Neuroendoscopic lavage for periventricular-intraventricular hemorrhage [Neurosurgery Wiki]

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======  Neuroendoscopic lavage for periventricular-intraventricular hemorrhage ======

//[[J.Sales-Llopis]]//

//Neurosurgery Department, [[General University Hospital Alicante]], [[Spain]]//
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[[Neuroendoscopic lavage]] for [[periventricular-intraventricular hemorrhage]] (PIVH) is an emerging surgical [[approach]] aimed at improving the [[clearance]] of [[intraventricular]] [[blood clot]]s, reducing [[hydrocephalus]], and improving [[neurological outcome]]s in affected patients. Here's an overview of the technique and its implications:

===== Indications =====

Neuroendoscopic lavage is typically indicated in cases of:

1. **Severe [[intraventricular hemorrhage]] (IVH)** associated with [[periventricular hemorrhage]].

2. **[[Obstructive hydrocephalus]]** caused by [[blood clot]]s in the [[ventricular]] [[system]].

3. Cases where [[conservative management]] or [[external ventricular drainage]] (EVD) alone is insufficient for clot resolution.

===== Procedure =====

The procedure involves using a neuroendoscope to directly access the ventricular system. Key steps include:

1. **Ventricular [[access]]:** A [[burr hole]] is created to access the affected ventricle under [[neuronavigation]] [[guidance]].

2. **Neuroendoscopic [[insertion]]:** A flexible or rigid [[endoscope]] is introduced into the [[ventricle]].

3. **[[Clot]] [[removal]]:** [[Blood clot]]s are aspirated or fragmented under direct [[visualization]] using specialized instruments or saline irrigation.

4. **[[Irrigation]]:** The ventricles are irrigated with warmed saline to ensure clearance of debris and residual clots.

5. **EVD [[placement]]:** Often, an [[external ventricular drain]] is left in place to monitor [[intracranial pressure]] (ICP) and facilitate further [[drainage]] of blood or [[cerebrospinal fluid]] (CSF).

===== Advantages =====

1. **Enhanced clot [[clearance]]:** Direct visualization allows for targeted and effective removal of clots, reducing clot burden and the associated risk of persistent hydrocephalus.

2. **Reduced [[inflammation]]:** By removing blood and its breakdown products, neuroendoscopic lavage may decrease the inflammatory response that contributes to ventricular scarring and hydrocephalus.

3. **[[Minimally invasive]]:** Compared to open surgical approaches, it involves smaller incisions and reduced disruption of brain tissue.

4. **Potential for improved [[outcome]]s:** Studies have suggested better neurological recovery and lower rates of shunt dependency in some cases.

===== Challenges and Limitations =====

1. **Technical [[expertise]]:** The procedure requires advanced neuroendoscopic skills and specialized equipment.

2. **[[Risk]]s:** Complications include infection, hemorrhage, or damage to ventricular structures.

3. **Not universally applicable:** It is most effective in cases where clot consistency and location are suitable for endoscopic removal.

4. **Limited [[evidence]]:** While promising, robust [[clinical trial]]s are needed to establish its [[efficacy]] compared to [[standard]] treatments.


===== Outcomes =====

- Early studies indicate that [[neuroendoscopic lavage]] can reduce [[mortality]] and improve [[functional outcome]]s in patients with PIVH and hydrocephalus.

- It may decrease the need for permanent CSF shunting and lower rates of complications related to prolonged EVD use.

===== Future Directions =====

1. **[[Standardization]]:** Developing standardized protocols for patient selection and procedural techniques.

2. **Technological [[advance]]s:** Innovations in endoscopic [[tool]]s and [[navigation system]]s to enhance safety and efficacy.

3. **Long-term studies:** Further research to evaluate the long-term benefits and cost-effectiveness of neuroendoscopic lavage.
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The current [[neurosurgical procedure]] for [[periventricular-intraventricular hemorrhage]] resulting in [[posthemorrhagic hydrocephalus]] (PHH) seeks to reduce [[intracranial pressure]] with temporary and then [[Cerebrospinal fluid shunt]]. In contrast, [[neuroendoscopic lavage]] (NEL) directly addresses the [[intraventricular]] [[blood]] that is hypothesized to damage the [[ependyma]] and [[parenchyma]], leading to ventricular [[dilation]] and [[hydrocephalus]]. 

