INTRAVENTRICULAR HAEMORRHAGE

Introduction:

 Intracerebral haemorrhage remains the most common type of neonatal intracranial lesion and is
the main cause of cerebral palsy in preterm infants following the reduction in cystic
periventricular leukomalacia (cPVL)
 The grades of intraventricular hemorrhage is in accordance with Papile classification:

Grades of Intracerebral hemorrhage Description

Grade 1 Haemorrhage confined to the subependymal

region

Grade 2 Bleeding into the ventricular cavity but not

distending it

Grade 3 Intraventricular bleed with ventricular

enlargement due to blood clot

Grade 4 Any parenchymal lesion

Timing of Intraventricular hamorrhage:

 Various studies has revealed that the majority of lesions occurred within 72 hours of birth, with
more than half occurring during the first 24 hours.
 Only about 10% of lesions occur beyond the end of the first week.

Risk factors:

 Prematurity and the presence of respiratory distress syndrome are the main risk factors.
 Various prenatal, natal and postnatal factors have been found to be associated and are as
follows:
a. Prenatal - Failure to give steroids, Male sex, Vaginal delivery, Very preterm delivery
b. Natal - Birth depression, Birth trauma
c. Postnatal - Acidosis, hypercarbia, hypernatremia, fluctuating cerebral blood flow, coagulation
disorders

Pathogenesis:

 Subependymal germinal matrix, a structure that is most prominent between 24 and 34 weeks of
gestation is the initial site of hemorrhage.
  Germinal matrix tissue is abundant over the head of the caudate nucleus, and within the
germinal matrix there is a rich capillary bed with large, irregular endothelial-lined vessels.
 Majority of germinal matrix receives it's blood supply from a branch of the anterior cerebral
artery known as Heubner’s artery. The rest of the blood supply is derived from the anterior
choroidal artery and the terminal branches of the lateral striate arteries.
 The best unifying hypothesis is that Germinal Matrix Hemorrhage - Intraventricular hemorrhage
(GMH-IVH) occurs as a result of a combination of vulnerable immature anatomy, haemodynamic
instability and the propensity to bleeding which is intrinsic to the newborn as depicted in the
flowchart.

Diagnosis:

(A) Clinical diagnosis -

There are three clinical syndromes as described by Volpe.

 Asymptomatic - 25–50% of infants with GMH-IVH have no obvious clinical signs.

 Saltatory syndrome - gradual in onset, presenting with a change in spontaneous general
movements. There may be subtle seizures with eye deviation or lip smacking.
 Catastrophic deterioration - Sudden deterioration is noted, like increase in oxygen or ventilatory
requirement, a fall in blood pressure and/or peripheral mottling, pallor, feed intolerance and
acidosis.

(B) Ultrasound diagnosis -

The most reliable and convenient method of diagnosis is by portable ultrasound scanning using a
transducer applied to the skin over the anterior fontanelle.

(C) CSF Analysis -

CSF examination may be useful as well. Elevated RBC count, xanthochromia and elevated protein
content suggest bleeding. Glucose usually becomes very low within 5-15 days of the hemorrhage
(hypoglycorrhacia).

Complications:

1. Posthaemorrhagic ventricular dilatation

2. Periventricular hemorrhagic infarction

Prevention:

 Prenatal medical intervention

 Transportation in utero
 Postnatal drug therapy
 Avoidance of cerebral hyperperfusion

Treatment:

Once hemorrhage occurs, initial therapy is primarily supportive. The major aspect is maintenance of
cerebral perfusion by maintaining adequate arterial blood pressure. Other important aspects of care
include:

a. Maintain adequate ventilation/oxygenation

b. Maintain blood pressure

c. Maintain glucose homeostasis

d. Control seizures

e. Correct acidosis

f. Maintain hematocrit

g. Maintain fluid and electrolyte balance

h. Decrease intracranial pressure

Prognosis:

 Uncomplicated GMH-IVH has a good prognosis.

 Once ventricular dilatation develops, the risk of adverse neurodevelopmental outcome
increases.
 The outcome following shunting worsens if the baby suffers repeated episodes of shunt
infection.