What is hidden behind the abbreviation VZHK? Causes of intraventricular hemorrhages in newborns. Possibilities of modern medicine

IVH (intraventricular hemorrhage) of the brain is a neurological pathology that occurs quite often in newborn babies.

Etiology of this disease- this is, first of all, pathological intrauterine development of the child and complications birth process.

What is IVH of the brain?

IVH also occurs in adults and is a type of stroke that is almost 100.0% fatal. In this type of stroke, blood enters the cerebral ventricular chamber system from blood hematomas inside the brain.

During a stroke, intracerebral arteries rupture, which leads to hematomas.

Intraventricular hemorrhage (IVH) in newborns occurs in isolation. IVH is not associated with parenchymal hematomas, and therefore can be classified as an independent pathology.

Intraventricular hemorrhage (IVH) is one of the most common diseases in infancy in children born prematurely.

The cause of pathology in premature babies is an incompletely formed system of intracranial vessels.

Immature vessels are at risk even with the slightest variability in the index blood pressure in the circulatory system.

The cause of rupture of fragile arterial walls may be brain hypoxia, or head trauma when a child passes through birth canal. When the arteries rupture, blood enters various chambers of the brain and IVH is formed.

The importance of the IVH problem

The importance of IVH pathology in newborn babies is due to a rather complex diagnostic study of the pathology, as well as its drug treatment. After all, many medications for the treatment of hemorrhage are not suitable for therapy in newborns.

Also important place Time plays a role in solving the problem, because the baby’s nerve centers are not yet sufficiently adapted to stress, so they simply may not be able to endure a negative situation.

In addition to children who were injured during the birth process, IVH pathology is quite often diagnosed in children born ahead of schedule.

And the shorter the period of intrauterine development of the baby, the higher the percentage of intraventricular hemorrhages.

In this situation, the complexity of brain hypoxia increases with a shorter period of intrauterine formation.

According to statistics:

• 50.0.0% of premature babies suffer from hemorrhage in the ventricles of the brain on the 1st day after birth;
• In 25.0% of infants, bleeding into the chambers of the cerebral ventricles occurs on the 2nd calendar day from the moment of birth.

Etiology of IVH in newborn infants

The causes of hemorrhage in newborn babies are completely different from the causes that provoke stroke in adults.

Causes of stroke in adults:

• Arterial hypertension (hypertensive crisis);
• Atherosclerosis of large diameter arteries;
• Cardiac ischemia;
• Coronary insufficiency;
• Arterial thrombosis;
• Stenosis of cerebral vessels.

In adults, during a stroke, a hematoma occurs inside the brain, and blood entering the chambers of the ventricles is a secondary manifestation of a stroke.

In infancy, a stroke (intracerebral hemorrhage) occurs immediately in the chambers of the ventricles.

The main reasons for what happens in the children’s brain are directly related with the course of pregnancy and labor:

• Premature baby;
• Hypoxia from a long period of the child being in the womb after the rupture of amniotic fluid;
• Hypoxia of the brain during the passage of the baby through the mother’s birth canal;
• Injury to the baby during obstetric care during childbirth;
• Low birth weight of a child - less than one kilogram;
• Pathologies of blood plasma coagulation, congenital genetic hereditary nature.

In children born prematurely main reason IVH is considered to be the presence of a germinal matrix in such children.

The germinal matrix is ​​a major risk factor for IVH.

Germinal matrix type

The germinal matrix is ​​the cells of the organ tissue that are located around the ventricles. This matrix contains immature cells, which, when entering parts of the brain, are transformed upon further maturation into neurons, or into cells of neuroglial molecules.

In addition to these immature cells, the matrix also includes immature vessels that have a very weak shell, which, at the slightest deviation from the index norm blood pressure can burst and cause blood to enter the newborn's brain.

Hemorrhage into the cells of the germinal matrix is ​​not yet a pathology of IVH, but this type of hemorrhage leads to blood entering the chambers of the ventricles of the brain.

A hematoma can form next to the ventricular wall and blood will begin to leak into the spatial ventricular lumen.

When a minimal volume of biological fluid enters the ventricles, a separate type of disease can be identified—IVH.

The stages of IVH pathology indicate the severity of the disease, and also determine the type of therapy and prognosis for the possibility of cure.

IVH grades according to CT method

Based on the results of deciphering the methodology computed tomography 4 degrees of development of IVH pathology were identified:

• 1st degree- subependymal hematoma. Blood collects under the lining of the ventricle chambers of the brain. The liquid does not enter the ventricles and does not destroy the state of the brain space. The danger of a breakthrough of the subependymal membrane and intracerebral effusion of blood exists constantly;
• 2nd degree- This is a typical intraventricular hemorrhage without an expanded organ cavity. The filled subependymal space releases blood into the cavities of the ventricular chambers. The ventricles are filled with biological fluid to half their volume;
• 3rd degree- this is the entry of blood into the ventricles and filling them more than half, and in this situation the intraventricular chamber expands;
• Degree 4 premature babies - this is the degree of the most severe course of the disease. At this degree, the ventricles are completely filled with blood, and biological fluid enters the tissue of the nerve endings. Parenchymal hemorrhage begins inside the brain.

Stages of IVH according to brain damage

According to the results of the tomographic study, changes in the structure of brain cells are visible, and Based on these indicators, 3 stages of brain cell destruction are distinguished:

• Stage 1 organ damage. The ventricles are filled with biological fluid less than half, there is an option to stop the bleeding on their own, the chambers are not dilated. There is a possibility of normal functioning of the organ's liquorodynamics;
• Stage 2 The lateral ventricles fill with blood and expand. The lateral ventricles are filled with biological fluid by more than half and the blood proceeds to fill ventricles No. 3 and No. 4;
• Stage 3 pathology- This is the most severe stage of damage to brain cells. Blood enters the protective membrane of the cerebellum, an organ medulla, as well as into the cells of the spinal cord. More than 90.0% of cases of this pathology are fatal.

A disruption in the proper circulation of cerebrospinal fluid (CSF) and the development of hydrocephalus occurs due to blood entering the cerebral ventricle, where it mixes with the cerebrospinal fluid and does not immediately clot.

A partial volume of blood penetrates into other organs of the brain. The coagulation process begins in the blood, and blood clots close the pathways for the normal passage of cerebrospinal fluid (CSF).

Symptoms of IVH

Up to 90% of all blood effusions in the brain occur in the first 3 calendar days after birth. The likelihood of hemorrhage in premature babies directly depends on the weight of the child - the higher his weight, the lower the likelihood of developing IVH.

After 7 calendar days, the risk of IVH is reduced, which is due to adaptation arterial system brain to external environment, and also the maturation of the germ cell type matrix is ​​currently taking place.

After the first 3 days, premature babies should be under the close attention of neonatologists to avoid IVH.

First degree pathology occurs without visible symptoms. The second degree of pathology also quite often passes without visible symptoms.

The third and fourth degrees are a dangerous course of the disease, which can provoke the following complications:

• Dropsy of the brain;
• Hydrocephalus:
• Encephalia;
• Atrophy of brain cells.

Symptoms with IVH may not always be with characteristic features hemorrhages inside the ventricular, and may also express other concomitant pathologies.

Symptoms that occur most often with IVH:

• The reflex disappears external stimuli(reduced or completely absent Moro reflex);
• Muscle tone is significantly reduced;
• Drowsiness;
• Apnea attacks are attacks of respiratory arrest that immediately resume;
• Cyanosis of the skin;
• The skin is pale;
• The sucking reflex is very weak or completely absent;
• Refusal to eat;
• Visual function is impaired (the child practically does not move his eyes, but looks at one point);
• The cry is very weak;
• Muscle tissue spasms;
• Paresis;
• Acidosis (there is an imbalance between the acidic environment in the body and the alkaline environment);
• Impaired hematocrit;
• Blood transfusion develops;
• The fontanel is enlarged and constantly swells;
• Comatose state with hemorrhagic hemorrhages;
• A state of coma with greatly distended cerebral ventricles, even if biological fluid does not enter the cerebral cortex.

