simple ppt on phvd in newborn......practically useful one for neomatologists

1. Post hemorrhagic ventricular
dilation
Shanu chandran

2. • Progressive enlargement of ventricles
following IVH until the ventricular width at
intraventricular foramen exceeds 97th centile
for gestational age.
• 20-30% of <34wks babies develop IVH and
50% of them can go for PVHD

3. Criteria for PVHD
• anterior horn width, measured diagonally
(>4mm),
• third ventricular width, measured in the
coronal plane (>3mm) and
• thalamo-occipital dimension, measured in the
sagittal plane (>26mm)

9. Ventricular enlargement due to excessive
build up of csf
Ventricular enlargement due to cerebral
atrophy
Ventricles are usually round Ventricle are not round
Enlargement rapid Enlargement slow
Increased head enlargement No increased head enlargement

10. Pathophysiology
• Normally csf is absorbed through arachnoid
villi and across the ependyma…..blocked by
small blood clots
• Endogenous attempt to lyse blod
clots…..ineffecient due to low plasminogen
and high inhibitor of plasminogen activator

11. Role of TGFb1
• Released into CSF following IVH
• Upregulates genes for extracellular matrix
proteins such as fibronectin and laminin- scar
formation
• If Scar tissue block the exit from 4th ventricle-
obstructive hydrocephalus; if blocks channels
of reabsorption- communicating
hydrocephalus

12. • Following dilation, periventricular wm gets
damaged
 rapid pressure and oedema
 free radical damage from iron
 proinflammatory cytokines

13. Reasons for ventricular dilation before
rapid head growth
• Paucity of cerebral myelin
• Relative excess of water in centrum semiovale
• Relatively large subarachnoid space(this space
could be encroached on even after ventricular
dilation, but before separation of sutures)

15. Effects of PHVD

16. Initial assessment
• Diagnosis using recognised criteria and
measurement of ventricular width
• Clinical assessment-irritability, increased
tendon reflex,tension in fontanelle,squamous
sutue >5mm, head circumference)
• Ascertainment of parenchymal brain lesions
that may affect infants prognosis

17. • Head circumference increases by about 1 mm
daily between 26 and 32 weeks’ gestation;
between 32 and 40 weeks it increases by 0.7
mm daily
• An increase of 2mm per day is considered
excessive

18. Objectives of Mx
• To protect the infant from damage secondary
to raised ICP
• To avoid the need for a permanent shunt –to
prevent blockage and infection necessitating
multiple revisions

19. Basic groups for management
Based on
• USG progression of ventricular dilation
• Rate of head growth
• Signs of increased ICP
• Resistance index and dRI

20. • Slowly progressive VD: moderate dilation,
appropriate rate of head growth , stable RI,
dRI, <2wk---- close follow up
• Persistent slowly progr VD: similar to I, except
duartion is >2wks and increase in head growth
and RI/dRI----close follow up till 4 wks;if rapid
progression/>4wks, serial lumbar puncture

22. Rapidly progressive VD: moderate to severe
dilation, clearly excessive rate of head
growth,RI,dRI clearly increased
Management-
serial lumbar punctures
ventricular drainage- EVD, VSGS
VP shunt

23. • Arrested progression: spontaneous arrest of
ventricular dilation or arrest following lumbar
puncture
• Management-close surveillance for 1 yr
• Late progressive ventricular dilation can occur
in 5%

24. USG evaluation of ventricular size
• First sign of incr in ICP- rounding of frontal horns
with increase in ant horn width-ballooning
• AHW-most sensitive marker for mild ventri
enlargement
• A normal AHW is less than 3 mm, with the 95th
percentile curve reaching 2 mm at 36 weeks and
3 mm at 40 weeks
• an AHW greater than 6 mm is generally
considered abnormal

27. • Thalamo occipital distance-depth of occipital
horn of lat ventricle
• visible before any increase in frontal horn
dimensions
• dilated to a greater extent than the frontal
horns

29. Levene index and ventricular index
• The Levene index is the absolute distance between the
falx and the lateral wall of the anterior horn in the
coronal plane at the level of the third ventricle.
• Up to 40 weeks of GA the Levene-index s and after 40
weeks the ventricular index-the ratio of the distance
between the lateral sides of the ventricles and the
biparietal diameter.
• Levine ventricular index 97th percentile + 4 mm curve-
threshold for intervention for PHVD, increases from 14
to 15 to 16 mm at 27, 31, and 33 weeks

33. Resistive index
• RI of ant cerebral artery- assessment of raised
ICP
• As the ICP increases it decreases the end
diastolic velocity, thus causing the RI to
increase towards 1.0.
• Not sensitive, not specific

34. Repeated lumbar punctures
• simplest way to reduce ventricular size and
intracranial pressure
• limit CSF removal to a maximum of 20 mL / kg so
as to minimise the risk of cardiovascular
disturbance
• Repeated LPs or ventricular taps do not reduce
the risk of requiring formal CSF diversion, have no
effect on neuromotor impairment and are
associated with a significant risk of ventriculitis,
(Ventriculomegaly Trial Group study)

