Intraventricular hemorrhage

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Intraventricular hemorrhage
Other namesintraventricular hemorrhage, intraventricular bleeding
Intracerebral hemorrhage.jpg
CT scan showing spontaneous intracerebral hemorrhage with bleeding in the third and both lateral ventricles and hydrocephalus [1]
Specialty Neurology   OOjs UI icon edit-ltr-progressive.svg

Intraventricular hemorrhage (IVH), also known as intraventricular bleeding, is a bleeding into the brain's ventricular system, where the cerebrospinal fluid is produced and circulates through towards the subarachnoid space. It can result from physical trauma or from hemorrhagic stroke.

Contents

30% of intraventricular hemorrhage (IVH) are primary, confined to the ventricular system and typically caused by intraventricular trauma, aneurysm, vascular malformations, or tumors, particularly of the choroid plexus. [2] However 70% of IVH are secondary in nature, resulting from an expansion of an existing intraparenchymal or subarachnoid hemorrhage. [2] Intraventricular hemorrhage has been found to occur in 35% of moderate to severe traumatic brain injuries. [3] Thus the hemorrhage usually does not occur without extensive associated damage, and so the outcome is rarely good. [4] [5]

Symptoms

Adults

Symptoms of IVH are similar to other intracerebral hemorrhages and include sudden onset of headache, nausea and vomiting, together with an alteration of the mental state and/or level of consciousness. [6] Focal neurological signs are either minimal or absent, but focal and/or generalized seizures may occur. [6] Xanthochromia, yellow-tinged CSF, is the rule. [6]

Infants

Some infants are asymptomatic and others may present with hard to detect abnormalities of consciousness, muscle tone, breathing, movements of their eyes, and body movements. [7]

Causes

Adults

Causes of IVH in adults include physical trauma or from hemorrhagic stroke. [2]

Infants

Infants that are preterm and very low birth weight are also at high risk. [8] IVH in the preterm brain usually arises from the germinal matrix whereas IVH in the term infants originates from the choroid plexus. However, it is particularly common in premature infants or those of very low birth weight. [9] The cause of IVH in premature infants, unlike that in older infants, children or adults, is rarely due to trauma. Instead it is thought to result from changes in perfusion of the delicate cellular structures that are present in the growing brain, augmented by the immaturity of the cerebral circulatory system, which is especially vulnerable to hypoxic ischemic encephalopathy. The lack of blood flow results in cell death and subsequent breakdown of the blood vessel walls, leading to bleeding. While this bleeding can result in further injury, it is itself a marker for injury that has already occurred. Most intraventricular hemorrhages occur in the first 72 hours after birth. [9] The risk is increased with use of extracorporeal membrane oxygenation in preterm infants. [10] Congenital cytomegalovirus infection can be an important cause. [11]

Mechanism

Diagnosis

Diagnosis can be confirmed by the presence of blood inside the ventricles on CT. [7]

Infants

In term and preterm infants with IVH, the amount of bleeding varies. IVH is often described in four grades:[ citation needed ]

Grades I and II are most common, and often there are no further complications. Grades III and IV are the most serious and may result in long-term brain injury to the infant. After a grade III or IV IVH, blood clots may form which can block the flow of cerebrospinal flud, leading to increased fluid in the brain (hydrocephalus).

Prevention

In the prenatal period, a single course of corticosteroids given from gestational ages of 24 weeks 0 days to 33 weeks 6 days has been shown in several studies to reduce the risk of intraventricular hemorrhage in the neonatal period. [12] Head positioning in very preterm infants has been suggested as an approach to prevent germinal matrix hemorrhage; however, further research is required to determine the effectiveness at reducing mortality and the most appropriate positioning technique. [13] Approaches include bed tilting, supine mid-line head positioning, supine head rotation 90 degrees, prone mid-line head positioning, head tiling. [13]

