Management Of Hydrocephalus In Children Research Articles

Optimal management of hydrocephalus in children with posterior fossa tumors

Optimal management of hydrocephalus in children with posterior fossa tumors

Endoscopic third ventriculostomy for management of hydrocephalus associated with Chiari malformation type II in children

BackgroundHydrocephalus is commonly associated with Chiari malformation (CM) particularly CM type II. The traditional treatment of hydrocephalus in these patients has been cerebrospinal fluid diversion by shunts. Endoscopic third ventriculostomy (ETV) has emerged as an alternative procedure in these patients.PurposeAssessment of the clinical and radiological outcomes of ETV in the management of hydrocephalus in children with CM II.MethodsThis is a prospective study conducted on 18 patients with CM II associated with hydrocephalus admitted to Cairo University hospitals between January 2020 and June 2021. These patients had been managed surgically by ETV. Clinical outcome was assessed based on improvement of manifestations of increased intracranial pressure while radiological outcome was based on the findings of postoperative computed tomography. In cases with early failure, serial lumbar puncture (LP) was performed for 2 days.ResultsETV was performed as a secondary procedure in 4 cases. The overall success rate of the procedure was 72%, and its success rate as a secondary procedure was 100%. Serial LP was effective in decreasing early failure in 44.4% of cases. Radiological regression of hydrocephalic changes was detected in 50% of the cases.ConclusionETV is an efficient and safe procedure in the treatment of hydrocephalus in children with Chiari malformation II, particularly when performed as a secondary procedure. Serial LP following the procedure increases the success rate in patients with early failure.

A validation study of the modified Canadian Preoperative Prediction Rule for Hydrocephalus in children with posterior fossa tumors

OBJECTIVE Perioperative management of hydrocephalus in children with posterior fossa tumors (PFTs) remains challenging. The modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH) has been previously described as a useful tool in predicting which children are at higher risk for permanent hydrocephalus following PFT resection and can be used in guiding treatment. The aim of this study was to externally validate this predictive model. METHODS A retrospective review of the children treated in a single unit was conducted, recording all of the mCPPRH parameters (age, preoperative radiological diagnosis, presence of moderate/severe hydrocephalus, transependymal edema, and metastatic disease at the time of diagnosis), the need for a CSF diversion procedure at 6 months, time to surgery, and management of hydrocephalus. A receiver operating characteristic (ROC) curve was plotted using the mCPPRH, age, Evans index (EI), and frontooccipital horn ratio (FOHR), and an area under the curve (AUC) was calculated. A point-biserial correlation was run to determine the relationship between time to surgery, the insertion of an external ventricular drain (EVD), or initial EVD clamping and the development of postoperative persistent hydrocephalus. RESULTS From a total of 75 patients (mean age 6.99 years, 62.7% male) who were included in the study, 8 (10.7%) required permanent CSF diversion following PFT resection. The AUC of the ROC curve was 0.618 for the mCPPRH (p = 0.18, SE 0.088, 95% CI 0.446–0.791), 0.633 for age (p = 0.26, SE 0.119, 95% CI 0.4–0.867), 0.604 for the EI (p = 0.34, SE 0.11, 95% CI 0.389–0.818), and 0.663 for the FOHR (p = 0.17, SE 0.121, 95% CI 0.427–0.9). A significant positive correlation between EVD insertion (r = 0.239, p = 0.03) and insertion of a ventriculoperitoneal shunt was found. A negative correlation between the postoperative clamping of the EVD (r = −0.158, p = 0.4) and the time to PFT surgery (r = −0.06, p = 0.6) did not reach statistical significance. CONCLUSIONS The implementation of the mCPPRH score failed to reliably predict which children would require permanent CSF diversion following PFT resection when applied to this cohort. Clinical judgment remains the mainstay of choosing the perioperative treatment of hydrocephalus.

