Timing of Permanent Ventricular Shunt Placement Following External Ventricular Drain Placement in Primary Intracerebral Hemorrhage.

BACKGROUND: Intraventricular hemorrhage requiring ventriculostomy placement is a frequent complication of spontaneous intracerebral hemorrhage. Although a subset of patients will require permanent ventricular shunt placement, little is known about contemporary practices regarding the timing of ventriculostomy and ventricular shunt placement after intracerebral hemorrhage. METHODS: Using the 2010-2012 National Inpatient Sample, we identified patients with International Classification of Diseases, Ninth Revision codes for intracerebral hemorrhage, excluded secondary causes, and examined procedure dates. RESULTS: Of 35,899 patients with primary intracerebral hemorrhage, 2443 (6.8%) received ventriculostomy, 93% within the first 3 days of admission and 66% within the first day. Permanent shunt placement occurred in 173 (7.1%) patients following ventriculostomy at a median interval of 15 days (interquartile range: 11-20). Among those remaining alive and in hospital at 14, 21, and 28 days, 5%, 11%, and 15%, respectively, underwent shunt placement following ventriculostomy, and 24% of those with multiple ventriculostomy insertions required permanent shunt by 4 weeks of hospitalization. Multiple ventriculostomies, tracheostomy, and black race were associated with longer time to permanent shunt. CONCLUSIONS: A wide variation in delay to permanent shunt placement is present, with substantial and increasing prevalence with time in hospital. Better understanding of the risk factors associated with persistent hydrocephalus will help optimize patient selection and timing of treatment.

Communicating Hydrocephalus Associated with Small- to Medium-Sized Vestibular Schwannomas: Clinical Significance of the Tumor Apparent Diffusion Coefficient Map.

BACKGROUND: The etiology of hydrocephalus associated with the small- to medium-sized vestibular schwannomas is still controversial. We investigated tumor-specific factors related to the association of hydrocephalus with small- to medium-sized vestibular schwannomas. METHODS: Among the 77 patients with vestibular schwannoma smaller than 30 mm, 9 patients demonstrated associated communicating hydrocephalus. Patient medical records, radiologic data, and histopathologic specimens were reviewed retrospectively. The age of the patients, and size, mean apparent diffusion coefficient (ADC) value, and histologic features of the tumors were compared with those of patients without hydrocephalus. RESULTS: The symptoms related to hydrocephalus improved in all patients after tumor removal. Both the mean size and ADC values exhibited a statistically significant difference between the tumors with and without hydrocephalus (P < 0.01). CONCLUSIONS: The size and ADC value of the tumor were significantly related to the association with hydrocephalus. The increased tumor ADC value was considered to be the result of degenerative change and suggested the involvement of protein sloughing in the etiology of the associated hydrocephalus.

Ventricular reservoir versus ventriculosubgaleal shunt for posthemorrhagic hydrocephalus in preterm infants: infection risks and ventriculoperitoneal shunt rate.

OBJECT: The most common neurosurgical condition observed in preterm infants is intraventricular hemorrhage (IVH), which often results in posthemorrhagic hydrocephalus (PHH). These conditions portend an unfavorable prognosis; therefore, the potential for poor neurodevelopmental outcomes necessitates a better understanding of the comparative effectiveness of 2 temporary devices commonly used before the permanent insertion of a ventriculoperitoneal (VP) shunt: the ventricular reservoir and the ventriculosubgaleal shunt (VSGS). METHODS: The authors analyzed retrospectively collected information for 90 patients with IVH and PHH who were treated with insertion of a ventricular reservoir (n = 44) or VSGS (n = 46) at their institution over a 14-year period. RESULTS: The mean gestational age and weight at device insertion were lower for VSGS patients (30.1 ± 1.9 weeks, 1.12 ± 0.31 kg) than for reservoir patients (31.8 ± 2.9 weeks, 1.33 ± 0.37 kg; p = 0.002 and p = 0.004, respectively). Ventricular reservoir insertion was predictive of more CSF taps prior to VP shunt placement compared with VSGS placement (10 ± 8.7 taps vs 1.6 ± 1.7 taps, p < 0.001). VSGS patients experienced a longer time interval prior to VP shunt placement than reservoir patients (80.8 ± 67.5 days vs 48.8 ± 26.4 days, p = 0.012), which corresponded to VSGS patients gaining more weight by the time of shunt placement than reservoir patients (3.31 ± 2.0 kg vs 2.42 ± 0.63 kg, p = 0.016). Reservoir patients demonstrated a trend toward more positive CSF cultures compared with VSGS patients (n = 9 [20.5%] vs n = 5 [10.9%], p = 0.21). There were no significant differences in the rates of overt device infection requiring removal (reservoir, 6.8%; VSGS, 6.5%), VP shunt insertion (reservoir, 77.3%; VSGS, 76.1%), or early VP shunt infection (reservoir, 11.4%; VSGS, 13.0%) between the 2 cohorts. CONCLUSIONS: Although the rates of VP shunt requirement and device infection were similar between patients treated with the reservoir versus the VSGS, VSGS patients were significantly older and had achieved greater weights at the time of VP shunt insertion. The authors' results suggest that the VSGS requires less labor-intensive management by ventricular tapping; the VSGS patients also attained higher weights and more optimal surgical candidacy at the time of VP shunt insertion. The potential differences in long-term developmental and neurological outcomes between VSGS and reservoir placement warrant further study.

