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Surgical treatment of posthemorrhagic infantile hydrocephalus
1Department of Pediatric Neurosurgery, Sacro Cuore Catoholic University, Policlinico A. Gemelli, Rome, Italy - lmassimi@email.it.
Insights
Post-hemorrhagic hydrocephalus (PHH) affects surviving preterm infants. While shunts are common, they have high complication rates, and endoscopic options offer limited success, often requiring reoperation.
Area of Science:
- Neuroscience
- Pediatric Surgery
- Neonatology
Background:
- Post-hemorrhagic hydrocephalus (PHH) incidence remains stable despite improved perinatal care, with more survivors developing this condition.
- Symptomatic ventriculomegaly, often following severe preterm brain hemorrhage (Papile's grade III-IV), necessitates treatment.
Purpose of the Study:
- To review current treatment strategies for PHH, focusing on temporary measures, shunting, and neuroendoscopic interventions.
- To analyze the efficacy and complication rates associated with various PHH treatments, including ventriculo-peritoneal shunts and endoscopic procedures.
Main Methods:
- Review of literature on PHH management, including medical therapies, transient surgical maneuvers, ventriculo-peritoneal shunting, and neuroendoscopy.
- Analysis of complication rates (infection, obstruction, erosion) associated with shunts and reoperation rates for endoscopic procedures.
Main Results:
- Ventriculo-peritoneal shunts are the primary surgical treatment but have high complication rates, especially in low-weight infants, leading to frequent reoperations (approx. 30%).
- Neuroendoscopy can address hemorrhage complications (blood clots, cysts) and isolated ventricles, potentially avoiding multiple shunts.
- Endoscopic third ventriculostomy, a definitive endoscopic option, is effective in only about one-third of PHH cases, often necessitating reoperation due to CSF re-absorption issues, subarachnoid obstruction, or low intracranial pressure.
Conclusions:
- PHH management remains challenging, with significant reoperation rates for both shunt-based and endoscopic treatments.
- While neuroendoscopy offers benefits in managing complications, its definitive success rate for PHH is limited.
- Further research is needed to improve the long-term efficacy of PHH treatments and reduce the need for multiple interventions.
Abstract:
The incidence of post-hemorrhagic hydrocephalus (PHH) remains stable over the time since the improvement in the perinatal assistance permits to reduce the risk of preterm brain hemorrhage and, at the same time, to increase the rate of surviving children potentially developing PHH. Children showing symptomatic ventriculomegaly (usually following Papile's grade III or IV hemorrhage) are candidate to treatment. Temporary treatment is based on medical therapy or on transient surgical manoeuvres (lumbar tapping, subcutaneous reservoir, external ventricular drainage, brain wash) with the goal of avoiding or to postponing the definitive surgical operation. Ventriculo-peritoneal shunt still represents the main surgical procedure for PHH. Especially in low-weight babies, however, this procedure is burdened by a high rate of complications as shunt infection or obstruction, skin erosion. PHH is actually one of the types of hydrocephalus more frequently requiring multiple operations (about 30% of the cases). The advent of neuroendoscopy reduced the risk of complications but did not affect the risk of reoperations significantly. Endoscopy is useful in treating the complications of the hemorrhage, for example by aspirating ventricular blood clots, by fenestrating intraventricular cysts or septa, or by treating isolated ventricles (septostomy, aqueductoplasty). These procedures allows the patient to avoid multiple shunts and, therefore, to reduce the risk of complications. However, endoscopic third ventriculostomy, which is the endoscopic definitive option for PHH, is effective in about one third of the cases, thus resulting in the need of reoperation. Immaturity of the CSF re-adsorption pathways, obstruction of the subarachnoid spaces and low intracranial pressure are the main causes of endoscopy failures.
