Neurological disease in a child: Intraventricular haemorrhage

Question 1

Define intraventricular haemorrhage.

Answer 1

Intraventricular haemorrhage usually arising in the germinal matrix and periventricular regions of the brain.

Question 2

What are the 4 grades of intraventricular haemorrhage?

Answer 2

Grade I: Germinal matrix hemorrhage only

Grade II: Blood within the lateral ventricle without ventricular dilation

Grade III: Blood within the lateral ventricle with ventricular dilation

Grade IV: IVH with periventricular parenchymal haemorrhagic infarct

Question 3

What are risk factors for intraventricular haemorrhage?

Answer 3

Prematurity (major factor)

Factors that increase or decrease BP: Hypovolaemia, hypotension, hypertension, pulmonary haemorrhage, mechanical ventilation, increase pCO2, decrease pO2, Prolonged labour, PDA

Others: Acidosis, hypothermia, severe RDS, pneumothorax, coagulopathy

Association/Related: Maternal smoking

Question 4

Explain the pathophysiology of intraventricular haemorrhage?

Answer 4

The germinal matrix tissue is located adjacent to the lateral ventricles. It is the site of origin of migrating neuroblasts from the end of the first trimester and has become highly cellular and richly vascularised by 24-26 weeks. The vessels are thin-walled and fragile and susceptible to damage from fluctuations in cerebral blood flow leading to haemorrhage.

Haemorrhage in this area may destroy the migrating neuroblasts and impair subsequent brain development. The germinal matrix involutes by the 36th gestational week which is why preterm infants are most affected.

Periventricular parenchymal haemorrhaic infarct occurs due to compromised venous return rather than direct extension of bleeding from the germinal matrix.

Question 5

Summarise the epidemiology of intraventricular haemorrhage.

Answer 5

Most common in very low-birthweight infants: 30-40% of infants weighing <1500g, 50-60% of infants weighing <1000g

Question 6

What are signs and symptoms of intraventricular haemorrhage?

Answer 6

Highest incidence in first 72 hours of life, 60% within 24 hours, 85% within 72 hours, <5% after 1 week postnatal age.

Signs and symptoms: May be asymptomatic (grade I or II), seizures, poor tone, apnoea, lethargy, shock and anaemia (grade III or IV).

Signs of raised ICP: Bulging fontanelle, cushing response (increased BP, decreased HR)

Monitor head circumference: For progressive hydrocephalus

Question 7

What are appropriate investigations for intraventricular haemorrhage?

Answer 7

Bloods: FBC, clotting, capillary gas for acid/base balance

USS: Used in the diagnosis and classification of IVH

Question 8

What is the management for intraventricular haemorrhage?

Answer 8

Routine screening: USS indicated in infants < 32 weeks gestational age within the first week of life and should be repeated in the second week.

Prevention: Maintain acid/base balance and avoid fluctuations in BP

Supportive care: Ventilatory support and blood transfusion in large haemorrhage

Treatment of increased ICP: Diuretics (mannitol) may be required

Interventional: External ventriculostomy or permanent ventricular-peritoneal shunt

Question 9

What are the complications associated with intraventricular haemorrhage?

Answer 9

Hydrocephalus (10-15%)

Neurological impairment

Question 10

What is the prognosis of an intraventricular haemorrhage?

Answer 10

Grade I and II: Rarely have harmful neurological consequences, as they originate in the germinal matrix (which disappears) and do not normally extend into the white matter.

Grade III: 30-45% incidence of neurological impairment

Grade IV: 60-80% incidence of neurological impairment