Interobserver reliability between pediatric radiologists and residents in ultrasound evaluation of intraventricular hemorrhage in premature infants

BACKGROUND Germinal matrix intraventricular hemorrhage(IVH)may contribute to significant morbidity and mortality in premature infants.Timely identification and grading of IVH affect decision-making and clinical outcomes.There is possibility of misinterpretation of the ultrasound appearances,and the interobserver variability has not been investigated between radiology resident and board-certified radiologist.AIM To assess interobserver reliability between senior radiology residents performing bedside cranial ultrasound during on-call hours and pediatric radiologists.METHODS From June 2018 to June 2020,neonatal cranial ultrasound examinations were performed in neonatal intensive care unit.Ultrasound findings were recorded by the residents performing the ultrasound and the pediatric attending radiologists.RESULTS In total,200 neonates were included in the study,with a mean gestational age of 30.9 wk.Interobserver agreement for higher grade(Grade III&IV)IVH was excellent.There was substantial agreement for lower grade(Grade I&II)IVH.CONCLUSION There is strong agreement between radiology residents and pediatric radiologists,which is higher for high grade IVHs.

MODIFIED GRAEB CRITERIA FOR PREDICTING THE POST-HEMORRHAGIC HYDROCEPHALUS IN INTRAVENTRICULAR HEMORRHAGE

Objective To set up a new grading system of intraventricular hemorrhage (IVH) and determine the value of predicting the probability of post-hemorrhagic hydrocephalus (PHH) in IVH. Methods We first modified the Graeb criteria, then compared the value of prediction for PHH assessed by the Graeb criteria with the modified Graeb criteria. One hundred and thirty one IVH patients were divided into two groups: the upper group (n=67) and the lower group (n=64). Gold standard of PHH was assessed by CT scan or by out-drainage. The diagno-stic parameters such as sensitivity (SE), specificity (SP) were analyzed. In the cutoff point of SE and SP curves, diagnostic efficiency (DE), and Kappa value (K) were analyzed. The probability of PHH was estimated by binary logistic regressions. Results In all ventricular group, to Graeb criteria in the cutoff point, SE, SP, and K was 0.78, 0.84, and 0.60; and to modified Graeb criteria SE, SP, and K was 0.90, 0.84, and 0.74 respectively. The probability of PHH from point of 3-12 was 0.011, 0.032, 0.085, 0.212, 0.435, 0.689, 0.865, 0.949, 0.981, and 0.994 respectively according to modified Graeb criteria. Conclusion The modified Graeb criteria combined with logistic regression were useful methods to assess the severity of IVH and to predict the probability of PHH in IVH.

Restoration of an injured lower dorsal ascending reticular activating system in a patient with intraventricular hemorrhage

The ascending reticular activating system（ARAS）plays a key role in the control of arousal and awareness for consciousness（Paus,2000;Zeman,2001;Van der Werf et al.,2002;Weiss et al.,2007;Siposan and Aliu,2014）.It is well known that the ARAS originates from the reticular formation（RF）of the brainstem,and connects to the cerebral cortex via intralaminar to the cerebral cortex （Paus, 2000; Zeman, 2001; Van der Werf et al., 2002; Yeo et al., 2013; Jang and Kwon, 2015）. The hypothalamus is involved in the regulation of sleep and awareness which is associated with the main timekeeper of consciousness （Lin, 2000; Lin et al., 2011）.

MECHANISM OF PATHOLOGICAL CHANGES OF INTRAVENTRICULAR HEMORRHAGE IN DOGS

Objective To probe the mechanism of pathological changes of intraventricular hemorrhage(IVH). Methods The evaluation of neurological status,serial CT scans and pathological examination were applied on the canine model of IVH. The ventricular volume and blood clot volume were measured based on the CT images. Results The normal adult canine ventricle tend to be slitlike. After injection, the ventricle was obviously dilated by the blood clot. The linear regression of ventricular volume against blood clot volume was significant in the first week. From then on, however, while the clots continued to shrink, the ventricular volume showed progressive enlargement. The clots were lysed completely within 3 to 4 weeks. The linear regression of the degree of ventricular dilatation against the first clot volume was also significant. In the pathological examination, we found the ependymal lining of ventricular system was destroyed and neurons in the subependymal areas developed acidophil necrosis, which was prominent around Sylvian aqueduct. Conclusion Hemorrhagic ventricular dilatation(HVD) is a prominent feature of IVH and also is a strong indicator for poor prognosis. Ischemic changes of periventricular neurons in some important structures may be the most direct cause for poor outcome of IVH. It may be induced by periventricular vascular structures compressed by HVD, increased intracranial pressure, cerebral vasospasm and others.

