Progressive Posthaemorrhagic Ventricular Dilatation Research Articles

Prediction of post-hemorrhagic ventricular dilatation trajectory using a growth mixture model in preterm infants.

Early intervention for post-hemorrhagic ventricular dilatation (PHVD), guided by ventricular size measurements from cranial ultrasound (cUS), is associated with improved neurodevelopmental outcomes in preterm infants but benefits must be balanced against intervention risks. Anterior horn width (AHW) and ventricular index (VI) were measured from cUS for preterm infants (<29 weeks) with intraventricular hemorrhage admitted from 2010-2018. PHVD was defined as AHW > 6 mm or VI >97th percentile for postmenstrual age. Individual ventricular size trajectories were plotted, and a growth mixture model (GMM) used to identify latent trajectory classes and compare these to predetermined outcome of neurosurgical intervention. Measurements were obtained from 1543 cUS in 249 infants, of whom 39 had PHVD without and 17 PHVD with neurosurgical intervention based on signs of raised intracranial pressure. The GMM predicted trajectory identified: 93.3% of infants without PHVD, 88.2% and 30.8% of infants with PHVD with and without intervention using AHW; 100% of infants without PHVD, 52.9% and 59.0% of infants with PHVD with and without intervention using VI. The AHW GMM identified a significant proportion of infants with severe PHVD. Model refinement offers a promising approach for identifying differences in PHVD trajectory at an early stage to guide management. It is difficult to distinguish the trajectory of PHVD in the early stage of development, in particular PHVD that spontaneously arrests from slowly progressive PHVD which eventually requires intervention. We report the first modeling-based evaluation of PHVD trajectory for the prediction of short-term outcome of PHVD progression and neurosurgical intervention. With additional clinical validation and optimization to increase accuracy, predictive modeling has the potential to identify important differences in PHVD trajectory at an early stage in the clinical course, allowing for more individualized data-driven risk-benefit assessments to guide decisions on early intervention.

Decreased Cerebral Oxygenation in Premature Infants with Progressive Posthemorrhagic Ventricular Dilatation May Help with Timing of Intervention.

The objective of this study was to determine the degree of progressive posthemorrhagic ventricular dilatation (PHVD) that is associated with a significant decrease in regional cerebral oxygen saturation (rScO2) in premature infants at risk for periventricular-intraventricular hemorrhage (PIVH). Cranial ultrasound (US) and near-infrared spectroscopy (NIRS) measurements of rScO2 were performed on inborn infants with birth weights less than 1,250 g on admission and at 1, 4, and 8 weeks of age. Infants with severe PIVH were studied weekly. A 1-hour average of rScO2 was compared with the frontal-occipital horn ratio (FOHR) measured the same day. Generalized linear models were used to analyze the relationship between FOHR and rScO2, by severity of PIVH, and adjusted for gestational age. Cut-off points of 0.55 for FOHR and 45% for rScO2 were used to calculate odds ratios (OR) and 95% confidence intervals (CI). The study cohort included 63 infants with normal US, 15 with grade-1 or -2 PIVH (mild group), and 21 with grade-3 or -4 PIVH (severe group). Increases in FOHR in the severe group were associated with decreases in rScO2 at 1 week (p = 0.036), 4 weeks (p = 0.013), and 8 weeks of life (p = 0.001) compared with the normal and mild groups. Infants with FOHR greater than 0.55 were 92% more likely to have rScO2 less than 45% when compared with infants with FOHR less than 0.55 (OR = 0.08, 95% CI: [0.04, 0.13], p < 0.001). Progressive PHVD (FOHR > 0.55) is a strong predictor of compromised cerebral oxygenation. A combination of rScO2 and FOHR measurements may aid in identifying infants with PHVD that would benefit from early intervention. · Earlier intervention in PHVD may improve outcomes.. · PHVD is diagnosed with US measurements of ventricular size.. · FOHR > 0.55 is associated with decreased cerebral perfusion..

