Dear Editor

We read this article with interest, and it prompted us to review our own experience with progressive ventricular dilatation (PVD) over the past 22 years at the Maine Medical Center (MMC) in Portland, Maine.

Since 1980, we have used a single approach to management of PVD. As noted in previous publications, we have considered the need for intervention to be rapid head growth defined as an increase in OFC of 2 cm per week or more rather than relying on imaging.[1,2] As this degree of head growth suggests increased intracranial pressure,[3] we have intervened by directly draining ventricular fluid via a 21 gauge angiocath placed through the right coronal suture into the right lateral ventricle. This catheter is connected to a ventriculostomy drainage system and drainage is continued for 7 days if possible. The catheter is then removed and the drop in head circumference and ventricular size recorded. The infant is watched for return of rapid head growth and an angiocath is reinserted as needed. This procedure is repeated until the infant reaches approximately 2 kg, and if rapid head growth continues, a permanent VP shunt is placed.[2] We do not use pharmacological treatment or repeat LP to treat PVD.

As pointed out by the authors, PVD sufficient to require intervention occurs almost exclusively in infants with grade 3 or 4 IVH. As expected, the VLBW infants with high grade IVH have a high mortality. The table below shows a comparison between the outcomes for grade 3-4 IVH at MMC during the 1980s and over the past 5 years (1997-2001 inclusive), and the authors' data grouped in the same way. As noted, there is little difference over time or between studies. Overall mortality for grade 3-4 IVH was 33 % (26/79) for Murphy et al, 33 % (31/94) for MMC 1980s and 31 % (9/29) for MMC 1997-2001. Until grade 3-4 IVH can be eliminated, post-haemorraghic hydrocephalus will continue to occur with high morbidity and mortality.

* Rate for all infants <_35 weeksbr="weeksbr"> ** Rate for all deaths <_30 days="days" _="_" font="font">

References

(1) Allan WC, Holt PJ, Sawyer LR, et al. Ventricular dilation after neonatal periventricular-intraventricular hemorrhage. Natural history and therapeutic implications. American Journal of Diseases in Children 1982;136:589-93.

(2) Marro PJ, Dransfield DA, Mott SH, et al. Posthemorrhagic hydrocephalus: Use of an intravenous-type catheter for cerebrospinal fluid drainage. American Journal of Diseases in Children 1991;145:1141-6.

(3) Hill A, Volpe JJ. Normal pressure hydrocephalus in the newborn Pediatrics 1981;68:623-9.

(4) Murphy BP, Inder TE, Rooks V, et al. Posthaemorrhagic ventricular dilatation in the premature infant: natural history and predictors of outcome. Arch Dis Child Fetal Neonatal Ed 2002;87:F37-F41