Intraventricular Haemorrhage and Periventricular Leucomalacia

Question 1

What is the significance of IVH in preterm infants?

Answer 1

IVH is a major long-term health burden for prematurely born infants, causing devastating brain injuries.

Question 2

What is the location of the primitive neural cells in the fetal brain?

Answer 2

The primitive neural cells are located around the base of the lateral ventricles, forming the germinal matrix.

Question 3

Why is the germinal matrix vulnerable in preterm infants?

Answer 3

The germinal matrix is vulnerable due to its transient vascular system, lacking autoregulation for changes in flow or pressure.

Question 4

What is PVL?

Answer 4

PVL refers to the necrosis of white matter around the ventricles of the brain in premature infants.

Question 5

What can cause PVL?

Answer 5

PVL can be caused by hypoxic-ischemic injury or inflammation in the periventricular region.

Question 6

What are the long-term consequences of PVL?

Answer 6

PVL can lead to motor and cognitive impairments in affected infants.

Question 7

What is the germinal matrix?

Answer 7

The germinal matrix is a region around the base of the lateral ventricles in the fetal brain where primitive neural cells migrate and develop.

Question 8

What occurs in the germinal matrix before 34 weeks of gestation?

Answer 8

Before 34 weeks of gestation, primitive neural cells in the germinal matrix migrate to form long corticospinal neurons or supporting cells.

Question 9

How is the vascular system in the germinal matrix described?

Answer 9

The vascular system in the germinal matrix is transient and rich, suited for intrauterine life but with minimal capacity to autoregulate flow or pressure.

Question 10

What events in a preterm infant’s life can affect cerebral blood pressure and vessel integrity?

Answer 10

Intubation,
a patent ductus arteriosus,
sudden volume expansion from IV fluids,
septicaemia, and
artificial ventilation can alter cerebral blood pressure and vessel integrity.

Question 11

What can happen if the vessels in the germinal matrix rupture?

Answer 11

If the vessels rupture, blood can leak into the brain parenchyma, damaging the evolution of long tracts and their supporting stroma, especially those serving the legs closest to the ventricles

Question 12

What is the potential consequence of blood leaking into the ventricles?

Answer 12

Blood leaking into the ventricles can cause altered cerebrospinal fluid (CSF) production and flow, potentially leading to hydrocephalus.

Question 13

What grading system is used to describe the severity of GMH/IVH?

Answer 13

The grading system consists of Grades I to IV, based on the volume of blood in the parenchyma and ventricles.

Question 14

Describe Grade I GMH/IVH.

Answer 14

Grade I indicates bleeding confined to the germinal matrix.

Question 15

What defines Grade II GMH/IVH?

Answer 15

Grade II involves GMH and IVH occupying less than 50 percent of the lateral ventricle volume.

Question 16

Explain Grade III GMH/IVH.

Answer 16

Grade III comprises GMH and IVH occupying more than 50 percent of the lateral ventricle volume and is associated with acute ventricular distension.

Question 17

What characterizes Grade IV GMH/IVH?

Answer 17

Grade IV indicates hemorrhagic infarction in periventricular white matter ipsilateral to a large IVH, also known as periventricular hemorrhagic infarction (PVHI).

Question 18

When do the majority of GMH/IVH bleeds occur?

Answer 18

The majority of bleeds occur within the first 5 days of life.

Question 19

Clinical signs

Answer 19

• Small degrees of haemorrhage are usually asymptomatic.
• Reduced spontaneous movement.
• Apnoeas.
• Occasionally a full fontanelle with large haemmorhage.
• Coma and death.

Question 20

Some associated metabolic features

Answer 20

• A drop in haemoglobin concentration.
• Hyperglycaemia.
• Metabolic acidosis from a shock like state if severe

Question 21

How are GMH/IVH typically discovered in preterm infants?

Answer 21

GMH/IVH are usually discovered through routine cranial ultrasounds performed in neonatal units.

Question 22

What imaging techniques provide better definition for diagnosing GMH/IVH?

Answer 22

CT scanning and MRI provide better definition, but they are difficult to perform and are seldom done in practice.

Question 23

What options are available for managing GMH/IVH once they have occurred?

Answer 23

here is little available to mitigate the effects of GMH/IVH once they have occurred. Hydrocephalus may be managed with shunting if it progresses or causes raised intracranial pressure.

Question 24

How can GMH/IVH be prevented?

Answer 24

Prevention may be possible through antenatal steroids and avoiding precipitating factors, such as minimizing and gently handling the preterm infant during all aspects of care.

Question 25

Why is long-term neurodevelopmental follow-up important for preterm infants?

Answer 25

Long-term neurodevelopmental follow-up is crucial to detect early evidence of neurological sequelae and initiate therapy if needed.

Question 26

Prevention may be possible by

Answer 26

• Antenatal steroids.
• Being aware of the precipitants above and avoiding them, including minimal and
  gentle handling of the preterm infant during all aspects of care.