Intraventricular Hemorrhage (IVH) of the Newborn

What is an intraventricular hemorrhage (IVH)?

Intraventricular hemorrhage (IVH) is a type of bleeding from fragile blood vessels in the brain. These blood vessels are very fragile in premature infants. Babies who are born more than 8 weeks early (before 32 weeks of pregnancy) are most likely to have this bleeding.

A baby with IVH may:

• have no symptoms from the bleeding
• get sick from the bleeding, with symptoms of paleness, breathing problems, weak heart rate, and low blood pressure
• have seizures if the bleeding is severe
• develop hydrocephalus (increased fluid in the brain) because the blood plugs up the brain's fluid pathways (the ventricles).

Most intraventricular hemorrhages occur within the first 5 days of life. They seldom occur after the first week.

What causes an IVH?

Some very fragile blood vessels surround the ventricles of the brain. The ventricles are cavities in the brain through which cerebrospinal fluid (CSF) flows. The blood vessels are underdeveloped in the very young infant. They start getting stronger after 32 weeks of gestation. These blood vessels are very sensitive to changes in blood flow. If the blood flow changes, the blood vessels break down and start bleeding. If the bleeding is slight, the blood remains around the blood vessels. If the bleeding gets worse, the blood breaks into the ventricles. In the worst cases of bleeding, the blood may leak into the brain tissue.

Small amounts of bleeding do not usually cause any long-term damage. Larger amounts of bleeding cause long-term problems. Severe bleeding causes blood clots that can block the circulation system for the cerebrospinal fluid. This blockage is called hydrocephalus.

The brain makes cerebrospinal fluid (also called spinal fluid), which circulates through the brain and the central canal of the spinal cord. With hydrocephalus, the circulation of fluid is blocked and the fluid begins to build up and the ventricles start to swell. The fluid can press on the brain and cause damage.

After IVH occurs, the hospital staff will watch closely for the development of hydrocephalus. If it occurs, there are treatments to keep the pressure under control.

How is IVH diagnosed?

Your healthcare provider will order an ultrasound scan of the baby's brain if the baby is more than 6 weeks premature or he or she thinks the baby might have IVH. The scan is done at the bedside and does not bother the baby.

Ultrasound scans of the baby's head are done at 7 to 14 days of age to find out if there is any bleeding. Bleeding occurs during the first week after birth. If there is no bleeding the first week, it is unlikely to happen later. Every baby born more than 10 weeks early (before 30 weeks of gestation) is checked for IVH. The screening will be done again when baby reaches 36 and 40 weeks gestational age. Babies less than 32 weeks of age should be screened if they have risk factors for IVH, such as breathing problems or infection.

If there is bleeding, head ultrasound scans are used to check if the bleeding has gotten worse and look for clearing of any blood clots. Most of the time, the body gets rid of small amounts of the blood over several weeks. The size of the baby's ventricles are measured to check for hydrocephalus. Many times the ventricles get slightly bigger but in a few weeks come back to a normal size without any treatment.

What is the treatment?

When IVH occurs, it is treated by looking for and treating the complications of the bleeding.

The best treatment is to keep the baby as stable as possible during the first week of life. Your healthcare provider will treat any lung conditions and infections and, if necessary, help the baby breathe. If needed, the baby will be given a blood transfusion to keep the blood pressure and blood count stable. The baby will be treated for any seizures that occur.

What is the treatment for hydrocephalus?

It is more common for hydrocephalus to develop in the more severe cases of IVH. Your doctor can tell if hydrocephalus develops by looking at the size of the ventricles on the ultrasounds.

A baby who has hydrocephalus may not have any symptoms at first. Sometimes as hydrocephalus gets worse, the baby gets sleepy, has more apnea (breathing pauses), has seizures or is very irritable with a high-pitched cry, or vomits. Sometimes the only sign of hydrocephalus is that the head grows too quickly.

If the baby has symptoms, or if the ventricles grow too big, the baby will be treated with:

• Spinal taps

  A spinal tap can be used to remove spinal fluid from the spinal canal to relieve pressure. A needle is put in the baby's back to let fluid drip out. Spinal taps can be done several timesy. This procedure may allow time for the blood clots to clear by themselves and for the fluid pathways to open up. However, spinal taps may not work if the blockage keeps fluid from circulating from the ventricles to the spinal canal in the back. Spinal taps are a temporary solution.

• Ventricular reservoirs

  When hydrocephalus cannot be treated by spinal taps, tubing can be surgically placed into the ventricles. This tubing in the ventricles is called a ventricular reservoir. It allows fluid to be withdrawn from the ventricles to control the pressure. If the hydrocephalus clears up, then the reservoir can be removed. If the hydrocephalus persists, permanent tubing, called a shunt, can be placed in the ventricles.

• Ventricular peritoneal shunts
• If the hydrocephalus does not clear up on its own, the baby will have surgery to put in a permanent shunt. The shunt takes the fluid from the ventricle and drains it into the abdominal cavity where spinal fluid is absorbed by the body. One end of the tubing is inserted into a ventricle in the brain. The tubing is tunneled under the skin and the other end is placed into the abdominal cavity.

  The shunt must be replaced as the child grows or if the shunt gets blocked or infected. The shunt tubing is not noticeable after the baby grows bigger and has more hair.

How long will the effects last?

Sometimes other parts of the baby's brain may be able to take over the function of any damaged areas. This means that babies often do much better than expected. Babies do much better than an adult with a similar brain injury. Love, care, and encouragement that the child receives from his family also have a very important effect on his outcome.

In general, babies who have had small amounts of bleeding do not have any more problems than other premature babies who did not have IVH. Babies who have had more severe bleeding are more likely to have developmental problems as they grow. Many children who have had a severe hemorrhage may have problems controlling movement on one side of their body. Only time will tell to what extent a child's brain is injured and what long-term problems he will have.

What follow-up care in needed?

Children who have had IVH need to be checked regularly to see if the bleeding has hurt the brain. Their developmental progress should be tested regularly. If problems develop, special therapy and education programs can help.