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Posthemorrhagic hydrocephalus — Clinical Guidelines

Overview

Posthemorrhagic hydrocephalus (PHH) is a neurological complication following intraventricular hemorrhage (IVH), particularly prevalent in preterm infants, characterized by cerebrospinal fluid (CSF) accumulation leading to ventricular dilation and potential brain damage 1 12.

Diagnosis

Key Diagnostic Criteria: Ventricular dilation on cranial ultrasound, clinical signs of increased intracranial pressure (e.g., irritability, vomiting, bulging fontanelle) 1 12.

Recommended Tests: Cranial ultrasonography for monitoring ventricular size, lumbar puncture to assess CSF characteristics 1 13 22.

Grading: Use of Levene's index or other standardized scales to quantify ventricular dilatation 3.

Management

First-Line Treatments:

- Serial Lumbar Punctures: For temporary CSF diversion and monitoring ventricular size 22 23. - Ventriculoperitoneal (VP) Shunts: Indicated for persistent hydrocephalus 3 13 20.

Adjunctive Treatments:

- Endoscopic Third Ventriculostomy (ETV): Alternative to shunting, particularly in selected cases 10 16. - Intraventricular Urokinase: Pilot studies suggest potential for fibrinolysis in acute cases 14. - C3/C3aR Inhibition: Targeting microglia-astrocyte interactions to potentially mitigate PHH progression 2.

Special Populations

Preterm Infants: Early intervention with VP shunts or ETV is crucial due to high risk of neurological sequelae 1 3 13 20.

Comorbidities: Necrotizing enterocolitis (NEC) significantly impacts morbidity and mortality in infants with PHH 17.

Racial and Economic Disparities: Higher mortality rates observed in disadvantaged groups, highlighting the need for equitable care 6.

Key Recommendations

Initiate Early Intervention: Perform serial lumbar punctures or consider VP shunting early in infants with posthemorrhagic ventricular dilation to prevent neurological deterioration (Evidence: Moderate 22 23).

Monitor Ventricular Size: Regular cranial ultrasonography using standardized indices like Levene's index to guide treatment decisions (Evidence: Moderate 3).

Consider ETV in Selected Cases: Evaluate endoscopic third ventriculostomy as an alternative to shunting, especially in cases where shunt complications are anticipated (Evidence: Weak 10 16).

Address Comorbidities: Closely monitor and manage comorbidities such as NEC to improve outcomes in infants with PHH (Evidence: Moderate 17).

Equitable Care Practices: Implement strategies to mitigate racial and socioeconomic disparities affecting mortality in preterm infants with PHH (Evidence: Expert opinion 6).

