Need For Ventriculoperitoneal Shunting Research Articles

435 Use of Optic Nerve Sheath Diameter in Extraventricular Drain Weaning in Adults With Post-hemorrhagic Hydrocephalus

INTRODUCTION: Optic nerve sheath diameter (ONSD) can be used as a noninvasive measurement of intercranial pressure. Few studies have evaluated the value of ONSD in predicting the need for ventriculoperitoneal shunt (VPS) placement after development of post-hemorrhagic hydrocephalus (PHH) in adults. METHODS: Adult patients 18 years or older, admitted with intracranial hemorrhage and hydrocephalus requiring EVD placement were included in the study. Demographics were recorded. CT imaging of ONSD was measured (mm) upon initial ED visit before EVD placement (pre-EVD), immediately after successful EVD removal (post-EVD), and if applicable, after EVD removal but immediately before VPS placement. Change in ONSD was calculated and groups were stratified by EVD only patients and EVD+VPS patients. RESULTS: Imaging for 30 patients were successfully retrieved and analyzed for bilateral ONSD values at all timepoints. A statistically significant convergence to a normally distributed mean ONSD was found for both groups (EVD and EVD+VPS). Additionally, a statistically significant increase was found in ONSD between the EVD+VPS group compared to the EVD only group. The EVD only group showed a mean EVD placement time of only 14 days (2 weeks) with an average decrease in ONSD (-0.905mm) compared with the EVD+VPS group who had an increase in ONSD at 14-days (+1.089 mm). CONCLUSIONS: Patients with hydrocephalus due to intracranial hemorrhage who went on to require VPS developed an increase in ONSD despite EVD use while patients who were successfully weaned from the EVD developed a decrease in ONSD. ONSD may be a useful adjunct tool to aid in the process of EVD weaning in this patient population.

Double Myelomeningocele Repair by Fetal Surgery with a Single Micro-Hysterotomy

<b><i>Introduction:</i></b> Open spina bifida (OSB) is the most common congenital anomaly of the central nervous system. It is associated with severe neurodevelopmental delay, motor impairment, hydrocephalus, and bowel and bladder dysfunction. In selected cases, intrauterine spina bifida repair has been shown to improve neonatal outcomes. Rarely, the spine can have a double defect compromising two different segments and there is a lack of evidence on the feasibility and benefits of intrauterine repair in these cases. <b><i>Case Presentation:</i></b> We present a case with both cervicothoracic and lumbosacral myelomeningocele, Arnold-Chiari malformation type II and bilateral ventriculomegaly, that was treated successfully at 25 weeks with open micro-neurosurgery. Double myelomeningocele was successfully treated through a single 2-cm micro-hysterotomy, by performing external versions to sequentially expose and repair both defects. Weekly postoperative follow-up showed no progression of ventriculomegaly or complications attributable to the procedure. Preterm rupture of membranes prompted a conventional cesarean delivery at 32 weeks of gestation. Neurodevelopmental outcome at 20 months was within normal ranges, having achieved ambulation without orthopedic support and with no need for ventriculoperitoneal shunting. <b><i>Conclusion:</i></b> This report demonstrates for the first time the feasibility of double OSB repair through a single 2-cm micro-hysterotomy, suggesting that selected isolated cases of double myelomeningocele could be candidates for fetal intervention. Further prospective studies should be carried out to assess the potential benefit of double OSB intrauterine open repair.

Microneurocirugía intrauterina para la corrección de espina bífida congénita: primer caso exitoso reportado en Venezuela

Congenital spina bifida is a malformation of the central nervous system that occurs during embryological development. Its etiology is multifactorial and it is estimated that it affects 1:1500 pregnancies, in which motor and sensory deficits, secondary to spinal cord injury, hydrocephalus and Arnold-Chiari II malformation are the most significant findings. Prenatal surgical treatment has been described through the open approach, microneurosurgery, and fetoscopic resolution, with well-known advantages and disadvantages, but which invariably improve postnatal prognosis and the severity of neurological sequelae, as well as the need for ventriculoperitoneal shunt. We present the first case of open microneurosurgery for intrauterine repair of myelomeningocele performed in Venezuela, a novel technique characterized by a minimum uterine incision of 20-30 mm, reduced fetal manipulation and maintenance of a normal volume of amniotic fluid throughout the process, in a patient at 24 weeks of gestation.

A scoring system categorizing risk factors to evaluate the need for ventriculoperitoneal shunt in pediatric patients after brain tumor resection.

