CSF drainage in patients with posterior fossa tumours

Treatment of hydrocephalus following posterior fossa tumor resection: a multicenter collaboration from the Hydrocephalus Clinical Research Network

OBJECTIVE

Persistent hydrocephalus following posterior fossa brain tumor (PFBT) resection is a common cause of morbidity in pediatric brain tumor patients, for which the optimal treatment is debated. The purpose of this study was to compare treatment outcomes between VPS and ETV in patients with persistent hydrocephalus following surgical resection of a PFBT.

METHODS

A post-hoc analysis was performed of the Hydrocephalus Clinical Research Network (HCRN) prospective observational study evaluating VPS and ETV for pediatric patients. Children who experienced hydrocephalus secondary to PFBT from 2008 to 2021 were included. Primary outcomes were VPS/ETV treatment failure and time-to-failure (TTF).

RESULTS

Among 241 patients, the VPS (183) and ETV (58) groups were similar in age, extent of tumor resection, and preoperative ETV Success Score. There was no difference in overall treatment failure between VPS and ETV (33.9% vs 31.0%, p = 0.751). However, mean TTF was shorter for ETV than VPS (0.45 years vs 1.30 years, p = 0.001). While major complication profiles were similar, compared to VPS, ETV patients had relatively higher incidence of minor CSF leak (10.3% vs. 1.1%, p = 0.003) and pseudomeningocele (12.1% vs 3.3%, p = 0.02). No ETV failures were identified beyond 3 years, while shunt failures occurred beyond 5 years. Shunt infections occurred in 5.5% of the VPS cohort.

CONCLUSIONS

ETV and VPS offer similar overall success rates for PFBT-related postoperative hydrocephalus. ETV failure occurs earlier, while susceptibility to VPS failure persists beyond 5 years. Tumor histology and grade may be considered when selecting the optimal means of CSF diversion.

Management of Posterior Fossa Tumors in Adults Based on the Predictors of Postoperative Hydrocephalus

Objective

This study aims to identify the predictors of postoperative hydrocephalus in patients with posterior fossa tumors (PFTs) and guide the management of perioperative hydrocephalus.

Methods

We performed a single-institution, retrospective analysis of patients who underwent resection of PFTs in our department over a 10-year period (2011–2021). A total of 682 adult patients met the inclusion criteria and were divided into either a prophylactic external ventricular drainage (EVD) group or a nonprophylactic-EVD group. We analyzed data for the nonprophylactic-EVD group by univariate and multivariate analyses to identify predictors of postoperative acute hydrocephalus. We also analyzed all cases by univariate and multivariate analyses to determine the predictors of postoperative ventriculoperitoneal (VP) shunt placement.

Results

Tumor infiltrating the midbrain aqueduct [P = 0.001; odds ratio (OR) = 9.8], postoperative hemorrhage (P < 0.001; OR = 66.7), and subtotal resection (P = 0.006; OR = 9.3) were independent risk factors for postoperative EVD. Tumor infiltrating the ventricular system (P < 0.001; OR = 58.5) and postoperative hemorrhage (P < 0.001; OR = 28.1) were independent risk factors for postoperative VP shunt placement.

Conclusions

These findings may help promote more aggressive monitoring and earlier interventions for postoperative hydrocephalus in patients with PFTs.

Artificial neural networks predict the need for permanent cerebrospinal fluid diversion following posterior fossa tumor resection

Background

Resection of posterior fossa tumors (PFTs) can result in hydrocephalus that requires permanent cerebrospinal fluid (CSF) diversion. Our goal was to prospectively validate a machine-learning model to predict postoperative hydrocephalus after PFT surgery requiring permanent CSF diversion.

Methods

We collected preoperative and postoperative variables on 518 patients that underwent PFT surgery at our center in a retrospective fashion to train several statistical classifiers to predict the need for permanent CSF diversion as a binary class. A total of 62 classifiers relevant to our data structure were surveyed, including regression models, decision trees, Bayesian models, and multilayer perceptron artificial neural networks (ANN). Models were trained using the (N = 518) retrospective data using 10-fold cross-validation to obtain accuracy metrics. Given the low incidence of our positive outcome (12%), we used the positive predictive value along with the area under the receiver operating characteristic curve (AUC) to compare models. The best performing model was then prospectively validated on a set of 90 patients.

Results

Twelve percent of patients required permanent CSF diversion after PFT surgery. Of the trained models, 8 classifiers had an AUC greater than 0.5 on prospective testing. ANNs demonstrated the highest AUC of 0.902 with a positive predictive value of 83.3%. Despite comparable AUC, the remaining classifiers had a true positive rate below 35% (compared to ANN, P < .0001). The negative predictive value of the ANN model was 98.8%.

Conclusions

ANN-based models can reliably predict the need for ventriculoperitoneal shunt after PFT surgery.

Palliative endoscopic third ventriculostomy for pediatric primary brain tumors: a single-institution case series

OBJECTIVE

Children with nonoperative brain tumors, such as diffuse intrinsic pontine gliomas (DIPGs), often have life-threatening hydrocephalus. Palliative shunting is common in such cases but can be complicated by hardware infection and mechanical failure. Endoscopic third ventriculostomy (ETV) is a minimally invasive alternative to treat hydrocephalus without implanted hardware. Herein, the authors report their institutional experience with palliative ETV for primary pediatric brain tumors.

METHODS

The authors conducted a retrospective review of consecutive patients who had undergone palliative ETV for hydrocephalus secondary to nonresectable primary brain tumors over a 10-year period at Rady Children's Hospital. Collected variables included age, sex, tumor type, tumor location, presence of leptomeningeal spread, use of a robot for ETV, complications, ETV Success Score (ETVSS), functional status, length of survival, and follow-up time. A successful outcome was defined as an ETV performed without clinically significant perioperative complications or secondary requirement for a new shunt.

