Letter to the Editor. Canadian Preoperative Prediction Rule for Hydrocephalus: suggestions to improve validity

Noor Ul Huda Maria Punjab Institute of Neurosciences, Lahore, Pakistan

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Qurrat Ul Ain Siddiq Postgraduate Medical Institute/Ameeruddin Medical College, Lahore, Pakistan and

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Noor Ul Ain Fatima Institute of Developmental Studies, University of Sussex, Brighton, United Kingdom

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TO THE EDITOR: We congratulate Pitsika et al.1 on publishing their wonderful article (Pitsika M, Fletcher J, Coulter IC, Cowie CJA. A validation study of the modified Canadian Preoperative Prediction Rule for Hydrocephalus in children with posterior fossa tumors. J Neurosurg Pediatr. 2021;28[2]:121-127). Indeed, it is an important clinical issue that needs to be studied and discussed. We need more studies on this important topic to avoid inadvertent surgical exposures and lifelong commitments to ventriculoperitoneal shunts given their inherent complications in patients operated on for posterior cranial fossa tumors. In fact, in one study, it was estimated that about 70% of patients were inadvertently exposed to preresection CSF diversionary procedures and that hydrocephalus resolved after tumor resection in 70%–90% of pediatric patients and 96% of adult patients.2,3 With all of these points, it is prudent to explore, evaluate, and introduce new or to modify existing predictive criteria such as those of the Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH) in order to make a judicious decision regarding preresection permanent CSF diversionary procedures.

We agree with the authors regarding the validity of the CPPRH. We also believe in the beauty of medicine, which always has the capacity to improve and evolve. We think that in order to improve its value, the CPPRH needs a few more important parameters added. The existing modified CPPRH parameters of age, preoperative radiological diagnosis, presence of moderate/severe hydrocephalus, transependymal edema, and metastatic disease at the time of diagnosis can be made more comprehensive by adding more important parameters and including objective measures to avoid interobserver variations. We suggest the following modifications in order to improve the rule’s validity: 1) modification of the radiological criterion to include sigmoid and transverse sinus diameter, frontal occipital horn ratio (FOHR), and the Evans index; 2) updating and applying a postoperative scoring criterion that takes into account extent of resection, duration of surgery, and intraoperative bleeding; and 3) adding tumor specifications of midline location, superior extension, and intra-/extraparenchymal locations.

Having suggested the abovementioned additions to the predictive rule, we believe that we should briefly discuss these points. We think that in this scoring system, no special consideration has been given to the midline tumor, which is as an important predictive factor for hydrocephalus.4 Similarly, the superior extension of posterior fossa tumors into the aqueduct of Sylvius is another important factor that should be considered.5 Venous sinus compression by tumor, which is an independent predictive factor for postresection hydrocephalus, has not been added. We believe that it should be added with a score of 3. It has been shown to be an extremely important predictor, and the minimum cross-sectional area of the transverse and sigmoid sinuses measurement has been shown to accurately predict the need for CSF diversion.6 Radiological indices such as an FOHR > 0.46 and an Evans index > 0.4 can be added as a separate category of the scoring system.7 These indices are highly predictive and, to a great extent, objective when it comes to scoring. Intraparenchymal and extraparenchymal tumor location should be included in the scoring.8 We suggest intraoperative bleeding and duration of surgery for consideration as predictors. Postoperative factors were not considered, including the extremely important extent of resection.9 We strongly suggest that the score should be updated after tumor resection, as the status of the patient is changed after surgery, along with additional important predictors such as extent of resection. Pseudomeningocele and CSF leakage should also be considered as minor factors and should be considered postoperatively.10 Duration of symptoms is another important factor to consider. We also suggest that an additional age range of 2–3 years9 should be added for broader categorization while keeping a higher score for an age < 2 years.

We ask the authors to kindly share their opinion regarding such modifications, which may prove to be essential in the future and may revolutionize the management of such an important clinical entity.

Disclosures

The author reports no conflict of interest.