Randomized Controlled Early versus Late Ventricular Intervention Study in Posthemorrhagic Ventricular Dilatation: Outcome at 2 Years

To compare the effect of intervention at low vs high threshold of ventriculomegaly in preterm infants with posthemorrhagic ventricular dilatation on death or severe neurodevelopmental disability. This multicenter randomized controlled trial reviewed lumbar punctures initiated after either a low threshold (ventricular index of >p97 and anterior horn width of >6mm) or high threshold (ventricular index of >p97+4mm and anterior horn width of >10mm). The composite adverse outcome was defined as death or cerebral palsy or Bayley composite cognitive/motor scores <-2 SDs at 24months corrected age. Outcomes were assessed in 113 of 126 infants. The composite adverse outcome was seen in 20 of 58 infants (35%) in the low threshold group and 28 of 55 (51%) in the high threshold (P=.07). The low threshold intervention was associated with a decreased risk of an adverse outcome after correcting for gestational age, severity of intraventricular hemorrhage, and cerebellar hemorrhage (aOR, 0.24; 95% CI, 0.07-0.87; P=.03). Infants with a favorable outcome had a smaller fronto-occipital horn ratio (crude mean difference, -0.06; 95% CI, -0.09 to -0.03; P<.001) at term-equivalent age. Infants in the low threshold group with a ventriculoperitoneal shunt, had cognitive and motor scores similar to those without (P=.3 for both), whereas in the high threshold group those with a ventriculoperitoneal shunt had significantly lower scores than those without a ventriculoperitoneal shunt (P=.01 and P=.004, respectively). In a post hoc analysis, earlier intervention was associated with a lower odds of death or severe neurodevelopmental disability in preterm infants with progressive posthemorrhagic ventricular dilatation. ISRCTN43171322.

Role of beta-2-microglobulin as a biomarker in very preterm and extremely preterm infants with CNS inflammation

BackgroundPremature infants are at risk for severe sepsis and meningitis, both infections associated with high mortality and morbidity. Cerebro-spinal fluid (CSF) culture is the gold standard method for meningitis diagnosis, but interpretation of biochemical parameters of CSF is essential at the moment of the analysis in order to start the appropriate treatment. The main objective of this study was to determine whether levels of CSF beta-2-microglobulin (B2M) were elevated in preterm infants with CNS infections or other inflammatory processes, and to establish if there were differences in B2M concentrations amongst various inflammatory settings (sepsis, meningitis, and progressive post-hemorrhagic ventricular dilatation (PHVD)).MethodsThis is a retrospective study of all very preterm and extremely preterm infants (< 32 weeks of gestation) admitted to our NICU between 2012 and 2017. All those who underwent a lumbar puncture during their stay as part of a sepsis work-up or PHVD were considered for inclusion. CSF biochemical parameters and B2M were tested in all of the patients.ResultsFifty-nine patients were included in the study. In patients with CNS infections, the median value of B2M was 8.69 mg/L (3.92–18.5). B2M levels above 3.92 mg/L showed greater sensitivity and specificity than leukocyte levels in discriminating between patients with CNS infections or other inflammatory processes and those without CNS inflammation.ConclusionsIn this population, CSF B2M proved to be an effective biomarker to discriminate between patients with CNS infections and other inflammatory processes and those without CNS inflammation.

An MR-based quantitative intraventricular hemorrhage porcine model for MR-guided focused ultrasound thrombolysis.

