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Musiime GM, Mohammad K, Momin S, Kwong GPS, Riva-Cambrin J, Scott J, Zein H, Hendson L, Leijser LM. Prediction of post-hemorrhagic ventricular dilatation trajectory using a growth mixture model in preterm infants. Pediatr Res 2024:10.1038/s41390-024-03396-w. [PMID: 38982166 DOI: 10.1038/s41390-024-03396-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 06/20/2024] [Accepted: 06/25/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Early intervention for post-hemorrhagic ventricular dilatation (PHVD), guided by ventricular size measurements from cranial ultrasound (cUS), is associated with improved neurodevelopmental outcomes in preterm infants but benefits must be balanced against intervention risks. METHODS Anterior horn width (AHW) and ventricular index (VI) were measured from cUS for preterm infants (<29 weeks) with intraventricular hemorrhage admitted from 2010-2018. PHVD was defined as AHW > 6 mm or VI >97th percentile for postmenstrual age. Individual ventricular size trajectories were plotted, and a growth mixture model (GMM) used to identify latent trajectory classes and compare these to predetermined outcome of neurosurgical intervention. RESULTS Measurements were obtained from 1543 cUS in 249 infants, of whom 39 had PHVD without and 17 PHVD with neurosurgical intervention based on signs of raised intracranial pressure. The GMM predicted trajectory identified: 93.3% of infants without PHVD, 88.2% and 30.8% of infants with PHVD with and without intervention using AHW; 100% of infants without PHVD, 52.9% and 59.0% of infants with PHVD with and without intervention using VI. CONCLUSIONS The AHW GMM identified a significant proportion of infants with severe PHVD. Model refinement offers a promising approach for identifying differences in PHVD trajectory at an early stage to guide management. IMPACT It is difficult to distinguish the trajectory of PHVD in the early stage of development, in particular PHVD that spontaneously arrests from slowly progressive PHVD which eventually requires intervention. We report the first modeling-based evaluation of PHVD trajectory for the prediction of short-term outcome of PHVD progression and neurosurgical intervention. With additional clinical validation and optimization to increase accuracy, predictive modeling has the potential to identify important differences in PHVD trajectory at an early stage in the clinical course, allowing for more individualized data-driven risk-benefit assessments to guide decisions on early intervention.
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Affiliation(s)
- Grace M Musiime
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Khorshid Mohammad
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Sarfaraz Momin
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Grace P S Kwong
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
- Department of Community Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Faculty of Veterinary Medicine, University of Calgary, Calgary, AB, Canada
| | - Jay Riva-Cambrin
- Division of Neurosurgery, Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - James Scott
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Hussein Zein
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Leonora Hendson
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada
| | - Lara M Leijser
- Department of Pediatrics, Section of Newborn Critical Care, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, AB, Canada.
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada.
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Wassef CE, Thomale UW, LoPresti MA, DeCuypere MG, Raskin JS, Mukherjee S, Aquilina K, Lam SK. Experience in endoscope choice for neuroendoscopic lavage for intraventricular hemorrhage of prematurity: a systematic review. Childs Nerv Syst 2024:10.1007/s00381-024-06408-6. [PMID: 38801444 DOI: 10.1007/s00381-024-06408-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2024] [Accepted: 04/13/2024] [Indexed: 05/29/2024]
Abstract
OBJECTIVE Intraventricular hemorrhage (IVH) of prematurity occurs in 20-38% of infants born < 28 weeks gestational age and 15% of infants born in 28-32 weeks gestational age. Treatment has evolved from conservative management and CSF diversion of temporizing and shunting procedures to include strategies aimed at primarily clearing intraventricular blood products. Neuroendoscopic lavage (NEL) aims to decrease the intraventricular blood burden under the same anesthetic as temporizing CSF diversion measures in cases of hydrocephalus from IVH of prematurity. Given the variety of neuroendoscopes, we sought to review the literature and practical considerations to help guide neuroendoscope selection when planning NEL. METHODS We conducted a systematic review of the literature on neuroendoscopic lavage in IVH of prematurity to examine data on the choice of neuroendoscope and outcomes regarding shunt rate. We then collected manufacturer data on neuroendoscopic devices, including inflow and outflow mechanisms, working channel specifications, and tools compatible with the working channel. We paired this information with the advantages and disadvantages reported in the literature and observations from the experiences of pediatric neurosurgeons from several institutions to provide a pragmatic evaluation of international clinical experience with each neuroendoscope in NEL. RESULTS Eight studies were identified; four neuroendoscopes have been used for NEL as reported in the literature. These include the Karl Storz Flexible Neuroendoscope, LOTTA® system, GAAB system, and Aesculap MINOP® system. The LOTTA® and MINOP® systems were similar in setup and instrument options. Positive neuroendoscope features for NEL include increased degrees of visualization, better visualization with the evolution of light and camera sources, the ability to sterilize with autoclave processes, balanced inflow and outflow mechanisms via separate channels, and a working channel. Neuroendoscope disadvantages for NEL may include special sterilization requirements, large outer diameter, and limitations in working channels. CONCLUSIONS A neuroendoscope integrating continuous irrigation, characterized by measured inflow and outflow via separate channels and multiple associated instruments, appears to be the most commonly used technology in the literature. As neuroendoscopes evolve, maximizing clear visualization, adequate inflow, measured outflow, and large enough working channels for paired instrumentation while minimizing the footprint of the outer diameter will be most advantageous when applied for NEL in premature infants.
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Affiliation(s)
- Catherine E Wassef
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Ulrich W Thomale
- Pediatric Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Melissa A LoPresti
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, USA
| | - Michael G DeCuypere
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jeffrey S Raskin
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Shreya Mukherjee
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Kristian Aquilina
- Department of Pediatric Neurosurgery, Great Ormond Street Hospital, London, UK
| | - Sandi K Lam
- Division of Pediatric Neurosurgery, Lurie Children's Hospital, 225 E Chicago Ave, Box 28, Chicago, IL, 60611, USA.
- Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
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3
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Kahle KT, Klinge PM, Koschnitzky JE, Kulkarni AV, MacAulay N, Robinson S, Schiff SJ, Strahle JM. Paediatric hydrocephalus. Nat Rev Dis Primers 2024; 10:35. [PMID: 38755194 DOI: 10.1038/s41572-024-00519-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/11/2024] [Indexed: 05/18/2024]
Abstract
Hydrocephalus is classically considered as a failure of cerebrospinal fluid (CSF) homeostasis that results in the active expansion of the cerebral ventricles. Infants with hydrocephalus can present with progressive increases in head circumference whereas older children often present with signs and symptoms of elevated intracranial pressure. Congenital hydrocephalus is present at or near birth and some cases have been linked to gene mutations that disrupt brain morphogenesis and alter the biomechanics of the CSF-brain interface. Acquired hydrocephalus can develop at any time after birth, is often caused by central nervous system infection or haemorrhage and has been associated with blockage of CSF pathways and inflammation-dependent dysregulation of CSF secretion and clearance. Treatments for hydrocephalus mainly include surgical CSF shunting or endoscopic third ventriculostomy with or without choroid plexus cauterization. In utero treatment of fetal hydrocephalus is possible via surgical closure of associated neural tube defects. Long-term outcomes for children with hydrocephalus vary widely and depend on intrinsic (genetic) and extrinsic factors. Advances in genomics, brain imaging and other technologies are beginning to refine the definition of hydrocephalus, increase precision of prognostication and identify nonsurgical treatment strategies.
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Affiliation(s)
- Kristopher T Kahle
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA.
- Broad Institute of Harvard and MIT, Cambridge, MA, USA.
- Department of Neurosurgery and Division of Genetics and Genomics, Boston Children's Hospital, Boston, MA, USA.
| | - Petra M Klinge
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Jenna E Koschnitzky
- Department of Neurosurgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, USA
| | - Abhaya V Kulkarni
- Division of Paediatric Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Nanna MacAulay
- Department of Neuroscience, University of Copenhagen, Copenhagen, Denmark
| | - Shenandoah Robinson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Paediatrics, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Steven J Schiff
- Department of Neurosurgery, Yale University, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale University, New Haven, CT, USA
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University School of Medicine, Saint Louis, MO, USA
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4
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Sewell E, Cohen S, Zaniletti I, Couture D, Dereddy N, Coghill CH, Flanders TM, Foy A, Heuer GG, Jano E, Kemble N, Lee S, Ling CY, Malaeb S, Mietzsch U, Ocal E, Padula MA, Welch CD, White B, Wilson D, Flibotte J. Surgical interventions and short-term outcomes for preterm infants with post-haemorrhagic hydrocephalus: a multicentre cohort study. Arch Dis Child Fetal Neonatal Ed 2024:fetalneonatal-2024-327084. [PMID: 38697810 DOI: 10.1136/archdischild-2024-327084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 04/17/2024] [Indexed: 05/05/2024]
Abstract
OBJECTIVE To (1) describe differences in types and timing of interventions, (2) report short-term outcomes and (3) describe differences among centres from a large national cohort of preterm infants with post-haemorrhagic hydrocephalus (PHH). DESIGN Cohort study of the Children's Hospitals Neonatal Database from 2010 to 2022. SETTING 41 referral neonatal intensive care units (NICUs) in North America. PATIENTS Infants born before 32 weeks' gestation with PHH defined as acquired hydrocephalus with intraventricular haemorrhage. INTERVENTIONS (1) No intervention, (2) temporising device (TD) only, (3) initial permanent shunt (PS) and (4) TD followed by PS (TD-PS). MAIN OUTCOME MEASURES Mortality and meningitis. RESULTS Of 3883 infants with PHH from 41 centres, 36% had no surgical intervention, 16% had a TD only, 19% had a PS only and 30% had a TD-PS. Of the 46% of infants with TDs, 76% were reservoirs; 66% of infants with TDs required PS placement. The percent of infants with PHH receiving ventricular access device placement differed by centre, ranging from 4% to 79% (p<0.001). Median chronological and postmenstrual age at time of TD placement were similar between infants with only TD and those with TD-PS. Infants with TD-PS were older and larger than those with only PS at time of PS placement. Death before NICU discharge occurred in 12% of infants, usually due to redirection of care. Meningitis occurred in 11% of the cohort. CONCLUSIONS There was significant intercentre variation in rate of intervention, which may reflect variability in care or referral patterns. Rate of PS placement in infants with TDs was 66%.
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Affiliation(s)
- Elizabeth Sewell
- Pediatrics, Emory University School of Medicine, Atlanta, Georgia, USA
- Children's Healthcare of Atlanta at Egleston, Atlanta, Georgia, USA
| | - Susan Cohen
- University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | | | - Dan Couture
- Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Narendra Dereddy
- AdventHealth for Children, Orlando, Florida, USA
- University of Central Florida College of Medicine, Orlando, Florida, USA
| | - Carl H Coghill
- Children's of Alabama, Birmingham, Alabama, USA
- The University of Alabama at Birmingham Heersink School of Medicine, Birmingham, Alabama, USA
| | - Tracy M Flanders
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew Foy
- University of Wisconsin-Milwaukee, Milwaukee, Wisconsin, USA
| | - Gregory G Heuer
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Eni Jano
- Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Nicole Kemble
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Stephanie Lee
- University of Iowa Health Care, Iowa City, Iowa, USA
| | - Con Yee Ling
- The University of Utah School of Medicine, Salt Lake City, Utah, USA
- Primary Children's Hospital, Salt Lake City, Utah, USA
| | - Shadi Malaeb
- Drexel University College of Medicine, Philadelphia, Pennsylvania, USA
| | - Ulrike Mietzsch
- Pediatrics, University of Washington School of Medicine, Seattle, Washington, USA
| | - Eylem Ocal
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Michael A Padula
- The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Cherrie D Welch
- Wake Forest School of Medicine, Winston-Salem, North Carolina, USA
| | | | - Diane Wilson
- Division of Neonatology, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - John Flibotte
- Division of Neonatology, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
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5
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Park J, Park SH, Kwon YR, Yoon SJ, Lim JH, Han JH, Shin JE, Eun HS, Park MS, Lee SM. Long-term outcomes of very low birth weight infants with intraventricular hemorrhage: a nationwide population study from 2011 to 2019. World J Pediatr 2024:10.1007/s12519-024-00799-x. [PMID: 38615088 DOI: 10.1007/s12519-024-00799-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Accepted: 01/30/2024] [Indexed: 04/15/2024]
Abstract
BACKGROUND Advancements in neonatal care have increased preterm infant survival but paradoxically raised intraventricular hemorrhage (IVH) rates. This study explores IVH prevalence and long-term outcomes of very low birth weight (VLBW) infants in Korea over a decade. METHODS Using Korean National Health Insurance data (NHIS, 2010-2019), we identified 3372 VLBW infants with IVH among 4,129,808 live births. Health-related claims data, encompassing diagnostic codes, diagnostic test costs, and administered procedures were sourced from the NHIS database. The results of the developmental assessments are categorized into four groups based on standard deviation (SD) scores. Neonatal characteristics and complications were compared among the groups. Logistic regression models were employed to identify significant changes in the incidence of complications and to calculate odds ratios with corresponding 95% confidence intervals for each risk factor associated with mortality and morbidity in IVH. Long-term growth and development were compared between the two groups (years 2010-2013 and 2014-2017). RESULTS IVH prevalence was 12% in VLBW and 16% in extremely low birth weight (ELBW) infants. Over the past decade, IVH rates increased significantly in ELBW infants (P = 0.0113), while mortality decreased (P = 0.0225). Major improvements in certain neurodevelopmental outcomes and reductions in early morbidities have been observed among VLBW infants with IVH. Ten percent of the population received surgical treatments such as external ventricular drainage (EVD) or a ventriculoperitoneal (VP) shunt, with the choice of treatment methods remaining consistent over time. The IVH with surgical intervention group exhibited higher incidences of delayed development, cerebral palsy, seizure disorder, and growth failure (height, weight, and head circumference) up to 72 months of age (P < 0.0001). Surgical treatments were also significantly associated with abnormal developmental screening test results. CONCLUSIONS The neurodevelopmental outcomes of infants with IVH, especially those subjected to surgical treatments, continue to be a matter of concern. It is imperative to prioritize specialized care for patients receiving surgical treatments and closely monitor their growth and development after discharge to improve developmental prognosis. Supplementary file2 (MP4 77987 kb).
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Affiliation(s)
- Joonsik Park
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Sook-Hyun Park
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Yu-Ra Kwon
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - So Jin Yoon
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Joo Hee Lim
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Jung Ho Han
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Jeong Eun Shin
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Ho Seon Eun
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Min Soo Park
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea
| | - Soon Min Lee
- Department of Pediatrics, Yonsei University College of Medicine, 211 Eonjuro Gangnamgu, Seoul, 06273, Republic of Korea.
