Intraventricular hemorrhage (IVH) in preterm infants:
Clinical findings and complications
Authors: Alexa Scarcello Reviewers: Nicola Adderley, Emily Ryznar, Yan Yu*, Jennifer Unrau* * MD at time of publication
Volpe Grading Grade I: germinal matrix
hemorrhage with no or minimal IVH (<10% of ventricular area) Grade II: IVH (10-50% of ventricle) Grade III: IVH (>50% of ventricle;
usually distends lateral ventricle)
Grade IV/Intra-parenchymal echodensity (IPE): periventricular hemorrhagic infarction
Inflammation/dysfunction of arachnoid villi
↓ absorption of CSF 2° to obstruction of arachnoid villi
Communicating hydrocephalus (IVH grades II-IV)
Venous congestion
Venous infarction
Periventricular hemorrhagic necrosis
Destruction of periventricular motor tracts
Cerebral palsy
Rapid significant blood loss
↓ intravascular blood volume
Hypotension
↓ bloodflow to the brain to support brain function
Intraventricular Hemorrhage (IVH)
hemorrhage in periventricular subependymal germinal matrix
Ultrasound: blood in germinal matrix, ventricles, or cerebral parenchyma
Sudden ↓ hematocrit
Blood irritates contiguous structures
Variable neurologic findings; including altered level of consciousness, hypotonia, apnea, etc
Neuro- developmental abnormalities (varying severity)
See slide – Hydrocephalus: Clinical Findings in Pediatrics
This mechanism leads to three different possible clinical manifestations:
1. Silent Presentation (most common)
2. Stuttering/Saltatory Course: non-specific findings – hypotonia, apnea, altered level of consciousness, bradycardia, and ↓ Spontaneous movements
3. Catastrophic Deterioration (least common) Stupor or coma, decerebrate posturing, seizures, bradycardia, metabolic acidosis, bulging fontanelles, abnormal pupillary reflexes, inappropriate ADH secretion
Notes
• Incidence & severity are inversely proportional to gestational age
• 50% occur within 1st day of life, 90% by 3rd day
• As explained in the flow chart, the postnatal clinical presentations of
IVH fall into three categories (1-3)
• Symptoms of catastrophic bleeds are uncommon and usually caused
by rapid significant blood loss with subsequent neurologic findings 2° to meningeal irritation, inflammation, and potential mass effect/acute hydrocephalus; severe bleeds may also occur in the absence of clinical findings attributable to IVH
Legend:
Pathophysiology
Mechanism
Sign/Symptom/Lab Finding
Complications
Published July 27, 2019 on www.thecalgaryguide.com