Intraventricular hemorrhage and posthemorrhagic hydrocephalus in preterm infants: diagnosis, classification, and treatment options

Delayed symptomatic TFV in neonatal posthemorrhagic hydrocephalus-pathophysiology and therapeutic strategy: A case report and review of the literature

INTRODUCTION

Trapped fourth ventricle (TFV), which is a rare neurosurgical condition with multifactorial etiology, requires a prompt diagnosis and appropriate therapeutic method selection. We report a case of post-hemorrhagic hydrocephalus and TFV incited/worsened by prematurity, sepsis, acute respiratory distress syndrome (ARDS), mechanical ventilation, and concomitant fourth ventricle outlets stenosis; which displayed a delayed onset. This article addresses the proposed pathophysiology and the clinical importance of appropriate therapeutic strategies with a mini-review of the literature.

CASE PRESENTATION

We encountered a case involving a premature Asian male newborn with sepsis and posthemorrhagic hydrocephalus who required ventriculoperitoneal shunt surgery. However, after three years, the baby was diagnosed with a trapped fourth ventricle and subsequently underwent retrograde endoscopic surgery with stent insertion.

DISCUSSION

TFV is traditionally known as a complication of lateral ventricle shunting. However, in rare cases such as our neonate patient, it develops as a consequence of multiple pathophysiological processes including ventricular system inflammation along with associated anatomic and physiologic alterations, which necessitates prompt diagnosis and a case-specific therapeutic strategy.

CONCLUSION

Understanding the multifactorial pathophysiological mechanisms leading to the development of TFV is crucial. The presence of comorbidities such as prematurity, neonatal sepsis, and ARDS increased the risk of intraventricular hemorrhage and subsequent inflammation and further exacerbated obstructions in cerebrospinal fluid pathways. When posthemorrhagic TFV is accompanied by collapsed lateral ventricles, the optimal treatment approach is retrograde endoscopic fenestration with stent insertion. This treatment option has proven effective in alleviating the condition and restoring proper cerebrospinal fluid flow.

Neurodevelopmental outcome in preterm infants with intraventricular hemorrhages: the potential of quantitative brainstem MRI

OBJECTIVES

This retrospective study aimed to identify quantitative magnetic resonance imaging markers in the brainstem of preterm neonates with intraventricular hemorrhages. It delves into the intricate associations between quantitative brainstem magnetic resonance imaging metrics and neurodevelopmental outcomes in preterm infants with intraventricular hemorrhage, aiming to elucidate potential relationships and their clinical implications.

MATERIALS AND METHODS

Neuroimaging was performed on preterm neonates with intraventricular hemorrhage using a multi-dynamic multi-echo sequence to determine T1 relaxation time, T2 relaxation time, and proton density in specific brainstem regions. Neonatal outcome scores were collected using the Bayley Scales of Infant and Toddler Development. Statistical analysis aimed to explore potential correlations between magnetic resonance imaging metrics and neurodevelopmental outcomes.

RESULTS

Sixty preterm neonates (mean gestational age at birth 26.26 ± 2.69 wk; n = 24 [40%] females) were included. The T2 relaxation time of the midbrain exhibited significant positive correlations with cognitive (r = 0.538, P < 0.0001, Pearson's correlation), motor (r = 0.530, P < 0.0001), and language (r = 0.449, P = 0.0008) composite scores at 1 yr of age.

CONCLUSION

Quantitative magnetic resonance imaging can provide valuable insights into neurodevelopmental outcomes after intraventricular hemorrhage, potentially aiding in identifying at-risk neonates. Multi-dynamic multi-echo sequence sequences hold promise as an adjunct to conventional sequences, enhancing the sensitivity of neonatal magnetic resonance neuroimaging and supporting clinical decision-making for these vulnerable patients.

Surgical interventions and short-term outcomes for preterm infants with post-haemorrhagic hydrocephalus: a multicentre cohort study

OBJECTIVE

To (1) describe differences in types and timing of interventions, (2) report short-term outcomes and (3) describe differences among centres from a large national cohort of preterm infants with post-haemorrhagic hydrocephalus (PHH).

DESIGN

Cohort study of the Children's Hospitals Neonatal Database from 2010 to 2022.

SETTING

41 referral neonatal intensive care units (NICUs) in North America.

PATIENTS

Infants born before 32 weeks' gestation with PHH defined as acquired hydrocephalus with intraventricular haemorrhage.

INTERVENTIONS

(1) No intervention, (2) temporising device (TD) only, (3) initial permanent shunt (PS) and (4) TD followed by PS (TD-PS).

MAIN OUTCOME MEASURES

Mortality and meningitis.

RESULTS

Of 3883 infants with PHH from 41 centres, 36% had no surgical intervention, 16% had a TD only, 19% had a PS only and 30% had a TD-PS. Of the 46% of infants with TDs, 76% were reservoirs; 66% of infants with TDs required PS placement. The percent of infants with PHH receiving ventricular access device placement differed by centre, ranging from 4% to 79% (p<0.001). Median chronological and postmenstrual age at time of TD placement were similar between infants with only TD and those with TD-PS. Infants with TD-PS were older and larger than those with only PS at time of PS placement. Death before NICU discharge occurred in 12% of infants, usually due to redirection of care. Meningitis occurred in 11% of the cohort.

CONCLUSIONS

There was significant intercentre variation in rate of intervention, which may reflect variability in care or referral patterns. Rate of PS placement in infants with TDs was 66%.

Neurosurgical Management of Myelomeningocele in Premature Infants: A Case Series

Introduction Myelomeningocele (MMC) is the most common neural tube defect, but rarely seen in premature infants. Most centers advocate for closure of MMC within 24 hours of birth. However, this is not always possible in severely premature infants. Given the rarity of this patient population, we aimed to share our institutional experience and outcomes of severely premature infants with MMC. Methods We performed a retrospective, observational review of premature infants (≤ 32 weeks gestational age) identified through our multidisciplinary spina bifida clinic (1995-2021) and surgical logs. Descriptive statistics were compiled about this sample including timing of MMC closure and incidence of adverse events such as sepsis, CSF diversion, meningitis, and death. Results Eight patients were identified (50% male) with MMC who were born ≤ 32 weeks gestational age. Mean gestational age of the population was 27.3 weeks (SD 3.5). Median time to MMC closure was 1.5 days (IQR = 1-80.8). Five patients were taken for surgery within the recommended 48 hours of birth; 2 patients underwent significantly delayed closure (107 and 139 days); and one patient's defect epithelized without surgical intervention. Six of eight patients required permanent cerebrospinal fluid (CSF) diversion (2 patients were treated with ventriculoperitoneal shunting (VPS), three were treated with endoscopic third ventriculostomy (ETV) with choroid plexus cauterization (CPC) and 1 patient treated with ETV; mean of 3 years after birth, ranging from 1 day to 16 years). Two patients required more than one permanent CSF diversion procedure. Two patients developed sepsis (defined as meeting at least 2/4 SIRS criteria), and 2 patients had intraventricular hemorrhage (both grade III). No patients developed meningitis (defined as positive CSF cultures) prior to MMC closure. Median follow up duration was 9.7 years. During this time epoch, 3 patients died: Two before 2 years of age of causes unrelated to surgical intervention. One of the two patients with grade III IVH died within 24 hours of MMC closure. Conclusions In our institutional experience with premature infants with MMC, some patients underwent delayed MMC closure. The overall rate of meningitis, sepsis, and mortality for preterm children with MMC was similar to MMC patients born at term.