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Venkatraman V, Harward SC, Bhasin S, Calderon K, Atkins SL, Liu B, Lee HJ, Chow SC, Fuchs HE, Thompson EM. Ratios of head circumference to ventricular size vary over time and predict eventual need for CSF diversion in intraventricular hemorrhage of prematurity. Childs Nerv Syst 2024; 40:673-684. [PMID: 37812266 PMCID: PMC10922544 DOI: 10.1007/s00381-023-06176-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 09/30/2023] [Indexed: 10/10/2023]
Abstract
PURPOSE Intraventricular hemorrhage (IVH) of prematurity can lead to hydrocephalus, sometimes necessitating permanent cerebrospinal fluid (CSF) diversion. We sought to characterize the relationship between head circumference (HC) and ventricular size in IVH over time to evaluate the clinical utility of serial HC measurements as a metric in determining the need for CSF diversion. METHODS We included preterm infants with IVH born between January 2000 and May 2020. Three measures of ventricular size were obtained: ventricular index (VI), Evan's ratio (ER), and frontal occipital head ratio (FOHR). The Pearson correlations (r) between the initial (at birth) paired measurements of HC and ventricular size were reported. Multivariable longitudinal regression models were fit to examine the HC:ventricle size ratio, adjusting for the age of the infant, IVH grade (I/II vs. III/IV), need for CSF diversion, and sex. RESULTS A total of 639 patients with an average gestational age of 27.5 weeks were included. IVH grade I/II and grade III/IV patients had a positive correlation between initial HC and VI (r = 0.47, p < 0.001 and r = 0.48, p < 0.001, respectively). In our longitudinal models, patients with a low-grade IVH (I/II) had an HC:VI ratio 0.52 higher than those with a high-grade IVH (p-value < 0.001). Patients with low-grade IVH had an HC:ER ratio 12.94 higher than those with high-grade IVH (p-value < 0.001). Patients with low-grade IVH had a HC:FOHR ratio 12.91 higher than those with high-grade IVH (p-value < 0.001). Infants who did not require CSF diversion had an HC:VI ratio 0.47 higher than those who eventually did (p < 0.001). Infants without CSF diversion had an HC:ER ratio 16.53 higher than those who received CSF diversion (p < 0.001). Infants without CSF diversion had an HC:FOHR ratio 15.45 higher than those who received CSF diversion (95% CI (11.34, 19.56), p < 0.001). CONCLUSIONS There is a significant difference in the ratio of HC:VI, HC:ER, and HC:FOHR size between patients with high-grade IVH and low-grade IVH. Likewise, there is a significant difference in HC:VI, HC:ER, and HC:FOHR between those who did and did not have CSF diversion. The routine assessments of both head circumference and ventricle size by ultrasound are important clinical tools in infants with IVH of prematurity.
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Affiliation(s)
| | - Stephen C Harward
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | | | | | | | - Beiyu Liu
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Hui-Jie Lee
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Shein-Chung Chow
- Department of Biostatistics & Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Herbert E Fuchs
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA
| | - Eric M Thompson
- Department of Neurosurgery, Duke University Medical Center, Durham, NC, USA.
- Department of Neurological Surgery, University of Chicago, 5841 S Maryland Ave, MC3026, Chicago, IL, 60637, USA.
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Garcia-Bonilla M, Yahanda AT, Isaacs AM, Baksh B, Akbari SHA, Botteron H, Morales DM, Han RH, McAllister Ii JP, Mathur AM, Strahle JM, Smyser CD, Limbrick DD. Pro-inflammatory cerebrospinal fluid profile of neonates with intraventricular hemorrhage: clinical relevance and contrast with CNS infection. Fluids Barriers CNS 2024; 21:17. [PMID: 38383424 PMCID: PMC10880312 DOI: 10.1186/s12987-024-00512-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 01/16/2024] [Indexed: 02/23/2024] Open
Abstract
BACKGROUND Interpretation of cerebrospinal fluid (CSF) studies can be challenging in preterm infants. We hypothesized that intraventricular hemorrhage (IVH), post-hemorrhagic hydrocephalus (PHH), and infection (meningitis) promote pro-inflammatory CSF conditions reflected in CSF parameters. METHODS Biochemical and cytological profiles of lumbar CSF and peripheral blood samples were analyzed for 81 control, 29 IVH grade 1/2 (IVH1/2), 13 IVH grade 3/4 (IVH3/4), 15 PHH, 20 culture-confirmed bacterial meningitis (BM), and 27 viral meningitis (VM) infants at 36.5 ± 4 weeks estimated gestational age. RESULTS PHH infants had higher (p < 0.02) CSF total cell and red blood cell (RBC) counts compared to control, IVH1/2, BM, and VM infants. No differences in white blood cell (WBC) count were found between IVH3/4, PHH, BM, and VM infants. CSF neutrophil counts increased (p ≤ 0.03) for all groups compared to controls except IVH1/2. CSF protein levels were higher (p ≤ 0.02) and CSF glucose levels were lower (p ≤ 0.003) for PHH infants compared to all other groups. In peripheral blood, PHH infants had higher (p ≤ 0.001) WBC counts and lower (p ≤ 0.03) hemoglobin and hematocrit than all groups except for IVH3/4. CONCLUSIONS Similarities in CSF parameters may reflect common pathological processes in the inflammatory response and show the complexity associated with interpreting CSF profiles, especially in PHH and meningitis/ventriculitis.
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Affiliation(s)
- Maria Garcia-Bonilla
- Department of Neurosurgery, Washington University School of Medicine, One Children's Place, Suite 420, St. Louis, MO, USA.
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA.
| | - Alexander T Yahanda
- Department of Neurosurgery, Washington University School of Medicine, One Children's Place, Suite 420, St. Louis, MO, USA
| | - Albert M Isaacs
- Department of Neurosurgery, Nationwide Children's Hospital, Ohio State University, Columbus, OH, USA
| | - Brandon Baksh
- University of Miami Miller School of Medicine, Miami, FL, USA
| | - S Hassan A Akbari
- John Hopkins University School of Medicine, Johns Hopkins All Children's Hospital, St. Petersburg,, FL, USA
| | - Haley Botteron
- Medical School, University of Kansas, Kansas City, KS, USA
| | - Diego M Morales
- Department of Neurosurgery, Washington University School of Medicine, One Children's Place, Suite 420, St. Louis, MO, USA
| | - Rowland H Han
- Department of Neurosurgery, Washington University School of Medicine, One Children's Place, Suite 420, St. Louis, MO, USA
| | - James P McAllister Ii
- Department of Neurosurgery, Washington University School of Medicine, One Children's Place, Suite 420, St. Louis, MO, USA
| | - Amit M Mathur
- Department of Pediatrics, Saint Louis University School of Medicine, St. Louis, MO, USA
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University School of Medicine, One Children's Place, Suite 420, St. Louis, MO, USA
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Christopher D Smyser
- Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
- Department of Neurology, Washington University School of Medicine, St. Louis, MO, USA
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - David D Limbrick
- Department of Neurosurgery, Washington University School of Medicine, One Children's Place, Suite 420, St. Louis, MO, USA
- Department of Neurosurgery, Virginia Commonwealth University School of Medicine, Richmond, VA, USA
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8
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Benavente-Fernández I, Steggerda SJ, Liem KD, Lubián-López S, de Vries LS. Ultrasonographic Estimation of Ventricular Volume in Infants Born Preterm with Posthemorrhagic Ventricular Dilatation: A Nested Substudy of the Randomized Controlled Early Versus Late Ventricular Intervention Study (ELVIS) Trial. J Pediatr 2023; 261:113578. [PMID: 37353143 DOI: 10.1016/j.jpeds.2023.113578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 05/29/2023] [Accepted: 06/16/2023] [Indexed: 06/25/2023]
Abstract
OBJECTIVE To study the potential role of ventricular volume (VV) estimation in the management of posthemorrhagic ventricular dilatation related to the need for ventriculoperitoneal (VP)-shunt insertion and 2-year neurodevelopmental outcome in infants born preterm. STUDY DESIGN We included 59 patients from the Early vs Late Ventricular Intervention Study from 4 participating centers. VV was manually segmented in 209 3-dimensional ultrasound scans and estimated from 2-dimensional ultrasound linear measurements in a total of 1226 ultrasounds. We studied the association of both linear measurements and VV to the need for VP shunt and 2-year neurodevelopmental outcome in the overall cohort and in the 29 infants who needed insertion of a reservoir. We used general estimating equations to account for repeated measures per individual. RESULTS Maximum pre-reservoir VV (β coefficient = 0.185, P = .0001) and gestational age at birth (β = -0.338; P = .0001) were related to the need for VP shunt. The estimated optimal single VV measurement cut point of 17 cm3 correctly classified 79.31% with an area under the curve of 0.76 (CI 95% 0.74-0.79). Maximum VV (β = 0.027; P = .012) together with VP shunt insertion (β = 3.773; P = .007) and gestational age (β = -0.273; P = .0001) were related to cognitive outcome at 2 years. Maximum ventricular index and anterior horn width before reservoir insertion were independently associated with the need of VP shunt and the proposed threshold groups in the Early vs Late Ventricular Intervention Study trial were associated with long-term outcome. CONCLUSIONS Pre-reservoir VV measurements were associated with the need for VP-shunt insertion and 2-year cognitive outcome among infants born preterm with posthemorrhagic ventricular dilatation. TRIAL REGISTRATION ISRCTN43171322.
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Affiliation(s)
- Isabel Benavente-Fernández
- Area of Paediatrics, Department of Child and Mother Health and Radiology, Medical School, University of Cádiz, Cádiz, Spain; Division of Neonatology, Department of Paediatrics, Puerta del Mar University Hospital, Cádiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University, Cádiz, Spain.
| | - Sylke J Steggerda
- Division of Neonatology, Department of pediatrics, Leiden University Medical Center, Willem-Alexander Children's Hospital, Leiden, The Netherlands
| | - Kian D Liem
- Division of Neonatology, Department of Paediatrics, Radboud University Medical Centre Nijmegen, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Simón Lubián-López
- Division of Neonatology, Department of Paediatrics, Puerta del Mar University Hospital, Cádiz, Spain; Biomedical Research and Innovation Institute of Cádiz (INiBICA) Research Unit, Puerta del Mar University, Cádiz, Spain
| | - Linda S de Vries
- Division of Neonatology, Department of pediatrics, Leiden University Medical Center, Willem-Alexander Children's Hospital, Leiden, The Netherlands; Department of Neonatology, Wilhelmina Children's Hospital, Utrecht, The Netherlands
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9
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Groulx-Boivin E, Paquette M, Khairy M, Beltempo M, Dudley R, Ferrand A, Guillot M, Bizgu V, Garfinkle J. Spontaneous resolution of post-hemorrhagic ventricular dilatation in preterm newborns and neurodevelopment. Pediatr Res 2023; 94:1428-1435. [PMID: 37179437 DOI: 10.1038/s41390-023-02647-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 04/12/2023] [Accepted: 04/17/2023] [Indexed: 05/15/2023]
Abstract
BACKGROUND We investigated the temporal evolution of post-hemorrhagic ventricular dilatation (PHVD) and compared neurodevelopmental impairments (NDI) in newborns with (Group 1) spontaneous resolution of PHVD, (Group 2) persistent PHVD without neurosurgical intervention, and (Group 3) progressive PHVD receiving neurosurgical intervention. METHODS A multicenter retrospective cohort study of newborns born at ≤34 weeks with PHVD (ventricular index [VI] >97th centile for gestational age and anterior horn width [AHW] >6 mm) from 2012 to 2020. Severe NDI was defined as global developmental delay or cerebral palsy GMFCS III-V at 18 months. RESULTS Of 88 survivors with PHVD, 39% had a spontaneous resolution, 17% had persistent PHVD without intervention, and 44% had progressive PHVD receiving intervention. The median time between PHVD diagnosis and spontaneous resolution was 14.0 days (IQR 6.8-32.3) and between PHVD diagnosis and first neurosurgical intervention was 12.0 days (IQR 7.0-22.0). Group 1 had smaller median maximal VI (1.8, 3.4, 11.1 mm above p97; p < 0.001) and AHW (7.2, 10.8, 20.3 mm; p < 0.001) than Groups 2 and 3. Neurodevelopmental outcome data were available for 82% of survivors. Group 1 had reduced severe NDI compared to Group 3 (15% vs 66%; p < 0.001). CONCLUSION Newborns with PHVD without spontaneous resolution are at higher risk for impairments despite neurosurgical interventions, which may be due to larger ventricular dilatation. IMPACT The natural evolution of post-hemorrhagic ventricular dilatation (PHVD) and developmental implications of spontaneous resolution are not well established. In this study, approximately one in three newborns with PHVD experienced spontaneous resolution and this subset of newborns had reduced rates of neurodevelopmental impairments. More prominent ventricular dilatation was associated with reduced rates of spontaneous resolution and increased rates of severe neurodevelopmental impairment among newborns with PHVD. Understanding clinically relevant time points in the evolution of PHVD and predictors of spontaneous resolution may help inform the discussion around the optimal timing for intervention and allow for more precise prognostication in this population.
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Affiliation(s)
- Emilie Groulx-Boivin
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal Children's Hospital, Montreal, QC, Canada
| | - Mariane Paquette
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal Children's Hospital, Montreal, QC, Canada
| | - May Khairy
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal Children's Hospital, Montreal, QC, Canada
| | - Marc Beltempo
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal Children's Hospital, Montreal, QC, Canada
| | - Roy Dudley
- Department of Pediatric Surgery, Division of Neurosurgery, McGill University, Montreal Children's Hospital, Montreal, QC, Canada
| | - Amaryllis Ferrand
- Division of Neonatology, Department of Pediatrics, McGill University, Jewish General Hospital, Montréal, QC, Canada
| | - Mireille Guillot
- Department of Pediatrics, Université Laval, Centre Hospitalier Universitaire de Québec-Université Laval, Quebec, QC, Canada
| | - Victoria Bizgu
- Division of Neonatology, Department of Pediatrics, McGill University, Jewish General Hospital, Montréal, QC, Canada
| | - Jarred Garfinkle
- Division of Neonatology, Department of Pediatrics, McGill University, Montreal Children's Hospital, Montreal, QC, Canada.
