Predictors of the Need for Cerebrospinal Fluid Diversion in Patients with Myelomeningocele

Abstract

Background There is no consensus about the optimal timing and the criteria for cerebrospinal fluid diversion in children with myelomeningocele (MM). The aim of this work is to assess the predictors of the need for cerebrospinal fluid diversion in patients with myelomeningocele to avoid the unnecessary shunting with its complications. Patients and Methods This prospective study included fifty infants with myelomeningocele that were managed in the Neurosurgical department in Ain shams University hospital and October health insurance hospital from August 2016 till December 2018. Results In this study, 22 (44%) patients needed a shunt surgery after repair of the myelomeningocele. The age at presentation was highly significant (HS) for the need for shunt (P-value 0.006), with median age of 4.25 months. There were 22 cases (44%) that crossed the head circumference percentile for age while 28 cases (56%) matched; This was statistically highly significant (P-value 0.000). All patients with lax anterior fontanel (AF) or with mild bulge didn’t need a shunt, while all patients with tense AF needed a shunt (P-value 0.000). It was noticed that persistent vomiting was a sensitive indicator of the increased intracranial pressure since it occurred in all the cases who required shunt, this was statistically highly significant (P-vale 0.000). Four cases (8% of the cases) suffered from cerebrospinal fluid leak from the myelomeningocele wound within the first week post MM repair. Conclusion AF status & HC percentile for age represent the most reliable clinical signs to identify those who will need & benefit from a CSF diversion. The VP shunt should be preserved for cases exhibiting progressive signs of increased ICP (moderate to severe AF bulge- HC crossing percentile for age), while cases showing ventriculomegaly on imaging without signs of increased ICP should be followed up.