Intracranial Hemorrhage of the Newborn
Etiology and Epidemiology of ICH
? Trauma (epidural,subdural,or subarachnoid)
? fetal head is too large in proportion to the size of the pelvic outlet
? prolonged labor/breech or precipitate deliveries
? Mechanical assistance with delivery
? Asphyxia/Hypoxic ischemic encephalopathy
? Premature infants (peri-/intraventricular hemorrhage,PVH/IVH)
? Primary hemorrhagic disturbance (subarachnoid or intracerebral)
? DIC
? isoimmune thrombocytopenia
? neonatal vitamin K deficiency (maternal phenobarbital or phenytoin)
? Congenital vascular anomaly
? Iatrogenic hemorrhage (sucktioning,infusing,ventilating)
Incidence of PVH/IVH
? Most common neonatal intracranial hemorrhage
? Occurs primarily in premature infants
? Incidence increases with decreasing birthweight:
60~70% of 500- to 750-g infants,10~20% of 1000- to 1500-g infants
? Occasionally seen in near-term and term infants
? Rarely present at birth
? 50% occur on the 1st day,80~90% occur between birth and the 3rd day
? 20~40% progress during the 1st week
? Delayed hemorrhage may occur after the 1st week in 10~15% of the cases
? New-onset IVH is rare after the 1st month of life regardless of the birthweight
Pathogenesis of PVH/IVH
? Gelatinous subependymal germinal matrix (periventricular)
? Embryonal neurons and fetal glial cells
? Immature blood vessels and highly vascular area
? Poor tissue vascular support
? Predisposing factors or events
? Prematurity,RDS,Hypoxic-ischemic or hypotensive injury,reperfusion,
increased or decreased CBF,pneumothorax,hypervolemia,hypertension,etc
? Periventricular leukomalacia (PVL)
? Prenatal or neonatal ischemic or reperfusion injury
? Necrosis of the periventricular white matter
? Damage to the cortico-spinal fibers in the internal capsule
Pathogenesis of PVH/IVH
? Intravascular factors
? Fluctuating cerebral blood flow (related to mechanics of ventilation)
? Increasing in CBF (pressure-passive cerebral circulation in premature infants)
? Increases in cerebral venous pressure
? Decreases in CBF (occurring prenatally or postnatally)
? Platelet and coagulation disturbances (hypercoagulable state,vitamin K)
? Vascular factors
? Immature vessels in the germinal matrix
? Lack muscle and collagen,susceptible to rupture
? Vascular border zone with more mitochondria,more vulnerable to ischemia
? Extravascular factors
? No supportive stroma around the vessels
? Excessive fibrinolytic activity
Common Clinical Signs/Symptoms
? Change of consciousness
? Abnormal eyes signs/movement
? Increased intracranial pressure
? Irregular respiratory pattern or apnea
? Changes of muscle tone
? Pupils signs
? Others,jaundice,anemia,etc
Clinical Manifestation
? Most common symptoms are diminished or absent Moro
reflex,poor muscle tone,lethargy,apnea and somnolence
? Often have a precipitous deterioration on the 2nd or 3rd days
? Periods of apnea,pallor,or cyanosis
? Failure to suck well
? Abnormal eye signs,fixed pupils
? A high-pitched,shrill cry
? Muscular twitching,convulsion,decreased muscle tone,or paralysis
? Metabolic acidosis,shock,decreased hematocrit
? Tense and bulging of fontanel
? Severe neurological depression or coma
? Asymptomatic periods or no clinical manifestations
Clinical Manifestation
? Periventriular Leukomalacia (PVL)
? Symmetric,non-hemorrhagic ischemic injury
? Often coexists with IVH
? Usually asymptomatic at early days
? Becoming spastic diplegia in later infancy when the neurologic
sequelae of white matter necrosis become apparent
? Early echodense phase (3~10 days of life)
? Echolucent (cystic) phase (14~20 days of life)
Classification of PVH/IVH (Grading)
? Mild (70%,40% I + 30% II)
? Grade I,Isolated periventricular hemorrhage
? Grade II,Intraventricular hemorrhage with normal ventricular size
? Moderate (20%)
? Grade III,Intraventricular hemorrhage with acute ventricular dilation
? Severe (10%)
? Grade IV,Intraventricular hemorrhage with parenchymal hemorrhage
Papile LA,J Pediatr 1978; 92:529~534.
Diagnosis
? History
? Clinical manifestation
? Transfontanel cranial ultrasonography (real-time)
? Computed tomography (CT)
? Magnetic resonance imaging (MRI)
? Magnetic resonance spectroscopy (MRS)
Possible Prenatal Interventions
? Prevention of prematurity
Most effective means of prevention of PVH/IVH
? Transportation of infants in-utero
decreased incidence of ICH compared to postnatal transport
? Antenatal corticosteroids
↓PVH/IVH,maturation of blood vessels/↓prostaglandinsynthesis
? Antenatal administration of vitamin K
↓PVH/IVH,improvement in prothrombin activity
? Antenatal phenobarbital
↓severePVH/IVH,controversial
? Optimal management of labor and delivery
no consistent results
Possible Postnatal Interventions
? Appropriate neonatal resuscitation
avoid hypercarbia,rapid infusion and hypertonic solutions
? Correction/prevention of hemodynamic disturbances
avoid excessive handling,suctioning; use adequate ventilation
? Correction of abnormalities of coagulation
fresh frozen plasma can decrease incidence of PVH/IVH,not severe type
? Postnatal phenobarbital
inconsistent,current data do not support routine use for prevention
? Ethamsylate
stabilization of the fragile germinal matrix vessels
? Vitamin E
free-radical scavenger; conflicting data
? Indomethacin
↓CBF and fluctuations in systemic BP; closure of PDA;
accelerates maturationof the germinal matrix microvasculature
Prognosis of PVH/IVH
? Germinal Matrix Destruction
? Destruction of the matrix and its glial precursors
? Disrupt the development of neuron-glial units in the cortex
? Hemorrhage is frequently replaced by formation of a cyst (US visible)
? Hydrocephalus
? 50% of grade III/IV PVH/IVH will have static/transient ventriculamegaly
? 50% will require treatment for posthemorrhagic hydrocephalis
? Acute (within 2 wks) or indolent (evolves over weeks)
? Periventricular Hemorrhagic Infraction
? Parenchymal hemorrhage occurs in 10% of surviving infants
? Usually occurs on the same side of the larger IVH