Predictors of the need for cerebrospinal fluid diversion in patients with myelomeningocele

Clinical article

Free access

Object

Many patients with myelomeningocele (MMC) develop hydrocephalus, and most will undergo CSF diversion. The goal of this retrospective study was to determine whether there was a change in the shunt rate over the 7 consecutive years of the study. The authors will also identify the criteria used to determine the need for shunt placement.

Methods

During a 7-year period, 73 patients underwent MMC closure at Arkansas Children's Hospital. The shunt rate for each year was calculated. Clinical characteristics were evaluated, including apneic and bradycardic spells, CSF leak, level of the MMC, head circumference, and rate of head growth. In addition, radiological images were reviewed, and the frontooccipital horn ratio (FOHR), ventricular index (VI), and thalamooccipital distance (TOD) were calculated. Comparisons were made between those patients who underwent shunt placement and those who did not.

Results

One patient was excluded due to death in the perinatal period. Of the 72 remaining patients, 54 (75%) underwent placement of a ventriculoperitoneal shunt. This rate did not change significantly over time. Between the cohorts with and without a shunt there was no significant difference in age, sex, or race. There was no significant difference in apneic episodes or bradycardic episodes. There was a statistically significant difference in fontanelle characteristics, head circumference at birth, and rate of head growth. Patients who required CSF diversion had a mean head growth of 0.32 cm/day compared with those who did not receive a shunt (0.13 cm/day; p < 0.05). All radiological parameters were found to be statistically significant.

Conclusions

In this study, several classic indicators of hydrocephalus in the neonate were not found to be significantly associated with the need for CSF diversion. Fontanelle characteristics, head circumference at birth, and head growth velocity were associated with the need for shunt placement. Imaging information including the VI, TOD, and FOHR are statistically significant measures to evaluate prior to placement of a ventriculoperitoneal shunt. The optimal patient with MMC for CSF diversion will have full to tense fontanelle, increasing head circumference of more than 3 mm/day, and radiological evidence of an elevated VI, TOD, and/or FOHR.

Abbreviations used in this paper:FOHR = frontooccipital horn ratio; MMC = myelomeningocele; MOMS = Management of Myelomeningocele Study; OFC = occipitofrontal circumference; TOD = thalamooccipital distance; VI = ventricular index.

Object

Many patients with myelomeningocele (MMC) develop hydrocephalus, and most will undergo CSF diversion. The goal of this retrospective study was to determine whether there was a change in the shunt rate over the 7 consecutive years of the study. The authors will also identify the criteria used to determine the need for shunt placement.

Methods

During a 7-year period, 73 patients underwent MMC closure at Arkansas Children's Hospital. The shunt rate for each year was calculated. Clinical characteristics were evaluated, including apneic and bradycardic spells, CSF leak, level of the MMC, head circumference, and rate of head growth. In addition, radiological images were reviewed, and the frontooccipital horn ratio (FOHR), ventricular index (VI), and thalamooccipital distance (TOD) were calculated. Comparisons were made between those patients who underwent shunt placement and those who did not.

Results

One patient was excluded due to death in the perinatal period. Of the 72 remaining patients, 54 (75%) underwent placement of a ventriculoperitoneal shunt. This rate did not change significantly over time. Between the cohorts with and without a shunt there was no significant difference in age, sex, or race. There was no significant difference in apneic episodes or bradycardic episodes. There was a statistically significant difference in fontanelle characteristics, head circumference at birth, and rate of head growth. Patients who required CSF diversion had a mean head growth of 0.32 cm/day compared with those who did not receive a shunt (0.13 cm/day; p < 0.05). All radiological parameters were found to be statistically significant.

Conclusions

In this study, several classic indicators of hydrocephalus in the neonate were not found to be significantly associated with the need for CSF diversion. Fontanelle characteristics, head circumference at birth, and head growth velocity were associated with the need for shunt placement. Imaging information including the VI, TOD, and FOHR are statistically significant measures to evaluate prior to placement of a ventriculoperitoneal shunt. The optimal patient with MMC for CSF diversion will have full to tense fontanelle, increasing head circumference of more than 3 mm/day, and radiological evidence of an elevated VI, TOD, and/or FOHR.

