Intraventricular haemorrhage and posthaemorrhagic ventricular dilatation: moving beyond CSF diversion

Abstract

Advances in medical care have led to more premature babies surviving the neonatal period. In these babies, germinal matrix haemorrhage (GMH), intraventricular haemorrhage (IVH) and posthaemorrhagic ventricular dilatation (PHVD) are the most important determinants of long-term cognitive and developmental outcomes. In this review, we discuss current neurosurgical management of IVH and PHVD, including the importance of early diagnosis of PHVD, thresholds for intervention, options for early management through the use of temporising measures and subsequent definitive CSF diversion. We also discuss treatment options for the evolving paradigm to manage intraventricular blood and its breakdown products. We review the evidence for techniques such as drainage, irrigation, fibrinolytic therapy (DRIFT) and neuroendoscopic lavage in the context of optimising cognitive, neurodevelopmental and quality of life outcomes in these premature infants.

A Standardised Protocol for Neuro-endoscopic Lavage for Post-haemorrhagic Ventricular Dilatation: A Delphi Consensus Approach

“…Advantages have been described which favour NEL, for example, allowing direct visualisation of the progress of haematoma removal and therefore enabling targeted irrigation and clot removal under direct vision[1]. Another advantage is that this procedure is often delivered during the time of insertion of a temporising device within the same operative session, avoiding additional risks associated with repeated procedures and sessions under general anaesthetic [19]. With neuro-endoscopic lavage emerging as a feasible and safe technique, technical variation between operating paediatric neurosurgeons exists [1–8, 19, 20].…”

“…Another advantage is that this procedure is often delivered during the time of insertion of a temporising device within the same operative session, avoiding additional risks associated with repeated procedures and sessions under general anaesthetic [19]. With neuro-endoscopic lavage emerging as a feasible and safe technique, technical variation between operating paediatric neurosurgeons exists [1–8, 19, 20]. Whilst this made the consensus process challenging, the discussion and multiple iterations that arose from the staged consensus process during this study were valuable and relevant.…”

“…Whilst the principles of ventricular lavage in PHVD have remained consistent over time, there has been variation in the techniques proposed to deliver ventricular lavage [2,[18][19][20]. Advantages have been described which favour NEL, for example, allowing direct visualisation of the progress of haematoma removal and therefore enabling targeted irrigation and clot removal under direct vision [1].…”

Mechanisms of neuroinflammation in hydrocephalus after intraventricular hemorrhage: a review

“…In adults with IVH, the data are more mixed with some studies showing a reduced need for shunting after administration of intraventricular fibrinolytics after IVH [17][18][19][20]. In the case of GMH-IVH, prevention is crucial, a complete discussion of which is outside the scope of this review [21,22].…”

Secondary Brain Injury Following Neonatal Intraventricular Hemorrhage: The Role of the Ciliated Ependyma

“…Building on the findings of the DRIFT trial, neuroendoscopic clot lavage at the time of temporizing intervention (e.g., ventricular subgaleal shunt or ventricular access device) has been proposed ( 58 ) ( Figure 1 ). This approach reduces the risk associated with 72 h of irrigation to a single operative procedure and removes the need for prolonged drainage on the neonatal intensive care unit, also the mechanical effect of direct endoscopic lavage obviates the need for a fibrinolytic drug, which, in the DRIFT study was associated with a significant rebleeding rate.…”