CT detection and course of intracranial hemorrhage in premature infants.

Twenty neonates with a suspected intracranial hemorrhage were studied by computed tomography (CT). The exact site and extent of the hemorrhage in all infants were clearly demonstrated on serial CT scans. In intraventricular hemorrhage, a dense subependymal halo lined the ventricular system and could be recognized for up to 2 weeks. Discrete hemorrhage adjacent to the ventricular system also appeared as discrete nodules rather than as a diffuse hemorrhage. Blood in the ventricular system could be recognized up to 2 weeks when there were blood-cerebrospinal fluid levels. Hydrocephalus was a common sequela and was readily detectable before a measurable change in head size.     

Brain single photon emission computed tomography in neonates

This study was designed to rate the clinical value of [123I]iodoamphetamine (IMP) or [99mTc] hexamethyl propylene amine oxyme (HM-PAO) brain single photon emission computed tomography (SPECT) in neonates, especially in those likely to develop cerebral palsy. The results showed that SPECT abnormalities were congruent in most cases with structural lesions demonstrated by ultrasonography. However, mild bilateral ventricular dilatation and bilateral subependymal porencephalic cysts diagnosed by ultrasound were not associated with an abnormal SPECT finding. In contrast, some cortical periventricular and sylvian lesions and all the parasagittal lesions well visualized in SPECT studies were not diagnosed by ultrasound scans. In neonates with subependymal and/or intraventricular hemorrhage the existence of a parenchymal abnormality was only diagnosed by SPECT. These results indicate that [123I]IMP or [99mTc]HM-PAO brain SPECT shows a potential clinical value as the neurodevelopmental outcome is clearly related to the site, the extent, and the number of cerebral lesions. Long-term clinical follow-up is, however, mandatory in order to define which SPECT abnormality is associated with neurologic deficit.     

Choroid plexus hemorrhage in premature neonates: recognition by sonography

In 34 consecutive infants admitted to the neonatal intensive care unit with birth weight of less than 1,500 g, 80 cranial real-time sonograms were obtained to determine the incidence of choroid plexus hemorrhage. Choroid plexus hemorrhage was diagnosed only in the absence of germinal matrix hemorrhage. Diagnostic criteria included choroid plexus nodularity, enlargement (greater than 12 mm in anteroposterior diameter), or asymmetry between right and left (greater than 5 mm). Ipsilateral intraventricular clots or occipital horn dilatation supported the diagnosis of choroid plexus hemorrhage in most cases. Choroid plexus hemorrhage appeared to be the sole bleeding site in 10 (59%) of the 17 patients with intracranial hemorrhage. Hemorrhage in the region of the caudate nucleus was seen in the other seven cases (41%). Ventricular dilatation and/or intraventricular hemorrhage accompanied nine (90%) of the 10 cases of choroid plexus hemorrhage. This study suggests that in very low-birth-weight premature neonates, the choroid plexus may be a more frequent site of intracranial hemorrhage than previously believed.     

Neurosonographic recognition of subependymal cysts in high-risk neonates

Serial neurosonography was performed in 210 high-risk, preterm neonates. Eleven (5.8%) demonstrated small cystic formations in the subependymal lining of the lateral ventricles. These subependymal cysts were unilateral and were detected at the exact site of a previous subependymal hemorrhage in two cases. These 11 infants were not significantly different in maturity, size, or clinical parameters from our main high-risk newborn population. Ten survivors had marked motor retardation at follow-up ages of 9-13 months, and one died from neonatal sepsis.     

Intraparenchymal hemorrhage in preterm neonates: a broadening spectrum

Among 800 neonates screened for cerebral bleeding, perinatal sonography identified 35 preterm neonates with intraparenchymal hemorrhage (IPH). The observed IPHs were categorized in five general groups: classical grade-IV hemorrhage (16 patients), grade-IV hemorrhage with coexisting but anatomically separate hemorrhages (four patients), grade-IV hemorrhage with later development of secondary parenchymal hemorrhages at distant sites (five patients), hemorrhagic periventricular leukomalacia (four patients), and parenchymal hemorrhage unrelated to grade-IV hemorrhages (six patients). Thirty IPHs had concurrent germinal matrix hemorrhages, but in only 16 patients did the IPH represent an extension of the subependymal hematoma and therefore qualify as pure grade-IV hemorrhage according to the most popular classification. The high concurrence of periventricular leukomalacia (80-100% in most groups) and germinal-matrix-remote IPHs supports the concept that most IPHs in preterm neonates represent secondary hemorrhages into ischemic brain tissue.     

Neonatal intraventricular hemorrhage: a serial computed tomography study.

