Role of External Ventricular Drainage (EVD) in Treating Spontaneous Intraventricular Haemorrhage

Background: There is no consensus in the literature on the effects of the development of hydrocephalus on survival and disability after intracerebral haemorrhage (ICH) and the benefits of external ventricular drainage (EVD). This study is planned to describe the role of external ventricular drainage in treating patients of spontaneous, either primary or secondary, intraventricular haemorrhage with hydrocephalus.Material & Methods:A hospital based prospective interventional study was conducted in the Department of Neurosurgery of Dhaka Medical College Hospital, which is a tertiary level hospital, from April 2016 to September 2017.Total 42 patients of spontaneous intraventricular haemorrhage, either primary or secondary, with hydrocephalus were selected for this study. All the collected data were entered into IBM SPSS software, Version 24. For statistical analysis, paired t-test to compare the preoperative GCS with postoperative GCS at 24 hours was done.Results:Among 42 patients, age range was 26-75 years with the mean age 65.2 � 10.87 years. Male were 26 (61.9%) and female were 16 (38.1%). Male-Female ratio was 1.625:1. No patient needed conversion of EVD into VP shunt. EVD drain became blocked in 5 cases which were managed accordingly. 5 patients developed ventriculitis among which 2 patients died and rest 3 improved with antibiotics.Conclusions:The results of present study shows that EVD has a good role in the treatment of spontaneous IVH with hydrocephalus when ICH volume is low (<30ml) and modified Graeb Score is low (?10 found in this in this study. Preoperative higher GCS or initial improvement in GCS or initial improvement in GCS at 24 hours positively correlates with Glasgow outcome scale which is an indication of good function outcome.

The incidence and risk factors of periventricular-intraventricular hemorrhage in extremely preterm infants / 中国新生儿科杂志

Objective:To study the incidence and risk factors of periventricular- intraventricular hemorrhage (PIVH) in extremely preterm infants (EPI) with gestational age (GA)<28 weeks.Methods:A retrospective study was performed in 304 cases of EPI hospitalized between January 2016 and December 2018. The infants were assigned into two groups according to whether PIVH occurred. Univariate analysis and Logistic regression analysis were used to determine the risk factors of PIVH.Results:Among the 304 cases,101 (33.2%) developed PIVH and 44 (14.5%) developed severe PIVH.The incidences of PIVH and severe PIVH in EPI with birth weight (BW) <750 g were 50.6% and 31.0%. The incidences of PIVH and severe PIVH in EPI with GA<26 weeks were 51.4% and 27.5%. Logistic regression analysis revealed that advanced GA ( OR=0.697, 95% CI 0.543~0.895, P=0.005) decreased the risk of PIVH. Prolonged invasive mechanical ventilation ( OR=1.121, 95% CI 1.007~1.249, P=0.037) and use of vasoactive drugs ( OR=1.373, 95% CI 1.040~1.812, P=0.025) within the first week of life increased the risk of PIVH. Conclusions:The incidences of PIVH and severe PIVH in EPI are quite high. Smaller GA, longer use of invasive mechanical ventilation and vasoactive drugs within the first week will increase the risk of PIVH in EPI.

Intraventricular haemorrhage as the first manifestation of congenital Cytomegalovirus infection

Congenital Cytomegalovirus infection (CCMV) is the most common intrauterine infection. Early diagnosis of CCMV is hindered by three factors: There is no screening programme for CMV infection in pregnant women; a high percentage of infections in neonates are asymptomatic; the clinical signs of CCMV infection are uncharacteristic. The aim of this article is to analyse the clinical picture and course of CCMV treatment in a 3-week-old newborn, analyse adverse events in 14-week-long antiviral therapy and also assess intraventricular bleeding as an early indicator for the diagnosis of CCMV.

