, Tamber MS, Oakes WJ, Drake J, Luerssen TG, Kestle J. Shunting outcomes in posthemorrhagic hydrocephalus: results of a Hydrocephalus Clinical Research Network prospective cohort study. J Neurosurg Pediatr 2017; 20:19-29. [PMID: 28452657 DOI: 10.3171/2017.1.peds16496] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Previous Hydrocephalus Clinical Research Network (HCRN) retrospective studies have shown a 15% difference in rates of conversion to permanent shunts with the use of ventriculosubgaleal shunts (VSGSs) versus ventricular reservoirs (VRs) as temporization procedures in the treatment of hydrocephalus due to high-grade intraventricular hemorrhage (IVH) of prematurity. Further research in the same study line revealed a strong influence of center-specific decision-making on shunt outcomes. The primary goal of this prospective study was to standardize decision-making across centers to determine true procedural superiority, if any, of VSGS versus VR as a temporization procedure in high-grade IVH of prematurity. METHODS The HCRN conducted a prospective cohort study across 6 centers with an approximate 1.5- to 3-year accrual period (depending on center) followed by 6 months of follow-up. Infants with premature birth, who weighed less than 1500 g, had Grade 3 or 4 IVH of prematurity, and had more than 72 hours of life expectancy were included in the study. Based on a priori consensus, decisions were standardized regarding the timing of initial surgical treatment, upfront shunt versus temporization procedure (VR or VSGS), and when to convert a VR or VSGS to a permanent shunt. Physical examination assessment and surgical technique were also standardized. The primary outcome was the proportion of infants who underwent conversion to a permanent shunt. The major secondary outcomes of interest included infection and other complication rates. RESULTS One hundred forty-five premature infants were enrolled and met criteria for analysis. Using the standardized decision rubrics, 28 infants never reached the threshold for treatment, 11 initially received permanent shunts, 4 were initially treated with endoscopic third ventriculostomy (ETV), and 102 underwent a temporization procedure (36 with VSGSs and 66 with VRs). The 2 temporization cohorts were similar in terms of sex, race, IVH grade, head (orbitofrontal) circumference, and ventricular size at temporization. There were statistically significant differences noted between groups in gestational age, birth weight, and bilaterality of clot burden that were controlled for in post hoc analysis. By Kaplan-Meier analysis, the 180-day rates of conversion to permanent shunts were 63.5% for VSGS and 74.0% for VR (p = 0.36, log-rank test). The infection rate for VSGS was 14% (5/36) and for VR was 17% (11/66; p = 0.71). The overall compliance rate with the standardized decision rubrics was noted to be 90% for all surgeons. CONCLUSIONS A standardized protocol was instituted across all centers of the HCRN. Compliance was high. Choice of temporization techniques in premature infants with IVH does not appear to influence rates of conversion to permanent ventricular CSF diversion. Once management decisions and surgical techniques are standardized across HCRN sites, thus minimizing center effect, the observed difference in conversion rates between VSGSs and VRs is mitigated.
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Affiliation(s)
- John C Wellons
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard Holubkov
- Data Coordinating Center, University of Utah, Salt Lake City, Utah
| | - Jay Riva-Cambrin
- Division of Neurosurgery, University of Calgary, Alberta, Canada
| | | | - David D Limbrick
- Department of Neurosurgery, Washington University St. Louis, Missouri
| | - William Whitehead
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Samuel Browd
- Department of Neurosurgery, University of Washington Medical Center, Seattle, Washington
| | - Curtis Rozzelle
- Department of Neurosurgery, University of Alabama-Birmingham, Alabama
| | - Tamara D Simon
- Department of Pediatrics, University of Washington Medical Center, Seattle, Washington
| | - Mandeep S Tamber
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - W Jerry Oakes
- Department of Neurosurgery, University of Alabama-Birmingham, Alabama
| | - James Drake
- Department of Neurosurgery, University of Toronto, Ontario, Canada
| | - Thomas G Luerssen
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - John Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Kumar N, Al-Faiadh W, Tailor J, Mallucci C, Chandler C, Bassi S, Pettorini B, Zebian B. Neonatal post-haemorrhagic hydrocephalus in the UK: a survey of current practice. Br J Neurosurg 2016; 31:307-311. [PMID: 27687144 DOI: 10.1080/02688697.2016.1226260] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Naveen Kumar
- Faculty of Medicine, King’s College London, London, UK
| | | | - Jignesh Tailor
- Department of Neurosurgery, King’s College Hospital, Denmark Hill, London, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children’s Hospital, Eaton Road, West Derby, Liverpool, UK
| | - Chris Chandler
- Department of Neurosurgery, King’s College Hospital, Denmark Hill, London, UK
| | - Sanj Bassi
- Department of Neurosurgery, King’s College Hospital, Denmark Hill, London, UK
| | - Benedetta Pettorini
- Department of Neurosurgery, Alder Hey Children’s Hospital, Eaton Road, West Derby, Liverpool, UK
| | - Bassel Zebian
