Intervention Review

Repeated lumbar or ventricular punctures in newborns with intraventricular hemorrhage

  1. Andrew Whitelaw*

Editorial Group: Cochrane Neonatal Group

Published Online: 22 JAN 2001

Assessed as up-to-date: 1 NOV 2000

DOI: 10.1002/14651858.CD000216

How to Cite

Whitelaw A. Repeated lumbar or ventricular punctures in newborns with intraventricular hemorrhage. Cochrane Database of Systematic Reviews 2001, Issue 1. Art. No.: CD000216. DOI: 10.1002/14651858.CD000216.

Author Information

  1. University of Bristol Medical School, Neonatal Intensive Care Unit, Bristol, UK

*Andrew Whitelaw, Neonatal Intensive Care Unit, University of Bristol Medical School, Southmead Hospital, Bristol, BS10 5NB, UK. andrew.whitelaw@bristol.ac.uk.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 22 JAN 2001

SEARCH

 

Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

Although it has been possible to reduce the percentage of premature infants suffering intraventricular hemorrhage, posthemorrhagic hydrocephalus remains a serious problem without a good treatment. There is a high rate of cerebral palsy, and ventriculoperitoneal shunt surgery makes the child permanently dependent on the valve and catheter system. Shunt surgery cannot be carried out early because of the blood in the cerebrospinal fluid (CSF) and the brain may be subjected to periods of raised pressure. Early tapping of CSF by lumbar puncture or ventricular tap was suggested as a way of temporarily reducing pressure and removing blood and protein and thereby avoiding permanent hydrocephalus.

Objectives

To determine whether repeated CSF tapping, by lumbar puncture or ventricular tap, reduced the risk of permanent shunt dependence, neurodevelopmental disability or death in neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus (PHH). This form of treatment was based on the hypothesis that repeated tapping removed protein and blood from the CSF, thus clearing obstruction from the channels of CSF absorption.

Search methods

Pediatric, Neurosurgical and General Medical Journals were handsearched from 1976 up to October 2000, as well as the Medline database (via PubMed) and the Cochrane Controlled Trials Register. Personal contacts were used.

Selection criteria

Four controlled trials ( with five published papers) were identified, three being randomised and the fourth using alternative allocation. Two trials evaluated repeated lumbar punctures in neonates with intraventricular hemorrhage (IVH) and two trials evaluated repeated CSF tapping infants with IVH followed by progressive ventricular dilatation.

Data collection and analysis

In addition to details of the patient selection and patient allocation, the interventions were extracted. The end-points examined were: ventriculoperitoneal shunt, death, disability, multiple disability and death or disability.

Main results

The studies were sufficiently similar in the question they were asking and the interventions were sufficiently in common that they could be combined when assessing the effect of the intervention. When repeated CSF tapping was compared to conservative treatment, the relative risks for shunt placement, death, disability and multiple disability were very close to 1.0 with no statistically significant effect. There is also evidence that this form of treatment increased the risk of CSF infection.

Authors' conclusions

Early repeated CSF tapping cannot be recommended for neonates at risk of, or actually developing, post-hemorrhagic hydrocephalus.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Repeated lumbar or ventricular punctures in newborns with intraventricular hemorrhage

Intraventricular hemorrhage (IVH) is a major complication of premature birth and a cause of cerebral palsy and hydrocephalus. Repeated early lumbar puncture or ventricular taps have been advocated as a way of avoiding hydrocephalus and protecting the brain from pressure. It was thought that the risk of hydrocephalus and the need for a ventriculoperitoneal shunt might be reduced by the removal of protein and old blood in the cerebrospinal fluid. This hypothesis has been tested in four randomised trials involving premature infants in whom IVH (with or without established enlargement) was diagnosed by ultrasound. There is no evidence that early tapping of cerebrospinal fluid by lumbar puncture or ventricular tap reduces the risk of shunt dependence, disability, multiple disability or death. The use of repeated taps was associated with an increased risk of central nervous system infection. Thus the early use of early tapping cannot be recommended. Removing cerebrospinal fluid should be reserved for cases where there is symptomatic raised intracranial pressure.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