Necrostatin-1 decreases necroptosis and inflammatory markers after intraventricular hemorrhage in mice

Necrostatin-1,an inhibitor of necroptosis,can effectively inhibit necrotic apoptosis in neurological diseases,which results in the inhibition of inflammation,endoplasmic reticulum stress,and reactive oxygen species production and substantial improvement of neurological function.However,the effects of necrostatin-1 on intraventricular hemorrhage(IVH)remain unknown.In this study,we established a mouse model of IVH by injecting autologous blood into the lateral ventricle of the brain.We also injected necrostatin-1 into the lateral ventricle one hour prior to IVH induction.We found that necrostatin-1 effectively reduced the expression levels of the necroptosis markers receptor-interacting protein kinase(RIP)1,RIP3,mixed lineage kinase domain-like protein(MLKL),phosphorylated(p)-RIP3,and p-MLKL and the levels of interleukin-1β,interleukin-6,and tumor necrosis factor-αin the surrounding areas of the lateral ventricle.However,necrostatin-1 did not reduce ependymal ciliary injury or brain water content.These findings suggest that necrostatin-1 can prevent local inflammation and microglial activation induced by IVH but does not greatly improve prognosis.

Endoscopic surgery for intraventricular hemorrhage:A comparative study and single center surgical experience

BACKGROUND Intraventricular hemorrhage is a neurosurgical emergency,and a dangerous condition associated with high morbidity and mortality.Previously,hematoma evacuation is generally executed by external intracranial drainage(EVD)or surgical evacuation.Nowadays,endoscopic evacuation is emerging as a good alternative because it brings relatively less invasion and injury.However,successful endoscopic evacuation requires skilled manipulation of endoscopic devices and the evidence supporting its efficacy differs in different reports.AIM To improve the technique usage and provide more evidence of endoscopic evacuation efficacy,we summarize our surgical experience and compared the outcomes of the endoscopic evacuation with EVD using real-world data.METHODS We retrospectively studied 96 consecutive patients with intraventricular hemorrhage who underwent either endoscopic surgery(n=43)or non-endoscopic surgery(n=53)for hemorrhage evacuation between November 2013 and September 2019 in our center.Patients’conditions prior to and after the operation were evaluated and analyzed to assess the efficacy of the operation.The consciousness status improvement and perioperative in-hospital parameters in the two types of operation groups were assessed and compared.RESULTS Patients in the endoscopic and non-endoscopic groups presented with a similar state of consciousness,with a comparable Glasgow Coma Scale(GCS)index.The average operation time of the endoscopic group was longer than that of the nonendoscopic group(median 2.42 h vs 1.08 h,P<0.001).Although the endoscopic group was older and had a baseline Graeb score that indicated more severe hemorrhage than the non-endoscopic group(Graeb median:Endoscopic group=9 vs non-endoscopic group=8,P=0.023),the clearance rate of hematoma was as high as 60.5%.Both the endoscopic and non-endoscopic groups showed an improved GCS index after surgery.However,this improvement was more marked in patients in the endoscopic group(median improvement of GCS index:Endoscope group=4 vs non-endoscopic group=1,P<0.001).Additionally,the endoscopic group had a lower Graeb score than the non-endoscopic group after the operation.The intensive care unit stay of the endoscopic group was significantly shorter than that of the non-endoscopic group(median:endoscopic group=6 d vs non-endoscope group=7 d,P=0.017).CONCLUSION Endoscopic evacuation of intraventricular hemorrhage was generally an effective and efficient way for hemorrhage evacuation,and contributed remarkably to the improvement of consciousness in patients with intraventricular hemorrhage.

Selective verbal memory impairment due to left fornical crus injury in a patient with intraventricular hemorrhage

The fornix, a part of the Papez circuit, transfers information of episodic memory between the medial temporal lobe and the medial diencephalon （Aggleton and Brown, 1999）. The right medial temporal lobe is known to be specialized for visual memory and the left medial temporal lobe for verbal memory （Tucker et al., 1988; Aegleton and Brown, 1999）.

Advances in surgical treatment of intraventricular hemorrhage

Intraventricular hemorrhage(IVH)is a dangerous acute cerebrovascular disease.The 30-day mortality rate of patients with IVH is 5 times that of patients with cerebral hemorrhage.In recent years,more and more studies have shown that timely clearance of intraventricular hematoma is closely related to good prognosis.The advantages of surgical intervention in patient management are impressive.This article briefly reviews the positive advances in the surgical treatment of IVH such as external ventricular drainage(EVD)combined with intraventricular fibrinolysis(IVF)and continuous lumbar cistern drainage(LCD),as well as their safety and efficacy,especially the remarkable role of neuroendoscopy in the removal of intraventricular hematomas.

