When are shunt surgeries considered in neonates with intraventricular hemorrhage (IVH)?

Shunt Surgery Indications in Neonates with Intraventricular Hemorrhage

Shunt surgeries in neonates with intraventricular hemorrhage (IVH) should be considered after initial temporizing measures when there is progressive hydrocephalus with increased intracranial pressure that cannot be managed by other means. 1

Initial Management Approach

• Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are all acceptable initial temporizing treatment options for posthemorrhagic hydrocephalus (PHH), with clinical judgment required to select the most appropriate option 1
• VSG shunts reduce the need for daily CSF aspiration compared with VADs and are preferred when frequent CSF drainage is anticipated 1
• VADs have been shown to reduce morbidity and mortality compared with EVDs in premature infants 1
• External ventricular drainage is effective in decreasing ventricular size in neonates with PHH 1, 2
• Serial lumbar punctures are NOT recommended as routine treatment to reduce shunt placement need or prevent hydrocephalus progression 1

Indications for Permanent Shunt Placement

• Progressive ventricular dilation despite temporizing measures 1, 3
• Clinical signs of increased intracranial pressure including:
  • Bulging fontanelle 4
  • Splayed cranial sutures 4
  • Rapidly increasing head circumference 4
  • Neurological symptoms (lethargy, seizures, apnea, bradycardia) 1, 4

Timing of Permanent Shunt Placement

• 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 1
• Clinical judgment is required regarding the optimal timing for permanent shunt placement 1
• Many centers use temporizing measures until the infant reaches adequate weight (typically >1500-2000g) for permanent shunt placement 3, 5
• Permanent shunting is often delayed until CSF protein levels decrease and the risk of infection is lower 3

Factors Affecting Shunt Outcomes

• Lower gestational age and higher-grade IVH are associated with increased mean revision rates over a 5-year follow-up period 5
• Risk factors for requiring VP shunt include IVH grade, later estimated gestational age at birth, and age at time of IVH 1
• The presence of accompanying intracerebral hemorrhage is associated with poorer outcomes 2

Alternative Approaches

• Intraventricular thrombolytic agents (tPA, urokinase, streptokinase) are NOT recommended to reduce shunt placement need in premature infants with PHH 1
• Acetazolamide and furosemide are NOT recommended as methods to reduce shunt placement need 1
• Early endoscopic ventricular irrigation has shown promise in some studies with lower shunt dependency rates (60.8% vs 93.1% with conventional methods) and fewer complications such as infection and multiloculated hydrocephalus 6
• There is insufficient evidence to recommend endoscopic third ventriculostomy (ETV) in premature infants with PHH 1

Surgical Outcomes and Considerations

• Approximately 50-90% of infants with PHH who undergo temporizing measures will eventually require permanent VP shunt placement 1, 6, 5
• Ventricular drainage is an effective temporizing measure in small infants with rapidly progressive PHH when VP shunt placement is not immediately feasible 2
• Shunt complications include infection (reported rates 8-20%) and revision needs (reported rates 20-53%) 1
• Careful consideration of infection risk is essential, as repeated LPs may contribute to subsequent shunt infection 1

Special Considerations

• For neonates with IVH associated with cerebral sinovenous thrombosis without significant hemorrhage, anticoagulation with unfractionated heparin or low-molecular-weight heparin may be considered 1, 7
• Supportive care including treatment of dehydration and anemia is reasonable in neonates with stroke-related IVH 1