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10
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Gialeli A, Spaull R, Plösch T, Uney J, Llana OC, Heep A. The miRNA transcriptome of cerebrospinal fluid in preterm infants reveals the signaling pathways that promote reactive gliosis following cerebral hemorrhage. Front Mol Neurosci 2023; 16:1211373. [PMID: 37790884 PMCID: PMC10544345 DOI: 10.3389/fnmol.2023.1211373] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/22/2023] [Indexed: 10/05/2023] Open
Abstract
Introduction Germinal Matrix-Intraventricular Haemorrhage (GM-IVH) is one of the most common neurological complications in preterm infants, which can lead to accumulation of cerebrospinal fluid (CSF) and is a major cause of severe neurodevelopmental impairment in preterm infants. However, the pathophysiological mechanisms triggered by GM-IVH are poorly understood. Analyzing the CSF that accumulates following IVH may allow the molecular signaling and intracellular communication that contributes to pathogenesis to be elucidated. Growing evidence suggests that miRs, due to their key role in gene expression, have a significant utility as new therapeutics and biomarkers. Methods The levels of 2,083 microRNAs (miRs) in 15 CSF samples from 10 infants with IVH were measured using miRNA whole transcriptome sequencing. Gene ontology (GO) and miR family analysis were used to uncover dysregulated signalling which were then validated in vitro in human foetal neural progenitor cells treated with IVH-CSF. Results Five hundred eighty-seven miRs were differentially expressed in the CSF extracted at least 2 months after injury, compared to CSF extracted within the first month of injury. GO uncovered key pathways targeted by differentially expressed miRs including the MAPK cascade and the JAK/STAT pathway. Astrogliosis is known to occur in preterm infants, and we hypothesized that this could be due to abnormal CSF-miR signaling resulting in dysregulation of the JAK/STAT pathway - a key controller of astrocyte differentiation. We then confirmed that treatment with IVH-CSF promotes astrocyte differentiation from human fetal NPCs and that this effect could be prevented by JAK/STAT inhibition. Taken together, our results provide novel insights into the CSF/NPCs crosstalk following perinatal brain injury and reveal novel targets to improve neurodevelopmental outcomes in preterm infants.
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Affiliation(s)
- Andriana Gialeli
- School of Medicine and Health Science, Research Centre Neurosensory Science, University of Oldenburg, Oldenburg, Germany
| | - Robert Spaull
- Bristol Medical School, Translational Health Sciences, Dorothy Hodgkin Building, University of Bristol, Bristol, United Kingdom
| | - Torsten Plösch
- School of Medicine and Health Science, Research Centre Neurosensory Science, University of Oldenburg, Oldenburg, Germany
| | - James Uney
- Bristol Medical School, Translational Health Sciences, Dorothy Hodgkin Building, University of Bristol, Bristol, United Kingdom
| | - Oscar Cordero Llana
- Bristol Medical School, Translational Health Sciences, Dorothy Hodgkin Building, University of Bristol, Bristol, United Kingdom
| | - Axel Heep
- School of Medicine and Health Science, Research Centre Neurosensory Science, University of Oldenburg, Oldenburg, Germany
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11
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Miranda P, Simal JA, Plaza E, Pancucci G, Escrig R, Boronat N, Llorens R. Preterm-related posthemorrhagic hydrocephalus: Review of our institutional series with a long-term follow-up. NEUROCIRUGIA (ENGLISH EDITION) 2023; 34:122-127. [PMID: 36774256 DOI: 10.1016/j.neucie.2022.11.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/05/2022] [Indexed: 05/06/2023]
Abstract
INTRODUCTION Preterm-related posthemorrhagic hydrocephalus is a major cause of neurological impairment and a common indication for a ventriculoperitoneal shunt in infants that are prone to diverse complications. Protocols of diagnosis and treatment are in continuous evolution and require evaluation of their results. OBJECTIVE To review the clinical characteristics and results of a series of preterm-related posthemorrhagic hydrocephalus needing a definitive shunt from 1982 to 2020 in our institution. As a secondary objective we evaluated the safety of the changes in our protocol of treatment from 2015. METHODS Retrospective review, clinical investigation. RESULTS 133 patients were implanted a shunt in the study period. Shunt infection was diagnosed in 15 patients. Proximal shunt obstruction as the first complication was diagnosed in 30% of cases at one year, 37% at two years and 46% at five years. 61 patients developed very small or collapsed ventricles at last follow-up. Two thirds of our patients achieved normal neurological development or mild impairment. Changes in protocol did not significantly modify clinical results although improvement in most outcomes was observed. Mean follow-up was over nine years. CONCLUSIONS Clinical outcomes are comparable to previous reported data. Changes in protocol proved to be safe and improved our results. Programmable shunts can be used safely in preterm patients although they may not prevent tendency towards ventricular collapse, which is very common after long follow-up.
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Affiliation(s)
- Pablo Miranda
- Servicio de Neurocirugía, Hospital Universitario y Politécnico La Fe, Valencia, Spain.
| | - Juan Antonio Simal
- Servicio de Neurocirugía, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Estela Plaza
- Servicio de Neurocirugía, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Giovanni Pancucci
- Servicio de Neurocirugía, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Raquel Escrig
- Servicio de Neonatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Nuria Boronat
- Servicio de Neonatología, Hospital Universitario y Politécnico La Fe, Valencia, Spain
| | - Roberto Llorens
- Servicio de Radiología Pediátrica, Hospital Universitario y Politécnico La Fe, Valencia, Spain
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12
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Three-dimensional cranial ultrasound and functional near-infrared spectroscopy for bedside monitoring of intraventricular hemorrhage in preterm neonates. Sci Rep 2023; 13:3730. [PMID: 36878952 PMCID: PMC9988970 DOI: 10.1038/s41598-023-30743-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2022] [Accepted: 02/28/2023] [Indexed: 03/08/2023] Open
Abstract
Germinal Matrix-Intraventricular Hemorrhage (GMH-IVH) remains a significant cause of adverse neurodevelopment in preterm infants. Current management relies on 2-dimensional cranial ultrasound (2D cUS) ventricular measurements. Reliable biomarkers are needed to aid in the early detection of posthemorrhagic ventricular dilatation (PHVD) and subsequent neurodevelopment. In a prospective cohort study, we incorporated 3-dimensional (3D) cUS and functional near-infrared spectroscopy (fNIRS) to monitor neonates with GMH-IVH. Preterm neonates (≤ 32 weeks' gestation) were enrolled following a GMH-IVH diagnosis. Neonates underwent sequential measurements: 3D cUS images were manually segmented using in-house software, and the ventricle volumes (VV) were extracted. Multichannel fNIRS data were acquired using a high-density system, and spontaneous functional connectivity (sFC) was calculated. Of the 30 neonates enrolled in the study, 19 (63.3%) had grade I-II and 11 (36.7%) grade III-IV GMH-IVH; of these, 7 neonates (23%) underwent surgical interventions to divert cerebrospinal fluid (CSF). In infants with severe GMH-IVH, larger VV were significantly associated with decreased |sFC|. Our findings of increased VV and reduced sFC suggest that regional disruptions of ventricular size may impact the development of the underlying white matter. Hence, 3D cUS and fNIRS are promising bedside tools for monitoring the progression of GMH-IVH in preterm neonates.
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13
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Afifi J, Leijser LM, de Vries LS, Shah PS, Mitra S, Brouwer MJ, Walling S, McNeely PD. Variability in the diagnostic and management practices of post-hemorrhagic ventricular dilatation in very preterm infants across Canadian centers and comparison with European practices. J Neonatal Perinatal Med 2022; 15:721-729. [PMID: 36463462 DOI: 10.3233/npm-221071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
OBJECTIVES To investigate the variability in diagnostic and therapeutic approaches to posthemorrhagic ventricular dilatation (PHVD) among Canadian neonatal centers, and secondary exploration of differences in approaches between Canadian and European practices. METHODS We conducted a survey among Canadian tertiary neonatal centers on their local practices for managing very preterm infants with PHVD. The survey covered questions on the diagnostic criteria, timing and type of interventions and resources utilization (transfer to neurosurgical sites and neurodevelopmental follow-up). In a secondary exploration, Canadian responses were compared with responses to the same survey from European centers. RESULTS 23/30 Canadian centers (77%) completed the survey. There was no consensus among Canadian centers on the criteria used for diagnosing PHVD or to initiate intervention. The therapeutic interventions also vary, both for temporizing procedures or permanent shunting. Compared to European practices, the Canadian approach relied less on the sole use of ultrasound criteria for diagnosing PHVD (43 vs 94%, p < 0.0001) or timing intervention (26 vs 63%, p = 0.007). Majority of European centers intervened early in the development of PHVD based on ultrasound parameters, whereas Canadian centers intervened based on clinical hydrocephalus, with fewer centers performing serial lumbar punctures prior to neurosurgical procedures (40 vs 81%, p = 0.003). CONCLUSION Considerable variability exists in diagnosis and management of PHVD in preterm infants among Canadian tertiary centers and between Canadian and European practices. Given the potential implications of the inter-center practice variability on the short- and long-term outcomes of preterm infants with PHVD, efforts towards evidence-based Canada-wide practice standardization are underway.
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Affiliation(s)
- J Afifi
- Department of Pediatrics, Neonatal Perinatal Medicine, Dalhousie University, Halifax, Canada
| | - L M Leijser
- Department of Pediatrics, Division of Neonatology, University of Calgary, Calgary, Canada
| | - L S de Vries
- Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - P S Shah
- Department of Pediatrics, Mount Sinai Hospital, University of Toronto, Toronto, Canada
| | - S Mitra
- Department of Pediatrics, Neonatal Perinatal Medicine, Dalhousie University, Halifax, Canada
| | - M J Brouwer
- Department of Neonatology, University Medical Center Utrecht, Utrecht, the Netherlands
| | - S Walling
- Department of Surgery, Division of Neurosurgery, Dalhousie University, Halifax, Canada
| | - P D McNeely
- Department of Surgery, Division of Neurosurgery, Dalhousie University, Halifax, Canada
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14
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Liu G, Nie C. Ultrasonic Diagnosis and Management of Posthemorrhagic Ventricular Dilatation in Premature Infants: A Narrative Review. J Clin Med 2022; 11:jcm11247468. [PMID: 36556084 PMCID: PMC9784170 DOI: 10.3390/jcm11247468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Revised: 12/08/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022] Open
Abstract
The survival rate of preterm infants is increasing as a result of technological advances. The incidence of intraventricular hemorrhages (IVH) in preterm infants ranges from 25% to 30%, of which 30% to 50% are severe IVH (Volpe III-IV, Volpe III is defined as intraventricular bleeding occupying more than 50% of the ventricular width and acute lateral ventricle dilatation, Volpe IV is defined as intraventricular hemorrhage combined with venous infarction) and probably lead to posthemorrhagic ventricular dilatation (PHVD). Severe IVH and subsequent PHVD have become the leading causes of brain injury and neurodevelopmental dysplasia in preterm infants. This review aims to review the literature on the diagnosis and therapeutic strategies for PHVD and provide some recommendations for management to improve the neurological outcomes.
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Affiliation(s)
- Gengying Liu
- Neonatology Department, Guangdong Women and Children Hospital, Guangzhou 510010, China
- Guangdong Neonatal ICU Medical Quality Control Center, Guangzhou 510010, China
| | - Chuan Nie
- Neonatology Department, Guangdong Women and Children Hospital, Guangzhou 510010, China
- Guangdong Neonatal ICU Medical Quality Control Center, Guangzhou 510010, China
- Correspondence:
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15
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Whitehead WE, Weiner HL. Infantile and Childhood Hydrocephalus. N Engl J Med 2022; 387:2067-2073. [PMID: 36449422 DOI: 10.1056/nejmra2116504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- William E Whitehead
- From the Department of Neurosurgery, Baylor College of Medicine, and the Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital - both in Houston (W.E.W., H.L.W.)
| | - Howard L Weiner
- From the Department of Neurosurgery, Baylor College of Medicine, and the Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital - both in Houston (W.E.W., H.L.W.)
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16
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Lai GY, Aouad P, DeRegnier RAO, Dizon MLV, Palasis S, Lam SK. Ventriculomegaly thresholds for prediction of symptomatic post-hemorrhagic ventricular dilatation in preterm infants. Pediatr Res 2022; 92:1621-1629. [PMID: 35184137 DOI: 10.1038/s41390-022-01993-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Revised: 01/17/2022] [Accepted: 01/31/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Benefits from early surgical intervention in preterm infants with intraventricular hemorrhage (IVH) prior to symptomatic ventriculomegaly must be weighed against risks of surgery. We calculated thresholds of common ventriculomegaly indices at a late-intervention institution to predict subsequent symptomatic ventriculomegaly requiring neurosurgery. METHODS We retrospectively reviewed neuroimaging and neurosurgical outcomes in preterm infants with grade III/IV IVH between 2007 and 2020. Frontal-occipital horn ratio (FOHR), frontal-temporal horn ratio (FTHR), anterior horn width (AHW), and ventricular index (VI) were measured. Area under the receiver operating curve (AUC) for predicting intervention (initiated after progressive symptomatic ventriculomegaly) was calculated for diagnostic scan, scans during weeks 1-4, and maximum measurement prior to intervention. Threshold values that optimized sensitivity and specificity were derived. RESULTS A total of 1254 scans in 132 patients were measured. In all, 37 patients had a neurosurgical intervention. All indices differed between those with and without intervention from the first diagnostic scan (p < 0.001). AUC of maximum measurement was 97.1% (95% CI 94.6-99.7) for FOHR, 97.7% (95% CI 95.6-99.8) for FTHR, 96.6% (95% CI 93.9-99.4) for AHW, and 96.8% (95% CI 94.0-99.5) for VI. Calculated thresholds were FOHR 0.66, FTHR 0.62, AHW 15.5 mm, and VI 8.4 mm > p97 (sensitivities >86.8%, specificities >90.1%). CONCLUSION Ventriculomegaly indices were greater for patients who developed progressive persistent ventriculomegaly from the first diagnostic scan and predicted neurosurgical intervention. IMPACT We derived thresholds of common ventriculomegaly indices (ventricular index, anterior frontal horn width, fronto-occipital horn and fronto-temporal horn index) to best predict the development of progressive symptomatic post-hemorrhage hydrocephalus in preterm infants with intraventricular hemorrhage. While current thresholds were established by a priori expert consensus, we report the first data-driven derivation of ventriculomegaly thresholds across all indices for the prediction of symptomatic hydrocephalus. Data-derived thresholds will more precisely weigh the risks and benefits of early intervention.
