Shunting outcomes in posthemorrhagic hydrocephalus: results of a Hydrocephalus Clinical Research Network prospective cohort study

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>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.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>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.</jats:p></jats:sec>

Treatment thresholds for intervention in posthaemorrhagic ventricular dilation: a randomised controlled trial

“…Once again, there was no significant difference between the number of infants VP shunted between the two groups (38% and 39%). A recent prospective cohort study from the Hydrocephalus Clinical Research Network reported that 56% of those treated when the frontal-occipital horn ratio exceeded 0.55 with clinical symptoms were VP shunted 19. In a recent observational cohort study, as many as 92% of preterm infants required a shunt when treatment was started following onset of clinical symptoms 20…”

Assessment of Brain Injury and Brain Volumes after Posthemorrhagic Ventricular Dilatation: A Nested Substudy of the Randomized Controlled ELVIS Trial

“…5 Given the high rates of infection, dysfunction and life-long dependence after VP-shunt insertion, it would be beneficial if a treatment could reduce the risk of shunt requirement. 6,7 Removing the hemorrhagic CSF by lumbar punctures or taps from a ventricular reservoir may reduce the need for VP-shunt placement, since removal of CSF that contains blood components, protein, and cytokines might re-establish normal CSF circulation. 8 Although, optimum timing of intervention continues to be a matter of debate in the neonatal literature, there is accumulating evidence showing the beneficial effects of early intervention on ventricular dilatation and outcomes.…”

Predictors of mortality for preterm infants with intraventricular hemorrhage: a population-based study

“…Most studies on IVH outcomes have relied on single-institution data, collaborative networks, or patient registries, but there is a dearth of longitudinal, population-level data regarding IVH [8, 17, 23, 25, 34, 43]. Few studies have investigated the long-term neurosurgical outcomes of infants affected with IVH, such as shunt complications [2, 9, 10, 21, 29, 30, 39, 40].…”