Prevalence of Shunt Dependency and Clinical Outcome in Patients with Massive Intraventricular Haemorrhage Treated with Endoscopic Washout and External Ventricular Drainage

Background: Intraventricular haemorrhage (IVH) causes blockage of ventricular conduits leading to hydrocephalus, increased intracranial pressure (ICP), and a reduced level of consciousness. The current standard management of IVH is insertion of an external ventricular drainage (EVD) catheter. However, this procedure addresses only the problems of acute hydrocephalus and raised ICP. Endoscopic washout allows for a more complete removal of the intraventricular clot. This study compared these two types of treatment in terms of shunt dependency and relevant clinical outcomes. Methods: Patients who were 10–80 years old and presented with a Graeb score of more than six were randomised into endoscopic washout and EVD treatment groups. A CT brain was repeated on each patient within 24 hours after surgery, and if a patient’s Graeb score was still more than six, a repeat endoscopic washout was performed to clear the remaining clots. All patients were monitored for shunt dependency at two weeks and three months, and clinical outcomes were measured at six months after the procedure. Results: A total of 39 patients were recruited; 19 patients were randomised into the endoscopic washout group, and 20 were randomised into the EVD group. However, three patients in the endoscopic group refused that treatment and opted for EVD insertion. Patients treated with endoscopic washout had significantly less drainage dependency at two weeks (P < 0.005) and at three months (P < 0.004) as compared to patients in the external ventricular drainage group. The reduction in Graeb scores was also significantly greater in the endoscopic washout group (P < 0.001). However, the functional outcome at six months measured via a modified Rankin scale score was no different in the two groups of patients. The difference in the functional outcome of the patients was mainly dependent on the initial pathology, with those presenting with a thalamic bleed with IVH showing a poor functional outcome. This parameter was also influenced by the Glasgow Coma Scale (GCS) score on admission, with those patients with a score of 12 or less having a poor functional outcome (MRS 5–6) at three and six months after the surgery. Conclusions: The use of neuroendoscopy in patients with a massive IVH significantly reduced drainage dependency. However, it did not alter the final functional outcome.

Alternativas de derivación de LCR en pacientes de alta complejidad. Revisión de la literatura a raíz del caso de un recién nacido con Hidrocefalia post hemorrágica / Alternatives CSF shunt in patients highly complex: review of the literature following the case of a newborn with post hemorrhagic hydrocephalus

La hemorragia intraventricular (HIV) es una causa importante de daño cerebral en los recién nacidos prematuros. Su impacto negativo en el resultado del desarrollo neurológico se relaciona no sólo a su impacto directo, sino que también a las lesiones asociadas, como la hidrocefalia posthemorrágica (HPH). En la mayoría de los casos, la hidrocefalia es causada por la alteración de la reabsorción del líquido cefalorraquídeo (LCR) debido a la inflamación de las vellosidades subaracnoideas por el contacto con la sangre. El drenaje ventricular se utiliza a menudo como un procedimiento temporal para manejo de la HPH y algunos pacientes tratados con drenaje ventricular no requieren una derivación permanente; de no ser así, las derivaciones más usadas en los prematuros incluyen la ventriculoperitoneal (DVP), seguida por las derivaciones ventriculosubgaleal y ventriculoatrial. Las derivativas se consideran el tratamiento definitivo para la HPH; pero puede asociarse a complicaciones, tales como la infección, obstrucción, rechazo y el drenaje insuficiente. Otra alternativa, es la derivación ventrículopleural. Sin embargo, esta alternativa de derivación se vincula a otras complicaciones específicas, principalmente el neumotórax y el derrame pleural. Se presenta el caso clínico de EAV, quien a raíz de un parto prematuro, complicado con Hemorragia intraventricular, desarrolló Hidrocefalia y un quiste de Fosa Posterior, debiendo intervenirse en 36 oportunidades, por múltiples complicaciones. Durante su evolución se instalaron catéteres en prácticamente todos los sitios posibles, lográndose finalmente la solución del problema. Se revisa la literatura

Ventricular haemorrhage is an important cause of neurologic damage in preterm babies. Its negative impact in the final neurologic damage is not just related with the direct impact, but also with associated lesions like posthaemorrhagic hydrocephalus (PHH). In most of cases, hydrocephalus is caused by impaired cerebrospinal fluid (CEF) resorption due to the inflammation of the Arachnoid granulations because of the contact with blood. Ventricular drainage system is often used as a temporal procedure for the management of the PHH in children who have not a good response to serials lumbar punctures. Some patients treated with ventricular drainage don't need a permanent derivation, but if they do the most used in preterm babies include ventriculoperitoneal derivation (VPD) followed by ventriculosubgaleal and ventriculoatrial derivation. Derivation is considered the definitive treatment for PHH, but it can be associated with some complications as infection, obstruction and insufficient drainage. Another option is ventriculopleural derivation but this alternative is related to other complications like pneumothorax and pleural effusion. The presentation is about the case of the newborn EAV, who after preterm birth, complicated with intraventricular haemorrhage, developed hydrocephalus and a posterior fossa cyst, requiring 36 surgical interventions because of multiple complications. During its evolution he needed catheters installations in almost every possible sites, finally getting the problem solved. The literature is reviewed