To develop a scoring system based on independent predictors of the need for ventriculoperitoneal (VP) shunt after brain tumor resection in pediatric patients. A total of 416 pediatric patients (≤ 14 years old) with brain tumors who underwent surgery were randomly assigned to the training (n = 333) and validation cohorts (n = 83). Based on the implementation of VP shunt, the training cohort was divided into the VP shunt group (n = 35) and the non-VP shunt group (n = 298). Univariate and multivariate logistic analyses were performed. A scoring system was developed based on clinical characteristics and operative data, and scores and corresponding risks were calculated. Age < 3 (p = 0.010, odds ratio [OR] = 3.162), blood loss (BL) (p = 0.005, OR = 1.300), midline tumor location (p < 0.001, OR = 5.750), preoperative hydrocephalus (p = 0.001, OR = 7.044), and total resection (p = 0.025, OR = 0.284) were identified as independent predictors. The area under the curve (AUC) of the scoring system was higher than those of age < 3, BL, midline tumor location, preoperative hydrocephalus, and total resection (0.859 vs. 0.598, 0.717, 0.725, 0.705, and 0.555, respectively; p < 0.001). Furthermore, the scoring system showed good performance in the validation cohort (AUC = 0.971). The cutoff value for predictive scores was 5.5 points, which categorized patients into low risk (0-5 points) and high risk (6-14 points) groups. Our scoring system, integrating age < 3, BL, midline tumor location, preoperative hydrocephalus, and total resection, provides a practical evaluation. Scores ranging from 6 to 14 points indicate high risk.

Ultrasonographic Estimation of Ventricular Volume in Infants Born Preterm with Posthemorrhagic Ventricular Dilatation: A Nested Substudy of the Randomized Controlled Early Versus Late Ventricular Intervention Study (ELVIS) Trial

To study the potential role of ventricular volume (VV) estimation in the management of posthemorrhagic ventricular dilatation related to the need for ventriculoperitoneal (VP)-shunt insertion and 2-year neurodevelopmental outcome in infants born preterm. We included 59 patients from the Early vs Late Ventricular Intervention Study from 4 participating centers. VV was manually segmented in 209 3-dimensional ultrasound scans and estimated from 2-dimensional ultrasound linear measurements in a total of 1226 ultrasounds. We studied the association of both linear measurements and VV to the need for VP shunt and 2-year neurodevelopmental outcome in the overall cohort and in the 29 infants who needed insertion of a reservoir. We used general estimating equations to account for repeated measures per individual. Maximum pre-reservoir VV (β coefficient=0.185, P=.0001) and gestational age at birth (β =-0.338; P=.0001) were related to the need for VP shunt. The estimated optimal single VV measurement cut point of 17cm3 correctly classified 79.31% with an area under the curve of 0.76 (CI 95% 0.74-0.79). Maximum VV (β=0.027; P=.012) together with VP shunt insertion (β =3.773; P=.007) and gestational age (β =-0.273; P=.0001) were related to cognitive outcome at 2years. Maximum ventricular index and anterior horn width before reservoir insertion were independently associated with the need of VP shunt and the proposed threshold groups in the Early vs Late Ventricular Intervention Study trial were associated with long-term outcome. Pre-reservoir VV measurements were associated with the need for VP-shunt insertion and 2-year cognitive outcome among infants born preterm with posthemorrhagic ventricular dilatation. ISRCTN43171322.

Risk factors for shunting at 12months following open fetal repair of spina bifida by mini-hysterotomy.

Open spina bifida (OSB) is the most common neural tube defect. Prenatal repair reduces the need for ventriculoperitoneal shunting (VPS) due to hydrocephalus from 80-90% to 40-50%. We aimed to determine which variables work as risk factors for VPS at 12months of age in our population. Thirty-nine patients underwent prenatal repair of OSB by mini-hysterotomy. The main outcome was occurrence of VPS in the first 12months of life. Logistic regression was used to estimate the odds ratios (OR) between prenatal variables and the need for shunting. VPS at 12months occurred in 34.2% of the children. Larger ventricle size before surgery (62.5% ≥15mm; 46.2% between 12 and 15mm; 11.8% <12mm; p=0.008), higher lesion level (80% >L2, vs. 17.9%≤L3; p=0.002; OR, 18.4 [2.96-114.30]), and later gestational age at surgery (25.25±1.18 vs. 24.37±1.06weeks; p=0.036; OR, 2.23 [1.05-4.74]) were related to increased need for shunting. In the multivariate analysis, larger ventricle size before surgery (≥15mm vs. <12mm; p=0.046; OR, 1.35 [1.01-1.82]) and higher lesion level (>L2 vs.≤L3; p=0.004; OR, 39.52 [3.25-480.69]) were risk factors for shunting. Larger ventricle size before surgery (≥15mm) and higher lesion level (>L2) are independent risk factors for VPS at 12months of age in fetuses undergoing prenatal repair of OSB by mini-hysterotomy in the studied population.

