Isaacs Albert M, Shannon Chevis N, Browd Samuel R, Hauptman Jason S, Holubkov Richard, Jensen Hailey, Kulkarni Abhaya V, McDonald Patrick J, McDowell Michael M, Naftel Robert P, Nunn Nichol, Pindrik Jonathan, Pollack Ian F, Reeder Ron, Riva-Cambrin Jay, Rozzelle Curtis J, Rocque Brandon G, Strahle Jennifer M, Tamber Mandeep S, Whitehead William E, Kestle John R W, Limbrick David D, Wellons John C
1Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio.
2Section of Pediatric Neurosurgery, Division of Neurosurgery, Children's Hospital of Alabama, University of Alabama-Birmingham, Alabama.
J Neurosurg Pediatr. 2025 Jan 31;35(4):315-326. doi: 10.3171/2024.10.PEDS24257. Print 2025 Apr 1.
This study investigated neurodevelopmental outcomes in preterm neonates with posthemorrhagic hydrocephalus (PHH), focusing on the comparative effectiveness of temporary and permanent CSF diversion strategies.
This multicenter prospective observational cohort study (2012-2021) involved preterm infants diagnosed with PHH who underwent either initial permanent or temporary CSF diversion. Patients were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), at 15-30 months and, when possible, at 36-42 months of corrected age. Statistical analyses included univariable and multivariable regression models to examine the associations between BSID-III scores and various treatment and patient factors.
Among 106 patients, 15 (14%) underwent initial permanent CSF diversion, while 91 (86%) received temporary diversion. Patients who underwent permanent diversion had lower cognitive scores (58.2 ± 5.7) compared to those temporized (69.0 ± 15.9) (p = 0.01). Temporized patients who later required conversion to permanent diversion demonstrated poorer composite (66.6 ± 18.0 vs 79.9 ± 18.8, p = 0.02), expressive (4.6 ± 3.2 vs 7.0 ± 3.7, p = 0.03), and receptive (4.2 ± 3.3 vs 6.1 ± 3.0, p = 0.04) language scores compared to those weaned from temporary CSF diversion. No significant difference in outcomes was observed between patients temporized with a ventriculosubgaleal shunt versus a ventricular reservoir. Ventricle size at the time of initial CSF diversion was not associated with BSID-III scores. However, univariable analysis showed that a larger ventricle size at the time of conversion to permanent diversion was associated with lower neurodevelopmental scores across all domains. Multivariate analysis, adjusting for intraventricular hemorrhage (IVH) grade, complex chronic conditions, and postmenstrual age, revealed that larger ventricle size at the time of conversion correlated negatively with composite motor (effect size -0.47, CI -0.82 to -0.11, p = 0.01) and fine motor (-0.08, CI -0.15 to -0.01, p = 0.03) scores.
This study suggested that the choice between permanent and temporary CSF diversion as initial treatments may affect neurodevelopmental outcomes in preterm neonates with PHH, which are influenced by IVH severity and timing of intervention. The findings support early temporization and avoiding delays to optimize permanent shunting. Monitoring ventricular size closely during this phase is critical, as larger ventricular size at the time of conversion is associated with poorer outcomes. These results highlight the necessity for adapting treatment strategies on the basis of individual patient characteristics, responses, and progress in managing PHH.
本研究调查出血后脑积水（PHH）早产儿的神经发育结局，重点关注临时性和永久性脑脊液分流策略的比较效果。
这项多中心前瞻性观察队列研究（2012 - 2021年）纳入了被诊断为PHH且接受了初始永久性或临时性脑脊液分流的早产儿。使用贝利婴幼儿发展量表第三版（BSID - III）在矫正年龄15 - 30个月时对患者进行评估，如有可能，在矫正年龄36 - 42个月时也进行评估。统计分析包括单变量和多变量回归模型，以检验BSID - III评分与各种治疗及患者因素之间的关联。
106例患者中，15例（14%）接受了初始永久性脑脊液分流，而91例（86%）接受了临时性分流。接受永久性分流的患者认知得分（58.2±5.7）低于接受临时性分流的患者（69.0±15.9）（p = 0.01）。后来需要转为永久性分流的临时性分流患者在综合（66.6±18.0对79.9±18.8，p = 0.02）、表达性（4.6±3.2对7.0±3.7，p = 0.03）和接受性（4.2±3.3对6.1±3.0，p = 0.04）语言得分方面比从临时性脑脊液分流中撤分流的患者差。使用脑室 - 帽状腱膜下分流与脑室储液器进行临时性分流的患者在结局上未观察到显著差异。初始脑脊液分流时的脑室大小与BSID - III评分无关。然而，单变量分析显示，转为永久性分流时较大的脑室大小与所有领域较低的神经发育评分相关。在调整脑室内出血（IVH）分级、复杂慢性病和月经后年龄的多变量分析中，转为永久性分流时较大的脑室大小与综合运动（效应大小 - 0.47，CI - 0.82至 - 0.11，p = 0.01）和精细运动（ - 0.08，CI - 0.15至 - 0.01，p = 0.03）得分呈负相关。
本研究表明，作为初始治疗，永久性和临时性脑脊液分流的选择可能会影响PHH早产儿的神经发育结局，这受到IVH严重程度和干预时机的影响。研究结果支持早期临时性处理并避免延迟以优化永久性分流。在此阶段密切监测脑室大小至关重要，因为转为永久性分流时较大的脑室大小与较差的结局相关。这些结果突出了根据个体患者特征、反应和PHH管理进展调整治疗策略的必要性。
