Posthemorrhagic ventricular dilatation in preterm infants: When best to intervene?

Lara M Leijser; Steven P Miller; Gerda van Wezel-Meijler; Annemieke J Brouwer; Jeffrey Traubici; Ingrid C van Haastert; Hilary E Whyte; Floris Groenendaal; Abhaya V Kulkarni; Kuo S Han; Peter A Woerdeman; Paige T Church; Edmond N Kelly; Henrica L M van Straaten; Linh G Ly; Linda S de Vries

doi:10.1212/WNL.0000000000004984

Posthemorrhagic ventricular dilatation in preterm infants: When best to intervene?

Neurology. 2018 Feb 20;90(8):e698-e706. doi: 10.1212/WNL.0000000000004984. Epub 2018 Jan 24.

Authors

Lara M Leijser¹, Steven P Miller¹, Gerda van Wezel-Meijler¹, Annemieke J Brouwer¹, Jeffrey Traubici¹, Ingrid C van Haastert¹, Hilary E Whyte¹, Floris Groenendaal¹, Abhaya V Kulkarni¹, Kuo S Han¹, Peter A Woerdeman¹, Paige T Church¹, Edmond N Kelly¹, Henrica L M van Straaten¹, Linh G Ly¹, Linda S de Vries²

Affiliations

¹ From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada.
² From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada. l.s.devries@umcutrecht.nl.

Abstract

Objective: To compare neurodevelopmental outcomes of preterm infants with and without intervention for posthemorrhagic ventricular dilatation (PHVD) managed with an "early approach" (EA), based on ventricular measurements exceeding normal (ventricular index [VI] <+2 SD/anterior horn width <6 mm) with initial temporizing procedures, followed, if needed, by permanent shunt placement, and a "late approach" (LA), based on signs of increased intracranial pressure with mostly immediate permanent intervention.

Methods: Observational cohort study of 127 preterm infants (gestation <30 weeks) with PHVD managed with EA (n = 78) or LA (n = 49). Ventricular size was measured on cranial ultrasound. Outcome was assessed at 18-24 months.

Results: Forty-nine of 78 (63%) EA and 24 of 49 (49%) LA infants received intervention. LA infants were slightly younger at birth, but did not differ from EA infants for other clinical measures. Initial intervention in the EA group occurred at younger age (29.4/33.1 week postmenstrual age; p < 0.001) with smaller ventricles (VI 2.4/14 mm >+2 SD; p < 0.01), and consisted predominantly of lumbar punctures or reservoir taps. Maximum VI in infants with/without intervention was similar in EA (3/1.5 mm >+2 SD; p = 0.3) but differed in the LA group (14/2.1 mm >+2 SD; p < 0.001). Shunt rate (20/92%; p < 0.001) and complications were lower in EA than LA group. Most EA infants had normal outcomes (>-1 SD), despite intervention. LA infants with intervention had poorer outcomes than those without (p < 0.003), with scores <-2 SD in 81%.

Conclusion: In preterm infants with PHVD, those with early intervention, even when eventually requiring a shunt, had outcomes indistinguishable from those without intervention, all being within the normal range. In contrast, in infants managed with LA, need for intervention predicted worse outcomes. Benefits of EA appear to outweigh potential risks.

Classification of evidence: This study provides Class III evidence that for preterm infants with PHVD, an EA to management results in better neurodevelopmental outcomes than a LA.

Publication types

Multicenter Study
Observational Study
Research Support, Non-U.S. Gov't

MeSH terms

Cerebral Hemorrhage / complications*
Cerebral Hemorrhage / therapy
Cerebral Ventricles / diagnostic imaging
Cerebral Ventricles / pathology
Cerebrospinal Fluid Shunts
Child, Preschool
Cohort Studies
Dilatation, Pathologic / diagnostic imaging
Dilatation, Pathologic / etiology*
Dilatation, Pathologic / pathology
Dilatation, Pathologic / therapy*
Echoencephalography
Humans
Infant
Infant, Premature* / growth & development
Organ Size
Spinal Puncture
Time-to-Treatment
Treatment Outcome