Hydrocephalus In Pediatric Patients Research Articles

Current Trends in the Treatment of Pediatric Hydrocephalus: A Narrative Review Centered on the Indications, Safety, Efficacy, and Long-Term Outcomes of Available Treatment Modalities

The pathophysiologic substrate of pediatric hydrocephalus has not been thoroughly elucidated. Valve-based shunt systems have constituted the main therapeutic option since the late 1950s. The initially used systems were concerning the ventricular system and the atrium. In the 1970s, VA shunts were not the main stay of treatment as the preferred option for the terminal end of the drainage system was the peritoneum. Our review analyzes these valve types and attempts a comparison, based on their functional characteristics. Nowadays, the only available surgical alternative for the treatment of hydrocephalus is ETV. This technique is associated with lower infection rates as well as, on average, a lower re-operation rate. Another term that deserves special mention is related to the outcome of ETV in children who had a medical history of previously incorporated shunts and who were subsequently suffering from shunt malfunction. Well-recognized predictive factors associated with secondary ETV failure include age, early onset of hydrocephalus, and prematurity. Although several attempts have been made in order to establish the optimum surgical treatment management in the different subgroups of patientswho are suffering from shunt dysfunction, there is no universal agreement. Therefore, this review attempts to identify the specific subpopulations of patients in whom the insertion of a drainage system as the preferred treatment modality is associated with an optimum long-term prognosis, compared to ETV, and vice versa. The objective of our study is to analyze the safety, efficacy, and outcomes of drainage devices and ETV in pediatric hydrocephalus patients.

Long-Term Success of Endoscopic Third Ventriculostomy in the Pediatric Population with Aqueductal Stenosis

To evaluate the long-term success rate of endoscopic third ventriculostomy (ETV) in the treatment of hydrocephalus due to aqueductal stenosis in the pediatric population. Between January 2007 and June 2023, a total of 82 children underwent ETV surgery for hydrocephalus and met the inclusion criteria for our study. The children's medical records were reviewed, and cases requiring additional surgery in the months and years following surgery for ventriculostomy failure were reviewed. The mean age was 5.35years. Successful ETV was observed in 74 children with a successful ETV rate of 90%. The median follow-up was 6.75years (2 months to 15.5years). Eight children (10%) underwent additional surgery. In 7 cases, additional surgery was performed within 3months, while in the remaining case; a delayed failure was noted (more than 3years later). At 6months and 3years, the cumulative proportion of children with revision-free survival was 91%, declining slightly to 89% at 5years. ETV is highly effective in treating hydrocephalus in pediatric patients with aqueductal stenosis, with a 91% success rate at 6months and 3years. Although the success rate drops slightly to 89% at 5years, it still demonstrates durability. Late failures are usually characterized by symptoms of increased intracranial pressure. While patients with a confirmed successful ETV at 6months may be considered for reduced follow-up frequency, it is critical to educate them about the symptoms of intracranial hypertension and the importance of seeking medical attention promptly if such symptoms occur.

Low surgical weight associated with ETV failure in pediatric hydrocephalus patients.

The use of endoscopic third ventriculostomy (ETV) for treatment of pediatric hydrocephalus has higher failure rates in younger patients. Here we investigate the impact of select perioperative variables, specifically gestational age, chronological age, birth weight, and surgical weight, on ETV failure rates. A retrospective review was performed on patients treated with ETV - with or without choroid plexus cauterization (CPC) - from 2010 to 2021 at a large academic center. Analyses included Cox regression for independent predictors and Kaplan-Meier survival curves for time to-event outcomes. In total, 47 patients were treated with ETV; of these, 31 received adjunctive CPC. Overall, 66% of the cohort experienced ETV failure with a median failure of 36 days postoperatively. Patients aged < 6 months at time of surgery experienced 80% failure rate, and those > 6 months at time of surgery experienced a 41% failure rate. Univariate Cox regression analysis showed weight at the time of ETV surgery was significantly inversely associated with ETV failure with a hazard ratio of 0.92 (95% CI 0.82, 0.99). Multivariate analysis redemonstrated the inverse association of weight at time of surgery with ETV failure with hazard ratio of 0.76 (95% CI 0.60, 0.92), and sensitivity analysis showed < 4.9kg as the optimal cutoff predicting ETV/CPC failure. Neither chronologic age nor gestational age were found to be significantly associated with ETV failure.In this study, younger patients experienced higher ETV failure rates, but multivariate regression found that weight was a more robust predictor of ETV failure than chronologic age or gestational age, with an optimal cutoff of 4.9kg in our small cohort. Given the limited sample size, further study is needed to elucidate the independent role of weight as a peri-operative variable in determining ETV candidacy in young infants. Previous presentations: Poster Presentation, Congress of Neurological Surgeons.

