import json

data = {
 "topic": "Intraventricular Hemorrhage",
 "slug": "intraventricular-hemorrhage",
 "category_id": 15905,
 "summary": "Germinal matrix/intraventricular hemorrhage (GMH/IVH) is the most common form of intracranial hemorrhage in preterm infants, graded I-IV by cranial ultrasound, with severity strongly predicting long-term neurologic outcome and mortality.",
 "written_by": "claude-sonnet",
 "references": [
  {"title": "Cover", "author": "Vitalsource Download", "pages": [1004, 1010, 1013]},
  {"title": "Gomella's Neonatology: Management, Procedures, On-Call Problems, Diseases, and Drugs, Eighth Edition", "author": "Tricia Lacy Gomella, Fabien G. Eyal and Fayez Bany-Mohammed", "pages": [992, 994]},
  {"title": "Zitelli and Davis' Atlas of Pediatric Physical Diagnosis: Expert Consult - Online", "author": None, "pages": [1012]},
  {"title": "Netters Pediatrics (Florin Т., Ludwig St.)", "author": None, "pages": [664]},
  {"title": "Kliegman R. Nelson Textbook of Pediatrics 2-Volume Set 22ed 2024", "author": None, "pages": [1069, 1070, 1071, 3787]},
  {"title": "CURRENT Diagnosis and Treatment Pediatrics, Twenty-Fourth Edition", "author": "Hay, William W., Levin, Myron J., Deterding, Robin R., Abzug, Mark J.", "pages": [75]},
  {"title": "Diagnostic Imaging: Pediatrics", "author": "A. Carlson Merrow Jr. MD", "pages": [1095]},
  {"title": "Pediatric ICD-10-CM 2023", "author": "American Academy of Pediatrics Committee on Coding and Nomenclature;", "pages": [320]}
 ],
 "short": [
  {"title": "In short", "content": (
   "- Germinal matrix hemorrhage/intraventricular hemorrhage (GMH/IVH) is the most common form of intracranial hemorrhage in preterm infants and an important cause of long-term morbidity among NICU survivors\n"
   "- Incidence is 15-25% in infants born before 31 weeks' gestation and weighing under 1,500 g, with the highest incidence in the most immature infants (<26 weeks); risk of severe hemorrhage is inversely related to gestational age\n"
   "- Bleeding originates in the germinal matrix (subependymal, between the caudate nucleus and the ependymal lining of the lateral ventricle, in the caudothalamic groove), a region of undifferentiated cells that involutes by 34 weeks' gestation and is not normally visible on cranial ultrasound - it becomes visible only when hemorrhage occurs\n"
   "- Standard 4-grade classification by cranial ultrasound: Grade I - hemorrhage confined to the germinal matrix (~40% of cases); Grade II - hemorrhage extends into the lateral ventricle(s) without ventricular dilation (~25%); Grade III - hemorrhage fills more than 50% of the lateral ventricle(s) with resulting ventricular dilation (~20%); Grade IV - hemorrhage extends into the surrounding brain parenchyma, now more precisely termed periventricular hemorrhagic infarction (PVHI) rather than a direct grade of IVH (~15%)\n"
   "- Periventricular hemorrhagic infarction (PVHI, historically \"grade IV\") is not simply an extension of the IVH but a separate venous hemorrhagic infarct from obstructed venous drainage; it can evolve into a porencephalic cyst on follow-up imaging\n"
   "- Periventricular leukomalacia (PVL), a form of white matter injury in the periventricular arterial border zones, is commonly associated with GMH/IVH, thought to result from ischemia/inflammation with glial activation and preoligodendrocyte injury\n"
   "- Risk factors/associations include chorioamnionitis, acidosis, birth asphyxia, shock, blood pressure fluctuations, and respiratory distress with hypocapnia, hypercapnia, hypoxemia, or mechanical ventilation; the critical pathogenic event is ischemia-reperfusion injury to germinal matrix capillaries combined with immature cerebral pressure autoregulation\n"
   "- GMH/IVH is usually detected in the first 4-5 days of life: about 40-50% occur on day 1, and up to 90% within the first 72 hours; about 20% of early-onset hemorrhages progress to become more severe, typically reaching maximum extent within the first week\n"