RESULTS

Fifteen patients met the study inclusion criteria (11 males, 4 females; average age 7.9 years, range 0.8-21 years). Thirteen patients underwent manual ETV, and 2 patients underwent robotic ETV. Preoperative symptoms included gaze palsy, nausea/vomiting, headache, lethargy, hemiparesis, and seizures. Tumor types included DIPG (3), intraventricular/thalamic glioblastoma (2), and leptomeningeal spread of medulloblastoma (2), anaplastic oligo-/astrocytoma (2), rhabdoid tumor (2), primitive neuroectodermal tumor (1), ganglioglioma (1), pineoblastoma (1), and embryonal carcinoma (1). The mean preoperative ETVSS was 79 ± 8.8. There was 1 perioperative complication, a wound breakdown consistent with refractory hydrocephalus. The mean follow-up was 4.9 ± 5.5 months overall, and mean survival for the patients who died was 3.2 ± 3.6 months. Two patients remained alive at a mean follow-up of 15.7 months. Palliative ETV was successful in 7 patients (47%) and unsuccessful in 8 (53%). While patients with successful ETV were significantly older (11.9 ± 5.6 vs 4.4 ± 4.1 years, p = 0.010), there were no significant differences in preoperative ETVSS (p = 0.796) or postoperative survival (p = 0.476) between the successful and unsuccessful groups. Overall, functional outcomes were similar between the two groups; there was no significant difference in posttreatment Karnofsky Performance Status scores (68.6 ± 19.5 vs 61.3 ± 16.3, p = 0.454), suggesting that including ETV in the treatment algorithm did not worsen outcomes.

CONCLUSIONS

Palliative ETV is a safe and potentially efficacious treatment option in selected pediatric patients with hydrocephalus from nonoperative brain tumors. Close follow-up, especially in younger children, is required to ensure that patients with refractory symptoms receive appropriate secondary CSF diversion.

Characteristics and management of hydrocephalus in adult patients with cerebellar glioblastoma: lessons from a French nationwide series of 118 cases

The characteristics of hydrocephalus associated with cerebellar glioblastoma (cGB) remain poorly known. The objectives were to describe the occurence of hydrocephalus in a French nationwide series of adult patients with cGB, to identify the characteristics associated with hydrocephalus and to analyze the outcomes associated with the different surgical strategies, in order to propose practical guidelines. Consecutive cases of adult cGB patients prospectively recorded into the French Brain Tumor Database between 2003 and 2017 were screened. Diagnosis was confirmed by a centralized neuropathological review. Among 118 patients with cGB (mean age 55.9 years), 49 patients (41.5%) presented with pre-operative hydrocephalus. Thirteen patients (11.0%) developed acute (n=7) or delayed (n=6) hydrocephalus postoperatively. Compared to patients without hydrocephalus at admission, patients with hydrocephalus were younger (52.0 years vs 58.6 years, p=0.03) and underwent more frequently tumor resection (93.9% vs 73.9%, p=0.006). A total of 40 cerebrospinal-fluid diversion procedures were performed, including 18 endoscopic third ventriculostomies, 12 ventriculoperitoneal shunts and 10 external ventricular drains. The different cerebrospinal-fluid diversion options had comparable functional results and complication rates. Among the 89 patients surgically managed for cGB without prior cerebrospinal-fluid diversion, 7 (7.9%) were long-term shunt-dependant. Hydrocephalus is frequent in patients with cGB and has to be carefully managed in order not to interfere with adjuvant oncological treatments. In case of symptomatic hydrocephalus, a cerebrospinal-fluid diversion is mandatory, especially if surgical resection is not feasible. In case of asymptomatic hydrocephalus, a cerebrospinal-fluid diversion has to be discussed only if surgical resection is not feasible.

Predictors of ventriculostomy infection in a large single-center cohort

OBJECTIVE

External ventricular drain (EVD) placement is a common neurosurgical procedure. While this procedure is simple and effective, infection is a major limiting factor. Factors predictive of infection reported in the literature are not conclusive. The aim of this retrospective, single-center large series was to assess the rate and independent predictors of ventriculostomy-associated infection (VAI).

METHODS

The authors performed a retrospective chart review of consecutive patients who underwent EVD placement between January 2012 and January 2018.

RESULTS

A total of 389 patients were included in the study. The infection rate was 3.1% (n = 12). Variables that were significantly associated with VAI were EVD replacement (OR 10, p = 0.001), bilateral EVDs (OR 9.2, p = 0.009), duration of EVD placement (OR 1.1, p = 0.011), increased CSF output/day (OR 1.0, p = 0.001), CSF leak (OR 12.9, p = 0.001), and increased length of hospital stay (OR 1.1, p = 0.002). Using multivariate logistic regression, independent predictors of VAI were female sex (OR 7.1, 95% CI 1.1–47.4; p = 0.043), EVD replacement (OR 8.5, 95% CI 1.44–50.72; p = 0.027), increased CSF output/day (OR 1.01, 95% CI 1.0–1.02; p = 0.023), and CSF leak (OR 15.1, 95% CI 2.6–87.1; p = 0.003).

CONCLUSIONS

The rate of VAI was 3.1%. Routine CSF collection (every other day or every 3 days) and CSF collection when needed were not associated with VAI. The authors recommend CSF collection when clinically needed rather than routinely.

Risk factors for hydrocephalus following fourth ventricle tumor surgery: A retrospective analysis of 121 patients

BACKGROUND AND AIM

Most patients who present with a fourth ventricle tumor have concurrent hydrocephalus, and some demonstrate persistent hydrocephalus after tumor resection. There is still no consensus on the management of hydrocephalus in patients with fourth ventricle tumor after surgery. The purpose of this study was to identify the factors that predispose to postoperative hydrocephalus and the need for a postoperative cerebrospinal fluid (CSF) diversion procedure.

