Hydrocephalus In Pediatric Patients Research Articles

CSF levels of myelin basic protein in pediatric patients with ventriculoperitoneal shunt infection.

IntroductionHydrocephalus is a common disorder of the central nervous system (CNS) in the pediatric population. Surgical treatment options involve ventriculoperitoneal shunt (VPS) placement. VPS infection is the most common complication of surgically treated hydrocephalus in pediatric patients [1, 2],which may lead to neuronal damage. Myelin basic protein (MBP) has been proposed as a marker of neuronal injury in a variety of contexts, and MBP levels in the cerebrospinal fluid (CSF) may be used to assess the severity of neuronal damage [1, 3, 4]. Therefore, the aim of this study was to evaluate the CSF level of myelin basic protein (MBP) in a group of pediatric patients with VPS infection.Material and methodsThirty CSF samples were collected from pediatric patients with VPS infection. CSF levels of MBP were measured at three time points, marked by contamination detection, obtention of the first sterile CSF culture, and VPS shunt implantation. The collected data were compared with those of the control group composed of children with active congenital hydrocephalus and valid CSF values.ResultsThe MBP level in the study group was higher than the corresponding control values in the second and third measurements. The highest MBP level was reached in the study group in the second and third measurements.ConclusionsThe lack of normalization of MBP level in the CSF of children with shunt infection could be connected with ongoing brain damage. It takes longer than the normalization of CSF protein level and pleocytosis. The delay is associated with a prolonged reaction of the immunological system.

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

The 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. Pediatric 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. The 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. These 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.

Perioperative near-infrared spectroscopy cerebral oxygen saturation in symptomatic pediatric hydrocephalus patients at risk for intracranial hypertension.

The lack of a continuous, noninvasive modality for monitoring intracranial pressure (ICP) is a major obstacle in the care of pediatric patients with hydrocephalus who are at risk for intracranial hypertension. Intracranial hypertension can lead to cerebral ischemia and brain tissue hypoxia. In this study, the authors evaluated the use of near-infrared spectroscopy (NIRS) to measure regional cerebral oxygen saturation (rSO2) in symptomatic pediatric patients with hydrocephalus concerning for elevated ICP. The authors evaluated the NIRS rSO2 trends in pediatric patients presenting with acute hydrocephalus and clinical symptoms of intracranial hypertension. NIRS rSO2 values were recorded hourly before and after neurosurgical intervention. To test for significance between preoperative and postoperative values, the authors constructed a linear regression model with the rSO2 values as the outcome and pre- and postsurgery cohorts as the independent variable, adjusted for age and sex, and used the generalized estimating equation method to account for within-subject correlation. Twenty-two pediatric patients underwent NIRS rSO2 monitoring before and after CSF diversion surgery. The mean durations of NIRS rSO2 recording pre- and postoperatively were 13.95 and 26.82 hours, respectively. The mean pre- and postoperative rSO2 values were 73.84% and 80.65%, respectively, and the adjusted mean difference estimated from the regression model was 5.98% (adjusted p < 0.0001), suggestive of improved cerebral oxygenation after definitive neurosurgical CSF diversion treatment. Postoperatively, all patients returned to baseline neurological status with no clinical symptoms of elevated ICP. Cerebral oxygenation trends measured by NIRS in symptomatic pediatric hydrocephalus patients with intracranial hypertension generally improve after CSF diversion surgery.

Intraoperative Injection of Intraventricular Antibiotics is Associated With a Decreased Incidence of Infection and Revision Surgery in Pediatric Hydrocephalus Patients Undergoing Shunt Placement