Thirty infants weighing less than 1,500 g at birth and requiring assisted ventilation were studied by computed tomography (CT) as soon as possible after birth and at intervals thereafter. Hemorrhage were frequently detected within the first 48 hr of birth. Two infants had normal scans initially but developed intraventricular hemorrhage later. One infant had subependymal hemorrhage that later ruptured into the ventricles. Six deaths were due directly to intracranial hemorrhages. Hydrocephalus developed in seven and atrophy in two survivors. There was poor correlation between CT scan and clinical evidence of intracranial hemorrhage.     

Isolation of the fourth ventricle causing transtentorial herniation: neurosonographic findings in premature infants.

OBJECTIVE. Significant posthemorrhagic enlargement of the fourth ventricle occurs only in a small minority of patients. Although entrapment or isolation of any ventricle can occur, the fourth ventricle is the most common site. This study was undertaken to better understand enlargement of the fourth ventricle after intraventricular hemorrhage and the neurosonographic features of isolation and transtentorial herniation. MATERIALS AND METHODS. The sonographic records of 1535 premature neonates were reviewed for evidence of intracranial hemorrhage and ventriculomegaly. Cranial sonography was performed within the first 3 days of life in all neonates born in our hospital and within the first week of admission for transferred neonates. Follow-up sonograms were obtained at weekly intervals until discharge from the nursery. Intracranial hemorrhages were classified as severe when the hemorrhage was associated with hydrocephalus, intraparenchymal hemorrhage, or both. RESULTS. Intracranial hemorrhage occurred in 761 (50%) of 1535 patients, with severe hemorrhages in 229. Ten had massive enlargement of the fourth ventricle with isolation in six of the 10 after shunt placement. Isolation of the fourth ventricle causing transtentorial herniation occurred in three. Of the patients with isolation of the fourth ventricle, two had associated infection and ventriculitis caused by Klebsiella oxytoca and one had Candida ventriculoencephalitis. CONCLUSION. The early recognition of the neurosonographic features of an enlarged fourth ventricle causing transtentorial herniation has important therapeutic implications. Although isolation can occur after intraventricular hemorrhage alone, infection and ventriculitis are significant factors in the development of an isolated fourth ventricle.     

Intracranial calcification in the infant and neonate: evaluation by sonography and CT

This study reports the sonographic and computed tomography (CT) findings in seven infants and neonates with intracranial calcifications and a spectrum of underlying disorders, including toxoplasmosis, cytomegalic inclusion disease, transverse/straight sinus thrombosis, and probable anoxia. Neurotropic infectious disease usually produced clumped or subependymal calcifications accompanied by sometimes bizarre ventricular configurations and prominent periventricular cystic encephalomalacia. Sonography failed to identify prospectively intracranial calcifications in two of the three patients without infection, although calcifications were visible in retrospect. Overall, CT provided optimum visualization of intracranial calcifications.     

Early diagnosis of perinatal cerebral lesions in apparently normal full-term newborns by ultrasound of the brain

Summary The brains of 1000 consecutive, clinically normal, full-term neonate without signs of perinatal distress were examined by ultrasound 3 days postpartum. We found 35 cases of intracranial haemorrhage (periventricular, choroid plexus and intraventricular); 34 possible sequelae of bleeding (subependymal and choroid plexus pseudocysts; local dilatation of the lateral ventricles) and 21 morphological aberrations. Most of these 90 abnormalities were checked several times. Four children with intracranial haemorrhage developed symptoms (3 hemipareses, 1 infantile spasm) within a year of birth. No child without sonographic abnormalities has so far been recognized as developing a clinical deficit.     

Brain abnormalities in infants on extracorporeal membrane oxygenation: sonographic and CT findings

The findings of cranial sonography performed before and during extracorporeal membrane oxygenation (ECMO) in 50 near-term infants and CT findings after ECMO in 18 of those patients are reported. Hemorrhage is uncommon in patients being considered for ECMO: subependymal hemorrhage was seen in one case and subependymal cyst possibly due to in utero hemorrhage was seen in five cases. Hypoxic ischemic ischemic injury is more common: severe cerebral edema was seen in two cases, occipital hemorrhagic infarct in one case, and mild cerebral edema in 17 cases. During ECMO, sonograms showed that the hemorrhage in patients with small subependymal hemorrhage or cyst before ECMO did not extend while on ECMO. Typical germinal matrix/intraventricular hemorrhage was seen uncommonly (three cases). Unusual parenchymal hemorrhage did occur. Hypoxic ischemic brain injury was more common: parenchymal hemorrhage was seen in three cases, severe cerebral edema in three cases, and infarction in three cases. Hypoxic ischemic brain injury probably occurs before ECMO, with a delay in visualization. CT after ECMO detected additional abnormalities, particularly peripheral areas of hemorrhage and infarction not visible on sonograms, and is now being performed on all patients. More emphasis should be placed on better screening of infants being considered for ECMO treatment to identify irreversible anoxic brain injury, not just hemorrhage.     

