Intracranial Hemorrhage (IVH)


Hemorrhaging inside the brain, clinically referred to as intracranial hemorrhage (IVH), can damage or kill areas of the brain crucial to development and motor function. When this happens, resulting impairment — as well as the severity of impairment — is dependent upon the location and degree of damage. The hemorrhage can be arterial or venous.

  • Arterial bleeding results in additional loss of oxygen to tissue as arteries carry oxygenated blood to the heart.
  • Venous bleeding is internal hemorrhages affecting the veins that return blood to the heart. Arterial hemorrhages are harder to control than venous.

Hemorrhaging is bleeding. When bleeding is isolated in a particular organ or tissue, localized swelling, known as a hematoma, can occur. A hematoma can damage and kill surrounding tissue by compressing the tissue or reducing its blood supply. Clotting mechanisms or swelling that block blood supply will eventually stop a hematoma.

What Are the Four Grades of Intracranial Hemorrhage?

Intraventricular hemorrhage is a significant risk factor for cerebral palsy. It is most common in premature babies, especially those who have experienced respiratory distress syndrome, collapsed lung, or high blood pressure. Intracranial hemorrhage occurs most frequently in the first 48 hours after birth and with diminished likelihood as the infant ages. Intracranial hemorrhage is categorized into four grades (Grades I through IV) of increasing severity.

Grades I and II usually involve a small amount of bleeding contained in the ventricles, and do not normally cause long-term problems. Grades III and IV entail more substantial bleeding, which leads to swelling or obstruction in the brain. The swelling and obstruction, in turn, can lead to a condition called hydrocephalus — increased fluid in the brain — which causes dangerous pressure and may require surgical procedures to relieve.

Changes in blood pressure can also cause delicate infant blood vessels to rupture. Infants placed on ventilators are of particular concern; although great care is taken to prevent rupture, it is possible the child can breathe out of sync with the respirator and cause increased pressure in the lungs and brain.

What Are the Risk Factors for Intracranial Hemorrhage?

Risk factors for intracranial hemorrhage, include:

  • Placental blood clots
  • Malformed or weak blood vessels in the brain
  • Blood-clotting abnormalities
  • Maternal high blood pressure (hypertension)
  • Maternal infection
  • Pelvic inflammatory disease
  • Shaken baby syndrome
  • Head injury

What Are the Most Common Signs of Intracranial Hemorrhage?

Most common signs of intracranial hemorrhage, include:

  • Apnea (breathing pauses)
  • Pale or blue coloring
  • Abnormal eye movement
  • Shrill cry
  • Seizures
  • Decreased muscle tone
  • Decreased reflexes
  • Excessive sleep
  • Lethargy
  • Weak suck
  • Fallen blood count

It is recommended that infants born prematurely receive a routine cranial ultrasound between seven and 14 days of life, with a second administered at the baby’s original due date. Additional ultrasounds are ordered if a premature baby has new signs or symptoms, especially if his or her health worsens suddenly. It is estimated that an ultrasound will detect problems requiring additional follow-up in 25% of babies born before 30 weeks gestation.

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What Are the Five Forms of Intracranial Hemorrhage?

The five forms of intracranial hemorrhage are:

Intraventricular Hemorrhage

Intraventricular hemorrhage and hyperbilirubinemia, an elevated level of bilirubin in the blood, pose a strong risk for the development of cerebral palsy. This type of hemorrhage is usually caused by an intraparenchymal bleed in the corpus callosum, the bridge of nervous tissue that connects the two cerebral hemispheres allowing communication between them. Upon examination, blood is usually found in the lateral ventricles. Intracranial hemorrhage is more commonly associated with premature babies who have been exposed to physical stress from respiratory distress syndrome, high blood pressure, or abnormal presence of air or gas in the lungs, which causes the lungs to collapse. This condition may occur, on rare occasions, in full-term babies, but is rarely present at birth. Head injury, shaken baby syndrome, or fetal stroke are common causes of intraventricular hemorrhage. Risk factors that increase likelihood of fetal stroke include placental blood clots, malformed or weak blood vessels in the brain, maternal high blood pressure (hypertension), maternal infection, pelvic inflammatory disease, or blood-clotting abnormalities.

Epidural Hematoma

Epidural hematoma is the result of ruptured arteries and superficial venous sinuses, and is most often associated with sudden head trauma or accident. While the brain is unharmed, an underlying fracture exists in 60 to 90% of epidural hematomas. Surgery is often required to remove the hematoma and relieve pressure. In children, the classic symptom of brief and gradual loss of consciousness is rare. In children over 6 years of age it is believed that an injury to the side of the head, such as that sustained in a bicycle fall, is the most common event that can result in epidural hematoma.

Subdural Hematoma

Subdural hematoma is generally a more serious condition than an epidural hematoma, and is often a component in more severe head injuries. Subdural hematoma is caused by direct trauma, severe acceleration-deceleration trauma or a shaking injury. In children, subdural hematomas may result from birth trauma, child abuse, or shaken baby syndrome. Clinical signs of subdural hematoma in infants include irritability, lethargy, vomiting and bulging soft spot. In cases of abuse, the child will often incur an immediate loss of consciousness, headache, personality change, neck stiffness, seizures, vomiting, low-grade fever, and papillary dilation. Typically, some recovery may occur after head trauma and loss of consciousness, but the child is unlikely to return to his or her normal state. The mortality rate for those with subdural hematoma is significant due to the high incidence of associated irreversible brain damage.

Subarachnoid Hematoma

Subarachnoid hematoma is usually venous (relating to the veins). It is the most common type of intracranial hemorrhage following birth trauma. Intracranial hemorrhages resulting from birth trauma are most commonly subarachnoid (bleeding in the head between two membranes surrounding the brain). Subarachnoid hematomas result in the classic posterior interhemispheric region similarly found in cases of shaken baby syndrome, but will also hemorrhage in the subarachnoid space, as well. A baby with subarachnoid hematoma will likely develop seizures within 48 hours of birth. The baby may appear to have a stiff neck and be lethargic. Medical practitioners will likely use a lumbar puncture to rule out meningitis before diagnosing this type of hematoma. A noncontrast CT scan is often used to detect up to 90% of all subarachnoid bleeds within the first 24 hours of injury.

Intracerebral Hemorrhage

Intracerebral hemorrhage (ICH) is the bursting of blood vessels between the brain and skull, which often occurs when the brain is unable to absorb the force of impact from a head injury. Neurological damage may occur if additional bleeding occurs and contains cerebrospinal fluid. The two most common areas of the brain to experience this type of hemorrhage are the anterior portion of the temporal lobe and the posterior portion of the frontal lobe. Although the head injury can appear minor, the hematoma can be life-threatening and often requires immediate surgical procedures to relieve pressure caused by compressed brain tissue. This type of hemorrhage is not common in children.