Ratios of head circumference to ventricular size vary over time and predict eventual need for CSF diversion in intraventricular hemorrhage of prematurity

PURPOSE

Intraventricular hemorrhage (IVH) of prematurity can lead to hydrocephalus, sometimes necessitating permanent cerebrospinal fluid (CSF) diversion. We sought to characterize the relationship between head circumference (HC) and ventricular size in IVH over time to evaluate the clinical utility of serial HC measurements as a metric in determining the need for CSF diversion.

METHODS

We included preterm infants with IVH born between January 2000 and May 2020. Three measures of ventricular size were obtained: ventricular index (VI), Evan's ratio (ER), and frontal occipital head ratio (FOHR). The Pearson correlations (r) between the initial (at birth) paired measurements of HC and ventricular size were reported. Multivariable longitudinal regression models were fit to examine the HC:ventricle size ratio, adjusting for the age of the infant, IVH grade (I/II vs. III/IV), need for CSF diversion, and sex.

RESULTS

A total of 639 patients with an average gestational age of 27.5 weeks were included. IVH grade I/II and grade III/IV patients had a positive correlation between initial HC and VI (r = 0.47, p < 0.001 and r = 0.48, p < 0.001, respectively). In our longitudinal models, patients with a low-grade IVH (I/II) had an HC:VI ratio 0.52 higher than those with a high-grade IVH (p-value < 0.001). Patients with low-grade IVH had an HC:ER ratio 12.94 higher than those with high-grade IVH (p-value < 0.001). Patients with low-grade IVH had a HC:FOHR ratio 12.91 higher than those with high-grade IVH (p-value < 0.001). Infants who did not require CSF diversion had an HC:VI ratio 0.47 higher than those who eventually did (p < 0.001). Infants without CSF diversion had an HC:ER ratio 16.53 higher than those who received CSF diversion (p < 0.001). Infants without CSF diversion had an HC:FOHR ratio 15.45 higher than those who received CSF diversion (95% CI (11.34, 19.56), p < 0.001).

CONCLUSIONS

There is a significant difference in the ratio of HC:VI, HC:ER, and HC:FOHR size between patients with high-grade IVH and low-grade IVH. Likewise, there is a significant difference in HC:VI, HC:ER, and HC:FOHR between those who did and did not have CSF diversion. The routine assessments of both head circumference and ventricle size by ultrasound are important clinical tools in infants with IVH of prematurity.

Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants

BACKGROUND

Lumbar puncture (LP) is a common invasive procedure, most frequently performed to diagnose infection. Physicians perform LP in newborn infants with the help of an assistant using a strict aseptic technique; it is important to monitor the infant during all the steps of the procedure. Without adequate analgesia, LP can cause considerable pain and discomfort. As newborns have increased sensitivity to pain, it is crucial to adequately manage the procedural pain of LP in this population.

OBJECTIVES

To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non-pharmacological interventions, or other pharmacological interventions.

SEARCH METHODS

We searched CENTRAL, PubMed, Embase, and three trial registries in December 2022. We also screened the reference lists of included studies and related systematic reviews for studies not identified by the database searches.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) and quasi-RCTs comparing drugs used for pain management, sedation, or both, during LP. We considered the following drugs suitable for inclusion. • Topical anesthetics (e.g. eutectic mixture of local anesthetics [EMLA], lidocaine) • Opioids (e.g. morphine, fentanyl) • Alpha-2 agonists (e.g. clonidine, dexmedetomidine) • N-Methyl-D-aspartate (NMDA) receptor antagonists (e.g. ketamine) • Other analgesics (e.g. paracetamol) • Sedatives (e.g. benzodiazepines such as midazolam) DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. We used the fixed-effect model with risk ratio (RR) for dichotomous data and mean difference (MD) or standardized mean difference (SMD) for continuous data, with their 95% confidence intervals (CIs). Our main outcomes were successful LP on first attempt, total number of LP attempts, episodes of bradycardia, pain assessed with validated scales, episodes of desaturation, number of episodes of apnea, and number of infants with one or more episodes of apnea. We used the GRADE approach to evaluate the certainty of the evidence.

MAIN RESULTS

We included three studies (two RCTs and one quasi-RCT) that enrolled 206 newborns. One study included only term infants. All studies assessed topical treatment versus placebo or no intervention. The topical anesthetics were lidocaine 4%, lidocaine 1%, and EMLA. We identified no completed studies on opioids, non-steroidal anti-inflammatory drugs, alpha-2 agonists, NMDA receptor antagonists, other analgesics, sedatives, or head-to-head comparisons (drug A versus drug B). Based on very low-certainty evidence from one quasi-RCT of 100 LPs in 76 infants, we are unsure if topical anesthetics (lidocaine), compared to no anesthesia, has an effect on the following outcomes. • Successful LP on first attempt (first-attempts success in 48% of LPs in the lidocaine group and 42% of LPs in the control group) • Number of attempts per LP (mean 1.9 attempts, [standard error of the mean 0.2] in the lidocaine group, and mean 2.1 attempts [standard error of the mean 2.1] in the control group) • Episodes of bradycardia (0% of LPs in the lidocaine group and 4% of LPs in the control group) • Episodes of desaturation (0% of LPs in the lidocaine group and 8% of LPs in the control group) • Occurrence of apnea (RR 3.24, 95% CI 0.14 to 77.79; risk difference [RD] 0.02, 95% CI -0.03 to 0.08). Topical anesthetics compared to placebo may reduce pain assessed with the Neonatal Facial Coding System (NFCS) score (SMD -1.00 standard deviation (SD), 95% CI -1.47 to -0.53; I² = 98%; 2 RCTs, 112 infants; low-certainty evidence). No studies in this comparison reported total number of episodes of apnea. We identified three ongoing studies, which will assess the effects of EMLA, lidocaine, and fentanyl. Three studies are awaiting classification.

AUTHORS' CONCLUSIONS

The evidence is very uncertain about the effect of topical anesthetics (lidocaine) compared to no anesthesia on successful lumbar puncture on first attempt, the number of attempts per lumbar puncture, episodes of bradycardia, episodes of desaturation, and occurrence of apnea. Compared to placebo, topical anesthetics (lidocaine or EMLA) may reduce pain assessed with the NFCS score. One ongoing study will assess the effects of systemic treatment.

Short Efficacy Evaluation of External Ventricular Drains Versus Ventriculosubgaleal Shunt in the Management of Neonatal Posthemorrhagic Hydrocephalus: A Retrospective Single-Center Cohort Study

BACKGROUND

Different temporizing neurosurgical procedures are available for the management of posthemorrhagic hydrocephalus in preterm newborns.

OBJECTIVE

To evaluate the short efficacy of the external ventricular drains (EVDs) and the ventriculosubgaleal (VSG) shunt.

METHODS

This is a Strengthening the Reporting of Observational Studies in Epidemiology-conformed retrospective cohort study. The inclusion criteria were (1) gestational age <37 weeks, (2) birth weight <1500 g, (3) posthemorrhagic hydrocephalus because of intraventricular hemorrhage grade II/III, and (4) EVD or VSG shunt procedure before ventriculoperitoneal (VP)-definite shunt. Twenty-four newborns were collected from 2006 to 2022. The end points considered were infectious events, proteinorrachia, reintervention rate, and time to conversion to definite VP shunt.

RESULTS

Overall, 12/24 newborns underwent EVD, and the remnant had a VSG shunt. The results showed a statistically significant difference ( P = .02) concerning cerebrospinal fluid infections between the EVD group (50%) and VSG shunt 1 (8.33%). The reintervention rate of EVD was significantly higher (66.67%) compared with that of the VSG shunt group (8.33%). A statistically significant difference was stated between the 2 groups (t[13] = -8.250; P < .001) (mean difference ± standard error; 10.5 ± 1.273) in the mean number of days elapsed from the achievement of the ideal weight (2000 g) to the definitive VP drainage.

