Reposted with permission from ©AANS, 2014
J Neurosurg Pediatrics (Suppl) 14:8–23, 2014
AANS, 2014
(Original text of the guideline was edited to reflect the update. Please click here for the original publication.)

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines

Part 2: Management of posthemorrhagic hydrocephalus in premature infants

UPDATE

 Catherine A. Mazzola, MD¹, Asim F. Choudhri MD^2,3, Kurtus I. Auguste, MD⁴, David D. Limbrick Jr., MD, PhD⁵, Marta Rogido, MD⁶, Laura Mitchell, MA⁷, Ann Marie Flannery, MD⁸

¹Division of Pediatric Neurological Surgery, Goryeb Children’s Hospital, Morristown, New Jersey; ²Departments of Radiology and Neurosurgery, University of Tennessee Health Science Center, and ³Le Bonheur Neuroscience Institute, Le Bonheur Children’s Hospital, Memphis, Tennessee; ⁴Department of Neurosurgery, University of California, San Francisco, California; ⁵Division of Pediatric Neurosurgery, St. Louis Children’s Hospital, St. Louis, Missouri; ⁶Division of Neonatology, Department of Pediatrics, Goryeb Children’s Hospital, Morristown; and Rutgers New Jersey Medical School, Newark, New Jersey; ⁷Congress of Neurological Surgeons, Schaumburg, Illinois; and ⁸Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri

Object. The objective of this systematic review and analysis was to answer the following question: What are the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants?

Methods. Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to PHH. Two hundred thirteen abstracts were reviewed, after which 98 full-text publications that met inclusion criteria that had been determined a priori were selected and reviewed.

Results. Following a review process and an evidentiary analysis, 68 full-text articles were accepted for the evidentiary table and 30 publications were rejected. The evidentiary table was assembled linking recommendations to strength of evidence (Classes I–III).

Conclusions. There are 7 recommendations for the management of PHH in infants. Three recommendations reached Level I strength, which represents the highest degree of clinical certainty. There were two Level II and two Level III recommendations for the management of PHH.

Recommendation concerning Surgical temporizing measures: I. Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of PHH. Clinical judgment is required. Strength of Recommendation: Level II, moderate degree of clinical certainty.

Recommendation concerning Surgical temporizing measures: II. The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs. Strength of Recommendation: Level II, moderate degree of clinical certainty.

Recommendation concerning Routine use of Serial lumbar puncture: The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants. Strength of Recommendation: Level I, high clinical certainty.

Recommendation concerning nonsurgical temporizing Agents: i. Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Strength of Recommendation: Level I, high clinical certainty.

Recommendation concerning nonsurgical temporizing Agents. ii. Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Strength of Recommendation: Level I, high clinical certainty.

Recommendation concerning timing of Shunt placement: There is insufficient evidence to recommend a specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Clinical judgment is required. Strength of Recommendation: Level III, unclear clinical certainty.

Recommendation concerning endoscopic third Ventriculostomy: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with posthemorrhagic hydrocephalus. Strength of Recommendation: Level III, unclear clinical certainty.

Recommendation: Neuro-endoscopic lavage is a feasible and safe option and therefore may be used for the removal of intraventricular clots and may lower the rate of shunt placement. Strength of Recommendation: Level III, unclear clinical certainty.

(http://thejns.org/doi/abs/10.3171/2014.7.PEDS14322)

Key Words: hydrocephalus, infant, case management, magnetic resonance imagining, posthemorrhagic hydrocephalus, premature infant, preterm infant, ventriculomegaly, intraventricular hemorrhage, meningitis, ventricular dilation, ventricular index,  head circumference, in utero, shunt, reservoir, endoscopic third ventriculostomy, ventriculoperitoneal shunt, practice guidelines

Abbreviations used in this paper: AANS = American Association of Neurological Surgeons; CDC = Centers for Disease Control and Prevention; CNS = Congress of Neurological Surgeons; ELBW = extremely low birth weight; ETV = endoscopic third ventriculostomy; EVD = external ventricular drain; HUS = head ultrasound; IVH = intraventricular hemorrhage; LBW = low birth weight; LP = lumbar puncture; OFC = occipitofrontal circumference; PHH = posthemorrhagic hydrocephalus; PHVD = posthemorrhagic ventricular dilation; tPA = tissue plasminogen activator; VAD = ventricular access device; V/BP = ventricular/biparietal; VP = ventriculoperitoneal; VSG = ventriculosubgaleal.

