Clinical Reference Systems: Pediatric Advisor 10.0

DESCRIPTION

Intraventricular hemorrhage (IVH) is a type of bleeding from fragile blood vessels in the brain. These blood vessels are especially fragile in premature infants. Babies who are born more than 8 weeks early (before 32 weeks of pregnancy, or 32 weeks of gestation) are most likely to have this bleeding.

A baby with IVH may:

• have no symptoms from the bleeding
• become sick from the bleeding, with symptoms of paleness, breathing problems, weak heart rate, and low blood pressure
• have seizures if the bleeding is severe
• develop hydrocephalus (increased fluid in the brain) because the blood plugs up the brain's fluid pathways (the ventricles).

Most intraventricular hemorrhages occur in the first week of life. They seldom occur after the first week.

Your physician will order an ultrasound scan of the baby's brain if the baby is more than 6 weeks premature (less than 34 weeks post-conceptional age) or if he or she thinks the baby might have IVH. The scan is done at the bedside and does not bother the baby. Ultrasounds are done every few days for the first week and then as needed.

CAUSE

Some very fragile blood vessels surround the ventricles of the brain. The ventricles are cavities in the brain through which cerebrospinal fluid (CSF) flows. The blood vessels are very underdeveloped in the very young infant. They start getting stronger after 32 weeks of gestation. These blood vessels are very sensitive to changes in blood flow. If the blood flow changes, the blood vessels break down and start bleeding. If the bleeding is slight, the blood remains around the blood vessels. If the bleeding gets worse, the blood breaks into the ventricles. In the worst cases of bleeding, the blood may leak into the brain tissue.

The hemorrhages are graded from 1 to 4 according to the severity of the bleeding. Small amounts of bleeding--grades 1 to 2--do not usually cause any long-term damage. Larger amounts of bleeding--grades 3 to 4--cause long-term problems. Grades 3 and 4 cause a blockage of the circulation system for cerebrospinal fluid. This blockage is called hydrocephalus.

The brain makes cerebrospinal fluid (also called spinal fluid), which circulates through the ventricular system in the brain and the central canal of the spinal cord. Hydrocephalus results from the blockage of the spinal fluid circulation pathways by blood clots. If the circulation of fluid is blocked, the fluid begins to build up and the ventricles begin to swell. If the ventricles swell to a large size, the fluid can press on the brain and cause damage. After IVH occurs, the hospital staff will watch closely for the development of hydrocephalus. If it occurs, there are treatments to keep the pressure under control.

TREATMENT

Unfortunately, there are no proven ways to stop IVH from happening. The best approach is to try to keep the brain from bleeding by keeping the baby as stable as possible. When IVH does occur, it is treated by looking for and treating the complications of the bleeding.

1. Early care
   • Head ultrasounds

     Ultrasound scans of the baby's head are done every few days during the first week to find out whether bleeding has occurred or if it has gotten worse (progressed). Bleeding occurs during the first week after birth. If there is no bleeding the first week, it is unlikely to happen later. Every baby born more than 6 weeks early (before 34 weeks of gestation) is checked for IVH.

   • Supportive care

     The best treatment is to keep the baby as stable as possible during the first week of life. Your physician will treat any lung conditions and infections and, if necessary, help the baby breathe. If necessary, the baby will be given a blood transfusion to keep the blood pressure and blood count stable. The baby will be treated for any seizures that occur.

2. Follow-up of IVH

   If IVH occurs, head ultrasound scans will be used to look for clearing of the blood clot. Most of the time, the body gets rid of small amounts of the blood over several weeks. Hydrocephalus can be detected by measuring the size of the ventricles. Many times the ventricles get slightly bigger but in a few weeks come back to a normal size without any treatment.

3. Hydrocephalus

   It is more common for hydrocephalus to develop in the more severe cases of IVH (grades 3 to 4). Your physician can tell if hydrocephalus develops by looking at the size of the ventricles on the ultrasounds.

   A baby who has hydrocephalus may not have any symptoms at first. Sometimes as the hydrocephalus progresses, the baby becomes sleepy, has more apnea (breathing pauses), or throws up feedings. Sometimes the only sign of hydrocephalus is that the head grows too quickly.

   Treatment for hydrocephalus is begun if the ventricles grow to a size that is thought to be harmful or if the baby has symptoms.

   • Spinal taps

     A spinal tap is used to remove spinal fluid from the spinal canal to relieve pressure. This means a needle is put in the baby's back to let fluid drip out. Spinal taps can be performed repeatedly. This procedure may allow time for the blood clots to clear by themselves and for the fluid pathways to open up. However, spinal taps may not work if the blockage prevents fluid from circulating from the ventricles to the spinal canal in the back.

   • Ventricular reservoirs

     When hydrocephalus cannot be treated by spinal taps, tubing can be surgically placed into the ventricles. This tubing in the ventricles is called a ventricular reservoir. It allows fluid to be withdrawn from the ventricles to control the pressure. If the hydrocephalus clears up, then the reservoir can be removed. If the hydrocephalus persists, permanent tubing, called a shunt, can be placed in the ventricles.

   • Ventricular peritoneal shunts

     If the hydrocephalus does not clear up on its own, a permanent shunt is placed in the ventricle. The shunt takes the fluid from the ventricle and drains it into the abdominal cavity where spinal fluid is absorbed by the body. One end of the tubing is inserted into a ventricle in the brain. The tubing is tunneled under the skin and the other end is placed into the abdominal cavity.

     Placement of the ventricular peritoneal shunt is performed by a neurosurgeon (brain surgeon) in the operating room. The baby is given anesthesia for the surgery.

     The shunt must be replaced as the child grows or if the shunt is blocked or infected. The shunt tubing is not noticeable after the baby grows bigger and has more hair.

LONG-TERM OUTCOME

1. Predicting outcome

   There is no test or examination that can accurately predict what a baby will be like as a child or adult. Only time and growth will show whether the brain has been permanently hurt.

   Sometimes other parts of the baby's brain may be able to take over the function of any damaged areas. This means that babies often do much better than expected. They do much better than an adult with a similar brain injury. Love, care, and encouragement that the child receives from his family also have a very important effect on his outcome.

2. Follow-up

   Children who have had IVH need to be observed and evaluated for several years to determine if the bleeding has hurt the brain. Their developmental progress should be tested regularly. If problems develop, special therapy and education programs can be begun. These programs will help the child do her very best.

3. Relating grade of hemorrhage to outcome

   In general, babies who have had small amounts of bleeding (grades 1 and 2) do not have any more problems than other premature babies who did not have IVH. Babies who have had more severe bleeding are more likely to have developmental problems as they grow. Many children who have had a grade-4 hemorrhage may have problems controlling movement on the side of their body opposite that of the injured part of the brain. If the other side of the brain is normal, these children can often function well enough to attend regular school.

   Only time will tell to what extent a child's brain is injured and what long-term problems he will have.