Neonatal Posthemorrhagic Hydrocephalus Research Articles

The impact of neonatal posthemorrhagic hydrocephalus of prematurity on family function at preschool age

AimsTo determine the impact on families (IOF) of former preterm infants (gestational age < 32 weeks) after posthemorrhagic hydrocephalus requiring shunt (PHH-S), and to identify risk factors of family dysfunction. Study design38 preterm infants with PHH-S were matched for gestational age, birthweight, and gender with preterm infants with normal cranial ultrasonography. IOF questionnaire was administered at 5.7 ± 2 years (higher IOF score indicates worse impact). ResultsFamilies of PHH-S children exhibited significantly worse IOF compared to controls in financial (9.2 ± 2.2 vs 5.9 ± 1.4), family-personal (26.6 ± 5.2 vs 20.2 ± 2.8), and disruptive social (21.4 ± 4.9 vs 16.7 ± 3.1) domains (P < 0.001).Multivariate regression incorporating neonatal risk factors revealed an independent effect of parenchymal brain involvement (β:0.4, P:0.002) and neonatal seizures (β:0.3, p:0.007) on total IOF.Neurosensory morbidity was significantly higher in the PHH-S group, including cerebral palsy (81.6%), epilepsy (47.4%), problems with vision (63.2%), feeding (39.5%) and hearing (18.4%), chronic health problems (44.7%) and hospital admissions in the last 6 months (44.7%).Worse IOF scores of PHH-S families were associated with socioeconomic status and neurodevelopmental morbidities: cerebral palsy severity, feeding problems, number of neurosurgeries, low cognitive, personal-social, and adaptive scores (P < 0.05). Multivariate analysis indicated an independent contribution from cerebral palsy severity (β:0.5, p:0.002) and socioeconomic status (β:-0.4, P: 0.01). ConclusionsFamilies of preterm children after PHH-S exhibit significantly worse IOF scores compared to families of preterm peers. Worse IOF is associated with severe hemorrhage, neurodevelopmental morbidities and socioeconomic status.A family centered intervention is warranted after PHH-S.

Astrogliosis inhibition attenuates hydrocephalus by increasing cerebrospinal fluid reabsorption through the glymphatic system after germinal matrix hemorrhage

Germinal matrix hemorrhage (GMH) results from the rupture of the immature thin-walled blood vessels and consequent bleeding into the subependymal germinal matrix and possible lateral ventricles. The purpose of this study is to investigate how astrogliosis impacts the glymphatic-meningeal lymphatic system in cerebrospinal fluid (CSF) reabsorption after GMH and how the anti-scarring agent olomoucine attenuates post-hemorrhagic hydrocephalus. GMH was induced by stereotaxic collagenase infusion into P7 Sprague-Dawley rats of both sexes. Western blot and immunofluorescence were used to assess astrogliosis and how astrogliosis affects glymphatic function by measuring Aquaporin-4 expression. Intracisternal injection of fluorescence tracer was used to measure CSF diffusion throughout the brain, its dispersion in the paravascular area and CSF drainage into the deep cervical lymph nodes at 28 days after GMH. Both short-term and long-term behavioral tests were used to assess the neurological outcomes. Nissl staining was used to assess the morphological changes at 28 days after hemorrhage. GMH elicited astrogliotic scarring and reduced the exchange between CSF and interstitial fluid, as well as CSF reabsorption through the meningeal lymphatic vessels. This might be associated with redistribution of Aquaporin-4. Olomoucine ameliorated scar tissue formation and attenuated post-hemorrhagic hydrocephalus. These findings of this study suggested that the glymphatic system might play a role in CSF reabsorption in neonates following GMH. Scar tissue formation impairs this CSF clearance route, and therefore astrogliosis inhibition might be a potential therapeutic strategy for neonatal post-hemorrhagic hydrocephalus.

