1st neurosurgical journal club

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Welcome to

• 1st Neurosurgical journal club

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• Neonatal Post-hemorrhagic Hydrocephalus From
  Prematurity
• Pathophysiology And
• Current Treatment Concepts

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• Post-publication review

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Shenandoah Robinson, M.D.

• 38 publications,
• mostly as
• co-author

• gt500 citations

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• J Neurosurg Pediatr. 2012 Mar 9(3)

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• Scientific article

• Review Article

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CONTENTS

• Introduction
• Methods
• Results
• Discussion
• References 129

129
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Results

• Epidemiology
• Pathophysiology of germinal matrix hemorrhage
• Biomarkers
• Neonatal interventions
• Pathophysiology of PHH
• Clinical presentation
• Temporary treatment options
• Permanent shunts
• ETV
• Neuro-developmental outcome

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Complications of prematurity

• IVH
• Periventricular cystic mylomalacia
• Cerebellar hemorrhage
• Cerebellar volume loss

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Germinal matrixA.24 wks post conceptionB.34 WKS
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IVH

• Germinal matrix
• Grade 1
• Grade 11
• Grade 111
• Grade 1V

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Natural history of IVH

• 1990 Boston NZ
• 50 ventricular dilation
• 25 progressive dilatation
• 25 non progressive dilation
• 60 have arrest of PHH
• 40 required PS

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• 1999-2008
• 29 symptomatic hydrocephalus
• 21 required PS
• 2003-2007
• Survival to discharge is 92
• 20 of preterm will develop IVH
• One third will develop ventricular dilatation
• Rainbow experience 15 PS 1997-2008

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Factors that influence the risk of IVH in preterm
infants
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Neonatal interventions that influence the risk of
IVH

• Antenatal Corticosteroid
• Caesarean Delivery
• Prophylactic intravenous Indomethacin
• Etamsylate synthetic haemostatic agent

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Interventions w/ no impact on IVH

• Phenobarbital treatment
• prophylactic synthetic surfactant treatment
• Early postnatal corticosteroid

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Interventions that increase risk of IVH

• Red blood cell transfusion
• Rapid volume expansion
• Intraventricular streptokinase

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Prevention or at least lower the incidence of

• Premature Birth LBW
• IVH
• Hydrocephalus
• Permanent Shunting

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Clinical Presentation

• catastrophic
• saltatory
• clinically silent. 
• Catastrophic deterioration over minutes to hours
• a grave prognosis.
• The saltatory course evolves over hours to days,
  and involves decreased alertness and activity,
  hypotonia, abnormal eye movements, and
  respiratory difficulties.
• Many IVHs are clinically silent,
• An unexplained decline in the hematocrit may
  suggest that an IVH has occurred

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Temporary Treatment Options for Symptomatic PHH

• Medicines ----- acetazolamide and furosemide
• Intraventricular streptokinase
• Intraventricular tissue plasminogen activator
• Intraventricular Urokinase
• DRIFT study
• Drainage, irrigation, fibrinolytic therapy
• No use

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Serial Lumbar punctures

• Recommended treatment transient period of
  hydrocephalus

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Early versus late intervention

• 29 needed temporary shunting
• 16 needed permanent shunting
• 62 needed permanent shunting if intervened late.
• Author experienced 50 temporary shunting

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ELVIS Trial

• Early versus late ventricular intervention study
• Ongoing Multicentre randomized study

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Ventricular reservoirs

• 1980 McComb
• 20 expired
• 10 developed infection
• 75 required permanent shunting
• 1990
• 8 infection rate
• 88 needed permanent shunting

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Ventriculo-subgaleal shunt

• First reported in 1977.
• No infection
• 82 needed permanent shunting
• No need to replace unless it failed

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Comparison of 2 temporary diversions

• No difference
• Revision
• Infection
• Mortality
• Permanent shunting

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SOPHH

• Shunting outcomes in post-hemorragic
  hydrocephalus trial
• By
• Hydrocephalus clinical research network
• Compare early late outcome of VSG VR

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Permanent shunts

• Those who need TS need PT
• Timing is issue
• Delay
• 2.5 kg
• no infection
• clear CSF

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Endoscopic third ventriculostomy

• Coagulation of choroid plexus

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