Ministry of Health

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Grade 4 GM-IVH

The characteristic feature of Grade 4 haemorrhage is parenchymal involvement.  This traditionally was considered to be due to an extension from a ventricular bleed.  However, it is now considered to be due to periventricular haemorrhagic infarction.  Deep veins pass lateral to the lateral ventricles.  Following a presumed hypoperfusion-reperfusion injury, it is thought that there is haemorrhage at this site, resulting in obstruction of these veins and then venous haemorrhagic infarction.  Approximately 80% of Grade 4 bleeds are associated with an ipsilateral GM-IVH.  These lesions are frequently associated with neurodevelopmental sequelae.  However, the severity and extent depends on size and location.  Bilateral parenchymal involvement is an indicator of poor neurodevelopmental prognosis.

Early Scan

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	This series of images demonstrates the evolution of a left parenchymal bleed in the parietal region. The initial images on Day 7 show an area of haemorrhage (increased echogenicity) on the left side.  This is clearly dissociated from the lateral ventricle.  There is a small germinal matrix haemorrhage without obvious intraventricular haemorrhage or dilatation.  The choroid plexus is irregular and this may represent haemorrhage.

Two week scan

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	The images from about 3 weeks of age show some asymmetry of the lateral ventricles.  This may indicate white matter loss.  The haemorrhage is resolving, with cavitation of the parenchymal component and possibly a subependymal pseudocyst.

One month scan

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By the time the follow-up scan is performed at approximately 4 weeks, the haemorrhage has resolved but has left a cystic space in communication with the ventricle. This 23 week gestation infant had significant lung disease.  There was never any discussion about withdrawal of care solely because of the haemorrhage, although it was understood that some degree of neurodevelopmental problems would follow (most likely a right hemiplegia).  His lung disease progressed and eventually he deteriorated to such an extent that care was withdrawn for respiratory reasons.