Intraventricular hemorrhage (IVH) in newborns. View full version What is 1st degree IVH in a child

The birth of a child is a rather unpredictable process and often the baby’s health suffers as a result. Brain damage resulting from and is of particular danger to the baby’s health. Oxygen starvation of the brain can lead to intraventricular hemorrhage (IVH) in newborns. The risk of such a complication lies mainly in children who were born prematurely. This is due to the immaturity of blood vessels and structural features of the brain in this group of newborns. Premature babies have a special structure in the brain - the germinal matrix, the cells of which subsequently create the framework of the brain, migrating to the cortex. Intraventricular hemorrhage in newborns occurs as a result of rupture of the vessels of the germinal matrix and the flow of blood into the lateral ventricles. As a result of IVH, the migration of germinal matrix cells occurs with disturbances, which has a detrimental effect on the development of the child, causing delays.

Degrees of residential housing complex

1. IVH stage 1 - hemorrhage is limited to the wall of the ventricles, without spreading to their cavity.
2. IVH stage 2 – hemorrhage penetrates into the ventricular cavity.
3. IVH stage 3 – disturbances in the circulation of cerebrospinal fluid occur, causing hydrocephalus.
4. IVH stage 4 – hemorrhage spreads to the brain tissue.

IVH of grade 1 and 2 in newborns are usually characterized by an asymptomatic course, and they can only be detected through examination with additional methods (computed tomography, neurosonography).

Consequences of IVH

The consequences of IVH for the health of a newborn depend on many factors, in particular the severity of hemorrhage, the gestational age of the baby, the presence of developmental pathologies and concomitant diseases. IVH of the 1st and 2nd degrees in newborns in 90% of cases resolves without a trace, without causing serious harm to the health of the child. IVH grades 3 and 4 cause motor disorders and neuropsychological problems.

01.05.2010, 07:21

Hello.
Please help me cure the child.
Extract data from the RD:

Pregnancy: 2 births, 2nd pregnancy, at 39-40 weeks, ACS, clear waters, “boiled” placenta. Pregnancy 1.2 halves - without features. Apgar score 8-9 points, boy 4070 g, 56 cm, approx. Goal. 35 cm, approx. breasts 37 cm.
The child's condition in the following days: satisfactory. at birth, deterioration by the end of 1 day to moderate severity due to the syndrome of vegetative-visceral disorders, regurgitation (after each feeding in the volume of the mixture eaten).
Attached to the breast on the 5th day, the umbilical cord fell off on the 4th day, jaundice: no.
MUMT on day 6: 354 g, 8.6% Weight at discharge: 3716 (maximum weight loss) The mother refused further stay in the RD.
Examination carried out:
NSG on the 2nd day of the child’s life: In the projection of the caudate nuclei, a hematoma of 1.4-0.5 cm is located supependimally on the left. It has a heterogeneous structure due to small pseudocysts, the stage of lysis, intrauterine hemorrhage cannot be excluded. IVH 1st degree, left.
X-ray of the cervical spine: signs of trauma in the cervical spine at the level of C3 (dislocation of C3 posteriorly within 1.0 mm)
Examination by a surgeon on the second day of life: endoscopy - acute erymatous reflux esophagitis, acute erosive-hemorrhagic gastritis.
Neurologist: Cerebral ischemia of hypoxic origin, vegetative-visceral disorders, regurgitation, 1st degree IVH on the left.
Treatment carried out: c. Shantsa, Infusion therapy according to indications for up to 6 days. according to physiological needs.
Audiological screening on the 5th day: BP - normal, AC - no. Repeated screening at 1 month is recommended.
Clinical analysis: Cerebral ischemia stage 2 of hypoxic origin, IVH stage 1, see vegetative-visceral disorders, regurgitation, o. erythematous reflux esophagitis, o. erosive-hemorrhagic gastritis. Gr. risk for IUI.
Health group: 3
Risk factors: 16 b.

Examination by a pediatrician on the 7th day:
Breastfeeding, on demand, sufficient lactation. Wakefulness is calm, sleep is calm, with a total duration of up to 20 hours per day, the physique is correct, muscle tone is dystonic, reduced in the arms (more in the proximal parts of the arms) more than in the legs.
Reflexes of a newborn: proboscis +, searching +, sucking +, grasping +, support: no 2 phases of p. Robinson, leg abilities quickly fade, crawling+, automatic gait+.
Visual analyzer: 7 days, auditory analyzer: 7 days.
The skin has a physiological color, turgor is reduced, subcutaneous tissue is developed moderately and evenly. Musculoskeletal system: no visible deficiencies, short neck (underlined by the pediatrician with a wavy line), “doll’s hand”
Fontana: 2.0x2.0 at the level of bone formations, the skull bones are dense.

Examination by a neurologist on the 25th day:
Complaints about changes in the NSG, chin tremor
Ob.but: about goal. 38 cm, br 3.0x3.0, not tense. General cerebral issues: regurgitation of the IMN - the gaze fixes, there is no ptosis. Smoothness of the right nasolabial fold. There are no bulbar disorders. Is your hearing reduced on the left? Muscle strength is not reduced. Muscular dystonia with increased tone in the bends of the arms, adductor muscles of the thighs (more on the right). The doll's head, lying on its stomach, does not rest well on its right arm. When verticalizing, rest on the top edge of the feet, tuck the toes, step reflex with the legs crossing at the level of the feet. The reflexes of a newborn are alive. D-z: post-hypoxic-ischemic post-hemorrhagic perinatal encephalopathy, hydrocephalic s-m, syndrome of neuromuscular dystonia, vegetative-visceral disorders.
Recommended:
1. EPH with 1% aminophylline solution at SHOP according to Rabner 10
2. gliatilin 1.0 IM N12
3. Actovegin 0.5 IM No. 10
4. glycine 0.1, 1/2 tablet. under the tongue 1 month.
5. Repeat NSG after treatment
6. Examination by a neurologist, pediatrician

Examination by a pediatrician at 1 month: height 56.5, weight 5170 (+1100 in 1 month) OB 38.5 (+3.5 cm), chest 40 (+3.0), BR 2.0x2.0
Functional state: no complaints, satisfactory condition. Satisfied nutrition, the skin is clean, dry on the cheeks and behind the ears. Muscle tone is satisfied. Periodically throws back his head. Reflexes of newborns: grasping, Babkin, Robinson lively symmetrical, Moro 1 phase, support on curled toes, stepping, protective, Bauer, Gallant, Perez - it seems, VI VPR.
Conclusion: RF macrosomia, disharmony. due to the environment breast, NPR 1 gr.
D-z: PEP, ChChS, s-m NMD, vegetative-visceral dysfunctions. BP, infant var-t, lok. f-ma, beginning p-d

Parents' comment: the child is 1.5 months old, regurgitation sometimes disappears completely, but now it has become more frequent, occurring after almost every feeding (volume of 0.5 teaspoon-3 tablespoons) with both curdled and watery milk. The stool is normally yellow without mucus. Rarely with green splashes. The stomach is swollen. The child is calm, sleeps all night, feeds 2-3 times at night. During the day, the period of wakefulness increases to 4-6 hours. Burps more often when pushing. The child grunts and rarely cries. He can distinguish his mother's voice, perks up at the sight of a breast, turns his head from side to side behind a toy, smiles when addressed to him.
The smile is sometimes asymmetrical, the mouth is slightly curved.
In a lying position on his stomach, he holds his head for 15-20 seconds. The child arches while crying; if you carry it vertically, he throws his head back.

Questions:
1. Stage 1 IVH - what does it mean in the future? What are the prognoses taking into account medical history and pregnancy.
2. Is it worth using the medications prescribed by the neurologist?
3. After three electrophoresis procedures, a mast rash appeared (in the area where the electrodes were inserted), treatment was stopped. The rash is going away, but slowly (for a week now). Is it worth continuing EFZ?
Thank you!

01.05.2010, 10:56

Such intrauterine hemorrhage does not require any treatment. A hematoma of similar size lyses (dissolves) on its own to form a small cyst.
You will not be able to influence this process with medication, especially with the drugs prescribed by the neurologist. This treatment is not necessary. Moreover, in addition to being useless, it can also be harmful to the child.
Electrophoresis is also not indicated. Only developmental classes are needed. Children are quite flexible, and in the vast majority of cases such problems go away relatively without leaving a trace.

01.05.2010, 11:40

Thank you very much for your answer. But local doctors, on the contrary, say that the worst thing is the formation of a cyst, and in order to prevent this, such drugs are prescribed.
Please advise what to pay attention to in the future, so as not to miss the moment and start treating the child (if necessary).
Is it a worrying symptom that a child sometimes falls asleep with his eyes open, i.e. Does he sleep with his eyes open at first, and then fall into deep sleep and close his eyes?
And one more thing... Will massage and gymnastics provoke any negative phenomena, because... the neurologist categorically forbade physical procedures, because this, according to her, will provoke negative dynamics.

01.05.2010, 12:34

Such cysts are the result of lysis of hematomas. This is a natural normal recovery process. Nature came up with such a mechanism; there is absolutely nothing scary about it. I repeat once again - it is IMPOSSIBLE to influence him with these drugs.
Neither massage nor gymnastics can provoke negative phenomena and negative dynamics.
And in general, after such statements, I would run away from this neurologist until the child begins to be treated with something even more extravagant.

22.07.2010, 16:57

First of all, thank you very much, dear doctors, for saving my child from a bunch of meaningless injections.:ax::ax::ax: Indeed, according to the results of the NSG, by the end of the second month only a pseudocyst with a diameter of 1.5 mm was discovered.
Everything resolved without Actovegin and gliatilin. We did one course of massage and that was it.

Secondly, there is a question about the current condition of the child.

The child is 4 months old. Grabs toys with both hands, brings his hands in front of him, actively babbles, from 3.5 months. rolls over onto his stomach, distinguishes between relatives. What worries me is what the child started doing quite recently.

In other words, this is something similar to a hemorrhagic stroke, when blood enters certain structures of the central nervous system - the ventricles of the brain (they form cerebrospinal fluid, i.e. cerebrospinal fluid, there are four of them in total - two lateral, as well as a third and fourth) .

An important role in the development of cerebral hemorrhages in newborns belongs to the anatomical features of the immature body of a premature baby. The greater the degree of prematurity and immaturity, the higher the risk of hemorrhage, especially in children with extremely low and very low body weight (less than 1000 and 1500 grams, respectively). The blood vessels around the ventricles of the brain are very fragile and require very little force to damage and rupture them.