- Department of Neurosurgery, King’s College Hospital, Denmark Hill, London, UK
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Management of post-haemorrhagic hydrocephalus in premature infants. J Clin Neurosci 2016; 31:30-4. [DOI: 10.1016/j.jocn.2016.02.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2016] [Accepted: 02/29/2016] [Indexed: 11/23/2022]
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Christian EA, Melamed EF, Peck E, Krieger MD, McComb JG. Surgical management of hydrocephalus secondary to intraventricular hemorrhage in the preterm infant. J Neurosurg Pediatr 2016; 17:278-84. [PMID: 26565942 DOI: 10.3171/2015.6.peds15132] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Posthemorrhagic hydrocephalus (PHH) in the preterm infant remains a major neurological complication of prematurity. The authors first described insertion of a specially designed low-profile subcutaneous ventricular catheter reservoir for temporary management of hydrocephalus in 1983. This report presents the follow-up experience with the surgical management of PHH in this population and describes outcomes both in infants who were stable for permanent shunt insertion and those initially temporized with a ventricular reservoir (VR) prior to permanent ventriculoperitoneal (VP)/ventriculoatrial (VA) shunt placement. METHODS A retrospective review was undertaken of the medical records of all premature infants surgically treated for posthemorrhagic hydrocephalus (PHH) between 1997 and 2012 at Children's Hospital Los Angeles. RESULTS Over 14 years, 91 preterm infants with PHH were identified. Fifty neonates received temporizing measures via a VR that was serially tapped for varying time periods. For the remaining 41 premature infants, VP/VA shunt placement was the first procedure. Patients with a temporizing measure as their initial procedure had undergone CSF diversion significantly earlier in life than those who had permanent shunting as the initial procedure (29 vs 56 days after birth, p < 0.01). Of the infants with a VR as their initial procedure, 5/50 (10%) did not undergo subsequent VP/VA shunt placement. The number of shunt revisions and the rates of loculated hydrocephalus and shunt infection did not statistically differ between the 2 groups. CONCLUSIONS Patients with initial VR insertion as a temporizing measure received a CSF diversion procedure significantly earlier than those who received a permanent shunt as their initial procedure. Otherwise, the outcomes with regard to shunt revisions, loculated hydrocephalus, and shunt infection were not different for the 2 groups.
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Affiliation(s)
- Eisha A Christian
- Department of Neurosurgery, Keck School of Medicine, University of Southern California; and
| | - Edward F Melamed
- Division of Neurosurgery, Children's Hospital, Los Angeles, California
| | - Edwin Peck
- Department of Neurosurgery, Keck School of Medicine, University of Southern California; and
| | - Mark D Krieger
- Department of Neurosurgery, Keck School of Medicine, University of Southern California; and.,Division of Neurosurgery, Children's Hospital, Los Angeles, California
| | - J Gordon McComb
- Department of Neurosurgery, Keck School of Medicine, University of Southern California; and.,Division of Neurosurgery, Children's Hospital, Los Angeles, California
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Fountain DM, Chari A, Allen D, James G. Comparison of the use of ventricular access devices and ventriculosubgaleal shunts in posthaemorrhagic hydrocephalus: systematic review and meta-analysis. Childs Nerv Syst 2016; 32:259-67. [PMID: 26560885 PMCID: PMC4749661 DOI: 10.1007/s00381-015-2951-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 10/29/2015] [Indexed: 11/27/2022]
Abstract
INTRODUCTION Ventricular access devices (VAD) and ventriculosubgaleal shunts (VSGS) are currently both used as temporising devices to affect CSF drainage in neonatal posthaemorrhagic hydrocephalus (PHH), without clear evidence of superiority of either procedure. In this systematic review and meta-analysis, we compared the VSGS and VAD regarding complication rates, ventriculoperitoneal shunt conversion and infection rates, and mortality and long-term disability. METHODS The review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42015019750) and was conducted in accordance with PRISMA guidelines. RESULTS AND CONCLUSIONS The literature search of five databases identified 338 publications, of which 5 met the inclusion criteria. All were retrospective cohort studies (evidence class 3b and 4). A significantly lower proportion of patients with a VSGS required CSF tapping compared to patients with a VAD (log OR -4.43, 95% CI -6.14 to -2.72). No other significant differences between the VAD and VSGS were identified in their rates of infection (log OR 0.03, 95% CI -0.77 to 0.84), obstruction (log OR 1.25, 95% CI -0.21 to 2.71), ventriculoperitoneal shunt dependence (log OR -0.06, 95% CI -0.93 to 0.82), subsequent shunt infection (log OR 0.23, 95% CI -0.61 to 1.06), mortality (log OR 0.37, 95% CI -0.95 to 1.70) or long-term disability (p = 0.9). In all studies, there was a lack of standardised criteria, variations between surgeons in heterogeneous cohorts of limited sample size and a lack of neurodevelopmental follow-up. This affirms the importance of an ongoing multicentre, prospective pilot study comparing these two temporising procedures to enable a more robust comparison.
