|Year : 2019 | Volume
| Issue : 3 | Page : 115-118
Ventriculosubgaleal shunt in children with hydrocephalus
Sandeep Iratwar, Akshay Patil, Chetan Rathod, Paresh Korde, Vijay Mundhe, H Deshpande
Department of Neurosurgery, AVBRH, JNMC, Datta Meghe Institute of Medical Sciences, Wardha, Maharashtra, India
|Date of Submission||28-Jun-2019|
|Date of Decision||15-Jul-2019|
|Date of Acceptance||10-Aug-2019|
|Date of Web Publication||2-May-2020|
Dr. Sandeep Iratwar
Department of Neurosurgery, AVBRH, JNMC, Datta Meghe Institute of Medical Sciences, Sawangi (Meghe), Wardha - 442 001, Maharashtra
Source of Support: None, Conflict of Interest: None
Objective: To determine the rate of conversion to ventriculoperitoneal (VP) shunt in children treated with ventriculosubgaleal (VSG) shunt for hydrocephalus of infective and noninfective etiology. Materials and Methods: A prospective, observational study was conducted at the department of neurosurgery in a tertiary care medical institute in children who underwent VSG shunt for congenital and acquired hydrocephalus of infective and noninfective etiology. Primary outcome measure was rate of conversion to VP shunt. Results: In total 58 children, 65.5% were aged 5 days to 12 months and 67.2% were male. Meningitis (70.7%) was the most common cause of hydrocephalus, followed by hemorrhage (20.7%) and congenital causes (8.6%). The rate of conversion to VP shunt was 58.6%. Moreover, 25.9% of the children had spontaneous resolution of hydrocephalus with no further requirement of shunt, whereas 15.5% required endoscopic third ventriculostomy. Shunt revision was required in 6.9% of the children and shunt malfunction rate was 5.2%. Other complications such as cerebrospinal fluid (CSF) leak (3.4%), wound infection (1.7%), and shunt tip migration (1.7%) were uncommon. Conclusion: VSG shunt is a simple and effective treatment for temporary diversion of CSF for infective and noninfective hydrocephalus in children who are not ideal for a permanent method of CSF diversion even in the presence of active meningitis and shunt infection. In experienced hands and in selected cases, VSG shunt alone can help resolve the hydrocephalus.
Keywords: Hydrocephalus, India, mortality, outcome, ventriculoperitoneal shunt, ventriculosubgaleal shunt
|How to cite this article:|
Iratwar S, Patil A, Rathod C, Korde P, Mundhe V, Deshpande H. Ventriculosubgaleal shunt in children with hydrocephalus. J Datta Meghe Inst Med Sci Univ 2019;14:115-8
| Introduction|| |
Hydrocephalus is the condition wherein an accumulation of cerebrospinal fluid (CSF) occurs in the ventricles and brain spaces and is associated with increased intracranial pressure (ICP). Hydrocephalus in children is either congenital or acquired. Acquired hydrocephalus is the results infections, hemorrhage in the ventricles, trauma or structural abnormalities such as cysts and tumor. A systematic review identified that the prevalence of pediatric hydrocephalus was 88/100,000 population. It was also reported that the International Clearinghouse for Birth Defects Surveillance and Research-based incidence of hydrocephalus diagnosed at birth remained stable over 11 years (i.e., 81/100,000 population). It is important to assess the severity and etiology to plan the treatment of pediatric hydrocephalus. Magnetic resonance imaging has more diagnostic yield and helps in planning treatment decision. As the mainstay of treatment is relief of increased ICP, CSF diversion is the choice of treatment. Early intervention may be necessary in children who develop persistent head growth, neurologic deficits, or symptoms attributable to hydrocephalus., Initial decompression using temporary device is used in small infants and when the need of permanent shunting remains unclear. Ventricular access device, external ventricular drain, ventriculosubgaleal (VSG) shunt, and serial lumbar punctures are some routinely employed methods. Among these, VSG shunt is considered to be less invasive and has low morbidity., VSG shunt was found to be a safe and effective procedure for hydrocephalus of either infectious or noninfectious origin for infants awaiting definitive shunting. As the clinical studies assessing the use of VSG shunting in children is sparse in India, we planned this observational study to determine the outcomes with the use of VSG shunt in children with hydrocephalus.
| Materials and Methods|| |
This study was conducted in a tertiary care superspecialty medical institute and hospital which caters to urban, semiurban, as well as rural population. The institute provides superspecialty services in various domains including neurosurgery.