Treatment

Treatment focuses on monitoring and should be accomplished with inpatient floor service for individuals responsive to commands or neurological ICU observation for those with impaired levels of consciousness. [14] Extra attention should be placed on intracranial pressure (ICP) monitoring via an intraventricular catheter and medications to maintain ICP, blood pressure, and coagulation. [2] In more severe cases an external ventricular drain may be required to maintain ICP and evacuate the hemorrhage, and in extreme cases an open craniotomy may be required. [2] [14] In cases of unilateral IVH with small intraparenchymal hemorrhage the combined method of stereotaxy and open craniotomy has produced promising results. [15]

Infants

There have been various therapies employed into preventing the high rates of morbidity and mortality, including diuretic therapy, [16] repeated lumbar puncture, [17] streptokinase therapy [18] and a combination novel intervention called DRIFT (drainage, irrigation and fibrinolytic therapy).[ citation needed ] More research is required, in the form of high quality randomized controlled trials, to determine the safety, dosing, and effectiveness of prophylactic heparin and antithrombin treatment for preterm neonates. [8] [19]

Prognosis

In infants, germinal matrix hemorrhage is associated with cerebral palsy, problems with cognition, and hydrocephalus. [7] With improved technological advances in science and medicine, survival for preterm infants with this type of neurological disorder has improved and less preterm infants with germinal matrix hemorrhage have severe cerebral palsy. [7] An estimated 15% of preterm infants who survive develop cerebral palsy and 27% of the infants who survive experience moderate to severe neurosensory deficits by the time they reach 18–24 months old. [7]

Prognosis is very poor when IVH results from intracerebral hemorrhage related to high blood pressure and is even worse when hydrocephalus follows. [1] It can result in dangerous increases in ICP and can cause potentially fatal brain herniation. [1] Even independently, IVH can cause morbidity and mortality. First, intraventricular blood can lead to a clot in the CSF conduits blocking its flow and leading to obstructive hydrocephalus which may quickly result in increased intracranial pressure and death. [14] Second, the breakdown products from the blood clot may generate an inflammatory response that damages the arachnoid granulations, inhibiting the regular re-absorption of CSF and resulting in permanent communicating hydrocephalus. [2] [14]

Associated conditions

Brain contusions and subarachnoid hemorrhages are commonly associated with IVH. [20] The bleeding can involve the anterior communicating artery or the posterior communicating artery.

In both adults and infants, IVH can cause dangerous increases in ICP, damage to the brain tissue, and hydrocephalus. [9] [21]

Epidemiology

IVH has been reported to occur in approximately 25% of infants who are born with a very low birth weight. [8] In preterm infants, intraventricular hemorrhage and germinal matrix hemorrhage are the most widely reported neurological disorders. [7] Approximately 2,000 infants each year are diagnosed with germinal matrix hemorrhage or intraventricular hemorrhage in the United States. [7]

Research

In 2002, a Dutch retrospective study [22] analysed cases where neonatologists had intervened and drained CSF by lumbar or ventricular punctures if ventricular width (as shown on ultrasound) exceeded the 97th centile as opposed to the 96th centile plus 4 mm. [23] Professors Whitelaw's original Cochrane review [16] published in 2001 as well as evidence from previous randomized control trials indicated that interventions should be based on clinical signs and symptoms of ventricular dilatation. An international trial has instead looked an early (97th centile) versus late (97th centile plus 4 mm) for intervening and draining CSF. [24]

DRIFT has been tested in an international randomized clinical trial; although it did not significantly lower the need for shunt surgery, severe cognitive disability at two years Bayley (MDI <55) was significantly reduced. [25] Repeated lumbar punctures are used widely to reduce the effects in increased intracranial pressure and an alternative to ventriculoperitonael (VP) shunt surgery that cannot be performed in case of intraventricular hemorrhage. The relative risk of repeated lumbar puncture is close to 1.0, therefore it is not statistically therapeutic when compared to conservative management and does raise the risk of subsequent CSF infection. [17]

Related Research Articles

<span class="mw-page-title-main">Idiopathic intracranial hypertension</span> Medical condition

Idiopathic intracranial hypertension (IIH), previously known as pseudotumor cerebri and benign intracranial hypertension, is a condition characterized by increased intracranial pressure without a detectable cause. The main symptoms are headache, vision problems, ringing in the ears, and shoulder pain. Complications may include vision loss.