The association between race and frequent shunt failure: a single-center study.

OBJECT: Children experiencing frequent shunt failure consume medical resources and represent a disproportionate level of morbidity in hydrocephalus care. While biological causes of frequent shunt failure may exist, this study analyzed demographic and socioeconomic patient characteristics associated with frequent shunt failure. METHODS: A survey of 294 caregivers of children with shunt-treated hydrocephalus provided demographic and socioeconomic characteristics. Children experiencing at least 10 shunt failures were considered frequent shunt-failure patients. Multivariate regression models were used to control for variables. RESULTS: Frequent shunt failure was experienced by 9.5% of the patients (28 of 294). By univariate analysis, white race (p = 0.006), etiology of hydrocephalus (p = 0.022), years-with-shunt (p < 0.0001), and surgeon (p = 0.02) were associated with frequent shunt failure. Upon multivariate analysis, white race remained the key independent factor associated with frequent shunt failure (OR 5.8, 95% CI 1.2-27.8, p = 0.027). Race acted independently from socioeconomic factors, including income, level of education, and geographic location, and clinical factors, such as etiology of hydrocephalus, surgeon, and years-with-shunt. Additionally, after multivariate analysis surgeon and years-with-shunt remained associated with frequent shunt failure (p = 0.043 and p = 0.0098, respectively), although etiology of hydrocephalus was no longer associated (p = 0.1). CONCLUSIONS: White race was the primary independent factor associated with frequent shunt failure. Because races use health care differently and the diagnosis of shunt failure is often subjective, a disparity in diagnosis and treatment has arisen. These findings call for objective criteria for the preoperative and intraoperative diagnosis of shunt failure.

Posthemorrhagic hydrocephalus in preterm neonates: socioeconomic characteristics in a single-institution experience.

UNLABELLED: Patients with posthemorrhagic hydrocephalus (PHH) from germinal matrix hemorrhage of prematurity often require numerous early interventions, as well as long-term follow-up care from pediatric neurosurgeons, which continues to place high demands on the existing workforce and pediatric health care system. There are established correlations between premature birth and low socioeconomic status. The aim of this study is to characterize the demographic profile and follow-up patterns in this subpopulation of surgically treated infants with PHH from prematurity. METHODS: A retrospective analysis of the electronic patient records for a single institution, from 2007 to 2010, was performed. All patients who underwent neurosurgical intervention for the treatment of PHH were selected for further analysis. Data elements available within the records included patient demographic features, inpatient treatments and procedures, inpatient mortality rates, length of stay, and postoperative follow-up at the institution. Socioeconomic status was assessed using the median household income for the patient's zip code, as reported in the United States Census for the year 2000. RESULTS: A total of 40 patients who underwent neurosurgical intervention for PHH at a single institution were identified. More patients were female (52.5%); the majority of patients were Black (57.5%). No patients were uninsured; most patients had public insurance (62.5%), and 65% were below the Maryland State median household income (USD 52,868). There were trends toward more frequent emergency room visits among those covered by public insurance and those below the state and national median house income, although differences were not statistically significant. CONCLUSIONS: Our data indicate that the majority of patients fall within lower household income brackets, are born into households earning less than the statewide median household income, and are covered by public insurance. In light of the socioeconomic profile of the patient population reported here, these data may prove to be useful in preventative strategies aimed toward prematurity, PHH, and the ongoing treatment of hydrocephalus by pediatric neurosurgeons and other pediatric subspecialists.

Descriptive epidemiology of selected heritable birth defects in Texas.