P94 Ventricular subgaleal shunting is a safe and effective temporising measure for the treatment of neonatal post haemorrhagic hydrocephalus

ObjectivesThe use of a temporising device to facilitate neonatal maturation prior to permanent ventricular peritoneal shunt (VPS) remains gold standard treatment for neonatal posthaemorrhagic hydrocephalus (PHH). The relative superiority of ventricular access device (VAD) or ventricular subgaleal shunt (VSG) remains contentious.DesignRetrospective case note review.Subjects49 neonates born between Sept 2012 to April 2018: (M:F 34:15); Average: gestation 26+3 (23 to 32+5); birth weight 870 g (±355 g); Papile grade 3:4 (ratio ≈ 1:2).MethodsComputer records from neonatal VSG at a single tertiary care children’s hospital reviewed.ResultsEarly complications associated with VSG seen in 13 cases (27%). Migration of shunt n=3, infection n=2, inadequate control of ventricular volume n=5, decompression haemorrhage n=2, wound leak n=1. All patients managed on NICU with an average inpatient stay of 5 days (range 2 to 15). 5 outcome groups defined: 1. Patient died (non neurological cause) (n=4) 2. VSG in situ for &lt;1 year (n=7) 3. VSG and no VPS (n=6 16%) 4. VSG and VPS X1 never revised (n=17 45%) 5. VSG and VPS with revisions (n=15 39%) Rate of shunting in patients with VSG &gt;1 year=84%. All patients that needed permanent VPS were operated within the first year. The average time elapsed prior to VPS was 86 days with over 80% of cases shunted within 100 days.ConclusionsVSG remains a safe method of temporary CSF drainage for the treatment of neonatal PHH with rates of shunting in line with the published literature.

TROPHY registry study design: a prospective, international multicenter study for the surgical treatment of posthemorrhagic hydrocephalus in neonates.

Among children with hydrocephalus, neonates with intraventricular hemorrhage (IVH) and posthemorrhagic hydrocephalus (PH) are considered a group with one of the highest complication rates of treatment. Despite continued progress in neonatal care, a standardized and reliable guideline for surgical management is missing for this challenging condition. Thus, further research is warranted to compare common methods of surgical treatment. The introduction of neuroendoscopic lavage has precipitated the establishment of an international registry aimed at elaborating key elements of a standardized surgical treatment. The registry is designed as a multicenter, international, prospective data collection for neonates aged 41weeks gestation, with an indication for surgical treatment for IVH with ventricular dilatation and progressive hydrocephalus. The following initial temporizing surgical interventions, each used as standard treatment at participating centers, will be compared: external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). Type of surgery, perioperative data including complications and mortality, subsequent shunt surgeries, ventricular size, and neurological outcome will be recorded at 6, 12, 36, and 60months. An online, password-protected website will be used to collect the prospective data in a synchronized manner. As a prospective registry, data collection will be ongoing, with no prespecified endpoint. A prespecified analysis will take place after a total of 100 patients in the NEL group have been entered. Analyses will be performed for safety (6months), shunt dependency (12, 24months), and neurological outcome (60months). The design and online platform of the TROPHY registry will enable the collection of prospective data on different surgical procedures for investigation of safety, efficacy, and neurodevelopmental outcome of neonates with IVH and hydrocephalus. The long-term goal is to provide valid data on NEL that is prospective, international, and multicenter. With the comparison of different surgical treatment modalities, we hope to develop better therapy guidelines for this complex neurosurgical condition.