The leading factors in the occurrence of IVH are episodes of hypoxia, as well as traumatic damage to blood vessels (usually due to difficult childbirth). Hypoxia is oxygen starvation, which is accompanied by fluctuations in blood pressure both in general and directly in the vessels of the brain. Hemorrhages are much less commonly associated with primary coagulopathies (blood clotting disorders) or congenital vascular anomalies. IVH also occurs with disseminated intravascular coagulation, isoimmune thrombocytopenia, and vitamin K deficiency.

IVH occurs most often in the first three days of life and can increase in the first week, and much less often occurs after the first week of life.

There are some differences in the classifications of cerebral hemorrhages depending on the location and causes of the hemorrhage; the classification presented below is most often used.

There are four degrees of hemorrhage:

II degree - blood enters the cavity of the ventricle of the brain, but the further development of the child is usually only slightly affected, and often disappears on its own and without a trace.

III degree - the exit from the ventricles is closed by a blood clot, and the ventricles begin to expand. Some cases are accompanied by spontaneous resolution of the problem, but if this does not happen, surgery is necessary to install a shunt that unblocks the ventricles of the brain, otherwise there is a high risk of developing hydrocephalus. At this degree, manifestations of neurological symptoms are not uncommon.

IV degree - blood enters not only the ventricles of the brain, but also the surrounding brain tissue - the parenchyma. Such hemorrhage is life-threatening and is accompanied by severe neurological symptoms - most often convulsions, repeated episodes of apnea, the development of anemia, as well as ocular symptoms.

Causes of hemorrhage development.

It is definitely not known why some babies develop hemorrhage and others do not, and what is the immediate cause of brain hemorrhage in premature babies. But the more stable conditions are created for the child, the better, because premature babies require a strict protective regime and stay in a comfortable microenvironment, for which a special incubator is used.

Symptoms of hemorrhage may vary. Most often they are absent. However, with extensive hemorrhage, the child’s condition worsens, he becomes agitated, and convulsions and ocular symptoms may occur. The child may be lethargic and less mobile, and muscle tone changes. Anemia develops, and in severe cases, shock and coma. Until the sonographer makes a diagnosis using ultrasound, the clinical picture may be difficult to distinguish from that of a rapidly developing infection.

Treatment is aimed at eliminating the consequences of hemorrhages and their complications. For example, correction of anemia, anticonvulsant therapy, and for progressive hydrocephalus, a neurosurgical operation is performed - ventriculoperitoneal shunting.

Long-term consequences of hemorrhages.

Minor hemorrhages (grade I), as a rule, do not lead to neurological pathology. Grade II hemorrhages also slightly increase its risk. Data from domestic and foreign studies show that extensive hemorrhages in the ventricles of the brain (III degree) lead to death in approximately 25% of children and a high percentage of disability, while 25% develop progressive expansion of the ventricular cavity, but approximately 50% of children do not experience complications. Of those children who have dilatation of the ventricular cavity, approximately half require surgery to install a shunt. With severe bleeding and hemorrhage into the brain tissue (IV degree), 50-60% of children die. With III and especially IV degrees of hemorrhage, surviving children experience significant impairment of motor functions in the form of cerebral palsy (cerebral palsy), developmental delays, decreased vision and hearing or their complete absence with the development of blindness and deafness. Fortunately, grade III and IV hemorrhages are not that common. It is noted that IVH is more severe in full-term infants than in premature infants.

Intraventricular hemorrhage in newborns

I. Definition. Intraventricular hemorrhage (IVH) is a disease characteristic mainly of premature infants. IVH is diagnosed in 45% of newborns with a birth weight of less than 1500 g and in 80% of newborns with a birth weight of less than 1000 g. Although there are reports of prenatal IVH, hemorrhage into the cerebral ventricles usually occurs soon after birth: 60% in the first 24 hours, 85% in the first 72 hours and 95% in the first week of life.

A. Subependymal germinal matrix. The germinal matrix is ​​present in premature newborns, but it disappears by 40 weeks of pregnancy. This is an area rich in thin-walled vessels that is the site of production of neurons and glial cells from the cortex and basal ganglia.

B. Changes in blood pressure. A sudden increase in arterial or venous pressure leads to hemorrhage into the germinal matrix.

B. Breakthrough hemorrhage into the germinal matrix through the ependyma leads to IVH in 80% of newborns.

G. Hydrocephalus. Acute development of hydrocephalus may result from obstruction of the cerebral aqueduct or, less commonly, the foramen of Monroe. Slowly progressive hydrocephalus sometimes develops due to obliterating arachnoiditis in the posterior fossa.

D. Parenchymal hemorrhage. In 20% of newborns with IVH, there is concomitant parenchymal hemorrhage in the area of ​​cerebral ischemia or infarction.

A. High risk factors

1. Extreme prematurity.

2. Asphyxia during childbirth.

6. Respiratory distress syndrome.

8. Sudden increase in blood pressure.

B. Other risk factors include administration of sodium bicarbonate, rapid replenishment of circulating blood volume, a functioning ductus arteriosus, increased central venous pressure, and impaired hemostasis.

IV. Classification. Any classification of IVH must take into account the location of hemorrhage and the size of the ventricles. Many classifications have been proposed, but the classification developed by Papile is currently the most widely used. Although it was based on computed tomography data, it is used to interpret ultrasound results.

A. Grade I. Subependymal hemorrhage into the germinal matrix.

B. Degree II. Breakthrough hemorrhage into the ventricles of the brain without their dilatation.

B. Grade III. Intraventricular hemorrhage with ventricular dilatation.

D. Degree IV. Intraventricular and parenchymal hemorrhage.

V. Clinical manifestations. The clinical manifestations of IVH are extremely diverse. Symptoms may be completely absent or expressed in fontanel tension, a sudden decrease in hematocrit, apnea, bradycardia, acidosis, convulsions, changes in muscle tone and consciousness. The catastrophic course of the disease is characterized by the rapid development of stupor or coma, respiratory failure, tonic convulsions, “decerebrate” posture, lack of pupillary response to light, lack of eye movements in response to vestibular stimuli, and quadriparesis.

A. Symptoms and signs of IVH may be similar to those of other common diseases in the neonatal period, such as metabolic disorders, asphyxia, sepsis and meningitis,

B. Diagnosis based on clinical symptoms may be erroneous.

1. Among newborns with IVH confirmed by computed tomography, only 60% were diagnosed with this diagnosis based on clinical data.

2. Among newborns with IVH documented by computed tomography, only 25% were diagnosed with hemorrhage based on clinical criteria.

A. Laboratory research

1. The results of a study of cerebrospinal fluid correspond to normal values ​​in approximately 20% of newborns with IVH.

2. Examination of the cerebrospinal fluid usually reveals an increased number of red and white blood cells in combination with an increase in protein concentration.

3. Very often it is difficult to differentiate IVH from “traumatic puncture”.

4. A few days after the hemorrhage, the cerebrospinal fluid becomes xanthochromic, and the sugar concentration decreases.

5. It is often difficult to make a correct diagnosis based on the results of a cerebrospinal fluid study, so the use of echoencephalography or computed tomography is required to confirm IVH.

B. Radiological studies. Ultrasound and computed tomography are of great diagnostic value.

1. Prevention of premature birth and perinatal asphyxia can prevent many cases of IVH.

2. It is necessary to follow the general principles of care for premature infants in order to maintain a stable acid-base balance and avoid fluctuations in arterial and venous pressure.

3. Pharmacological prevention. None of the drugs listed below have been proven effective or safe.

(1) Mother. Give a dose of 500 mg slowly intravenously, followed by 100 mg orally every 24 hours until labor occurs or ends.

(2) Newborn. Give 2 doses of 10 mg/kg each IV 12 hours apart, then give 2.5 mg/kg every 12 hours IV, IM, or orally for 6 days.

b. Pancuronium; Administer 0.1 mg/kg IV as many times as necessary to achieve muscle relaxation in the first 72 hours of life.

V. Indomethacin. The course consists of 5 doses of 0.1 mg/kg intravenously every 12 hours.

g. Etamsylate (125 mg/ml). Give 0.1 mL/kg IV in the first 2 hours of life, then every 6 hours for 4 days. (Currently not applicable in the US.)

e. Vitamin E. Administer 20 mg/kg intramuscularly once daily for 3 days.

B. Screening ultrasound or computed tomography

1. All newborns weighing less than 1500 g should be examined.

2. Higher birth weight infants should be evaluated if they have risk factors for IVH or signs of increased intracranial pressure and hydrocephalus.

3. The optimal age for diagnosing IVH is 4-7 days of life; a repeat study should be performed on the 14th day.

4. The optimal age for diagnosing hydrocephalus is 14 days of life; a control study is indicated at the age of 3 months.

5. The advantages of echoencephalography are satisfactory resolution, portability of equipment and lack of radiation. IVH may not be identified on CT scans for 7–14 days after hemorrhage.

B. Acute hemorrhage

1. Stabilization of the condition and general supportive measures

A. Maintain cerebral perfusion pressure by maintaining adequate blood pressure.

b. Maintain adequate blood volume and acid-base balance.

2. Carry out dynamic studies (ultrasound or computed tomography) to exclude the progression of hydrocephalus.

3. Randomized controlled studies of the effectiveness of serial lumbar punctures to prevent the development of posthemorrhagic hydrocephalus did not reveal a significant difference between the main group of newborns who received lumbar punctures along with supportive therapy, and the control group, which received only supportive therapy.

In mild forms of hydrocephalus, the size of the ventricles stops increasing without additional treatment.

VIII. Forecast. The prognosis depends on the severity of the hemorrhage.

A. Degree I and II. There is no difference in morbidity and mortality rates among newborns with stage I and II IVH and children without IVH under 2 years of age.

B. Degree III. Up to 80% of children have severe neurological disorders.

B. Grade IV. Almost all children (90%) die or have severe complications.

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Intracerebral hemorrhages in premature newborns: consequences, treatment, prognosis

Bleeding in or around the brain can occur in any newborn, but is especially common in premature babies.

Ischemia-hypoxia, changes in blood pressure and pressure. The presence of germinal matrix makes bleeding more likely. The risk also increases with hematologic diseases (eg, vitamin K deficiency, hemophilia, disseminated intravascular coagulation).

Subarachnoid hemorrhage is probably the most common type of intracranial hemorrhage. These newborns may have apnea, seizures, lethargy, or unusual neurological findings. Heavy bleeding associated with meningeal inflammation can lead to hydrocephalus as the infant grows.