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Affiliation(s)
| | - Aswin Chari
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, London, UK.
- Division of Brain Sciences, Faculty of Medicine, Imperial College London, 5th Floor, Burlington Danes Building, Du Cane Road, London, W12 0NN, UK.
| | - Dominic Allen
- School of Medicine, Imperial College London, London, UK
| | - Greg James
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK
- Developmental Neurosciences Programme, Institute of Child Health, University College London, London, UK
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Badhiwala JH, Hong CJ, Nassiri F, Hong BY, Riva-Cambrin J, Kulkarni AV. Treatment of posthemorrhagic ventricular dilation in preterm infants: a systematic review and meta-analysis of outcomes and complications. J Neurosurg Pediatr 2015; 16:545-555. [PMID: 26314206 DOI: 10.3171/2015.3.peds14630] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Jetan H Badhiwala
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto
| | - Chris J Hong
- Faculty of Medicine, University of Ottawa, Ontario, Canada; and
| | - Farshad Nassiri
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto
| | - Brian Y Hong
- Faculty of Medicine, University of Ottawa, Ontario, Canada; and
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto
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Wang JY, Jackson EM, Jallo GI, Ahn ES. Shunt revision requirements after posthemorrhagic hydrocephalus of prematurity: insight into the time course of shunt dependency. Childs Nerv Syst 2015; 31:2123-30. [PMID: 26248674 DOI: 10.1007/s00381-015-2865-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2015] [Accepted: 07/29/2015] [Indexed: 11/26/2022]
Abstract
PURPOSE Intraventricular hemorrhage (IVH) is a common affliction of preterm infants and often results in posthemorrhagic hydrocephalus (PHH). These patients typically eventually require permanent CSF diversion and are presumed to be indefinitely shunt-dependent. To date, however, there has been no study of long-term shunt revision requirements in patients with PHH. METHODS We analyzed retrospectively collected data for 89 preterm patients diagnosed with grades III and IV IVH and PHH at our institution from 1998 to 2011. RESULTS Sixty-nine out of 89 patients (77.5%) underwent ventriculoperitoneal (VP) shunt placement, and 33 (47.8%) required at least one shunt revision and 18 (26.1%) required multiple revisions. The mean ± standard deviation follow-up time for shunted patients was 5.0 ± 3.3 years. The majority of early failures were due to proximal catheter malfunction, while later failures were mostly due to distal catheter problems. There was a significant difference in the number of patients requiring revisions in the first 3 years following initial VP shunt insertion compared after 3 years, with 28 revisions versus 10 (p < 0.004). In 8 out of 10 patients who underwent shunt revisions after 3 years, evidence of obstructive hydrocephalus was found on imaging either in the form of an isolated fourth ventricular cyst or aqueductal stenosis. CONCLUSIONS Our results suggest that in a distinct subset of patients with PHH, obstructive hydrocephalus may develop, resulting in long-term dependence on CSF diversion. Further study on the factors associated with long-term shunt dependence and revision requirements within the PHH group is warranted.
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Affiliation(s)
- Joanna Y Wang
- Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 560A, Baltimore, MD, 21287, USA
| | - Eric M Jackson
- Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 560A, Baltimore, MD, 21287, USA
| | - George I Jallo
- Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 560A, Baltimore, MD, 21287, USA
| | - Edward S Ahn
- Division of Pediatric Neurosurgery, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 560A, Baltimore, MD, 21287, USA.
