Medical Care
General supportive care includes the correction of underlying medical disturbances that might be related to the development of germinal matrix/intraventricular hemorrhage (GM/VH), as well as cardiovascular, respiratory, and neurologic support. Such measures include the following:
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Correction of anemia, acidosis, and hypotension, as well as ventilatory support, might be required in those neonates who present with acute deterioration.
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Serial lumbar puncture is not indicated, although it was once used to prevent progressive hydrocephalus.
Mazzola et al published recommendations on the management of posthemorrhagic hydrocephalus in premature infants in 2014. [21]
Long-term monitoring includes neurologic and developmental follow-up. Developmental intervention programs are indicated in individuals with GM/IVH.
Consultations
Consult neurosurgery specialists in the event of rapidly progressive ventricular enlargement or prolonged (>4 wk) slowly progressive ventricular enlargement.
Neurology consultation may be of value in the event of intractable seizures in an individual with germinal matrix/intraventricular hemorrhage (GM/IVH).
A developmental interventionist might be of help with a patient with high-grade hemorrhages.
Surgical Care
Surgical support for germinal matrix/intraventricular hemorrhage (GM/IVH) is limited to intervention for posthemorrhagic hydrocephalus (PHH). Because most patients with hydrocephalus following periventricular hemorrhage (PVH)-IVH demonstrate spontaneous resolution within weeks of onset, surgical intervention is usually unnecessary. Note the following:
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Serial lumbar punctures have been used to manage early hydrocephalus. However, because spontaneous resolution of hydrocephalus is usually observed, the use of this intervention has been questioned. A multicenter evaluation of serial lumbar punctures demonstrated no benefit when the individual with GM/IVH is aged 30 months. A more recent systematic analysis showed no evidence that repeated cerebrospinal fluid (CSF) removal via lumbar puncture, ventricular puncture, or from a ventricular reservoir has any benefit over conservative management in infants at risk for developing PHH with regard to reducing disability, mortality, or requirement for permanent shunt placement. [22] The role of serial lumbar punctures in the management of late or rapidly progressive hydrocephalus remains controversial.
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Acetazolamide may be used to diminish CSF production and limit late or rapidly progressive hydrocephalus. Its use in the treatment of early ventricular dilatation is probably limited.
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Ventriculostomy placement may be required for the management of significant hydrocephalus while awaiting definitive surgical drainage.
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Ventriculoperitoneal and ventriculosubgaleal shunting remain the definitive treatments for PHH requiring surgical intervention.
In a retrospective study that evaluated early surgical management and long-term surgical outcome for IVH-related PHH in ventriculoperitoneal shunt (VPS)-treated premature infants, investigators noted low gestational age and higher-order IVH in these patients had no significant impact on time to first shunt revision (revision-free shunt survival), but there were marked differences in mean revision rates at 5-year follow-up. [23] They concluded that use of a ventricular access device as a temporizing measure is a reasonable measure to gain time and decision guidance before insertion of a permanent VPS in preterm infants with PHH.
Prevention
Antenatal steroids and the prevention of prematurity are important elements in the prevention of periventricular hemorrhage/intraventricular hemorrhage (PVH/IVH).
Prevention of germinal matrix/IVH (GM/IVH) begins with avoidance of conditions that do the following:
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Interfere with autoregulation (eg, hypocarbia, hypercarbia, hypoxia, acidosis)
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Overwhelm autoregulatory abilities (eg, hypertension)
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Contribute to rapid fluctuations of cerebral blood flow (eg, ventilatory asynchrony, rapid volume expansion, noxious stimuli, frequent handling)
Perform correction of host factors (eg, coagulopathy, acid-base balance, hydration, hypoxia-ischemia).
Pharmacologic prophylaxis can be accomplished through the use of indomethacin. Although the mechanism of action is currently unknown, indomethacin has been shown to reduce the incidence of GM/IVH and, specifically, high-grade hemorrhages. [13] Follow-up of patients enrolled in a multicenter prophylaxis study conducted by Ment et al was less convincing, [12] although sex-related differences favoring treatment in male infants have been postulated. Another large multicenter trial yielded contradictory evidence. [24] With such contradictory evidence regarding benefit, a lack of a definitive demonstration of improvement in developmental outcomes, and a concern for complications, this therapy is not universally accepted and remains controversial.
In addition to effects on pulmonary development, prenatal treatment with glucocorticoids has a protective effect with regard to PVH/IVH.
The use of other pharmacologic modalities to prevent GM/IVH has been proposed; however, this use is not widely accepted. The other pharmacologic modalities include prenatal treatment with vitamin K and phenobarbital and postnatal treatment with ethamsylate, phenobarbital, and vitamin E. Although positive reports concerning the efficacy of these agents are noted, further investigation is required to prove conclusive evidence of benefit.
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Coronal midline ultrasonographic appearance of a normal neonatal brain.
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Normal neonatal brain shown with a left sagittal ultrasonographic scan.
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Normal neonatal brain shown with midline sagittal ultrasonographic scan.
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Grade I hemorrhage minimal or grade I periventricular hemorrhage (PVH).
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Moderate or grade II hemorrhage (subependymal, with no or little ventricular enlargement).
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Severe or grade III hemorrhage (subependymal, with significant ventricular enlargement).
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Intraventricular hemorrhage (IVH) with periventricular hemorrhagic infarction (PVHI).
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Periventricular hemorrhagic infarction (PVHI) with porencephalic cyst formation.
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Periventricular hemorrhagic infarction (PVHI) on magnetic resonance imaging (MRI).
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Ultrasonogram revealing hydrocephalus.