Efficacy Comparison of Ventriculoperitoneal Shunt and Endoscopic Third Ventriculostomy as Treatment of Hydrocephalus in Children in Developing Countries: A Meta-Analysis

Introduction: In Indonesia, cases of hydrocephalus in children are found in 40% to 50% of medical visits or neurosurgical operations. Endoscopic third ventriculostomy was one of choices for treat the patient but efficacy and effects still unknown. Purpose of this study is to broadly assess the outcome of treatments and review evidence that one treatment may have greater efficacy than another. Method: Researchers develop PICO questions. Demographic information, detailed methods, interventions, and results were extracted from the selected manuscripts. Of the 122 articles identified using optimized search parameters, 52 were withdrawn for full-text review. In total, 6 articles were accepted for inclusion in the evidentiary table and 8 were excluded for various reasons. Result: The tabulated evidence provides sufficient data to allow our evaluation of the CSF versus ETV shunt. Conclusion: CSF shunt and endoscopic third ventriculostomy (ETV) are options in the management of hydrocephalus in children

Management of Hydrocephalus in Children: Anatomic Imaging Appearances of CSF Shunts and Their Complications.

OBJECTIVE. This article addresses the management of hydrocephalus and the CSF shunts used to treat this entity. CONCLUSION. CSF shunts have a high failure rate. Imaging plays a pivotal role in assessing CSF shunt failure and determining the need for surgical revision. An in-depth knowledge of CSF shunt components, their failure modes, and the corresponding findings on anatomic imaging studies is necessary to ensure timely diagnosis and prevent permanent neurologic damage.

Clinical study and management of hydrocephalus in children

Background: Hydrocephalus is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain. Hydrocephalus can occur at any age, but it is more common in infants. Long-term complications of hydrocephalus can vary widely and are often difficult to predict and may result in significant intellectual, developmental and physical disabilities. Ventriculoperitoneal shunt remains mainstay of treatment even today as it is easily available and inexpensive.Methods: The study was conducted in Dr. V. M. Government Medical College and Hospital located in Solapur (Maharashtra) from September 2016 to 2018. It was a prospective descriptive study. 30 cases up to the age 14 years with diagnosis of hydrocephalus undergoing VP (ventriculo-peritoneal) shunt surgery were included in the study.Results: Aqueductal stenosis and tuberculous meningitis were the commonest causes of congenital and acquired hydrocephalus in children respectively. Shunt infection and shunt obstruction were the commonest post-operative complications required shunt revision. Low birth weight and other associated congenital anomalies increased the mortality rate.Conclusions: VP shunt placement has been the main treatment modality for hydrocephalus. VP shunts procedures are associated with complications and morbidity. Number of revision shunt procedures, low birth weight, associated congenital anomalies adversely affected the final surgical outcome.

Endoscopic third ventriculostomy in posterior fossa tumor

Posterior fossa (PF) tumors are among the most frequent primary neoplasms in children. Proximity to the fourth ventricle, and therefore cerebrospinal fluid (CSF) pathways, predisposes children with PF tumors to the development of obstructive hydrocephalus. Some patients with PF tumors require a permanent CSF diversion procedure prior to or after tumor removal. However, management of hydrocephalus in children with resectable PF tumors is still controversial. In order to minimize the use of permanent shunts and to avoid associated complications, some investigators have advocated routine preoperative application of endoscopic third ventriculostomy (ETV) only in selected patients. We showed a clinical video case who experienced a preoperatively ETV before the surgical resection of their posterior fossa tumor. The patient is a 5 year-old boy presented with progressive headaches, vomits and somnolence. Young children with severe preoperative hydrocephalus and a midline tumor should be considered at risk when preoperative treatment decisions are made. *de Oliveira RS and Ballestero MFM contributed equally to this manuscript

Intrathecal CSF dynamic measurements in hydrocephalus associated with MMC – Experience of the Republican center of neurosurgery of Uzbekistan