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Bowers C, Taussky P, Kestle JR, Park MS. A Neurosurgical Call to Arms: Lessons from ARUBA, Mr. Clean, and the Hydrocephalus Clinical Research Network. World Neurosurg 2015; 84:202-4. [DOI: 10.1016/j.wneu.2015.06.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Norooz F, Urlesberger B, Giordano V, Klebermasz-Schrehof K, Weninger M, Berger A, Olischar M. Decompressing posthaemorrhagic ventricular dilatation significantly improves regional cerebral oxygen saturation in preterm infants. Acta Paediatr 2015; 104:663-9. [PMID: 25619108 DOI: 10.1111/apa.12942] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 09/25/2014] [Accepted: 01/14/2015] [Indexed: 11/27/2022]
Abstract
AIM This study aimed to delineate the impact of posthaemorrhagic ventricular dilatation (PHVD) on regional cerebral oxygen saturation (rcSO2) in preterm infants before and after ventricular decompression using near-infrared spectroscopy (NIRS). METHODS rcSO2 values were recorded, fractional tissue oxygen extraction (FTOE) was calculated, cerebral ultrasound scans were performed, and resistive indices and ventricular width were collected before and after decompression. Where possible, amplitude-integrated electroencephalography (aEEG) and visual evoked potentials (VEPs) were recorded before and after decompression. RESULTS We included nine preterm infants: nine with cranial ultrasound scan data, eight with NIRS data, seven with aEEG data and four with VEPs. The resistive index was stable and remained unchanged after decompression in all patients. Before decompression, the mean rcSO2 value was 42.6 ± 12.9% and increased to 55 ± 12.2% after decompression. With increasing ventricular width, FTOE showed a mean value of 0.51 ± 0.05 and decreased to a mean of 0.39 ± 0.12 after decompression. Amplitude-integrated electroencephalography showed a more continuous pattern, and VEPs showed delayed latencies in all patients before intervention, improving afterwards. CONCLUSION Near-infrared spectroscopy may be of additional clinical value in progressive PHVD to determine the optimal time point for ventricular decompression.
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Affiliation(s)
- F Norooz
- Division of Neonatology, Intensive Care and Neuropediatrics; Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - B Urlesberger
- Division of Neonatology; Department of Pediatrics and Adolescent Medicine; Medical University of Graz; Graz Austria
| | - V Giordano
- Division of Neonatology, Intensive Care and Neuropediatrics; Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - K Klebermasz-Schrehof
- Division of Neonatology, Intensive Care and Neuropediatrics; Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - M Weninger
- Division of Neonatology, Intensive Care and Neuropediatrics; Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - A Berger
- Division of Neonatology, Intensive Care and Neuropediatrics; Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
| | - M Olischar
- Division of Neonatology, Intensive Care and Neuropediatrics; Department of Pediatrics and Adolescent Medicine; Medical University of Vienna; Vienna Austria
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Morales DM, Holubkov R, Inder TE, Ahn HC, Mercer D, Rao R, McAllister JP, Holtzman DM, Limbrick DD. Cerebrospinal fluid levels of amyloid precursor protein are associated with ventricular size in post-hemorrhagic hydrocephalus of prematurity. PLoS One 2015; 10:e0115045. [PMID: 25738507 PMCID: PMC4349693 DOI: 10.1371/journal.pone.0115045] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2014] [Accepted: 11/18/2014] [Indexed: 02/03/2023] Open
Abstract
Background Neurological outcomes of preterm infants with post-hemorrhagic hydrocephalus (PHH) remain among the worst in infancy, yet there remain few instruments to inform the treatment of PHH. We previously observed PHH-associated elevations in cerebrospinal fluid (CSF) amyloid precursor protein (APP), neural cell adhesion molecule-L1 (L1CAM), neural cell adhesion molecule-1 (NCAM-1), and other protein mediators of neurodevelopment. Objective The objective of this study was to examine the association of CSF APP, L1CAM, and NCAM-1 with ventricular size as an early step toward developing CSF markers of PHH. Methods CSF levels of APP, L1CAM, NCAM-1, and total protein (TP) were measured in 12 preterm infants undergoing PHH treatment. Ventricular size was determined using cranial ultrasounds. The relationships between CSF APP, L1CAM, and NCAM-1, occipitofrontal circumference (OFC), volume of CSF removed, and ventricular size were examined using correlation and regression analyses. Results CSF levels of APP, L1CAM, and NCAM-1 but not TP paralleled treatment-related changes in ventricular size. CSF APP demonstrated the strongest association with ventricular size, estimated by frontal-occipital horn ratio (FOR) (Pearson R = 0.76, p = 0.004), followed by NCAM-1 (R = 0.66, p = 0.02) and L1CAM (R = 0.57,p = 0.055). TP was not correlated with FOR (R = 0.02, p = 0.95). Conclusions Herein, we report the novel observation that CSF APP shows a robust association with ventricular size in preterm infants treated for PHH. The results from this study suggest that CSF APP and related proteins at once hold promise as biomarkers of PHH and provide insight into the neurological consequences of PHH in the preterm infant.
