The cost of serial cerebrospinal fluid aspirations between ventricular access device (VAD) and ventriculosubgaleal shunt (VSGS) for treatment of post-hemorrhagic ventricular dilatation (PHVD) in premature infants

Introduction: Ventriculosubgaleal shunts (VSGS) require fewer cerebrospinal (CSF) aspirations than ventricular access devices (VAD) for temporization of post-hemorrhagic ventricular dilatation (PHVD) in preterm infants. Cost of postoperative CSF aspiration has not been quantified. Methods: We reviewed CSF aspiration and laboratory studies obtained in preterm infants with PHVD and VAD at our institution between 2009-2020. Cost per aspiration was calculated for materials, labs, and Medicare fee schedule for ventricular puncture through implanted reservoir. We searched PubMed, Cochrane Library, Embase, CINAHL, and Web of Science for meta-analysis of pooled mean number of CSF aspirations and proportion of patients requiring aspiration. Results: Thirty-five preterm infants with PHVD had VAD placed with 22.2±18.4 aspirations per patient. Labs were obtained after every aspiration per local protocol. Cost per aspiration at our institution was $935.51. Of 269 published studies, 77 reported on VAD, 29 VSGS, and 13 both. Five studies on VAD (including the current study) had a pooled mean of 25.8 aspirations per patient (95%CI:16.7-34.8). One study on VSGS reported a mean of 1.6±1.7 aspirations. 3 studies on VAD (including the current study) had a pooled proportion of 97.4% of patients requiring aspirations (95%CI: 87.9-99.5). Four studies on VSGS had a pooled proportion of 36.5% requiring aspirations (95%CI:26.9-47.2). Frequency of lab draws ranged from weekly to daily. Based on costs at our institution, mean number of aspirations, and proportion of patients requiring aspirations, cost difference ranged between $4,243 to $23,235 per patient and $500,903 to 2.36 million per 100 patients depending on frequency of taps and Medicare locality. Discussion/Conclusion: Lower number of CSF aspirations using VSGS can be associated with considerably lower cost compared to VAD.

Ventriculosubgaleal shunt and neuroendoscopic lavage: refining the treatment algorithm of neonatal post-hemorrhagic hydrocephalus

Background The optimal management of neonatal post-hemorrhagic hydrocephalus (PHH) is still debated, though several treatment options have been proposed. In the last years, ventriculosubgaleal shunt (VSgS) and neuroendosdcopic lavage (NEL) have been proposed to overcome the drawbacks of more traditional options, such as external ventricular drainage and ventricular access device. Methods We retrospectively reviewed neonates affected by PHH treated at our institution since September 2012 to September 2020. Until 2017 patients received VSgS as initial treatment. After the introduction of NEL, this treatment option was offered to patients with large intraventricular clots. After NEL, VSgS was always placed. Primary VSgS was reserved to patients without significant intraventricular clots and critically ill patients that could not be transferred to the operating room and undergo a longer surgery. Results We collected 63 babies (38 males and 25 females) with mean gestational age of 27.8 ± 3.8SD weeks (range 23–38.5 weeks) and mean birthweight of 1199.7 ± 690.6 SD grams (range 500–3320 g). In 6 patients, hemorrhage occurred in the third trimester of gestation, while in the remaining cases hemorrhage complicated prematurity. This group included 37 inborn and 26 outborn babies. Intraventricular hemorrhage was classified as low grade (I–II according to modified Papile grading scale) in 7 cases, while in the remaining cases the grade of hemorrhage was III to IV. Mean age at first neurosurgical procedure was 32.2 ± 3.6SD weeks (range 25.4–40 weeks). Death due to prematurity occurred in 5 patients. First-line treatment was VSgS in 49 patients and NEL in the remaining 14 cases. Mean longevity of VSgS was 30.3 days (range 10–97 days) in patients finally requiring an additional treatment of hydrocephalus. Thirty-two patients required one to three redo VSgS. Interval from initial treatment to permanent shunt ranged from 14 to 312 days (mean 70.9 days). CSF infection was observed in 5 patients (7.9%). Shunt dependency was observed in 51 out of 58 surviving patients, while 7 cases remained shunt-free at the last follow-up. Multiloculated hydrocephalus was observed in 14 cases. Among these, only one patient initially received NEL and was complicated by isolated trapped temporal horn. Conclusions VSgS and NEL are two effective treatment options in the management of PHH. Both procedures should be part of the neurosurgical armamentarium to deal with PHH, since they offer specific advantages in selected patients. A treatment algorithm combining these two options may reduce the infectious risk and the risk of multiloculated hydrocephalus.

Ventricular reservoir versus ventriculosubgaleal shunt for posthemorrhagic hydrocephalus in preterm infants: infection risks and ventriculoperitoneal shunt rate

Object The most common neurosurgical condition observed in preterm infants is intraventricular hemorrhage (IVH), which often results in posthemorrhagic hydrocephalus (PHH). These conditions portend an unfavorable prognosis; therefore, the potential for poor neurodevelopmental outcomes necessitates a better understanding of the comparative effectiveness of 2 temporary devices commonly used before the permanent insertion of a ventriculoperitoneal (VP) shunt: the ventricular reservoir and the ventriculosubgaleal shunt (VSGS). Methods The authors analyzed retrospectively collected information for 90 patients with IVH and PHH who were treated with insertion of a ventricular reservoir (n = 44) or VSGS (n = 46) at their institution over a 14-year period. Results The mean gestational age and weight at device insertion were lower for VSGS patients (30.1 ± 1.9 weeks, 1.12 ± 0.31 kg) than for reservoir patients (31.8 ± 2.9 weeks, 1.33 ± 0.37 kg; p = 0.002 and p = 0.004, respectively). Ventricular reservoir insertion was predictive of more CSF taps prior to VP shunt placement compared with VSGS placement (10 ± 8.7 taps vs 1.6 ± 1.7 taps, p < 0.001). VSGS patients experienced a longer time interval prior to VP shunt placement than reservoir patients (80.8 ± 67.5 days vs 48.8 ± 26.4 days, p = 0.012), which corresponded to VSGS patients gaining more weight by the time of shunt placement than reservoir patients (3.31 ± 2.0 kg vs 2.42 ± 0.63 kg, p = 0.016). Reservoir patients demonstrated a trend toward more positive CSF cultures compared with VSGS patients (n = 9 [20.5%] vs n = 5 [10.9%], p = 0.21). There were no significant differences in the rates of overt device infection requiring removal (reservoir, 6.8%; VSGS, 6.5%), VP shunt insertion (reservoir, 77.3%; VSGS, 76.1%), or early VP shunt infection (reservoir, 11.4%; VSGS, 13.0%) between the 2 cohorts. Conclusions Although the rates of VP shunt requirement and device infection were similar between patients treated with the reservoir versus the VSGS, VSGS patients were significantly older and had achieved greater weights at the time of VP shunt insertion. The authors' results suggest that the VSGS requires less labor-intensive management by ventricular tapping; the VSGS patients also attained higher weights and more optimal surgical candidacy at the time of VP shunt insertion. The potential differences in long-term developmental and neurological outcomes between VSGS and reservoir placement warrant further study.