Long-term outcomes of very low birth weight infants with intraventricular hemorrhage: a nationwide population study from 2011 to 2019

BACKGROUND

Advancements in neonatal care have increased preterm infant survival but paradoxically raised intraventricular hemorrhage (IVH) rates. This study explores IVH prevalence and long-term outcomes of very low birth weight (VLBW) infants in Korea over a decade.

METHODS

Using Korean National Health Insurance data (NHIS, 2010-2019), we identified 3372 VLBW infants with IVH among 4,129,808 live births. Health-related claims data, encompassing diagnostic codes, diagnostic test costs, and administered procedures were sourced from the NHIS database. The results of the developmental assessments  are categorized into four groups based on standard deviation (SD) scores. Neonatal characteristics and complications were compared among the groups. Logistic regression models were employed to identify significant changes in the incidence of complications and to calculate odds ratios with corresponding 95% confidence intervals for each risk factor associated with mortality and morbidity in IVH. Long-term growth and development were compared between the two groups (years 2010-2013 and 2014-2017).

RESULTS

IVH prevalence was 12% in VLBW and 16% in extremely low birth weight (ELBW) infants. Over the past decade, IVH rates increased significantly in ELBW infants (P = 0.0113), while mortality decreased (P = 0.0225). Major improvements in certain neurodevelopmental outcomes and reductions in early morbidities have been observed among VLBW infants with IVH. Ten percent of the population received surgical treatments such as external ventricular drainage (EVD) or a ventriculoperitoneal (VP) shunt, with the choice of treatment methods remaining consistent over time. The IVH with surgical intervention group exhibited higher incidences of delayed development, cerebral palsy, seizure disorder, and growth failure (height, weight, and head circumference) up to 72 months of age (P < 0.0001). Surgical treatments were also significantly associated with abnormal developmental screening test results.

CONCLUSIONS

The neurodevelopmental outcomes of infants with IVH, especially those subjected to surgical treatments, continue to be a matter of concern. It is imperative to prioritize specialized care for patients receiving surgical treatments and closely monitor their growth and development after discharge to improve developmental prognosis. Supplementary file2 (MP4 77987 kb).

Cyclic Thrombocytopenia in the Setting of Intracranial Hemorrhage: A Diagnostic and Therapeutic Challenge

Cyclic thrombocytopenia (CTP) as the name suggests presents with cyclic episodes of thrombocytopenia and is frequently initially misdiagnosed as immune thrombocytopenia. Following a lack of sustained response or abnormally increased response to common treatments used for immune thrombocytopenia, a proper diagnosis of CTP can then be made. Prior reports have shown a subset of patients who respond to cyclosporin A. Here, we present a case of CTP that was initially at another facility presumed to have and treated for immune thrombocytopenic purpura. However, after multiple attempts to treat with steroids, intravenous immunoglobulin (IVIG), rituximab, and eltrombopag, episodes of severe thrombocytopenia followed by thrombocytosis continued. The patient ultimately developed intracerebral hemorrhage (ICH) in the setting of one of the episodes of severe thrombocytopenia and developed multiple subsequent complications from which the patient unfortunately did not recover. It was only after developing ICH that the patient had been evaluated at a center with hematology consultation capabilities, at which time after a detailed review of his case and pattern recognition the proper diagnosis of CTP was made with initiation of cyclosporine. This case was further complicated by need to maintain an adequate platelet threshold post-ventriculoperitoneal shunt placement which was necessary due to his ICH and was placed before diagnosis of CTP could be made. While CTP is a rare diagnosis, this case reinforces a greater need to properly diagnose and consider cyclosporine treatment for CTP, as it has been effective in some patients and may help to prevent patient morbidity and especially catastrophic bleeding complications.

Long-term Tractography Evaluation of Corpus Callosum Impairment After Severe Traumatic Brain Injury in Patients With Isolated Intraventricular Hemorrhage on Admission CT: Two Illustrative Cases and a Literature Review

Severe traumatic brain injury (TBI) is often associated with diffuse axonal injury. Diffuse axonal injury affecting the corpus callosum may present with intraventricular hemorrhage on baseline computed tomography (CT) scan. Posttraumatic corpus callosum damage is a chronic condition that can be diagnosed over the long term using various magnetic resonance imaging (MRI) sequences. Here, we present two cases of severe survivors of TBI with isolated intraventricular hemorrhage detected on an initial CT scan. After acute trauma management, long-term follow-up was performed. Diffusion tensor imaging and subsequent tractography revealed a significant decrease in the fractional anisotropy values and the number of corpus callosum fibers compared with those in healthy control patients. This study presents a possible correlation between traumatic intraventricular hemorrhage on admission CT and long-term corpus callosum impairment detected on MRI in patients with severe head injury by presenting demonstrative cases and conducting a literature review.