Reassessing the Related Factors of Hydrocephalus in Pediatric Patients with Posterior Fossa Tumours: 5-year Single-Center Data

Reassessing the Related Factors of Hydrocephalus in Pediatric Patients with Posterior Fossa Tumours: 5-year Single-Center Data

Percutaneous Ventriculoatrial Shunting as a Salvage Method in the Pediatric Hydrocephalus Patients with Peritoneal Problems.

To evaluate the efficacy of percutaneous ventriculoatrial shunting as a salvage method for pediatric patients with abdominal complications. Data obtained from 9 patients with ventriculoperitoneal shunt dysfunctions owing to abdominal complications, who underwent ventriculoatrial shunting as salvage treatment at a single institution between January 2019 and September 2021 were retrospectively analyzed. All operations were conducted under the guidance of intraoperative fluoroscopy and ultrasound. The mean age of the enrolled patients was 8.1 ± 1.2 years (2-15 years). Six (67%) patients were male and 3 (33%) were female. The mean number of the patients? ventriculoperitoneal shunt revisions until atrial catheter placement was 7.5 times. The reasons for intraperitoneal catheter failure included peritoneal adhesions in 4 (44.5%) patients, pseudocyst formation in 3 (33.3%), and peritonitis in 2 (22.2%). Seven patients from the study cohort had no problem after ventriculoatrial shunt placement. Only 1 patient had shunt dysfunction related to the ventricular catheter, and ventricular catheter and shunt valve revision was performed 26 months after ventriculoatrial shunt placement. The atrial catheter of the patient was intact. One patient died from the progression of her primary disease (medulloblastoma in the 4 < sup > th < /sup > ventricle), which was unrelated to the ventriculoatrial shunt. Percutaneous ventriculoatrial shunting under the guidance of intraoperative fluoroscopy and ultrasound is a safe, effective, and easy alternative in patients with peritoneal complications and a history of multiple operations.

Association between altered white matter networks and post operative ventricle volume in shunt-treated pediatric hydrocephalus

ObjectiveThe objective of this study was to use probabilistic tractography in combination with white matter microstructure metrics to characterize differences in white matter networks between shunt-treated pediatric hydrocephalus patients relative to healthy controls. We were also able to explore the relationship between these white matter networks and postoperative ventricle volume. MethodsNetwork-based statistics was used in combination with whole-brain probabilistic tractography to determine dysregulated white matter networks in a sample of patients with pediatric hydrocephalus (n = 8), relative to controls (n = 36). Metrics such as streamline count (SC), as well as the mean of the fractional anisotropy along a tract, axial diffusivity (AD), mean diffusivity (MD), and radial diffusivity (RD) were assessed. In networks that were found to be significantly different for patients with hydrocephalus, tracts were evaluated to assess their relationship with postoperative lateral ventricle volume. ResultsPatients with pediatric hydrocephalus had various networks that were either upregulated or downregulated relative to controls across all white matter measures. Predominately, network dysregulation occurred in tracts involving structures located outside of the frontal lobe. Furthermore tracts with values suggesting decreased white matter integrity were not only found between subcortical structures, but also cortical structures. While there were various tracts with white matter metrics that were initially predicted by lateral ventricle volume, only two tracts remained significant following multiple comparisons. ConclusionsThis cross-sectional study in pediatric patients with hydrocephalus and healthy controls demonstrated using whole-brain probabilistic tractography that there are various networks with dysregulated white matter integrity in hydrocephalus patients relative to controls. These dysregulated networks have tracts connecting structures throughout the brain, and the regions were predominately located centrally and posteriorly. Postoperative ventricle volume did not predict the white matter integrity of many tracts. Future studies with larger sample sizes are needed to further understand these results.

Long-term follow-up and comparison of programmable and non-programmable ventricular cerebrospinal fluid shunts among adult patients with different hydrocephalus etiologies: a retrospective cohort study.