Abstract INTRODUCTION Infection is the most common cause of morbidity and additional intervention following the placement of a ventriculoperitoneal shunt, even with the use of antibiotic-impregnated catheters. At present, no studies have demonstrated the utility of intraoperative, intraventricular antibiotic injection in reducing the rates of infection and shunt revision. METHODS A prospective, multicenter, shunt-specific neurosurgical registry was used to identify all pediatric patients undergoing first-time placement of a shunt for the definitive treatment of hydrocephalus. All patients who received intraventricular antibiotics (eg, vancomycin or gentamicin) via the shunt catheter during surgery were identified. A variety of variables, including prior temporizing measures (ventriculostomy, subgaleal shunt, reservoir, etc), use of surgical adjuncts (antibiotic-impregnated catheter, stereotactic guidance, choroid plexus coagulation), and reasons for unplanned interventions (infection, CSF leak, catheter obstruction) were collected for each patient. Bivariate statistics and multivariable regression modeling were used to explore the relationship between prophylactic, intraventricular antibiotic placement and subsequent outcomes. RESULTS A total of 2193 pediatric patients undergoing shunt placement for hydrocephalus were identified. Of these, 552 (25.2%) underwent intraoperative injection of antibiotics into the ventricular space. Postoperatively, 104 (4.7%) patients had unplanned removal, replacement, or revision of their shunt at a mean of 14.2 +/− 9 d following the initial procedure. A total of 29 (27.9%) of these interventions were secondary to infection. In a multivariable regression model controlling for patient characteristics, etiology of hydrocephalus, prior temporizing measures, use of image guidance, and placement of an antibiotic-impregnated shunt, intraoperative injection of intraventricular antibiotics was associated with a significant reduction in postoperative infections (OR = 0.217, 95% CI: 0.051–0.916, P = .038). Of those receiving intraventricular antibiotics, only 2 (0.36%) went on to develop an infection. CONCLUSION Pediatric patients who received prophylactic, intraoperative injection of intraventricular antibiotics experienced a significantly decreased incidence of additional surgery secondary to infection, even when controlling for the use of antibiotic-impregnated catheters.

Feasibility of fast brain diffusion MRI to quantify white matter injury in pediatric hydrocephalus.

Traditionally, diffusion MRI (dMRI) has been performed in parallel with high-resolution conventional MRI, which requires long scan times and may require sedation or general anesthesia in infants and young children. Conversely, fast brain MRI permits image acquisition without the need for sedation, although its short pulse sequences, susceptibility to motion artifact, and contrast resolution have limited its use to assessing ventricular size or major structural variations. Here, the authors demonstrate the feasibility of leveraging a 3-direction fast brain MRI protocol to obtain reliable dMRI measures. Fast brain MRI with 3-direction dMRI was performed in infants and children before and after hydrocephalus treatment. Regions of interest in the posterior limbs of the internal capsules (PLICs) and the genu of the corpus callosum (gCC) were drawn on diffusion-weighted images, and mean diffusivity (MD) data were extracted. Ventricular size was determined by the frontal occipital horn ratio (FOHR). Differences between and within groups pre- and posttreatment, and FOHR-MD correlations were assessed. Of 40 patients who met inclusion criteria (median age 27.5 months), 15 (37.5%), 17 (42.5%), and 8 (20.0%) had posthemorrhagic hydrocephalus (PHH), congenital hydrocephalus (CH), or no intracranial abnormality (controls), respectively. A hydrocephalus group included both PHH and CH patients. Prior to treatment, the FOHR (p < 0.001) and PLIC MD (p = 0.027) were greater in the hydrocephalus group than in the controls. While the mean gCC MD in the hydrocephalus group (1.10 × 10-3 mm2/sec) was higher than that of the control group (0.98), the difference was not significant (p = 0.135). Following a median follow-up duration of 14 months, decreases in FOHR, PLIC MD, and gCC MD were observed in the hydrocephalus group and were similar to those in the control group (p = 0.107, p = 0.702, and p = 0.169, respectively). There were no correlations identified between FOHR and MDs at either time point. The utility of fast brain MRI can be extended beyond anatomical assessments to obtain dMRI measures. A reduction in PLIC and gCC MD to levels similar to those of controls was observed within 14 months following shunt surgery for hydrocephalus in PHH and CH infants. Further studies are required to assess the role of fast brain dMRI for assessing clinical outcomes in pediatric hydrocephalus patients.

The cost of hydrocephalus: a cost-effectiveness model for evaluating surgical techniques.

In BriefThe authors analyzed the costs associated with the three different procedures used to treat hydrocephalus in the pediatric population. They believe this study highlights the importance of patient-specific treatment decisions that are based on etiology and previous intervention. The patient-specific medical characteristics are a driving force in the cost of care.

