What patients and families need to know
Newborn Neurologic Disorders
What is intraventricular hemorrhage (IVH)?
Intraventricular hemorrhage (IVH) is bleeding inside or around the ventricles, the spaces in the brain containing the cerebral spinal fluid.
- Intraventricular means within the ventricles
- Hemorrhage means excessive bleeding
Intraventricular hemorrhage is most common in premature babies, especially very low birthweight babies weighing less than 1,500 grams (3 pounds, 5 ounces).
What is periventricular leukomalacia (PVL)?
Periventricular leukomalacia (PVL) is characterized by the death or damage and softening of the white matter, the inner part of the brain that transmits information between the nerve cells and the spinal cord, as well as from one part of the brain to another.
- Periventricular means around or near the ventricles, the spaces in the brain containing the cerebrospinal fluid
- Leuko means white
- Malacia means softening
It is not clear why IVH occurs. Bleeding can occur because blood vessels in a premature baby's brain are very fragile and immature and easily rupture. Babies with respiratory problems, such as hyaline membrane disease, or other complications of prematurity, are more likely to have IVH. The smaller and more premature the baby, the more likely IVH will occur. Nearly all IVH occurs within the first four days of life.
Bleeding in the brain can put pressure on the nerve cells and damage them. Severe damage to cells can lead to brain injury.
The amount of bleeding varies. IVH is often described in four grades:
- Grade 1. Bleeding occurs just in a small area of the ventricles.
- Grade 2. Bleeding also occurs inside the ventricles.
- Grade 3. Ventricles are enlarged by the blood.
- Grade 4. Bleeding into the brain tissues around the ventricles.
Grades 1 and 2 are most common, and often there are no further complications. Grades 3 and 4 are the most serious and may result in long-term brain injury to the baby. Hydrocephalus (too much cerebral spinal fluid in the brain) may develop after severe IVH.
The following are the most common symptoms of intraventricular hemorrhage (IVH). However, each baby may experience symptoms differently. Symptoms may include:
- Apnea and bradycardia (stopping breathing and low heart rate)
- Pale or blue coloring (cyanosis)
- Weak suck
- High-pitched cry
- Swelling or bulging of the fontanelles, the "soft spots" between the bones of the baby's head
- Anemia (low blood count)
The symptoms of IVH may resemble other conditions or medical problems. Always consult your baby's doctor for a diagnosis.
In addition to a complete medical history and a physical examination, a cranial (head) ultrasound is usually used to diagnose IVH. This test uses sound waves to create a picture of internal structures. A cranial ultrasound can view the inside of the baby's brain through the fontanelles, the spaces between the bones of the baby's head. With the ultrasound, the amount of bleeding can be graded.
There is no specific treatment for IVH, except to treat any other health problems that may worsen the condition. Although care of sick and premature babies has advanced greatly, it is not possible to prevent IVH from occurring. However, giving the mother corticosteroid medications before delivery has been shown to lower the risk of IVH in the baby. These steroids are often given to women between 24 and 34 weeks gestation who are at risk of early delivery. Sometimes, surgery is necessary to stabilize the condition of the baby. This may occasionally involve placement of a catheter into the baby's skull, although this is rarely necessary in babies because of the flexibility of their skull bones.
With PVL, the area of damaged brain tissue can affect the nerve cells that control motor movements. As the baby grows, the damaged nerve cells cause the muscles to become spastic, or tight, and resistant to movement. Babies with PVL have a higher risk of developing cerebral palsy (a group of disorders that prevent the child from controlling their muscles normally), and may have intellectual or learning difficulties. PVL may occur alone or in addition to intraventricular hemorrhage (bleeding inside the brain).
It is not clear why PVL occurs. This area of the brain is very susceptible to injury, especially in premature babies whose brain tissues are fragile. PVL may happen when the brain receives too little oxygen. However, it is not clear when the trigger for PVL occurs — before, during or after birth. Most babies who develop PVL are premature, especially those born before 30 weeks gestation. Other factors that may be associated with PVL include early rupture of membranes (amniotic sac) and infection inside the uterus.
PVL may not be apparent until later months. Each baby may experience symptoms differently. The most common symptom of PVL is spastic diplegia, a form of cerebral palsy characterized by tight, contracted muscles, especially in the legs. The symptoms of PVL may resemble other conditions or medical problems. Always consult your baby's doctor for a diagnosis.
In addition to a complete medical history and physical examination, diagnostic procedures for PVL may include:
- Cranial ultrasound. A painless test that uses sound waves to view the baby's brain through the fontanelles, the soft openings between the skull bones. With PVL, the ultrasound shows cysts or hollow places in the brain tissue.
- Magnetic resonance imaging (MRI). This test uses a combination of a large magnet, radio frequencies, and a computer to produce detailed images of internal structures. MRI may show some of the early changes in the brain tissue that occur with PVL.
There are no treatments for PVL. Management of the problems that can result from PVL will be determined by your baby's doctor based on:
- Your baby's gestational age, overall health and medical history
- Extent of the condition
- Your baby's tolerance for specific medications, procedures or therapies
- Expectations for the course of the condition
- Your opinion or preference
Babies at risk for PVL may need special care after discharge from the hospital. Follow-up may include physical therapy, occupational therapy and speech therapy.
Director, Neonatal Neurology and Neonatal Neurocritical Care Program
Neonatal and Prenatal Neurologist
Sadie is one of hundreds of infants with acute encephalopathy who have received whole-body therapeutic hypothermia at the Children's National neonatal intensive care unit. Whole-body therapeutic hypothermia is offered in the first few hours of life to preserve brain cells and to stave off disability or death.
Faced with an APGAR score of one, which indicated Avery was struggling, the team quickly recognized the infant had hypoxic-ischemic encephalopathy (HIE), one of the most severe complications that can affect full-term infants.
The Neonatal Neurology and Neurocritical Care Program at Children’s National is the only one of its kind in the mid-Atlantic region and a leader in advancing neurologic care to some of our most critically ill newborns.
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