MATERIALS AND METHODS

We performed a retrospective analysis of patients who underwent surgery of the fourth ventricle tumor between January 2013 and December 2018 at the Department of Neurosurgery in West China Hospital of Sichuan University. The characteristics of patients and the tumor location, tumor size, tumor histology, and preventive external ventricular drainage (EVD) that were potentially correlated with CSF circulation were evaluated in univariate and multivariate analysis.

RESULTS

A total of 121 patients were enrolled in our study; 16 (12.9%) patients underwent postoperative CSF drainage. Univariate analysis revealed that superior extension (p = 0.004), preoperative hydrocephalus (p<0.001), and subtotal resection (p<0.001) were significantly associated with postoperative hydrocephalus. Multivariate analysis revealed that superior extension (p = 0.013; OR = 44.761; 95% CI 2.235-896.310) and subtotal resection (p = 0.005; OR = 0.087; 95% CI 0.016-0.473) were independent risk factors for postoperative hydrocephalus after resection of fourth ventricle tumor.

CONCLUSION

Superior tumor extension (into the aqueduct) and failed total resection of tumor were identified as independent risk factors for postoperative hydrocephalus in patients with fourth ventricle tumor.

The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review

Posterior cranial fossa tumours frequently develop hydrocephalus as first presentation in up to 80% of paediatric patients and 21.4% of adults, although it resolves after tumour removal in 70-90% and 96%, respectively. New onset hydrocephalus is reported in about 2.1% of adult and 10-40% of paediatric patients after posterior fossa surgery. There is no consensus concerning prophylactic external ventricular drainage (EVD) placement that is frequently used before posterior fossa lesion removal, as well in those cases without clear evidence of hydrocephalus. The aim of the study was to define the most correct management for patients who undergo posterior fossa tumour surgery, thus identifying cohorts of patients who are at risk of persistent hydrocephalus prior to surgery. A systematic review of literature has been performed, following PRISMA guidelines. Most of the studies reported CSF shunt only in the presence of hydrocephalus, whereas only a few authors suggested its prophylactic use in the absence of signs of ventricular dilatation. Predictive factors for postoperative hydrocephalus has been identified, including young age (< 3 years), severe symptomatic hydrocephalus at presentation, EVD placement before surgery, FOHR index > 0.46 and Evans index > 0.4, pseudomeningocele, CSF leak and infection. The use of pre-resection CSF shunt in case of signs and symptoms of hydrocephalus is mandatory, although it resolves in the majority of cases. As reported by several studies included in the present review, we suggest CSF shunt also in case of asymptomatic hydrocephalus, whereas it is not indicated without evidence of ventricular dilatation.

Management of hydrocephalus after resection of posterior fossa lesions in pediatric and adult patients-predictors for development of hydrocephalus

The surgical management of hydrocephalus in patients with posterior fossa lesions (PFL) is critical for optimal patient outcome(s). Accordingly, it is prudent to identify patients in need of aggressive surgical intervention (i.e., ventriculoperitoneal [VP] shunting). To analyze prevalence of, and risk factors associated with, the development of post-operative hydrocephalus in both pediatrics and adults. A retrospective institutional analysis and review of patient records in those who had undergone PFL surgery was performed. In so doing, the authors identified patients that went on to develop post-operative hydrocephalus. The study included pediatric and adult patients treated between 2009 and 2017. Fifteen of 40 pediatric (37.5%) and 18 of 262 adult (6.9%) patients developed hydrocephalus after PFL surgery. The most common tumor entity in pediatrics was medulloblastoma (34%), astrocytoma (24.4%), and pilocytic astrocytoma (22%), whereas in adults, metastasis (29.5%), meningioma (22%), and acoustic neuroma (17.8%) were most common. Young age ≤ 2 years, medulloblastoma (OR 13.9), and brain stem compression (OR 5.4) were confirmed as independent predictors for hydrocephalus in pediatrics and pilocytic astrocytoma (OR 15.4) and pre-operative hydrocephalus (OR 3.6) in adults, respectively. All patients received VP shunts for hydrocephalus management and the mean follow-up was 29.5 months in pediatrics vs 19.2 months in adults. Overall complication rates related to VP shunts were 33.3% in pediatrics and 16.7% in adults, respectively. Shunt dependency and associated complications in pediatrics were noted to be higher than in adults. Given the identification of predictors for hydrocephalus, it is authors' contention that certain patients with those predictors may ultimately benefit from an alternative treatment regimen (e.g., pre-operative interventions) prior to PFT surgery.

A novel grading system for the prediction of the need for cerebrospinal fluid drainage following posterior fossa tumor surgery

OBJECTIVE

Prophylactic placement of an external ventricular drain (EVD) is often performed prior to resection of a posterior fossa tumor (PFT); however, there is no general consensus regarding the indications. The purpose of this study was to establish a novel grading system for the prediction of required CSF drainage due to symptomatic elevated intracranial pressure (ICP) after resection of a PFT to identify patients who require an EVD.

METHODS

The authors performed a retrospective analysis of data from a prospective database. All patients who had undergone resection of a PFT between 2012 and 2017 at the University Hospital, Goethe University Frankfurt, were identified and data from their cases were analyzed. PFTs were categorized as intraparenchymal (iPFT) or extraparenchymal (ePFT). Prior to resection, patients underwent EVD placement, prophylactic burr hole placement, or neither. The authors assessed the amount of CSF drainage (if applicable), rate of EVD placement at a later time point, and complication rate and screened for factors associated with CSF drainage. By applying those factors, they established a grading system to predict the necessity of CSF drainage for elevated ICP.

