HCP is an abnormal intraventricular collection of CSF in the brain caused by an increase in the rate of CSF formation or a reduced rate of CSF absorption. The management might be challenging. [9].
In the context of PIH cases, protinaceous CSF leads to reduction of CSF flow making (VPS) more prone to blockage[10]. A lot of therapeutic approaches are used which include temporary ways such as EVD, Ommaya reservoir, recurrent lumbar punctures or VSGS. Every therapeutic method has its benefits and drawbacks; to select the proper approach depends on various parameters, which include environmental, medical & patient factors [11].
We compared between VSGS and EVD for management of PIH in a study involving 42 randomized cases (n = 21 per group), group A: 21 patients operated by VSGS and group B; 21 patients operated by EVD. No significant differences were observed in age, gender distribution, or procedural causes between the two groups. Complications incidence did not significantly differ.
In harmony with our findings, Kitchen and his colleagues found that infection has been considered as the main complication of EVD up to 45% and this was accompanied by significant morbimortality, prolonged hospital stay, and increased financial burden [14]. Also, Amen et al., demonstrated the rate of infections and exposure in 20% of VSGS cases. VSGS obstructions and migrations were recorded in about 6% of their patients [12].
Sil and his colleagues recorded that blockage and infection were observed in 15% and 2% respectively of their 215 participants who had hydrocephalus of various causes, such as the PIH who underwent VSGS [10]. Even though certain researches recorded mild infection frequencies following VSGS (about 5%) [15], different researches recorded a higher incidence frequency (47.6%) [16]. It is important to consider that most of these researches were performed in the post hemorrhagic hydrocephalus patients instead of the PIH ones, aside from one study that included PIH cases and recorded a higher frequency in comparison with our study. In addition, it is of great importance to consider that the operation was conducted in an already contaminated field [16].
Our study showed that median duration was 65 days for group A versus 33 for group B with significant difference between the 2 groups. Amen et al., showed that the average duration of VSGS was thirty five days [12]. Such duration was in accordance with the one recorded by Tubbs et al., in 2003 which had an average value of thirty seven days [17]. Different researches recorded more prolonged durations 56 days, as recorded by Kariyattil and his colleagues applying VSGS in PIH cases [16].Additionally, Kutty et al study revealed an average duration of 40 days (range 20–60 days) until resolution of infection occurs [20]. An essential factor which enhances durability is the absorptive capacity of the subgaleal space and the formation of generous spaces during the dissection process [18].
The current study demonstrated a statistically significant higher frequency of PICU admission among group B than group A (80.9% versus 23.8%, respectively). Also, higher median hospital stay duration was detected among group B than group A (35 days versus 5 days for groups B & A, respectively). Hypothetically, EVD has been demonstrated to be accompanied by a higher possibility of infection in comparison with the VSGS, as EVD makes the CSF subjected to the external environment, and that was formerly verified by a lot of researches. Therefore, it leads to a consequent increase in the LOS due to the need for drain repositioning along with the increase in morbidities among ill neurosurgical patients [19].
On the other hand, Elzain et al., in 2022 evaluated 35 children (in Sudan) who were managed by EVD due to different cranial conditions. They have revealed that; one-third was admitted to the PICU. The longest LOS was 61 days with the mean duration of 3 weeks. Therefore, cases with EVD are favorably nursed in the ICU to avoid the device-associated complications, which include slippage, over-drainage, and different medical non-neurosurgical side effects [13].
No significant difference was detected between current studied groups in terms of revision frequency; 6 cases (28.6%) of group A versus 10 cases (47.6%) of group B need revision. Amen et al., found that 16 cases with VSGS (32%) needed shunt revision [12].
The current study illustrated no statistically significant difference between studied groups in terms of mortality rates with (33.3%) of cases died in group A versus 38.1% in group B. The primary cause of mortality was disease progression leading to uncontrolled infection and septicemia. Kutty et al study revealed that mortality was observed in 44.4% of patients with PIH[20]. Conversely, Elzain et al., in 2022 ten patients who underwent EVD (n = 10/35, 28.6%) died; 5 secondary to cardiac arrest; four secondary to sepsis; and one secondary to respiratory arrest [13].
Amen et al., showed that mortality was encountered in 4 cases (8%) owing to sepsis [12]. Death rates after VSGS is ranging from 9–20% and the majority of such cases died due to different complications instead of shunt-related ones [20].
Amen et al.reported that VSGS provides a lot of benefits compared to other transient approaches in PIH cases. It isn’t accompanied by fluid or electrolytes loss. Additionally, the closed drainage system doesn’t expose the CSF to the external environment which reduces the risk of infection. In addition, the time of the surgical approach was short, and most of patients were followed on at outpatient clinic. This was accompanied by a reduction in the LOS and decrease in socio-economic burden [12].
Additional data from different institutions are now required to elaborate on our results in such conditions. Data on the rates of infections associated with VSGS and EVD placement in developing nations are scant.