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Figure 1. Coronal ultrasound images demonstrating Grade I (A), II (B), III (C) and IV (D) germinal matrix and intraventricular hemorrhages. The arrows demonstrate the echogenic hematoma in panels A-C. Cystic change in the brain parenchyma is illustrated in panel D (arrow).

The decision to treat PHH is made after measuring the head circumference over a period of time, following ventricular size on serial head ultrasound examinations, and assessing whether or not the infant is symptomatic. Interventions begin with minimally invasive procedures such as multiple lumbar punctures (LP), or ventricular taps (see Chapter 14). Neither LPs or ventricular taps have been shown to affect the ultimate need for permanent shunt placement in patients with PHH.

If there is evidence of ongoing CSF accumulation despite needle aspirations, a permanent CSF shunt is preferred. Technical problems related to shunt placement in neonates include proteinaceous CSF leading to earlier shunt obstruction, the fragility of the abdominal viscera, wound breakdown from erosion of the skin over the shunt hardware and delayed wound healing. Permanent shunt placement is avoided until infants weigh more than 1750 to 2000 g. Those infants requiring CSF

diversion can be treated by other alternatives such as external ventricular drainage or placement of a subcutaneous tapping reservoir. In the former, a ventricular catheter is placed in the frontal horn of the lateral ventricle and is connected to an external drainage bag, while in the latter, the catheter is attached to small subcutaneous silicone reservoir that can be aspirated repeatedly. Placement of a subcutaneous tapping reservoir is the preferred method of CSF drainage in most centers, with continuous drainage through an external catheter being avoided because of infectious complications. A newer option is placement of a ventriculosubgaleal shunt that directs CSF from the ventricle into the subgaleal space where some absorption occurs into the soft tissues of the scalp. This avoids the need for repeated aspirations, but does not work in all situations.

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