ICH In Younger

Question 1

Intracerebral hemorrhage in the 👶 other names

Answer 1

subependymal hemorrhage (SEH), germinal matrix hemorrhage (GMH), periventricular-intraventricular hemorrhage (PIVH). I

Question 2

Source of PIVH or GMH

Answer 2

highly vascular germinal matrix is part of the primordial tissue located beneath the ependymal lining of the lateral ventricles

progressive involution until 36 weeks gestational age (GA) progressive involution until 36 weeks gestational age (GA)➡️ progressive involution until 36 weeks gestational age (GA)
Disproportionately CBF to periventricular with immature and fragile and have impaired autoregulation.

Question 3

Involuation of GM

Answer 3

undergoes progressive involution until 36 weeks gestational age (GA)

Question 4

📍 GMH

Answer 4

GA 24-28 ➡️ body of cudate
GA > 29 ➡️ head of cudate

Question 5

Pathogenesis of PIVH / causes

Answer 5

GM watershed zone supply by Heubner’s ( ACA) , lateral striate arteries ( MCA) , anterior choroidal artery ( ICA/ MCA )
1 - hypoxia ➡️ RDS ➡️ ⬇️ o2 metabolic GM active ➡️ ischmic to endothelial cell BV ➡️ infarction ➡️ disruption
2 - ⬆️ co2 ➡️ ⭕️ dilatation BV➡️ sudden 🔺 ⬆️ prefusion ➡️ rupture BV
3- ⬆️ venous pressure ➡️ venous pressure GM ➡️ bleeding 🩸
4- dehydration followed by rapid resuscitation➡️⬆️ intravascular volume ➡️⬆️ BP GM ➡️ rupture

Question 6

RF PIVH

Answer 6

1- ⬆️ CBF & CPP➡️ asphyxia, ⬆️co2 , rapid volume expansion , seizure , pneumothorax, cynotice HD , ventilation , anemia , ⬇️ RBS , A - line , 🩸🔺 BP
2- young GA early preterm 👶 < 32 or late preterm34-36
3- LBW < 1500 g
4- flaiure to give sterile within 48 hr befor preterm delivery
5- APGAR <4 at 1 m , < 8 at 5 m
6-acute amnionitis
7- acidosis
8- coagulopathies
9- GA for CS
10- extracorporeal membrane oxygenation (ECMO): due to heparinization in addition to increased CPP
11- 🤰🏼 cocaine or ASA

Question 7

MCC affected age

Answer 7

Very pre- term < 32
Later preterm 34-36
LBW < 1500g

Question 8

PIVH Papile stage

Answer 8

MC presente stage preterm grade 3 and 4

Question 9

Timing of PIVH

Answer 9

Occurred in within 6 in 50% and others 50% within 12 hr
2nd peak day 3-4

Question 10

⬆️ mortality

Answer 10

Early onset PIVH

Question 11

Prevention PIVH

Answer 11

Avoid preterm delivery 🚚

antenatal corticosteroids

indomethacin vasoconstriction ⬇️ 🔺 CO2 , ⬇️ CBF , ⬆️ o2 ⬇️ PDA
A antenatal vitamin K given IM > 4 hrs prior to delivery decreases PIVH from 33% to 5%

delaying umbilical cord clamping by 30–120 seconds➡️ ⬆️hct,⬇️ PIVH

using surfactant to reduce RDS

7. minimizing external stimulation

steroids to stabilize the GM vessels

Question 12

Presentation PIVH

Answer 12

Asymptomatic ➡️⬇️ HC , developmental delay , ⬇️ HCT ➡️ 70 % have 6 m survival

Subacute presentation ➡️ irritability, ⬇️ motor activity , abnormal 👀 movement
Acute ➡️
🔺 tone ➡️ decerebrate or decorticate or flaccid paralysis, seizure , tens AF , ⬇️ BP , 🔺Cushing ( apnea,bradycardia)
👀 unreactive pupils , Loss EOM
> 10% HCt

Question 13

Hydrocephalus in PIVH

Answer 13

Communicating HC in the first 1-3 weeks in grade 3 and 4
DDX transient ventriculomegaly , true HC , hydrocephalus ex vacuo OFC ⬇️

Question 14

Pathophysiologic effects of PIVH

Answer 14

1- destruction GM
2- direct injury to brain from hematoma ➡️ porencephaly or cystic lesions
3- pressure of hematoma and ⬆️ ICP ➡️⬇️ CBF
4- hypoxia
5- ⬇️CPP periventricular leukomalacia (PVL) and cerebral infarction
6- periventricular hemorrhagic infarction
7- HC
8 - seizure

Question 15

Dx PIVH

Answer 15

US sensitivity 90 % , 85% specificity)

CT indication ➡️ Us NA , complicated anatomy
MRI

Question 16

TX aim

Answer 16

Optimize CPP
Normal MAP and pco2
Tx HC

Question 17

Indication for intervention

Answer 17

progressive ventriculomegaly
⬆️ ICP split sutures, tense AF

Question 18

Serial lumbar tap

Answer 18

10 ml / kg/ tap

temporizing mangment
🚫 < 800 g not tolerated LP alternative ventricular tap

Question 19

VP shunt not reconsider weight less than < 2000g

Answer 19

⬆️ infection rate

Question 20

Temporary ventricular access device (TVAD)

Answer 20

+➡️ avoid shunt , clear protein and cellular debris, avoid brain penetration,posit for medication , risk of EVD dislodged,25% will not need shunt
- nesurosurgen , infection , csf leak , bleeding, over drainage

Question 21

Serial tap

Answer 21

5-20 cc qod to 15 cc TID for tense AF

Question 22

Risk of serial tap

Answer 22

⬇️ na

Question 23

Follow up PIVH

Answer 23

Serial US on 3rd and 5 days then weekely then bi weekly
CT befor shunt insertion

Question 24

Indication for Vp shunt in PIVH

Answer 24

Sx HC
Extubated
Weight > 2000 g
No NEC
CSF protein < 100mg/ dl to avoid blockages

Shunt low or very low pressure

Question 25

Other causes ICH newborn 👶

Answer 25

Truma SDH , tentorial hemorrhage,
CP hemorrhage
Hemorrhagic Strok
Tumors
Vascular malformations