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Evaluation of neonatal intracranial hemorrhage by computerized tomography
342
Evaluation of neonatal intracranial hemorrhage by computerized tomography
T. Kotlarek, Abteilung Kinderheilkunde der Medizinischen Fakult2it an der RWTH Aachen, Goethestrasse 27/29, D-5100 Aachen, F.R.G.
Summary Between 1977 and 1980, we admitted to cranial computerized tomography (CT), 200 preterm and fullterm neonates suspected of hypoxemically or traumatically induced encephalopathy. 57 of them had intracranial hemorrhage. In 25 cases, plane subdural bleeding along the sinus was noted, especially in fullterm neonates. Intracerebral hemorrhage also developed more frequently in fullterm neonates (6 cases). On the other hand, intraventricular hemorrhage predominated in infants with birthweights below 1500 g (26 cases). The different types of CT patterns offer guidelines for the individual prognosis of the afflicted children. Introduction Despite improved obstetric and neonatal intensive care, preterm infants below a birthweight of 1500 g and asphyxial neonates are now just as much in danger as ever of not surviving at all or only with damage. Cranial computerized tomography (CT) allows a direct insight into the macroscopic-neuropathological details of a neonatal cerebral lesion. Materials and methocis -Between 1977 and 1980, we admitted to CT 200 preterm and fullterm neonates, within 2 wk of birth, suspected of hypoxemically or traumatically induced encephalopathy. The severity of intraventricular hemorrhage (IVH) noted on the CT scan was graded using the .system developed by Papile et al. [ 11. The follow-up, consisting of neurologic and developmental assessments, was carried out at the ages of 3, 6, 9, 12, 18, 24 and 36 mth. Neurologic findings, categorized as psychoneurological defect, were hydrocephalus, cerebral palsy, seizure disorder, mental defect, blindness, and hearing loss. The diagnosis, “developmental delay”, was based on developmental performance utilizing the Denver Developmental Screening Test. A child considered “roughly normal” had a normal neurologic and developmental assessment between 18 and 36 mth chronological age. The CT apparatus used was a Siretom 2000 with a matrix of 256 X 256, a 10 mm collimator and an exposure time of 75 s. Results A normal primary CT scan was found in 118 out of 200 preterm and fullterm neonates, whereas various morphological changes were detected by initial CT scan in relation to birthweight in 82 of them [2]. 57 of them had intracranial hemorrhage. In 25 cases, plane subdural bleeding along the sinus was noted especially in fullterm neonates. Intracerebral hemorrhage also developed more frequently in fullterm neonates (6 cases). On the other hand, intraventricular hemorrhage predominated in infants with ‘birthweights below 1500 g (26 cases). The different types of CT
343 TABLE
I
Mortality
of neonatal
intracranial
Hemorrhage
None IVH grades I and II IVH grades III and IV Intracerebral hemorrhage Plane subdural hemorrhage
TABLE
hemorrhage No. of
Mean
patients
birthweight
11 13 13 6 25
1340 1300 1230 3050 3130
Survived (g)
No
Yes
2 2 11 1 0
9 11 2 5 25
II
Short term outcome
related
to grade of hemorrhage No. of patients
No hemorrhage ( < 1500 g) IVH grades I and II IVH grades III and IV Intracerebral hemorrhage Plane subdural bleeding
9 11 2 5 25
based on location
and severity
Clinical status in infancy until 3 yr of age Psychoneurological defect
Developmental delay
1
2 2
1 2 4
1
1
4
Roughly normal
6 8
20
patterns of neonatal intracranial hemorrhage offer guidelines for the individual prognosis of the afflicted children (Tables I and II). Discussion Plane subdural bleeding along the sinus is possibly the result of a birth trauma, but seems nevertheless to correspond to a benign finding, and has a favourable prognosis. Intracerebral hemorrhages have an unfavourable prognosis in respect to psychoneurological development. After quick resorption of the hemorrhages within 14-21 days, there remains a cystic defect with or without progressive dilation of the ventricles. It seems that posthemorrhagic hydrocephalus is more likely to occur with increased severity of hemorrhage. Of the cystic defects, only lesions in the pyramidal tract region lead to clear-cut neurological syndromes, e.g. hemiparesis. In our study, there is a positive relationship between the severity of intraventricular hemorrhage and mortality in premature neonates, a finding consistent with those of Krishnamoorthy et al. [3], Fitzhardinge et al. [4] and Williamson et al. [5]. In addition, we found mortality to be very high for grade III and total for grade IV IVH. On the other hand IVH grades I and II are overcome as a rule - if additional complications are absent (Table I). There was also a correlation between the degree of intraventricular hemorrhage and subsequent outcome in our study (Table II).
