sAlexander Zouros - LLUCH · 2017-09-12 · Sequelae of IVH -Prevention of secondary neurological injuries: -seizures ... Medications - Acetazolamide and Furosemide Drain CSF - Lumbar

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

THE PLASTIC SURGEONS OF LOMA LINDA UNIVERSITY

Pediatric Neurosurgery in the NICU

-Neonatal IVH

-Congenital

hydrocephalus

-Spina bifida

-Craniosynostosis

Loma Linda University Department of Neurosurgery


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



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



Risk factors slide



IVH Grading Scales – Papille vs. Volpe




Grade 1 IVH (bilateral) – confined to germinal matrix




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



Grade IV - Periventricular Hemorrhagic Infarct



Prevention of IVH

Effective:

-Antenatal corticosteroids

-C-section

ANY measure that

prevents antenatal

distress

Ineffective, Unproven:

-nitrous oxide

-phenobarbital

-post-natal steroids



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



Sequelae of IVH

-Prevention of secondary neurological injuries:

-seizures

-cerebral perfusion/oxygenation

-normalize glucose and Na

Peri-Ventricular Leukomalacia (PVL)

Post-Hemorrhagic Hydrocephalus





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



Ventriculomegaly



Post-IVH Hydrocephalus



Signs of Hydrocephalus

Increasing head

circumference (>1.5 cm

per week)

Bulging fontanelle

Splayed Sutures

Upgaze paresis or

“Parinaud’s”, “Sunsetting”

Apneas

Bradycardias



Natural History of Hydrocephalus

Pre-Shunt era:

20% survival with significant

disabilities

VP Shunt era:

>90 - 97% survival

depending on etiology





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)



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



Temporizing CSF diversion procedures

External Ventriculostomy Drain

Implants

– Ventricular access Device

- Ventriculo-subgaleal shunt

Risk of implant or drain infection



Timing of VP Shunt

Weight >1200-1500 grams

No active infections (sepsis, NEC, pneumonia,

meningitis)

Improvement of CSF viscosity, blood breakdown

products and protein



Ventricular Shunts

Ventricular catheter- occipital vs. frontal

Want catheter surrounded by CSF

Valve-regulates flow

Distal catheter

Peritoneal

Atrial

Pleural

Gall bladder



A Typical VP Shunt



A Typical VP Shunt



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%



Shunt Problems - Malfunction

- Occlusion (usually debris, blood or choroid plexus)



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


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



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



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)



Documents

sAlexander Zouros - LLUCH · 2017-09-12 · Sequelae of IVH -Prevention of secondary neurological injuries: -seizures ... Medications - Acetazolamide and Furosemide Drain CSF - Lumbar