Myelomeningocele (MMC) is one of the most common developmental anomalies of the CNS. Many of these patients also develop hydrocephalus, most of whom eventually undergo CSF diversion. The rate of CSF shunt placement in these patients varies significantly in published studies, from 52% to 92%, with at least 1 group reporting a decrease in shunt rate over time at their institution.1,6

Cerebrospinal fluid shunting has numerous complications, most notably shunt failure and shunt infection. Studies have suggested that patients with greater numbers of shunt revisions have poorer performance on neuropsychological testing.7,8 Another study showed that shunt infection has an adverse effect on the patient's intelligence quotient.17 These data provide incentive to reduce the rate of shunt placement in patients with MMC and to ensure that only patients who will benefit from CSF shunting will have this procedure performed.

In 10% of infants with MMC, hydrocephalus is apparent at birth, with patients having macrocrania and massive ventriculomegaly.2 While these patients will likely benefit from CSF shunting, there are no widely applied criteria for CSF shunting in other patients with MMC with less profound hydrocephalus. Previously reported indicators of the need for a shunt include level of the lesion, clinical signs of elevated intracranial pressure such as a tense or bulging fontanelle, bradycardia, sunsetting eyes, increasing head circumference, and increasing ventricular size.6,14,16

The Management of Myelomeningocele Study (MOMS) explored the shunt rate of patients with prenatal versus postnatal MMC repair as one of its primary end points. This study demonstrated a statistically significant difference in CSF diversion, with the rate of shunting in the fetal closure group (65%) lower than in the postnatal closure group (92%).1 Another recent publication indicated a shunt rate of 52% from 1 institution using stringent shunt criteria.6 This institution was not involved in the MOMS trial and performed exclusively postnatal MMC repair. Also, while the results of the MOMS trial are compelling, the rate of shunt placement for the postnatal repair group was high compared with other published results.6

The goal of this retrospective study was to determine the shunt rate over 7 consecutive years for patients at our institution and to determine whether there was a change in the shunt rate over time. We also sought to identify the criteria used to determine the requirement for shunting at our institution and identify which factors were the most predictive of the need for CSF shunting.

Methods

Study Population

Retrospective data were collected on all infants with MMCs repaired at Arkansas Children's Hospital from January 1, 2005, to December 31, 2011. This cohort consisted of 73 total patients, with 1 exclusion due to death in the immediate perinatal period from multiple congenital anomalies and withdrawal of care. All MMC repairs were performed postnatally. This study was approved by the Institutional Review Board of the University of Arkansas for Medical Sciences.

Clinical and Anatomical Measurements

The anatomical level of the lesion was determined from the neurosurgical operative report. The anatomical level for this study was defined as the most rostral level of the bone defect and compared using a 2-sample t-test. Data on apneic spells, bradycardic spells, and fontanelle characteristics were gathered from the neonatal intensive care daily notes and confirmed in nursing documentation. These data were compared using Fisher's exact test. Gestational age was determined from the obstetric report on the admissions records. Occipitofrontal circumference (OFC) measurements were included only if performed by a member of the division of neurosurgery. Primary OFC measurements at birth were compared between those patients with and without shunts as well as the rate of change in OFC measurement when applicable. Rate of change was calculated using Time 0 as birth and Time 1 as OFC just prior to shunt placement (for those with shunts) or OFC at 3-month follow-up (for those without shunts). These results were compared using a 2-sample t-test.

The frontooccipital horn ratio (FOHR) was obtained using CT scans prior to CSF diversion in those receiving shunts (48 of 54 patients) and the most recent follow-up for those who did not require a shunt (15 of 18 patients). The FOHR was determined on axial images by averaging the frontal and occipital horn widths and then dividing by the interparietal distance.12 Measurements made on 3 consecutive slices were evaluated and the largest measurement was used for each value. The FOHR was measured in triplicate on 3 separate days by a single observer (B.C.P.). The average of the 3 measurements for each patient was used in the final analysis. The FOHR for patients with and without shunts was compared using a 2-sample t-test, with comparisons made independent of age.

The ventricular index (VI) and the thalamooccipital distance (TOD) were obtained from cranial ultrasonography examinations when performed prior to placement of a ventriculoperitoneal shunt in those receiving shunts (49 of 54 patients) and within the first month of life for those who did not require a shunt (17 of 18 patients). The VI was defined as the distance between the falx cerebri and the lateral wall of the anterior horn at its widest point in the coronal plane.4 The TOD was defined as the distance between the outermost point of the thalamus at its junction with the choroid plexus and the outermost part of the occipital horn in a parasagittal plane.3,4 The VI and TOD were measured in triplicate on 3 consecutive days by a single observer (B.C.P.). The average of the 3 measurements for each value for each patient was used in the final analysis. These measurements for patients with and without shunts were compared using a 2-sample t-test with comparisons made independent of age.