Cerebral Hemodynamics During Neonatal Cerebrospinal Fluid Removal

BackgroundStandard treatment of neonatal posthemorrhagic hydrocephalus is cerebrospinal fluid removal. The aim of this study was to assess how much cerebrospinal fluid volume removal, by ventricular reservoir taps, is needed to improve cerebral hemodynamics and oxygenation in neonatal posthemorrhagic hydrocephalus. MethodsCerebral hemodynamics and oxygenation were continuously monitored by near-infrared spectroscopy in four newborns (one term and three preterm) during 28 ventricular reservoir taps. At each tap, 10 mL/kg of cerebrospinal fluid was removed. Near-infrared spectroscopy detected changes in the concentration of oxy-hemoglobin and total hemoglobin, considered as estimates of cerebral blood flow and volume, respectively. Cerebral tissue oxygenation index was also measured. During cerebrospinal fluid removal, variation in cerebral blood flow, volume, and oxygenation were analyzed by repeated measures analysis of variance. The associations between changes in cerebral hemodynamics and oxygenation, during cerebrospinal fluid removal and after its conclusion, were analyzed by Pearson's r correlation coefficient. ResultsA significant increase in cerebral blood flow and volume was already evident at 50% of targeted cerebrospinal fluid volume removal (P < 0.001). Although cerebral tissue oxygenation index absolute value remained unchanged, variations in cerebral blood flow and oxygenation were positively correlated, both during cerebrospinal fluid removal and after its conclusion (r = 0.57; P = 0.002). ConclusionsOn the basis of the results from this small cohort, the volume of cerebrospinal fluid removal associated with an improvement in cerebral hemodynamics and perfusion seems to be less than the traditional 10 mL/kg. Further research is needed to define the potential role of near-infrared spectroscopy monitoring to individualize cerebrospinal fluid removal.

Neonatal post-haemorrhagic hydrocephalus in the UK: a survey of current practice

Objectives: The management of neonatal post-haemorrhagic hydrocephalus (nPHH) varies considerably between centres and even between neurosurgeons in the same centre. We performed a nationwide survey to evaluate current practice in the UK and reviewed the evidence for each intervention.Methods: An online semi-structured questionnaire was emailed to all units registered on the British Paediatric Neurosurgery Group Mailing List. The survey consisted of 18 questions designed to establish the status quo in the management of nPHH, including preferred temporising procedure, factors guiding the timing of intervention and willingness to participate in a prospective study.Results: A total of 24 consultants responded to the survey. Ventricular access device (VAD), trans-fontanelle tap, ventriculosubgaleal shunt (VSGS) and lumbar puncture (LP) were used by 33, 25, 17 and 17%, respectively, as the first temporising measure. Almost all reported that the timing of this intervention was guided by increasing head circumference and tense fontanelle. If the first temporising procedure fails, VAD, external ventricular drainage (EVD), trans-fontanelle tap, VSGS and other procedures (including ventriculoperitoneal (VP) shunting and endoscopic third ventriculostomy (ETV)) were performed by 42, 17, 13, 8 and 21%, respectively. Almost all respondents reported that VP shunting would be their preferred method of definitive cerebrospinal fluid (CSF) diversion. Almost all responded that they would be willing to participate in a prospective study in the future to determine best practice.Conclusion: As expected there was a significant heterogeneity between respondents in the initial management of nPHH in the UK. VAD was the most popular first and second choice temporising measure. On reviewing the literature, it is clear that more work still needs to be done to establish which temporising measure is best. There is willingness in the UK to participate in a study to help determine this.

Frequency and long-term follow-up of trapped fourth ventricle following neonatal posthemorrhagic hydrocephalus.

OBJECTIVE Intraventricular hemorrhage (IVH) is a common complication of premature neonates with small birth weight, which often leads to hydrocephalus and treatment with ventriculoperitoneal (VP) shunting procedures. Trapped fourth ventricle (TFV) can be a devastating consequence of the subsequent occlusion of the cerebral aqueduct and foramina of Luschka and Magendie. METHODS The authors retrospectively reviewed 8 consecutive cases involving pediatric patients with TFV following VP shunting for IVH due to prematurity between 2003 and 2012. The patients ranged in gestational age from 23.0 to 32.0 weeks, with an average age at first shunting procedure of 6.1 weeks (range 3.1-12.7 weeks). Three patients were managed with surgery. Patients received long-term radiographic (mean 7.1 years; range 3.4-12.2 years) and clinical (mean 7.8 years; range 4.6-12.2 years) follow-up. RESULTS The frequency of TFV following VP shunting for neonatal posthemorrhagic hydrocephalus was found to be 15.4%. Three (37.5%) patients presented with symptoms of posterior fossa compression and were treated surgically. All of these patients showed signs of radiographic improvement with stable or improved clinical examinations during postoperative follow-up. Of the 5 patients treated conservatively, 80% experienced stable ventricular size and 1 patient experienced a slight increase (3 mm) on imaging. All of the nonsurgical patients showed stable to improved clinical examinations over the follow-up period. CONCLUSIONS The frequency of TFV among premature IVH patients is relatively high. Most patients with TFV are asymptomatic at presentation and can be managed without surgery. Symptomatic patients may be treated surgically for decompression of the fourth ventricle.