This was a single-center, prospective, observational study.
In this study, we included children with hydrocephalus who had undergone VSG shunting as a temporary method of CSF diversion. Hydrocephalus of any etiology was included. Children receiving other methods of shunting were excluded.
The study was conducted between March 2012 and December 2018. Based on the inclusion and exclusion criteria, 58 children undergoing VSG shunting were included.
Procedure of ventriculosubgaleal shunt
Children were fasted 4 h before the procedure. Under local anesthesia and mild sedation, children were subjected to the procedure in the operating room. Nearly 1.5-cm skin incision was taken at the right corner of the anterior fontanelle. After dissecting the periosteum, blunt dissection was performed to reach the subgaleal space. A large pocket was created by separating the periosteum from the galea over parietal and temporal bones. Dura was exposed with pulling of incision; vascular structures were cauterized for the insertion of ventricular catheter. With a small incision in the dura, a tip ventricular catheter was inserted in the right ventricle (nearly 3 cm) and was fixed to the dura. External end was placed in the subgaleal pouch (approximately 10 cm × 10 cm). Incision was sutured. Patients were encouraged to lay as possible on the left temporal surface to allow subgaleal draining of CSF. A stepwise approach in VSG shunting is shown in [Figure 1].
|Figure 1: Creating ventriculosubgaleal shunt. (a) Incision and pouch creation. (b) Ventricular end insertion. (c) Subgaleal end insertion. (d) At completion|
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Data on demographics, clinical parameters, and outcomes of VSG shunting were recorded in a structured pro forma. Demographic data included age, gender, birth weight, being term, or preterm. Clinical data on etiology of hydrocephalus was sought. Outcomes of VSG shunt, such as failure, revision, and infection, were also noted.
Main outcome measure of the study was the conversion to permanent method of CSF diversion or nonrequirement of shunt.
| Results|| |
[Table 1] enlists the baseline characteristics of patients. Among total 58 children, 39 were male and 19 were female. Age ranged from 5 days to 7 years and most children were in the age group of 1–12 months (65.5%). The average weight was 1860 g. By birth, 48.3% of the children were born premature and the rest were term infants. Etiologically, meningitis (70.7%) was the most frequent cause of hydrocephalus, followed by posthemorrhagic hydrocephalus (20.7%) and congenital (8.6%) as shown in [Table 2].
Among complications [Table 3], revision was necessary in 6.9% of the patients, 5.2% had shunt malfunction, whereas CSF leak (3.4%) was seen in two patients only. One patient each had wound infection and shunt tip migration.
Outcome of patients is shown in [Figure 2]. Conversion to ventriculoperitoneal (VP) shunt was noted in 58.6% of the patients and 15.5% had endoscopic third ventriculostomy. 25.9% of the patients did not require any VP shunts. Clinical and radiological evidence on resolution of hydrocephalus in an index patient is shown in [Figure 3].
|Figure 3: Clinical (a) and radiological (b) evidence of hydrocephalus resolution. Arrow, ventriculosubgaleal shunt in situ|
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| Discussion|| |
Hydrocephalus can be congenital or acquired. Etiologies in both types can vary substantially. We observed congenital etiology in 8.6% of the patients, whereas the rest were acquired, of which 70.7% were developed after infection (meningitis) and 20.7% were caused by hemorrhage. A study of 50 hydrocephalus patients (aged 0–14 years) from India identified congenital etiology in 38% of patients, infective in 44%, and 18% were due to neoplasms. We observed a slight male (67.2%) predisposition to hydrocephalus. Jaiswal and Jaiswalreported a similar finding, with 62% of males being affected by hydrocephalus. A small study by Kutty et al. reported 10 (62.5%) females and 6 (37.5%) males were affected by hydrocephalus. As such, hydrocephalus may not show gender differences. However, a recent, large observational study from UK and Ireland identified slight male preponderance children (male-to-female ratio: 7:5) and adolescents (6:5), whereas the ratio reverses in adults (5:6).