Complications

Complications were recorded after reviewing daily progress and operative notes. Special attention was paid to complications in regard to hydrocephalus, including the development of a pseudomeningocele or CSF leak from the operative site. Any event of death was recorded. All shunt revisions and infections were recorded.

Statistical Analyses

The statistical significance of all clinical and radiological variables was determined using the univariate Cox proportional hazards model. Multivariate Cox proportional hazards analysis was also performed. In this analysis, 3 models were used. Model 1 included only clinical characteristics (gestational age, sex, apneic episodes, bradycardic episodes, fontanelle description, head circumference at birth, and head growth rate). Model 2 included the clinical characteristics from Model 1 in addition to the radiological parameters obtained from head ultrasonography (VI and TOD). Model 3 included all clinical and radiological variables.

Results

Of the 72 patients reviewed, 54 (75%) underwent CSF diversion, with 81% of these patients requiring the insertion of a ventriculoperitoneal shunt within the first month. Annual shunt rates varied from 45% to 100% (Fig. 1). There was not a statistically significant change in the rate of patients with MMC undergoing CSF diversion through the study period.

Fig. 1.
Fig. 1.

Line graph displaying the percentage of patients with MMC who received shunts per year. There was not a statistically significant change in shunt rate over the period evaluated.

The anatomical level of the MMC was thoracic in 7 patients, lumbar in 64 patients, and sacral in 1 patient. Seventy-five percent of the patients with thoracic-level MMC had shunts, and 75.4% of the patients with lumbar MMC had shunts. The single patient with a sacral MMC did not have a shunt. There was no statistically significant difference in anatomical level between patients with and without shunts in this study.

Apneic and bradycardic spells were measured to determine their predictive value for CSF diversion. Of the 72 patients, apneic spells were recorded in 17 patients (Table 1). Apneas were recorded in 11 (20.4%) of the 54 patients with shunts and 6 (33.3%) of the 18 patients without shunts. This difference was not statistically significant. Bradycardic episodes were recorded in 19 (35.2%) of the 54 patients with shunts and 5 (27.8%) of the 18 patients without shunts (Table 1). This difference was also not statistically significant.

TABLE 1:

Characteristics of hydrocephalus in a cohort with MMC

VariableWithout Shunts (n = 18)With Shunts (n = 54)p Value
mean gestational age ± SD (wks)36.3 ± 3.337.5 ± 2.30.1850*
males (%)11 (61.1)29 (53.7)0.7848
race (%)0.8270
 Caucasian14 (77.8)42 (77.8)
 African American1 (5.6)5 (9.3)
 Hispanic2 (11.1)6 (11.1)
 other1 (5.6)1 (1.9)
apneic episodes (%)6 (33.3)11 (20.4)0.3379
bradycardic episodes (%)5 (27.8)19 (35.2)0.7737
CSF leak (%)04 (7.4)0.5660
fontanelle description (%)0.0003
 sunken/flat14 (77.8)13 (24.1)
 full/soft3 (16.7)33 (61.1)
 tense1 (5.6)8 (14.8)
mean OFC ± SD (cm)32.8 ± 3.834.8 ± 3.50.0611*
mean head growth ± SD (cm/day)0.13 ± 0.0770.316 ± 0.2640.0126*
mean FOHR ± SD0.446 ± 0.0840.549 ± 0.0890.0004*
mean VI ± SD§1.77 ± 0.362.33 ± 0.830.0004*
mean TOD ± SD§2.35 ± 0.974.04 ± 1.61<0.0001*

Two-sample t-test with Satterthwaite adjustment for unequal variances.

Fisher's exact test.

Forty-six patients with shunts, 15 without shunts.

Forty-nine patients with shunts, 17 without shunts.

