Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 2: Management of posthemorrhagic hydrocephalus in premature infants

Abstract

Object: The objective of this systematic review and analysis was to answer the following question: What are the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants?

Methods: Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to PHH. Two hundred thirteen abstracts were reviewed, after which 98 full-text publications that met inclusion criteria that had been determined a priori were selected and reviewed.

Results: Following a review process and an evidentiary analysis, 68 full-text articles were accepted for the evidentiary table and 30 publications were rejected. The evidentiary table was assembled linking recommendations to strength of evidence (Classes I-III).

Conclusions: There are 7 recommendations for the management of PHH in infants. Three recommendations reached Level I strength, which represents the highest degree of clinical certainty. There were two Level II and two Level III recommendations for the management of PHH. Recommendation Concerning Surgical Temporizing Measures: I. Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of PHH. Clinical judgment is required.

Strength of recommendation: Level II, moderate degree of clinical certainty. Recommendation Concerning Surgical Temporizing Measures: II. The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs.

Strength of recommendation: Level II, moderate degree of clinical certainty. Recommendation Concerning Routine Use of Serial Lumbar Puncture: The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants.

Strength of recommendation: Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents: I. Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH.

Strength of recommendation: Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents. II. Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH.

Strength of recommendation: Level I, high clinical certainty. Recommendation Concerning Timing of Shunt Placement: There is insufficient evidence to recommend a specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Clinical judgment is required.

Strength of recommendation: Level III, unclear clinical certainty. Recommendation Concerning Endoscopic Third Ventriculostomy: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with posthemorrhagic hydrocephalus.

Strength of recommendation: Level III, unclear clinical certainty.

Keywords: AANS = American Association of Neurological Surgeons; CDC = Centers for Disease Control and Prevention; CNS = Congress of Neurological Surgeons; ELBW = extremely low birth weight; ETV = endoscopic third ventriculostomy; EVD = external ventricular drain; HUS = head ultrasound; IVH = intraventricular hemorrhage; LBW = low birth weight; LP = lumbar puncture; OFC = occipitofrontal circumference; PHH = posthemorrhagic hydrocephalus; PHVD = posthemorrhagic ventricular dilation; V/BP = ventricular/biparietal; VAD = ventricular access device; VP = ventriculoperitoneal; VSG = ventriculosubgaleal; case management; endoscopic third ventriculostomy; head circumference; hydrocephalus; in utero; infant; intraventricular hemorrhage; magnetic resonance imaging; meningitis; posthemorrhagic hydrocephalus; practice guidelines; premature infant; preterm infant; reservoir; shunt; tPA = tissue plasminogen activator; ventricular dilation; ventricular index; ventriculomegaly; ventriculoperitoneal shunt.