<span class="mw-page-title-main">Hydrocephalus</span> Abnormal increase in cerebrospinal fluid in the ventricles of the brain

Hydrocephalus is a condition in which an accumulation of cerebrospinal fluid (CSF) occurs within the brain. This typically causes increased pressure inside the skull. Older people may have headaches, double vision, poor balance, urinary incontinence, personality changes, or mental impairment. In babies, it may be seen as a rapid increase in head size. Other symptoms may include vomiting, sleepiness, seizures, and downward pointing of the eyes.

<span class="mw-page-title-main">Colpocephaly</span> Brain malformation in which the lateral ventricles are enlarged

Colpocephaly is a cephalic disorder involving the disproportionate enlargement of the occipital horns of the lateral ventricles and is usually diagnosed early after birth due to seizures. It is a nonspecific finding and is associated with multiple neurological syndromes, including agenesis of the corpus callosum, Chiari malformation, lissencephaly, and microcephaly. Although the exact cause of colpocephaly is not known yet, it is commonly believed to occur as a result of neuronal migration disorders during early brain development, intrauterine disturbances, perinatal injuries, and other central nervous system disorders. Individuals with colpocephaly have various degrees of motor disabilities, visual defects, spasticity, and moderate to severe intellectual disability. No specific treatment for colpocephaly exists, but patients may undergo certain treatments to improve their motor function or intellectual disability.

Porencephaly is an extremely rare cephalic disorder involving encephalomalacia. It is a neurological disorder of the central nervous system characterized by cysts or cavities within the cerebral hemisphere. Porencephaly was termed by Heschl in 1859 to describe a cavity in the human brain. Derived from Greek roots, the word porencephaly means 'holes in the brain'. The cysts and cavities are more likely to be the result of destructive (encephaloclastic) cause, but can also be from abnormal development (malformative), direct damage, inflammation, or hemorrhage. The cysts and cavities cause a wide range of physiological, physical, and neurological symptoms. Depending on the patient, this disorder may cause only minor neurological problems, without any disruption of intelligence, while others may be severely disabled or die before the second decade of their lives. However, this disorder is far more common within infants, and porencephaly can occur both before or after birth.

<span class="mw-page-title-main">Lumbar puncture</span> Procedure to collect cerebrospinal fluid

Lumbar puncture (LP), also known as a spinal tap, is a medical procedure in which a needle is inserted into the spinal canal, most commonly to collect cerebrospinal fluid (CSF) for diagnostic testing. The main reason for a lumbar puncture is to help diagnose diseases of the central nervous system, including the brain and spine. Examples of these conditions include meningitis and subarachnoid hemorrhage. It may also be used therapeutically in some conditions. Increased intracranial pressure is a contraindication, due to risk of brain matter being compressed and pushed toward the spine. Sometimes, lumbar puncture cannot be performed safely. It is regarded as a safe procedure, but post-dural-puncture headache is a common side effect if a small atraumatic needle is not used.

<span class="mw-page-title-main">Preterm birth</span> Birth at less than a specified gestational age

Preterm birth, also known as premature birth, is the birth of a baby at fewer than 37 weeks gestational age, as opposed to full-term delivery at approximately 40 weeks. Extreme preterm is less than 28 weeks, very early preterm birth is between 28 and 32 weeks, early preterm birth occurs between 32 and 34 weeks, late preterm birth is between 34 and 36 weeks' gestation. These babies are also known as premature babies or colloquially preemies or premmies. Symptoms of preterm labor include uterine contractions which occur more often than every ten minutes and/or the leaking of fluid from the vagina before 37 weeks. Premature infants are at greater risk for cerebral palsy, delays in development, hearing problems and problems with their vision. The earlier a baby is born, the greater these risks will be.