A description of the fontanelle characteristics was available for all 72 patients. Fontanelle description was divided into sunken/flat, full/soft, and tense, and recorded in the perinatal period or immediately prior to CSF diversion. For the 18 patients without shunts, the fontanelle was described as sunken/flat in 14 patients, full/soft in 3 patients, and tense in 1. For the 54 patients with shunts, the fontanelle was described as sunken/flat in 13 patients, full/soft in 33 patients, and tense in 8 patients (Table 1). These values were found to be statistically significant, with a fontanelle described as sunken/flat less likely to require a shunt than those with a fontanelle described as full/soft or tense (p < 0.05). Using sunken/flat as the referent, the calculated odds ratios for the full/soft and tense groups were 11.9 (95% CI 2.91–48.15) and 8.6 (95% CI 0.94–78.67), respectively.

The OFC was available for all 72 patients. For patients who underwent shunt placement, the OFC percentile was determined using the last measurement recorded before shunt placement. Among patients without shunts, the OFC percentile was determined using the measurement taken at the last recorded follow-up with the patient, up to 3 months of age. The rate of CSF diversion was analyzed to determine if there was a statistically higher or lower shunt rate among OFC percentile ranges (Table 1). The mean OFC was found to be 32.8 cm for patients without shunts and 34.8 cm for patients with shunts. These values were not statistically significant. Forty-five of the 72 patients with recorded OFC had multiple recordings available for analysis of rate of change. The mean rate of head growth was 0.13 cm/day and 0.32 cm/day for patients without and with shunts, respectively (Table 1). This difference in the rates between patients with and without shunts was statistically significant (p < 0.05).

Radiological imaging was available for all 72 patients, with CT performed in 62 of 72 patients and head ultrasonography performed in 68 of 72 patients. Computed tomography was used to determine the FOHR. The mean FOHR for patients without and with shunts was 0.45 and 0.55, respectively (Table 1). Head ultrasonography was used to determine the VI and TOD. The mean VI for patients without and with shunts was 1.77 cm and 2.33 cm, respectively (Table 1). The mean TOD for patients without and with shunts was 2.35 cm and 4.04 cm, respectively (Table 1). All radiological measurements were compared using a 2-sample t-test and were found to be statistically significant (p < 0.05).

Univariate Cox proportional hazards analysis demonstrated statistical significance for fontanelle description, head circumference at birth, rate of head growth, and all radiological parameters (Table 2). Multivariable Cox proportional hazards analysis was performed using 3 models (Table 3). Considering only clinical characteristics and excluding the radiological parameters, fontanelle description and head circumference at birth were significant predictors of the need for shunt placement. Considering these clinical characteristics and radiological parameters from head ultrasonography, fontanelle description and TOD were significant. Considering clinical characteristics and all radiological parameters, head growth rate and FOHR were significant.

TABLE 2:

Results of univariate Cox proportional hazards models examining the association between time to shunt placement and each variable*

VariableNo. MissingHR (95% CI)p Value
gestational age (1-wk Δ)01.13 (0.99–1.28)0.0673
female01.16 (0.68–1.99)0.5813
Caucasian01.14 (0.60–2.17)0.6890
apneic episodes01.33 (0.62–2.57)0.4068
bradycardic episodes01.06 (0.61–1.86)0.8342
soft/full/tense fontanelle03.23 (1.71–6.09)0.0003
head circumference (1-cm Δ)01.11 (1.03–1.20)0.0042
rate of head growth (0.01-cm/day Δ)121.28 (1.16–1.40)<0.0001
FOHR (0.2-unit Δ)111.17 (1.08–1.25)<0.0001
VI (1-unit Δ)61.77 (1.31–2.39)0.0002
TOD (1-unit Δ)61.48 (1.25–1.74)<0.0001

Δ = change; HR = hazard ratio.

TABLE 3:

Results of multivariate Cox proportional hazards models

Variable*HR (95% CI)p Value
Model 1 (n = 72)<0.0001
 soft/full/tense fontanelle3.23 (1.70–6.12)0.0003
 head circumference (1-cm Δ)1.11 (1.03–1.20)0.0042
Model 2 (n = 66)<0.001
 soft/full/tense fontanelle2.26 (1.26–4.56)0.0219
 TOD (1-unit Δ)1.37 (1.15–1,63)0.0005
Model 3 (n = 48)<0.0001
 rate of head growth (0.01-cm/day Δ)1.22 (1.09–1.37)0.0009
 FOHR (0.2-unit Δ)1.12 (1.04–1.22)0.0047

In Model 1, the predictor pool included patient characteristic variables that had no missing values (see Table 2); only fontanelle type and head circumference remained in the model after a stepwise variable selection procedure. In Model 2, the predictor pool included the same set from Model 1 as well as the radiological measures VI and TOD. In Model 3, all variables were included in the predictor set.

