Management of Symptomatic Chronic Extra-Axial Fluid Collections in Pediatric Patients

Abstract

The records of 103 pediatric patients having symptomatic chronic extra-axial fluid collections treated at Children's Hospital of Los Angeles from 1977 to 1988 were reviewed. Patients were treated with observation, serial percutaneous needle drainage, drainage through burr holes, drainage into a closed external drainage system, or subdural to peritoneal shunt. If the initial treatment was not effective, additional forms of treatment were instituted. Shunts, ultimately used in 73% of the patients, proved to be the most effective treatment. Of the group with shunts, the extra-axial fluid was unilateral in 20% and bilateral in 80%. In those patients with bilateral effusions, no difference in efficacy of shunts was seen in patients treated with bilateral versus unilateral shunts. Of the 75 patients with shunts, 12% required a shunt revision for progressive or recurrent symptoms. Shunt infections occurred in 3% of the patients, necessitating removal of the shunt and treatment with antibiotics. Eosinophilia in the subdural fluid was associated with shunt obstruction requiring revision. The shunt was never removed in 51% of patients with no untoward effects. This study demonstrates that the most efficacious treatment of symptomatic chronic extra-axial fluid collections in children is a unilateral subdural to peritoneal shunt. The shunt need not be removed after resolution of the fluid collections.

Outcome of Surgical Treatment for Subdural Fluid Collections in Infants

“…In most cases, an unvalved shunt is sufficient [18, 21]. Subdural shunts, though, have a reported obstruction rate of up to 14% and an infection rate of 5% [18, 21, 22, 24]. The absence of these complications in this study is probably due to the overall small number of shunts implanted.…”

“…The quickest and most effective method of eliminating the subdural collections appears to be the surgical insertion of a subdural-peritoneal shunt. While invasive, it has a very high reported success rate in eliminating subdural collections judged by CT scan, between 80 and 100% [9, 18, 21, 22]. Unilateral shunt controls sufficiently bilateral collections [17, 18, 21, 23].…”

“…While invasive, it has a very high reported success rate in eliminating subdural collections judged by CT scan, between 80 and 100% [9, 18, 21, 22]. Unilateral shunt controls sufficiently bilateral collections [17, 18, 21, 23]. In most cases, an unvalved shunt is sufficient [18, 21].…”

“…Unilateral shunt controls sufficiently bilateral collections [17, 18, 21, 23]. In most cases, an unvalved shunt is sufficient [18, 21]. Subdural shunts, though, have a reported obstruction rate of up to 14% and an infection rate of 5% [18, 21, 22, 24].…”

“…While the diagnostic dilemmas have now been resolved, management of subdural collections is still a subject of controversy. Reports in the literature support 6 different modalities: conservative management (no surgery, observation alone) [2, 10], repeated subdural taps [11, 12, 13, 14, 15], burr hole drainage [13, 14], external subdural drainage [16], subdural shunting [9, 17, 18]and craniotomy with open drainage [11, 13, 19, 20]. Evaluating the literature, it is apparent that there is no clear superiority of one treatment modality over the others, although there is some bias in favour of shunting.…”