Risk Factors of Persistent Hydrocephalus in Children with Brain Tumor: A Retrospective Analysis

<b><i>Object:</i></b> Hydrocephalus is one of the main complications of brain tumors in children, being present in about 50% of cases at the time of the tumor diagnosis and persisting up to 10–40% of cases after surgical resection. This is a single-institution retrospective study on the variables that may predict the need for treatment of persistent hydrocephalus in pediatric patients presenting with a brain tumor. <b><i>Methods:</i></b> Retrospective case note review of 43 newly diagnosed brain tumors in children referred between April 2012 and January 2018 to our regional pediatric neuro-oncology service was carried out. Diagnosis of hydrocephalus was carried out using both preoperative and postoperative MRI to determine Evans’ index (EI) and the fronto-occipital horn ratio (FOHR) from each scan. Simple logistic regression was used to analyze categorical variables as appropriate. A <i>p</i> value &#x3c;0.05 was considered significant. <b><i>Results:</i></b> Forty-three children were analyzed, 26 males and 17 females with a median age at diagnosis 10.4 years (IQR: 5.2–13.5). Hydrocephalus was present in 22/43 children (51%) preoperatively; in 8/22 children (36%) with hydrocephalus undergoing tumor resection, hydrocephalus persisted also in the postoperative period. An EI &#x3e;0.34 (<i>p</i> = 0.028) and an FOHR &#x3e;0.46 (<i>p</i> = 0.05) before surgery were associated with a higher prevalence of persistent hydrocephalus and therefore to the need for a cerebrospinal fluid drain device in the postoperative phase. <b><i>Conclusion:</i></b> Preoperative identification of children at risk for developing persistent hydrocephalus would avoid delays in planning the permanent cerebrospinal fluid drain devices. This study finds that an EI &#x3e;0.34 and an FOHR &#x3e;0.46 at diagnosis could impact on the therapeutic management of children with hydrocephalus associated with brain tumors. Prospective and larger-scale studies are needed to standardize this approach.

Ventriculosubgaleal shunting in the treatment of posthemorrhagic hydrocephalus of premature infants: case series

Introduction: Posthemorrhagic hydrocephalus(PHH) comprises the most common complication in preterm infants (PTI) who suffered germinative matrix hemorrhage (GMH), and its treatment is still matter of controversies. These infants usually weigh less than 1,500g and a temporary CSF diversion is needed. VSGS is preferred in those cases because it is a simple and rapid method, no need for repetitive aspiration for the evacuation of CSF, gives a permanent decompression without causing electrolyte and nutritional losses, and still protects the cerebral development of newborns with GMH. Methods: We analyzed a series of 22 PTI who underwent VSGS for PHH, between July 2015 and April 2019, and minimum follow-up 6 months. The median gestation age was 28 weeks (range 23-32). The median weigh was 985g (range 625-1615). The mean period harboring de VSGS was 61,8 days (range 35-80). Results: The cases were studied for: 1) Shunt dependency: 11 children (50%) showed persistent hydrocephalus at further investigation and underwent to VP shunt after stable clinical condition. 2) Infection: 6 subjects (27,2%) showed positive cultures, and were converted to External Ventricular Device (EVD), and further VP shunt; 3) Outcome: the results were separated in Excellent/Good (GOS 5-4) 12 subjects (54%); Poor (GOS 3-2): 8 subjects (36%) and Death (GOS 1): 2 subjects (10%). Conclusions: VSGS is a good alternative method to treat PHH, especially in a preterm infant who needs a temporary shunt device. The low rate of severe complications and encouraging results about persistent hydrocephalus should guide further investigation and larger cases series.

Graft dural closure is associated with a reduction in CSF leak and hydrocephalus in pediatric patients undergoing posterior fossa brain tumor resection

