Neuroendoscopic surgery in neonates — indication and results over a 10-year practice

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.

Post-haemorrhagic hydrocephalus is associated with poorer surgical and neurodevelopmental sequelae than other causes of infant hydrocephalus

Purpose This retrospective cohort study aimed to investigate the surgical and neurodevelopmental outcomes (NDO) of infant hydrocephalus. We also sought to determine whether these outcomes are disproportionately poorer in post-haemorrhagic hydrocephalus (PHH) compared to other causes of infant hydrocephalus. Methods A review of all infants with hydrocephalus who had ventriculoperitoneal (VP) shunts inserted at Great Ormond Street Hospital (GOSH) from 2008 to 2018 was performed. Demographic, surgical, neurodevelopmental, and other clinical data extracted from electronic patient notes were analysed by aetiology. Shunt survival, NDO, cerebral palsy (CP), epilepsy, speech delay, education, behavioural disorders, endocrine dysfunction, and mortality were evaluated. Results A total of 323 infants with median gestational age of 37.0 (23.29–42.14) weeks and birthweight of 2640 g (525–4684 g) were evaluated. PHH was the most common aetiology (31.9%) and was associated with significantly higher 5-year shunt revision rates, revisions beyond a year, and median number of revisions than congenital or “other” hydrocephalus (all p < 0.02). Cox regression demonstrated poorest shunt survival in PHH, related to gestational age at birth and corrected age at shunt insertion. PHH also had the highest rate of severe disabilities, increasing with age to 65.0% at 10 years, as well as the highest CP rate; only genetic hydrocephalus had significantly higher endocrine dysfunction (p = 0.01) and mortality rates (p = 0.04). Conclusions Infants with PHH have poorer surgical and NDO compared to all other aetiologies, except genetic hydrocephalus. Research into measures of reducing neurodisability following PHH is urgently required. Long-term follow-up is essential to optimise support and outcomes.

Long-term Risk of Shunt Failure After Brain Tumor Surgery

Long-term risks and survival times of ventriculoperitoneal (VP) shunts implanted due to hydrocephalus (HC) after craniotomy for brain tumors are largely unknown. The aim of this study was to establish the overall VP shunt survival rates during a decade post-shunt insertion and to determine risks of failure after brain tumor surgery in the long-term period. In this population-based cohort from a well-defined geographical region, all adult patients (> 18 years) from 2004-2013 who underwent craniotomies for intracranial tumors leading to VP shunt dependency were included. Our brain tumor database was cross-linked to procedure codes for shunt surgery (codes AAF) to extract brain tumor patients who became VP shunt dependent after craniotomy. The VP shunt survival times, i.e. the shunt longevity, was calculated from the day of shunt insertion after brain tumor surgery until the day of its failure. A total of 4174 patients underwent craniotomies, of whom 85 became VP shunt-dependent (2%) afterwards. Twenty-eight patients (33%) had one or more shunt failures during their long-term follow-up, yielding 1-, 5- and 10-year shunt success rates of 77%, 71%, and 67%, respectively. Patient age, sex, tumor location, primary/repeat craniotomy, ventricular entry, post-craniotomy hemorrhage, post-shunting meningitis/infection and multiple shunt revisions were not statistically significant risk factors for shunt failure. Median shunt longevity was 457.5 days and 21.5 days for those with and without pre-craniotomy HC, respectively (p < 0.01). This study can serve as benchmark for future studies.

The survival of reimplanted shunts following externalization: a single-institution cohort study

OBJECTIVEThe failure-free survival of ventriculoperitoneal shunts (VPSs) following externalization for distal catheter infection or malfunction has not been adequately explored. Conversion to a ventriculoatrial shunt (VAS) may allow earlier reinternalization in lieu of waiting for the peritoneum to be suitable for reimplantation. This option is tempered by historical concerns regarding high rates of VAS failure, and the risks of rare complications are rampant.METHODSIn this retrospective cohort study, all patients undergoing externalization of a VPS at a single institution between 2005 and 2020 were grouped according to the new distal catheter terminus location at the time of reinternalization (VPS vs VAS). The primary outcomes were failure-free shunt survival and duration of shunt externalization. Secondary outcomes included early (< 6 months) shunt failure.RESULTSAmong 36 patients, 43 shunt externalization procedures were performed. Shunts were reinternalized as VPSs in 25 cases and VASs in 18 cases. The median failure-free survival was 1002 (interquartile range [IQR] 161–3449) days for VPSs and 1163 (IQR 360–2927) days for VASs. There was no significant difference in shunt survival according to the new distal catheter terminus (log-rank, p = 0.73). Conversion to a VAS was not associated with shorter duration of shunt externalization (Wilcoxon rank-sum, p = 0.64); the median duration was 7 (IQR 5–11) days for VPSs and 8 (IQR 6–15) days for VASs. No rare complications occurred in the VAS group.CONCLUSIONSShunt failure-free survival rates following externalization are similar to published survival rates for nonexternalized shunts. There was no significant difference in survival between reinternalized VPSs and VASs. Although the VAS was not associated with a shortened duration of externalization, this finding is confounded by strong institutional preference for the VPS over the VAS. Early conversion to the VAS may be a viable treatment option in light of reassuring modern VAS survival data.