CONCLUSION

The increased infectious risk and the higher reintervention rate in EVD were confirmed in this study. In addition, a significant delay in the time to -conversion from EVD to VP shunt was demonstrated. Despite these optimal results, the VSG shunt remains a low practiced intervention, probably because of the limited operator experience.

Outcomes and prognostic factors of infantile acquired hydrocephalus: a single-center experience

AIM

To assess the etiologies and adverse outcomes of infantile acquired hydrocephalus and predict prognosis.

METHODS

A total of 129 infants diagnosed with acquired hydrocephalus were recruited from 2008 to 2021. Adverse outcomes included death and significant neurodevelopmental impairment which was defined as Bayley Scales of Infant and Toddler Development III score < 70, cerebral palsy, visual or hearing impairment, and epilepsy. Chi-squared was used to evaluate the prognostic factors of adverse outcomes. A receiver operating characteristic curve was calculated to determine the cutoff value.

RESULTS

Of 113 patients with outcome data, 55 patients (48.7%) had adverse outcomes. Late surgical intervention time (13 days) and severe ventricular dilation were associated with adverse outcomes. The combination of surgical intervention time and cranial ultrasonography (cUS) indices was a better predictive marker compared with any of them (surgical intervention time, P = 0.05; cUS indices, P = 0.002). Post-hemorrhage (54/113, 48%), post-meningitis (28/113, 25%), and hydrocephalus arising from both hemorrhage and meningitis (17/113, 15%) accounted for a large proportion of the etiologies in our study. Hydrocephalus occurs secondary to post-hemorrhage and had a favorable outcome compared with other etiologies in both preterm and term groups. A significant difference in adverse outcomes between the inherited error of metabolism as a cause and other etiologies (P = 0.02).

CONCLUSION

Late surgical treatment times and severe ventricular dilation can predict adverse outcomes in infants with acquired hydrocephalus. It is crucial to identify the causes of acquired hydrocephalus to predict the adverse outcomes. Research into measures of improving adverse outcomes following infantile acquired hydrocephalus is urgently necessary.

Preterm-related posthemorrhagic hydrocephalus: Review of our institutional series with a long-term follow-up

INTRODUCTION

Preterm-related posthemorrhagic hydrocephalus is a major cause of neurological impairment and a common indication for a ventriculoperitoneal shunt in infants that are prone to diverse complications. Protocols of diagnosis and treatment are in continuous evolution and require evaluation of their results.

OBJECTIVE

To review the clinical characteristics and results of a series of preterm-related posthemorrhagic hydrocephalus needing a definitive shunt from 1982 to 2020 in our institution. As a secondary objective we evaluated the safety of the changes in our protocol of treatment from 2015.

METHODS

Retrospective review, clinical investigation.

RESULTS

133 patients were implanted a shunt in the study period. Shunt infection was diagnosed in 15 patients. Proximal shunt obstruction as the first complication was diagnosed in 30% of cases at one year, 37% at two years and 46% at five years. 61 patients developed very small or collapsed ventricles at last follow-up. Two thirds of our patients achieved normal neurological development or mild impairment. Changes in protocol did not significantly modify clinical results although improvement in most outcomes was observed. Mean follow-up was over nine years.

CONCLUSIONS

Clinical outcomes are comparable to previous reported data. Changes in protocol proved to be safe and improved our results. Programmable shunts can be used safely in preterm patients although they may not prevent tendency towards ventricular collapse, which is very common after long follow-up.

Neuroimaging of Germinal Matrix and Intraventricular Hemorrhage in Premature Infants

Germinal matrix and intraventricular hemorrhage (GM-IVH) are the major causes of intracranial hemorrhage in premature infants. Cranial ultrasound (cUS) is the imaging modality of choice for diagnosing and classifying GM-IVH. Magnetic resonance imaging (MRI), usually performed at term-equivalent age, is more sensitive than cUS in identifying hemorrhage in the brain. Post-hemorrhagic ventricular dilatation is a significant complication of GM-IVH and correlates with adverse neurodevelopmental outcomes. In this review, we discuss the various imaging findings of GM-IVH in premature infants, focusing on the role of cUS and MRI.

Neurodevelopmental outcomes of neonatal posthemorrhagic hydrocephalus and psychological effects on the parents

BACKGROUND

Neonatal posthemorrhagic hydrocephalus remains a common complication in preterm infants, with high rates of mortality and morbidity, placing parents at high risk of anxiety and depression. We sought to investigate the neurodevelopmental outcomes of infants with posthemorrhagic hydrocephalus who underwent surgery and the psychological effect on their parents.

METHODS

We retrospectively analysed all infants with posthemorrhagic hydrocephalus born between 2014 and 2020 in the Children's Hospital of Chongqing Medical University, China. The neurodevelopmental outcomes of 28 patients were evaluated by the Pediatric Stroke Outcome Measure score, and the psychological states of the parents of survivors were assessed by the Hospital Anxiety and Depression Scale.

RESULTS

The families of the 28 patients were followed up for a median duration of 3 years; 6 (21.4%) patients died within 6 months after discharge, 12 (42.9%) patients had moderate to severe dysfunction, and only 10 (35.7%) patients had good outcomes. Regarding the 22 parents of the survivors, 5 (22.7%) and 4 (18.2%) had borderline anxiety and depression symptoms, respectively. Two (9.1%) caregivers had exact anxiety and depression symptoms. Leukomalacia after intraventricular haemorrhage was associated with adverse neurological outcomes. The infants' histories of epileptic seizures during the neonatal period were associated with the anxiety of their parents.

CONCLUSION

The overall outcome of posthemorrhagic hydrocephalus patients is unsatisfactory, and children with leukomalacia after haemorrhage tend to have poor outcomes. A history of epileptic seizures during the course of the disease may exacerbate the anxiety of the caregivers.

Three-dimensional cranial ultrasound and functional near-infrared spectroscopy for bedside monitoring of intraventricular hemorrhage in preterm neonates

Germinal Matrix-Intraventricular Hemorrhage (GMH-IVH) remains a significant cause of adverse neurodevelopment in preterm infants. Current management relies on 2-dimensional cranial ultrasound (2D cUS) ventricular measurements. Reliable biomarkers are needed to aid in the early detection of posthemorrhagic ventricular dilatation (PHVD) and subsequent neurodevelopment. In a prospective cohort study, we incorporated 3-dimensional (3D) cUS and functional near-infrared spectroscopy (fNIRS) to monitor neonates with GMH-IVH. Preterm neonates (≤ 32 weeks' gestation) were enrolled following a GMH-IVH diagnosis. Neonates underwent sequential measurements: 3D cUS images were manually segmented using in-house software, and the ventricle volumes (VV) were extracted. Multichannel fNIRS data were acquired using a high-density system, and spontaneous functional connectivity (sFC) was calculated. Of the 30 neonates enrolled in the study, 19 (63.3%) had grade I-II and 11 (36.7%) grade III-IV GMH-IVH; of these, 7 neonates (23%) underwent surgical interventions to divert cerebrospinal fluid (CSF). In infants with severe GMH-IVH, larger VV were significantly associated with decreased |sFC|. Our findings of increased VV and reduced sFC suggest that regional disruptions of ventricular size may impact the development of the underlying white matter. Hence, 3D cUS and fNIRS are promising bedside tools for monitoring the progression of GMH-IVH in preterm neonates.

