Intraventricular Haemorrhage (IVH)

Why is this topic important?

Intraventricular haemorrhage is one of the most important neurological complications of prematurity. It is a high-yield MRCPCH topic because candidates must understand risk factors, cranial ultrasound findings, grading, complications and neurodevelopmental implications.

Definition

Intraventricular haemorrhage is bleeding into the germinal matrix and ventricular system of the brain, most commonly seen in very preterm infants.

The germinal matrix is fragile and highly vascular, making it vulnerable to bleeding.

Key MRCPCH Facts

Most common in very preterm and extremely low birth weight infants.
Highest risk is in the first week of life.
Cranial ultrasound is the main screening investigation.
Severe IVH is associated with worse neurodevelopmental outcome.
Post-haemorrhagic ventricular dilatation is an important complication.

Pathophysiology

The germinal matrix in preterm infants is fragile.

Bleeding may occur due to:

Fluctuating cerebral blood flow
Respiratory instability
Hypotension
Sepsis
Coagulopathy
Rapid changes in carbon dioxide

Once bleeding occurs, it may extend:

Within germinal matrix
Into ventricles
Into brain parenchyma
Causing ventricular dilatation

Risk Factors

Infant Factors

Extreme prematurity
Very low birth weight
Respiratory distress
Hypotension
Sepsis
Coagulopathy

Perinatal Factors

Lack of antenatal steroids
Difficult resuscitation
Hypoxia
Acidosis

Clinical Features

Many babies are asymptomatic.

Possible features include:

Apnoea
Bradycardia
Desaturation
Hypotension
Seizures
Bulging fontanelle
Sudden fall in haemoglobin
Reduced tone or activity

Investigations

Cranial Ultrasound

Main bedside investigation.

Advantages:

Safe
Portable
Repeatable
No radiation

MRI Brain

Useful for:

Defining extent of injury
Prognosis
Follow-up planning

Other Tests

If clinically indicated:

FBC
Coagulation profile
Blood gas
Infection screen

Grading

Common grading concept:

Grade I

Bleeding limited to germinal matrix.

Grade II

Blood in ventricles without ventricular dilatation.

Grade III

Blood in ventricles with ventricular dilatation.

Grade IV

Parenchymal haemorrhagic infarction.

Higher grades are associated with poorer outcomes.

Management

Supportive Care

Optimise ventilation
Avoid hypoxia and hyperoxia
Maintain stable blood pressure
Correct coagulopathy
Treat sepsis

Monitoring

Serial cranial ultrasound
Head circumference
Fontanelle assessment
Neurological examination

Post-Haemorrhagic Ventricular Dilatation

May require:

Neurosurgical discussion
CSF drainage procedures
Ventricular reservoir or shunt in selected cases

Complications

Short-Term

Ventricular dilatation
Hydrocephalus
Seizures
Anaemia

Long-Term

Cerebral palsy
Developmental delay
Learning difficulties
Epilepsy
Visual impairment

Common Exam Traps

Trap 1

Many IVHs are clinically silent.

Trap 2

Cranial ultrasound is first-line, not CT.

Trap 3

Severe IVH with ventricular dilatation has higher risk of adverse outcome.

Trap 4

Grade I and II IVH usually have better prognosis than severe IVH.

One Minute Revision

IVH = complication of prematurity.
Germinal matrix is fragile.
Screen with cranial ultrasound.
Severe IVH + ventricular dilatation = poor prognostic marker.
Monitor head circumference and ventricular size.

Suggested References

BAPM Guidance
RCPCH Guidance
Nelson Textbook of Pediatrics
Rennie & Roberton’s Textbook of Neonatology
Volpe’s Neurology of the Newborn

Disclaimer

These notes are intended for MRCPCH revision and educational purposes only. They do not replace local, national or institutional guidelines. Clinical decisions should always be based on current guidance, senior advice and individual patient circumstances.

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