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Implementing early posthemorrhagic ventricular dilation intervention in preterm neonates: does a standardized pathway
Jennifer C Keene1, Betsy Ostrander1, Katherine Hartman1
11Department of Pediatrics, Division of Child Neurology, University of Utah, Salt Lake City.
Insights
A new standardized care pathway for posthemorrhagic ventricular dilation (PHVD) in preterm infants reduced ventricular size and improved neurodevelopmental outcomes, decreasing death or severe cerebral palsy by 29%.
Area of Science:
- Neonatal neurology
- Pediatric neurosurgery
- Developmental pediatrics
Background:
- Posthemorrhagic ventricular dilation (PHVD) is a severe complication in extremely preterm infants following intraventricular hemorrhage.
- PHVD is linked to significant rates of mortality and long-term neurodevelopmental deficits.
- Current treatment practices for PHVD vary, with ongoing debate regarding optimal timing for cerebrospinal fluid (CSF) diversion.
Purpose of the Study:
- To evaluate the impact of a standardized multidisciplinary treatment pathway for PHVD implemented in 2021.
- To determine if the new pathway reduced ventricular dilation and improved neurodevelopmental outcomes in neonates with PHVD.
- To assess the association between ventricular size and adverse outcomes.
Main Methods:
- A single-center cohort study analyzed neonates with PHVD treated between 2017 and 2023.
- Patients were divided into pre-pathway and post-pathway implementation groups.
- Interventions included lumbar puncture (LP), ventricular reservoir, and ventriculoperitoneal shunt (VPS) placement, with ventricular size measured by anterior horn width (AHW) and ventricular index (VI).
Main Results:
- The post-pathway group showed significantly lower median maximum anterior horn width (AHW) and ventricular index (VI) compared to the pre-pathway group (p=0.03 and p=0.04, respectively).
- Among infants with 18-month follow-up, death or severe cerebral palsy decreased by 29% post-pathway implementation (62% vs. 33%, p=0.03).
- Larger ventricular size independently predicted higher odds of death or severe cerebral palsy.
Conclusions:
- A standardized care pathway for PHVD can potentially improve neurodevelopmental outcomes in extremely preterm infants.
- Pathway implementation led to reduced ventricular size, and smaller ventricular size is a strong predictor of better neurodevelopmental outcomes.
- Findings support earlier, standardized interventions for PHVD and suggest the need for multicenter validation.
Objective:
Posthemorrhagic ventricular dilation (PHVD) is a serious complication of intraventricular hemorrhage in extremely preterm infants, associated with high rates of death and neurodevelopmental impairment. Earlier CSF diversion might reduce adverse outcomes, but variability in practice persists. In 2021, a tertiary care center implemented a standardized multidisciplinary PHVD treatment pathway that emphasized standardized ventricular measurements and earlier thresholds for intervention. The aim of this study was to evaluate whether this treatment pathway reduced ventricular dilation and improved developmental outcomes in neonates with PHVD.
Methods:
This single-center cohort study analyzed outcomes of neonates born between 2017 and 2023 who underwent PHVD intervention. Patients were dichotomized according to whether they were born before the treatment pathway was implemented (pre-pathway group) or after (post-pathway group). Data were extracted from the Hydrocephalus Clinical Research Network prospective registry and clinical records. Interventions included lumbar puncture (LP), ventricular reservoir placement, and ventriculoperitoneal shunt (VPS) placement. Ventricular dilation was measured using the anterior horn width (AHW) and ventricular index (VI). Developmental outcomes were assessed at ≥ 18 months using standardized development assessments and neurological evaluation.
Results:
Overall, 104 patients were included; 59 in the pre-pathway group and 45 in the post-pathway group (10 of whom underwent only LP and were included only in an LP subset analysis). Following pathway implementation, high-volume LP was completed in 93% of patients. The median maximum AHW and VI greater than 2 standard deviations above the mean were significantly lower in the post-pathway group (AHW: 32 mm vs 26 mm, p = 0.03; VI: 18 vs 15 mm > 2 standard deviations, p = 0.04). Among 74 infants with 18 months of follow-up, the primary outcome of death or severe cerebral palsy was reduced by 29% after pathway implementation (62% pre-pathway vs 33% post-pathway, p = 0.03). The multivariable analysis of all neonates demonstrated that larger ventricular size at VPS placement and at maximum ventricular dilation independently predicted higher odds of death or severe cerebral palsy, with a 9% increase per 1-mm increase in maximum AHW (adjusted OR 1.09, 95% CI 1.03-1.16, p = 0.006) and 14% increase per 1-mm increase in pre-VPS AHW (adjusted OR 1.14, 95% CI 1.05-1.24, p = 0.002).
Conclusions:
This study found potential for improved neurodevelopmental outcomes with pragmatic implementation of a collaborative standardized pathway for PHVD care. Pathway implementation was associated with reduced ventricular size at VPS placement, and smaller maximum ventricular size was a strong independent predictor of improved neurodevelopmental outcomes. These findings support earlier standardized PHVD intervention and highlight the need for larger multicenter studies to validate standardized and pragmatic early intervention approaches for PHVD.
