Neonatal Intra-Ventricular-Hemorrhage Prevention in Premature at < 30 Weeks Gestational Age

Introduction: Intraventricular Hemorrhage (IVH) is a devastating condition mostly in preterm infants at &lt; 30 weeks GA with large morbidities and mortality usually in the first 72 hours after birth. Prevention seems to be the only way to completely deal with this problem. The IVH prevention in this age group has been studied and includes some strategies such as prenatal corticosteroids, cesarean delivery, careful extraction among others, but still, it has an unacceptably high incidence in this population.Objective: To measure the application of a quality improvement project develop from the "Drive to Zero IVH Prevention Project" presented in a Epiclatino lecture in our unit.Material and method: We design a before and after observational study and measured the incidence of IVH before and after October 2017 when a minimum manipulation protocol was implemented at the Cl&iacute;nica del Country (CDC) unit. We also compare these findings to those of other units in the EpicLatino network. All patients born &lt;30 weeks GA with less than 2 days of age, who survived at least 3 days, and had a neuroimaging taken were included. We compared demographics, diagnosis, and frequency of IVH cases, before Nov 2017 and after from CDC and the from 2018-2019 EpicLatino registry using a bivariate analysis. Results: We collected data from 46 cases before, 40 after implementation, and 203 cases from the EpicLatino registry. Demographic characteristics were very similar in the post-intervention with few statistically significant differences in antenatal steroid use (97.5% post, 96% before and 79.3% Epilatino, p=0.016), prolonged rupture of membranes (15% post, 4% before and 15% EpicLatino, p &lt;0.001), vaginal deliveries (7.5% post, 10.9% before and 24.1% Epilatino, p=0.01), suspended chorioamnionitis (12.5% post, 6% before and 20.2% Epiclatino). We found a significant reduction in IVH after the protocol was implemented with only 5 (7.5%) cases post-intervention compared to 19 (29.4%) case before, and when compared to the 81 (39.1%) cases in the registry, p&lt; 0.001. Most of the cases that occurred in the post-intervention occurred before admission to the unit due to obstetric trauma.Discussion: If a well-controlled delivery minimizing obstetric trauma is achieved, a minimal manipulation protocol appears to significantly decrease the incidence of HIV. Controlled, multicenter studies are still required to confirm these findings.

Clinical Application of Microsurgery Using the Cerebellar Medulla Fissure Approach in Severe Ventricular Hemorrhage with Casting of the Fourth Ventricle and Its Influence on Neurological Recovery

Objective. To investigate the clinical application of microsurgery using the cerebellar medulla fissure approach in severe ventricular hemorrhage with casting of the fourth ventricle and its effect on neurological recovery. Methods. A total of 80 patients with severe intraventricular hemorrhage accompanied by casting and dilation of the fourth ventricle who were admitted to the neurosurgery department between July 2019 and December 2020 were randomly divided into an observation group and a control group, with 40 patients in each group. The drainage tube extubation time and length of hospital stay of the two groups were compared. The 3-day hematoma clearance of the two groups was observed. Postoperative consciousness was evaluated by GCS, and the patients’ recovery was evaluated by GOS at three months. The activities of daily living (ADL) scores of the two groups were compared to evaluate patients’ postoperative self-care ability. The incidence of postoperative complications in the two groups was collected. Independent risk factors for poor prognosis were analyzed by logistics regression. Results. The postoperative hospitalization time and the drainage tube extubation time in the observation group were significantly lower than those in the control group. The ratio of hematoma clearance ≥90% in the observation group was significantly higher than that of the control group. Postoperative GCS scores and GOS scores in the observation group were significantly higher than those of the control group. The rate of postoperative complications in the observation group was significantly lower than that of the control group. The rate of good ADL grading in the observation group was significantly higher than that in the control group. Age and surgical method were independent risk factors for poor prognosis. Conclusion. Microsurgery using the cerebellar medulla fissure approach can effectively improve the condition of severe ventricular hemorrhage with casting of the fourth ventricle and promote the recovery of patients’ neurological function.

