Neuroendoscopic lavage for the management of posthemorrhagic hydrocephalus in preterm infants: safety, effectivity, and lessons learned

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  • 1 Neurosurgery Service Virgen del Rocío, University Hospital, Seville; and
  • 2 Group of Applied Neuroscience, Biomedicine Institute of Seville, Spain
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OBJECTIVE

Treatment of posthemorrhagic hydrocephalus in preterm infants is a matter of debate among pediatric neurosurgeons. Neuroendoscopic lavage (NEL) has been proposed as a suitable technique for the management of this pathology. The authors present their experience with 46 patients treated with NEL after germinal matrix hemorrhage, describe their technique, and analyze the outcomes.

METHODS

A retrospective analysis of patients affected by grade III or IV intraventricular hemorrhage (IVH) treated with NEL was performed. Nonmodifiable risk factors such as gestational age, weight at birth, modified Papile grade, and intercurrent diseases were reviewed. Safety analysis was performed, evaluating the incidence of postoperative complications. Effectivity was measured using radiological (frontal horn index and white matter injury), CSF biochemical (proteins, blood, and cellularity), and clinical variables. Permanent shunt rate and shunt survival were analyzed. The motor outcome was measured using the Gross Motor Function Classification System (GMFCS) at 18–24 months, and the neurocognitive outcome was evaluated according to the grade of adaptation to schooling.

RESULTS

Forty-six patients met the inclusion criteria. Patients were treated with a single NEL in 21 cases, 2 lavages in 13 cases, and 3 lavages in 12 cases. The mean gestational age at birth was 30.04 weeks, and the mean weight at birth was 1671.86 g. Hyaline membrane disease was described in 4.8% of the cases, hematological sepsis in 43.47%, persistent ductus arteriosus in 23.9%, and necrotizing enterocolitis in 10.9% of the cases. Modified Papile grade III and IV IVHs were observed in 60.9% and 39.1% of the cases, respectively. Postoperative infection was diagnosed in 10 of the 46 cases, CSF leak in 6, and rebleeding in 3. The mean frontal horn index decreased from 49.54 mm to 45.50 mm after NEL. No white matter injury was observed in 18 of 46 patients, focal injury was described in 13 patients, and diffuse bilateral white matter injury was observed in 15 patients. All CSF biochemical levels improved after lavage. The shunt rate was 58.7%, and shunt survival at 1 year was 50%. GMFCS grades I, II, III, IV, and V were observed in 44.74%, 21.05%, 2.63%, 15.79%, and 15.79% of patients, respectively. Good neurocognitive results were observed in 53.3% of the cases.

CONCLUSIONS

Neuroendoscopic lavage was a suitable alternative for the management of IVH in preterm infants in our series. Good motor and neurocognitive results were achieved by this technique, and the permanent shunt rate was reduced compared with historical controls.

ABBREVIATIONS DRIFT = drainage, irrigation, and fibrinolytic therapy; FHI = frontal horn index; GMFCS = Gross Motor Function Classification System; IVH = intraventricular hemorrhage; NEL = neuroendoscopic lavage; VAD = ventricular access device; VPS = ventriculoperitoneal shunt; VSGS = ventriculosubgaleal shunt.

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Contributor Notes

Correspondence Jorge Tirado-Caballero: University Hospital, Seville, Spain. jtiradocaballero@gmail.com.

INCLUDE WHEN CITING Published online May 15, 2020; DOI: 10.3171/2020.2.PEDS2037.

Disclosures The authors report no conflict of interest concerning the materials or methods used in this study or the findings specified in this paper.

  • 1

    Mukerji A, Shah V, Shah PS. Periventricular/intraventricular hemorrhage and neurodevelopmental outcomes: a meta-analysis. Pediatrics. 2015;136(6):11321143.

    • Search Google Scholar
    • Export Citation
  • 2

    Chan K, Ohlsson A, Synnes A, Survival, morbidity, and resource use of infants of 25 weeks’ gestational age or less. Am J Obstet Gynecol. 2001;185(1):220226.

    • Search Google Scholar
    • Export Citation
  • 3

    Heuchan AM, Evans N, Henderson Smart DJ, Simpson JM. Perinatal risk factors for major intraventricular haemorrhage in the Australian and New Zealand Neonatal Network, 1995-97. Arch Dis Child Fetal Neonatal Ed. 2002;86(2):F86F90.

    • Search Google Scholar
    • Export Citation
  • 4

    Christian EA, Melamed EF, Peck E, Surgical management of hydrocephalus secondary to intraventricular hemorrhage in the preterm infant. J Neurosurg Pediatr. 2016;17(3):278284.

    • Search Google Scholar
    • Export Citation
  • 5

    Bassan H, Eshel R, Golan I, Timing of external ventricular drainage and neurodevelopmental outcome in preterm infants with posthemorrhagic hydrocephalus. Eur J Paediatr Neurol. 2012;16(6):662670.

    • Search Google Scholar
    • Export Citation
  • 6

    Fulmer BB, Grabb PA, Oakes WJ, Mapstone TB. Neonatal ventriculosubgaleal shunts. Neurosurgery. 2000;47(1):8084.

  • 7

    García-Méndez A, Álvarez-Vázquez L, Agustín-Aguilar F, Ventriculo subgaleal shunt in hydrocephalus secondary to intraventricular hemorrhage in prematures. Article in Spanish. Gac Med Mex. 2014;150(suppl 3):279281.

    • Search Google Scholar
    • Export Citation
  • 8

    Whitelaw A, Pople I, Cherian S, Phase 1 trial of prevention of hydrocephalus after intraventricular hemorrhage in newborn infants by drainage, irrigation, and fibrinolytic therapy. Pediatrics. 2003;111(4 pt 1):759765.

