Intraventricular Hemorrhage Ken Schroeter, DO

I. Head Ultrasound (HUS) Guidelines

Birth Weight Day of Life

-All infants with a birth weight <1500 gm get HUS at discharge -Obtain HUS more frequently if pathology exists

II. Intraventricular Hemorrhage (IVH). IVH is an intracranial hemorrhage that originates in the subependymal germinal matrix, and may extend into the ventricles of the brain, may progress to dilation of the ventricles, and may include areas of periventricular white matter infarction. The diagnosis is made by HUS, but more serious cases (Grade III, IV) are evaluated further with cranial computed tomography or magnetic resonance imaging. Incidence and severity are inversely related to gestational age. The highest risk for developing IVH of any grade is in the first 3 days of life. HUS done in the first 4-7 days of life will detect 90-100% of all IVH.

Grade I Subependymal (germinal matrix) hemorrhage

-Majority resolve completely -88-95% will have normal neurological outcome

Grade II IVH without ventricular dilatation (blood in the ventricle)

-Majority resolve completely -85% will have normal neurological outcome

Grade III IVH with ventricular dilatation

-65-73% will have a normal neuro outcome, but associated mortality is 8%

Grade IV IVH with periventricular hemorrhagic infarction

-86-90% will have major motor deficits, 64% will have major cognitive problems, and associated mortality approaches 60%, especially < 1.5 kg

Periventricular Leukomalacia (PVL)

-Focal necrosis of periventricular white matter, dorsal and lateral to the ventricles,ischemic (not hemorrhagic). Large cysts form in severe PVL. 25-40% of preterm infantsaffected. It is not caused by IVH, but frequently associated with it.-HUS not as sensitive, CT/MRI not initially helpful-Cystic formation is associated with poorer neurologic outcome.-82% of children with cerebral palsy have PVL. Most with PVL will have someneurocognitive disorder such as attention disorders, learning disabilities, and subtlebehavior problems.

Examples of Head Ultrasounds

Normal Coronal HUS. V: lateral ventricles, C: caudate head, Arrows: choroid plexus,

L: lentiform nucleus, S: Sylvian fissure.

Normal Sagittal HUS. V: Ventricle, C: Caudate, T: Thalamus, Arrows: Caudothalamic groove.

Grade I Subependymal hemorrhage (sagittal view).

Grade II extension into the ventricle (sagittal view).

Grade III extension with dilatation (coronal view).

Grade IV Periventricular infarction (coronal view)

Ref: Bulas, D and Vezina, G, Preterm Anoxic Injury -Radiologic evaluation, NeonatalImaging, Radiologic Clinics of North America, Volume 37, Number 6, November 1999