Posthemorrhagic Ventricular Dilatation Research Articles

EFFECT OF CHANGES IN INTRACRANIAL PRESSURE ON CYTOCHROME AA3 (CYTAA3) AND HAEMOGLOBINVOLUME (HBVOL): A NEAR INFRARED SPECTROSCOPY (NIRS)

Treatment of posthaemorrhagic ventricular dilatation in neonates is still a matter of debate. In 8 neonates between 26 and 31 weeks with posthemorrhagic hydrocephalus the effect of a decrease in intracranial pressure (ICP) on cerebral oxygenation was evaluated by NIRS. Lumbar puncture (LP) had been performed postnatally between 31 and 38 weeks. All infants had intraventricular haemorrhage grade III or IV (Papille).

Cerebral arterial and venous flow-velocity measurements in post-haemorrhagic ventricular dilatation and hydrocephalus.

Simultaneous anterior cerebral artery (ACA) and internal cerebral vein (ICV) flow-velocities were measured in 18 babies with post-haemorrhagic ventricular dilatation (PHVD) and hydrocephalus (PHH). Compared with a control group matched for post-conceptional age, the resistance index of the ACA was increased. This was shown to occur at an early stage of PHVD in a longitudinal study of seven of the babies. There were no significant changes in ACA or ICV time-averaged velocities. Eight babies with PHH had ventricular taps on 18 occasions to relieve raised intracranial pressure. There was a significant decrease in the resistance index of the ACA, accompanied by an increase in the ACA time-averaged velocity, but no change in the ICV time-averaged velocity.

Neurosonographic findings in premature infants and infants with intrauterine growth retardation with a birth weight below 1,500 grams

The cranial ultrasound of 111 preterm infants were reviewed. 57 patients were appropriate for gestational age (AGA) and 54 small for gestational age (SGA). In the two groups, the incidence of peri-intraventricular hemorrhage (PIVH), posthemorrhagic ventricular dilation (VM) and peri-ventricular leucomalacia (PVL) was compared. PIVH was more common in AGA than in SGA babies (36.8% vs 18.5%). In both groups (AGA and SGA), birth weight less than 1000 g should be considered a further risk factor for hemorrhagic brain lesion (72.2% in AGA babies less than 1000 g and 20.5% ind AGA babies greater than 1000 g birth weight, p less than 0.01) (34.8% in SGA babies less than 1000 g and 6.4% in SGA babies greater than 1000 g birth weight, p less than 0.05). However, ischemic brain lesions (PVL) were not dependent from birth weight (p greater than 0.5). This study shows that low birth weight infants are an eterogeneous group of babies with different risk of hemorrhagic or ischemic cerebral lesion depending on gestational age and birth weight.

Serum creatine-kinase-BB concentration in very low birth weight babies with posthemorrhagic ventricular dilatation

The association between measurements of lateral ventricle dilatation determined by serial ultrasound and brain specific creatine-kinase isoenzyme patterns (CK-BB) is studied in 60 very low birth weight preterm neonates of 1,500 g birth weight or 32 weeks gestation or less. The patients were divided into three groups according to cranial ultrasonographic findings: Group A (n = 20) had isolated peri-intraventricular hemorrhage (PIVH); group B (n = 20) had PIVH and dilated ventricles (VM); group C (n = 20) were normal matched preterms and formed the control group. Compared to control babies or those with isolated PIVH, high serum concentrations of CK-BB were observed after birth in babies with persistent dilated ventricles at two weeks postnatal age (p less than 0.01). No difference was found between CK-BB levels of babies with isolated PIVH and control group (p greater than 0.05). We suggest that an elevated CK-BB value is found in babies with persistent ventricular dilatation suggesting severe and diffuse brain damage after post-hemorrhagic ventriculomegaly (VM).

Low dose intraventricular fibrinolytic treatment to prevent posthaemorrhagic hydrocephalus.

Posthaemorrhagic ventricular dilatation (PHVD) is thought to be due to clots from intraventricular haemorrhage obstructing cerebrospinal fluid pathways involved in reabsorption. Over 60% of infants with progressive PHVD have gone on to require surgical shunt placement. Previous treatments all have major problems. The object of this pilot study was to achieve enough fibrinolysis to restore pathways of cerebrospinal fluid reabsorption and so avoid shunt surgery. Nine preterm infants with progressive PHVD were treated with intraventricular infusion of streptokinase for 12-72 hours. All the infants survived and surgical shunting was required in only one case. A 200% increase in fibrinolytic activity was demonstrated in both ventricular and spinal fluid during streptokinase treatment. There were no cases of infection. Minor rebleeding occurred in one case and was not a serious problem. This represents the first direct therapeutic approach to the pathology of PHVD.

