The cost of serial cerebrospinal fluid aspirations between ventricular access device (VAD) and ventriculosubgaleal shunt (VSGS) for treatment of post-hemorrhagic ventricular dilatation (PHVD) in premature infants

Introduction: Ventriculosubgaleal shunts (VSGS) require fewer cerebrospinal (CSF) aspirations than ventricular access devices (VAD) for temporization of post-hemorrhagic ventricular dilatation (PHVD) in preterm infants. Cost of postoperative CSF aspiration has not been quantified. Methods: We reviewed CSF aspiration and laboratory studies obtained in preterm infants with PHVD and VAD at our institution between 2009-2020. Cost per aspiration was calculated for materials, labs, and Medicare fee schedule for ventricular puncture through implanted reservoir. We searched PubMed, Cochrane Library, Embase, CINAHL, and Web of Science for meta-analysis of pooled mean number of CSF aspirations and proportion of patients requiring aspiration. Results: Thirty-five preterm infants with PHVD had VAD placed with 22.2±18.4 aspirations per patient. Labs were obtained after every aspiration per local protocol. Cost per aspiration at our institution was $935.51. Of 269 published studies, 77 reported on VAD, 29 VSGS, and 13 both. Five studies on VAD (including the current study) had a pooled mean of 25.8 aspirations per patient (95%CI:16.7-34.8). One study on VSGS reported a mean of 1.6±1.7 aspirations. 3 studies on VAD (including the current study) had a pooled proportion of 97.4% of patients requiring aspirations (95%CI: 87.9-99.5). Four studies on VSGS had a pooled proportion of 36.5% requiring aspirations (95%CI:26.9-47.2). Frequency of lab draws ranged from weekly to daily. Based on costs at our institution, mean number of aspirations, and proportion of patients requiring aspirations, cost difference ranged between $4,243 to $23,235 per patient and $500,903 to 2.36 million per 100 patients depending on frequency of taps and Medicare locality. Discussion/Conclusion: Lower number of CSF aspirations using VSGS can be associated with considerably lower cost compared to VAD.

Decreased Cerebral Oxygenation in Premature Infants with Progressive Posthemorrhagic Ventricular Dilatation May Help with Timing of Intervention

Objective The objective of this study was to determine the degree of progressive posthemorrhagic ventricular dilatation (PHVD) that is associated with a significant decrease in regional cerebral oxygen saturation (rScO2) in premature infants at risk for periventricular–intraventricular hemorrhage (PIVH). Study Design Cranial ultrasound (US) and near-infrared spectroscopy (NIRS) measurements of rScO2 were performed on inborn infants with birth weights less than 1,250 g on admission and at 1, 4, and 8 weeks of age. Infants with severe PIVH were studied weekly. A 1-hour average of rScO2 was compared with the frontal–occipital horn ratio (FOHR) measured the same day. Generalized linear models were used to analyze the relationship between FOHR and rScO2, by severity of PIVH, and adjusted for gestational age. Cut-off points of 0.55 for FOHR and 45% for rScO2 were used to calculate odds ratios (OR) and 95% confidence intervals (CI). Results The study cohort included 63 infants with normal US, 15 with grade-1 or -2 PIVH (mild group), and 21 with grade-3 or -4 PIVH (severe group). Increases in FOHR in the severe group were associated with decreases in rScO2 at 1 week (p = 0.036), 4 weeks (p = 0.013), and 8 weeks of life (p = 0.001) compared with the normal and mild groups. Infants with FOHR greater than 0.55 were 92% more likely to have rScO2 less than 45% when compared with infants with FOHR less than 0.55 (OR = 0.08, 95% CI: [0.04, 0.13], p < 0.001). Conclusion Progressive PHVD (FOHR > 0.55) is a strong predictor of compromised cerebral oxygenation. A combination of rScO2 and FOHR measurements may aid in identifying infants with PHVD that would benefit from early intervention. Key Points

Dyke-Davidoff-Masson Syndrome as a rare congenital hemiatrophy: a case report

Introduction: Dyke-Davidoff-Masson syndrome (DDMS) is a rare condition in childhood with very few cases reported in sub-Saharan Africa. Typically, the patient presents with facial asymmetry, seizures, and hemiparesis. Radiological findings include cerebral hemiatrophy, ipsilateral lateral ventricular dilatation, and hypertrophy of the calvarium and sinuses. Case presentation: We present the report of a 3-year-old male with weakness of right upper and lower limbs, facial asymmetry, and seizures. Physical examination showed a well-nourished child with a squint of the right eye. There were brisk tendon reflexes with right-sided hemiplegia which is spastic with left limb preference. Computer tomography of the brain showed atrophy of the left cerebral hemisphere, ipsilateral lateral ventricular dilatation, and thickening of the ipsilateral cranium. The diagnosis of Dyke-Davidoff-Masson syndrome was made. He was treated with sodium valproate and lamotrigine and presently physiotherapy and he had remained seizure-free. Conclusion: Dyke-Davidoff-Masson syndrome still affects children despite being a rare condition. There is a need for appropriate clinical and radiological assessment for the diagnosis of DDMS. Early identification and appropriate treatment will improve the general outcome of children with DDMS.

