Medical Management of Neonatal Posthemorrhagic Hydrocephalus

The surgical management of pediatric hydrocephalus

The surgical management of hydrocephalus has undergone incredible changes over the past generation of neurosurgeons, including dramatic improvements in imaging, especially computed tomographic scanning and magnetic resonance imaging, and remarkably innovative advances in cerebrospinal fluid valve technology, complex computer models, and endoscopic equipment and techniques. In terms of overall patient outcomes, however, one could conclude that things are a little better, but "not much." This frustrating yet fascinating dichotomy between technological advancements and clinical outcomes makes hydrocephalus, first described by the ancients, as one of the most understated and complex disorders that neurosurgeons treat. The challenge to the next generation of neurosurgeons is to solve this vexing problem through better understanding of the basic science, improved computer models, additional technological advances, and, most importantly, a broad-based, concerted multidisciplinary attack on this disorder. This review focuses on the evolution of surgery for hydrocephalus over the last 30 years, the current state of the art of hydrocephalus treatment, and what appear to be the most promising future directions.

Accumulation of Transforming Growth Factor-β2 and Nitrated Chondroitin Sulfate Proteoglycans in Cerebrospinal Fluid Correlates with Poor Neurologic Outcome in Preterm Hydrocephalus

BACKGROUND

Progressive post-hemorrhagic hydrocephalus in preterm infants strongly predicts abnormal neurologic development, and often accompanies cystic periventricular leukomalacia (cPVL). Transforming growth factor-beta1 (TGF-beta1), associated with hydrocephalus, can upregulate the chondroitin sulfate proteoglycan (CSPG) synthesis. To date, CSPG and their nitrated metabolites (NT-CSPG) have not been evaluated in hydrocephalus.

OBJECTIVES

We hypothesized that TGF-beta1, TGF-beta2, CSPG, and NT-CSPG would accumulate in cerebrospinal fluid (CSF) in preterm hydrocephalus, and their concentrations would correlate with poor long-term outcomes.

METHODS

TGF-beta1, TGF-beta2, CSPG, and NT-CSPG concentrations in CSF were measured prospectively by ELISA in 29 preterm newborns with (n=22) or without (n=34) progressive post-hemorrhagic hydrocephalus, and correlated with progressive neonatal hydrocephalus and neurologic outcome. Only concentrations from each patient's initial CSF sample were used for statistical analysis.

RESULTS

Compared to neonates without hydrocephalus, CSF [TGF-beta1], [TGF-beta2], [CSPG] and [NT-CSPG] were significantly greater by >3-, >35-, >8-, and >3-fold, respectively. Unlike CSF [TGF-beta2] and [CSPG], [TGF-beta1] correlated with CSF [total protein]. Only CSF [NT-CSPG] correlated with cPVL. Unlike [TGF-beta2] or [CSPG], [NT-CSPG] correlation with preterm progressive post-hemorrhagic hydrocephalus (PPHH) was explained entirely by the presence of cPVL among these patients. [TGF-beta2] was >20-fold greater in preterm survivors who required a ventriculoperitoneal shunt for PPHH (n=9), as compared to survivors who did not require a shunt (n=2), or those without hydrocephalus (n=12). [TGF-beta2] and [NT-CSPG] correlated inversely with Bayley Index Scores (15.0 months median adjusted age).

CONCLUSIONS

This is the first report that [TGF-beta2], [CSPG], and [NT-CSPG], measured well before term, accumulate abnormally in preterm progressive post-hemorrhagic hydrocephalus CSF, and correlate with adverse neurologic outcome.

Use of a novel double-sandwich enzyme-linked immunosorbent assay method for assaying chondroitin sulfate proteoglycans that bear 3-nitrotyrosine core protein modifications, a previously unrecognized proteoglycan modification in hydrocephalus

3-Nitrotyrosine is a useful marker for nitric oxide-mediated tissue injury. However, which proteins are preferred peroxynitrite modification targets is unclear. Chondroitin sulfate proteoglycans (CSPGs) abnormally accumulate in cerebrospinal fluid of human neonates with hydrocephalus and may be a target for peroxynitrite modification. We examined (1). whether CSPG core protein can be modified by peroxynitrite in vitro; (2). to what degree in comparison to bovine serum albumin (BSA), the most commonly used nitrated protein standard; (3). whether nitrated CSPGs can be measured directly in biological samples; and (4). whether nitrated proteoglycan concentrations in cerebrospinal fluid correlate with disease. In vitro nitration of bovine aggrecan was performed by exposure to different peroxynitrite concentrations, and 3-nitrotyrosine products were measured. Bovine serum albumin (BSA) nitration was also performed in comparison. A larger percentage of tyrosine residues were nitrated in aggrecan than in BSA under all conditions tested. An enzyme-linked immunosorbent assay (ELISA) for 3-nitrotyrosine consistently overestimated aggrecan nitration when nitrated BSA was used as the standard. This is important as most current assays of nitration in biological samples use nitrated BSA as the standard. Therefore, if nitrated CPSGs were a substantial portion of the nitrated proteins in a sample, total nitrated protein content would be overestimated. Aggrecan retained its function of binding hyaluronic acid despite substantial nitration. A double-sandwich ELISA was developed for nitrated CSPGs in biological samples, using nitrated aggrecan as standard. [Nitrated CSPG] was found to be significantly elevated in preterm hydrocephalus cerebrospinal fluid (P<0.02), but correlated poorly with cerebrospinal fluid [nitric oxide] (P>0.069), suggesting that nitrated CSPG and NO levels may be independant markers of tissue injury. Peroxynitrite-mediated protein tyrosine nitration is a previously unrecognized modification of CSPGs, and may reflect level of brain injury in hydrocephalus.