Intraventricular hemorrhage (IVH) affects approximately 50% of premature births where 50% further develop post-hemorrhagic ventricular dilation (PHVD). Patients face significant impact to long-term development if PHVD is not managed. Unfortunately, there is no accepted treatment to remove the thrombus caused by IVH. This paper describes an acute and chronic IVH model for use with magnetic resonance-guided focused ultrasound (MRgFUS) thrombolysis. A total of 12 pigs (~ 1month in age) were used in the model (eight acute and four chronic). A pre-operative brain MRI was obtained for ventricular targeting. 1.25cm3/kg of autologous blood was injected through a burr hole lateral to the midline and anterior of the coronal suture at a rate of 0.6cm3/min. A craniotomy was performed to simulate a "fontanelle". Post-operative MRI was used to calculate the clot volume. Chronic piglets were recovered, monitored daily with a neurological scoring system (NSS), and MRI scanned for 21days. The clot injection was well tolerated. The average clot size was 3987mm3 (median = 4330mm, standard deviation = 739mm3). Postmortem examination validated the presence of the clot. In the chronic animals, there was an increase in ventricular volume of 30%. Transient neurological impairment immediately followed clot injection and with onset of hydrocephalus in the chronic animals. This model establishes a measurable and targetable IVH clot in an MRI-based neonatal porcine model. The progressive post-hemorrhagic ventricular dilation in the chronic model is a potential alterable outcome from MRgFUS thrombolysis.

Changes in Cerebral Oxygenation in Preterm Infants With Progressive Posthemorrhagic Ventricular Dilatation

BackgroundOptimal timing of intervention in neonatal progressive posthemorrhagic hydrocephalus is often a difficult decision. Unchecked hydrocephalus can lead to irreversible brain injury through impaired perfusion, while placement of a shunt is not without long-term morbidity. The purpose of this study was to assess the use of near-infrared spectroscopy to measure changes in regional cerebral oxygen saturation as an indicator of cerebral perfusion in infants with progressive posthemorrhagic ventricular dilatation. MethodsNear-infrared spectroscopy was used to measure regional cerebral oxygen saturation for more than a one-hour period in infants within 24 hours of cranial ultrasound. Simultaneous pulse oximetry was recorded and oxygen extraction was calculated. Ventricular size was measured by ultrasound using the frontal-occipital horn ratio and compared with average oxygen saturation and oxygen extraction. Statistical analysis was done using the Spearman rank test and analysis of variance. ResultsVentricular measurements were made in 20 very low birth weight premature infants with periventricular-intraventricular hemorrhage and 12 infants with normal ultrasound scans. Ventricular dilatation was associated with lower cerebral oxygen saturation and higher oxygen extraction (P < 0.001). Progressive ventricular dilatation was inversely related to changes in cerebral oxygen saturation (P < 0.001). ConclusionsProgressive posthemorrhagic ventricular dilatation is associated with a significant decrease in cerebral oxygenation and increase in oxygen extraction suggesting a decrease in cerebral perfusion. Near-infrared spectroscopy could potentially provide additional clinical information to assist in determining optimal timing of surgical intervention in preterm infants with progressive ventricular enlargement.

Decompressing posthaemorrhagic ventricular dilatation significantly improves regional cerebral oxygen saturation in preterm infants

This study aimed to delineate the impact of posthaemorrhagic ventricular dilatation (PHVD) on regional cerebral oxygen saturation (rcSO2) in preterm infants before and after ventricular decompression using near-infrared spectroscopy (NIRS). rcSO2 values were recorded, fractional tissue oxygen extraction (FTOE) was calculated, cerebral ultrasound scans were performed, and resistive indices and ventricular width were collected before and after decompression. Where possible, amplitude-integrated electroencephalography (aEEG) and visual evoked potentials (VEPs) were recorded before and after decompression. We included nine preterm infants: nine with cranial ultrasound scan data, eight with NIRS data, seven with aEEG data and four with VEPs. The resistive index was stable and remained unchanged after decompression in all patients. Before decompression, the mean rcSO2 value was 42.6 ± 12.9% and increased to 55 ± 12.2% after decompression. With increasing ventricular width, FTOE showed a mean value of 0.51 ± 0.05 and decreased to a mean of 0.39 ± 0.12 after decompression. Amplitude-integrated electroencephalography showed a more continuous pattern, and VEPs showed delayed latencies in all patients before intervention, improving afterwards. Near-infrared spectroscopy may be of additional clinical value in progressive PHVD to determine the optimal time point for ventricular decompression.

