OBJECTIVEHydrocephalus treatment in extremely low-birth-weight (ELBW) infants still represents a challenge for the pediatric neurosurgeon, particularly when the patient weighs far less than 1000 g. In such cases, the benefits in terms of neurological outcome following early treatment do not always outweigh the surgical risks, especially considering the great difference in the surgical risk before patient weight increases. To assess the efficacy and reliability of a percutaneous-tunneled, transfontanellar external ventricular drain (PTTEVD) in ELBW infants, the authors started a new protocol for the early surgical treatment of hydrocephalus.METHODSTen cases of posthemorrhagic hydrocephalus (PHH) in ELBW infants (5 cases < 700 g, range for all cases 550–1000 g) were treated with a PTTEVD that was implanted at bedside as the first measure in a stepwise approach.RESULTSThe average duration of the procedure was 7 minutes, and there was no blood loss. The drain remained in place for an average of 24 days (range 8–45 days). In all cases early control of the hydrocephalus was achieved. One patient had a single episode of CSF leakage (due to insufficient CSF removal). In another patient Enterococcus in the CSF sample was detected the day after abdominal surgery with ileostomy (infection resolved with intrathecal vancomycin). One patient died of Streptococcus sepsis, a systemic infection existing prior to drain placement that never resolved. One patient had Pseudomonas aeruginosa sepsis prior to drain insertion; a PTTEVD was implanted, the infection resolved, and the hydrocephalus was treated in the same way as with a traditional EVD, while the advantages of a quick, minimally invasive, bedside procedure were maintained. Once a patient reached 1 kg in weight, when necessary, a ventriculoperitoneal shunt was implanted and the PTTEVD was removed.CONCLUSIONSThe introduction of PTTEVD placement in our standard protocol for the management of PHH has proved to be a wise option for small patients.
Background: The link between the effects of recombinant human growth hormone (rhGH) therapy in patient with growth hormone deficiency (GHD) and Chiari malformation type I (CM-1) is controversial.
Summary: We report the case of a patient with an unusual association of growth hormone deficiency (GHD) due to ectopic posterior pituitary and Chiari malformation type I (CM-1). Our patient developed headache and worsening of CM-1 after initiation of rhGH therapy. Following an atlo-occipital decompression surgery, the patient was able to resume therapy with a marked growth improvement. Based on this observation, we provide a systematic review of the current literature about these two pathologies. Key Messages: A careful follow-up of all patients with CM-1 treated with GH is mandatory, paying particular attention to the appearance of any neurological signs and symptoms.
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