Periventricular and intraventricular hemorrhage in the neonate Cecile

Periventricular and intraventricular hemorrhage in the neonate Cecile Osman April 9, 2010

What is PVH/IVH? Ø Bleeding into the periventricular white matter (motor tracts) Ø Is associated with hydrocephalus and long -term disability

Where does it occur? Ø Subependymal germinal matrix l l l Where neuroblasts and glioblasts divide and migrate into the cerebral parenchyma Cells of the germinal matrix are rich in mitochondria so are quite sensitive to ischemia Usually regresses by term

What are the subtypes: Ø Grade I – Subependymal region and/or germinal matrix

What are the subtypes: Ø Grade II: Subependymal hemorrhage with extension into lateral ventricles without ventricular enlargement

What are the subtypes: Ø Grade III: Subependymal hemorrhage with extension into lateral ventricles with ventricular enlargement

What are the subtypes: Ø Grade IV: Intraparenchymal hemorrhage

Why does it occur? Ø GM supplied by primitive and fragile retelike capillary network Ø Thought to be due to: l l 1) loss of cerebral autoregulation 2) abrupt alterations in cerebral blood flow and pressure

Autoregulation Ø Term infants and most “healthy” premature have the ability to regulate cerebral blood flow Ø Preemie has more narrow range of perfusion pressures over which he can control regional cerebral blood flow Ø Without autoregulation, systemic BP is what mostly controls cerebral perfusion/pressure

Cerebral Blood Flow / Pressures Ø Many things can affect CBF l Asynchrony between spontaneous and mechanically delivered breaths; birth; noxious procedures of caregiving; tracheal suctioning; pneumothorax; rapid volume expansion; seizures; and changes in p. H, Pa. CO 2, and Pa. O 2

Cerebral Blood Flow and Respiratory Pattern Ø When mechanical breaths are not synchronized with efforts of the patient, beat-to-beat fluctuations in blood pressure occur Ø Patients without asynchrony between mechanical ventilation and patient efforts had stable blood pressures, stable cerebral perfusion, and a lower incidence of hemorrhage

Why do we care? Ø The bleeding leads to destruction of the cerebral parenchyma necrosis Ø Eventually causing hydrocephalus may end up needing VP shunt Ø Depending on WHAT part of the brain is destroyed seizures / cerebral palsy / mental retardation

Who gets affected? Ø All premature infants, especially <32 weeks Ø Can see in term infants if has trauma / asphyxia Ø Most occur within first 72 hrs of life, 50% in the first 24 hours Ø Can occur after 3 rd day of life esp if neonate develops significant life threatening event

What should we do? Ø Initial screen usually at ~7 days of life Ø Cranial ultrasound is tool of choice l Serial ultrasounds to follow progression / evolution of the bleed

What should we do? Ø Supportive care l l Minimize risk factors NO NEED for serial LP Ø Eventually may need venticulostomy VP shunt for those who have post-hemorhagic hydrocephalus that need surgical intervention

Medications? Ø Indomethacin: l l Controversial, but possibly indicated in patients at risk for PVH-IVH, including those <32 weeks' gestation or those who weigh <1250 g at birth. Inhibits the formation of prostaglandins by decreasing the activity of cyclo-oxygenase. Thought to cause maturation of the germinal matrix microvasculature (mechanism unclear) 0. 1 mg/kg/dose IV when aged 6 h, then q 24 h for 2 d for a total of 3 doses

Prognosis Ø Grade I and grade II hemorrhage: l Neurodevelopmental prognosis is excellent (ie, perhaps slightly worse than infants of similar gestational ages without PVH-IVH).

Prognosis: Ø Grade III hemorrhage without white matter disease: l Mortality is less than 10%. Of these patients, 30 -40% have subsequent cognitive or motor disorders.

Prognosis Ø Grade IV (severe PVH-IVH) IVH with either periventricular hemorrhagic infarction and/or periventricular leukomalacia (PVL): l Mortality approaches 80%. A 90% incidence of severe neurological sequelae including cognitive and motor disturbances is noted