Periventricular-Intraventricular Haemorrhage ✅ Flashcards
What is the most common neurological complication of preterm infants?
Periventricular-intraventricular (PVH-IVH)
How does gestational age affect the incidence of PVH-IVH?
Inversely related
What can PVH-IVH lead to?
Neurodevelopmental impairment and death
What causes PVH-IVH?
Rupture of the fragile capillary network in the subependymal (also called germinal) matrix of the developing brain
Where is the subependymal matrix of the brain found?
Overlies the head of the caudate nucleus
What is it called when the haemorrhage is confined to the subependymal region in PVH-IVH?
Germinal matrix haemorrhage (GMH)
Where might the haemorrhage also involve in PVH-IVH?
- Body of the lateral ventricles
- Cerebral cortical parenchyma
What is it called when a PVH-IVH haemorrhage extends into the body of the lateral ventricles?
Intraventricular haemorrhage
What is it called when a PVH-IVH involves the cerebral cortical parenchyma?
Parenchymal haemorrhage
Is involvement of the cerebral cortical parenchyma an extension of the haemorrhage in PVH-IVH?
No
What causes cerebral cortical parenchymal involvement in PVH-IVH?
Venous infarct related to obstruction to the venous drainage of the white matter
What happens following venous infarct of the cerebral cortical parenchyma in PVH-IVH?
It undergoes cystic degeneration
What has developed by term when there is cerebral cortical parenchyma involvement in PVH-IVH?
A porencephalic cyst
What are intraventricular haemorrhages classified into?
Grade (1-4)
What lesions may be found on cranial ultrasound?
- Haemorrhage
- Cystic periventricular leukomalacia (PVL)
- Periventricular white matter echo density (PVE)
- Post-haemorrhagic ventricular dilation/hydrocephalus
What is the grade of a intraventricular haemorrhage determined by?
Ultrasound appearances
What is a grade I haemorrhage?
Isolated germinal matrix haemorrhage
What is a grade 2 haemorrhage?
Intraventricular haemorrhage (GMH-IVH) - <50% of ventricular area on parasagittal view
What is a grade 3 haemorrhage?
GMH-IVH with dilatation - >50% of ventricular area on parasagittal view, usually distends lateral ventricle
What is a grade 4 haemorrhage?
Haemorrhage parenchymal infarct (parenchyma lesion)
What may a grade 4 haemorrhage evolve into?
A porencephalic cyst
What might a periventricular white matter echodensity evolve into?
Periventricular or deep white matter cysts
What is the use of serial cranial ultrasound in PVH-IVH?
Detect intraventricular haemorrhage, porencephalic cysts, and ventricular dilatation or hydrocephalus
Why might hydrocephalus be found on serial cranial ultrasound in PVH-IVH?
It is a complication of intraventricular haemorrhage
What is the concordance between cranial USS diagnosis and autopsy diagnosis?
> 90%
What are the key factors in the pathogenesis of PVH-IVH?
- Immature germinal matrix capillary network
- Impaired cerebral autoregulation
- Abnormal coagulation
What is meant by impaired cerebral autoregualtion as a risk factor for IVH-PVH?
Failure to maintain cerebral blood flow within normal limits in spite of wide fluctuations in blood pressure
What are the prenatal risk factors for PVH-IVH and PVL?
- IUGR
- Hypoxia-ischaemia
- Chorioamnionitis
- Twin-to-twin transfusion
What are the postnatal risk factors for PVH-IVH?
- Preterm
- Respiratory distress syndrome
- Cardiovascular instability
- Pneumothorax
- Rapid volume expansion
What is considered to be ‘uncomplicated IVH’?
Grades 1 and 2
What can uncomplicated IVH cause long-term?
Motor and cognitive impairment
What is the risk of developing cerebral palsy in uncomplicated IVH?
9%
What % of infants with grade III haemorrhage will develop cerebral palsy by 2 years of age?
25%
What % of infants with grade V haemorrhage will develop cerebral palsy by 2 years of age?
50%
What is periventricular leukomalacia (PVL)?
A periventricular white matter injury
What does PVL usually result from?
A combination of ischaemia and inflammation
What causes the ischaemia causing PVL?
Hypoperfusion of the periventricular white matter
How does inflammation result in PVL?
Causes oligodendroglial injury and failure of myelination
What are the prenatal risk factors for PVL?
- Hypoxia-ischaemia
- Chorioamnionitis
- Twin-twin transfusion
What are the postnatal risk factors for PVL?
- Prematurity
- Hypocarbia and alkalosis
- Cardiovascular instability/collapse
- Necrotising enterocolitis
- Postnatal corticosteroid treatment
What is seen in cystic PVL?
There are focal macroscopic areas of necrosis in the periventricular white matter
What do the focal areas of necrosis in the periventricular white matter lead to in cystic PVL?
Small bilateral periventricular cysts
When will periventricular cysts be visible on cranial USS in cystic PVL?
From 2 weeks after birth
What is the incidence of cystic PVL in VLBW infants?
3%
What is the clinical significance of cystic PVL?
It has a significant impact on neurodevelopment outcome
What neurodevelopmental sequence have a high incidence in cystic PVL?
- Diplegic CP
- Poor visuospatial skills
- Low IQ scores
Is PVL always cystic?
No
Is cystic or non-cystic PVL more common?
Non-cystic
What is the difference between cystic and non-cystic PVL?
In non-cystic PVL, focal lesions are microscopic in size
What happens to the microscopic lesions in non-cystic PVL?
They evolve into small glial scars
Can glial scars from non-cystic PVL be detected on ultrasound?
Not usually
How can glial scars from non-cystic PVL be detected?
MRI
What is the clinical significance of non-cystic PVL?
May be responsible for some of the characteristic cognitive difficulties many extremely preterm babies have at school age, rather than cerebral palsy
