Outcome, cost analysis, and long-term follow-up in preterm infants with massive Grade IV germinal matrix hemorrhage and progressive hydrocephalus

OBJECTIVE: The benefit of aggressive management and surgical intervention in preterm infants with massive Grade IV intracranial hemorrhage has been questioned based on the poor outcome of this group of patients despite such therapy. To further delineate this problem, we reviewed the records of premature neonates in this category as to outcome and initial hospital cost. METHODS: We performed a retrospective review of the medical records at our institution from 1977 to 1987 to identify premature neonates who had sustained massive hemorrhagic infarction of one hemisphere in addition to having blood in both ventricles and progressive hydrocephalus. RESULTS: During the study, a total of 52 such patients were identified, only 19 (6 female and 13 male patients) of whom survived. Intellectual function was observed to be greater than 2 standard deviations below the mean in 15 of the 19 patients, between 1 and 2 standard deviations below the mean in 1 of 19, and 1 standard deviation below the mean in 3 of 19. Motor function was as follows: 12 of 19 had marked spastic quadriparesis, 2 of 19 had moderate spastic quadriparesis, 3 of 19 had spastic hemiplegia, 1 of 19 had spastic diplegia, and 1 of 19 had mild spastic hemiparesis. Eleven of 19 had chronic seizure disorders. The first hospitalization cost for the group of patients exceeded, on the average, $150,000 per patient for the 19 long-term survivors. CONCLUSION: As we have previously reported, logistic regression analysis determined that grade of hemorrhage was the only significant predictor of cognitive and motor outcomes. Most premature neonates with massive intracranial hemorrhages do not survive. The outcomes in those who do is very poor and the cost so high that we suggest that until therapeutic intervention exhibits efficacy, the consideration of withdrawal of life support should be presented as an option to the parents of these unfortunate children.