The mildest stage of the pathology does not cause a blockage to the passage of cerebrospinal fluid (CSF), the size of the chambers of the cerebral ventricles does not change, and the course of this type of hemorrhage can be determined only by the result clinical analysis biochemistry - hematocrit.

When there is periventricular bleeding in the brain, the child exhibits the following symptoms in the body:

• Depressed emotional condition(the child does not react to external stimuli and bright light);
• Weakness of muscle tone;
• Paresis;
• Violations in nerve endings eye organ- strabismus develops, as well as nystagmus;
• Violations in respiratory system(signs of heavy breathing appear, as well as temporary apnea).

With the spasmodic type of the disease, symptoms appear for only a couple of days, and then the symptoms gradually subside. This is a consequence of the restoration of the functionality of the brain organs, or, on the contrary, a deviation in the performance of brain cells.

Deviations with this type of pathology are minor, which does not fundamentally affect the life prognosis.

Diagnostics

The pathology of IVH cannot be independently diagnosed and diagnosed. There are many diseases that exhibit the same or similar symptoms. Therefore instrumental diagnostic test cerebral arteries and their interpretation is prescribed by a neonatologist, as well as ultrasound examination of all organs abdominal cavity.

At timely diagnosis, you can begin drug treatment for pathologies of organs that are not visible visually, but are identified during an instrumental examination of the body.

At weak vessels in the brain, ultrasound simply must be done immediately after birth in order to avoid advanced stages of ventricular hemorrhage.

Treatment

IVH is quite difficult to treat, because this pathology is not a disease, but IVH is a process in the brain that provokes quite serious complications and severe consequences.

In the first degree of hemorrhage and in the second degree of the disease - constant monitoring of the course of the pathology.

If the state of the brain is in a stable development of pathology, then drug therapy is used to eliminate the consequences of bleeding inside the cerebral ventricles.

When the first and second degrees of hemorrhage occur, there is no destruction of brain cells, abnormalities in the brain occur extremely rarely, and with 1st degree consequences, and with 2nd degree complications occur very rarely.

When treating such children, they are given all the conditions that are close to intrauterine interruption:

• Air circulation;
• The temperature regime is similar to the mother's womb;
• Required air humidity;
• Light indicators.

These conditions can be provided by a special pressure chamber, in which the baby is kept until the condition stabilizes after a cerebral hemorrhage.

Course of drug therapy medicines includes:

• Preparations for stabilizing the blood pressure index in order to avoid the consequences of its sharp drop - hypoxia of brain cells, as well as hypoxia of nerve fibers;
• Oxygen therapy technique;
• Anticonvulsants;
• Drugs to normalize blood coagulation - coagulants, anticoagulants.

To reduce pressure in the arteries of the intracranial box, drugs are used intravenously orally, as well as intramuscularly:

Therapy with anticonvulsants:

• Medicinal drug Diazepam;
• Valproic acid.

An infusion is also carried out to cleanse the body of intoxication, and an intravenous injection of sodium bicarbonate is used to relieve the symptoms of acidosis.

For the treatment of more complex stages of IVH disease, they are used the following techniques surgical intervention:

• Ventricular puncture (via the fontanelle);
• Lumbar puncture (through the lumbar region);
• Liquor filtration technique;
• Liquor absorption method;
• A technique for washing the brain chambers of the ventricles using an artificial fluid, which is identical in properties to cerebrospinal fluid;
• Ventriculoperitoneal shunting. This technique is carried out when there is a blockage of the cerebrospinal fluid channel, or in case of hydrocephalic type syndrome. The treatment method involves inserting a drainage tube into the ventricles. This tube extends from the brain under the skin into the abdominal cavity, where cerebrospinal fluid (CSF) is absorbed. The drainage system must operate continuously and the drainage hose must be replaced as necessary.

Is there a cure for hydrocephalus?

If the pathology hydrocephalus has produced in the organ irreversible actions, and there is no positive result from drug therapy with fibrinolytics, then the only the right way out to save life - This surgery into the body to install permanent drainage of cerebrospinal fluid:

• Installation of permanent drainage with a silicone tube. The tube is removed after the child’s condition has normalized and only after hydrocephalus has stopped progressing;
• Anastomosis using an endoscopic technique between the ventricles of the brain organ and the basal basin.

Preventive measures for pathology within the ventricular effusion of blood

There are no techniques that can 100.0% avoid IVH cerebral hemorrhage, but To reduce the number of risk factors, you can take some precautions:

• The first event is to determine the tactics of the birth process;
• With a narrow pelvis of the woman in labor and with a large diameter of the baby’s head, the birth process should be a method C-section;
• If there is poor blood coagulation in the fetus (genetic intrauterine pathologies), or in the woman in labor, a caesarean section is used.

Immediately after the birth of the child, drug therapy is prescribed to adjust blood plasma coagulation:

• Drugs from the corticosteroid group;
• Medicines of the immunoglobulin group;
• A platelet mass solution is administered by intra-arterial injection.

Preventive measures (IVH) for the expectant mother

Because this pathology impossible to warn Then, to facilitate the birth process, you can take some preventive measures:

• During the period of intrauterine formation of the baby, a pregnant woman should visit the attending doctor regularly;
• Systematically undergo clinical laboratory research, in order to determine deviations in the formation of the fetus and the development of intrauterine pathologies;
• Promptly treat infectious diseases in a pregnant woman, as well as treat pathologies in a baby in utero;
• Undergo instrumental examination;
• Consult your doctor about the risk of having a baby prematurely. If there is a provoking factor premature birth, then the doctor will prescribe a course of medications to strengthen the cerebral arteries of the fetus, which will reduce the risk of intrapartum IVH;
• A pregnant woman must maintain a healthy lifestyle: no nervous stress, refuse nicotine addiction, do not drink alcoholic beverages;
• Constantly adjust the blood pressure index;
• Avoid sudden changes in temperature;
• Don't be in the heat.

Prognosis for life with IVH

The prognosis for life with IVH directly depends on the degree of cerebral hemorrhage.

• 1st degree (mild) in which important centers of the brain are not affected, the prognosis is favorable.
• 2nd degree ( average severity) , in which the ventricles are half filled, but do not have stretched membranes - the prognosis is favorable with the qualified help of the treating doctors.
• 3rd degree (severe) hemorrhage is aggravated by hydrocephalus of the brain.

Hydrocephalus occurs in 55.0% of newborns with hemorrhage.

35.0% receive significant deviations in the functioning of the brain of a neurological nature.

20.0% of IVH cases result in infant death.

With timely surgery to drain cerebrospinal fluid, the chances of life increase slightly and the prognosis is slightly favorable.

IVH degree 4 is the most difficult degree in treatment. Applies only surgical technique, but even with timely therapy, 50.0% of babies die in the first day after the birth process.

80.0% of children suffer from the pathology of hydrocephalus, which also often leads to death - the prognosis is unfavorable.

90.0% of infants have neurological disorders that lead to a shortened life span.

Grade 3 and grade 4 IVH - the prognosis is unfavorable.

The traumatic genesis of epidural, subdural or subarachnoid hemorrhage is especially likely when the size of the head does not correspond to the size of the mother’s pelvis, long period expulsion, rapid labor, breech presentation, obstetric operations. Massive subdural hemorrhages accompanying rupture of the tentorium or falx cerebellum are rare. They are more common in full-term newborns than in premature ones. Primary coagulopathies and vascular malformations, which can cause subarachnoid and parenchymal hemorrhages, are also rare. Intracranial hemorrhages are also observed with disseminated intravascular coagulation, isoimmune thrombocytopenia and vitamin K deficiency (in particular, in children whose mothers received phenobarbital or phenytoin). In premature infants, intracranial (mainly intraventricular) hemorrhages occur in the absence of obvious trauma.