35. • Repeated lumbar punctures are frequently
associated with high rate of infection and the
amount of cerebrospinal fluid drained may be
insufficient
• External ventricular drainage - more effective
than lumbar punctures in evacuating sufficient
volumes of cerebrospinal fluid

36. Temporary Csf diversion
• A ventricular access device provides an easy
and safe route for repeated aspiration of
ventricular CSF, with low infection rates
• Insertion, through a frontal burr hole, requires
a brief anaesthetic
• VSGshunt alternative
• Timing – controversial

37. Ommaya VAD

38. Temporary csf diversion devices-
merits/demerits
• The ventricular reservoir is a ventricular catheter
capped by a reservoir.
• The reservoir is tapped through the scalp on a
regular basis to remove CSF and maintain a stable
clinical condition.
• VSG shunt- allows continuous CSF diversion, and
thus sustained relief of elevated ICP, rather than
the intermittent diversion provided by ventricular
reservoir taps
• The family must be prepared for the subgaleal
fluid collection that forms in the scalp

39. When to act??
• In a retrospective study done in Dutch
NICUs(devries et al), early insertion, before
crossing the 97th + 4mm ventricular index line,
showed lower rates of ventriculoperitoneal
shunt(odds ratio- 0.22)
• The Early versus Late Ventricular Intervention
Study (ELVIS) is currently randomising between
the two treatment thresholds, with death or
shunt dependence and disability at two years the
main treatment outcomes
De vries et al Acta Paediatr. 2002

40. ELVIS
• Preterms<34 wks with IVH 3/4- serial cus 1-3
times weekly till 21 days
• Intervention-surgical placement of VAD
• Standard threshold arm- intervene if Levene
index>97 cent +4 or diagnonal frontal horn
width >10mm
• Low threshold- LI >97 centile, FHW 7-10, TOD
>24
• VP shunt if csf removal still required at 44 wks

41. Other treatment options
• DRIFT( drainage , irrigation and fibrinolytic
therapy)
• Drugs that decrease CSF production

42. DRIFT
• A catheter is inserted into rt ventricle frontally
and another into lt ventricle posteriorly
• Rh tPA is (0.5mg/kg) is injected into right
ventricle and left for 8 hours
• Artificial CSF is inserted into right ventricle at
20ml/kg/hr
• Old blood and debris are drained from left
ventricular drain to keep ICP below 7
• Irrigation is continued till draining fluid is clear
of old blood.

43. • Aims to decompress the distended ventricles
early
• Reducing pressure and distortion and
• Removing intraventricular blood,
inflammatory cytokines, and iron, thereby
reducing secondary injury to the cerebral
hemispheres

44. RCT comparing DRIFT and std
treatment
• Despite an increase in secondary
intraventricular bleeding, DRIFT reduced
severe cognitive disability in survivors and
overall death or severe disability
Whitelaw et al .Pediatrics April 2010

45. Drug therapy
• Carbonic anhydrase inhibitor acetazolamide reduces
CSF production
• RCT compared standard therapy with std + drug
therapy( 100mg/kg/day acetazolamide +1mg/kg/day
furosemide)
• Infants enrolled at mean post natal age of 3.6wks
• 85% who were allocated to drug therapy either died or
were disabled or impaired at 1 year compared with
70% who were treated with standard therapy
Kennedy et al Pediatics 2001 sept

46. • Acetazolamide and furosemide therapy is neither
effective nor safe in treating post hemorrhagic
ventricular dilatation
• Increase the risk of motor impairment at 1yr
• Increase the risk of nephrocalcinosis(RR-5.31)
• No significant increase in combined outcome of
death/disability
Cochrane database systematic review 2001

47. • Ineffective in decreasing shunt placement
• Increased neurological morbidity?
Carb anhydrase is involved in myelination
and glial differentiation.

48. Streptokinase inj
• Effect of intraventricular streptokinase after IVH on the
risk of permanent shunt dependence,
neurodevelopmental disability or death
• When intraventricular streptokinase was compared
with conservative management of PHVD, the number
of deaths and babies with shunt dependence were
similar in both groups
• Cannot be recommended
Cochrane database systematic review 2007

49. VP shunt
• Once baby reaches 2 kg
• CSF protein <1.5g/dl
• Early shunt-more risk of infections,shunt block
and revisions
• ETV with choroid plexus cauterization
alternative

51. Prognosis
• Quadriparesis and significant cognitive
impairment if associated PVL or PVHI

52. References
• Volpes tb of neurology of newborn 5 th ed
• Chloherty manual of nb care 7th ed
• Ultrasound measurements of the lateral
ventricles in neonates: why, how and when? A
systematic review. Acta pediatrics 2010
• IVH in newborn.ACNR 2011
• PHVD-review article -Arch Dis Child Fetal
Neonatal Ed 2002;86
• Radiology assisstant.com/ emedicine

53. Thank
you