Early Endoscopic Ventricular Irrigation for the Treatment of Neonatal Posthemorrhagic Hydrocephalus: A Feasible Treatment Option or Not? A Multicenter Study.

Neonatal intraventricular hemorrhage (IVH) usually results in posthemorrhagic hydrocephalus (PHH). This multicenter study describes the approach of early neuroendoscopic ventricular irrigation for the treatment of IVH/PHH and compares the results with the cases that have been initially treated only with conventional temporary cerebrospinal fluid (CSF) diversion techniques. The data of 74 neonatal PHH cases, that have been treated at three pediatric neurosurgery centers, were retrospectively analyzed. 23 neonates with PHH underwent early endoscopic ventricular irrigation (Group-A). 29 neonates were initially treated with conventional methods (Group-B). 22 neonates underwent ventriculosubgaleal shunt placement (Group-C). Complications, shunt dependency rates, incidence of multiloculated hydrocephalus and incidence of CSF infection were evaluated and compared retrospectively. Group-A, Group-B and Group-C cases did not differ significantly regarding gestational age and birth weight. In Group-A, 60.8% of the patients required a later shunt insertion, as compared with 93.1% of the cases in Group-B and 77.2% of the cases in Group-C. Group-A patients were also associated with significantly fewer CSF infections as well as significantly lower incidence for multiloculated hydrocephalus development as compared with Group-B and Group-C. Early removal of intraventricular blood degradation products and residual hematoma via neuroendoscopic ventricular irrigation is feasible and safe for the treatment of PHH in neonates with IVH. Neuroendoscopic technique seems to offer significantly lower shunt rates and fewer complications such as infection and development of multiloculated hydrocephalus in those cases.

Neonatal cerebrospinal fluid plasminogen and plasminogen activator inhibitor-1 assay as predictors of posthemorrhagic hydrocephalus

Massive intraventricular hemorrhage (IVH) in neonates is followed by progressive ventricular dilatation in 55-80% of cases if the infant survives. The initial mechanism of posthemorrhagic hydrocephalus (PHH) is thought to be obstruction by multiple small blood clots of the channels of the cerebrospinal fluid (CSF) to areas of absorption. Plasminogen activator inhibitor-1 (PAI-1) is the principal regulator of fibrinolysis in blood and one of the most highly controlled of the fibrinolytic components. The aim of this study is to measure plasminogen and PAI-1 levels in plasma and CSF of the neonates after IVH to assess endogenous fibrinolytic activity and to predict the development of PHH. Fifteen full term and preterm neonates with IVH were enrolled in the study. Ten neonates without IVH were used as a control group. Cranial ultrasound was performed at age of 2 weeks and 2 months. Plasma and CSF plasminogen and PAI-1 levels were assessed for these neonates. CSF PAI-1 was significantly higher in infants with IVH than in the controls ( P 0.05). CSF PAI-1 was significantly higher in infants with PHH than in infants with posthemorrhagic ventricular dilatation ( P< 0.05), with a sensitivity (100%) and specificity (100%). CSF PAI-1 is a very sensitive and specific parameter than CSF plasminogen for prediction of PHH in neonates with IVH, and this might be useful to evaluate the specific therapeutic programs of these neonates.

Descending transtentorial herniation, a rare complication of the treatment of trapped fourth ventricle: case report.

Descending transtentorial herniation (DTH) is a complication of raised pressure in the supratentorial compartment, usually resulting from mass lesion of several etiologies. The authors report an exceptional case of DTH complicating the implant of a CSF shunting device in the trapped fourth ventricle of a 17-year-old boy in whom a second CSF shunting device had been implanted for neonatal posthemorrhagic and postinfectious hydrocephalus. The insidious clinical and radiological presentation of DTH, mimicking a malfunction of the supratentorial shunt, is documented. Ultimately, the treatment consisted of removal of the infratentorial shunt and endoscopic acqueductoplasty with stenting. The absence of supratentorial mass lesion and other described etiologies of DTH prompted the authors to speculate on the hydrodynamic pathogenesis of DTH in the present case.