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Affiliation(s)
- Grace Y Lai
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA. .,Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
| | - Pascale Aouad
- Department of Medical Imaging, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Pediatric Neuroradiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Raye-Ann O DeRegnier
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Maria L V Dizon
- Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Neonatology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Susan Palasis
- Department of Medical Imaging, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Pediatric Neuroradiology, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Sandi K Lam
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.,Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
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Valverde E, Ybarra M, Benito AV, Bravo MC, Pellicer A. Posthemorrhagic ventricular dilatation late intervention threshold and associated brain injury. PLoS One 2022; 17:e0276446. [PMID: 36301835 PMCID: PMC9612444 DOI: 10.1371/journal.pone.0276446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2022] [Accepted: 10/06/2022] [Indexed: 01/24/2023] Open
Abstract
OBJECTIVE To systematically assess white matter injury (WMI) in preterm infants with posthemorrhagic ventricular dilatation (PHVD) using a high-threshold intervention strategy. STUDY DESIGN This retrospective analysis included 85 preterm infants (≤34 weeks of gestation) with grade 2-3 germinal matrix-intraventricular hemorrhage. Cranial ultrasound (cUS) scans were assessed for WMI and ventricular width and shape. Forty-eight infants developed PHVD, 21 of whom (intervention group) underwent cerebrospinal fluid drainage according to a predefined threshold (ventricular index ≥p97+4 mm or anterior horn width >10 mm, and the presence of frontal horn ballooning). The other 27 infants underwent a conservative approach (non-intervention group). The two PHVD groups were compared regarding ventricular width at two stages: the worst cUS for the non-intervention group (scans showing the largest ventricular measurements) versus pre-intervention cUS in the intervention group, and at term equivalent age. WMI was classified as normal/mild, moderate and severe. RESULTS The intervention group showed significantly larger ventricular index, anterior horn width and thalamo-occipital diameter than the non-intervention group at the two timepoints. Moderate and severe WMI were more frequent in the infants with PHVD (p<0.001), regardless of management (intervention or conservative management). There was a linear relationship between the severity of PHVD and WMI (p<0.001). CONCLUSIONS Preterm infants with PHVD who undergo a high-threshold intervention strategy associate an increased risk of WMI.
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Affiliation(s)
- Eva Valverde
- Department of Neonatology, La Paz University Hospital, Madrid, Spain,NeNe Foundation, Madrid, Spain,Hospital La Paz Institute for Health Research-IdiPAZ, Madrid, Spain,* E-mail:
| | - Marta Ybarra
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Andrea V. Benito
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - María Carmen Bravo
- Department of Neonatology, La Paz University Hospital, Madrid, Spain,Hospital La Paz Institute for Health Research-IdiPAZ, Madrid, Spain
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain,Hospital La Paz Institute for Health Research-IdiPAZ, Madrid, Spain
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Abstract
While intraventricular hemorrhage (IVH) predominantly damages the periventricular white matter, it induces substantial injury to the cerebral gray matter. IVH destroys the germinal matrix, suppresses neurogenesis, and disrupts corticogenesis, thereby reducing the number of neurons in the upper cortical layer and volume of the cerebral gray matter. The pathogenesis of gray matter injury is attributed to IVH-induced oxidative stress, inflammation, and mass effect damaging the germinal matrix as well as to post-hemorrhagic ventricular dilation (PHVD). The IVH-induced cerebral gray matter injury and PHVD contribute to cognitive deficits and neurobehavioral disorders. Neuroimaging has enhanced our understanding of cerebral gray matter injury and is a valuable predictor of neurodevelopmental outcomes. Evidence from therapies tested in preclinical models and clinical trials suggests that strategies to promote neurogenesis, reduce cerebral inflammation and oxidative stress, and remove blood clots from the ventricles might enhance the outcome of these infants. This review offers an integrated view of new insights into the mechanisms underlying gray matter injury in premature infants with IVH and highlights the imminent therapies to restore neurodevelopmental dysfunction in IVH survivors.
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Affiliation(s)
- Deep Sharma
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Alex Agyemang
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY
| | - Praveen Ballabh
- Department of Pediatrics, Albert Einstein College of Medicine, Bronx, NY; Dominick P. Purpura Department of Neuroscience, Albert Einstein College of Medicine, Bronx, NY, USA.
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Abstract
During the last decade, an increasing number of studies have been conducted to improve the outcome of post-hemorrhagic hydrocephalus (PHH), a complication of severe intraventricular hemorrhage (IVH) in preterm infants. Two randomized controlled trials have shown that treatment should be initiated prior to the onset of clinical symptoms. Ventricular access devices and subgaleal shunts are used as temporary neurosurgical interventions whereas ventriculoperitoneal shunts are performed for infants with progressive hydrocephalus. Recently, techniques such as neuro-endoscopic lavage have also been introduced to eliminate toxic blood products and debris from the cerebral ventricles and have shown promise in early clinical studies. The objective of this review is to provide an update on management of PHVD and PHH in the preterm infant.
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Affiliation(s)
- David D Limbrick
- T.S. Park Chair and Chief of Pediatric Neurosurgery, Executive Vice Chair of Neurological Surgery, Washington University School of Medicine; Neurosurgeon-in-Chief, St. Louis Children's Hospital.
| | - Linda S de Vries
- Em. Professor in Neonatal Neurology, Department of Neonatology, University Medical Center Utrecht and Leiden University Medical Center, the Netherlands
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Nieuwets A, Cizmeci MN, Groenendaal F, Leijser LM, Koopman C, Benders MJNL, Dudink J, de Vries LS, van der Aa NE. Post-hemorrhagic ventricular dilatation affects white matter maturation in extremely preterm infants. Pediatr Res 2022; 92:225-232. [PMID: 34446847 DOI: 10.1038/s41390-021-01704-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2021] [Revised: 07/20/2021] [Accepted: 08/08/2021] [Indexed: 12/28/2022]
Abstract
BACKGROUND Data on microstructural white matter integrity in preterm infants with post-hemorrhagic ventricular dilatation (PHVD) using diffusion tensor imaging (DTI) are limited. Also, to date, no study has focused on the DTI changes in extremely preterm (EP) infants with PHVD. METHODS A case-control study of EP infants <28 weeks' gestation with PHVD was conducted. Diffusivity and fractional anisotropy (FA) values of corticospinal tracts (CST) and corpus callosum (CC) were measured using DTI at term-equivalent age. Outcomes were assessed at 2-years-corrected age. RESULTS Twenty-one infants with PHVD and 21 matched-controls were assessed. FA values in the CC were lower in infants with PHVD compared with controls (mean difference, 0.05 [95% confidence interval (CI), 0.02-0.08], p < 0.001). In infants with periventricular hemorrhagic infarction, FA values in the CC were lower than in controls (mean difference, 0.05 [95% CI, 0.02-0.09], p = 0.005). The composite cognitive and motor scores were associated with the FA value of the CC (coefficient 114, p = 0.01 and coefficient 147, p = 0.004; respectively). CONCLUSIONS Extremely preterm infants with PHVD showed lower FA values in CC. A positive correlation was also shown between the composite cognitive and motor scores and FA value of the CC at 2-years-corrected age. IMPACT Extremely preterm infants with post-hemorrhagic ventricular dilatation showed lower fractional anisotropy values in their corpus callosum compared with controls reflecting the impaired microstructure of these commissural nerve fibers that are adjacent to the dilated ventricles. Impaired microstructure of the corpus callosum was shown to be associated with cognitive and motor scores at 2-years-corrected age.
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Affiliation(s)
- Astrid Nieuwets
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Mehmet N Cizmeci
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, ON, Canada
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Lara M Leijser
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Section of Neonatology, Department of Pediatrics, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Corine Koopman
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Manon J N L Benders
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jeroen Dudink
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands.,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Niek E van der Aa
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht, The Netherlands. .,Utrecht Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands.
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21
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Cizmeci MN, Groenendaal F, van der Aa NE, Vandewouw MM, Young JM, Han K, Benders MJNL, Taylor MJ, de Vries LS, Woerdeman PA. Corpus callosum injury after neurosurgical intervention for posthemorrhagic ventricular dilatation and association with neurodevelopmental outcome at 2 years. J Neurosurg Pediatr 2022; 30:31-38. [PMID: 35395637 DOI: 10.3171/2022.2.peds21577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 02/21/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Direct injury to the corpus callosum (CC) due to neurosurgical interventions in infants with posthemorrhagic ventricular dilatation (PHVD) has not been reported in the literature. The authors observed a subset of infants who had suffered penetrating CC injury after neurosurgical interventions for PHVD and hypothesized that this pattern of injury may result in suboptimal CC maturation and neurodevelopmental impairment. METHODS In this multicenter, retrospective, observational study, 100 preterm and 17 full-term infants with PHVD were included and compared with 23 preterm controls. Both neonatal and postneonatal brain MRI scans were assessed for injury, and measurements were performed on postneonatal MRI scans at 2 years' corrected age. Neurodevelopmental outcome was assessed at 2 years' corrected age. RESULTS A total of 269 brain MRI scans of 140 infants were included. Of infants with PHVD, 48 (41%) had penetrating CC injury following neurosurgical interventions. The median (IQR) CC midsagittal surface area was smaller in infants with CC injury when compared with infants with PHVD who had intact CC and controls (190 mm2 [149-262 mm2] vs 268 mm2 [206-318 mm2] vs 289 mm2 [246-320 mm2], respectively; p < 0.001). In the univariate analysis, the area of the CC was associated with cognitive Z score (coefficient 0.009 [95% CI 0.005-0.012], p < 0.001) and motor Z score (coefficient 0.009 [95% CI 0.006-0.012], p < 0.001). In the multivariable model, CC injury was not independently associated with cognitive and motor Z score after adjusting for gestational age and presence of periventricular hemorrhagic infarction (coefficient 0.04 [95% CI -0.36 to 0.46] and -0.37 [95% CI -0.83 to 0.09], p = 0.7 and 0.1, respectively). CONCLUSIONS CC injury was not uncommon following neurosurgical interventions for PHVD in both preterm and full-term infants. At the age of 2 years, the CC midsagittal surface area was smaller in infants with injury, but CC injury was not independently associated with cognitive and motor outcomes at 2 years' corrected age.
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Affiliation(s)
- Mehmet N Cizmeci
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
- 3Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto
| | - Floris Groenendaal
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
| | - Niek E van der Aa
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
| | - Marlee M Vandewouw
- 4Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto
- 5Program in Neurosciences and Mental Health, The Hospital for Sick Children, University of Toronto
- 6Autism Research Centre, Bloorview Research Institute, Holland Bloorview Kids Rehabilitation Hospital, Toronto
- 7Institute of Biomedical Engineering, University of Toronto
| | - Julia M Young
- 5Program in Neurosciences and Mental Health, The Hospital for Sick Children, University of Toronto
- 8Department of Psychology, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Kuosen Han
- 9Department of Neurosurgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht; and
| | - Manon J N L Benders
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
| | - Margot J Taylor
- 4Department of Diagnostic Imaging, The Hospital for Sick Children, University of Toronto
- 5Program in Neurosciences and Mental Health, The Hospital for Sick Children, University of Toronto
| | - Linda S de Vries
- 1Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University
- 2University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
- 10Department of Neonatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter A Woerdeman
- 9Department of Neurosurgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, and Utrecht University, Utrecht; and
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22
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Preterm-related posthemorrhagic hydrocephalus: Review of our institutional series with a long-term follow-up. Neurocirugia (Astur) 2022. [DOI: 10.1016/j.neucir.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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23
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Degree of ventriculomegaly predicts school-aged functional outcomes in preterm infants with intraventricular hemorrhage. Pediatr Res 2022; 91:1238-1247. [PMID: 34215837 DOI: 10.1038/s41390-021-01631-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 05/21/2021] [Accepted: 06/11/2021] [Indexed: 11/08/2022]
Abstract
BACKGROUND Greater ventriculomegaly in preterm infants with intraventricular hemorrhage (IVH) has been associated with worse neurodevelopmental outcomes in infancy. We aim to explore the relationship between ventriculomegaly and school-age functional outcome. METHODS Retrospective review of preterm infants with Grade III/IV IVH from 2006 to 2020. Frontal-occipital horn ratio (FOHR) was measured on imaging throughout hospitalization and last available follow-up scan. Pediatric Cerebral Performance Category (PCPC) scale was used to assess functional outcome at ≥4 years. Ordinal logistic regression was used to determine the relationship between functional outcome and FOHR at the time of Neurosurgery consult, neurosurgical intervention, and last follow-up scan while adjusting for confounders. RESULTS One hundred and thirty-four infants had Grade III/IV IVH. FOHR at consult was 0.62 ± 0.12 and 0.75 ± 0.13 at first intervention (p < 0.001). On univariable analysis, maximum FOHR, FOHR at the last follow-up scan, and at Neurosurgery consult predicted worse functional outcome (p < 0.01). PVL, longer hospital admission, and gastrotomy/tracheostomy tube also predicted worse outcome (p < 0.05). PVL, maximum FOHR, and FOHR at consult remained significant on multivariable analysis (p < 0.05). Maximum FOHR of 0.61 is a fair predictor for moderate-severe impairment (AUC 75%, 95% CI: 62-87%). CONCLUSIONS Greater ventricular dilatation and PVL were independently associated with worse functional outcome in Grade III/IV IVH regardless of neurosurgical intervention. IMPACT Ventriculomegaly measured by frontal-occipital horn ratio (FOHR) and periventricular leukomalacia are independent correlates of school-age functional outcomes in preterm infants with intraventricular hemorrhage regardless of need for neurosurgical intervention. These findings extend the known association between ventriculomegaly and neurodevelopmental outcomes in infancy to functional outcomes at school age. FOHR is a fair predictor of school-age functional outcome, but there are likely other factors that influence functional status, which highlights the need for prospective studies to incorporate other clinical and demographic variables in predictive models.
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24
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Cohen S, Flibotte J. Treatment of Posthemorrhagic Hydrocephalus. Clin Perinatol 2022; 49:15-25. [PMID: 35209998 DOI: 10.1016/j.clp.2021.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The incidence of intraventricular hemorrhage (IVH) has overall declined to 15% to 20% of preterm infants with birth weight less than 1500 g. One of the major complications of severe IVH is posthemorrhagic ventricular dilation (PHVD). Nearly 10% of all infants with IVH and 20% of infants with severe IVH will develop progressive PHVD requiring surgical intervention to prevent parenchymal damage in the developing brain. This review focuses on the controversies regarding posthemorrhagic hydrocephalus interventions with a focus on how to interpret recent data from trials that some have seen as heralding a call toward more aggressive intervention.
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Affiliation(s)
- Susan Cohen
- Department of Pediatrics, Division of Neonatology, Medical College of Wisconsin, 999 North 92nd Street, CCC 410, Milwaukee, WI 53226, USA.
| | - John Flibotte
- Department of Pediatrics, Division of Neonatology, Children's Hospital of Phildealphia & the Perelman School of Medicine at the University of Pennsylvania, 34th & Civic Center Boulevard, Philadelphia, PA 19104, USA
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25
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Abstract
Intraventricular hemorrhage (IVH) remains a major complication of prematurity, worldwide. The severity of IVH is variable, ranging from a tiny germinal matrix bleed to a moderate-to-large ventricular hemorrhage or periventricular hemorrhagic infarction. Survivors with IVH often suffer from hydrocephalus and white matter injury. There is no tangible treatment to prevent post-hemorrhagic cerebral palsy, cognitive deficits, or hydrocephalus in these infants. White matter injury is attributed to blood-induced damage to axons and maturing oligodendrocyte precursors, resulting in reduced myelination and axonal loss. Hydrocephalus results from obstructed CSF circulation by blood clots, increased CSF production, and reduced CSF absorption by lymphatics and arachnoid villi. Several strategies to promote neurological recovery have shown promise in animal models, including the elimination of blood and blood products, alleviating cerebral inflammation and oxidative stress, as well as promoting survival and maturation of oligodendrocyte precursors. The present review integrates novel mechanisms of brain injury in IVH and the imminent therapies to alleviate post-hemorrhagic white matter injury and hydrocephalus in the survivors with IVH.