Subdural hemorrhage, now less common due to improved obstetric techniques, results from bleeding into the falciform space, tentorium, or commissuruven. Such bleeding typically occurs in newborns of first-time mothers, large newborns, or after a complicated birth—conditions that can produce unusual pressure on intracranial vessels. Symptoms may include seizures; rapid head enlargement or abnormal neurological examination results.

Intraventricular and/or intraparenchymal hemorrhages are the most serious type of intracranial hemorrhage. They are often bilateral and usually develop in the germinal matrix. Hypoxia - ischemia damages the capillary endothelium, reduces cerebral vascular autoregulation, and can increase cerebral blood flow and venous pressure, which make bleeding more likely. In most cases, intraventricular hemorrhages are asymptomatic.

Risk: In preterm infants, the risk and severity of intracerebral hemorrhage is directly proportional to the degree of immaturity:

• 25 weeks of gestation - 50% risk.
• 26 weeks - 38%.
• 28 weeks - 20%.
• Statistics vary, sometimes significantly, between clinics.

Time of manifestation. In premature infants, about 50% of hemorrhages appear on the 1st day of life, 25% on the second and 15% on the third.

Premature infants have a germinal matrix (regresses by 32-36 weeks of gestation) with vulnerable vessels (sensitive to pressure fluctuations, ischemia, hypoxia, acidosis, coagulation disorders). During the gestational week, most of the terminal matrix is ​​located at the caudothalamic junction, just posterior to the foramen of Monro. The fourth ventricle also contains a vulnerable germinal matrix.

As the newborn matures, the importance of the germinal matrix as a source of intracerebral hemorrhage decreases, and the importance of the choroid plexus increases.

Classification of intracerebral hemorrhage in newborns

Advice. Instead of the above classifications (there are others), it is better to use a brief, precise description using the terms “germinal matrix”, “intraventricular”, “parenchymal” and indicating the location.

The Papile classification is the most commonly used classification of hemorrhages in NN, based on computed tomography data:

• Hemorrhage of the II degree: with a breakthrough into the ventricle without its expansion.
• Hemorrhage of the III degree: with a breakthrough into the ventricle and its expansion.
• Hemorrhage of the IV degree: a combination of hemorrhage of I-III degrees with hemorrhage in the brain parenchyma.

Classification by DEGUM (German Society for Medical Ultrasound). Developed by the pediatric department of DEGUM in 1998 and based on ultrasound data:

• Hemorrhage of the 1st degree: subependymal.
• Grade II hemorrhage: intraventricular with filling< 50 % просвета.
• Hemorrhage grade 111: intraventricular with filling > 50% of the lumen.
• Parenchymal hemorrhages (cerebrum, cerebellum, basal ganglia, brain stem) are described separately (location and size).

Diagnosis of intracerebral hemorrhage in newborns

Intracranial hemorrhage should be suspected in a newborn with apnea, seizures, lethargy, or unusual neurological symptoms; such children need a CT scan of the head. Although cranial ultrasound is not dangerous, CT is more sensitive for thin layers of blood. However, for screening very preterm infants (e.g.<30 нед гестации) некоторые врачи предпочитают проведение УЗИ. Если диагноз вызывает сомнение, СМЖ может быть проверена на содержание эритроцитов: она обычно содержит много крови. Однако некоторое количество эритроцитов часто присутствует в спинномозговой жидкости доношенных новорожденных.

In addition, blood tests, CBC and metabolic studies should be performed.

Ultrasonography

Premature infants should undergo cranial ultrasound on the first, third and seventh days of life. It also makes sense to perform an ultrasound after the child’s admission to the department (in case of forensic investigations to clarify the time of the first manifestation of the lesion).

If a lesion is detected, a thorough examination of the midbrain and infratentorial structures is necessary through additional approaches (anterior and posterior lateral fontanelles). In approximately 10% of premature infants with post-hemorrhagic dilation of the ventricles, small hemorrhages are detected in the cerebellum, which are poorly visible through the large fontanel (this clinical problem is underestimated).

If hemorrhage is detected near the arteries, especially in a full-term newborn, Doppler examination of the venous vessels (superior sagittal sinus, internal veins of the skull) is necessary.

In full-term infants, in addition to ultrasound, it is necessary to perform MRI and, if this is important for treatment, angiography.

Intraparenchymal areas of echo enhancement (the term periventricular venous perfusion or edema is often used) are the sites of infarction in most cases. Sometimes they go away without the formation of cysts, and then in retrospect we can only talk about venous stagnation. After the onset of cystic transformation (weeks), areas of echo enhancement should be called infarctions or hemorrhages (important for conversation with parents).

Differential diagnosis

Unlike hemorrhages in premature infants, which are explained by immaturity, hemorrhages in full-term infants require a thorough search for the cause: resuscitation, birth trauma, hemorrhagic diathesis (coagulation and platelets), thrombophilia, venous and arterial thrombosis, embolism, polyglobulia, hypernatremia, aneurysms, arteriovenous malformations, coarctation of the aorta, tumor, ECMO therapy, etc.

Treatment of intracerebral hemorrhage in newborns

Treatment is primarily supportive unless hematologic abnormalities contribute to bleeding. All children should receive vitamin K if it has not been previously provided. If platelets or clotting factors are insufficient, they must be replenished. Subdural hematomas should be treated by a neurosurgeon; removal of the hemorrhage may be necessary.

Make the most of all conservative treatment options:

• Stabilize blood pressure: avoid surges in blood pressure, use catecholamines carefully, sedation. The principle of correction with minimal means.
• Normalization of oxygenation.
• Avoid hyper- and hypocapnia (decreased brain perfusion).
• Control of coagulogram, correction of deviations.
• Avoid hypoglycemia.
• Widespread use of anticonvulsants.

Caution: It is better to intubate electively than in an emergency situation with apnea.

For full-term infants, early consultation with a neurosurgeon.

Prognosis of intracerebral hemorrhage in newborns

In preterm infants, grades I-II intracerebral hemorrhage probably does not significantly increase the risk of neurological complications.

The risk of severe neurological complications in premature infants with grade III hemorrhages is approximately 30%, and with parenchymal hemorrhages - approximately 70%.

In mature neonates, prognosis depends on location and cause; hemorrhages in the basal ganglia, cerebellum and brainstem have an unfavorable prognosis, but the individual course is unpredictable.

The prognosis for subarachnoid hemorrhage is usually good. For subdural, cautious, but some babies do well. Most infants with small intraventricular hemorrhages survive the episode of acute bleeding and appear well. Children with large intraventricular hemorrhage have a poor prognosis, especially if the bleeding continues into the parenchyma. Premature infants with a history of severe intraventricular hemorrhage are at risk of developing posthemorrhagic hydrocephalus and should be closely monitored with repeat cranial ultrasound and frequent repeat head circumference measurements. Infants with progressive hydrocephalus require neurosurgical intervention to place a subcutaneous ventricular reservoir (for CSF aspiration) or a ventriculoperitoneal shunt. The CSF associated with posthemorrhagic hydrocephalus has very low glucose concentrations, known as hypoglycorrachia. Because many children have persistent neurological deficits, close monitoring and referral for early intervention are important.

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Intraventricular hemorrhage (IVH) grade 2

Comments

Love and protect your children no matter what!

I am writing this to those who have encountered such a problem and found this blog, I was in your place and I know that first of all you want to know that everything will be fine with your child. But often if such a misfortune has passed by, then they do not return to it and therefore you will see mostly sad comments, but I promised myself to return here in a year. My baby was born a year ago and with such happiness I was informed that she has IVH of the 1st-2nd degree. And now everything is fine) At the moment, according to the NSG, a very small cavity of the transparent septum remains and the fontanel is not yet closed, but otherwise it is developing as normal) But of course, not without the help of specialists, over the year we have done a lot of work and invested a lot of money and now it under the supervision of doctors. I don’t know what will happen next, but I’m ready to do everything to keep her healthy.

My son also has stage 2 vzhk. I pray every day. We are 4.5 months old. We take medicine and do massage for the second course. electropheresis. so scary.

I can only advise you to strengthen yourself with the strength that you will really need for the rest of your days.

Whatever doctors say good “about the future” of a child who has suffered such a monstrous injury at such an early age as brain damage is just another attempt to console you, because such children, as a rule, have no future. and their personal fear for your abandonment of your own child (understand for yourself, it is not profitable for the state to support such children, and the staff of the maternity hospital where children are abandoned receive a good beating.).

Intraventricular hemorrhage in the brain does not bring anything good. As a result, a child who has had the “fortune” of falling into the hands of inexperienced midwives or doctors at its initial stage, that is, during childbirth, remains a disabled child with all the ensuing consequences for the rest of his life, sadly. Yes, the hemorrhage is healed/treated/cured (as you wish), but the consequences remain and appear after years.

The child is growing, he is turning one year old. then two. three. We think that everything is fine and the child seems to be outwardly healthy. And then the problems begin. Problems of a psychological/neurological/psychiatric nature.

ZY I’m writing so harshly and truthfully not because it’s all hearsay. I myself have been in this shoes and remain to this day. I gave birth the same way. the child was also received incorrectly. also a month-and-a-half stay in the hospital in the neonatal pathology department and ardent attempts at treatment by doctors at huge expense. diagnosis of stage II IVH. and assurances from doctors that everything will be fine in the future. . Then repeated treatment and discharge from the hospital stating that the child is practically healthy and unobtrusive recommendations to visit a pediatrician/neurologist.

As a result: disabled since childhood, disabled group 3, your grown-up child is not needed by the state, and will not be assigned to study/work anywhere in the future due to pathology.

That's it. Some may think that it’s just me who was unlucky, but for others everything is much better. But no, mommies, it doesn’t get better (I have been/have been communicating for many years with mommies who have the same diagnosis for their children).

Many people refuse such “difficult” children, but I couldn’t. I couldn’t even imagine that my child would be in some institution and would wait year after year for his mother, who would never come to him.

IVH is a serious lifelong diagnosis for your child. And the worst thing is that this is a test not only for your child, but for your entire family. Be strong!

We received the same diagnosis today. They said if you treat it, everything goes away. Actovegin and Pantogam were prescribed. and what was prescribed for you

We were prescribed a lot of things and treated other manifestations of hypoxia. From rehabilitation we took Cortexin (a course of 10 injections), now we are taking drops of lymphomiazot and the anticonvulsant Finlepsin. And because of dilated ventricles of the brain, we were prescribed Diacarb + Asparkam. Regarding the hemorrhage, 2 weeks after birth, a repeat NSG was performed, the degree was changed to the first, milder one. At the moment, the hemorrhage has turned into choroid plexus cysts - they say it’s not scary and they go away on their own.

