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Serial lumbar punctures and intraventricular hemorrhage
EDITOR'S C O L U M N
Serial lumbar punctures and intraventricular hemorrhage
"I"H E I N C R E A S I N G N U M B E R o f l o w - b i r t h - w e i g h t i n f a n t s
who are surviving with a good prognosis for normal development and the technologic advance of computerized tomography have focused attention more sharply on the potential morbidity associated with some intraventricular hemorrhages. This issue of THE JOURNAL includes two very differently structured studies in which serial lumbar punctures were used to attempt to decrease the risk of injury from developing hydrocephalus following IVH in two very dissimilar groups of low-birth-weight infants. During a one-year period, Mantovani screened all infants under 2,000 gm for IVH by performing diagnostic lumbar punctures within several days of their admission to a NICU, and subsequently employed a CT scan to identify 48 infants with IVH among 76 with an initially abnormal cerebrospinal fluid examination. Those with the mildest CT scan-defined lesions (10) and alternate infants with more severe CT scan lesions (19) were not treated; the others with similarly severe CT scan lesions (19) were subjected to daily lumbar puncture removal of 3 to 5 ml of CSF until the fluid was clear and had a protein concentration of less than 180 mg/dl. Serial lumbar punctures so performed on these 19 infants selected for their CT scan lesions did not reduce the risk of death or the development of hydrocephalus. In contrast to the Mantovani study, Papile identified 63 surviving infants of less than 1,500 gm who were admitted to a NICU over a three-year period and who, on clinical suspicion of IVH, had CT scans obtained which confirmed IVH. Twenty-eight of these infants had moderateto severe lesions"(using a different grading system than for Mantovani's group), and 15 of these had progressive ventricular dilatation noted on repeat CT scan. In 12 of these 15 in whom it was possible to perform lumbar punctures, CSF was collected until, it no longer flowed freely; the remaining three required ventriculoperitoneal shunts. Of the 12 treated infants, six had decreases in ventricular size, five had ventricular dilatation which
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The Journal of P E D I A T R I C S Vol. 97, No. 2, p. 250
eventually stabilized, and one infant had progressive ventricular dilatation requiring a shunt. The authors concluded that the treatment had been helpful. These two very limited and disparate studies reaching conflicting conclusions after study of a total of 3 ! infants treated with serial lumbar punctures certainly do not establish the efficacy of this mode of treatment in the prevention or management of hydrocephalus. At best, the uncontrolled study by Papile only suggests that six of 15 study infants m a y have had their progressive ventricular enlargement reversed by serial lumbar puncture. See related articles, pp. 273 and 278.
Abbreviations used CT: computed tomography IVH: intraventricular hemorrhage CSF: cerebrospinal fluid NICU: neonatal intensive care Obviously, this problem needs more investigation before adopting serial lumbar punctures as a therapeutic approach to hydrocephalus. In addition, we need to know more about the risks of hydrocephalus from IVH in different weight groups, the correlation of CT scan with clinical observations, and the ultimate prognostic significance of different types of CT scan IVH lesions. At the very least, it seems indicated to carry out a wellcontrolled, short-term, randomized study of serial lumbar puncture drainage of a substantial quantity of CSF from a larger, homogeneous group of low-birth-weight infants with similar CT scan lesions who are not subjected to any other unproven treatment at the same time. Richard E. Behrman, M.D. Rainbow Babies and Childrens Hospital Case Western Reserve University 2101 Adelbert Road Cleveland, O H 44106
0022-3476/80/080250+01500.10/0 9 1980 The C. V. Mosby Co.
Serial lumbar punctures and intraventricular hemorrhage
"I"H E I N C R E A S I N G N U M B E R o f l o w - b i r t h - w e i g h t i n f a n t s
who are surviving with a good prognosis for normal development and the technologic advance of computerized tomography have focused attention more sharply on the potential morbidity associated with some intraventricular hemorrhages. This issue of THE JOURNAL includes two very differently structured studies in which serial lumbar punctures were used to attempt to decrease the risk of injury from developing hydrocephalus following IVH in two very dissimilar groups of low-birth-weight infants. During a one-year period, Mantovani screened all infants under 2,000 gm for IVH by performing diagnostic lumbar punctures within several days of their admission to a NICU, and subsequently employed a CT scan to identify 48 infants with IVH among 76 with an initially abnormal cerebrospinal fluid examination. Those with the mildest CT scan-defined lesions (10) and alternate infants with more severe CT scan lesions (19) were not treated; the others with similarly severe CT scan lesions (19) were subjected to daily lumbar puncture removal of 3 to 5 ml of CSF until the fluid was clear and had a protein concentration of less than 180 mg/dl. Serial lumbar punctures so performed on these 19 infants selected for their CT scan lesions did not reduce the risk of death or the development of hydrocephalus. In contrast to the Mantovani study, Papile identified 63 surviving infants of less than 1,500 gm who were admitted to a NICU over a three-year period and who, on clinical suspicion of IVH, had CT scans obtained which confirmed IVH. Twenty-eight of these infants had moderateto severe lesions"(using a different grading system than for Mantovani's group), and 15 of these had progressive ventricular dilatation noted on repeat CT scan. In 12 of these 15 in whom it was possible to perform lumbar punctures, CSF was collected until, it no longer flowed freely; the remaining three required ventriculoperitoneal shunts. Of the 12 treated infants, six had decreases in ventricular size, five had ventricular dilatation which
250
The Journal of P E D I A T R I C S Vol. 97, No. 2, p. 250
eventually stabilized, and one infant had progressive ventricular dilatation requiring a shunt. The authors concluded that the treatment had been helpful. These two very limited and disparate studies reaching conflicting conclusions after study of a total of 3 ! infants treated with serial lumbar punctures certainly do not establish the efficacy of this mode of treatment in the prevention or management of hydrocephalus. At best, the uncontrolled study by Papile only suggests that six of 15 study infants m a y have had their progressive ventricular enlargement reversed by serial lumbar puncture. See related articles, pp. 273 and 278.
Abbreviations used CT: computed tomography IVH: intraventricular hemorrhage CSF: cerebrospinal fluid NICU: neonatal intensive care Obviously, this problem needs more investigation before adopting serial lumbar punctures as a therapeutic approach to hydrocephalus. In addition, we need to know more about the risks of hydrocephalus from IVH in different weight groups, the correlation of CT scan with clinical observations, and the ultimate prognostic significance of different types of CT scan IVH lesions. At the very least, it seems indicated to carry out a wellcontrolled, short-term, randomized study of serial lumbar puncture drainage of a substantial quantity of CSF from a larger, homogeneous group of low-birth-weight infants with similar CT scan lesions who are not subjected to any other unproven treatment at the same time. Richard E. Behrman, M.D. Rainbow Babies and Childrens Hospital Case Western Reserve University 2101 Adelbert Road Cleveland, O H 44106
0022-3476/80/080250+01500.10/0 9 1980 The C. V. Mosby Co.