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Affiliation(s)
| | - Praveen Ballabh
- Children's Hospital at Montefiore, Department of Pediatrics and Dominick P, Purpura Department of Neuroscience, Albert Einstein College of Medicine, Bronx, NY, USA.
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26
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Bębenek AK, Kwiatkowski S, Milczarek O. Potential Risk Factors for Ventriculoperitoneal Shunt Implantation in Paediatric Patients with Posthemorrhagic Hydrocephalus of Prematurity Treated with Subcutaneous Reservoir: An Institutional Experience. Neuropediatrics 2022; 53:1-6. [PMID: 34255331 DOI: 10.1055/s-0041-1732311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Posthemorrhagic hydrocephalus of prematurity (PHHP) is a result of intraventricular hemorrhage (IVH). IVH occurs in 6 to 23% of the preterms in countries with advanced medical health care. Most of these patients will eventually require the use of ventriculoperitoneal shunt (VPS). The purpose of this study is to assess the risk factors of VPS implantation in patients with PHHP who have been treated with ventricular catheter with subcutaneous reservoir (VCSR). METHODS The retrospective study was conducted evaluating 35 premature patients who suffered from severe IVH. Their mean gestational age was 28 weeks. The assessment included antenatal factors such as gestational age, birth weight, and intrauterine and perinatal infection. Postparturient period factors such as the IVH grade, time between diagnosis, and VCSR implantation and body weight on VCSR implantation were also considered in the study. Postprocedural complications, such as bacterial cerebrospinal fluid (CSF) infection, sepsis, and skin lesions, were evaluated. Data were calculated with R program, version 4.04. RESULTS From among 35 evaluated patients, 23 (65.71%) required a VPS. Median of birth weight was 1,190 g. Infections were observed in 11 (31.43%) cases. Mean time between IVH diagnosis and VCSR implantation was 2.6 weeks. Postprocedural complications occurred in 19 (54.29%) patients. None of the evaluated factors has proven its statistical significance (p > 0.05) for being a potential risk factor for VPS implantation. CONCLUSION External factors seem to not affect the necessity of VPS implantation in patients after the severe IVH. Ostensibly, there seems to be no difference between the grades III and the IV of Papile's IVH scale regarding VPS implantation necessity.
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Affiliation(s)
- Adam K Bębenek
- Department of Children's Neurosurgery, Jagiellonian University Medical College, Cracow, Poland
| | - Stanisław Kwiatkowski
- Department of Children's Neurosurgery, Jagiellonian University Medical College, Cracow, Poland
| | - Olga Milczarek
- Department of Children's Neurosurgery, Jagiellonian University Medical College, Cracow, Poland
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27
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Whittemore BA, Swift DM, M Thomas J, F Chalak L. A neonatal neuroNICU collaborative approach to neuromonitoring of posthemorrhagic ventricular dilation in preterm infants. Pediatr Res 2022; 91:27-34. [PMID: 33627823 DOI: 10.1038/s41390-021-01406-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2020] [Revised: 01/25/2021] [Accepted: 01/26/2021] [Indexed: 01/31/2023]
Abstract
Morbidity and mortality in prematurely born infants have significantly improved due to advancement in perinatal care, development of NeuroNICU collaborative multidisciplinary approaches, and evidence-based management protocols that have resulted from a better understanding of perinatal risk factors and neuroprotective treatments. In premature infants with intraventricular hemorrhage (IVH), the detrimental secondary effect of posthemorrhagic ventricular dilation (PHVD) on the neurodevelopmental outcome can be mitigated by surgical intervention, though management varies considerably across institutions. Any benefit derived from the use of neuromonitoring to optimize surgical timing and technique stands to improve neurodevelopmental outcome. In this review, we summarize (1) the approaches to surgical management of PHVD in preterm infants and outcome data; (2) neuromonitoring modalities and the effect of neurosurgical intervention on this data; (3) our resultant protocol for the monitoring and management of PHVD. In particular, our protocol incorporates cerebral near-infrared spectroscopy (NIRS) and transcranial doppler ultrasound (TCD) to better understand cerebral physiology and to enable the hypothesis-driven study of the management of PHVD. IMPACT: Review of the published literature concerning the use of near-infrared spectroscopy (NIRS) and a cerebral Doppler ultrasound to study the effect of cerebrospinal fluid drainage on infants with posthemorrhagic ventricular dilation. Presentation of our institution's evidence-based protocol for the use of NIRS and cerebral Doppler ultrasound to study the optimal neurosurgical treatment of posthemorrhagic ventricular dilation, an as yet inadequately studied area.
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Affiliation(s)
- Brett A Whittemore
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Dale M Swift
- Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jennifer M Thomas
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Lina F Chalak
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX, USA
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28
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Paturu M, Triplett RL, Thukral S, Alexopoulos D, Smyser CD, Limbrick DD, Strahle JM. Does ventricle size contribute to cognitive outcomes in posthemorrhagic hydrocephalus? Role of early definitive intervention. J Neurosurg Pediatr 2022; 29:10-20. [PMID: 34653990 PMCID: PMC8743027 DOI: 10.3171/2021.4.peds212] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 04/28/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posthemorrhagic hydrocephalus (PHH) is associated with significant morbidity, smaller hippocampal volumes, and impaired neurodevelopment in preterm infants. The timing of temporary CSF (tCSF) diversion has been studied; however, the optimal time for permanent CSF (pCSF) diversion is unknown. The objective of this study was to determine whether cumulative ventricle size or timing of pCSF diversion is associated with neurodevelopmental outcome and hippocampal size in preterm infants with PHH. METHODS Twenty-five very preterm neonates (born at ≤ 32 weeks' gestational age) with high-grade intraventricular hemorrhage (IVH), subsequent PHH, and pCSF diversion with a ventriculoperitoneal shunt (n = 20) or endoscopic third ventriculostomy (n = 5) were followed until 2 years of age. Infants underwent serial cranial ultrasounds from birth until 1 year after pCSF diversion, brain MRI at term-equivalent age, and assessment based on the Bayley Scales of Infant and Toddler Development, Third Edition, at 2 years of age. Frontooccipital horn ratio (FOHR) measurements were derived from cranial ultrasounds and term-equivalent brain MRI. Hippocampal volumes were segmented and calculated from term-equivalent brain MRI. Cumulative ventricle size until the time of pCSF diversion was estimated using FOHR measurements from each cranial ultrasound performed prior to permanent intervention. RESULTS The average gestational ages at tCSF and pCSF diversion were 28.9 and 39.0 weeks, respectively. An earlier chronological age at the time of pCSF diversion was associated with larger right hippocampal volumes on term-equivalent MRI (Pearson's r = -0.403, p = 0.046) and improved cognitive (r = -0.554, p = 0.047), motor (r = -0.487, p = 0.048), and language (r = -0.414, p = 0.021) outcomes at 2 years of age. Additionally, a smaller cumulative ventricle size from birth to pCSF diversion was associated with larger right hippocampal volumes (r = -0.483, p = 0.014) and improved cognitive (r = -0.711, p = 0.001), motor (r = -0.675, p = 0.003), and language (r = -0.618, p = 0.011) outcomes. There was no relationship between time to tCSF diversion or cumulative ventricle size prior to tCSF diversion and neurodevelopmental outcome or hippocampal size. Finally, a smaller cumulative ventricular size prior to either tCSF diversion or pCSF diversion was associated with a smaller ventricular size 1 year after pCSF diversion (r = 0.422, p = 0.040, R2 = 0.178 and r = 0.519, p = 0.009, R2 = 0.269, respectively). CONCLUSIONS In infants with PHH, a smaller cumulative ventricular size and shorter time to pCSF diversion were associated with larger right hippocampal volumes, improved neurocognitive outcomes, and reduced long-term ventriculomegaly. Future prospective randomized studies are needed to confirm these findings.
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Affiliation(s)
- Mounica Paturu
- Department of Neurological Surgery, Washington University in St. Louis, Missouri
| | | | - Siddhant Thukral
- Department of Neurological Surgery, Washington University in St. Louis, Missouri
| | | | - Christopher D. Smyser
- Department of Neurology, Washington University in St. Louis, Missouri
- Department of Pediatrics, Washington University in St. Louis, Missouri
- Department of Radiology, Washington University in St. Louis, Missouri
| | - David D. Limbrick
- Department of Neurological Surgery, Washington University in St. Louis, Missouri
| | - Jennifer M. Strahle
- Department of Neurological Surgery, Washington University in St. Louis, Missouri
- Department of Pediatrics, Washington University in St. Louis, Missouri
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29
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Goeral K, Schwarz H, Hammerl M, Brugger J, Wagner M, Klebermass-Schrehof K, Kasprian G, Kiechl-Kohlendorfer U, Berger A, Olischar M. Longitudinal Reference Values for Cerebral Ventricular Size in Preterm Infants Born at 23-27 Weeks of Gestation. J Pediatr 2021; 238:110-117.e2. [PMID: 34214587 DOI: 10.1016/j.jpeds.2021.06.065] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 06/09/2021] [Accepted: 06/24/2021] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To establish longitudinal reference values for cerebral ventricular size in the most vulnerable patients at risk for intraventricular hemorrhage (IVH) and posthemorrhagic ventricular dilatation (PHVD). STUDY DESIGN This retrospective study included neurologically healthy preterm neonates born at 230/7-266/7 weeks of gestational age between September 2011 and April 2019. Patients were treated at 2 Austrian tertiary centers, Medical University of Vienna and Medical University of Innsbruck. All available cerebral ultrasound scans until 30 weeks corrected age were analyzed. Ventricular measurements included ventricular index, anterior horn width (AHW), and thalamo-occipital distance (TOD) and longitudinal percentiles were created. RESULTS The study cohort consisted of 244 preterm neonates, with a median gestational age of 253/7 weeks (IQR, 244/7-260/7 weeks) and a median birth weight of 735 g (IQR, 644-849 g). A total of 993 ultrasound scans were available for analysis, resulting in >1800 measurements of ventricular index, AHW, and TOD. Special attention was given to the 97th percentile as well as 2 mm and 4 mm above the 97th percentile, which are used internationally as cutoffs for intervention in the presence of PHVD. CONCLUSIONS We present percentile charts based on a cohort of extremely premature infants including neonates born at the border of viability suited to follow-up the most vulnerable patients at risk for IVH and PHVD. Furthermore, we provide an extensive literature research and comparison of all available reference values, focusing on ventricular index, AHW, and TOD.
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Affiliation(s)
- Katharina Goeral
- Division of Neonatology, Intensive Care, and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria.
| | - Hannah Schwarz
- Division of Neonatology, Intensive Care, and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Marlene Hammerl
- Department of Pediatrics II (Neonatology), Medical University of Innsbruck, Innsbruck, Austria
| | - Jonas Brugger
- Section for Medical Statistics, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Michael Wagner
- Division of Neonatology, Intensive Care, and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Katrin Klebermass-Schrehof
- Division of Neonatology, Intensive Care, and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Gregor Kasprian
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Radiology, Medical University of Vienna, Vienna, Austria
| | | | - Angelika Berger
- Division of Neonatology, Intensive Care, and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
| | - Monika Olischar
- Division of Neonatology, Intensive Care, and Neuropediatrics, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria
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30
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De Angelis LC, Parodi A, Sebastiani M, Consales A, Ravegnani GM, Severino M, Tortora D, Rossi A, Malova M, Minghetti D, Cama A, Piatelli G, Ramenghi LA. External ventricular drainage for posthemorrhagic ventricular dilatation in preterm infants: insights on efficacy and failure. J Neurosurg Pediatr 2021; 28:563-571. [PMID: 34479205 DOI: 10.3171/2021.5.peds20928] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 05/12/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The objective of this study was to describe the clinical and neuroradiological characteristics of a cohort of preterm infants who had undergone external ventricular drain insertion as a temporary measure to treat posthemorrhagic ventricular dilatation. In addition, the authors investigated the factors predicting permanent shunt dependency. METHODS The authors retrospectively reviewed the medical records of a cohort of preterm infants who had undergone external ventricular drain insertion at Gaslini Children's Hospital (Genoa, Italy) between March 2012 and February 2018. They also analyzed clinical characteristics and magnetic resonance imaging data, including diffusion- and susceptibility-weighted imaging studies, which were obtained before both catheter insertion and removal. RESULTS Twenty-eight infants were included in the study. The mean gestational age was 28.2 ± 2.7 weeks, and the mean birth weight was 1209 ± 476 g. A permanent ventriculoperitoneal shunt was inserted in 15/28 (53.6%) infants because of the failure of external ventricular drainage as a temporary treatment option. Compared with the shunt-free group, the shunt-dependent group had a significantly lower gestational age (29.3 ± 2.3 vs 27.2 ± 2.7 weeks, p = 0.035) and tended toward a lower birth weight (p = 0.056). None of the clinical and neuroradiological characteristics significantly differed between the shunt-free and shunt-dependent groups at the time of catheter insertion. As expected, ventricular parameters as well as the intraventricular extension of intracerebral hemorrhage, as assessed using the intraventricular hemorrhage score, were reportedly higher in the shunt-dependent group than in the shunt-free group before catheter removal. CONCLUSIONS External ventricular drainage is a reliable first-line treatment for posthemorrhagic hydrocephalus. However, predicting its efficacy as a unique treatment remains challenging. A lower gestational age is associated with a higher risk of posthemorrhagic hydrocephalus progression, suggesting that the more undeveloped the mechanisms for the clearance of blood degradation products, the greater the risk of requiring permanent cerebrospinal fluid diversion, although sophisticated MRI investigations are currently unable to corroborate this hypothesis.
