Presentation of Hydrocephalus After Intraventricular Hemorrhage in Infants

Premature infants usually are treated in a neonatal intensive care unit. The younger the gestational age at which they are born, the more coexisting heath problems they have. Cardiopulmonary insufficiency, metabolic disorders, and immune deficiency are the major risk factors; and the neonates are often intubated under sedation. Under those circumstances a small hemorrhage easily can go undetected, and a high suspicion index is needed.

Symptoms

Patterns of evolution

• Enlarging head circumference: Typically, hydrocephalus due to IVH is first manifest by accleration in the rate of head growth.

Time for evolution

• Days to weeks after hemorrhage: The time course from the initial hemorrhage to clinically evident ventriculomegaly and, even further, to progressive hydrocephalus varies from days to weeks. Close evaluation and follow-up of those infants cannot be supported by clinical data alone, and diagnostic tools are mandatory (42, 44).

Intervention

Stabilization

After the diagnosis of post-IVH hydrocephalus has been established, the definitive therapeutic step would be the insertion of a ventriculoperitoneal shunt. If the neonate is not yet an appropriate candidate for that (due to low body weight, CSF composition unsuitable for permanent shunting, or systemic concomitant issues) some temporary measures can be applied in order to control hydrocephalus. The most acceptable surgical options are the subcutaneous reservoirs and subgaleal shunts, and to a lesser extent EVDs. Serial taps (lumbar punctures and ventricular taps) should be avoided and performed only in cases of symptomatic excessive ICP (> 12mmHg) as measured with a fluid-filled manometer (14, 16, 67, 93, 102, 105).

Preparation for definitive intervention, nonemergent

• CSF studies: From a previously placed ventricular access device, CSF samples need to be sent for biochemistry (protein, glucose) and microbiology sensitivities. Ideally the last CSF examination should be 24–48 hours before the operation.
• Blood tests: Baseline tests (FBC, U&Es, coagulation) and CRP to rule out any coexistent infection are needed
• Recent imaging: A recent scan of sufficient quality is important for the preoperative planning of the ventricular catheter insertion. A cranial ultrasound should do, but a CT or MRI is more useful, especially if the use of a navigation system is planned or the ventricular anatomy is distorted.
• Informed consent: Parents and caregivers should be informed of the intended benefits of any procedure, the basic operative steps, and the risks or postoperative complications that can occur.
• Antiseptic bath: The previous night and 2 hours before the operation, a whole body wash with antiseptic regimen helps to minimize the hazardous skin flora.

Preparation for definitive intervention, emergent

• LP or ventricular tap: In case of an emergency that requires an urgent intervention done at bedside, a proper antiseptic preparation is required. LPs can be performed by the neonatologists, and a 3-minute preparation with non-alcoholic povidone iodine is sufficient. The same preparation is used for the ventricular taps (right frontal area), with care taken to protect the eyes.
• Insertion of ventricular access device or EVD: These procedures are performed in the operating room. Usually there is enough time to obtain informed consent and to do a cranial ultrasound to visualize the ventricular anatomy.

Admission Orders

These patients are already admitted to neonatal intensive care units where specific treatment and nursing protocols are followed.

• HOB, positioning, and activity: If there is no contraindication from the respiratory perspective, the head of the bed can be set from 0–30 degrees to assist venous drainage and reduce ICP. The neonate can be positioned supine, prone, or decubitus. If there is already a ventricular access device or valve in situ, care should be taken to avoid prolonged pressure between the hardware and the bed so that pressure ulcerations do not occur.
• VS: The advanced neonate ICU monitoring records directly many parameters such as arterial blood pressure, heart rate, ECG, temperature, and oxygen saturation. If the patient is under mechanical ventilation, many more parameters are monitored with highly sophisticated equipment.