BACKGROUND: Few population-based studies exist on descriptive epidemiologic characteristics of rare heritable birth defects. The number of birth defect cases in the Texas Birth Defects Registry (one of the largest active birth defects surveillance systems in the world) enabled us to examine six different heritable disorders (aqueductal stenosis, infantile polycystic kidney disease, achondroplasia, thanatophoric dwarfism, chondrodysplasia/dwarfism not otherwise specified (NOS), and osteogenesis imperfecta) for a variety of descriptive demographic variables. METHODS: The Texas Birth Defects Registry was used to identify infants or fetuses with heritable birth defects. Crude prevalence rates were calculated and Poisson regression was used to test the association of each demographic variable (e.g., maternal age) with each of the selected genetic birth defects. RESULTS: White non-Hispanics exhibited higher rates of achondroplasia and osteogenesis imperfecta than other race/ethnic groups. Lower maternal education level and to a lesser extent, paternal education level, was associated with higher rates of several disorders. The birth prevalence rate for achondroplasia decreased from 1999 through 2006. CONCLUSION: The use of a large birth defects registry provides a sufficient count of cases to perform some basic epidemiologic analysis on selected rare heritable birth defects.

Health care expenditures among children with and those without spina bifida enrolled in Medicaid in North Carolina.

BACKGROUND: National data on health care use among children with special needs are limited and do not address children with spina bifida (SB). One recent study examined health care costs during 2003 among privately insured individuals with SB. Our objective was to compare health care use and expenditures among publicly insured children with SB to children without a major birth defect and among children with SB with and without hydrocephalus. METHODS: Data from the North Carolina Birth Defects Monitoring Program and Medicaid were linked to identify continuously enrolled children with SB (case children) and children without a major birth defect (control children) born from 1995 to 2002. Medicaid expenditures per child for medical, inpatient, outpatient, dental, well-child care, developmental/behavioral services, and home health for those aged 0 to 4 years old were calculated for case and control children and for case children with and without hydrocephalus. RESULTS: Of 373 case children who survived infancy, 205 (55%) were enrolled in Medicaid. Expenditures were assessed for 144 case and 5674 control children aged 0 to 4 years old continuously enrolled in Medicaid. During infancy, mean expenditure was $33,135 per child with SB and $3900 per unaffected child. The biggest relative expenditures were for developmental/behavioral services (82 times higher for case than control child [$1401 vs. $17]) and home health services (20 times higher [$821 vs. $41]). Average expenditure for an infant with SB and hydrocephalus was 2.6 times higher than an infant with SB without hydrocephalus ($40,502 vs. $15,699). CONCLUSIONS: Expenditure comparisons by SB subtype are important for targeting health care resources.

CSF shunt complications in infants--an experience from Pakistan.

AIMS AND OBJECTIVE: The main aim of the study was to find out the postoperative complications and long-term outcome of cerebrospinal fluid-shunted patients in an infantile age group with a poor socioeconomic background. MATERIAL AND METHODS: A prospective study of 100 cases of infantile hydrocephalus was conducted at Pakistan Institute of Medical Sciences, Islamabad, Pakistan. All selected patients suffering from congenital and post-meningitic hydrocephalus were operated on for ventriculoperitoneal shunt. However, cases of hydrocephalus secondary to myelomeningocele were not included. Patients were followed postoperatively for 2 years. Prior consent for surgery was taken from all parents and the study was approved by the hospital's academic and ethical council. RESULTS: The majority of patients were brought quite late to the medical facilities because of social taboos and socioeconomic conditions. Early signs and symptoms of hydrocephalus were either ignored or misunderstood. Shunt infection and shunt failure rates remained at 14 and 10%, respectively. 50% of shunt blocks occurred in the first postoperative year and another 50% within 2 years. The highest percentage (40-45%) of death occurred in patients suffering from congenital hydrocephalus, in the first postoperative year. CONCLUSIONS: This study concluded that the outcome and prognosis of shunted infantile hydrocephalus in developing countries is suboptimal due to different socioeconomic conditions. However, under such circumstances, careful selection of patients, timely intervention and adherence to meticulous aseptic surgical techniques can alter the prognosis of cerebrospinal fluid-shunted infants.

Neuroimaging features of tuberculous meningitis.

Tuberculous meningitis leads to a high mortality rate. However, it responds well to chemotherapy if the treatment is started early. Neuroimaging is one of the most important initial investigations. There were 42 patients diagnosed with tuberculous meningitis in Kuala Lumpur Hospital based on clinical criteria, cerebrospinal fluid analysis and response to anti-tuberculous treatment over a 7 year period. Relevant information was obtained from patients' medical case notes and neuroimaging findings were evaluated. Male to female ratio was 3:1. The three major ethnics and the immigrant groups in Malaysia were represented in this study. The majority of the cases involved the Malays followed by immigrants, Chinese and Indians. The patients' age ranged from 18 to 62 years old with the mean age of 34.4 years. There were 95.2% (n = 40) of patients who presented with various neuroimaging abnormalities and only 2 (4.8%) patients had normal neuroimaging findings. Hydrocephalus and meningeal enhancement were the two commonest neuroimaging features. Other features include infarction, enhancing lesion, tuberculoma, abcess, oedema and calcification. Contrasted CT scan is an adequate neuroimaging tool to unmask abnormal findings in tuberculous meningitis.

