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Intraventricular Hemorrhage

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Outline

  • Anatomy and pathophysiology
  • Clinical signs
  • IVH grades
  • Epidemiology and incidence
  • Prognosis
  • Treatment
  • Prevention
  • Mechanism of white matter injury
  • Summary

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Content prepared by

�Dr. Benjamin Courchia MD

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&

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Dr. Daphna Yasova Barbeau MD

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Anatomy and Pathophysiology of IVH

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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BALLABH, P. Intraventricular Hemorrhage in Premature Infants: Mechanism of Disease. Pediatr Res 67, 1–8 (2010).

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Karnik et al. Anesthesia for neurosurgical procedure in children

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Clinical Signs

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Dubowitz, L. M. S., Levene, M. I., Morante, A., Palmer, P. & Dubowitz, V. Neurologic signs in neonatal intraventricular hemorrhage: A correlation with real-time ultrasound. J Pediatrics 99, 127–133 (1981).

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Dubowitz, L. M. S., Levene, M. I., Morante, A., Palmer, P. & Dubowitz, V. Neurologic signs in neonatal intraventricular hemorrhage: A correlation with real-time ultrasound. J Pediatrics 99, 127–133 (1981).

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Papile, L. A., Burstein, J., Burstein, R. & Koffler, H. Incidence and evolution of subependymal and intraventricular hemorrhage: A study of infants with birth weights less than 1,500 gm. J Pediatrics 92, 529--534 (1978).

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Papile, L. A., Burstein, J., Burstein, R. & Koffler, H. Incidence and evolution of subependymal and intraventricular hemorrhage: A study of infants with birth weights less than 1,500 gm. J Pediatrics 92, 529--534 (1978).

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Grade I

Grade II

Grade III

Grade IV

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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What is the deal with Grade IV?

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Epidemiology

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Incidence

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Volpe. Neurology of the Newborn

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Volpe. Neurology of the Newborn

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Prognosis

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Volpe. Neurology of the Newborn

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Volpe. Neurology of the Newborn

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Prevention

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Lim, J. & Hagen, E. Reducing Germinal Matrix-Intraventricular Hemorrhage: Perinatal and Delivery Room Factors. Neoreviews 20, e452–e463 (2019).

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1.McGoldrick, E., Stewart, F., Parker, R. & Dalziel, S. R. Antenatal corticosteroids for accelerating fetal lung maturation for women at risk of preterm birth. Cochrane Db Syst Rev 2021, CD004454 (2020).

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Lim, J. & Hagen, E. Reducing Germinal Matrix-Intraventricular Hemorrhage: Perinatal and Delivery Room Factors. Neoreviews 20, e452–e463 (2019).

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Katheria, A. et al. Association of Umbilical Cord Milking vs Delayed Umbilical Cord Clamping With Death or Severe Intraventricular Hemorrhage Among Preterm Infants. Jama 322, 1877–1886 (2019).

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Neonatal Neuro-protective Best Practice Guidelines. NICU Brain Sensitive Care CommitteeSwedish Medical Center

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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Curtis, S. F. et al. Indomethacin Prophylaxis in Preterm Infants: Changes over Time. Am J Perinat (2022)

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Interventions

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Whitelaw, A. Core Concepts: Intraventricular Hemorrhage. Neoreviews 12, e94–e101 (2011). 

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  • Symptomatic management: Blood, inotropes, volume, etc.
  • EEG for seizures
  • DRIFT (see next slides)

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Whitelaw, A., Pople, I., Cherian, S., Evans, D. & Thoresen, M. Phase 1 Trial of Prevention of Hydrocephalus After Intraventricular Hemorrhage in Newborn Infants by Drainage, Irrigation, and Fibrinolytic Therapy. Pediatrics 111, 759–765 (2003).

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Whitelaw, A., Pople, I., Cherian, S., Evans, D. & Thoresen, M. Phase 1 Trial of Prevention of Hydrocephalus After Intraventricular Hemorrhage in Newborn Infants by Drainage, Irrigation, and Fibrinolytic Therapy. Pediatrics 111, 759–765 (2003).