References

1 Andreato C, Uccella S, Battaglini M, Pacetti M, Tortora D, Ramenghi LA. The Possible Role of the Superior Sagittal Sinus in Regulating Cerebrospinal Fluid Dynamics among Preterm Infants: A Case Report and a Review of the Literature. Neuropediatrics 2024. link 2 Tang J, Jila S, Luo T, Zhang B, Miao H, Feng H et al.. C3/C3aR inhibition alleviates GMH-IVH-induced hydrocephalus by preventing microglia-astrocyte interactions in neonatal rats. Neuropharmacology 2022. link 3 Garcia-Navarro V, Perez-Vega C, Robles-Lomelín P, Valdez-Sandoval P, Vazquez PMG, Rodriguez YL et al.. Early intervention and neurodevelopmental outcome of infants with posthemorrhagic hydrocephalus: A case series and literature review. Clinical neurology and neurosurgery 2021. link 4 Ratliff M, Unterberg A, Bächli H. Ventriculo-bipleural shunt as last resort in a 4-year-old child in whom a VP and VA shunt failed. Journal of neurosurgery. Pediatrics 2016. link 5 Christian EA, Melamed EF, Peck E, Krieger MD, McComb JG. Surgical management of hydrocephalus secondary to intraventricular hemorrhage in the preterm infant. Journal of neurosurgery. Pediatrics 2016. link 6 Jin DL, Christian EA, Attenello F, Melamed E, Cen S, Krieger MD et al.. Cross-Sectional Analysis on Racial and Economic Disparities Affecting Mortality in Preterm Infants with Posthemorrhagic Hydrocephalus. World neurosurgery 2016. link 7 Benvenisti H, Bassan H, Shiran S, Constantini S, Roth J. "Growing" cerebellum in an infant after shunt insertion. Pediatric neurology 2015. link 8 Seeburg D, Ahn E, Huisman T. Secondary pediatric encephalocele after ventriculosubgaleal shunting for posthemorrhagic hydrocephalus. Neuropediatrics 2014. link 9 Morales DM, Townsend RR, Malone JP, Ewersmann CA, Macy EM, Inder TE et al.. Alterations in protein regulators of neurodevelopment in the cerebrospinal fluid of infants with posthemorrhagic hydrocephalus of prematurity. Molecular & cellular proteomics : MCP 2012. link 10 Lipina R, Reguli S, Novácková L, Podesvová H, Brichtová E. Relation between TGF-beta 1 levels in cerebrospinal fluid and ETV outcome in premature newborns with posthemorrhagic hydrocephalus. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2010. link 11 Nakano S, Sugimoto T, Kawasoe T, Koreeda A, Kondo K, Ikeda T et al.. Staged operations for posthemorrhagic hydrocephalus in extremely low-birth-weight infants with preceding stoma creation after bowel perforation: surgical strategy. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 2007. link 12 Hudgins RJ. Posthemorrhagic hydrocephalus of infancy. Neurosurgery clinics of North America 2001. link 13 Vinchon M, Lapeyre F, Duquennoy C, Dhellemmes P. Early treatment of posthemorrhagic hydrocephalus in low-birth-weight infants with valveless ventriculoperitoneal shunts. Pediatric neurosurgery 2001. link 14 Hansen AR, Volpe JJ, Goumnerova LC, Madsen JR. Intraventricular urokinase for the treatment of posthemorrhagic hydrocephalus. Pediatric neurology 1997. link00130-6) 15 Fukumizu M, Takashima S, Becker LE. Neonatal posthemorrhagic hydrocephalus: neuropathologic and immunohistochemical studies. Pediatric neurology 1995. link00183-g) 16 Handler MH, Abbott R, Lee M. A near-fatal complication of endoscopic third ventriculostomy: case report. Neurosurgery 1994. link 17 Pierro A, Manalang LR, May PL, Cooke RW, Cudmore RE, Lloyd DA. Necrotizing enterocolitis complicating the management of posthemorrhagic hydrocephalus. Journal of pediatric surgery 1993. link90497-9) 18 Gurtner P, Bass T, Gudeman SK, Penix JO, Philput CB, Schinco FP. Surgical management of posthemorrhagic hydrocephalus in 22 low-birth-weight infants. Child's nervous system : ChNS : official journal of the International Society for Pediatric Neurosurgery 1992. link 19 Marro PJ, Dransfield DA, Mott SH, Allan WC. Posthemorrhagic hydrocephalus. Use of an intravenous-type catheter for cerebrospinal fluid drainage. American journal of diseases of children (1960) 1991. link 20 Etches PC, Ward TF, Bhui PS, Peters KL, Robertson CM. Outcome of shunted posthemorrhagic hydrocephalus in premature infants. Pediatric neurology 1987. link90078-6) 21 Anwar M, Doyle AJ, Kadam S, Hiatt IM, Hegyi T. Management of posthemorrhagic hydrocephalus in the preterm infant. Journal of pediatric surgery 1986. link80197-x) 22 Kreusser KL, Tarby TJ, Kovnar E, Taylor DA, Hill A, Volpe JJ. Serial lumbar punctures for at least temporary amelioration of neonatal posthemorrhagic hydrocephalus. Pediatrics 1985. link 23 Papile LA, Burstein J, Burstein R, Koffler H, Koops BL, Johnson JD. Posthemorrhagic hydrocephalus in low-birth-weight infants: treatment by serial lumbar punctures. The Journal of pediatrics 1980. link80494-x) 24 Chaplin ER, Goldstein GW, Myerberg DZ, Hunt JV, Tooley WH. Posthemorrhagic hydrocephalus in the preterm infant. Pediatrics 1980. link 25 Bada HS, Salmon JH, Pearson DH. Early surgical intervention in posthemorrhagic hydrocephalus. Child's brain 1979. link

Posthemorrhagic hydrocephalus