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Periventricular and intraventricular hemorrhage in the neonate

Periventricular and intraventricular hemorrhage in the neonate. Cecile Osman April 9, 2010. What is PVH/IVH?. Bleeding into the periventricular white matter (motor tracts) Is associated with hydrocephalus and long-term disability. Where does it occur?. Subependymal germinal matrix

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Periventricular and intraventricular hemorrhage in the neonate

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  1. Periventricular and intraventricular hemorrhage in the neonate Cecile Osman April 9, 2010

  2. What is PVH/IVH? • Bleeding into the periventricular white matter (motor tracts) • Is associated with hydrocephalus and long-term disability

  3. Where does it occur? • Subependymal germinal matrix • Where neuroblasts and glioblasts divide and migrate into the cerebral parenchyma • Cells of the germinal matrix are rich in mitochondria so are quite sensitive to ischemia • Usually regresses by term

  4. What are the subtypes: • Grade I – Subependymal region and/or germinal matrix

  5. What are the subtypes: • Grade II: Subependymal hemorrhage with extension into lateral ventricles without ventricular enlargement

  6. What are the subtypes: • Grade III: Subependymal hemorrhage with extension into lateral ventricles with ventricular enlargement

  7. What are the subtypes: • Grade IV: Intraparenchymal hemorrhage

  8. Why does it occur? • GM supplied by primitive and fragile retelike capillary network • Thought to be due to: • 1) loss of cerebral autoregulation • 2) abrupt alterations in cerebral blood flow and pressure

  9. Autoregulation • Term infants and most “healthy” premature have the ability to regulate cerebral blood flow • Preemie has more narrow range of perfusion pressures over which he can control regional cerebral blood flow • Without autoregulation, systemic BP is what mostly controls cerebral perfusion/pressure

  10. Cerebral Blood Flow / Pressures • Many things can affect CBF • Asynchrony between spontaneous and mechanically delivered breaths; birth; noxious procedures of caregiving; tracheal suctioning; pneumothorax; rapid volume expansion; seizures; and changes in pH, PaCO2, and PaO2

  11. Cerebral Blood Flow and Respiratory Pattern • When mechanical breaths are not synchronized with efforts of the patient, beat-to-beat fluctuations in blood pressure occur • Patients without asynchrony between mechanical ventilation and patient efforts had stable blood pressures, stable cerebral perfusion, and a lower incidence of hemorrhage

  12. Why do we care? • The bleeding leads to destruction of the cerebral parenchyma  necrosis • Eventually causing hydrocephalus  may end up needing VP shunt • Depending on WHAT part of the brain is destroyed  seizures / cerebral palsy / mental retardation

  13. Who gets affected? • All premature infants, especially <32 weeks • Can see in term infants if has trauma / asphyxia • Most occur within first 72 hrs of life, 50% in the first 24 hours • Can occur after 3rd day of life esp if neonate develops significant life threatening event

  14. What should we do? • Initial screen usually at ~7 days of life • Cranial ultrasound is tool of choice • Serial ultrasounds to follow progression / evolution of the bleed

  15. What should we do? • Supportive care • Minimize risk factors • NO NEED for serial LP • Eventually may need venticulostomy  VP shunt for those who have post-hemorhagic hydrocephalus that need surgical intervention

  16. Medications? • Indomethacin: • Controversial, but possibly indicated in patients at risk for PVH-IVH, including those <32 weeks' gestation or those who weigh <1250 g at birth. • Inhibits the formation of prostaglandins by decreasing the activity of cyclo-oxygenase. • Thought to cause maturation of the germinal matrix microvasculature (mechanism unclear) • 0.1 mg/kg/dose IV when aged 6 h, then q24h for 2 d for a total of 3 doses

  17. Prognosis • Grade I and grade II hemorrhage: • Neurodevelopmental prognosis is excellent (ie, perhaps slightly worse than infants of similar gestational ages without PVH-IVH).

  18. Prognosis: • Grade III hemorrhage without white matter disease: • Mortality is less than 10%. Of these patients, 30-40% have subsequent cognitive or motor disorders.

  19. Prognosis • Grade IV (severe PVH-IVH) IVH with either periventricular hemorrhagic infarction and/or periventricular leukomalacia (PVL): • Mortality approaches 80%. A 90% incidence of severe neurological sequelae including cognitive and motor disturbances is noted

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