Ventriculosubgaleal shunt-Proposed technique for post-infectious hydrocephalus in infants

Based on the recent findings published in Child's Nervous System, ventriculosubgaleal shunt (VSGS) could be a safe and efficacious option for temporary CSF diversion in patients with post-infectious hydrocephalus (PIH) before the permanent VPS, especially in resource-limited settings. It is associated with an acceptable complication rate.

Hydrocephalus is a term describing an active enlargement of brain ventricles. This occurs secondary to impaired pas- sage of cerebrospinal fluid (CSF) from its secretion site in the ventricles to its absorption site and then to the systemic circulation.

For about six decades, shunting CSF from the ventricles to another anatomical location, mostly the peritoneum, was the main management plan for such patients. However, some patients might need a temporary method of CSF diversion due to the presence of local or systemic infection, concomitant abdominal pathology hindering diversion to the peritoneum. These comorbidities must be corrected before insertion of the permanent shunt to decrease the rate of shunt infection. These temporary methods include repeated transfontanel- lar tapping, external ventricular drainage (EVD), frequent lumbar drainage, Ommaya reservoir, and ventriculosub- galeal shunting (VSGS).

In the past, the application of VSGS was limited to neo- nates with intraventricular hemorrhage and consequent post- hemorrhagic hydrocephalus (PHH). However, little is published regarding its application in pediatric patients with post-infectious hydrocephalus.

The VSGS procedure entails creating an artificial shunt between the lateral ventricle and a pouch created in the sub- galeal space, leading to the formation of a fluid collection of variable sizes. In contrast to other drainage methods, this approach offers a natural way for CSF absorption through the cervical lymphatics draining the subgaleal region. This method was initially described by Mickulicz in 1896.

Mohamed Mohsen Amen et al retrospectively investigated and analyzed the data of 50 consecutive cases, ranging between 1 and 10 months, who underwent VSGS for PIH.

Regarding the fate of VSGS, arresting of hydrocephalic manifestations clinically and radiologically was noted in ten patients (20%), while another 36 cases required the perma- nent VPS procedure within 35 days after the initial tempo- rary one (range, 24–45 days). Mortality was encountered in four cases (8%) because of sepsis (Table 4).

Morbimortality was encountered in 16 patients in the cur- rent study (32%). Risk factors for that outcome were younger age, lower weight, male gender, and previous meningitis or ventriculitis, as illustrated in Table 5.

In their study, the mean duration between the tem- porary and permanent shunt procedure was 35 days, after excluding cases that had arresting of their hydrocephalus. 16 cases (32%) required shunt revision to extend the life expectancy of the temporary shunt (due to infection, migration, or obstruction). In another study evaluating the role of VSGS in post-hemorrhagic hydrocephalus, at least one revision was needed in 35% of the included cases. Their findings showed the incidence of infection and expo- sure in 20% of our patients. Although some studies reported a low infection rates after VSGS (0–10%). CSF leakage was encountered in 12 cases (24%). Their findings showed that shunt obstruction and migration were detected in 8% and 4% of our cases, respectively. Mortality was encountered in only four patients (8%) because of sepsis, and most of these cases died because of other complications rather than shunt- related ones. Their findings also showed arresting of the hydrocephalus in ten patients (20%). The cases were clinically and radiologically free from any manifestations of increased ICP.

They conclude that the VSGS is a safe and effective procedure in infants awaiting definitive VPS for postinfectious hydrocephalus. It was proven that VSGS has shortened the hospital stay and the economic burden on the country.

Reference : Mohamed Mohsen Amen· Ahmed Zaher · Hatem Ibraheem Badr · Mohammad Fekry Elshirbiny · Ahmed Mahmoud Elnaggar · Amr Farid Khalil Child's Nervous System (2022) 38:2155–2162 https://doi.org/10.1007/s00381-022-05661-x