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Affiliation(s)
- Laura C De Angelis
- 1Department Mother and Child, Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa.,5Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Alessandro Parodi
- 1Department Mother and Child, Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa.,5Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Marianna Sebastiani
- 1Department Mother and Child, Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa.,5Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | | | | | | | | | - Andrea Rossi
- 3Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa.,4Department of Health Sciences (DISSAL), University of Genoa, Genoa; and
| | - Mariya Malova
- 1Department Mother and Child, Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa.,5Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Diego Minghetti
- 1Department Mother and Child, Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa.,5Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Armando Cama
- 2Department of Neurosurgery, IRCCS Istituto Giannina Gaslini, Genoa.,4Department of Health Sciences (DISSAL), University of Genoa, Genoa; and
| | | | - Luca A Ramenghi
- 1Department Mother and Child, Neonatal Intensive Care Unit, IRCCS Istituto Giannina Gaslini, Genoa.,5Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
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Pavlek LR, Rivera BK, Smith CV, Randle J, Hanlon C, Small K, Bell EF, Rysavy MA, Conroy S, Backes CH. Eligibility Criteria and Representativeness of Randomized Clinical Trials That Include Infants Born Extremely Premature: A Systematic Review. J Pediatr 2021; 235:63-74.e12. [PMID: 33894262 PMCID: PMC9348995 DOI: 10.1016/j.jpeds.2021.04.028] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2021] [Revised: 03/23/2021] [Accepted: 04/15/2021] [Indexed: 02/08/2023]
Abstract
OBJECTIVE To assess the eligibility criteria and trial characteristics among contemporary (2010-2019) randomized clinical trials (RCTs) that included infants born extremely preterm (<28 weeks of gestation) and to evaluate whether eligibility criteria result in underrepresentation of high-risk subgroups (eg, infants born at <24 weeks of gestation). STUDY DESIGN PubMed and Scopus were searched January 1, 2010, to December 31, 2019, with no language restrictions. RCTs with mean or median gestational ages at birth of <28 weeks of gestation were included. The study followed the PRISMA guidelines; outcomes were registered prospectively. Data extraction was performed independently by multiple observers. Study quality was evaluated using a modified Jadad scale. RESULTS Among RCTs (n = 201), 32 552 infants were included. Study participant characteristics, interventions, and outcomes were highly variable. A total of 1603 eligibility criteria were identified; rationales were provided for 18.8% (n = 301) of criteria. Fifty-five RCTs (27.4%) included infants <24 weeks of gestation; 454 (1.4%) infants were identified as <24 weeks of gestation. CONCLUSIONS The present study identifies sources of variability across RCTs that included infants born extremely preterm and reinforces the critical need for consistent and transparent policies governing eligibility criteria.
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Affiliation(s)
- Leeann R. Pavlek
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH
| | - Brian K. Rivera
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital
| | - Charles V. Smith
- Center for Integrated Brain Research, Seattle Children’s Research Institute, Seattle, WA
| | - Joanie Randle
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Cory Hanlon
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Kristi Small
- Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH
| | - Edward F. Bell
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Matthew A. Rysavy
- Stead Family Department of Pediatrics, University of Iowa, Iowa City, IA
| | - Sara Conroy
- Center for Biostatistics, Department of Biomedical Informatics, The Ohio State University,Biostatistics Resource at Nationwide Children’s Hospital
| | - Carl H. Backes
- Center for Perinatal Research, The Abigail Wexner Research Institute at Nationwide Children’s Hospital,Department of Pediatrics and The Ohio State University Wexner Medical Center, Columbus, OH,Ohio Perinatal Research Network at Nationwide Children’s Hospital, Columbus, OH,Obstetrics and Gynecology, The Ohio State University Wexner Medical Center,The Heart Center, Nationwide Children’s Hospital, Columbus, OH
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32
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Leijser LM, Scott JN, Roychoudhury S, Zein H, Murthy P, Thomas SP, Mohammad K. Post-hemorrhagic ventricular dilatation: inter-observer reliability of ventricular size measurements in extremely preterm infants. Pediatr Res 2021; 90:403-410. [PMID: 33184496 DOI: 10.1038/s41390-020-01245-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2020] [Revised: 10/09/2020] [Accepted: 10/16/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND Post-hemorrhagic ventricular dilatation (PHVD) in preterm infants can be assessed with ventricular size indices from cranial ultrasound. We explored inter-observer reliability of these indices for prediction of severe PHVD. METHODS For all 139 infants with IVH, serial neonatal ultrasound at 3 time points (days 4-7, day 14, 36 weeks PMA) were assessed independently by 3 observers with differing levels of training/experience. Ventricular index (VI), anterior horn width (AHW), and fronto-temporal horn ratio (FTHR) were measured and used to diagnose PHVD. For all, inter-observer reliability and predictive values for receipt of surgical intervention were calculated. RESULTS Inter-observer reliability for all observers varied from poor to excellent, with higher reliability for VI/AHW (ICC 0.49-0.84/0.51-0.81) than FTHR (0.41-0.82), particularly from the second week. Good-excellent inter-expertise reliability was found between observers with ample experience/training (0.65-0.99), particularly for VI and AHW, while poor-moderate when comparing with an inexperienced observer (0.28-0.88). Slightly higher predictive value for PHVD intervention (n = 12) was found for AHW (AUC 0.86-0.96) than for VI and FTHR (0.80-0.96/0.80-0.95). CONCLUSIONS AHW and VI are highly reproducible in experienced hands compared to FTHR, with AHW from the second week onwards being the strongest predictor for receiving surgical intervention for severe PHVD. AHW may aid in early PHVD diagnosis and decision-making on intervention. IMPACT While ventricular size indices from serial cUS are superior to clinical signs of increased intracranial pressure to assess PHVD, questions remained on their inter-observer reproducibility and reliability to predict severity of PHVD. AHW and VI are highly reproducible when performed by experienced clinicians. AHW from the second week of birth is the strongest predictor of PHVD onset and severity. AHW, combined with VI, may aid in early PHVD diagnosis and decision-making on need for surgical intervention. Consistent use of these indices has the potential to improve PHVD management and therewith the long-term outcomes in preterm infants.
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Affiliation(s)
- Lara M Leijser
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada.
| | - James N Scott
- Department of Diagnostic Imaging, University of Calgary, Calgary, AB, Canada
| | - Smita Roychoudhury
- Department of Pediatrics, McMaster Children's Hospital, Hamilton Health Sciences, Hamilton, ON, Canada
| | - Hussein Zein
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Prashanth Murthy
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Sumesh P Thomas
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
| | - Khorshid Mohammad
- Section of Neonatology, Department of Pediatrics, University of Calgary, Calgary, AB, Canada
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Cohen S, Mietzsch U, Coghill C, Dereddy N, Ducis K, El Ters N, Heuer GG, Sewell E, Flibotte J. Survey of Quaternary Neonatal Management of Posthemorrhagic Hydrocephalus. Am J Perinatol 2021; 40:883-892. [PMID: 34293803 DOI: 10.1055/s-0041-1732417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE This study aimed to determine clinical care practices for infants at risk for posthemorrhagic hydrocephalus (PHH) across level IV neonatal intensive care units (NICUs). STUDY DESIGN Cross-sectional survey that addressed center-specific surveillance, neurosurgical intervention, and follow-up practices within the Children's Hospitals Neonatal Consortium. RESULTS We had a 59% (20/34 sites) response rate, with 10 sites having at least two participants. Respondents included neonatologists (53%) and neurosurgeons (35%). Most participants stated having a standard guideline for PHH (79%). Despite this, 42% of respondents perceive inconsistencies in management. Eight same-center pairs of neonatologists and neurosurgeons were used to determine response agreement. Half of these pairs disagreed on nearly all aspects of care. The greatest agreement pertained to a willingness to adopt a consensus-based protocol. CONCLUSION Practice variation in the management of infants at risk of PHH in level IV NICUs exists despite the perception that a common practice is available and used. KEY POINTS · Practice variation exists despite the perception that common practices are available/used for PHH.. · Our survey had same-center pairs of neonatologist and neurosurgeons to determine response agreement.. · The greatest agreement pertained to a willingness to adopt a consensus-based protocol..
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Affiliation(s)
- Susan Cohen
- Division of Neonatology, Department of Pediatrics, Medical College of Wisconsin, Children's Wisconsin, Milwaukee, Wisconsin
| | - Ulrike Mietzsch
- Division of Neonatology, Department of Pediatrics, University of Washington Medical School, Seattle Children's Hospital, Seattle, Washington
| | - Carl Coghill
- Division of Neonatology, Department of Pediatrics, University of Alabama, Children's of Alabama, Birmingham, Alabama
| | - Narendra Dereddy
- Division of Neonatology, Department of Pediatrics, University of Central Florida College of Medicine, AdventHealth for Children, Orlando, Florida
| | - Katerina Ducis
- Division of Neurosurgery, Department of Surgery, University of Vermont College of Medicine, Burlington, Vermont
| | - Nathalie El Ters
- Department of Pediatrics, Washington University School of Medicine, St. Louis Children's Hospital, St. Louis, Missouri
| | - Gregory G Heuer
- Division of Neurosurgery, Department of Surgery, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Elizabeth Sewell
- Division of Neonatology, Department of Pediatrics, Children's Healthcare of Atlanta & Emory University School of Medicine, Atlanta, Georgia
| | - John Flibotte
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
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34
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Cizmeci MN, Groenendaal F, de Vries LS. Timing of Intervention for Posthemorrhagic Ventricular Dilatation: An Ongoing Debate. J Pediatr 2021; 234:14-16. [PMID: 33592220 DOI: 10.1016/j.jpeds.2021.02.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/07/2021] [Indexed: 01/06/2023]
Affiliation(s)
- Mehmet N Cizmeci
- Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht University, University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center, Utrecht University, University Medical Center Utrecht, Utrecht Brain Center, Utrecht, The Netherlands.
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35
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Lai GY, Chu-Kwan W, Westcott AB, Kulkarni AV, Drake JM, Lam SK. Timing of Temporizing Neurosurgical Treatment in Relation to Shunting and Neurodevelopmental Outcomes in Posthemorrhagic Ventricular Dilatation of Prematurity: A Meta-analysis. J Pediatr 2021; 234:54-64.e20. [PMID: 33484696 DOI: 10.1016/j.jpeds.2021.01.030] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 12/11/2020] [Accepted: 01/14/2021] [Indexed: 12/25/2022]
Abstract
OBJECTIVE To determine the relationship between timing of initiation of temporizing neurosurgical treatment and rates of ventriculoperitoneal shunt (VPS) and neurodevelopmental impairment in premature infants with post-hemorrhagic ventricular dilatation (PHVD). STUDY DESIGN We searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Database of Systematic Reviews, and the Cochrane Center Register of Controlled Trials for studies that reported on premature infants with PHVD who underwent a temporizing neurosurgical procedure. The timing of the temporizing neurosurgical procedure, gestational age, birth weight, outcomes of conversion to VPS, moderate-to-severe neurodevelopmental impairment, infection, temporizing neurosurgical procedure revision, and death at discharge were extracted. RESULTS Sixty-two full-length articles and 6 conference abstracts (n = 2533 patients) published through November 2020 were included. Pooled rate for conversion to VPS was 60.5% (95% CI, 54.9-65.8), moderate-severe neurodevelopmental impairment 34.8% (95% CI, 27.4-42.9), infection 8.2% (95% CI, 6.7-10.1), revision 14.6% (95% CI, 10.4-20.1), and death 12.9% (95% CI, 10.2-16.4). The average age at temporizing neurosurgical procedure was 24.2 ± 11.3 days. On meta-regression, older age at temporizing neurosurgical procedure was a predictor of conversion to VPS (P < .001) and neurodevelopmental impairment (P < .01). Later year of publication predicted increased survival (P < .01) and external ventricular drains were associated with more revisions (P = .001). Tests for heterogeneity reached significance for all outcomes and a qualitative review showed heterogeneity in the study inclusion and diagnosis criteria for PHVD and initiation of temporizing neurosurgical procedure. CONCLUSIONS Later timing of temporizing neurosurgical procedure predicted higher rates of conversion to VPS and moderate-severe neurodevelopmental impairment. Outcomes were often reported relative to the number of patients who underwent a temporizing neurosurgical procedure and the criteria for study inclusion and the initiation of temporizing neurosurgical procedure varied across institutions. There is need for more comprehensive outcome reporting that includes all infants with PHVD regardless of treatment.
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Affiliation(s)
- Grace Y Lai
- Department of Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, IL; Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada.
| | - William Chu-Kwan
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Departments of Surgery and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Annie B Westcott
- Galter Health Science Library, Northwestern University, Chicago, IL
| | - Abhaya V Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Departments of Surgery and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - James M Drake
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Ontario, Canada; Departments of Surgery and Biomedical Engineering, University of Toronto, Toronto, Ontario, Canada
| | - Sandi K Lam
- Department of Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, IL; Division of Neurosurgery, Ann & Robert Lurie Children's Hospital, Chicago, IL
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36
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Deger J, Goethe EA, LoPresti MA, Lam S. Intraventricular Hemorrhage in Premature Infants: A Historical Review. World Neurosurg 2021; 153:21-25. [PMID: 34144164 DOI: 10.1016/j.wneu.2021.06.043] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 11/29/2022]
Abstract
Intraventricular hemorrhage (IVH) is common in premature newborns and poses a high risk for morbidity with lifelong disability. We searched the available literature for original and secondary literature regarding the epidemiology, pathogenesis, and treatment of IVH in order to trace changes in the management of this disease over time. We examined IVH pathogenesis and epidemiology and reviewed the history of medical and surgical treatment for intraventricular hemorrhage in preterm children. Initial medical management strategies aimed at correcting coagulopathy and eventually targeted mediators of perinatal instability including respiratory distress. Surgical management centered around cerebrospinal fluid diversion, initially through serial lumbar punctures, progressing to ventriculoperitoneal shunting, with more recent interventions addressing intraventricular clot burden. We provide a historical review of the evolution of treatment for IVH in newborns. While the management of IVH has grown significantly over time, IVH remains a common neurosurgical disease that continues to affect patient and caregiver quality of life and health care costs. Despite advances in treatment over more than a century, IVH remains a significant cause of morbidity and mortality in premature infants, and an understanding of past approaches may inform the development of new treatments.
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Affiliation(s)
- Jennifer Deger
- Department of Neurosurgery, Baylor College of Medicine, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Eric A Goethe
- Department of Neurosurgery, Baylor College of Medicine, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Melissa A LoPresti
- Department of Neurosurgery, Baylor College of Medicine, Division of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Sandi Lam
- Department of Neurosurgery, Northwestern University School of Medicine, Division of Neurosurgery, Lurie Children's Hospital, Chicago, Illinois, USA.
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Fronto-temporal horn ratio: yet another marker of ventriculomegaly? Pediatr Res 2021; 89:1602-1603. [PMID: 33531678 DOI: 10.1038/s41390-021-01379-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 01/01/2021] [Indexed: 11/08/2022]
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38
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Obeid R, Jacobs M, Chang T, Massaro AN, Bluth E, Murnick JG, Bulas D, Bandarkar A, Oluigbo C, Penn AA. The utility of the fronto-temporal horn ratio on cranial ultrasound in premature newborns: a ventriculomegaly marker. Pediatr Res 2021; 89:1715-1723. [PMID: 33504959 DOI: 10.1038/s41390-020-01337-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/30/2020] [Accepted: 12/09/2020] [Indexed: 11/09/2022]
Abstract
BACKGROUND The aims of this study were to find the normal value of fronto-temporal horn ratio (FTHR) as a marker of ventriculomegaly on cranial ultrasound (CUS) in premature newborns and the relation to white matter injury (WMI) and cerebral palsy (CP). METHODS This is a retrospective study of newborns admitted between 2011 and 2014. Inclusion criteria were: (1) gestation <29 weeks, (2) birth weight ≤1500 g, (3) referred within 7 days of life, (4) at least two CUS preformed, (5) brain magnetic resonance imaging (MRI) at term age-equivalent. Intraventricular hemorrhage (IVH) grade was identified and FTHR was measured on all CUS. WMI on MRI was evaluated through (1) injury score (Kidokoro 2013) and (2) fractional anisotropy (FA) on the MRI diffusion tensor imaging. CP was estimated using the gross motor function classification system (GMFCS). RESULTS One hundred neonates met the inclusion criteria: 37 with no IVH, 36 with IVH grade 1-2, and 27 with IVH grade 3-4. The FTHR cut-point of 0.51 had the highest sensitivity and specificity for moderate-to-severe WMI. In the IVH grade 3-4 group, the elevated FTHR correlated with lower FA and higher GMFCS. CONCLUSIONS FTHR is a useful quantitative biomarker of ventriculomegaly in preterm newborns. It may help standardize ventricular measurement and direct intervention. IMPACT The fronto-temporal horn ratio has the potential to become a standardized tool that can provide an actionable measure to direct intervention for post-hemorrhagic ventricular dilation. This current study will provide the basis of a future clinical trial to optimize intervention timing to decrease the risk of white matter injury in this vulnerable population.
