Clinical and Radiological Predictors of Ventriculoperitoneal Shunt Insertion in Myelomeningocele Patients
Keywords:Myelomeningocele, Hydrocephalus, Ventriculoperitoneal shunt, Chiari malformation type II, Cerebrospinal fluid, Intracranial pressure, Intra uterine myelomeningocele repair
BACKGROUND: Myelomeningocele (MMC) is one of the most common developmental anomalies of the CNS. Many of these patients develop hydrocephalus (HCP). The rate of cerebrospinal fluid diversion in these patients varies significantly in literature, from 52% to 92%. MMC repair conventionally occurs in the post-natal period. With the technological advances in surgical practice and fetal surgeries, intra uterine MMC repair IUMR is adopted in some centers. Cerebrospinal fluid shunting has numerous complications, most notably shunt failure and shunt infection. Studies have suggested that patients with greater numbers of shunt revisions have poorer performance on neuropsychological testing. There is also good evidence to suggest that the IQs of patients with MMC who do not undergo shunt placement are higher than that of their shunt treated counterparts.
AIM: In this study, we are trying to identify strong clinical and radiological predictors for the need of ventriculoperitoneal (VP) shunt insertion in patients with MMC who underwent surgical repair and closure of the defect initially. This will decrease the overall rate of shunt placement in this group of patients through applying a strict policy adopting only shunt insertion for the desperately needing patient.
METHODS: Prospective clinical study conducted on 96 patients with MMC presented to Aboul Reish Pediatric Specialized Hospital, Cairo University. After confirming the diagnosis through clinical and radiological aids, patients are carefully examined, if HCP is evident clinically and radiologically a shunt is inserted together with MMC repair at the same session after excluding sepsis or cerebrospinal fluid (CSF) infection, (GROUP A). If there are no signs of increased ICP, MMC repair shall be done alone (GROUP B). Those patients shall be monitored carefully postoperatively and after discharge and shall be followed up regularly to early detect and promptly manage latent HCP. Multiple clinical and radiological indices were used throughout the follow-up period and statistical significance of each was measured.
RESULTS: Shunt placement was required in 45 (46.88%) of the 96 patients. Eighteen patients (18.75%) needed the shunt as soon as they presented to us (GROUP A), because they were having clinically active HCP. Twenty-seven (28.13%) patients were operated on by MMC repair initially without shunt placement because they did not have signs of increased ICP at the time of presentation. Yet, they developed latent HCP requiring shunt placement during the follow-up period (GROUP B2). Fifty-one patients of the study population (53.13%) underwent surgical repair of the MMC without the need of further VP insertion and they were followed up for 6 months period after the repair without developing latent HCP (GROUP B1). Patients of GROUP B were the study population susceptible for the development of latent HCP. Out of 78 patients in GROUP B, only 27 patients (34.62%) needed a VP shunt.CONCLUSION: In our study, we found that the rate of shunt insertion in patients with MMC is lower than the previously reported rate in the literature. A more thorough evaluation of the patient’s post-operative need for a shunt is mandatory. We suggest that we could accept postoperative (after MMC repair) ventriculomegaly provided it does not mean any deterioration in the patient’s clinical or developmental state. We assume that reduction of shunt insertion rate will eventually reduce what has previously been an enormous burden for a significant proportion of children with MMC.