We also have two 5mm cysts. and we became allergic to Actovegin. while we drink pantogam.

Irin, no one here will tell you when this goes away. Hemorrhage is no joke, it is necessary to be observed and treated, I am not scaring you, but there can be all sorts of consequences. Due to certain circumstances, it is necessary to often meet with children of IVH. For some, everything passed without a trace, while for others it takes a long time to get out of such a situation.

What were the consequences? Did the NSG do it?

An ultrasound was performed and it revealed IVH. It’s too early to talk about the consequences; we are just emerging from this state.

How IVH is expressed, in our case it was expressed by cysts and dilatation of the ventricles.

We only got it a few days ago and there can’t be cysts yet, as I understand it. The doctor said bilateral hemorrhage in both ventricles without dilation seems to be equivalent to grade 2.

Here you need to see a doctor!

We are in the hospital, actively undergoing treatment. I would just like to know how long it takes for such IVHs to take place.

It took us 1.5 months.

Happy birthday!

When did the ventricular dilatation go away?

Thank you)) And God bless our children!

Finally got around to writing) In general, we had such a situation: a birth injury, namely a cerebral hemorrhage. After 4 months, everything resolved, as the ultrasound doctor said, it’s like a bruise)) but that’s not the point. Now.

Hello girls. I am writing about my niece. The girl is 2.3 years old. Doctor's note from a neurologist (perhaps not entirely accurate since I don't have an amb. card in my hands) PMTCT. Hypotonicity of muscles. Mild paresis of the lower extremities. The pregnancy was difficult, it was.

An ultrasound of the brain revealed a small hemorrhage. The diagnosis indicated SEC on the left of 3.4 mm. The uzist woman said it’s not a big deal, it might go away on its own within a month. But show the results to a neurologist. Control ultrasound at 3.

The results of a brain ultrasound came back. After a second examination by a neurologist, we were prescribed pantogam (pantocalcin), the doctor said that a vessel had burst and a slight hemorrhage had occurred and immediately reassured us that this happens. But we were still very scared of the brain. Tell me who.

Dear girls, someone please respond. It's like I'm in a nightmare right now. I won’t write details... it’s very difficult to remember everything again. The fact is that my 2-year-old son had a brain hemorrhage and had surgery.

Anyone who has encountered this, please write whether there will be traces of a 1-2 degree burn, I’m very worried.

Girls, if you have encountered a similar diagnosis in your children, please write how things were later and, most importantly, after the birth of the child. I had an ultrasound today at 34 weeks and we were taken aback by this.

a section of the brain 8 by 8 mm, as I understand it, this hemorrhage is already considered and not just a cyst. who encountered it and how was it treated? what were the consequences?

Good afternoon My son Maxim is 6.5 months old. We have a birth injury and, as a consequence, grade 1 cerebral ischemia and strabismus. We were not diagnosed right away - at first we treated hypertonic hydrocephalus syndrome with diacarb and asparkam (diagnosed by a neurologist.

Eh, I stopped hesitating. Today I bought antibiotics Amoxiclav 875/125 and Ginocaps suppositories. I will treat. Then retake. At first I didn’t believe the doctor (mine was on vacation), I wanted to wait for mine. But it’s too long to wait (3 weeks) before the appointment. You will open it.

Intraventricular hemorrhage (IVH) in newborns: causes, degrees, manifestations, prognosis

Neurological pathology in newborns and children in the first years of life is a very serious problem, and, unfortunately, brain damage in children is by no means uncommon. IVH is an intraventricular hemorrhage, which is very characteristic of the newborn period and often accompanies the pathological course of labor.

Intraventricular hemorrhages also occur in adults, representing a form of stroke with high mortality. As a rule, blood penetrates into the ventricular system from intracerebral hematomas when they break into the brain cavity.

Hemorrhage into the ventricles of the brain in children is usually isolated and not associated with parenchymal hematomas, that is, it can be considered as an independent separate disease.

intraventricular hemorrhage in a newborn

The significance of the problem of intraventricular hemorrhage in newborns is due not only to the difficulties of diagnosing and treating the pathology, because many drugs are contraindicated for babies, and immature nervous tissue is extremely sensitive to any unfavorable circumstances, but also to the prognosis, which cannot always reassure young parents.

In addition to children born during an abnormal course of the labor period, IVH is diagnosed in premature infants, and the shorter the gestational age at which premature birth occurred, the greater the likelihood of IVH and the more severe the degree of ischemic-hypoxic brain damage.

In babies born prematurely, half of the hemorrhages in the ventricles occur on the first day of life, up to 25% of IVH occurs on the second day after birth. The older the child, the lower the likelihood of circulatory disorders in the brain, even if the course of labor is abnormal.

Today, neonatologists have highly informative research methods in their arsenal that allow timely diagnosis of intraventricular hemorrhage, but problems with classification and determination of the stage of pathology have not yet been resolved. A unified classification of IVH has not been developed, and when formulating stages, the features of the topography of the lesion are taken into account rather than the clinical severity and prognosis.

Causes of intraventricular hemorrhages in newborns

The reasons for the development of IVH in young children are fundamentally different from those that cause hemorrhages in adults. If in the latter vascular factors come to the fore - hypertension, atherosclerosis, which underlie strokes, and the penetration of blood into the ventricles is secondary to intracerebral hematoma, then in newborn babies the situation is somewhat different: hemorrhage immediately occurs inside the ventricles or under their lining , and the reasons are somehow related to pregnancy and childbirth:

• State of prematurity;
• Long waterless period;
• Severe hypoxia during childbirth;
• Injuries during obstetric care (rare);
• Birth weight less than 1000 g;
• Congenital disorders of blood coagulation and vascular structure.

In premature babies, the main cause of intraventricular hemorrhages is considered to be the presence of the so-called germinal matrix, which should gradually disappear as the fetal brain and vascular system mature. If birth occurs prematurely, then the presence of this structure creates the prerequisites for IVH.

The germinal matrix is ​​a region of neural tissue around the lateral ventricles that contains immature cells that move into the brain and, when mature, become neurons or neuroglial cells. In addition to cells, this matrix contains immature capillary-type vessels, the walls of which are single-layered, therefore very fragile and can rupture.

Hemorrhage into the germinal matrix is ​​not yet IVH, but it most often leads to the penetration of blood into the ventricles of the brain. A hematoma in the nervous tissue adjacent to the wall of the ventricle breaks through its lining, and blood rushes into the lumen. From the moment even a minimal volume of blood appears in the ventricle of the brain, we can talk about the onset of an independent disease - intraventricular hemorrhage.

Determining the stages of IVH is necessary to assess the severity of the disease in a particular patient, as well as determine the prognosis in the future, which depend on the amount of blood entering the ventricles and the direction of its spread towards the nervous tissue.

Radiologists base IVH staging on CT scan results. They highlight:

• IVH of the 1st degree - subependymal - blood accumulates under the lining of the ventricles of the brain, without destroying it and without entering the ventricle. In fact, this phenomenon cannot be considered a typical IVH, but at any moment a breakthrough of blood into the ventricles can occur.
• IVH grade 2 is a typical intraventricular hemorrhage without expansion of its cavity, when blood exits the subependymal space. On ultrasound, this stage is characterized as IVH with less than half the volume of the ventricle filled with blood.
• IVH stage 3 - blood continues to flow into the ventricle, filling more than half of its volume and expanding the lumen, which can be observed on CT and ultrasound.
• IVH of the 4th degree is the most severe, accompanied not only by the filling of the brain ventricles with blood, but also by its spread further into the nervous tissue. CT scan reveals signs of IVH of one of the first three degrees along with the formation of foci of parenchymal intracerebral hemorrhage.

Based on structural changes in the brain and its cavities, three stages of IVH are distinguished:

1. At the first stage, the ventricles are not completely filled with blood content, they are not expanded, spontaneous cessation of bleeding is possible and normal liquor dynamics are maintained.
2. Continued filling of the lateral ventricles with possible expansion, when at least one of the ventricles is filled with blood by more than 50%, and the blood spreads into the 3rd and 4th ventricles of the brain occurs in the second stage.
3. The third stage is accompanied by progression of the disease, blood entering the choroid of the cerebellum, medulla oblongata and spinal cord. The likelihood of fatal complications is high.

The severity of IVH and its manifestations will depend on how quickly blood penetrates the brain tissue and its cavities, as well as on its volume. Hemorrhage always spreads along the flow of cerebrospinal fluid. In very premature babies, as well as those who have suffered deep hypoxia, disorders of the blood coagulation system occur, so clots do not appear in the cavities of the brain for a long time, and liquid blood “spreads” unhindered throughout the parts of the brain.

The basis for the disorder of cerebrospinal fluid circulation and the subsequent increase in hydrocephalus is the penetration of blood into the ventricle, where it mixes with the cerebrospinal fluid, but does not immediately coagulate. Some of the liquid blood penetrates into other cavities of the brain, but as it coagulates, clots begin to block the narrow zones through which the cerebrospinal fluid circulates. Blocking any of the openings of the brain entails blockage of the cerebrospinal fluid pathway, dilatation of the ventricles and hydrocephalus with characteristic symptoms.

Manifestations of IVH in young children

Up to 90% of all hemorrhages in the ventricular system occur in the first three days of a baby’s life, and the lower his weight, the higher the likelihood of pathology. After the first week of a child’s life, the risk of hemorrhage decreases significantly, which is associated with the adaptation of the vascular system to new conditions and the maturation of the structures of the germinal matrix. If a child was born prematurely, then for the first few days he should be under close supervision of neonatologists - on the 2-3rd day the condition may worsen sharply due to the onset of IVH.

Small subependymal hemorrhages and grade 1 IVH may be asymptomatic. If the disease does not progress, the condition of the newborn will remain stable, and neurological symptoms will not even arise. With multiple hemorrhages under the ependyma, signs of brain damage will appear closer to a year with the phenomena of leukomalacia.

A typical intracerebral hemorrhage is manifested by symptoms such as:

• Decreased muscle tone;
• Sluggish tendon reflexes;
• Breathing disorders up to stopping (apnea);
• Convulsions;
• Focal neurological symptoms;
• Coma.