Although reviews have been recently published, there exists a paucity of guidelines or evidence based recommendations for the management of posthemorrhagic hydrocephalus (PHH) in infants.¹ According to 2007 data provided by the Division of Vital Statistics of the Centers for Disease Control and Prevention (CDC), infants born with very low birth weight and gestational age have a significantly higher risk of mortality.² In fact, more than 50% of all infant deaths in 2007 occurred in infants born before 32 weeks’ gestation.² In 2008, the reported preterm birth rate declined for the second consecutive year to 12.3%, but this decrease primarily involved those infants born in the later preterm period (34–36 weeks).³ Low birth weight (LBW) also contributes to increased infant mortality, and the CDC has reported that the percentage of LBW infants, or infants born weighing less than 2500 g, increased by 24% between 1984 and 2006.³

A recent study of 15,454 extremely low birth weight (ELBW) infants, each weighing between 401 g and 1000 g, was undertaken to assess neurodevelopmental outcome.⁴ More than 5000 infants died while in the hospital or before the follow-up visit. Among the 7693 children in whom follow-up studies were available, 2530 (33%) had a history of intraventricular hemorrhage (IVH). The IVH was Grade III or IV for 998 (13%) of the 7693 infants. Remarkably, in only 246 (3%) of the 7693 ELBW infants with follow-up was a shunt placed for PHH.⁴ There are still many questions about the optimal time to intervene for infants with PHH, and there are many different opinions about the best temporizing mechanism for symptomatic infants too small or unstable for permanent shunt placement.

The objective of this systematic review and analysis was to answer the following question: What are the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants? We evaluated the current literature and constructed evidence-based recommendations supported by the strength of the available data for the management of PHH in premature infants. Specifically, we wanted to investigate relevant evidence for the following:

• Use of surgical temporizing methods such as ventricular reservoirs, external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, and lumbar punctures (LPs).
• Routine use of serial LPs to reduce the need to shunt or to avoid the progression of hydrocephalus in premature infants.
• Use of intraventricular thrombolytic agents, including tissue plasminogen activator (tPA), urokinase, and streptokinase, to reduce the need for shunt placement in premature infants with PHH.
• Use of acetazolamide or furosemide to reduce the need for shunt placement in premature infants with PHH.
• Efficacy of endoscopic third ventriculosomy (ETV) in this population.
• Specific CSF parameters to direct the timing of shunt placement in premature infants with PHH.

Methods

Search Criteria

Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to PHH.

Key Words. The following key words were used in this study: (((preterm[All Fields] AND Intraventricular[All Fields] AND (“haemorrhage”[All Fields] OR “hemorrhage”[MeSH Terms] OR “hemorrhage”[All Fields])) OR ((“infant, premature”[MeSH Terms] OR (“infant”[All Fields] AND “premature”[All Fields]) OR “premature infant”[All Fields] OR (“preterm”[All Fields] AND “infant”[All Fields]) OR “preterm infant”[All Fields]) AND (“hydrocephalus”[MeSH Terms] OR “hydro cephalus”[All Fields]))) OR ((preterm[All Fields] AND (“heart ventricles”[MeSH Terms] OR (“heart”[All Fields] AND “ventricles”[All Fields]) OR “heart ventricles”[All Fields] OR “ventricular”[All Fields]) AND reservoir[All Fields])) AND shunt[All Fields].

Strategy

Two hundred thirteen abstracts were reviewed, after which 98 publications that met the inclusion criteria were selected. In addition to the overall inclusion/exclusion criteria specified in the Methods section of the Guidelines (Part 1), additional inclusion criteria included studies in which infants younger than 12 months with all forms of hydrocephalus—both congenital and acquired—were evaluated to ensure that the maximum number of studies were reviewed. The analysis focused on studies evaluating infants with PHH because of the treatment strategies and challenges unique to this patient population.