Of the 72 MMCs closed, 4 had CSF leaks documented at the MMC repair site, which is consistent with previous studies.11 All 4 of these patients eventually required CSF diversion (Table 1). During the study period, 26 (48%) of the 54 patients who underwent CSF diversion required a revision. Seven (27%) of these revisions were due to shunt infection. During the reporting period, the mortality rate was 6.8% (5/73) prior to exclusions, similar to previously reported rates.14 Two of the deceased were in the cohort without shunts, but after thorough chart review, neither of these deaths was due to hydrocephalus: one was from alleged child neglect, and the other was due to necrotizing enterocolitis. The death of the only excluded patient was due to multiple congenital anomalies requiring withdrawal of care. Of the 2 patients who died in the shunt group, one death was from cardiac arrest after septic shock, and the other from an indeterminate cause.

Discussion

The overall shunt rate of our patient population was 75%, which is lower than the more commonly reported range of 80% to 85% in the MMC population.1,14 This rate is also lower than the 92% shunt rate for infants in the MOMS trial who underwent postnatal closure.1 The shunt rate by anatomical level was not statistically significant as has been reported in other studies, likely due to small sample size.14 The rate of shunt placement for patients with thoracic defects was 75%, with reported rates in excess of 90%.14 The rate of shunt placement for patients with a lumbar defect in this study was 75.4%, which is similar to reported rates in other studies.14 Lower shunt rates for lumbar defects were reported as well for patients with both prenatal and postnatal repair.5,9,13 No significant trend was observed in changes in shunt rate over time, likely due to the small sample size and relatively short time period of the study.

This study found a statistically significant correlation between the fontanelle description and eventual need of CSF diversion. Patients with a fontanelle described as full/soft or tense had a statistically higher shunt rate compared with patients with a fontanelle described as sunken/flat. While in this study none of the surgeons used the fontanelle description as the sole indication for placement of a shunt, it appears that independent of other signs/symptoms or radiological data, it was the most useful clinical indicator for need of CSF diversion. This simple noninvasive test should be objectively quantified and used in pediatric neurosurgical practice for evaluating hydrocephalus and detecting elevated intracranial pressure in the neonate.

Apneic and bradycardic spells have long been associated with hydrocephalus in the neonate. Unfortunately, both apnea and bradycardia are associated with a myriad of neonatal morbidities, ranging from gastroesophageal reflux to cardiac anomalies. Patients with MMC are often afflicted with many of these anomalies. These 2 objective signs of hydrocephalus were analyzed in this MMC cohort and neither had a statistically significant association with the eventual shunt status of the patients. Therefore, although it may be reasonable to consider further testing for hydrocephalus in a patient with apneic or bradycardic spells, these signs do not have a significant correlation with eventual need for CSF diversion.

Increasing OFC is often noted in infants with hydrocephalus. Patients requiring CSF diversion did have a rate of head growth almost 2.5 times greater than those patients who did not undergo placement of a shunt. The OFC is a noninvasive measurement that can be useful in the assessment of hydrocephalus, but at a single time point it was not found to be predictive for CSF shunting. The initial OFC was not predictive of the need for CSF diversion, consistent with the widely held belief that hydrocephalus worsens after MMC closure. Rather, we found that a more valuable use for OFC is to follow the measurement of individual patients over an extended period of time. In children who “cross percentiles” for OFC measurements, this may be indicative of the progression of hydrocephalus and the subsequent need for shunt placement. Additionally, in this study we found that patients whose head circumference increased by more than 3 mm per day were more likely to require CSF diversion.