The severity of the pathology and the characteristics of the symptoms are associated with the volume of blood entering the ventricular system and the rate of increase in pressure in the cranial cavity. Minimal IVH, which does not cause obstruction of the cerebrospinal fluid ducts and changes in the volume of the ventricles, will be accompanied by an asymptomatic course, and it can be suspected by a decrease in the hematocrit number in the baby’s blood.

An intermittent course is observed in moderate and submassive IVH, which are characterized by:

1. Depression of consciousness;
2. Paresis or muscle weakness;
3. Oculomotor disorders (histagmus, strabismus);
4. Respiratory disorders.

Symptoms with spasmodic flow are expressed over several days, after which they gradually decrease. Both complete restoration of brain activity and minor deviations are possible, but the prognosis is generally favorable.

The catastrophic course of IVH is associated with severe disorders of the brain and vital organs. Characterized by coma, respiratory arrest, generalized convulsions, bluish skin, bradycardia, decreased blood pressure, and thermoregulation disorders. Intracranial hypertension is indicated by the bulging of a large fontanel, clearly visible in newborns.

In addition to clinical signs of impaired nervous activity, there will be changes in laboratory parameters. IVH in newborns may be indicated by a drop in hematocrit level, a decrease in calcium, fluctuations in blood sugar, and frequent blood gas disorders (hypoxemia) and electrolyte disturbances (acidosis).

The progression of bleeding leads to the spread of blood from the ventricles into the cisterns of the brain and nervous tissue. Parenchymal intracerebral hematomas are accompanied by severe focal symptoms in the form of paresis and paralysis, sensory disturbances, and generalized convulsive seizures. When IVH is combined with intracerebral hemorrhage, the risk of an unfavorable outcome is extremely high.

Among the long-term consequences of IVH are ischemic-hypoxic damage and residual changes in the brain in the form of cysts, periventricular leukomalacia, white matter gliosis, and cortical atrophy. By about a year, a developmental delay becomes noticeable, motor skills suffer, the child cannot walk or perform correct movements of the limbs in due time, does not speak, and is lagging behind in mental development.

Diagnosis of IVH in children is based on an assessment of symptoms and examination data. The most informative is CT, neurosonography and ultrasound. CT is accompanied by radiation, so ultrasound is preferable for premature babies and newborns in the first days of life.

IVH on a diagnostic image

Treatment and prognosis

Neurosurgeons and neonatologists treat children with IVH. Conservative therapy is aimed at restoring the functioning of vital organs and blood counts. If the child did not receive vitamin K at birth, it must be administered. Deficiency of coagulation factors and platelets is compensated by transfusion of plasma components. If breathing stops, artificial ventilation of the lungs is performed, but it is better to arrange it as planned if there is a risk of respiratory disorders.

Drug therapy includes:

• Normalization of blood pressure to prevent sharp decreases or surges that aggravate hypoxia and damage to nervous tissue;
• Oxygen therapy;
• Anticonvulsants;
• Blood clotting control.

To reduce intracranial pressure, the administration of magnesium sulfate intravenously or intramuscularly is indicated; diacarb, furosemide, and veroshpiron are used for full-term children. Anticonvulsant therapy consists of prescribing diazepam and valproic acid drugs. To relieve symptoms of intoxication, infusion therapy is carried out; acidosis (blood acidification) is eliminated by using a solution of sodium bicarbonate intravenously.

In addition to medication, surgical treatment of IVH is carried out: evacuation of blood from the ventricles of the brain through their puncture under ultrasound control, introduction of fibrinolytic agents (actelyse) into the lumen of the ventricles to prevent thrombosis and occlusive hydrocephalus. It is possible to combine puncture with the administration of fibrinolytic drugs.

In order to remove tissue breakdown products and eliminate symptoms of intoxication, liquor filtration, liquor absorption and intraventricular lavage with artificial cerebrospinal fluid preparations are indicated.

In case of blockage of the cerebrospinal fluid ducts and hydrocephalus syndrome, temporary drainage of the ventricles is established with the evacuation of blood and clots until the cerebrospinal fluid is cleared and the obstruction of its outflow tract is eliminated. In some cases, repeated lumbar and ventricular punctures, external ventricular drainage, or temporary internal drainage with implantation of artificial drainage under the skin are used.

insertion of a catheter for ventricular drainage

If hydrocephalus has become persistent and irreversible, and there is no effect from fibrinolytic therapy, then neurosurgeons provide permanent drainage surgically:

1. Installation of permanent shunts with the outflow of cerebrospinal fluid into the abdominal cavity (a silicone tube passes under the skin from the head to the abdominal cavity, the shunt can be removed only if the child’s condition has stabilized and hydrocephalus has not progressed);
2. Endoscopic anastomosis between the ventricles of the brain and the basal cistern.

The most common method of surgical treatment of occlusive hydrocephalus due to IVH is ventriculoperitoneal drainage. It is affordable, allows drugs to be administered into the ventricles, has a low probability of infection, can be carried out for a long time, and caring for the child is not accompanied by difficulties. The use of alteplase, which accelerates the dissolution of blood clots in the ventricles, can reduce mortality and maximize brain function.

The prognosis for IVH is determined by the stage of the disease, the volume of hemorrhage and the location of brain tissue damage. In the first two degrees of IVH, blood clots resolve on their own or under the influence of treatment, without causing significant neurological disorders, therefore, with minor hemorrhages, the child can develop normally.

Massive intraventricular hemorrhages, especially if they are accompanied by damage to brain tissue, can lead to the death of an infant in a short time, and if the patient survives, it is difficult to avoid neurological deficits and severe disturbances in psychomotor development.

All children with intracranial hemorrhages are subject to careful monitoring in intensive care settings and timely surgical treatment. After installing a permanent shunt, the disability group is determined, and the baby should be regularly shown to a neurologist.

To avoid the severe changes described, it is important to follow measures to prevent brain damage in newborns and very premature infants. Expectant mothers need to undergo the necessary preventive examinations and examinations in a timely manner, and if there is a threat of premature birth, the task of obstetricians and gynecologists is to prolong the pregnancy as much as possible with medications until such a time when the risk of hemorrhages becomes minimal.

If the baby is still born prematurely, he is placed in the intensive care unit for observation and treatment. Modern methods of diagnosing and treating IVH can not only save babies’ lives, but also significantly improve their quality, even if this requires surgery.

When it comes to hemorrhages in newborns, many people associate them with severe traumatic births and medical errors. However, not all hemorrhages are associated with tissue trauma. We will talk about intraventricular hemorrhage (IVH) in newborns. They are typical for children born prematurely and are caused by the physiological characteristics of premature infants. IVH are a very serious problem, because the prognosis for the full life of premature babies largely depends on the nature of the pathological process and its proper treatment.

What are the ventricles of the brain?

To make it easier to understand the origin of IVH and their consequences, it is necessary to know what the ventricles of the brain are. The ventricles of the brain are small cavities that are filled with cerebrospinal fluid. A person has several ventricles connected to each other.

The largest are the paired lateral ventricles, located symmetrically in the brain relative to the midline (one ventricle in each hemisphere). They are connected through small openings to the unpaired third ventricle. The third ventricle is located centrally, it communicates with the cerebral aqueduct. The cerebral aqueduct communicates with the fourth ventricle. This ventricle is formed by the surfaces of the pons and medulla oblongata. It, in turn, communicates with the cerebrospinal fluid spaces surrounding the brain and spinal cord.

Why is liquor needed?

Liquor is a cerebrospinal fluid that is produced in the lateral ventricles of the brain, in their choroid plexuses. The process of liquor production is ongoing. But where does he go? It is continuously absorbed into the venous sinuses located in the dura mater, as well as through the granulations of the arachnoid membrane.

Liquor plays an important role in the human body. The main functions of cerebrospinal fluid:

• Protective role - protects the brain and spinal cord from mechanical influences.
• Maintain intracranial pressure at normal levels.
• Participates in metabolic processes between the blood and the brain (transfer of hormones, electrolytes, etc.), transfers nutrients to nerve cells.
• It is the place where waste products of brain tissue are released.
• It is an immunological barrier to dangerous microorganisms.

What is intraventricular hemorrhage (IVH)?

Intraventricular hemorrhages are hemorrhages in the ventricles of the brain. IVH are typical for children who were born prematurely with very low body weight (less than 1500 g). The shorter the period at which the child was born, the greater the chance that he will develop IVH. Thus, with a gestation period of less than 29 weeks, IVH occurs in almost every third child. When a baby is born at 34-36 weeks, the risk of IVH is significantly lower and is less than 5%.

Why are IVH typical for premature babies?

Premature babies have structural features of the lateral ventricles and periventricular (periventricular) areas. Namely, that the vessels in them are in an embryonic state and have a primitive structure. These vessels are called the subependymal germinal matrix. They are very fragile and can easily be injured.

The difficulty of the outflow of venous blood from the periventricular areas plays a role, as well as a violation of the constancy of the internal environment of the body.

The influence of concomitant problems in the blood coagulation system, which can be both congenital and transient, that is, transient (usually due to the effects of certain medications), cannot be excluded.

But IVH does not occur in all premature babies. Certain factors have been identified that contribute to the occurrence of IVH in a child. Some of them are listed below:

• Birth of a very premature baby;
• Acute episodes of hypoxia (that is, lack of oxygen to body tissues).
• Increased pressure in the venous bed (either during childbirth, or during artificial ventilation);
• Increased blood pressure, which increases cerebral blood flow;
• Fluctuations in the intensity of blood flow to the brain;
• Problems of the blood coagulation system;
• Infectious and other inflammatory processes in the mother before childbirth or in the child after birth.
• Defective or untimely primary resuscitation care in the delivery room.
• Repeated attacks of respiratory arrest (apnea) and breathing disorders that are typical for premature babies.
• Injecting electrolyte solutions into a child’s vein, the concentration of substances in which exceeds their permissible values ​​(this is called hyperosmolarity).

Division of IVHK by degrees

Intraventricular hemorrhages are classified by degree. Some authors distinguish 3 degrees of IVH, others - 4 degrees (dividing the second degree into two).

• In grade I, the hemorrhage is localized in the area of ​​the embryonic vessels, that is, under the ependyma of the ventricles.
• In grade II, hemorrhage breaks through into the ventricular cavity. The ventricle remains the same size or slightly expands.
• In grade III, IVH is also localized in the ventricular cavity, but it expands significantly.
• In grade IV, there is a breakthrough of hemorrhage into the brain tissue.