As a result of the US National Library of Medicine’s search engine functionalities, additional search terms (heart ventricles) not relevant to topics addressed in this chapter were added to the search strategy. Although these search terms remained in the search strategy, we did not recall any references retrieved using them for full-text review. We excluded those references because they were not relevant to the overall scope of this project or the patient population addressed in this chapter and, therefore, did not meet the article inclusion criteria specified in the methodology section of this guideline (Part 1).⁵

Following an evidentiary analysis and a review of the 98 full-text articles, 68 publications were accepted for inclusion in the evidentiary table and 30 publications were excluded.^1,6-33 The evidentiary table was assembled linking recommendations to the strength of the evidence (Levels I–III).

Authors performed an updated literature search (in PubMed and Cochrane Central) for this guideline chapter through a medical librarian at the Congress of Neurological Surgeons Guidelines office using the below-mentioned existing search terms to update the original search through November 30, 2019.

Search Results

Fig. 1.  Flowchart showing the process involved in identifying relevant literature. The criteria for “records excluded” and “fulltext articles excluded with reasons” are detailed in Part 1 of the Guidelines.

Fig. 2.  Flowchart showing the process involved in identifying relevant literature for the 2020 Update. The criteria for “records excluded” and “full text articles excluded with reasons” are detailed in Part 1 of the Guidelines.

Of the 98 full-text articles selected for review, 30 full-text publications were rejected based on the criteria listed above and only 68 articles were used to construct the evidentiary table (Fig. 1). An additional 11 studies out of the 122 yielded by the 2020 update met inclusion criteria from the original guideline and were included (Figure 2). The criteria for the decision to treat were quite variable among different institutions and different study groups. For example, we evaluated 1 Class II study in which hydrocephalus was defined as the atrium of the lateral ventricle measuring > 10 mm on the horizontal plane of a head ultrasound (HUS) study or the body of the lateral ventricle at the level of the midthalamus measuring > 10 mm on a sagittal ultrasound image.³⁴ We reviewed another Class III study in which hydrocephalus was defined as anterior cortical mantle thickness < 20 mm at an average postnatal age of 21 days along with increasing occipitofrontal circumference (OFC) as an indicator of hydrocephalus that should be treated.³⁵ Bada et al³⁵ reported that of 10 infants requiring shunts, 5 (50%) experienced normal development, which was defined by physical and neurological assessment and evaluation using the Denver developmental screening tool. Evan’s ratio, which is described as the lateral measurement of the ventricle across the frontal horns divided by the lateral measurement across the brain (biparietal diameter; also known as the ventricular/biparietal [V/BP] ratio) can also be used to describe the severity of PHH.³⁶ The majority of studies that were evaluated based on an initial diagnosis of PHH on HUS, CT, and MRI studies were also used. Choudhury described mild hydrocephalus as a V/ BP ratio of 0.26–0.40, moderate hydrocephalus as a V/ BP ratio of 0.40–0.60, severe hydrocephalus as a V/BP ratio of 0.60–0.90, and extreme hydrocephalus as a V/ BP ratio of 0.91–1.0.³⁶ These authors also reported that the thickness of the cortical mantle was not a statistically significant indicator of outcome because several infants with extreme hydrocephalus displayed normal motor development.³⁶ One Class II and 1 Class III study indicated that when ventriculoperitoneal (VP) shunts were placed, even in cases of severe or extreme hydrocephalus, there were some infants with normal development and motor outcome (50 of 82 patients in the Choudhury study).^35,36 Numerous studies have reported that good neurodevelopmental outcomes may be seen if and when infants with hydrocephalus are aggressively treated and cortical mantle thickness is restored.

Results

Surgical Temporizing Measures

Recommendation: Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of PHH. Clinical judgment is required. Strength of Recommendation: Level II, moderate degree of clinical certainty.

Recommendation: The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs. Strength of Recommendation: Level II, moderate degree of clinical certainty.