The spectrum of pyridoxine dependent epilepsy across the age span: A nationwide retrospective observational study

BACKGROUND

Pyridoxine-dependent epilepsy (PDE) is a rare seizure disorder usually presenting with neonatal seizures. Most cases are caused by biallelic pathogenic ALDH7A1variants. While anti-seizure medications are ineffective, pyridoxine provides seizure control, and dietary interventions may be of benefit. As the natural history beyond adolescence is insufficiently explored, our study aimed to assess the spectrum of PDE at various ages in Norway.

METHODS

Patients were ascertained by contacting all Norwegian paediatric, neurological, and neurohabilitation departments and relevant professional societies. Medical records were collected and reviewed.

RESULTS

We identified 15 patients treated for PDE; 13 had ALDH7A1 variants (PDE-ALDH7A1), one had PNPO deficiency, and in one, aetiology remained obscure. Of those with PDE-ALDH7A1, 12 were alive at time of study; five were > 18 years old and six were < 4 years. Median age was 10 years (range 2 months-53 years). Estimated minimum prevalence was 6.3/million among children and 1.2/million among adults. Ten had seizure onset on the first day of life. Perinatal complications and neuroradiological abnormalities suggested additional seizure aetiologies in several patients. Pyridoxine had immediate effect in six, while six had delayed (>1 h) or uncertain effect. Median delay from first seizure to continuous treatment was 11 days (range 0-42). Nine experienced breakthrough seizures with intercurrent disease or due to pyridoxine discontinuation. Cognitive outcomes ranged from normal to severe intellectual disability. The condition appeared to remain stable in adult life.

SIGNIFICANCE

We found a much higher prevalence of PDE-ALDH7A1 in children relative to adults, suggesting previous underdiagnosis and early mortality. Perinatal complications are common and can delay diagnosis and initiation of pyridoxine treatment. Lifelong and continuous treatment with pyridoxine is imperative. Due to better diagnostics and survival, the number of adult patients is expected to rise.

Outcomes of the 2019 hydrocephalus association workshop, "Driving common pathways: extending insights from posthemorrhagic hydrocephalus"

The Hydrocephalus Association (HA) workshop, Driving Common Pathways: Extending Insights from Posthemorrhagic Hydrocephalus, was held on November 4 and 5, 2019 at Washington University in St. Louis. The workshop brought together a diverse group of basic, translational, and clinical scientists conducting research on multiple hydrocephalus etiologies with select outside researchers. The main goals of the workshop were to explore areas of potential overlap between hydrocephalus etiologies and identify drug targets that could positively impact various forms of hydrocephalus. This report details the major themes of the workshop and the research presented on three cell types that are targets for new hydrocephalus interventions: choroid plexus epithelial cells, ventricular ependymal cells, and immune cells (macrophages and microglia).

Ultrasonic Diagnosis and Management of Posthemorrhagic Ventricular Dilatation in Premature Infants: A Narrative Review

The survival rate of preterm infants is increasing as a result of technological advances. The incidence of intraventricular hemorrhages (IVH) in preterm infants ranges from 25% to 30%, of which 30% to 50% are severe IVH (Volpe III-IV, Volpe III is defined as intraventricular bleeding occupying more than 50% of the ventricular width and acute lateral ventricle dilatation, Volpe IV is defined as intraventricular hemorrhage combined with venous infarction) and probably lead to posthemorrhagic ventricular dilatation (PHVD). Severe IVH and subsequent PHVD have become the leading causes of brain injury and neurodevelopmental dysplasia in preterm infants. This review aims to review the literature on the diagnosis and therapeutic strategies for PHVD and provide some recommendations for management to improve the neurological outcomes.

Pharmacological interventions for the management of pain and discomfort during lumbar puncture in newborn infants

This is a protocol for a Cochrane Review (intervention). The objectives are as follows:

To assess the benefits and harms, including pain, discomfort, and success rate, of any pharmacological intervention during lumbar puncture in newborn infants, compared to placebo, no intervention, non‐pharmacological interventions, or other pharmacological interventions.

Association of clinical signs of chorioamnionitis with histological chorioamnionitis and neonatal outcomes

BACKGROUND

Chorioamnionitis is a risk factor for fetal and neonatal outcomes. Therefore, predicting histological chorioamnionitis (HCA) and neonatal outcomes using clinical parameters could be helpful in management and preventing morbidities.

OBJECTIVE

To determine if parameters of clinical chorioamnionitis (CCA) would be associated with HCA and neonatal outcomes.

STUDY DESIGN

In this cohort study using a retrospective design, we analyzed the performance of signs of CCA in predicting HCA, and neonatal outcomes. Data were extracted from the electronic health record for all neonates with documented CCA delivered at our institution from 2011 to 2016. We compared our findings based on the old ACOG definition of CCA and the new definition released in 2017 - maternal fever plus any of fetal tachycardia, maternal leukocytosis, and purulent vaginal discharge. Maternal tachycardia and uterine tenderness were removed from the new criteria. Neonatal laboratory samples on admission, 12 h and 24 h were used to define the three time points of neonatal suspected sepsis.

RESULTS

There were 530 mothers-infant dyads with chorioamnionitis. Seventy-three were preterm, and 457 were term. Eighty-eight percent of the preterm mothers had CCA, and HCA was present in 62.5% of 72 preterm placentas. Preterm infants with placental HCA significantly had lower birth weight, gestational age, placental weight, and more infants with lower 5-minute Apgar scores, compared to those with no HCA. In preterm infants, maternal urinary tract infection was significantly associated with decreased odds for HCA (OR 0.22, CI 0.10 - 0.71). More preterm babies with suspected sepsis criteria at the 3 time points had HCA (all p ≤ .01). In the term cohort, 95.4% and 65.6% had CCA and HCA, respectively. In term infants (n = 457), maternal leukocytosis (p = .002) and prolonged rupture of membranes (PROM; p = 002) were associated with HCA. Suspected sepsis was associated with PROM (p = .04), HCA (p = .0001), and maternal leukocytosis (p ≤ .05) in at least 1 of the 3 time points.

CONCLUSION

Though maternal leukocytosis was significantly associated with the presence of HCA in the term cohort, there were no CCA criteria that accurately predicted presence of HCA in either the preterm or the term infants.

Caffeine Restores Neuronal Damage and Inflammatory Response in a Model of Intraventricular Hemorrhage of the Preterm Newborn

Germinal matrix-intraventricular hemorrhage (GM-IVH) is the most frequent intracranial hemorrhage in the preterm infant (PT). Long-term GM-IVH-associated sequelae include cerebral palsy, sensory and motor impairment, learning disabilities, or neuropsychiatric disorders. The societal and health burden associated with GM-IVH is worsened by the fact that there is no successful treatment to limit or reduce brain damage and neurodevelopment disabilities. Caffeine (Caf) is a methylxanthine that binds to adenosine receptors, regularly used to treat the apnea of prematurity. While previous studies support the beneficial effects at the brain level of Caf in PT, there are no studies that specifically focus on the role of Caf in GM-IVH. Therefore, to further understand the role of Caf in GM-IVH, we have analyzed two doses of Caf (10 and 20 mg/kg) in a murine model of the disease. We have analyzed the short (P14) and long (P70) effects of the treatment on brain atrophy and neuron wellbeing, including density, curvature, and phospho-tau/total tau ratio. We have analyzed proliferation and neurogenesis, as well as microglia and hemorrhage burdens. We have also assessed the long-term effects of Caf treatment at cognitive level. To induce GM-IVH, we have administered intraventricular collagenase to P7 CD1 mice and have analyzed these animals in the short (P14) and long (P70) term. Caf showed a general neuroprotective effect in our model of GM-IVH of the PT. In our study, Caf administration diminishes brain atrophy and ventricle enlargement. Likewise, Caf limits neuronal damage, including neurite curvature and tau phosphorylation. It also contributes to maintaining neurogenesis in the subventricular zone, a neurogenic niche that is severely affected after GM-IVH. Furthermore, Caf ameliorates small vessel bleeding and inflammation in both the cortex and the subventricular zone. Observed mitigation of brain pathological features commonly associated with GM-IVH also results in a significant improvement of learning and memory abilities in the long term. Altogether, our data support the promising effects of Caf to reduce central nervous system complications associated with GM-IVH.

