Posthemorrhagic ventricular dilatation in preterm infants: When best to intervene?

Abstract

Objective: To compare neurodevelopmental outcomes of preterm infants with and without intervention for posthemorrhagic ventricular dilatation (PHVD) managed with an "early approach" (EA), based on ventricular measurements exceeding normal (ventricular index [VI] <+2 SD/anterior horn width <6 mm) with initial temporizing procedures, followed, if needed, by permanent shunt placement, and a "late approach" (LA), based on signs of increased intracranial pressure with mostly immediate permanent intervention.

Methods: Observational cohort study of 127 preterm infants (gestation <30 weeks) with PHVD managed with EA (n = 78) or LA (n = 49). Ventricular size was measured on cranial ultrasound. Outcome was assessed at 18-24 months.

Results: Forty-nine of 78 (63%) EA and 24 of 49 (49%) LA infants received intervention. LA infants were slightly younger at birth, but did not differ from EA infants for other clinical measures. Initial intervention in the EA group occurred at younger age (29.4/33.1 week postmenstrual age; p < 0.001) with smaller ventricles (VI 2.4/14 mm >+2 SD; p < 0.01), and consisted predominantly of lumbar punctures or reservoir taps. Maximum VI in infants with/without intervention was similar in EA (3/1.5 mm >+2 SD; p = 0.3) but differed in the LA group (14/2.1 mm >+2 SD; p < 0.001). Shunt rate (20/92%; p < 0.001) and complications were lower in EA than LA group. Most EA infants had normal outcomes (>-1 SD), despite intervention. LA infants with intervention had poorer outcomes than those without (p < 0.003), with scores <-2 SD in 81%.

Conclusion: In preterm infants with PHVD, those with early intervention, even when eventually requiring a shunt, had outcomes indistinguishable from those without intervention, all being within the normal range. In contrast, in infants managed with LA, need for intervention predicted worse outcomes. Benefits of EA appear to outweigh potential risks.

Classification of evidence: This study provides Class III evidence that for preterm infants with PHVD, an EA to management results in better neurodevelopmental outcomes than a LA.

Figure 1. Flow diagram of eligible and included preterm infants in the EA and LA groups, and division of infants within the groups

Flow diagram of eligible (total 193), excluded (total 66), and included (total 127) infants in the EA (A) and the LA (B) groups, and subsequent division of infants within the EA and LA groups based on intervention requirement. Type of first and subsequent interventions is also shown. *A ventricular reservoir was placed after VP shunt as temporary measure in case of shunt dysfunction. EA = early approach; LA = late approach; LP = lumbar puncture; VP = ventriculoperitoneal.

Figure 2. Median maximum ventricular measurements for infants without and with intervention in EA and LA groups

Maximum ventricular measurements, including VI in millimeters above the +2 SD line adjusted for postmenstrual age on the y-axis in panel A and AHW in millimeters above the 6 mm line on the y-axis in panel B, for the infants without and with intervention in the EA and the LA groups depicted on the x-axis. Similar graphs were obtained for median maximum VI and AHW measurements for the right lateral ventricles. AHW = anterior horn width; VI = ventricular index.

Figure 3. Median outcome scores for survivors without and with intervention in EA and LA groups

Median cognitive outcome scores on the y-axis in panel A and median motor outcome scores on the y-axis in panel B for the infants who survived up to 24 months’ corrected age without and with intervention in the EA and LA groups depicted on the x-axis. Comparison between infants without and with intervention within both groups is also shown. EA = early approach; LA = late approach.