BRISTOL, United Kingdom -- March 8, 2010 -- Research published online in the journal Pediatrics has shown that, after a haemorrhage, the fluid inside the ventricles contains substances potentially toxic to the immature brain. However, if the brain is "washed out" to remove the toxic substances, the outcomes of the premature babies improve.
One of the most feared complications of being born very early is bleeding into the ventricles in the centre of the brain. A large haemorrhage usually injures the developing brain with consequent cerebral palsy and serious learning difficulties in several hundred children each year in the UK. In about half of the children, fluid builds up inside the brain causing the brain and head to expand excessively.
Until now, no treatment in these premature babies has been shown to reduce disability, or improve any aspect of health. The standard approach has been to repeatedly insert needles into the spine or head to remove fluid until, after several months, a permanent surgical shunt drains fluid from the brain to the abdomen.
"Premature babies are particularly at risk of bleeding because in the middle of pregnancy, the fetus has many fragile blood vessels in the centre of the brain," said Andrew Whitelaw, MD, Neonatal Medicine, University of Bristol, Bristol, United Kingdom. "These blood vessels shrink by full term and bleeding is rare in babies born at 40 weeks."
Dr. Whitelaw and Ian Pople, MD, North Bristol NHS Trust, Bristol, United Kingdom, have researched the mechanisms and treatment of hydrocephalus over the last 20 years.
If a premature baby was shown by repeated ultrasound scans to have had a large haemorrhage and then expanded ventricles, the baby was anaesthetised and 2 tubes were inserted into the ventricles in the brain. One tube was used to continuously drain out the cola-coloured fluid while the other tube was used to let clear fluid flow in. The pressure in the brain was measured continuously and more fluid was drained out than flowed in so the brain slowly decompressed. When the fluid draining out cleared, the 2 tubes were removed. This took on average 3 days. After 4 years work on the feasibility and practicality of the technique, a randomised trial was started.
From 2003 to 2006, 77 premature babies with large brain haemorrhages in Bristol, Glasgow, Katowice (Poland) and Bergen (Norway) were recruited. Thirty-nine babies had the ventricles washed out using the Drainage, Irrigation and Fibrinolytic Therapy (DRIFT) and 38 had standard treatment.
When they were aged 2 years, independent assessors examined all the survivors. Of 39 infants assigned to being washed out, 21 (54%) died or were severely disabled versus 27 of 38 (71%) in the standard group. Amongst the survivors, 11 of 35 (31%) in the DRIFT group had severe cognitive disability versus 19 of 32 (59%) in the standard group.
Median Mental Development Index was 68 (out of 100) in the washout group, and below 50 with standard care. These results are clinically significant.
"This is the first time that any treatment anywhere in the world has been shown to benefit these very vulnerable babies," said Dr. Pople. "Initially known as 'Drainage, Irrigation and Fibrinolytic Therapy (DRIFT)' this treatment is now called ventricular lavage."
SOURCE: University of Bristol
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