The evidence demonstrates that VADs reduce morbidity and mortality compared with EVDs. Three Class II and 7 Class III studies were included as evidence to support the first recommendation, and these lower-quality studies documented the safety and efficacy of VADs, or Ommaya reservoirs, for the aspiration of CSF, ventricular decompression, and lowering of intracranial pressure.^37-46 The authors of 2 Class II studies reported that ventricular reservoirs may reduce the incidence of shunt infection as well as noninfectious shunt complications.^38,41 In one Class II study and one class III study, repeated aspiration of CSF from a VAD did not significantly increase the risk of infection.^41,44 Three Class III studies reported that ventricular reservoirs did not significantly reduce the need for permanent shunt placement.^42,43,47 One Class III study reported that the use of VADs, compared with the use of continuous ventricular drainage, significantly reduced morbidity and mortality rates that were associated with the surgical treatment of PHH in LBW infants with reservoirs, instead of EVDs (Table 1).⁴¹

The placement of an EVD has also been used to treat hydrocephalus in preterm infants with PHH and is an option for these children, as shown in 1 Class II and 7 Class III studies.^48-55 Three Class III studies reported that an EVD obviated the need for VP shunt placement in fewer than one-third of infants treated.^48,52,54 More than 50% of preterm infants with PHH did require permanent VP shunt placement following removal of an EVD (95 out of 132 survivors required a shunt).^48,52-55

It has been reported that placement of a VSG shunt may reduce the need for permanent shunt placement. The authors of Class II and Class III studies reported trends toward shunt independence, but the studies only enrolled 32 and 95 patients, respectively, and the results were not statistically significant.^56,57 In their report of a Class II, retrospective historical cohort study, Lam and Heilman demonstrated that VSG shunting significantly reduced the need for daily CSF aspiration, which may decrease the risk of introducing a de novo CSF infection.⁵⁶ A chi square test performed on their data indicated that a VSG shunt did significantly reduce the need for daily CSF aspiration when compared with a VAD (c² = 19.2, df = 1, p = 0.000016, p < 0.05).⁵⁶ This may reduce the risk of infection or other complications. A larger, prospective study reported a statistically significant decreased need for permanent CSF diversion in infants treated with VSG shunts.⁵⁷ This study reported that 66% of infants (20 of 30) treated with VSG shunts required VP shunts and 33% (10 of 30) remained shunt free; this was compared with a group of infants treated with VADs in which 75% (49 of 65) required VP shunts and only 25% of infants (16 of 65) remained shunt free.⁵⁷

In 2 studies, 1 intervention was compared to another with specific recommendations about the timing of the intervention for temporizing measures for the treatment of PHH in very LBW infants. In 1 Class III study, the authors compared early versus late intervention, as assessed by ventricular dilation in 5 collaborating neonatal centers.⁵⁸ Ninety-five patients were subdivided into early intervention or late intervention groups, depending on their ventricular index at the time of initial treatment. Early treatment was safe and effective regardless of whether LP and/or reservoir placement was used. Early intervention was associated with a reduced requirement for a VP shunt (OR = 0.22) and reduced risk of moderate-to-severe disability.⁵⁸ Additionally, there was a single Class III observational study of outcomes in which LPs, EVD, VSG shunts, and reservoirs were used.²⁴ All interventional studies were found to be safe and effective.²⁴

Routine Use of Serial Lumbar Puncture

Recommendation: The routine use of serial lumbar puncture (LP) is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants. Strength of Recommendation: Level I, high degree of clinical certainty.

 One Class I study was included, and it reported no statistical differences in outcomes of preterm infants with PHH treated with observation alone or infants treated with daily LP (Table 2).⁵⁹ Lumbar puncture is often used early in the treatment of PHH, despite the fact that there is no statistically significant reduction in the need for a shunt or progression of PHH.^59,60 In fact, LP neither predicts nor prevents the need for a permanent VP shunt.⁵¹ A second study, a Class III study, also reported no difference in adverse outcome regardless of whether infants were untreated or treated with serial LP.⁶¹ Without aggressive treatment of hydrocephalus and with persistent ventricular dilation, outcome was poor.⁶¹ Additionally, there was a single Class III study that concluded that repeated LPs may cause or contribute to subsequent shunt infection.⁶² Although LP may be useful for drawing off CSF as an immediate treatment for elevated intracranial pressure in infants with PHH, or for sampling CSF, we do not recommend the routine use of LP to eliminate the need for a VP shunt.⁶¹

Nonsurgical Temporizing Agents

Intraventricular Thrombolytic Agents. Recommendation: Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Strength of Recommendation: Level I, high clinical certainty.