Programmable valve (PV) has been shown as a solution to the high revision rate in pediatric hydrocephalus patients, but it remains controversial among adults. This study is to compare the overall revision rate, revision cause, and revision-free survival between PV and non-programmable valve (NPV) in adult patients with different hydrocephalus etiologies. We reviewed the chart of all patients with hydrocephalus receiving index ventricular cerebrospinal fluid (CSF) shunt operations conducted at a single institution from January 2017 to December 2017. Patients included in the study were followed up for at least 5years. Statistical tests including independent t-test, chi-square test, and Fisher's exact test were used for comparative analysis, and Kaplan-Meier curve using log-rank test was performed to compare the revision-free survival between the PV and NPV groups. A total of 325 patients were included in the study, of which 181 patients were receiving PVs and 144 patients receiving NPV. There were 23 patients (12.8%) with PV and 22 patients (15.3%) with NPV receiving initial revision. No significant statistical difference in the initial revision rate was observed between the two groups (p = 0.52). No survival difference was found between the PV and NPV groups. However, better revision-free survival was noted in the PV group among idiopathic normal pressure hydrocephalus (iNPH) (p = 0.0274) and post-traumatic hydrocephalus (p = 0.017). The combination of the different etiologies of hydrocephalus and the features of PV and NPV results in different outcomes-revision rate and revision-free survival. PV use might be superior to NPV in iNPH and post-traumatic hydrocephalus patients. Further studies are needed to clarify the indications of PV use in adult hydrocephalus patients.

Fully automated measurement of intracranial CSF and brain parenchyma volumes in pediatric hydrocephalus by segmentation of clinical MRI studies.

Brain parenchyma (BP) and intracranial cerebrospinal fluid (iCSF) volumes measured by fully automated segmentation of clinical brain MRI studies may be useful for the diagnosis and follow-up of pediatric hydrocephalus. However, previously published segmentation techniques either rely on dedicated sequences, not routinely used in clinical practice, or on spatial normalization, which has limited accuracy when severe brain distortions, such as in hydrocephalic patients, are present. We developed a fully automated method to measure BP and iCSF volumes from clinical brain MRI studies of pediatric hydrocephalus patients, exploiting the complementary information contained in T2- and T1-weighted images commonly used in clinical practice. The proposed procedure, following skull-stripping of the combined volumes, performed using a multiparametric method to obtain a reliable definition of the inner skull profile, maximizes the CSF-to-parenchyma contrast by dividing the T2w- by the T1w- volume after full-scale dynamic rescaling, thus allowing separation of iCSF and BP through a simple thresholding routine. Validation against manual tracing on 23 studies (four controls and 19 hydrocephalic patients) showed excellent concordance (ICC>0.98) and spatial overlap (Dice coefficients ranging from 77.2% for iCSF to 96.8% for intracranial volume). Accuracy was comparable to the intra-operator reproducibility of manual segmentation, as measured in 14 studies processed twice by the same experienced neuroradiologist. Results of the application of the algorithm to a dataset of 63 controls and 57 hydrocephalic patients (19 with parenchymal damage), measuring volumes' changes with normal development and in hydrocephalic patients, are also reported for demonstration purposes. The proposed approach allows fully automated segmentation of BP and iCSF in clinical studies, also in severely distorted brains, enabling to assess age- and disease-related changes in intracranial tissue volume with an accuracy comparable to expert manual segmentation.

A comparative study of Outcome in Ventriculoperitoneal Shunt and Endoscopic Third Ventriculostomy in Cases of Tubercular Meningitis with Hydrocephalus in Pediatric Patients

Introduction: Tuberculous meningitis (TBM) is becoming a rare illness in industrialized nations, but it is still widespread in underdeveloped nations. Ventriculoperitoneal shunt surgery is the GOLD Standard and is time tested procedure. Shunts, however, are associated with multiple problems. Material and Method: This is an observational study that compares the outcome of Endoscopic Third Ventriculostomy (ETV) with Ventriculoperitoneal shunt in patients of TBM with hydrocephalus at a 6-month follow-up. This study was done at a single tertiary care center. Data was collected from the patient records as per selection criteria. 100 consecutive cases in each ETV and Shunt group fulfilling selection criteria were included in the study. The two procedures were compared for their clinical outcome based on modified Vellore grade at 6 months of follow-up. Discussion: Evaluation of outcome at 6 months revealed an overall success rate of 68.5%. The success rate was higher for shunt (71%) as compared to ETV (66 %). However, the difference between the two groups was not significant statistically. For children with advanced TBM and elevated ICP, shunt surgery may not be necessary. While some authors have considered the potential of delaying surgery for these kids, others have argued that even a single positive outcome warrants shunt placement for every kid with tuberculous hydrocephalus. Conclusion: In pediatric cases of TBM with Hydrocephalus ETV should be considered as a first-line treatment in lower grades of TBM. Though for definitive comparison, a long-term randomized study is needed, and the study to look into factors responsible for the failure of ETV in TBM cases needs to be identified to formulate an ETV success score.

