Summary

Intraventricular Haemorrhage (IVH), or Germinal Matrix Haemorrhage (GMH-IVH), is the most common neurological morbidity in preterm infants. It originates from the rupture of the fragile Germinal Matrix vessels in the subependymal layer of the lateral ventricles. The bleeding can range from a small, contained clot (Grade 1) to massive ventricular flooding with parenchymal infarction (Grade 4). The condition is critically linked to gestational age, hemodynamic instability, and rapid volume shifts.

Key Facts

• Definition: Bleeding into the ventricles of the brain, typically starting in the Germinal Matrix.
• Timing: 50% occur within the first 24 hours. 90% occur within 72 hours. "If scan is normal at Day 7, risk is negligible."
• Prevalence: 20-25% of VLBW (<1500g) infants.
• Grading: The Papile Classification (Grade 1-4) is the global standard.
• Key Outcome: Grade 1-2 has near-normal neurodevelopment. Grade 3-4 carries high risk of Cerebral Palsy and Hydrocephalus.
• Prevention: "The Golden Hour" - Minimal handling, gentle ventilation, delayed cord clamping.

Clinical Pearls

The "Silent Killer": A massive IVH can present simply as a sudden drop in haematocrit or unexplained acidosis. The fontanelle may not bulge immediately if the skull sutures are mobile. ALWAYS scan if a baby "crashes" without explanation.

"Grade 4" is not just "Big Bleed": Grade 4 (Periventricular Haemorrhagic Infarction) is NOT blood pushing into the brain. It is a venous infarct. The large clot in the ventricle blocks the terminal vein, causing blood to back up and the brain tissue to die from congestion. This distinction matters because the damage is usually asymmetric.

The 72-Hour Danger Zone: The germinal matrix is most fragile in the first 3 days. Any rapid change in blood pressure (e.g., rapid bolus, pneumothorax, intubation fight) can pop these vessels. "Handte" handling is neuroprotection.

Why This Matters Clinically

IVH is the primary driver of adverse neurodevelopmental outcomes in survivable preterm infants. Preventing IVH is preventing Cerebral Palsy. Every intervention in the NICU (suctioning, positioning, fluids) must be weighed against its potential to cause a bleed.

Standard Grading used globally.

Note: Volpe classification is similar but Grade 4 is strictly "Periventricular Haemorrhagic Infarction" (PVHI).

Signs of Acute Haemorrhage

Often subtle or "Silent".

• Catastrophic: sudden collapse, apnea, flaccidity, fixed pupils (rare).
• Saltatory: Stuttering deterioration over hours. Hypotonia, decreased movement.
• Silent: Only detected on routine ultrasound (most common).

Signs of Post-Haemorrhagic Ventricular Dilation (PHVD)

Develops 1-4 weeks later.

• Rapid increase in Head Circumference (>1cm/week).
• Bulging Fontanelle.
• Splayed Sutures (palpable gap).
• Sunset Eyes (cannot look up).
• Apnea/Bradycardia (Brainstem compression).

Detailed Neurodevelopmental Outcomes (at 2 Years)

Based on EPIPAGE-2 and ELGAN cohorts.

Key Prognostic Factors:

1. Unilateral vs Bilateral: Bilateral Grade 4 has near 100% adverse outcome rate. Unilateral can be surprisingly resilient (hemiplegia but normal IQ).
2. Shunt Requirement: If the baby needs a permanent shunt, IQ is typically 10-15 points lower than if they didn't.
3. Parental Education: Higher maternal education is the strongest protective factor for cognitive development.

Outcome Modifiers

• Site: Unilateral Grade 4 is better than Bilateral.
• Cerebellum: If the cerebellum is also damaged (blood in fossa), outcomes are significantly worse (cognitive/motor).
• Environment: Early Intervention/Physio improves plasticity.

The Psychological Impact: "The NICU Rollercoaster"

IVH is often the first "bad news" parents receive.