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Affiliation(s)
- Diego M. Morales
- Department of Neurological Surgery, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
- * E-mail:
| | - Richard Holubkov
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, Utah, United States of America
| | - Terri E. Inder
- Department of Pediatrics, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
| | - Haejun C. Ahn
- Department of Neurological Surgery, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
| | - Deanna Mercer
- Department of Neurological Surgery, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
| | - Rakesh Rao
- Department of Newborn Medicine, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
| | - James P. McAllister
- Department of Neurological Surgery, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
| | - David M. Holtzman
- Department of Neurology, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
- The Hope Center for Neurological Disorders, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
| | - David D. Limbrick
- Department of Neurological Surgery, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
- Department of Pediatrics, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
- The Hope Center for Neurological Disorders, Washington University in St. Louis, School of Medicine, Saint Louis, Missouri, United States of America
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Spader HS, Hertzler DA, Kestle JRW, Riva-Cambrin J. Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants. J Neurosurg Pediatr 2015; 15:156-60. [PMID: 25479576 DOI: 10.3171/2014.9.peds14215] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- Heather S Spader
- Department of Neurosurgery, Rhode Island Hospital, Brown University, Providence, Rhode Island
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Tröbs RB, Sander V. Posthemorrhagic hydrocephalus in extremely low birth weight infants: Ommaya reservoir vs. ventriculoperitoneal shunt. Childs Nerv Syst 2015; 31:1261-6. [PMID: 26018211 PMCID: PMC4513217 DOI: 10.1007/s00381-015-2754-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2014] [Accepted: 05/18/2015] [Indexed: 12/02/2022]
Abstract
PURPOSE The aim of this study was to analyze morbidity and initial surgery in infants with posthemorrhagic hydrocephalus (PHH) by comparing infants who were treated with a subcutaneous cerebrospinal fluid reservoir (Ommaya reservoir = CSF_R) with infants who primarily received a ventriculoperitoneal shunt (VPS). METHOD Inclusion criteria were infants born between January 2006 and June 2014 who had a diagnosis of intraventricular hemorrhage (IVH) and underwent surgical intervention for hydrocephalus. RESULTS Twenty-five infants, with a median gestational age (GA) of 26.5 (28 ± 4) weeks and a median birth weight (BW) of 980 g (1205 ± 837), were included. The median umbilical artery pH (UApH) was 7.30 (7.20 ± 0.25). The median Apgar score at 10 min was 8 (7.4 ± 2). Twenty-five peri- and postnatal adverse events were encountered preoperatively. The IVH grades were grade II (n = 1), grade III (n = 17), grade IV (n = 6), and unknown grade (n = 1). Primary treatment consisted of CSF_R (n = 18) or VPS (n = 7) placement. There was a statistically significant difference between the postnatal ages of infants with CSF_R (32.5 days; 42 ± 28) and infants with VPS (163 days; 161 ± 18). Furthermore, we found a difference regarding GA but not BW between both groups. Arrest of PHH with shunt independence occurred in two infants from the CSF_R group (11%). CONCLUSIONS In the present study, early insertion of CSF_R allowed stabilization of the infants and thus postponement of permanent VPS insertion. However, in a subgroup of patients, PHH develops over a more prolonged course, and VPS insertion can be performed initially without the need for CSF_R.
