Keywords
ventricular-peritoneal shunt - neurosurgery - pediatrics
Palavras-chave
derivação ventrículo-peritoneal - neurocirurgia - pediatria
Introduction
Postneurosurgical complications for ventricular-peritoneal shunt (VPS) placement are
frequent, especially in the pediatric population during the neonatal period.[1] It is fundamental to know the time of placement of shunt and the clinical manifestations
suggestive of potential complications, since these factors can help in an earlier
and efficient management of patients.[2]
The negative aspects of the VPS system are complications, especially those of a mechanical
nature, with valve malfunction representing the majority of cases.[1]
[3] Thus, the most common complications of VPS are obstruction, followed by infection
and catheter migration.[3]
[4]
The pediatric population undergoing VPS has more frequent complications than adults.[1] However, there are still few studies on the complications related to the immediate
postoperative period of VPS in newborns, especially those born in high-risk gestational
maternity referrals.
The present study aims to identify the factors related to the occurrence of complications
associated with postoperative neurosurgery for placement of VPS in pediatric patients
at the only public maternity specialized in high-risk gestation in the state of Sergipe,
Brazil.
Methods
We prospectively selected, between September/2018 and June/2019, newborns submitted
to neurosurgery for placement of VPS at the only public maternity unit specialized
in high-risk gestation in the state of Sergipe, Brazil. The exclusion criteria of
the study included previous neurosurgery procedure for the placement of ventricular
shunts and/or non-signing of the informed consent form by the patient's supervisors.
We analyzed factors related to the parents (age and previous history of other children
requiring ventricular diversion), prenatal (use of folic acid, gestational intercurrences
and maternal comorbidities), route of birth (route of birth and postpartum procedures),
neurosurgery (time of surgery, place of incision for VPS implantation, and intraoperative
complications) and postoperative (complications related to VPS, length of hospital
stay, and cephalic perimeter). These factors were associated with neurosurgery-related
complications for VPS placement.
The study uses the concept of adequate prenatal care adopted by the Ministry of Health,
Brazil.[5] The diagnosis of hydrocephalus was made by transfontanelle ultrasonography, and
a ventricular-cranial index above 0.15 was adopted as an abnormality.[6]
Data were systematized, analyzed, and described by absolute, relative and arithmetic
mean frequencies. The variables were analyzed by the Student t-test, adopting p < 0.05 as statistical significance. The research complies with all required ethical
principles and is approved by the Research Ethics Committee of the Universidade Federal
do Sergipe, under protocol 2.976.561.
Results
In the period seven patients were included in the study, all of them electively operated
for VPS placement. The indication of neurosurgery for placement of VPS in newborns
that were part of the study was hydrocephalus, confirmed by transfontanelle ultrasonography.
All neurosurgeries were performed by pediatric neurosurgeons, the valves used were
medium pressure and had the same model and manufacturer.
All mothers had single pregnancies, cesarean births, were multiparous, and had no
other children who required neurosurgery for VPS. The average maternal age was 27
years. Only one (14.28%) mother had a previous history of abortion. Most pregnant
women (n = 5; 71.42%) had adequate prenatal care.
Of the gestational complications and incidence of maternal prenatal diseases, the
most frequent was urinary tract infection, which was present in more than half of
the pregnant women (n = 04; 57.14%). In the prenatal period, no pregnant woman used alcohol or other drugs
and did not present serological alterations for syphilis, rubella, toxoplasmosis,
hepatitis, HIV, and cytomegalovirus.
Of the newborns who participated in the study, 03 (42.85%) were male and 04 (57.14%)
were female, as shown in [Table 1]. Newborns of pregnant women who did not receive folic acid supplementation during
pregnancy (n = 03; 42.85%) presented 1st minute Apgar < 7. Folic acid supplementation during pregnancy was considered a positive
influence factor in the 1st minute Apgar, showing statistical significance with p = 0.04 (p < 0.05). Newborns of pregnant women using folic acid had an average 1st minute Apgar score of 8.0, and a lack of folic acid resulted in newborns with an
average score of 4.3.
Table 1
Characteristics of newborns who underwent ventricular-peritoneal shunt neurosurgery
|
Variables
|
n
|
%
|
|
Gender
|
Female
|
3
|
42.85
|
|
Male
|
4
|
57.14
|
|
Gestational age
|
< 31 weeks
|
2
|
28.57
|
|
31–36 weeks
|
2
|
28.57
|
|
37–42 weeks
|
3
|
42.85
|
|
Weight
|
< 2,500 g
|
4
|
57.14
|
|
> 2,500 g
|
3
|
42.85
|
|
First minute Apgar
|
< 7
|
4
|
57.14
|
|
> 7
|
3
|
42.85
|
Of the newborns, 4 (57.14%) had a gestational age < 37 weeks. Hemorrhage due to prematurity
was the main etiology of hydrocephalus, and it was present in 3 preterm infants. Only
one premature newborn had the etiology of hydrocephalus as hydranencephaly. Results
are shown in [Table 2].
Table 2
Etiology of hydrocephalus of newborns who underwent ventricular-peritoneal shunt neurosurgery
|
Etiology of hydrocephalus
|
Gestational age (week)
|
n
|
%
|
|
Hydranencephaly
|
> 37
|
1
|
28.57
|
|
< 37
|
1
|
|
Myelomeningocele
|
> 37
|
2
|
28.57
|
|
Prematurity hemorrhage
|
< 37
|
3
|
42.85
|
The average age at which newborns underwent neurosurgery was 6.5 weeks of life (minimum
0 and maximum 14 weeks). The average time of neurosurgery was 1 h and 30 min (maximum
2 h and minimum 50 min). Most incisions for distal and proximal fixation of the VPS
catheter occurred in the transumbilical (n = 05; 71.42%) and parietal (n = 05; 71.42%) regions, respectively.