Cranial computed tomography and real-time sonography in full-term neonates and infants

The results of cranial ultrasonography (US) and computed tomography (CT) were compared in 52 full-term neonates and young infants. The chief indications for examination included: increasing head size, dysmorphic features, myelomeningocele, inflammatory disease, and asphyxia. Disorders detected included hydrocephalus, parenchymal abnormalities, intracranial hemorrhage, extraparenchymal fluid collections, and vascular and other developmental malformations. Hydrocephalus and subdural collections were seen in patients referred for all clinical indications, whereas diffuse parenchymal abnormalities, subarachnoid hemorrhage, and intraventricular hemorrhage occurred primarily in patients with hypoxia. CT and US essentially were equivalent in detecting hydrocephalus, moderate to large intraventricular hemorrhages or subdural collections, and large focal parenchymal lesions, although CT was somewhat better in determining the level and cause of obstruction in patients with hydrocephalus and characterizing parenchymal abnormalities. CT was more sensitive than ultrasound in detecting subarachnoid hemorrhage (100% vs. 0%), diffuse parenchymal abnormality (100% vs. 33%), and small intraventricular hemorrhages (100% vs. 0%) but these lesions often were not clinically significant. The results suggest that US should be used as the primary neuroradiological examination in term infants; CT probably should be reserved for further investigation after US in those patients with a history of hypoxia and progressive clinical deterioration.     

Periventricular leukomalacia in combination with intraventricular hemorrhage: sonographic features and sequelae

Periventricular leukomalacia (PVL) is well recognized as a relatively uncommon yet particularly serious complication of prematurity. Although the sonographic features of PVL have been described, its association with intraventricular hemorrhage (IVH) has not been emphasized. Reviewing 26 consecutive cases of PVL in neonates of 34 weeks or less gestational age, significant associated hemorrhage was found in six (23%). Small quantities of blood were also noted in most of the other 20 infants. Of the six infants with both significant IVH and PVL, five required ventricular shunt and all had particularly poor clinical outcomes. In the neonates who required surgical intervention, rapid ventricular enlargement was accompanied by extensive periventricular cyst formation. Eventually, the septations within the cysts and frequently even the ependyma of superior/posterior lateral ventricles degenerated. Cysts merged imperceptibly with the ventricles giving an appearance that mimicked severe hydrocephalus. This was termed "pseudoventricle formation," as the large intracerebral cerebrospinal fluid spaces are primarily porencephaly and not enlarged ventricles. Response to shunting was minimal by sonography in all five cases and multiple shunt revisions were required in four. Clinical follow-up in children with significant IVH in combination with PVL has shown severe mental retardation and tetraplegia in all cases.     

高危新生儿头颅CT表现（附41例分析）

目的：提高对高危新生儿头颅CT异常表现的认识。方法：41例均为高危新生儿,出生后1．5h-12天内行CT检查,扫描前半小时肌注鲁米那钠或10％水合氯醛口服或灌肠,使其安睡。结果：单纯蛛网膜下腔出血13例,脑实质出血5例,脑室内出血3例,室管膜下出血4例,硬膜下出血5例,单纯脑缺氧缺血性损害9例,正常CT表现2例。结论：高危新生儿大部分存在颅内出血或脑缺氧缺血性损害,CT检查对这些病变有极高的诊断价值。     

High-field spin-echo MR imaging of superficial and subependymal siderosis secondary to neonatal intraventricular hemorrhage

Summary Two cases of superficial siderosis with subependymal siderosis, secondary to neonatal intraventricular hemorrhage, are presented. High-field spin-echo MR imaging (1.5 Tesla) showed marginal hypointensity of the ventricular walls as well as of the subpial regions. These findings were most evident on T₂ weighted images, characteristic of hemosiderotic deposits.     

Sonographic diagnosis of cisternal subarachnoid hemorrhage in the premature infant.