The FOHR makes an accurate estimation of the ventricle size using CT. The FOHR does not change with age in normal patients.10 In this study, we found a statistically significant difference in this parameter between patients with and without shunts. As an indirect assessment of ventricular volume, this finding may indicate that the degree of ventriculomegaly in patients with MMC is a significant factor in the requirement for CSF shunting regardless of other signs and symptoms that a patient may have. Although bias may exist from selective imaging of patients with suspected hydrocephalus, the FOHR can be a useful factor as an objective estimate of ventricular size when deciding if a patient requires a shunt. Almost all of the MMC patients in this study underwent head ultrasonography as part of our admission protocol. It was also interesting to find that nearly all of the patients also had at least 1 CT scan. While there was statistical significance for both imaging modalities, it appears that head ultrasonography for VI and TOD measurements was as good if not better than CT for predicting the need for CSF diversion. Therefore, because of the radiation exposure associated with CT, it may be advisable to reserve CT for those patients with complex intracranial anatomy prior to shunt placement who cannot undergo MRI.

Many of the variables collected in this study are subjective in nature. Thus, there may be bias when collecting this information. Additionally, the measured head circumference was performed by an array of neurosurgical staff, and while all use the same method of measurement, it may be subject to some nuances. Experienced neurosurgical caregivers recognize that there can be significant differences of OFC measurements between examiners.15 In the end, determining which patients will benefit from a shunt is based on the surgeon's gestalt and is somewhat subjective. Although we use placement of a shunt as a marker for need of a shunt, the two are likely not the same. Future studies may include a blinded prospective analysis of CSF diversion to help eliminate the previously described biases.

Conclusions

Creating a synopsis of variables that facilitate targeting patients with MMC needing CSF diversion will aid both the consulting physician and treating specialist. Eliminating unnecessary CSF diversion and treating only those who require CSF diversion is the ultimate goal. While there are a number of signs and symptoms that have long been associated with hydrocephalus in the neonate, this study has shown that several of them were not significantly associated with the need for CSF diversion, particularly apneic and bradycardic episodes. Fontanelle description and the rate of change of the OFC appear to be the most important clinical signs when determining the need for shunt. Additional information collected by head ultrasonography and CT, including the VI, TOD, and FOHR, are statistically significant measures to evaluate prior to placement of a ventriculoperitoneal shunt. The optimal patient with MMC for CSF diversion will have a soft/full to tense fontanelle, increasing head circumference of more than 3 mm/day, and radiological evidence of elevated VI, TOD, and/or FOHR as described.

Disclosure

The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

Author contributions to the study and manuscript preparation include the following. Conception and design: Ocal, O'Brien, Albert. Acquisition of data: Phillips, Gelsomino, Pownall, Albert. Analysis and interpretation of data: Phillips, Pownall, Spencer, Albert. Drafting the article: Phillips, Gelsomino. Critically revising the article: all authors. Reviewed submitted version of manuscript: all authors. Approved the final version of the manuscript on behalf of all authors: Phillips. Statistical analysis: Spencer. Administrative/technical/material support: O'Brien, Albert. Study supervision: Albert.

References

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    Adzick NSThom EASpong CYBrock JW IIIBurrows PKJohnson MP: A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med 364:99310042011

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    Bowman RMMcLone DG: Neurosurgical management of spina bifida: research issues. Dev Disabil Res Rev 16:82872010

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    Brouwer MJde Vries LSGroenendaal FKoopman CPistorius LRMulder EJ: New reference values for the neonatal cerebral ventricles. Radiology 262:2242332012

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    Brouwer MJde Vries LSPistorius LRademaker KJGroenendaal FBenders MJ: Ultrasound measurements of the lateral ventricles in neonates: why, how and when? A systematic review. Acta Paediatr 99:129813062010

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    Bruner JPTulipan NReed GDavis GHBennett KLuker KS: Intrauterine repair of spina bifida: preoperative predictors of shunt-dependent hydrocephalus. Am J Obstet Gynecol 190:130513122004

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    Chakraborty ACrimmins DHayward RThompson D: Toward reducing shunt placement rates in patients with myelomeningocele. J Neurosurg Pediatr 1:3613652008

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    Dennis MJewell DDrake JMisakyan TSpiegler BHetherington R: Prospective, declarative, and nondeclarative memory in young adults with spina bifida. J Int Neuropsychol Soc 13:3123232007

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    Hetherington RDennis MBarnes MDrake JGentili F: Functional outcome in young adults with spina bifida and hydrocephalus. Childs Nerv Syst 22:1171242006

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    Johnson MPSutton LNRintoul NCrombleholme TMFlake AWHowell LJ: Fetal myelomeningocele repair: short-term clinical outcomes. Am J Obstet Gynecol 189:4824872003