Peripheral Neutrophil- Lymphocyte Ratio as a Predictor of Seizure in Preterm Infants with Intra-Ventricular Hemorrhage

Background: Preterm infants with Intra-Ventricular Hemorrhage (IVH) are at risk for developing significant complications, including post hemorrhagic hydrocephalus and seizures. Neonatal seizures are the most common overt manifestation of neurological dysfunction in the newborn, and is associated with short- and long-term adverse effects. Objective: The aim of the study is to evaluate the value of Peripheral Neutrophil- lymphocyte ratio (NLR) as a predictor of seizure in preterm infants with intra-ventricular hemorrhage. Methods: This prospective cohort study that comprised 60 Preterm infants with IVH admitted at NICU pediatric department Tanta university hospital from November 2019 to May 2020, Preterm infants were divided into two groups according to incidence of seizure. Preterm infants in this study subjected to Careful history taking, clinical examination and investigations (laboratory and Trans-cranial ultrasound) as well as analysis of result and follow up clinical status for development of seizure. Results: There was a statistically highly significant difference regarding NLR and development of seizure with p value <0.001 (NLR ≥ 2.3 with sensitivity 96%, specificity 93%, Area under the curve 0.849 and accuracy 84.9%). Conclusion: NLR is a predictor of seizure in preterm infants with intra-ventricular hemorrhage.

Frequency and Treatment Outcomes of Isolated Ventricular Hemorrhage Cases Among Traumatic Intracranial Hemorrhage Patients

Background: Bleeding into the ventricular system of brain is called intraventricular hemorrhage (IVH). It may be associated with brain parenchyma. Cases of isolated ventricular hemorrhages are found less. Ventricular hemorrhage due to trauma is more commonly seen in premature babies and infants than adults. Uncertainty in recovery is a important issue for such cases. Aim of the study: The aim of this study was to evaluate the frequency and the treatment outcomes of isolated ventricular hemorrhage cases among patients with traumatic intracranial hemorrhage. Methods: This prospective observational study was directed in the neurosurgery department of Sylhet MAG Osmani Medical College, Sylhet, Bangladesh from January 2015 to December 2020. In total 890 Admitted diagnosed cases of traumatic intracranial hemorrhage were chosen for this study as study population. Ultrasonography CT scan, MRI of the brain, MRA, MRV, and CSF were performed according to the patient’s status. Those were collected, processed, analyzed, and disseminated by using MS office and SPSS version 23 as per need. Results: According to this study, in total participants, the highest number was with parenchymal hemorrhage which was 34% (n=302). Besides these, cases with extradural hemorrhage were 33% (n=298), cases with subdural hemorrhage were 17% (n=149%), cases with subarachnoid hemorrhage were 14% (n=124) and cases with isolated ventricular hemorrhage (IVH) were 2% (n=17). So, in this study, the frequency of IVH was found only 2% among all types of traumatic intracranial hemorrhage cases. Among a total of 17 IVH patients, most of the cases were infants or baby which was 59%. And 41% of the IVH patients were adults. In analyzing the outcomes among the IVH patients we observed, early recovery was found in 1 child (5.88%) and in 2 adults (11.76%). Besides these, death was occurred in 6 children (35.29%) and in 3 adults (17.65%). Conclusion: Traumatic isolated ventricular hemorrhage (IVH) causes the worst prognosis in most cases. The survival rate with no residual effect is very minimum. In this study in 2 patients’ history of long coma, for more than 12 weeks was found. Besides these, moderate to severe morbidity was found in some cases.

Preterm Severe Neonatal Morbidity and Mortality in Breech Presentation Regarding the Onset Mode of Labor

PurposeThe objective was to assess neonatal severe morbidity in case of cervical ripening, in premature breech fetuses, comparatively at spontaneous labor. MethodsThis is a retrospective study conducted in a tertiary center.Women with alive singleton breech between 28 and 36+6 weeks of gestation were considered. We compared women with an unfavorable cervix, who had an indication to deliver, to women in spontaneous labor.The primary outcome was a composite morbi-mortality criterion including perinatal death, traumatic event, 5-min Apgar < 4, moderate / severe encephalopathy, seizures, Intra Ventricular Hemorrhage grade 3-4, necrotizing enterocolitis grade 2-3. The association between the onset of labor and severe neonatal morbidity was assessed by logistic regression model. A propensity score approach with inverse probability of treatment weighting was performed to control indication bias. ResultsWe included 212 patients: 64 in the induced labor group and 136 in the spontaneous labor group. Labor was induced mostly for fetal growth restriction (34.4%), oligoamnios (18.7%) and pre-eclampsia (18.7%). When induced labor, 45.3% of patients delivered vaginally, and 86% when spontaneous labor.The rate of neonatal morbidity was similar in two groups (4.7% versus 5.2%, p=0.889). There was no association between the onset of labor and severe neonatal morbidity (OR 0.99, 95% CI 0.2-3.6)). After applying propensity scores, induction of labor was not associated with improved severe neonatal morbidity (OR 0.9, 95% IC 0.4-2.5).ConclusionThe onset mode of labor do not seem to have an effect on severe neonatal morbidity and mortality in preterm breech fetuses.

