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Objectives: The management of neonatal post-haemorrhagic hydrocephalus (nPHH) varies considerably between centres and even between neurosurgeons in the same centre. We performed a nationwide survey to evaluate current practice in the UK and reviewed the evidence for each intervention. Methods: An online semi-structured questionnaire was emailed to all units registered on the British Paediatric Neurosurgery Group Mailing List. The survey consisted of 18 questions designed to establish the status quo in the management of nPHH, including preferred temporising procedure, factors guiding the timing of intervention and willingness to participate in a prospective study. Results: A total of 24 consultants responded to the survey. Ventricular access device (VAD), trans-fontanelle tap, ventriculosubgaleal shunt (VSGS) and lumbar puncture (LP) were used by 33, 25, 17 and 17%, respectively, as the first temporising measure. Almost all reported that the timing of this intervention was guided by increasing head circumference and tense fontanelle. If the first temporising procedure fails, VAD, external ventricular drainage (EVD), trans-fontanelle tap, VSGS and other procedures (including ventriculoperitoneal (VP) shunting and endoscopic third ventriculostomy (ETV)) were performed by 42, 17, 13, 8 and 21%, respectively. Almost all respondents reported that VP shunting would be their preferred method of definitive cerebrospinal fluid (CSF) diversion. Almost all responded that they would be willing to participate in a prospective study in the future to determine best practice. Conclusion: As expected there was a significant heterogeneity between respondents in the initial management of nPHH in the UK. VAD was the most popular first and second choice temporising measure. On reviewing the literature, it is clear that more work still needs to be done to establish which temporising measure is best. There is willingness in the UK to participate in a study to help determine this.
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For Peer Review Only
Neonatal
post
-
haemorrhagic hydrocephalus in the UK: a
survey of current practice
Journal:
British Journal of Neurosurgery
Manuscript ID
CBJN-2016-0108
Manuscript Type:
Original Article
Date Submitted by the Author:
13-Apr-2016
Complete List of Authors:
Kumar, Naveen; King\'s College London School of Medical Education,
Faculty of Life Sciences and Medicine
Al-Faiadh, Wisam; King\'s College London School of Medical Education
Tailor, Jignesh; King\'s College Hospital, Department of Neurosurgery
Mallucci, Conor; Alder Hey Children’s Hospital,
Chandler, Christopher; Kings College Hospital, Department of Paediatric
Neurosurgery
Bassi, Sanjeev; King's College Hospital, Neurosurgery
pettorini, benedetta ludovica; alder hey foundation trust,
Zebian, Bassel; King\'s College Hospital, Department of Paediatric
Neurosurgery
Keywords:
Intraventricular haemorrhage, Hydrocephalus, Ventricular access device,
Ventriculosubgaleal shunt, External ventricular drain, Ventriculoperitoneal
shunt
URL: http://mc.manuscriptcentral.com/cbjn
British Journal of Neurosurgery
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Neonatal post-haemorrhagic hydrocephalus in the UK: a survey of current
practice
Naveen Kumar
a
, Wisam Al-Faiadh
a
, Jignesh Tailor
b
, Conor Mallucci
c
, Chris
Chandler
b
, Sanj Bassi
b
, Benedetta Pettorini
c
and Bassel Zebian
b
a
Faculty of Medicine, King’s College London;
b
Department of Neurosurgery, King’s College
Hospital, Denmark Hill, London SE5 9RS;
c
Department of Neurosurgery, Alder Hey
Children’s Hospital, Eaton Road, West Derby, Liverpool L12 2AP
Keywords: neonate, premature, preterm, intraventricular haemorrhage, hydrocephalus,
cerebrospinal fluid, ventricular tap, lumbar puncture, ventricular access device,
reservoir, ventriculosubgaleal shunt, external ventricular drain, ventriculoperitoneal
shunt, endoscopic third ventriculostomy
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Objectives: The management of neonatal posthaemorrhagic hydrocephalus (nPHH)
varies considerably between centres and even between neurosurgeons in the same
centre. We performed a nationwide survey to evaluate current practice in the UK and
reviewed the evidence for each intervention.
Methods: An online semi-structured questionnaire was emailed to all units registered
on the British Paediatric Neurosurgery Group Mailing List. The survey consisted of 18
questions designed to establish the status quo in the management of nPHH, including
preferred temporising procedure, factors guiding the timing of intervention and
willingness to participate in a prospective study.
Results: 24 consultants responded to the survey. Ventricular access device (VAD),
trans-fontanelle tap, ventriculosubgaleal shunt (VSGS) and lumbar puncture (LP) were
used by 33%, 25%, 17% and 17%, respectively, as the first temporising measure.
Almost all reported that the timing of this intervention was guided by increasing head
circumference and tense fontanelle. If the first temporising procedure fails, VAD,
external ventricular drainage (EVD), trans-fontanelle tap, VSGS and other procedures
(including ventriculoperitoneal (VP) shunting and endoscopic third ventriculostomy
(ETV)) were performed by 42%, 17%, 13%, 8% and 21%, respectively. Almost all
respondents reported that VP shunting would be their preferred method of definitive
cerebrospinal fluid (CSF) diversion. Almost all responded that they would be willing to
participate in a prospective study in the future to determine best practice.
Conclusion: As expected there was a significant heterogeneity between respondents in
the initial management of nPHH in the UK. VAD was the most popular first and
second choice temporising measure. On reviewing the literature, it is clear that more
work still needs to be done to establish which temporising measure is best. There is
willingness in the UK to participate in a study to help determine this.
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Introduction
Intraventricular haemorrhage (IVH) is diagnosed in about 25% of preterm and very low birth
weight (VLBW) infants
(1,2)
. The incidence is inversely proportional to gestational age and
weight. As a result of improvements in antenatal and perinatal care, the survival of preterm
and VLBW infants has increased
(3)
and therefore IVH remains a significant problem.
The origin of IVH is the germinal matrix, a subependymal proliferative region from which
both neuronal and glial cells migrate out during development. This area is especially
vulnerable to haemorrhage due to its fragile vasculature and relatively poor autoregulation in
response to low cardiac output and cerebral hypoperfusion
(4)
. The severity of germinal matrix
haemorrhage (GMH) is commonly described according to the Papile classification
(5)
. In
Grade I, the haemorrhage is restricted to the germinal matrix, with only minimal or no
involvement of the ventricles; in Grade II, there is filling of less than 50% of the ventricles,
without ventriculomegaly; in Grade III, there is filling of more than 50% of the ventricles,
often with ventriculomegaly; in Grade IV, there is parenchymal haemorrhage, with
periventricular venous infarction as a result of terminal venous occlusion. Higher grades of
IVH are associated with increased mortality and morbidity, including post-haemorrhagic
hydrocephalus (PHH).