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    Kan PWalker MLDrake JMKestle JR: Predicting slit-like ventricles in children on the basis of baseline characteristics at the time of shunt insertion. J Neurosurg 106:5 Suppl3473492007

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    Müslüman AMKarşıdağ SSucu Akçal AYılmaz ASirinoğlu D: Clinical outcomes of myelomeningocele defect closure over 10 years. J Clin Neurosci 19:9849902012

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    O'Hayon BBDrake JMOssip MGTuli SClarke M: Frontal and occipital horn ratio: a linear estimate of ventricular size for multiple imaging modalities in pediatric hydrocephalus. Pediatr Neurosurg 29:2452491998

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    Radmanesh FNejat FEl Khashab MGhodsi SMArdebili HE: Shunt complications in children with myelomeningocele: effect of timing of shunt placement. Clinical article. J Neurosurg Pediatr 3:5165202009

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    Rintoul NESutton LNHubbard AMCohen BMelchionni JPasquariello PS: A new look at myelomeningoceles: functional level, vertebral level, shunting, and the implications for fetal intervention. Pediatrics 109:4094132002

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    Sutter KEngstrom JLJohnson TSKavanaugh KIfft DL: Reliability of head circumference measurements in preterm infants. Pediatr Nurs 23:4854901997

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    Wakhlu AAnsari NA: The prediction of postoperative hydrocephalus in patients with spina bifida. Childs Nerv Syst 20:1041062004

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    Wills KEHolmbeck GNDillon KMcLone DG: Intelligence and achievement in children with myelomeningocele. J Pediatr Psychol 15:1611761990

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Article Information

Address correspondence to: Blake C. Phillips, M.D., University of Arkansas for Medical Sciences, Department of Neurosurgery, 4301 West Markham St., Slot 507, Little Rock, AR 72205. email: phillipsblakec@uams.edu.

Please include this information when citing this paper: published online May 30, 2014; DOI: 10.3171/2014.4.PEDS13470.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Line graph displaying the percentage of patients with MMC who received shunts per year. There was not a statistically significant change in shunt rate over the period evaluated.

References

  • 1

    Adzick NSThom EASpong CYBrock JW IIIBurrows PKJohnson MP: A randomized trial of prenatal versus postnatal repair of myelomeningocele. N Engl J Med 364:99310042011

  • 2

    Bowman RMMcLone DG: Neurosurgical management of spina bifida: research issues. Dev Disabil Res Rev 16:82872010

  • 3

    Brouwer MJde Vries LSGroenendaal FKoopman CPistorius LRMulder EJ: New reference values for the neonatal cerebral ventricles. Radiology 262:2242332012

  • 4

    Brouwer MJde Vries LSPistorius LRademaker KJGroenendaal FBenders MJ: Ultrasound measurements of the lateral ventricles in neonates: why, how and when? A systematic review. Acta Paediatr 99:129813062010

  • 5

    Bruner JPTulipan NReed GDavis GHBennett KLuker KS: Intrauterine repair of spina bifida: preoperative predictors of shunt-dependent hydrocephalus. Am J Obstet Gynecol 190:130513122004

  • 6

    Chakraborty ACrimmins DHayward RThompson D: Toward reducing shunt placement rates in patients with myelomeningocele. J Neurosurg Pediatr 1:3613652008

  • 7

    Dennis MJewell DDrake JMisakyan TSpiegler BHetherington R: Prospective, declarative, and nondeclarative memory in young adults with spina bifida. J Int Neuropsychol Soc 13:3123232007

  • 8

    Hetherington RDennis MBarnes MDrake JGentili F: Functional outcome in young adults with spina bifida and hydrocephalus. Childs Nerv Syst 22:1171242006

  • 9

    Johnson MPSutton LNRintoul NCrombleholme TMFlake AWHowell LJ: Fetal myelomeningocele repair: short-term clinical outcomes. Am J Obstet Gynecol 189:4824872003

  • 10

    Kan PWalker MLDrake JMKestle JR: Predicting slit-like ventricles in children on the basis of baseline characteristics at the time of shunt insertion. J Neurosurg 106:5 Suppl3473492007

  • 11

    Müslüman AMKarşıdağ SSucu Akçal AYılmaz ASirinoğlu D: Clinical outcomes of myelomeningocele defect closure over 10 years. J Clin Neurosci 19:9849902012

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