早产儿出血后脑室扩张：何时最佳干预？
Posthemorrhagic ventricular dilatation in preterm infants: When best to intervene?
机构信息
From the Divisions of Neonatology (L.M.L., H.E.W., L.G.L.), Neurology (L.M.L., S.P.M.), and Neurosurgery (A.V.K.), Department of Pediatrics, The Hospital for Sick Children and The University of Toronto, Canada; Department of Neonatology (G.v.W.-M., H.L.M.v.S.), Isala Women-Children's Hospital, Zwolle, the Netherlands; Department of Neonatology (A.J.B., I.C.v.H., F.G., L.S.d.V.), Wilhelmina Children's Hospital, University Medical Center Utrecht, the Netherlands; University of Applied Sciences (A.J.B.), Utrecht, the Netherlands; Department of Radiology (J.T.), The Hospital for Sick Children and The University of Toronto, Canada; Department of Neurology and Neurosurgery (K.S.H., P.A.W.), University Medical Center Utrecht, the Netherlands; Department of Newborn and Developmental Pediatrics (P.T.C.), Sunnybrook Health Sciences Centre and The University of Toronto; and Division of Neonatology (E.N.K.), Department of Pediatrics, Mount Sinai Hospital and The University of Toronto, Canada.
出版信息
Neurology. 2018 Feb 20;90(8):e698-e706. doi: 10.1212/WNL.0000000000004984. Epub 2018 Jan 24.
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; < 0.001) with smaller ventricles (VI 2.4/14 mm >+2 SD; < 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; = 0.3) but differed in the LA group (14/2.1 mm >+2 SD; < 0.001). Shunt rate (20/92%; < 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 ( < 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.
目的
比较采用“早期治疗法”（EA）和“晚期治疗法”（LA）治疗出血后脑室扩张（PHVD）的早产儿神经发育结局，前者根据脑室测量值（脑室指数[VI]＞+2 标准差/前角宽度＜6 毫米）和初始临时程序对超过正常范围的患者进行干预，必要时进行永久性分流，后者根据颅内压升高的迹象对患者进行干预，且大多数患者立即进行永久性干预。
方法
对 127 例接受 EA（n=78）或 LA（n=49）治疗的 PHVD 早产儿（胎龄＜30 周）进行了观察性队列研究。使用头颅超声测量脑室大小。在 18-24 个月时评估结局。
结果
EA 组 49 例（63%）和 LA 组 24 例（49%）婴儿接受了干预。LA 组婴儿出生时略小，但在其他临床指标上与 EA 组婴儿无差异。EA 组婴儿的初始干预年龄更小（29.4/33.1 周龄；＜0.001），脑室更小（VI 2.4/14 毫米＞+2 标准差；＜0.01），且主要采用腰椎穿刺或储液池穿刺。EA 组有/无干预的最大 VI 相似（3/1.5 毫米＞+2 标准差；=0.3），但 LA 组不同（14/2.1 毫米＞+2 标准差；＜0.001）。EA 组的分流率（20/92%；＜0.001）和并发症低于 LA 组。尽管进行了干预，大多数 EA 组婴儿的结局仍正常（＞-1 SD）。LA 组接受干预的婴儿的结局比未接受干预的婴儿差（＜0.003），81%的婴儿评分＜-2 SD。
结论
在患有 PHVD 的早产儿中，早期干预（即使最终需要分流）的婴儿的结局与未接受干预的婴儿无差异，均处于正常范围内。相比之下，在接受 LA 治疗的婴儿中，干预的需求预测了更差的结局。EA 的益处似乎超过了潜在风险。
证据分类
本研究提供了 III 级证据，表明对于患有 PHVD 的早产儿，与 LA 相比，采用 EA 进行治疗可获得更好的神经发育结局。
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