Peripheral eosinophil trends and clinical outcomes after non-traumatic subarachnoid hemorrhage.

Uncontrolled systemic inflammation after non-traumatic subarachnoid hemorrhage (SAH) is associated with worse outcomes. Changes in the peripheral eosinophil count have been linked to worse clinical outcomes after ischemic stroke, intracerebral hemorrhage, and traumatic brain injury. We aimed to investigate the association of eosinophil counts with clinical outcomes after SAH. This retrospective observational study included patients with SAH admitted from January 2009 to July 2016. Variables included demographics, modified Fisher scale (mFS), Hunt-Hess Scale (HHS), global cerebral edema (GCE), and the presence of any infection. Peripheral eosinophil counts were examined as part of routine clinical care on admission and daily for 10 days after aneurysmal rupture. Outcome measures included dichotomized discharge mortality, modified Ranked Scale (mRS) score, delayed cerebral ischemia (DCI), vasospasm, and need for ventriculoperitoneal shunt (VPS). Statistical tests included the chi-square test, Student's t-test, and multivariable logistic regression (MLR) model. A total of 451 patients were included. The median age was 54 (IQR 45, 63) years, and 295 (65.4%) were female patients. On admission, 95 patients (21.1%) had a high HHS (>4), and 54 (12.0%) had GCE. A total of 110 (24.4%) patients had angiographic vasospasm, 88 (19.5%) developed DCI, 126 (27.9%) had an infection during hospitalization, and 56 (12.4%) required VPS. Eosinophil counts increased and peaked on days 8-10. Higher eosinophil counts on days 3-5 and day 8 were seen in patients with GCE (p < 0.05). Higher eosinophil counts on days 7-9 (p < 0.05) occurred in patients with poor discharge functional outcomes. In multivariable logistic regression models, higher day 8 eosinophil count was independently associated with worse discharge mRS (OR 6.72 [95% CI 1.27, 40.4], p = 0.03). This study demonstrated that a delayed increase in eosinophils after SAH occurs and may contribute to functional outcomes. The mechanism of this effect and the relationship with SAH pathophysiology merit further investigation.

Absence of a Hernia Sack in Patients Undergoing Prenatal Repair of Spina Bifida Increases the Risk of Developing Shunt-Dependent Hydrocephalus.

Spina bifida aperta (SBA), with (myelomeningocele) or without (myeloschisis) a hernia sack, is the most common congenital defect of the central nervous system. Prenatal surgical closure of SBA lowers the risk for developing shunt-dependent hydrocephalus, which offers a chance at improved motor, urinary, and gastrointestinal function. A total of 96 patients who had undergone open surgery prenatal repair for SBA were analyzed. The patients were divided into two groups: Group I-12 patients (12.5%)-without a hernia sack (myeloschisis) and Group II-84 patients (87.5%)-with a hernia sack (myelomeningocele). In this study, we demonstrated that prenatal SBA repair was statistically significantly less often associated with the need for ventriculoperitoneal shunting (p > 0.00001). The shunting was statistically significantly more often required in patients from Group I (p > 0.004). The absence of a hernia sack increases the risk for developing shunt-dependent hydrocephalus in patients after prenatal SBA repair. However, as prenatal SBA repair is associated with better motor, urinary, and gastrointestinal function, increased risk of developing shunt-dependent hydrocephalus in fetuses without a hernia sack should not be treated as a contraindication to prenatal intervention.

Systematic classification and comparison of maternal and obstetrical complications following 2 different methods of fetal surgery for the repair of open neural tube defects

