320 - Standardized Post-Hemorrhagic Hydrocephalus Management in Preterm Infants: Early Lumbar Puncture and Outcomes

Publication Number: 4314.320

Caitlin R. Royse, UCSF Benioff Children's Hospital San Francisco, San Mateo, CA, United States; Mark A. Petersen, University of California, San Francisco, School of Medicine, San Francisco, CA, United States; Hannah Glass, University of California, San Francisco, School of Medicine, San Francisco, CA, United States; Katelin Kramer, UCSF Benioff Children's Hospital San Francisco, Burlingame, CA, United States; Elizabeth E. Rogers, University of California, San Francisco, School of Medicine, San Francisco, CA, United States; Marie-Coralie Cornet, UCSF Benioff Children's Hospital San Francisco, San Francisco, CA, United States

Background: Post-hemorrhagic hydrocephalus (PHH) is a complication of intraventricular hemorrhage (IVH) in preterm infants and a leading cause of neurodevelopmental impairment. Early cerebrospinal fluid (CSF) diversion-before intracranial hypertension develops-may improve outcomes, yet management practices vary. The Levene Index provides an objective head ultrasound (HUS) threshold to guide timely intervention.

Objective: To evaluate outcomes of preterm infants with PHH exceeding the Levene Index threshold (>97th percentile + 4 mm) after implementation of a standardized PHH management guideline (Figure 1), including timing and frequency of lumbar punctures (LPs) and CSF diversion.

Design/Methods: We performed a retrospective review of preterm infants with PHH admitted to a single-center level IV NICU (01/2023-02/2025) following implementation of a standardized PHH management guideline. Data included perinatal characteristics, IVH grade, clinical ventriculomegaly (defined as subjective assessment of dilated ventricles on HUS), Levene Index threshold (Levene index exceeds 97%ile + 4mm curve for gestational age), LP timing, and need for CSF diversion. Descriptive analyses were performed. This study was approved by the UCSF IRB as an exempt, no-patient-contact study.

Results: Before guideline adoption, management was highly variable. Among 168 infants born at < 30 weeks' gestation admitted to our center after implementation, 33/168 (20%) developed grade II-IV IVH and 14/33 (42%) developed ventriculomegaly that exceeded the Levene Index threshold for intervention (Table 1). One resolved without intervention, four were redirected to palliative care without intervention, and LP was attempted in nine infants (successful in eight; six within 48 hours of threshold exceedance). The number of LPs performed varied between 1 and 4 (median 3). Eight of 14 (57%) received neurosurgical CSF diversion: tappable intraventricular reservoir (n=4) in 3/4 cases associated with a subgaleal shunt, ventricular lavage (n=3), and immediate VP shunt (n=1). Four infants later received a ventriculoperitoneal (VP) shunt as a secondary intervention. Detailed information on patients who underwent diversion is presented in Table 2.

Conclusion(s): Implementation of a standardized PHH management guideline was associated with timely and consistent LP use among infants exceeding the Levene Index threshold. Multiple LPs were often required for temporization, and all but one received permanent neurosurgical diversion. Our findings support the feasibility of structured PHH pathways and highlight opportunities to optimize early interventions.

Preterm Post-Hemorrhagic Management Guideline
Adapted from El Dib et al, Pediatr 2020. HUS: head ultrasound; HC: head circumference; DOL: days of life; IVH: intraventricular hemorrhage

Characteristics of Infants with Post-Hemorrhagic Ventriculomegaly Stratified by exceeding Levene Index Threshold


Description of the 8 Infants Who Required Neurosurgical Interventions
LP: lumbar puncture