How to suspect IVH?

• With stage I IVH there are no specific signs; it can be detected during a routine examination of a newborn child.
• The course of stage II-III IVH can be catastrophic and wave-like.

In the catastrophic course of the process, very clear symptoms are noted: suddenly the child becomes excited for a short time, then his activity subsides sharply, consciousness is depressed until coma. Respiratory disorders, changes in skin color, convulsions, eye symptoms, heart rhythm disturbances, drop in blood pressure, and instability of thermoregulation are noted. The undulating course of IVH is characterized by a gradual change in symptoms: changes in phases of brain activity, episodes of respiratory arrest, impaired muscle tone (decrease), and convulsive attacks.

• IVH of stage IV is accompanied by the same symptoms as IVH of stage III, but the process is characterized by a catastrophic course.

There is a disturbance of consciousness up to coma. Additional symptoms appear due to the breakthrough of hemorrhage into the tissue (parenchyma) of the brain. They depend on the size of the hemorrhage and its location. Many children die within the first days of life.

The development of hydrocephalus (dropsy of the brain) is characteristic in many cases after suffering severe IVH. In addition, at the site of hemorrhage in the brain parenchyma, a cystic cavity is subsequently formed, which is filled with cerebrospinal fluid. Depending on the location and size of the cystic cavity, the child will have certain neurological symptoms (eye symptoms, seizures, etc.)

How to confirm the diagnosis?

• The most accessible and very effective method for detecting intraventricular hemorrhages is neurosonography (NSG). In another way, NSG is an ultrasound examination of the brain. It allows you to get results quickly, right at the baby’s incubator. Often in departments where premature babies are cared for, there are small transport ultrasound machines. During the examination, the doctor notes areas of increased echogenicity in the projection of the brain ventricles, which can be on one or both sides and be of different sizes. When performing NSG, it is possible to determine the degree of hemorrhage, assess the size of the ventricles, and the displacement of brain structures relative to the central line.
• Computed tomography (CT), magnetic resonance imaging (MRI) are applicable for the diagnosis of IVH, but these methods do not have advantages over NSG, so their use only for the primary diagnosis of IVH is not advisable.
• Doppler examination of cerebral vessels is of auxiliary value in the diagnosis of IVH; it allows one to assess changes in blood flow in the main cerebral arteries before and after a hemorrhage occurs.
• It is very important to constantly measure blood pressure in severely premature infants and evaluate heart rhythm. A sharp drop in blood pressure for no apparent reason may indicate IVH has occurred.
• It is necessary to monitor red blood counts (drop in hemoglobin and hematocrit levels), monitor electrolyte disturbances, and blood gas values.
• Spinal puncture - increased pressure during the flow of cerebrospinal fluid in combination with changes in its other parameters: blood in the cerebrospinal fluid, increased protein levels, decreased sugar levels, pleocytosis (increased number of cells in the cerebrospinal fluid), etc.

All of the above methods for examining a sick child with IVH are carried out repeatedly. This is necessary to assess the dynamics of the process and to identify complications of hemorrhage.

Why does hydrocephalus occur after IVH?

The formation of hydrocephalus after intraventricular hemorrhage is a frequent and serious complication. This can happen with any degree of IVH, but the greater the degree of hemorrhage, the greater the risk of developing the problem.

As IVH resolves, blood clots form, which can clog the already small areas of cerebrospinal fluid outflow from the ventricles. When the outflow is disrupted, cerebrospinal fluid accumulates in the cavity of the ventricle, which leads to its expansion and compression of the surrounding brain tissue. The correct name for this process is posthemorrhagic ventriculomegaly. Ventriculomegaly means the ventricles become enlarged.

In 65% of cases, ventriculomegaly increases slowly, and the process itself spontaneously stops in less than a month. This is the most favorable outcome for a sick child.

In approximately 30% of cases, there is a long-term and slow increase in the size of the ventricles (that is, longer than 1 month). Of these, in every third child the process does not stop spontaneously. In the remaining 67% of children in this group, ventriculomegaly ceases spontaneously. However, in 5% of children, after the ventricles stop increasing in size, the process resumes.

In 5% of cases, the process of enlargement of the ventricles occurs very quickly, which requires urgent surgical intervention.

All these statistics indicate that children who have suffered IVH are observed by specialists for a long time. These include a pediatrician, neurologist, ophthalmologist, and, if necessary, a neurosurgeon and other specialists.

Observation and treatment of children with IVH

Considering that intraventricular hemorrhages are the fate of mainly very premature babies, they are monitored in the neonatal intensive care unit and the nursing department for children born prematurely. The medical and protective regime in the department is very important. Doctors and nurses try to schedule most manipulations at the same time, so as not to disturb the child again. After all, even weighing a very premature baby outside the incubator is very stressful for him and can provoke IVH. The hospital staff takes very careful care of premature babies.

It is necessary to take into account that in addition to IVH, very premature babies have a lot of other associated problems: immaturity of the lungs and difficulties with breathing, cardiovascular disorders, problems with digestion of food, frequent layering of the infectious process, etc. Therefore, the symptoms of a hemorrhage that occurs are “mixed” with signs of related problems. This requires careful monitoring of premature babies, taking a large number of tests and conducting additional research methods.

In premature babies, it is important to monitor head circumference. If it grows by more than 10 mm in 1 week, it is necessary to periodically monitor the size of the ventricles using the NSG method.

As for the treatment of IVH, it depends on the degree of hemorrhage and its complications.

• Carrying out serial spinal punctures. Some specialists use this treatment method for persistent ventriculomegaly in order to “unload” the ventricles. Although there is evidence of the ineffectiveness of such therapy.
• Prescription of medications that reduce intracranial pressure, have anti-edematous and diuretic effects. These drugs only help combat concomitant problems with ventriculomegaly, but do not “cure” it.
• External ventricular drainage. During the operation, the child is fitted with a shunt (tube) connecting the ventricle and a reservoir for cerebrospinal fluid, which is implanted under the skin. This allows you to “dump” excess cerebrospinal fluid from the ventricles. This treatment measure is temporary.
• Installation of a permanent shunt. This operation is usually performed when the child grows up and gets stronger. The shunt is installed as follows: one end goes into the ventricle, the other is brought into the child’s abdominal cavity (most often), where excess cerebrospinal fluid will be discharged. Sometimes complications from the operation occur, such as blockage of the shunt or infection.

Long-term forecasts and consequences

It is difficult to talk about the prognosis and consequences of IVH for children, since many problems of very premature children are explained by other concomitant pathologies. Although there are some statistics about these consequences.

Severe neurological abnormalities, such as convulsive syndrome, cerebral palsy, mental retardation, occur in 5% of cases after IVH of the first degree, in 15% of cases after IVH of the second degree. Every third child suffers from severe neurological problems after stage III IVH, and 90% of children suffer from stage IV IVH. Naturally, less severe neurological consequences after intraventricular hemorrhages are very common.

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Germinal matrix and intraventricular hemorrhage

Definition. HM/IVH predominantly develops in premature infants and is the most threatening complication that predicts lifelong neurological consequences in these patients. HM/IVH is caused by short gestation and the vulnerability of the immature cerebral vasculature. Perinatal stressors are typically associated with the development of HM/IVH.

In this case, the newborn at birth has asphyxia, hypoxemia, hypotension and acidosis.

The germinal matrix is ​​located between the caudate nucleus and the epindyma of the lateral ventricle. As a rule, the GM is not normally visualized by ultrasound. When hemorrhage occurs in the brain, the structure becomes easy to identify with ultrasound and this

the condition is verified as a subepindymal hemorrhage arising between the thalamus and the head of the caudate nucleus. Bleeding may be limited to the germinal matrix or result from rupture of the wall of the lateral ventricle. The process can be one-sided or two-sided.

IVH is rare in full-term infants, but when it occurs, it is largely due to birth trauma. By postconceptional age (PCA) of 36 weeks, the germinal matrix in most children has involuted, although in some cases it may remain in a residual form. When IVH develops in full-term newborns, the source of bleeding is most often the choroid plexus, but in some cases it may be residual germinal matrix. As a result, venous thrombosis and thalamic infarction develop.

Tests on neonatology and pediatrics with answers for advanced training.

Epidemiology. Specific incidence figures are unknown, but the incidence of HM/IVH is approximately 25-40% among all preterm infants. These estimates are based mainly on data from 1990-2000, but over the past decade there has been a decline in the lower end of the range of development of the above pathology by 2-20%. The incidence varies depending on the stage of pregnancy, with the highest risk of developing HM/IVH in preterm infants with a birth weight of less than 750 g. Since IVH is rare in full-term newborns, the incidence rate in this category of children is extremely low and is associated with concomitant intrapartum trauma and asphyxia. Interestingly, silent IVH was reported to occur in 2-3% of seemingly full-term neonates in a prospective study.

Pathophysiology. The germinal matrix is ​​a poorly supported and highly vascularized region. The blood vessels (arterioles, venules, and capillaries) in this region of the brain are immature at birth and are particularly prone to hypoxic-ischemic injury.

These vessels have an irregular shape with pronounced areas of lumen and are prone to easy rupture. The germinal matrix undergoes involution into the PCV at 34 weeks and is thus vulnerable to the development of HM/IVH in preterm neonates. It is in this category of children that the amount of matrix is ​​reduced, but not completely removed. Premature newborns born later (gestational age 34-37 weeks) are also at less risk of developing IVH. Cerebral blood flow (CBF) fluctuations play an important role in the pathogenesis of HM/IVH, as pressure-mediated cerebral circulation occurs in preterm infants. A sudden increase or decrease in systemic

blood pressure can lead to an increase in BMC with subsequent rupture of germinal matrix vessels. A decrease in BMC can cause the development of ischemic damage to the vessels of the germinal matrix and surrounding tissues.

The unique anatomy of the deep veins at the level of the foramen of Monro and the open connection between the vessels of the germinal matrix and the venous circulation influence the occurrence of sharp fluctuations in cerebral venous pressure. In 80% of newborns with HM/IVH, periventricular hemorrhages are interrupted through the ependyma into the ventricular system of the brain.

