Minimally Invasive Brain Surgery Saves 22-Day-Old Infant in Coimbatore

A premature infant, just 22 days old and weighing only 1,200 grams, successfully underwent a groundbreaking endoscopic third ventriculostomy (ETV) procedure. Born at 29 weeks of gestation, the baby had experienced a germinal matrix hemorrhage and displayed clinical signs of hydrocephalus, necessitating prompt medical intervention to prevent potential neurological damage.

Traditional treatment methods like ventriculoperitoneal (VP) and ventriculoatrial (VA) shunts are widely used for managing hydrocephalus. However, these approaches often come with higher risks of infection and mechanical failure. In contrast, ETV provides a minimally invasive alternative that improves cerebrospinal fluid (CSF) drainage without requiring foreign devices, significantly reducing associated complications.

This case sets a new benchmark, surpassing the previous record for the youngest patient to undergo ETV, previously documented at 25 days old and weighing 1,850 grams. The procedure was expertly performed by a multidisciplinary team from KG Hospital, including Dr. G. Bhaktatchalam (Chairman), Dr. Rajkumar (Neurosurgeon), Dr. Ramakrishna (Neurologist), Dr. Srinivasan (Pediatrician), and Dr. Selvakumar (Anesthetist).

Understanding Germinal Matrix Hemorrhage:

The germinal matrix, located in the subependymal region, is a key site for the development of future neuronal and glial cells. During the prenatal and fetal stages, when cerebrovascular autoregulation is underdeveloped, the thin-walled blood vessels of the germinal matrix can rupture, leading to hemorrhage. Factors such as extreme prematurity and very low birth weight significantly increase the risk of germinal matrix hemorrhage (GMH). This highly vascular tissue, situated near the caudothalamic groove beneath the lateral ventricles, is present between the 24th and 32nd weeks of gestation. During this period, the germinal matrix is particularly sensitive to conditions like hypoxemia and ischemia.

Later in pregnancy, the neuroectodermal cells from the germinal matrix migrate to form the cerebral cortex. Hemorrhages originating in the germinal matrix, commonly referred to as periventricular-intraventricular hemorrhages (PVIH), are the most prevalent type of intracranial hemorrhages in neonates. These hemorrhages are often triggered by perinatal stress affecting the delicate and vascularized subependymal region. Most cases occur in premature infants within their first week of life, contributing to significant morbidity and mortality in this population.^[1][2]

Hydrocephalus: Causes and Implications

Hydrocephalus refers to the abnormal accumulation of cerebrospinal fluid (CSF) within the brain. This condition causes the ventricles, the cavities in the brain, to enlarge, exerting harmful pressure on surrounding brain tissues. Hydrocephalus may develop at birth (congenital) or arise later due to injury or damage, such as complications from GMH.

CSF is crucial for protecting and cushioning the brain and spinal cord. It flows through the ventricles, bathing the brain and spinal cord, and is eventually reabsorbed into the bloodstream. However, when CSF builds up excessively, it disrupts normal brain function, potentially causing severe brain damage or even death.

Hydrocephalus can affect people of all ages but is particularly concerning in infants. Congenital hydrocephalus occurs at or shortly after birth, often requiring early intervention.^[3]

Endoscopic Third Ventriculostomy: A Modern Solution

Endoscopic Third Ventriculostomy (ETV) is a surgical procedure designed to enhance the flow of cerebrospinal fluid (CSF) from the brain. During the procedure, a small opening is created at the base of the third ventricle, allowing CSF to bypass any obstructions and relieve pressure. In some cases, ETV is performed in conjunction with choroid plexus cauterization (CPC) to reduce CSF production. CPC involves using an electric current to cauterize the choroid plexus, the tissue responsible for producing CSF, located in the lateral ventricles. This combined approach helps lower CSF levels more effectively, reducing the risk of complications associated with excessive fluid buildup.^[3]

References:

1. ScienceDirect. "Germinal Matrix Hemorrhage." Accessed January 16, 2025. https://www.sciencedirect.com/topics/medicine-and-dentistry/germinal-matrix-hemorrhage.

2. Radiopaedia. "Germinal Matrix Haemorrhage." Accessed January 16, 2025. https://radiopaedia.org/articles/germinal-matrix-haemorrhage.

3. National Institute of Neurological Disorders and Stroke (NINDS). "Hydrocephalus." Accessed January 16, 2025. https://www.ninds.nih.gov/health-information/disorders/hydrocephalus.

(Input from various sources)

(Rehash/Sai Sindhuja K/MSM)