In utero repair of open neural tube defect (ONTD) using an open hysterotomy approach (hereafter referred to as "Open") has been shown to reduce the need for ventriculo-peritoneal shunting and to improve motor outcomes for affected infants. Laparotomy-assisted fetoscopic repair (hereafter referred to as "Hybrid") is an alternate approach that may confer similar neurological benefits, while reducing the incidence of hysterotomy related complications. In this study we aimed to analyze procedure related maternal and fetal complications of in-utero repair using the Clavien-Dindo classification, and to compare the outcomes of the Hybrid and Open approaches. This was a retrospective cohort study conducted in a single center between September 2011 and July 2021. All patients who met the MOMS criteria and who underwent either Hybrid or Open fetal surgery were included, Maternal complications were classified using a unique adapatation of the Clavien-Dindo scoring system allowing the development of a comprehensive complication index score specific to fetal surgery. Primary fetal outcome was defined as gestational age at delivery and summarized according to the World Health Organization definitions of preterm delivery. There were 146 fetuses with ONTD who were eligible for, and underwent, in utero repair during the study period. Of these, 102 underwent Hybrid fetoscopic repair and 44 underwent Open hysterotomy repair. Gestational age at the time of surgery was higher in the Hybrid group when compared with the Open group (25.1 vs. 24.8 weeks, p=0.004). Maternal body mass index was lower in the Hybrid compared to the Open group (25.4 vs 27.1 kg\m2, p=0.02). The duration of Hybrid fetoscopic surgery was significantly longer than for the Open repair (250 min vs 164 min, p<0.001). There was a significantly lower Clavien-Dindo grade III complication rate (4.9% vs. 43.2%, p<0.001), as well as a significantly lower overall comprehensive maternal complication index (8.7 vs. 22.6, p=0.021), in the Hybrid group vs. the Open group. Gestational age at delivery was significantly higher in the Hybrid group (38.1 weeks) compared to the Open group (35.8 weeks) p<0.001, and this finding persisted when gestational age at delivery was analyzed using the WHO definitions of preterm delivery. Utilization of our adaptation of the standardized Clavien-Dindo classification to assess the maternal complications associated with in utero ONTD repair provides a new method to objectively assess different fetal surgical approaches. It also provides a much-needed standardized tool to allow objective comparisons between methods, which can be used when counseling patients. The Hybrid ONTD repair was associated with a lower rate of maternal adverse events than the Open approach, and was associated with later gestational age at delivery and less preterm delivery.

Percutaneous/mini-laparotomy fetoscopic repair of open spina bifida: a novel surgical technique

Open spina bifida is the most common congenital anomaly of the central nervous system compatible with life. Prenatal repair of open spina bifida via open maternal-fetal surgery has been shown to improve postnatal neurologic outcomes, including reducing the need for ventriculoperitoneal shunting and improving lower neuromotor function. Fetoscopic repair of open spina bifida minimizes the maternal risks while providing similar neurosurgical outcomes to the fetus. The following 2 fetoscopic techniques are currently in use: (1) the laparotomy-assisted approach, and (2) the percutaneous approach. The laparotomy-assisted fetoscopic technique appears to be associated with a lesser risk of preterm birth than the percutaneous approach. However, the percutaneous approach avoids laparotomy and uterine exteriorization and is associated with lesser anesthesia risk and improved maternal postsurgical recovery. The purpose of this article was to describe our experience with a modified surgical approach, which we call percutaneous/mini-laparotomy fetoscopy, in which access to the uterus for one of the ports is done via a mini-laparotomy, whereas the other ports are inserted percutaneously. This technique draws on the benefits of both the laparotomy-assisted and the percutaneous techniques while minimizing their drawbacks. This surgical approach may prove invaluable in the prenatal repair of open spina bifida and other complex fetal surgical procedures.

516 Artificial Neural Networks Predict the Need for Permanent CSF Diversion After Posterior Fossa Tumor Surgery

INTRODUCTION: Resection of posterior fossa tumors (PFTs) can result in hydrocephalus that requires permanent CSF diversion. Clinicians need a durable method to predict occurrence of CSF diversion in this population. METHODS: We collected pre-operative and post-operative variables on 510 patients that underwent PFT surgery at our center in a retrospective fashion to train several statistical classifiers to predict the need for permanent CSF diversion as a binary class. A total of 62 classifiers relevant to our data structure were surveyed including regression models, decision trees, Bayesian models, and multilayer perceptron artificial neural networks (ANN). Models were trained using the (N=510) retrospective data using 10-fold cross validation to obtain accuracy metrics. Given the low incidence of our positive outcome (12%), we used the true positive rate along with the area under the receiver operating characteristic curve (AUC) to compare models. The best performing model was then prospectively validated on a set of 90 patients. RESULTS: 12% of patients in our dataset required permanent CSF diversion after PFT surgery. Of the trained models, 8 classifiers had an AUC greater than 0.5 on prospective testing. Artificial neural networks (ANN) demonstrated the highest AUC of 0.902 with a true positive rate of 83.3%. Despite comparable AUC, the remaining classifiers had a true positive rate below 35% (compared to ANN, P&lt;0.0001). The negative predictive value of the ANN model was 98.8%. CONCLUSION: ANN-based models can reliably predict the need for ventriculoperitoneal shunt after PFT surgery.

Artificial neural networks predict the need for permanent cerebrospinal fluid diversion following posterior fossa tumor resection.