    • Search Google Scholar
    • Export Citation
  • 9

    D’Arcangues C, Schulz M, Bührer C, Extended experience with neuroendoscopic lavage for posthemorrhagic hydrocephalus in neonates. World Neurosurg. 2018;116:e217e224.

    • Search Google Scholar
    • Export Citation
  • 10

    Schulz M, Bührer C, Pohl-Schickinger A, Neuroendoscopic lavage for the treatment of intraventricular hemorrhage and hydrocephalus in neonates. J Neurosurg Pediatr. 2014;13(6):626635.

    • Search Google Scholar
    • Export Citation
  • 11

    Koschnitzky JE, Keep RF, Limbrick DD Jr, Opportunities in posthemorrhagic hydrocephalus research: outcomes of the Hydrocephalus Association Posthemorrhagic Hydrocephalus Workshop. Fluids Barriers CNS. 2018;15(1):11.

    • Search Google Scholar
    • Export Citation
  • 12

    Palisano R, Rosenbaum P, Walter S, Development and reliability of a system to classify gross motor function in children with cerebral palsy. Dev Med Child Neurol. 1997;39(4):214223.

    • Search Google Scholar
    • Export Citation
  • 13

    Bolisetty S, Dhawan A, Abdel-Latif M, Intraventricular hemorrhage and neurodevelopmental outcomes in extreme preterm infants. Pediatrics. 2014;133(1):5562.

    • Search Google Scholar
    • Export Citation
  • 14

    Bystron I, Blakemore C, Rakic P. Development of the human cerebral cortex: Boulder Committee revisited. Nat Rev Neurosci. 2008;9(2):110122.

    • Search Google Scholar
    • Export Citation
  • 15

    Xu G, Broadbelt KG, Haynes RL, Late development of the GABAergic system in the human cerebral cortex and white matter. J Neuropathol Exp Neurol. 2011;70(10):841858.

    • Search Google Scholar
    • Export Citation
  • 16

    Valdez Sandoval P, Hernández Rosales P, Quiñones Hernández DG, Intraventricular hemorrhage and posthemorrhagic hydrocephalus in preterm infants: diagnosis, classification, and treatment options. Childs Nerv Syst. 2019;35(6):917927.

    • Search Google Scholar
    • Export Citation
  • 17

    Brouwer AJ, Groenendaal F, van den Hoogen A, Incidence of infections of ventricular reservoirs in the treatment of post-haemorrhagic ventricular dilatation: a retrospective study (1992-2003). Arch Dis Child Fetal Neonatal Ed. 2007;92(1):F41F43.

    • Search Google Scholar
    • Export Citation
  • 18

    Spader HS, Hertzler DA, Kestle JR, Riva-Cambrin J. Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants. J Neurosurg Pediatr. 2015;15(2):156160.

    • Search Google Scholar
    • Export Citation
  • 19

    Badhiwala JH, Hong CJ, Nassiri F, Treatment of posthemorrhagic ventricular dilation in preterm infants: a systematic review and meta-analysis of outcomes and complications. J Neurosurg Pediatr. 2015;16(5):545555.

    • Search Google Scholar
    • Export Citation
  • 20

    Wang JY, Amin AG, Jallo GI, Ahn ES. Ventricular reservoir versus ventriculosubgaleal shunt for posthemorrhagic hydrocephalus in preterm infants: infection risks and ventriculoperitoneal shunt rate. J Neurosurg Pediatr. 2014;14(5):447454.

    • Search Google Scholar
    • Export Citation
  • 21

    Whitelaw A, Jary S, Kmita G, Randomized trial of drainage, irrigation and fibrinolytic therapy for premature infants with posthemorrhagic ventricular dilatation: developmental outcome at 2 years. Pediatrics. 2010;125(4):e852e858.

    • Search Google Scholar
    • Export Citation
  • 22

    Luyt K, Jary S, Lea C, Ten-year follow-up of a randomised trial of drainage, irrigation and fibrinolytic therapy (DRIFT) in infants with post-haemorrhagic ventricular dilatation. Health Technol Assess. 2019;23(4):1116.

    • Search Google Scholar
    • Export Citation
  • 23

    Wellons JC III, Shannon CN, Holubkov R, Shunting outcomes in posthemorrhagic hydrocephalus: results of a Hydrocephalus Clinical Research Network prospective cohort study. J Neurosurg Pediatr. 2017;20(1):1929.

    • Search Google Scholar
    • Export Citation
  • 24

    Larroque B, Marret S, Ancel PY, White matter damage and intraventricular hemorrhage in very preterm infants: the EPIPAGE study. J Pediatr. 2003;143(4):477483.

    • Search Google Scholar
    • Export Citation
  • 25

    Bassan H, Limperopoulos C, Visconti K, Neurodevelopmental outcome in survivors of periventricular hemorrhagic infarction. Pediatrics. 2007;120(4):785792.

    • Search Google Scholar
    • Export Citation
  • 26

    Pierrat V, Duquennoy C, van Haastert IC, Ultrasound diagnosis and neurodevelopmental outcome of localised and extensive cystic periventricular leucomalacia. Arch Dis Child Fetal Neonatal Ed. 2001;84(3):F151F156.

    • Search Google Scholar
    • Export Citation
  • 27

    Thomale UW, Cinalli G, Kulkarni AV, TROPHY registry study design: a prospective, international multicenter study for the surgical treatment of posthemorrhagic hydrocephalus in neonates. Childs Nerv Syst. 2019;35(4):613619.

    • Search Google Scholar
    • Export Citation

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