Pathogenesis

Premature babies are especially susceptible to brain damage. Most of these lesions are intraventricular hemorrhages and periventricular leukomalacia. Intraventricular hemorrhages in premature infants originate from the gelatinous germinal matrix. It contains embryonic neurons and glial cells that migrate from here to the cerebral cortex. The presence of immature vessels in this richly vascularized area that do not have sufficient tissue support in premature infants predisposes them to hemorrhages. In full-term infants, the vessels of the germinal matrix mature and acquire stronger support in the tissues. Factors predisposing to intraventricular hemorrhage in newborns include prematurity, hyaline membrane disease, hypoxia and cerebral ischemia, arterial hypotension, restoration of blood flow in ischemic areas of the brain, fluctuations in cerebral blood flow, disruption of integrity vascular wall, increased venous pressure, pneumothorax, hypovolemia, arterial hypertension. These disorders lead to rupture of the germinal matrix vessels. The same damaging effects (hypoxia, ischemia, arterial hypotension), venous obstruction due to intraventricular hemorrhage in newborns and some other unidentified disorders cause periventricular hemorrhages and necrosis (they look like echo-dense areas).

Clinical manifestations

The frequency of intraventricular hemorrhages in newborns is inversely proportional to birth weight and gestational age: for mass - 60-70%, for g - 10-20%. At birth, intraventricular hemorrhages are rare. 80-90% of them occur in the first 3 days of life, 50% - on the 1st day. In 12-40% of cases, hemorrhage increases in the first week. 10-15% of hemorrhages occur after the first week of life. After the first month of life, regardless of birth weight, hemorrhages rarely occur. The most common symptoms of intraventricular hemorrhage in newborns are a decrease or disappearance of the Moro reflex, muscle hypotonia, drowsiness, and episodes of apnea. In premature infants, intraventricular hemorrhages are manifested by a rapid deterioration of the condition on the 2-3rd day of life: episodes of apnea, pallor, cyanosis, refusal to eat, oculomotor disorders, weak high-pitched cry, muscle twitching and cramps, muscle hypotonia or paresis, metabolic acidosis, shock, a drop in hematocrit or the absence of its increase after blood transfusion due to its fall. The large fontanel is often tense and bulging. With severe intraventricular hemorrhages, accompanying hemorrhages in the cerebral cortex, and stretching of the ventricles, the depression of the central nervous system deepens to the point of coma.

Periventricular leukomalacia in newborns is usually asymptomatic and manifests itself closer to the age of 1 year with spastic paresis and delayed motor development.

Diagnostics

The diagnosis of intraventricular hemorrhage is made on the basis of anamnesis, clinical picture, transfontanelle ultrasound or CT data, and an assessment of risk factors associated with birth weight. Subdural hemorrhages in large full-term newborns, whose head size does not correspond to the size of the mother's pelvis, are often diagnosed late, at the age of about 1 month, when the gradual accumulation of subdural exudate leads to an increase in head circumference, drooping of the forehead, bulging of the large fontanelle, convulsive seizures and anemia. Delayed manifestation sometimes suggests child abuse. Subarachnoid hemorrhages can cause short-term seizures in a relatively mild condition.

Although in premature infants massive intraventricular hemorrhages quickly give rise to vivid clinical manifestations - shock, marbled cyanotic coloration of the skin, anemia, coma, bulging of the large fontanel, many of their symptoms are absent or not specific. Ultrasound of the brain through the greater fontanel is recommended for all premature infants to detect intraventricular hemorrhages. Newborns with a birth weight of less than 1500 g and a gestation of less than 30 weeks, i.e., belonging to the risk group for intraventricular hemorrhage, should undergo an ultrasound scan at 7-14 days of life and repeat it later. post-conceptional age. If the first ultrasound revealed pathological changes, it is necessary to repeat it earlier so as not to miss post-hemorrhagic hydrocephalus. Multiple ultrasounds make it possible to diagnose later developing atrophy of the cerebral cortex, porencephaly, and to judge the severity, increase or decrease of post-hemorrhagic hydrocephalus. Diffusion-weighted MRI facilitated early diagnosis Extensive periventricular leukomalacia, damage white matter and isolated cerebral infarction and parenchymal hemorrhages.

According to ultrasound data, three degrees of severity of intraventricular hemorrhage in premature infants are distinguished: I - subependymal hemorrhage within the germinal matrix or occupying less than 10% of the ventricular volume (35% of cases), II - hemorrhage into the ventricle, occupying 10-50% of its volume (40% of cases ) and III - hemorrhage into the ventricle, occupying more than 50% of its volume. Another classification also includes grade IV, which corresponds to III + parenchymal hemorrhage. Ventriculomegaly is classified as mild (0.5–1.0 cm), moderate (1.0–1.5 cm), and severe (>1.5 cm).

CT or MRI is indicated for full-term infants with a clinical picture of brain damage, since ultrasound does not always detect parenchymal hemorrhages and infarctions. If symptoms of intracranial hypertension occur against a background of deterioration, a lumbar puncture is necessary to exclude bacterial meningitis and confirm the diagnosis of massive subarachnoid hemorrhage. With the latter, the content of protein and red blood cells in the CSF is increased, leukocytosis and a slight decrease in glucose levels are common. Slight increase in red blood cell count and mild xanthochromia diagnostic value do not have, since small subarachnoid hemorrhages occur with normal birth and even caesarean section. Conversely, CSF may be completely normal in cases of massive subdural or parenchymal hemorrhage that do not communicate with the subarachnoid space.

Forecast

Massive hemorrhages with rupture of the tentorium cerebellum or falx cause rapid deterioration of the condition and death soon after birth. Massive intrauterine hemorrhages in the brain, in particular in its cortex, occur with isoimmune thrombocytopenic purpura in the mother or, more often, with isoimmune thrombocytopenia. After their resorption, porencephalic cysts remain.

Intraventricular hemorrhages and acute ventricular dilatation in most cases do not cause posthemorrhagic hydrocephalus. The latter develops in 10-15% of premature intraventricular hemorrhages. At first, it may not be accompanied by characteristic symptoms ( fast growth head circumference, episodes of apnea and bradycardia, depression of the central nervous system, bulging of the large fontanel, dehiscence of the sutures of the skull). They, despite the steady expansion of the ventricles, compression and atrophy of the cerebral cortex, appear only after 2-4 weeks. In 65% of cases, posthemorrhagic hydrocephalus stops growing or undergoes reverse development.

For progressive hydrocephalus, ventriculoperitoneal shunting is indicated. Parenchymal hemorrhages and extensive periventricular leukomalacia aggravate the prognosis. Intraventricular hemorrhages in newborns, in which the size of the echo-dense area in the parenchyma exceeds 1 cm, is accompanied by high mortality and frequent motor and cognitive disorders. Intraventricular hemorrhages of I-II degrees are not associated with severe hypoxia and ischemia and, in the absence of concomitant parenchymal hemorrhages and periventricular leukomalacia, rarely cause severe residual neurological disorders.

Prevention

Careful assessment of the ratio of the size of the fetal head and the mother's pelvis when determining delivery tactics significantly reduces the incidence of traumatic intracranial hemorrhage. The incidence of perinatal intracranial hemorrhage associated with idiopathic thrombocytopenic purpura in the mother or isoimmune thrombocytopenia in the fetus is reduced when the mother receives corticosteroid therapy and intravenous administration her immunoglobulin, platelet transfusion to the fetus and delivery by cesarean section. All women receiving phenobarbital and phenytoin during pregnancy should receive vitamin K before delivery. Blood pressure fluctuations in newborns should be avoided.

