Periventricular-Intraventricular Haemorrhage ✅

Question 1

What is the most common neurological complication of preterm infants?

Answer 1

Periventricular-intraventricular (PVH-IVH)

Question 2

How does gestational age affect the incidence of PVH-IVH?

Answer 2

Inversely related

Question 3

What can PVH-IVH lead to?

Answer 3

Neurodevelopmental impairment and death

Question 4

What causes PVH-IVH?

Answer 4

Rupture of the fragile capillary network in the subependymal (also called germinal) matrix of the developing brain

Question 5

Where is the subependymal matrix of the brain found?

Answer 5

Overlies the head of the caudate nucleus

Question 6

What is it called when the haemorrhage is confined to the subependymal region in PVH-IVH?

Answer 6

Germinal matrix haemorrhage (GMH)

Question 7

Where might the haemorrhage also involve in PVH-IVH?

Answer 7

• Body of the lateral ventricles

- Cerebral cortical parenchyma

Question 8

What is it called when a PVH-IVH haemorrhage extends into the body of the lateral ventricles?

Answer 8

Intraventricular haemorrhage

Question 9

What is it called when a PVH-IVH involves the cerebral cortical parenchyma?

Answer 9

Parenchymal haemorrhage

Question 10

Is involvement of the cerebral cortical parenchyma an extension of the haemorrhage in PVH-IVH?

Answer 10

No

Question 11

What causes cerebral cortical parenchymal involvement in PVH-IVH?

Answer 11

Venous infarct related to obstruction to the venous drainage of the white matter

Question 12

What happens following venous infarct of the cerebral cortical parenchyma in PVH-IVH?

Answer 12

It undergoes cystic degeneration

Question 13

What has developed by term when there is cerebral cortical parenchyma involvement in PVH-IVH?

Answer 13

A porencephalic cyst

Question 14

What are intraventricular haemorrhages classified into?

Answer 14

Grade (1-4)

Question 15

What lesions may be found on cranial ultrasound?

Answer 15

• Haemorrhage
• Cystic periventricular leukomalacia (PVL)
• Periventricular white matter echo density (PVE)
• Post-haemorrhagic ventricular dilation/hydrocephalus

Question 16

What is the grade of a intraventricular haemorrhage determined by?

Answer 16

Ultrasound appearances

Question 17

What is a grade I haemorrhage?

Answer 17

Isolated germinal matrix haemorrhage

Question 18

What is a grade 2 haemorrhage?

Answer 18

Intraventricular haemorrhage (GMH-IVH) - <50% of ventricular area on parasagittal view

Question 19

What is a grade 3 haemorrhage?

Answer 19

GMH-IVH with dilatation - >50% of ventricular area on parasagittal view, usually distends lateral ventricle

Question 20

What is a grade 4 haemorrhage?

Answer 20

Haemorrhage parenchymal infarct (parenchyma lesion)

Question 21

What may a grade 4 haemorrhage evolve into?

Answer 21

A porencephalic cyst

Question 22

What might a periventricular white matter echodensity evolve into?

Answer 22

Periventricular or deep white matter cysts

Question 23

What is the use of serial cranial ultrasound in PVH-IVH?

Answer 23

Detect intraventricular haemorrhage, porencephalic cysts, and ventricular dilatation or hydrocephalus

Question 24

Why might hydrocephalus be found on serial cranial ultrasound in PVH-IVH?

Answer 24

It is a complication of intraventricular haemorrhage

Question 25

What is the concordance between cranial USS diagnosis and autopsy diagnosis?

Answer 25

>90%

Question 26

What are the key factors in the pathogenesis of PVH-IVH?

Answer 26

- Immature germinal matrix capillary network - Impaired cerebral autoregulation - Abnormal coagulation

Question 27

What is meant by impaired cerebral autoregualtion as a risk factor for IVH-PVH?

Answer 27

Failure to maintain cerebral blood flow within normal limits in spite of wide fluctuations in blood pressure

Question 28

What are the prenatal risk factors for PVH-IVH and PVL?

Answer 28

- IUGR - Hypoxia-ischaemia - Chorioamnionitis - Twin-to-twin transfusion

Question 29

What are the postnatal risk factors for PVH-IVH?

Answer 29

- Preterm - Respiratory distress syndrome - Cardiovascular instability - Pneumothorax - Rapid volume expansion

Question 30

What is considered to be 'uncomplicated IVH'?

Answer 30

Grades 1 and 2

Question 31

What can uncomplicated IVH cause long-term?

Answer 31

Motor and cognitive impairment

Question 32

What is the risk of developing cerebral palsy in uncomplicated IVH?

Answer 32

9%

Question 33

What % of infants with grade III haemorrhage will develop cerebral palsy by 2 years of age?

Answer 33

25%

Question 34

What % of infants with grade V haemorrhage will develop cerebral palsy by 2 years of age?

Answer 34

50%

Question 35

What is periventricular leukomalacia (PVL)?

Answer 35

A periventricular white matter injury

Question 36

What does PVL usually result from?

Answer 36

A combination of ischaemia and inflammation

Question 37

What causes the ischaemia causing PVL?

Answer 37

Hypoperfusion of the periventricular white matter

Question 38

How does inflammation result in PVL?

Answer 38

Causes oligodendroglial injury and failure of myelination

Question 39

What are the prenatal risk factors for PVL?

Answer 39

- Hypoxia-ischaemia - Chorioamnionitis - Twin-twin transfusion

Question 40

What are the postnatal risk factors for PVL?

Answer 40

- Prematurity - Hypocarbia and alkalosis - Cardiovascular instability/collapse - Necrotising enterocolitis - Postnatal corticosteroid treatment

Question 41

What is seen in cystic PVL?

Answer 41

There are focal macroscopic areas of necrosis in the periventricular white matter

Question 42

What do the focal areas of necrosis in the periventricular white matter lead to in cystic PVL?

Answer 42

Small bilateral periventricular cysts

Question 43

When will periventricular cysts be visible on cranial USS in cystic PVL?

Answer 43

From 2 weeks after birth

Question 44

What is the incidence of cystic PVL in VLBW infants?

Answer 44

3%

Question 45

What is the clinical significance of cystic PVL?

Answer 45

It has a significant impact on neurodevelopment outcome

Question 46

What neurodevelopmental sequence have a high incidence in cystic PVL?

Answer 46

- Diplegic CP - Poor visuospatial skills - Low IQ scores

Question 47

Is PVL always cystic?

Answer 47

No

Question 48

Is cystic or non-cystic PVL more common?

Answer 48

Non-cystic

Question 49

What is the difference between cystic and non-cystic PVL?

Answer 49

In non-cystic PVL, focal lesions are microscopic in size

Question 50

What happens to the microscopic lesions in non-cystic PVL?

Answer 50

They evolve into small glial scars

Question 51

Can glial scars from non-cystic PVL be detected on ultrasound?

Answer 51

Not usually

Question 52

How can glial scars from non-cystic PVL be detected?

Answer 52

MRI

Question 53

What is the clinical significance of non-cystic PVL?

Answer 53

May be responsible for some of the characteristic cognitive difficulties many extremely preterm babies have at school age, rather than cerebral palsy