Plum Analytics Artifact Widget Block
Chakraborty A, Crimmins D, Hayward R, Thompson D. Toward reducing shunt placement rates in patients with myelomeningocele. J Neurosurg Pediatr. 2008;1(5):361-5. https://doi.org/10.3171/ped/2008/1/5/361 PMid:18447669
Tulipan N, Sutton LN, Bruner JP, Cohen BM, Johnson M, Adzick NS. The effect of intrauterine myelomeningocele repair on the incidence of shunt-dependent hydrocephalus. Pediatr Neurosurg. 2003;38(1):27-33. https://doi.org/10.1159/000067560 PMid:12476024
Dennis M, Landry SH, Barnes M, Fletcher JM. A model of neurocognitive function in spina bifida over the life span. J Int Neuropsychol Soc. 2006;12:285-96. https://doi.org/10.1017/s1355617706060371 PMid:16573862
Mapstone TB, Rekate HL, Nulsen FE, Dixon MS Jr., Glaser N, Jaffe J. Relationship of CSF shunting and IQ in children with myelomeningocele: A retrospective analysis. Pediatr Neurosurg. 1984;11(2):112-8. https://doi.org/10.1159/000120166 PMid:6723425
Davis BE, Daley CM, Shurtleff DB, Duguay S, Seidel K, Loeser JD, et al. Long-term survival of individuals with myelomeningocele. Pediatr Neurosurg. 2005;41(4):186-91. https://doi.org/10.1159/000086559 PMid:16088253
Tuli S, Tuli J, Drake J, Spears J. Predictors of death in pediatric patients requiring cerebrospinal fluid shunts. J Neurosurg Pediatr. 2004;100(5):442-6. https://doi.org/10.3171/ped.2004.100.5.0442 PMid:15287452
Hunt GM, Oakeshott P, Kerry S. Link between the CSF shunt and achievement in adults with spina bifida. J Neurol Neurosurg Psychiatry. 1999;67(5):591-5. https://doi.org/10.1136/jnnp.67.5.591 PMid:10519863
Iskandar BJ, Tubbs S, Mapstone TB, Grabb PA, Bartolucci AA, Jerry Oakes W. Death in shunted hydrocephalic children in the 1990s. Pediatr Neurosurg. 1998;28(4):173-6. https://doi.org/10.1159/000028644 PMid:9732242
Sankhla S, Khan GM. Reducing CSF shunt placement in patients with spinal myelomeningocele. J Pediatr Neurosci. 2009;4(1):2-9. https://doi.org/10.4103/1817-1745.49098 PMid:21887167
Sutton LN. Fetal surgery for neural tube defects. Best Pract Res Clin Obstetr Gynaecol. 2008;22(1):175-88. https://doi.org/10.1016/j.bpobgyn.2007.07.004 PMid:17714997
Tulipan N, Wellons JC III, Thom EA, Gupta N, Sutton LN, Burrows PK, et al. Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement. J Neurosurg Pediatr. 2015;16(6):613-20. https://doi.org/10.3171/2015.7.peds15336 PMid:26369371
Steinbok P, Irvine B, Douglas Cochrane D, Irwin BJ. Long-term outcome and complications of children born with meningomyelocele. Childs Nerv Syst. 1992;8(2):92-6. https://doi.org/10.1007/bf00298448 PMid:1591753
Bowman RM, McLone DG, Grant JA, Tomita T, Ito JA. Spina bifida outcome: A 25-year prospective. Pediatr Neurosurg. 2001;34(3):114-20. https://doi.org/10.1159/000056005 PMid:11359098
Caldarelli M, Di Rocco C, La Marca F. Shunt complications in the first postoperative year in children with meningomyelocele. Childs Nerv Syst. 1996;12(12):748-54. https://doi.org/10.1007/bf00261592 PMid:9118142
Tamburrini G, Frassanito P, Iakovaki K, Pignotti F, Rendeli C, Murolo D, et al. Myelomeningocele: The management of the associated hydrocephalus. Childs Nerv Syst. 2013;29(9):1569-79. https://doi.org/10.1007/s00381-013-2179-4 PMid:24013327
Phillips BC, Gelsomino M, Pownall AL, Ocal E, Spencer HJ, O’Brien MS, et al. Predictors of the need for cerebrospinal fluid diversion in patients with myelomeningocele. J Neurosurg Pediatr. 2014;14(2):167-72. https://doi.org/10.3171/2014.4.peds13470 PMid:24877604
Norkett W, McLone DG, Bowman R. Current management strategies of hydrocephalus in the child with open spina bifida. Top Spinal Cord Inj Rehabil. 2016;22(4):241-6. https://doi.org/10.1310/sci2204-241 PMid:29339864
Khan B, Hamayun S, Haqqani U, Khanzada K, Ullah S, Khattak R, et al. Early complications of ventriculoperitoneal shunt in pediatric patients with hydrocephalus. Cureus. 2021;13(2):e13506. https://doi.org/10.7759/cureus.13506 PMid:33786215
How to Cite
Copyright (c) 2020 Ahmed M. F. El Ghoul, Ahmed Hamdy Ashry, Mohamed Hamdy El-Sissy , Ibrahim Mohamed Ibrahim Lotfy (Author)
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.
All rights reserved.