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Repeated lumbar or ventricular punctures in newborns with intraventricular hemorrhage
1Division of Child Health, University of Bristol, Division of Child Health, University of Bristol Medical School, Southmead Hospital, Bristol, UK, BS9 1PJ. andrew.whitelaw@bristol.ac.uk
Insights
Early CSF tapping in neonates with post-hemorrhagic hydrocephalus does not reduce shunt dependence or death. This intervention may even increase the risk of cerebrospinal fluid infection.
Area of Science:
- Neonatal Neurology
- Pediatric Neurosurgery
- Critical Care Medicine
Background:
- Post-hemorrhagic hydrocephalus (PHH) is a serious complication in premature infants following intraventricular hemorrhage.
- Current treatments like ventriculoperitoneal shunt surgery lead to lifelong dependence and complications.
- There is a need for effective early interventions to prevent severe outcomes.
Purpose of the Study:
- To evaluate the efficacy of repeated cerebrospinal fluid (CSF) tapping in reducing shunt dependence, neurodevelopmental disability, or death in neonates at risk of PHH.
- To test the hypothesis that CSF tapping removes blood and protein, thereby preventing CSF absorption pathways obstruction.
Main Methods:
- A systematic review of controlled trials was conducted using multiple databases (Medline, Cochrane) and handsearching.
- Four controlled trials (three randomized) involving neonates with intraventricular hemorrhage and developing hydrocephalus were included.
- Data on patient selection, interventions (repeated CSF tapping vs. conservative care), and outcomes (shunt placement, death, disability) were extracted.
Main Results:
- Combining data from the trials showed no statistically significant reduction in the relative risks for shunt placement, death, disability, or multiple disability with repeated CSF tapping.
- The intervention showed no benefit compared to conservative management.
- Evidence suggested an increased risk of cerebrospinal fluid infection associated with repeated CSF tapping.
Conclusions:
- Early repeated CSF tapping is not recommended for neonates at risk of or developing post-hemorrhagic hydrocephalus.
- The intervention failed to demonstrate a benefit in preventing shunt dependence or improving neurodevelopmental outcomes.
- Potential increased risk of infection necessitates caution with this approach.
Background:
Although it has been possible to reduce the percentage of premature infants suffering intraventricular hemorrhage, posthemorrhagic hydrocephalus remains a serious problem without a good treatment. There is a high rate of cerebral palsy, and ventriculoperitoneal shunt surgery makes the child permanently dependent on the valve and catheter system. Shunt surgery cannot be carried out early because of the blood in the cerebrospinal fluid (CSF) and the brain may be subjected to periods of raised pressure. Early tapping of CSF by lumbar puncture or ventricular tap was suggested as a way of temporarily reducing pressure and removing blood and protein and thereby avoiding permanent hydrocephalus.
Objectives:
To determine whether repeated CSF tapping, by lumbar puncture or ventricular tap, reduced the risk of permanent shunt dependence, neurodevelopmental disability or death in neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus (PHH). This form of treatment was based on the hypothesis that repeated tapping removed protein and blood from the CSF, thus clearing obstruction from the channels of CSF absorption.
Search Strategy:
Pediatric, Neurosurgical and General Medical Journals were handsearched from 1976 up to October 2000, as well as the Medline database (via PubMed) and the Cochrane Controlled Trials Register. Personal contacts were used.
Selection Criteria:
Four controlled trials ( with five published papers) were identified, three being randomised and the fourth using alternative allocation. Two trials evaluated repeated lumbar punctures in neonates with intraventricular hemorrhage (IVH) and two trials evaluated repeated CSF tapping infants with IVH followed by progressive ventricular dilatation.
Data Collection And Analysis:
In addition to details of the patient selection and patient allocation, the interventions were extracted. The end-points examined were: ventriculoperitoneal shunt, death, disability, multiple disability and death or disability.
Main Results:
The studies were sufficiently similar in the question they were asking and the interventions were sufficiently in common that they could be combined when assessing the effect of the intervention. When repeated CSF tapping was compared to conservative treatment, the relative risks for shunt placement, death, disability and multiple disability were very close to 1.0 with no statistically significant effect. There is also evidence that this form of treatment increased the risk of CSF infection.
Reviewer'S Conclusions:
Early repeated CSF tapping cannot be recommended for neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus.