A 24 4/7 week infant was born by cesarean section for pre-term labor and vaginal bleeding.
The past medical history shows that the pregnancy was complicated by teenage motherhood, little prenatal care, suspected placental previa and prolonged rupture of membranes.
The pertinent physical exam shows him to be 695 grams, appropriate for gestation age, and in respiratory distress.
The radiologic evaluation of a screening head ultrasound on day of life 7 showed a diagnosis of bilateral grade II intraventricular hemorrhage (IVH). The second follow-up examination at day 21 of life showed progression to bilateral grade III intraventricular hemorrhage. He was treated conservatively and monitored closely. Repeat examination at day 42 showed resolving intraventricular hemorrhage and decreasing ventricle size.
The patient’s clinical course was complicated by multiple organ system problems because of his extreme prematurity. At discharge on day of life 121, he was to follow-up in the high risk infant follow-up program for bronchopulmonary dysphasia, retinopathy of prematurity, and neurodevelopmental follow-up and care coordination.
Intracranial hemorrage is of 4 major types in a neonate: subdural hemorrhage, primary subarachnoid hemorrhage, intracerebellar hemorrhage and intraventricular hemorrhage (IVH). IVH is the most common and usually of greatest clinical significance as it is a major cause of mortality and morbidity in premature infants.
The incidence of IVH in infants <1500 g or <35 weeks' gestation has been reported to be as high as 50%, but appears to have fallen in recent years. Mortality is 27-50% depending on the group studied with an inverse relationship between grade and survival.
The pathogenesis of IVH is not known but is likely multifactoral. Two major factors that contribute are the loss of cerebral autoregulation and abrupt alterations in cerebral blood flow and pressure. IVH originates in the subependymal germinal matrix adjacent to the lateral ventricle often at the level of the Foramen of Monroe in full-term neonates and further posterior in premature infants < 28 weeks.
Most remain in the germinal matrix. Many hemorrhages are clinically asymptomatic while others are catastrophic.
- Physical examination
- Alteration in mentation – seizures, posturing, coma or decreased consciousness
- Respiratory distress including tachypnea and retractions
- Irregular breathing
- Fontannel – full or bulging
- Hypotension or blood pressure lability
- Poor perfusion
- Bloody cerebrospinal fluid
- Hematocrit drop
Since IVH may be asymptomatic, all infants < 1500 g should have a scheduled screening head ultrasound examination at day of life 5-7 and again at day of life 28-30. Most IVH occurs in the first week of life, but may be delayed so that the second ultrasound examination is scheduled at 28-30 days.
If IVH is suspected clinically, an emergent ultrasound should be ordered. If IVH occurs, follow-up sonograms often occur weekly to monitor and evaluate for development of hydrocephalus and the rate of ventricular dilatation, or for any periventricular cystic change that occurs.
Fortunately, post-hemorrhagic hydrocephalus is relatively uncommon. Management of post hemorrhagic hydrocephalous needs to be individualized but may require ventricular shunting, serial lumbar punctures or other treatment.
The term intraventricular hemorrhage refers to all 4 grades. The term periventricular hemorrhage refers to a grade IV IVH.
- Grade I: hemorrhage limited to the subependymal germinal matrix
- Grade II: hemorrhage in the subependymal germinal matrix with extension into the ventricular system but without lateral ventricular dilation
- Grade III: hemorrhage in the subependymal germinal matrix with extension into the ventricular system with lateral ventricular dilatation
- Grade IV: hemorrhage in the subependymal germinal matrix with extension into the brain tissue (i.e. intraparenchymal hemorrhage)
– Images from a head ultrasound performed on day of life seven showing Grade II intraventricular hemorrhage. The image on the left is a coronal image of the brain showing intraventricular hemorrhage in the left germinal matrix. The image in the center is a sagittal image of the left side of the brain showing intraventricular hemorrhage extending from the left germinal matrix into the left lateral ventricle without any ventricular dilation. The image on the right is a sagittal image of the right side of the brain which is normal.
– Images from a head ultrasound performed on day of life twenty-one showing interval development of Grade III intraventricular hemorrhage. The image on the left is a coronal image of the brain showing interval development of ventricular dilation and resorption and retration of the intraventricular clot. The image in the middle is a sagittal image of the left side of the brain showing interval development of ventricular dilation and resorption and retraction of the intraventricular clot and ventricular dilation. The image on the right is a sagittal image of the right side of the brain showing interval development of ventricular dilation.
Determination of ventricular dilation can be difficult on sonography, but is important clinically. Most follow-up studies have found that the neurological outcome is associated with the grading of the IVH.
Grades I and II does not increase the chance of neurologic morbidity measurably.
Grades III and IV have a high rate of morbidity including cerebral palsy, seizures, and mental retardation. Periventricular white matter ischemia often evolve into cystic lesions called periventricular leukomalacia or PVL. The presence of PVL carries a high risk of neurologic morbidity.
Questions for Further Discussion
1. What treatment should be given to infants with symptomatic IVH while an emergent ultrasound is completed?
2. What are the indications for serial lumbar punctures?
3. What kinds of long-term follow-up will patients with Grade III or IV IVH need?
To Learn More
To view pediatric review articles on this topic from the past year check PubMed.
Periventricular Hemorrhage-Intraventricular Hemorrhage. eMedicine.
Available from the Internet at http://www.emedicine.com/ped/topic2595.htm (rev. 5/14/03, cited 1/31/05).
Acarregui MJ. Intracranial Hemorrhage.
Iowa Neonatology Handbook. Bell EF and Seger JL, eds.
Available from the Internet at http://www.vh.org/pediatric/provider/pediatrics/iowaneonatologyhandbook/neurology/hemorrhage.html (rev. 12/03, cited/31/05).
Donna M. D’Alessandro, MD
Associate Professor of Pediatrics, Children’s Hospital of Iowa
March 14, 2005