Currently, the most effective definitive treatment for neonatal posthaemorrhagic
hydrocephalus (nPHH) remains ventriculoperitoneal shunting (VPS). However, it is
recognised that a minority of patients will not need definitive cerebrospinal fluid (CSF)
diversion and may benefit from temporising measures. It is also clear that failure rates of
definitive shunts are higher in the very young and very low birth weight neonates
(6)
. With
this in mind, many will initially treat nPHH with temporary CSF diversion before considering
permanent VPS. Temporising measures that have been reported include insertion of external
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ventricular drain (EVD), ventricular access device (VAD), ventriculosubgaleal shunt
(VSGS), and serial CSF aspiration via a trans-fontanelle tap or lumbar puncture. Some also
advocate endoscopic third ventriculostomy (ETV) with or without choroid plexus coagulation
(CPC) and others ventricular irrigation with fibrinolytic material
(7,8)
.
There is neither consensus nor evidence-based guidelines on best practice in the initial
management of nPHH and thus we suspected a large degree of variability in practice between
centres in the UK. Therefore, we conducted a survey of UK centres to define current practice.
We also reviewed the literature for evidence for the various treatment options.
Materials and method
An online semi-structured questionnaire was sent to all units registered on the British
Paediatric Neurosurgery Group mailing list. The questionnaire consisted of 18 questions
enquiring about current management of nPHH including the preferred temporising measure
used, demographic and clinical factors which guide management and willingness to
participate in a randomised control trial (Supplement 1). The questionnaire was designed to
establish the status quo of current practice rather than the opinions of individual clinicians.
Results
A total of 24 responses were received from consultants in 15 neurosurgical units. The
responses are summarised in Table 1.
Preferred temporising measure
Of the respondents, 8 (33%) listed VAD as their first choice temporising measure, 6 (25%)
listed trans-fontanelle tap, 4 (17%) listed VSGS, 4 (17%) listed LP, none listed EVD and 2
(8%) listed other (Figure 1). Twenty-three respondents (96%) reported that the timing of this
temporising intervention was guided by increasing head circumference, 22 (92%) were
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guided by a bulging or tense fontanelle, 20 (83%) by apnoeas or bradycardia, 19 (79%) by
sun-setting, 15 (63%) by lethargy or irritability and 5 (21%) by other factors, including
weight, increasing Ventricular Index, seizures and vomiting.
(Figure 1)
(Table 1)
If first measure fails
If the first temporising measure fails, 10 (42%) respondents answered that VAD would be
their next choice, 4 (17%) listed EVD, 3 (13%) listed trans-fontanelle ventricular tap, 2 (8%)
listed VSGS, none listed LP and 5 (21%) listed other (including VP shunt and ETV).
Definitive CSF diversion
If definitive CSF diversion is required, 21 (88%) responded that VPS was their preferred
procedure, whilst 3 (12%) listed ETV.
Most (17; 71%) reported that there was no minimum gestational age at which they would
attempt permanent CSF diversion. Of the remaining 7 respondents, 6 (86%) reported that
they would only perform the procedure on infants who had reached term, and one (14%)
reported 26/40 as the minimal gestational age. Nineteen (79%) of the 24 respondents gave a
minimum weight at which they would perform the procedure. Most specified a weight of
about 2kg and one specified a weight as low as 690g. Five (21%) replied that there was no
minimum weight at which they would perform permanent CSF diversion. Figure 2 shows that
the most common minimum weight was between 1500 and 2000 grams.
(Figure 2)
Eighteen (75%) reported that they used Bactiseal tubing and 6 (25%) used standard tubing for
their first definitive VPS.
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Number of temporising procedures performed per annum
Twelve consultants (50%) reported that they performed fewer than 5 temporising procedures
per year, 4 (17%) reported 5-10, 3 (13%) 10-15, and 4 (17%) performed more than 15. For 14
consultants (58%), this represented fewer than 5 patients, for 5 (21%) it was 5-10 patients, for
7 (29%) it was 10-15 patients and for 2 (8%) it was more than 15 patients.
Willingness to participate in a prospective trial
Most (21 consultants; 88%) would consider taking part in a prospective trial of the
commonest temporising procedures to establish best practice. Nineteen (79%) would be
prepared to randomise patients to different treatment arms.
Discussion
As suspected, there was a great deal of variation in the preferred temporising measure for the
management of nPHH in the UK.
LP/Ventricular Tap
The most common procedure was serial CSF tapping if lumbar punctures and trans-fontanelle
taps are combined. This was performed by 10 of the 24 consultants (42%). Six of the 10
preferred trans-fontanelle tap and 4 preferred LP. This may initially seem surprising, as four
randomised controlled trials have concluded that neither technique is effective in reducing
progression to VPS or disability or mortality when compared to conservative treatment
(9)
. A
Cochrane review confirmed this and additionally identified a 7% increased risk of CSF
infection in patients treated with serial CSF tapping
(9)
. Moreover, repeat trans-fontanelle
tapping results in parenchymal needle track injury and there is even a report of a traumatic
aneurysm of the pericallosal artery associated with a trans-fontanelle tap
(3)
. It has previously
been suggested that at least 10ml/kg/day of CSF needs to be tapped for at least 7 days for the
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treatment to reduce ventricular size effectively
(10)
.
VAD
Here we considered LP and trans-fontanelle tap separately, therefore, the most popular first-
and second-choice procedure was VAD. This is consistent with the trend reported in the US
(11)
, and seems a reasonable choice as it is, similarly to VSGS, a relatively effective procedure
with reasonably few complications
(12)
. Some retrospective studies have shown that insertion
of a VAD is associated with a lower incidence of VPS revision, possibly due to clearance of
blood products from the CSF as a result of repeated tapping
(13)
, although a number of others
have reported no significant difference
(14)
.
Although VAD represents a significant improvement on serial lumbar or ventricular tapping,
it is not without complications. Infection rate typically ranges between 6 and 10%
(15)
but has
been reported to be as high as 22%
(16)
. Other recognised complications include leaking of
CSF
(13)
and migration of the catheter or reservoir
(17)
.
