Neonatal intraventricular hemorrhage-Hydrocephalus
ALEXIOU G.A., GOUVIAS T.H., SFAKIANOS G., PRODROMOU N.
Children's Hospital "Agia Sofia", Athens, Greece

Intraventricular hemorrhage (IVH) is still one of the most serious complications of premature birth and the risk for severe IVH varies inversely with gestational age. About 50% of IVH occur within the first day of life. Post-hemorrhagic hydrocephalus is the most serious complication of IVH and occur in about 1/3 of infants. It is of paramount importance to identify this pathology as early as possible because of the associated high rate of mortality. Furthermore, the most severe IVH cases are related to a high risk of neurodevelopmental handicaps. IVH is often classified according to Papile in four grades. Grade I refers to bleeding restricted to the germinal matrix, grade II to hemorrhage within the ventricular system and without ventricular dilatation, grade III to intraventricular hemorrhage with ventricular dilatation and grade IV to parenchymal hemorrhage. The site of origin of IVH is hemorrhage into the subependymal germinal matrix, a region of the developing brain that regresses by term, with or without subsequent rupture into the lateral ventricle. Various risk factors have been increasingly recognized over the recent years. Birth age, gestation age, gender, acute perinatal asphyxia, vacuum-assisted delivery, coagulopathy, metabolic acidosis, tracheal suctioning, early onset sepsis, pneumothorax, maternal smoking and diabetes have been implicated in the development of IVH because they can impair the autoregulatory mechanisms of the neonate. Symptoms of IVH are usually bulging fontanela and macrocrania, apnea, bradycardia, cyanosis, seizures, high-pitched cry and anemia. Cranial ultrasound is the main imaging modality for the screening and diagnosis of IVH. Serial ultrasounds are usually performed to assess the size of the ventricles. Computed tomography scanning and magnetic resonance imaging are also used as supplementary tools and have better interobserver agreement. Regarding treatment there is always supportive care for the underlying disorders. When hydrocephalus occurs there is always a likelihood for spontaneous resolution. Serial lumbar punctures, ventricular punctures or reservoir placement can be used. If resolution of the hydrocephalus does not occur then a ventriculoperitoneal shunt is needed. Moreover, this type of hydrocephalus is more difficult to be treated due to the large amount of blood and proteins in the cerebrospinal fluid and patient’s vulnerability. Prognosis varies considerably with the extent of the intracranial lesion. Grade I and II usually have a good outcome. Grade III and IV may be associated more often with hydrocephalus and carry a less optimal prognosis. In order to reduce the incidence of IVH various interventions have been evaluated. Antenatal corticosteroid treatment of premature infants has been reported to have a favorable effect. Furthermore, antenatal exposure of very low birth weight infants to ritodrine tocolysis, in contrast with tocolysis induced by magnesium sulphate or indomethacin, was associated with a lower incidence of severe IVH. Indomethacin and prenatal phenobarbital have also proven very usefull. Nevertheless other pharmacological interventions such as ethamsylate did not decrease the incidence of IVH. Regarding hydrocephalus, because shunt placement is associated with various complications there have been efforts to overcome its need. Streptokinase was thought to be useful in the treatment of post-hemorrhagic hydrocephalus based on the hypothesis that can result in lysis of clots and reopen the pathways of cerebrospinal fluid circulation. Nevertheless in clinical studies was proven ineffective. Furthermore, contineous drainage, irrigation, and fibrinolytic therapy did not reduce shunt placement when tested in a multicenter, randomized trial. The transforming growth factor-beta has been implicated in the pathogenesis of posthaemorrhagic ventricular dilatation. Nevertheless, drugs that block transforming growth factor-beta do not reduce ventricular dilatation in an animal model. To conclude, during the last 2 decades there has been much improvement in the survival of low birth weight infants. Nevertheless, severe IVH remains a major complication that affect the infant’s functional and neurocognitive outcome. Encephalos 2010, 47(1):43-48.

Key words: Premature, intraventricular hemorrhage, hydrocephalus.