Ventriculo-Peritoneal Shunt Complications at Emergency Teaching Hospital in Duhok City

Background: Ventriculoperitoneal (VP) shunt surgery is the predominant mode of therapy for patients with hydrocephalus. However, it has potential complications that may require multiple surgical procedures during a patient’s lifetime. The aim of the article was to review the experience in a 2-year teaching hospital and to evaluate the risk factors for PV shunt failure after initial shunt surgery and after subsequent reviews. Methods: The study was carried out at The Emergency Teaching Hospital in Duhok City in Iraq. All complications of VP shunted patients admitted to the hospital from January 2013 to January 2015, were included in the study. Forty six patients (out of 170 VP shunt operations), with all shunt related complications, qualified for this study. Identification of patients with complications of VP shunt is done by obtaining proper history, examination, and identification of ventricular enlargement with periventricular edema on imaging (brain computed tomography (CT) or magnetic resonance study (MRI); also, identification of any evidence of device migration by direct vision, chest and abdominal X-ray and evidence of infection on CSF analysis. Results: The incidence of the complications was (27.1%). There were 24 (52.2%) males and 22 (47.8%) females. Males were affected more than females with a ratio 1.1:1. Their age ranged from 2 months to 67 years, with mean age 8.6 years. The most common cause for the initial VP shunt implantation was congenital hydrocephalus and was noticed in 34 (73.9%) patients. Mean duration to develop VP shunt complication was 26.6 months. The most common presenting symptom in pediatric patients was decreased oral intake in 37 (80.4%) patients; however, in adult patients, it was headache, 4 (80%) patients. The most common complication was obstruction, 25 (54.3%) patients, followed by infection in 9 (19.6%) patients. The most common treatment option given to the patients who suffered from VP shunt complications was whole system change for a new one, in 15 (32.6%) patients. Conclusions: The findings of the study indicate that age of the patient at time of shunt placement, etiology of hydrocephalus, and previous treatments before shunt surgery were independently significantly associated with the shunt survival. Prospective controlled studies are required to address the observed associations between the risk factors and incidence of shunt revisions in these patients.

Ultrasound-Guided Insertion of the Ventricular Catheter in Ventriculoperitoneal Shunt Surgery: Evaluation of Accuracy and Feasibility in a Prospective Cohort

Objective Ventriculoperitoneal shunt (VPS) placement is one of the most frequent neurosurgical procedures. The position of the proximal catheter is important for shunt survival. Shunt placement is done either without image guidance (“freehand”) according to anatomical landmarks or by use of various image-guided techniques. Studies evaluating ultrasound-guided (US-G) VPS placement are sparse. We evaluate the accuracy and feasibility of US-G VPS placement, and compare it to freehand VPS placement. Methods We prospectively collected data of consecutive patients undergoing US-G VPS placement. Thereafter, the US cohort was compared with a cohort of patients in whom VPS was inserted using the freehand technique (freehand cohort). Primary outcome was accuracy of catheter positioning, and secondary outcomes were postoperative improvement in Evans' index (EI), rates of shunt dysfunction and revision surgery, perioperative complications, as well as operation, and anesthesia times. Results We included 15 patients undergoing US-G VPS insertion. Rates of optimally placed shunts were higher in the US cohort (67 vs. 49%, p = 0.28), whereas there were no malpositioned VPS (0%) in the US cohort, compared with 10 (5.8%) in the freehand cohort (p = 0.422). None of the factors in the univariate analysis showed significant association with nonoptimal (NOC) VPS placement in the US cohort. The mean EI improvement was significantly better in the US cohort than in the freehand cohort (0.043 vs. 0.014, p = 0.035). Conclusion Based on our preliminary results, US-G VPS placement seems to be feasible, safe, and increases the rate of optimally placed catheters.

