J Korean Neurosurg Soc.  2023 May;66(3):298-307. 10.3340/jkns.2023.0020.

Perspectives : Understanding the Pathophysiology of Intraventricular Hemorrhage in Preterm Infants and Considering of the Future Direction for Treatment

• Park YS

• KMID: 2542015
• DOI: http://doi.org/10.3340/jkns.2023.0020

Abstract

Remarkable advances in neonatal care have significantly improved the survival of extremely low birth weight infants in recent years. However, intraventricular hemorrhage (IVH) continues to be a major complication in preterm infants, leading to a high incidence of cerebral palsy and cognitive impairment. IVH is primarily caused by disruption of the fragile vascular network of the subependymal germinal matrix, and subsequent ventricular dilatation adversely affects the developing infant brain. Based on recent research, periventricular white matter injury is caused not only by ischemia and morphological distortion due to ventricular dilatation but also by free iron and inflammatory cytokines derived from hematoma and its lysates. The current guidelines for the treatment of posthemorrhagic hydrocephalus (PHH) in preterm infants do not provide strong recommendations, but initiating treatment intervention based on ultrasound measurement values before the appearance of clinical symptoms of PHH has been proposed. Moreover, in the past decade, therapeutic interventions that actively remove hematomas and lysates have been introduced. The era is moving beyond cerebrospinal fluid shunt toward therapeutic goals aimed at improving neurodevelopmental outcomes.

Keyword

Preterm infant; Intraventricular hemorrhage; Hydrocephalus; Brain inury; Future directions

Figure

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  Fig. 1. Typical views of neuroendoscopic surgery for post hemorrhagic hydrocephalus. A : Numerous hemosiderin deposits on the ventricular wall. B : Obstruction of the Sylvian aqueduct (arrow).

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  Fig. 2. A case of progressive ventricular dilatation after intraventricular hemorrhage (IVH). A female infant was born at 23 weeks 3 days of gestation and weighed 487 g. A : IVH occurred on day 4 of birth. B : Ultrasonography on postnatal day 14. Severe ventricular dilation developed during just 10 days. C : On day 20, the cerebral mantle became paper thin. The progressive accumulation of cerebrospinal fluid changed the shape of the lateral ventricles to balloon-like.

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  Fig. 3. Various ventricular measurements on ultrasonography. Ventricular index (VI) is the distance between the lateral wall of the anterior horn of the lateral ventricle and the falx cerebri in the coronal view at the level of the foramen of Monro, just anterior to the choroid plexus in the third ventricle. Anterior horn width (AHW) is the oblique width of the anterior horn of the lateral ventricle at the widest point in the coronal plane. Thalamo-occipital distance (TOD) is the distance between the external walls of the thalamus and lateral border of the occipital horn of the lateral ventricle in parasagittal plane. A : Coronal view. B : Sagittal view.

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  Fig. 4. A male infant was born at 23 weeks 4 days of gestation and weighed 501 g. Intraventricular hemorrhage occurred on day 3 of birth. Ultrasonography on postnatal day 8 revealed a ventricular index : 10.5 mm (right) and 12.9 mm (left), anterior horn width : 6.85 mm (right) and 7.64 mm (left). Neuroendoscopic surgery at this stage is dangerous and invasive. Other treatments need to be initiated to obtain favorable neurofunctional outcomes.

Reference

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