Neuroendoscopic lavage for the management of posthemorrhagic hydrocephalus in preterm infants: safety, effectivity, and lessons learned

Abstract

<jats:sec><jats:title>OBJECTIVE</jats:title><jats:p>Treatment of posthemorrhagic hydrocephalus in preterm infants is a matter of debate among pediatric neurosurgeons. Neuroendoscopic lavage (NEL) has been proposed as a suitable technique for the management of this pathology. The authors present their experience with 46 patients treated with NEL after germinal matrix hemorrhage, describe their technique, and analyze the outcomes.</jats:p></jats:sec><jats:sec><jats:title>METHODS</jats:title><jats:p>A retrospective analysis of patients affected by grade III or IV intraventricular hemorrhage (IVH) treated with NEL was performed. Nonmodifiable risk factors such as gestational age, weight at birth, modified Papile grade, and intercurrent diseases were reviewed. Safety analysis was performed, evaluating the incidence of postoperative complications. Effectivity was measured using radiological (frontal horn index and white matter injury), CSF biochemical (proteins, blood, and cellularity), and clinical variables. Permanent shunt rate and shunt survival were analyzed. The motor outcome was measured using the Gross Motor Function Classification System (GMFCS) at 18–24 months, and the neurocognitive outcome was evaluated according to the grade of adaptation to schooling.</jats:p></jats:sec><jats:sec><jats:title>RESULTS</jats:title><jats:p>Forty-six patients met the inclusion criteria. Patients were treated with a single NEL in 21 cases, 2 lavages in 13 cases, and 3 lavages in 12 cases. The mean gestational age at birth was 30.04 weeks, and the mean weight at birth was 1671.86 g. Hyaline membrane disease was described in 4.8% of the cases, hematological sepsis in 43.47%, persistent ductus arteriosus in 23.9%, and necrotizing enterocolitis in 10.9% of the cases. Modified Papile grade III and IV IVHs were observed in 60.9% and 39.1% of the cases, respectively. Postoperative infection was diagnosed in 10 of the 46 cases, CSF leak in 6, and rebleeding in 3. The mean frontal horn index decreased from 49.54 mm to 45.50 mm after NEL. No white matter injury was observed in 18 of 46 patients, focal injury was described in 13 patients, and diffuse bilateral white matter injury was observed in 15 patients. All CSF biochemical levels improved after lavage. The shunt rate was 58.7%, and shunt survival at 1 year was 50%. GMFCS grades I, II, III, IV, and V were observed in 44.74%, 21.05%, 2.63%, 15.79%, and 15.79% of patients, respectively. Good neurocognitive results were observed in 53.3% of the cases.</jats:p></jats:sec><jats:sec><jats:title>CONCLUSIONS</jats:title><jats:p>Neuroendoscopic lavage was a suitable alternative for the management of IVH in preterm infants in our series. Good motor and neurocognitive results were achieved by this technique, and the permanent shunt rate was reduced compared with historical controls.</jats:p></jats:sec>

Intraventricular haemorrhage and posthaemorrhagic ventricular dilatation: moving beyond CSF diversion

“…4), which involves the use of an endoscope to gently irrigate the ventricular CSF, clearing the ventricles of any large clots and restoring CSF flow via a septostomy and ensuring patency of the foramina of Monro. To date, there is no class I evidence of its efficacy but retrospective evaluations have had encouraging results with the procedure showing safety, reductions in VP shunt insertion and revision rates and favourable neurodevelopmental outcome [45][46][47][48][49]. There have been no prospective comparative trials.…”

Ventriculosubgaleal shunt and neuroendoscopic lavage: refining the treatment algorithm of neonatal post-hemorrhagic hydrocephalus

“…In this context, ventriculo subgaleal shunt (VSgS) has emerged in the last years as a solution reducing the infectious risk and allowing to control hydrocephalus until the patient reaches an adequate body weight and the CSF clarifies [5]. More recently, neuroendoscopic lavage (NEL) has been adopted as an alternative treatment option warranting a significantly reduced risk of shunt dependency and multiloculated hydrocephalus [6][7][8][9], with good neurodevelopmental outcome [10].…”

Technical Nuances in Neuroendoscopic Lavage for Germinal Matrix Hemorrhage in Preterm Infants: Twenty Tips and Pearls after More than One Hundred Procedures

“…We recently published our experience with this technique in a 46-patient series, showing good results in both motor and cognitive outcome analysis and reducing the need for permanent ventriculoperitoneal shunts [7].…”