Intraventricular hemorrhage
Encyclopedia
An intraventricular hemorrhage (or intraventricular haemorrhage in British English), often abbreviated "IVH," is a bleeding into the brain's ventricular system
, where the cerebrospinal fluid
is produced and circulates through towards the subarachnoid space
. It can result from physical trauma
or from hemorrhaging in stroke
.
infants or those of very low birth weight. The cause of IVH in premature infants, unlike that in older infants, children or adults, is rarely due to trauma. Instead it is thought to result from changes in perfusion of the delicate cellular structures that are present in the growing brain, augmented by the immaturity of the cerebral circulatory system, which is especially vulnerable to hypoxic ischemic encephalopathy
. The lack of blood flow results in cell death and subsequent breakdown of the blood vessel walls, leading to bleeding. While this bleeding can result in further injury, it is itself a marker for injury that has already occurred. Most intraventricular hemorrhages occur in the first 72 hours after birth. The risk is increased with use of extracorporeal membrane oxygenation
in preterm infants.
The amount of bleeding varies. IVH is often described in four grades:
Grades I and II are most common, and often there are no further complications. Grades III and IV are the most serious and may result in long-term brain injury to the infant. After a grade III or IV IVH, blood clots may form which can block the flow of cerebrospinal fluid, leading to increased fluid in the brain (hydrocephalus).
There has been various therapies employed into preventing the high rates of morbidity and mortality, including diuretic therapy, repeated lumbar puncture, streptokinase therapy and most recently combination a novel intervention DRIFT (drainage, irrigation and fibrinolytic therapy).
In 2002 a Dutch retrospective study analysed cases where neonatologists had intervened and drained CSF by lumbar or ventricular punctures if ventricular width (as shown on Ultrasound) exceeded the 97th centile as opposed to the 97th centile plus 4mm. Professors Whitelaw's original cochrane review published in 2001 as well as evidence from previous randomised control trials indicated that interventions should be based on clinical signs and symptoms of ventricular dilatation. An international trial has instead looked a early (97th centile) versus late (97th centile plus 4mm) for intervening and draining CSF.
DRIFT has been tested in an international randomised clinical trial, although it did not significantly lower the need for shunt surgery, severe cognitive disability at 2 years Bayley (MDI <55) was significantly reduced. Repeated Lumbar punctures is used widely to reduce the effects in increased intracranial pressure and an alternative to ventriculo-shunt (VP) surgery that cannot be preformed incase of intraventricular haemorrhage. The relative risk of repeated lumbar puncture is close to 1.0 therefore it is not statistically therapeutic when compared to conservative management and does raise the risk of subsequent CSF infection. Another DRFIT trial is planned involving a large number of infants to validate previous data and expand on the viability of performing the invasive procedure nationwide.
Prognosis is also dismal when IVH results from intracerebral hemorrhage related to high blood pressure
and is even worse when hydrocephalus
follows. It can result in dangerous increases in intracranial pressure
and can cause potentially fatal brain herniation
.
s are commonly associated with IVH. The bleeding can involve the middle communicating artery or the posterior communicating artery
.
In both adults and infants, IVH can cause dangerous increases in intracranial pressure
, damage to the brain tissue, and hydrocephalus
.
Ventricular system
The ventricular system is a set of structures containing cerebrospinal fluid in the brain. It is continuous with the central canal of the spinal cord.-Components:The system comprises four ventricles:* right and left lateral ventricles* third ventricle...
, where the cerebrospinal fluid
Cerebrospinal fluid
Cerebrospinal fluid , Liquor cerebrospinalis, is a clear, colorless, bodily fluid, that occupies the subarachnoid space and the ventricular system around and inside the brain and spinal cord...
is produced and circulates through towards the subarachnoid space
Subarachnoid space
In the central nervous system, the subarachnoid cavity is the interval between the arachnoid membrane and pia mater....
. It can result from physical trauma
Physical trauma
Trauma refers to "a body wound or shock produced by sudden physical injury, as from violence or accident." It can also be described as "a physical wound or injury, such as a fracture or blow." Major trauma can result in secondary complications such as circulatory shock, respiratory failure and death...
or from hemorrhaging in stroke
Stroke
A stroke, previously known medically as a cerebrovascular accident , is the rapidly developing loss of brain function due to disturbance in the blood supply to the brain. This can be due to ischemia caused by blockage , or a hemorrhage...
.
In infants
This type of hemorrhage is particularly common in infants, especially prematurePremature
Premature can refer to:*Premature aging: see Senescence*Premature birth or prematurity: see Preterm birth*Premature ejaculation*Premature menopause*Premature stop codon: see Nonsense mutation*Premature ventricular contraction...
infants or those of very low birth weight. The cause of IVH in premature infants, unlike that in older infants, children or adults, is rarely due to trauma. Instead it is thought to result from changes in perfusion of the delicate cellular structures that are present in the growing brain, augmented by the immaturity of the cerebral circulatory system, which is especially vulnerable to hypoxic ischemic encephalopathy
Encephalopathy
Encephalopathy means disorder or disease of the brain. In modern usage, encephalopathy does not refer to a single disease, but rather to a syndrome of global brain dysfunction; this syndrome can be caused by many different illnesses.-Terminology:...