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Affiliation(s)
- Ralf-Bodo Tröbs
- Klinik für Kinderchirurgie, Marienhospital Herne, St. Elisabeth Gruppe Rhein-Ruhr, Ruhr-Universität Bochum, Widumer Str. 8, D-44627 Herne, Germany
| | - Volker Sander
- Klinik für Kinderchirurgie, Marienhospital Herne, St. Elisabeth Gruppe Rhein-Ruhr, Ruhr-Universität Bochum, Widumer Str. 8, D-44627 Herne, Germany
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Wang JY, Amin AG, Jallo GI, Ahn ES. Ventricular reservoir versus ventriculosubgaleal shunt for posthemorrhagic hydrocephalus in preterm infants: infection risks and ventriculoperitoneal shunt rate. J Neurosurg Pediatr 2014; 14:447-54. [PMID: 25148212 DOI: 10.3171/2014.7.peds13552] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The most common neurosurgical condition observed in preterm infants is intraventricular hemorrhage (IVH), which often results in posthemorrhagic hydrocephalus (PHH). These conditions portend an unfavorable prognosis; therefore, the potential for poor neurodevelopmental outcomes necessitates a better understanding of the comparative effectiveness of 2 temporary devices commonly used before the permanent insertion of a ventriculoperitoneal (VP) shunt: the ventricular reservoir and the ventriculosubgaleal shunt (VSGS). METHODS The authors analyzed retrospectively collected information for 90 patients with IVH and PHH who were treated with insertion of a ventricular reservoir (n = 44) or VSGS (n = 46) at their institution over a 14-year period. RESULTS The mean gestational age and weight at device insertion were lower for VSGS patients (30.1 ± 1.9 weeks, 1.12 ± 0.31 kg) than for reservoir patients (31.8 ± 2.9 weeks, 1.33 ± 0.37 kg; p = 0.002 and p = 0.004, respectively). Ventricular reservoir insertion was predictive of more CSF taps prior to VP shunt placement compared with VSGS placement (10 ± 8.7 taps vs 1.6 ± 1.7 taps, p < 0.001). VSGS patients experienced a longer time interval prior to VP shunt placement than reservoir patients (80.8 ± 67.5 days vs 48.8 ± 26.4 days, p = 0.012), which corresponded to VSGS patients gaining more weight by the time of shunt placement than reservoir patients (3.31 ± 2.0 kg vs 2.42 ± 0.63 kg, p = 0.016). Reservoir patients demonstrated a trend toward more positive CSF cultures compared with VSGS patients (n = 9 [20.5%] vs n = 5 [10.9%], p = 0.21). There were no significant differences in the rates of overt device infection requiring removal (reservoir, 6.8%; VSGS, 6.5%), VP shunt insertion (reservoir, 77.3%; VSGS, 76.1%), or early VP shunt infection (reservoir, 11.4%; VSGS, 13.0%) between the 2 cohorts. CONCLUSIONS Although the rates of VP shunt requirement and device infection were similar between patients treated with the reservoir versus the VSGS, VSGS patients were significantly older and had achieved greater weights at the time of VP shunt insertion. The authors' results suggest that the VSGS requires less labor-intensive management by ventricular tapping; the VSGS patients also attained higher weights and more optimal surgical candidacy at the time of VP shunt insertion. The potential differences in long-term developmental and neurological outcomes between VSGS and reservoir placement warrant further study.
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Affiliation(s)
- Joanna Y Wang
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland; and
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Piatt JH, Freibott CE. Quality measurement in the shunt treatment of hydrocephalus: analysis and risk adjustment of the Revision Quotient. J Neurosurg Pediatr 2014; 14:48-54. [PMID: 24766308 DOI: 10.3171/2014.3.peds13618] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
UNLABELLED OBJECT.: The Revision Quotient (RQ) has been defined as the ratio of the number of CSF shunt revisions to the number of new shunt insertions for a particular neurosurgical practice in a unit of time. The RQ has been proposed as a quality measure in the treatment of childhood hydrocephalus. The authors examined the construct validity of the RQ and explored the feasibility of risk stratification under this metric. METHODS The Kids' Inpatient Database for 1997, 2000, 2003, 2006, and 2009 was queried for admissions with diagnostic codes for hydrocephalus and procedural codes for CSF shunt insertion or revision. Revision quotients were calculated for hospitals that performed 12 or more shunt insertions annually. The univariate associations of hospital RQs with a variety of institutional descriptors were analyzed, and a generalized linear model of the RQ was constructed. RESULTS There were 12,244 admissions (34%) during which new shunts were inserted, and there were 23,349 admissions (66%) for shunt revision. Three hundred thirty-four annual RQs were calculated for 152 different hospitals. Analysis of variance in hospital RQs over the 5 years of study data supports the construct validity of the metric. The following factors were incorporated into a generalized linear model that accounted for 41% of the variance of the measured RQs: degree of pediatric specialization, proportion of initial case mix in the infant age group, and proportion with neoplastic hydrocephalus. CONCLUSIONS The RQ has construct validity. Risk adjustment is feasible, but the risk factors that were identified relate predominantly to patterns of patient flow through the health care system. Possible advantages of an alternative metric, the Surgical Activity Ratio, are discussed.