Influence of deferoxamine on hydrocephalus after intraventricular hemorrhage and expressions of Wnt1 and Wnt3a in rat

Objective To observe the effect of deferoxamine on chronic hydrocephalus after intraventricular hemorrhage (IVH) and the role of Wnt (Wnt1 and Wnt3a) . Methods A total of 130 Sprague Dawley male rats were randomly assigned into 4 groups: normal control group, sham IVH group,IVH group and deferoxamine-treated group.

Long-term outcomes of very low birth weight infants with intraventricular hemorrhage:a nationwide population study from 2011 to 2019

Background Advancements in neonatal care have increased preterm infant survival but paradoxically raised intraventricular hemorrhage(IVH)rates.This study explores IVH prevalence and long-term outcomes of very low birth weight(VLBW)infants in Korea over a decade.Methods Using Korean National Health Insurance data(NHIS,2010-2019),we identified 3372 VLBW infants with IVH among 4,129,808 live births.Health-related claims data,encompassing diagnostic codes,diagnostic test costs,and administered procedures were sourced from the NHIS database.The results of the developmental assessments are categorized into four groups based on standard deviation(SD)scores.Neonatal characteristics and complications were compared among the groups.Logistic regression models were employed to identify significant changes in the incidence of complications and to calculate odds ratios with corresponding 95%confidence intervals for each risk factor associated with mortality and morbidity in IVH.Long-term growth and development were compared between the two groups(years 2010-2013 and 2014-2017).Results IVH prevalence was 12%in VLBW and 16%in extremely low birth weight(ELBW)infants.Over the past decade,IVH rates increased significantly in ELBW infants(P=0.0113),while mortality decreased(P=0.0225).Major improvements in certain neurodevelopmental outcomes and reductions in early morbidities have been observed among VLBW infants with IVH.Ten percent of the population received surgical treatments such as external ventricular drainage(EVD)or a ventriculoperitoneal(VP)shunt,with the choice of treatment methods remaining consistent over time.The IVH with surgical intervention group exhibited higher incidences of delayed development,cerebral palsy,seizure disorder,and growth failure(height,weight,and head circumference)up to 72 months of age(P<0.0001).Surgical treatments were also significantly associated with abnormal developmental screening test results.Conclusions The neurodevelopmental outcomes of infants with IVH,especially those subjected to surgical treatments,continue to be a matter of concern.It is imperative to prioritize specialized care for patients receiving surgical treatments and closely monitor their growth and development after discharge to improve developmental prognosis.

Aneurysmal isolated intracerebral hemorrhage and/or intraventricular hemorrhage without subarachnoid hemorrhage: a rare and perplexing scenario in neurosurgical practice

Ruptured aneurysms with a presentation of intracerebral hemorrhage (ICH) and/or intraventricular hemorrhage (IVH)without subarachnoid hemorrhage (SAH) are rarely reported.Issues on the clinical characteristics,mechanism,diagnosis,treatment and prognosis of this rare entity are obscure to us.We present two cases of ruptured aneurysms with a presentation of isolated ICH.A systematic review of the literature was also conducted.There were 21 cases plus our cases.Good recovery was achieved in 10 patients (47.6 ％).Pertaining to location,38 ％ of presenting aneurysms were on the right side,52 ％ were on the left side,and 10 ％ were midline.Anterior circulation aneurysms were identified in 81％ of patients (7 PComA,8 MCA,1 ICA,1 AComA) and posterior in 19 ％ of patients (3 PCA,1 BA).Sizes of the aneurysms ranged from 3 mm to 40 mm (16.21 ± 8.45).Ruptured aneurysms at the main trunks of the Willis cycle with a presentation of isolated ICH and/or IVH without SAH is extremely rare.The cause of this rare entity is multifactorial.The diagnosis and management of this entity pose a great challenge to us.The prognosis was discouraging based on the now available data.