Surgical treatment of post-inflammatory hydrocephalus. Analysis of 101 cases

ObjectiveThe aim of this paper was to evaluate the outcomes of surgical treatment for post-inflammatory hydrocephalus in pediatric patients. The patient’s age, surgical technique and type of implants, revision rate (depending on the cause for revision and shunt type), and final outcome measured with Neurologic Outcome Scale for Infants and Children (NOSIC) scale were evaluated.MethodsWe performed a retrospective analysis of 101 patients with post-inflammatory hydrocephalus, treated in Polish Mother’s Memorial Hospital Research Institute since 2005. Children with comorbidities (e.g., tumors or hemorrhages) were excluded from the study. The assessment included patient age, surgical technique (ventriculoperitoneal shunt (VPS) or neuroendoscopy) and type of implant, revision rate (considering its cause), and final outcome measured in Neurologic Outcome Scale for Infants and Children (NOSIC) scale.ResultsVPS implantation was the most common surgical technique. It was performed in 66.33% (n = 67) of cases. Neuroendoscopic procedure was used in 33.66% of cases (n = 34). Revision rate of VPS was 52.23% (n = 35). Endoscopic third ventricle ventriculostomy (ETV) was efficient only in 5 cases (14.7%), whereas in 29 cases (85.3%), it was followed by VPS implantation. Revision rate in VPS implantation after ETV reached 55.17% (n = 16). In all age groups, VPS implantation was the most frequently used procedure. Revisions of the shunt systems occurred most frequently in the 1–3 (n = 21 41.18%) and < 1 (n = 12, 23.53%) age ranges. The type of valve that most often underwent dysfunction was flow-regulated type (n = 23, 62.16%). The type of valve that was the least frequently revised was differential pressure type (n = 11, 17.18%). In all age groups, mechanical dysfunction was the most frequent cause of shunt disability. Average NOSIC score ranged from 39 to 98 (average 80.58, standard deviation ± 13.34). NOSIC result relative to individual operational techniques was as follows: ETV + VPS—80.17 (n = 29, standard deviation ± 11.44), VPS—80.44 (n = 67, standard deviation ± 14.30), and ETV—80.80 (n = 5, standard deviation ± 11.62). There was no difference between the outcome of the NOSIC and the type of implanted valve or its dysfunction.ConclusionsIn our analysis, post-inflammatory hydrocephalus accounts for 11.7% of all hydrocephalus types. Of post-inflammatory hydrocephalus, multiloculated type accounts for 14.9%. The most common type of surgery in these patients is implantation of the ventriculoperitoneal system. The most frequent revisions of the VPS system occur in the group of the younger children (< 3). The most common type of a dysfunction shunt is the differential pressure valve, and the rarest type the flow-regulated type. In the case of mechanical dysfunction, occlusion of the intraventricular catheter is the most common reason. ETV does not affect the frequency of VPS revisions. The average NOSIC score in children treated with hydrocephalus is below normal, and the best results are observed in the youngest children.

2418 Post-traumatic stress symptoms in caregivers of pediatric hydrocephalus population

OBJECTIVES/SPECIFIC AIMS: The goal of this study is to characterize traumatic events and post-traumatic stress symptom severity experienced by caregivers of children with hydrocephalus. Results will eventually be evaluated and compared with demographic and medical characteristics. This study is part of a larger research project that aims to (1) determine the prevalence and risk factors for post-traumatic stress symptoms in pediatric hydrocephalus patients and their caregivers; (2) develop a targeted intervention to mitigate its effects and pilot test the intervention. METHODS/STUDY POPULATION: Caregivers of children with hydrocephalus that have received surgical treatment (CSF shunt or ETV/CPC) were enrolled during routine follow up visit in a pediatric neurosurgery clinic. Caregivers completed the PTSD Checklist for DSM-5 (PCL-5), a 20-item self-report measure that assesses the presence and severity of post-traumatic stress disorder (PTSD) symptoms. RESULTS/ANTICIPATED RESULTS: Participant responses (n=56) revealed that 57.14% of caregivers indicated that their most traumatic event was directly related to their child’s medical condition. In total, 23.21% of caregivers did not specify their most traumatic event and 1.79% of caregivers indicated that they had never experienced a traumatic event. Median Total Symptom Severity Score was 11 (mean: 15.32±14.92), and scores ranged from 0 to 67; 32.14% of caregivers scored 19 or greater, and 16.07% of caregivers scored 33 or greater, a value suggestive of a provisional diagnosis of PTSD. Severity scores by DSM-V clusters were as follows: cluster B—intrusion symptoms (mean: 4.91±4.77, median: 4, range: 0–20), cluster C—avoidance symptoms (mean: 1.27±1.87, median: 0.5, range: 0–8), cluster D—negative alterations in cognition and mood (mean: 4.86±6.07, median: 2, range: 0–22), and cluster E—alterations in arousal and reactivity (mean: 4.29±4.07, median: 3, range: 0–17). DISCUSSION/SIGNIFICANCE OF IMPACT: Preliminary results from this study indicate that post-traumatic stress symptoms are prevalent among caregivers of children with hydrocephalus. These results suggest that psychosocial issues such as PTSS may be a significant problem in need of treatment, that is not traditionally addressed as part of routine care for families of children with hydrocephalus. Characterizing post-traumatic stress symptoms in this population sets the foundation for the development of screening and treatment protocols for post-traumatic stress symptoms in caregivers of children with hydrocephalus. This study is the first step towards fundamentally improving routine clinical care and quality of life for patients with hydrocephalus and their caregivers by understanding and addressing the effects of traumatic stress.

