A review of the current treatment methods for posthaemorrhagic hydrocephalus of infants

Abstract

Posthaemorrhagic hydrocephalus (PHH) is a major problem for premature infants, generally requiring lifelong care. It results from small blood clots inducing scarring within CSF channels impeding CSF circulation. Transforming growth factor -beta is released into CSF and cytokines stimulate deposition of extracellular matrix proteins which potentially obstruct CSF pathways. Prolonged raised pressures and free radical damage incur poor neurodevelopmental outcomes. The most common treatment involves permanent ventricular shunting with all its risks and consequences. This is a review of the current evidence for the treatment and prevention of PHH and shunt dependency. The Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library) and PubMed (from 1966 to August 2008) were searched. Trials using random or quasi-random patient allocation for any intervention were considered in infants less than 12 months old with PHH. Thirteen trials were identified although speculative interventions were also evaluated.The literature confirms that lumbar punctures, diuretic drugs and intraventricular fibrinolytic therapy can have significant adverse effects and fail to prevent shunt dependence, death or disability. There is no evidence that postnatal phenobarbital administration prevents intraventricular haemorrhage (IVH). Subcutaneous reservoirs and external drains have not been tested in randomized controlled trials, but can be useful as a temporising measure. Drainage, irrigation and fibrinolytic therapy as a way of removing blood to inhibit progressive deposition of matrix proteins, permanent hydrocephalus and shunt dependency, are invasive and experimental. Studies of ventriculo-subgaleal shunts show potential as a temporary method of CSF diversion, but have high infection rates.At present no clinical intervention has been shown to reduce shunt surgery in these infants. A ventricular shunt is not advisable in the early phase after PHH. Evidence exists that pre-delivery corticosteroid therapy reduces mortality and IVH and there may be trends towards reduced disability in the short term. There is also evidence that postnatal indomethacin reduces IVH but with no effect on mortality or disability. Overall, there is still no definitive algorithm for the treatment of PHH or prevention of shunt dependence. New therapeutic approaches in neonatal care, including those aimed at pre-empting PHH, offer the best hope of improving neurodevelopmental outcomes.

Hidrocefalia poshemorrágica asociada a la prematuridad: evidencia disponible diagnóstica y terapéutica

“…Whitelaw 98 analizó en 2001 para la Colaboración Cochrane de forma sistemática el papel de las punciones lumbares de repetición en los neonatos con hemorragia intraventricular y no encontró una disminución en la necesidad posterior de derivación permanente de LCR, si bien las punciones se asociaron a un mayor número de complicaciones infecciosas. Shooman y colaboradores revisaron esta misma materia en 2009 y confirmaron las conclusiones descritas: las punciones lumbares de repetición aumentan la probabilidad de complicaciones infecciosas y no disminuyen la probabilidad de requerir una derivación permanente de LCR 73 . 10. b. Punciones ventriculares de repetición.…”

“…Sin embargo, la principal complicación asociada a esta medida de tratamiento es el desarrollo de infecciones de LCR que pueden resultar devastadoras 22 . La revisión de Shooman y colaboradores 73 pone de relieve que se trata de una medida que no ha sido evaluada mediante ensayos bien diseñados y que puede resultar útil como medida temporal en el control de la hidrocefalia extremando las medidas de prevención infecciosa y el cuidado de la asepsia y el funcionamiento del drenaje.…”

“…El uso de estos sistemas podría permitir alcanzar unas mejores condiciones del LCR y de la situación clínica del paciente lo que a su vez podría traducirse en una menor tasa posterior de malfunciones de la derivación permanente 29 . Por este motivo ha sido recomendada como medida transitoria de tratamiento 73 .…”

Ventricular access device infection rate: a retrospective study and review of the literature

“…The pathophysiology behind GMH/IVH is thought to be fragile vasculature susceptible to rupture with fluctuations in cerebral perfusion [2]. Infants with grade III or IV GMH/IVH are prone to developing posthemorrhagic hydrocephalus (PHH) and are at risk for further neurological injury from increased intracranial pressure (ICP).…”

Evaluation of cerebrospinal fluid parameters in preterm infants with intraventricular reservoirs

“…[1][2][3][4][5][6] Serial lumbar punctures and pharmacological agents such as acetazolamide and furosemide have been tried as treatment modalities to reduce intracranial pressure but the optimal management remains controversial. [7][8][9] Insertion of intraventricular reservoir (IVR) is frequently used as a temporary measure for drainage of cerebrospinal fluid (CSF) in infants with PHVD. [10][11][12] In most centers, CSF is tested for infection routinely at periodic intervals since IVR placement has been shown to increase the risk of infection.…”