Intraventricular hemorrhage (IVH) means bleeding into the normal fluid spaces (ventricles) within the brain. IVH is also used to refer to bleeding in areas near the ventricles even if the blood is not within them. The extent of IVH is graded:
Grade I- bleeding confined to the tiny area where it first begins
Grade II- blood is also within the ventricles
Grade III - more blood in the ventricles, usually with the ventricles increasing in size
Grade IV - a collection of blood within the brain tissue, also called INTRAPARENCHYMAL ECHODENSITIES because of its appearance on the ultrasound picture. This can be seen with Gr. I, II, or III IVH. It reflects brain injury.
The brain is still developing. The area where IVH usually begins has a very fragile network of tiny blood vessels. These burst easily causing the bleeding. The more premature and the sicker the baby is, the greater the risk that s/he will develop IVH. The infants at highest risk are those weighing less than 1000 grams (2 1/4 lbs).
Most of the time there are no outward signs that the bleeding has occurred; occasionally babies have seizures or sudden anemia. Babies at risk for IVH usually have an ultrasound of the head in the first 3-10 days of life. This painless test, performed in the isolette or bed, uses sound waves to give a picture of the baby's brain. If IVH is present, the baby may have this test repeated at regular intervals to see if the hemorrhage or the size of the ventricles are increasing.
There is no specific treatment for IVH. Surgery will not prevent or cure the bleeding. Improved overall care and monitoring of premature babies has decreased the rate of IVH, but some babies still get it.
Complications are most common with grades III and IV IVH. The most frequent complication of IVH is HYDROCEPHALUS or too much fluid collecting in the ventricles. This extra fluid may cause:
the baby's head to grow more rapidly than normal
pressure on the baby's brain
The brain has four ventricles. Fluid, called cerebral spinal fluid (CSF), is normally made in the two larger ventricles. It passes between the ventricles by tiny channels and eventually goes outside the brain to bathe the outer brain and spinal cord. The fluid is absorbed into the body from outside the brain. Abnormal amounts of fluid collect in the ventricles when:
the fluid cannot get out due to a blood clot blocking a channel, or
irritation from blood and scarring prevent absorption of the fluid around the brain
If your baby develops hydrocephalus, s/he needs some way for the fluid to escape from inside the brain. This may include:
frequent lumbar punctures (LPs). In an LP, a needle is put into the spinal canal in the lower back and fluid is withdrawn. This therapy will not work if a clot is blocking a channel. The baby may need a shunt later.
a reservoir. This is a tube placed into one of the larger ventricles that then connects to a chamber. This chamber may be placed under the scalp or be outside the scalp. Whenever necessary, fluid can be withdrawn from the chamber by a needle. This is usually a temporary solution to the problem and the baby will need to have a shunt at some later time.
a shunt. In this surgical procedure a tiny tube is placed into one of the two larger ventricles. It attaches to another longer piece of tubing. This connection is behind the ear, under the skin. The longer tubing continues under the skin, down the neck and chest to the baby's abdomen where the fluid can be absorbed. Sometimes a baby will need a temporary shunt first. The temporary shunt connects the fluid from the ventricles to the space under the scalp (subgalial shunt). When the baby is larger or healthier this is replaced by the permanent shunt to the abdomen.
Grades I and II IVH are most common. They usually do not cause identifiable brain injury. The blood is slowly absorbed by the body. Babies with Grade III IVH are at increased risk of brain damage, but most are normal or near normal. Babies who have needed treatment for hydrocephalus and those with grade IV IVH are at very high risk for permanent brain injury.
This can only be determined over time by monitoring his/her development. For this reason it is important for premature infants, especially those with IVH, to have their development followed carefully after discharge.
Serious abnormalities that may appear are:
motor (movement) problems:
tight or stiff muscles
slow to crawl, stand, or walk
abnormal crawling, toe walking
moving one side more than the other
frequent arching of the back (not just when angry or at play)
slow mental development
does not listen to your voice by age 3-4 months after hospital discharge
does not make different sounds by 8-9 months after discharge
doesn't seem to understand or say any words by 12-13 months after discharge
seizures, also called convulsions
Less serious problems appear more slowly, are more difficult to detect, and may not be obvious until preschool or grade school. These can include:
poor coordination or balance
specific learning disabilities (math or reading)
very short attention span
difficulty with activities that require coordination of the eyes and hands, for example, catching a ball or copying a simple drawing
need for glasses
If your baby has Grade III or IV IVH, s/he may be eligible for a developmental intervention program. Anytime in the future, if you are concerned about something that you think might be abnormal, have it checked out by your baby's regular doctor soon.
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