Chapter 78 Intraventricular Hemorrhage (Case 37)
Patient Care
Clinical Thinking
• A requirement for intubation or for resuscitation in the delivery room indicates a sicker infant who may be more predisposed to IVH.
• Bulging fontanel or abnormal movements, including posturing or seizure activity, may indicate presence of IVH.
• Evaluations of arterial blood gas (ABG) will provide information on oxygenation as well as acid-base balance.
History
• Prematurity is the most common association with IVH with increasing likelihood of bleeding occurring in the most immature infants.
• Antenatal history of maternal sepsis and nontreatment with corticosteroids has been associated with IVH.
• In the postnatal period, the requirement for intubation shortly after delivery, as well the presence of pneumothorax, has been associated with IVH.
Clinical Entities: Medical Knowledge
| Intraventricular Hemorrhage | |
|---|---|
| Pϕ | Intraventricular-periventricular hemorrhage is the end result of bleeding from capillaries within the subependymal germinal matrix, a vascular network that lies in the periventricular region of the brain and is the source of cortical neurons and glial cells. |
| TP | Presentation generally occurs within the first 72 hours of life, and earlier in premature infants <750 grams. Most cases are silent and are found on surveillance ultrasound. Others may be associated with clinical changes such as metabolic acidosis, drop in hematocrit, glucose instability, and pulmonary hemorrhage. |
| Dx | Diagnosis is made by cranial ultrasound, computed tomography (CT), or MRI imaging. Grading is classically into four stages. Grade 1 is hemorrhage confined to the germinal matrix. Grade 2 has extension and filling of <50% of the lateral ventricle on sagittal view. Grade 3 has >50% ventricular filling with distension of the lateral ventricle. Grade 4 is associated with parenchymal extension of the hemorrhage. Extension of the bleed into the parenchyma of the brain predisposes to the development of porencephalic cyst formation and may have associated periventricular leukomalacia, which carries a worse neurodevelopmental prognosis. |
| Tx | There is no treatment currently available. Therapy is directed at prevention of further neurologic damage that may result from the development of obstructive hydrocephalus. Approximately 50% of hemorrhages will lead to hydrocephalus, and approximately 50% of these will resolve spontaneously. For those infants who develop increasing ventricles, serial lumbar puncture with removal of 10 to 15 mL/kg per tap is occasionally performed, usually to attempt to decompress before shunt placement in smaller infants. Some infants ultimately may require placement of a ventriculoperitoneal shunt when the infant approaches 1800 g. See Nelson Essentials 64. |
| Cerebellar Hemorrhage | |
|---|---|
| Pϕ | Cerebellar hemorrhage is a potentially underrecognized problem of bleeding into the posterior fossa. It may occur independently or associated with severe intraventricular hemorrhage. It has been described in 10% to 25% of autopsies of low-birth-weight infants and occurs more frequently in surviving extremely low-birth-weight infants. |
| TP | The presentation may be clinically silent, or it may occur in conjunction with a supratentorial bleed and be associated with alterations in blood pressure, glucose control, and metabolic acidosis. Perinatal risk factors include an abnormal fetal heart rate, delivery by emergent caesarian delivery, and lower Apgar scores, and postnatal risk factors include high-frequency ventilation, requirement for volume expanders or pressor support, as well as the presence of a patent ductus arteriosus (PDA) or pulmonary hemorrhage. |
| Dx | Because the cerebellar vermis and tentorium are more echogenic, it is more difficult to diagnose a cerebellar bleed by head ultrasound. Performing imaging via the posterolateral or mastoid fontanel, at the junction of the squamosal, lamboidal, and occipital sutures allows for better visualization. CT imaging may provide better visualization when the infant is stable enough for transport. |
| Tx | Management of a posterior fossa bleed involves serial evaluation. There is no treatment offered. Longer neurodevelopmental follow-up of infants suggests a worse outcome may be associated with the presence of a cerebellar bleed. See Nelson Essentials 64. |
| Epidural Hemorrhage | |
|---|---|
| Pϕ | Epidural bleeds are caused by rupture of branches of the middle meningeal artery or bleeding from major veins or venous sinuses. It is a rare lesion in the newborn and may be associated with a skull fracture. |
| TP | Bleeding into the epidural space may follow a traumatic or instrumented delivery and should be suspected in any infant who demonstrates signs of raised intracranial pressure with bulging fontanel, decreased tone, and increasing stupor in the first day of life. Seizures may occur. A unilateral fixed dilated pupil may indicate uncal herniation. Progressive scalp swelling may occur. |
| Dx | An emergency CT or MRI should be performed to identify the site and size of the hemorrhage. Ultrasound is not a reliable modality to identify an epidural bleed. |
| Tx | Surgical evacuation of the clot or needle aspiration may be performed. See Nelson Essentials 184. |
| Subdural Hemorrhage | |
|---|---|
| Pϕ | Subdural bleeding occurs as a result of laceration or injury to the veins and sinuses of the brain. It may occur in the subdural space over the cerebral convexity, in the posterior fossa, or along the longitudinal cerebral fissure. Bleeding results from trauma, usually rotational movements of the brain within the skull. Posterior fossa bleeds result from rupture of the transverse or straight sinuses or the vein of Galen. |
| TP | Acute neurologic changes may be present with hemiparesis or impaired oculomotor motion. Seizures can also occur. |
| Dx | CT or MRI imaging is required to confirm the location and size of the bleed. |
| Tx | Occasionally neurosurgical evacuation is required. Approximately 80% of infants who undergo evacuation of the hematoma have normal or minor developmental deficits on follow-up. See Nelson Essentials 184. |
| Subarachnoid Hemorrhage | |
|---|---|
| Pϕ | Blood may be found in the subarachnoid space by extension from subdural, intraventricular, or intracerebellar hemorrhage. Blood may be found over the cerebral convexities, especially posteriorly, as well as in the posterior fossa. It is thought to originate from bleeding between small vascular channels derived from anastomoses between leptomeningeal arteries or from bridging veins. |
| TP | Significant increase in intracranial pressure is rare. Hydrocephalus may develop secondary to adhesion formation, which may obstruct the flow of cerebrospinal fluid. It may be associated with hypoxic events and occurs more commonly in the term infant. It may be asymptomatic or may present with onset of seizures. More rarely, with massive subarachnoid hemorrhage, clinical deterioration is rapid and irreversible. |
| Dx | A bloody lumbar puncture with elevated protein count may be the first sign. Ultrasound is not the best modality to visualize a subarachnoid bleed because there is normally some increased echogenicity around the brain. CT is considered the best means of imaging the subarachnoid space and differentiating hemorrhage there from other intracerebral bleeds. |
| Tx | Close monitoring of the clinical presentation is the most usual course of action. There is no specific treatment. The outcome is generally favorable for infants who develop subarachnoid hemorrhage. Almost 90% of those infants who develop seizures will have normal follow-up. Hydrocephalus is a rare and late-occurring complication. See Nelson Essentials 184. |
Only gold members can continue reading. Log In or Register to continue
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