OBJECTIVEThe authors aimed to evaluate clinical, radiological, and surgical factors associated with posterior fossa tumor resection (PFTR)–related outcomes, including postoperative complications related to dural augmentation (CSF leak and wound infection), persistent hydrocephalus ultimately requiring permanent CSF diversion after PFTR, and 90-day readmission rate.METHODSPediatric patients (0–17 years old) undergoing PFTR between 2000 and 2016 at Monroe Carell Jr. Children’s Hospital of Vanderbilt University were retrospectively reviewed. Descriptive statistics included the Wilcoxon signed-rank test to compare means that were nonnormally distributed and the chi-square test for categorical variables. Variables that were nominally associated (p < 0.05) with each outcome by univariate analysis were included as covariates in multivariate linear regression models. Statistical significance was set a priori at p < 0.05.RESULTSThe cohort consisted of 186 patients with a median age at surgery of 6.62 years (range 3.37–11.78 years), 55% male, 83% Caucasian, and average length of follow-up of 3.87 ± 0.25 years. By multivariate logistic regression, the variables primary dural closure (PDC; odds ratio [OR] 8.33, 95% confidence interval [CI] 1.07–100, p = 0.04), pseudomeningocele (OR 7.43, 95% CI 2.23–23.76, p = 0.0007), and hydrocephalus ultimately requiring permanent CSF diversion within 90 days of PFTR (OR 9.25, 95% CI 2.74–31.2, p = 0.0003) were independently associated with CSF leak. PDC versus graft dural closure (GDC; 35% vs 7%, OR 5.88, 95% CI 2.94–50.0, p = 0.03) and hydrocephalus ultimately requiring permanent CSF diversion (OR 3.30, 95% CI 1.07–10.19, p = 0.0007) were associated with wound infection requiring surgical debridement. By multivariate logistic regression, GDC versus PDC (23% vs 37%, OR 0.13, 95% CI 0.02–0.87, p = 0.04) was associated with persistent hydrocephalus ultimately requiring permanent CSF diversion, whereas pre- or post-PFTR ventricular size, placement of peri- or intraoperative extraventricular drain (EVD), and radiation therapy were not. Furthermore, the addition of perioperative EVD placement and dural closure method to a previously validated predictive model of post-PFTR hydrocephalus improved its performance from area under the receiver operating characteristic curve of 0.69 to 0.74. Lastly, the authors found that autologous (vs synthetic) grafts may be protective against persistent hydrocephalus (p = 0.02), but not CSF leak, pseudomeningocele, or wound infection.CONCLUSIONSThese results suggest that GDC, independent of potential confounding factors, may be protective against CSF leak, wound infection, and hydrocephalus in patients undergoing PFTR. Additional studies are warranted to further evaluate clinical and surgical factors impacting PFTR-associated complications.

Persistent Hydrocephalus and Activated Microglia Drive the Spatial Memory Decline After Intraventricular Hemorrhage in Rodents

INTRODUCTION Intraventricular hemorrhage (IVH) can result in significant cognitive deficits and spatial memory impairments that can prevent over half of IVH patients from returning to work after recovery. The mechanism of this memory decline, however, is incompletely understood. METHODS To understand the role of mechanical trauma caused by rapid ventricular expansion vs the presence of blood components, such as thrombin, in IVH deficits, we developed a rodent model of IVH by injecting 200 μL of autologous arterial blood into the animals' ventricles. The IVH animals’ memories were then assessed along with sham (no injection), vehicle control (200 μL aCSF), and intraventricular thrombin (IVT) (20 U thrombin in 5 μL aCSF) animals using Morris water maze. RESULTS The IVH group performed worse on this spatial memory task compared to all other groups, indicating that ventricular expansion and presence of blood components both contribute to memory deficits. Based on magnetic resonance imaging (MRI) results, the IVH group was also the only group that developed persistent hydrocephalus. Contrary to our hypothesis that the cognitive deficits of IVH are due to decreased hippocampal neurogenesis, we did not find any statistical difference in the numbers of dentate gyrus progenitor cells (labeled with BrdU and DCX) or neurons (labeled with NeuN) between the different groups. The number of microglia (labeled with Iba1) was also compared among the groups and found to be not statistically different. The microglia in IVH and vehicle control animals, however, were found to have significantly lower fractal dimension (P < .001) and higher lacunarity (P < .001) numbers compared to those of sham animals, indicating a more activated state, likely caused by the mechanical trauma. CONCLUSION Based on our results, persistent hydrocephalus microglial activation seem to be the drivers of spatial memory deficit after IVH.

Abstract TP327: Timing of Ventriculostomy and Ventricular Shunting for Intracranial Hemorrhage: A National Inpatient Sample Study