PURPOSETo evaluate sonographic criteria for the diagnosis of subarachnoid, and particularly cisternal, hemorrhage in the preterm infant.METHODSThe subarachnoid cisterns were studied on cadaveric anatomic sections and on postmortem ultrasonograms, as well as on in vivo ultrasonograms of healthy neonates. Based on the normal ultrasound appearances of these cisterns, criteria were developed for the recognition of abnormal cisternal fluid collections, which strongly suggest the presence of subarachnoid hemorrhage in the premature infant. These criteria were evaluated prospectively in a group of 63 preterm infants who underwent subsequent autopsy.RESULTSIn the 63 infants with neuropathologic verification, increased echogenicity and/or increased echo-free content of the subarachnoid cisterns correctly predicted subarachnoid hemorrhage with an accuracy of 75%, sensitivity of 69%, and specificity of 93%. The positive and negative predictive values were 97% and 46%, respectively. In 47% of the cases, ultrasound correctly detected cisternal subarachnoid hemorrhage before intraventricular hemorrhage could be diagnosed.CONCLUSIONA highly specific, although somewhat insensitive, sonographic diagnosis of subarachnoid hemorrhage can be made from the appearance of the subarachnoid cisterns. The diagnosis of subarachnoid hemorrhage may predate the ultrasound diagnosis of intraventricular hemorrhage and may alert the neonatologist to the need for follow-up sonograms in the absence of ultrasound evidence of intraventricular hemorrhage.     

Real-time sonography of the brain through the anterior fontanelle

Noninvasive, rapid evaluation of the neonate and young infants with reproducible results is feasible with real-time cranial sonography through the anterior fontanelle. Cerebral anatomy in coronal and sagittal planes is visualized, and the entire ventricular system and adjacent brain parenchyma are identified. This rapid (5-10 min) procedure can be done at/in the incubator making transport of sick neonates unnecessary, thus preserving their thermal stability. Images are recorded on videotape and "hard copy" is obtained afterward. Ventricular size, intracranial hemorrhage (both intraventricular and parenchymal), abnormalities of the the ventricular system, subdural effusion, and fluid-filled lesions are recognized by the usual sonographic criteria. In addition, "solid" parenchymal lesions such as diffuse hemangiomas and brain tumors are depicted as changes in sonographic parenchymal architecture.     

新生儿颅内出血的CT特征

研究新生儿颅内出血的ＣＴ特征性表现。对４８例新生儿颅内出血的ＣＴ表现进行了回顾性分析，并对１７例进行了追踪观察。蛛网膜下腔出血２９例，脑实质出血２例，脑室管膜下出血１例，脑室出血４例，混合型脑出血１２例。（１）ＳＡＨ为新生颅内出血最常见的类型约占６０％，仅表现为直窦高密度者，确定超过５ｍｍ为诊断标准，并根据其形态特征分为前窄后宽，前宽后窄和全长增宽３种类型；（２）ＳＥＨ见于早产儿，ＣＴ诊断较困难。     

Posterior fossa intracranial hemorrhage in infants treated with extracorporeal membrane oxygenation: sonographic findings

Posterior fossa hemorrhage was documented by autopsy in five infants who had been treated with extracorporeal membrane oxygenation over a 5-year-period. In all five cases, the diagnosis was made prospectively by cranial sonography. Sonographic findings were compared with those in a control group of 15 infants with normal posterior fossae at autopsy. The following sonographic abnormalities were exhibited in neonates with posterior fossae hemorrhage: loss of definition of the cerebellum and fourth ventricle on midline sagittal images, heterogeneous cerebellar parenchyma, focal hypoechoic lesions, ventricular dilatation, and tentorial abnormalities. Bright foci inferior to the third ventricle were seen in four neonates in the normal control group. These foci measured 5-10 mm in diameter. One cranial sonogram was falsely interpreted as showing a posterior fossa hemorrhage because of prominent echoes in the interpeduncular cistern. Infants treated with extracorporeal membrane oxygenation are at risk for developing posterior fossa hemorrhage. Awareness of sonographic signs and potential pitfalls in the interpretation of posterior fossa hemorrhage is important for early and accurate recognition of these unusual and sometimes treatable hemorrhages.     

Intraventricular Hemorrhage Caused by Lateral Ventricular Meningioma: A Case Report

Meningiomas causing intracranial hemorrhage are rare, and hemorrhage from a lateral ventricular meningioma seems to be even rarer. We report a case of trigonal meningioma in a 43-year-old woman who presented with intraventricular hemorrhage, and describe the CT, MRI and angiographic findings.     

Hemorrhage in the cavum septi pellucidi,and a brief review of the literature

The aim of this study is to present the cases of four neonates with hemorrhage within the cavum septi pellucidi (CSP). The sonographic findings of this rare location of intracranial hemorrhage, the related pathology and the possible underlying mechanisms are discussed, with a brief review of the literature. Three out of four of the neonates were premature and the fourth was a full-term infant with Down's syndrome. In all the patients the hemorrhage in the CSP was associated with severe intracranial hemorrhage.