新生儿脑室内出血致脑积水的储液囊埋植引流治疗15例报告

Role of Ommaya reservoir in the management of neonates with post-hemorrhagic hydrocephalus

目的脑室内出血后脑积水是新生儿严重的并发症，存活后往往伴有严重的神经系统后遗症，目前对脑室内出血后脑积水处理仍然相当棘手，没有统一的方案。用储液囊埋植引流治疗新生儿脑室出血后脑积水，就其疗效和安全性作一初步评价。方法对2003年1月至2005年12月期间，相继入住我院的15例新生儿脑室内出血Ⅲ度以上合并脑积水，且1周内脑室进行性扩大，头围每天增大〉2mm伴有颅内压增高症状患儿，进行储液囊埋植引流治疗。储液囊埋植后根据临床和头颅超声或头颅CT检查结果，决定脑脊液引流次数，间歇引流时间和引流量，并观察脑脊液中细胞数、蛋白质和葡萄糖浓度的变化及术中和术后的并发症。若储液囊引流无效，改行脑室-腹腔分流术。出院后临床随访3．5～3年。结果15例患儿中早产儿11例，孕龄（31．5±0．5）周；足月儿4例，其中3例为维生素K缺乏性颅内出血。脑室出血Ⅲ级13例，Ⅳ级2例。脑室出血平均诊断日龄：早产儿（9±1）d，足月儿（22±7）d。埋植Ommaya囊时日龄：早产儿（18±3）d，足月儿（31±7）d。平均每例患儿脑脊液引流次数（23．5±4．6）次，每次引流量为（30．2±3．3）mL／kg。35例经储液囊脑脊液引流后30d脑脊液中细胞计数和葡萄糖分别为（34±6）×10^6个／L、（2．2±0．2）mmol／L；引流后39d蛋白质为（0．48±0．10）g／L。33例经储液囊脑脊液引流后在3～4周内头围增长速度每周〈3cm，病情改善，其中12例至12～38个月时脑室恢复正常大小，1例在36个月时仍有轻度扩大。2例储液囊脑脊液引流无效，其中1例转行脑室-腹腔分流术后好转，1例放弃治疗出院后3个月死亡。术中和术后病情稳定，1例术后16d储液囊出现渗漏，并发颅内感染（感染发生率为1／35），加用抗菌素治疗痊愈。14例术后1．5～3年时间随访：11例生长发育正常；2例早产儿发生两下肢痉挛性脑瘫，其中1例合并弱视；1例足月儿有癫痫发作。结论采用储液囊脑室埋植引流治疗新生儿重型脑室出血合并脑积水，初步显示疗效满意和比较安全，为进一步明确其疗效需前瞻性临床多中心随机对照试验。

Objective Intra-ventricular hemorrhage （IVH） is one of the most serious complications of preterm infants. Significant numbers of the surviving infants with severe IVH go on to develop posthemorrhagic hydrocephalus （PHH）. The management of PHH remains a very challenging problem for both neonatologists and pediatric neurosurgeons. This study aimed to evaluate the efficacy and safety of the use of Ommaya reservoirs and serial cerebrospinal fluid （CSF） drainage in the management of a series of neonates with PHH. Method Between January 1, 2003 and December 30, 2005, 15 consecutive newborn infants with IVH grades Ⅲ to Ⅳ, complicated with progressive ventrieular dilatation, underwent placement of an Ommaya reservoir. CSF was intermittently aspirated percutaneously from the reservoir. The amount and frequency of CSF aspiration were based on the clinical presentation and the follow-up results of serial cranial ultrasonograms or CT scans. The changes of CSF cell counts and chemistries were also followed. Patients whose progressive ventricular dilatation persisted despite serial CSF aspiration through Ommaya reservoir eventually had ventriculo-peritoneal shunts （ V-P shunt） placed. All the patients were followed up in the outpatient clinic after discharge from the hospital and the neurodevelopmental outcomes were evaluated through 18-36 months of age. Result A total of 15 infants were included in this series. Of them, 11 were preterm infants who were at gestational ages of 29 to 34 weeks and d infants were full-term. All of the 4 full term infants presented with progressive ventricular dilatation after suffering from the intra-cranial hemorrhage （3 infants were due to vitamin K deficiency and 1 was due to birth trauma）. Thirteen infants had grade Ⅲ IVH, and 2 had grade Ⅳ IVH based on initial cranial ultrasonographic and CT scans. The mean age when IVH was diagnosed was （9 ± 1 ） days in preterm infants and （22 -± 7 ） days in full-term infants ; the mean age when Ommaya reservoir was placed was （18 ± 11 ） days in preterm infants and （31 ±7） days in fullterm infants, All the infants tolerated the surgical procedure well. The Ommaya reservoir was tapped for an average of （21.5 ±4. 6） times per patient. The mean CSF volume per tap was （ 10. 2 ± 1.3） ml/kg. The values of CSF protein, glucose and cell counts slowly reached normal levels at approximately 3-5 weeks after the placement of the reservoir. The velocity of head circumference increase per week was less than 1 cm in 13 patients in 1-4 weeks after the placement of the reservoir and the size of ventricles decreased gradually. By 12-18 months, 12 infants had normal size ventricles, and 1 patient still had mild ventricular dilation at 36 months. Two infants developed progressive hydrocephalus after serial CSF aspiration through Ommaya reservoir. One infant had a V-P shunt placed at 2 months of age and another infant died at 3 months of age at home after parents refused further therapy. Complications consisted of reservoir leaking and CSF infection at 16th day of placement in one patient after repeated tapping. By the end of 18-36 months of follow-up, 11 of 14 infants were considered normal, two patients had mild impairment in neurodevelopmental outcome （both had spastic bilateral lower limbs paresis, and one of whom also had ambliopia） and the other had seizure disorder. Conclusion The results from this series indicate that the placement of an Ommaya reservoir is relatively safe in newborn infants and is useful in the initial management of neonates with PHH and may be beneficial in improving their neurodevelopmental outcomes. A multicenter randomized trial may be needed to further validate the results of this report.