Randomized clinical trial of prevention of hydrocephalus after intraventricular hemorrhage in preterm infants: brain-washing versus tapping fluid.
OBJECTIVE
Hydrocephalus is a serious complication of intraventricular hemorrhage in preterm infants, with adverse consequences from permanent ventriculoperitoneal shunt dependence. The development of hydrocephalus takes several weeks, but no clinical intervention has been shown to reduce shunt surgery in such infants. The aim of this study was to test a new treatment intended to prevent hydrocephalus and shunt dependence after intraventricular hemorrhage.


METHODS
We randomly assigned 70 preterm infants who had gestational ages of 24 to 34 weeks and were progressively enlarging their cerebral ventricles after intraventricular hemorrhage to either (1) drainage, irrigation, and fibrinolytic therapy to wash out blood and cytokines or (2) tapping of cerebrospinal fluid by reservoir as required to control excessive expansion and signs of pressure (standard treatment). We evaluated outcomes at 6 months of age or hospital discharge (if later).


RESULTS
Of 34 infants who were assigned to drainage, irrigation, and fibrinolytic therapy, 2 died and 13 underwent shunt surgery (dead or shunt: 44%). Of 36 infants who were assigned to standard therapy, 5 died and 14 underwent shunt surgery (dead or shunt: 50%). This difference was not significant. Twelve (35%) of 34 infants who received drainage, irrigation, and fibrinolytic therapy had secondary intraventricular hemorrhage compared with 3 (8%) of 36 in the standard group. Secondary intraventricular hemorrhage was associated with an increased risk for subsequent shunt surgery and more blood transfusions.


CONCLUSIONS
Despite its logical basis and encouraging pilot data, drainage, irrigation, and fibrinolytic therapy did not reduce shunt surgery or death when tested in a multicenter, randomized trial. Secondary intraventricular hemorrhage is a major factor that counteracts any possible therapeutic effect from washing out old blood.
Whitelaw
Andrew
A
Department of Clinical Science at North Bristol, University of Bristol, Bristol, United Kingdom. andrew.whitelaw@bristol.ac.uk
Evans
David
D
Carter
Michael
M
Thoresen
Marianne
M
Wroblewska
Jolanta
J
Mandera
Marek
M
Swietlinski
Janusz
J
Simpson
Judith
J
Hajivassiliou
Constantinos
C
Hunt
Linda P
LP
Pople
Ian
I
D002552:Cerebral Ventricles / Q000000981:diagnostic imaging*; D004322:Drainage / Q000295:instrumentation / Q000379:methods*; D005260:Female; D006801:Humans; D006849:Hydrocephalus / Q000000981:diagnostic imaging* / Q000209:etiology / Q000517:prevention & control*; D007231:Infant, Newborn; D007234:Infant, Premature; D020300:Intracranial Hemorrhages / Q000150:complications / Q000000981:diagnostic imaging* / Q000628:therapy; D008297:Male; D013129:Spinal Puncture; D007507:Therapeutic Irrigation / Q000295:instrumentation / Q000379:methods; D015912:Thrombolytic Therapy / Q000379:methods; D014463:Ultrasonography; D014696:Ventriculostomy / Q000295:instrumentation / Q000379:methods