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Affiliation(s)
- Joseph H Piatt
- Nemours Neuroscience Center, A I duPont Hospital for Children, Wilmington, Delaware
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Simon TD, Butler J, Whitlock KB, Browd SR, Holubkov R, Kestle JR, Kulkarni AV, Langley M, Limbrick DD, Mayer-Hamblett N, Tamber M, Wellons JC, Whitehead WE, Riva-Cambrin J. Risk factors for first cerebrospinal fluid shunt infection: findings from a multi-center prospective cohort study. J Pediatr 2014; 164:1462-8.e2. [PMID: 24661340 PMCID: PMC4035376 DOI: 10.1016/j.jpeds.2014.02.013] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2013] [Revised: 12/04/2013] [Accepted: 02/04/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To quantify the extent to which cerebrospinal fluid (CSF) shunt revisions are associated with increased risk of CSF shunt infection, after adjusting for patient factors that may contribute to infection risk. STUDY DESIGN We used the Hydrocephalus Clinical Research Network registry to assemble a large prospective 6-center cohort of 1036 children undergoing initial CSF shunt placement between April 2008 and January 2012. The primary outcome of interest was first CSF shunt infection. Data for initial CSF shunt placement and all subsequent CSF shunt revisions prior to first CSF shunt infection, where applicable, were obtained. The risk of first infection was estimated using a multivariable Cox proportional hazard model accounting for patient characteristics and CSF shunt revisions, and is reported using hazard ratios (HRs) with 95% CI. RESULTS Of the 102 children who developed first infection within 12 months of placement, 33 (32%) followed one or more CSF shunt revisions. Baseline factors independently associated with risk of first infection included: gastrostomy tube (HR 2.0, 95% CI, 1.1, 3.3), age 6-12 months (HR 0.3, 95% CI, 0.1, 0.8), and prior neurosurgery (HR 0.4, 95% CI, 0.2, 0.9). After controlling for baseline factors, infection risk was most significantly associated with the need for revision (1 revision vs none, HR 3.9, 95% CI, 2.2, 6.5; ≥2 revisions, HR 13.0, 95% CI, 6.5, 24.9). CONCLUSIONS This study quantifies the elevated risk of infection associated with shunt revisions observed in clinical practice. To reduce risk of infection risk, further work should optimize revision procedures.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/ Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Jerry Butler
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Kathryn B. Whitlock
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Samuel R. Browd
- Department of Neurosurgery, University of Washington/ Seattle Children’s Hospital, Seattle, Washington
| | - Richard Holubkov
- Department of Neurosurgery, University of Washington/ Seattle Children’s Hospital, Seattle, Washington
| | - John R.W. Kestle
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Abhaya V. Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - David D. Limbrick
- Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in Saint Louis, St. Louis, Missouri
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/ Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Mandeep Tamber
- Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - John C. Wellons
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama (during this work, currently at Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee)
| | - William E. Whitehead
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Schulz M, Bührer C, Pohl-Schickinger A, Haberl H, Thomale UW. Neuroendoscopic lavage for the treatment of intraventricular hemorrhage and hydrocephalus in neonates. J Neurosurg Pediatr 2014; 13:626-35. [PMID: 24702621 DOI: 10.3171/2014.2.peds13397] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Chamiraju P, Bhatia S, Sandberg DI, Ragheb J. Endoscopic third ventriculostomy and choroid plexus cauterization in posthemorrhagic hydrocephalus of prematurity. J Neurosurg Pediatr 2014; 13:433-9. [PMID: 24527862 DOI: 10.3171/2013.12.peds13219] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The aim of this study was to determine the role of endoscopic third ventriculostomy and choroid plexus cauterization (ETV/CPC) in the management of posthemorrhagic hydrocephalus of prematurity (PHHP) and to analyze which factors affect patient outcomes. METHODS This study retrospectively reviewed medical records of 27 premature infants with intraventricular hemorrhage (IVH) and hydrocephalus treated with ETV and CPC from 2008 to 2011. All patients were evaluated using MRI before the procedure to verify the anatomical feasibility of ETV/CPC. Endoscopic treatment included third ventriculostomy, septostomy, and bilateral CPC. After ETV/CPC, all patients underwent follow-up for a period of 6-40 months (mean 16.2 months). The procedure was considered a failure if the patient subsequently required a shunt. The following factors were analyzed to determine a relationship to patient outcomes: gestational age at birth, corrected age and weight at surgery, timing of surgery after birth, grade of IVH, the status of the prepontine cistern and cerebral aqueduct on MRI, need for a ventricular access device prior to the endoscopic procedure, and scarring of the prepontine cistern noted at surgery. RESULTS Seventeen (63%) of 27 patients required a shunt after ETV/CPC, and 10 patients did not require further CSF diversion. Several factors studied were associated with a higher rate of ETV/CPC failure: Grade IV hemorrhage, weight 3 kg or less and age younger than 3 months at the time of surgery, need for reservoir placement, and presence of a normal cerebral aqueduct. Two factors were found to be statistically significant: the patient's corrected gestational age of less than 0 weeks at surgery and a narrow prepontine cistern on MRI. The majority (83%) of ETV/CPC failures occurred in the first 3 months after the procedure. None of the patients had a complication directly related to the procedure. CONCLUSIONS Endoscopic third ventriculostomy/CPC is a safe initial procedure for hydrocephalus in premature infants with IVH and hydrocephalus, obviating the need for a shunt in selected patients. Even though the success rate is low (37%), the lower rate of complications in comparison with shunt treatment may justify this procedure in the initial management of hydrocephalus. As several of the studied factors have shown influence on the outcome, patient selection based on these observations might increase the success rate.