RESULTS

A total of 197 patients met the inclusion criteria. Of these 197, 70.6% received an EVD, 15.7% underwent prophylactic burr hole placement, and 29.4% required temporary CSF drainage. In the prophylactic burr hole group, 1 of 32 patients (3.1%) required EVD placement at a later time. Independent predictors for postoperative need for CSF drainage due to symptomatic intracranial hypertension in patients with iPFTs were preoperative hydrocephalus (OR 2.9) and periventricular CSF capping (OR 2.9), whereas semi-sitting surgical position (OR 0.2) and total resection (OR 0.3) were protective factors. For patients with ePFTs, petroclival/midline tumor location (OR 12.2/OR 5.7), perilesional edema (OR 10.0), and preoperative hydrocephalus (OR 4.0) were independent predictors of need for CSF drainage. According to our grading system, CSF drainage after resection of iPFT or ePFT, respectively, was required in 16.7% and 5.1% of patients with a score of 0, in 21.1% and 12.5% of patients with a score of 1, in 47.1% and 26.3% of patients with a score of 2, and in 100% and 76.5% of patients with a score ≥ 3 (p < 0.0001). The rate of relevant EVD complications was 4.3%, and 10.1% of patients were shunt-dependent at 3-month follow-up.

CONCLUSIONS

This novel grading system for the prediction of need for CSF drainage following resection of PFT might be of help in deciding in favor of or against prophylactic EVD placement.

Frequency and treatment of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients

BACKGROUND

There is paucity of information about the frequency of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients and about the best way it should be managed. The present study was conducted to determine the frequency of hydrocephalus prior to and after posterior fossa tumor surgery in adult patients as well as the value of an endoscopic third ventriculostomy (ETV) prior to posterior fossa tumor surgery with regard to the rate of perioperative complications and persistent hydrocephalus.

METHODS

A single-institution retrospective chart review of all posterior fossa tumor surgeries of our department in a 10-year period (2005 to 2014) has been done.

RESULTS

Fifty-two of 243 adult patients with posterior fossa tumors presented with hydrocephalus at the time of admission prior to tumor surgery. 39/52 received early tumor surgery, 11/52 an ETV prior to tumor surgery and in 2/52 an external ventricular drainage (EVD) was inserted prior to tumor surgery. 3/52 patients required a permanent cerebrospinal fluid (CSF) diverting procedure for persistent hydrocephalus after tumor removal. One hundred ninety-one patients did not demonstrate a hydrocephalus before surgical treatment and four of them developed a post-resection hydrocephalus.

CONCLUSION

The frequency of hydrocephalus prior to posterior fossa tumor surgery in adult patients is 21.4% and therefore much lower than in respective reports of pediatric patients. The risk of persistent hydrocephalus and newly developed hydrocephalus after tumor surgery was very low, too (5.7 and 2.1%, respectively). An ETV is not justified in every adult patient prior to posterior fossa tumor surgery.

The durability of endoscopic third ventriculostomy and ventriculoperitoneal shunts in children with hydrocephalus following posterior fossa tumor resection: a systematic review and time-to-failure analysis

OBJECTIVE Up to one-third of patients with a posterior fossa brain tumor (PFBT) will experience persistent hydrocephalus mandating permanent CSF diversion. The optimal hydrocephalus treatment modality is unknown; the authors sought to compare the durability between endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) therapy in the pediatric population. METHODS The authors conducted a systematic review of articles indexed in PubMed between 1986 and 2016 describing ETV and/or VPS treatment success/failure and time-to-failure rate in patients < 19 years of age with hydrocephalus related to a PFBT. Additionally, the authors conducted a retrospective review of their institutional series of PFBT patients requiring CSF diversion. Patient data from the systematic review and from the institutional series were aggregated and a time-to-failure analysis was performed comparing ETV and VPS using the Kaplan-Meier method. RESULTS A total of 408 patients were included from 12 studies and the authors' institutional series: 284 who underwent ETV and 124 who underwent VPS placement. The analysis included uncontrolled studies with variable method and timing of CSF diversion and were subject to surgeon bias. No significant differences between cohorts were observed with regard to age, sex, tumor grade or histology, metastatic status, or extent of resection. The cumulative failure rate of ETV was 21%, whereas that of VPS surgery was 29% (p = 0.105). The median time to failure was earlier for ETV than for VPS surgery (0.82 [IQR 0.2-1.8] vs 4.7 months [IQR 0.3-5.7], p = 0.03). Initially the ETV survival curve dropped sharply and then stabilized around 2 months. The VPS curve fell gradually but eventually crossed below the ETV curve at 5.7 months. Overall, a significant survival advantage was not demonstrated for one procedure over the other (p = 0.21, log-rank). However, postoperative complications were higher following VPS (31%) than ETV (17%) (p = 0.012). CONCLUSIONS ETV failure occurred sooner than VPS failure, but long-term treatment durability may be higher for ETV. Complications occurred more commonly with VPS than with ETV. Limited clinical conclusions are drawn using this methodology; the optimal treatment for PFBT-related hydrocephalus warrants investigation through prospective studies.

Childhood hydrocephalus secondary to posterior fossa tumor is both an intra- and extraaxial process

OBJECTIVE Ventricular dilation secondary to tumor obstruction of the posterior fossa CSF outflow in childhood is an intraaxial process. However, third ventriculostomy or complete tumor removal often fails to reduce the pressure in some children, and in others there is a delayed reduction in intracranial pressure; this is termed the adaptation period. The cause of this adaptation period has not been studied. Venous sinus compression is highly correlated with other forms of childhood hydrocephalus, and this study seeks to follow the changes that occur in sinus cross-sectional area after surgery. METHODS Twelve children with posterior fossa tumors underwent MRI examination that included standard T2-weighted and 3D contrast-enhanced images obtained preoperatively, in the immediate postoperative period, and after several months. The volumes of the lateral and third ventricles and the minimum cross-sectional area of the transverse and sigmoid sinuses were measured. Patients were categorized by 1) shunt status (those who required a shunt vs those who did not) and 2) by age (those younger than 3 years vs those older than 3 years at diagnosis). RESULTS There was a significant reduction in ventricular volume in both the immediate and secondary follow-up periods for all patients. There was preoperative venous sinus compression in all groups, which did not change significantly in the immediate postoperative period but did improve in the secondary follow-up period. The younger children had larger ventricles and smaller sinuses before surgery compared with the older children. CONCLUSIONS In children with obstructed hydrocephalus caused by tumor, there is secondary compression of venous outflow, indicating both an intra- and extraaxial process. The expansion of the sinuses following decompression of the posterior fossa is delayed and may correlate with the adaptation period. Younger children have greater sinus compression than older ones.