A single administration of corticosteroids to a woman giving birth prematurely reduces the incidence of intraventricular hemorrhage in newborns (betamethasone and dexamethasone) and periventricular leukomalacia (betamethasone only). How effective their repeated administration is and whether it will affect brain growth and psychomotor development is unknown. Prophylactic use of small doses of indomethacin reduces the incidence of intraventricular hemorrhages, but in general does not affect the prognosis.

Treatment of intraventricular hemorrhages in newborns

There are no treatment methods. Therapy is aimed at their complications. Convulsions require active anticonvulsant therapy, massive blood loss and shock require transfusions of red blood cells and fresh frozen plasma. Correction of acidosis is necessary, including sodium bicarbonate, provided it is administered slowly. External CSF drainage by placement in the lateral ventricle permanent catheter used in early period rapidly and steadily progressing hydrocephalus as a temporary measure until general state a child with a very low birth weight will allow for ventriculoperitoneal shunting. Serial lumbar punctures, diuretics and acetazolamide (Diacarb) do not play a real role in the treatment of post-hemorrhagic hydrocephalus.

Clinically significant subdural hematomas are aspirated by inserting a lumbar puncture needle through the greater fontanel at its lateral edge. It should be remembered that the cause of subdural hemorrhage can be not only birth trauma, but also child abuse.

Intraventricular hemorrhage in newborns: how to reduce risks and consequences?

Intraventricular hemorrhage (IVH) is a pathology in which small vessels burst and bleed into the ventricles of the newborn baby's brain.

The ventricles are cavities in the brain that are filled with cerebrospinal fluid (CSF). A person has several of them and they are all connected to each other.

The diagnosis of IVH is often made in premature infants, due to their physiological characteristics. The shorter the gestational age, the higher the likelihood of hemorrhage.

Hemorrhage does not appear just like that; there must be reasons for this disorder.

Who is at risk?

Brain hemorrhage in newborns can be associated both with damage to the skull itself and with a lack of oxygen.

Prerequisites for DRC:

1. Post-maturity or, conversely, under-maturity. Premature babies are especially susceptible to intracranial hemorrhages, since their immature vessels do not yet have sufficient support in the tissues. In children born late, the bones become denser and the head is unable to adjust during childbirth. According to statistics, IVH occurs in every fifth premature baby and every tenth post-term baby.
2. The size of the fetal head does not correspond to the size of the birth canal. IN in this case natural delivery is contraindicated, because it is fraught with injury and hypoxia for the newborn baby.
3. Difficult pregnancy (fetal hypoxia, intrauterine infection various infections).
4. Difficult (protracted or rapid) labor, breech presentation.
5. Incorrect actions of obstetricians during childbirth.

Based on the above, several risk groups can be identified.

The risk of cerebral hemorrhage in a child increases with:

• prematurity;
• low birth weight (less than 1.5 kg);
• oxygen deficiency (hypoxia);
• child's head injury during childbirth;
• breathing complications during childbirth;
• infections leading to blood clotting disorders.

Characteristic symptoms

Not always there visible signs hemorrhages. Also, if a child has any of the symptoms listed below, then it is not at all necessary that this is due to IVH; they can also be caused by other diseases.

The most common symptoms of intraventricular hemorrhage in infants:

• decrease or disappearance of the Moro reflex (to external stimuli);
• decreased muscle tone;
• drowsy state;
• episodes of apnea (stopping breathing);
• pale skin, cyanosis;
• refusal to eat, weak sucking reflexes;
• oculomotor disorders;
• weak and shrill cry;
• muscle twitching, convulsions;
• paresis;
• metabolic acidosis (disturbed acid-base balance);
• decrease in hematocrit or absence of its increase due to blood transfusion;
• a large fontanel is tense and bulging;
• coma (with severe hemorrhages, as well as concomitant hemorrhages in the cerebral cortex, significant stretching of the ventricles).

Severity

There are several classifications of hemorrhages, most of them include 4 stages. Below is the gradation most often used in modern medicine:

1. IVH of 1st and 2nd degrees. Hemorrhage is observed in the projection of the germinal matrix and does not spread into the lumen of the lateral ventricles. In the second stage, the hemorrhage has a slightly larger size(>1 cm) than in the first.
2. At grade 3, hemorrhage from the germinal matrix enters the lumen of the lateral ventricles. As a result, posthemorrhagic ventriculomegaly or hydrocephalus develops. On the tomogram and section, expansion of the ventricles is observed, in which blood elements are clearly visible.
3. Grade 4 is the most severe, IVH breaks through into the periventricular parenchyma. Hemorrhage is observed not only in lateral ventricles, but also into the substance of the brain.

It is possible to establish one or another degree of hemorrhage only with the help of a special study.

Diagnostic methods and criteria

For diagnosis in the presence of corresponding symptoms, as a rule, ultrasound of cerebral vessels is used (using sound waves vascular ruptures and bleeding are determined). Blood tests are also taken to check for anemia, metabolic acidosis, and infections.

When diagnosing a pathology of any degree, the specialist selects individual treatment for the patient.

Possibilities of modern medicine

If a child is found to have hemorrhage in the ventricles of the brain, he should be under the vigilant supervision of medical staff. The baby's condition is monitored to ensure his stability.

Basically, therapy for IVH is aimed at eliminating complications and consequences. If any diseases arise as a result of hemorrhage, appropriate treatment is prescribed.

Sometimes (if it accumulates too much a large number of fluid in the brain) the following measures are applied:

1. Ventricular (through the fontanel) or lumbar (through the lower back) puncture.
2. Ventriculoperitoneal shunting, when a special device is inserted into the ventricles drainage tube. It is pulled under the skin into the patient's abdomen, where excess cerebrospinal fluid is absorbed. Drainage system must remain in the body at all times, and the tube is replaced if necessary.

It should be noted that for the majority of patients (with degrees 1 and 2 IVH) no therapy is required at all; one can count on a favorable outcome.

Prognosis depending on the degree of hemorrhage

The consequences will depend on the degree of IVH and the adequacy of the actions of the medical staff:

1. Grades 1 and 2 hemorrhage often do not require any treatment. Such infants need to be monitored; the likelihood that any neurological abnormalities will occur is low. Cases of development of hydrocephalus and fatal outcome with grades 1 and even 2, violations are extremely rare.
2. 3rd degree. When hemorrhage breaks through into the ventricles, the likelihood of developing hydrocephalus increases; it can occur in approximately 55 percent of cases. Neurological abnormalities observed in 35%. On average, death occurs in every fifth child. Patients are indicated for surgical intervention, and the outcome depends on the extent of brain damage and location (prognosis is more favorable if IVH is present within only one lobe, especially only in the frontal lobe).
3. 4th degree. Unfortunately, the prognosis for such severe pathology is disappointing. Surgical intervention in this case is inevitable, but the risks of death remain high - approximately half of infants with stage 4 IVH die. In 80% of cases, hydrocephalus develops, in 90% - neurological abnormalities.

Preventive measures

It is impossible to prevent hemorrhage in the baby’s brain one hundred percent, but to reduce the risk, some measures can and should be taken.

Correct determination of delivery tactics

Often perinatal intracranial hemorrhages occur due to birth injuries Therefore, it is extremely important to carefully assess the relationship between the mother’s pelvis and the fetal head.

If there is a discrepancy, natural childbirth is contraindicated and a caesarean section is prescribed. This operation It is also carried out for diseases associated with a decrease in platelets in the blood of a pregnant woman or fetus (poor coagulation).

In addition, in this case, special therapy is prescribed (corticosteroids, immunoglobulin, platelet mass). During childbirth, it is important to monitor the baby's blood pressure; it is necessary to avoid its fluctuations so that cerebral blood flow does not increase.