===== Systematic reviews =====
Wassef et al. conducted a [[systematic review]] of the literature on neuroendoscopic lavage in IVH of prematurity to examine data on the choice of [[neuroendoscope]] and outcomes regarding shunt rate. They then collected manufacturer data on neuroendoscopic [[device]]s, including inflow and outflow mechanisms, working channel specifications, and tools compatible with the working channel. We paired this information with the advantages and disadvantages reported in the literature and observations from the experiences of pediatric neurosurgeons from several institutions to provide a pragmatic evaluation of international clinical experience with each neuro endoscope in NEL.

Eight studies were identified; four [[neuroendoscope]]s have been used for NEL as reported in the literature. These include the Karl Storz Flexible Neuroendoscope, [[LOTTA]]® system, GAAB system, and Aesculap [[MINOP]]® system. The LOTTA® and MINOP® systems were similar in setup and instrument options. Positive neuroendoscope features for NEL include increased degrees of visualization, better visualization with the evolution of light and camera sources, the ability to sterilize with autoclave processes, balanced inflow and outflow mechanisms via separate channels, and a working channel. Neuroendoscope disadvantages for NEL may include special sterilization requirements, large outer diameter, and limitations in working channels.

A neuroendoscope integrating continuous irrigation, characterized by measured inflow and outflow via separate channels and multiple associated instruments, appears to be the most commonly used technology in the literature. As neuro endoscopes evolve, maximizing clear visualization, adequate inflow, measured outflow, and large enough working channels for paired instrumentation while minimizing the footprint of the outer diameter will be most advantageous when applied for NEL in premature infants
((Wassef CE, Thomale UW, LoPresti MA, DeCuypere MG, Raskin JS, Mukherjee S, Aquilina K, Lam SK. Experience in endoscope choice for neuroendoscopic lavage for intraventricular hemorrhage of prematurity: a systematic review. Childs Nerv Syst. 2024 Aug;40(8):2373-2384. doi: 10.1007/s00381-024-06408-6. Epub 2024 May 27. PMID: 38801444; PMCID: PMC11269422.)).
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Wassef et al.'s review provides an essential contribution to the understanding of neuroendoscopic technology in the context of NEL for IVH in premature infants. While the study outlines critical device features and evolving trends, its conclusions are constrained by limited data and a lack of quantitative analysis. Nevertheless, the work highlights key priorities for technological and clinical advancement, serving as a foundation for future research and innovation in this challenging yet promising area of pediatric neurosurgery.

===== Retrospective cohort studies =====

The [[record]]s of patients with a diagnosis of grade III or IV IVH were reviewed between September [[2022]] and February [[2024]]. The [[Papile-Burstein classification]] grade was determined on cranial [[ultrasonography]]. Demographic information collected included gestational age, birth weight, weight at the time of surgical [[intervention]], [[infection]] confirmed with CSF, and hemorrhage. Standard local [[guideline]]s for temporary (CSF reservoir) and permanent (shunt or [[endoscopic third ventriculostomy]] ([[ETV]]) CSF [[diversion]] was implemented. Warmed [[Lactated Ringer's]] was utilized for NEL. The primary outcome was the need for permanent CSF diversion ([[shunt]] or [[ETV]]).

Twenty consecutive patients with grade III or IV IVH complicated by PHH were identified. Twelve patients underwent CSF reservoir placement and NEL, 4 underwent CSF reservoir placement only, 1 underwent shunt placement only, and 3 did not require neurosurgical intervention. Of the 12 patients who underwent reservoir placement and NEL, 8 (67%) ultimately met the criteria for permanent CSF diversion compared with 2 of 4 (50%) who underwent CSF reservoir placement only. The mean gestational age at birth, birth weights, and age/weight at the time of temporary CSF diversion were similar across groups. The average time interval between temporary and permanent CSF diversion was longer in patients who underwent NEL (2.5 months for shunt and 6.5 months for ETV) compared with CSF reservoir placement only (1.1 months).

