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Grade 1 GM-IVH
Grade 2 GM-IVH
Grade 3 GM-IVH
Grade 4 GM-IVH
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Germinal Matrix-Intraventricular Haemorrhage (GM-IVH) is the most common form of intracranial haemorrhage in preterm infants.  It can occur in up to 20% of infants delivered at less than 32 weeks gestation.


The site of origin of GM-IVH is at the subependymal germinal matrix.  This is the area of the brain where neuroblasts migrate from between 10 and 20 weeks, and becomes the source of glioblasts.  It is a very vascular structure.  At a microscopic level, destruction of the germinal matrix occurs when there has been a GM-IVH.

In approximately 15% of infants, there is also intraparenchymal involvement.  This was previously though to represent parechymal extension of an intraventricular haemorrhage.  It is associated with an ipsilateral GM-IVH in 80% of cases.  However, it is now thought to represent periventricular haemorrhagic venous infarction, due to occlusion of medullary veins which return adjacent to lateral ventricle and germinal matrix.

Terminology and Classification

GM-IVH is frequently described according to where the bleed is, and how extensive.  However, most neonatal units also use a grading system (Grades 1 to 4) according to extent of the haemorrhage.  This is useful for audit purposes and for some prognostic categories, but is not as precise as a detailed description in this regard.

For the purposes of this website, images are presented according to their Papile grading 1.  Links to the left will take you to the appropriate images.

The grading system is as follows:

Grade 1

  • Germinal matrix haemorrhage

Grade 2

  • Extension into the lateral ventricle(s), with haemorrhage filling less than 50% of the ventricular area

Grade 3

  • Extensive haemorrhage with distension or dilatation of the lateral ventricles

Grade 4

  • Parenchymal involvement

Grade 1 and 2 haemorrhage make up about 75% of IVH.

1.  Papile LA, Burnstein J, Burnstein R, et al.  Incidence and evolution of subependymal and  intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm.  J Pediatr 1978; 92;529-34.