Pharmacological neuroprotection and clinical trials of novel therapies for neonatal peri-intraventricular hemorrhage: a comprehensive review

Peri-intraventricular hemorrhage (PIVH) is a serious condition for preterm infants, caused by traumatic or spontaneous rupture of the germinal matrix (GM) capillary network in the cerebral ventricles. It is a common source of morbidity and mortality in neonates, and risk correlates with earlier delivery, low birth weight, maternal-fetal infection, and vital sign derangements, among others. PIVH typically occurs in the first 72 h of life, and symptoms, when present, manifest most commonly within the first week of life. Prevention remains the primary goal in management, predominantly via prolonging of gestation. Current therapy protocols are center-dependent without consistent consensus guidelines, but infant positioning, homeostatic stabilization, and neuroprotection offer potential options. In this update of pharmacologic neuroprotective therapies for PIVH, we highlight commonly utilized therapies and review the investigative literature. Further multi-institutional clinical trials and basic research studies are required.

Recognition and management of traumatic fetal injuries

Trauma during pregnancy is the leading non-obstetric cause of morbidity and mortality, and accounts for five per 1000 fetal deaths. Direct fetal injury due to trauma during pregnancy is rare, and limited information is available about how to optimize fetal outcomes after injury. Early recognition and appropriate management of direct fetal trauma may improve outcomes for the fetus. There are currently no available guidelines to direct management of the injured fetus. We provide a detailed literature review of the management and outcomes of direct fetal injury following blunt and penetrating injury during pregnancy, and describe a suggested initial approach to the injured pregnant patient with a focus on evaluation for fetal injury. We identified 45 reported cases of blunt trauma resulting in direct fetal injury, with 21 surviving past the neonatal period, and 33 of penetrating trauma resulting in direct fetal injury, with 24 surviving past the neonatal period. Prenatal imaging identified fetal injury in 19 cases of blunt trauma and was used to identify bullet location relative to the fetus in 6 cases. These reports were used to develop management algorithms for the injured fetus.

Development of machine learning-based predictor algorithm for conversion of an Ommaya reservoir to a permanent cerebrospinal fluid shunt in preterm posthemorrhagic hydrocephalus

BACKGROUND

Ommaya reservoir can be used to treat posthemorrhagic hydrocephalus secondary to intraventricular hemorrhage of prematurity until an acceptable weight can be obtained to place a permanent shunt. Identifying newborns at higher risk of developing shunt conversion may improve the management of these patients.

OBJECTIVE

Develop a predictive algorithm for the conversion of an Ommaya reservoir to a permanent shunt using artificial intelligence techniques and "classical" statistics.

METHODS

Database of 43 preterm patients weighing ≤ 1500g with posthemorrhagic hydrocephalus (Papile Grades III and IV with Levene index > 4 mm above the 97th percentile) managed with Ommaya reservoir at our institution between 2002 and 2017 was used to train a KNN algorithm. Validation of results with cross validation technique. Three scenarios were calculated. 1: considering all features regardless whether or not they are correlated with the output variable. 2: consider the features as predictors if they have a correlation greater than a 30% with the output variable. 3: consider the output of the previous analysis.

RESULTS

Results show that when considering the outputs of a previous multivariate analysis the algorithm reaches an 86% of cross validation accuracy.

CONCLUSION

The use of machine learning-based algorithms can help in the early identification of patients with permanent need of shunt. We present the development of a predictive algorithm for permanent shunt with an accuracy of 86%, accuracy of the algorithm can be improved with larger volume of data and previous analysis.

Gestational Age-Related Associations between Early-Life Feeding Trajectories and Growth Outcomes at Term Equivalent Age in Very Preterm Infants

Establishing the different feeding trajectories based on daily enteral feeding data in preterm infants at different gestational ages (GAs), may help to identify the risks and extrauterine growth restriction (EUGR) outcomes associated with the adverse feeding pattern. In a single center, we retrospectively included 625 infants born at 23-30 weeks of gestation who survived to term-equivalent age (TEA) from 2009 to 2020. The infants were designated into three GA groups: 23-26, 27-28, and 29-30 weeks. The daily enteral feeding amounts in the first 56 postnatal days were analyzed to determine the feeding trajectories. The primary outcomes were EUGR in body weight and head circumference calculated, respectively, by the changes between birth and TEA. Clustering analysis identified two feeding trajectories, namely the improving and adverse patterns in each GA group. The adverse feeding pattern that occurred in 49%, 20%, and 17% of GA 23-26, 27-28, and 29-30 weeks, respectively, was differentiated from the improving feeding pattern as early as day 7 in infants at GA 23-26 and 27-28 weeks, in contrast to day 21 in infants at GA 29-30 weeks. The adverse feeding patterns were associated with sepsis, respiratory, and gastrointestinal morbidities at GA 23-26 weeks; sepsis, hemodynamic and gastrointestinal morbidities at GA 27-28 weeks; and preeclampsia, respiratory, and gastrointestinal morbidities at GA 29-30 weeks. Using the improving feeding group as a reference, the adverse feeding group showed significantly higher adjusted odds ratios of EUGR in body weight and head circumference in infants at GA 23-26 and 27-28 weeks. Identifying the early-life adverse feeding trajectories may help recognize the related EUGR outcomes of preterm infants in a GA-related manner.

Neuroendoscopic lavage versus traditional surgical methods for the early management of posthemorrhagic hydrocephalus in neonates

OBJECTIVE

Despite advances observed in neonatal neurosurgery, treatment of posthemorrhagic hydrocephalus (PHH) remains a major challenge. This study aims to observe the outcomes of the application of the neuroendoscopic method for treating early-stage posthemorrhagic hydrocephalus.

METHODS

A total of 60 medical cases were studied retrospectively. From 2016-2021, the patients were treated at the neonatal intensive care unit (NICU). As an initial neurosurgical intervention, 19 neonates (A) underwent neuroendoscopic lavage (NEL) of the ventricular system and evacuation of posthemorrhagic debris via ventricular washout. A total of 36 neonates (B) were treated via traditional surgical methods, out of which 24 neonates underwent ventricular reservoir implantation (VAD) and 12 underwent ventriculostomy (EVD). Of the 60 patients, there were 5 neonates (C), who were treated directly by ventriculoperitoneal (VP) shunting after serial ventricular/lumbar punctures. As the inclusion and surgical criteria were significantly different for this group, their data were evaluated separately. Accordingly, these patients were divided into three (A, B, and C) groups.

RESULTS

The gestational age of group A neonates (31 weeks) was slightly higher than the gestational age of group B (29.1 weeks). During their hospitalization, 15 neonates (78.94%) from group A and 26 (83.87%) neonates from group B required shunting. In group B, 5 patients (12.19%) died before the need for shunting occurred. No lethal outcomes were observed in group A, and 9 (25%) patients from group B died during hospitalization. In group A, central nervous system (CNS) infections developed in 3 patients, which is much less than the 18 patients in group B. NEL was found to give better neurological outcomes in patients with intraventricular hemorrhages. Serial ventricular/lumbar puncture can be used as a life-saving manipulation in very unstable patients to temporarily decreasing intracranial pressure. Its frequent use is associated with brain parenchymal damage and poor neurological outcome.