VSGS
Another commonly performed temporising measure was VSGS. Those who advocate it
believe it is a more physiological alternative to VAD and EVD. CSF is diverted to a
subgaleal pocket, where some of it is resorbed, with decreased requirement for frequent
tapping. This is hypothesised to reduce intermittent build-up of ICP. As yet, there is little
class 1 evidence demonstrating improved outcome with the use of VSGS
(18)
. Some limited
studies have reported that VSGS reduces the need for permanent CSF diversion slightly
compared to VAD (66.7% vs 75.4%), although these have been small, single-institution
studies, which have failed to reach statistical significance
(19)
. Another associated benefit of
decreased frequency of tapping is the reduced risk of infection, which has been reported to be
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9.2% in a recent meta-analysis
(12)
. Fountain et al. performed a systematic review
(20)
comparing VAD with VSGS and found that the only significant difference is the reduced
requirement of CSF tapping in the VSGS group. They highlighted the lack of good quality
evidence and standardised criteria as well as the heterogeneity of cohorts with limited sample
size.
EVD
EVD was not the first choice temporising measure of any of the respondents, despite
evidence from a recent meta-analysis suggesting that treatment with EVD resulted in a higher
resolution (31.8%) of PHH compared with VAD (17.5%) and VSGS (13.9%). This reached
statistical significance in the comparison with VSGS
(12)
.
The rate of infection with EVD has variously been reported to range between 0%
(21)
and 22%
(22)
. Additionally, treatment with EVD leads to later VP shunt dependence in up to 68% of
patients
(23)
, possibly as a result of long-term inactivity of endogenous CSF resorption
mechanisms
(12)
. EVD is further limited by its potential to lead to overdrainage and the need
for the child to remain in a neurosurgical unit for the management of the EVD.
Definitive CSF diversion
Almost all participants stated that their first choice for definitive CSF diversion would be
VPS. This is still the most effective definitive treatment for nPHH, but is prone to failure and
frequent revision, particularly in patients of low gestational age and weight. An alternative
treatment is endoscopic third ventriculotomy (ETV) which is particularly effective in cases
where there may be congenital obstruction in the 3
rd
ventricular outflow in addition to nPHH
(24)
.
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Other techniques and future directions
One new and innovative technique piloted in Bristol, UK – the DRIFT (drainage, irrigation
and fibrinolytic therapy) trial – performed drainage of the intraventricular haemorrhage and
wash out of cytokines which have been associated with the pathogenesis of PHH, including
TGF-β1
(25)
. The initial results suggested that DRIFT was associated with reduced need for
permanent VPS
(25)
, but the most recent Class I evidence shows that the procedure does not
significantly reduce death nor progression to VPS, and is also associated with secondary IVH
in 35% of cases
(7)
. Despite this, at 2 year follow up, patients treated with DRIFT showed a
lower mortality and morbidity
(7)
. A DRIFT 2 trial is planned and has funding to test the
technique with a larger patient sample size.
This report has a number of strengths. It was compiled using data from a representative range
of regions in the UK with good response rates when units are considered, producing results
which are consistent with previous findings on the heterogeneity of procedures performed in
the management of nPHH. It also has a number of limitations, including the relatively poor
response rate of individual paediatric neurosurgical consultants. Additionally, the aim of the
study was to summarise the current practice in the UK and highlight a lack of consensus,
rather than to determine best practice.
Conclusion
In conclusion, these results highlight the wide variation in practice in a group of patients for
which, as yet, there is no consensus nor guidelines on the safest, most effective procedure.
Next steps could include support for specific national data collections and audits through a
UK working group, leading to appropriately designed, prospective, multicentre studies
producing evidence-based guidelines through agreed and accepted methods such as
systematic review of best evidence and Delphi consensus where it is lacking. There is
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willingness in the UK to participate in a randomised controlled trial to establish best practice.
Declaration of interest
The authors report no declaration of interest.
Acknowledgements
We are grateful to the fifteen institutions that responded to the survey as listed here: Addenbrooke’s
Hospital; Alder Hey Children’s Hospital; Birmingham Children’s Hospital; Bristol Children’s
Hospital; Children’s University Hospital, Temple Street; Great Ormond Street Hospital; James Cook
University Hospital; King’s College Hospital; Leeds General Infirmary; Royal Hospital for Sick
Children, Yorkhill, Glasgow; Sheffield Children’s Hospital; Southampton General Hospital; St
George’s Hospital, Tooting; The Royal Victoria Infirmary; University Hospital of Wales.
Figures
Figure 1: Frequency of first- and second-choice temporising procedures performed
Figure 2: Minimum weight reported for permanent CSF diversion
Tables
Table 1: Survey responses
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Zaben M, Finnigan A, Bhatti MI, Leach P. The initial neurosurgical interventions for the
treatment of posthaemorrhagic hydrocephalus in preterm infants: A focused
review. Br J Neurosurg. 2015.
16.
Richard E, Cinalli G, Assis D, Pierre-Kahn A, Lacaze-Masmonteil T. Treatment of post-
hemorrhage ventrciular dilatation with an Ommaya's reservoir: management and
outcome of 64 preterm infants. 2001; 17(6): p. 334-40.
17.
Speder B, Ketter G, Ernestus RI. Migration of a ventricular access device. Br J
Neurosurg. 2000; 14: p. 589-90.
18.
and current treatment concepts: A review. J Nurosurg Pediatr. 2012; 9(3).
19.
Limbrick DD, Mathur A, Johnston JM, Munro R, Sagar J, Inder T, et al. Neurosurgical
treatment of progressive posthemorrhagic ventricular dilation in preterm infants: a
10-year single-institution study. J Neurosurg Pediatrics. 2010; 6: p. 224-30.
20.
Fountain DM, Chari A, Allen D, James G. Comparison of the use of ventricular access
devices and ventriculosubgaleal shunts in posthaemorrhagic hydrocephalus:
systematic review and meta-analysis. Childs Nerv Syst. 2016 February; 32(2): p.
259-67.
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Cornips E, Van Calenbergh F, Plets C, Devlieger H, Casaer P. Use of external drainage
for posthemorrhagic hydrocephalus in very low birth weight premature infants.
Childs Nerv Syst. 1997; 1(7): p. 369-74.
22.
Dasic D, Hanna SJ, Bojanic S, Kerr RS. External ventricular drain infection: the effect of
a strict protocol on infection rates and a review of the literature. Br J
Neurosurgery. 2006; 20(5): p. 296-300.
23.
Rhodes TT, Edwards WH, Saunders RL, Harbaugh RE, Little CL, Morgan LJ, et al.