Although the incidence of hydrocephalus requiring VPS neurosurgery was higher in male
newborns, the postneurosurgical hospitalization time was higher in female newborns,
with the average number of days of hospitalization being 7.5 among boys and of 9.6
among girls. However, gender was not considered a risk factor for longer postoperative
hospital stay, with p = 0.5 (p > 0.05).
In addition, it was associated with gestational age, newborn weight, Apgar in the
1st minute and use of folic acid in pregnancy on the days of hospital stay after neurosurgery
for placing VPS, as shown in table 03. Although newborns younger than 37 weeks, with
a 1st minute Apgar score < 7 and weighing < 2,500 g have a higher average of postoperative
hospitalization, these factors do not represent a significant negative risk factor
for hospitalization after the neurosurgery.
Table 3
Factors related to the number of days of hospitalization after neurosurgery for ventricular-peritoneal
shunt
|
Variables
|
n
|
Average days of postoperative hospitalization
|
p-value[*]
|
|
Gestational age (weeks)
|
< 37
|
4
|
8.25
|
0.9
|
|
> 37
|
3
|
8.66
|
|
Birth weight (grams)
|
< 2,500
|
4
|
8.25
|
0.9
|
|
> 2,500
|
3
|
8.66
|
|
1° minute Apgar
|
< 7
|
4
|
10
|
0.2
|
|
> 7
|
3
|
6.3
|
|
Folic acid in pregnancy
|
Used
|
4
|
7
|
0.3
|
|
Did not use
|
3
|
10.3
|
*
p < 0.05 is considered statistical significance.
All newborns who underwent VPS also underwent postoperative antibiotic prophylaxis,
with intravenous cephalothin (1 g/10 ml) being the antibiotic used, according to maternity
standardization, from the first postoperative day. The duration of cephalothin use
was an average of 5.14 days (minimum of 3 and maximum of 6 days). In addition, prophylaxis
against intraoperative infections was performed in all neurosurgeries by vancomycin
irrigation of the VPS catheter.
The mean time of postoperative observation until hospital discharge was 8.4 days (minimum
of 4 and maximum of 14 days). During the postoperative observation, only 1 newborn
(14.28%) presented complication related to neurosurgery for placement of VPS. This
newborn was female, the only one with intraoperative intercurrent events and congenital
heart disease (the other newborns had no associated comorbidities). The complication
developed was cerebrospinal fluid infection, and the procedure adopted was the removal
of the VPS.
Discussion
Congenital or acquired childhood hydrocephalus represents a major medical and social
problem, and some studies attribute an incidence of 1 to 3 per 1,000 births only for
congenital or early onset hydrocephalus, to which are added the acquired hydrocephalus.[7] Other studies indicate that the congenital form occurs from 3 to 4 per 1,000 live
births.[8] However, not all patients with hydrocephalus will place a ventricular shunt, and
there is no consensus in the literature about the rate of hydrocephalus patients submitted
to neurosurgery for VPS implantation.[9]
Most of the patients with hydrocephalus undergoing VPS neurosurgery were boys, and
other published studies show a higher prevalence of hydrocephalus in boys.[2]
[10]
Folic acid supplementation showed no influence on the occurrence of hydrocephalus,
but studies indicated that folic acid supplementation during pregnancy reduces the
incidence of neural tube defects.[11] In the research, babies born to mothers who did not supplement with folic acid during
pregnancy had a 1st minute Apgar score < 7. This is the first scientific research that associates the
benefits of folic acid supplementation during pregnancy to better newborn Apgar score
values. Newborns of pregnant women using folic acid had an average 1st minute Apgar score of 8.0, and a lack of folic acid resulted in newborns with an
average score of 4.3.
In the current study, hemorrhage due to prematurity was the cause of hydrocephalus
in most preterm infants. Preterm neonates, especially those with < 32 weeks of gestation,
and birth weight <1,500 g, and very low birth weight infants are more likely to develop
intracranial hemorrhage, mainly from the germinative matrix, soon after birth or on
the 1st day after birth.[8]
There was no relationship between postneurosurgical complications for VPS implantation
and Apgar scores, birth weight, or gestational age, but some studies show that low
weight and prematurity are associated with increased incidence of hydrocephalus.[8]
[9]
[10] Although the incidence of hydrocephalus requiring VPS is higher in newborn boys,
the average length of hospitalization after neurosurgery was higher among newborn
girls.
In all neurosurgeries performed in the present study, the VPS catheter was flushed
with vancomycin, and antibiotic impregnation of the catheters may have been associated
with a reduction in infectious complications.[1]
Conclusion
Although the incidence of hydrocephalus requiring VPS is higher in newborn boys, the
average length of hospitalization after neurosurgery was higher among newborn girls.
Gestational < 37 weeks, 1st minute Apgar score < 7, and birth weight < 2,500 g did not represent a significant
negative risk factor for longer hospital stay after neurosurgery.
This is the first scientific research that associates the benefits of maternal supplementation
with folic acid during pregnancy to the better newborn Apgar score values. Folic acid
supplementation during pregnancy was considered a positive influence factor in the
1st minute Apgar score, showing statistical significance with p = 0.04 (p < 0.05).
Only one newborn developed complications after neurosurgery, the only one with an
associated comorbidity. However, further studies are needed to expand the sample size
and provide additional evidence on the risk factors related to complications of VPS
implantation in newborns.
This neurosurgical procedure in a high-risk maternity hospital contributed to the
early treatment of hydrocephalus, with patients undergoing VPS before the 4th month of life.