CONCLUSION

The neuroendoscopic method of treating neonatal posthemorrhagic hydrocephalus is a safe and effective one. Its application reduces the period of patient hospital stay, the incidence of meningitis, and the frequency of development of multiloculated hydrocephalus.

A prediction model of pulmonary hypertension in preterm infants with bronchopulmonary dysplasia

OBJECTIVE

Pulmonary hypertension (PH) is a severe cardiovascular complication of bronchopulmonary dysplasia (BPD) that contributes to the high mortality rates for preterm infants. The objective of this study is to establish a prediction model of BPD-associated PH (BPD-PH) by integrating multiple predictive factors for infants with BPD.

METHOD

A retrospective investigation of the perinatal clinical records and data of echocardiography in all the preterm infants with BPD was performed from January 2012 to December 2019. A prediction model of BPD-PH was established based on the univariate and multivariate logistic regression analysis of the clinical data and evaluated by using the area under the receiver operating characteristic (ROC) curve (AUC), combined with the Hosmer-Lemeshow (HL) test. Internal validation was performed with bootstrap resampling.

RESULT

A total of 268 infants with BPD were divided into the BPD-PH group and the no-PH group. Multivariate logistic regression analysis showed that the independent predictive factors of BPD-PH were moderate to severe BPD, small for gestational age, duration of hemodynamically significant patent ductus arteriosus ≥ 28 days, and early PH. A prediction model was established based on the β coefficients of the four predictors. The area under the ROC curve of the prediction model was 0.930. The Hosmer-Lemeshow test (p = 0.976) and the calibration curve showed good calibration.

CONCLUSION

The prediction model based on the four risk factors predicts the development of BPD-PH with high sensitivity and specificity and might help clinicians to make individualized interventions to minimize the disease risk.

Effect of surgical treatment on prognosis in preterm infants with obstructive hydrocephalus

OBJECTIVES

To study the effect of surgical treatment on prognosis in preterm infants with obstructive hydrocephalus.

METHODS

A retrospective analysis was performed on the medical data of 49 preterm infants with obstructive hydrocephalus. According to the treatment regimen, they were divided into two groups: surgical treatment (n=12) and conservative treatment (n=37). The drainage methods, drainage complications, and eventual shunt outcome were analyzed in the surgical treatment group. The two groups were compared in terms of the etiology of hydrocephalus and prognosis.

RESULTS

Among the 49 preterm infants with obstructive hydrocephalus, severe intracranial hemorrhage (37 cases; 76%) and central nervous system infection (10 cases, 20%) were the main causes of hydrocephalus. There was no significant difference in the composition of etiology between the two groups (P>0.05). In the surgical treatment group, 4 infants were treated with ventriculosubgaleal shunt and 8 were treated with Ommaya reservoir. One infant had secondary infection and 8 infants eventually underwent ventriculoperitoneal shunt. The surgical treatment group had a significantly higher survival rate than the conservative treatment group (P<0.05). As for the 37 preterm infants with severe intracranial hemorrhage, the surgical treatment group had a significantly higher proportion of infants with normal neurodevelopment than the conservative treatment group (P<0.05). As for the 10 preterm infants with central nervous system infection, neurodevelopmental abnormalities were observed in each of the two groups.

CONCLUSIONS

Surgical treatment can improve the survival rate of preterm infants with obstructive hydrocephalus and the prognosis of preterm infants with severe intracranial hemorrhage.

Use of emerging technologies to enhance the treatment paradigm for spontaneous intraventricular hemorrhage

The presence of intraventricular hemorrhage (IVH) portends a worse prognosis in patients presenting with spontaneous intracerebral hemorrhage (ICH). Intraventricular hemorrhage increases the rates of hydrocephalus, ventriculitis, and long-term shunt dependence. Over the past decade, novel medical devices and protocols have emerged to directly treat IVH. Presently, we review new technological adaptations to treating intraventricular hemorrhage in an effort to focus further innovation in treating this morbid neurosurgical pathology. We summarize current and historical treatments as well as innovations in IVH including novel procedural techniques, use of the Integra Surgiscope, use of the Artemis evacuator, use of BrainPath, novel catheter technology, large bore external ventricular drains, the IRRAflow, the CerebroFlo, and the future directions of the field. Technology and medical devices for both surgical and nonsurgical methods are advancing the treatment of IVH. With many promising new technologies on the horizon, prospects for improved clinical care for IVH and its etiologies remain hopeful.

Timing of Temporizing Neurosurgical Treatment in Relation to Shunting and Neurodevelopmental Outcomes in Posthemorrhagic Ventricular Dilatation of Prematurity: A Meta-analysis

OBJECTIVE

To determine the relationship between timing of initiation of temporizing neurosurgical treatment and rates of ventriculoperitoneal shunt (VPS) and neurodevelopmental impairment in premature infants with post-hemorrhagic ventricular dilatation (PHVD).

STUDY DESIGN

We searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Database of Systematic Reviews, and the Cochrane Center Register of Controlled Trials for studies that reported on premature infants with PHVD who underwent a temporizing neurosurgical procedure. The timing of the temporizing neurosurgical procedure, gestational age, birth weight, outcomes of conversion to VPS, moderate-to-severe neurodevelopmental impairment, infection, temporizing neurosurgical procedure revision, and death at discharge were extracted.

RESULTS

Sixty-two full-length articles and 6 conference abstracts (n = 2533 patients) published through November 2020 were included. Pooled rate for conversion to VPS was 60.5% (95% CI, 54.9-65.8), moderate-severe neurodevelopmental impairment 34.8% (95% CI, 27.4-42.9), infection 8.2% (95% CI, 6.7-10.1), revision 14.6% (95% CI, 10.4-20.1), and death 12.9% (95% CI, 10.2-16.4). The average age at temporizing neurosurgical procedure was 24.2 ± 11.3 days. On meta-regression, older age at temporizing neurosurgical procedure was a predictor of conversion to VPS (P < .001) and neurodevelopmental impairment (P < .01). Later year of publication predicted increased survival (P < .01) and external ventricular drains were associated with more revisions (P = .001). Tests for heterogeneity reached significance for all outcomes and a qualitative review showed heterogeneity in the study inclusion and diagnosis criteria for PHVD and initiation of temporizing neurosurgical procedure.

CONCLUSIONS

Later timing of temporizing neurosurgical procedure predicted higher rates of conversion to VPS and moderate-severe neurodevelopmental impairment. Outcomes were often reported relative to the number of patients who underwent a temporizing neurosurgical procedure and the criteria for study inclusion and the initiation of temporizing neurosurgical procedure varied across institutions. There is need for more comprehensive outcome reporting that includes all infants with PHVD regardless of treatment.

Cerebellum and Prematurity: A Complex Interplay Between Disruptive and Dysmaturational Events

The cerebellum plays a critical regulatory role in motor coordination, cognition, behavior, language, memory, and learning, hence overseeing a multiplicity of functions. Cerebellar development begins during early embryonic development, lasting until the first postnatal years. Particularly, the greatest increase of its volume occurs during the third trimester of pregnancy, which represents a critical period for cerebellar maturation. Preterm birth and all the related prenatal and perinatal contingencies may determine both dysmaturative and lesional events, potentially involving the developing cerebellum, and contributing to the constellation of the neuropsychiatric outcomes with several implications in setting-up clinical follow-up and early intervention.

