Intraventricular Hemorrhage in the Preterm Infant Workup

Updated: Jul 24, 2018
  • Author: David J Annibale, MD; Chief Editor: Santina A Zanelli, MD  more...
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Workup

Approach Considerations

Work-up and diagnosis

The diagnosis of germinal matrix/intraventricular hemorrhage (GM/IVH) is made by bedside cranial ultrasonography, including views of the cerebellum. Following the initial diagnosis of GM/IVH, continued surveillance is required to assess the progression and the development of posthemorrhagic hydrocephalus (PHH).

Serial daily measurements of frontal-occipital head circumference should be performed in infants with ultrasonographic evidence of PHH as an adjunct tool in monitoring the progression of PHH.

Grade III GM/IVH and periventricular hemorrhagic infarction (PVHI) have been associated with abnormally high (odds ratio [OR], 2.931 [1.825-4.707]) or, to a lesser degree, low (OR, 1.24 [1.036-1.484]) lymphocyte counts, [18]  based on reference ranges the authors defined. Although these are nondiagnostic for GM/IVH, abnormalities may lead to further evaluation.

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Laboratory Studies

 

 

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Imaging Studies

The following imaging studies are indicated in patients at risk for periventricular hemorrhage/intraventricular hemorrhage (PVH/IVH) and those who have germinal matrix/IVH (GM/IVH).

Cranial ultrasonography

Ultrasonography is the diagnostic tool of choice for screening examination and follow-up of individuals with PVH/IVH. Current recommendations by the Quality Standards Subcommittee of the American Academy of Neurology suggest that all infants younger than 30 weeks' gestation be screened by cranial ultrasonography at 7-14 days of postnatal life and at 36-40 weeks of postmenstrual age. [19]

Ultrasonography is also the diagnostic tool of choice for the follow-up of individuals with PVH/IVH and posthemorrhagic hydrocephalus, as shown below. Serial ultrasonography is indicated weekly to follow for progression of the hemorrhage and the development of posthemorrhagic hydrocephalus.

Ultrasonogram revealing hydrocephalus. Ultrasonogram revealing hydrocephalus.

 

Normal neonatal brain images are shown below.

Coronal midline ultrasonographic appearance of a n Coronal midline ultrasonographic appearance of a normal neonatal brain.
Normal neonatal brain shown with a left sagittal u Normal neonatal brain shown with a left sagittal ultrasonographic scan.
Normal neonatal brain shown with midline sagittal Normal neonatal brain shown with midline sagittal ultrasonographic scan.

Computed tomography (CT) scanning

Prior to the availability of ultrasonography, CT scanning was used for diagnosis and follow-up of IVH. CT scanning is no longer used for diagnosis and follow-up in view of the safety and cost effectiveness of ultrasonography.

Magnetic resonance imaging (MRI)

MRI of the brain is useful in determining the need and opimal intervention for posthemorrhagic hydrocephalus.

The use of MRI to diagnose associated white mater injury (periventricular leukomalacia [PVL]) is evolving.

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Staging

Germinal matrix/intraventricular hemorrhage (GM/IVH) is graded according to the most extensive ultrasonographic appearance of the hemorrhage, as follows:

  1. Grade I: Presence of hemorrhage in the germinal matrix
  2. Grade II: Hemorrhage into the cerebral ventricles without ventricular dilatation
  3. Grade III: Hemorrhage into the cerebral ventricles with ventricular dilatation
  4. Periventricular hemorrhagic infarction (PVHI): Associated PVHI

In addition, laterality (unilateral vs bilateral) and extent (frontal to occipital extent) may be useful in prognosis. 

In a study of 58 infants with PVHI, standardized ultrasonographic findings, including bilaterality, midline shift, and extent of the PVHI lesion, were used to predict neurologic outcomes. [20]  In this scoring system, high scores were statistically associated with death, early seizures, and abnormal meuromotor examinations. Such information may be of use in determining prognosis as well as follow-up and the initiation of intervention programs.

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