What is intraventricular haemorrhage (IVH)?

Intraventricular haemorrhage (IVH) is bleeding into the deep spaces inside the brain called ventricles, where the cerebro-spinal fluid (CSF) is produced.
 
The bleeding comes from a special tissue in the ventricles (called the germinal matrix), which normally disappears at around 34 weeks of gestation, so IVH is very rare after then. 

The blood vessels in the germinal matrix are thin and vulnerable to instabilities in blood flow, which can cause them to rupture. This causes bleeding which may stay in the tissue or rupture out into the ventricular spaces, where it clots and can be seen using ultrasound.

These clots can sometimes block the drainage of CSF (which flows through pathways from one ventricle to the next, then out across the outside of the brain and down the spinal cord), leading to a build up of the fluid under pressure. On other occasions, the clot can disturb the blood flow from the brain, leading to bleeding into the tissues around the ventricle. These two complications are now relatively rare and most very preterm babies do not develop IVH.

Professionals group IVH into four grades of severity:

 

Grade I

The bleeding is restricted to the germinal matrix and blood does not enter the ventricles.

Grade II

Some blood clot is present in the ventricles, but not enough to enlarge them.

Grade III

The ventricles are enlarged or distended by the blood and clot inside them.

Grade IV

The IVH has affected drainage of blood from the brain tissue around the ventricle leading to tissue damage and bleeding outside the ventricle.


Once damage has occurred to brain tissue, it cannot be reversed. However, a physical injury to the brain tissue does not necessarily mean later problems with brain function. The injury that is detected on ultrasound scan may lead to problems with motor function, vision, and later learning. The position and the severity of the bleeding determines the long-term effects.


Who is affected and what are the risk factors?

IVH tends to occur in the most immature and smallest babies; it is also more common in babies who need help with their breathing in the first few days or have unstable blood pressure. IVH usually starts within the first two days following birth, but the effects may develop over the following days and weeks. What is the cause? Because of the very fragile blood vessels in the germainal matrix, IVH can be caused by changes of blood pressure or blood flow that occur during the birth process or as a result of many other conditions, such as breathing or blood pressure difficulties.


How is it diagnosed?

Most babies do not show any outward sign that an IVH has occurred and it is identified during routine screening using ultrasound which is carried out at the cotside, through the soft spot on their head (where the bones haven’t fused together yet) called the fontanelle. Other ways of imaging the body (such as Magnetic Resonance Imaging or MRI) are sometimes recommended but they are only used in specialist centres when the baby’s condition is stable. With more severe grades of IVH, signs and symptoms may sometimes be seen. Where flow of CSF is blocked, as the ventricles enlarge,  swelling of fontanelle may be noticeable. Other symtoms can also include abnormally low blood pressure and heart rate, seizures, anaemia, apnoea, decreased muscle tone and reflexes. Other tests may be helpful in determining the effects of IVH such as EEG, video recording of the baby’s movements and tests of visual function.


How is it managed?

In general, the bleeding stops fairly quickly and the clots resolve as the body responds to them. Therefore, immediate treatment is not needed. The healthcare team keeps the baby stable and treats any symptoms.

If the flow of cerebrospinal fluid is interrupted due to the bleeding, and pressure increases within the ventricles, it may cause a condition called hydrocephalus. This important condition can result in rapid head growth as the bones of the skull are not yet fused, as in older children. Several treatments are available including surgery for the placement of a “shunt”, which is a small tube that drains the fluid from the brain to another part of the body, usually the abdomen, and relieves the pressure.

 

 

 
© 2017 EFCNI - European Foundation for the Care of Newborn Infants
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