Whitelaw A
Division of Child Health, University of Bristol, Division of Child Health, University of Bristol Medical School, Southmead Hospital, Bristol, UK, BS9 1PJ.
Cochrane Database Syst Rev. 2001(1):CD000216. doi: 10.1002/14651858.CD000216.
Although it has been possible to reduce the percentage of premature infants suffering intraventricular hemorrhage, posthemorrhagic hydrocephalus remains a serious problem without a good treatment. There is a high rate of cerebral palsy, and ventriculoperitoneal shunt surgery makes the child permanently dependent on the valve and catheter system. Shunt surgery cannot be carried out early because of the blood in the cerebrospinal fluid (CSF) and the brain may be subjected to periods of raised pressure. Early tapping of CSF by lumbar puncture or ventricular tap was suggested as a way of temporarily reducing pressure and removing blood and protein and thereby avoiding permanent hydrocephalus.
To determine whether repeated CSF tapping, by lumbar puncture or ventricular tap, reduced 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 treatment was based on the hypothesis that repeated tapping removed protein and blood from the CSF, thus clearing obstruction from the channels of CSF absorption.
Pediatric, Neurosurgical and General Medical Journals were handsearched from 1976 up to October 2000, as well as the Medline database (via PubMed) and the Cochrane Controlled Trials Register. Personal contacts were used.
Four controlled trials ( with five published papers) were identified, three being randomised and the fourth using alternative allocation. Two trials evaluated repeated lumbar punctures in neonates with intraventricular hemorrhage (IVH) and two trials evaluated repeated CSF tapping infants with IVH followed by progressive ventricular dilatation.
In addition to details of the patient selection and patient allocation, the interventions were extracted. The end-points examined were: ventriculoperitoneal shunt, death, disability, multiple disability and death or disability.
The studies were sufficiently similar in the question they were asking and the interventions were sufficiently in common that they could be combined when assessing the effect of the intervention. When repeated CSF tapping was compared to conservative treatment, the relative risks for shunt placement, death, disability and multiple disability were very close to 1.0 with no statistically significant effect. There is also evidence that this form of treatment increased the risk of CSF infection.
REVIEWER'S CONCLUSIONS: Early repeated CSF tapping cannot be recommended for neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus.
尽管已经能够降低早产儿发生脑室内出血的百分比，但出血后脑积水仍然是一个严重问题，且尚无良好的治疗方法。脑瘫发生率很高，脑室腹腔分流手术会使患儿永久依赖瓣膜和导管系统。由于脑脊液（CSF）中有血液，分流手术不能早期进行，大脑可能会经历一段时间的压力升高。有人建议通过腰椎穿刺或脑室穿刺早期抽取脑脊液，作为暂时降低压力、清除血液和蛋白质从而避免永久性脑积水的一种方法。
确定通过腰椎穿刺或脑室穿刺反复抽取脑脊液是否能降低有出血后脑积水（PHH）风险或实际已发生PHH的新生儿永久依赖分流、神经发育残疾或死亡的风险。这种治疗形式基于这样的假设，即反复穿刺可从脑脊液中清除蛋白质和血液，从而清除脑脊液吸收通道的梗阻。
手工检索了1976年至2000年10月的儿科、神经外科和普通医学期刊，以及Medline数据库（通过PubMed）和Cochrane对照试验注册库。还进行了个人联系。
确定了四项对照试验（有五篇发表的论文），三项为随机试验。第四项使用交替分配法。两项试验评估了脑室内出血（IVH）新生儿反复腰椎穿刺，两项试验评估了IVH且随后出现进行性脑室扩张的婴儿反复抽取脑脊液。
除了患者选择和患者分配的详细信息外，还提取了干预措施。所检查的终点包括：脑室腹腔分流、死亡、残疾、多重残疾以及死亡或残疾。
这些研究在研究问题上足够相似，干预措施也足够相同，以至于在评估干预效果时可以合并。将反复抽取脑脊液与保守治疗进行比较时，分流置管、死亡、残疾和多重残疾的相对风险非常接近1.0，无统计学显著效果。也有证据表明这种治疗形式增加了脑脊液感染的风险。
对于有出血后脑积水风险或实际已发生出血后脑积水的新生儿，不建议早期反复抽取脑脊液。
