This is a significant cause of morbidity and mortality in infants who are born prematurely.

Neurological complications include life-long problems:

• Seizures
• Developmental delay
• Cerebral palsy

Intraventricular haemorrhage (IVH) is uncommon in term infants, but can be seen in association with trauma and asphyxia. In these cases the bleeding is usually in the choroid plexus.

Classification

It is classified according to radiological appearance as follows:¹

• Grade I:germinal matrix haemorrhage. Bleeding confined to the germinal matrix/subependymal region. Bleed occupies <10% of ventricle.
• Grade II: intraventricular blood without distension of the ventricular system. Bleed fills 10-50% of ventricle - approximately 40% of cases.
• Grade III: blood filling and distending the ventricular system. Dilated ventricles that are >50% full of blood.
• Grade IV: parenchymal involvement of haemorrhage, also known as periventricular venous infarction.

Epidemiology

Incidence

Intraventricular haemorrhage (IVH) occurs in 60-70% of neonates weighing 500-750 g and 10-20% of those weighing 1,000-1,500 g.² Prematurity and low birthweight are the most important risk factors for Grade IV haemorrhage.³ Research is also underway looking at the role of ventilation in the aetiology of IVH.⁴ There is an inverse relationship between the severity of the haemorrhage and the likelihood of survival.

Risk factors

• Prematurity - particularly <32 weeks
• Low birthweight
• Respiratory distress syndrome
• Hypoxia
• Sepsis
• Hypotension
• Hypovolaemia
• Hypertension
• Altered cerebral blood flow

Presentation

Symptoms

Most cases present by the third day of life - 50% on first day. 10-15% may show delayed haemorrhage occurring after the first week.
The most common symptoms are:

• Diminished/absent Moro reflex
• Poor muscle tone
• Sleepiness
• Lethargy
• Apnoea

Premature babies often show sudden deterioration on day two or three, with periods of apnoea, pallor or cyanosis, failure to suck properly, abnormal eye signs, shrill cry, twitching or convulsions, reduced muscle tone or paralysis.

Signs

• Fontanelle may be tense and bulging with severe intraventricular haemorrhage (IVH).
• Neurological depression may progress to coma.
• In mild forms there may be no clinical signs, or there may be alternating symptomatic and asymptomatic periods.

Differential diagnosis

• Apnoea of prematurity
• Neonatal sepsis
• Hypoglycaemia
• Hypermagnesaemia
• Periventricular leukomalacia

Investigations

• Arterial blood gases show metabolic acidosis.
• Reduced haemoglobin level that may fail to improve on transfusion.
• Transfontanelle ultrasound; this is the diagnostic tool of choice. All premature babies at less than 30 weeks of gestation have cranial ultrasound at 7-14 days of age.

Management

This is mainly supportive and may include the correction of anaemia, acidosis, and hypotension. Ventilatory support may also be required for some who deteriorate acutely.

Fluid/volume replacement

• Packed red blood cells or fresh frozen plasma for anaemia and shock.
• Sodium bicarbonate infusion (carefully) for metabolic acidosis.

Pharmacological

• Anticonvulsants for seizures.
• Acetazolamide can be used to decrease cerebrospinal fluid production.⁵ This limits late, or rapidly progressive hydrocephalus.
• Intraventricular fibrinolytic therapy with streptokinase has been attempted. However, a 2007 Cochrane review felt it could not be recommended for neonates following intraventricular haemorrhage (IVH).⁶

Surgical

• Ventriculoperitoneal and ventriculosubgaleal shunts are the definitive treatments for posthaemorrhagic hydrocephalus.
• Serial lumbar punctures have been used in the management of late or rapidly progressive hydrocephalus; however, this role remains controversial.⁷

Prognosis

• 10-15% have hydrocephalus that may not appear for 2-4 weeks.
• Infants with massive haemorrhage often rapidly deteriorate and die. Mortality from high-grade intraventricular haemorrhage (IVH) may be 27-50%.⁸
• A significant proportion will show motor and cognitive deficits.
• Extremely low birthweight infants with grades I-II IVH have poorer neurodevelopmental outcomes at 20 months than infants with normal cranial ultrasound.⁹

Prevention

• Antenatal steroids to mother and low-dose indometacin to infant. Indometacin has been shown to decrease the risk of high-grade intraventricular haemorrhage (IVH), without improving developmental outcome.¹
• The Department of Health "recommends that all newborn babies are given vitamin K in the newborn period". Optimum timing and method of administration are unsure.
• Careful timing and management of delivery to avoid birth trauma and immaturity. Choice of tocolytic agent may be important.¹⁰

Document references

1. McCrea HJ, Ment LR; The diagnosis, management, and postnatal prevention of intraventricular Clin Perinatol. 2008 Dec;35(4):777-92, vii. [abstract]
2. Koksal N, Baytan B, Bayram Y, et al; Risk factors for intraventricular haemorrhage in very low birth weight infants. Indian J Pediatr. 2002 Jul;69(7):561-4. [abstract]
3. Sarkar S, Bhagat I, Dechert R, et al; Severe intraventricular hemorrhage in preterm infants: comparison of risk factors Am J Perinatol. 2009 Jun;26(6):419-24. Epub 2009 Mar 6. [abstract]
4. Aly H, Hammad TA, Essers J, et al; Is mechanical ventilation associated with intraventricular hemorrhage in preterm Brain Dev. 2011 Jun 14. [abstract]
5. Poca MA, Sahuquillo J; Short-term medical management of hydrocephalus. Expert Opin Pharmacother. 2005 Aug;6(9):1525-38. [abstract]
6. Whitelaw A, Odd DE; Intraventricular streptokinase after intraventricular hemorrhage in newborn infants. Cochrane Database Syst Rev. 2007 Oct 17;(4):CD000498. [abstract]
7. Whitelaw A; Repeated lumbar or ventricular punctures in newborns with intraventricular hemorrhage. Cochrane Database Syst Rev. 2001;(1):CD000216. [abstract]
8. Annibale DJ et al, Periventricular Hemorrhage-Intraventricular Hemorrhage, Medscape, Jul 2010
9. Patra K, Wilson-Costello D, Taylor HG, et al; Grades I-II intraventricular hemorrhage in extremely low birth weight infants: effects on neurodevelopment. J Pediatr. 2006 Aug;149(2):169-73. [abstract]
10. Petrova A, Mehta R; Magnesium Sulfate Tocolysis and Intraventricular Hemorrhage in Very Preterm Indian J Pediatr. 2011 May 28. [abstract]

Internet and further reading

• Shooman D, Portess H, Sparrow O; A review of the current treatment methods for posthaemorrhagic hydrocephalus of infants. Cerebrospinal Fluid Res. 2009 Jan 30;6(1):1. [abstract]