O-161 Cerebral Oxygenation Before And After Neurosurgical Placement Of A Ventricular Reservoir In Neonates With Phvd

Background There is no consensus regarding optimal timing in treating posthaemorrhagic ventricular dilatation (PHVD). Near-InfraRed Spectroscopy (NIRS) is a non invasive method, measuring cerebral regional oxygenation (rScO 2 ). rScO 2 values below 40–45% might be associated with cerebral ischaemia. Hypothesis: rScO 2 can provide additional information about cerebral oxygenation in infants with PHVD and may therefore be of value to determine timing of intervention. Methods We measured rcSO 2 in 13 neonates before and after neurosurgical placement of a ventricular reservoir. Based on ventricular index (VI; Levene), distinction was made in neonates treated early (VI Results Median GA 31 wks (27–37 wks) and median BW 1750 g (1145–3270 g). Five neonates were treated early and 8 late. In the early intervention group, pre-, and postoperative rScO2 values were comparable (median 52%, 45–58% IQR vs 57%, 44–60% IQR). Preoperative rScO 2 was lower in the late intervention group compared to postoperative values (median 33%, 26–43% IQR vs 47%, 39–49% IQR). In 7 late intervention infants rScO 2 was 2 remained Conclusions Neonates with VI≥97 + 4 mm do have a compromised cerebral oxygenation, and usually react to cerebrospinal fluid drainage with recovery of the rScO 2 values to within the normal range. Infants in the early intervention group were within normal range pre- and postoperatively. NIRS might be of additional clinical value in progressive PHVD in order to determine optimal timing for intervention.

Can neurophysiological assessment improve timing of intervention in posthaemorrhagic ventricular dilatation?

ObjectiveIntraventricular haemorrhage is still the most common cause of brain lesion in preterm infants and development of a posthaemorrhagic ventricular dilatation (PHVD) can lead to additional neurological sequelae. Flash visual...

Posthemorrhagic Ventricular Dilatation—Impact on Early Neurodevelopmental Outcome

This study evaluates the impact of ventricular dilatation following severe (grades III or IV) intraventricular hemorrhage (IVH) in preterm neonates and the current practice of neurosurgical interventions in infants with posthemorrhagic ventricular dilatation (PHVD) and early neurodevelopmental outcome. Premature neonates born at ≤34 weeks' gestational ages with severe IVH were identified retrospectively over a 5-year period (2005 to 2009). Standard measures of ventricular dilatation on head ultrasound (HUS) were recorded. The treatment of PHVD, timing of surgery including the type of temporizing neurosurgical procedure (TNP)-either a ventricular reservoir or a subgaleal shunt-and the subsequent need for ventriculoperitoneal (VP) shunt were evaluated. Patients were retrospectively stratified to an "early" versus "late" intervention group based on HUS measures. Early intervention was defined as TNP performed when the ventricular index (VI) was >97th percentile but <97th percentile + 4 mm. Late intervention was defined as TNP performed when VI was ≥97th percentile + 4 mm. Neurodevelopmental outcomes were evaluated at 18 to 24 months. Infants followed up for neurodevelopmental testing were stratified as group A (progressive PHVD with TNP), group B (PHVD without TNP), and group C (severe IVH without PHVD). One hundred seventy-three preterm neonates with severe IVH were identified during the study period, of whom 139/173 (80%) developed PHVD. Of these, 54 (54/139, 39%) received TNP either early (4/54, 7%) or late (50/54, 93%). Of those who received TNP, 32/54 (59%) required subsequent VP shunt placement. Neurodevelopmental testing was available in 39/109 (36%) infants who survived to discharge. The mean ± standard deviation cognitive, motor, and language composite scores were 77 ± 14.8, 67 ± 15.2, 70 ± 13.8 for group A (n = 16/39), 90 ± 7.8, 84 ± 9.6, 82 ± 18.2 for group B (n = 12/39), and 95 ± 14.3, 86 ± 10.7, 94 ± 15.8 for group C (n = 11/39), respectively (p < 0.006 for group A versus group B and p < 0.004 for group A versus group C across all domains). Increasing ventricular dilatation was associated with adverse motor, cognitive, and language outcomes (p = 0.002) and neonates with progressive PHVD requiring a TNP were most adversely affected (p = 0.0006). There were no differences in any outcome measures between the two types of TNPs. Clinical and demographic characteristics of infants lost to follow-up were not significantly different than those available for follow-up. Increasing ventricular size adversely affects neurodevelopmental outcome in infants with PHVD.