Neurosurgical management of hydrocephalus by a general surgeon in an extremely low resource setting: initial experience in North Kivu province of Eastern Democratic Republic of Congo.

Evaluate the management of hydrocephalus in pediatric patients in the Eastern Democratic Republic of Congo by a general surgeon. Retrospective review of a single institution in the province of North Kivu. Patient charts and surgical notes were reviewed from 2003 to 2016. 116 procedures were performed for an average of 8.9 per year. 51.7% of surgeries were on female patients with an average age of 13.6 ± 22.7. The average distance traveled from home to hospital was 153.7km but ranged from 5 to 1420km. The majority of hydrocephalus was due to neonatal sepsis (57%); 33.6% were classified as congenital; 9.5% of cases followed myelomeningocele closure. 97.4% had a ventriculoperitoneal (VP) shunt placed. Endoscopic third ventriculostomy combined choroid plexus cauterization (ETV/CPC) was performed in 2.5% of patients. Shunt infection occurred in 9.5% of patients, shunt dysfunction or obstruction in 5.2% and shunt exteriorization in 1.7%; no complications occurred in patients who underwent ETV/CPC. VP shunt is the predominant management for hydrocephalus in this environment with increasing use of ETV/CPC. Further research is needed to evaluate variability by etiology, short and long-term outcomes of procedures performed by neurosurgeons and general surgeons, and regional epidemiologic variability.

Implementing a digital real-time Hydrocephalus and Shunt Registry to evaluate contemporary pattern of care and surgical outcome in pediatric hydrocephalus.

Treatment monitoring and outcome evaluation in pediatric hydrocephalus require gapless documentation regarding surgical and clinical follow-up data beginning from day 1 of treatment in order to apply high quality of care. Endoscopic procedures, shunt insertion and revision surgeries, and individual modifications of valve hardware or pressure settings during follow-up as well as established outcome measurements are highly relevant for complete illustration of the patient's hydrocephalus histories. A digital tool to capture, organize, and analyze comprehensive treatment-related data was estimated long overdue, consequentially developed, and implemented in daily pediatric neurosurgical routine. We established a self-contained, network-capable database application to supply and back up clinical information of complete surgical treatment history with implant status and follow up for all institutional pediatric hydrocephalus patients from 1995 to date. The application content has been prospectively complemented since 2012 during daily pediatric neurosurgical routine. Beside surgical data, neurological outcome and quality of life assessment were integrated according to validated scales to be recordable 2, 3, and 5years after initial surgical intervention for prospective administration. The application is in continuous and problem-free use since implementation offering homogeneous and structured real-time information of surgical and corresponding neurological hydrocephalus-related data. By using an automatized data extraction tool, an exemplary surgical outcome evaluation reviewing institutional ventriculo-peritoneal shunt (VPS) treatment in infants over a period of more than 20years was performed. To validate applicability, the Registry was successfully implemented in an external institution under identical conditions continuously serving for the same purpose until today. Upon completion of the developing process, the application was successfully implemented into routine clinical workflow of our institution. In total, 579 pediatric hydrocephalus patients entered into the Registry with collectively 1874 corresponding hydrocephalus-related surgeries (9% neuro-endoscopic procedures, 18% temporary CSF-diversions, 73% shunt surgeries) so far. For exemplary surgical outcome analysis, the total volume of complex data sets could easily be reduced stepwise in regard to requested inclusion criteria. The selection process generated conclusive data of 256 institutional pediatric VPS patients providing a median follow-up of 8.5years. Surgical outcome was evaluated in regard to hydrocephalus etiology, applied valve design, valve augmentation, cause of initial malfunction, time to initial shunt revision, and number of total revisions. The pediatric hydrocephalus registry application delivers easy access to contemporary and up-to-date clinical information during daily clinical routine and proves comprehensive value for various scientific purposes. Institutional hydrocephalus etiologies, treatment modalities, and surgical outcome could be reviewed for a selected pediatric patient collective during an interval of more than 20years and confirmed initial shunt treatment within the first year of age, communicating hydrocephalus and a history of prematurity as significant variables for unfavorable shunt survival and long-term revision rate. At our institution, the Registry emerged to an essential and sustainable tool to capture, organize, and analyze patterns of care in pediatric hydrocephalus patients of all etiologies and treatment modalities. Because of its adaptable and reliable predicate, a prospective multi-center utilization is currently in preparation.

