Infant Brain Bleeds: Intraventricular Hemorrhages (IVH)

An intraventricular hemorrhage (IVH) is a serious type of infant brain bleed that occurs when there is bleeding within the brain’s ventricular system. It usually takes place in an area called the germinal matrix, which holds many important cells in a developing brain (1). The ventricular system is where spinal fluid is produced. Intraventricular hemorrhages can result from hypoxia (oxygen deprivation) or from physical trauma during birth. Premature and low birth weight infants are particularly susceptible because blood vessels in their brains are not fully developed and are therefore weak. As a result, roughly 12,000 premature infants experience IVH in the U.S. every year (1). Improper management of birth and neonatal care can result in intraventricular hemorrhages, which can cause permanent brain injury and conditions such as hydrocephalus, cerebral palsy (CP), periventricular leukomalacia (PVL), seizure disorders, and intellectual/developmental disabilities.

As previously noted, intraventricular hemorrhages (IVH) occur most frequently in babies who are born at less than 32 weeks of gestation or have a birth weight of less than 1500 grams and are not properly managed (1). The numbers are higher in infants born extremely premature, with IVHs occurring in 45% of infants born weighing 500-750g. Other risk factors for IVH include hypoxic-ischemic encephalopathy (HIE), birth trauma, lack of prenatal steroid (betamethasone) therapy in babies who are expected to be born preterm, prolonged neonatal resuscitation, and respiratory distress.

IVH is not usually present at birth, but rather found within three or four days following birth (2). It can be caused by a lack of oxygen to the baby’s brain and brain trauma. Oxygen deprivation can cause bleeding because when the brain receives insufficient oxygen, cells start to degrade. When the cells that make up the blood vessel walls start to break down, the vessels become fragile and can rupture very easily.

IVH is not usually present at birth, but rather found within three or four days following birth (2). It can be caused by a lack of oxygen to the baby’s brain and brain trauma. Oxygen deprivation can cause bleeding because when the brain receives insufficient oxygen, cells start to degrade. When the cells that make up the blood vessel walls start to break down, the vessels become fragile and can rupture very easily.

Traumatic head injury can also result in ruptured blood vessels. Head trauma is often caused by the use of forceps and vacuum extractors. These devices are placed directly on the baby’s head to help ease them out of the birth canal. Unfortunately, physicians often apply excessive pressure or misuse these devices, resulting in a brain bleed. The main causes of IVH are (3):

• Prematurity: The germinal matrix is more fragile and less structurally sound in infants that are born prematurely.
• Hypoxic-ischemic encephalopathy (HIE): Babies with HIE are more likely to have IVH as well. Prolonged labor, labor-enhancing drugs such as Pitocin or Cytotec, macrosomia (a condition in which the baby is large for gestational age and cannot easily fit through the birth canal), cephalopelvic disproportion (when there is a size mismatch between the baby’s head and the mother’s pelvis) and other conditions increase the risk of a baby having birth asphyxia and HIE.
• Trauma during delivery
• Intrapartum hypoxia: The “hypoxic” part of HIE, wherein the baby experiences a lack of oxygen.
• Abnormal changes in fetal blood pressure

These are just a few examples of conditions and complications that may result in IVH. For more detailed information, please visit our pages on hypoxic-ischemic encephalopathy (HIE) and birth trauma.

Babies with IVH may not present with symptoms. In fact, between 25-50% of IVH cases present without symptoms (3). It is important that screening cranial ultrasounds be administered if it is suspected. Listed below are some signs that the baby may have IVH (1, 2):

• The baby is limp (hypotonic) and/or weak
• The baby has decreased movement
• The baby’s breathing is abnormal – in severe cases, the baby is not breathing enough, has irregular breathing, and/or has periods in which they stop breathing (apnea)
• Changes in eye positioning and movement
• The baby has pale or blue coloring
• The baby has seizures
• The baby’s heart rate is slow and/or their blood pressure is low
• The baby has high-pitched crying
• The baby is sleeping for abnormally long periods
• The baby has slow or decreased reflexes

In severe cases, IVH can involve more severe symptoms, including, but not limited to (3):

• Flaccid weakness
• Seizures
• Coma or stupor
• Apnea or hypoventilation
• Pupils fixed to light
• Bulging anterior fontanelle
• Bradycardia
• Hypotension

Intraventricular hemorrhages are diagnosed with a head (cranial) ultrasound. Physicians use the ultrasound to determine the location and extent of the IVH. All babies born prematurely should be given a cranial ultrasound (3).

Grading of the severity of the IVH is as follows (2):

• Grade I IVH – Bleeding is confined to the germinal matrix, which is very important in brain development.
• Grade II IVH – Bleeding is occurring inside the ventricles.
• Grade III IVH – Bleeding has caused the ventricles to become enlarged and press on the brain tissue.
• Grade IV IVH – Bleeding extends into the brain tissue around the ventricles, which is also called an intraparenchymal hemorrhage.

Since IVH occurs most frequently in babies who are less than 32 weeks of gestation or have a birth weight of less than 1500 grams, these infants should have ultrasounds to screen for IVH (2).

IVH is generally managed by (3):

• Providing necessary fluid, nutrition, and metabolic support
• Providing adequate ventilation and oxygenation
• Maintaining arterial perfusion to preserve blood flow to the brain
• Monitoring for posthemorrhagic ventricular dilation (PHVD) or hydrocephalus
• Treating seizures to avoid further damage

As with any brain bleed, an intraventricular hemorrhage can damage the brain by causing a decreased amount of oxygen-rich blood in certain areas. If recognized right away and properly managed, IVH may cause no permanent injury in the baby (2). If mismanaged, however, the hemorrhage can extend into other areas of the brain. Specifically, the ventricles can swell due to too much cerebrospinal fluid, which is called hydrocephalus (3). Hydrocephalus can lead to damaged blood vessels and white matter damage (periventricular leukomalacia), and an important part of the brain, called the cerebral cortex, may not develop properly.

White matter is important because it regulates the electrical signals between cells of the nervous system. White matter is responsible for transmitting information throughout the brain, to the spinal cord, and outside the brain to the rest of the body. These signals control our bodily functions; nerve cells that transmit signals to the brain and cells that regulate breathing or heart rate would be unable to perform their tasks without white matter.

Ultimately, IVH can cause a child to develop lifelong conditions such as seizures, cerebral palsy, and developmental delays.