   "- Most hemorrhages, particularly small ones, are asymptomatic and detected only by routine cranial ultrasound; larger hemorrhages can present with sudden deterioration, anemia, seizures, tense/bulging fontanels, split/wide sutures, apnea/bradycardia with desaturation, poor perfusion, hypotension, severe metabolic acidosis, and increased oxygen/ventilator requirements\n"
   "- Long-term neurologic outcome and mortality rise with increasing hemorrhage grade; total mortality (early plus late deaths) is roughly 50-100% higher than early-death-only figures for any given grade and birthweight"
  )}
 ],
 "long": [
  {"title": "Definition", "content": (
   "Germinal matrix hemorrhage/intraventricular hemorrhage (GMH/IVH) is bleeding that originates in the subependymal germinal matrix - a region of undifferentiated cells located between the caudate nucleus and the ependymal lining of the lateral ventricle (in the caudothalamic groove) - and that may remain confined there or rupture into the adjacent lateral ventricle(s), becoming unilateral or bilateral IVH. The germinal matrix normally involutes by 34 weeks' gestation and is not visible on cranial ultrasound in the absence of hemorrhage. GMH/IVH is the most common form of intracranial hemorrhage in preterm infants and an important cause of long-term morbidity among survivors of neonatal intensive care."
  )},
  {"title": "Epidemiology", "content": (
   "GMH/IVH occurs almost exclusively in premature infants. Incidence is 15-25% in infants born before 31 weeks' gestation and weighing less than 1,500 g (very low birthweight), with the highest incidence occurring in the most immature infants, those born before 26 weeks' gestation. The risk of severe hemorrhage is inversely related to gestational age."
  )},
  {"title": "Pathophysiology", "content": (
   "The critical pathogenic event is ischemia with reperfusion injury to the fragile capillaries of the germinal matrix in the immediate perinatal period, occurring in the setting of immature cerebral pressure autoregulation. The actual volume of bleeding is further influenced by factors affecting the pressure gradient across the injured capillary wall, such as venous congestion. This same pathogenetic scheme (ischemia followed by reperfusion in a region with immature autoregulation) also underlies intraparenchymal bleeding, understood as venous infarction in a region rendered ischemic. Periventricular hemorrhagic infarction (PVHI) - the entity previously classified as \"grade IV\" IVH - is not, as originally proposed, a direct extension of the intraventricular hemorrhage into the parenchyma; rather, it results from obstruction of venous drainage causing a venous hemorrhagic infarct that is strongly associated with, but mechanistically distinct from, the IVH itself. The area of infarction evolves over time into tissue loss, which may appear as a porencephalic cyst on follow-up cranial ultrasound. Periventricular leukomalacia (PVL), a form of white matter injury occurring in the periventricular arterial border zones, is commonly associated with GMH/IVH; its mechanism is not fully defined but is thought to involve ischemia and inflammation with glial activation and damage to preoligodendrocytes. Recognized clinical risk factors and associations for GMH/IVH include chorioamnionitis, acidosis, birth asphyxia, shock, blood pressure fluctuations, and respiratory distress associated with hypocapnia, hypercapnia, hypoxemia, or mechanical ventilation."
  )},
  {"title": "Clinical features", "content": (
   "GMH/IVH is usually detected within the first 4-5 days of life, with approximately 40-50% of hemorrhages occurring on the first day of life and up to 90% occurring within the first 72 hours. About 20% of early-onset hemorrhages evolve to become more severe, typically reaching their maximum extent within the first week of life. The majority of hemorrhages, particularly small ones, are asymptomatic and detected only through routine cranial ultrasound screening. Larger hemorrhages, especially with significant blood loss, may present with sudden clinical deterioration, anemia, seizures, tense/full/bulging fontanels, split and widened cranial sutures, apnea and bradycardia with desaturation episodes, poor perfusion, hypotension, severe metabolic acidosis, and increasing oxygen or ventilator support requirements."