ENDOSCOPIC THIRD VENTRICULOSTOMY VERSUS VENTRICULOPERITONEAL SHUNT IN TREATMENT OF OBSTRUCTIVE HYDROCEPHALUS COMPLICATING PEDIATRIC POSTERIOR FOSSA TUMORS

Background:Posterior fossa tumors are the most common solid tumors found in the pediatric population. Approximately, 70–90% of patients with posterior fossa tumors present with hydrocephalus. This presents an interesting problem to pediatric neurosurgeons for which there remains no consensus: What is the best management strategy for hydrocephalus at the time of the initial presentation of the patient? Objective: This multicenter prospective cohort study compared endoscopic third ventriculostomy (ETV) and ventriculoperitoneal shunt (VPS) in the treatment of pediatric patients with secondary obstructive hydrocephalus due to posterior fossa tumors. Patients and Methods: Sixty four patients with posterior fossa tumors (24 medulloblastoma, 12 ependymoma, 27 astrocytoma and 1 schwannoma) associated with secondary hydrocephalus were divided into two equal groups according to the treatment procedure done to the secondary hydrocephalus either ETV or VP shunts, with a follow-up period of 6 months, were prospectively studied in this work. Results: Both procedures (ETV and VP shunt) proved to be effective clinically and radiographically. Endoscopic third ventriculostomy (ETV) proved to be superior due to shorter duration of surgery (17 min versus 58 min), no mortality (0% versus 6.25%), and lower incidence of procedure failure (15.6% versus 21.9%) with highest success rate of 100% was for astrocytomas followed by 80% for ependymomas and 63.6% for medulloblastomas. Conclusion: Both procedures (ETV and VP shunt) proved to be effective clinically and radiographically in the treatment of secondary obstructive hydrocephalus in pediatric patients with posterior fossa tumors. For ETV, the safety, simplicity, a more physiological of internal shunting, a significantly shorter surgery duration, absence of mortality, lower significant complications rate, a lower rate of procedure failure, the significant advantages of not becoming shunt dependent and avoidance of hardware complications (malfunction, obstruction, infection) and making safe handling and resection of the posterior fossa tumors feasible, all the previous factors made the ETV to be recommended as the first choice in the treatment of pediatric patients with obstructive hydrocephalus due to posterior fossa tumors.