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Affiliation(s)
- Rawad Obeid
- Neurology, Beaumont Children Hospital/Oakland University School of Medicine, Royal Oak, MI, USA.
| | - Marni Jacobs
- Children's Research Institute, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Taeun Chang
- Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - An N Massaro
- Neonatology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.,Center for Neuroscience Research, Children's Research Institute, Washington, DC, USA.,Fetal and Translational Medicine, Children's National Hospital, Washington, DC, USA
| | - Eresha Bluth
- Center for Neuroscience Research, Children's Research Institute, Washington, DC, USA
| | - Jonathan G Murnick
- Radiology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Dorothy Bulas
- Radiology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anjum Bandarkar
- Radiology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Chima Oluigbo
- Pediatric Neurosurgery, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Anna A Penn
- Neonatology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA.,Center for Neuroscience Research, Children's Research Institute, Washington, DC, USA.,Fetal and Translational Medicine, Children's National Hospital, Washington, DC, USA.,Chief, Division of Neonatology, Department of Pediatrics, Columbia University, New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, 10032, USA
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39
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Iglesias S, Ros B, Ros A, Selfa A, Linares J, Rius F, Arráez MA. Quality of life in school-age children with shunt implantation due to neonatal posthemorrhagic hydrocephalus. Childs Nerv Syst 2021; 37:1127-1135. [PMID: 33185712 DOI: 10.1007/s00381-020-04945-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 10/23/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE To assess the functional outcome in school-age children shunted in the neonatal period due to post-hemorrhagic hydrocephalus (PHH), using the HOQ-Spanish version (HOQ-sv), and to analyze predictors of quality of life in this group. METHODS A cross-sectional study was performed between 2015 and 2018. Parents of pediatric patients with PHH attending our neurosurgery outpatient clinic were invited to complete the HOQ-sv and to enroll in the study. Clinical variables regarding the patients' neonatal course and surgical outcome were recorded. A descriptive analysis was done, and independent variables related to the HOQ scores were studied in univariate and multivariate analyses with regression trees. RESULTS The study comprised a total of 52 patients. The mean overall HOQ score was 0.67 (on a scale from 0 [worse] to 1 [best]). The quality of life for the PHH children at school age was related to perinatal factors (gestational age at birth, time until shunt surgery, length of hospitalization at the time of shunt implantation, and comorbidity), shunt complications (symptomatic overdrainage, number of shunt revisions, and shunt revisions related to infection during the first year after treatment), and clinical background (seizures, spasticity, Gross Motor Function Classification System level or visual impairment). CONCLUSION HOQ dimension scores in school-age children shunted due to PHH in our center were similar to those of referral centers for other etiologies of pediatric hydrocephalus. Future goals should be the prevention of complications related to worse outcomes at the time of diagnosis and to try to improve shunt performance later.
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Affiliation(s)
- Sara Iglesias
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Malaga, Spain.
| | - Bienvenido Ros
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Malaga, Spain
| | - Angela Ros
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Malaga, Spain
| | - Antonio Selfa
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Malaga, Spain
| | - Jorge Linares
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Malaga, Spain
| | - Francisca Rius
- Statistics Department, Universidad de Málaga, Malaga, Spain
| | - Miguel Angel Arráez
- Department of Neurosurgery, Hospital Regional Universitario de Málaga, Avenida de Carlos Haya s/n, 29010, Malaga, Spain
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White matter injury in infants with intraventricular haemorrhage: mechanisms and therapies. Nat Rev Neurol 2021; 17:199-214. [PMID: 33504979 PMCID: PMC8880688 DOI: 10.1038/s41582-020-00447-8] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/07/2020] [Indexed: 01/31/2023]
Abstract
Intraventricular haemorrhage (IVH) continues to be a major complication of prematurity that can result in cerebral palsy and cognitive impairment in survivors. No optimal therapy exists to prevent IVH or to treat its consequences. IVH varies in severity and can present as a bleed confined to the germinal matrix, small-to-large IVH or periventricular haemorrhagic infarction. Moderate-to-severe haemorrhage dilates the ventricle and damages the periventricular white matter. This white matter injury results from a constellation of blood-induced pathological reactions, including oxidative stress, glutamate excitotoxicity, inflammation, perturbed signalling pathways and remodelling of the extracellular matrix. Potential therapies for IVH are currently undergoing investigation in preclinical models and evidence from clinical trials suggests that stem cell treatment and/or endoscopic removal of clots from the cerebral ventricles could transform the outcome of infants with IVH. This Review presents an integrated view of new insights into the mechanisms underlying white matter injury in premature infants with IVH and highlights the importance of early detection of disability and immediate intervention in optimizing the outcomes of IVH survivors.
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Cerebrospinal fluid NCAM-1 concentration is associated with neurodevelopmental outcome in post-hemorrhagic hydrocephalus of prematurity. PLoS One 2021; 16:e0247749. [PMID: 33690655 PMCID: PMC7946285 DOI: 10.1371/journal.pone.0247749] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Accepted: 02/12/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE Efforts directed at mitigating neurological disability in preterm infants with intraventricular hemorrhage (IVH) and post hemorrhagic hydrocephalus (PHH) are limited by a dearth of quantifiable metrics capable of predicting long-term outcome. The objective of this study was to examine the relationships between candidate cerebrospinal fluid (CSF) biomarkers of PHH and neurodevelopmental outcomes in infants undergoing neurosurgical treatment for PHH. STUDY DESIGN Preterm infants with PHH were enrolled across the Hydrocephalus Clinical Research Network. CSF samples were collected at the time of temporizing neurosurgical procedure (n = 98). Amyloid precursor protein (APP), L1CAM, NCAM-1, and total protein (TP) were compared in PHH versus control CSF. Fifty-four of these PHH subjects underwent Bayley Scales of Infant Development-III (Bayley-III) testing at 15-30 months corrected age. Controlling for false discovery rate (FDR) and adjusting for post-menstrual age (PMA) and IVH grade, Pearson's partial correlation coefficients were used to examine relationships between CSF proteins and Bayley-III composite cognitive, language, and motor scores. RESULTS CSF APP, L1CAM, NCAM-1, and TP were elevated in PHH over control at temporizing surgery. CSF NCAM-1 was associated with Bayley-III motor score (R = -0.422, p = 0.007, FDR Q = 0.089), with modest relationships noted with cognition (R = -0.335, p = 0.030, FDR Q = 0.182) and language (R = -0.314, p = 0.048, FDR Q = 0.194) scores. No relationships were observed between CSF APP, L1CAM, or TP and Bayley-III scores. FOHR at the time of temporization did not correlate with Bayley-III scores, though trends were observed with Bayley-III motor (p = 0.0647 and R = -0.2912) and cognitive scores (p = 0.0506 and R = -0.2966). CONCLUSION CSF NCAM-1 was associated with neurodevelopment in this multi-institutional PHH cohort. This is the first report relating a specific CSF protein, NCAM-1, to neurodevelopment in PHH. Future work will further investigate a possible role for NCAM-1 as a biomarker of PHH-associated neurological disability.
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Vesoulis ZA, Whitehead HV, Liao SM, Mathur AM. The hidden consequence of intraventricular hemorrhage: persistent cerebral desaturation after IVH in preterm infants. Pediatr Res 2021; 89:869-877. [PMID: 33038871 PMCID: PMC8035346 DOI: 10.1038/s41390-020-01189-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 08/05/2020] [Accepted: 08/10/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND Previous studies describe a short-term decrease in cerebral oxygen saturation (StO2) after intraventricular hemorrhage (IVH) in premature infants; little is known about long-term implications. METHODS Infants born <30 weeks gestational age (GA) were included. Clinical characteristics, hemoglobin measurements, the highest grade of IVH, and white matter injury (WMI) were noted. NIRS monitoring occurred daily or every other day for 4 weeks; weekly through 36 weeks GA. Recordings were error-corrected before calculation of mean StO2 and fractional tissue oxygen extraction (FTOE). Mean StO2 and FTOE were plotted by postnatal age and injury group (IVH/no IVH; WMI/no WMI). Non-linear regression by locally estimated scatterplot smoothing was used to generate the best-fit line and CI. RESULTS A total of 1237 recordings from 185 infants were included; mean length = 6.5 h; mean GA = 26.3 w; mean BW = 951 g; overall/severe IVH incidence was 29/8%, WMI incidence was 16%. IVH was independently associated with an acute drop in StO2, which remained lower for 68 d. Severe IVH was associated with lower StO2 values than mild IVH. WMI was associated with early and persistent elevation of FTOE. CONCLUSION IVH of any grade is associated with a prolonged cerebral desaturation and WMI is associated with prolonged elevation of FTOE. This finding is exacerbated for infants with severe IVH. IMPACT The longitudinal impact of IVH on cerebral oxygenation has not been previously studied. IVH is associated with persistent cerebral desaturation, months in length, and is independent of anemia. More severe IVH is associated with worsened cerebral hypoxia. Infants later diagnosed with white matter injury have an early and persistent elevation of cerebral oxygen extraction (cFTOE). This cerebral desaturation, below previously identified normative ranges, may provide insight into the mechanistic link between IVH and white matter injury.
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Affiliation(s)
- Zachary A Vesoulis
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA.
| | - Halana V Whitehead
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Steve M Liao
- Division of Newborn Medicine, Department of Pediatrics, Washington University School of Medicine, St. Louis, MO, USA
| | - Amit M Mathur
- Division of Neonatal-Perinatal Medicine, Department of Pediatrics, Saint Louis University, St. Louis, MO, USA
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Goeral K, Hauck A, Atkinson A, Wagner MB, Pimpel B, Fuiko R, Klebermass-Schrehof K, Leppert D, Kuhle J, Berger A, Olischar M, Wellmann S. Early life serum neurofilament dynamics predict neurodevelopmental outcome of preterm infants. J Neurol 2021; 268:2570-2577. [PMID: 33566157 PMCID: PMC8217001 DOI: 10.1007/s00415-021-10429-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 01/23/2021] [Accepted: 01/27/2021] [Indexed: 02/07/2023]
Abstract
Background and purpose To determine whether neurofilament light chain (NfL), a promising serum and cerebrospinal fluid (CSF) biomarker of neuroaxonal damage, predicts functional outcome in preterm infants with neonatal brain injury. Methods Our prospective observational study used a sensitive single-molecule array assay to measure serum and CSF NfL concentrations in preterm infants with moderate to severe peri/intraventricular hemorrhage (PIVH). We determined temporal serum and CSF NfL profiles from the initial diagnosis of PIVH until term-equivalent age and their association with clinical and neurodevelopmental outcome until 2 years of age assessed by Bayley Scales of Infant Development (3rd edition). We fitted univariate and multivariate logistic regression models to determine risk factors for poor motor and cognitive development. Results The study included 48 infants born at < 32 weeks of gestation. Median serum NfL (sNfL) at PIVH diagnosis was 251 pg/mL [interquartile range (IQR) 139–379], decreasing markedly until term-equivalent age to 15.7 pg/mL (IQR 11.1–33.5). CSF NfL was on average 113-fold higher (IQR 40–211) than corresponding sNfL values. Additional cerebral infarction (n = 25)-but not post-hemorrhagic hydrocephalus requiring external ventricular drainage (n = 29) nor any other impairment-was independently associated with sNfL. Multivariate logistic regression models identified sNfL as an independent predictor of poor motor outcome or death at 1 and 2 years. Conclusions Serum neurofilament light chain dynamics in the first weeks of life predict motor outcome in preterm infants with PIVH. Supplementary Information The online version contains supplementary material available at 10.1007/s00415-021-10429-5.
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Affiliation(s)
- Katharina Goeral
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | - Annalisa Hauck
- Division of Neonatology, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland
| | - Andrew Atkinson
- Division of Pediatric Pharmacology and Pharmacometrics, University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Michael B Wagner
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | - Birgit Pimpel
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | - Renate Fuiko
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | - Katrin Klebermass-Schrehof
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | - David Leppert
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Jens Kuhle
- Neurologic Clinic and Policlinic, Departments of Medicine, Biomedicine and Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Angelika Berger
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | - Monika Olischar
- Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Pediatric Intensive Care and Neuropediatrics, Comprehensive Center for Pediatrics, Medical University Vienna, Vienna, Austria
| | - Sven Wellmann
- Division of Neonatology, University Children's Hospital Basel (UKBB), University of Basel, Basel, Switzerland. .,Division of Neonatology, Campus Hospital St. Hedwig, University Children's Hospital Regensburg (KUNO), University of Regensburg, Steinmetzstr 1-3, 93049, Regensburg, Germany.
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Automatic segmentation of ventricular volume by 3D ultrasonography in post haemorrhagic ventricular dilatation among preterm infants. Sci Rep 2021; 11:567. [PMID: 33436974 PMCID: PMC7803781 DOI: 10.1038/s41598-020-80783-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2020] [Accepted: 12/23/2020] [Indexed: 11/11/2022] Open
Abstract
To train, evaluate, and validate the application of a deep learning framework in three-dimensional ultrasound (3D US) for the automatic segmentation of ventricular volume in preterm infants with post haemorrhagic ventricular dilatation (PHVD). We trained a 2D convolutional neural network (CNN) for automatic segmentation ventricular volume from 3D US of preterm infants with PHVD. The method was validated with the Dice similarity coefficient (DSC) and the intra-class coefficient (ICC) compared to manual segmentation. The mean birth weight of the included patients was 1233.1 g (SD 309.4) and mean gestational age was 28.1 weeks (SD 1.6). A total of 152 serial 3D US from 10 preterm infants with PHVD were analysed. 230 ventricles were manually segmented. Of these, 108 were used for training a 2D CNN and 122 for validating the methodology for automatic segmentation. The global agreement for manual versus automated measures in the validation data (n = 122) was excellent with an ICC of 0.944 (0.874–0.971). The Dice similarity coefficient was 0.8 (± 0.01). 3D US based ventricular volume estimation through an automatic segmentation software developed through deep learning improves the accuracy and reduces the processing time needed for manual segmentation using VOCAL. 3D US should be considered a promising tool to help deepen our current understanding of the complex evolution of PHVD.