External ventricular drainage for intial treatment of neonatal posthemorrhagic
hydrocephalus: surgical and neurodevelopmental outcome. Pediatr Neurosci.
1987; 13(5): p. 255-62.
24.
Siomin V, Cinalli G, Grotenhuis A, Golash A, Oi S, Kothbauer K, et al. Endoscopic third
ventriculostomy in patients with cerebrospinal fluid infection and/or hemorrhage.
J Neurosurg. 2002; 97(3): p. 519-24.
25.
Whitelaw A, Pople I, Cherian S, Evans D, Thoreson M. Phase 1 trial of prevention of
hydrocephalus after intraventricular hemorrhage in newborn infants by drainage,
irrigation, and fibrinolytic therapy. Paediatrics. 2003; 111(4 Pt 1): p. 759-65.
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Figure 1: Frequency of first- and second-choice temporising procedures performed
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Figure 1: Minimum weight reported for permanent CSF diversion
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Table 1: Survey responses
Preferred
temporising
method
If the
first
measure
fails
Preferred
definitive
CSF
diversion
procedure
Min.
gestation
for
definitive
CSF
diversion
(weeks)
Min.
weight
for
definitive
CSF
diversion
(g)
Preferred
valve
Preferred
tubing
Number of
procedures
performed
per annum
Number
of
patients
per
annum
Willing to
participate
in
prospective
trial
Willing to
randomise
to
different
treatment
arms
1.
VSGS
EVD
VPS
37
1000
Miethke
4/24
Standard
>15
10-15
Yes
Yes
2.
VAD
EVD
ETV
36
2000
Delta
Neonatal
1.0
Bactiseal
<5
<5
Yes
Yes
3.
VAD
EVD
VPS
None
1800
Miethke
9/29
Bactiseal
10-15
10-15
Yes
Yes
4.
VAD
VSGS
ETV
None
1500
Codman
Micro
Bactiseal
<5
<5
Yes
Yes
5.
LP
VSGS
VPS
None
1200
Miethke
4/24
Bactiseal
5
-
10
5
-
10
Yes
Yes
6.
Tap
VAD
VPS
None
3000
Miethke Standard
5-10
5-10
Yes
Yes
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ProGav
7.
VSGS
Tap
VPS
37
1600
Medtronic
Ultrasmall
Neonatal
Bactiseal
10-15
10-15
Yes
Yes
8.
VSGS
Other
VPS
None
1500
OSVII
Bactiseal
<5
<5
Yes
Yes
9.
VAD
Other
(ETV)
VPS
37
2500
OSVII
Bactiseal
>15
>15
No
No
10.
VAD
VAD
VPS
None
1200
Delta
Neonatal
1.0
Bactiseal
<5
<5
Yes
No
11.
Other
Other
VPS
26
690
Valveless
Bactiseal
<5
<5
Yes
Yes
12.
Tap
VAD
VPS
36
1500
Pudenz
Medium
Bactiseal
<5
<5
Yes
Yes
1
3
.
VSGS
EVD
VPS
37
1000
Miethke
4/24
Standard
>15
10
-
15
Yes
Yes
14.
VAD
EVD
ETV
36
2000
Delta Bactiseal
<5
<5
Yes
Yes
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Neonatal
1.0
15.
VAD
EVD
VPS
None
1800
Miethke
9/29
Bactiseal
10-15
10-15
Yes
Yes
16
.
VAD
VSGS
ETV
None
1500
Codman
Micro
Bactiseal
<5
<5
Yes
Yes
17.
LP
VSGS
VPS
None
1200
Miethke
4/24
Bactiseal
5-10
5-10
Yes
Yes
18
.
Tap
VAD
VPS
None
3000
Miethke
ProGav
Standard
5
-
10
5
-
10
Yes
Yes
19.
VSGS
Tap
VPS
37
1600
Medtronic
Ultrasmall
Neonatal
Bactiseal
10-15
10-15
Yes
Yes
20
.
VSGS
Other
VPS
None
1500
OSVII
Bactiseal
<5
<5
Yes
Yes
21
.
VAD
Other
(ETV)
VPS
37
2500
OSVII
Bactiseal
>15
>15
No
No
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22.
VAD
VAD
VPS
None
1200
Delta
Neonatal
1.0
Bactiseal
<5
<5
Yes
No
23
.
Other
Other
VPS
26
690
Valveless
Bactiseal
<5
<5
Yes
Yes
24
.
Tap
VAD
VPS
36
1500
Pudenz
Medium
Bactiseal
<5
<5
Yes
Yes
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07/04/2014 00:48Neonatal Post-Haemorrhagic Hydrocephalus
Page 1 of 3https://docs.google.com/forms/d/1CTL3Ij518j9hME9l2Jojwm7U_AI0LluP4ecuyjFP1-M/printform
Neonatal Post-Haemorrhagic Hydrocephalus
* Required
1. What is your name? *
2. What country do you practice in? *
3. What hospital / unit do you practice in? *
4. What is your grade? *
Mark only one oval.
Consultant / attending
Registrar / resident
Other:
5. What is your preferred temporising measure if any (assuming child not ready/suitable for
permanent CSF diversion)? *
(due to age, birth weight, blood load and/or co-morbidities)
Mark only one oval.
LP
Trans-fontanelle tap
EVD
Reservoir/ventricular access device
Ventriculo-subgaleal shunt
Other:
6. What guides the timing of your temporising intervention? *
Check all that apply.
Increasing head circumference
Bulging/tense fontanelle
Apnoeas/bradycardias
Sunsetting
Lethargy/irritability
Other:
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Page 2 of 3https://docs.google.com/forms/d/1CTL3Ij518j9hME9l2Jojwm7U_AI0LluP4ecuyjFP1-M/printform
7. If the first measure fails what is your next measure? *
(assuming still not ready/suitable for permanent CSF diversion)
Mark only one oval.
LP
Trans-fontanelle tap
EVD
Reservoir/ventricular access device
Ventriculo-subgaleal shunt
Other:
8. If a definitive CSF diversion procedure is required, which is your preferred one? *
Mark only one oval.
