THE PLASTIC SURGEONS OF LOMA LINDA UNIVERSITY Loma Linda University Department of Neurosurgery
Neurosurgical Management Of Neonatal Intraventricular Hemorrhage (IVH)
sAlexander Zouros
MD, FRCS(C), FAAP,
FAANS
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Pediatric Neurosurgery in the NICU
-Neonatal IVH
-Congenital
hydrocephalus
-Spina bifida
-Craniosynostosis
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Prematurity and Germinal Matrix Hemorrhage
Germinal Matrix is a
transient zone of neural cell
proliferation that involutes
in 3rd trimester
Located Bilaterally,
adjacent to the lateral
ventricles
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Epidemiology and Timing
20-30% of all infants <1500
grams and <30 weeks
gestation
Incidence of IVH increases
with decreasing gestational
age at birth and birth
weight
50% occur within 12
hours of delivery
40% occur around
postnatal day 3-4
5% occur around
postnatal day 5
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Risk factors slide
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IVH Grading Scales – Papille vs. Volpe
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Grade 1 IVH (bilateral) – confined to germinal matrix
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Grade IV: Periventricular hemorrhagic infarction (PVHI)
- Grade IV is an extension of the hemorrhage from the
germinal matrix region to the surrounding brain
- Blood may also (and often does) spill into ventricles
- Enlargement of ventricles or hydrocephalus is not
a diagnostic criteria
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Grade IV - Periventricular Hemorrhagic Infarct
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Prevention of IVH
Effective:
-Antenatal corticosteroids
-C-section
ANY measure that
prevents antenatal
distress
Ineffective, Unproven:
-nitrous oxide
-phenobarbital
-post-natal steroids
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Acute Clinical Presentation of IVH
Catastrophic (hours) or Saltatory (hours-days):
- sudden change in activity/alertness, seizures,
respiratory effort, hypotonia, bradycardias,
drop in hct
- prognosis grim
Clinically Silent – majority
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Sequelae of IVH
-Prevention of secondary neurological injuries:
-seizures
-cerebral perfusion/oxygenation
-normalize glucose and Na
Peri-Ventricular Leukomalacia (PVL)
Post-Hemorrhagic Hydrocephalus
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Hydrocephalus vs. Ventriculomegaly
HYDROCEPHALUS
Pathologic
accumulation of CSF
within the intracranial
compartment resulting
in higher pressures or
impairment of
neurologic function
VENTRICULOMEGALY
Radiologic
demonstration of
enlarged CSF spaces or
ventricles
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Ventriculomegaly
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Post-IVH Hydrocephalus
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Signs of Hydrocephalus
Increasing head
circumference (>1.5 cm
per week)
Bulging fontanelle
Splayed Sutures
Upgaze paresis or
“Parinaud’s”, “Sunsetting”
Apneas
Bradycardias
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Natural History of Hydrocephalus
Pre-Shunt era:
20% survival with significant
disabilities
VP Shunt era:
>90 - 97% survival
depending on etiology
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Management of Hydrocephalus
>50 % of patients with IVH will have asymptomatic
ventriculomegaly
Many symptomatic patients can be temporized and
may not need a shunt
Many symptomatic patients who need a shunt
cannot get one, yet….(too small, unstable, septic)
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Buying Time with Post IVH Hydro
Medications - Acetazolamide and Furosemide
Drain CSF - Lumbar Punctures
- Ventricular Punctures
All of these can be tried very briefly (once or
twice) but not serially
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Temporizing CSF diversion procedures
External Ventriculostomy Drain
Implants
– Ventricular access Device
- Ventriculo-subgaleal shunt
Risk of implant or drain infection
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Timing of VP Shunt
Weight >1200-1500 grams
No active infections (sepsis, NEC, pneumonia,
meningitis)
Improvement of CSF viscosity, blood breakdown
products and protein
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Ventricular Shunts
Ventricular catheter- occipital vs. frontal
Want catheter surrounded by CSF
Valve-regulates flow
Distal catheter
Peritoneal
Atrial
Pleural
Gall bladder
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A Typical VP Shunt
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A Typical VP Shunt
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Shunt Problems
Malfunction or infection can present at anytime but most commonly within first 6 months after a shunt procedure
1-year failure rate of over 40%
Infection rates greater 10-15%
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Shunt Problems - Malfunction
- Occlusion (usually debris, blood or choroid plexus)
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IVH Grades 1-3 and Outcome
- Differences in study methodologies has resulted in
confusion of Cerebral palsy rates (motor and
intellectual development) for IVH
- Grade 1 or 2 (<5%)
- Grade 3 (<10%)
- Developmental and functional outcome is
independent of unilateral vs. bilateral
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Grade 4 IVH/PHVI and Neurologic Outcome
- Unilateral Grade 4/PVHI - 64% no or mild CP
- Bilateral Grade 4/PVHI - 7% no or mild CP
Unilateral injury more likely to result in spastic
hemiparesis/hemiplegia
Bilateral injury more likely to result in spastic diplegia (legs)
or quadriparesis/plegia
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Summary
-IVH incidence is related to severity
of prematurity and birth weight
-Antenatal interventions to decrease
distress also decrease the likelihood
of IVH
-IVH is rarely lethal and often
subclinical
- Ventricular enlargement is
common with Grade 3 IVH (over
50%) but not necessarily
hydrocephalus
- Hydrocephalus is diagnosed by
severity of ultrasounds or
development of signs of
symptoms of elevated ICP
- Temporizing measure for
hydrocephalus - like LPs,
ventricular access devices -
may be used in very small or
septic infants
- VP Shunts remain the only
definitive long-term treatment
for hydrocephalus
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Summary
- Hydrocephalus should never be
used as a justification for
withdrawal of care (often non-
lethal and death is by failure to
thrive/malnutrition)
- Hydrocephalus is a readily
treatable, and prevents
worsening neurological outcome
and eases patient care at home
Patients with Grade 1-3 IVH have
low rates of CP, irrespective of
unilateral vs bilateral
Unilateral Grade 4 IVH/PVHI have
<40% risk mental retardation and
hemiparesis/plegia (majority of these
will ambulate)
Bilateral Grade 4 IVH has > 90%
likelihood of mental retardation and
spastic diplegia/quadriplegia
(majority will be in wheelchairs)
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