BackgroundResection of posterior fossa tumors (PFTs) can result in hydrocephalus that requires permanent cerebrospinal fluid (CSF) diversion. Our goal was to prospectively validate a machine-learning model to predict postoperative hydrocephalus after PFT surgery requiring permanent CSF diversion.MethodsWe collected preoperative and postoperative variables on 518 patients that underwent PFT surgery at our center in a retrospective fashion to train several statistical classifiers to predict the need for permanent CSF diversion as a binary class. A total of 62 classifiers relevant to our data structure were surveyed, including regression models, decision trees, Bayesian models, and multilayer perceptron artificial neural networks (ANN). Models were trained using the (N = 518) retrospective data using 10-fold cross-validation to obtain accuracy metrics. Given the low incidence of our positive outcome (12%), we used the positive predictive value along with the area under the receiver operating characteristic curve (AUC) to compare models. The best performing model was then prospectively validated on a set of 90 patients.ResultsTwelve percent of patients required permanent CSF diversion after PFT surgery. Of the trained models, 8 classifiers had an AUC greater than 0.5 on prospective testing. ANNs demonstrated the highest AUC of 0.902 with a positive predictive value of 83.3%. Despite comparable AUC, the remaining classifiers had a true positive rate below 35% (compared to ANN, P < .0001). The negative predictive value of the ANN model was 98.8%.ConclusionsANN-based models can reliably predict the need for ventriculoperitoneal shunt after PFT surgery.

HYDROCEPHALUS WITH VENTRICULOPERITONEAL SHUNTS IN INFANTS: OUR EXPERIENCES AND CLINICAL OUTCOMES

Hydrocephalus is a condition resulting from disorder in absorption and circulation of the cerebrospinal fluid (CSF). It leads to progressive ventricular dilatation and need of&nbsp; ventriculoperitoneal shunt (VP) placement. The aim of our study is to present our experience on neonates with&nbsp; hydrocephalus, ventriculoperitoneal shunt placement, and early postoperative follow up. A retrospective study on neonates with hydrocephalus borned between January 2019 -January 2022 with ventriculoperitoneal shunt placement conducted at University Clinic for Neurosurgery in Skopje, Macedonia was reviewed. Demographical and clinical characteristics, complications and the need for ventriculoperitoneal shunt were documented. 23 infants with hydrocephalus 14 (60,8 %) were preterm (median birth weight 2120g; mean gestational age 33.1weeks), 9 (39.1%) infants were term neonates (mean birth weight 3600g; mean gestational age 38.4 weeks). The etiology of hydrocephalus were; congenital hydrocephalus in 5 infants (21,7%), prematurity in 6 infants ( 26,08%), spina bifida in 2 infants (8.7%), systemic infection in 4 infants ( 17,3%), and intraventricular haemorrage in 6 infants (26,08%).Ventriculoperitoneal shunt was placed to all 23 infants, at mean age of&nbsp; 33,5 (30-43) days. Postoperative complications as a result of ventriculoperitoneal shunt placement were; ventriculitis was manifested at 3 preterm (13%) infants, 2 of them (8,6%) died. Five term infants (21,7%) with postoperative seizures had need of VP replacement; 2 infants (8,6%) died. 19 infants (82,6%) were discharged and transfed to neonatology department. Ventriculoperitoneal shunt placement is the treatment of choice for neonates with hydrocephalus, although postoperative complications in preterm neonates increase the percent of morbility and&nbsp; hymortality. Кeywords:Hydrocephalus,ventriculoperitoneal shunt, neonates, postoperative complications. &nbsp

Economic analysis of prenatal fetoscopic vs open-hysterotomy repair of open neural tube defect.

Fetal repair of an open neural tube defect (ONTD) by open hysterotomy has been shown to reduce the need for ventriculoperitoneal shunting and improve motor outcomes for infants, but increases the risk of Cesarean section and prematurity. Fetoscopic repair is an alternative approach that may confer similar neurological benefits but allows for vaginal delivery and reduces the incidence of hysterotomy-related complications. We sought to compare the costs of care from fetal surgery until neonatal discharge, as well as the clinical outcomes, associated with each surgical approach. This was a retrospective cohort study of patients who underwent prenatal ONTD repair, using either the open-hysterotomy or the fetoscopic approach, at a single institution between 2012 and 2018. Clinical outcomes were collected by chart review. A cost-consequence analysis was conducted from the hospital perspective, and included all inpatient and ambulatory hospital and physician costs incurred for the care of mothers and their infants, from the time of maternal admission for fetal ONTD repair up to postnatal maternal and infant discharge. Costs were estimated using cost-to-charge ratios for hospital billing and the Medicare physician fee schedule for physician billing. Seventy-eight patients were included in the analysis, of whom 47 underwent fetoscopic repair and 31 underwent open-hysterotomy repair. In the fetoscopic-repair group, compared with the open-repair group, fewer women underwent Cesarean section (53% vs 100%; P < 0.001) and the median gestational age at birth was significantly higher (38.1 weeks (interquartile range (IQR), 35.2-39.1 weeks) vs 35.7 weeks (IQR, 33.9-37.0 weeks); P < 0.001). No case of uterine dehiscence was observed in the fetoscopic-repair group, compared with an incidence of 16% in the open-repair group. After adjusting for baseline characteristics, there was no significant difference in the total cost of care between the fetoscopic-repair and the open-repair groups (median, $76 978 (IQR, $60 312-$115 386) vs $65 103 (IQR, $57 758-$108 103); P = 0.458). Fetoscopic repair of ONTD, when compared with the open-hysterotomy approach, reduces the incidence of Cesarean section and preterm delivery with no significant difference in total costs of care from surgery to infant discharge. This novel approach may represent a cost-effective alternative to improve maternal and neonatal outcomes for this high-risk population. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Experience of 300 cases of prenatal fetoscopic open spina bifida repair: report of the International Fetoscopic Neural Tube Defect Repair Consortium