Ventriculo-peritoneal shunt
Ventriculo-atrial shunt
Endoscopic third ventriculostomy
Other:
9. Do you have a minimum gestational age before attempting the permanent CSF diversion? *
Mark only one oval.
yes
no
10. If so, what age? *
11. Do you have a minimum weight before attempting the permanent CSF diversion? *
Mark only one oval.
yes
no
12. If so, what weight? *
(in grams)
13. Which valve do you use for the first definitive
shunt? *
(make and model and pressure setting and
whether fixed or programmable)
14. Which tubing? *
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Page 3 of 3https://docs.google.com/forms/d/1CTL3Ij518j9hME9l2Jojwm7U_AI0LluP4ecuyjFP1-M/printform
Powered by
Mark only one oval.
Standard
Bactiseal
Silver
15. Do you have an approximate number (per annum) of temporising procedures performed? *
(not the definitive shunts; if more than one type of procedure used please choose Other and if possible
include a breakdown)
Mark only one oval.
less than 5
5-10
10-15
more than 15
Other:
16. In how many patients (per annum)? *
Mark only one oval.
less than 5
5-10
10-15
more than 15
Other:
17. Would you consider taking part in a prospective trial of the commonest temporising
procedures to establish best practice? *
(a prospective database and data collection across multicenters)
Mark only one oval.
yes
no
18. Would you be prepared to randomise patients to different treatment arms? *
Mark only one oval.
yes
no
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... Neonatal IVH with consecutive hydrocephalus is a complex disease in respect to the fragile newborn mostly premature babies, which is not rarely accompanied with other relevant comorbidities. Previous surveys as well as the recent guidelines of the treatment of pediatric hydrocephalus have shown that no consistent treatment recommendations currently exist for the treatment of neonatal posthemorrhagic hydrocephalus (nPHH) [1][2][3]. The major aims of the neurosurgical treatment are to reduce secondary brain damage by stabilizing the hydrocephalus and avoiding treatment-related complications. ...
Article
Full-text available
Introduction The TROPHY registry has been established to conduct an international multicenter prospective data collection on the surgical management of neonatal intraventricular hemorrhage (IVH)-related hydrocephalus to possibly contribute to future guidelines. The registry allows comparing the techniques established to treat hydrocephalus, such as external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). This first status report of the registry presents the results of the standard of care survey of participating centers assessed upon online registration. Methods On the standard of treatment forms, each center indicated the institutional protocol of interventions performed for neonatal post-hemorrhagic hydrocephalus (nPHH) for a time period of 2 years (Y1 and Y2) before starting the active participation in the registry. In addition, the amount of patients enrolled so far and allocated to a treatment approach are reported. Results According to the standard of treatment forms completed by 56 registered centers, fewer EVDs (Y1 55% Y2 46%) were used while more centers have implemented NEL (Y1 39%; Y2 52%) to treat nPHH. VAD (Y1 66%; Y2 66%) and VSGS (Y1 42%; Y2 41%) were used at a consistent rate during the 2 years. The majority of the centers used at least two different techniques to treat nPHH (43%), while 27% used only one technique, 21% used three, and 7% used even four different techniques. Patient data of 110 infants treated surgically between 9/2018 and 2/2021 (13% EVD, 15% VAD, 30% VSGS, and 43% NEL) were contributed by 29 centers. Conclusions Our results emphasize the varying strategies used for the treatment of nPHH. The international TROPHY registry has entered into a phase of growing patient recruitment. Further evaluation will be performed and published according to the registry protocol.
... Ventricular access device (VAD) partly overcomes limits of EVD [17,18], but repeated tapping of the subcutaneous reservoir is burdened by ineluctable risk of infection and raises concerns on the alternate control of raised intracranial pressure. ...
Article
Full-text available
Background The optimal management of neonatal post-hemorrhagic hydrocephalus (PHH) is still debated, though several treatment options have been proposed. In the last years, ventriculosubgaleal shunt (VSgS) and neuroendosdcopic lavage (NEL) have been proposed to overcome the drawbacks of more traditional options, such as external ventricular drainage and ventricular access device. Methods We retrospectively reviewed neonates affected by PHH treated at our institution since September 2012 to September 2020. Until 2017 patients received VSgS as initial treatment. After the introduction of NEL, this treatment option was offered to patients with large intraventricular clots. After NEL, VSgS was always placed. Primary VSgS was reserved to patients without significant intraventricular clots and critically ill patients that could not be transferred to the operating room and undergo a longer surgery. Results We collected 63 babies (38 males and 25 females) with mean gestational age of 27.8 ± 3.8SD weeks (range 23–38.5 weeks) and mean birthweight of 1199.7 ± 690.6 SD grams (range 500–3320 g). In 6 patients, hemorrhage occurred in the third trimester of gestation, while in the remaining cases hemorrhage complicated prematurity. This group included 37 inborn and 26 outborn babies. Intraventricular hemorrhage was classified as low grade (I–II according to modified Papile grading scale) in 7 cases, while in the remaining cases the grade of hemorrhage was III to IV. Mean age at first neurosurgical procedure was 32.2 ± 3.6SD weeks (range 25.4–40 weeks). Death due to prematurity occurred in 5 patients. First-line treatment was VSgS in 49 patients and NEL in the remaining 14 cases. Mean longevity of VSgS was 30.3 days (range 10–97 days) in patients finally requiring an additional treatment of hydrocephalus. Thirty-two patients required one to three redo VSgS. Interval from initial treatment to permanent shunt ranged from 14 to 312 days (mean 70.9 days). CSF infection was observed in 5 patients (7.9%). Shunt dependency was observed in 51 out of 58 surviving patients, while 7 cases remained shunt-free at the last follow-up. Multiloculated hydrocephalus was observed in 14 cases. Among these, only one patient initially received NEL and was complicated by isolated trapped temporal horn. Conclusions VSgS and NEL are two effective treatment options in the management of PHH. Both procedures should be part of the neurosurgical armamentarium to deal with PHH, since they offer specific advantages in selected patients. A treatment algorithm combining these two options may reduce the infectious risk and the risk of multiloculated hydrocephalus.
... There is little consensus or standardisation of temporising procedure to perform with significant variation between surgeons and units. This is exemplified in a recent UK survey, which demonstrated a wide variation in practice where respondents noted a preference for VAD (33%), ventricular puncture (25%), VSGS (17%) or repeated lumbar puncture (17%) [24]. ...
Article
Full-text available
Advances in medical care have led to more premature babies surviving the neonatal period. In these babies, germinal matrix haemorrhage (GMH), intraventricular haemorrhage (IVH) and posthaemorrhagic ventricular dilatation (PHVD) are the most important determinants of long-term cognitive and developmental outcomes. In this review, we discuss current neurosurgical management of IVH and PHVD, including the importance of early diagnosis of PHVD, thresholds for intervention, options for early management through the use of temporising measures and subsequent definitive CSF diversion. We also discuss treatment options for the evolving paradigm to manage intraventricular blood and its breakdown products. We review the evidence for techniques such as drainage, irrigation, fibrinolytic therapy (DRIFT) and neuroendoscopic lavage in the context of optimising cognitive, neurodevelopmental and quality of life outcomes in these premature infants.
