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# Intraventricular haemorrhage of prematurity

Bleeding inside the brain's fluid spaces in babies born very early, usually in the first days of life. Severe bleeds can cause hydrocephalus.

Updated 2026-11-01

## Structures involved

Tap one to see what it is and open it in 3D.

- [Lateral ventricles](https://durgical.com/en/anatomy/lateral-ventricle/)
- [Caudate nucleus](https://durgical.com/en/anatomy/caudate-nucleus/)
- [Choroid plexus](https://durgical.com/en/anatomy/choroid-plexus/)
- [Third ventricle](https://durgical.com/en/anatomy/third-ventricle/)
- [Cerebral aqueduct](https://durgical.com/en/anatomy/aqueduct-of-midbrain/)
- [Fourth ventricle](https://durgical.com/en/anatomy/fourth-ventricle/)
- [White matter](https://durgical.com/en/anatomy/white-matter-of-telencephalon/)
- [Thalamus](https://durgical.com/en/anatomy/thalamus/)

## Why it happens

- [Hemorrhage: petechiae, purpura, ecchymosis, hematoma, and what blood loss does](https://durgical.com/en/general-pathology/hemorrhage-petechiae-purpura-ecchymosis-hematoma-and-what-blood-loss-does/)
- [Prematurity and fetal growth restriction](https://durgical.com/en/general-pathology/prematurity-and-fetal-growth-restriction/)
- [Neonatal respiratory distress syndrome: surfactant and hyaline membranes](https://durgical.com/en/general-pathology/neonatal-respiratory-distress-syndrome-surfactant-and-hyaline-membranes/)
- [Cerebral blood flow, brain metabolism and intracranial pressure](https://durgical.com/en/physiology/cerebral-blood-flow-brain-metabolism-and-intracranial-pressure/)

## What it is

Bleeding that starts in the germinal matrix, a fragile vascular zone next to the [lateral ventricles](https://durgical.com/en/anatomy/lateral-ventricle/) over the [caudate nucleus](https://durgical.com/en/anatomy/caudate-nucleus/), and may spread into the ventricles or brain tissue. It mainly affects babies born before 32 weeks, most often in the first 72 hours of life.

## Who gets it

Frequency is inversely related to gestational age; it is most common in extremely preterm and very low birth weight infants. It remains a key cause of neurological disability among preterm survivors in Latin American neonatal units.

## Causes

- Rupture of fragile germinal matrix capillaries
- Fluctuating cerebral blood flow with impaired autoregulation
- Venous congestion and raised venous pressure

## Risk factors

- Gestational age under 32 weeks and very low birth weight
- No antenatal corticosteroids
- Respiratory distress syndrome, mechanical ventilation and pneumothorax
- Hypotension or rapid fluid boluses, hypercapnia and acidosis
- Perinatal hypoxia, sepsis and coagulopathy
- Outborn birth and transport

## Pathophysiology

The germinal matrix is richly vascular but has thin-walled vessels with poor support, and the preterm brain cannot keep flow steady when blood pressure swings. Bleeding begins in the subependymal matrix and may enter the ventricles; a large clot can block venous drainage and cause periventricular hemorrhagic infarction, and blood products can obstruct CSF flow and cause post-hemorrhagic hydrocephalus.

## Classification

- Grade I: germinal matrix hemorrhage only
- Grade II: blood in the ventricles without dilation
- Grade III: intraventricular blood with ventricular dilation
- Grade IV (periventricular hemorrhagic infarction): bleeding into the adjacent brain tissue

## Symptoms and signs

- Often silent; found on routine cranial ultrasound
- Apnea and bradycardia
- Hypotonia, decreased activity and poor suck
- Pallor and an unexplained fall in hematocrit
- Seizures in larger bleeds

## Red flags

- Sudden deterioration with a bulging fontanelle, hypotension and falling hematocrit (catastrophic bleed)
- Seizures
- Rapidly increasing head circumference or splayed sutures (hydrocephalus)
- Persistent apnea

## Diagnosis

**Clinical**
Suspected in a very preterm infant with sudden instability; most cases are found by screening.

**Tests**
Hemoglobin and hematocrit, platelets and coagulation tests, blood gases and glucose.

**Imaging**
Cranial ultrasound through the anterior fontanelle is the test of choice for screening and grading, repeated over the first weeks; MRI near term-equivalent age assesses [white matter](https://durgical.com/en/anatomy/white-matter-of-telencephalon/) injury.