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Whitelaw, A., Pople, I., Cherian, S., Evans, D. & Thoresen, M. Phase 1 Trial of Prevention of Hydrocephalus After Intraventricular Hemorrhage in Newborn Infants by Drainage, Irrigation, and Fibrinolytic Therapy. Pediatrics 111, 759–765 (2003).

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Whitelaw, A. et al. Randomized Trial of Drainage, Irrigation and Fibrinolytic Therapy for Premature Infants with Posthemorrhagic Ventricular Dilatation: Developmental Outcome at 2 years. Pediatrics 125, e852–e858 (2010).

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Whitelaw, A. et al. Randomized Trial of Drainage, Irrigation and Fibrinolytic Therapy for Premature Infants with Posthemorrhagic Ventricular Dilatation: Developmental Outcome at 2 years. Pediatrics 125, e852–e858 (2010).

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Whitelaw, A. et al. Randomized Trial of Drainage, Irrigation and Fibrinolytic Therapy for Premature Infants with Posthemorrhagic Ventricular Dilatation: Developmental Outcome at 2 years. Pediatrics 125, e852–e858 (2010).

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Luyt, K. et al. Drainage, irrigation and fibrinolytic therapy (DRIFT) for posthaemorrhagic ventricular dilatation: 10-year follow-up of a randomised controlled trial. Archives Dis Child - Fetal Neonatal Ed fetalneonatal--2019--318231 (2020) doi:10.1136/archdischild-2019-318231.

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Luyt, K. et al. Drainage, irrigation and fibrinolytic therapy (DRIFT) for posthaemorrhagic ventricular dilatation: 10-year follow-up of a randomised controlled trial. Archives Dis Child - Fetal Neonatal Ed fetalneonatal--2019--318231 (2020) doi:10.1136/archdischild-2019-318231.

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Luyt, K. et al. Drainage, irrigation and fibrinolytic therapy (DRIFT) for posthaemorrhagic ventricular dilatation: 10-year follow-up of a randomised controlled trial. Archives Dis Child - Fetal Neonatal Ed fetalneonatal--2019--318231 (2020) doi:10.1136/archdischild-2019-318231.

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Mechanism of white matter injury

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Polin. Fetal and Neonatal Physiology

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Romantsik, O., Bruschettini, M. & Ley, D. Intraventricular Hemorrhage and White Matter Injury in Preclinical and Clinical Studies. Neoreviews 20, e636–e652 (2019).

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Romantsik, O., Bruschettini, M. & Ley, D. Intraventricular Hemorrhage and White Matter Injury in Preclinical and Clinical Studies. Neoreviews 20, e636–e652 (2019).

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Romantsik, O., Bruschettini, M. & Ley, D. Intraventricular Hemorrhage and White Matter Injury in Preclinical and Clinical Studies. Neoreviews 20, e636–e652 (2019).

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Romantsik, O., Bruschettini, M. & Ley, D. Intraventricular Hemorrhage and White Matter Injury in Preclinical and Clinical Studies. Neoreviews 20, e636–e652 (2019).

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Romantsik, O., Bruschettini, M. & Ley, D. Intraventricular Hemorrhage and White Matter Injury in Preclinical and Clinical Studies. Neoreviews 20, e636–e652 (2019).

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Summary

  • Early in pregnancy, the germinal matrix produces new brain cells that migrate toward the cortex.
  • The germinal matrix blood vessels are more prone to injury.
  • The vulnerability of the germinal matrix is due to anatomic and physiologic factors.
  • Prematurity is the most significant risk factor for IVH.
  • Grade 1-2-3 represents a progression of hemorrhage, while grade 4 represents infarction of the medullary vein territory.
  • IVH, even low grades, is associated with poor neurodevelopmental outcomes.
  • Antenatal prevention of IVH mostly consists of glucocorticoids.
  • Postnatal prevention includes neuroprotection bundles and possibly indomethacin.
  • Treatment intervention includes DRIFT and VP shunt in cases of post-hemorrhagic ventricular dilation.
  • Post hemorrhagic white matter injury involves a primary injury followed by secondary injury mostly due to hemolysis degradation products.

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Thank You

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