Based on 1 high-quality Class I study, the DRIFT procedure—Drainage, Irrigation, and Fibrinolytic Therapy (intraventricular tPA)—is not recommended for PHH.⁶³ DRIFT did not significantly reduce shunt surgery or death, but it was associated with an increased rate of secondary IVH (Table 3).⁶³ Forty-four percent (15 of 34) of infants in the DRIFT group died or required a shunt, compared with 50% (19 of 36) of infants who received standard treatment. Thirty-five percent (12 of 34) of preterm infants in the DRIFT study had secondary IVH, compared with 8% (3 of 34) who received standard treatment.⁶³ These results differ from those of earlier Class II and Class III studies in which a decreased rate for the need for permanent shunt placement was reported when low-dose urokinase or fibrinolytic therapy with tPA was used for ventricular irrigation and clot reduction.^33,64-66

Reviews conducted by Whitelaw and Odd⁶³ have also revealed that intraventricular injection of streptokinase has not been shown to be beneficial.⁶⁷ A single case report of intravenous streptokinase, published in 1998, suggested that there may be some benefit.⁶⁸ This report was followed by an early Class III study that found benefit in a nonrandomized cohort of preterm infants with PHH who were treated with intravenous low-dose streptokinase.⁶⁹ However, data from a later Class II study led to the conclusion that routine use of intraventricular streptokinase in PHH was not recommended.⁷⁰ These studies were included in the 2007 Whitelaw and Odd Cochrane review,^63,67 which argues against intravenous streptokinase for the treatment of PHH in preterm infants (Table 3).

Despite increased short-term morbidity and recurrent IVH, some benefits were noted in the DRIFT survivors.⁷¹ In the most recent Whitelaw study,⁷¹ the reduction in the primary long-term outcome—death or severe disability— at 2 years in the DRIFT group reached statistical significance when adjusted for sex, birth weight, and grade of IVH. Severe cognitive disability also was reduced, and this improvement in cognitive function was statistically significant. There was also a reduction in severe sensorimotor disability with DRIFT, but this clinical improvement did not reach statistical significance. The authors hypothesized that the greater effect on cognitive rather than sensorimotor function may be attributed to parenchymal infarction in the periventricular white matter, which was seen in about half of the infants enrolled in the trial.⁷¹

Acetazolamide and Furosemide.

Recommendation: Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Strength of Recommendation: Level I, high clinical certainty.

After our review of the literature, we found two Class I studies that reported that preterm infants with a diagnosis of PHH who were treated with acetazolamide and furosemide demonstrated higher risks of neurological complications, morbidity, and mortality (Table 4).^72,73 The International Posthemorrhagic Ventricular Dilation (PHVD) Drug Trial Group reported that administration of acetazolamide plus furosemide leads to higher rates of shunt placement (relative risk 1.42) and morbidity (84% vs 60%) compared with standard therapy.⁷² Kennedy etal.⁷³ reported that treatment of PHVD with acetazolamide and furosemide did not decrease the rate of shunt placement (64% in the acetazolamide/furosemide group vs 52% in the control group, not treated with acetazolamide/furosemide).⁷³ However, treatment was associated with an increased rate of neurological morbidity (81% vs 66%).⁷³

Treatment of PHVD with acetazolamide and furosemide was not recommended.⁷³ One Class III study reported this treatment was not associated with VP shunt placement, but the severity of IVH (based on IVH grade) and the patient age at the time of IVH were significantly associated with the need for permanent CSF diversion.⁵¹ Kennedy et al. also noted that the ventricular index at time of entry into trial was the only factor significantly predictive of death or need for shunt, after multiple logistic regression analysis.⁷³

Timing of Shunt Placement

Recommendation: There is insufficient evidence to recommend a specific infant weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Strength of Recommendation: Level III, unclear degree of clinical certainty.