<span class="mw-page-title-main">Intracranial pressure</span> Pressure exerted by fluids inside the skull and on the brain

Intracranial pressure (ICP) is the pressure exerted by fluids such as cerebrospinal fluid (CSF) inside the skull and on the brain tissue. ICP is measured in millimeters of mercury (mmHg) and at rest, is normally 7–15 mmHg for a supine adult. This equals to 9–20 cmH2O, which is a common scale used in lumbar punctures. The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF.

<span class="mw-page-title-main">Patent ductus arteriosus</span> Condition wherein the ductus arteriosus fails to close after birth

Patent ductus arteriosus (PDA) is a medical condition in which the ductus arteriosus fails to close after birth: this allows a portion of oxygenated blood from the left heart to flow back to the lungs through the aorta, which has a higher blood pressure, to the pulmonary artery, which has a lower blood pressure. Symptoms are uncommon at birth and shortly thereafter, but later in the first year of life there is often the onset of an increased work of breathing and failure to gain weight at a normal rate. With time, an uncorrected PDA usually leads to pulmonary hypertension followed by right-sided heart failure.

<span class="mw-page-title-main">Subarachnoid hemorrhage</span> Bleeding into the brains subarachnoid space

Subarachnoid hemorrhage (SAH) is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain. Symptoms may include a severe headache of rapid onset, vomiting, decreased level of consciousness, fever, weakness, numbness, and sometimes seizures. Neck stiffness or neck pain are also relatively common. In about a quarter of people a small bleed with resolving symptoms occurs within a month of a larger bleed.

<span class="mw-page-title-main">Infant respiratory distress syndrome</span> Human disease affecting newborns

Infant respiratory distress syndrome (IRDS), also known as surfactant deficiency disorder (SDD), and previously called hyaline membrane disease (HMD), is a syndrome in premature infants caused by developmental insufficiency of pulmonary surfactant production and structural immaturity in the lungs. It can also be a consequence of neonatal infection and can result from a genetic problem with the production of surfactant-associated proteins.

<span class="mw-page-title-main">Intracranial hemorrhage</span> Hemorrhage, or bleeding, within the skull

Intracranial hemorrhage (ICH), also known as intracranial bleed, is bleeding within the skull. Subtypes are intracerebral bleeds, subarachnoid bleeds, epidural bleeds, and subdural bleeds.

Antenatal steroids, also known as antenatal corticosteroids, are medications administered to pregnant women expecting a preterm birth. When administered, these steroids accelerate the maturation of the fetus' lungs, which reduces the likelihood of infant respiratory distress syndrome and infant mortality. The effectiveness of this corticosteroid treatment on humans was first demonstrated in 1972 by Sir Graham Liggins and Ross Howie, during a randomized control trial using betamethasone.

<span class="mw-page-title-main">Intracerebral hemorrhage</span> Type of intracranial bleeding that occurs within the brain tissue itself

Intracerebral hemorrhage (ICH), also known as hemorrhagic stroke, is a sudden bleeding into the tissues of the brain, into its ventricles, or into both. An ICH is a type of bleeding within the skull and one kind of stroke. Symptoms can vary dramatically depending on the severity, acuity, and location (anatomically) but can include headache, one-sided weakness, numbness, tingling, or paralysis, speech problems, vision or hearing problems, memory loss, attention problems, coordination problems, balance problems, dizziness or lightheadedness or vertigo, nausea/vomiting, seizures, decreased level of consciousness or total loss of consciousness, neck stiffness, and fever.

In anatomy, the germinal matrix is a highly cellular and highly vascularized region in the brain out from which cells migrate during brain development. The germinal matrix is the source of both neurons and glial cells and is most active between 8 and 28 weeks gestation. It is a fragile portion of the brain that may be damaged leading to a germinal matrix hemorrhage.

Germinal matrix hemorrhage is a bleeding into the subependymal germinal matrix with or without subsequent rupture into the lateral ventricle. Such intraventricular hemorrhage can occur due to perinatal asphyxia in preterm neonates.