Endoscopic Third Ventriculostomy with Choroid Plexus Cauterization in Infantile Hydrocephalus: An Experience from Mali

Introduction: Pediatric hydrocephalus is a common disease in sub-Saharan Africa. In Mali, 350–400 new cases are diagnosed in our center yearly. With a total land mass of 1,241,000 km², patients in remote areas must travel up to 1,500 km to access neurosurgical care. Hence, treatment and follow-ups of “shunted” patients are difficult. In this context, endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) provides an opportunity for an affordable and less constraining treatment for hydrocephalus children under 12 months of age. Methods: We performed a retrospective analysis of ETV/CPC performed on infants from July 2013 to January 2015. Patients were followed postoperatively on day 15, month 6, and month 12. Statistical analysis was conducted using Prism 9 GraphPad software. ETV successes were categorized according to the patient’s age into 3 groups: ≤3 months, 3–6 months, and 6–12 months. Statistical significance was defined at p < 0.05. Results: During the study period, 199 patients were included with 40% of patients aged between 0 and 6 months. The head circumference ranged from 35 cm to 79 cm. The etiology was congenital malformation in 55%. ETV/CPC was a success in 69% of 6- to 12-month-old patients, 54% in the 3- to 6-month-old patients, and 29% in ≤3-month-old patients. Overall, 94 (47%) patients were successfully treated without a shunt. The postoperative infection rate was 1% and mortality at 12 months was 8%. Conclusion: In a low-income environment such as Mali, ETV/CPC stands as a viable and alternative treatment option for pediatric hydrocephalus patients; our findings suggest that age is an important factor in predicting ETV success.

Phase-contrast magnetic resonance imaging in evaluation of hydrocephalus in pediatric patients

BackgroundHydrocephalus is an increase in cerebrospinal fluid volume leading to cerebral ventricular enlargement (ventriculomegaly). Phase-contrast magnetic resonance imaging is a sensitive technique to cerebrospinal fluid flow allowing noninvasive quantitative and qualitative evaluation of cerebrospinal fluid flow.AimThe purpose of our study was to assess the role of cerebrospinal fluid flowmetry using phase-contrast magnetic resonance imaging in evaluation of hydrocephalus in pediatric patients.MethodsThis prospective study included a group of 50 patients with ventriculomegaly diagnosed by a previous magnetic resonance imaging study. A control group of 20 subjects of matched age group were also included. All the participants were subjected to cerebrospinal fluid flow study.ResultsAfter quantitative assessment of cerebrospinal fluid flow at aqueduct level, the mean values of flow and velocity parameters were compared in both patients and control groups. The mean values in patients with aqueduct stenosis and Dandy–Walker malformation were significantly lower than those of the control group (no flow with hypodynamic circulation) with p < 0.001, < 0.017 for mean velocity, respectively, the mean values in patients with brain atrophy and Arnold–Chiari malformation, bilateral obstructive hydrocephalus at foramen of Monro were significantly lower than those of the control group (diminished flow with hypodynamic circulation) with p < 0.001, < 0.001, 0.046 for mean velocity, respectively, and 0.002, 0.001, 0.160 for stroke volume, respectively, the mean values in patients with communicating hydrocephalus and unilateral obstructive hydrocephalus at foramen of Monro were significantly higher than those of the control group (hyperdynamic flow) with p < 0.001 for mean velocity and stroke volume, and the mean values in patients with arachnoid cysts were within normal as compared to control group (normal dynamic flow).ConclusionPhase-contrast magnetic resonance imaging is a noninvasive technicality used for evaluation of cerebrospinal fluid flow both qualitatively and quantitatively for determining the type of hydrocephalus seen.

Predictive models for postoperative hydrocephalus in pediatric patients with posterior fossa tumors.

