Intraventricular streptokinase after intraventricular hemorrhage in newborn infants

Abstract

Background: Hydrocephalus following intraventricular hemorrhage (IVH) is still one of the most serious complications of premature birth. Ventriculoperitoneal shunt surgery cannot be carried out early and permanent dependence on a shunt is associated with several serious complications.

Objectives: To determine whether intraventricular streptokinase after intraventricular hemorrhage reduces the risk of permanent shunt dependence, neurodevelopmental disability or death in neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus (PHH). This form of therapy is based on the hypothesis that multiple blood clots in the CSF are the initial cause of post-hemorrhagic ventricular dilatation and lysis of clots could reopen the pathways of circulation and re-absorption of CSF.

Search strategy: Pediatric, Neurosurgical and General Medical Journals were handsearched from 1976, as well as the Medline database. Personal contacts were used.

Selection criteria: One randomised trial evaluated intraventricular streptokinase in infants developing post-hemorrhagic ventricular dilatation.

Data collection and analysis: Details of patient selection, patient allocation and the interventions were extracted. The end-points examined were: ventriculoperitoneal shunt, death, meningitis, and secondary hemorrhage.

Main results: When intraventricular streptokinse was compared with conservative management of post-hemorrhagic ventricular dilatation, the numbers of deaths and babies with shunt dependence were identical in both groups. No information on the effect of intraventricular streptokinase on disability is available. There is cause for concern about meningitis and secondary intraventricular hemorrhage but numbers are insufficient to quantify the risks.

Reviewer's conclusions: Intraventricular fibrinolytic therapy with streptokinase, given when post-hemorrhagic ventricular dilatation is established, cannot be recommended for neonates following IVH. A conservative approach with CSF drainage applied only to symptomatic raised intracranial pressure seems appropriate.