PurposeWe sought to determine methods of precise gradation of hydrocephalus in patients with spina bifida. Symptomatic hydrocephalus is a common condition associated with myelomeningocele (open spina bifida). Traditionally, hydrocephalus is treated with insertion of the ventriculo-peritoneal (VP) shunt. This has been the standard of treatment since the introduction of the Holter shunt valve for the VP shunt in the early 1960s. MethodsWe have analized the results of surgical treatment of 81 patients aged between 1 month and 1.5 year old with hydrocephalus and MMC. All patients underwent surgery in Republican center of neurosurgery of Uzbekistan for MMC with hydrocephalus in the period of 2013–2018. We suggest to use the ventricular index to determine the precise degree of hydrocephalus in patients with spina bifida and the method for selecting valve parameters. ResultsPatients with suspection of associated hydrocephalus, in order to arresting the risk of MMC rupture and prevention of possible leakage after the back closure a VP shunt was performed. According to above mentioned 52 (64.2%) patients for the 1st stage underwent VP shunt surgery with a low-pressure valve, 23 (28.4%) patients with medium pressure and 6 (7.4%) with high pressure valve. MMC repair was done in 1–3 month after VP shunt placement. To all patients we used regular valve shunts due to high cost of adjustable one and lack of official distributors (health insurance has not yet implemented in our country). ConclusionThe implantable shunt systems parameters were chosen before surgery in the surgical management of hydrocephalus in children with MMC are essential. This is important in order to prevent under or over drainage states, CSF leakage from the MMC sac. Management of hydrocephalus should be performed by considering MMC affecting craniospinal balance.

Ventriculoperitoneal shunt infection in Haji Adam Malik Hospital, Medan

Installation of ventriculoperitoneal shunts (VP) represented a substantial progress in the neurosurgical management of hydrocephalus in children. However, infection is the most commonpostoperative complication of aventriculoperitoneal shunt. It is important because it is related to substantial morbidity and mortality, and exerts a negative impact on the quality of life of patients. We retrospectively analyzed all 20 cases of shunt infection from 2013 to 2016. The types of infections found were exposed shunts15 cases (75%), and 5 cases of ventriculitis (25%). Length of infection time which calculated from the beginning of surgery was 350.20 days or 11 months. The most common pathogen types are S. epidermidis followed by P. aeruginosa, E. coli, and A. baumanii. There were many risk factors for shunt infection, but the interesting fact was the level of pre-operative albumin. There was a significant difference between low albumin levels (<3.0) and normal albumin (≥3.0) levels against the risk of exposure shunt, p = 0.015. It means there is asignificant difference between low pre-operative albumin and normal level for the risk of theexposed shunt.

Extrusion of peritoneal end of ventriculoperitoneal shunt through urethra in an infant: A rare complication

Ventriculoperitoneal (VP) shunt is a common procedure performed in the management of hydrocephalus in children. The peritoneal end of the shunt can migrate in the peritoneal cavity and extrude through the mouth, umbilicus, anus, vagina or urethra after injuring the overlying structures. Timely removal is necessary to prevent transmission of infection. We are reporting a case in which there is extrusion of shunt per urethra.

Efficacy of endoscopic third ventriculostomy in the management of hydrocephalus in children under 2 years of age: experience from a tertiary institution in Nigeria.

The management of hydrocephalus in developing countries is challenging. Hydrocephalus is a common childhood disorder in developing countries in particular and its management is quite challenging. Ventriculoperitoneal (VP) shunt is associated with high failure rates and complications. Endoscopic third ventriculostomy (ETV) with potentially lower complication rate could improve care and reduce cost of management of hydrocephalus. The aim of this study was to evaluate the efficacy (success rate) of ETV in children ≤2 years and to find out factors that may be responsible for good outcome of ETV. This prospective observational study was conducted at Lagos University Teaching Hospital, Lagos. Nigeria. All consecutive children ≤2 years of age with hydrocephalus were recruited into the study. Relevant demographic and clinical data documented. All cases had ETV and were followed up to document 6 months outcome. A total of 34 patients (M: F ratio 1.1:1) were recruited over a 2-year period. Age, sex, presumed aetiology and image findings were not statistically significant in influencing outcome of ETV. Good outcome (defined as uneventful postoperative period, not requiring repeat ETV or VP shunt) was documented in 26 (73.5%). A total of 8 (26.5%) experienced poor outcome. Complication occurred in 2 (5.9%) as follows: Wound infection 1 (2.9%) and ventriculitis 1 (2.9%). Aetiology was divided into non post-infective hydrocephalus-20 (58.8%), post-infective hydrocephalus-5 (14.7%) and post-myelomeningocoele repair-9 (26.5%). This study shows that ETV success rate is high in the management of hydrocephalus in children ≤2 years in our clinical practice. Regardless of the clinical diagnosis, where the facilities are available, children with hydrocephalus will benefit from ETV irrespective of the age and aetiology in sub Saharan Africa.

