Intracranial Hemorrhage of the newborn (ICH)

purpose To be familiar with etiology, pathogenesis and prognosis To master clinical manifestation To master diagnosis and treatment

Introduction The intracranial hemorrhage (ICH) is one of the most common and dangerous disease with very high mortality & disability rate in alive cases. The morbidity of ICH: premature infants > term infants

Introduction There are different etiology and varying prognosis. With improvement in perinatal care, survival percentage of ICH has considerable improvement recently.

Etiology & Pathology Premature Ischemic and hypoxia Birth trauma Others

Clinical manifestation Symptoms are relevant to the amount of hemorrhage and hemorrhage position. Mild ICH may have no symptoms, severe case may die.

Clinical manifestation Common symptoms and signs: Conscious disturbance Increased intracranial pressure Breathing disorder

Clinical manifestation Abnormal eye signs Muscular tension Primary reflex Jaundice and anemia without reasons

Clinical manifestation According to hemorrhage position, ICH be divided into 5 types Periventricular-intraventricular hemorrhage (PVH-IVH) Primary subarachnoid hemorrhage (SAH) Intraparenchymal hemorrhage (IPH) Subdural hemorrhage (SDH) Cerebellar hemorrhage (CH)

Clinical manifestation Periventricular-intraventricular hemorrhage (PVH-IVH): 1. Preterm infants (GA<32weeks, VLBW) are high risk baby. 2. Incidence in preterm infant: 40-50% Incidence in term infant: 2-3% 3. Occurrence of hemorrhage : 50% within 24hr 90% within 72hr.

Clinical manifestation PVH-IVH: according to ultrasound and CT scan, PVH-IVH be divided into 4 degrees Ⅰ: Subependymal hemorrhage Ⅱ: Intraventricular hemorrhage without enlarged cerebral ventricular Ⅲ: Intraventricular hemorrhage with enlarged cerebral ventricular Ⅳ : Intraventricular hemorrhage with intraparenchymal hemorrhage

PVH-IVH Ⅰ Ⅱ Ⅲ Ⅳ

Subependymal hemorrhage ultrasound Subependymal hemorrhage

ultrasound Intraventricular hemorrhage without enlarged cerebral ventricular

ultrasound Intraventricular hemorrhage with enlarged cerebral ventricular

ultrasound Intraventricular hemorrhage with intraparenchymal hemorrhage

Clinical manifestation Primary subarachnoid hemorrhage (SAH) Very common, especially in preterm infants. Position: subarachnoid space Reason: relevant with hypoxia, acidosis and birth trauma. Blood effusion from capillary of subarachnoid space, no damage of vein, the amount of hemorrhage is small. Typical manifestation: convulsion at 2ndday, normal between convulsion. Majority no symptoms, prognosis is good. Rarely die

Clinical manifestation Intraparenchymal hemorrhage (IPH) Veinlet thromb is the most common reason Symptoms are different for different position and amount of hemorrhage If hemorrhage of brain stem occurs, neonate presents change of pupils, irregular respiration, bradycardia Poor prognosis

Clinical manifestation Subdural hemorrhage（SDH） Most common ICH caused by birth trauma Most of neonates with SDH are macrosomia of term Incidence decrease with improved technology of obstetrics Onset early: <24h. Symptoms: convulsion, hemiparalysis, anorthopia, etc. severe cases may die.

Clinical manifestation Cerebellar hemorrhage (CH) Most cases are premature infants (GA < 32 weeks, VLBW) Severe case presents symptoms of brain stem Poor prognosis

Diagnosis History Symptoms & signs Radiological evidence: the basis of diagnosis.

Treatment General treatment: Keep quiet Maintain PaO2, PaCO2 and pH normal

Treatment Hemostasis vitamin K1 Reptilase (Hemocoagulase Dicynone

Treatment Control seizure Phenobarbital Diazepam 10%Chloral hydrate

Treatment Decreasing intracranial pressure Furosemide 20%Mannitol

Treatment Treatment of hydrocephalus acetazolamide: decrease produce of cerebrospinal fluid.

Prognosis Related to the severity of bleeding and locations. High mortality and instabilities.

Prevention Prenatal care Prevention of asphyxia & birth injury Improve level of doctor and nurse.