Letter to the Editor. Management of preterm infants with posthemorrhagic ventricular dilatation

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  • 1 Isfahan University of Medical Sciences, Isfahan, Iran
  • | 2 Tabriz University of Medical Sciences, Tabriz, Iran
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TO THE EDITOR: We read with enormous interest the article by De Angelis et al.1 highlighting external ventricular drainage for posthemorrhagic ventricular dilatation in preterm infants (De Angelis LC, Parodi A, Sebastiani M, et al. External ventricular drainage for posthemorrhagic ventricular dilatation in preterm infants: insights on efficacy and failure. J Neurosurg Pediatr. 2021;28[5]:563-571). We appreciate the views of the authors and their discussion of the important aspects of management of preterm infants with posthemorrhagic ventricular dilatation. As a result, we wish to present our comments related to this valuable article.

First of all, the aim of the study was to describe the clinical and neuroradiological characteristics of preterm infants who had undergone external ventricular drain insertion as a temporary measure to treat posthemorrhagic ventricular dilatation. The authors investigated factors predictive of permanent shunt dependency. We think that the most important part of this paper is its conclusion: "External ventricular drainage is a reliable first-line treatment for posthemorrhagic hydrocephalus." However, predicting its efficacy as a unique treatment remains challenging.

Lower gestational age is associated with higher risk of posthemorrhagic hydrocephalus progression. This finding suggests that undeveloped mechanisms for the clearance of blood degradation products may be associated with greater risk of permanent cerebrospinal fluid diversion, although sophisticated MRI investigations are currently unable to corroborate this hypothesis. We want to focus on this part of this valuable article. Some researchers believe that endoscopic ventricular lavage is a safe and feasible treatment for neonates with posthemorrhagic hydrocephalus.2 However, there are no comments regarding this technique in the article. Our experience and the results of other studies have confirmed that the rate of shunt insertion is considerably reduced in patients treated with irrigation, and this effect does not depend on age.3

Additionally, we think that other variables, such as the sizes of the temporal, frontal, and occipital horns; Evans ratio; exact volume of hemorrhage;4 periventricular intensity signal on T2-weighted MRI; findings on sagittal MRI; and evaluation of probable thinning and/or bowing of the corpus callosum, can be considered predisposing factors for prognosis in these patients.5 Tables 1–3 provide excellent comparisons of patient characteristics and brain MRI data between the shunt-free and shunt-dependent groups. Additional data could be collected in future studies. However, the retrospective nature of the study, narrow inclusion criteria, time period, and sample size were limiting factors.

Once again, we appreciate that the authors performed this research and hope that our explanations and observations will help this valuable journal’s readership.

Disclosures

The authors report no conflict of interest.

References

  • 1

    De Angelis LC, Parodi A, Sebastiani M, et al. External ventricular drainage for posthemorrhagic ventricular dilatation in preterm infants: insights on efficacy and failure. J Neurosurg Pediatr. 2021;28(5):563571.

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  • 2

    Etus V, Kahilogullari G, Karabagli H, Unlu A. Early endoscopic ventricular irrigation for the treatment of neonatal posthemorrhagic hydrocephalus: a feasible treatment option or not? A multicenter study. Turk Neurosurg. 2018;28(1):137141.

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  • 3

    Cherian S, Whitelaw A, Thoresen M, Love S. The pathogenesis of neonatal post-hemorrhagic hydrocephalus. Brain Pathol. 2004;14(3):305311.

  • 4

    Ellenbogen JR, Waqar M, Pettorini B. Management of post-haemorrhagic hydrocephalus in premature infants. J Clin Neurosci. 2016;31(30):34.

  • 5

    Diwakar K, Hader WJ, Soraisham A, et al. Long-term neurodevelopmental and growth outcomes of premature infants born at <29 week gestational age with post-hemorrhagic hydrocephalus treated with ventriculo-peritoneal shunt. Indian J Pediatr. 2017;84(9):662669.