... Currently, no treatment has demonstrated improved clinical outcome in either adult or neonatal IVH. Current treatments focus on methods of CSF drainage to limit PHH [4,5]. While there is continued interest in the use of intraventricular thrombolytics to remove IVH, the recent large clot lysis: evaluation of accelerated resolution of intraventricular hemorrhage III (CLEAR III) trial in adult IVH, failed to show a significant benefit on neurological outcome with tissue plasminogen activator (tPA), although mortality was reduced [6]. ...
Article
Full-text available
Introduction - Intraventricular hemorrhage (IVH) affects both premature infants and adults. In both demographics, it has high mortality and morbidity. There is no FDA approved therapy that improves neurological outcome in either population highlighting the need for additional focus on therapeutic targets and treatments emerging from preclinical studies. Areas Covered – IVH induces both initial injury linked to the physical effects of the blood (mass effect) and secondary injury linked to the brain response to the hemorrhage. Preclinical studies have identified multiple secondary injury mechanisms following IVH, and particularly the role of blood components (e.g. hemoglobin, iron, thrombin). This review, with an emphasis on pre-clinical IVH research, highlights therapeutic targets and treatments that may be of use in prevention, acute care, or repair of damage. Expert Opinion – An IVH is a potentially devastating event. Progress has been made in elucidating injury mechanisms, but this has still to translate to the clinic. Some pathways involved in injury also have beneficial effects (coagulation cascade/inflammation). A greater understanding of the downstream pathways involved in those pathways may allow therapeutic development. Iron chelation (deferoxamine) is in clinical trial for intracerebral hemorrhage and preclinical data suggest it may be a potential treatment for IVH.
Article
Full-text available
Quality of medicinal product is an important facet throughout lifecycle owing to its importance as acceptance criteria at customer’s end. Drugs regulatory agencies have issued guidelines for quality risk evaluation, miti- gation and review management. Quality risk management has become an integral part of quality management system at manufacturing plants. Procedures for deviation control, change control, investigations of market complaints and batch failures are dealt with the principle of quality risk management at the manufacturing facility. The exploratory study shows a dearth of research on quality risk management during supply chain operation, however, a few study has been carried out by keeping financial risk into account. This study addresses the gap in literature on quality risk management during supply chain operations. There are cases of unresolved customer complaints and batch failures originated due to inadequacies during distribution of pharmaceutical products. In absence of established quality risk management system during product shipment, there is no effective preventive plan related to risk factors. A corollary of manufacturing quality risk management has been drawn to the distribution of pharmaceutical products through this study. The quality risk management during pharmaceutical distribution may be useful to avoid market complaints, drug recalls, and regulatory actions. This study produces one unique model solution for industry professionals and policymakers opening a scope to reduce the product rejection thereby paving the way for substantial business growth.
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Background: Although in recent years the percentage of preterm infants who suffer intraventricular haemorrhage (IVH) has reduced, posthaemorrhagic hydrocephalus (PHH) remains a serious problem with a high rate of cerebral palsy and no evidence-based treatment. Survivors often have to undergo ventriculoperitoneal shunt (VPS) surgery, which makes the child permanently dependent on a valve and catheter system. This carries a significant risk of infection and the need for surgical revision of the shunt. Repeated removal of cerebrospinal fluid (CSF) by either lumbar puncture, ventricular puncture, or from a ventricular reservoir in preterm babies with IVH has been suggested as a treatment to reduce the risk of PHH development. Objectives: To determine the effect of repeated cerebrospinal fluid (CSF) removal (by lumbar/ventricular puncture or removal from a ventricular reservoir) compared to conservative management, where removal is limited to when there are signs of raised intracranial pressure (ICP), on reduction in the risk of permanent shunt dependence, neurodevelopmental disability, and death in neonates with or at risk of developing posthaemorrhagic hydrocephalus (PHH). Search methods: We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE via PubMed (1966 to 24 March 2016), Embase (1980 to 24 March 2016), and CINAHL (1982 to 24 March 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs. Selection criteria: RCTs and quasi-RCTs that compared serial removal of CSF (via lumbar puncture, ventricular puncture, or from a ventricular reservoir) with conservative management (removing CSF only when there were symptoms of raised ICP). Trials also had to report on at least one of the specified outcomes of death, disability, or shunt insertion. Data collection and analysis: We extracted details of the participant selection, participant allocation and the interventions. We assessed the following outcomes: VPS, death, death or shunt, disability, multiple disability, death or disability, and CSF infection. We assessed the quality of the evidence using the GRADE approach. Main results: Four trials (five articles) met the inclusion criteria of this review; three were RCTs and one was a quasi-RCT; and included a total of 280 participants treated in neonatal intensive care units in the UK. The trials were published between 1980 and 1990. The studies were sufficiently similar regarding the research question they asked and the interventions that we could combine the trials to assess the effect of the intervention.Meta-analysis showed that the intervention produced no significant difference when compared to conservative management for the outcomes of: placement of hydrocephalus shunt (typical risk ratio (RR) 0.96, 95% confidence interval (CI) 0.73 to 1.26; 3 trials, 233 infants; I² statistic = 0%; moderate quality evidence), death (RR 0.88, 95% CI 0.53 to 1.44; 4 trials, 280 infants; I² statistic = 0%; low quality evidence), major disability in survivors (RR 0.98, 95% CI 0.81 to 1.18; 2 trials, 141 infants; I² statistic = 11%; high quality evidence), multiple disability in survivors (RR 0.9, 95% CI 0.66 to 1.24; 2 trials, 141 infants; I² statistic = 0%; high quality evidence), death or disability (RR 0.99, 95% CI 0.86 to 1.14; 2 trials, 180 infants; I² statistic = 0%; high quality evidence), death or shunt (RR 0.91, 95% CI 0.75 to 1.11; 3 trials, 233 infants; I² statistic = 0%; moderate quality evidence), and infection of CSF presurgery (RR 1.73, 95% CI 0.53 to 5.67; 2 trials, 195 infants; low quality evidence).We assessed the quality of the evidence as high for the outcomes of major disability, multiple disability, and disability or death. We rated the evidence for the outcomes of shunt insertion, and death or shunt insertion as of moderate quality as one included trial used an alternation method of randomisation. For the outcomes of death and infection of CSF presurgery, the quality of the evidence was low as one trial used an alternation method, the number of participants was too low to assess the objectives with sufficient precision, and there was inconsistency regarding the findings in the included trials regarding the outcome of infection of CSF presurgery. Authors' conclusions: There was no evidence that repeated removal of CSF via lumbar puncture, ventricular puncture or from a ventricular reservoir produces any benefit over conservative management in neonates with or at risk for developing PHH in terms of reduction of disability, death, or need for placement of a permanent shunt.
