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Neurosurgical treatment of progressive posthemorrhagic ventricular dilation in preterm infants: a 10-year
David D Limbrick1, Amit Mathur, James M Johnston
1Department of Neurological Surgery, St. Louis Children's Hospital, Washington University School of Medicine, St. Louis, Missouri 63110-1077, USA. limbrickd@nsurg.wustl.edu
Insights
This study found no significant difference in complication rates or the need for permanent shunts between ventricular access devices (VADs) and ventriculosubgaleal (VSG) shunts for treating posthemorrhagic ventricular dilation in preterm infants.
Area of Science:
- Neonatal Neurology
- Pediatric Neurosurgery
- Critical Care Medicine
Background:
- Intraventricular hemorrhage (IVH) and progressive posthemorrhagic ventricular dilation (PPHVD) are significant concerns in preterm infants.
- Optimal timing and type of neurosurgical intervention for PPHVD remain debated.
- Ventricular access devices (VADs) and ventriculosubgaleal (VSG) shunts are common temporizing neurosurgical procedures (TNPs).
Purpose of the Study:
- To compare the efficacy and limitations of VADs versus VSG shunts for treating PPHVD in preterm infants.
- To evaluate complication rates, need for permanent shunting, and mortality associated with each TNP type.
Main Methods:
- A 10-year retrospective review of preterm infants with Papile Grade III-IV IVH was conducted.
- Infants requiring TNP for PPHVD were identified, and data on VADs and VSG shunts were collected.
- Complication rates, VP shunt implantation, shunt infections, and mortality were compared between the two TNP groups.
Main Results:
- Of 325 preterm infants with Grade III-IV IVH, 95 underwent TNP (65 VADs, 30 VSG shunts).
- Permanent VP shunt implantation was required in 72.6% of infants post-TNP.
- No statistically significant differences were found in TNP complications, VP shunt requirement, shunt infections, or mortality between VADs and VSG shunts.
Conclusions:
- The study observed increasing rates of IVH and PPHVD over time.
- Contrary to some literature, this study found no difference in complication rates or need for permanent VP shunts between VADs and VSG shunts.
- Larger, prospective trials are needed to draw definitive conclusions.
Object:
Intraventricular hemorrhage (IVH) and progressive posthemorrhagic ventricular dilation (PPHVD) may result in significant neurological morbidity in preterm infants. At present, there is no consensus regarding the optimal timing or type of neurosurgical procedure to best treat PPHVD. Conflicting data exist regarding the relative risks and benefits of two commonly used temporizing neurosurgical procedures (TNPs), ventricular access devices ([VADs] or ventricular reservoirs) versus ventriculosubgaleal (VSG) shunts. This study was designed to address this issue.
Methods:
This is a single-center, 10-year retrospective review of all preterm infants admitted to the St. Louis Children's Hospital neonatal intensive care unit (NICU) with Papile Grade III-IV IVH. The development of PPHVD and the requirement for and type of TNP were recorded. Rates of TNP complication, ventriculoperitoneal (VP) shunt implantation, shunt infection, and mortality rates were used to compare the efficacy and limitations of each TNP type.
Results:
Over this 10-year interval, 325 preterm infants with Grade III-IV IVH were identified, with trends showing an increasing number of affected infants annually, and an increasing number of TNPs were required annually. Ninety-five (29.2%) of the 325 infants underwent a TNP for PPHVD (65 VADs, 30 VSG shunts). The rate of permanent VP shunt implantation for all TNPs was 72.6% (69 of 95 infants). Forty-nine (75.4%) of the 65 infants treated with VADs and 20 (66.7%) of the 30 treated with VSG shunts required VP shunts (p = 0.38). There was no statistical difference between VAD or VSG shunt with regard to TNP-related infection (p = 0.57), need for TNP revision (p = 0.16), subsequent shunt infection (p = 0.77), shunt revision rate (p = 0.58), or mortality rate (p = 0.24).
Conclusions:
Rates of IVH and PPHVD observed at the authors' center have increased over time. In contrast to recent literature, the results from the current study did not demonstrate a difference in complication rate or requirement for permanent VP shunt placement between VADs and VSG shunts. Definitive conclusions will require a larger, prospective trial.
