Sections

Intraventricular Hemorrhage in the Preterm Infant

Sections Intraventricular Hemorrhage in the Preterm Infant
Overview
Presentation
DDx
Workup
Treatment
Medication
Media Gallery
References

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.

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.

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Normal neonatal brain images are shown below.

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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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.

Staging

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

Grade I: Presence of hemorrhage in the germinal matrix
Grade II: Hemorrhage into the cerebral ventricles without ventricular dilatation
Grade III: Hemorrhage into the cerebral ventricles with ventricular dilatation
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.

Treatment & Management

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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.