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INTRODUCTION: Ventricular access devices (VAD) and ventriculosubgaleal shunts (VSGS) are currently both used as temporising devices to affect CSF drainage in neonatal posthaemorrhagic hydrocephalus (PHH), without clear evidence of superiority of either procedure. In this systematic review and meta-analysis, we compared the VSGS and VAD regarding complication rates, ventriculoperitoneal shunt conversion and infection rates, and mortality and long-term disability. METHODS: The review was registered with the PROSPERO international prospective register of systematic reviews (registration number CRD42015019750) and was conducted in accordance with PRISMA guidelines. RESULTS AND CONCLUSIONS: The literature search of five databases identified 338 publications, of which 5 met the inclusion criteria. All were retrospective cohort studies (evidence class 3b and 4). A significantly lower proportion of patients with a VSGS required CSF tapping compared to patients with a VAD (log OR -4.43, 95 % CI -6.14 to -2.72). No other significant differences between the VAD and VSGS were identified in their rates of infection (log OR 0.03, 95 % CI -0.77 to 0.84), obstruction (log OR 1.25, 95 % CI -0.21 to 2.71), ventriculoperitoneal shunt dependence (log OR -0.06, 95 % CI -0.93 to 0.82), subsequent shunt infection (log OR 0.23, 95 % CI -0.61 to 1.06), mortality (log OR 0.37, 95 % CI -0.95 to 1.70) or long-term disability (p = 0.9). In all studies, there was a lack of standardised criteria, variations between surgeons in heterogeneous cohorts of limited sample size and a lack of neurodevelopmental follow-up. This affirms the importance of an ongoing multicentre, prospective pilot study comparing these two temporising procedures to enable a more robust comparison.
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OBJECT The optimal clinical management of intraventricular hemorrhage (IVH) and posthemorrhagic ventricular dilation (PHVD)/posthemorrhagic hydrocephalus (PHH) in premature infants remains unclear. A common approach involves temporary treatment of hydrocephalus in these patients with a ventriculosubgaleal shunt (VSGS), ventricular access device (VAD), or external ventricular drain (EVD) until it becomes evident that the patient needs and can tolerate permanent CSF diversion (i.e., ventriculoperitoneal shunt). The present systematic review and meta-analysis aimed to provide a robust and comprehensive summary of the published literature regarding the clinical outcomes and complications of these 3 techniques as temporizing measures in the management of prematurity-related PHVD/PHH. METHODS The authors searched MEDLINE, EMBASE, CINAHL, Google Scholar, and the Cochrane Library for studies published through December 2013 on the use of VSGSs, VADs, and/or EVDs as temporizing devices for the treatment of hydrocephalus following IVH in the premature neonate. Data pertaining to patient demographic data, study methods, interventions, and outcomes were extracted from eligible articles. For each of the 3 types of temporizing device, the authors performed meta-analyses examining 6 outcomes of interest, which were rates of 1) obstruction; 2) infection; 3) arrest of hydrocephalus (i.e., permanent shunt independence); 4) mortality; 5) good neurodevelopmental outcome; and 6) revision. RESULTS Thirty-nine studies, representing 1502 patients, met eligibility criteria. All of the included articles were observational studies; 36 were retrospective and 3 were prospective designs. Nine studies (n = 295) examined VSGSs, 24 (n = 962) VADs, and 9 (n = 245) EVDs. Pooled rates of outcome for VSGS, VAD, and EVD, respectively, were 9.6%, 7.3%, and 6.8% for obstruction; 9.2%, 9.5%, and 6.7% for infection; 12.2%, 10.8%, and 47.3% for revision; 13.9%, 17.5%, and 31.8% for arrest of hydrocephalus; 12.1%, 15.3%, and 19.1% for death; and 58.7%, 50.1%, and 56.1% for good neurodevelopmental outcome. CONCLUSIONS This study provides robust estimates of outcomes for the most common temporizing treatments for IVH in premature infants. With few exceptions, the range of outcomes was similar for VSGS, VAD, and EVD.
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We have performed brain scanning by computed tomography on 46 consecutive live-born infants whose birth weights were less than 1,500 gm; 20 of them had evidence of cerebral intraventricular hemorrhage. Nine of the 29 infants who survived had IVH. Four grades of IVH were identified. Grade I and II lesions resolved spontaneously, but there was prominence of the interhemispheric fissue on CT of the infants at six months of age. Hydrocephalus developed in infants with Grade III and IV lesions. Seven of the surviving infants with IVH did not have clinical evidence of hemorrhage. There were no significant differences between the infants with and without IVH in birth weight, gestational age, one- and five-minute Apgar scores, or the need for resuscitation at birth or for subsequent respiratory assistance.
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Background: Post-haemorrhagic hydrocephalus (PHH), a potential consequence of grade II-IV germinal matrix haemorrhage, remains a significant problem in premature infants with long-term neurodevelopmental disabilities and high mortality rates. Early ventriculoperitoneal shunt (VPS) insertion is associated with a high failure rate and many complications; hence, temporising measures are always instituted until the infant is mature (age and/or weight) enough. Methods: We have reviewed the recently available literature on the usefulness and complications of the initial measures used in the treatment of PHH; particularly, focusing on serial cerebrospinal fluid (CSF) tapping, external ventricular drainage (EVD), ventriculosubgaleal shunts (VSG), ventricular access devices (VADs), endoscopic third ventriculostomy (ETV) with and without coagulation of the choroid plexus. Results: Randomised controlled trials (RCTs) have failed to demonstrate a significant effect of serial lumbar punctures on the rates of morbidity, mortality or conversion to permanent VPS in the treatment of PHH. Retrospective studies, mostly with small patients' numbers, provide not only a considerable controversy regarding EVD, VSG, VADs and ETV usefulness in the management of PHH but also variable rates on their complications. None of these variables have, however, been tested using RCTs. Conclusion: There is no level-one evidence to support the superiority of any of the currently available temporising measures in the initial treatment of PHH over others. The need for such rigorous studies remains largely unmet. We feel that a UK multi-centre-RCT is paramount to provide neurosurgeons with the evidence needed to choose the best initial approach for PPH treatment, yet with minimal complications' rate.
