Table 2:
Comparisons between the criteria, interventions, numbers and outcomes reported in major studies of management of PHVD
| Study | Ventriculomegaly trial Group- Early 1 | Ventriculomegaly trial Group- Late1 | Acetazolamide Trial (Standard Arm)2 | DRIFT – Cases3 | DRIFT-Control3 | HCRN 4 | ELVIS Early5 | ELVIS-Late5 | Two Dutch Units6 | North America6 |
|---|---|---|---|---|---|---|---|---|---|---|
| Criteria | VI > 97th percentile + 4 mm | VI > 97th percentile + 4 mm | (a) VI 4 mm over the 97th centile OR (b) all of the following: - AHW > 4 mm - TOD > 26 mm - third ventricle width > 3 mm OR (c) Measurements above a or b on 1 side combined with obvious midline shift indicating a pressure effect. |
FOHR >0.55 + 2 of 3 of: - Bradycardia - Split suture - Bulging Fontanel |
VI > 97th percentile +AHW >6 mm and/or the TOD >25 mm | VI > 97th percentile + 4mm +AHW >10 mm | Based on ventricular measurements VI exceeding the 97th centile and increasing towards the p97+4mm line and an AHW >6mm | Based on signs of increased intracranial pressure | ||
| Intervention | Immediate CSF Drainage • LP for max 2% of body weight • Repeat as many as possible if increase VI > 2mm above measurement before first tap • If LP < 2 ml then shift for Ventricular tap • Shunt if tapping continued for 4 weeks and head enlargement continues and other factors |
Only CSF Drainage if: • Increase in head circumference of twice the normal velocity for gestational age after entry to the trial Or • Symptomatic raised intracranial pressure with a measured cerebrospinal fluid pressure greater than 12 mm Hg) |
The study advised for removal of CSF to be delayed until either head growth exceeded twice the normal rate for 2 weeks or the infant showed clinical symptoms or signs of raised intracranial pressure |
DRIFT Drainage Irrigation and Fibrinolytic Therapy (DRIFT) till fluid clears (usually 72 h) |
Standard Intervention only if 1- Signs of raised ICP (irritability, apnea, reduced consciousness, bulging fontanelle, or loss of diastolic velocities on cerebral arteries) or excessive Or 2- head enlargement over time (> 2 mm/d) Intervention: LP x 2 or failed LP then reservoir |
• Temporize till 1800–2000 gm | • LPs (max 3), and followed by insertion and taps from a VR, aiming for VI<p97 over the next 7–10 days. • Ten mL/kg were removed one or two taps a day, the volume adjusted according to cUS. • When taps from a VR were still needed 28days after insertion to keep the VI well below the p97+4 mm, one or two ‘challenges’ were performed with discontinuation of taps. Reservoir taps were resumed in case of expanding ventricles, clinical symptoms and/or excessive head growth. |
LPs or reservoir followed by VP shunt in the absence of stabilization | LP, reservoir or VP shunt (mostly immediate VP shunt placement) | |
| Number | 79 | 78 | 89 | 39 | 38 | 102 Temporize | 64 | 62 | 78 (48 received intervention) | 49 (24 received intervention) |
| Parenchyma l Lesions | 46 (58%) | 55 (71%) | 40 (45%) | 20 (51%) | 18 (47%) | 54 (53%) | 24 (38%) | 19 (30.6%) | ||
| VP shunt | 41 (52%) | 42 (54%) | 40 (45%) | 16 (41%) | 15 (39%) | 66 (65%) | 12 (19%) | 14 (23%) | 10 (13%) | 22 (45%) |
| Death | 14 (18%) | 18 (23%) | 10 (11%) | 3 (8%) | 5 (13%) | 13 (13%) | 8 (12.5%) | 9 (15%) | 11 (14%) | 20 (41%) |
| Numbers at FU | 59 | 53 | 79 | 39 | 38 | 50 | 45 | 62 | 27 | |
| FU age (CA) | 30 m | 30 m | 12 m | 24m | 24m | 24 m | 24 m | 18–24 m | 18–24 m | |
| Impairment |
Overall Griffiths Scale < 70 29/59 (49%) |
Overall Griffiths Scale < 70 25/53 (47%) |
Impaired or Disabled 52/79 (66%) |
Severe Disability 18/39 (46%) |
Severe Disability 22/38 (58%) | ? |
Combined Cognitive and Motor Scores < 70= 6 (12%) |
Combined Cognitive and Motor Scores < 70 11 (24%) |
Combined Cognitive and Motor Scores < 70= 3 (4.8%) | Combined Cognitive and Motor Scores < 70= 14 (52%) |
Group VT. Randomised trial of early tapping in neonatal posthaemorrhagic ventricular dilatation: results at 30 months. Ventriculomegaly Trial Group. Arch Dis Child Fetal Neonatal Ed. 1994;70:F129–36.
Kennedy CR, Ayers S, Campbell MJ, Elbourne D, Hope P, Johnson A. Randomized, controlled trial of acetazolamide and furosemide in posthemorrhagic ventricular dilation in infancy: follow-up at 1 year. Pediatrics. 2001;108:597–607.
Whitelaw A, Jary S, Kmita G, Wroblewska J, Musialik-Swietlinska E, Mandera M, et al. Randomized trial of drainage, irrigation and fibrinolytic therapy for premature infants with posthemorrhagic ventricular dilatation: developmental outcome at 2 years. Pediatrics. 2010;125:e852–8.
Wellons JC, 3rd, Shannon CN, Holubkov R, Riva-Cambrin J, Kulkarni AV, Limbrick DD, Jr., et al. Shunting outcomes in posthemorrhagic hydrocephalus: results of a Hydrocephalus Clinical Research Network prospective cohort study. Journal of neurosurgery Pediatrics. 2017;20:19–29.
Cizmeci MN, Groenendaal F, Liem KD, van Haastert IC, Benavente-Fernandez I, van Straaten HLM, et al. Randomized Controlled Early versus Late Ventricular Intervention Study (ELVIS) in Posthemorrhagic Ventricular Dilatation: Outcome at 2 Years. Submitted. 2020.
Leijser LM, Miller SP, van Wezel-Meijler G, Brouwer AJ, Traubici J, van Haastert IC, et al. Posthemorrhagic ventricular dilatation in preterm infants: When best to intervene? Neurology. 2018;90:e698-e706.