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

Abstract

Background The optimal management of neonatal post-hemorrhagic hydrocephalus (PHH) is still debated, though several treatment options have been proposed. In the last years, ventriculosubgaleal shunt (VSgS) and neuroendosdcopic lavage (NEL) have been proposed to overcome the drawbacks of more traditional options, such as external ventricular drainage and ventricular access device. Methods We retrospectively reviewed neonates affected by PHH treated at our institution since September 2012 to September 2020. Until 2017 patients received VSgS as initial treatment. After the introduction of NEL, this treatment option was offered to patients with large intraventricular clots. After NEL, VSgS was always placed. Primary VSgS was reserved to patients without significant intraventricular clots and critically ill patients that could not be transferred to the operating room and undergo a longer surgery. Results We collected 63 babies (38 males and 25 females) with mean gestational age of 27.8 ± 3.8SD weeks (range 23–38.5 weeks) and mean birthweight of 1199.7 ± 690.6 SD grams (range 500–3320 g). In 6 patients, hemorrhage occurred in the third trimester of gestation, while in the remaining cases hemorrhage complicated prematurity. This group included 37 inborn and 26 outborn babies. Intraventricular hemorrhage was classified as low grade (I–II according to modified Papile grading scale) in 7 cases, while in the remaining cases the grade of hemorrhage was III to IV. Mean age at first neurosurgical procedure was 32.2 ± 3.6SD weeks (range 25.4–40 weeks). Death due to prematurity occurred in 5 patients. First-line treatment was VSgS in 49 patients and NEL in the remaining 14 cases. Mean longevity of VSgS was 30.3 days (range 10–97 days) in patients finally requiring an additional treatment of hydrocephalus. Thirty-two patients required one to three redo VSgS. Interval from initial treatment to permanent shunt ranged from 14 to 312 days (mean 70.9 days). CSF infection was observed in 5 patients (7.9%). Shunt dependency was observed in 51 out of 58 surviving patients, while 7 cases remained shunt-free at the last follow-up. Multiloculated hydrocephalus was observed in 14 cases. Among these, only one patient initially received NEL and was complicated by isolated trapped temporal horn. Conclusions VSgS and NEL are two effective treatment options in the management of PHH. Both procedures should be part of the neurosurgical armamentarium to deal with PHH, since they offer specific advantages in selected patients. A treatment algorithm combining these two options may reduce the infectious risk and the risk of multiloculated hydrocephalus.

A standardised protocol for neuro-endoscopic lavage for post-haemorrhagic ventricular dilatation: A Delphi consensus approach

“…Components of the protocol that were not mandated or specified, such as type of temporising device, reflect areas where there is limited evidence to suggest that these factors have any influence on outcome, highlighting areas of practice that would benefit from future research should NEL be validated and implemented as routine management for PHVD. Interestingly, despite variation in the published practice of NEL [ 1 , 4 – 6 , 8 , 9 ], all participating paediatric neurosurgeons in this consensus ultimately agreed that NEL should be performed as an adjunct and not replacement to the procedure of temporising device insertion, particularly when NEL is being performed at the time of development of PHVD (when the ventricular index crosses the 97th centile + 4 mm). In this consensus process, the timing of NEL was agreed as when the ventricular index crosses the 97th centile + 4 mm; however, there is recognised variation in practice documented in literature with regard to the timing of NEL [ 4 , 18 ].…”

Neuroendoscopic lavage versus traditional surgical methods for the early management of posthemorrhagic hydrocephalus in neonates

“…They concluded that VSgS and NEL are two effective treatment options. Both procedures should be part of the neurosurgical armamentarium to deal with PHH [17]. Honeyman et al confirmed that NEL is a safe and potentially efficacious treatment for neonatal IVH [18].…”

A Standardised Protocol for Neuro-endoscopic Lavage for Post-haemorrhagic Ventricular Dilatation: A Delphi Consensus Approach

“…Components of the protocol that were not mandated or specified, such as type of temporising device, reflect areas where there is limited evidence to suggest that these factors have any influence on outcome, highlighting areas of practice that would benefit from future research should NEL be validated and implemented as routine management for PHVD. Interestingly, despite variation in the published practice of NEL [1, 3–5, 7, 8], all participating paediatric neurosurgeons in this consensus ultimately agreed that NEL should be performed as an adjunct and not replacement to the procedure of temporizing device insertion, particularly when NEL is being performed at the time of development of PHVD (when the ventricular index crosses the 97 th centile + 4mm).…”

“…Retrospective studies have suggested that NEL may be effective at reducing shunt dependence and allowing good motor and cognitive outcomes [3][4][5][6][7]. However, there is considerable variation in NEL practice and currently there is no randomised trial evidence supporting the use of NEL [8].…”