There were two Class III studies which evaluated the lower limits of infant weight at time of initial shunt insertion (Table 5).^38,59 A weight of 1500 g was safely used as a criterion for VP shunt placement in the Benzel study.³⁸ A single Class III study showed that CSF cell count, protein, and glucose levels were not statistically related to the occurrence of shunt failure or infection in the study population.⁷⁴ The authors recommended that placement of the shunt be timed when the infant’s age, weight, and overall stability allow.⁷⁴

Endoscopic Third Ventriculostomy

Recommendation: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with PHH. Strength of Recommendation: Level III, unclear degree of clinical certainty.

Although ETV was discussed in several full-text articles that we reviewed, there was insufficient evidence available for us to make a recommendation for or against its use for the treatment of PHH in premature infants (Table 6). Endoscopic third ventriculostomy for the treatment of hydrocephalus in infants and children will be discussed more thoroughly in subsequent chapters (in particular, Part 4).⁷⁵

2020 Update

There was one new recommendation yielded by the update stating that that neuro-endoscopic lavage is a feasible and safe option for the removal of intraventricular clots and may lower the rate of shunt placement.⁷⁶ The remaining new literature confirmed the previous recommendations.^76-83 (Table 7)

There was no change in the Level I recommendation against the routine use of serial lumbar punctures (LP) to reduce the need to shunt or to avoid the progression of HC in premature infants.  In the management of PHH, there is still insufficient evidence to recommend one surgical temporizing method over another. Authors suggested that ventriculo-subgaleal shunts (VSG) reduce the need of daily CSF aspiration as compared to other ventricular access devices (VAD) and that Ommaya type ventricular access reservoirs reduce in morbidity and mortality compared to external ventricular drains (EVD) (Level II). There were some benefits of VSG over VAD identified in 2014 and affirmed in 2019 (Level II).^80-82 Intraventricular thrombolytic agents are still not recommended as a method to reduce the need for shunt placement in premature infants with PHH; there was no change in this Level I recommendation. Acetazolamide/ Furosemide are also not recommended as methods to reduce the need for shunt placement in premature infants with PHH (Level I).

Excluded Studies

We excluded 1 Class III study for low “preterm” patient representation (7 patients); in the review of 52 consecutive ETV procedures in 49 infants with hydrocephalus, most infants (31 patients) had aqueductal stenosis.⁸⁴ Of the 7 infants with preterm PHH, 6 required a shunt even after ETV. Infants with PHH from premature birth did not benefit from ETV.⁸⁴ We excluded another Class III study including patients with different etiologies for hydrocephalus.⁸⁵ Although ETV was successful in 57% of patients (8 of 14), the majority of those infants had congenital aqueductal stenosis without PHH. In the remaining 6 patients, a VP shunt was needed. In 1 Class III single-institution retrospective case series, 18 preterm infants with PHH were treated initially with Ommaya reservoir placement: 1 patient died, 5 patients received a VP shunt, and 9 patients underwent ETV.⁸⁶ Three patients did not require any further intervention. While overall, 59% were shunt free at the last follow-up, 5 of the 9 patients who were treated with ETV had to undergo repeated surgery for VP shunt placement. The authors recommended combining placement of an Ommaya reservoir with ETV to reduce shunt dependency for preterm infants with PHH.⁸⁶ There was a large (101 patients) Class III multicenter, retrospective study evaluating the success rate of ETV in patients with hydrocephalus from subarachnoid hemorrhage, IVH, and/or CSF infection; a minority of the patients (25% [25 of 101]) had PHH of prematurity.⁸⁷ Overall, ETV was successful in 52% of the infants with PHH of prematurity. Endoscopic third ventriculostomy was successful in 100% (13 of 13) of children with a history of preterm PHH, even though these patients were initially treated with a shunt. Endoscopic third ventriculostomy was unsuccessful in 12 of 12 infants treated with ETV as the first-line treatment, following preterm PHH. In patients with both hemorrhage and infection, ETV was not successful.⁸⁷

Three studies were excluded from the update after full text review because (although the populations studied and results that were reported included some data about premature infants with PHH) there were mixed populations included and results for premature infants with PHH could not be separately identified, tracked or otherwise determined.^88-90

Conclusions

Surgical Temporizing Measures

Recommendation: Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of posthemorrhagic hydrocephalus (PHH). Clinical judgment is required. Strength of Recommendation: Level II, moderate degree of clinical certainty.

