INTRACRANIAL HEMORRHAGE

Dr. Siti Lintang Kawuryan SpA(K)

Overview
The incidence: 2-30% depending on gestational age at birth and type of ICH Bleeding in the skull can occure:
External to the brain into the epidural, sudural,subarachnoid space. To the parenchyma of the cerebrum and cerebellum Into the ventricel from subependimalgerminal matrix or choroid plexus

Type ( location) of hemorrhage

1. Subdural and epidural hemorrhage 2. Subarachnoid hemorrhage 3. Intraparenchyma hemorrhage 1. Cerebral 2. cerebellar 4. Germinal matrix/ intraventricular hemorrhage

Subdural and epidural hemorrhage

Etiology and patogenesis:
Rupture of the draining veins and sinuses of the brain that occupy the subdural space Vertical molding(batas) Fronto-occipital elongation(pemanjangan)

Clinical manifestation:
Accumulation of blood- compression of brainstem -
Nuchal regidity / epistotonus Abnormal respiratory pattern Unreactive pupils Abnormal occular movements ICP Bulging fontanella and/or wide spilt suture

With large hemorrhage:

Hypovolemic Anemia

With small hemorrhage Seizure Subtle focal cerebral sign Disturbances of consiousness

Diagnosis
History Clinical sign Confirmed with CT scan Lumbar puncture ( if large LP should not be performed

Management and prognosis

Supportive treatment
Stabilisation with fluid repleacement Respiratory support

Treatment anticonvulsants drug

Subarachnoid hemorrhage
Etiology and patogenesis
Common from ICH Local trauma Cerebral contusion

Clinical manifestation
Blood loss Neurology disfunction
Seizure Irritabillity Alteration of mental status

Diagnosis
Seizure, irritability,lethargy, local neurologic sign CT scan

Management& prognosis:
Do not require surgical intervention, if the sign is progresive of braistem disfunction( coma,apnea,cranial nerve disfunction, epistotonus,bulging fontanelle) - open surgical evacuation of the blood clot Suportive care
Stabilization with volume replacement Respiratory support

Anticonvulsan Without sequelle

Subarachnoid hemorrhage
Etiology and pathogenesis
The source of bleeding is usually rupture veins of the subarachnoid space, leptomeningeal vessels Local trauma resulting venous compression / oclusion in setting of vaginal delivery

Clinical presentation
my result because of blood loss
Large enough to provoke catastropic result

neurologic dysfunction;
Seizure Irritability Alteration of mental status

Diagnosis
MRJ, CT LP

MANAGEMENT AND PROGNOSIS

Symptomatic therapy:
Anticonvulsan NGT feeds/ IV fluid if the infants is too lethargic to feed orally Most of them without squelae

INTRAPARECHYMAL HEMORRHAGE Etiology and Pathogenesis

Rupture of arteriovenous malformation or aneurysma Coagulation disturbance ( hemophilia, thrombocytopenia Preterm more common than term infants

Clinical presentation
Focal neurologic sign; seizure, hemiparesis, irritable, depressed level of consciousness

Diagnosis
CT / MRI lP to rule out infection

Management and prognosis

Small hemorrhage
Symptomatic Supportive

Large
Neurological intervention

Prognosis relates location and size of hemprrhage

Long seizure, hemiparesis,cerebral palsy,feeding difficulties, cognitive impairment ranging learning disabilities to mental retardation depending on the location

GERMINAL MATRIX / INTRAVENTRICULAR HEMORRHAGE Etiology and Pathogenesis

Incidense : 15-20% in infant born < 32 weeks, but uncommon in term Originates in the choroid plexus, thrombosis , infarction, trauma, asphyxia Fragil involuting vessels of subepidymal germinal matrix, located in the caudothalamic groove Risk factors; ischamia, reperfusion, increasescerebral blood flow, fluctuating, increasesin cerebral venous pressure

Clinical manifestation
Decrease level of consiousness Spontaneous movement Hypotonia Abnormal eyes movements, skew deviation

Diagnosis
CT / MRI

Management and prognosis

Prevention: improvement maternal and neonatal care
Glucocorticoid Vit K Infusion of colloid/ hyperosmolar should be given slowly Avoiding hypotension and large fluctuation , sustain increases increases cerebral blood pressure Sedative

Suportive care
Maintaning stable cerebral perfusion Maintaning normal blood pressure, circulating volume, electrolyte and blood gas Transfusion PRC my be requare in cases of large IVH to restore normal blood volume and hematocrit Thromocytopenia or coagulation disturbances should be corrected Anticonvulsant

Prognosis
Depending on the severity of IVH, complication, brain lessions