Differentiation of cerebrospinal fluid inflammatory biomarkers between neonatal post-hemorrhagic and congenital hydrocephalus

Neonatal Post-hemorrhagic hydrocephalus (PHH) develops partly due to an inflammatory process occurring after intraventricular hemorrhage whereas the majority of congenital hydrocephalus (CH) results from primary and secondary CNS malformations. We hypothesize that cerebrospinal fluid (CSF) content of inflammatory biomarkers is higher in neonatal PHH relative to CH. To test this hypothesis, we measured CSF concentrations of CCL-3, CXCL-12, CX3CL-1, IL-10 and P-selectin in both conditions.

Novel cerebrospinal fluid inflammatory biomarkers in neonatal post-hemorrhagic hydrocephalus

Although inflammation is believed to play a major role in the pathogenesis of post-hemorrhagic hydrocephalus (PHH), a comprehensive characterization of cerebrospinal fluid (CSF) inflammatory biomarkers in PHH has not been performed. Therefore, the aim of this study is to measure concentrations of chemokine and cytokine biomarkers that have yet to be studied in neonatal PHH. These biomarkers include CCL-3, CXCL-12, CX3CL-1, IL-10 and P-selectin.

Neuroendoscopic lavage for the treatment of intraventricular hemorrhage and hydrocephalus in neonates

Object Neonatal intraventricular hemorrhage (IVH) may evolve into posthemorrhagic hydrocephalus and cause neurodevelopmental impairment. In this study, an endoscopic surgical approach directed toward the removal of intraventricular hematoma was evaluated for its safety and efficacy. Methods Between August 2010 and December 2012 (29 months), 19 neonates with posthemorrhagic hydrocephalus underwent neuro endoscopic lavage for removal of intraventricular blood remnants. During a similar length of time (29 months) from March 2008 to July 2010, 10 neonates were treated conventionally, initially using temporary CSF diversion via lumbar punctures, a ventricular access device, or an external ventricular drain. Complications and shunt dependency rates were evaluated retrospectively. Results The patient groups did not differ regarding gestational age and birth weight. In the endoscopy group, no relevant procedure-related complications were observed. After the endoscopic lavage, 11 (58%) of 19 patients required a later shunt insertion, as compared with 100% of infants treated conventionally (p < 0.05). Endoscopic lavage was associated with fewer numbers of overall necessary procedures (median 2 vs 3.5 per patient, respectively; p = 0.08), significantly fewer infections (2 vs 5 patients, respectively; p < 0.05), and supratentorial multiloculated hydrocephalus (0 vs 4 patients, respectively; p < 0.01) [corrected].Conclusions Within the presented setup the authors could demonstrate the feasibility and safety of neuro endoscopic lavage for the treatment of posthemorrhagic hydrocephalus in neonates with IVH. The nominally improved results warrant further verification in a multicenter, prospective study.

未熟児脳室内出血と出血後水頭症の周術期管理

未熟児の水頭症の主な病因は脳室内出血であり, 出血の程度と水頭症の発症には相関がある. 髄鞘化に乏しい未熟な脳は圧迫を受けると容易に変形するため, 未熟児では頭囲が拡大する前に著明な脳室拡大を生じる. 周術期管理は, 利尿剤やステロイド剤の投与などの内科的治療と腰椎穿刺の反復, 髄液リザーバー留置による間欠的髄液穿刺排液, 脳室帽状腱膜下シャント, PIカテーテルによる持続脳室ドレナージなどの外科的治療がある. その後進行性に脳室拡大を認める場合は, 患児の体重が2,000gを超えた時点で, VPシャントを行う. シャント術は機能不全や髄液過剰排出などの合併症が問題となるが, 特に未熟児脳室内出血後水頭症では, 治療に難渋する多嚢胞性水頭症や孤立性第4脳室をきたしやすい. 将来の精神運動発達障害の要因は, 水頭症よりも出血の重症度と分娩前後の問題によると考えられている. 未熟児水頭症では, その周術期管理が患児の予後を左右する重要な要因になる.