Recommendation: The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs. Strength of Recommendation: Level II, moderate degree of clinical certainty.

The evidence demonstrates that VADs reduce morbidity and mortality compared with EVDs.

Routine Use of Serial Lumbar Punctures

Recommendation: The routine use of serial lumbar puncture (LP) is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants. Strength of Recommendation:  Level I, high clinical certainty.

Nonsurgical Temporizing Measures

Recommendation: Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Strength of Recommendation:  Level I, high clinical certainty.

Recommendation: Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Strength of Recommendation: Level I, high clinical certainty.

Timing of Shunt Placement

Recommendation: There is insufficient evidence to recommend a specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Clinical judgment is required. Strength of Recommendation: Level III, unclear clinical certainty.

Endoscopic Third Ventriculostomy

Recommendation: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with PHH. Strength of Recommendation: Level III, unclear clinical certainty.

Recommendation: Neuro-endoscopic lavage is a feasible and safe option and therefore may be used for the removal of intraventricular clots and may lower the rate of shunt placement. Strength of Recommendation: Level III, unclear clinical certainty.

Acknowledgments

We acknowledge the American Association of Neurological Surgeons (AANS)/Congress of Neurological Surgeons (CNS) Joint Guidelines Committee for the members’ reviews, comments, and suggestions; the Hydrocephalus Association and Debby Buffa, patient advocate representative, for participation and input throughout the guidelines development; Pamela Shaw, research librarian, for her assistance with the literature searches; Kevin Boyer for his assistance with data analysis; and Sue Ann Kawecki for her assistance with editing.

We acknowledge the following individuals for their contributions throughout the review process: Timothy Ryken, M.D.; Kevin Cockroft, M.D.; Sepideh Amin-Hanjani, M.D.; Steven N. Kalkanis, M.D.; David P. Adelson, M.D.; Brian L. Hoh, M.D.; Mark D. Krieger, M.D.; Mark E. Linskey, M.D.; Jeffrey J. Olson, M.D.; Patricia Raskin, M.D.; Krystal L. Tomei, M.D.; and Monica Wehby, M.D. We also acknowledge the following peer reviewers for their contributions to review the update to the guidelines: Jennifer Sweet, MD, Brandon Rocque, MD, Christoph Greissenauer, MD, Jeffrey Olson, MD.

Disclosure

Dr. Limbrick receives research funding from the National Institute of Neurological Disorders and Stroke. The systematic review and evidence-based guidelines were funded exclusively by the CNS and AANS Pediatric Section, which received no funding from outside commercial sources to support the development of this document.

Conflict(s) of Interest: None. All Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force members declared any potential conflicts of interest prior to beginning work on this systematic review and evidence-based guidelines.

Conflict(s) of Interest: None. All Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Update Task Force members declared any potential conflicts of interest prior to beginning work on this systematic review and evidence-based guidelines.

Author contributions to the study and manuscript preparation include the following. Conception and design: AANS/CNS Joint Section on Pediatrics. Acquisition of data: all authors. Analysis and interpretation of data: all authors. Drafting the article: Mazzola. 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: Flannery. Administrative/technical/material support: all authors. Study supervision: Flannery.

Table 1. Surgical Temporizing Measures Evidence Table

Table 2. Serial Lumbar Punctures Evidence Table

Table 3.  Intraventricular Thrombolytic Agents Evidence Table

Table 4. Acetazolamide/Furosemide Evidence Table

Table 5. Timing of Shunt Placement: Specific Weight or CSF Parameter Evidence Table

Table 6.  Endoscopic Third Ventriculostomy for PHH in Premature Infants Evidence Table

Table 7.  New evidence included in 2020 Update

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