. The lack of blood flow results in cell death and subsequent breakdown of the blood vessel walls, leading to bleeding. While this bleeding can result in further injury, it is itself a marker for injury that has already occurred. Most intraventricular hemorrhages occur in the first 72 hours after birth. The risk is increased with use of extracorporeal membrane oxygenation
Extracorporeal membrane oxygenation
In intensive care medicine, extracorporeal membrane oxygenation is an extracorporeal technique of providing both cardiac and respiratory support oxygen to patients whose heart and lungs are so severely diseased or damaged that they can no longer serve their function...
in preterm infants.
The amount of bleeding varies. IVH is often described in four grades:
- Grade I - bleeding occurs just in the germinal matrixGerminal matrixIn anatomy, the germinal matrix is a highly cellular and highly vascularized region in the brain from which cells migrate out during brain development. The germinal matrix is the source of both neurons and glial cells and is most active between 8 and 28 weeks gestation...
. - Grade II - bleeding also occurs inside the ventricles.
- Grade III - ventricles are enlarged by the blood.
- Grade IV - there is bleeding into the brain tissues around the ventricles.
Grades I and II are most common, and often there are no further complications. Grades III and IV are the most serious and may result in long-term brain injury to the infant. After a grade III or IV IVH, blood clots may form which can block the flow of cerebrospinal fluid, leading to increased fluid in the brain (hydrocephalus).
There has been various therapies employed into preventing the high rates of morbidity and mortality, including diuretic therapy, repeated lumbar puncture, streptokinase therapy and most recently combination a novel intervention DRIFT (drainage, irrigation and fibrinolytic therapy).
In 2002 a Dutch retrospective study analysed cases where neonatologists had intervened and drained CSF by lumbar or ventricular punctures if ventricular width (as shown on Ultrasound) exceeded the 97th centile as opposed to the 97th centile plus 4mm. Professors Whitelaw's original cochrane review published in 2001 as well as evidence from previous randomised control trials indicated that interventions should be based on clinical signs and symptoms of ventricular dilatation. An international trial has instead looked a early (97th centile) versus late (97th centile plus 4mm) for intervening and draining CSF.
DRIFT has been tested in an international randomised clinical trial, although it did not significantly lower the need for shunt surgery, severe cognitive disability at 2 years Bayley (MDI <55) was significantly reduced. Repeated Lumbar punctures is used widely to reduce the effects in increased intracranial pressure and an alternative to ventriculo-shunt (VP) surgery that cannot be preformed incase of intraventricular haemorrhage. The relative risk of repeated lumbar puncture is close to 1.0 therefore it is not statistically therapeutic when compared to conservative management and does raise the risk of subsequent CSF infection. Another DRFIT trial is planned involving a large number of infants to validate previous data and expand on the viability of performing the invasive procedure nationwide.
In adults
Intraventricular hemorrhage has been found to occur in 35% of moderate to severe traumatic brain injuries. The injury requires a great deal of force to cause. Thus the hemorrhage usually does not occur without extensive associated damage, and so the outcome is rarely good.Prognosis is also dismal when IVH results from intracerebral hemorrhage related to high blood pressure
Hypertension
Hypertension or high blood pressure is a cardiac chronic medical condition in which the systemic arterial blood pressure is elevated. What that means is that the heart is having to work harder than it should to pump the blood around the body. Blood pressure involves two measurements, systolic and...
and is even worse when hydrocephalus
Hydrocephalus
Hydrocephalus , also known as "water in the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head,...
follows. It can result in dangerous increases in intracranial pressure
Intracranial pressure
Intracranial pressure is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid . The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF...
and can cause potentially fatal brain herniation
Brain herniation
Brain herniation, also known as cistern obliteration, is a deadly side effect of very high intracranial pressure that occurs when the brain shifts across structures within the skull...
.
Associated conditions
Brain contusions and subarachnoid hemorrhageSubarachnoid hemorrhage
A subarachnoid hemorrhage , or subarachnoid haemorrhage in British English, is bleeding into the subarachnoid space—the area between the arachnoid membrane and the pia mater surrounding the brain...
s are commonly associated with IVH. The bleeding can involve the middle communicating artery or the posterior communicating artery
Posterior communicating artery
In human anatomy, the posterior communicating artery is one of a pair of right-sided and left-sided blood vessels in the circle of Willis. It connects the three cerebral arteries of the same side. Anteriorly, it connects to the internal carotid artery prior the terminal bifurcation of the ICA...
.
In both adults and infants, IVH can cause dangerous increases in intracranial pressure
Intracranial pressure
Intracranial pressure is the pressure inside the skull and thus in the brain tissue and cerebrospinal fluid . The body has various mechanisms by which it keeps the ICP stable, with CSF pressures varying by about 1 mmHg in normal adults through shifts in production and absorption of CSF...
, damage to the brain tissue, and hydrocephalus
Hydrocephalus
Hydrocephalus , also known as "water in the brain," is a medical condition in which there is an abnormal accumulation of cerebrospinal fluid in the ventricles, or cavities, of the brain. This may cause increased intracranial pressure inside the skull and progressive enlargement of the head,...
.
External links
- Ultrasound Pictures of Germinal Matrix IVH MedPix Image Database