Prenatal screening

Although these studies are not mandatory for a pregnant woman, they should not be ignored.

In addition, you should know that intracranial hemorrhages are possible not only in newborns. They can occur as a result of injury at absolutely any age.

Intraventricular hemorrhage (IVH) in newborns: causes, degrees, manifestations, prognosis

Neurological pathology in newborns and children in the first years of life is a very serious problem, and, unfortunately, brain damage in children is by no means uncommon. IVH is an intraventricular hemorrhage, which is very characteristic of the newborn period and often accompanies the pathological course of labor.

Intraventricular hemorrhages also occur in adults, representing a form of stroke with high mortality. As a rule, blood penetrates into the ventricular system from intracerebral hematomas when they break into the brain cavity.

Hemorrhage into the ventricles of the brain in children is usually isolated and not associated with parenchymal hematomas, that is, it can be considered as an independent separate disease.

intraventricular hemorrhage in a newborn

The significance of the problem of intraventricular hemorrhage in newborns is due not only to the difficulties of diagnosing and treating the pathology, because many drugs are contraindicated for babies, and immature nervous tissue is extremely sensitive to any unfavorable circumstances, but also to the prognosis, which cannot always reassure young parents.

In addition to children born during an abnormal course of the labor period, IVH is diagnosed in premature infants, and the shorter the gestational age at which the premature birth occurred, the more likely IVH and the more severe the degree of ischemic-hypoxic brain damage.

In babies born ahead of schedule, half of the hemorrhages in the ventricles occur already in the first day of life, up to 25% of IVH occurs on the second day after birth. How older child, the lower the likelihood of circulatory disorders in the brain, even under the condition of an abnormal course of labor.

Today, neonatologists have highly informative research methods in their arsenal that allow timely diagnosis of intraventricular hemorrhage, but problems with classification and determination of the stage of pathology have not yet been resolved. A unified classification of IVH has not been developed, and when formulating stages, the features of the topography of the lesion are taken into account rather than the clinical severity and prognosis.

Causes of intraventricular hemorrhages in newborns

The reasons for the development of IVH in young children are fundamentally different from those that cause hemorrhages in adults. If the latter come to the fore vascular factors- hypertension, atherosclerosis, which underlie strokes, and the penetration of blood into the ventricles is secondary to intracerebral hematoma, then in newborn babies the situation is somewhat different: hemorrhage immediately occurs inside the ventricles or under their lining, and the causes are somehow related to pregnancy and childbirth:

• State of prematurity;
• Long waterless period;
• Severe hypoxia during childbirth;
• Injuries during obstetric care (rare);
• Birth weight less than 1000 g;
• Congenital disorders of blood coagulation and vascular structure.

In premature babies, the main cause of intraventricular hemorrhages is considered to be the presence of the so-called germinal matrix, which should gradually disappear as the fetal brain and vascular system mature. If birth occurs prematurely, then the presence of this structure creates the prerequisites for IVH.

The germinal matrix is ​​a region of neural tissue around the lateral ventricles that contains immature cells that move into the brain and, when mature, become neurons or neuroglial cells. In addition to cells, this matrix contains immature capillary-type vessels, the walls of which are single-layered, therefore very fragile and can rupture.

Hemorrhage into the germinal matrix is ​​not yet IVH, but it most often leads to the penetration of blood into the ventricles of the brain. A hematoma in the nervous tissue adjacent to the wall of the ventricle breaks through its lining, and blood rushes into the lumen. From the moment even the minimum volume of blood appears in the ventricle of the brain, we can talk about the beginning independent illness- intraventricular hemorrhage.

Determining the stages of IVH is necessary to assess the severity of the disease in a particular patient, as well as determine the prognosis in the future, which depend on the amount of blood entering the ventricles and the direction of its spread towards the nervous tissue.

Radiologists base IVH staging on CT scan results. They highlight:

• IVH of the 1st degree - subependymal - blood accumulates under the lining of the ventricles of the brain, without destroying it and without entering the ventricle. In fact, this phenomenon cannot be considered a typical IVH, but at any moment a breakthrough of blood into the ventricles can occur.
• IVH grade 2 is a typical intraventricular hemorrhage without expansion of its cavity, when blood exits the subependymal space. On ultrasound, this stage is characterized as IVH with less than half the volume of the ventricle filled with blood.
• IVH stage 3 - blood continues to flow into the ventricle, filling more than half of its volume and expanding the lumen, which can be observed on CT and ultrasound.
• IVH of the 4th degree is the most severe, accompanied not only by the filling of the brain ventricles with blood, but also by its spread further, into nerve tissue. CT scan reveals signs of IVH of one of the first three degrees along with the formation of foci of parenchymal intracerebral hemorrhage.

Based on structural changes in the brain and its cavities, three stages of IVH are distinguished:

1. At the first stage, the ventricles are not completely filled with blood content, they are not expanded, spontaneous cessation of bleeding is possible and normal liquor dynamics are maintained.
2. Continued filling of the lateral ventricles with possible expansion, when at least one of the ventricles is filled with blood by more than 50%, and the blood spreads into the 3rd and 4th ventricles of the brain occurs in the second stage.
3. The third stage is accompanied by progression of the disease, blood entering the choroid cerebellum, medulla oblongata and spinal cord. The likelihood of fatal complications is high.

The severity of IVH and its manifestations will depend on how quickly blood penetrates the brain tissue and its cavities, as well as on its volume. Hemorrhage always spreads along the flow of cerebrospinal fluid. In very premature babies, as well as those who have suffered deep hypoxia, disorders of the blood coagulation system occur, so clots do not appear in the cavities of the brain for a long time, and liquid blood “spreads” unhindered throughout the parts of the brain.

The basis for the disorder of cerebrospinal fluid circulation and the further increase in hydrocephalus is the penetration of blood into the ventricle, where it mixes with cerebrospinal fluid, but does not collapse immediately. Part liquid blood penetrates into other cavities of the brain, but as it coagulates, its clots begin to block the narrow zones through which cerebrospinal fluid circulates. Blocking any of the openings of the brain entails blockage of the cerebrospinal fluid pathway, dilatation of the ventricles and hydrocephalus with characteristic symptoms.

Manifestations of IVH in young children

Up to 90% of all hemorrhages in the ventricular system occur in the first three days of a baby’s life, and the lower his weight, the higher the likelihood of pathology. After the first week of a child’s life, the risk of hemorrhage decreases significantly, which is associated with the adaptation of the vascular system to new conditions and the maturation of the structures of the germinal matrix. If a child was born prematurely, then for the first few days he should be under close supervision of neonatologists - on the 2-3rd day the condition may worsen sharply due to the onset of IVH.

Small subependymal hemorrhages and grade 1 IVH may be asymptomatic. If the disease does not progress, the condition of the newborn will remain stable, and neurological symptoms will not even arise. With multiple hemorrhages under the ependyma, signs of brain damage will appear closer to a year with the phenomena of leukomalacia.

A typical intracerebral hemorrhage is manifested by symptoms such as:

• Decreased muscle tone;
• Sluggish tendon reflexes;
• Breathing disorders up to stopping (apnea);
• Convulsions;
• Focal neurological symptoms;
• Coma.

The severity of the pathology and the characteristics of the symptoms are associated with the volume of blood entering the ventricular system and the rate of increase in pressure in the cranial cavity. Minimal IVH, which does not cause obstruction of the cerebrospinal fluid ducts and changes in the volume of the ventricles, will be accompanied by an asymptomatic course, and it can be suspected by a decrease in the hematocrit number in the baby’s blood.

An intermittent course is observed in moderate and submassive IVH, which are characterized by:

Symptoms with spasmodic flow are expressed over several days, after which they gradually decrease. Perhaps as full recovery brain activity, and minor deviations, but the prognosis is generally favorable.