Fibrinolysis in cerebrospinal fluid after intraventricular haemorrhage.

Concentrations of cross linked fibrin degradation products were measured in the cerebrospinal fluid from five 'normal' preterm infants (median 102 ng/ml), four preterm infants with intraventricular haemorrhage (median 315 ng/ml), and five infants with progressive post-haemorrhagic ventricular dilatation (median 1000 ng/ml). Serial samples of cerebrospinal fluid from one infant showed a peak concentration two weeks after the haemorrhage.

Significance of ultrasound appearances in the neurological development and cognitive abilities of preterm infants at 5 years

The developmental outcome at 5 years of age was studied in 93 preterm infants who had been prospectively examined for peri-ventricular leucomalacia (PVL). Standardised neurological examination and developmental assessment, including tests of cognitive function, were carried out. Major sequelae (n = 10) could be ascribed in most cases to the presence of large PVL lesions. Children with normal scans (n = 51), with isolated haemorrhage (n = 15) and with post-haemorrhagic ventricular dilatation (n = 3) had a favourable prognosis. Patients with small focal PVL changes (n = 16) had lower cognitive abilities on the McCarthy scale and presented more abnormal neuromotor signs and more attention deficits when compared to children with normal scans and isolated haemorrhage. Small focal PVL changes seem therefore to interfere with development at 5 years of age and might represent a morphological marker of a more diffuse brain injury. This study demonstrated also the effect of socioeconomic status on outcome at the age of 5 years.

Asymmetric growth of the lateral cerebral ventricle in infants with posthemorrhagic ventricular dilation

Lateral cerebral ventricular volume in 36 preterm infants with or without an intraventricular hemorrhage, and with or without posthemorrhagic hydrocephalus, was measured longitudinally and compared with the ventricular index measurements of the same ventricles. A poor correlation was found (r2 = 0.67). To determine a reason for this poor relationship, we analyzed the volumes of the regions of the ventricles by a segmental volume analysis. The occipital region of the lateral cerebral ventricle enlarged at a much faster rate (1.904 +/- 0.477 ml/day) than either the anterior region (0.546 +/- 0.253 ml/day; p less than 0.01) or the middle region (-0.209 +/- 0.334 ml/day; p less than 0.01) in infants with posthemorrhagic hydrocephalus. The rate of growth of the middle region of the lateral cerebral ventricles was the same for all infants. Linear indexes, such as the ventricular index and the lateral ventricular ratio, do not allow for accurate serial estimates of ventricular size in posthemorrhagic hydrocephalus because of asymmetric growth of the lateral cerebral ventricle. We conclude that sequential volume measurements are more useful than ventricular index measurements to follow ventricular size sequentially in infants with posthemorrhagic hydrocephalus.

A study of periventricular haemorrhage, post‐haemorrhagic ventricular dilatation and periventricular leucomalacia in Chinese preterm infants

Serial cranial ultrasound scans were performed in 178 preterm Chinese infants (gestation less than 35 weeks, birthweight less than 2000 g) to study the incidence, age of onset and associating risk factors of periventricular haemorrhage (PVH), and also the occurrence of post-haemorrhagic ventricular dilatation and periventricular leucomalacia (PVL). Sixty-four infants developed haemorrhage, giving an incidence of 36%. Among infants of birthweight less than 1500 and less than 1000 g the respective incidence was 52 and 69%. Seventy-two per cent (46 of 64) of haemorrhages were initially detected within the first 3 days of life, but delayed haemorrhage occurring after 1 week of age occurred in nine infants. In eight of these infants PVH had been shortly preceded by a major clinical disaster. Eleven perinatal factors were found to be significantly associated with PVH but only systemic hypotension showed a significant independent association. Post-haemorrhagic ventricular dilatation developed in 17 (46%) of the 37 infants who survived for more than 1 month after PVH. This was transient in 41%, persistent but stable in 29% and progressive in 29%. PVL was detected in eight infants who survived the initial period following PVH.