Neuropathological consequences of IVH

1. The germinal matrix of the ventriculo-subventricular zone contains migrating cells of the cerebral cortex. This is the area of ​​production of neurons, glial cells of the cerebral cortex and basal ganglia. Destruction of the germinal matrix can lead to disruption of myelination, brain growth and subsequent cortical development.
2. Periventricular hemorrhagic infarction is of venous origin, associated with severe and usually asymmetric IVH, and always occurs on the side of the larger amount of blood inside the ventricles. These various pathological events subsequently lead to the development of venous stasis, which is often mistaken for the “dilation” corresponding to IVH. In addition, PVHI is neuropathologically distinct from periventricular leukomalacia. See previous discussions in the PVGI section.
3. Posthemorrhagic hydrocephalus is more common in newborns with the highest degree of hemorrhage. PHH is mainly associated with obliterating arachnoiditis due to occlusion of the arachnoid villi or in the posterior fossa with obstruction of the outflow of cerebrospinal fluid from the fourth ventricle. Aqueductal stenosis is rarely due to a clot or reactive gliosis.
4. Periventricular leukomalacia often accompanies IVH, but is not its direct consequence. PVL is characterized by the occurrence of foci of coagulative necrosis in the periventricular zones of the white matter adjacent to the lateral ventricles of the brain of newborns and has an ischemic nature of brain damage. PVL, as a rule, is a non-hemorrhagic symmetrical lesion, characterized by hypotension, shortness of breath and other pathology of hypoxic-ischemic origin, accompanied by a decrease in BMC.
5. Risk factors. Prematurity and RDS are most often associated with GM/IVH pathology. As mentioned previously, the immature cerebral vascular structures of preterm infants are extremely vulnerable to changes in volume and pressure. Clinically, this pathology is characterized by hypoxia and acidosis. Secondly, respiratory failure, decreased oxygenation, further weakening of the walls of immature blood vessels in the brain of premature newborns. Fetal asphyxia at birth, pneumothorax, stroke/hypotension, acidosis, hypothermia and osmotic overload - all of these symptoms increase the risk of developing HM/IVH. Even procedures that we perceive as routine care for premature newborns (debridement of the tracheobronchial tree, palpation of the anterior abdominal wall, checking reflexes and administering mydritic agents to test vision) can also trigger the development of GM/IVH. Recently, inflammatory reactions have become increasingly important in understanding the pathophysiology of GM/IVH. Chorionic amnionitis and funisitis may be precursors of postpartum cerebral vascular pathology leading to GM/IVH. The fetal inflammatory response and subsequent hypotension and neonatal sepsis are closely associated with the development of IVH. Mediators of the inflammatory response are cytokines. Their vasoactive properties may cause an increase in blood pressure, which adversely affects the germinal matrix.
6. Clinical manifestations. Clinical manifestations are varied, and the diagnosis requires confirmation using neuroimaging techniques. Symptoms may mimic other ICH or other neonatal pathologies such as metabolic disorders, asphyxia, sepsis, or meningitis. IVH may be completely asymptomatic or cause mild symptoms (eg, bulging fontanelle, sudden decrease in hematocrit, apnea, bradycardia, acidosis, seizures, and changes in muscle tone or level of consciousness). Fulminant syndrome is characterized by a rapid onset with a level of consciousness in the form of stupor or coma, respiratory failure, convulsions, convulsive seizures, light intolerance, and deep flaccid tetraparesis.

Diagnostics

Ultrasound of the skull and brain (see Chapter 10) is the method of choice for screening and diagnosing GM/IVH. CT and MRI are informative, but are significantly more expensive and require transportation of the patient to a specialized computer diagnostics department. These studies are more valuable in maximizing the diagnosis or confirmation of brain injury before hospital discharge. There are two classification systems for HM/IVH that are applicable for clinical use. The older one is the classic

Papile fication, originally based on CT, but subsequently adapted for the interpretation of ultrasound data. The second classification is presented by Wolpe and is also based on ultrasound imaging data of the brain and skull. Both classifications allow clinicians to determine the severity of the injury and obtain the information needed to compare the area of ​​injury, as well as determine the progression or regression of the IVH process. Classification of GM/IVF according to JI. Papila (L. Papile) distinguishes four degrees of severity of hemorrhages:

• I degree - reflects isolated subependymal hemorrhage;
• Grade II - subependymal hemorrhage with a breakthrough into the ventricular cavity, but without dilatation.
• III degree - subependymal hemorrhage with breakthrough into the ventricles and the development of ventriculomegaly;
• IV degree - breakthrough of intraventricular hemorrhages into the parenchyma.

Volpe's classification of IVH offers a slightly different point of view. Class I - presence of minor or no ICH. Class II - IVH, visualized during parasagittal V3 examination and extending to more than 50% of the lateral ventricles. Class III - IVH, detected >50% on parasagittal examination and characterized by distension of the lateral ventricles. Finally, Wolpe points out that on cranial and brain ultrasound, the presence of any decrease in periventricular echodensity is a clear and more serious sign of intracranial vascular injury such as PVHI or PVL.

Ultrasound of the skull and brain is indicated for screening examination of premature infants with suspected IVH on the first day of life and during hospitalization. Typically, ultrasound is performed between days 1 and 7 of life, depending on the clinical presentation and institutional protocols of the hospital, taking into account that at least 50% of HM/IVH develop on the 1st day of life, in 90% of newborns by 4th day of life. Of all hemorrhages/IVHs detected on the 4th day of life, 20-40% develop into more extensive hemorrhages. Most doctors recommend performing an ultrasound, CT, or MRI before discharge from the hospital or at 36 weeks.

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IVH (intraventricular hemorrhage)

Intraventricular hemorrhages (IVH, PIVC, cerebral hemorrhages, periventricular hemorrhages) are hemorrhages in the ventricles of the brain. In other words, this is something similar to a hemorrhagic stroke, when blood enters certain structures of the central nervous system - the ventricles of the brain (they form cerebrospinal fluid, i.e. cerebrospinal fluid, there are four of them in total - two lateral, as well as a third and fourth) .

An important role in the development of cerebral hemorrhages in newborns belongs to the anatomical features of the immature body of a premature baby. The greater the degree of prematurity and immaturity, the higher the risk of hemorrhage, especially in children with extremely low and very low body weight (less than 1000 and 1500 grams, respectively). The blood vessels around the ventricles of the brain are very fragile and require very little force to damage and rupture them.

The leading factors in the occurrence of IVH are episodes of hypoxia, as well as traumatic damage to blood vessels (usually due to difficult childbirth). Hypoxia is oxygen starvation, which is accompanied by fluctuations in blood pressure both in general and directly in the vessels of the brain. Hemorrhages are much less commonly associated with primary coagulopathies (blood clotting disorders) or congenital vascular anomalies. IVH also occurs with disseminated intravascular coagulation, isoimmune thrombocytopenia, and vitamin K deficiency.

IVH occurs most often in the first three days of life and can increase in the first week, and much less often occurs after the first week of life.

There are some differences in the classifications of cerebral hemorrhages depending on the location and causes of the hemorrhage; the classification presented below is most often used.

There are four degrees of hemorrhage:

I degree - a small amount of blood is observed around the vessels. Such subependymal hemorrhage is considered minor and most often disappears on its own without any consequences.

II degree - blood enters the cavity of the ventricle of the brain, but the further development of the child is usually only slightly affected, and often disappears on its own and without a trace. III degree - the exit from the ventricles is closed by a blood clot, and the ventricles begin to expand. Some cases are accompanied by spontaneous resolution of the problem, but if this does not happen, surgery is necessary to install a shunt that unblocks the ventricles of the brain, otherwise there is a high risk of developing hydrocephalus. At this degree, manifestations of neurological symptoms are not uncommon. IV degree - blood enters not only the ventricles of the brain, but also the surrounding brain tissue - the parenchyma. Such hemorrhage is life-threatening and is accompanied by severe neurological symptoms - most often convulsions, repeated episodes of apnea, the development of anemia, as well as ocular symptoms.

Causes of hemorrhage development.

It is definitely not known why some babies develop hemorrhage and others do not, and what is the immediate cause of brain hemorrhage in premature babies. But the more stable conditions are created for the child, the better, because premature babies require a strict protective regime and stay in a comfortable microenvironment, for which a special incubator is used.

Symptoms of IVH.

Symptoms of hemorrhage may vary. Most often they are absent. However, with extensive hemorrhage, the child’s condition worsens, he becomes agitated, and convulsions and ocular symptoms may occur. The child may be lethargic and less mobile, and muscle tone changes. Anemia develops, and in severe cases, shock and coma. Until the sonographer makes a diagnosis using ultrasound, the clinical picture may be difficult to distinguish from that of a rapidly developing infection.

Treatment of IVH.

Treatment is aimed at eliminating the consequences of hemorrhages and their complications. For example, correction of anemia, anticonvulsant therapy, and for progressive hydrocephalus, a neurosurgical operation is performed - ventriculoperitoneal shunting.

Long-term consequences of hemorrhages.

Minor hemorrhages (grade I), as a rule, do not lead to neurological pathology. Grade II hemorrhages also slightly increase its risk. Data from domestic and foreign studies show that extensive hemorrhages in the ventricles of the brain (III degree) lead to death in approximately 25% of children and a high percentage of disability, while 25% develop progressive expansion of the ventricular cavity, but approximately 50% of children do not experience complications. Of those children who have dilatation of the ventricular cavity, approximately half require surgery to install a shunt. With severe bleeding and hemorrhage into the brain tissue (IV degree), 50-60% of children die. With III and especially IV degrees of hemorrhage, surviving children experience significant impairment of motor functions in the form of cerebral palsy (cerebral palsy), developmental delays, decreased vision and hearing or their complete absence with the development of blindness and deafness. Fortunately, grade III and IV hemorrhages are not that common. It is noted that IVH is more severe in full-term infants than in premature infants.

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Intracerebral hemorrhages in premature newborns: consequences, treatment, prognosis

Bleeding in or around the brain can occur in any newborn, but is especially common in premature babies.

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Ischemia-hypoxia, changes in blood pressure and pressure. The presence of germinal matrix makes bleeding more likely. The risk also increases with hematologic diseases (eg, vitamin K deficiency, hemophilia, disseminated intravascular coagulation).

Subarachnoid hemorrhage is probably the most common type of intracranial hemorrhage. These newborns may have apnea, seizures, lethargy, or unusual neurological findings. Heavy bleeding associated with meningeal inflammation can lead to hydrocephalus as the infant grows.

Subdural hemorrhage, now less common due to improved obstetric techniques, results from bleeding into the falciform space, tentorium, or commissuruven. Such bleeding typically occurs in newborns of first-time mothers, large newborns, or after a complicated birth—conditions that can produce unusual pressure on intracranial vessels. Symptoms may include seizures; rapid head enlargement or abnormal neurological examination results.