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  • 1 IRCCS Istituto Giannina Gaslini, Genoa, Italy
  • | 2 IRCCS Istituto Giannina Gaslini, Genoa, Italy
  • | 3 University of Genoa, Genoa, Italy

Response

We read with interest the comments expressed by Riazi et al. regarding our article, and we thank them for such words of appreciation.

As reported in the relevant literature, the best treatment procedure and its timing for neonatal posthemorrhagic ventricular dilatation (PHVD) have not been established.1 Riazi et al. have properly highlighted that, in addition to the most common temporary treatments (ventriculosubgaleal shunt, ventricular access device, external ventricular drain, etc.), endoscopic lavage of the ventricular system is gaining attention as an alternative therapeutic strategy for the initial management of PHVD.2,3 This type of treatment has shown good results, such as those cited by Riazi and colleagues, and it certainly rests on a valid rationale: namely the removal of intraventricular hemorrhage–related blood debris and inflammatory cytokines from the cerebrospinal fluid spaces. However, the same goal may be achieved with other therapeutic procedures, the validities of which have been established by larger case series.1

Moreover, in view of the complex physiopathological mechanisms underlying PHVD, in our experience we believe that a constant and therefore more physiological exchange of cerebrospinal fluid, such as that obtained with an external ventricular drain, allows easier neurosurgical management of these patients and provides more accurate information about the chemical and physical characteristics of the cerebrospinal fluid.

In addition to the possibility of including the technique mentioned by Riazi et al. in future prospective multicenter studies in order to further validate its efficacy, it would also be interesting to collaborate with Iranian colleagues, whereby each neurosurgical center would prospectively collect data on their patients in order to compare adopted surgical techniques.

We again thank Riazi and colleagues for their comments and contributions to the debate on this interesting topic.

References

  • 1

    Badhiwala JH, Hong CJ, Nassiri F, Hong BY, Riva-Cambrin J, Kulkarni AV. 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.

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    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

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

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Etus V, Kahilogullari G, Karabagli H, Unlu A. Early endoscopic ventricular irrigation for the treatment of neonatal posthemorrhagic hydrocephalus: a feasible treatment option or not? A multicenter study. Turk Neurosurg. 2018;28(1):137141.

    • Search Google Scholar
    • Export Citation

Diagram from Behbahani et al. (pp 488–496).

  • 1

    De Angelis LC, Parodi A, Sebastiani M, et al. External ventricular drainage for posthemorrhagic ventricular dilatation in preterm infants: insights on efficacy and failure. J Neurosurg Pediatr. 2021;28(5):563571.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

    Etus V, Kahilogullari G, Karabagli H, Unlu A. Early endoscopic ventricular irrigation for the treatment of neonatal posthemorrhagic hydrocephalus: a feasible treatment option or not? A multicenter study. Turk Neurosurg. 2018;28(1):137141.

    • Search Google Scholar
    • Export Citation
  • 3

    Cherian S, Whitelaw A, Thoresen M, Love S. The pathogenesis of neonatal post-hemorrhagic hydrocephalus. Brain Pathol. 2004;14(3):305311.

  • 4

    Ellenbogen JR, Waqar M, Pettorini B. Management of post-haemorrhagic hydrocephalus in premature infants. J Clin Neurosci. 2016;31(30):34.

  • 5

    Diwakar K, Hader WJ, Soraisham A, et al. Long-term neurodevelopmental and growth outcomes of premature infants born at <29 week gestational age with post-hemorrhagic hydrocephalus treated with ventriculo-peritoneal shunt. Indian J Pediatr. 2017;84(9):662669.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 1

    Badhiwala JH, Hong CJ, Nassiri F, Hong BY, Riva-Cambrin J, Kulkarni AV. 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.

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 2

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

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Etus V, Kahilogullari G, Karabagli H, Unlu A. Early endoscopic ventricular irrigation for the treatment of neonatal posthemorrhagic hydrocephalus: a feasible treatment option or not? A multicenter study. Turk Neurosurg. 2018;28(1):137141.

    • Search Google Scholar
    • Export Citation

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