Management of hydrocephalus in children with posterior fossa tumors.

Case 1: A 2-year-old male with no prior medical history presented to the emergency room with a 3-week history of constant headache and daily vomiting. Computed tomography (CT) and subsequent magnetic resonance imaging (MRI) of the brain [Figure 1] showed a minimally enhancing mass in the fourth ventricle, which extended out through the foramen of Luschka on the left. There was associated supratentorial hydrocephalus. He had no evidence of spinal metastasis on MRI of the spine. There was no papilledema on the fundoscopic exam. He underwent placement of a right frontal external ventricular drain (EVD) and gross total resection of the tumor through a modified telovelar approach at the same time. The pathology was consistent with a grade II ependymoma. Postoperatively, the ventricular drain was unable to be weaned, and he underwent ventriculoperitoneal shunt placement without complication 1.5 weeks after initial surgery. He was eating and ambulatory after recovery. He went on to radiation therapy. Figure 1 Magnetic resonance images of patient described in case 1. (a) Sagittal precontrast. (b) Axial fluid-attenuated inversion recovery. (c) Axial postcontrast Case 2: A 9-year-old male with no prior medical history presented to an outside hospital emergency room with 2 weeks of progressive headaches and 1-day of vomiting. A CT of the head showed a posterior fossa mass. MRI of the brain [Figure 2] showed an enhancing fourth ventricular tumor with associated metastatic lesions throughout both cerebellar hemispheres and supratentorial hydrocephalus. There was no evidence of spinal metastasis. Fundoscopic exam was positive for papilledema. He underwent placement of a right frontal EVD and resection of the fourth ventricular mass through a modified telo-velar approach at the same time. The infiltrative lesions in the cerebellum were not resected. The pathology was consistent with medulloblastoma. Postoperatively, his EVD was weaned over the course of 2 weeks and removed. He did not require permanent cerebrospinal fluid diversion. He was discharged home after recovery and went on for adjuvant radiation therapy. Figure 2 Magnetic resonance images of patient described in case 2. (a) Sagittal precontrast. (b) Axial fluid-attenuated inversion recovery. (c) Axial postcontrast

Factors Predicting the Need for Cerebrospinal Fluid Diversion following Posterior Fossa Tumor Surgery in Children

Background: No consensus exists regarding the management of hydrocephalus in children with posterior fossa tumors before, during or after surgery. In the present study we analyze the factors that predispose to persistent hydrocephalus and the need for a postoperative cerebrospinal fluid (CSF) diversion procedure. Methods: Pediatric patients who underwent surgery for posterior fossa tumors with hydrocephalus at our hospital were reviewed to evaluate the need for a postoperative CSF diversion procedure. Patients having undergone CSF diversion preoperatively were excluded from the study group. The case records of 84 patients were reviewed. The factors evaluated included age at diagnosis, duration of symptoms, severity of preoperative hydrocephalus, tumor size, tumor location, tumor histology, extent of tumor resection and postoperative complications that could be related to CSF circulation disorders. Results: At the time of presentation, 80/84 (95.2%) patients had symptomatic hydrocephalus; 25/84 (29.8%) patients required a CSF diversion procedure in the postoperative period. Children presenting with symptom duration of less than 3 months had a significantly higher requirement for postoperative CSF diversion in comparison to those with longer symptomatology (p = 0.016). Evan’s index and frontal and occipital horn ratio on preoperative imaging were found to correlate closely with the need for postoperative shunt (p = 0.001 and p < 0.001, respectively). The requirement for shunt was statistically higher in patients with midline tumors in comparison to laterally placed lesions (p = 0.04) and in children with medulloblastoma (p < 0.001) and ependymoma (p = 0.016) as the tumor subtypes. Children who underwent intraoperative external ventricular drainage (EVD) had a shunt insertion rate of 39.6% compared with 16.7% of those who did not have an EVD (p < 0.001). Patients with meningitis and pseudomeningocele in the postoperative period had a statistically significant higher risk of shunt requirement (p = 0.008 and p = 0.016, respectively). The mean age at diagnosis and the extent of tumor resection did not correlate with the need for CSF diversion. Conclusion: The fact that less than one-third of patients require a CSF diversion after posterior fossa tumor resection refutes the role of prophylactic endoscopic third ventriculostomy. Awareness regarding the factors that can predict persistent postoperative hydrocephalus is essential for the surgeon during patient counseling and surgical planning, and also in deciding the intensity of postoperative clinical and radiological monitoring.