Neonatal post-hemorrhagic hydrocephalus resulting in foraminal septae—radiological technique and surgical implications

Intraventricular haemorrhage is the most common cause of hydrocephalus in a pre-term baby and may require surgical intervention depending on severity. This case illustrates foraminal septae as a subtle cause of progressive quadriventricular hydrocephalus in a child born pre-term with a history of grade III intraventricular haemorrhage. The septae within the fourth ventricular exits were clearly demonstrated with 3D-FIESTA (fast imaging employing steady-state acquisition) MRI acquisitions and assisted in differentiation from communicating hydrocephalus. This finding guided the decision to a successful endoscopic third ventriculostomy. 3D-FIESTA sequence is recommended for investigating children with hydrocephalus secondary to intraventricular haemorrhage due to its diagnostic potential and implications on surgical technique.

Neonatal posthemorrhagic hydrocephalus from prematurity: pathophysiology and current treatment concepts

Preterm infants are at risk for perinatal complications, including germinal matrix-intraventricular hemorrhage (IVH) and subsequent posthemorrhagic hydrocephalus (PHH). This review summarizes the current understanding of the epidemiology, pathophysiology, management, and outcomes of IVH and PHH in preterm infants. The MEDLINE database was systematically searched using terms related to IVH, PHH, and relevant neurosurgical procedures to identify publications in the English medical literature. To complement information from the systematic search, pertinent articles were selected from the references of articles identified in the initial search. This review summarizes the current knowledge regarding the epidemiology and pathophysiology of IVH and PHH, primarily using evidence-based studies. Advances in obstetrics and neonatology over the past few decades have contributed to a marked improvement in the survival of preterm infants, and neurological morbidity is also starting to decrease. The incidence of IVH is declining, and the incidence of PHH will likely follow. Currently, approximately 15% of preterm infants who suffer severe IVH will require permanent CSF diversion. The clinical presentation and surgical management of symptomatic PHH with temporary ventricular reservoirs (ventricular access devices) and ventriculosubgaleal shunts and permanent ventriculoperitoneal shunts are discussed. Preterm infants who develop PHH that requires surgical treatment remain at high risk for other related neurological problems, including cerebral palsy, epilepsy, and cognitive and behavioral delay. This review highlights numerous opportunities for further study to improve the care of these children. A better grasp of the pathophysiology of IVH is beginning to impact the incidence of IVH and PHH. Neonatologists conduct rigorous Class I and II studies to advance the outcomes of preterm infants. The need for well-designed multicenter trials is essential because of the declining incidence of IVH and PHH, variations in referral patterns, and neonatal ICU and neurosurgical management. Well-designed multicenter trials will eventually produce evidence to enable neurosurgeons to provide their smallest, most vulnerable patients with the best practices to minimize perioperative complications and permanent shunt dependence, and most importantly, optimize long-term neurodevelopmental outcomes.

Changes in neural dendrites and synapses in rat somatosensory cortex following neonatal post-hemorrhagic hydrocephalus

Neonatal post-hemorrhagic hydrocephalus is associated with cognitive decline and a serious deterioration in the patient's quality of life. The underlying impairments to neurons are not well understood. Here, we used the method described by Cherian et al. to construct a model of hydrocephalus after intra-ventricular hemorrhage and then observed the subsequent pathological changes in the morphology of neurons labeled by enhanced green fluorescent proteins (EGFP) using the in utero electroporation technique. Injection of venous blood into the lateral ventricles of 7-day-old rats in the operation group caused marked enlargement of the ventricles in 60% (9/15) of the rats after 2 weeks and in 53.3% (8/15) of the rats after 3 weeks. Compared with the control group, the length of the neural dendrites in the somatosensory cortex was shortened and the number of both neuron dendrite branches and synapses was significantly decreased. There was no evidence of cerebral cortical neuron death as shown by positive EGFP cell counting which suggest that neurological dysfunction after intra-ventricular hemorrhage-induced hydrocephalus may be related to the shortening of neural dendrites and the decreased number of synapses in somatosensory cortex and thus provides a possible neurological cause for hydrocephalus-induced cognitive decline and motor dysfunction.