White matter injury in infants with intraventricular haemorrhage: mechanisms and therapies

Intraventricular haemorrhage (IVH) continues to be a major complication of prematurity that can result in cerebral palsy and cognitive impairment in survivors. No optimal therapy exists to prevent IVH or to treat its consequences. IVH varies in severity and can present as a bleed confined to the germinal matrix, small-to-large IVH or periventricular haemorrhagic infarction. Moderate-to-severe haemorrhage dilates the ventricle and damages the periventricular white matter. This white matter injury results from a constellation of blood-induced pathological reactions, including oxidative stress, glutamate excitotoxicity, inflammation, perturbed signalling pathways and remodelling of the extracellular matrix. Potential therapies for IVH are currently undergoing investigation in preclinical models and evidence from clinical trials suggests that stem cell treatment and/or endoscopic removal of clots from the cerebral ventricles could transform the outcome of infants with IVH. This Review presents an integrated view of new insights into the mechanisms underlying white matter injury in premature infants with IVH and highlights the importance of early detection of disability and immediate intervention in optimizing the outcomes of IVH survivors.

Germinal Matrix-Intraventricular Hemorrhage: A Tale of Preterm Infants

Germinal matrix-intraventricular hemorrhage (GM-IVH) is a common intracranial complication in preterm infants, especially those born before 32 weeks of gestation and very-low-birth-weight infants. Hemorrhage originates in the fragile capillary network of the subependymal germinal matrix of the developing brain and may disrupt the ependymal lining and progress into the lateral cerebral ventricle. GM-IVH is associated with increased mortality and abnormal neurodevelopmental outcomes such as posthemorrhagic hydrocephalus, cerebral palsy, epilepsy, severe cognitive impairment, and visual and hearing impairment. Most affected neonates are asymptomatic, and thus, diagnosis is usually made using real-time transfontanellar ultrasound. The present review provides a synopsis of the pathogenesis, grading, incidence, risk factors, and diagnosis of GM-IVH in preterm neonates. We explore brief literature related to outcomes, management interventions, and pharmacological and nonpharmacological prevention strategies for GM-IVH and posthemorrhagic hydrocephalus.

Cerebrospinal fluid NCAM-1 concentration is associated with neurodevelopmental outcome in post-hemorrhagic hydrocephalus of prematurity

OBJECTIVE

Efforts directed at mitigating neurological disability in preterm infants with intraventricular hemorrhage (IVH) and post hemorrhagic hydrocephalus (PHH) are limited by a dearth of quantifiable metrics capable of predicting long-term outcome. The objective of this study was to examine the relationships between candidate cerebrospinal fluid (CSF) biomarkers of PHH and neurodevelopmental outcomes in infants undergoing neurosurgical treatment for PHH.

STUDY DESIGN

Preterm infants with PHH were enrolled across the Hydrocephalus Clinical Research Network. CSF samples were collected at the time of temporizing neurosurgical procedure (n = 98). Amyloid precursor protein (APP), L1CAM, NCAM-1, and total protein (TP) were compared in PHH versus control CSF. Fifty-four of these PHH subjects underwent Bayley Scales of Infant Development-III (Bayley-III) testing at 15-30 months corrected age. Controlling for false discovery rate (FDR) and adjusting for post-menstrual age (PMA) and IVH grade, Pearson's partial correlation coefficients were used to examine relationships between CSF proteins and Bayley-III composite cognitive, language, and motor scores.

RESULTS

CSF APP, L1CAM, NCAM-1, and TP were elevated in PHH over control at temporizing surgery. CSF NCAM-1 was associated with Bayley-III motor score (R = -0.422, p = 0.007, FDR Q = 0.089), with modest relationships noted with cognition (R = -0.335, p = 0.030, FDR Q = 0.182) and language (R = -0.314, p = 0.048, FDR Q = 0.194) scores. No relationships were observed between CSF APP, L1CAM, or TP and Bayley-III scores. FOHR at the time of temporization did not correlate with Bayley-III scores, though trends were observed with Bayley-III motor (p = 0.0647 and R = -0.2912) and cognitive scores (p = 0.0506 and R = -0.2966).

CONCLUSION

CSF NCAM-1 was associated with neurodevelopment in this multi-institutional PHH cohort. This is the first report relating a specific CSF protein, NCAM-1, to neurodevelopment in PHH. Future work will further investigate a possible role for NCAM-1 as a biomarker of PHH-associated neurological disability.

Effects of nutrition therapy on growth, inflammation and metabolism in immature infants: a study protocol of a double-blind randomized controlled trial (ImNuT)

Background

Current nutritional management of infants born very preterm results in significant deficiency of the essential fatty acids (FAs) arachidonic acid (ARA) and docosahexaenoic acid (DHA). The impact of this deficit on brain maturation and inflammation mediated neonatal morbidities are unknown. The aim of this study is to determine whether early supply of ARA and DHA improves brain maturation and neonatal outcomes in infants born before 29 weeks of gestation.

Methods

Infants born at Oslo University Hospital are eligible to participate in this double-blind randomized controlled trial. Study participants are randomized to receive an enteral FA supplement of either 0.4 ml/kg MCT-oil™ (medium chain triglycerides) or 0.4 ml/kg Formulaid™ (100 mg/kg of ARA and 50 mg/kg of DHA). The FA supplement is given from the second day of life to 36 weeks’ postmenstrual age (PMA). The primary outcome is brain maturation assessed by Magnetic Resonance Imaging (MRI) at term equivalent age. Secondary outcomes include quality of growth, incidence of neonatal morbidities, cardiovascular health and neuro-development. Target sample size is 120 infants (60 per group), this will provide 80% power to detect a 0.04 difference in mean diffusivity (MD, mm²/sec) in major white matter tracts on MRI.

Discussion

Supplementation of ARA and DHA has the potential to improve brain maturation and reduce inflammation related diseases. This study is expected to provide valuable information for future nutritional guidelines for preterm infants.

Trial registration

Clinicaltrials.gov ID: NCT03555019. Registered 4 October 2018- Retrospectively registered.

Efficacy and safety of intraventricular fibrinolytic therapy for post-intraventricular hemorrhagic hydrocephalus in extreme low birth weight infants: a preliminary clinical study

PURPOSE

To evaluate the efficacy and safety of our unique therapy for treating post-intraventricular hemorrhagic hydrocephalus (PIVHH) in low birth weight infants (LBWls) through an early stage fibrinolytic therapeutic strategy involving urokinase (UK) injection into the lateral ventricle, called the "Ventricular Lavage (VL) therapy."

METHODS

Overall, 43 consecutive infants with PIVHH were included. Most were extremely LBWIs (n = 39). Other cases included very LBWIs (n = 2) and full-term infants (n = 2). VL therapy involved continuous external ventricular drainage (EVD) management using a very fine catheter and intermittent slow injection of 6000 IU of UK every 3-6 h to actively dissolve hematomas.

RESULTS

Early EVD management (within 3 weeks of IVH onset) was performed in 25 infants, with combination VL therapy in 21 infants. Five initiated late EVD management (≥ 3 weeks after IVH onset); the remaining 13 were treated conservatively for several weeks, delaying surgical intervention. Eighteen of 21 (86%) infants who received VL therapy did not require permanent shunt surgery. There were no serious complications, including the absence of secondary hemorrhage and infection. Two-thirds of the infants treated in the late stages required permanent shunt, and various shunt-related complications frequently occurred. A good outcome occurred in 13/17 infants in the early treatment group, despite most subjects having an IVH grade IV, and in 6/15 in the late treatment group.