Neuroendoscopic lavage for the management of posthemorrhagic hydrocephalus in preterm infants: safety, effectivity, and lessons learned

OBJECTIVETreatment of posthemorrhagic hydrocephalus in preterm infants is a matter of debate among pediatric neurosurgeons. Neuroendoscopic lavage (NEL) has been proposed as a suitable technique for the management of this pathology. The authors present their experience with 46 patients treated with NEL after germinal matrix hemorrhage, describe their technique, and analyze the outcomes.METHODSA retrospective analysis of patients affected by grade III or IV intraventricular hemorrhage (IVH) treated with NEL was performed. Nonmodifiable risk factors such as gestational age, weight at birth, modified Papile grade, and intercurrent diseases were reviewed. Safety analysis was performed, evaluating the incidence of postoperative complications. Effectivity was measured using radiological (frontal horn index and white matter injury), CSF biochemical (proteins, blood, and cellularity), and clinical variables. Permanent shunt rate and shunt survival were analyzed. The motor outcome was measured using the Gross Motor Function Classification System (GMFCS) at 18–24 months, and the neurocognitive outcome was evaluated according to the grade of adaptation to schooling.RESULTSForty-six patients met the inclusion criteria. Patients were treated with a single NEL in 21 cases, 2 lavages in 13 cases, and 3 lavages in 12 cases. The mean gestational age at birth was 30.04 weeks, and the mean weight at birth was 1671.86 g. Hyaline membrane disease was described in 4.8% of the cases, hematological sepsis in 43.47%, persistent ductus arteriosus in 23.9%, and necrotizing enterocolitis in 10.9% of the cases. Modified Papile grade III and IV IVHs were observed in 60.9% and 39.1% of the cases, respectively. Postoperative infection was diagnosed in 10 of the 46 cases, CSF leak in 6, and rebleeding in 3. The mean frontal horn index decreased from 49.54 mm to 45.50 mm after NEL. No white matter injury was observed in 18 of 46 patients, focal injury was described in 13 patients, and diffuse bilateral white matter injury was observed in 15 patients. All CSF biochemical levels improved after lavage. The shunt rate was 58.7%, and shunt survival at 1 year was 50%. GMFCS grades I, II, III, IV, and V were observed in 44.74%, 21.05%, 2.63%, 15.79%, and 15.79% of patients, respectively. Good neurocognitive results were observed in 53.3% of the cases.CONCLUSIONSNeuroendoscopic lavage was a suitable alternative for the management of IVH in preterm infants in our series. Good motor and neurocognitive results were achieved by this technique, and the permanent shunt rate was reduced compared with historical controls.

Survival and failure trends of cerebrospinal fluid shunts with distal slit valves: comparative study and literature review

OBJECTIVEThe malfunction rates of and trends in various cerebrospinal fluid (CSF) shunt designs have been widely studied, but one area that has received little attention is the comparison of the peritoneal distal slit valve (DSV) shunt to other conventional valve (CV) type shunts. The literature that does exist comes from older case series that provide only indirect comparisons, and the conclusions are mixed. Here, the authors provide a direct comparison of the overall survival and failure trends of DSV shunts to those of other valve type shunts.METHODSThree hundred seventy-two new CSF shunts were placed in pediatric patients at the authors’ institution between January 2011 and December 2015. Only ventriculoperitoneal (VP) shunts were eligible for study inclusion. Ventriculoatrial, lumboperitoneal, cystoperitoneal, subdural-peritoneal, and spinal shunts were all excluded. Rates and patterns of shunt malfunction were compared, and survival curves were generated. Patterns of failure were categorized as proximal failure, distal failure, simultaneous proximal and distal (proximal+distal) failure, removal for infection, externalization for abdominal pseudocyst, and addition of a ventricular catheter for loculated hydrocephalus.RESULTSA total of 232 VP shunts were included in the final analysis, 115 DSV shunts and 117 CV shunts. There was no difference in the overall failure rate or time to failure between the two groups, and the follow-up period was statistically similar between the groups. The DSV group had a failure rate of 54% and a mean time to failure of 17.8 months. The CV group had a failure rate of 50% (p = 0.50) and a mean time to failure of 18.5 months (p = 0.56). The overall shunt survival curves for these two groups were similar; however, the location of failure was significantly different between the two groups. Shunts with DSVs had proportionately more distal failures than the CV group (34% vs 14%, respectively, p = 0.009). DSV shunts were also found to have proximal+distal catheter occlusions more frequently than CV shunts (23% vs 5%, respectively, p = 0.005). CV shunts were found to have significantly more proximal failures than the DSV shunts (53% vs 27%, p = 0.028). However, the only failure type that carried a statistically significant adjusted hazard ratio in a multivariate analysis was proximal+distal catheter obstruction (CV vs DSV shunt: HR 0.21, 95% CI 0.05–0.81).CONCLUSIONSThere appears to be a difference in the location of catheter obstruction leading to the malfunction of shunts with DSVs compared to shunts with CVs; however, overall shunt survival is similar between the two. These failure types are also affected by other factors such etiology of hydrocephalus and endoscope use. The implications of these findings are unclear, and this topic warrants further investigation.