335 - Management of Post-Hemorrhagic Ventricular Dilation: Identification and Comparison of Treatment Pathways from Level IV NICUs in North America

Publication Number: 335.5884

Kristen Coletti, Childrens Hospital of Philadelphia, Wynnewood, PA, United States; Stephanie S. Lee, University of Iowa Roy J. and Lucille A. Carver College of Medicine, Iowa City, IA, United States; Laura Carroll, University of Arkansas for Medical Sciences College of Medicine, Little Rock, AR, United States; Susan Cohen, CW HOPE Developmental Follow Up Clinic, Milwaukee, WI, United States; Maria Dizon, Northwestern University, CHICAGO, IL, United States; David Hersh, Connecticut Children's, West Hartford, CT, United States; Ulrike Mietzsch, University of Washington School of Medicine, Seattle, WA, United States; Eylem Ocal, Arkansas Children's Hospital, Little Rock, AR, United States; Diane Wilson, Hospital for Sick Children, Toronto, ON, Canada; Elizabeth K. Sewell, Emory University School of Medicine; Children's Healthcare of Atlanta, Atlanta, GA, United States

Background: Post-hemorrhagic ventricular dilation (PHVD) is a severe complication of prematurity, resulting in death or disability in up to 68% of affected newborns. Prior research demonstrates marked differences in the timing of surgical intervention between centers.

Objective: To (1) evaluate the percent of Children’s Hospitals Neonatal Consortium (CHNC) centers that have clinical pathways for PHVD, and (2) compare institutional pathways among CHNC centers.

Design/Methods: A survey was distributed to a neonatologist at 49 CHNC level IV NICUs. The survey was open for 3.5 months and included questions about center demographics and PHVD pathways. Centers with written PHVD pathways provided their guidelines. Analyses included descriptive statistics.

Results: Surveys were completed by neonatologists from 40 of 49 centers (82% response rate). Institutional and pathway characteristics are presented in Table 1. Of the 40 responding centers, 30% (n=12) had written PHVD pathways, 27.5% (n=11) had informal consensus in management, and 42.5% (n=17) had no consensus. Among centers with written pathways, most documented measurements of ventriculomegaly (VM) on cranial ultrasound (CUS): 7 (58%) used ventricular index (VI), 4 (33%) used fronto-occipital/temporal horn ratio (FOHR/FTHR), and 1 (8%) did not use CUS measurements (Figure 1). The threshold for surgical intervention included CUS measurements and/or clinical symptoms at most centers (n=8, 67%) but 3 (25%) and 1 (8%) only specified CUS measurements or clinical symptoms, respectively (Figure 1). Need for conversion from a temporizing device to a shunt was determined by pausing tapping and checking for progression of VM (n=5, 42%) or persistent need for tapping of VAD (n=4, 33%, Figure 2A). Following VAD placement, most (n=9, 75%) centers follow serial CUS, though variation exists in frequency (Figure 2B). Seven (58%) centers specify indications for tapping VADs but differences exist in whether this is based on CUS alone or alongside clinical symptoms (Figure 2B). Only 42% of centers (n=5) specify follow-up recommendations.

Conclusion(s): Many level IV NICUs in North America do not have formal guidelines for the management of PHVD. Among centers with formal pathways for PHVD, most rely on measurements of VM and screening CUS. Areas of heterogeneity include type of VM measurement used, timing of intervention, indications for tapping VAD, and indications for conversion to shunt. Opportunities exist for the creation and implementation of evidence-based consensus guidelines to improve patient care and outcomes.

Table 1
Institutional and Pathway Characteristics

Figure 1
PVHD Screening

Figure 2
Neurosurgical Management of PHVD (A) and Management of VAD (B)