  )},
  {"title": "Diagnostics", "content": (
   "Cranial ultrasound is the primary diagnostic and grading tool, given its bedside availability and ability to detect the germinal matrix once hemorrhage has occurred. The standard 4-grade classification is: Grade I - hemorrhage confined to the germinal matrix, seen in approximately 40% of all IVH cases; Grade II - hemorrhage extending from the germinal matrix into the lateral ventricle(s) without ventricular dilation (filling less than 50% of ventricular area), approximately 25% of cases; Grade III - hemorrhage filling more than 50% of the lateral ventricle(s), which are consequently enlarged/dilated, approximately 20% of cases; and Grade IV - historically defined as extension of hemorrhage into the surrounding brain parenchyma (associated parenchymal echogenicity/hemorrhagic infarct), approximately 15% of cases, though current terminology now favors calling this periventricular hemorrhagic infarction (PVHI) rather than a grade of IVH proper, reflecting its distinct venous-infarction mechanism. Because early-onset hemorrhages can progress in the first week of life, and up to 20% of early hemorrhages become more severe, serial cranial ultrasound follow-up is important rather than relying on a single early scan."
  )},
  {"title": "Complications", "content": (
   "Long-term neurologic sequelae and mortality both increase with increasing severity (grade) of hemorrhage and are also influenced by birthweight; overall (early plus late) mortality rates run approximately 50-100% higher than figures reflecting early deaths alone, for any given combination of grade and birthweight. Posthemorrhagic ventricular dilation (progressive ventricular dilation, PVD) is a recognized complication requiring ongoing monitoring after significant IVH. Periventricular leukomalacia, when it accompanies GMH/IVH, contributes additional white-matter injury and associated long-term neurodevelopmental risk. Periventricular hemorrhagic infarction can evolve into a porencephalic cyst, visible on later follow-up imaging, reflecting the tissue loss from the venous infarct."
  )}
 ],
 "clinical": [
  {"title": "Management and monitoring at the bedside", "content": (
   "In any infant born before 31 weeks' gestation or weighing less than 1,500 g, anticipate the need for cranial ultrasound screening for GMH/IVH given the 15-25% incidence in this population, with the highest risk in infants born before 26 weeks. Because up to 90% of hemorrhages occur within the first 72 hours of life and most are clinically silent, do not rely on clinical signs alone - obtain a screening cranial ultrasound according to unit protocol rather than waiting for symptoms, and repeat imaging over the first week given that about 20% of early hemorrhages progress to greater severity during this window.\n\nWatch for the clinical signs of a larger hemorrhage in a preterm infant - sudden deterioration, unexplained anemia, new seizures, tense or bulging fontanels, split/widened sutures, new apnea/bradycardia with desaturation, poor perfusion, hypotension, worsening metabolic acidosis, or rising oxygen/ventilator requirements - and obtain urgent cranial ultrasound if these develop. When a hemorrhage is identified, grade it using the standard I-IV system to guide prognostic counseling and follow-up intensity, understanding that grade IV findings (parenchymal extension) reflect periventricular hemorrhagic infarction from venous obstruction rather than simple IVH extension, with a correspondingly worse prognosis. Continue serial ultrasound surveillance for posthemorrhagic ventricular dilation after any grade II or higher hemorrhage, and coordinate long-term neurodevelopmental follow-up proportional to hemorrhage severity, since both mortality and neurologic sequelae increase substantially with higher grades and lower birthweight. Address modifiable perinatal contributors where possible - avoiding blood pressure fluctuations, hypocapnia/hypercapnia, and hypoxemia during ventilatory management - since these are recognized associations with GMH/IVH risk."
  )}
 ]
}

with open("/tmp/ivh.article.json", "w") as f:
    json.dump(data, f, indent=1)
print("written")