Comparison of shunt infection incidence in high-risk subgroups receiving antibiotic-impregnated versus standard shunts

This paper confirms the role of antibiotic-impregnated internal shunts (AIS) in significantly reducing the incidence of shunt infections also in high-risk pediatric patients. What I found particularly interesting in this paper was the similar incidence of oxacillin-resistant Staphylococcus aureus infections between the group with AIS implantations (1.4%) and those with non-antibiotic-impregnated (NAIS) shunts (1.6%). In the same direction, the paper indicates that the AIS result in a reduction of nonstaphylococcal gram-positive infections (AIS group 0% vs. NAIS 1.05%). Furthermore, the authors confirm the similar overall incidence of gram-negative germ infections in the two groups (AIS=0.79%; NAIS=1.05%), demonstrating that implanting an AIS does not favor infections by germs which are not covered by the locally released antibiotics. In a different but also “high-risk” environment, our recent experience with the perioperative management of hydrocephalus in children operated on for a posterior fossa tumor is somewhat similar to that reported by the authors. Actually, in our series, the use of non-antibiotic-impregnated external ventricular drainages (AIEVD) significantly decreased the occurrence of contamination of the cerebrospinal fluid (intended as early CSF detection of germs without any clinical manifestation) if compared with an homogeneous group of children managed with nonimpregnated catheters (non-antibiotic-impregnated external ventricular drainages, NAIEVD); namely, the rate of CSF contamination in the

Management of Hydrocephalus in Children with Plasminogen Deficiency

Congenital plasminogen deficiency is an infrequent disorder, which usually becomes symptomatic as ligneous conjunctivitis. However, pseudomembranous lesions in the mucosa of the pharynx, tracheobronchial tree, and the peritoneum may likewise occur. An accompanying hydrocephalus is extremely rare; only 16 cases have been reported to date. The reports indicate that hydrocephalus, even if treated by ventriculoperitoneal (VP) cerebrospinal fluid (CSF) shunting, worsens the prognosis substantially. Thus, VP CSF shunting does not seem to be the optimal therapy for hydrocephalic children with plasminogen deficiency. We add two cases to the literature, and, on the base of our experience, we propose a management strategy for the hydrocephalus. We report the case history of two children with plasminogen deficiency and associated hydrocephalus. Both children initially were treated with VP shunts and had a very similar clinical course with multiple shunt malfunctions due to nonabsorption by the peritoneum. In the first child, the attempt to treat the hydrocephalus with a ventriculoatrial (VA) shunt failed due to catheter thrombosis. Finally, a ventriculocholecystic shunt was placed in both children, which worked well. In patients with plasminogem deficiency and associated hydrocephalus, special care must be taken in the management of hydrocephalus. The absorptive capacity of the peritoneum is reduced by pseudomembrane formation, which results in VP shunt malfunction. The plasminogen deficiency results in early thrombus formation if atrial catheters are used. Therefore, the authors believe that ventriculocholecystic shunting should be considered early on in the course of the disease.

Management of Hydrocephalus in Children with Posterior Fossa Tumors: Role of Tumor Surgery