References

  • 1

    Pitsika M, Fletcher J, Coulter IC, Cowie CJA. A validation study of the modified Canadian Preoperative Prediction Rule for Hydrocephalus in children with posterior fossa tumors. J Neurosurg. 2021;28(2):121127.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Fritsch MJ, Doerner L, Kienke S, Mehdorn HM. Hydrocephalus in children with posterior fossa tumors: role of endoscopic third ventriculostomy. J Neurosurg. 2005;103(1 Suppl):4042.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Anania P, Battaglini D, Balestrino A, et al. The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review. Neurosurg Rev. 2021;44(3):12431253.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Santos de Oliveira R, Barros Jucá CE, Valera ET, Machado HR. Hydrocephalus in posterior fossa tumors in children. Are there factors that determine a need for permanent cerebrospinal fluid diversion? Childs Nerv Syst. 2008;24(12):13971403.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Chen T, Ren Y, Wang C, et al. Risk factors for hydrocephalus following fourth ventricle tumor surgery: a retrospective analysis of 121 patients. PLoS One. 2020;15(11):e0241853.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Bateman GA, Fiorentino M. Childhood hydrocephalus secondary to posterior fossa tumor is both an intra- and extraaxial process. J Neurosurg Pediatr. 2016;18(1):2128.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Patra DP, Bir SC, Maiti TK, et al. Role of radiological parameters in predicting overall shunt outcome after ventriculoperitoneal shunt insertion in pediatric patients with obstructive hydrocephalus. Neurosurg Focus. 2016;41(5):E4.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Won S, Gessler F, Dubinski D, et al. A novel grading system for the prediction of the need for cerebrospinal fluid drainage following posterior fossa tumor surgery. J Neurosurg. 2020;132(1):296305.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Kumar V, Phipps K, Harkness W, Hayward RD. Ventriculo-peritoneal shunt requirement in children with posterior fossa tumours: an 11-year audit. Br J Neurosurg. 1996;10(5):467470.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Culley DJ, Berger MS, Shaw D, Geyer R. An analysis of factors determining the need for ventriculoperitoneal shunts after posterior fossa tumor surgery in children. Neurosurgery. 1994;34(3):402408.

    • PubMed
    • Search Google Scholar
    • Export Citation

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No response was received from the authors of the original article.

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  • 1

    Pitsika M, Fletcher J, Coulter IC, Cowie CJA. A validation study of the modified Canadian Preoperative Prediction Rule for Hydrocephalus in children with posterior fossa tumors. J Neurosurg. 2021;28(2):121127.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Fritsch MJ, Doerner L, Kienke S, Mehdorn HM. Hydrocephalus in children with posterior fossa tumors: role of endoscopic third ventriculostomy. J Neurosurg. 2005;103(1 Suppl):4042.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Anania P, Battaglini D, Balestrino A, et al. The role of external ventricular drainage for the management of posterior cranial fossa tumours: a systematic review. Neurosurg Rev. 2021;44(3):12431253.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 4

    Santos de Oliveira R, Barros Jucá CE, Valera ET, Machado HR. Hydrocephalus in posterior fossa tumors in children. Are there factors that determine a need for permanent cerebrospinal fluid diversion? Childs Nerv Syst. 2008;24(12):13971403.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Chen T, Ren Y, Wang C, et al. Risk factors for hydrocephalus following fourth ventricle tumor surgery: a retrospective analysis of 121 patients. PLoS One. 2020;15(11):e0241853.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Bateman GA, Fiorentino M. Childhood hydrocephalus secondary to posterior fossa tumor is both an intra- and extraaxial process. J Neurosurg Pediatr. 2016;18(1):2128.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 7

    Patra DP, Bir SC, Maiti TK, et al. Role of radiological parameters in predicting overall shunt outcome after ventriculoperitoneal shunt insertion in pediatric patients with obstructive hydrocephalus. Neurosurg Focus. 2016;41(5):E4.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Won S, Gessler F, Dubinski D, et al. A novel grading system for the prediction of the need for cerebrospinal fluid drainage following posterior fossa tumor surgery. J Neurosurg. 2020;132(1):296305.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Kumar V, Phipps K, Harkness W, Hayward RD. Ventriculo-peritoneal shunt requirement in children with posterior fossa tumours: an 11-year audit. Br J Neurosurg. 1996;10(5):467470.

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Culley DJ, Berger MS, Shaw D, Geyer R. An analysis of factors determining the need for ventriculoperitoneal shunts after posterior fossa tumor surgery in children. Neurosurgery. 1994;34(3):402408.

    • PubMed
    • Search Google Scholar
    • Export Citation

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