What is the management of neonatal intracranial hemorrhage?

Management of Neonatal Intracranial Hemorrhage

The management of neonatal intracranial hemorrhage requires a progressive approach starting with close monitoring and potentially escalating to neurosurgical intervention, with the primary goal of preventing neurological deterioration and improving long-term outcomes. 1, 2

Epidemiology and Risk Factors

• Intracranial hemorrhage (ICH) is most commonly diagnosed in preterm infants, affecting approximately 15-20% of infants weighing less than 1500g at birth 1
• In term neonates, subdural hemorrhage is the most common type (95.2%), often associated with traumatic delivery (47.6%) and perinatal asphyxia (50%) 3
• Risk factors include:
  • Prematurity
  • Low birth weight
  • Traumatic delivery
  • Coagulation disorders
  • Perinatal asphyxia
  • Genetic factors (Gly380Arg mutation associated with higher risk of ICH in factor X deficiency) 1

Pathophysiology

• Germinal matrix-intraventricular hemorrhage (GM-IVH) is the most commonly diagnosed brain lesion in preterm infants 1
• Posthemorrhagic ventricular dilation (PHVD) may develop as a consequence of IVH, which can be due to:
  • Hydrocephalus ex vacuo from encephalomalacia
  • Progressive posthemorrhagic hydrocephalus (PHH) with increased intracranial pressure 1
• Blood breakdown products and inflammatory mediators can impair CSF absorption through arachnoid granulations 1

Clinical Presentation

Neonatal ICH typically presents in one of three patterns:

1. Catastrophic deterioration: Rapid neurological decline over minutes to hours, similar to large intracranial hemorrhages in older patients
2. Saltatory course: Evolving over hours to days with decreased alertness, hypotonia, abnormal eye movements, and respiratory difficulties
3. Clinically silent: Often detected only through surveillance imaging 1

Signs of increased intracranial pressure may include:

• Increasing head circumference
• Full or bulging fontanel
• Splaying of cranial sutures (especially sagittal suture)
• Apnea, bradycardia
• Lethargy and decreased activity 1

Diagnosis

• Cranial ultrasonography: First-line bedside imaging modality for preterm infants 1

  • Levene ventricular index: Horizontal measurement from midline falx to lateral aspect of anterior horn
  • Ventricular index >97th percentile + 4mm often used as threshold for intervention

• CT scan: Gold standard for identifying acute hemorrhage in emergency settings 1, 2

  • Should be completed within 45 minutes of emergency department arrival

• MRI with gradient echo (GRE) and T2 susceptibility-weighted imaging*: Equally sensitive for acute blood detection and more sensitive for prior hemorrhage 2

Management

Initial Stabilization

1. Airway and Ventilation Support:

   • Secure airway if GCS ≤8 or deteriorating respiratory status
   • Monitor end-tidal CO2 to maintain appropriate PaCO2
   • Avoid hypercapnia or hypocapnia which can impact intracranial pressure 2

2. Blood Pressure Management:

   • Target systolic BP <140 mmHg within 6 hours of ICH onset
   • Maintain cerebral perfusion pressure (CPP) between 50-70 mmHg in patients with ICP monitoring 2

3. Coagulopathy Management:

   • Correct coagulopathy immediately by reversing anticoagulants when present
   • Prothrombin complex concentrate is preferred over fresh frozen plasma
   • Administer vitamin K in combination with reversal agents 2

Progressive Management Approach for PHH

Management of posthemorrhagic hydrocephalus follows a stepwise approach:

1. Observation and Monitoring:

   • Serial cranial ultrasonography
   • Head circumference measurements
   • Clinical assessment for signs of increased ICP

2. Temporary CSF Diversion:

   • Serial lumbar punctures
   • Ventricular access devices (ventricular reservoirs)
   • Ventriculosubgaleal shunts 1

3. Permanent CSF Diversion:

   • Ventriculoperitoneal (VP) shunting for persistent symptomatic hydrocephalus 1

Specific Management Based on Hemorrhage Type

1. For Intraventricular Hemorrhage with PHH:

   • Approximately 15% of preterm infants with severe IVH will require permanent CSF diversion 1
   • For factor X deficiency with intracranial hemorrhage, prothrombin complex concentrate (PCC) prophylaxis at 40-70 U/kg factor IX once or twice weekly has shown success 1
   • Activated PCC prophylaxis at 50 IU/kg twice weekly has been effective in preventing recurrent bleeding in severe factor X deficiency 1

2. For Cerebellar Hemorrhage:

   • Consider surgical evacuation with neurological deterioration or brainstem compression 2

3. For Subdural Hematoma:

   • Surgical evacuation for significant acute subdural hematomas with thickness >5mm and midline shift >5mm 2

4. For Hydrocephalus:

   • CSF diversion procedures as needed 2

Neurosurgical Interventions

Indications for neurosurgical intervention include:

1. ICP Monitoring: Indicated for GCS score ≤8, clinical evidence of transtentorial herniation, significant intraventricular hemorrhage, or hydrocephalus 2

2. Surgical Evacuation: Consider for:

   • Cerebellar hemorrhages with neurological deterioration or brainstem compression
   • Large hemispheric lesions with impending herniation
   • Hydrocephalus requiring CSF diversion 2

3. Decompressive Craniectomy: Indicated for patients with:

   • Coma
   • Large hematomas
   • Significant midline shift
   • Elevated ICP refractory to medical management 2

Rehabilitation and Follow-up

• All patients should have access to multidisciplinary rehabilitation 2
• Initial monitoring and management should take place in an ICU or dedicated stroke unit 2
• Formal screening for dysphagia should be performed before initiating oral intake 2
• Monitor glucose and avoid both hyperglycemia and hypoglycemia 2
• Treat clinical seizures with antiseizure drugs 2

Outcomes and Prognosis

• Preterm infants who develop PHH requiring surgical treatment remain at high risk for:

  • Cerebral palsy
  • Epilepsy
  • Cognitive and behavioral delays 1

• Poor prognostic factors include:

  • Larger hematoma volume
  • Lower initial GCS score
  • Presence of intraventricular hemorrhage
  • History of perinatal asphyxia (strongest predictor of poor outcome) 2, 3

• Better outcomes are observed in younger patients (<60 years) 2

Prevention Strategies

• Antenatal use of steroids in mothers at risk for preterm delivery 4
• Postnatal prophylactic use of surfactant in premature infants 4
• For neonates with severe factor X deficiency, cranial ultrasound scanning and prophylactic replacement therapy are recommended due to high risk of intracranial hemorrhage 1