Sodium channel-blocking agents are not of benefit to rats with kaolin-induced hydrocephalus

OBJECTIVE

Hydrocephalus causes damage to periventricular white matter at least in part through chronic ischemia. The sodium channel-blocking agents mexiletine and riluzole have been shown to be of some protective value in various models of neurological injury. We hypothesized that these agents would ameliorate the effects of experimental childhood-onset hydrocephalus.

METHODS

Hydrocephalus was induced in 4-week-old rats by injection of kaolin into the cisterna magna. Tests of cognitive and motor function were performed on a weekly basis. In a blinded and randomized manner, mexiletine (0.7, 7, or 42 mg/kg/d) or riluzole (1.4 or 13.6 mg/kg/d) was administered by osmotic minipump for 2 weeks, beginning 2 weeks after induction of hydrocephalus. The brains were then subjected to histopathological and biochemical analyses.

RESULTS

Compared with untreated hydrocephalic rats, neither mexiletine nor riluzole was associated with a protective effect on behavioral, structural, or biochemical abnormalities.

CONCLUSION

Protection of hydrocephalic brains through pharmacological sodium channel blockade is probably an approach not worth pursuing.

Posthemorrhagic hydrocephalus: a complication of intraventricular hemorrhage

SURVIVAL OF PREMATURE AND LOW birth weight (LBW) neonates has increased in the past decade, and it continues to improve with recent advances in neonatal care. The use of antenatal corticosteroids and surfactant has played a major role in the improved survival of these LBW infants. Stevenson and colleagues documented survival-to-discharge rates of 49 percent for infants weighing 501–750 gm at birth, 85 percent for those 751–1,000 gm, 93 percent for those 1,001–1,250 gm, and 96 percent for those 1,251–1500 gm. With increasing survival rates, developmental outcome remains a concern, particularly in the lowest birth weight groups. Approximately 32 percent of very low birth weight (VLBW) infants (defined as weighing 501–1,500 gm) show evidence of intracrenial hemorrhage.

Protective effect of nimodipine on behavior and white matter of rats with hydrocephalus

OBJECT

Hydrocephalus, a pathological dilation of the ventricles of the brain, causes damage to periventricular white matter, at least in part, through chronic ischemia. The authors tested the hypothesis that treatment with nimodipine, an L-type calcium channel-blocking agent with demonstrated efficacy in a range of cerebral ischemic disorders, would ameliorate the adverse effects of experimental hydrocephalus.

METHODS

Hydrocephalus was induced in 3-week-old rats by injection of kaolin into the cisterna magna. The rats were treated by continuous administration of nimodipine or control vehicle for 2 weeks, beginning 2 weeks after induction of hydrocephalus. During the treatment period, the animals underwent repeated tests of motor and cognitive behavior. At the end of the treatment period, the rat brains were analyzed by histopathological and biochemical means. Nimodipine treatment prevented the declines in motor and cognitive behavior that were observed in untreated control rats. During the treatment period, ventricular enlargement, determined by magnetic resonance imaging, was equal in the two groups, although the corpus callosum was thicker in the treated rats. Myelin content in white matter and synaptophysin content in gray matter, an indicator of synapses, did not differ.

CONCLUSIONS

The protective effect of nimodipine is most likely based on improved blood flow, although prevention of calcium influx-mediated proteolytic processes in axons cannot be excluded. Adjunctive pharmacological therapy may be beneficial to patients with hydrocephalus.

Sonographic assessment of posthemorrhagic ventricular dilatation

Sonography plays a key role in the initial evaluation and monitoring of ventricular dilatation in the newborn. The use of supplemental imaging approaches by the mastoid fontanelle and foramen magnum can help identify the cause and location of obstruction. Duplex Doppler of intracranial vessels during anterior fontanelle compression is a useful indicator of altered cranial compliance in these infants. Additional views of the thoracolumbar spine can help identify which infants will likely benefit from lumbar puncture for therapy of progressive ventricular dilatation.

Calcium-mediated proteolytic damage in white matter of hydrocephalic rats?

Hydrocephalus is a pathological dilatation of the cerebrospinal fluid (CSF)-containing ventricles of the brain. Damage to periventricular white matter is multifactorial with contributions by chronic ischemia and gradual physical distortion. Acute ischemic and traumatic brain injuries are associated with calcium-dependent activation of proteolytic enzymes. We hypothesized that hydrocephalus is associated with calcium ion accumulation and proteolytic enzyme activation in cerebral white matter. Hydrocephalus was induced in immature and adult rats by injection of kaolin into the cisterna magna and several different experimental approaches were used. Using the glyoxal bis (2-hydroxyanil) method, free calcium ion was detected in periventricular white matter at sites of histological injury. Western blot determinations showed accumulation of calpain I (mu-calpain) and immunoreactivity for calpain I was increased in periventricular axons of young hydrocephalic rats. Proteolytic cleavage of a fluorogenic calpain substrate was demonstrated in white matter. Immunoreactivity for spectrin breakdown products was detected in scattered callosal axons of young hydrocephalic rats. The findings support the hypothesis that periventricular white matter damage associated with experimental hydrocephalus is due, at least in part, to calcium-activated proteolytic processes. This may have implications for supplemental drug treatments of this disorder.