The catastrophic course of IVH is associated with severe disorders of brain function and vital important organs. Characterized by coma, respiratory arrest, generalized convulsions, bluish skin, bradycardia, decreased blood pressure, and thermoregulation disorders. Intracranial hypertension is indicated by the bulging of a large fontanel, clearly visible in newborns.

Besides clinical signs disturbances in nervous activity, there will be changes in laboratory indicators. The occurrence of IVH in newborns may be indicated by a drop in hematocrit level, a decrease in calcium, fluctuations in blood sugar, and frequent disorders of the blood gas composition (hypoxemia), electrolyte disturbances(acidosis).

The progression of bleeding leads to the spread of blood from the ventricles into the cisterns of the brain and nervous tissue. Parenchymal intracerebral hematomas are accompanied by severe focal symptoms in the form of paresis and paralysis, sensory disturbances, and generalized convulsive seizures. When IVH is combined with intracerebral hemorrhage, the risk of an unfavorable outcome is extremely high.

Among the long-term consequences of IVH are ischemic-hypoxic damage and residual changes in the brain in the form of cysts, periventricular leukomalacia, white matter gliosis, and cortical atrophy. By about a year, a developmental delay becomes noticeable, motor skills suffer, the child cannot walk or perform correct movements of the limbs in due time, does not speak, and lags behind in mental development.

Diagnosis of IVH in children is based on an assessment of symptoms and examination data. The most informative is CT, neurosonography and ultrasound. CT is accompanied by radiation, so ultrasound is preferable for premature babies and newborns in the first days of life.

IVH on a diagnostic image

Treatment and prognosis

Neurosurgeons and neonatologists treat children with IVH. Conservative therapy is aimed at restoring the functioning of vital organs and blood counts. If the child did not receive vitamin K at birth, it must be administered. Deficiency of coagulation factors and platelets is compensated by transfusion of plasma components. If breathing stops, artificial ventilation of the lungs is performed, but it is better to arrange it as planned if there is a risk of respiratory disorders.

Drug therapy includes:

• Normalize blood pressure to prevent a sharp decline or surges that aggravate hypoxia and damage to nerve tissue;
• Oxygen therapy;
• Anticonvulsants;
• Blood clotting control.

To reduce intracranial pressure, the administration of magnesium sulfate intravenously or intramuscularly is indicated; diacarb, furosemide, and veroshpiron are used for full-term children. Anticonvulsant therapy consists of prescribing diazepam, drugs valproic acid. To relieve symptoms of intoxication, carry out infusion therapy, acidosis (blood acidification) is eliminated by using sodium bicarbonate solution intravenously.

In addition to medication, surgical treatment of IVH is carried out: evacuation of blood from the ventricles of the brain through their puncture under ultrasound control, introduction of fibrinolytic agents (actelyse) into the lumen of the ventricles to prevent thrombosis and occlusive hydrocephalus. It is possible to combine puncture with the administration of fibrinolytic drugs.

In order to remove tissue breakdown products and eliminate symptoms of intoxication, liquor filtration, liquor sorption and intraventricular lavage with artificial cerebrospinal fluid preparations are indicated.

In case of blockage of the cerebrospinal fluid ducts and hydrocephalus syndrome, temporary drainage of the ventricles is established with the evacuation of blood and clots until the cerebrospinal fluid is cleared and the obstruction of its outflow tract is eliminated. In some cases, repeated lumbar and ventricular punctures, external ventricular drainage, or temporary internal drainage with implantation of artificial drainage under the skin are used.

insertion of a catheter for ventricular drainage

If hydrocephalus has become persistent and irreversible, and there is no effect from fibrinolytic therapy, then neurosurgeons provide permanent drainage surgically:

1. Installation of permanent shunts with the outflow of cerebrospinal fluid into the abdominal cavity (a silicone tube passes under the skin from the head to the abdominal cavity, the shunt can be removed only if the child’s condition has stabilized and hydrocephalus has not progressed);
2. Endoscopic anastomosis between the ventricles of the brain and the basal cistern.

The most common method of surgical treatment of occlusive hydrocephalus due to IVH is ventriculoperitoneal drainage. It is affordable, allows drugs to be administered into the ventricles, has a low probability of infection, can be carried out for a long time, and caring for the child is not accompanied by difficulties. The use of alteplase, which accelerates the dissolution of blood clots in the ventricles, can reduce mortality and maximize brain function.

The prognosis for IVH is determined by the stage of the disease, the volume of hemorrhage and the location of brain tissue damage. In the first two degrees of IVH, blood clots resolve on their own or under the influence of treatment, without causing significant neurological disorders, therefore, with minor hemorrhages, the child can develop normally.

Massive intraventricular hemorrhages, especially if they are accompanied by damage to brain tissue, in short time can lead to the death of the baby, and if the patient survives, then neurological deficits and severe disturbances in psychomotor development are problematic to avoid.

All children with intracranial hemorrhages are subject to careful monitoring in intensive care and timely surgical treatment. After installing a permanent shunt, the disability group is determined, and the baby should be regularly shown to a neurologist.

To avoid the severe changes described, it is important to follow measures to prevent brain damage in newborns and very premature infants. Expectant mothers need to undergo the necessary procedures in a timely manner preventive examinations and examinations, and if there is a threat of premature birth, the task of obstetricians-gynecologists is to prolong the pregnancy as much as possible medications until such a time when the risk of hemorrhage becomes minimal.

If the baby is still born prematurely, he is placed in the intensive care unit for observation and treatment. Modern methods Diagnosis and treatment of IVH can not only save babies’ lives, but also significantly improve their quality, even if this requires surgery.

Ischemia-hypoxia, changes in blood pressure and pressure. The presence of germinal matrix makes bleeding more likely. The risk also increases with hematologic diseases (eg, vitamin K deficiency, hemophilia, disseminated intravascular coagulation).

Subarachnoid hemorrhage is probably the most common type of intracranial hemorrhage. These newborns may have apnea, seizures, lethargy, or unusual findings. neurological examination. Heavy bleeding associated with meningeal inflammation can lead to hydrocephalus as the infant grows.

Subdural hemorrhage, now less common due to improved obstetric techniques, results from bleeding into the falciform space, tentorium, or commissuruven. Such bleeding typically occurs in newborns of first-time mothers, large newborns, or after a complicated birth—conditions that can produce unusual pressure on intracranial vessels. Symptoms may include seizures; rapid head enlargement or abnormal neurological examination results.

Intraventricular and/or intraparenchymal hemorrhages are the most serious look intracranial bleeding. They are often bilateral and usually develop in the germinal matrix. Hypoxia - ischemia damages the capillary endothelium, reduces cerebral vascular autoregulation, and can increase cerebral blood flow and venous pressure, which make bleeding more likely. In most cases, intraventricular hemorrhages are asymptomatic.

Risk: In premature newborns, the risk of intracerebral hemorrhage and its severity are directly proportional to the degree of immaturity:

• 25 weeks of gestation - 50% risk.
• 26 weeks - 38%.
• 28 weeks - 20%.
• Statistics vary, sometimes significantly, between clinics.

Time of manifestation. In premature infants, about 50% of hemorrhages appear on the 1st day of life, 25% on the second and 15% on the third.

Sources of bleeding:

Premature infants have a germinal matrix (regresses by 32-36 weeks of gestation) with vulnerable vessels (sensitive to pressure fluctuations, ischemia, hypoxia, acidosis, coagulation disorders). At 28–32 weeks of gestation, most of the terminal matrix is ​​located at the caudothalamic junction, just posterior to the foramen of Monro. The fourth ventricle also contains a vulnerable germinal matrix.

As the newborn matures, the importance of the germinal matrix as a source of intracerebral hemorrhage decreases, and the importance of the choroid plexus increases.