Management of posterior fossa tumors and hydrocephalus in children: a review

OBJECT

Most pediatric patients that present with a posterior fossa tumor have concurrent hydrocephalus. There is significant debate over the best management strategy of hydrocephalus in this situation. The objectives of this paper were to review the pathophysiology model of posterior fossa tumor hydrocephalus, describe the individual risks factors of persistent hydrocephalus, and discuss the current management options. Specifically, the debate over preresection cerebrospinal fluid diversion is discussed.

RESULTS

Only 10-40 % demonstrate persistent hydrocephalus after posterior fossa tumor resection. It appears that young age, moderate to severe hydrocephalus, transependymal edema, the presence of cerebral metastases, and tumor pathology (medulloblastoma and ependymoma) on presentation predict postresection or persistent hydrocephalus. The Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH), a validated prediction model, can be used to stratify patients at point of first contact into high and low risk for persistent hydrocephalus.

CONCLUSIONS

A protocol is proposed for managing hydrocephalus that utilizes the CPPRH. Low-risk patients can be monitored conservatively with or without an intraoperative extraventricular drain, while high-risk patients require the use of an intraoperative extraventricular drain, higher postoperative hydrocephalus surveillance, and even consideration for a preoperative endoscopic third ventriculostomy.

Validation and modification of a predictive model of postresection hydrocephalus in pediatric patients with posterior fossa tumors

OBJECT

Postresection hydrocephalus is observed in approximately 30% of pediatric patients with posterior fossa tumors. However, which patients will develop postresection hydrocephalus is not known. The Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH) was developed in an attempt to identify this subset of patients, allowing for the optimization of their care. The authors sought to validate and critically appraise the CPPRH.

METHODS

The authors conducted a retrospective chart review of 99 consecutive pediatric patients who presented between 2002 and 2010 with posterior fossa tumors and who subsequently underwent resection. The data were then analyzed using bivariate and multivariate analyses, and a modified CPPRH (mCPPRH) was applied.

RESULTS

Seventy-six patients were evaluated. Four variables were found to be significant in predicting postresection hydrocephalus: age younger than 2 years, moderate/severe hydrocephalus, preoperative tumor diagnosis, and transependymal edema. The mCPPRH produced observed likelihood ratios of 0.737 (95% CI 0.526-1.032) and 4.688 (95% CI 1.421-15.463) for low- and high-risk groups, respectively.

CONCLUSIONS

The mCPPRH utilizes readily obtainable and reliable preoperative variables that together stratify children with posterior fossa tumors into high- and low-risk categories for the development of postresection hydrocephalus. This new predictive model will aid patient counseling and tailor the intensity of postoperative clinical and radiographic monitoring for hydrocephalus, as well as provide evidence-based guidance for the use of prophylactic CSF diversion.

Impact of a standardized protocol and antibiotic-impregnated catheters on ventriculostomy infection rates in cerebrovascular patients

BACKGROUND

Ventriculostomy infections create significant morbidity. To reduce infection rates, a standardized evidence-based catheter insertion protocol was implemented. A prospective observational study analyzed the effects of this protocol alone and with antibiotic-impregnated ventriculostomy catheters.

OBJECTIVE

To compare infection rates after implementing a standardized protocol for ventriculostomy catheter insertion with and without the use of antibiotic-impregnated catheters.

METHODS

Between 2003 and 2008, 1961 ventriculostomies and infections were documented. A ventriculostomy infection was defined as 2 positive CSF cultures from ventriculostomy catheters with a concurrent increase in cerebrospinal fluid white blood cell count. A baseline (preprotocol) infection rate was established (period 1). Infection rates were monitored after adoption of the standardized protocol (period 2), institution of antibiotic-impregnated catheter A (period 3), discontinuation of antibiotic-impregnated catheter A (period 4), and institution of antibiotic-impregnated catheter B (period 5).

RESULTS

The baseline infection rate (period 1) was 6.7% (22/327 devices). Standardized protocol (period 2) implementation did not change the infection rate (8.2%; 23/281 devices). Introduction of catheter A (period 3) reduced infections to 1.0% (2/195 devices, P=.0005). Because of technical difficulties, this catheter was discontinued (period 4), resulting in an increase in infection rate (7.6%; 12/157 devices). Catheter B (period 5) significantly decreased infections to 0.9% (9 of 1001 devices, P=.0001). The Staphylococcus infection rate for periods 1, 2, and 4 was 6.1% (47/765) compared with 0.2% (1/577) during use of antibiotic-impregnated catheters (periods 3 and 5).

CONCLUSION

The use of antibiotic-impregnated catheters resulted in a significant reduction of ventriculostomy infections and is recommended in the adult neurosurgical population.