Role of MRI CSF Flowmetry in Evaluation of Hydrocephalus in Pediatric Patients

Background: phase contrast MR imaging is a rapid, simple and non-invasive technique which is sensitive to even small CSF flows, and can be used to evaluate CSF flow both qualitatively and quantitatively. Cine phase contrast MR images show CSF flow in a dynamic, more easily appreciable, and in a more pleasing manner, allowing the delineation of obstruction, if present, along the portions of CSF pathway where obstruction is common (foramen of Monro, acqueduct of Sylvius) Patients and Methods: the study includes 20 patients from the pediatric population with ventriculomegaly (diagnosed by a radiological report) referred from Ain Shams Pediatric Hospital, Neurosurgery department at Ain Sahms University, clinic, and outpatients. Control group of 20 pediatric patients of matched age group underwent CSF flow study to obtain normal reference values. These patients had no hydrocephalus and came to our institute to undergo MRI for other neurological causes. CSF flowmetry was added to their study after obtaining oral informed consent from their parents. Results: our study included 20 patients, 8 males and 12 females, with age range 2 months - 12 years and average age 3.5 years old. All patients included were diagnosed with hydrocephalus by a previous radiological report. All patients underwent conventional MRI brain and CSF flowmetry. Patients were given diagnosis based on findings of conventional MR images, and were categorized into groups according to their underlying etiologies. 9 patients had aqueductal stenosis, 4 patients had atrophy, 2 patients had communicating hydrocephalus, 2 patients had Arnold Chiari malformation, 1 patient had Dandy-Walker variant, 1 patient had obstruction at foramen of Monro, and 1 had obstruction at foramen of Magendi. CSF flowmetry was added to evaluate the cause of hydrocephalus. Conclusion: phase contrast MR imaging is a rapid, simple and non-invasive technique which is sensitive to even small CSF flows, and can be used to evaluate CSF flow both qualitatively and quantitatively, and could be used in conjunction with conventional MRI in assessment of cases of hydrocephalus.

Left hemisphere structural connectivity abnormality in pediatric hydrocephalus patients following surgery

Neuroimaging research in surgically treated pediatric hydrocephalus patients remains challenging due to the artifact caused by programmable shunt. Our previous study has demonstrated significant alterations in the whole brain white matter structural connectivity based on diffusion tensor imaging (DTI) and graph theoretical analysis in children with hydrocephalus prior to surgery or in surgically treated children without programmable shunts. This study seeks to investigate the impact of brain injury on the topological features in the left hemisphere, contratelateral to the shunt placement, which will avoid the influence of shunt artifacts and makes further group comparisons feasible for children with programmable shunt valves. Three groups of children (34 in the control group, 12 in the 3-month post-surgery group, and 24 in the 12-month post-surgery group, age between 1 and 18 years) were included in the study. The structural connectivity data processing and analysis were performed based on DTI and graph theoretical analysis. Specific procedures were revised to include only left brain imaging data in normalization, parcellation, and fiber counting from DTI tractography. Our results showed that, when compared to controls, children with hydrocephalus in both the 3-month and 12-month post-surgery groups had significantly lower normalized clustering coefficient, lower small-worldness, and higher global efficiency (all p < 0.05, corrected). At a regional level, both patient groups showed significant alteration in one or more regional connectivity measures in a series of brain regions in the left hemisphere (8 and 10 regions in the 3-month post-surgery and the 12-month post-surgery group, respectively, all p < 0.05, corrected). No significant correlation was found between any of the global or regional measures and the contemporaneous neuropsychological outcomes [the General Adaptive Composite (GAC) from the Adaptive Behavior Assessment System, Second Edition (ABAS-II)]. However, one global network measure (global efficiency) and two regional network measures in the insula (local efficiency and between centrality) tested at 3-month post-surgery were found to correlate with GAC score tested at 12-month post-surgery with statistical significance (all p < 0.05, corrected). Our data showed that the structural connectivity analysis based on DTI and graph theory was sensitive in detecting both global and regional network abnormality when the analysis was conducted in the left hemisphere only. This approach provides a new avenue enabling the application of advanced neuroimaging analysis methods in quantifying brain damage in children with hydrocephalus surgically treated with programmable shunts.

The role of MRI in pediatric obstructive hydrocephalus: An update

Hydrocephalus can be defined as ventriculomegaly secondary to excessive increment of cerebrospinal fluid in ventricular system. The diagnosis of hydrocephalus is not a challenge presently, but the exact definition of this entity and its etiology is often difficult. Early detection of the etiology of hydrocephalus is vital for accurate and early treatment. In childhood, obstructive hydro- cephalus is the most common type of hydrocephalus. Magnetic resonance imaging (MRI) is the radiological method providing the maximal clinicallyuseful data neededforreachingthe precise diagnosis andinitiating the correct treatment.In thisreview, wediscuss the role of MRI in the evaluation of pediatric obstructive hydrocephalus patients based on new techniques and recent literature.