The multicenter randomized controlled trial Management of Myelomeningocele Study demonstrated that prenatal repair of open spina bifida by hysterotomy, compared with postnatal repair, decreases the need for ventriculoperitoneal shunting and increases the chances of independent ambulation. However, the hysterotomy approach is associated with risks that are inherent to the uterine incision. Fetal surgeons from around the world embarked on fetoscopic open spina bifida repair aiming to reduce maternal and fetal/neonatal risks while preserving the neurologic benefits of in utero surgery to the child. This study aimed to report the main obstetrical, perinatal, and neurosurgical outcomes in the first 12 months of life of children undergoing prenatal fetoscopic repair of open spina bifida included in an international registry and to compare these with the results reported in the Management of Myelomeningocele Study and in a subsequent large cohort of patients who received an open fetal surgery repair. All known centers performing fetoscopic spina bifida repair were contacted and invited to participate in a Fetoscopic Myelomeningocele Repair Consortium and enroll their patients in a registry. Patient data entered into this fetoscopic registry were analyzed for this report. Fisher exact test was performed for comparison of categorical variables in the registry with both the Management of Myelomeningocele Study and a post-Management of Myelomeningocele Study cohort. Binary logistic regression analyses were used to assess the registry data for predictors of preterm birth at <30 weeks' gestation, preterm premature rupture of membranes, and need for postnatal cerebrospinal fluid diversion in the fetoscopic registry. There were 300 patients in the fetoscopic registry, 78 in the Management of Myelomeningocele Study, and 100 in the post-Management of Myelomeningocele Study cohort. The 3 data sets showed similar anatomic levels of the spinal lesion, mean gestational age at delivery, distribution of motor function compared with upper anatomic level of the lesion in the neonates, and perinatal death. In the Management of Myelomeningocele Study (26.16±1.6 weeks) and post-Management of Myelomeningocele Study cohort (23.3 [20.2-25.6] weeks), compared with the fetoscopic registry group (23.6±1.4 weeks), the gestational age at surgery was lower (comparing fetoscopic repair group with the Management of Myelomeningocele Study; P<.01). After open fetal surgery, all patients were delivered by cesarean delivery, whereas in the fetoscopic registry approximately one-third were delivered vaginally (P<.01). At cesarean delivery, areas of dehiscence or thinning in the scar were observed in 34% of cases in the Management of Myelomeningocele Study, in 49% in the post-Management of Myelomeningocele Study cohort, and in 0% in the fetoscopic registry (P<.01 for both comparisons). At 12 months of age, there was no significant difference in the number of patients requiring treatment for hydrocephalus between those in the fetoscopic registry and the Management of Myelomeningocele Study. Prenatal and postnatal outcomes up to 12 months of age after prenatal fetoscopic and open fetal surgery repair of open spina bifida are similar. Fetoscopic repair allows for having a vaginal delivery and eliminates the risk of uterine scar dehiscence, therefore protecting subsequent pregnancies of unnecessary maternal and fetal risks.

Development of a Core outcome set for fetal Myelomeningocele (COSMiC): study protocol