Background: Intraventricular hemorrhage requiring ventriculostomy (EVD) placement is a frequent complication of spontaneous intracerebral hemorrhage (ICH). Urgent EVD may be warranted for management of acute hydrocephalus, and a subset of these patients will require permanent ventricular shunt (VS) placement. In contrast to hydrocephalus following sub-arachnoid hemorrhage, less is known about the frequency and timing of EVD and VS placement after ICH. Methods: Using the 2010-2012 National Inpatient Sample, we selected patients with ICD-9 codes for ICH, excluded secondary causes, and examined procedure dates for EVD and VS placement. Results: Of 35,991 primary ICH patients, 2,392 (6.7%) received an EVD, 89% within the first 3 days of admission and 64% within the first day. Placement of a VS occurred in 268 patients (0.7%) overall. VS placement occurred in 143 of 2,129 (6.7%) of those receiving an EVD in the first 72 hours and 34 of 263 (12.9%) receiving an EVD after 72 hours (p<0.001). Median time to shunt placement following EVD was 15 days (IQR 11-21) vs 16.5 (IQR 13-21) for those with EVD within vs after 72 hours (p=0.2). 82 (0.2%) received a VS without an initial EVD at a median of 14 days (IQR 9-18). Kaplan-Meier analysis revealed that among those remaining alive and in hospital at 14 and 21 days, 5% and 11%, respectively, underwent shunt placement following EVD. To analyze the effect of VS timing following EVD, we compared those undergoing VS in the first two weeks versus later than two weeks. Following multivariate logistic regression, only age 70 -80 was associated with early shunt placement (OR 4.8, 95%CI 1.2-19). No effect on mortality or rate of home discharge was seen. Length of stay was shorter in those with early versus later VS (20 vs 32 days, p<0.001) Conclusion: Persistent hydrocephalus following EVD placement for ICH is rare overall but VS is required in up to 12% of a subset of patients. EVD placement after the initial 72 hours was associated with an increased rate of VS, while older age was associated with earlier VS placement after EVD. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.

Neurosurgical treatment of low-grade cerebellar astrocytoma in children and adolescents: a single consecutive institutional series of 100 patients

Object The objective of this study was to delineate the long-term results of surgical treatment of pediatric low-grade cerebellar astrocytoma. Methods One hundred consecutive children and adolescents (0–19 years old) who underwent primary tumor resection for a low-grade cerebellar astrocytoma during the years 1980–2011 were included in this retrospective study on surgical morbidity, mortality rate, academic achievement, and/or work participation. Gross motor function and activities of daily living were scored according to the Barthel Index. Results Of the 100 patients, 61 children were in the 1st decade, and 39 were 10–19 years old. The male/female ratio was 1.13:1 (53 males, 47 females). No patients were lost to follow-up. There were no deaths in this series and all 100 patients are currently alive. In 29 patients, the follow-up duration was less than 10 years, in 37 it was between 10 and 19 years, and in 34 it was between 20 and 31 years. The Barthel Index was 100 (normal) in 97 patients, 90 in 2 patients, and 40 in the last patient. A total of 113 tumor resections were performed. Two patients underwent further tumor resection due to MRI-confirmed residual tumor demonstrated on the immediate postoperative MR image (obtained the day after the initial procedure). Furthermore, 9 children underwent repeat tumor resection after MRI-confirmed progressive tumor recurrence up to 10 years after the initial operation. Two of these patients also underwent a third resection, without subsequent radiation therapy, and have experienced 8 and 12 years of tumor-free follow-up thereafter, respectively. A total of 15% of the patients required treatment for persistent hydrocephalus. Conclusions Low-grade cerebellar astrocytoma is a surgical disease, in need of long-term follow-up, but with excellent long-term results. Nine percent of the children in this study underwent repeated surgery due to progressive tumor recurrence, and 15% were treated for persistent hydrocephalus.

POSTOPERATIVE HYDROCEPHALUS IN PATIENTS UNDERGOING DECOMPRESSIVE HEMICRANIECTOMY FOR ISCHEMIC OR HEMORRHAGIC STROKE

OBJECTIVE We have frequently observed the development of postoperative communicating hydrocephalus in patients undergoing decompressive hemicraniectomy. This condition may persist in some patients after cranioplasty and require permanent cerebrospinal fluid (CSF) diversion. To confirm an independent correlation between hemicraniectomy and the development of communicating hydrocephalus, and to detail the frequency and potential clinical factors contributing to this complication, we evaluated our series of patients undergoing hemicraniectomy for life-threatening increases in intracranial pressure secondary to ischemic or hemorrhagic stroke. METHODS A retrospective analysis was performed with a cohort of consecutive patients who underwent emergent hemicraniectomy for medically refractory elevations in intracranial pressure. Patients with known independent risk factors for the development of communicating hydrocephalus were excluded. Clinical and imaging data were reviewed to determine the incidence and type of hydrocephalus after hemicraniectomy, the persistence of hydrocephalus after cranioplasty, and the need for permanent CSF diversion. RESULTS Eighty-eight percent of the eligible patients undergoing hemicraniectomy in our cohort developed postoperative communicating hydrocephalus. Half of these patients harbored persistent hydrocephalus after cranioplasty and required placement of a ventriculoperitoneal shunt. We noted a strong correlation between prolonged time to replacement of the bone flap and persistence of hydrocephalus. CONCLUSION Communicating hydrocephalus is an almost universal finding in patients after hemicraniectomy. Delayed time to cranioplasty is linked with the development of persistent hydrocephalus, necessitating permanent CSF diversion in some patients. We propose that early cranioplasty, when possible, may restore normal intracranial pressure dynamics and prevent the need for permanent CSF diversion in patients after hemicraniectomy.