NEL is an innovative alternative for the treatment of PHH of prematurity. Flanders et al. from the New York University Grossman School of Medicine,  Department of Pediatrics, Children's Hospital of Philadelphia, Pennsylvania established an [[endoscopic]] lavage program at their [[institution]] and herein report the first published account in the [[United States]] of the feasibility of NEL for PHH
((Flanders TM, Hwang M, Julian NW, Sarris CE, Flibotte JJ, DeMauro SB, Munson DA, Heimall LM, Collins YC, Bamberski JM, Sturak MA, Storm PB, Lang SS, Heuer GG. [[Neuroendoscopic lavage]] for [[posthemorrhagic hydrocephalus]] of [[prematurity]]: [[preliminary]] [[result]]s at a single [[institution]] in the [[United States]]. J Neurosurg Pediatr. 2025 Jan 24:1-8. doi: 10.3171/2024.10.PEDS24119. Epub ahead of print. PMID: 39854725.)).
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Flanders et al. provide an intriguing glimpse into the potential of neuroendoscopic lavage for managing PHH of prematurity. While the approach is innovative and technically feasible, the study's small sample size, lack of randomization, and limited long-term outcome data temper the enthusiasm for immediate adoption. Further research is essential to confirm the efficacy, safety, and cost-effectiveness of NEL, ensuring its role as a viable alternative or adjunct to existing treatment paradigms for PHH.

===== Comparative retrospective studies =====

Between August 2010 and December 2012 (29 months), 19 neonates with posthemorrhagic hydrocephalus underwent neuroendoscopic lavage for removal of intraventricular blood remnants. During a similar length of time (29 months) from March 2008 to July 2010, 10 neonates were treated conventionally, initially using temporary CSF diversion via lumbar punctures, a ventricular access device, or an external ventricular drain. Complications and shunt dependency rates were evaluated retrospectively. Results The patient groups did not differ regarding gestational age and birth weight. In the endoscopy group, no relevant procedure-related complications were observed. After the endoscopic lavage, 11 (58%) of 19 patients required a later shunt insertion, as compared with 100% of infants treated conventionally (p < 0.05). Endoscopic lavage was associated with fewer numbers of overall necessary procedures (median 2 vs 3.5 per patient, respectively; p = 0.08), significantly fewer infections (2 vs 5 patients, respectively; p < 0.05), and supratentorial multiloculated hydrocephalus (0 vs 4 patients, respectively; p < 0.01) [corrected]. Conclusions Within the presented setup the authors could demonstrate the feasibility and safety of neuro-endoscopic lavage for the treatment of posthemorrhagic hydrocephalus in neonates with IVH. The nominally improved results warrant further verification in a multicenter, prospective study
((Schulz M, Bührer C, Pohl-Schickinger A, Haberl H, Thomale UW. [[Neuroendoscopic lavage]] for the [[treatment]] of [[intraventricular hemorrhage]] and [[hydrocephalus]] in [[neonate]]s. J Neurosurg Pediatr. 2014 Jun;13(6):626-35. doi: 10.3171/2014.2.PEDS13397. Epub 2014 Apr 4. Erratum in: J Neurosurg Pediatr. 2014 Jun;13(6):706. PMID: 24702621.)).
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The study provides a compelling case for the feasibility and safety of neuroendoscopic lavage in neonates with posthemorrhagic hydrocephalus. The lower rates of shunt dependency, infections, and multiloculated hydrocephalus are encouraging and suggest a potential benefit of NEL over conventional management.

However, the study's limitations, particularly its retrospective design, small sample size, and lack of long-term outcomes, necessitate further investigation. A multicenter, prospective study is critical to validate these findings, optimize patient selection, and determine the technique's broader applicability and impact on long-term neurodevelopment.

This study represents a promising step forward, but cautious interpretation is essential until more robust evidence emerges.