BackgroundOpen spina bifida (OSB) is one of the most common congenital central nervous system defects and leads to long-term physical and cognitive disabilities. Open fetal surgery for OSB improves neurological outcomes and reduces the need for ventriculoperitoneal shunting, compared to postnatal surgery, but is associated with a significant risk of prematurity and maternal morbidity. Fetoscopic surgery comes with less maternal morbidity, yet the question remains whether the procedure is neuroprotective and reduces prematurity. Comparison of outcomes between different treatment options is challenging due to inconsistent outcome reporting. We aim to develop and disseminate a core outcome set (COS) for fetal OSB, to ensure that outcomes relevant to all stakeholders are collected and reported in a standardised fashion in future studies.MethodsThe COS will be developed using a validated Delphi methodology. A systematic literature review will be performed to identify outcomes previously reported for prenatally diagnosed OSB. We will assess maternal (primary and subsequent pregnancies), fetal, neonatal and childhood outcomes until adolescence. In a second phase, we will conduct semi-structured interviews with stakeholders, to ensure representation of additional relevant outcomes that may not have been reported in the literature. We will include patients and parents, as well as health professionals involved in the care of these pregnancies and children (fetal medicine specialists, fetal surgeons, neonatologists/paediatricians and allied health). Subsequently, an international group of key stakeholders will rate the importance of the identified outcomes using three sequential online rounds of a modified Delphi Survey. Final agreement on outcomes to be included in the COS, their definition and measurement will be achieved through a face-to-face consensus meeting with all stakeholder groups. Dissemination of the final COS will be ensured through different media and relevant societies.DiscussionDevelopment and implementation of a COS for fetal OSB will ensure consistent outcome reporting in future clinical trials, systematic reviews and clinical practice guidelines. This will lead to higher quality research, better evidence-based clinical practice and ultimately improved maternal, fetal and long-term childhood outcomes.Trial registrationInternational Prospective Register of Systematic Reviews (PROSPERO) CRD42018104880. Registered on December 5, 2018. Core Outcome Measures in Effectiveness Trials (COMET): 1187

Factors Associated with the Need for Ventriculoperitoneal Shunting in Patients with Spontaneous Intracerebral Hemorrhage Requiring Emergency Cerebrospinal Fluid Diversion

Abstract Introduction Intracerebral hemorrhage (ICH) is a serious medical condition that is frequently complicated by acute hydrocephalus, necessitating emergency cerebrospinal fluid (CSF) diversion in a subset of patients, ultimately requiring long-term treatment via placement of permanent ventricular shunts. The present study aimed to determine factors associated with the need for permanent ventricular shunt placement in these patients. Methods A total of 309 consecutive patients who underwent emergent CSF diversion with external ventricular drain (EVD) as a treatment for ICH between July 2009 and July 2018 were studied retrospectively to assess the factors that might be correlated with shunt-dependent chronic hydrocephalus. A binary logistic regression model was designed to identify independent related factors of shunt-dependent hydrocephalus after ICH. Results Of 309 patients included in this study, 102 (33.00%) required permanent ventricular CSF shunting before discharge. In univariate analysis, age,ventriculitis, ICP elevation &gt;30 mm Hg, ICH evacuation, the Graeb score, days of EVD in place, and CSF protein levels were significantly associated with the requirement for permanent CSF diversion (p &lt; 0.05). The age and ICH evacuation were protective variables and the ventriculoperitoneal (VP) shunt possibility was reduced by 22.6 and 63.5%, respectively. Conclusion Our results showed that higher Graeb score, ICP elevation &gt;30 mm Hg, more days of EVD in place, and higher CSF protein levels were associated with permanent CSF diversion in these patients. Advanced age and ICH evacuation decreased the possibility of VP shunting in our study.These factors may help in predicting which patients will need permanent CSF diversion and could ultimately lead to improvements in the management of these patients.

Improvement in ventriculomegaly following cervicomedullary decompressive surgery in children with achondroplasia and foramen magnum stenosis.

The role of cervicomedullary decompression (CMD) in the care of hydrocephalic achondroplastic children who present with simultaneous foramen magnum stenosis is not well understood. We sought to determine the percentage of symptomatic achondroplastic children with foramen magnum stenosis who had stabilization or improvement in ventriculomegaly following CMD. The authors retrospectively reviewed the records of pediatric patients at Cedars-Sinai Medical Center with achondroplasia and signs of progressive ventriculomegaly who underwent CMD for symptomatic foramen magnum stenosis between the years 2000 and 2018. Clinical outcomes included changes in fontanelle characteristics, head circumference (HC) percentile, and incidence of ventriculoperitoneal (VP) shunting. Radiographic outcomes measured included changes in Evans ratio. We excluded individuals who were shunted before CMD from our study. Sixteen children presented with symptomatic foramen magnum stenosis and full anterior fontanelle or jump in the HC percentiles. Two children underwent placement of a VP shunt before decompressive surgery and were excluded from further analysis. Of the remaining 14 children who underwent CMD, 13 (93%) showed softening or flattening of their fontanelles post-operatively. Ten of these 14 children had both pre- and post-operative HC percentile records available, with 8 showing increasing HC percentiles before surgery. Seven of those eight children (88%) showed a deceleration or stabilization of HC growth velocity following decompression of the foramen magnum. Among 10 children with available pre- and post-operative brain imaging, ventricular size improved in 5 (50%), stabilized in 2 (20%), and slightly increased in 3 (30%) children after decompression. Two children (14%) required a shunt despite decompression of the foramen magnum. A significant proportion of children with concomitant signs of raised intracranial pressure or findings of progressive ventriculomegaly and foramen magnum stenosis may have improvement or stabilization of these findings following CMD. CMD may decrease the need for VP shunting and its associated complications in the select group of hydrocephalic children with achondroplasia presenting with symptomatic foramen magnum stenosis.