Evaluation of the therapies for neonatal posthaemorrhagic hydrocephalus / 临床儿科杂志

Although the percentage of preterm infants developing intraventricular haemorrhage (IVH) has been greatly re-duced in the past three decades, increased survival of extremely preterms has meant that severe IVH with subsequent posthae-morrhagic hydrocephalus is still one of the serious unsolved problems for managements of preterms. Therapeutic interventions for posthaemorrhagic hydrocephalus include serial lumbar punctures, repeated aspiration through a ventricular access device, ventriculoperitoneal shunting, drainage, irrigation and fibrinolytic therapy, diuretic therapy treatment to reduce cerebrospinal fluid production, intraventricular fibrinolytic therapy, etc. This review summarizes the current concepts on the pathophysiology, inter-vention indications, and the effectiveness and safety of different interventions of subsequent posthaemorrhagic hydrocephalus.

The incidence of periventricular/intraventricular haemorrhages among premature infants in a tertiary care hospital in Sri Lanka.

Objectives: To describe the incidence and associated risk factors for periventricular/intraventricular haemorrhages (PVH/IVH) among premature infants in the neonatal intensive care unit (NICU) at Sri Jayewardenepura General Hospital (SJGH). Method: A prospective descriptive study was conducted on all babies <37weeks with birth weights <2500g managed in NICU at SJGH over a period of 6 months. Data was collected using a pre-tested form. Previously defined ultrasound findings were used to diagnose and categorize the PVH/IVH. Birth weight, gestational age, hypocarbia, mechanical ventilation, vasopressor infusions and use of antenatal steroids were assessed as risk factors for PVH/IVH. Results: A total of 126 babies was studied. The overall incidence of PVH/IVH was 12 (9.5%), 92% being grade 1. The incidence of PVH/IVH according to gestational age was 24.5% for <32 week old babies and 3.5% for 32-36 week old babies. Incidences according to birth weights were 43% (<1000g), 22% (1000-1500g) and 7% (1501-2000g). Of the babies with PVH/IVH 8% had been ventilated with CPAP mode whilst 92% had been given IPPV (p<0.0001); 83% had hypocarbia (p<0.0001) and 75% had been given vasopressors (p<0.0001). PVH/IVH was seen in 8% and 13% of those receiving and not receiving antenatal steroids respectively (p>0.05). Conclusions: Incidence of PVH/IVH was inversely proportional to birth weight and gestational age. It was significantly higher (p<0.0001) in babies requiring IPPV, in those with hypocarbia and in those treated with vasopressors but was not significantly associated with administration of antenatal steroids (p>0.05).

An analysis of related risk factors in preterm infants with cerebral injury / 中国小儿急救医学

Objective To evaluate the related risk factors in preterm infants with cerebral injury. Methods A total of 268 cases whose gestational age less than 36 weeks had cranial ultrasound scans between 0 to 7 days after birth from January 1, 2006 to October 31,2007, and their clinical data were reviewed. Results One hundred and thirty patients (48.5 %) were diagnosed cerebral injury, total incidence of intraventricular haemorrhge and periventricular leukomalacia were 43.3% (116/268) and 14.3% (38/268) respectively. The incidence of cerebral injury was correlated with low birth weight, prematurity, asphyxia, respiratory distress syndrome, apnea, respiratory failure, pulmonary haemorrhge, anemia, hypotension, hypoglycemia, infection, premature rupture of membrane, low gestaional age at birth and ventilation. Conclusion The incidence of preterm brain injury are related to many factors. Risk factors of cerebral injury should be prevented in clinical practice and cranial ultrasound scans are required for early diagnosis of preterm cerebral injury.

significance and prognosis (IH) of intraventricular haemorrhage in severe head injury

After utilization of CT scanner in the diagnosic of patients with severe head injuries, IH is more frequently reported. Patients with head injuries associated with IH have worse prognosis than that with no IH. This suggests that cranio-cerebral trauma is the major cause of that bad prognosis.