Authors: Thomas W. Larrew, MD
Despite advances in neonatal care, post-hemorrhagic hydrocephalus (PHH) remains the largest subtype of hydrocephalus in North America and accounts for a significant amount of morbidity and mortality in preterm infants. Protocols for temporizing treatment and the need for definitive cerebrospinal fluid (CSF) diversion vary dramatically. In this report, we describe findings using early ventricular access device (VAD) placement with prolonged VAD weaning instead of early shunting and the implications for permanent CSF diversion.Methods: Preterm infants with PHH with VADs between 2017-2021 were included. Weight-based VAD tapping protocol until 38 weeks gestational age (GA) was followed by weaning through decreasing VAD tap frequency. Wean success was ultrasound based using biventricular diameter (BVD) and third ventricle measurements. Definitive CSF diversion followed two unsuccessful wean attempts. Demographics, ventricle size, and outcomes were analyzed.
33 patients were included, 11 (33.3%) were weaned from VAD tapping, not requiring permanent CSF diversion. Successfully weaned patients trended towards older GA at birth (30.7 weeks vs 27.8 weeks) and at VAD placement (p=0.08 and 0.06 respectively). Although not statistically significant, patients not requiring definitive CSF diversion demonstrated smaller BVD at VAD placement and at 38 weeks GA and a greater decrease in BVD from tapping initiation to 38 weeks.
Patients historically who were shunted at a certain weight were able to be successfully weaned using prolonged weaning protocol. Non-modifiable factors (GA at birth) and modifiable (ventricular size and amount of decrease in ventricular size) may be predictive of successful weaning. This study demonstrates promising results yet more patients will improve our predictive ability.