Introduction of percutaneous-tunneled transfontanellar external ventricular drainage in the management of hydrocephalus in extremely low-birth-weight infants

Abstract

<jats:sec> <jats:title>OBJECTIVE</jats:title> <jats:p>Hydrocephalus 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.</jats:p></jats:sec> <jats:sec> <jats:title>METHODS</jats:title> <jats:p>Ten cases of posthemorrhagic hydrocephalus (PHH) in ELBW infants (5 cases &lt; 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.</jats:p></jats:sec> <jats:sec> <jats:title>RESULTS</jats:title> <jats:p>The 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 <jats:italic>Enterococcus</jats:italic> in the CSF sample was detected the day after abdominal surgery with ileostomy (infection resolved with intrathecal vancomycin). One patient died of <jats:italic>Streptococcus</jats:italic> sepsis, a systemic infection existing prior to drain placement that never resolved. One patient had <jats:italic>Pseudomonas aeruginosa</jats:italic> 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.</jats:p></jats:sec> <jats:sec> <jats:title>CONCLUSIONS</jats:title> <jats:p>The introduction of PTTEVD placement in our standard protocol for the management of PHH has proved to be a wise option for small patients.</jats:p></jats:sec>

Surgical Antimicrobial Prophylaxis in Neonates and Children Undergoing Neurosurgery: A RAND/UCLA Appropriateness Method Consensus Study

“…In fact, the risk of contamination is extremely low in the absence of CSF fistula and, so far, no increase in antibiotic resistance has been observed with antibiotic-impregnated catheters. With these premises, preoperative cefazolin can be used in older patients in whom it is possible to use catheters impregnated with antibiotic and carry out long tunneling to reduce the risk of CSF fistula; in neonates (especially in those low-birth-weight), if it is not possible to use medicated catheters, and when the CSF fistula is almost certain, the combination with vancomycin is the most suitable strategy [ 84 , 85 ]. However, further studies are needed to clarify the optimal SAP and the effectiveness of catheters impregnated with antibiotic when external ventricular drainages are positioned.…”

Ventriculosubgaleal shunt and neuroendoscopic lavage: refining the treatment algorithm of neonatal post-hemorrhagic hydrocephalus

“…External ventricular drainage (EVD) may be inserted at bedside, theoretically warrants continuous CSF drainage, and can be easily removed [ 13 ]. These advantages are counterbalanced by the ineluctable infectious risk.…”

Bedside placement of ventricular access devices under local anaesthesia in neonates with posthaemorrhagic hydrocephalus: preliminary experience

“…Januschek et al and Zucchelli et al have described the bedside placement of external ventricular reservoirs in the NICU with good results in these two small series (technical note and clinical series) and without observing increased infection rates. Zucchelli et al [25] performed these procedures in general anaesthesia, while Januschek et al [8] do not mention the type of anaesthesia. In both series, the procedure was performed as a temporizing measure for ultra and very low birth weight neonates (< 1000 g) while planning VPS placement (if indicated) once neonates reached a weight of > 1000 g. Both authors conclude that EVD placement can be safely performed in the NICU, avoiding transports through the hospital and getting the neonate outside the incubator.…”