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Repeated lumbar or ventricular punctures in newborns with intraventricular haemorrhage
Andrew Whitelaw1, Richard Lee-Kelland1
1Neonatal Neuroscience, University of Bristol, St Michael's Hospital, Bristol, UK, BS2 8EG.
Insights
Repeatedly removing cerebrospinal fluid (CSF) in preterm infants at risk for post-hemorrhagic hydrocephalus (PHH) showed no benefit over conservative management. This approach did not reduce shunt dependence, disability, or death in these vulnerable neonates.
Area of Science:
- Neonatalogy
- Pediatric Neurology
- Critical Care Medicine
Background:
- Post-hemorrhagic hydrocephalus (PHH) remains a significant complication in preterm infants, often leading to cerebral palsy and requiring ventriculoperitoneal shunt (VPS) surgery.
- VPS surgery carries risks of infection and re-operation, highlighting the need for alternative treatments.
- Serial cerebrospinal fluid (CSF) removal has been proposed to mitigate PHH development and its consequences.
Purpose of the Study:
- To evaluate the efficacy of repeated CSF removal versus conservative management in reducing shunt dependence, neurodevelopmental disability, and mortality in neonates at risk for PHH.
- To compare the outcomes of interventions including lumbar puncture, ventricular puncture, or ventricular reservoir CSF removal against limited CSF removal based on intracranial pressure signs.
Main Methods:
- A systematic review and meta-analysis of randomized controlled trials (RCTs) and quasi-RCTs were conducted.
- Searches included Cochrane Neonatal, MEDLINE, Embase, and CINAHL databases up to March 2016.
- Included trials compared serial CSF removal with conservative management, assessing outcomes like shunt insertion, death, disability, and CSF infection.
Main Results:
- Meta-analysis of four trials (280 infants) found no significant difference between repeated CSF removal and conservative management for shunt placement (RR 0.96), death (RR 0.88), or major disability (RR 0.98).
- Evidence quality varied from low to high, with moderate quality for shunt insertion and death/shunt outcomes.
- No significant reduction in death or disability (RR 0.99) was observed with repeated CSF removal.
Conclusions:
- Repeated CSF removal in neonates at risk for PHH does not offer significant benefits over conservative management.
- The intervention did not demonstrate a reduction in the need for permanent shunts, neurodevelopmental disability, or mortality.
- Current evidence does not support serial CSF removal as a superior treatment strategy for preventing PHH complications in preterm infants.
Background:
Although in recent years the percentage of preterm infants who suffer intraventricular haemorrhage (IVH) has reduced, posthaemorrhagic hydrocephalus (PHH) remains a serious problem with a high rate of cerebral palsy and no evidence-based treatment. Survivors often have to undergo ventriculoperitoneal shunt (VPS) surgery, which makes the child permanently dependent on a valve and catheter system. This carries a significant risk of infection and the need for surgical revision of the shunt. Repeated removal of cerebrospinal fluid (CSF) by either lumbar puncture, ventricular puncture, or from a ventricular reservoir in preterm babies with IVH has been suggested as a treatment to reduce the risk of PHH development.
Objectives:
To determine the effect of repeated cerebrospinal fluid (CSF) removal (by lumbar/ventricular puncture or removal from a ventricular reservoir) compared to conservative management, where removal is limited to when there are signs of raised intracranial pressure (ICP), on reduction in the risk of permanent shunt dependence, neurodevelopmental disability, and death in neonates with or at risk of developing posthaemorrhagic hydrocephalus (PHH).
Search Methods:
We used the standard search strategy of Cochrane Neonatal to search the Cochrane Central Register of Controlled Trials (CENTRAL; 2016, Issue 3), MEDLINE via PubMed (1966 to 24 March 2016), Embase (1980 to 24 March 2016), and CINAHL (1982 to 24 March 2016). We also searched clinical trials databases, conference proceedings, and the reference lists of retrieved articles for randomised controlled trials (RCTs) and quasi-RCTs.
Selection Criteria:
RCTs and quasi-RCTs that compared serial removal of CSF (via lumbar puncture, ventricular puncture, or from a ventricular reservoir) with conservative management (removing CSF only when there were symptoms of raised ICP). Trials also had to report on at least one of the specified outcomes of death, disability, or shunt insertion.
Data Collection And Analysis:
We extracted details of the participant selection, participant allocation and the interventions. We assessed the following outcomes: VPS, death, death or shunt, disability, multiple disability, death or disability, and CSF infection. We assessed the quality of the evidence using the GRADE approach.
Main Results:
Four trials (five articles) met the inclusion criteria of this review; three were RCTs and one was a quasi-RCT; and included a total of 280 participants treated in neonatal intensive care units in the UK. The trials were published between 1980 and 1990. The studies were sufficiently similar regarding the research question they asked and the interventions that we could combine the trials to assess the effect of the intervention.Meta-analysis showed that the intervention produced no significant difference when compared to conservative management for the outcomes of: placement of hydrocephalus shunt (typical risk ratio (RR) 0.96, 95% confidence interval (CI) 0.73 to 1.26; 3 trials, 233 infants; I² statistic = 0%; moderate quality evidence), death (RR 0.88, 95% CI 0.53 to 1.44; 4 trials, 280 infants; I² statistic = 0%; low quality evidence), major disability in survivors (RR 0.98, 95% CI 0.81 to 1.18; 2 trials, 141 infants; I² statistic = 11%; high quality evidence), multiple disability in survivors (RR 0.9, 95% CI 0.66 to 1.24; 2 trials, 141 infants; I² statistic = 0%; high quality evidence), death or disability (RR 0.99, 95% CI 0.86 to 1.14; 2 trials, 180 infants; I² statistic = 0%; high quality evidence), death or shunt (RR 0.91, 95% CI 0.75 to 1.11; 3 trials, 233 infants; I² statistic = 0%; moderate quality evidence), and infection of CSF presurgery (RR 1.73, 95% CI 0.53 to 5.67; 2 trials, 195 infants; low quality evidence).We assessed the quality of the evidence as high for the outcomes of major disability, multiple disability, and disability or death. We rated the evidence for the outcomes of shunt insertion, and death or shunt insertion as of moderate quality as one included trial used an alternation method of randomisation. For the outcomes of death and infection of CSF presurgery, the quality of the evidence was low as one trial used an alternation method, the number of participants was too low to assess the objectives with sufficient precision, and there was inconsistency regarding the findings in the included trials regarding the outcome of infection of CSF presurgery.
Authors' Conclusions:
There was no evidence that repeated removal of CSF via lumbar puncture, ventricular puncture or from a ventricular reservoir produces any benefit over conservative management in neonates with or at risk for developing PHH in terms of reduction of disability, death, or need for placement of a permanent shunt.