Article
Object The objective of this systematic review and analysis was to answer the following question: What are the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants? Methods Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to PHH. Two hundred thirteen abstracts were reviewed, after which 98 full-text publications that met inclusion criteria that had been determined a priori were selected and reviewed. Results Following a review process and an evidentiary analysis, 68 full-text articles were accepted for the evidentiary table and 30 publications were rejected. The evidentiary table was assembled linking recommendations to strength of evidence (Classes I-III). Conclusions There are 7 recommendations for the management of PHH in infants. Three recommendations reached Level I strength, which represents the highest degree of clinical certainty. There were two Level II and two Level III recommendations for the management of PHH. Recommendation Concerning Surgical Temporizing Measures: I. Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of PHH. Clinical judgment is required. Level II, moderate degree of clinical certainty. Recommendation Concerning Surgical Temporizing Measures: II. The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs. Level II, moderate degree of clinical certainty. Recommendation Concerning Routine Use of Serial Lumbar Puncture: The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants. Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents: I. Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents. II. Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Level I, high clinical certainty. Recommendation Concerning Timing of Shunt Placement: There is insufficient evidence to recommend a specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Clinical judgment is required. Level III, unclear clinical certainty. Recommendation Concerning Endoscopic Third Ventriculostomy: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with posthemorrhagic hydrocephalus. Level III, unclear clinical certainty.
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Background: Although it has been possible to reduce the percentage of premature infants suffering intraventricular hemorrhage, posthemorrhagic hydrocephalus remains a serious problem without a good treatment. There is a high rate of cerebral palsy, and ventriculoperitoneal shunt surgery makes the child permanently dependent on the valve and catheter system. Shunt surgery cannot be carried out early because of the blood in the cerebrospinal fluid (CSF) and the brain may be subjected to periods of raised pressure. Early tapping of CSF by lumbar puncture or ventricular tap was suggested as a way of temporarily reducing pressure and removing blood and protein and thereby avoiding permanent hydrocephalus. Objectives: To determine whether repeated CSF tapping, by lumbar puncture or ventricular tap, reduced the risk of permanent shunt dependence, neurodevelopmental disability or death in neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus (PHH). This form of treatment was based on the hypothesis that repeated tapping removed protein and blood from the CSF, thus clearing obstruction from the channels of CSF absorption. Search strategy: Pediatric, Neurosurgical and General Medical Journals were handsearched from 1976 up to October 2000, as well as the Medline database (via PubMed) and the Cochrane Controlled Trials Register. Personal contacts were used. Selection criteria: Four controlled trials ( with five published papers) were identified, three being randomised and the fourth using alternative allocation. Two trials evaluated repeated lumbar punctures in neonates with intraventricular hemorrhage (IVH) and two trials evaluated repeated CSF tapping infants with IVH followed by progressive ventricular dilatation. Data collection and analysis: In addition to details of the patient selection and patient allocation, the interventions were extracted. The end-points examined were: ventriculoperitoneal shunt, death, disability, multiple disability and death or disability. Main results: The studies were sufficiently similar in the question they were asking and the interventions were sufficiently in common that they could be combined when assessing the effect of the intervention. When repeated CSF tapping was compared to conservative treatment, the relative risks for shunt placement, death, disability and multiple disability were very close to 1.0 with no statistically significant effect. There is also evidence that this form of treatment increased the risk of CSF infection. Reviewer's conclusions: Early repeated CSF tapping cannot be recommended for neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus.
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To treat progressive posthemorrhagic hydrocephalus we used early external ventricular drainage (EVD) in 14 premature infants. We think it is important that the catheters in these critically ill infants be inserted in the neonatal intensive care unit, allowing us to keep the infants in an extremely stable environment. Only after prolonged external ventricular drainage (on average 38.4 days) is a ventriculoperitoneal shunt considered, preferably when the child has reached a body weight of 2000 g. There were no infections or other severe drainage-related problems. We report mean daily EVD volumes (which are related to body weight) and EVD duration. The 14 patients included 9 who required permanent shunting. Comparing the mortality, morbidity and follow-up data to at least 3 months of age in this group with similar data for an earlier cohort treated with lumbar punctures and late permanent shunting, we demonstrate the safety of the policy we have recently adopted.
Article
Preterm infants are at risk for perinatal complications, including germinal matrix-intraventricular hemorrhage (IVH) and subsequent posthemorrhagic hydrocephalus (PHH). This review summarizes the current understanding of the epidemiology, pathophysiology, management, and outcomes of IVH and PHH in preterm infants. The MEDLINE database was systematically searched using terms related to IVH, PHH, and relevant neurosurgical procedures to identify publications in the English medical literature. To complement information from the systematic search, pertinent articles were selected from the references of articles identified in the initial search. This review summarizes the current knowledge regarding the epidemiology and pathophysiology of IVH and PHH, primarily using evidence-based studies. Advances in obstetrics and neonatology over the past few decades have contributed to a marked improvement in the survival of preterm infants, and neurological morbidity is also starting to decrease. The incidence of IVH is declining, and the incidence of PHH will likely follow. Currently, approximately 15% of preterm infants who suffer severe IVH will require permanent CSF diversion. The clinical presentation and surgical management of symptomatic PHH with temporary ventricular reservoirs (ventricular access devices) and ventriculosubgaleal shunts and permanent ventriculoperitoneal shunts are discussed. Preterm infants who develop PHH that requires surgical treatment remain at high risk for other related neurological problems, including cerebral palsy, epilepsy, and cognitive and behavioral delay. This review highlights numerous opportunities for further study to improve the care of these children. A better grasp of the pathophysiology of IVH is beginning to impact the incidence of IVH and PHH. Neonatologists conduct rigorous Class I and II studies to advance the outcomes of preterm infants. The need for well-designed multicenter trials is essential because of the declining incidence of IVH and PHH, variations in referral patterns, and neonatal ICU and neurosurgical management. Well-designed multicenter trials will eventually produce evidence to enable neurosurgeons to provide their smallest, most vulnerable patients with the best practices to minimize perioperative complications and permanent shunt dependence, and most importantly, optimize long-term neurodevelopmental outcomes.