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Randomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation. Ventriculomegaly Trial Group
Insights
Early cerebrospinal fluid taps for posthaemorrhagic ventricular dilatation did not improve outcomes in infants. Most survivors experienced neuromotor impairments, regardless of treatment group.
Area of Science:
- Neonatal Medicine
- Pediatric Neurology
- Clinical Trials
Background:
- Posthaemorrhagic ventricular dilatation (PHVD) is a serious complication in preterm infants.
- Management strategies for PHVD aim to reduce intraventricular pressure and prevent further brain injury.
- Current treatment options include conservative management and invasive procedures.
Purpose of the Study:
- To compare the efficacy of early repeated cerebrospinal fluid (CSF) taps versus conservative management for PHVD.
- To assess the impact of early CSF tapping on mortality, shunt requirement, and neurodevelopmental outcomes in infants with PHVD.
Main Methods:
- A randomized controlled trial involving 157 infants across 15 centers.
- Infants were randomized to either early repeated CSF taps or conservative management.
- Neurodevelopmental assessments were performed at 12 months in surviving infants.
Main Results:
- The early treatment group underwent significantly more CSF taps and had more CSF removed within the first 14 days.
- Cerebrospinal fluid infection rates were slightly higher in the early treatment group (7 vs. 4 infants).
- No significant difference in the ultimate need for ventricular shunts (62% in both groups).
- At 12 months, 85% of survivors had abnormal neuromotor signs and 73% had disabilities.
- Early treatment showed no benefit for infants without parenchymal lesions.
- Early treatment was associated with a reduction in other impairments for infants with parenchymal lesions.
Conclusions:
- Early repeated cerebrospinal fluid taps do not offer a detectable neurodevelopmental benefit for infants with posthaemorrhagic ventricular dilatation, especially those without initial parenchymal lesions.
- While early intervention did not worsen overall outcomes, it did not prevent the high rates of neuromotor impairment and disability observed in survivors.
- Further research is needed to identify optimal management strategies for PHVD, particularly for infants with parenchymal involvement.
Abstract:
Treatment of posthaemorrhagic ventricular dilatation by early repeated cerebrospinal fluid taps was compared with conservative management in a randomised controlled trial of 157 infants in 15 centres. Thirty infants died and six moved abroad before follow up. During the first 14 days after randomisation, the early treatment group had five times more taps, and 12 times more cerebrospinal fluid removed. Infection of the cerebrospinal fluid occurred in seven of the early treated and four of the conservatively managed infants. Of survivors, 62% in both groups ultimately had ventricular shunts. Neurodevelopmental assessment of survivors at 12 months was carried out by a single experienced examiner. Of survivors, 103 (85%) had abnormal neuromotor signs and 88 (73%) had disabilities. There was no detectable benefit of early treatment for children who did not have parenchymal lesions at the time they entered the trial. Nearly all those with parenchymal lesions had neuromotor impairment, but early treatment was associated with a significant reduction in other impairments.