Intraventricular Hemorrhage

Key Features

Essentials of Diagnosis

• 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

General Considerations

• 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)

Clinical Findings

• 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

Diagnosis

• 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

Treatment

• 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

Outcome

Follow-Up

• 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 ...