Infant Intracranial Hemorrhages (Brain Bleeds): Signs, Symptoms, Causes

Infant intracranial hemorrhages (otherwise known as brain bleeds) are birth injuries that range from minor to extremely severe. They can be caused by birth asphyxia (oxygen deprivation during or around the time of birth) or birth trauma (injuries caused by excessive mechanical force to the baby’s head).

In many cases, these complications stem from medical negligence. It is important to diagnose intracranial hemorrhages as soon as possible in order to provide treatment and to limit the extent of the damage.

There are many different types of brain bleeds, including intracranial (inside of the brain) and extracranial (outside of the brain).

• A hemorrhagic stroke occurs when a blood vessel ruptures, causing bleeding within the brain. This can deprive brain cells of oxygen and nutrients. Hemorrhagic strokes can also cause pressure buildup, irritation, and swelling, and may lead to neonatal brain injury. There are two main types of hemorrhagic stroke:
• Intracerebral hemorrhage: Also known as cerebral hemorrhage, this type of brain bleed is characterized by bleeding that originates from blood vessels within the brain.
• Subarachnoid hemorrhage: characterized by bleeding in the subarachnoid space, which is the area between the innermost of the two membranes that cover the brain.
• Intraventricular hemorrhage: (IVH) is a serious type of intracranial hemorrhage that occurs when there is bleeding in the brain’s ventricular system, where cerebrospinal fluid is produced. It is usually seen in premature infants and infants with low birth weight, because the blood vessels in their brains are not fully developed, and are therefore weaker than that of babies born at term. Oxygen deprivation and birth trauma can also contribute to intraventricular hemorrhage.
• Subdural hemorrhage or subdural hematoma: occurs when one or more blood vessels rupture in the subdural space, which is the area between the surface of the dura and the arachnoid membranes. These ruptures are usually caused by traumatic injuries, like birth trauma.

• Caput succedaneum is swelling of an infant’s scalp, which can hemorrhage. It extends across the suture lines and usually happens when a baby has had vacuum extraction or has been in the birth canal for a prolonged period.
• Cephalohematoma (cephalhematoma) brain bleeds are characterized by bleeding that occurs between the skull and its covering as the result of ruptured vessels. Cephalohematomas manifest as a raised bump on the baby’s head. They often result from forceps or vacuum extraction injuries. Cephalohematomas usually go away on their own, but should be carefully monitored by medical professionals. Sometimes, babies require treatment for associated complications such as anemia and jaundice.
• Subgaleal hematoma occurs when blood accumulates in the area between aponeurosis and the periosteum (the skull and the scalp) where there is loose areolar (connective) tissue.

Signs of brain bleeds in babies will vary based on the type and severity of the bleed, but include:

• Lethargy
• Neonatal seizures
• Apnea
• Feeding difficulties
• Irritability
• Bulging fontanelle/soft spot
• Shallow or strained breathing
• Abnormal tone
• Altered level of consciousness

Common risk factors for and causes of intracranial hemorrhages in babies include:

• Macrosomia: a pregnancy condition in which the fetus is larger than average for the gestational age, which can make vaginal birth dangerous.
• Cephalopelvic disproportion (CPD): a similar condition to macrosomia, except that it specifically refers to a size mismatch between the fetal head and the mother’s pelvis (the head is unusually big and/or the pelvis is unusually small).
• Abnormal fetal presentation: a baby that comes out of the birth canal  in the breech, face, or brow presentation
• Trauma from prolonged labor
• Abnormal changes in blood pressure
• Blood disorders, such as vitamin K deficiency or hemophilia
• Hypoxic-ischemic encephalopathy (HIE): a dangerous neonatal brain injury resulting from decreased oxygen and blood flow to the baby at or near the time of delivery. The lack of blood flow results in cell death and causes the blood vessel walls to break down, which leads to bleeding.

If risk factors for intracranial hemorrhage are present, medical professionals must closely monitor the baby for signs of fetal distress and discuss the possibility of C-section with the mother. If fetal distress occurs and normal methods of delivery are unsuccessful, an emergency C-section is required to minimize the risk of intracranial hemorrhage and other birth injuries. Unfortunately, severe head and brain trauma to newborns can also occur from medical intervention during labor and delivery. For example:

• Forceps and vacuum extractors: Improper use of delivery instruments such as forceps or vacuum extractors is well-documented as a cause of intracranial bleeding.
• Delivery techniques: Improper delivery technique (for instance, excessive twisting or pulling of the infant’s head) and traumatic breech delivery can cause severe intracranial hemorrhages.

Additionally, premature babies are at a much higher risk for intracranial hemorrhages due to the fragility of their underdeveloped blood vessels. Therefore, it is very important for medical professionals to do all they safely can to prevent premature birth and deliver a premature baby safely.

If medical professionals detect signs of an intracranial hemorrhage or suspect that one occurred, brain imaging studies are performed to confirm the presence of blood within the skull.

The best methods of detecting a brain bleed are MRIs and CT scans. MRI (magnetic resonance imaging) uses magnetic waves to generate pictures of the brain. CT (computed tomography) scans use computer software and x-rays to create pictures of structures inside the baby’s brain. Occasionally, ultrasonography and testing of cerebrospinal fluid is performed.

Treatment of infant brain bleeds is mostly of a supportive nature, although neurosurgical intervention may be necessary to manage certain types. The prognosis varies depending on the severity and location of the bleed. Some infants do very well with little or no residual effects.

More severe bleeds can result in mental and physical impairments such as developmental delays, learning disabilities, and cerebral palsy (CP). Diagnosing an intracranial hemorrhage is crucial—the earlier a baby is diagnosed with a brain bleed, the earlier treatment and therapy can begin.

Brain bleeds in babies have been proven to cause long-term cognitive and behavioral effects. One study found that, when evaluated at age 8, with neurologic, behavioral, academic, and cognitive assessments, and an evaluation of school performance record, the children who experienced intraventricular hemorrhage (IVH) as infants had more of these issues than those that didn’t have hemorrhages as infants.

The children who had IVH had higher rates of hearing impairment and cerebral palsy, and had lower rates of IQ, daily living skills, and test scores in reading and math. The long-term outcomes of infant brain bleeds vary depending on the severity of the bleed, as well as its treatment and management.