用重複性腰椎穿刺或腦室穿刺來治療新生兒之腦室內出血

儘管已經可以降低早產兒發生腦室內出血之比例,出血後之水腦症仍為一種嚴重的問題且無良好之治療方式。其會造成高腦性麻痺率,而腦室腹膜分流手術會使該名兒童永久依賴該閥門及導管系統。因為腦脊髓液 (cerebrospinal fluid;CSF) 有血液之存在而使分流手術並無法在早期進行,在這段時間中可能便會有腦壓升高之情形。已有建議使用腰椎穿刺或腦室穿刺來引流CSF,以暫時減除腦壓並除去腦室中之血液及蛋白質,並因此而可以避免產生永久性之水腦症。

目標

判定以腰椎穿刺或腦室穿刺所進行之重複性CSF穿刺引流,對於具有出血後水腦症 (posthemorrhagic hydrocephalus;PHH) 風險或是實際發生該病症之新生兒,是否可降低其產生永久性分流管依賴性、神經發展障礙、或死亡。此種形式之治療係假設重複穿刺可移除CSF中之蛋白質及血液,因此可清除CSF在吸收時之回流管道的阻礙。

搜尋策略

人工搜尋小兒科、神經科以及一般之醫學期刊,時間自1976 直到2000年10月,也搜尋Medline 資料庫 (透過PubMed搜尋) 與Cochrane Controlled Trials Register,並進行私人的聯繫。

選擇標準

共辨識出4組對照試驗 (共有5篇已刊登之論文) ,其中3組為隨機分派,而第4項則係使用選擇性分派方式。其中2項試驗係針對腦室內出血 (intraventricular hemorrhage;IVH) 之新生兒評估重複之腰椎穿刺,而另外2項試驗則係針對具有IVH並之後發生進行性腦室擴張之嬰兒來評估重複之CSF穿刺。

資料收集與分析

除了病患選擇以及病患分派的細節之外,亦摘錄處置措施。檢驗之端點為:腦室腹膜分流手術、死亡、殘障、多重殘障、以及死亡或殘障。

主要結論

這些研究在所要探究之問題具有足夠的相似度,而處置亦有足夠之相同性,因此在評估該處置之效果時得以合併在一起評估。在比較重複之CSF穿刺與保守性治療時,針對分流手術、死亡、殘障、及多重殘障之相對風險皆非常接近1.0,並不具有統計意義之效應。亦有證據顯示重複之CSF穿刺會增加CSF感染之風險。

作者結論

並無法對具有出血後水腦症風險或是實際發生該病症之新生兒推薦採用早期之重複性CSF穿刺。

翻譯人

此翻譯計畫由臺灣國家衛生研究院 (National Health Research Institutes, Taiwan) 統籌。

總結

腦室內出血 (intraventricular hemorrhage;IVH) 是早產的主要併發症之一,並為造成腦性痲痹及水腦症之肇因之一。重複性之早期腰椎穿刺或腦室穿刺已被主張為一種可用於避免水腦症並保護腦部不受壓力傷害之方法。咸認為,發生水腦症之風險以及對於腦室腹膜分流術之需求可藉著除去腦脊髓液中之蛋白及舊血液而降低。此一假設已在4項隨機試驗中檢驗,該等試驗係涉及經超音波診斷具有IVH (有或無既有之腦室擴大情形) 。並無證據可支持,以腰椎穿刺或腦室穿刺所進行之腦脊髓液早期穿刺能夠降低需要分流管依賴性、殘障、多重殘障、或死亡之風險。重複之穿刺具有較高的中樞神經系統感染風險。因此,無法推薦採用早期穿刺。腦脊髓液之抽取應保留用於有症狀之顱內壓升高之情形。