Echocardiographic markers of mortality at 60 days in patients with COVID-19 in the intensive care unit

Introduction Coronavirus disease (COVID)-19 predominantly produces its effects through lung damage, but an important component of multi-organ dysfunction is cardiac involvement. We have few reports that inform about the behavior of echocardiographic images of patients with the most severe forms of the disease. Purpose The present work aims to identify prognostic markers for 60-day mortality in patients hospitalized in intensive care based on echocardiographic findings. Methodology A single-center retrospective cohort was conducted. Hospitalized patients were included in one of the nine intensive care units for COVID-19 confirmed by RT-PCR from May to October 2020. Patients with previous conditions that determined a limitation of the therapeutic effort, those who died before 24 hours and pregnant women were excluded. Portable echocardiograms were performed by two expert cardiologists following the recommendations for isolation and personal protection. The time to death was evaluated as outcome. A Cox proportional hazards model was constructed, HR and 95% confidence intervals with their p values. The study was approved by the institutional ethics committee. Results Of 326 patients included, 153 patients had an echocardiogram. The mean age was 60.7 years, 47 (30.7%) were female and 67 (44.7%) had positive troponin. 91 patients (59.5%) not survive, the mean long of stay was 8.4 (SD: 4.2) days. 111 (72.5%) had shock, 128 (83.7%) severe ARDS (PaO2 / FiO2 &lt;100 mmHg), 142 (92.8%) required invasive ventilatory support, and 86 (56.2%) acute kidney injury. 27 (17.6%) patients had acute pulmonary embolism, 16 (10.4%) acute myocardial infarction and 9 (5.9%) myocarditis. The mean right ventricular ejection fraction was 37%, TAPSE was decreased in 16 cases (10.4%). 41 cases (26.8%) had right diastolic dysfunction. 34/48 (71%) cases had pulmonary hypertension. The average LVEF was 59.3% and 74 (48.4%) had some left ventricular diastolic dysfunction. 12 (7.8%) had left ventricular segmental wall motion abnormality and 16 (10.4%) had pericardial effusion. Univariate analysis identified TAPSE, PSAP, acute cor pulmonale and right ventricular dilatation as variables related to the outcome of mortality. The multivariate Cox model (Table 2) documented that acute cor pulmonale with a HR of 12.8 (95% CI 3.51 - 46.63, p&lt;0.001) and right ventricular dilation with a HR of 4, 87 (95% CI 1.36–17.46, P 0.016) were associated with mortality. Conclusions In patients hospitalized in the intensive care unit for COVID-19, acute cor pulmonale and right ventricular dilatation behaved as independent predictors of in-hospital death. FUNDunding Acknowledgement Type of funding sources: None. Table 1. Baselines characteristics Table 2. Multivariate analisys

External ventricular drainage for posthemorrhagic ventricular dilatation in preterm infants: insights on efficacy and failure

OBJECTIVE The objective of this study was to describe the clinical and neuroradiological characteristics of a cohort of preterm infants who had undergone external ventricular drain insertion as a temporary measure to treat posthemorrhagic ventricular dilatation. In addition, the authors investigated the factors predicting permanent shunt dependency. METHODS The authors retrospectively reviewed the medical records of a cohort of preterm infants who had undergone external ventricular drain insertion at Gaslini Children’s Hospital (Genoa, Italy) between March 2012 and February 2018. They also analyzed clinical characteristics and magnetic resonance imaging data, including diffusion- and susceptibility-weighted imaging studies, which were obtained before both catheter insertion and removal. RESULTS Twenty-eight infants were included in the study. The mean gestational age was 28.2 ± 2.7 weeks, and the mean birth weight was 1209 ± 476 g. A permanent ventriculoperitoneal shunt was inserted in 15/28 (53.6%) infants because of the failure of external ventricular drainage as a temporary treatment option. Compared with the shunt-free group, the shunt-dependent group had a significantly lower gestational age (29.3 ± 2.3 vs 27.2 ± 2.7 weeks, p = 0.035) and tended toward a lower birth weight (p = 0.056). None of the clinical and neuroradiological characteristics significantly differed between the shunt-free and shunt-dependent groups at the time of catheter insertion. As expected, ventricular parameters as well as the intraventricular extension of intracerebral hemorrhage, as assessed using the intraventricular hemorrhage score, were reportedly higher in the shunt-dependent group than in the shunt-free group before catheter removal. CONCLUSIONS External ventricular drainage is a reliable first-line treatment for posthemorrhagic hydrocephalus. However, predicting its efficacy as a unique treatment remains challenging. A lower gestational age is associated with a higher risk of posthemorrhagic hydrocephalus progression, suggesting that the more undeveloped the mechanisms for the clearance of blood degradation products, the greater the risk of requiring permanent cerebrospinal fluid diversion, although sophisticated MRI investigations are currently unable to corroborate this hypothesis.