Endoscopic third ventriculostomy and posterior fossa tumors

BACKGROUND

The management of hydrocephalus associated with a posterior fossa tumor is debated. Some authors emphasize the advantages of an immediate tumor removal that may normalize the cerebrospinal fluid (CSF) dynamics. However, in clinical practice, the mere excision of the lesion has been demonstrated to be accompanied by a persisting hydrocephalus in about one third of the cases. Preoperative endoscopic third ventriculostomy (ETV) offers several advantages. It may control the intracranial pressure (ICP), avoid the necessity of an emergency procedure, allow appropriate scheduling of the operation for tumor removal, and eliminate the risks related to the presence of an external drainage. The procedure also reduces the incidence of postoperative hydrocephalus. A final advantage, more difficult to weight, but obvious to the neurosurgeon, is the possibility to remove the lesion with a relaxed brain and normal ICP. In the postoperative phase, ETV can be used in case of persisting hydrocephalus, both in patients who underwent only the excision of the tumor and in those whose preoperative ETV failed as a consequence of intraventricular bleeding with secondary closure of the stoma (redoETV). The main advantage of postoperative ETV is that the procedure is carried out only in case of persisting hydrocephalus; its use is consequently more selective than preoperative ETV. The disadvantage consists in the common use of an external CSF drainage in the first few postoperative days, which is necessary to control the pressure and for ruling out those cases that reach a spontaneous cure of the hydrocephalus.

METHODS

The authors review the criteria for patient selection and the results of ETV performed in case of hydrocephalus secondary to a posterior fossa tumor.

RESULTS AND CONCLUSIONS

Preoperative ETV constitutes an effective procedure for controlling the hydrocephalus associated with posterior fossa tumors. It might lower the rate of persistent postoperative hydrocephalus and result in a short hospital stay. Low rates of patients requiring an extrathecal-CSF shunt device are also reported by authors who utilize ETV postoperatively. As, however, the assessment of the persistent hydrocephalus in these children is based on prolonged ICP monitoring through an external CSF drainage, their results are weighted by a major risk of infective complications and longer hospital stay.

Hydrocephalus with brain tumors in children

BACKGROUND

Tumor-associated hydrocephalus is common in primary pediatric brain tumors. The managements involve radical tumor resection, temporary external ventricular drainage, and different definite shunting procedures. The purpose of this study is to sum up our experience of definite shunting procedures for tumoral hydrocephalus in children and correlate with reported literatures.

METHODS

This is a retrospective review of a series of 1,250 cases of primary pediatric brain tumors in patients <18 years of age collected in Taipei Veterans General Hospital from 1971 to 2008. Cases with questionable records about hydrocephalus were excluded.

RESULTS

A total of 56.7% of cases presented hydrocephalus, including hydrocephalus that occurred at tumor diagnosis (51.5%), and hydrocephalus developed after tumor diagnosis (5.1%). At tumor diagnosis, the hydrocephalus was mainly obstructive type (98%) and rarely communicating type (1.9%). Definite shunting procedures in this series comprised of ventriculoperitoneal (VP) shunt in 54.4%, endoscopic third ventriculostomy (ETV) in 10.9%, subduroperitoneal (SP) shunt in 4.8%, septostomy in 0.7%, lumboperitoneal shunt in 0.6%, and ventriculoatrial shunt in 0.1% of patients with hydrocephalus. There was a tendency of decreasing requirement and changing timing for VP shunt implantation. There was a gradual increase in usage of ETV for hydrocephalus in specific types and locations of tumors.

CONCLUSION

In the past two decades, we tended to use the VP shunt more cautiously for obstructive tumoral hydrocephalus. We try to perform initial radical resection of tumors as indicated and the more frequent use of ETV in selective cases that help to decrease the requirement of VP shunt implantation.

Endoscopic third ventriculostomy versus ventriculoperitoneal shunt in the treatment of obstructive hydrocephalus due to posterior fossa tumors in children

OBJECT

This study compares endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of pediatric patients with marked obstructive hydrocephalus due to midline posterior fossa tumors.

METHODS

Fifty-three pediatric patients with a midline posterior fossa tumor (32 medulloblastomas and 21 ependymomas) associated with marked hydrocephalus were studied. Patients were divided into two groups: group A (32 patients) operated by ETV with a mean follow-up of 27.4 months and group B (21 patients) operated by VPS with a mean follow-up of 25 months.

RESULTS

Both procedures proved to be effective clinically and radiologically. In group A, intraoperative bleeding occurred in two cases (6.2%) and cerebrospinal fluid leakage in one case (3.1%). In group B, shunt infection occurred in two cases (9.4%), one of these two cases died 4.5 months postoperatively from ventriculitis. Subdural collection occurred in two cases (9.4%), epidural hematoma in one case (4.7%), and upward brain herniation in one case (4.7%). Endoscopic third ventriculostomy proved to be superior due to shorter duration of surgery (15 min versus 35 min), lower incidence of morbidity (9.3% versus 38%), no mortality (0% versus 4.7%), and lower incidence of procedure failure (6.2% versus 38%).

CONCLUSION

The shorter duration of surgery, the lower incidence of morbidity, the absence of mortality, the lower incidence of procedure failure, and the significant advantage of not becoming shunt dependent make ETV be recommended as the first choice in the treatment of pediatric patients with marked obstructive hydrocephalus due to midline posterior fossa tumors.

Predicting postresection hydrocephalus in pediatric patients with posterior fossa tumors

OBJECT

Approximately 30% of children with posterior fossa tumors exhibit hydrocephalus after tumor resection. Recent literature has suggested that prophylactic endoscopic third ventriculostomy diminishes the risk of this event. Because the majority of patients will not have postoperative hydrocephalus, a preoperative clinical prediction rule that identifies patients at high or low risk for postresection hydrocephalus would be helpful to optimize the care of these children.

METHODS

The authors evaluated a derivation cohort of 343 consecutive children with posterior fossa tumors who underwent treatment between 1989 and 2003. Multivariate methods were used on these data to generate the Canadian Preoperative Prediction Rule for Hydrocephalus. The rule's estimated risk of postresection hydrocephalus was compared with risk observed in 111 independent patients in the validation cohort.