In children with hydrocephalus, different types of temporary CSF diversion procedures can be employed. The choice of the procedure is determined by severity and resources available. VSG shunt involves simple procedure and helps protect the brain damage due to pressure. It also aids in performing diagnostic and therapeutic CSF aspirations. VSG shunts can be used in different etiologies of hydrocephalus including infective and noninfective ones. We observed that 34 (58.6%) cases had conversion to VP shunt. Kutty et al. observed that conversion to VP shunt was achieved in 55.5% of cases with infective etiology and in 85.7% of cases with noninfective etiology. Another study by Kariyattil et al. reported conversion to VP shunt in 80.9% of cases with hydrocephalus of infective etiology. Köksal and Öktem in their study of 21 premature infants with posthemorrhagic hydrocephalus observed that conversion to VP shunt was 60%. In 9 (15.5%) cases, we had to shift to endoscopic third ventriculostomy (ETV). ETV offers two unique advantages, namely, the avoidance of a foreign body implantation and establishment of a physiological CSF circulation. Thus, ETV can be useful in patients who are probably at a greater risk of shunt-associated complications. In 15 (25.9%) cases, no shunt was necessary. Temporary VSG shunting was able to reduce the hydrocephalus. Although reports of spontaneous resolution of hydrocephalus with VSG shunt are rare, Alan et al. reported spontaneous resolution in 2 (9.1%) cases of 22 very preterm infants with severe ventricular hemorrhage. Similarly, Petraglia et al. reported that among 21 children treated with VSG shunt, two patients did not require conversion to VP shunt. Nonrequirement of permanent shunting in other studies varied between 12% and 20%., This indicates that in selected children with hydrocephalus, use of VSG shunt alone might help in the resolution of hydrocephalus with no further need of VP shunt.
Among the complications, 6.9% of patients needed shunt revision. Petraglia et al. reported revision requirement after conversion to a VP shunt in 27.8% of cases. Alan et al. assessing very preterm infants with severe intraventricular hemorrhage reported requirement of at least one revision in 35% of cases after VP shunting during the 1st year. Ninety-day revision rates of 21.9% and 18.6% and 1st-year revision rates of 31.0% and 25.2% have been reported in infants and children, respectively. Another important complication is shunt malfunction, which occurred in 5.2% of patients. Malfunction is usually defined as failure to control symptomatic hydrocephalus. This can be due to wound dehiscence or CSF leak. Alan et al. reported VSG shunt malfunction rate of 9.1%. We observed CSF leak in 3.4% of cases. The rate of CSF leakage from the incision site in different studies was 4.7%, 5%, 16.6%, 29%, and 32%. The lower rates of CSF leak in our study suggest appropriate and adequate surgical closure technique. Wound dehiscence and shunt tip migration were seen in one patient each. We did not observe mortality outcome in any of the patient. However, mortality is reported in these patients. Kutty et al. from India reported mortality rate of 44% and 14.2% in preterm infants who were treated with VSG shunt for hydrocephalus caused by infectious and noninfectious etiology, respectively. In another study from India, Kariyattil et al. also reported mortality in 2 (9.5%) patients treated with VSG shunt. The rates of mortality in different studies varied from 9% to 20%.,,, Mortality is caused mainly because of underlying conditions rather than complications associated with shunts. In rare cases, intracerebral hemorrhage may be associated with valve application in VSG shunt. Further, acute ventricular decompression rarely accompanies the shunt procedure., As we did not employ valve in shunt, the likelihood of parenchymal hemorrhage may be reduced.
| Conclusion|| |
We observed that the use of VSG shunt for temporary diversion of CSF in infective and noninfective hydrocephalus was associated with 58.6% rate of conversion to VP shunt. Importantly, it was associated with spontaneous resolution of hydrocephalus in nearly one-fourth cases, suggesting that using temporary CSF diversion with VSG shunt is simple and effective method for relieving ICP in children with hydrocephalus, and that is the most rewarding, particularly for poor rural population of India. Relatively lower rates of complications and no mortality seen in any patient are indicative of excellent surgical techniques in the placement of VSG shunt. We, therefore, advise of VSG shunt as a simple and effective procedure for infective and noninfective hydrocephalus management in children.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3]