Neurology | Germinal Matrix and Intraventricular Hemorrhage

0:00Hi everyone, welcome back to the Met Bullets Step 2 and 3 podcast. In today's episode, we covered the topic of German Matrix and Interventricular Hemorrhage found under the neurology section at Met Bullets.com. Let's begin with a clinical snapshot. A two-day-old girl presents for multiple seizure episodes and is admitted to the neonatal intensive care unit. She was born to a 23-year-old woman at 29-weeks gestation via spontaneous vaginal delivery. On physical exam, there is altered consciousness, hypotonia, a bulging anterior fontanel, decreased spontaneous movement, and cyanosis. Craneal ultrasound biography demonstrates a German matrix and interventricular hemorrhage. This continue with an introduction to German matrix and interventricular hemorrhage. This is defined as hemorrhage within the German matrix and or ventricles.

1:01Risk factors include prematurity, which is defined as being born before 37-weeks of gestation. Extremely premature infants born at 28 weeks or before are at greatest risk. Another risk factor is low birth weight, defined as less than 1,500 grams. In terms of the pathogenesis, remember that prematurity does not provide adequate structural support for the German matrix. This increases the risk of the German matrix hemorrhaging. Moving on to the presentation. Symptoms may include seizures and altered consciousness. On exam, one may note hypotonia decreased or absent spontaneously or elicited movement, a bulging anterior fontanel and systemic hypotension. In terms of further imaging, cranial ultrasound biography is indicated as the initial imaging modality of choice. With regards to the differential, make sure to think about peri-ventricular locomolation, with differentiating factors being that peri-ventricular white matter echo density and white

2:03matter cyst will be seen on imaging. In terms of treatment, medical options include phenobarbital. This is used in the treatment of seizures and newborns. And lastly, complications related to germinal matrix and intraventricular hemorrhage include cerebral palsy, cognitive impairment, and neurodevelopmental delay. Now that we've discussed the major points relating to germinal matrix and intraventricular hemorrhage, let's walk through a question to apply what we've learned and get a sense of how the topic might be tested. For this question, consider the following clinical scenario. A three-day-old boy has admitted to the neonatal intensive care unit for seizures. He was born to a 33-year-old woman at 31-weeks gestation via cesarean section. His birth weight was 1400 grams. Vital signs are significant for systemic hypotension, bradycardia, and hypoventilation. On physical exam, the patient has an altered level of consciousness with decreased spontaneous

3:06and elicited movements. The patient is hypotonic on motor testing, has bulging anterior fontnel, and appear cyanotic. Which of the following is the best-next step in management? And the answer choices are choice one, complete blood count. Choice two, cranial ultrasonography. Choice three, electroencephalography. Choice four, head CT, or choice five, MRI of the head. The best answer to this question is choice two, cranial ultrasonography. This newborn seizures, cardiorespiratory failure, abnormal neurological exam, and bulging fontnel in the setting of prematurity is concerning for an intraventricular hemorrhage. Original ultrasonography is the best initial step in management. Prematurity does not provide adequate structural support of the germinal matrix, a highly vascular area where brain cells originate and migrate out from during brain development.

4:11The germinal matrix is found on the non-ventricular side of the appendama, which is the ventricular lining. An underdeveloped germinal matrix is very fragile and is vulnerable to hemorrhaging and may rupture through the appendama into the ventricles, resulting in an intraventricular hemorrhage. Given its high sensitivity, cranial ultrasonography is the imaging modality of choice for diagnosing IVH. Cranial ultrasonography also does not use radiation to generate imaging and is accessible to perform at the bedside. Let's also discuss why the other choices are incorrect. Choice one, complete blood count may demonstrate a decreased hemoglobin in hematocrit, secondary to the intracranial bleed. However, it is vital to determine the underlying cause of this patient's symptoms. Choice three, electroencephalography may capture epileptic form discharge given this patient seizures. However, his seizures are a symptom of his IVH. Thus, a cranial ultrasonogram is needed to determine its presence.

5:14Choice four, head CT can demonstrate the bleed, but it would expose the newborn to unnecessary radiation, which will create its own complications. Choice five, MRI of the head can certainly identify smaller bleeds that a cranial ultrasound may miss. However, the patient is not stable enough to have an MRI performed. Finally, a bullet summary. The imaging modality of choice in diagnosing intraventricular hemorrhage in a newborn is cranial ultrasonography. That's all for this review about germinal matrix and intraventricular hemorrhage. We hope that was helpful. This is the Med Bullets Step 2 and 3 podcast, a daily audio review session for Med Bullets, the free learning and collaboration community for medical student education. As a reminder, you can follow along with these podcast episodes by reviewing the topics directly on MedBullets.com. You can listen to these episodes on the Med Bullets website or phone app while reading through the topic.

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