Shunt Surgery Indications in Neonates with Intraventricular Hemorrhage

Initial Management Approach

The American Academy of Neurosurgery recommends ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) as acceptable initial temporizing treatment options for posthemorrhagic hydrocephalus (PHH), with clinical judgment required to select the most appropriate option 1, 3
VSG shunts reduce the need for daily CSF aspiration compared with VADs and are preferred when frequent CSF drainage is anticipated 1, 4
VADs have been shown to reduce morbidity and mortality compared with EVDs in premature infants 1, 5
External ventricular drainage is effective in decreasing ventricular size in neonates with PHH 6
Serial lumbar punctures are NOT recommended as routine treatment to reduce shunt placement need or prevent hydrocephalus progression 4, 5

Progressive ventricular dilation despite temporizing measures is an indication for permanent shunt placement 1
Clinical signs of increased intracranial pressure, including bulging fontanelle, splayed cranial sutures, rapidly increasing head circumference, and neurological symptoms, are indications for permanent shunt placement 1, 7

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, 2
Clinical judgment is required regarding the optimal timing for permanent shunt placement 1, 2

Risk factors for requiring VP shunt include IVH grade, later estimated gestational age at birth, and age at time of IVH 8, 9

Intraventricular thrombolytic agents are NOT recommended to reduce shunt placement need in premature infants with PHH 4, 10
Acetazolamide and furosemide are NOT recommended as methods to reduce shunt placement need 4
There is insufficient evidence to recommend endoscopic third ventriculostomy (ETV) in premature infants with PHH 1

Approximately 50-90% of infants with PHH who undergo temporizing measures will eventually require permanent VP shunt placement 1
Shunt complications include infection and revision needs 1, 8
Careful consideration of infection risk is essential, as repeated LPs may contribute to subsequent shunt infection 5

For neonates with IVH associated with cerebral sinovenous thrombosis without significant hemorrhage, anticoagulation with unfractionated heparin or low-molecular-weight heparin may be considered 11
Supportive care including treatment of dehydration and anemia is reasonable in neonates with stroke-related IVH 11