Direct Ventriculoatrial Shunt Placement for Cerebrospinal Fluid Diversion in the Management of Posthemorrhagic Hydrocephalus: 2-Dimensional Operative Video

In infants born prematurely, the fragility of the germinal matrix vasculature and its lack of vessel autoregulation increase the risk of germinal matrix hemorrhage and consequent intraventricular hemorrhage (IVH).1 The incidence of IVH in preterm infants is estimated to be 12% in infants weighing under 1500 g at birth and higher than 20% in infants weighing under 1000 g.2 IVH grade IV represents germinal matrix hemorrhage extending into the brain parenchyma with ventricular dilation, and it is associated with a 28% risk of developing posthemorrhagic hydrocephalus.3,4 We report the case of a 1-year-old premature female infant born at 22 weeks and 400 g with grade IV IVH shortly after birth. She developed a progressive hydrocephalus with a frontal occipital horn ratio of 0.66 before her index surgery. An endoscopic third ventriculostomy was first attempted, but it failed, so a ventriculoperitoneal shunt was placed in the patient. Distal shunt catheter malfunction due to bowel perforation required removal of the ventriculoperitoneal shunt. Afterward, the patient had 2 additional failures of a ventriculoatrial shunt placement due to thrombosis and stenosis in both the internal jugular and subclavian veins. As a result, consent was obtained from the patient's mother, and the patient underwent a direct ventriculoatrial shunt by a lower partial sternotomy. The distal end of the catheter was tunneled to the chest soft tissue over the heart and secured in the right atrial appendage. The procedure did not have any complications, and the patient was discharged on postoperative day 12.