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Parodi A, Giordano I, De Angelis L, Malova M, Calevo MG, Preiti D, Ravegnani M, Cama A, Bellini C, Ramenghi LA. Post-haemorrhagic hydrocephalus management: Delayed neonatal transport negatively affects outcome. Acta Paediatr 2021; 110:168-170. [PMID: 33007123 DOI: 10.1111/apa.15604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 07/20/2020] [Accepted: 09/28/2020] [Indexed: 11/28/2022]
Abstract
BACKGROUND Post-haemorrhagic ventricular dilatation (PHVD) still represents an important cause of brain injury in premature infants. Intervention for PHVD is recommended once Ventricular Index (VI) crosses the 97th percentile + 4 mm line according to Levene. OBJECTIVES We aimed to compare PHVD severity, timing of intervention, and outcome between outborn infants transferred to a level IV NICU in order to be treated for PHVD and a control population of inborn infants. METHODS Preterm infants with PHVD requiring treatment were divided into: outborn infants (transferred to our NICU in order to be treated for PHVD) and inborn infants (PHVD diagnosed at our NICU). Age at intervention, difference between VI and the 97th percentile according to postmenstrual age (VI-p97), permanent shunt rate, and developmental delay rate were compared between the two groups. Neurodevelopmental outcome was assessed using the Vineland Adaptive Behavior Scales II (VABS-II), a parental questionnaire investigating four domains of adaptive behaviour and overall adaptive functioning. Developmental delay was defined as a score <70 (-2 SD or less). RESULTS Twelve outborn and 15 inborn infants were included. Age at intervention (31.6 vs 17.4 days) and VI-p97 (left 10.0 vs 5.1 mm, right 7.7 vs 5.1 mm) were significantly higher among outborn infants. A permanent shunt was inserted in 66.7% of outborn and in 40.0% of inborn infants (p = 0.18). After excluding subjects with parenchymal lesions, a significantly higher rate of developmental delay was observed at 5 years in outborn patients compared to inborn patients (66.7% of outborn vs 18.2% of inborn patients with VABS-II composite score <70, p = 0.04). CONCLUSIONS Outborn infants reached a significantly more severe ventricular dilatation than inborn infants, largely exceeding the recommended cutoff for intervention. Our follow-up data showed a trend towards a higher rate of permanent shunt and developmental delay in outborn than in inborn patients. Infants requiring treatment should be timely transported to centres with adequate expertise in PHVD management.
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Affiliation(s)
- Alessandro Parodi
- Neonatal Intensive Care Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Ilaria Giordano
- Neonatal Intensive Care Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Laura De Angelis
- Neonatal Intensive Care Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Mariya Malova
- Neonatal Intensive Care Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Maria Grazia Calevo
- Epidemiology and Biostatistics Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Deborah Preiti
- Neonatal Intensive Care Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Marcello Ravegnani
- Paediatric Neurosurgery Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Armando Cama
- Paediatric Neurosurgery Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Carlo Bellini
- Neonatal Intensive Care Unit IRCCS Istituto Giannina Gaslini Genoa Italy
| | - Luca A. Ramenghi
- Neonatal Intensive Care Unit IRCCS Istituto Giannina Gaslini Genoa Italy
- Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics, Maternal and Child Health (DINOGMI) University of Genoa Genoa Italy
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Chari A, Mallucci C, Whitelaw A, Aquilina K. Intraventricular haemorrhage and posthaemorrhagic ventricular dilatation: moving beyond CSF diversion. Childs Nerv Syst 2021; 37:3375-3383. [PMID: 33993367 PMCID: PMC8578081 DOI: 10.1007/s00381-021-05206-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 05/04/2021] [Indexed: 11/28/2022]
Abstract
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.
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Affiliation(s)
- Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK ,Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Conor Mallucci
- Department of Neurosurgery, Alder Hey Children’s Hospital, Liverpool, UK
| | - Andrew Whitelaw
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, UK
| | - Kristian Aquilina
- Department of Neurosurgery, Great Ormond Street Hospital, London, UK. .,Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK.
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Garcia-Navarro V, Perez-Vega C, Robles-Lomelín P, Valdez-Sandoval P, Vazquez PMG, Rodriguez YL, Cortes SGL, Naranjo EC. Early intervention and neurodevelopmental outcome of infants with posthemorrhagic hydrocephalus: A case series and literature review. Clin Neurol Neurosurg 2020; 201:106432. [PMID: 33383466 DOI: 10.1016/j.clineuro.2020.106432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2020] [Revised: 11/28/2020] [Accepted: 12/09/2020] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Intraventricular hemorrhage (IVH) is the most common central nervous system pathology in preterm infants. No consensus has been reached over the best indication for intervention in patients with posthemorrhagic hydrocephalus (PHH). The authors present the neurological outcome of infants with IVH and an early treatment approach, defined as an intervention when ventricular dilation is less than 4-mm over the 97th-percentile of Levene's index. METHODS We performed a retrospective case-series study of 12 infants who had IVH and an early intervention, their neurological development was evaluated after 18-months of corrected age using the Bayley-III Scales. Measures of central tendency and Pearson's correlation were used for data analysis. RESULTS In a 15-month period, twelve patients were diagnosed with IVH and underwent an early intervention. At the time of diagnosis, 2 patients had grade II IVH, 7 grade III, and 3 grade IV. Subgaleal shunt was the first intervention. 9 (75 %) ultimately required a ventriculoperitoneal shunt. A total of 9 (75 %) patients had normal cognitive scores, 7 (58.3 %) for the language-composite, and 8 (66.7 %) for the motor-composite. 6 (50 %) patients had normal scores in all composites. The average scores reported normal results (CC:98.33 ± 22.59; LC:98.25 ± 23.93; MC:88.58 ± 21.47). There was a significant correlation between antenatal steroids and the LC-score (p = 0.044). CONCLUSIONS Half of the patients with PHH and early neurosurgical interventions had an average or above average neurodevelopmental score in all three areas. Current literature and undergoing clinical trials have shown promising results on the implementation of this type of intervention.
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Affiliation(s)
- Victor Garcia-Navarro
- Tecnologico De Monterrey, School of Medicine and Health Sciences, Guadalajara campus, Zapopan, Jalisco, México; Department of Neurology and Neurosurgery, Instituto Neurológico de Guadalajara S.C., Guadalajara, Jalisco, México; Department of Neurosurgery, Nuevo Hospital Civil de Guadalajara Juan I. Menchaca OPD, Guadalajara, Jalisco, México.
| | - Carlos Perez-Vega
- Tecnologico De Monterrey, School of Medicine and Health Sciences, Guadalajara campus, Zapopan, Jalisco, México
| | - Pilar Robles-Lomelín
- Tecnologico De Monterrey, School of Medicine and Health Sciences, Guadalajara campus, Zapopan, Jalisco, México
| | - Paola Valdez-Sandoval
- Tecnologico De Monterrey, School of Medicine and Health Sciences, Guadalajara campus, Zapopan, Jalisco, México
| | - Paola M Garnica Vazquez
- Department of Neonatology, Nuevo Hospital Civil de Guadalajara Juan I. Menchaca OPD, Guadalajara, Jalisco, México
| | - Yazmin Lemus Rodriguez
- Department of Neurosurgery, Nuevo Hospital Civil de Guadalajara Juan I. Menchaca OPD, Guadalajara, Jalisco, México
| | - Silvia G Leon Cortes
- Centro Universitario de Ciencias de la Salud CUCS, Universidad de Guadalajara, Guadalajara, Jalisco, México
| | - Eva Chavana Naranjo
- Department of Neonatology, Nuevo Hospital Civil de Guadalajara Juan I. Menchaca OPD, Guadalajara, Jalisco, México; Centro Universitario de Ciencias de la Salud CUCS, Universidad de Guadalajara, Guadalajara, Jalisco, México
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Outcomes Following Post-Hemorrhagic Ventricular Dilatation among Infants of Extremely Low Gestational Age. J Pediatr 2020; 226:36-44.e3. [PMID: 32739261 PMCID: PMC7855243 DOI: 10.1016/j.jpeds.2020.07.080] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Revised: 07/24/2020] [Accepted: 07/27/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE To assess outcomes following post-hemorrhagic ventricular dilatation (PHVD) among infants born at ≤26 weeks of gestation. STUDY DESIGN Observational study of infants born April 1, 2011, to December 31, 2015, in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network and categorized into 3 groups: PHVD, intracranial hemorrhage without ventricular dilatation, or normal head ultrasound. PHVD was treated per center practice. Neurodevelopmental impairment at 18-26 months was defined by cerebral palsy, Bayley Scales of Infant and Toddler Development, 3rd edition, cognitive or motor score <70, blindness, or deafness. Multivariable logistic regression examined the association of death or impairment, adjusting for neonatal course, center, maternal education, and parenchymal hemorrhage. RESULTS Of 4216 infants, 815 had PHVD, 769 had hemorrhage without ventricular dilatation, and 2632 had normal head ultrasounds. Progressive dilatation occurred among 119 of 815 infants; the initial intervention in 66 infants was reservoir placement and 53 had ventriculoperitoneal shunt placement. Death or impairment occurred among 68%, 39%, and 28% of infants with PHVD, hemorrhage without dilatation, and normal head ultrasound, respectively; aOR (95% CI) were 4.6 (3.8-5.7) PHVD vs normal head ultrasound scan and 2.98 (2.3-3.8) for PHVD vs hemorrhage without dilatation. Death or impairment was more frequent with intervention for progressive dilatation vs no intervention (80% vs 65%; aOR 2.2 [1.38-3.8]). Death or impairment increased with parenchymal hemorrhage, intervention for PHVD, male sex, and surgery for retinopathy; odds decreased with each additional gestational week. CONCLUSIONS PHVD was associated with high rates of death or impairment among infants with gestational ages ≤26 weeks; risk was further increased among those with progressive ventricular dilation requiring intervention.
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Cizmeci MN, Groenendaal F, Liem KD, van Haastert IC, Benavente-Fernández I, van Straaten HLM, Steggerda S, Smit BJ, Whitelaw A, Woerdeman P, Heep A, de Vries LS. Randomized Controlled Early versus Late Ventricular Intervention Study in Posthemorrhagic Ventricular Dilatation: Outcome at 2 Years. J Pediatr 2020; 226:28-35.e3. [PMID: 32800815 DOI: 10.1016/j.jpeds.2020.08.014] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 07/16/2020] [Accepted: 08/06/2020] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To compare the effect of intervention at low vs high threshold of ventriculomegaly in preterm infants with posthemorrhagic ventricular dilatation on death or severe neurodevelopmental disability. STUDY DESIGN This multicenter randomized controlled trial reviewed lumbar punctures initiated after either a low threshold (ventricular index of >p97 and anterior horn width of >6 mm) or high threshold (ventricular index of >p97 + 4 mm and anterior horn width of >10 mm). The composite adverse outcome was defined as death or cerebral palsy or Bayley composite cognitive/motor scores <-2 SDs at 24 months corrected age. RESULTS Outcomes were assessed in 113 of 126 infants. The composite adverse outcome was seen in 20 of 58 infants (35%) in the low threshold group and 28 of 55 (51%) in the high threshold (P = .07). The low threshold intervention was associated with a decreased risk of an adverse outcome after correcting for gestational age, severity of intraventricular hemorrhage, and cerebellar hemorrhage (aOR, 0.24; 95% CI, 0.07-0.87; P = .03). Infants with a favorable outcome had a smaller fronto-occipital horn ratio (crude mean difference, -0.06; 95% CI, -0.09 to -0.03; P < .001) at term-equivalent age. Infants in the low threshold group with a ventriculoperitoneal shunt, had cognitive and motor scores similar to those without (P = .3 for both), whereas in the high threshold group those with a ventriculoperitoneal shunt had significantly lower scores than those without a ventriculoperitoneal shunt (P = .01 and P = .004, respectively). CONCLUSIONS In a post hoc analysis, earlier intervention was associated with a lower odds of death or severe neurodevelopmental disability in preterm infants with progressive posthemorrhagic ventricular dilatation. TRIAL REGISTRATION ISRCTN43171322.
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Affiliation(s)
- Mehmet N Cizmeci
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center; Utrecht; University Medical Center Utrecht, Utrecht Brain Center, Utrecht, the Netherlands; Division of Neonatology, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Floris Groenendaal
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center; Utrecht; University Medical Center Utrecht, Utrecht Brain Center, Utrecht, the Netherlands
| | - Kian D Liem
- Department of Neonatology, Amalia Children's Hospital, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Ingrid C van Haastert
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center; Utrecht; University Medical Center Utrecht, Utrecht Brain Center, Utrecht, the Netherlands
| | | | | | - Sylke Steggerda
- Department of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Bert J Smit
- Directorate Quality & Patient Care, Erasmus MC, University Medical Center Rotterdam, the Netherlands
| | - Andrew Whitelaw
- Neonatal Intensive Care Unit, Southmead Hospital and Neonatal Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Peter Woerdeman
- Division of Neuroscience, Department of Neurosurgery, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Axel Heep
- Neonatal Intensive Care Unit, Southmead Hospital and Neonatal Neuroscience, University of Bristol, Bristol, United Kingdom
| | - Linda S de Vries
- Department of Neonatology, Wilhelmina Children's Hospital, University Medical Center; Utrecht; University Medical Center Utrecht, Utrecht Brain Center, Utrecht, the Netherlands.
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El-Dib M, Limbrick DD, Inder T, Whitelaw A, Kulkarni AV, Warf B, Volpe JJ, de Vries LS. Management of Post-hemorrhagic Ventricular Dilatation in the Infant Born Preterm. J Pediatr 2020; 226:16-27.e3. [PMID: 32739263 PMCID: PMC8297821 DOI: 10.1016/j.jpeds.2020.07.079] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Revised: 07/25/2020] [Accepted: 07/27/2020] [Indexed: 12/18/2022]
Affiliation(s)
- Mohamed El-Dib
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
| | - David D Limbrick
- Department of Neurological Surgery, St Louis Children's Hospital, Washington University School of Medicine, St Louis, MO
| | - Terrie Inder
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Andrew Whitelaw
- Neonatal Neuroscience, Translational Health Sciences, University of Bristol, Bristol, United Kingdom
| | - Abhaya V Kulkarni
- Department of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Benjamin Warf
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Joseph J Volpe
- Department of Pediatric Newborn Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA; Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, MA
| | - Linda S de Vries
- Department of Neonatology, University Medical Center Utrecht, the Netherlands; University Medical Center Utrecht, Utrecht Brain Center, the Netherlands
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