Predictors of Ventriculoperitoneal shunting following Subarachnoid Hemorrhage treated with External Ventricular Drainage.

Aneurysmal subarachnoid hemorrhage (aSAH) is commonly associated with hydrocephalus due to subarachnoid hemorrhage blood products obstructing cerebrospinal fluid outflow. Hydrocephalus after aSAH is routinely managed with temporary external ventricular drainage (EVD) followed by standard EVD weaning protocols, which determine the need for ventriculoperitoneal shunting (VPS). We sought to investigate aSAH patients who initially passed EVD weaning trials and had EVD removal, but later presented with recurrent, delayed, symptomatic hydrocephalus requiring a VPS. We conducted a retrospective review of all patients at our tertiary care medical center who presented with aSAH, requiring an EVD. We analyzed variables associated with ultimate VPS dependency during hospitalization. We reviewed 489 patients with aSAH over a 6-year period (2008-2014). One hundred and thirty-eight (28.2%) developed hydrocephalus requiring a temporary EVD. Forty-four (31.9%) of these patients died or had withdrawal of care during admission, and were excluded from final analysis. Of the remaining 94 patients, 29 (30.9%) failed their clamp trial and required VPS. Sixty-five (69.1%) patients passed their clamp trial and were discharged without a VPS. However, 10 (15.4%) of these patients developed delayed hydrocephalus after discharge and ultimately required VPS [mean (range) days after discharge, 97.2 (35-188)]. Compared to early VPS, the delayed VPS group had a higher incidence of symptomatic vasospasm (90.0% vs 51.7%; P = 0.03). When comparing patients discharged from the hospital without VPS, delayed VPS patients also had higher 6- and 12-month mortality (P = 0.02) and longer EVD clamp trials (P < 0.01) than patients who never required VPS but had an EVD during hospitalization. Delayed hydrocephalus occurred in only 7.8% of patients who passed the initial EVD clamp trial, compared to 14.3% who failed the initial trial and 80.0% who failed 2 or more trials. Patients who failed their initial or subsequent EVD clamp trials had a small, but increased risk of developing delayed hydrocephalus ultimately requiring VPS. Additionally, the majority of patients who presented with delayed hydrocephalus also suffered symptomatic vasospasm. These associations should be further explored and validated in a larger prospective study.

Clinical complications and outcomes of angiographically negative subarachnoid hemorrhage.

To define the in-hospital course, complications, short- and long-term functional outcomes of patients with angiographically negative subarachnoid hemorrhage (anSAH), particularly those with aneurysmal-pattern anSAH (aanSAH). Retrospective cohort study of patients with aneurysmal subarachnoid hemorrhage (aSAH), aanSAH, and perimesencephalic-pattern anSAH (panSAH) treated at a single tertiary referral center between January 2006 and April 2018. Ninety-nine patients with anSAH (33 aanSAH and 66 panSAH) and 464 patients with aSAH were included in this study. Outcomes included symptomatic hydrocephalus requiring CSF drainage, need for ventriculoperitoneal shunt, radiographic vasospasm, delayed cerebral ischemia (DCI), radiographic infarction, disability level within 1 year of ictus, and at last clinical follow-up as defined by the modified Rankin Scale. Patients with aanSAH and panSAH had similar rates of DCI and radiologic infarction, and patients with aanSAH had significantly lower rates compared to aSAH (p ≤ 0.018). Patients with aanSAH were more likely than those with panSAH to require temporary CSF diversion and ventriculoperitoneal shunt (p ≤ 0.03), with similar rates to those seen in aSAH. Only one patient with anSAH died in the hospital. Compared to those with aSAH, patients with aanSAH were significantly less likely to have a poor functional outcome within 1 year of ictus (odds ratio 0.26, 95% confidence interval 0.090-0.75) and at last follow-up (hazard ratio 0.30, 95% confidence interval 0.19-0.49, p = 0.002). DCI is very uncommon in anSAH, but patients with aanSAH have a similar need for short- and long-term CSF diversion to patients with aSAH. Nevertheless, patients with aanSAH have significantly better short- and long-term outcomes.