Cerebral blood-flow velocity patterns in post-hemorrhagic ventricular dilation

To evaluate the effect of ventricular dilation (VD) on cerebral hemodynamics, serial cerebral bloodflow velocity patterns from the anterior and middle cerebral, and circle of Willis arteries were examined by range-gated, pulsed Doppler sonography in premature infants developing post-hemorrhagic VD. Nine infants (25 to 30 weeks gestation) without a patent ductus arteriosus were studied until resolution of VD. Forty-nine cranial sonograms from all nine infants were reviewed independently and grouped cross-sectionally into mild, moderate and severe VD prior to shunt. The corresponding pulsatility index (PI) showed a consistent trend of increase with VD in all three studied vessels. In six infants, absent or reversed diastolic flow was observed at the height of VD. Four of these infants required V-P shunt. Immediate fall in PI occurred in all three vessels. Serial measurement of PI during VD reflects global changes in cerebrovascular resistance. Results confirmed PI could be a useful index in monitoring cerebral hemodynamic changes.

Quantification of neonatal cerebral ventricular volume by real-time ultrasonography. In vivo validation of the cylindrical coordinate method.

Posthemorrhagic ventricular dilation is a common clinical problem in preterm infants who have incurred an intraventricular hemorrhage. Presently there are no clinically applicable methods to follow quantitatively the progression of ventricular dilation at bedside. We describe the in vivo validation of a method to measure ventricular volume using bedside real-time cranial ultrasonography. Six infants undergoing either serial lumbar punctures or cerebral ventricular reservoir taps for posthemorrhagic hydrocephalus were studied. The cerebrospinal fluid (CSF) volume removed ranged from 5.5 mL to 30 mL. A strong correlation was found (r2 = 0.84) between the volume of CSF removed by reservoir tap and the change in ventricular volume calculated by the ultrasound method, whereas the correlation between the volume of CSF removed at lumbar puncture and the change in ventricular volume calculated by the ultrasound method was not as strong (r2 = 0.70). Limitations and sources of error in the method are discussed. We conclude that this procedure is accurate and offers a quantitative method to follow longitudinally posthemorrhagic progressive ventricular dilation.

Neurosonographic Assessment of Twin Pairs in the Perinatal Period

Twins have higher rates of perinatal mortality, prematurity and its complications, low birth weight, intrauterine growth retardation, congenital anomalies and long-term developmental morbidity. In 31 twin pairs we evaluated the incidence and severity of peri-intraventricular hemorrhage (PIVH) and post-hemorrhagic ventricular dilatation. On ultrasonography minor PIVH (grades I and II) was observed in 26% of A twins and 25% of B twins (p less than 0.5). Major PIVH (grades III and IV) was less common, occurring in 3% of A twins and 6% of B twins (p less than 0.5). Ventriculomegaly, mostly regressive was equally distributed between the two groups of babies. From these results it can be concluded that with efficient antenatal care and skillful perinatal management of twin pregnancy, the incidence of major perinatal neurological complications such as PIVH and ventriculomegaly are not higher in the second-born twin.

Randomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation. Ventriculomegaly Trial Group.

Treatment of posthaemorrhagic ventricular dilatation by early repeated cerebrospinal fluid taps was compared with conservative management in a randomised controlled trial of 157 infants in 15 centres. Thirty infants died and six moved abroad before follow up. During the first 14 days after randomisation, the early treatment group had five times more taps, and 12 times more cerebrospinal fluid removed. Infection of the cerebrospinal fluid occurred in seven of the early treated and four of the conservatively managed infants. Of survivors, 62% in both groups ultimately had ventricular shunts. Neurodevelopmental assessment of survivors at 12 months was carried out by a single experienced examiner. Of survivors, 103 (85%) had abnormal neuromotor signs and 88 (73%) had disabilities. There was no detectable benefit of early treatment for children who did not have parenchymal lesions at the time they entered the trial. Nearly all those with parenchymal lesions had neuromotor impairment, but early treatment was associated with a significant reduction in other impairments.

Auditory brain stem responses in infants with posthaemorrhagic ventricular dilatation.

Nineteen infants with posthaemorrhagic ventricular dilatation had auditory brain stem responses measured during the period of maximal ventricular dilatation. These showed various patterns ranging from normal, through various abnormalities, to complete absence of responses. When serial auditory brain stem responses were studied in parallel with the evolution of posthaemorrhagic ventricular dilatation it was seen that the abnormalities of auditory brain stem response usually resolved irrespective of the persistence or progression of ventricular dilatation. No correlation was found between cerebrospinal fluid pressure and prolonged interpeak intervals on the auditory brain stem response. In three patients with posthaemorrhagic ventricular dilatation improvement in the auditory brain stem response occurred when cerebrospinal fluid was withdrawn. Intermittent withdrawal of cerebrospinal fluid (by ventricular tap or lumbar puncture) in two of these infants was followed by improvement in the auditory brain stem response after a period of 24 hours (but not sooner). In one infant born at full term improvement in the auditory brain stem response was noted one week after shunting.