Intraventricular and/or intraparenchymal hemorrhages are the most serious type of intracranial hemorrhage. They are often bilateral and usually develop in the germinal matrix. Hypoxia - ischemia damages the capillary endothelium, reduces cerebral vascular autoregulation, and can increase cerebral blood flow and venous pressure, which make bleeding more likely. In most cases, intraventricular hemorrhages are asymptomatic.

Risk: In preterm infants, the risk and severity of intracerebral hemorrhage is directly proportional to the degree of immaturity:

• 25 weeks of gestation - 50% risk.
• 26 weeks - 38%.
• 28 weeks - 20%.
• Statistics vary, sometimes significantly, between clinics.

Time of manifestation. In premature infants, about 50% of hemorrhages appear on the 1st day of life, 25% on the second and 15% on the third.

Sources of bleeding:

Premature infants have a germinal matrix (regresses by 32-36 weeks of gestation) with vulnerable vessels (sensitive to pressure fluctuations, ischemia, hypoxia, acidosis, coagulation disorders). At 28–32 weeks of gestation, most of the terminal matrix is ​​located at the caudothalamic junction, just posterior to the foramen of Monro. The fourth ventricle also contains a vulnerable germinal matrix.

As the newborn matures, the importance of the germinal matrix as a source of intracerebral hemorrhage decreases, and the importance of the choroid plexus increases.

Classification of intracerebral hemorrhage in newborns

Advice. Instead of the above classifications (there are others), it is better to use a brief, precise description using the terms “germinal matrix”, “intraventricular”, “parenchymal” and indicating the location.

The Papile classification is the most commonly used classification of hemorrhages in NN, based on computed tomography data:

• Hemorrhage of the II degree: with a breakthrough into the ventricle without its expansion.
• Hemorrhage of the III degree: with a breakthrough into the ventricle and its expansion.
• Hemorrhage of the IV degree: a combination of hemorrhage of I-III degrees with hemorrhage in the brain parenchyma.

Classification by DEGUM (German Society for Medical Ultrasound). Developed by the pediatric department of DEGUM in 1998 and based on ultrasound data:

• Hemorrhage of the 1st degree: subependymal.
• Grade II hemorrhage: intraventricular with filling
• Hemorrhage grade 111: intraventricular with filling > 50% of the lumen.
• Parenchymal hemorrhages (cerebrum, cerebellum, basal ganglia, brain stem) are described separately (location and size).

Diagnosis of intracerebral hemorrhage in newborns

Intracranial hemorrhage should be suspected in a newborn with apnea, seizures, lethargy, or unusual neurological symptoms; such children need a CT scan of the head. Although cranial ultrasound is not dangerous, CT is more sensitive for thin layers of blood. However, for screening very preterm infants (e.g.

Hepatitis vaccination for newborns side effects Suction of mucus from the upper respiratory tract of a newborn

Ischemia-hypoxia, changes in blood pressure and pressure. The presence of germinal matrix makes bleeding more likely. The risk also increases with hematologic diseases (eg, vitamin K deficiency, hemophilia, disseminated intravascular coagulation).

Subarachnoid hemorrhage is probably the most common type of intracranial hemorrhage. These newborns may have apnea, seizures, lethargy, or unusual neurological findings. Heavy bleeding associated with meningeal inflammation can lead to hydrocephalus as the infant grows.

Subdural hemorrhage, now less common due to improved obstetric techniques, results from bleeding into the falciform space, tentorium, or commissuruven. Such bleeding typically occurs in newborns of first-time mothers, large newborns, or after a complicated birth—conditions that can produce unusual pressure on intracranial vessels. Symptoms may include seizures; rapid head enlargement or abnormal neurological examination results.

Intraventricular and/or intraparenchymal hemorrhages are the most serious type of intracranial hemorrhage. They are often bilateral and usually develop in the germinal matrix. Hypoxia - ischemia damages the capillary endothelium, reduces cerebral vascular autoregulation, and can increase cerebral blood flow and venous pressure, which make bleeding more likely. In most cases, intraventricular hemorrhages are asymptomatic.

Risk: In premature newborns, the risk of intracerebral hemorrhage and its severity are directly proportional to the degree of immaturity:

• 25 weeks of gestation - 50% risk.
• 26 weeks - 38%.
• 28 weeks - 20%.
• Statistics vary, sometimes significantly, between clinics.

Time of manifestation. In premature infants, about 50% of hemorrhages appear on the 1st day of life, 25% on the second and 15% on the third.

Sources of bleeding:

Premature infants have a germinal matrix (regresses by 32-36 weeks of gestation) with vulnerable vessels (sensitive to pressure fluctuations, ischemia, hypoxia, acidosis, coagulation disorders). At 28–32 weeks of gestation, most of the terminal matrix is ​​located at the caudothalamic junction, just posterior to the foramen of Monro. The fourth ventricle also contains a vulnerable germinal matrix.

As the newborn matures, the importance of the germinal matrix as a source of intracerebral hemorrhage decreases, and the importance of the choroid plexus increases.

Classification of intracerebral hemorrhage in newborns

Advice. Instead of the above classifications (there are others), it is better to use a brief, precise description using the terms “germinal matrix”, “intraventricular”, “parenchymal” and indicating the location.

Papile classification- the most commonly used classification of hemorrhages in NN, based on computed tomography data:

• Hemorrhage of the II degree: with a breakthrough into the ventricle without its expansion.
• Hemorrhage of the III degree: with a breakthrough into the ventricle and its expansion.
• Hemorrhage of the IV degree: a combination of hemorrhage of I-III degrees with hemorrhage in the brain parenchyma.

DEGUM classification(German Society for Medical Ultrasound). Developed by the pediatric department of DEGUM in 1998 and based on ultrasound data:

• Hemorrhage of the 1st degree: subependymal.
• Grade II hemorrhage: intraventricular with filling< 50 % просвета.
• Hemorrhage grade 111: intraventricular with filling > 50% of the lumen.
• Parenchymal hemorrhages (cerebrum, cerebellum, basal ganglia, brain stem) are described separately (location and size).

Diagnosis of intracerebral hemorrhage in newborns

Intracranial hemorrhage should be suspected in a newborn with apnea, seizures, lethargy, or unusual neurological symptoms; such children need a CT scan of the head. Although cranial ultrasound is not dangerous, CT is more sensitive for thin layers of blood. However, for screening very preterm infants (e.g.<30 нед гестации) некоторые врачи предпочитают проведение УЗИ. Если диагноз вызывает сомнение, СМЖ может быть проверена на содержание эритроцитов: она обычно содержит много крови. Однако некоторое количество эритроцитов часто присутствует в спинномозговой жидкости доношенных новорожденных.

In addition, blood tests, CBC and metabolic studies should be performed.

Ultrasonography

Premature infants should undergo cranial ultrasound on the first, third and seventh days of life. It also makes sense to perform an ultrasound after the child’s admission to the department (in case of forensic investigations to clarify the time of the first manifestation of the lesion).

If a lesion is detected, a thorough examination of the midbrain and infratentorial structures is necessary through additional approaches (anterior and posterior lateral fontanelles). In approximately 10% of premature infants with post-hemorrhagic dilation of the ventricles, small hemorrhages are detected in the cerebellum, which are poorly visible through the large fontanel (this clinical problem is underestimated).

If hemorrhage is detected near the arteries, especially in a full-term newborn, Doppler examination of the venous vessels (superior sagittal sinus, internal veins of the skull) is necessary.

In full-term infants, in addition to ultrasound, it is necessary to perform MRI and, if this is important for treatment, angiography.

Intraparenchymal areas of echo enhancement (the term periventricular venous perfusion or edema is often used) are the sites of infarction in most cases. Sometimes they go away without the formation of cysts, and then in retrospect we can only talk about venous stagnation. After the onset of cystic transformation (weeks), areas of echo enhancement should be called infarctions or hemorrhages (important for conversation with parents).

Differential diagnosis

Unlike hemorrhages in premature infants, which are explained by immaturity, hemorrhages in full-term infants require a thorough search for the cause: resuscitation, birth trauma, hemorrhagic diathesis (coagulation and platelets), thrombophilia, venous and arterial thrombosis, embolism, polyglobulia, hypernatremia, aneurysms, arteriovenous malformations, coarctation of the aorta, tumor, ECMO therapy, etc.

Treatment of intracerebral hemorrhage in newborns

Treatment is primarily supportive unless hematologic abnormalities contribute to bleeding. All children should receive vitamin K if it has not been previously provided. If platelets or clotting factors are insufficient, they must be replenished. Subdural hematomas should be treated by a neurosurgeon; removal of the hemorrhage may be necessary.

Make the most of all conservative treatment options:

• Stabilize blood pressure: avoid surges in blood pressure, use catecholamines carefully, sedation. The principle of correction with minimal means.
• Normalization of oxygenation.
• Avoid hyper- and hypocapnia (decreased brain perfusion).
• Control of coagulogram, correction of deviations.
• Avoid hypoglycemia.
• Widespread use of anticonvulsants.

Attention: It is better to intubate electively than in an emergency situation with apnea.

For full-term infants, early consultation with a neurosurgeon.

Prognosis of intracerebral hemorrhage in newborns

In preterm infants, grades I-II intracerebral hemorrhage probably does not significantly increase the risk of neurological complications.

The risk of severe neurological complications in premature infants with grade III hemorrhages is approximately 30%, and with parenchymal hemorrhages - approximately 70%.

In mature neonates, prognosis depends on location and cause; hemorrhages in the basal ganglia, cerebellum and brainstem have an unfavorable prognosis, but the individual course is unpredictable.

The prognosis for subarachnoid hemorrhage is usually good. For subdural, cautious, but some babies do well. Most infants with small intraventricular hemorrhages survive the episode of acute bleeding and appear well. Children with large intraventricular hemorrhage have a poor prognosis, especially if the bleeding continues into the parenchyma. Premature infants with a history of severe intraventricular hemorrhage are at risk of developing posthemorrhagic hydrocephalus and should be closely monitored with repeat cranial ultrasound and frequent repeat head circumference measurements. Infants with progressive hydrocephalus require neurosurgical intervention to place a subcutaneous ventricular reservoir (for CSF aspiration) or a ventriculoperitoneal shunt. The CSF associated with posthemorrhagic hydrocephalus has very low glucose concentrations, known as hypoglycorrachia. Because many children have persistent neurological deficits, close monitoring and referral for early intervention are important.