Intracranial hemorrhage, or bleeding in the brain, is a rare complication of traumatic birth, but one that can have life-long consequences. Thankfully, most infants who experience brain bleeding early in life will recover from their injuries, despite the trauma sustained during labor and delivery.
But not all prognoses are so favorable. Among other risks, brain bleeds in infants can severely damage a child’s brain cells, leading to cognitive and motor function impairment. In severe cases, a drastic decrease in vital blood circulation can prove fatal.
Intracranial Hemorrhage In Babies
Intracranial hemorrhage is a broad term used to describe bleeding that occurs inside the skull. When bleeding is found around or inside the brain, a more specific term, cerebral hemorrhage, is used.
Hematoma is a word you’ll often see used as a synonym for hemorrhage, although the two conditions are slightly different. Hemorrhage refers to bleeding in general, any time blood escapes from the circulatory system. Hematoma, on the other hand, is a collection of blood outside the circulatory system. Hemorrhage leads to hematoma, but not in all cases.
Brain bleeds are classified by where they occur:
- epidural hematoma – bleeding between the skull and the dura mater, the first of several membranes surrounding the brain
- subdural hematoma – bleeding between the brain and the dura mater
- subarachnoid hemorrhage – bleeding between the brain and the pia mater, a thin layer of tissues closest to brain tissue
- intraparenchymal hemorrhage – bleeding inside brain tissue itself
- intraventricular hemorrhage – bleeding inside the ventricles, channels within the brain that produce cerebrospinal fluid
Intracranial hemorrhage is particularly common in babies with a low-birth weight and premature babies, who have blood vessels that haven’t fully developed yet.
Infant Brain Bleed Causes
Many newborns experience some form of brain bleeding after birth, even after normal vaginal deliveries. In the vast majority of cases, blood vessels will heal in time, the bleeding will stop and the child will continue to develop normally.
Severe bleeding events, however, can lead to life-long disabilities, including neurological impairment and developmental delay. These serious forms of brain bleeding are more likely to be caused by mechanical head trauma. Assisted deliveries are a particular risk and doctors must use incredible care with forceps or vacuum extractors to prevent serious harm.
While severe brain bleeding in newborns is relatively rare, mechanical trauma is surprisingly common. Every year, an estimated 32,000 newborns sustain birth injuries due solely to physical trauma, according to Medscape. Researchers continue to debate the causal factors associated with birth injury, but some experts believe that at least half of these traumatic injuries are potentially avoidable.
Subgaleal Hemorrhage In Newborn
While rare, subgaleal hemorrhage (or hematoma) is a serious form of brain bleeding usually diagnosed in infants. The vast majority of cases occur during assisted deliveries, according to Seattle Children’s Hospital. In fact, nearly 90% of subgaleal hemorrhages are linked to the use of vacuum extractors, delicate instruments that can easily burst blood vessels inside a newborn’s fragile head.
- 4 in 10,000 vaginal births
- 59 in 10,000 vacuum-assisted births
Subgaleal hemorrhage can be fatal. One in four babies transferred to the NICU for treatment of subgaleal hemorrhage will die, according to researchers in the Canadian Medical Association Journal.
What Is Subgaleal Hemorrhage?
Subgaleal hemhorrage is bleeding that fills the “potential space” between two membranes that surround the skull:
- aponeurosis – a tough layer of interwoven fibers just below the skin
- periosteum – a dense network of connective tissue below the aponeurosis
Normally, these two layers of tissue are pressed tightly together. After head trauma, however, burst blood vessels can begin to fill this “potential space,” creating an actual one. Seeping blood pushes the tissues apart and creates a cavity that stretches from the edge of an infant’s eye socket to the nape of their neck. The subgaleal space can hold up to 260 milliliters of blood. At 7.5 pounds, the average newborn only has around 272 mL of blood to begin with.
Hypovolemic shock is a common result, as an infant’s blood supply is rerouted from vital organs. Blood flow drops precipitously, depriving organs and body tissues of oxygen and nutrients. Permanent organ damage is a possibility, and doctors pay particularly close attention for the development of hypoxic-ischemic encephalopathy, a form of brain damage caused by oxygen deprivation.
Signs & Symptoms Of Subgaleal Hemorrhage
The signs of subgaleal hemorrhage normally appear between 12 and 72 hours after a child’s delivery. Bruising on the outside of an infant’s head is accompanied by the growth of a “boggy,” or spongy feeling, mass on the scalp. In severe cases, doctors may notice an actual “wave” effect inside a child’s head, as the blood moves backward and forward under the skin.
Another common symptom occurs when blood from the skull seeps downward to fill soft tissue around the eyes, leading to a characteristic condition known as “raccoon eyes.”
Subgaleal Hemorrhage Treatment
Treating subgaleal hemorrhage is difficult, and noticing early signs of the condition critical. Within the first 48 hours after delivery, doctors may do nothing more than monitor a child’s progress, measuring vital signs and head circumference regularly. Once a diagnosis has been confirmed, treatment has four primary goals:
- replace the infant’s total blood volume
- improve the infant’s blood clotting ability
- treat symptoms of shock
- monitor and treat potential brain damage
Doctors will quickly attempt to stop the bleeding, often by administering blood clotting factors intravenously and replacing blood that has already been lost in the circulatory system. At the same time, physicians should closely monitor the effects the hemorrhage has had on brain tissue. Neurosurgeons may be called in to provide expert advice on the results of CT scans. As with most types of brain bleeding, infants who experience subgaleal hemorrhage are at an increased risk of developing seizures, abnormal discharges of electrical activity that can lead to further brain damage. Medications are usually prescribed to prevent seizures.
Intraventricular Hemorrhage In Infants
Intraventricular hemorrhage (IVH) is a form of bleeding deep within the brain, inside a group of fluid-filled cavities called ventricles. The condition is common among premature babies – so common that the US National Library of Medicine believes every child born before 30 weeks should be given an ultrasound exam to check for warning signs.
Bleeding within the ventricles places significant pressure on brain tissue, which can lead to cellular death. Even minor IVH can lead to permanent brain damage and neurological complications. Intraventricular hemorrhage events are graded on a scale of severity from one to four, but even low-grade hemorrhages can have long-term consequences. Severe cases frequently lead to developmental delays and movement disorders.
Symptoms & Signs Of Intraventricular Hemorrhage
Most children aren’t born with intraventricular hemorrhage, but develop the condition within the first few days of life. While bleeding inside the ventricles can happen without causing any symptoms, possible signs include:
- short pauses in breathing
- impaired reflexes
- excessive sleeping
- weak sucking
Once diagnosed, usually through a CT scan, intraventricular hemorrhage is a medical emergency. Although minor bleeds can heal of their own accord, severe cases require rigorous blood pressure monitoring and surgical intervention.