Predictive models for postoperative hydrocephalus in pediatric patients with posterior fossa tumors.

SURG-36. EVALUATION OF SURGICAL RESULTS AND PREDICTIVE FACTORS OF HYDROCEPHALUS IN PEDIATRIC PATIENTS WITH POSTERIOR FOSSA TUMORS

Abstract INTRODUCTION Infratentorial tumors represent 45 to 60% of all brain tumors in children and are associated with hydrocephalus in 70 to 90% of cases. The aim of this study is to describe and analyze the surgical results and correlate them with the incidence of hydrocephalus, as well as identify predictive factors of hydrocephalus in pediatric patients underwent to a surgical treatment of posterior fossa tumors. METHODS This is a retrospective observational study, based on demographic, clinical and radiological information of pediatric patients underwent to surgical resection of posterior fossa tumors by a single group between 2011 and 2019. RESULTS We included 135 patients with a mean age of 7.56 years, mean follow-up of 35.7 months and overall survival of 18.8 months. Considering the histology, most tumors were pilocytic astrocytomas (34.1%), followed by medulloblastomas (27.4%) Total resection was achieved in 77.8% and tumor recurrence was observed in 16.2%. The rate of hydrocephalus was 36.3%, with most shunt procedures performed preoperatively. There was a high rate of complications associated with shunting (42.9%), mostly represented by infection (71.5%). Patients with hydrocephalus were younger (p = 0.001), showing a faster evolution between the onset of symptoms and diagnosis (p = 0.008). Tumor volume (p = 0.1) and location (p = 0.32) were not statistically significant for hydrocephalus, however, the presence of leptomeningeal disease (p = 0.001) was. The resection rate was also significant, with lesions totally resected showing the best results (p = 0.009). Regarding tumor histology, 33.3% of patients with medulloblastoma and 62.5% of patients with ependymoma were shunted. CONCLUSION One third of children with posterior fossa tumors will require a shunt procedure. Some factors should guide the neurosurgeon during patient counseling and surgical planning to minimize the use of permanent shunts and avoid related complications.

Role of MRI CSF Flowmetry in Evaluation of Hydrocephalus in pediatric patients with Correlation between thin cuts T2, heavy T2 and Phase contrast.

Role of MRI CSF Flowmetry in Evaluation of Hydrocephalus in pediatric patients with Correlation between thin cuts T2, heavy T2 and Phase contrast.

Clinical outcomes in pediatric hydrocephalus patients treated with endoscopic third ventriculostomy and choroid plexus cauterization: a systematic review and meta-analysis.

Endoscopic third ventriculostomy and choroid plexus cauterization (ETV+CPC) is a novel procedure for infant hydrocephalus that was developed in sub-Saharan Africa to mitigate the risks associated with permanent implanted shunt hardware. This study summarizes the hydrocephalus literature surrounding the ETV+CPC intraoperative abandonment rate, perioperative mortality rate, cerebrospinal fluid infection rate, and failure rate. This systematic review and meta-analysis followed a prespecified protocol and abides by Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A comprehensive search strategy using MEDLINE, EMBASE, PsychInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Scopus, and Web of Science was conducted from database inception to October 2019. Studies included controlled trials, cohort studies, and case-control studies of patients with hydrocephalus younger than 18 years of age treated with ETV+CPC. Pooled estimates were calculated using DerSimonian and Laird random-effects modeling, and the significance of subgroup analyses was tested using meta-regression. The quality of the pooled outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. After screening and reviewing 12,321 citations, the authors found 16 articles that met the inclusion criteria. The pooled estimate for the ETV+CPC failure rate was 0.44 (95% CI 0.37-0.51). Subgroup analysis by geographic income level showed statistical significance (p < 0.01), with lower-middle-income countries having a lower failure rate (0.32, 95% CI 0.28-0.36) than high-income countries (0.53, 95% CI 0.47-0.60). No difference in failure rate was found between hydrocephalus etiology (p = 0.09) or definition of failure (p = 0.24). The pooled estimate for perioperative mortality rate (n = 7 studies) was 0.001 (95% CI 0.00-0.004), the intraoperative abandonment rate (n = 5 studies) was 0.04 (95% CI 0.01-0.08), and the postoperative CSF infection rate (n = 5 studies) was 0.0004 (95% CI 0.00-0.003). All pooled outcomes were found to be low-quality evidence. This systematic review and meta-analysis provides the most comprehensive pooled estimate for the ETV+CPC failure rate to date and demonstrates, for the first time, a statistically significant difference in failure rate by geographic income level. It also provides the first reported pooled estimates for the risk of ETV+CPC perioperative mortality, intraoperative abandonment, and CSF infection. The low quality of this evidence highlights the need for further research to improve the understanding of these critical clinical outcomes and their relevant explanatory variables and thus to appreciate which patients may benefit most from an ETV+CPC. Systematic review registration no.: CRD42020160149 (https://www.crd.york.ac.uk/prospero/).

