Treatment and outcome of neonatal haemorrhagic brain injury

Abstract

Treatment and outcome of neonatal haemorrhagic brain injury In this thesis we have described the treatment and outcome of preterm infants with a severe intraventricular haemorrhage (IVH) who subsequently developed post haemorrhagic ventricular dilatation (PHVD). In addition we described the treatment and outcome of term infants who suffered from an intracranial haemorrhage (ICH). There are considerable differences in the diagnostic and therapeutic approaches to the preterm infant with PHVD as described in the results of a European survey about the diagnosis and treatment of PHVD. In preterms with PHVD, subcutaneous reservoirs are placed to remove cerebral spinal fluid (CSF). A subcutaneous reservoir is a safe and effective method to ensure controlled CSF removal. The incidence of infections of subcutaneous reservoirs in preterm infants was retrospectively studied. The incidence of an infection or major complications remains <5%, which we consider within acceptable limits. A pilot study was performed, to implement nurses’ performance of ventricular punctures. The successful change in policy means that punctures are now performed on schedule and nurses have more control in planning periods of rest for infants. The natural evolution of GMH-IVH was evaluated: the need for intervention for PHVD, and neurodevelopmental outcome at 24 months corrected age in 214 preterm infants (? 34 weeks GA). It was of interest to find that there was no significant difference in DQ at 24 months corrected age between infants who did or did not need intervention. We could only speculate about the positive role of early intervention. Neurodevelopmental and cognitive outcome in preterm infants at school age, who had a severe IVH (grade III or IV) and required neurosurgical intervention was studied. The majority (59.4%) had no neuroimpairments in the form of learning disabilities, cerebral palsy (CP) or epilepsy. Thirty-nine percent of this population had definite motor problems. The mean IQ of the total population was 93.4 and 29% of the children had an IQ <85 (-1SD). None of the children with a grade III hemorrhage developed CP. We speculate that this is due to early intervention, avoiding prolonged periods of raised intracranial pressure with periventricular oedema and distortion of the developing axonal pathways and disturbance of the myelination process. Neonatal and follow-up data of 53 full-term infants with ICH with associated parenchymal involvement admitted to a level 3 NICU over a period of 17 years were studied. ICH with parenchymal involvement carries a risk of adverse neurological sequelae with a mortality of 24.5% and a development of CP in 8.6%. The high mortality rate could partly be explained by associated perinatal asphyxia. In spite of often large intraparenchymal lesions, 88.2% of the survivors without CP had a normal early neurodevelopmental outcome. Promising results are reported in this thesis about short and long-term outcome of preterm infants who did develop PHVD. Especially for the preterm infants with a grade III haemorrhage. However, care of infants with an intracranial haemorrhage can be improved further, with regard to prevention and timing of intervention.