High-Frequency Ultrasound in the Evaluation of Cerebral Intraventricular Haemorrhage in Preterm Rabbit Pups

Cerebral intraventricular haemorrhage (IVH) is the most common cause of severe neurologic impairment following preterm birth in human infants. Ideally, an animal model for cerebral IVH should allow for reliable noninvasive evaluation of haemorrhagic extension and of subsequent development of posthaemorrhagic ventricular dilatation (PHVD). The aim of this study was to evaluate the use of high-frequency ultrasound (HFU) in premature rabbit pups with cerebral IVH induced by IP glycerol injection. Serial examinations using HFU enabled an accurate description of haemorrhagic extension and measurement of progressive PHVD over 72 h. The coefficient of variation for inter- and intraobserver variability in two measurements of ventricular size was less than 8.8% and 9.3%, respectively. Repeated ultrasound-guided intraventricular injection and sampling could be performed in vivo excluding requirement of stereotactic procedures and sedation. Application of HFU is a powerful tool for the evaluation of mechanisms involved in cerebral IVH and PHVD in the preterm rabbit pup model.

Cognitive and Neurological Outcome at the Age of 5–8 Years of Preterm Infants with Post-Hemorrhagic Ventricular Dilatation Requiring Neurosurgical Intervention

Background: Preterm infants with progressive post-hemorrhagic ventricular dilatation (PHVD) in the absence of associated parenchymal lesions may have a normal neurodevelopmental outcome. Objectives: To evaluate neurodevelopmental and cognitive outcomes among preterm infants with severe intraventricular hemorrhage (IVH) and PHVD requiring neurosurgical intervention. Methods: 32 preterm infants were admitted to a neonatal intensive care unit with PHVD requiring neurosurgical intervention, and were seen in the follow-up clinic for standardized cognitive, behavioral and neurological assessments between 5 and 8 years of age. Only preterm infants with a gestational age (GA) of <30 weeks, as well as preterm and full-term infants with PHVD and full-term infants with perinatal asphyxia are seen in our follow-up clinic at this age. There were 23 infants with a GA of <30 weeks in this study population. For these 23, matched controls were available and compared with the IVH group. Results: The majority (59.4%) had no impairments. None of the children with grade III and 8 of the 15 children (53%) with grade IV hemorrhage developed cerebral palsy. More subtle motor problems assessed with the Movement-ABC score were seen in 39% (n = 9); the mean IQ of all children was 93.4, and 29% of the children had an IQ of <85 (–1 SD). Timing of intervention did not have a beneficial effect on outcome. With respect to cognition, no significant differences were found between the IVH and the control group. Conclusion: The majority of the children in our population had no impairments. Cerebral palsy was not seen in any of the infants with a grade III hemorrhage.