Objective: The majority of children with posterior fossa tumors have hydrocephalus (HC) at the time of presentation. There is no consensus regarding the management of HC in these children. Here, we report the rate of cure of HC with tumor surgery alone. Patients and Methods: This is a retrospective study of 87 children with posterior fossa tumors in which 35 patients had medulloblastoma, 38 had astrocytoma and 14 had ependymoma. The mean age at presentation was 7.3 years (range: 0.2–19.7 years). All patients underwent tumor resection and were followed with close clinical and image surveillance to detect persistent HC. HC was treated with endoscopic third ventriculostomy (ETV) or shunt. We have focused on patients who needed permanent cerebrospinal fluid diversion (ETV or shunt) within 30 days of tumor resection. HC presenting after this time period is, in the majority of cases, due to tumor recurrence or progression. In this series, 24/87 (28%) patients had a suboccipital craniectomy and 63/87 (72%) had a craniotomy. Results: At the time of presentation, 69/87 (79%) patients had symptomatic HC. In 41/69 (59%) patients presenting with HC, the HC was cured by tumor resection alone. The HC cure rate for patients with astrocytoma was 83%, whereas it was 47% for patients with medulloblastoma and 54% for patients with ependymoma. The cure rate was equal in the craniectomy and craniotomy groups. Conclusions: An 87% cure rate of HC by tumor resection alone in children with posterior fossa astrocytoma warrants no change in treatment strategy. However, the low cure rate of HC by tumor resection alone in patients with medulloblastoma and ependymoma raises the issue of whether these patients would benefit from preresection ETV.

814 Measurements of Magnet-induced Changes in Pressure Settings of Adjustable Hydrocephalus Shunt Valves

INTRODUCTION: The advent of adjustable shunt valves has added a new possibility for management of hydrocephalus in children by providing control of the pressure at which a ball-in-cone valve opens. The advantage of being able to change the valve characteristics using an external magnet system comes with the potential disadvantage of unintended resetting of the valve by ambient external magnetic fields. METHODS: We quantified the magnetic field strengths needed to reprogram the Codman Hakim Programmable Valve (CHPV, n = 7) and the Medtronic STRATA valve (n = 4). Using a specially constructed instrument, we determined threshold values (in gauss) of the external magnetic field that would change the valve setting. We compared different initial valve settings, directions of valve rotation, and valve type (CHPV versus STRATA). RESULTS: As expected, all valves are susceptible to setting changes in a rotating magnetic field. The magnetic field strength required to rotate the valves was dependent on the initial valve setting, with higher fields generally required for higher settings. Field strengths required to turn the valves to a higher setting were similar for the two types of valves (127–215 G, CHPV versus 73–150 G, STRATA), but the field strength required for the downward turn (other than from the lowest initial setting) for the STRATA was strikingly lower than for the CHPV (26–38 G versus 117–177 G, P < 0.0001, analysis of variance factorial design). CONCLUSION: Assuming that ambient exposures in real life are distributed favoring low field exposures with random direction of rotation, clinicians should expect more frequent inadvertent valve setting changes in STRATA valves, and accidental changes to a lower level would be far more likely than increases with either valve type. Safety issues would depend on the still somewhat conjectural idea that the pressure needed for opening the valve is highly correlated with shunt function and control of symptoms.

Current Management of Hydrocephalus in Children

Division of Neurosurgery, Children's Hospital of Philadelphia, 34th & Civic Center Boulevard, Philadelphia, PA 19104

Use of a ventriculosubgaleal shunt in the management of hydrocephalus in children with posterior fossa tumors.

We present our experience with the use of ventriculosubgaleal shunting (VSGS) for the management of hydrocephalus associated with posterior fossa tumors in a consecutive series of 63 children. In 42 children, a temporary VSGS was inserted. There were no complications associated with the procedure, and it gave a period of several days in which to improve the general condition of the child, and to perform the necessary imaging studies, without an encumbering external drainage device. In most cases the VSGS could be removed after the posterior fossa surgery, without new general anesthesia. Other advantages and drawbacks of this technique are discussed.

ISOSORBIDE IN THE MEDICAL MANAGEMENT OF HYDROCEPHALUS IN CHILDREN WITH MYELODYSPLASIA

Fourteen children with hydrocephalus associated with myelodysplasia were given isosorbide (8 to 12 g/kg/day) and compared with 17 children managed without it. Three of the treated and three of the untreated children did not require shunting. The mean interval between back closure and shunt placement was 33 days for the controls and 115 days for the treated children. Two of the treated children developed gastro-intestinal symptoms that necessitated withdrawal of the isosorbide. Although isosorbide did extend the interval between back closure and shunt placement, its side-effects and the availability of alternative treatments render it unsuitable for the management of hydrocephalus in children with myelodysplasia.