Classification of intracerebral hemorrhage in newborns

Advice. Instead of the above classifications (there are others), it is better to use a brief, precise description using the terms “germinal matrix”, “intraventricular”, “parenchymal” and indicating the location.

Papile classification- the most commonly used classification of hemorrhages in NN, based on computed tomography data:

• Hemorrhage of the II degree: with a breakthrough into the ventricle without its expansion.
• Hemorrhage of the III degree: with a breakthrough into the ventricle and its expansion.
• IV degree hemorrhage: combination of hemorrhage I-III degrees with hemorrhage into the brain parenchyma.

DEGUM classification(German Society for Medical Ultrasound). Developed by the pediatric department of DEGUM in 1998 and based on ultrasound data:

• Hemorrhage of the 1st degree: subependymal.
• Grade II hemorrhage: intraventricular with filling< 50 % просвета.
• Hemorrhage grade 111: intraventricular with filling > 50% of the lumen.
• Parenchymal hemorrhages (cerebrum, cerebellum, basal ganglia, brain stem) are described separately (location and size).

Diagnosis of intracerebral hemorrhage in newborns

Intracranial hemorrhage should be suspected in a newborn with apnea, seizures, lethargy, or unusual neurological symptoms; such children need a CT scan of the head. Although cranial ultrasound is not dangerous, CT is more sensitive for thin layers of blood. However, for screening very preterm infants (e.g.<30 нед гестации) некоторые врачи предпочитают проведение УЗИ. Если диагноз вызывает сомнение, СМЖ может быть проверена на содержание эритроцитов: она обычно содержит много крови. Однако некоторое количество эритроцитов часто присутствует в спинномозговой жидкости доношенных новорожденных.

In addition, blood tests, CBC and metabolic studies should be performed.

Ultrasonography

Premature infants should undergo cranial ultrasound on the first, third and seventh days of life. It also makes sense to perform an ultrasound after the child’s admission to the department (in case of forensic investigations to clarify the time of the first manifestation of the lesion).

If a lesion is detected, a thorough examination of the midbrain and infratentorial structures is necessary through additional approaches (anterior and posterior lateral fontanelles). In approximately 10% of premature infants with post-hemorrhagic dilation of the ventricles, small hemorrhages are detected in the cerebellum, which are poorly visible through the large fontanel (this clinical problem is underestimated).

If hemorrhage is detected near the arteries, especially in a full-term newborn, Doppler examination of the venous vessels (superior sagittal sinus, internal veins of the skull) is necessary.

In full-term infants, in addition to ultrasound, it is necessary to perform MRI and, if this is important for treatment, angiography.

Intraparenchymal areas of echo enhancement (the term periventricular venous perfusion or edema is often used) are the sites of infarction in most cases. Sometimes they go away without the formation of cysts, and then in retrospect we can only talk about venous stagnation. After the onset of cystic transformation (weeks), areas of echo enhancement should be called infarctions or hemorrhages (important for conversation with parents).

Differential diagnosis

Unlike hemorrhages in premature infants, which are explained by immaturity, hemorrhages in full-term infants require a thorough search for the cause: resuscitation, birth trauma, hemorrhagic diathesis (coagulation and platelets), thrombophilia, venous and arterial thrombosis, embolism, polyglobulia, hypernatremia, aneurysms, arteriovenous malformations, coarctation of the aorta, tumor, ECMO therapy, etc.

Treatment of intracerebral hemorrhage in newborns

Treatment is primarily supportive unless hematologic abnormalities contribute to bleeding. All children should receive vitamin K if it has not been previously provided. If platelets or clotting factors are insufficient, they must be replenished. Subdural hematomas should be treated by a neurosurgeon; removal of the hemorrhage may be necessary.

Make the most of all conservative treatment options:

• Stabilize blood pressure: avoid surges in blood pressure, use catecholamines carefully, sedation. The principle of correction with minimal means.
• Normalization of oxygenation.
• Avoid hyper- and hypocapnia (decreased brain perfusion).
• Control of coagulogram, correction of deviations.
• Avoid hypoglycemia.
• Widespread use of anticonvulsants.

Attention: It is better to intubate electively than in an emergency situation with apnea.

For full-term infants, early consultation with a neurosurgeon.

Prognosis of intracerebral hemorrhage in newborns

In preterm infants, grades I-II intracerebral hemorrhage probably does not significantly increase the risk of neurological complications.

The risk of severe neurological complications in premature infants with grade III hemorrhages is approximately 30%, and with parenchymal hemorrhages - approximately 70%.

In mature neonates, prognosis depends on location and cause; hemorrhages in the basal ganglia, cerebellum and brainstem have an unfavorable prognosis, but the individual course is unpredictable.

The prognosis for subarachnoid hemorrhage is usually good. For subdural, cautious, but some babies do well. Most infants with small intraventricular hemorrhages survive the episode of acute bleeding and appear well. Children with large intraventricular hemorrhage have a poor prognosis, especially if the bleeding continues into the parenchyma. Premature infants with a history of severe intraventricular hemorrhage are at risk of developing posthemorrhagic hydrocephalus and should be closely monitored with repeat cranial ultrasound and frequent repeat head circumference measurements. Infants with progressive hydrocephalus require neurosurgical intervention to place a subcutaneous ventricular reservoir (for CSF aspiration) or a ventriculoperitoneal shunt. The CSF associated with posthemorrhagic hydrocephalus has very low glucose concentrations, known as hypoglycorrachia. Because many children have persistent neurological deficits, close monitoring and referral for early intervention are important.

I don’t know if this post will be of any use to anyone, but at least maybe a little of the horror will go away.

The stupid website didn’t allow me to write from my phone, so I had to switch to another device.

Now my son is 1 year old and will soon be two months old. In appearance you couldn’t tell that he was hanging on the edge of something unknown. But.

On November 30 of that year, the child, my baby, was taken to intensive care. Two days without a child - I don’t remember how I survived it then. But it all started even earlier.

On the morning of November 25, the baby ate. I slept. And suddenly he started screaming. No, it won't even scream. Worse. It was as if his arm had just been torn off. What it was - I didn’t understand then. I screamed for a couple of minutes. Then he howled for another five minutes. Then he seemed to calm down. Then he vomited. Then he passed out and his temperature rose.

I called the doctor. Madam came, said something incomprehensible like a red throat, prescribed a standard set for colic and left. By the evening everything calmed down and November 26 passed without anything special.

On the 27th his stool went bad.

On the 28th the temperature rose. My stomach got worse. Maintenance therapy was provided.

On the 29th it became bad.

On the 30th, my relatives insisted on a deadline. Paid. The free one didn’t want to go.

The doctor arrived. She asked everything very carefully and examined the baby very carefully. I installed a gas outlet. And she called an ambulance herself, free of charge. I explained to them something about the baby’s poor condition and about the green stool. I didn’t know anything about it then.

An ambulance arrived and... took my son to the intensive care unit. Exicosis, toxicosis. Then I thought that these were all terrible words...

After a day of the baby’s stay in a good children’s hospital, after they took all the necessary tests and did all the research, they call me and say: Come, we need to talk. I'm definitely rushing there. And then, after describing the general condition of the baby, who is not even two months old, they tell me that he is being transferred to another clinic where there is a neurosurgery department. Because my baby has intraventricular hemorrhage. At that moment, for some reason I thought that it was a matter of the heart, because the school anatomy course was successfully forgotten along with the structure of the brain. But the doctors told me in great detail that it was all in my head. And here I thought I was going crazy.

The child was transported to the fifth children's hospital. We left at two o'clock in the afternoon. Or they said that they had left. An hour's drive is the limit. I traveled separately. As a result, the intensive care unit brought my son only at 8 pm. For several hours I simply did not know where my child was or what was wrong with him. It was bad. But since I expected it to be even worse, I tried to save my strength.