Neurosurgical treatment of progressive posthemorrhagic ventricular dilation in preterm infants: a 10-year single-institution study

Object Intraventricular hemorrhage (IVH) and progressive posthemorrhagic ventricular dilation (PPHVD) may result in significant neurological morbidity in preterm infants. At present, there is no consensus regarding the optimal timing or type of neurosurgical procedure to best treat PPHVD. Conflicting data exist regarding the relative risks and benefits of two commonly used temporizing neurosurgical procedures (TNPs), ventricular access devices ([VADs] or ventricular reservoirs) versus ventriculosubgaleal (VSG) shunts. This study was designed to address this issue. Methods This is a single-center, 10-year retrospective review of all preterm infants admitted to the St. Louis Children's Hospital neonatal intensive care unit (NICU) with Papile Grade III–IV IVH. The development of PPHVD and the requirement for and type of TNP were recorded. Rates of TNP complication, ventriculoperitoneal (VP) shunt implantation, shunt infection, and mortality rates were used to compare the efficacy and limitations of each TNP type. Results Over this 10-year interval, 325 preterm infants with Grade III–IV IVH were identified, with trends showing an increasing number of affected infants annually, and an increasing number of TNPs were required annually. Ninety-five (29.2%) of the 325 infants underwent a TNP for PPHVD (65 VADs, 30 VSG shunts). The rate of permanent VP shunt implantation for all TNPs was 72.6% (69 of 95 infants). Forty-nine (75.4%) of the 65 infants treated with VADs and 20 (66.7%) of the 30 treated with VSG shunts required VP shunts (p = 0.38). There was no statistical difference between VAD or VSG shunt with regard to TNP-related infection (p = 0.57), need for TNP revision (p = 0.16), subsequent shunt infection (p = 0.77), shunt revision rate (p = 0.58), or mortality rate (p = 0.24). Conclusions Rates of IVH and PPHVD observed at the authors' center have increased over time. In contrast to recent literature, the results from the current study did not demonstrate a difference in complication rate or requirement for permanent VP shunt placement between VADs and VSG shunts. Definitive conclusions will require a larger, prospective trial.

Cerebrospinal fluid drainage in posthaemorrhagic ventricular dilatation leads to improvement in amplitude‐integrated electroencephalographic activity

Progressive posthaemorrhagic ventricular dilatation (PHVD) may induce abnormal amplitude-integrated electroencephalographic (aEEG) activity prior to clinical deterioration or significant cerebral ultrasound changes. These abnormalities might be ameliorated with cerebrospinal fluid (CSF) drainage. The aims of this study were to investigate the occurrence of aEEG-abnormalities with progressive PHVD in relation to clinical and cerebral ultrasound changes and to evaluate whether CSF drainage results in aEEG improvement. aEEG and cerebral ultrasound scans were performed in 12 infants with PHVD, before and after CSF drainage, until normalization of aEEG occurred. aEEG was abnormal with progressive PHVD in all patients. Concurrently, 60% of the patients were clinically stable without deterioration in ultrasonographic cerebral abnormalities. Post drainage, continuous pattern was restored in all but one patient, whereas the frequency of discontinuous pattern decreased in nine patients and burst-suppression pattern decreased in all but one patient. Low-voltage pattern was only observed in one patient who suffered severe grade IV IVH and died one week after EVD placement. Sleep-wake cycling matured in 75%. These findings demonstrate the impact of CSF drainage on compromised aEEG-activity associated with PHVD. aEEG changes indicative of impaired cerebral function were apparent before clinical deterioration or major ultrasound changes. These changes were reversible with CSF drainage. aEEG should therefore be used in addition to clinical observation and ultrasound when monitoring PHVD.

Incidence of infections of ventricular reservoirs in the treatment of post-haemorrhagic ventricular dilatation: a retrospective study (1992–2003)

Background: Since 1992, infants with progressive posthaemorrhagic ventricular dilatation (PHVD) have been treated in the Neonatal Intensive Care Unit, Wilhelmina Children’s Hospital, Utrecht, The Netherlands, with a ventricular reservoir. Objective:...

