INTRACRANIAL HEMORRHAGE IN THE NEWBORN
Intracranial hemorrhage in the neonate is classified by location and in order of frequency as (1) periventricularintraventricular, (2) subarachnoid, (3) subdural, or (4) posterior fossa hemorrhage. All neonates should be followed closely for symptomatic anemia.
Periventricular-intraventricular hemorrhage (IVH) originates in the germinal matrix near the lateral ventricles and typically is observed in infants born preterm before 34 weeks’ gestation (Plate 1-12). In preterm infants, the inherent friability of the germinal matrix is often complicated by cardiopulmonary compromise during birth and physiologic stresses of adjusting to the extrauterine environment in the early neonatal period. Massive bleeding, now quite rare, precipitates a bulging fontanelle, respiratory difficulties, tonic posturing, seizures, anemia and, ultimately, multisystem failure. Minor bleeding detected with serial cranial ultrasonography is now more common. Some preterm infants will develop ventriculomegaly without cranial growth or elevated intracranial pressure, consistent with hydrocephalus ex vacuo from encephalomalacia. Approximately 15% of preterm infants with IVH will require surgical intervention for symptomatic hydrocephalus. Long-term neurologic deficits are common in preterm infants with IVH, including cerebral palsy, epilepsy, cognitive delay, and behavioral abnormalities. In full- term infants, IVH typically occurs secondary to deep central venous thrombosis, and approximately half of these infants will develop early or late hydrocephalus. Term infants with IVH are also prone to chronic neurologic deficits, including epilepsy, cognitive delay, and behavioral abnormalities.
Subarachnoid hemorrhage may be caused by asphyxia or by forces of normal delivery. In full-term infants, it may be asymptomatic or associated with focal or generalized seizures, with no focal deficits. Subdural hemorrhage results from tears in the falx cerebri and tentorium, rupture of bridging veins over the hemispheres, or occipital osteodiastasis in breech delivery. Causes include excessive molding forces during delivery, the infant’s size, and difficult extractions. Symptoms are acute or subacute hemiparesis, focal seizures, and ipsilateral pupillary abnormalities. Surgical drainage is the appropriate treatment in select cases. Cranial ultrasonography rarely provides adequate information, and either a rapid computed tomography (CT) or MRI scan is needed for management decisions.
Posterior fossa hemorrhage can result from tentorial trauma or occipital osteodiastasis. Either a rapid CT or MRI scan is needed for management decisions; cranial ultrasonography does not provide adequate imaging to assess the mass effect of the hematoma. Surgical drainage is rarely indicated.