PMD29 - Economic impact derived from the use of a catheter impregnated with Antibiotic in pediatric patients with hydrocephalus treated with external shunts in Mexico

Estimate the economic impact derived from the use of antibiotic-impregnated catheters vs. traditional, non-antibiotic-impregnated catheters for the treatment of hydrocephalus in pediatric patients with external shunts from a Mexican public hospital perspective (IMSS). An Excel-based decision tree was used to estimate the economic consequences of using an antibiotic-impregnated catheter (treatment group) vs. a catheter without antibiotic (control group) for target population. Given procedure volume variability in comparable hospitals, base-case scenario assumed 100 pediatric patients with hydrocephalus and only one potential infection after first catheter placement; the antibiotic-impregnated device was assumed as second-line treatment for both groups. Infection rates after catheter placement for considered alternatives were taken from published international meta-analyses (2.4% vs. 8.7% for treatment and control groups, respectively). Unitary costs were provided by internal resources (antibiotic-impregnated device) and by public bid results for base-case hospital (traditional catheter). Considered time horizon was <1 year, thus no annual discount rate for costs was necessary. Inflation-adjusted DRGs from IMSS´s high specialty hospitals were used as hospitalization (catheter placement) and catheter replacement costs. Results are shown in 2015-adjusted USD. Due to low reinfection rates documented in literature, posterior infections and mortality were not considered. The total cost of the catheter with antibiotic strategy resulted in $1,610,600, while the non-antibiotic catheter strategy in $1,542,200, resulting in additional $684 per patient treated with the antibiotic-impregnated device and $11,400 per avoided infection. The use of antibiotic-impregnated catheters appears to be a cost-effective alternative to treat hydrocephalus in pediatric patients in the Mexican setting. Local high-specialty hospitals should consider the adoption of this alternative as it yields less infections in target population.

Neuroendoscopic biopsy and the treatment of tumor-associated hydrocephalus of the ventricular and paraventricular region in pediatric patients: a nationwide study in Japan.

A neuroendoscopic biopsy is a minimally invasive and useful procedure for the diagnosis and initial management of tumor-associated hydrocephalus. We describe the nationwide investigation of the current status of neuroendoscopic biopsy for intra- and paraventricular tumors in children, as well as the treatment of tumor-associated hydrocephalus in pediatric patients. The main items examined included the patient's age and sex, location of the tumor, pathological diagnosis, complications, treatment and efficacy of treatment of the tumor-associated hydrocephalus, and the dissemination during the postoperative course. Two hundred twenty-one pediatric patients (mean 8.6years) from 67 institutions were registered. Endoscopic tumor biopsies were performed in 206 patients (93.2%), and a histopathological diagnosis could be performed in 195 of these 206 patients (94.7%). The most frequently histopathologically diagnosed tumor was a germ cell tumor (41.5%), followed by astrocytic tumors (24.1%) and cystic lesions (15.9%). Associated hydrocephalus was observed in 177 patients (80.1%), 101 of whom underwent endoscopic third ventriculostomy (ETV). The efficacy rate of the ETV in the perioperative period was 99.0%, and the long-term response rate was 90.1%. Perioperative complications other than fever were found in 24 patients (10.9%). In the statistical analysis, pediatric long-term response rate to ETV (p = 0.025) showed significantly more favorable results for pediatric than adult patients (p < 0.05). Neuroendoscopic procedures involving pediatric intra- and paraventricular tumors were considered to be very useful, with a low incidence of complication, and were associated with higher safety.

Endoscopic third ventriculostomy for post-inflammatory hydrocephalus in pediatric patients: is it worth a try?

Hydrocephalus is a very common disease in developing countries. Congenital aqueductal obstruction and post-inflammatory hydrocephalus come on the top of the list of causes of hydrocephalus. Till the recent introduction of cranial endoscopy and despite their frequent complications, shunts were considered as the mainstream treatment for this disease. Endoscopic third ventriculostomy (ETV), especially for obstructive hydrocephalus, introduced a new era of treatment that is free of lifetime shunt dependency. This study was done to assess the efficacy of ETV for treating post-inflammatory hydrocephalus in a unique group of patients thus preventing—if possible—the lifetime shunt dependency and suffering. ETV was tried as a first-line therapy in 35 children (23 males and 12 females) with hydrocephalus proved to be secondary to intracranial infection. Mean age was 9.2 months (4-15). Twenty-four patients (68.6%) were below the age of 6 months while 11 patients (31.4%) were above 6 months. Twenty-five patients (71.4%) had a head circumference of 3 cm and 10 patients (28.6%) had a 5 cm or more increase in the head circumference above the 95th percentile. All the patients included were followed postoperatively with regular clinical, computerized tomography (CT), and magnetic resonance imaging (MRI) examinations as well as cerebrospinal fluid (CSF) analysis and culture. The overall success of ETV was 55.9% (19/34). Nine (81.9%) out of the 11 patients that were endoscopically documented to have aqueductal obstruction showed improvement. While out of the 23 patients with patent aqueduct, only 10 patients (43.4%) had improved. Procedure-related complications were not encountered. CSF leakage from the surgical wound occurred in three patients and mild CSF infection occurred in one patient. ETV is a simple, safe, and effective method in treating not only obstructive hydrocephalus due to non-inflammatory etiology, but also post-inflammatory hydrocephalus especially when the aqueduct is obstructed. An overall 50% improvement in our study and even more in other series encourage the trial of getting rid of the lifetime shunt complications and suffering.

