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Key Features

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Essentials of Diagnosis
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  • Large bleeds cause hypotension, metabolic acidosis, and altered neurologic status; smaller bleeds can be asymptomatic

  • Routine cranial ultrasound scanning is essential for diagnosis in infants born before 32 weeks' gestation

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General Considerations
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  • Occurs almost exclusively in premature infants

  • Incidence is 15–25% in infants born before 31 weeks' gestation and weighing less than 1500 g

  • Highest incidence occurs in infants of the lowest gestational age (< 26 weeks)

  • Bleeding

    • Most commonly occurs in the subependymal germinal matrix (a region of undifferentiated cells adjacent to or lining the lateral ventricles)

    • Can extend into the ventricular cavity

    • Actual amount is influenced by a variety of factors that affect the pressure gradient across the injured capillary wall, such as venous congestion

    • This pathogenetic scheme applies also to intraparenchymal bleeding (venous infarction in a region rendered ischemic) and to periventricular leukomalacia (PVL) (ischemic white matter injury in a water-shed region of arterial supply)

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Clinical Findings

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  • Up to 50% of hemorrhages occur before 24 hours of age, and virtually all occur by the fourth day

  • Clinical syndrome ranges from rapid deterioration (coma, hypoventilation, decerebrate posturing, fixed pupils, bulging anterior fontanelle, hypotension, acidosis, or acute drop in hematocrit) to a more gradual deterioration with more subtle neurologic changes, to absence of any specific physiologic or neurologic signs

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Diagnosis

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  • Can be confirmed by real-time ultrasound scan

  • Routine scanning should be done at 10–14 days in all infants born before 29 weeks' gestation

  • Hemorrhages are graded as follows

    • Grade I, germinal matrix hemorrhage only

    • Grade II, intraventricular bleeding without ventricular enlargement

    • Grade III, intraventricular bleeding with ventricular enlargement

    • Grade IV, any intraparenchymal bleeding

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Treatment

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  • During acute hemorrhage, supportive treatment (restoration of volume and hematocrit, oxygenation, and ventilation) should be provided to avoid further cerebral ischemia

  • Progressive posthemorrhagic hydrocephalus is treated initially with a subgaleal shunt; when the infant is large enough, this can be converted to a ventriculoperitoneal shunt

  • Maternal antenatal treatment

    • Corticosteroids appear to decrease the risk of intracranial bleeding

    • Phenobarbital may have a role in the mother who has not received corticosteroids and is delivering before 28 weeks' gestation

    • Magnesium sulfate administered to the mother appears to reduce the rate of cerebral palsy, although not the rate of intraventricular hemorrhage per se

    • Infants delivered by cesarean section have a decreased rate of intracranial bleed

  • Postnatal strategies are less effective

  • Early indomethacin administration may have some benefit in minimizing bleeding, especially in males, with unclear influence on long-term outcome

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Outcome

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Follow-Up
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  • An initial follow-up scan should be done 1–2 weeks after the initial scan

  • Infants with intraventricular bleeding and ventricular enlargement should be monitored every 7–10 days until ventricular enlargement stabilizes or decreases

  • Infants born at 29–32 weeks' gestational age need only a single late ...

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