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

Shunt Surgery in Neonates with Intraventricular Hemorrhage and Hydrocephalus

Shunt surgeries in neonates with intraventricular hemorrhage (IVH) should be considered after initial temporizing measures when there is progressive posthemorrhagic hydrocephalus (PHH) with signs of increased intracranial pressure, though there is insufficient evidence to recommend specific timing based on weight or CSF parameters. 1

Initial Management Approach

Temporizing Measures

• Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are all acceptable initial treatment options for PHH, with clinical judgment required to select the most appropriate option 1
• VSG shunts reduce the need for daily CSF aspiration compared to VADs, making them potentially more practical in some clinical settings 1
• VADs have been shown to reduce morbidity and mortality compared with EVDs 1
• External ventricular drainage has been demonstrated to effectively decrease ventricular size in neonates with PHH 1
• Ventricular drainage should be considered when there are signs of increased intracranial pressure, including:
  • Rapidly increasing head circumference 2
  • Full or bulging fontanelle 2
  • Splayed cranial sutures 2
  • Neurological symptoms such as lethargy, seizures, or apnea 1, 2

Interventions Not Recommended

• Routine use of serial lumbar punctures is not recommended to reduce shunt placement need or avoid hydrocephalus progression (Level I, high clinical certainty) 1
• Intraventricular thrombolytic agents (tPA, urokinase, streptokinase) are not recommended for reducing shunt placement need (Level I, high clinical certainty) 1
• Acetazolamide and furosemide are not recommended as methods to reduce shunt placement need (Level I, high clinical certainty) 1

Timing of Permanent Shunt Placement

• There is insufficient evidence to recommend a specific infant weight or CSF parameter to direct the timing of permanent shunt placement (Level III, unclear clinical certainty) 1
• Clinical judgment is required when determining the appropriate timing for permanent shunt placement 1
• Most neonates (77-95%) who initially receive temporizing measures such as VAD insertion eventually require conversion to permanent ventriculoperitoneal shunting 3
• Permanent shunting is typically considered when:
  • The infant has reached adequate weight for the procedure 1
  • Medical condition has stabilized 4
  • Persistent progressive ventricular dilation despite temporizing measures 4
  • Signs of increased intracranial pressure persist 1, 4

Outcomes and Prognostic Factors

• Lower gestational age and higher-grade IVH are associated with increased mean revision rates over a 5-year follow-up period 3
• Early endoscopic ventricular irrigation may reduce shunt dependency rates (60.8% vs. 93.1% with conventional methods) and lower the incidence of CSF infections and multiloculated hydrocephalus 5
• Outcome is poorest for infants with accompanying intracerebral hemorrhage 4
• Approximately 44-50% of infants with PHH either die or require permanent shunt placement 6
• Of survivors treated with external ventricular drainage, approximately 44% may achieve normal cognitive development (DQ/IQ >75) 4

Pitfalls and Caveats

• Secondary intraventricular hemorrhage is a potential complication of interventions like drainage, irrigation, and fibrinolytic therapy, and is associated with increased risk for subsequent shunt surgery 6
• Repeated lumbar punctures may contribute to subsequent shunt infection 1
• Ventricular access devices require regular tapping, but there appears to be no increased risk of infection from repeated or daily aspiration when performed properly 1
• Preterm neonates are at high risk for both perinatal and treatment-related complications 3
• Without aggressive treatment of hydrocephalus, persistent ventricular dilation leads to poor outcomes 1

In conclusion, the management of neonates with IVH and PHH typically involves initial temporizing measures followed by permanent shunt placement when necessary. The decision-making process should be guided by clinical signs of increased intracranial pressure, with careful consideration of the risks and benefits of each intervention.