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Excerpt
A retrospective review was undertaken of 52 preterm neonates with grade IV IVH, all of whom had evidence of massive hemorrhagic parenchymal infarction, blood in the lateral ventricles, and progressive hydrocephalus. All required surgery. Infants with progressive ventriculomegaly had a low-profile ventricular catheter reservoir implanted and, if hydrocephalus persisted, received a ventriculoperitoneal shunt. Only 19 infants (36.5 percent) survived. The average number of shunt revisions required was more than six. During a mean follow-up of 16 years, the 19 surviving infants had cognitive function (assessed by the Bayley Scale of Infant Development and the Gesell Developmental Scale) more than 2.0 SD below the mean. None of them had a normal motor outcome, and nearly two thirds of the patients had marked spastic quadriparesis. Eleven patients had chronic seizures. On logistic regression analysis, the only significant predictor of the cognitive and motor outcome was the grade of hemorrhage. The cost of initial hospitalization averaged $162,000.
Most preterm infants having massive hemorrhagic infarction of the brain, with more blood than remaining parenchymal tissue, do not live, and those who do live may be expected to have poor cognitive and motor statuses. Reported results of early CSF diversion are mixed, although early drainage of posthemorrhagic hydrocephalus seems to reduce mortality and limit cognitive impairment. McCallum and Turbeville, analyzing a series with significantly better outcomes, estimated the cost per "quality life year" as $40,000. The authors conclude that it is reasonable and justifiable to withhold aggressive measures in selected cases depending on the imaging findings, the infant's clinical status, and the family's wishes.
(Attempting to relate prognostic variables to outcome, Pikus et al. performed a 10-year retrospective review of the medical records of 52 premature neonates who had massive grade IV intracranial hemorrhage and surgical treatment for their hydrocephalus; only 19 survived. In 15 of the 19, intellectual function was greater than 2.0 SDs below the mean. All of the children had some motor abnormality; in 12, the abnormality was severe. Eleven of the 19 had chronic seizure disorders. The authors recognized that most premature neonates with massive intracranial hemorrhage do not survive; for those who do, the outcome is poor, with high emotional and financial cost. The authors believe that consideration of withdrawal of life support should be presented as an option to the parents of these unfortunate children (Neurosurgery 1997;40:983). Usually within the first few days of life, 30 to 50 percent of infants with birth weights < 1500 gm display evidence of intraventricular hemorrhage. Hypoxic or ischemic events that occur in the antenatal, perinatal, or postnatal period have been associated with intraventricular hemorrhage. The grade of the intraventricular hemorrhage is the most important prognostic factor for neurodevelopmental outcome. The above-abstracted article presents the conundrum of a difficult management problem for the neonatologist and the neurosurgeon in dealing with children with massive intracranial hemorrhage. Modern medical technology may have outpaced our ability to frame important ethical questions regarding the use of that technology.
