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Ventriculosubgaleal shunts for posthemorrhagic hydrocephalus in premature infants
Brian K Willis1, Cherukuri Ravi Kumar, Esther L Wylen
1Department of Neurosurgery, Louisiana State University Health Sciences Center, Shreveport, LA 71130-3932, USA. bwillis5@lsuhsc.edu
Insights
Ventriculosubgaleal shunts effectively diverted cerebrospinal fluid in premature infants but led to a high rate of infections. This method is no longer used due to significant complications.
Area of Science:
- Neonatal Surgery
- Pediatric Neurosurgery
- Hydrocephalus Management
Background:
- Posthemorrhagic hydrocephalus is a common complication in premature infants.
- Temporary cerebrospinal fluid (CSF) diversion is necessary until permanent shunt placement.
- Ventriculosubgaleal shunts offer a less invasive temporary CSF diversion option.
Purpose of the Study:
- To evaluate the effectiveness and complication rates of ventriculosubgaleal shunts for interim CSF diversion in premature infants.
- To assess the suitability of ventriculosubgaleal shunts as a temporary measure for posthemorrhagic hydrocephalus.
Main Methods:
- A retrospective review of 6 premature infants who underwent ventriculosubgaleal shunt placement.
- Assessment of clinical and imaging data to evaluate hydrocephalus control and complication rates.
- Analysis of infection rates and causative organisms.
Main Results:
- Ventriculosubgaleal shunts successfully controlled hydrocephalus in all 6 patients.
- One patient (16.6%) avoided a permanent shunt.
- A high infection rate of 66.6% was observed, primarily staphylococcus species, significantly higher than other shunt types.
Conclusions:
- Ventriculosubgaleal shunts are effective for temporary CSF diversion in neonates with posthemorrhagic hydrocephalus.
- The procedure is associated with an unacceptably high CSF infection rate.
- The high infection rate led to the discontinuation of the procedure at the institution.
Objective:
The early management of posthemorrhagic hydrocephalus in premature infants is challenging and controversial. These infants need a temporary cerebrospinal fluid (CSF) diversion procedure until they gain adequate weight, and the blood and protein levels in CSF are reasonably low before permanent shunt can be placed. Various options are available with their associated advantages and disadvantages. Ventriculosubgaleal shunts have been recommended as a more physiologic and less invasive means of achieving this goal. We have performed this procedure in 6 premature infants to evaluate their effectiveness and complications.
Methods:
Six consecutive premature infants with posthemorrhagic hydrocephalus underwent placement of ventriculosubgaleal shunts over a 1-year period of time. We reviewed their clinical and imaging progress to assess the ability of the shunt to control hydrocephalus and the complication rates.
Results:
In all 6 patients, the ventriculosubgaleal shunt controlled the progression of hydrocephalus as assessed by clinical and imaging parameters. A permanent shunt was avoided in 1 patient (16.6%). However, 4 patients developed shunt infections, 1 involving the ventriculosubgaleal shunt itself, and 3 immediately after conversion to ventriculoperitoneal shunt. The total infection rate of the series was 66.6%. All infections were caused by staphylococcus species. There was only a 1% shunt infection rate in our institution for all nonventriculosubgaleal shunts during the same period of time.
Conclusion:
Placement of ventriculosubgaleal shunts for interim CSF diversion in neonates with posthemorrhagic hydrocephalus is effective as a temporary method of CSF diversion. However, our experience has shown that it is associated with a unacceptably high CSF infection rate. A potential cause for infection is CSF stasis just beneath the extremely thin skin of the premature infants, promoting colonization by skin flora. CSF sampling before conversion to a permanent shunt and replacement of the proximal hardware, which has been in situ for a prolonged period, may decrease the infection rates. At present, the procedure is no longer performed at our institution.
