History

Loss of autoregulation of cerebral blood flow is a pathophysiologic feature of germinal matrix/intraventricular hemorrhage (GM/IVH). Prematurity itself results in derangements in cerebral autoregulation. In some patients, a history of additional events that result in loss of autoregulation can be obtained. Furthermore, events that can result in beat-to-beat variability of cerebral blood flow may be identified in some patients.

In the majority of patients, GM/IVH is asymptomatic and diagnosed by surveillance ultrasonography.

The parent's/caregiver's history of the patient can be entirely noncontributory; however, they might note nonspecific, subtle signs.

Physical Examination

The physical examination is usually negative in germinal matrix/intraventricular hemorrhage (GM/IVH). Occasionally, severe GM/IVH may present with nonspecific systemic findings suggestive of cardiovascular collapse.

The presentation of GM/IVH widely varies. Most infants are asymptomatic or demonstrate subtle signs that are easily overlooked. GM/IVH is then subsequently found on surveillance sonography.

One subgroup of infants with GM/IVH presents with the following:

A sudden unexplained drop in hematocrit levels
Possible physical findings related to anemia (eg, pallor, poor perfusion) or hemorrhagic shock

Another subgroup of infants with GM/IVH presents with extreme signs, including the following:

A sudden and significant clinical deterioration associated with anemia, metabolic acidosis, glucose instability, respiratory acidosis, apnea, hypotonia, and stupor is present.
Physical findings related to these signs include poor perfusion, pallor or an ashen color, irregularities of respiratory pattern, signs of respiratory distress including retractions and tachypnea, hypotonia, and altered mental status (eg, decreased responsiveness, coma).
Additional neurologic signs, such as fullness of the fontanelles, seizures, and posturing, may also be observed.
Progression can be rapid and may result in shock and death.
Between the two extremes of presentation, infants may demonstrate varying degrees of neurologic and systemic signs. Those with symptoms are more likely to have a more serious grade of GM/IVH.

Differential Diagnoses

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Media Gallery

Coronal midline ultrasonographic appearance of a normal neonatal brain.
Normal neonatal brain shown with a left sagittal ultrasonographic scan.
Normal neonatal brain shown with midline sagittal ultrasonographic scan.
Grade I hemorrhage minimal or grade I periventricular hemorrhage (PVH).
Moderate or grade II hemorrhage (subependymal, with no or little ventricular enlargement).
Severe or grade III hemorrhage (subependymal, with significant ventricular enlargement).
Intraventricular hemorrhage (IVH) with periventricular hemorrhagic infarction (PVHI).
Periventricular hemorrhagic infarction (PVHI) with porencephalic cyst formation.
Periventricular hemorrhagic infarction (PVHI) on magnetic resonance imaging (MRI).
Ultrasonogram revealing hydrocephalus.

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Author

David J Annibale, MD Professor of Pediatrics, Medical University of South Carolina College of Medicine; Director of Neonatology, Director of Fellowship Training Program in Neonatal-Perinatal Medicine, Department of Pediatrics, Division of Neonatology, MUSC Children's Hospital

David J Annibale, MD is a member of the following medical societies: American Academy of Pediatrics, National Perinatal Association

Disclosure: Editorial staff for AAP NeoREVIEWS PLUS (includes reimbursement for meeting expecnses and $300 honorarium; Advisory meetings for the National Certification Corp. development of a QI certification test. (includes all expenses without honorarium) for: American Academy of Pediatrics, National Certification Corp.

Coauthor(s)

Jeanne G Hill, MD Professor of Radiology and Pediatrics, Division Director, Pediatric Radiology, Director of Medical Student Education, Department of Radiology and Radiologic Science, Medical University of South Carolina College of Medicine

Jeanne G Hill, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, American Roentgen Ray Society, Association of Program Directors in Radiology, Association of University Radiologists, Charleston County Medical Association, Radiological Society of North America, Society for Pediatric Radiology, Southern Pediatric Radiology Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Brian S Carter, MD, FAAP Professor of Pediatrics, University of Missouri-Kansas City School of Medicine; Attending Physician, Division of Neonatology, Children's Mercy Hospital and Clinics; Faculty, Children's Mercy Bioethics Center

Brian S Carter, MD, FAAP is a member of the following medical societies: Alpha Omega Alpha, American Academy of Hospice and Palliative Medicine, American Academy of Pediatrics, American Pediatric Society, American Society for Bioethics and Humanities, American Society of Law, Medicine & Ethics, Society for Pediatric Research, National Hospice and Palliative Care Organization

Disclosure: Nothing to disclose.

Chief Editor

Santina A Zanelli, MD Associate Professor, Department of Pediatrics, Division of Neonatology, University of Virginia Health System

Santina A Zanelli, MD is a member of the following medical societies: American Academy of Pediatrics, American Epilepsy Society, Society for Neuroscience, Society for Pediatric Research

Disclosure: Nothing to disclose.

Additional Contributors

Scott S MacGilvray, MD Clinical Professor, Department of Pediatrics, Division of Neonatology, The Brody School of Medicine at East Carolina University

Scott S MacGilvray, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Acknowledgements

Jeanne Hill, MD Radiology Program Director, Associate Professor, Departments of Radiology and Pediatrics, Medical University of South Carolina

Jeanne Hill, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Radiology, Association of Program Directors in Radiology, Association of University Radiologists, Radiological Society of North America, and Society for Pediatric Radiology

Disclosure: Nothing to disclose.