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Intracranial Hemorrhage - Types

In a newborn, one of five different types of intracranial hemorrhage (ICH) may be seen. Proper medical care has decreased death rates of infants in cases of a traumatic delivery. An accurate diagnosis is useful as well, and knowing the exact type of bleed helps physicians determine the appropriate course of treatment.

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The types of ICH include:

Subdural Hemorrhage: Blood collects between the brain and the tissues surrounding it. There are numerous veins in this region and are easily injured by trauma to an infant’s head. If there’s evidence of a skull fracture, this type of bleeding is a possibility. Neuroimaging is more often performed on newborns, allowing for this condition to be found more often, researchers contributing to The Lancet reported. In 111 babies studied, nine presented with signs of bleeding in an MRI, but did not require medical intervention. According to Intracranial Hemorrhage in the Newborn, this is the most common type among term newborns showing no symptoms.

Primary Subarachnoid Hemorrhage: This is a collection of venous blood in the region where cerebrospinal fluid is found. It is within a space located between the arachnoid membrane and the innermost of the meninges, or tissue layers surrounding the brain called the pia mater. A dilated pupil on the same side as the bleed is a symptom, as are seizures and partial paralysis. The bleeding is caused by head trauma and is a sign of shaken baby syndrome. Seizures are likely to occur within 48 hours of birth. Common signs include a baby that seems lethargic and looks as if it has a stiff neck.

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Cerebellar Hemorrhage: Not an uncommon occurrence in babies born preterm, according to The Journal of Pediatrics, this type comes with a high risk of neurological impairment and mortality. Research has found this condition occurs more frequently than thought before MRI scans were used to detect even smaller hemorrhages. It is especially common in preterm babies with an extremely low birth weight. Blood collects within the brain tissues, putting pressure on fragile structures in addition to possibly starving areas of oxygen.

Intraventricular Hemorrhage: Inside the brain, there are fluid-filled ventricles. Bleeding can occur into these areas, which especially affects premature infants because the blood vessels in this region are not fully developed. These vessels strengthen during the last ten weeks of gestation, according to the National Institutes of Health. It is most common among preterm babies with respiratory distress, unstable blood pressure, and a variety of other medical conditions. Symptoms include pauses in breathing, abnormal heart rate/blood pressure, decreased reflexes and muscle tone, lethargy, seizures, and weak sucking reflexes. The first two grades of IVH include smaller bleeds, often with no long-term effects. Grades 3 and 4 are more severe, with direct involvement of brain tissue.

Intraparenchymal Hemorrhage: The highest grade of IVH, it can form blood clots in the cerebrospinal fluid, blocking the normal flow. Fluid can build up in the brain, which is a condition called hydrocephalus. A Neuroradiology study found this to be more common in term infants. Although ICH in cases where parenchymal tissues are involved carries a mortality rate of around 24.5 percent, and development of cerebral palsy (CP) in 8.6 percent of cases, in the study, those without CP who survived (over 88 percent) had normal signs of early neurological development.

Another common term in this field is periventricular-intraventricular hemorrhage (PVH-IVH). A PHV occurs near the lateral ventricle, also called the germinal matrix. Its formation is complex and not fully understood, but sonograms can identify the signs of bleeding even if the lateral ventricles haven’t enlarged. The condition can, therefore, be identified before any visible changes in the baby’s head happen. In most cases, it occurs during the first week after birth, but late-onset cases can be discovered as long as a month into life.

An enlarged head circumference is a sign of post hemorrhagic hydrocephalus. Ventricles may start to change days or weeks before there are visible changes. The prognoses for those with hydrocephalus is poor compared to other types of intracranial hemorrhages. Outcomes depend on the exact type of bleed, its size, and the area of the brain affected.