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.

Keywords: Germinal matrix haemorrhage; Intraventricular haemorrhage; Neuroendoscopic lavage; Posthaemorrhagic ventricular dilatation; Premature; Temporising device.

Fig. 1

a CrUS representations of the different IVH grades. b Example measurement of the VI on CrUS

Fig. 2

The different temporising measures with accompanying advantages and disadvantages. This image illustrates the relative advantages of the VSG in comparison to other measures, having fully internalised hardware with low infection risk with pseudo-continuous drainage that can be managed remotely outside the neuroscience centre

Fig. 3

Example MRIs at term-equivalent age with VSG in situ. a Ongoing ventricular dilatation. A subsequent VP shunt was inserted to manage this. b Well-controlled ventricles. In combination with clinical assessment, VP shunt insertion was deemed not necessary in this infant and, a few weeks later, the VSG was removed

Fig. 4

Typical views during the a beginning, b middle and c end of a neuroendoscopic lavage procedure. Whilst the CSF is bloodstained and views are very difficult to obtain at the beginning of the procedure, as the procedure progresses, the CSF becomes clearer, affording better views of the ventricular walls and anatomy. Towards the end, the foramina of Monro are visualised and a septostomy is attempted to ensure CSF flow (not shown)