Center effect and other factors influencing temporization and shunting of cerebrospinal fluid in preterm infants with intraventricular hemorrhage

Clinical article

Jay Riva-Cambrin M.D., M.Sc. 1 , Chevis N. Shannon M.B.A., Dr.P.H. 2 , Richard Holubkov Ph.D. 3 , William E. Whitehead M.D. 4 , Abhaya V. Kulkarni M.D., Ph.D. 5 , James Drake M.B.B.Ch., M.Sc. 5 , Tamara D. Simon M.D., M.S.P.H. 6 , Samuel R. Browd M.D., Ph.D. 7 , John R. W. Kestle M.D. 1 , and John C. Wellons III M.D. 2
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  • 1 Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, and
  • 3 Department of Pediatrics, University of Utah, Salt Lake City, Utah;
  • 2 Section of Pediatric Neurosurgery, Division of Neurosurgery, Children's Hospital of Alabama, University of Alabama Birmingham, Alabama;
  • 4 Division of Pediatric Neurosurgery, Department of Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas;
  • 5 Division of Neurosurgery, Hospital for Sick Children, Toronto, Canada; and
  • 6 Departments of Pediatrics and
  • 7 Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington
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Object

There is little consensus regarding the indications for surgical CSF diversion (either with implanted temporizing devices [reservoir or subgaleal shunt] or shunt alone) in preterm infants with posthemorrhagic hydrocephalus. The authors determined clinical and neuroimaging factors associated with the use of surgical CSF diversion among neonates with intraventricular hemorrhage (IVH), and describe variations in practice patterns across 4 large pediatric centers.

Methods

The use of implanted temporizing devices and conversion to permanent shunts was examined in a consecutive sample of 110 neonates surgically treated for IVH related to prematurity from the 4 clinical centers of the Hydrocephalus Clinical Research Network (HCRN). Clinical, neuroimaging, and so-called processes of care factors were analyzed.

Results

Seventy-three (66%) of the patients underwent temporization procedures, including 50 ventricular reservoir and 23 subgaleal shunt placements. Center (p < 0.001), increasing ventricular size (p = 0.04), and bradycardia (p = 0.07) were associated with the use of an implanted temporizing device, whereas apnea, occipitofrontal circumference (OFC), and fontanel assessments were not. Implanted temporizing devices were converted to permanent shunts in 65 (89%) of the 73 neonates. Only a full fontanel (p < 0.001) and increased ventricular size (p = 0.002) were associated with conversion of the temporizing devices to permanent shunts, whereas center, OFCs, and clot characteristics were not.

Conclusions

Considerable center variability exists in neurosurgical approaches to temporization of IVH in prematurity within the HCRN; however, variation between centers is not seen with permanent shunting. Increasing ventricular size—rather than classic clinical findings such as increasing OFCs—represents the threshold for either temporization or shunting of CSF.

Abbreviations used in this paper:FOR = frontal and occipital horn ratio; HCRN = Hydrocephalus Clinical Research Network; IVH = intraventricular hemorrhage; LOS = length of stay; NEC = necrotizing enterocolitis; NICU = neonatal ICU; OFC = occipitofrontal circumference.

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Contributor Notes

Address correspondence to: Jay Riva-Cambrin, M.D., M.Sc., Department of Neurosurgery, Division of Pediatric Neurosurgery, 100 North Mario Capecchi Drive, Salt Lake City, Utah 84113. email: Jay.Riva-Cambrin@hsc.utah.edu.

Please include this information when citing this paper: DOI: 10.3171/2012.1.PEDS11292.

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