Neuroendoscopy Combined with Lateral Ventricle Drainage and Urokinase Infusion in the Treatment of 20 Patients with Hypertensive Intraventricular Hemorrhage

Objective:To explore the clinical efficacy of neuroendoscopy combined with lateral ventricle drainage and urokinase infusion for the treatment of hypertensive intraventricular hemorrhage.Methods:A retrospective analysis of 20 patients diagnosed with intraventricular hemorrhage between March 2017 and August 2018 at the First Affiliated Hospital of Medical College,Shihezi University(Shiohezi,China)was performed.While actively treating primary lesions,20 patients with intraventricular hemorrhage were selected and treated using minimally invasive neuroendoscopic removal of intraventricular hematoma combined with lateral ventricular drainage and urokinase perfusion according to each patient’s condition.Results:One day after surgery,head computed tomography examination revealed that>50% of the hematoma in the lateral ventricle was removed in 14 cases,and 20%-50% of the hematoma in the other 6 cases.After follow-up,13 patients exhibited satisfactory recovery,5 died(3 due to lung infection,1 due to intracranial infection,and 1 due to multiple organ failure),and 2 were in a vegetative state.Conclusion:Neuroendoscopy should be used as much as possible in treating intraventricular hemorrhage given its advantages of minimal injury,complete removal of hematoma,high safety,and wide clinical applicability.

In vivo Detection and Imaging of Intraventricular Hemorrhage in Neonatal Piglets Using Electrical Impedance Tomography

Intraventricular hemorrhage(IVH) is one of the most severe medical emergencies in neurosurgery. Early detection or diagnosis would significantly reduce the rate of disability and mortality, and improve the prognosis of the patients.Although present medical imaging techniques have high sensitivity to identify bleeding, the use of an additional, non-invasive imaging technique capable of continuously monitoring IVH is required to prevent contingent bleeding or re-bleeding. In this study, electrical impedance tomography(EIT) was applied to detect the onset of IVH modeled on 6 piglets in real time, with the subsequent process being monitored continuously. The experimental IVH model was introduced by one-time injection of 2 ml fresh autologous arterial blood into the ventricles of piglets.Results showed that resistivity variations within the brain caused by the added blood could be detected and imaged in vivo using the EIT method, and the magnitude and the size of region of interest on EIT images may be linearly associated with the volume of the blood. In conclusion, EIT has unique potential for use in clinical practice to provide invaluable real-time neuroimaging data for IVH after the improvement of electrode design, anisotropic realistic modeling, and instrumentation.

High SIOOB levels in cerebrospinal fluid and peripheral blood of patients with acute basal ganglial hemorrhage are associated with poor outcome

S100B is involved in brain injury. This study aimed to determine plasma and cerebral spinal fluid （CSF） levels of S100B in patients with spontaneous intracerebral hemorrhage （ICH）, and to correlate S100B levels with Glasgow Coma Scale （GCS） scores, ICH volumes, presence of intraventricular hemorrhage （IVH）, and survival rate, and to correlate CSF S100B levels with plasma 100B levels as well as CSF interleukin-1 beta （IL-1β）levels. Ten patients with suspicion of subarachnoid hemorrhage and 38 patients with spontaneous basal ganglia hemorrhage were included in the study. Their plasma and CSF samples were collected. The concentrations of IL-1β in CSF and S100B in plasma and CSF were analyzed by enzyme-linked immunosorbent assay. Plasma or CSF S100B levels in the ICH group were significantly higher than those in the control group （178.7±74.2 versus 63.2±23.0 pg/ml; P〈0.001 or 158.1±70.9 versus 1.8±0.7 ng/ml; P〈0.001）. S100B levels were highly associated with GCS scores, ICH volumes, presence of IVH, and survival rate （all P〈0.05）. CSF S100B levels were highly associated with plasma S100B levels as well as CSF IL-113 levels （both P〈0.01） in patients with ICH. A receiver operating characteristic curve identified CSF and plasma S100B cutoff levels that predicted 1-week mortality of patients with a high sensitivity and specificity. The areas under curves （AUCs） of GCS scores and ICH volumes were larger than those of CSF and plasma $100B levels, but the differences were not statistically significant （P〉0.05）. High levels of S100B are present in the cerebrospinal fluid and peripheral blood of patients with ICH and may contribute to the inflammatory processes of ICH. The levels of CSF and plasma S100B after spontaneous onset of ICH seem to correlate with clinical outcome in these patients. Increases in peripheral S100B properly reflect brain injury, and plasma S100B level may serve as a useful clinical marker for evaluating the prognosis of ICH.