SURG-11. Evaluation of surgical results and predictive factors of hydrocephalus in pediatric patients with posterior fossa tumors

Abstract INTRODUCTION: Infratentorial tumors represent 45 to 60% of all brain tumors in children and are associated with hydrocephalus in 70 to 90% of cases. The aim of this study is to describe and analyze the surgical results and correlate them with the incidence of hydrocephalus, as well as identify predictive factors of hydrocephalus in patients underwent to a surgical treatment of posterior fossa tumors. METHODS: This is a retrospective observational study, based on demographic, clinical and radiological information of pediatric patients underwent to surgical resection of posterior fossa tumors by a single group between 2011 and 2019. RESULTS: We included 135 patients with a mean age of 7.56 years, mean follow-up of 35.7 months and overall survival of 18.8 months. Considering the histology, most tumors were pilocytic astrocytomas (34.1%), followed by medulloblastomas (27.4%) Total resection was achieved in 77.8% and tumor recurrence was observed in 16.2%. The rate of hydrocephalus was 36.3%, with most shunt procedures performed preoperatively. There was a high rate of complications associated with shunting (42.9%), mostly represented by infection (71.5%). Patients with hydrocephalus were younger (p = 0.001), showing a faster evolution between the onset of symptoms and diagnosis (p = 0.008). Tumor volume (p = 0.1) and location (p = 0.32) were not statistically significant for hydrocephalus, however, the presence of leptomeningeal disease (p = 0.001) was. The resection rate was also significant, with lesions totally resected showing the best results (p = 0.009). Regarding tumor histology, 33.3% of patients with medulloblastoma and 62.5% of patients with ependymoma were shunted. CONCLUSION: One third of children with posterior fossa tumors will require a shunt procedure. Some factors should guide the neurosurgeon during patient counseling and surgical planning to minimize the use of permanent shunts and avoid related complications.

837 Shunt-dependent Post Traumatic Hydrocephalus in Pediatric Patients with Moderate to Severe Traumatic Brain Injury (TBI)

INTRODUCTION: Post-traumatic hydrocephalus (PTH) is a sequela of traumatic brain injury (TBI) causing significant morbidity among patients and treatment often requires placement of ventriculoperitoneal (VP) shunts. It is especially concerning in children given the often-lifelong dependency and quality-of-life issues over their life course. METHODS: The Nationwide Inpatient Sample 2000-2014 was queried and patients =18 years with moderate-severe TBI identified using ICD-9-CM codes. Weighted-data was analyzed and outcomes examined. RESULTS: A total 328,971 pediatric TBI cases were identified. Most patients were male (67.26%). The mean patient age was 9.74 years (SD=6.63), median 12 years (IQR=3-16). Age-group categories were: &lt;1-year (14.58%), 1-9 years (30.14%), 10-19 years (55.28%). Majority of cases were treated at teaching hospitals (81.98%). The most common injury-causes were falls (20.35%) followed by motor-vehicle accidents (18.47%). Approximately 1.47% developed PTH requiring VP-shunt placement. By age-group, VP-shunt placement occurred in &lt;1-year (3.69%), 1-9 years (1.14%), 10-19 years (1.07%), P&lt;0.001. The mean age of patients developing shunt-dependent PTH was 6.95 years (SD=7.08), median age 4 years (IQR=0-14). After multivariate regression, patients with shunt-dependent PTH demonstrated higher odds of inpatient mortality (OR=1.29; 95%CI=1.02-1.62, P&lt;0.001), tracheostomy (OR=5.93; 95%CI=4.75-7.40, P&lt;0.001) and PEG-placement (OR=5.54; 95%CI=4.40-6.96, P&lt;0.001), and also demonstrated significantly higher odds of medical complications including pulmonary insufficiency (OR=2.36; 95%CI=1.98-2.81, P&lt;0.001), acute respiratory failure (OR=2.58; 95%CI=2.15-3.10, P&lt;0.001), deep-vein thrombosis (OR=5.42; 95%CI=3.57-8.21, P&lt;0.001), pulmonary embolism (OR=3.31; 95%CI=1.01-10.82, P=0.04), ventilator associated pneumonia (OR=2.20; 95%CI=1.07-4.52, P&lt;0.001), congestive cardiac failure (OR=4.64; 95%CI=1.81-11.90, P&lt;0.001), acute renal failure (OR=2.57; 95%CI=1.45-4.56, P&lt;0.001), sepsis (OR=2.87; 95%CI=1.49-5.52, P&lt;0.001), and severe sepsis (OR=4.12; 95%CI=1.89-8.97, P&lt;0.001). CONCLUSIONS: Pediatric TBI patients developing shunt-dependent PTH have significantly higher inpatient morbidity and mortality. Research to better understand factors associated with post-traumatic hydrocephalus in pediatric patients are warranted.

