Outcome, Cost Analysis, and Long-term Follow-up in Preterm Infants with Massive Grade IV Germinal Matrix Hemorrhage and Progressive Hydrocephalus

Abstract

As we have previously reported, logistic regression analysis determined that grade of hemorrhage was the only significant predictor of cognitive and motor outcomes. Most premature neonates with massive intracranial hemorrhages do not survive. The outcomes in those who do is very poor and the cost so high that we suggest that until therapeutic intervention exhibits efficacy, the consideration of withdrawal of life support should be presented as an option to the parents of these unfortunate children.

Early Treatment of Posthemorrhagic Hydrocephalus in Low-Birth-Weight Infants with Valveless Ventriculoperitoneal Shunts

“…The use of a subcutaneous reservoir for repeated CSF tapping is also proposed as a temporary measure to alleviate PHH, allowing the use of intrathecal drugs. This technique is also associated with a high infection rate in premature infants [18]and does not allow shunt independence [19]. In situ fibrinolysis through a subcutaneous reservoir has been proposed as an alternative method, but it does not appear to represent a convincing alternative to CSF drainage for PHH [20]and is associated with a significant rate of complications [21].…”

“…The indications for shunting are debated; some authors consider that progressive macrocrania is a prerequisite for surgery [9, 15], but Gurtner et al [15]have also indicated that most patients with progressive ventriculomegaly eventually develop macrocrania. For others, decision making is based on the progression of ventricular size rather than head circumference [13, 19]. In premature infants, hydrocephalus may lead to brain atrophy in the absence of macrocrania, and we rely more on repeated ultrasonography than head circumference for the surgical decision.…”

“…Other authors consider that ‘shunt infections are not a concern in the low birth weight infant’ [9]; in a recent study, the infection rate was as low as 3% [19]. The incidence of shunt infection is highly dependent on its definition.…”

“…The risk of obstruction decreases as the ventricular clots dissolve, but delaying surgery may result in an unacceptable cost in terms of the effects on psychomotor development [9]. The total number of shunt revisions in LBWI shunted for PHH may be as high as 4–6.6 per patient in some series [4, 19], but we do not think that this number indicates a poorer prognosis. In this situation, shunt revision is the solution, not the problem, and all efforts to maintain shunt patency are warranted.…”

“…The mortality of LBWI with PHH may be as high as 27% [14]and peaks at 63.5% for patients with grade IV ventricular hemorrhage [19]. The functional outcome is plagued by a high incidence of cerebral palsy, mental retardation, epilepsy and visual disturbance [1, 3].…”