intracranial hemorrhage newborns

OVERVIEW © Incidence varies from 2% to >30% in newborns @ depends on the gestational age GA at birth and the type of ICH @ Diagnosis typically depends on clinical suspicion @ The presen

OVERVIEW

© Incidence varies from 2% to >30% in newborns

@ depends on the gestational age (GA) at birth and the type of ICH

@ Diagnosis typically depends on clinical suspicion

@ The presence and severity of parenchymal injury is the best predictor of

outcome

SUBDURAL HEMORRHAGE (SDH)

@ Rupture of the draining veins and sinuses of the brain

@ molding, fronto-occipital elongation, and torsional forces acting on the

head during delivery

@ provoke laceration of dural leaflets YW tentorium cerebelli or falx cerebri

© Often results from trauma in the full-term infant

@ SDH in the supratentorial space results from rupture of the bridging veins

Etiology

@ large head size,

© rigid pelvis (e.g., in a primiparous or older multiparous mother),

© nonvertex presentation (breech, face, etc.),

@ very rapid or prolonged labor or delivery,

© difficult instrumental delivery,

© or rarely, a bleeding diathesis

Clinical presentation

@ Large collection especially in infratentorial SDH results in rapid

deterioration

@ Systemic signs like hypovolemia and anemia

@ Seizures may occur in up to half of neonates with SDH,

particularly with SDH over the cerebral convexity

Diagnosis

© suspected on the basis of history and clinical signs and

confirmed with a computed tomography (CT) scan

© ultrasonic imaging subdural space is inadequate

© MRI- timing of the lesion and for detecting other lesions

© Lumbar puncture after CT

Management

© Most infants with do not require surgical intervention

© prompt stabilization with volume replacement

© Open surgical evacuation of the clot in case of large SDH

© The outcome for infants with nonsurgical SDH is usually

good

SUBARACHNOID HEMORRHAGE (SAH)

@ Primary SAH is probably frequent but clinically insignificant

@ normal “trauma” associated with the birth process

@ source of bleeding is usually ruptured bridging veins of the subarachnoid

Space or ruptured small leptomeningeal vessels

Et

Usual scenario is a well appearing term fant fa

© Clinical presentation is similar to other forms of ICH

© The diagnosis is best established with a CT scan or MRI, or by LP to

confirm or diagnose small SAH

© Ultrasonography is not sensitive for the detection of small SAH

@© Management of SAH usually requires only symptomatic therapy, such as

anticonvulsant therapy for seizures

INTRAPARENCHYMAL HEMORRHAGE (iph)

© Rare

@ Intracerebral or intracerebellar variety

® More commonly a secondary event

@ Hypoxic ischemic brain injury, venous infarction or thrombosis, ECMO

therapy, large ICH in another compartment

© Presentation and management similar to SDH

© mel - extent and age of hemorrhage and other associated

parenchymal lesions

© Lp to rule out meningitis

@ Symptomatic management

© Treat any coexisting pathology or predisposing factors

@ Monitoring for hydrocephalus

Intraventricular Hemorrhage

@© 15-20% at <32 weeks gestation

© Venous (or sinus)thrombosis and thalamic infarction in term

Infants

© Related to birth trauma or perinatal asphyxia

© No identifiable risk factors in 25%

° Fluctuating or increase CBF (Pressure passive circulation) °® Increase in cerebral venous pressure

° Platelet dysfunction

* Coagulation disturbances

Vascular factors ° Fragile, involuting capillaries with large

diameter lumen

Extravascular factors °® Deficient vascular support

Excess fibrinolytic activity

Clinical presentation

@ Usually a clinically silent syndrome in preterms

© Term newborns - seizures, apnea, irritability, lethargy, vomiting,

full fontanelle

© Catastrophic presentation less likely

© Complications

Diagnosis

®) Routine CUS in all infants born at <32 weeks and in older infants

at risk for IVH

© Days 3,7,30 and 60 days

© Monitoring for complications

© Grading of GMH/IVH is important for determining management

and prognosis

Grading Severity

Papile (CT) |

Ï [II

GMH with no or minimal IVH (<10% ventricular volume) IVH occupying 10-50% of ventricular area on parasagittal view IVH occupying >50% of ventricular area, usually distending

lateral ventricle

Periventricular echodensity

Prevention of IVH

© Antenatal steroids

© Slow infusion of colloid or hyperosmolar solutions

© Avoid rapid fluctuations in CBF and hypotension

© Sedative or paralytic medication in ventilated babies

IVH in preterm babies

© Supportive care and watch for complications

© Maintaining Normal BP, electrolytes and blood gases

© Transfusions as necessary

© Correct thrombocytopenia and coagulation disturbances

IVH in term infants

@ Supportive care and treatment of seizures

@ Serial LPs and eventual VP shunts

© Prognosis relates to factors other than IVH alone