A multicenter retrospective comparison of conversion from temporary to permanent cerebrospinal fluid diversion in very low birth weight infants with posthemorrhagic hydrocephalus

Abstract

<jats:sec> <jats:title>Object</jats:title> <jats:p>The purpose of this study was to define the incidence of permanent shunt placement and infection in patients who have undergone the 2 most commonly performed temporizing procedures for posthemorrhagic hydrocephalus (PHH) of prematurity: ventriculosubgaleal (VSG) shunt placement and ventricular reservoir placement for intermittent tapping.</jats:p></jats:sec> <jats:sec> <jats:title>Methods</jats:title> <jats:p>The 4 centers of the Hydrocephalus Clinical Research Network participated in a retrospective chart review of infants with PHH who underwent treatment at each institution between 2001 and 2006. Patients were included if they had received a diagnosis of Grade 3 or 4 intraventricular hemorrhage, weighed &lt; 1500 g at birth, and had received surgical intervention. The authors determined the incidence of conversion from a temporizing device to a permanent shunt, the incidence of CSF infection during temporization, and the 6-month CSF infection rate after permanent shunt placement.</jats:p></jats:sec> <jats:sec> <jats:title>Results</jats:title> <jats:p>Thirty-one (86%) of 36 patients who received VSG shunts and 61 (69%) of 88 patients who received ventricular reservoirs received permanent CSF diversion with a shunt (p = 0.05). Five patients (14%) in the VSG shunt group had CSF infections during temporization, compared with 11 patients (13%) in the ventricular reservoir group (p = 0.83). The 6-month incidence of permanent shunt infection in the VSG shunt group was 16% (5 of 31), compared with 12% (7 of 61) in the reservoir placement group (p = 0.65). For the first 6 months after permanent shunt placement, infants with no preceding temporizing procedure had an infection rate of 5% (1 of 20 infants) and those who had undergone a temporizing procedure had an infection rate of 13% (12 of 92; p = 0.45).</jats:p></jats:sec> <jats:sec> <jats:title>Conclusions</jats:title> <jats:p>The use of intermittent tapping of ventricular reservoirs in this population appears to lead to a lower incidence of permanent shunt placement than the use of VSG shunts. The incidence of infection during temporization and for the initial 6 months after conversion appears comparable for both groups. The apparent difference identified in this pilot study requires confirmation in a more rigorous study.</jats:p></jats:sec>

Cerebrospinal fluid drainage options for posthemorrhagic hydrocephalus in premature neonates

“…Most of the patients included in the current study were diagnosed with Papile grade III IVH. This finding is in agreement with previously reported risk of PHH in this patient population 6,13,23 . These patients are commonly referred to pediatric neurosurgery for either temporary or permanent CSF diversion to relieve PHH-induced intracranial hypertension 6,13,17,22,23 , while grade I and II patients are usually not referred for neurosurgical evaluation due to the lower incidence of PHH and intracranial hypertension.…”

“…This finding is in agreement with previously reported risk of PHH in this patient population 6,13,23 . These patients are commonly referred to pediatric neurosurgery for either temporary or permanent CSF diversion to relieve PHH-induced intracranial hypertension 6,13,17,22,23 , while grade I and II patients are usually not referred for neurosurgical evaluation due to the lower incidence of PHH and intracranial hypertension. The high number of patients with clinical complications such as hypotonia, bradycardia, cardiac arrest, respiratory failure, skin cyanosis, sepsis, and other infections, highlight the susceptibility of these patients as well as the challenges in their management 4,17 , both of which are clinically considered in deciding the appropriate treatment options for CSF diversion in PHH cases 23 .…”

“…The CSF drainage is commonly indicated in cases of progressive increases in cranial circumference (≥ 2 standard deviations above the patient' s age group during the first week), bulging fontanelles, or changes in respiratory patterns, associated with progressive widening of the ventricular system detected by transcranial ultrasonography 13,17,18 . In cases of ventriculomegaly from ex vacuo hydrocephalus (i.e.…”

“…As described in previous studies 8,10,13,17,19,20,21,22,23 , the following techniques were employed for CSF drainage to resolve PHH: Serial LP was performed at the L3-L4 or L4-L5 level, with the anatomical landmark as an imaginary line traced from the iliac crest to the lumbar column. A valveless ventriculosubgaleal shunt with subcutaneous reservoirs was placed with an incision near the external angle of the anterior fontanelle, followed by the detachment of subgaleal space and the introduction of a 3-cm catheter into the anterior ventricular horn; the catheter was then connected to the reservoir and the scalp.…”

“…Rather, a variety of approaches, ranging from serial lumbar punctures (LP), transcutaneous transfontanellar puncture, external ventricular drainage, and ventriculosubgaleal shunt (with or without subcutaneous reservoir) to the endoscopic third ventriculostomy are used 4,6,7,8,9,10,11,12,13 . Ventriculoperitoneal (VP) shunts are contraindicated as a first option in low birth-weight (< 1.500g) premature neonates due to the higher risk of complications associated with the implanted prosthesis and are reserved for selected cases 4,9,11,13 . The scope of this study was describing a case series of premature neonates with PHH and assessing the outcomes of different approaches used for CSF diversion.…”