Complications of Neonatal Intracranial Hemorrhage

After completing this article, readers should be able to: 1. Describe the pathologic injury to the brain caused by posthemorrhage ventriculomegaly (PHVM). 2. List the clinical diagnostic criteria for PHVM. 3. Describe findings on ultrasonography seen with PHVM. 4. Delineate the positive and negative aspects of techniques employed to manage PHVM. 5. Describe the neurologic and cognitive outcome of PHVM. The complications of intracranial hemorrhage (ICH) in preterm neonates are related to the location and severity of hemorrhage. Hemorrhage in the subependymal region resolves with no residual effects. The resolution of hemorrhage in the parenchymal region is based on location of the hemorrhage. Over the course of weeks, parenchymal hemorrhage evolves either into posthemorrhagic cysts or porencephalic dilatation of the ventricular system. Among infants who have intraventricular hemorrhage (IVH), in whom the initial hemorrhage in the periventricular germinal matrix progresses into the ventricular spaces, progressive posthemorrhagic ventricular dilation is the most frequent and serious complication. Ventricular size also can increase from blood clots at the time of the occurrence of IVH during the first week of life. Although this acute ventricular distention often subsides, 60% to 70% of infants who have IVH experience a progressive increase in ventricular size within 2 weeks of the initial occurrence due to accumulation of cerebrospinal fluid (CSF). Posthemorrhagic ventriculomegaly (PHVM) can progress slowly or rapidly. In the majority of cases (65%), slowly progressive PHVM spontaneously arrests. In the remaining 30% to 35% of affected infants, ventricular size increases rapidly over the course of days to weeks. PHVM is caused by obstruction of the CSF pathway by blood clots, usually at the posterior fossa cisterns and less commonly at the aqueduct of Sylvius or the foramen of Monroe. The PHVM caused by occlusion of the CSF pathways often progresses rapidly. In contrast, posthemorrhagic inflammatory changes in the arachnoid villi contribute …

Pinpoint for windows

<b>Background:</b> Since 1992, infants with progressive posthaemorrhagic ventricular dilatation (PHVD) have been treated in the Neonatal Intensive Care Unit, Wilhelmina Children’s Hospital, Utrecht, The Netherlands, with a ventricular reservoir. <b>Objective:</b> To retrospectively study the incidence of infection using this invasive procedure. <b>Methods:</b> Between January 1992 and December 2003, 76 preterm infants were treated with a ventricular reservoir. Infants admitted during two subsequent periods were analysed: group 1 included infants admitted during 1992–7 (n = 26) and group 2 those admitted during 1998–2003 (n = 50). Clinical characteristics and number of reservoir punctures were evaluated. The incidence of complications over time was assessed, with a focus on the occurrence of infection of the reservoir. <b>Results:</b> The number of punctures did not change during both periods. Infection was significantly less common during the second period (4% (2/50) <i>v</i> 19.2% (5/26), p = 0.029). <b>Conclusion:</b> The use of a ventricular reservoir is a safe treatment to ensure adequate removal of cerebrospinal fluid in preterm infants with PHVD. In experienced hands, the incidence of infection of the ventricular reservoir or major complications remains within acceptable limits.

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.

Sonographic depiction of changes in ventricular size associated with repeated ventricular aspirations.

Serial real-time cranial sonography was performed on 11 preterm neonates who had demonstrated progressive posthemorrhagic ventricular dilatation and were subjected to repeated ventricular aspirations. Changes in ventricular size were correlated with gestational age, birth weight, and extent and location of the intracranial hemorrhage, as well as the timing, frequency, and location of the ventricular aspirations and the average amount of cerebrospinal fluid removed. The sizes of both lateral ventricles of each neonate were measured and the occurrence of sequelae related to repeated ventricular aspiration was examined. Eleven ventricles diminished in size, eight increased, and there was no change in three. Two neonates had bleeding near the aspiration sites. It is concluded that repeated aspiration can be associated with a diminution in ventricular size in some neonates. It is recommended that alternative methods of treatment, such as serial lumbar puncture or external ventriculostomy, be attempted prior to initiating repeated ventricular aspirations.