Neurosurgical treatment for intracranial hemorrhage in neonates

Neurosurgical treatment of intracranial hemorrhage in neonates was discussed with a special emphasis on the difference between preterm low birth weight neonates and mature ones. Intracranial hemorrhage in neonates is observed in about 10 to 15% of the preterm low birth weight babies cared for in NICU. It develops more commonly in neonates with a less than 1,500 g birth weight. The periventricular germinal matrix layer (GML) develops in the fetus between 24 and 32 weeks' gestation. Because the GML involves not only a rich vascular supply but also hemodynamic weak points, it has been known as a bleeding source of subependymal or intraventricular hemorrhage observed in preterm low birth weight neonates. A poor general condition associated with an immature respiratory function and hemodynamic changes following the birth are also characteristics of the hemorrhage. Intracranial hemorrhage in neonates tends to be serious due to their fragile and immature vascular structure. Management of hydrocephalus following intraventricular hemorrhage in preterm low birth weight baby requires staged planning. It is important to note that less than 50% of neonates with ventriculomegaly following intraventricular hemorrhage develop hydrocephalus, which suggests that posthemorrhagic ventriculomegaly does not necessarily mean hydrocephalus. Once conservative treatment has failed, a ventriculo-subgaleal shunt or a cerebrospinal fluid reservoir is placed prior to the ventriculo-peritoneal (VP) shunt. The recommended body weight to install a VP shunt safely is 2,000 to 2,500 g depending on the institutional experience. The prevalence of intracranial hemorrhage in mature babies is regarded as much lower than that in preterm low birth weigt ones. In such cases, contrary to the preterm low birth weight baby, the mature baby often has a background pathology for hemorrhage and a detailed examination to locate the bleeding source and pathology are immperative before surgery. Pathological backgrounds known to cause intracranial hemorrhage in mature babies are organic disease (AVM and other vascular anomalies, angioma), coagulopathy such as hemophilia, vitamin K deficiency, and trauma (mainly birth trauma). Intracranial hemorrhage of unknown cause is not unusual. Surgical treatment for intracranial hemorrhage in neonates should be individualized based on the age, body weight and general condition. It should be remembered prior to surgery that different pathological backgrounds trigger intracranial hemorrhage in neonates with preterm low birth weight and in matured babies.