Pediatric Neurosurgery, Fondazione Policlinico Universitario A. Gemelli IRCCS, Largo Agostino Gemelli, 8, 00168, Rome, Italy.
Neonatal Intensive Care Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
Childs Nerv Syst. 2021 Nov;37(11):3531-3540. doi: 10.1007/s00381-021-05216-6. Epub 2021 May 20.
The optimal management of neonatal post-hemorrhagic hydrocephalus (PHH) is still debated, though several treatment options have been proposed. In the last years, ventriculosubgaleal shunt (VSgS) and neuroendosdcopic lavage (NEL) have been proposed to overcome the drawbacks of more traditional options, such as external ventricular drainage and ventricular access device.
We retrospectively reviewed neonates affected by PHH treated at our institution since September 2012 to September 2020. Until 2017 patients received VSgS as initial treatment. After the introduction of NEL, this treatment option was offered to patients with large intraventricular clots. After NEL, VSgS was always placed. Primary VSgS was reserved to patients without significant intraventricular clots and critically ill patients that could not be transferred to the operating room and undergo a longer surgery.
We collected 63 babies (38 males and 25 females) with mean gestational age of 27.8 ± 3.8SD weeks (range 23-38.5 weeks) and mean birthweight of 1199.7 ± 690.6 SD grams (range 500-3320 g). In 6 patients, hemorrhage occurred in the third trimester of gestation, while in the remaining cases hemorrhage complicated prematurity. This group included 37 inborn and 26 outborn babies. Intraventricular hemorrhage was classified as low grade (I-II according to modified Papile grading scale) in 7 cases, while in the remaining cases the grade of hemorrhage was III to IV. Mean age at first neurosurgical procedure was 32.2 ± 3.6SD weeks (range 25.4-40 weeks). Death due to prematurity occurred in 5 patients. First-line treatment was VSgS in 49 patients and NEL in the remaining 14 cases. Mean longevity of VSgS was 30.3 days (range 10-97 days) in patients finally requiring an additional treatment of hydrocephalus. Thirty-two patients required one to three redo VSgS. Interval from initial treatment to permanent shunt ranged from 14 to 312 days (mean 70.9 days). CSF infection was observed in 5 patients (7.9%). Shunt dependency was observed in 51 out of 58 surviving patients, while 7 cases remained shunt-free at the last follow-up. Multiloculated hydrocephalus was observed in 14 cases. Among these, only one patient initially received NEL and was complicated by isolated trapped temporal horn.
VSgS and NEL are two effective treatment options in the management of PHH. Both procedures should be part of the neurosurgical armamentarium to deal with PHH, since they offer specific advantages in selected patients. A treatment algorithm combining these two options may reduce the infectious risk and the risk of multiloculated hydrocephalus.
尽管已经提出了几种治疗选择，但新生儿出血后脑积水（PHH）的最佳治疗方法仍存在争议。在过去的几年中，脑室-皮下分流术（VSgS）和神经内镜灌洗术（NEL）已被提出，以克服更传统的治疗方法（如外引流和脑室引流装置）的缺点。
我们回顾性分析了 2012 年 9 月至 2020 年 9 月在我院治疗的 PHH 新生儿。直到 2017 年，患者均接受 VSgS 作为初始治疗。引入 NEL 后，将该治疗方案用于治疗大体积脑室内积血的患者。NEL 后，通常会放置 VSgS。对于没有明显脑室内积血且病情严重无法转至手术室并接受较长手术的患者，保留原发性 VSgS。
我们共收集了 63 名婴儿（38 名男性和 25 名女性），平均胎龄为 27.8 ± 3.8SD 周（范围 23-38.5 周），平均出生体重为 1199.7 ± 690.6 SD 克（范围 500-3320g）。在 6 名患者中，出血发生在妊娠晚期，而其余患者的出血合并早产。该组包括 37 名宫内婴儿和 26 名宫外婴儿。脑室内出血根据改良 Papile 分级标准分为低级别（I-II 级）7 例，其余为 III-IV 级。首次神经外科手术的平均年龄为 32.2 ± 3.6SD 周（范围 25.4-40 周）。5 名患者因早产死亡。49 名患者一线治疗为 VSgS，其余 14 名患者为 NEL。最终需要额外治疗脑积水的患者中，VSgS 的平均存活时间为 30.3 天（范围 10-97 天）。32 名患者需要进行 1-3 次重复 VSgS。从初始治疗到永久性分流的时间间隔为 14 至 312 天（平均 70.9 天）。5 名患者（7.9%）出现 CSF 感染。58 名存活患者中有 51 名存在分流依赖性，而最后一次随访时有 7 名患者无需分流。14 例患者出现多发性脑积水。其中，仅 1 名患者最初接受了 NEL 治疗，并伴有孤立性被困颞角。
VSgS 和 NEL 是治疗 PHH 的两种有效治疗选择。这两种方法都应该是神经外科治疗手段的一部分，以应对 PHH，因为它们在特定患者中提供了特定的优势。结合这两种方法的治疗算法可能会降低感染风险和多发性脑积水的风险。