<span class="mw-page-title-main">Cerebral shunt</span> Surgical implant to treat hydrocephalus

A cerebral shunt is a device permanently implanted inside the head and body to drain excess fluid away from the brain. They are commonly used to treat hydrocephalus, the swelling of the brain due to excess buildup of cerebrospinal fluid (CSF). If left unchecked, the excess CSF can lead to an increase in intracranial pressure (ICP), which can cause intracranial hematoma, cerebral edema, crushed brain tissue or herniation. The drainage provided by a shunt can alleviate or prevent these problems in patients with hydrocephalus or related diseases.

<span class="mw-page-title-main">External ventricular drain</span> Medical device

An external ventricular drain (EVD), also known as a ventriculostomy or extraventricular drain, is a device used in neurosurgery to treat hydrocephalus and relieve elevated intracranial pressure when the normal flow of cerebrospinal fluid (CSF) inside the brain is obstructed. An EVD is a flexible plastic catheter placed by a neurosurgeon or neurointensivist and managed by intensive care unit (ICU) physicians and nurses. The purpose of external ventricular drainage is to divert fluid from the ventricles of the brain and allow for monitoring of intracranial pressure. An EVD must be placed in a center with full neurosurgical capabilities, because immediate neurosurgical intervention can be needed if a complication of EVD placement, such as bleeding, is encountered.

Neonatal sepsis is a type of neonatal infection and specifically refers to the presence in a newborn baby of a bacterial blood stream infection (BSI) in the setting of fever. Older textbooks may refer to neonatal sepsis as "sepsis neonatorum". Criteria with regards to hemodynamic compromise or respiratory failure are not useful clinically because these symptoms often do not arise in neonates until death is imminent and unpreventable. Neonatal sepsis is divided into two categories: early-onset sepsis (EOS) and late-onset sepsis (LOS). EOS refers to sepsis presenting in the first 7 days of life, with LOS referring to presentation of sepsis after 7 days. Neonatal sepsis is the single most common cause of neonatal death in hospital as well as community in developing country.

Cranial ultrasound is a technique for scanning the brain using high-frequency sound waves. It is used almost exclusively in babies because their fontanelle provides an "acoustic window". A different form of ultrasound-based brain scanning, transcranial Doppler, can be used in any age group. This uses Doppler ultrasound to assess blood flow through the major arteries in the brain, and can scan through bone. It is not usual for this technique to be referred to simply as "cranial ultrasound". Additionally, cranial ultrasound can be used for intra-operative imaging in adults undergoing neurosurgery once the skull has been opened, for example to help identify the margins of a tumour.

Andrew G. L. Whitelaw is a British neonatologist and academic, known for his work on treating conditions affecting newborn babies. He holds the position of Emeritus Professor at Bristol Medical School, associated with Bristol Neuroscience.

