A Parent's Guide to the NICU

Intraventricular Hemorrhage

What is intraventricular hemorrhage (IVH)?

Intraventricular hemorrhage means bleeding into the normal fluid spaces (ventricles) within the brain. IVH is also used to refer to bleeding in areas near the ventricles even if the blood is not within them. The extent of IVH is graded:

• Grade I - bleeding confined to the tiny area where it first begins
• Grade II - blood is also within the ventricles
• Grade III - more blood in the ventricles, usually with the ventricles increasing in size
• Grade IV - a collection of blood within the brain tissue

Why do premature babies get IVH?

The brain is still developing. The area where IVH usually begins has a very fragile network of tiny blood vessels. These burst easily causing the bleeding. The more premature and the sicker the baby is, the greater the risk that s/he will develop IVH. The infants at highest risk are those weighing less than 1000 grams (2 1/4 lbs).

How will my doctors know if my baby has IVH?

Most of the time there are no outward signs that the bleeding has occurred; occasionally babies have seizures or sudden anemia. Babies at risk for IVH usually have an ultrasound of the head in the first 2-7 days of life. This painless test, performed at the bedside uses sound waves to give a picture of the baby's brain. If IVH is present, the baby may have this test repeated at regular intervals to see if the hemorrhage or the size of the ventricles are increasing.

How is IVH treated?

There is no specific treatment for IVH. Surgery will not prevent or cure the bleeding. Improved overall care and monitoring of premature babies has decreased the rate of IVH, but some babies still get it.

What are the complications of IVH?

Complications are most common with grades III and IV IVH. The most frequent complication of IVH is hydrocephalus or too much fluid collecting in the ventricles. This extra fluid may cause:

• the baby's head to grow more rapidly than normal
• pressure on the baby's brain

Why does a baby develop hydrocephalus?

The brain has four ventricles. Fluid, called cerebral spinal fluid (CSF), is normally made in the two larger ventricles. It passes between the ventricles by tiny channels and eventually goes outside the brain to bathe the outer brain and spinal cord. The fluid is absorbed into the body from outside the brain. Abnormal amounts of fluid collect in the ventricles when:

• the fluid cannot get out due to a blood clot blocking a channel, or
• irritation from blood and scarring prevent absorption of the fluid around the brain

Can hydrocephalus be treated?

If your baby develops hydrocephalus, s/he needs some way for the fluid to escape from inside the brain. This may include:

• shunt - In this surgical procedure a tiny tube is placed into one of the two larger ventricles. It attaches to another longer piece of tubing. This connection is behind the ear, under the skin. The longer tubing continues under the skin, down the neck and chest to the baby's abdomen where the fluid can be absorbed.
• reservoir - This is a tube placed into one of the larger ventricles that then connects to a chamber. This chamber may be placed under the scalp or be outside the scalp. Whenever necessary, fluid can be withdrawn from the chamber by a needle. This is usually a temporary solution to the problem and the baby will need to have a shunt at a later time.

Can IVH cause brain injury?

Grades I and II IVH are most common. They usually do not cause identifiable brain injury. The blood is slowly absorbed by the body. Babies with Grade III IVH are at increased risk of brain damage, but many are normal or near normal. Babies who have needed treatment for hydrocephalus, those with continued enlargement of the ventricles, and those with grade IV IVH are at very high risk for permanent brain injury.

How will I know if my baby will have long term problems?

This can only be determined over time by monitoring his/her development. For this reason it is important for premature infants, especially those with IVH, to have their development followed carefully after discharge.

Serious abnormalities that may appear are:

motor (movement) problems

• tight or stiff muscles
• slow to crawl, stand, or walk
• abnormal crawling, toe walking
• moving one side more than the other
• frequent arching of the back (not just when angry or at play)

slow mental development

• does not listen to your voice by age 3-4 months after hospital discharge
• does not make different sounds by 8-9 months after discharge
• doesn't seem to understand or say any words by 12-13 months after discharge

seizures, also called convulsions

deafness

blindness

Less serious problems appear more slowly, are more difficult to detect, and may not be obvious until preschool or grade school. These can include:

• poor coordination or balance
• specific learning disabilities (math or reading)
• very short attention span
• behavioral problems
• difficulty with activities that require coordination of the eyes and hands, for example, catching a ball or copying a simple drawing
• need for glasses

If your baby has Grade III or IV IVH, s/he may be eligible for a developmental intervention program. Anytime in the future, if you are concerned about something that you think might be abnormal, have it checked out by your baby's regular doctor.