Stem cells for neonatal brain injury - Lessons from the bench

Neonatal brain injury resulting from various intractable disorders including intraventricular hemorrhage and hypoxic ischemic encephalopathy still remains a major cause of mortality and morbidities with few effective treatments. Recent preclinical research results showing the pleiotropic neuroprotective effects of stem cell therapy, specifically mesenchymal stem cells (MSCs), suggest that MSCs transplantation might be a promising new therapeutic modality for neuroprotection against the currently intractable and devastating neonatal brain injury with complex multifactorial etiology. This review summarizes recent advances in preclinical stem cell research for treating neonatal brain injury with a focus on the important issues including the mechanism of neuroprotection, and determining the ideal cell source, route, timing and dose of MSCs transplantation.

The Long-Term Outcome and Rehabilitative Approach of Intraventricular Hemorrhage at Preterm Birth

Technological advances in neonatology led to the improvement of the survival rate in preterm babies with very low birth weights. However, intraventricular hemorrhage (IVH) has been one of the major complications of prematurity. IVH is relevant to neurodevelopmental disorders, such as cerebral palsy, language and cognitive impairments, and neurosensory and psychiatric problems, especially when combined with brain parenchymal injuries. Additionally, severe IVH requiring shunt insertion is associated with a higher risk of adverse neurodevelopmental outcomes. Multidisciplinary and longitudinal rehabilitation should be provided for these children based on the patients' life cycles. During the infantile period, it is essential to detect high-risk infants based on neuromotor examinations and provide early intervention as soon as possible. As babies grow up, close monitoring of language and cognitive development is needed. Moreover, providing continuous rehabilitation with task-specific and intensive repetitive training could improve functional outcomes in children with mild-to-moderate disabilities. After school age, maintaining the level of physical activity and managing complications are also needed.

Intracranial hemorrhage and Covid-19: A retrospective analysis of 1675 hospitalized Covid-19 Brazilian patients

Background

The present study seeks to overcome the lack of data on Covid-19 associated intracranial hemorrhage (ICH) in Brazil.

Methods

This is a retrospective, single-center case series of consecutive patients. It is a subanalysis of a larger study still in progress, which covers all neurological manifestations that occurred in patients admitted between March 1st, 2020 and June 1st, 2022, with active SARS-CoV-2 infection confirmed by polymerase chain reaction test. All patients with non-traumatic ICH were included.

Results

A total of 1675 patients were evaluated: 917 (54.75 %) had one or more neurological symptoms and 19 had non-traumatic ICH, comprising an incidence of 1.13 %. All patients had one or more risk factors for ICH. The presence of neurological manifestations before the ICH and ICU admission showed a statistically significant relationship with the occurrence of ICH (X² = 6.734, p = 0.0095; OR = 4.47; CI = 1.3-15.4; and FET = 9.13; p = <0.001; OR = 9.15; CI = 3.27-25.5 respectively).

Discussion and conclusion

Our findings were largely congruent with the world literature. We believe that the assessment of risk factors can accurately predict the subgroup of patients at increased risk of ICH, but further studies are needed to confirm these hypotheses.

Moderate-Severe White Matter Lesion Predicts Delayed Intraventricular Hemorrhage in Intracerebral Hemorrhage

BACKGROUND

Most existing studies have focused on the correlation between white matter lesion (WML) and baseline intraventricular hemorrhage (IVH) in patients with intracerebral hemorrhage (ICH), whereas few studies have investigated the relationship between WML severity and delayed IVH after admission. This study aimed to investigate the correlation between WML severity and delayed IVH and to verify the association between WML and baseline IVH.

METHODS

A total of 480 patients with spontaneous ICH from February 2018 to October 2020 were selected. WML was scored using the Van Swieten Scale, with scores of 0-2 representing nonslight WML and scores of 3-4 representing moderate-severe WML. We determined the presence of IVH on baseline (< 6 h) and follow-up computed tomography (< 72 h) images. Univariate analysis and multiple logistic regression were used to analyze the influencing factors of baseline and delayed IVH.

RESULTS

Among 480 patients with ICH, 172 (35.8%) had baseline IVH, and there was a higher proportion of moderate-severe WML in patients with baseline IVH (20.3%) than in those without baseline IVH (12.7%) (P = 0.025). Among 308 patients without baseline IVH, delayed IVH was found in 40 patients (12.9%), whose proportion of moderate-severe WML (25.0%) was higher than that in patients without delayed IVH (10.8%) (P = 0.012). Multiple logistic regression results showed that moderate-severe WML was independently correlated with baseline IVH (P = 0.006, odds ratio = 2.266, 95% confidence interval = 1.270-4.042) and delayed IVH (P = 0.002, odds ratio = 7.009, 95% confidence interval = 12.086-23.552).