References

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  3. ↑ Barkley JM, Morales D, Hayman LA, Diaz-Marchan PJ (2006). "Static neuroimaging in the evaluation of TBI". In Zasler ND, Katz DI, Zafonte RD (eds.). Brain Injury Medicine: Principles and Practice. Demos Medical Publishing. pp. 140–43. ISBN   1-888799-93-5.
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  10. ↑ Jobe, Alan H. (2004). "Post-conceptional age and IVH in ECMO patients". The Journal of Pediatrics. 145 (2): A2. doi:10.1016/j.jpeds.2004.07.010.
  11. ↑ Suksumek, N; Scott, JN; Chadha, R; Yusuf, K (July 2013). "Intraventricular hemorrhage and multiple intracranial cysts associated with congenital cytomegalovirus infection". Journal of Clinical Microbiology. 51 (7): 2466–8. doi:10.1128/JCM.00842-13. PMC   3697656 . PMID   23678057.
  12. ↑ "Antenatal Corticosteroid Therapy for Fetal Maturation".
  13. 1 2 Romantsik, Olga; Calevo, Maria Grazia; Bruschettini, Matteo (2020-07-07). "Head midline position for preventing the occurrence or extension of germinal matrix-intraventricular haemorrhage in preterm infants". The Cochrane Database of Systematic Reviews. 7 (7): CD012362. doi:10.1002/14651858.CD012362.pub3. ISSN   1469-493X. PMC   7389561 . PMID   32639053.
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  15. ↑ Jaliya R. Lokuketagoda, "Two cases of intraventricular hemorrhage evacuation by open craniotomy assisted with stereotaxy, leading to excellent results", world-sci.com
  16. 1 2 Whitelaw, Andrew; Brion, Luc P; Kennedy, Colin R; Odd, David (2001). Whitelaw, Andrew (ed.). "Diuretic therapy for newborn infants with posthemorrhagic ventricular dilatation". Cochrane Database of Systematic Reviews. 2010 (2): CD002270. doi:10.1002/14651858.CD002270. PMC   8436729 . PMID   11406041.
  17. 1 2 Whitelaw, Andrew (2001). Whitelaw, Andrew (ed.). "Repeated lumbar or ventricular punctures in newborns with intraventricular hemorrhage". Cochrane Database of Systematic Reviews. doi:10.1002/14651858.CD000216.
  18. ↑ Whitelaw, Andrew; Odd, David; Brion, Luc P; Kennedy, C R (2007). Whitelaw, Andrew (ed.). "Intraventricular streptokinase after intraventricular hemorrhage in newborn infants". Cochrane Database of Systematic Reviews. 2007 (4): CD000498. doi:10.1002/14651858.CD000498.pub2. PMC   7032544 . PMID   17943743.
  19. ↑ Bruschettini, Matteo; Romantsik, Olga; Zappettini, Simona; Banzi, Rita; Ramenghi, Luca Antonio; Calevo, Maria Grazia (2016-03-21). "Antithrombin for the prevention of intraventricular hemorrhage in very preterm infants". The Cochrane Database of Systematic Reviews. 2016 (3): CD011636. doi:10.1002/14651858.CD011636.pub2. ISSN   1469-493X. PMID   26998583.
  20. ↑ Leroux, Peter D.; Haglund, Michael M.; Newell, David W.; Grady, M. Sean; Winn, H. Richard (1992). "Intraventricular Hemorrhage in Blunt Head Trauma". Neurosurgery. 31 (4): 678–84, discussion 684–5. doi:10.1227/00006123-199210000-00010. PMID   1407453.
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  22. ↑ de Vries, LS; Liem, KD; Van Dijk, K; Smit, BJ; Sie, L; Rademaker, KJ; Gavilanes, AWD; Dutch Working Group of Neonatal Neurology (2007). "Early versus late treatment of post-haemorrhagic ventricular dilatation: Results of a retrospective study from five neonatal intensive care units in the Netherlands". Acta Paediatrica. 91 (2): 212–7. doi:10.1111/j.1651-2227.2002.tb01697.x. PMID   11952011. S2CID   24234952.
  23. ↑ Volpe, Joseph J. (1989). "Intraventricular hemorrhage in the premature infant?current concepts. Part I". Annals of Neurology. 25 (1): 3–11. doi:10.1002/ana.410250103. PMID   2913926. S2CID   41921817.
  24. ↑ Bristol, University of. "Bristol Neonatal Neurology Group - Bristol Medical School: Translational Health Sciences - University of Bristol". www.bris.ac.uk. Archived from the original on 6 January 2014. Retrieved 17 April 2018.
  25. ↑ Whitelaw, A.; Jary, S.; Kmita, G.; Wroblewska, J.; Musialik-Swietlinska, E.; Mandera, M.; Hunt, L.; Carter, M.; Pople, I. (2010). "Randomized Trial of Drainage, Irrigation and Fibrinolytic Therapy for Premature Infants with Posthemorrhagic Ventricular Dilatation: Developmental Outcome at 2 years". Pediatrics. 125 (4): e852–8. doi:10.1542/peds.2009-1960. PMID   20211949. S2CID   33833103.
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