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Affiliation(s)
- Parthasarathi Chamiraju
- Division of Pediatric Neurosurgery, University of Miami Miller School of Medicine and Miami Children's Hospital, Miami, Florida; and
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Romero L, Ros B, Ríus F, González L, Medina JM, Martín A, Carrasco A, Arráez MA. Ventriculoperitoneal shunt as a primary neurosurgical procedure in newborn posthemorrhagic hydrocephalus: report of a series of 47 shunted patients. Childs Nerv Syst 2014; 30:91-7. [PMID: 23881422 DOI: 10.1007/s00381-013-2177-6] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2013] [Accepted: 05/20/2013] [Indexed: 11/30/2022]
Abstract
PURPOSE Intraventricular hemorrhage is the most common cause of infantile acquired hydrocephalus. Our objective is to determine if the implantation of ventriculoperitoneal shunt in posthemorrhagic hydrocephalus as a primary and definitive neurosurgical treatment, with no previous temporary procedures, would decrease complication rates with good functional outcomes. METHODS Two hundred seventy-one patients with germinal matrix hemorrhage were diagnosed at the Carlos Haya Hospital between 2003 and 2010. Forty-seven patients underwent ventriculoperitoneal shunt after developing symptomatic hydrocephalus. The minimum weight required for shunt implantation was 1,500 g. We recorded complications related to the surgical procedure and analyzed functional state with a self-developed four-grade scale. RESULTS One hundred thirty-nine (51.3 %) patients with intraventricular hemorrhage developed ventricular dilatation, but only 47 patients (17.34 %) needed shunting. In seven cases, temporary neurosurgical procedures were performed, but in all of them, this was followed by ventriculoperitoneal shunt implantation. The infection rate was 4.25 %, and shunt obstruction rate was 4.25 %. More than 80 % of patients were classified as good or excellent functional state. Mean follow-up period was 38.75 months (SD, 27.09; range, 1-102 months). CONCLUSIONS Ventriculoperitoneal shunting as a primary neurosurgical treatment in posthemorrhagic hydrocephalus would decrease surgical morbidity with good functional outcome.
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Affiliation(s)
- L Romero
- Department of Neurosurgery, HRU Carlos Haya, Málaga, Spain,
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Kulkarni AV, Riva-Cambrin J, Butler J, Browd SR, Drake JM, Holubkov R, Kestle JRW, Limbrick DD, Simon TD, Tamber MS, Wellons JC, Whitehead WE. Outcomes of CSF shunting in children: comparison of Hydrocephalus Clinical Research Network cohort with historical controls: clinical article. J Neurosurg Pediatr 2013; 12:334-8. [PMID: 23909616 DOI: 10.3171/2013.7.peds12637] [Citation(s) in RCA: 102] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The Hydrocephalus Clinical Research Network (HCRN), which comprises 7 pediatric neurosurgical centers in North America, provides a unique multicenter assessment of the current outcomes of CSF shunting in nonselected patients. The authors present the initial results for this cohort and compare them with results from prospective multicenter trials performed in the 1990s. METHODS Analysis was restricted to patients with newly diagnosed hydrocephalus undergoing shunting for the first time. Detailed perioperative data from 2008 through 2012 for all HCRN centers were prospectively collected and centrally stored by trained research coordinators. Historical control data were obtained from the Shunt Design Trial (1993-1995) and the Endoscopic Shunt Insertion Trial (1996-1999). The primary outcome was time to first shunt failure, which was determined by using Cox regression survival analysis. RESULTS Mean age of the 1184 patients in the HCRN cohort was older than mean age of the 720 patients in the historical cohort (2.51 years vs 1.60 years, p < 0.0001). The distribution of etiologies differed (p < 0.0001, chi-square test); more tumors and fewer myelomeningoceles caused the hydrocephalus in the HCRN cohort patients. The hazard ratio for first shunt failure significantly favored the HCRN cohort, even after the model was adjusted for the prognostic effects of age and etiology (adjusted HR 0.82, 95% CI 0.69-0.96). CONCLUSIONS Current outcomes of shunting in general pediatric neurosurgery practice have improved over those from the 1990s, although the reasons remain unclear.
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