## Differential diagnosis

- Periventricular leukomalacia
- Hypoxic-ischemic encephalopathy
- Neonatal sepsis or meningitis
- Subdural or subarachnoid hemorrhage from birth trauma
- Congenital hydrocephalus

## Goal of treatment

Prevent bleeding and its extension by keeping blood flow and gas exchange stable, and detect and manage hydrocephalus early.

## Treatment

**Acute**
Supportive care: stable blood pressure and ventilation, avoiding swings in CO2, correcting coagulopathy and anemia, and gentle handling with the head in midline.

**Follow-up**
Serial cranial ultrasound and daily head circumference to detect progressive ventricular dilation.

**Procedure**
Temporary CSF drainage (lumbar or ventricular taps, a ventricular reservoir) for progressive post-hemorrhagic hydrocephalus.

**Surgical**
A ventriculoperitoneal shunt when hydrocephalus persists.

**Rehabilitation**
Early intervention programs, physiotherapy and neurodevelopmental follow-up.

## Complications

- Post-hemorrhagic hydrocephalus
- Periventricular hemorrhagic infarction
- Cerebral palsy, especially spastic diplegia or hemiplegia
- Cognitive delay and epilepsy
- Death in severe bleeds

## Prognosis

Grade I–II bleeds usually have a good outcome. Grade III and periventricular infarction carry a high risk of hydrocephalus, cerebral palsy and death.

## Prevention

- Antenatal corticosteroids and birth in a center with a neonatal intensive care unit
- Delayed cord clamping
- Avoiding rapid fluid shifts and blood-pressure swings in the first days

## Test yourself

Think of the answer, then tap the question to see it.

## Where does intraventricular hemorrhage of prematurity originate?

In the germinal matrix, the fragile vascular zone beside the lateral ventricles over the caudate nucleus.

## Which test is used to screen and grade it?

Cranial ultrasound through the anterior fontanelle.

## When does most intraventricular hemorrhage occur?

In the first 72 hours after birth.

## What is the main late complication of grade III bleeds?

Post-hemorrhagic hydrocephalus, along with a high risk of cerebral palsy.

## Which antenatal measure lowers its risk?

Antenatal corticosteroids given to mothers at risk of preterm birth.

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## Related conditions

- [Prematurity and its complications](https://durgical.com/en/conditions/prematurity-and-its-complications/)
- [Hydrocephalus](https://durgical.com/en/conditions/hydrocephalus/)
- [Cerebral palsy](https://durgical.com/en/conditions/cerebral-palsy/)
- [Neonatal respiratory distress syndrome (hyaline membrane disease)](https://durgical.com/en/conditions/neonatal-respiratory-distress-syndrome/)
- [Perinatal asphyxia and hypoxic-ischaemic encephalopathy](https://durgical.com/en/conditions/perinatal-asphyxia-and-hypoxic-ischaemic-encephalopathy/)
- [Neonatal sepsis](https://durgical.com/en/conditions/neonatal-sepsis/)
- [Apnoea of prematurity](https://durgical.com/en/conditions/apnoea-of-prematurity/)

Educational information, not medical advice. For any symptom, see a health professional.

Sources: [Intraventricular hemorrhage of the newborn](https://medlineplus.gov/ency/article/007301.htm) (MedlinePlus Medical Encyclopedia (U.S. National Library of Medicine), 2025).

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Source: https://durgical.com/en/conditions/intraventricular-haemorrhage-of-prematurity/
License: CC BY 4.0 (https://creativecommons.org/licenses/by/4.0/). Cite as: DurgiPedia (durgical.com), https://durgical.com/en/conditions/intraventricular-haemorrhage-of-prematurity/