Optimization of a Thermal Flow Meter for Failure Management of the Shunt in Pediatric Hydrocephalus Patients.

Hydrocephalus patients suffer from an abnormal buildup of cerebrospinal fluid (CSF) in their ventricles, and there is currently no known way to cure hydrocephalus. The most prevalent treatment for managing hydrocephalus is to implant a ventriculoperitoneal shunt, which diverts excess CSF out of the brain. However, shunts are prone to failure, resulting in vague symptoms. Our patient survey results found that the lack of specificity of symptoms complicates the management of hydrocephalus in the pediatric population. The consequences include persistent mental burden on caretakers and a significant amount of unnecessary utilization of emergency healthcare resources due to the false-positive judgement of shunt failure. In order to reliably monitor shunt failures for hydrocephalus patients and their caretakers, we propose an optimized design of the thermal flow meter for precise measurements of the CSF flow rate in the shunt. The design is an implantable device which slides onto the shunt and utilizes sinusoidal heating and temperature measurements to improve the signal-to-noise ratio of flow-rate measurements by orders of magnitude.Clinical Relevance- An implantable flow meter would be transformative to allow hydrocephalus patients to monitor their shunt function at home, resulting in reduced hospital visits, reduced exposure to radiation typically required to rule out shunt failure, and reduced caretaker anxiety.

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

Object: 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. Methods: 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 p value <0.05 was considered significant. Results: 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 >0.34 (p = 0.028) and an FOHR >0.46 (p = 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. Conclusion: 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 >0.34 and an FOHR >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.

Post-operative seizure after first time endoscopic third ventriculostomy in pediatric patients.

Post-operative seizure rates after endoscopic third ventriculostomy (ETV) are not definitively known. We analyzed our institution's experience for all causes of hydrocephalus in pediatric patients undergoing ETV to determine rates of post-ETV seizure. A retrospective review of institutional pediatric patients undergoing ETV from May 2014 to December 2018. Included were < 21 years, with 1-year follow-up. Exclusion criteria included ventriculoperitoneal shunts (VPS) prior to ETV, VPS within 7 days post-ETV, and prior seizure disorder. Data included age, gender, diagnosis, early post-operative seizure (within 7 days post-ETV), late post-operative seizures (after first 7 days and within first year post-ETV), concomitant choroid plexus cauterization (CPC), VPS conversion within 1 year, and administration of prophylactic antiepileptics. Sixty of 81 ETV cases were included; 41% underwent concomitant CPC. Of these, 53% (n = 32) were male, 46% (n = 28) female, averaging 5.8 years, with the most common diagnosis neoplasm-related obstructive hydrocephalus (38.3%, n = 23). Early post-operative seizure occurred in 6.7% (n = 4); late post-operative seizure occurred in 8.3% (n = 5). Late post-operative seizures were higher in patients experiencing early post-operative seizure versus those without (75% vs 3.7%, p = 0.003). Late post-operative seizure occurred in 13.6% (n = 3 patients) requiring VPS versus 5.3% (n = 2 patients) with successful ETV (p = 0.36). Rates did not correlate with pathology. No patients received prophylactic antiepileptics prior to surgery or exhibiting a seizure. Patients with early post-operative seizures have an increased likelihood of developing late post-operative seizures. Pediatric ETV patients may have a lower rate of both early and late post-operative seizure; underlying pathology may influence these rates.