CONCLUSIONS

Permanent shunt surgery needs were dramatically reduced following early VL therapy, and functional outcomes were favorable. VL therapy might be a promising strategy that could lead to the development of new treatments for PIVHH.

Early intervention and neurodevelopmental outcome of infants with posthemorrhagic hydrocephalus: A case series and literature review

OBJECTIVE

Intraventricular hemorrhage (IVH) is the most common central nervous system pathology in preterm infants. No consensus has been reached over the best indication for intervention in patients with posthemorrhagic hydrocephalus (PHH). The authors present the neurological outcome of infants with IVH and an early treatment approach, defined as an intervention when ventricular dilation is less than 4-mm over the 97th-percentile of Levene's index.

METHODS

We performed a retrospective case-series study of 12 infants who had IVH and an early intervention, their neurological development was evaluated after 18-months of corrected age using the Bayley-III Scales. Measures of central tendency and Pearson's correlation were used for data analysis.

RESULTS

In a 15-month period, twelve patients were diagnosed with IVH and underwent an early intervention. At the time of diagnosis, 2 patients had grade II IVH, 7 grade III, and 3 grade IV. Subgaleal shunt was the first intervention. 9 (75 %) ultimately required a ventriculoperitoneal shunt. A total of 9 (75 %) patients had normal cognitive scores, 7 (58.3 %) for the language-composite, and 8 (66.7 %) for the motor-composite. 6 (50 %) patients had normal scores in all composites. The average scores reported normal results (CC:98.33 ± 22.59; LC:98.25 ± 23.93; MC:88.58 ± 21.47). There was a significant correlation between antenatal steroids and the LC-score (p = 0.044).

CONCLUSIONS

Half of the patients with PHH and early neurosurgical interventions had an average or above average neurodevelopmental score in all three areas. Current literature and undergoing clinical trials have shown promising results on the implementation of this type of intervention.

Germinal Matrix-Intraventricular Hemorrhage of the Preterm Newborn and Preclinical Models: Inflammatory Considerations

The germinal matrix-intraventricular hemorrhage (GM-IVH) is one of the most important complications of the preterm newborn. Since these children are born at a critical time in brain development, they can develop short and long term neurological, sensory, cognitive and motor disabilities depending on the severity of the GM-IVH. In addition, hemorrhage triggers a microglia-mediated inflammatory response that damages the tissue adjacent to the injury. Nevertheless, a neuroprotective and neuroreparative role of the microglia has also been described, suggesting that neonatal microglia may have unique functions. While the implication of the inflammatory process in GM-IVH is well established, the difficulty to access a very delicate population has lead to the development of animal models that resemble the pathological features of GM-IVH. Genetically modified models and lesions induced by local administration of glycerol, collagenase or blood have been used to study associated inflammatory mechanisms as well as therapeutic targets. In the present study we review the GM-IVH complications, with special interest in inflammatory response and the role of microglia, both in patients and animal models, and we analyze specific proteins and cytokines that are currently under study as feasible predictors of GM-IVH evolution and prognosis.

Neuroendoscopic lavage for the management of posthemorrhagic hydrocephalus in preterm infants: safety, effectivity, and lessons learned

OBJECTIVE

Treatment of posthemorrhagic hydrocephalus in preterm infants is a matter of debate among pediatric neurosurgeons. Neuroendoscopic lavage (NEL) has been proposed as a suitable technique for the management of this pathology. The authors present their experience with 46 patients treated with NEL after germinal matrix hemorrhage, describe their technique, and analyze the outcomes.

METHODS

A retrospective analysis of patients affected by grade III or IV intraventricular hemorrhage (IVH) treated with NEL was performed. Nonmodifiable risk factors such as gestational age, weight at birth, modified Papile grade, and intercurrent diseases were reviewed. Safety analysis was performed, evaluating the incidence of postoperative complications. Effectivity was measured using radiological (frontal horn index and white matter injury), CSF biochemical (proteins, blood, and cellularity), and clinical variables. Permanent shunt rate and shunt survival were analyzed. The motor outcome was measured using the Gross Motor Function Classification System (GMFCS) at 18-24 months, and the neurocognitive outcome was evaluated according to the grade of adaptation to schooling.

RESULTS

Forty-six patients met the inclusion criteria. Patients were treated with a single NEL in 21 cases, 2 lavages in 13 cases, and 3 lavages in 12 cases. The mean gestational age at birth was 30.04 weeks, and the mean weight at birth was 1671.86 g. Hyaline membrane disease was described in 4.8% of the cases, hematological sepsis in 43.47%, persistent ductus arteriosus in 23.9%, and necrotizing enterocolitis in 10.9% of the cases. Modified Papile grade III and IV IVHs were observed in 60.9% and 39.1% of the cases, respectively. Postoperative infection was diagnosed in 10 of the 46 cases, CSF leak in 6, and rebleeding in 3. The mean frontal horn index decreased from 49.54 mm to 45.50 mm after NEL. No white matter injury was observed in 18 of 46 patients, focal injury was described in 13 patients, and diffuse bilateral white matter injury was observed in 15 patients. All CSF biochemical levels improved after lavage. The shunt rate was 58.7%, and shunt survival at 1 year was 50%. GMFCS grades I, II, III, IV, and V were observed in 44.74%, 21.05%, 2.63%, 15.79%, and 15.79% of patients, respectively. Good neurocognitive results were observed in 53.3% of the cases.

CONCLUSIONS

Neuroendoscopic lavage was a suitable alternative for the management of IVH in preterm infants in our series. Good motor and neurocognitive results were achieved by this technique, and the permanent shunt rate was reduced compared with historical controls.

This was the year that was: brain barriers and brain fluid research in 2019

This editorial highlights advances in brain barrier and brain fluid research published in 2019, as well as addressing current controversies and pressing needs. Topics include recent advances related to: the cerebral endothelium and the neurovascular unit; the choroid plexus, arachnoid membrane; cerebrospinal fluid and the glymphatic hypothesis; the impact of disease states on brain barriers and brain fluids; drug delivery to the brain; and translation of preclinical data to the clinic. This editorial also mourns the loss of two important figures in the field, Malcolm B. Segal and Edward G. Stopa.

Movement Imitation Therapy for Preterm Babies (MIT-PB): a Novel Approach to Improve the Neurodevelopmental Outcome of Infants at High-Risk for Cerebral Palsy

To improve the neurodevelopmental outcome in infants with high grade intraventricular haemorrhage and cramped-synchronised (CS) general movements (GMs). Four very preterm infants with intraventricular haemorrhage grade III (n = 3) or intraventricular haemorrhage with apparent periventricular haemorrhagic infarction (n = 1) were diagnosed with CS GMs at 33 to 35 weeks postmenstrual age. A few days later MIT-PB [Movement Imitation Therapy for Preterm Babies], an early intervention programme, was commenced: the instant an infant showed CS movements, the therapist intervened by gently guiding the infant's limbs so as to manoeuvre and smoothen the movements, thereby imitating normal GM sequences as closely as possible (at least for 10 min, 5 times a day, with increasing frequency over a period of 10 to 12 weeks). After a period of consistent CS GMs, the movements improved. At 14 weeks postterm age, the age specific GM pattern, fidgety movements, were normal in three infants, one infant had abnormal fidgety movements. At preschool age, all participants had a normal neurodevelopmental outcome. This report on four cases demonstrates that mimicking normal and variable GM sequences might have a positive cascading effect on neurodevelopment. The results need to be interpreted with caution and replication studies on larger samples are warranted. Nonetheless, this innovative approach may represent a first step into a new intervention strategy.