Time trends and demographics of deaths from congenital hydrocephalus in children in the United States: National Center for Health Statistics data, 1979 to 1998.

OBJECT: Congenital hydrocephalus has an estimated population incidence of 0.2 to 0.8/1000 live births. With improvements in techniques for cerebrospinal fluid shunting, treatment of hydrocephalus has become safe and routine, yet data describing mortality from congenital hydrocephalus or demonstrating improvements in mortality with the advent of modern treatment are scarce. The authors' analysis sought to rectify this situation. METHODS: The authors performed an electronic search of National Center for Health Statistics death certificate databases to identify deaths from 1979 to 1998 attributed to congenital hydrocephalus, spina bifida with hydrocephalus, and acquired hydrocephalus (both obstructive and communicating) in all children in the US aged 1 day to 20 years. Mortality rates were defined as deaths per 100,000 person-years and were analyzed for differences on the basis of age, race, sex, and year. The authors identified 10,406 deaths attributed to childhood hydrocephalus within the 20-year study period. The overall mortality rate was 0.71 per 100,00 person-years. Mortality rates were highest in infants, with 3979 deaths; they were similar between girls and boys. Compared with white infants, black infants had higher relative risk (RR) for death caused by congenital hydrocephalus (RR 1.46, p value < 0.0001) and acquired hydrocephalus (RR 2.58, p value < 0.0001) but not for that caused by hydrocephalus with spina bifida (RR 0.65, p value < 0.0001). From 1979 to 1998, the mortality rate due to congenital hydrocephalus declined 66.3%, from spina bifida with hydrocephalus it declined by 30.4%, and from acquired hydrocephalus it declined by 67.5%. CONCLUSIONS: Mortality rates from childhood hydrocephalus have declined in US children over the previous 20 years. Black race is associated with higher mortality rates in infants for both congenital and acquired hydrocephalus, whereas sex has no effect.

Comparison of endoscopic third ventriculostomy alone and combined with choroid plexus cauterization in infants younger than 1 year of age: a prospective study in 550 African children.

OBJECT: The aim of this prospective study was to determine whether, and in which patients, the outcome for bilateral choroid plexus cauterization (CPC) in combination with endoscopic third ventriculostomy (ETV) was superior to ETV alone. METHODS: A total of 710 children underwent ventriculoscopy as candidates for ETV as the primary treatment for hydrocephalus. The ETV was accomplished in 550 children: 266 underwent a combined ETV-CPC procedure and 284 underwent ETV alone. The mean and median ages were 14 and 5 months, respectively, and 443 patients (81%) were younger than 1 year of age. The hydrocephalus was postinfectious (PIH) in 320 patients (58%), nonpostinfectious (NPIH) in 152 (28%), posthemorrhagic in five (1%), and associated with myelomeningocele in 73 (13%). The mean follow up was 19 months for ETV and 9.2 months for ETV-CPC. Overall, the success rate of ETV-CPC (66%) was superior to that of ETV alone (47%) among infants younger than 1 year of age (p < 0.0001). The ETV-CPC combined procedure was superior in patients with a myelomeningocele (76% compared with 35% success, p = 0.0045) and those with NPIH (70% compared with 38% success, p = 0.0025). Although the difference was not significant for PIH (62% compared with 52% success, p = 0.1607), a benefit was not ruled out (power = 0.3). For patients at least 1 year of age, there was no difference between the two procedures (80% success for each, p = 1.0000). The overall surgical mortality rate was 1.3%, and the infection rate was less than 1%. CONCLUSIONS: The ETV-CPC was more successful than ETV alone in infants younger than 1 year of age. In developing countries in which a dependence on shunts is dangerous, ETV-CPC may be the best option for treating hydrocephalus in infants, particularly for those with NPIH and myelomeningocele.

Genetic disorders among Palestinian Arabs. 2. Hydrocephalus and neural tube defects.

Congenital hydrocephalus and/or open neural tube defect was present in at least one individual of 98 families out of the 2,000 Palestinian Arabic families who have visited the Genetic clinic at the Hadassah Medical Center. In 22 families the brain malformation was part of a syndrome: Meckel syndrome in 10, Warburg syndrome in another 5, Carpenter in one, and undiagnosed in 6 families. In 76 of the families the neural tube defect and/or the hydrocephalus were non-syndromal. It seems that most of the cases of isolated non-syndromal hydrocephalus represented autosomal recessive traits and that an abnormal allele is common among Palestinian Muslim Arabs.