Minimally invasive puncture and drainage or patients with hypertensive spontaneous basal ganglia intracerebral hemorrhage: A prospective non-randomized comparative study of 198 cases

Background: The treatment of hypertensive spontaneous intracranial hemorrhage(ICH) is still controversial. The purpose of the present study was to investigate whether minimally invasive puncture and drainage(MIPD) could provide improved patient outcome compared with decompressive craniectomy(DC).Methods: Eligible, consecutive patients with ICH(≥30 ml, in basal ganglia, within 24 hours of ictus) were nonrandomly assigned to receive MIPD(group A) or to undergo DC(group B) hematoma evacuation. The primary outcome was death at 30 days after onset. Functional independence was assessed at 1 year using the Glasgow Outcome Scale(GOS, scores range from 1 to 5, score 1 indicating death, ≥4 indicating functional independence, with lower scores indicating greater disability). Results: A total of 198 patients met the per protocol analysis(84 cases in group A and 114 cases in group B), including 9 cases lost during follow-up(2 cases in group A and 7 cases in group B). For these 9 patients, their last observed data were used as their final results for intention-to-treat analysis. The mean age of all patients was 57.1 years(range of 31-95 years), and 114 patients were male. The initial Glasgow Coma Scale(GCS) score was 8.1±3.4, and the National Institutes of Health Stroke Scale(NIHSS) score was 20.8±5.3. The mean hematoma volume(HV) was 56.7±23.0 ml(range of 30-144 ml), and there was extended intraventricular hemorrhage(IVH) in 134 patients(67.7%). There were no significant intergroup differences in the above baseline data, except group A had a higher mean age(59.4±14.5years) than the mean age of group B(55.3±11.1 years, P=0.025). The total cumulative mortalities at 30 days and 1 year were 32.3% and 43.4%, respectively, and there were no significant differences between groups A and B(30 days: 27.4% vs. 36.0%, P=0.203; 1 year: 36.1% vs. 48.2%, P=0.112, respectively). However, the mortality for patients ≤60 years, NIHSS【15 or HV≤60 ml was significantly lower in group A than that in group B(all P【0.05). The total cumulative functional independence at 1 year was 26.8%, and the difference between group A(33/43, 39.3%) and group B(20/144, 17.5%) was significant(absolute difference 21.7%, odds ratio [OR] 0.329, 95% confidence interval [CI] 0.171 to 0.631, P=0.001). For patient with severe IVH, the 30 days and 1 year mortality rates were significant lower in group B than those in group A(P=0.025, P=0.036). However, the number of favorable outcomes had no significant difference between groups at 1 year post ictus. Multivariate logistic regression analysis showed that a favorable outcome after 1 year was associated with the difference in therapies(OR 0.280, 95% CI 0.104–0.752, P=0.012), age(OR 0.215, 95% CI 0.069–0.671, P=0.008), GCS(OR 1.187, 95% CI 1.010–1.395, P=0.037), HV(OR 0.943, 95% CI 0.906–0.982, P=0.005), IVH(OR 0.655, 95% CI 0.506–0.849, P=0.001) and PI(OR 0.211, 95% CI 0.071–0.624, P=0.001). Conclusions: Our results suggest that for patients with hypertensive spontaneous ICH(HV≥30 ml in basal ganglia), MIPD may be a more effective treatment than DC, as assessed by a higher rate of functional independence at 1 year after onset as well as reduced mortality in patients ≤60 years of age, NIHSS【15 or HV≤60 ml. For patients with HV 】60 ml, deep coma and severe IVH, the outcomes of the two therapies were similar.

Intervention at an early threshold for post-hemorrhagic ventricular dilatation in preterm infants: a systematic review and meta-analysis

Background Very few adequately powered studies exploring early thresholds for intervention in the management of post-hemorrhagic ventricular dilatation(PHVD)in preterm infants have identified consistent neurodevelopmental advantages at 12–30 months.We aimed to conduct a meta-analysis on the efficacy and safety of early versus conservative thresholds for intervention,primarily aimed at normalizing cerebrospinal fluid(CSF)pressure,in the management of PHVD in preterm infants.Methods Multiple databases were searched for eligible papers,and prospective randomized trials involving preterm infants were selected.The results are expressed as relative risks(RRs)with 95%confidence intervals(CIs).The main outcome was survival without moderate-to-severe neurodevelopmental impairment at 12–30 months.Results Ten articles representing seven randomized trials comparing early versus conservative thresholds for interventions were included.Five trials(n=545 infants)reported no difference in the main outcome between early and conservative groups[RR 0.99(0.71,1.37)].Sensitivity analysis excluding data from a medication trial did not alter the main outcome[RR 1.15(0.95,1.39)].Infants in the early threshold group received significantly more interventions[RR 1.48(1.05,2.09)].Deaths before discharge/during the initial study period[RR 1.04(0.70,1.54)]or a composite of death or shunt insertion[RR 1.04(0.86,1.27)]were comparable between the two groups.Conclusions Early intervention for PHVD,before a clinical or ultrasound threshold is met,leads to additional clinical procedures but does not improve survival without moderate–severe neurodevelopmental impairment at 12–30 months.Caution should be exercised in interpreting these results due to significant variation between the studies.