18 ACUTE EFFECTS OF ACETAZOLAMIDE IN THE NEWBORN INFANT

Acetazolamlde is being increasingly used for the treatment of post-haemorrhagic ventricular dilatation. The aims of this study were to determine what effects acetazolamde had on cerebral blood flow, intra cranial pressure, and respiration in newborn infants7 infants were studied. 6 had post-haemorrhagic ventricular dilatation and one had external hydrocephalus. They received their first dose of acetazolamide 50 rag/kg IV at a postnatal age ranging from 2 to 17 weeks. Measurements of mean average cerebral blood velocity (CBV) were made from the middle cerebral artery using the duplex Doppler Vingmed CFM 700 system. Intracranial pressure was measured invaaively in 5 infants and with a fontanometer in 2.CBV increased in all cases by a median of 86% Maximum increase was reached within 2-15 minutes after slow IV injection. The duration of the effect varied from 30 minutes to more than 3.5 hours. Intracranial pressure increased in 5 infanta by a median of 7 mm Hg and was unchanged In 2. PCO2 rose by median of 0.2 kPa (range 0.2 to 0.6 kPa) and then fell as the respiratory rate increased by approximately 10 breaths/minute.

Outcome of infants shunted for post-haemorrhagic ventricular dilatation.

Between April 1980 and March 1986, 19 infants underwent cerebrospinal fluid (CSF) shunting procedures for post-haemorrhagic ventricular dilatation at the Hammersmith Hospital, London. A total of 58 shunt-related procedures have been performed on these children. The major perioperative complication was seizure activity (eight children). Postoperative complications included infection (12 shunts) and blockage (29 shunts). Prophylactic antibiotics failed to prevent shunt infection. The likelihood of the first shunt failing was significantly reduced by greater weight of the infant and lower CSF protein at surgery. Long-term outcome was poor: three have died and another four are quadriplegic with severe mental retardation. Only four children are developmentally normal. These outcomes cannot be related to the shunt surgery or its complications, but correlate best with pre-operative parenchymal brain-lesions, as shown on ultrasound scans.

Periventricular-Intraventricular Hemorrhage

This article reviews the pathophysiology of PV-IVH, the clinical aspects, the means of establishing the diagnosis, and the problem of posthemorrhagic ventricular dilation. The most recent advances are emphasized.

Post-haemorrhagic Ventricular Dilatation in Infants: Who and How to Treat

Post-haemorrhagic Ventricular Dilatation in Infants: Who and How to Treat

Cerebrospinal fluid pressure during post haemorrhagic ventricular dilatation in newborn infants.

Post haemorrhagic ventricular dilatation occurs in a minority of newborn infants, but is associated with a high risk of cerebral palsy and developmental delay. Neither the relation of ventricular size to cerebrospinal fluid (CSF) pressure, nor the effect of CSF removal on prognosis, have been established. Normal CSF pressure measured at subarachnoid cannulation was mean (SD) 2.8 (1.4) mm Hg. Values were significantly higher in post haemorrhagic ventricular dilatation--9.1 (3.7) mm Hg when the ventricles were expanding, and 4.5 (2.4) mm Hg when they were static or contracting. No significant relation between head circumference and CSF pressure was found in this series. Raised CSF pressure is associated with progressive ventricular dilatation, and may contribute to the increased risk of neurological abnormality.

PERIVENTRICULAR LEUKOMALACIA OF THE PRETERM INFANT AND NEURODEVELOPMENTAL OUTCOME AT 18 MONTHS

Periventricular leukomalacia(PVL) can be accurately identified in the neonatal period by means of ultrasonography and the use of high-frequency transducer. In order to establish its pronostic value, a prospective neurological and developmental assessment(Griffith's development quotient [DQ]) at 18 months corrected for prematurity was per formed on 82 infants of 34 weeks'gestation or less, alloca ted in 4 groups : 41 with normal scans(group I), 13 with isolated haemorrhage(group II), 4 with post-haemorrhagic ventricular dilatation(group III) and 24 with PVL associated or not with haemorrhage or dilatation(group IV). The outcome was good and similar in group I,II and III.By contrast, the outcome of group IV was worse and seemed to depend on the extent and site of PVL: 1)Frontal areas(n=13): all babies developed normally. 2)Frontal-parietal areas (n=6): 3 had major handicap. 3)Frontal-parietal-Occipital areas(n=5): all had major handicap. Our study indicate that major sequelae are more closely related to the extent and localisation of PVL than to haemorrhage or ventricular dilatation as previously reported.