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Posthemorrhagic ventricular dilatation in preterm infants: When best to intervene?
Lara M Leijser1, Steven P Miller1, Gerda van Wezel-Meijler1
1From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada.
Insights
An early approach to managing posthemorrhagic ventricular dilatation (PHVD) in preterm infants leads to better neurodevelopmental outcomes. Even with intervention, early management resulted in normal outcomes, unlike the late approach.
Area of Science:
- Neonatal Neurology
- Pediatric Neurosurgery
- Developmental Pediatrics
Background:
- Posthemorrhagic ventricular dilatation (PHVD) is a common complication in preterm infants.
- Management strategies for PHVD vary, impacting neurodevelopmental outcomes.
Purpose of the Study:
- To compare neurodevelopmental outcomes between an early approach (EA) and a late approach (LA) for managing PHVD in preterm infants.
- To evaluate the effectiveness of temporizing procedures versus immediate shunt placement in PHVD.
Main Methods:
- An observational cohort study included 127 preterm infants (<30 weeks gestation) with PHVD.
- Infants were managed with either an EA (ventricular measurements) or LA (signs of increased intracranial pressure).
- Neurodevelopmental outcomes were assessed at 18-24 months.
Main Results:
- The EA group had a higher intervention rate (63%) but initiated treatment earlier and with smaller ventricles compared to the LA group.
- Shunt rates and complications were significantly lower in the EA group (20%) versus the LA group (92%).
- Most EA infants achieved normal neurodevelopmental outcomes, while LA infants requiring intervention showed significantly poorer outcomes.
Conclusions:
- An early, less invasive approach to PHVD management in preterm infants leads to comparable or better neurodevelopmental outcomes than a late, more aggressive approach.
- EA, even if requiring eventual shunt placement, results in outcomes indistinguishable from non-intervention cases.
- The benefits of the EA for PHVD management appear to outweigh potential risks, offering improved neurodevelopmental trajectories.
Objective:
To compare neurodevelopmental outcomes of preterm infants with and without intervention for posthemorrhagic ventricular dilatation (PHVD) managed with an "early approach" (EA), based on ventricular measurements exceeding normal (ventricular index [VI] <+2 SD/anterior horn width <6 mm) with initial temporizing procedures, followed, if needed, by permanent shunt placement, and a "late approach" (LA), based on signs of increased intracranial pressure with mostly immediate permanent intervention.
Methods:
Observational cohort study of 127 preterm infants (gestation <30 weeks) with PHVD managed with EA (n = 78) or LA (n = 49). Ventricular size was measured on cranial ultrasound. Outcome was assessed at 18-24 months.
Results:
Forty-nine of 78 (63%) EA and 24 of 49 (49%) LA infants received intervention. LA infants were slightly younger at birth, but did not differ from EA infants for other clinical measures. Initial intervention in the EA group occurred at younger age (29.4/33.1 week postmenstrual age; p < 0.001) with smaller ventricles (VI 2.4/14 mm >+2 SD; p < 0.01), and consisted predominantly of lumbar punctures or reservoir taps. Maximum VI in infants with/without intervention was similar in EA (3/1.5 mm >+2 SD; p = 0.3) but differed in the LA group (14/2.1 mm >+2 SD; p < 0.001). Shunt rate (20/92%; p < 0.001) and complications were lower in EA than LA group. Most EA infants had normal outcomes (>-1 SD), despite intervention. LA infants with intervention had poorer outcomes than those without (p < 0.003), with scores <-2 SD in 81%.
Conclusion:
In preterm infants with PHVD, those with early intervention, even when eventually requiring a shunt, had outcomes indistinguishable from those without intervention, all being within the normal range. In contrast, in infants managed with LA, need for intervention predicted worse outcomes. Benefits of EA appear to outweigh potential risks.
Classification Of Evidence:
This study provides Class III evidence that for preterm infants with PHVD, an EA to management results in better neurodevelopmental outcomes than a LA.
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