RESULTS

Variables identified as significant in predicting postresection hydrocephalus were age < 2 years (score of 3), papilledema (score of 1), moderate to severe hydrocephalus (score of 2), cerebral metastases (score of 3), and specific estimated tumor pathologies (score of 1). Patients with scores > or = 5 were deemed as high risk. Predicted probabilities for the high- and low-risk groups were 0.73 and 0.25, respectively, from the derivation cohort, and 0.59 and 0.14 after prevalence adjustment compared with the observed values of 0.42 and 0.17 in the validation cohort.

CONCLUSIONS

A patient's score on the Preoperative Prediction Rule for Hydrocephalus will allow improved patient counseling and surgical planning by identifying patients at high risk of developing postresection hydrocephalus. These patients might selectively be exposed to the risks of preresection CSF diversion to improve outcome.

Hydrocephalus in posterior fossa lesions: ventriculostomy and permanent shunt rates by diagnosis

OBJECTIVES

The rate of ventriculostomy for acute hydrocephalus and progression to shunt-dependent chronic hydrocephalus in patients with posterior fossa lesions are not well known.

METHODS

We retrospectively reviewed 104 consecutive cases with posterior fossa lesions on admission to the University of Illinois Hospital from June 2002 to December 2005. We recorded the rate of ventriculostomy and permanent ventricular shunting, which were compared among etiologic groups, using chi-squared and Fisher's exact tests.

RESULTS

Overall, 35 patients had ventriculostomy for acute hydrocephalus and 16 had permanent shunting for shunt-dependent chronic hydrocephalus. Of those with primary posterior fossa intracranial hemorrhage (ICH) (42 cases), 19 (45%) required ventriculostomy, with five (26%) requiring subsequent permanent shunting; 13 patients had hematoma evacuation, with two having permanent shunting. Of those with cerebellar infarction (14 cases), four (29%) required ventriculostomy and one (25%) had a permanent shunt; two had a decompressive craniectomy. Of those with neoplasms (43 cases, 33 surgically resected), ten (23%) required ventriculostomy and nine (21%) required permanent shunting. In addition, two of the three cases with infectious processes required ventriculostomy and one required a permanent shunt. In-hospital mortality was 21% (9/42 cases) for patients with ICH, 14% (2/14 cases) for patients with infarction and 0% for all others.

DISCUSSION

Acute primary posterior fossa hemorrhage has the highest rate of ventriculostomy for acute hydrocephalus and highest inpatient mortality but a surprisingly low rate of permanent shunt-dependency. When hydrocephalus was caused by a neoplasm, there was a higher rate of permanent shunt placement.

Endoscopic third ventriculostomy: the best option in the treatment of persistent hydrocephalus after posterior cranial fossa tumour removal?

BACKGROUND

Ten to 40% of children operated on for a posterior fossa tumour require a further surgical procedure for the management of a persisting active ventricular dilation. The management of this kind of hydrocephalus is still controversial.

OBJECTIVE

To prospectively evaluate the effectiveness of post-operative endoscopic third ventriculostomy (ETV) in the management of persistent active hydrocephalus in a series of children operated on for a posterior cranial fossa tumour.

METHODS

The management protocol consisted of: (1) placement of a peri-operative antibiotic impregnated external ventricular catheter (Bactiseal) and tumour removal, (2) post-operative intracranial pressure (ICP) monitoring through the external ventricular drainage, (3) ETV in case of persistent ventricular dilation and persistently abnormal high ICP values and (4) ventriculoperitoneal shunt implantation in case of ETV failure.

RESULTS

Thirty on a total of 104 children (28.8%) operated on between January 2001 and February 2007 at our institution needed a further surgical treatment for the persistence of the hydrocephalus after the removal of their posterior cranial fossa tumour. They were sub-divided in two groups according to the early (group 1--21 patients) or later (group 2--nine patients) definition of the persistence of an active ventricular dilation based on clinical, radiological and ICP monitoring data. ETV was successful in 90.0% of the patients in the present series (27/30 patients), without statistically significant differences among the two groups considered.

CONCLUSIONS

Post-operative ETV should be considered the best option to treat persistent hydrocephalus after the removal of posterior fossa tumours.

Antibiotic impregnated external ventricular drainage and third ventriculostomy in the management of hydrocephalus associated with posterior cranial fossa tumours

BACKGROUND

The effectiveness of antibiotic pre-treated ventricular catheters in reducing the risk of CSF infections (determined on CSF cultures) resulting from the use of per-operative external ventricular drainages (EVD) and the success rate of post-operative endoscopic third ventriculostomy (ETV) in the management of persistent hydrocephalus after posterior cranial fossa tumour removal are assessed.

METHOD

Forty-seven children (group I) were prospectively managed by means of per-operative antibiotic impregnated EVD, post-operative ICP monitoring, and ETV. The results of this group were compared with those of a control group composed by 44 children treated with the same protocol as above except for the use of not-impregnated catheters (group II).

FINDINGS

The rate of positive CSF cultures due to EVD resulted significantly lower in group I (2.1% vs 31.8%); there was no clinical evidence of CSF infections. The success rate of ETV was the same in both groups (75%). Failures of ETV occurred in the patients with subarachnoid tumour seeding and/or tumour extension to the basal cisterns. All the children of group II with failed ETV also showed a bacterial growth in the CSF.

CONCLUSIONS

Antibiotic pre-treated catheters in our experience considerably limited EVD-related bacterial growth in the CSF. Preoperative hydrocephalus resolved in 60% of the cases after tumour removal, thus confirming recent data from the literature against the routine use of preoperative ETV. In our experience postoperative ETV had a high success rate; poor results were obtained in children with tumour seeding and/or the evidence of positive CSF cultures.

Intracranial pressure monitoring: why monitor?