1. Acute Grief

• Parents mourn the loss of the "healthy baby" they expected.
• Guilt: "Did I do something wrong in pregnancy?" (See FAQ).
• Fear: The fear of severe disability (wheelchairs, blindness) can be paralyzing.

2. Chronic Sorrow

• Learning to live with uncertainty.
• The "Scan Anxiety": The night before the weekly cranial ultrasound is terrifying.

3. PTSD

• 30-40% of NICU parents screen positive for PTSD. The sound of alarms triggers panic years later.
• Support: Psychology referral is part of standard neuro-NICU care.

Post-Discharge Follow-Up Schedule

For severe IVH (Grade 3/4).

Key Guidelines

1. British Association of Perinatal Medicine (BAPM). Management of PVHD.
2. American Academy of Neurology. Neuroimaging of the Neonate.

Landmark Trials

DRIFT Trial (Whitelaw et al)

• Intervention: Drainage, Irrigation and Fibrinolytic Therapy (washing ventricles).
• Finding: Reduced death or severe disability at 2 years and 10 years.
• Impact: Technically difficult, but proven efficacy. Only utilized in specialist neuro-NICUs.

ELVIS Trial (Early vs Late Intervention for PHVD)

• The Question: Historically, we waited until the head was huge (rapid growth) before tapping, fearing infection. Was this waiting causing brain damage?
• The Protocol: Randomized infants with PHVD to "Early" (Tap when VI > 97th centile + 4mm) vs "Late" (Wait for symptoms/massive head growth).
• The Finding:
  • Cognition: Early group had significantly better cognitive scores at school age.
  • Shunts: Early group needed fewer permanent shunts (19% vs 66% in some sub-analyses).
• Mechanism: High pressure compresses the white matter microvasculature. Relieving pressure early saves the white matter.
• Conclusion: We now intervene EARLIER. Be aggressive with the reservoir.

TIPP Trial (Indomethacin Prophylaxis)

• Hypothesis: Indomethacin constricts cerebral blood vessels. Giving it to all preterms <1000g should prevent bleeds.
• Protocol: 0.1mg/kg daily for 3 days starting at birth.
• Results:
  • Success: Statistically significant reduction in Grade 3/4 IVH.
  • Failure: No difference in survival without continuous disability at 18 months.
• Why?: It stops the bleed, but maybe the "Pre-IVH" white matter injury has already happened? Or maybe Indomethacin has side effects (GI perforation/Renal) that offset the benefit.
• Current Practice: Used in ~50% of NICUs. Protocol varies.

The Future: Neural Rescue?

Q: Will the blood go away? A: Yes. The body reabsorbs the blood clot over 4-6 weeks. However, the clot can leave behind a cyst (hole) or damage the drainage pathways (hydrocephalus).

Q: Did I cause this? A: No. IVH is a complication of premature birth itself. It is not caused by maternal stress, diet, or minor bumps.

Q: What is a "Reservoir"? A: It is a small plastic bubble under the skin of the scalp. It lets us draw off fluid with a small needle to relieve pressure, without hurting the baby every time. It buys time for the baby to grow big enough for a permanent shunt.

Q: Can the brain heal? A: The infant brain has amazing "plasticity". Other parts of the brain can sometimes take over the job of the damaged part. Early physiotherapy is key to helping this happen.

What lies on the horizon for IVH prevention and treatment?

1. Stem Cell Therapy

• Concept: Injecting mesenchymal stem cells (MSCs) to regenerate damaged white matter.
• Status: Phase 1 trials (safe). Efficacy unknown.

2. Erythropoietin (EPO)

• Concept: EPO is neuroprotective and promotes angiogenesis.
• Status: PENUT Trial showed no benefit for profound disability, but research continues for specific subgroups.

3. Artificial Womb (Ectogenesis)

• Concept: If we can keep the fetus submerged in fluid (like the Biobag), we avoid the "air breathing" transition that causes hemodynamic instability.
• Impact: Could theoretically eliminate IVH by maintaining fetal circulation.