A Case Report of Neonatal posthemorrhagic hydrocephalus in a premature infant.

Background: Neurosurgical services in the Maldives began around five years ago, but the first neurosurgical center is responsible for various emergency and clinical neurosurgical services. Published literature on neurosurgery from the Maldives Islands is limited. It is imperative to report unique cases from isolated countries to promote diversity for readers across the globe. Case Presentation: We present a case of a ventriculo-subgaleal shunt placement in an extremely premature male baby with intra-ventricular hemorrhage, causing communicating hydrocephalus born at 22 weeks of gestation weighing 600 grams to a young primigravida. The shunt was performed in the first month of life (780 grams) for communicating hydrocephalus secondary to the germinal matrix bleed into the ventricles. Conclusion: Ventriculo-subgalel shunt under local anesthesia is a promising measure to treat hydrocephalus in pre-term very low birth weight infants secondary to germinal matrix hemorrhage.

Comparative investigation of different telemetric methods for measuring intracranial pressure: a prospective pilot study

Objectives Measurement of intracranial pressure (ICP) plays an important role in long-term monitoring and neuro-intensive treatment of patients with a cerebral shunt. Currently, only two complete telemetric implants with different technical features are available worldwide. This prospective pilot study aims to examine patients who had both probes implanted at overlapping times for clinical reasons and represents the first in vivo comparison of both measurement methods. Materials and methods Patients with a primary subarachnoid hemorrhage or a spontaneous intracerebral hemorrhage with ventricular hemorrhage who had received a telemetric ICP probe (Raumedic® NEUROVENT®-P-tel) were included in the study. Conventional external ventricular drainages (EVD) and ventriculoperitoneal shunts with a telemetric ICP probe (Miethke Sensor Reservoir) were implanted in patients with hydrocephalus who required CSF (cerebrospinal fluid) drainage. Absolute ICP values from all systems were obtained. Due to the overlapping implantation time, parallel ICP measurements were performed via two devices simultaneously. ICP measurements via the sensor reservoir were repeated after 3 and 9 months. Differences between the absolute ICP values measured via the NEUROVENT®-P-tel probe, the Miethke sensor reservoir®, and the EVD were analyzed. Results Seventeen patients were included in the present study between 2016 and 2018. 63% of all patients were male. In 11 patients the ICP measurements were followed up with both devices for 3 months. ICP measurements of the sensor reservoir showed corresponding trends in 9 cases compared to ICP measurement via the telemetry probe or EVD. Difference in absolute ICP values ranged between 14.5 mmHg and 0.0 mmHg. The average difference of the absolute ICP values in 8 cases was ≤ 3.5 mmHg. Conclusion ICP measurements with both systems continuously showed synchronous absolute ICP values, however absolute values of ICP measurement with the different systems did not match.

Comparative investigation of different telemetric methods for measuring intracranial pressure: a prospective pilot study

Objectives: Measurement of intracranial pressure (ICP) plays an important role in long-term monitoring and neuro-intensive treatment of patients with a cerebral shunt. Currently, only two complete telemetric implants with different technical features are available worldwide. This prospective pilot study aims to examine patients who had both probes implanted at overlapping times for clinical reasons and represents the first in vivo comparison of both measurement methods.Materials and methods: Patients with a primary subarachnoid hemorrhage or a spontaneous intracerebral hemorrhage with ventricular hemorrhage who had received a telemetric ICP probe (Raumedic® NEUROVENT®-P-tel) were included in the study. Conventional external ventricular drainages (EVD) and ventriculoperitoneal shunts with a telemetric ICP probe (Miethke Sensor Reservoir) were implanted in patients with hydrocephalus who required CSF (cerebrospinal fluid) drainage. Absolute ICP values from all systems were obtained. Due to the overlapping implantation time, parallel ICP measurements were performed via two devices simultaneously. ICP measurements via the sensor reservoir were repeated after three and nine months. Differences between the absolute ICP values measured via the NEUROVENT®-P-tel probe, the Miethke sensor reservoir®, and the EVD were analyzed.Results: Seventeen patients were included in the present study between 2016 and 2018. 63% of all patients were male. In 11 patients the ICP measurements were followed up with both devices for 3 months. ICP measurements of the sensor reservoir showed corresponding trends in 9 cases compared to ICP measurement via the telemetry probe or EVD. Difference in absolute ICP values ranged between 14.5 mmHg and 0.0 mmHg. The average difference of the absolute ICP values in 8 cases was ≤ 3.5 mmHg.Conclusion: ICP measurements with both systems continuously showed synchronous absolute ICP values, however absolute values of ICP measurement with the different systems did not match.