Etiology
• Intracranial hemorrhage may occur due to trauma, asphyxia or, more rarely, bleeding diathesis or congenital vascular anomaly. It may also develop as a result of disseminated intravascular coagulation, isoimmune thrombocytopenia and maternal vitamin K deficiency (especially in maternal use of phenobarbital or phenytoin). Intracranial hemorrhage seen in preterms without trauma mostly includes the ventricles (intraventricular hemorrhage-IVH).
• IVH risk is inversely proportional to gestational age and birth weight.
Pathogenesis
• Typical bleeding site of PV-IVH is subependymal germinal matrix and choroid plexus.
Major Factors Playing a Role in the Pathogenesis of PV - IVH
Prematurity (most important)
prolonged labor, breech delivery
Asphyxia, sepsis, thrombocytopenia
Sudden changes in cerebral blood flow
sudden changes in blood pressure
Mechanical ventilation, sudden changes in pCO2 level
RDS, pneumothorax, PDA
fluid overload
Agitation
Clinical findings
• IVH is rare during delivery. 50% occur in the first day of life, and more than 75% occur in the first 3 days. in very few patients. Delayed bleeding between days 14-30 can be seen. It is rare from the end of the 1st month.
• The clinic may start suddenly. Clinical findings include periods of apnea, pallor or cyanosis, weak sucking, abnormal eye movements, loud-shrill crying, decreased tone, convulsions, metabolic acidosis, shock, or decreased hematocrit (no increase in hematocrit despite transfusion).
• Diagnosis and staging of intracranial hemorrhages is done by ultrasonography.
Grade I: Bleeding is limited to the germinal matrix and/or present in less than 10% of the ventricle.
Grade II· Bleeding covers 10-50% of the ventricle.
Grade III: Bleeding covers more than 50% of the ventricles and there is enlargement of the ventricles.
Grade IV: There is bleeding into the brain parenchyma.
• Some of IVH patients are asymptomatic. Babies with a gestational age of 32 weeks and a birth weight of less than 1000 grams are in the highest risk group, and it is recommended to perform USG every 3-7 days until they reach 36-40 weeks.
• If there is bleeding, the most appropriate radiological examination method for follow-up is cranial ultrasonography. Because it takes 2-4 weeks for PVL to become visible. Cranial MRI provides better images of periventricular injury and gives a better idea of long-term prognosis.
Prognosis
• Posthemorrhagic hydrocephalus and periventricular leukomalacia are the two most important complications of bleeding.
• Considering the long-term prognosis, the risk of developing cerebral palsy/mental retardation is 15% in Stage 1 bleeding, 25% in Stage 2, 50% in Stage 3, and 75% in Stage 3 and significant bleeding (stage IV).
Protection
• The first measure is the prevention of prematurity. Antenatal steroids reduce the risk of death, grade III and IV IVH and PVL. In addition, low-dose indomethacin (0.1 mg/kg/day, 3 days) reduces the incidence of severe IVH, but has no effect on long-term psychomotor development.