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Published on: March 28, 2025
Surgical complications in early versus late intervention centers for progressive posthemorrhagic ventricular
Grace Y Lai1,2, Niek E van der Aa3, Peter A Woerdeman4
11Department of Neurosurgery, Children's Nebraska, University of Nebraska Medical Center, Omaha, Nebraska.
Insights
Early CSF diversion in preterm infants with posthemorrhagic ventricular dilatation (PHVD) did not increase surgical complications. Lower gestational age and birth weight, not intervention timing, predicted complications, supporting cautious early intervention for eligible infants.
Area of Science:
- Neonatal Neurology
- Pediatric Neurosurgery
- Clinical Outcomes Research
Background:
- Posthemorrhagic ventricular dilatation (PHVD) is a serious complication in preterm infants following germinal matrix hemorrhage.
- Cerebrospinal fluid (CSF) diversion is a common neurosurgical intervention for PHVD.
- The optimal timing for CSF diversion (early vs. late intervention) remains debated.
Purpose of the Study:
- To compare clinical features and surgical complication rates in preterm infants with PHVD undergoing early intervention (EI) versus late intervention (LI).
- To identify factors predicting surgical complications in this vulnerable population.
Main Methods:
- Retrospective international multicenter study of preterm infants (≤34 weeks GA) with grade III/IV intraventricular hemorrhage requiring PHVD intervention.
- Data collected on gestational age, birth weight, timing of neurosurgical procedures (lumbar puncture, temporizing neurosurgical procedures, ventriculoperitoneal shunt insertion), and postoperative complications.
- Statistical analysis included univariable and multivariable logistic regression.
Main Results:
- No significant difference in postoperative surgical complication rates between EI and LI centers (11% vs. 24%, p=0.115).
- EI centers utilized lumbar puncture more frequently (97% vs. 58%) and required fewer ventriculoperitoneal shunt conversions (42% vs. 70%).
- Lower gestational age and lower birth weight were independently associated with increased surgical complications on multivariable analysis.
Conclusions:
- The timing of CSF diversion (early vs. late) did not impact neurosurgical complication rates in preterm infants with PHVD.
- Younger gestational age and lower birth weight are significant predictors of complications.
- These findings support a cautious approach to early CSF diversion in preterm infants with PHVD and lower birth weights.
Objective:
The aim of this study was to evaluate the clinical features and surgical complication rates of preterm infants with posthemorrhagic ventricular dilatation (PHVD) who underwent CSF diversion, comparing early intervention (EI) and late intervention (LI).
Methods:
This was a retrospective international multicenter study of infants born at ≤ 34 weeks' gestational age (GA) and treated between 2018 and 2022 for grade III or IV germinal matrix hemorrhage and intraventricular hemorrhage, who required intervention for PHVD. The primary outcome of interest was the rate of postoperative surgical complications. Secondary outcomes were rate of temporizing neurosurgical procedures (TNPs) after initial lumbar puncture (LP) if performed, rate of conversion from TNP to a ventriculoperitoneal shunt (VPS), and overall rate of VPS insertion. Summary statistics and univariable and multivariable logistic regression were performed to determine variables predictive of complications.
Results:
One hundred seventy infants from 6 centers in the United States, Canada, and the Netherlands were included. Infants at LI centers were more premature (GA 26.7 ± 2.8 vs 29.3 ± 2.4 weeks, p < 0.001) with lower birth weights (BWs; 1004 ± 448 vs 1438 ± 462 g, p < 0.001) compared to those at EI centers. The first neurosurgical intervention occurred at a median day of life after birth (DOL) of 31.5 (IQR 24-45) days at LI centers versus 18 (IQR 13-21) days at EI centers (p < 0.001). Ventricular index (> 97th percentile) at the first neurosurgical intervention (TNP and/or VPS placement) was lower at EI centers (5.05 ± 2.32 vs 12.88 ± 5.70 mm, p < 0.001). Infant weight at the first neurosurgical intervention did not differ between site types (p = 0.466). EI centers had a larger proportion of patients who underwent LP (97% vs 58%, p < 0.001) and smaller proportion who required a VPS after TNP (42% vs 70%, p = 0.002). The overall VPS insertion rate was higher at LI centers (62% vs 30%, p < 0.001). There was no statistical difference in the complication rate between EI and LI centers (11% vs 24%, respectively, OR 0.42, 95% CI 0.12-1.24, p = 0.115). On univariable analysis, lower GA (p = 0.002), lower BW (p = 0.003), later DOL at first neurosurgical intervention (p = 0.035), diagnosis of meningitis before neurosurgical intervention (p = 0.047), and of necrotizing enterocolitis (p = 0.017) during the neonatal intensive care unit admission were predictive of complications. However, only lower GA (p = 0.029) and BW (p = 0.031) remained significant on multivariable analysis.
Conclusions:
The neurosurgical complication rate did not differ between EI and LI centers. On multivariable analysis, neurosurgical complications were associated with younger GA and lower BW but not with variables regarding the timing of intervention. These observations support cautious early CSF diversion in more preterm infants with lower BWs.