Management and Treatment of Hydrocephalus in Pediatric Patients - Our Experience

Introduction: Hydrocephalus is a disturbance of cerebrospinal fluid (CFS) physiology, which causes an increase in the amount of CSF present in the cranium, which most commonly results in increased pressure against the brain tissue. CSF diversionary surgery still remains one of the most common procedures in neurosurgery. Cerebrospinal fluid diversion procedures remain the principal method of treatment of hydrocephalus. Commonly used procedures are ventriculo-peritoneal shunt, endoscopic third ventriculostomy and external ventricular drainage. Aim: The objective was to analyze incidence, indications, and complications related to ventriculoperitoneal shunt surgery in pediatric patients. Material and Methods: A retrospective study performed at the Clinic of Pediatric surgery - Department of Neurosurgery, Institute for Child and Youth Health Care of Vojvodina from 2009-2014. Demographic datas (age, sex), indications, complications and mortality/morbidity were analyzed. Results: The total number of performed procedure was 62 (35 girls and 27 boys). Ventriculoperitoneal shunt was performed in 57 patients. Endoscopic third ventriculostomy was performed in 5 patients. The most common indication for ventriculoperitoneal shunt was for congenital hydrocephalus (33), intracranial tumors (13), post infection (7), and for others (granulomatous lesion). Shunt obstruction (18.7%) was most common among the complications, followed by infection (7.15%). Conclusion: Hydrocephalus is a complicated condition to diagnose, and treatment options are limited. Current long-term treatment options are restricted to surgical interventions, including shunt placement and ETV. The treatment of hydrocephalus often requires long-term care and lifelong follow-up, especially in children and neonates in whom there is a congenital cause.

102 Validation and Modification of a Predictive Model of Post-Resection Hydrocephalus in Pediatric Patients With Posterior Fossa Tumors

102 Validation and Modification of a Predictive Model of Post-Resection Hydrocephalus in Pediatric Patients With Posterior Fossa Tumors

Validation and modification of a predictive model of postresection hydrocephalus in pediatric patients with posterior fossa tumors

Postresection hydrocephalus is observed in approximately 30% of pediatric patients with posterior fossa tumors. However, which patients will develop postresection hydrocephalus is not known. The Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH) was developed in an attempt to identify this subset of patients, allowing for the optimization of their care. The authors sought to validate and critically appraise the CPPRH. The authors conducted a retrospective chart review of 99 consecutive pediatric patients who presented between 2002 and 2010 with posterior fossa tumors and who subsequently underwent resection. The data were then analyzed using bivariate and multivariate analyses, and a modified CPPRH (mCPPRH) was applied. Seventy-six patients were evaluated. Four variables were found to be significant in predicting postresection hydrocephalus: age younger than 2 years, moderate/severe hydrocephalus, preoperative tumor diagnosis, and transependymal edema. The mCPPRH produced observed likelihood ratios of 0.737 (95% CI 0.526-1.032) and 4.688 (95% CI 1.421-15.463) for low- and high-risk groups, respectively. The mCPPRH utilizes readily obtainable and reliable preoperative variables that together stratify children with posterior fossa tumors into high- and low-risk categories for the development of postresection hydrocephalus. This new predictive model will aid patient counseling and tailor the intensity of postoperative clinical and radiographic monitoring for hydrocephalus, as well as provide evidence-based guidance for the use of prophylactic CSF diversion.