CONCLUSIONS

Moderate-severe WML was an independent risk factor for delayed IVH as well as baseline IVH.

Severe haemophilia a in a preterm girl with turner syndrome - a case report from the prenatal period to early infancy (part I)

BACKGROUND

Bleedings are more frequent in the population of preterm children than among those born at term, much less in older children. The reasons for such bleedings in preterms include plasma factor deficiencies, immaturity of small vessels in the germinal matrix region, prenatal hypoxia or sepsis. They affect the brain tissue, the gastrointestinal tract and the respiratory system, or are manifested by prolonged bleedings from injection sites. Haemophilia is a rare cause of haemorrhages in the neonatal period, and in the female population it is even seen as an extremely rare disorder. Its aetiology in girls is diverse: inheriting defective genes from their parents, skewed X inactivation or a single X chromosome.

CASE PRESENTATION

The article presents a case of a preterm girl born in the 28th week of pregnancy, who was diagnosed with severe haemophilia A stemming from the absence of the X chromosome. The girl's father is healthy, but her mother's brother suffers from haemophilia. On the second day of the child's life, a prolonged bleeding from the injection site was observed. A coagulation profile revealed prolonged APTT which pointed to haemophilia A diagnosis. Moreover, a marked clinical dysmorphy, female sex and a negative family history on the father's side led the treating team to extend the diagnostic procedures to encompass karyotype evaluation. The girl was diagnosed with Turner syndrome. No bleeding to the central nervous system was observed during her hospital stay.

CONCLUSIONS

Preterm children belong to the risk group of bleeding into the central nervous system or haemorrhages in the course of sepsis. Rare causes of such bleedings should also be borne in mind, including haemophilia. The initial symptoms of haemophilia in preterm children occur in the first days of their lives, which is connected with a number of invasive procedures required in that period. Genetic conditions may coexist with one another. Arriving at one diagnosis does not mean one should abandon further diagnostic procedures in cases where additional atypical symptoms are present which do not match the clinical image of a primary disease.

GENDER DIFFERENCES IN NEURODEVELOPMENTAL OUTCOMES AMONG FULL-TERM INFANTS WITH INTRAVENTRICULAR HEMORRHAGE

Intraventricular hemorrhage (IVH) is usually associated with premature infants; however, it has been estimated to occur in up to 5% of infants born at term and may be associated with different prenatal, perinatal and postnatal risk factors. The present retrospective study included toddlers aged 13-24 months, born at term (≥36 weeks), referred to the Department of Rheumatology, Physical Medicine and Rehabilitation in Zagreb, Croatia, because they had at least two risk factors for neurodevelopmental delay. A total of 63 patients without hemorrhage were control subjects, while 103 case patients were children with IVH. The ordinal logistic regression revealed that neurodevelopmental outcome in term infants was associated with IVH grade (p<0.05). Although more boys than girls suffered from severe IVH (grades III and IV), there were no statistically significant gender differences in the distribution of IVH or in neurodevelopmental outcomes (p>0.05).

The vitamin D level in umbilical cord blood in premature infants with or without intra-ventricular hemorrhage: A cross-sectional study

BACKGROUND

Intra-ventricular hemorrhage (IVH) is acute cerebral complications of premature infants which may lead to the long-term problems.

OBJECTIVE

According to the role of vitamin D in the stability of the blood vessels, the present study was carried out in order to compare the vitamin D level in the premature infants with or without IVH.

MATERIALS AND METHODS

This cross-sectional study was carried out on 180 premature infants in the Ghaem Hospital, Mashhad, Iran 97 infants without IVH (53.9%) and 83 with IVH (46.1%) through convenience sampling technique in 2015-2017. Serum vitamin D level of funiculus in the two groups was compared. A researcher made questionnaire was used which includes infants' personal and laboratory information; and their mother's information.

RESULTS

Seventy nine percent of infants suffered from vitamin D deficiency in which 33.9% had a severe deficiency (less than 10 ng/ml), 30% moderate deficiency (10.1-20 ng/ml), 15% slight deficiency (20.1-30 ng/ml) and 21.1% had normal vitamin D (>30.1 ng/ml). Vitamin D mean±SD of infants in the control group, 23.71±12.98 ng/ml and case group 15.92±10.27 ng/ml (p<0.001). In total 92.8% of infants with IVH had levels of vitamin D below30 ng/ml, while this rate was 67% in infants without IVH.

CONCLUSION

Vitamin D deficiency in the premature infants is very common. Also, the serum vitamin D level in infants with IVH was less than infants without IVH. Therefore, the recommendation of vitamin D may be effective in the prevention of neonatal IVH.