Evidence suggests that the mortality and morbidity of acquired brain injury could be reduced if clinicians used an aggressive intracranial pressure guided approach to care. Despite nearly 50 years of evidence that intracranial pressure monitoring benefits patient care, only about half of the patients who could benefit are monitored. Some clinicians express concerns regarding risks such as bleeding, infections, and inaccuracy of the technology. Others cite cost as the reason. This article discusses the risks and benefits of intracranial pressure monitoring and the current state of evidence of why patients should be monitored.

[Analysis of cerebrospinal fluid related complications (hydrocephalus, fistula, pseudomeningocele and infection) following surgery for posterior fossa tumors]

INTRODUCTION

Hydrocephalus, cerebrospinal fluid (CSF) leak, pseudomeningocele and CSF infection are potential complications related to surgical treatment of posterior fossa tumors. The objectives of this study were to review the incidence of such complications and to identify contributing factors related to them.

MATERIAL AND METHODS

This study is based on a retrospective review of the medical records of 71 consecutive patients who underwent posterior fossa surgery for a tumor between the period January 1997 and December 2001. Postoperative hydrocephalus was defined as enlargement of the ventricles and the subsequent clinical worsening requiring surgical treatment. Criteria for CSF leakage were:observed leak of CSF through the wound, rhinorrhea or otorrhea. Pseudomeningocele was determined when there was a large epidural CSF collection diagnosed in the postoperative period or by magnetic resonance imaging performed at least three months after posterior fossa surgery. Finally, CSF infection was defined on clinical ground and positive biochemical examination, but not necessarily positive cultures.

RESULTS

The series included 84 operations for resection of posterior fossa tumors on 71 patients. There were CSF related complications in 31% (26/84)with the following detailed incidence: 9.5% (8/84) postoperative hydrocephalus; 14.3% (12/84) CSF leak, 7.1% (6/84) pseudomeningocele; 8.3% (7/84) CSF infection. The mortality rate is 5.9% (5/84). The tumor size was the only statistically significant factor associated with the occurrence of CSF related complications (mean 39.43 mm, SD 18.51 mm vs.29.80 mm, SD 14.12 mm, p=0.015). In the subgroup of patients, in which hydrocephalus was managed preoperatively, the election of an external ventricular drain vs.other strategies (subcutaneous reservoir, definite shunt or endoscopic third ventriculostomy) was associated with a higher occurrence of CSF related complications (p=0.006). The mortality rate was associated with age (mean 63.60 years, SD 5.86 years vs.49.18 years, SD 16.39 years; p=0.002). The occurrence of CSF related complications also influenced mortality (p=0.030), particularly postoperative hydrocephalus (p< 0.001). Inpatient hospital stay was longer in the subgroup of patients who developed CSF related complications (p=0.002).

CONCLUSIONS

Tumor size was the only factor associated with the development of CSF related complications after surgery for posterior fossa tumors. In the subgroup of patients in which hydrocephalus was surgically treated preoperatively, the election of an external ventricular drain compared to other surgical modalities was associated with a higher rate of CSF related complications. The development of such complications, particularly hydrocephalus, was related with mortality.

Evolution of the management of hydrocephalus associated with acoustic neuroma

The management of hydrocephalus in association with a cerebellopontine angle tumor is controversial. There is a widely held belief that initial therapy should always be directed toward treatment of hydrocephalus before definitive surgery. The potential problems of cerebrospinal fluid (CSF) shunting and drainage have to led to an evolution in the management of hydrocephalus at St. Vincent's Hospital. There is growing evidence that complete removal of cerebellopontine angle tumors will result in resolution of hydrocephalus without requiring other methods of CSF decompression. The authors present their experience of 14 patients with hydrocephalus found in a recent series of 104 consecutive cases of acoustic neuroma. This study has detected a significant correlation between hydrocephalus and increasing tumor size (P = .0234). The mean tumor size in this series was 3.8 cm. The series has also demonstrated that successful. safe, and complete tumor removal can be achieved without CSF drainage before surgery.

Shunt failures and complications in adults as related to shunt type, diagnosis, and the experience of the surgeon

Data from 95 adult patients (43 males, 52 females) treated with ventriculoperitoneal shunts during an 8-year period were analyzed to investigate risk factors in shunt surgery. All patients were seen in the authors' department and were grouped according to the cause or type of hydrocephalus. The operating surgeons were divided into two categories: specialists and residents. The shunts were classified as single- (Orbis-Sigma) or multicomponent (Holter or Hakim) systems. Two types of unfavorable events were recognized: complications and shunt malfunction. A total of 143 surgical procedures (implantations and revisions) were performed in the 95 patients; 24 patients had their shunts revised, and there were 13 complications (one fatal, five severe) resulting from the shunt surgery. The following observations were statistically significant: 1) patients with normal pressure hydrocephalus had no complications from shunt surgery; 2) the number of shunt malfunctions was lower in patients with intracranial hemorrhages than in the other groups; 3) residents performed a higher number of inadequate operations than did specialists; and 4) the infection rate was higher among patients operated on by residents. The choice of shunt type, the perioperative use of antibiotics, and the degree of surgical emergency were not correlated with complication or failure rates.

Value of precraniotomy shunts in children with posterior fossa tumours

Seventy children with posterior fossa tumours treated over a period of 6 1/2 years were studied. Most patients presented in the late stage of disease. Sixty-four required insertion of a precraniotomy shunt for one or more of the following: persistent vomiting, severe headache, dehydration, poor general condition, failing vision, altered sensorium, marked periventricular lucency, and brain stem involvement deferring total removal of the tumour. Insertion of precraniotomy shunt improved the general condition and signs and symptoms of increased intracranial pressure. It also provided a lax brain during definitive surgery and a smooth postoperative course. Shunt-related complications, consisting of block and/or infection, were observed in 21 patients. It was concluded that precraniotomy shunt is important in the management of children with posterior fossa tumours in developing countries where these patients present in the late stage of disease.