Transforming growth factor‐βs in a rat model of neonatal posthaemorrhagic hydrocephalus

Posthaemorrhagic ventricular dilatation (PHVD) is a common complication of intraventricular haemorrhage in premature infants. The aim of this study was to investigate the role of transforming growth factor-betas (TGF-betas), a family of polypeptides with potent desmoplastic properties, in the aetiology of PHVD in a newly developed neonatal rat model of this disorder. Pups were injected with citrated rat blood or artificial cerebrospinal fluid (ACSF) into alternate lateral ventricles on postnatal days 7 and 8. The brains were perfusion-fixed 14 days later and immunohistochemistry was performed for TGF-beta1, -beta2 and -beta3, p44/42 mitogen-activated protein (MAP) kinases, and the extracellular matrix proteins laminin, vitronectin and fibronectin. Ventricular dilatation occurred in 58.3% of animals injected with blood and 36.7% of those injected with ACSF. Periventricular immunoreactivity for TGF-beta1 and -beta2 increased in injected animals irrespective of the presence or absence of ventricular dilatation, although the levels of both isoforms tended to be higher in animals with hydrocephalus. TGF-beta3 immunoreactivity was elevated in hydrocephalic rats only. The immunolabelling for phosphorylated p44/42 MAP kinases rose in a pattern similar to that for TGF-beta1 and -beta2. Expression of TGF-betas was accompanied by deposition of the extracellular matrix proteins fibronectin, laminin and vitronectin. The changes caused by injection of ACSF were the same as those caused by injection of blood. Our results raise the possibility that expression of TGF-betas, together with extracellular matrix protein deposition, may be involved in the development and/or maintenance of hydrocephalus after ventricular distension due to haemorrhage in the neonate.

Méningite à Clostridium perfringens d'évolution fatale chez un nourrisson de 3 semaines

Background. — Clostridium perfringens meningitis is a rare condition usually associated to skull injuries, surgery or gastro-intestinal disorders. Case report. — A 21 day-old infant was admitted for the sudden worsening of a neonatal post-hemorrhagic hydrocephalus. Eighteen hours after admission, she developed a septic status with acute meningitis. A CT scan revealed the presence of intracerebral gas suggesting the responsability of an anaerobic bacterium. The infant died within 24 hours from multiorgan failure, hemodynamic disorders, acute anemia with red urines. Clostridium perfringens was isolated both from the blood and CSF. Conclusions. — The tissue alterations following meningeal hemorrhage may favor anaerobic growth. The presence of intracerebral gas is highly suggestive of the diagnosis. The prognosis is very poor.

Glial reaction in periventricular areas of the brainstem in fetal and neonatal posthemorrhagic hydrocephalus and congenital hydrocephalus

This immunohistochemical, neuropathological study was performed on the ventricular wall of the brainstem in children with fetal and neonatal posthemorrhagic and congenital hydrocephalus. In posthemorrhagic hydrocephalus (PHH), hemosiderin deposits, nodular gliosis, ependymal cell loss and subsependymal rosette formation developed subventricularly after 2 weeks of age. Ferritin-positive reactive microglia were well stained until about 2 weeks of age and thereafter diminished as reactive astrocytosis occurred. In congenital hydrocephalus (CH), the damage to the ventricular wall was less than in PHH at all ages and was associated with only mild astrogliosis. These differences in the neuropathological findings of periventricular regions, consisting mainly of glial reactions between PHH and CH, are due to differences in pathophysiology, and the timing of the insult in both conditions. The differences may be due to the effects of intraventricular hemorrhage and/or rapidly increased intracranial pressure in PHH. These results may have implications for the neurological prognosis in children with PHH.