gms | German Medical Science

Objective: There is an on-going debate about the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants. Recent studies show a reduction of shunt dependency after endoscopic lavage and clot removal. To determine the role of endoscopic lavage, clot removal combined with septostomy, followed by temporizing methods (ventricular reservoir, subgaleal shunting) in order to provide a lower shunt complication rate or even to reduce shunt dependency. We demonstrate our single center experience.

Methods: We performed 17 endoscopic lavages in 11 preterm infants (gestational week: 23-36 (mean 27), birth weight: 595-2400 g (mean 971)) and 1 term neonate (41 wks, 3155 g) suffering from intraventricular hemorrhages (grade II-III+). Initial surgery was done 13-118 (mean 38) days after birth. Warmed Ringer solution (750-3000ml) was used. Furthermore, interventions included partial or nearly total clot removal, septostomy (n=6, incl. stent=3) followed by ventricular reservoir (all) and subgaleal shunting (n=5), followed by intermittent punctures (if necessary). The indications for operation were progressive ventricular enlargement, enlarging head circumference combined with symptoms of intracranial hypertension.

Results: Endoscopic procedures could be safely performed (LOTTA-Ventriculoscopic System, Storz, Tuttlingen). No direct secondary hemorrhage or endoscopy related morbidity/mortality occurred. One second hemorrhage of the other side occurred after 4 days. One premature infant died due to pulmonary insufficiency. Permanent shunting (incl. stent to fourth ventricle (n=1)) was performed after 14 -112 (mean 57) days after first operation. No avoidance of shunting was possible in this small cohort. Afterward, shunt revision was needed in only one patient due to a suspected shunt obstruction during the follow-up period of 15-76 (mean 55) months. One intraventricular cyst occurred and could be endoscopically fenestrated. No CSF infection occurred.

Conclusion: Neuroendoscopic interventions are safe treatment options for PHH in premature infants, and might reduce later shunt complications. Earlier referral/intervention and more complete clot removal may even reduce shunt dependency. Further prospective evaluations with larger cohorts and longer follow-up are needed in view of the most important point: functional outcome.