As a result, when the child was brought in, he was immediately sent for tests. They didn't let me see him. But the pediatrician came out and said that the child was smiling. I decided that not everything is so bad. But two hours later, after the CT scan, the neurosurgeon explained to me that everything was bad, that there were chances... no, I won’t even remember it.

In short, they sent me home. I was able to move the car probably two hours after I got into it.

The next day I was suddenly put in a ward with my son. This was very unexpected, considering what the doctor said the day before. The child looked bad, but better than when he was taken away.

No one really wanted to tell me anything further. We stayed in the infectious disease ward and were treated for staphylococcus, which later turned out not to be staphylococcus at all. Everyone tried to remain silent about the head. The neurologist came to us five days later. During this time, we spent one night normally and our son screamed for four nights. It only quieted down in a vertical position, and not for long. By morning I calmed down a little. The doctors avoided our room. The night ones tried not to come at all, even when I shook the soul out of them.

Then a neurologist came and finally started treatment. And it immediately became easier. She said that she was screaming because of a headache.

In general, the entire time I was in that hospital I had the impression that it was some kind of torture chamber.

We were transferred from the infectious diseases department to the neuro department. By the way, my stomach didn’t get any better. Yes, the poop has returned to its normal color. But the diarrhea was still there, along with a sore tummy. But they brushed us aside, like, what did you want? It was Staphylococcus. And then they generally stated that this would be the case for up to six months and that this was the norm. And they forgot to indicate the results of stool tests in the extract. But more on that in another post.

In neurology, we were further observed and released in peace. With a package of pills bought at their own expense because they ran out of them - it’s the end of the year. And with a diagnosis of stage 3 IVH. By that time, I had read a lot about IVH and degrees... and the number 3 really scared me, since various sources promised from 5 to 18% of consequences-free outcomes. And to be honest, I left the hospital with a double feeling. On the one hand, the diagnosis is serious. On the other hand, I saw enough children there with much greater problems than ours, and it is not clear why such a serious diagnosis was made.

And then the visits to neurologists began. Drug treatment. Walking again. And the most interesting thing is that the neurologist at the clinic somehow tried not to attach special importance to the disease. But the city's leading neurologists said something else...

Anyway, by April we ran out of pills.

At 6.5 months they turned over after a massage. At 7 months they were on all fours. At 8 we sat down and got up. At 10 we went ourselves.

We are now one year old and will soon be two months old. He is physically faster than many. TTT also seems to be good in development. I rarely remember everything that happened and mostly in anticipation of the moment when I still need to donate blood and dig deeper in order to determine the reason why my baby had late hemorrhagic disease, which resulted in hemorrhage. This is despite the fact that pregnancy and childbirth were quite easy and without unnecessary interventions.

In this whole story, two points are not clear. Why did the local pediatrician, called immediately after the hemorrhage, not pay any attention to what I told her about the child’s behavior? Nor did she see that one half of the child’s face was a little numb. It was visible, but you had to look and know that it was not a grimace, but a symptom (that’s what I thought it was, a grimace).

And secondly, what kind of stump were we treated for staphylococcus if we needed to be treated for Proteus? Probably because the tests were taken four days after they started injecting general antibiotics... and because you can easily cure Proteus horseradish. But that's a different story.

Why did I tell you this? I want to support and maybe give hope to those who have encountered something similar. Diagnoses can be scary. But for children up to one year old, replacing damaged areas of the brain with neighboring areas works very well in terms of functionality. Therefore, the earlier treatment is started, the more you think soberly and work correctly, the greater the chances of a favorable outcome.

Intraventricular hemorrhages (IVH, PIVC, cerebral hemorrhages, periventricular hemorrhages)- These are hemorrhages in the ventricles of the brain. In other words, this is something similar to a hemorrhagic stroke, when blood enters certain structures of the central nervous system - ventricles of the brain(they form cerebrospinal fluid, i.e. cerebrospinal fluid, there are four of them in total - two lateral ones, as well as a third and fourth).

An important role in the development of cerebral hemorrhages in newborns belongs to the anatomical features of the immature body of a premature baby. The greater the degree of prematurity and immaturity, the higher the risk of hemorrhage, especially in children with extremely low and very low body weight(less than 1000 and 1500 grams, respectively). The blood vessels around the ventricles of the brain are very fragile and require very little force to damage and rupture them.

The leading factors in the occurrence of IVH are episodes of hypoxia, as well as traumatic damage to blood vessels (usually due to difficult childbirth). Hypoxia is oxygen starvation, which is accompanied by fluctuations in blood pressure both in general and directly in the vessels of the brain. Hemorrhages are much less commonly associated with primary coagulopathies (blood clotting disorders) or congenital vascular anomalies. IVH also occurs with disseminated intravascular coagulation, isoimmune thrombocytopenia, and vitamin K deficiency.

IVH occurs most often in the first three days of life and can increase in the first week, and much less often occurs after the first week of life.

There are some differences in the classifications of cerebral hemorrhages depending on the location and causes of the hemorrhage; the classification presented below is most often used.

There are four degrees of hemorrhage:

I degree - A small amount of blood is observed around the vessels. Such subependymal hemorrhage is considered minor and most often disappears on its own without any consequences.
II degree - blood enters the cavity of the cerebral ventricle, but usually has a slight effect on the further development of the child and often disappears on its own and without a trace.
III degree - the exit from the ventricles is closed by a blood clot, and the ventricles begin to expand. Some cases are accompanied by spontaneous resolution of the problem, but if this does not happen, surgery is necessary to install a shunt that unblocks the ventricles of the brain, otherwise there is a high risk of developing hydrocephalus. At this degree, manifestations of neurological symptoms are not uncommon.
IV degree - blood enters not only the ventricles of the brain, but also the surrounding brain tissue - the parenchyma. Such hemorrhage is life-threatening and is accompanied by severe neurological symptoms - most often convulsions, repeated episodes of apnea, the development of anemia, as well as ocular symptoms.

Causes of hemorrhage development.

It is definitely not known why some babies develop hemorrhage and others do not, and what is the immediate cause of brain hemorrhage in premature babies. But the more stable conditions are created for the child, the better, because premature babies require a strict protective regime and stay in a comfortable microenvironment, for which a special incubator is used.

Symptoms of IVH.

Symptoms of hemorrhage may vary. Most often they are absent. However, with extensive hemorrhage, the child’s condition worsens, he becomes agitated, and convulsions and ocular symptoms may occur. The child may be lethargic and less mobile, and muscle tone changes. Anemia develops, and in severe cases, shock and coma. Until the sonographer makes a diagnosis using ultrasound, the clinical picture may be difficult to distinguish from that of a rapidly developing infection.

Treatment of IVH.

Treatment is aimed at eliminating the consequences of hemorrhages and their complications. For example, correction of anemia, anticonvulsant therapy, and for progressive hydrocephalus, a neurosurgical operation is performed - ventriculoperitoneal shunting.

Long-term consequences of hemorrhages.

Minor hemorrhages (grade I), as a rule, do not lead to neurological pathology. Grade II hemorrhage also slightly increases its risk. Data from domestic and foreign studies show that extensive hemorrhages in the ventricles of the brain (III degree) lead to death in approximately 25% of children and a high percentage of disability, while 25% develop progressive expansion of the ventricular cavity, but approximately 50% of children do not experience complications. Of those children who have dilatation of the ventricular cavity, approximately half require surgery to install a shunt. With severe bleeding and hemorrhage into the brain tissue (IV degree), 50-60% of children die. With III and especially IV degrees of hemorrhage, surviving children experience significant impairment of motor functions in the form of cerebral palsy (cerebral palsy), developmental delays, decreased vision and hearing or their complete absence with the development of blindness and deafness. Fortunately, grade III and IV hemorrhages are not that common. It is noted that IVH is more severe in full-term infants than in premature infants.