IVH grades I and II did not have a negative influence on the course of the infants development. The hemorrhage was resolved without dilation of the ventricles and the children show a development equally favourable to that of preterm neonates without hemorrhage. Poorest outcome is related to grade III. But the number of such cases in our investigation is small. The two babies, having survived IVH grade III, developed a posthemorrhagic hydrocephalus. These results differ from those of Fitzhardinge et al. [4], who could demonstrate a higher percentage of handicapped children both in former preterm neonates with IVH grades I and II and in preterm neonates without hemorrhage. This difference may be caused by the greater number of preterm infants with birthweights below 1000 g in Fitzhardinge’s study. The children under 1000 g examined by Williamson et al. [5] did not show any correlation between outcome and degree of intraventricular hemorrhage either. The incidence of abnormal outcome in these children was high. On the other hand, abnormal outcome for infants with birthweights greater than 1000 g appeared to be more directly related to grade of hemorrhage than to birthweight. Williamson’s study is consistent with our own in the case of IVH grades III and IV, but differs in IVH grades I and II. We believe that many of the infants in this study with IVH grades I and II were under 1000 g, whereas in the case of those of IVH grades III and IV, weight becomes a relatively unimportant factor. In our study there are almost exclusively infants weighing over 1000 g. This could account for the divergences in the results of our two studies. In our clinic, we try to keep up-to-date: as concerns the proof of hemorrhages, we have replaced the classical CT-method with the more elegant ultrasound imaging. This fact may explain why we have only a small number of infants with intracranial hemorrhages documented by CT-scan. References 1. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage; a study of infants with birthweights less than 1,500 gm. J Pediatr 1978; 92: 529-534. 2. Kotlarek F. Computertomographische Befunde bei natalen Enzephalopathien und ihre Wertigkeit fiir die Nah- und Langzeitprognose. Habilitationsschrift, Aachen 1981. 3. Krishnamoorthy KS, Shannon DC, DeLong GR et al. Neurologic sequelae in the survivors of neonatal .intraventricular hemorrhage. Pediatrics 1979; 64: 233-237. 4. Fitzhardinge PM, Flodmark 0, Fitz CR, Ashby S. The prognostic value of computed tomography of the brain in asphyxiated premature infants. J Pediatr 1982; 100: 476-481. 5. Williamson WD, Desmond MM, Wilson GS, Andrew L, Garcia-Prats JA. Early neurodevelopmental outcome of low birthweight’ infants surviving neonatal intraventricular hemorrhage. J Perinat Med 1982; 10: 34-41.
Treatment and outcome of intracranial hemorrhage P.M. Fitzhardinge, Department of Pediatrics, Unioersity of Toronto, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario MSG 1X5, Canada Computed tomography (CT) and ultrasound (U/S) surveys of the brains of very low. birthweight infants have shown a remarkably consistent incidence of germinal layer (GLH) and intraventricular hemorrhage (IVH). Most studies report such
Evaluation of neonatal intracranial hemorrhage by computerized tomography
T. Kotlarek, Abteilung Kinderheilkunde der Medizinischen Fakult2it an der RWTH Aachen, Goethestrasse 27/29, D-5100 Aachen, F.R.G.
Summary Between 1977 and 1980, we admitted to cranial computerized tomography (CT), 200 preterm and fullterm neonates suspected of hypoxemically or traumatically induced encephalopathy. 57 of them had intracranial hemorrhage. In 25 cases, plane subdural bleeding along the sinus was noted, especially in fullterm neonates. Intracerebral hemorrhage also developed more frequently in fullterm neonates (6 cases). On the other hand, intraventricular hemorrhage predominated in infants with birthweights below 1500 g (26 cases). The different types of CT patterns offer guidelines for the individual prognosis of the afflicted children. Introduction Despite improved obstetric and neonatal intensive care, preterm infants below a birthweight of 1500 g and asphyxial neonates are now just as much in danger as ever of not surviving at all or only with damage. Cranial computerized tomography (CT) allows a direct insight into the macroscopic-neuropathological details of a neonatal cerebral lesion. Materials and methocis -Between 1977 and 1980, we admitted to CT 200 preterm and fullterm neonates, within 2 wk of birth, suspected of hypoxemically or traumatically induced encephalopathy. The severity of intraventricular hemorrhage (IVH) noted on the CT scan was graded using the .system developed by Papile et al. [ 11. The follow-up, consisting of neurologic and developmental assessments, was carried out at the ages of 3, 6, 9, 12, 18, 24 and 36 mth. Neurologic findings, categorized as psychoneurological defect, were hydrocephalus, cerebral palsy, seizure disorder, mental defect, blindness, and hearing loss. The diagnosis, “developmental delay”, was based on developmental performance utilizing the Denver Developmental Screening Test. A child considered “roughly normal” had a normal neurologic and developmental assessment between 18 and 36 mth chronological age. The CT apparatus used was a Siretom 2000 with a matrix of 256 X 256, a 10 mm collimator and an exposure time of 75 s. Results A normal primary CT scan was found in 118 out of 200 preterm and fullterm neonates, whereas various morphological changes were detected by initial CT scan in relation to birthweight in 82 of them [2]. 57 of them had intracranial hemorrhage. In 25 cases, plane subdural bleeding along the sinus was noted especially in fullterm neonates. Intracerebral hemorrhage also developed more frequently in fullterm neonates (6 cases). On the other hand, intraventricular hemorrhage predominated in infants with ‘birthweights below 1500 g (26 cases). The different types of CT
343 TABLE
I
Mortality
of neonatal
intracranial
Hemorrhage
None IVH grades I and II IVH grades III and IV Intracerebral hemorrhage Plane subdural hemorrhage
TABLE
hemorrhage No. of
Mean
patients
birthweight
11 13 13 6 25
1340 1300 1230 3050 3130
Survived (g)
No
Yes
2 2 11 1 0
9 11 2 5 25
II
Short term outcome
related
to grade of hemorrhage No. of patients
No hemorrhage ( < 1500 g) IVH grades I and II IVH grades III and IV Intracerebral hemorrhage Plane subdural bleeding
9 11 2 5 25
based on location
and severity
Clinical status in infancy until 3 yr of age Psychoneurological defect
Developmental delay
1
2 2
1 2 4
1
1
4
Roughly normal
6 8
20
patterns of neonatal intracranial hemorrhage offer guidelines for the individual prognosis of the afflicted children (Tables I and II). Discussion Plane subdural bleeding along the sinus is possibly the result of a birth trauma, but seems nevertheless to correspond to a benign finding, and has a favourable prognosis. Intracerebral hemorrhages have an unfavourable prognosis in respect to psychoneurological development. After quick resorption of the hemorrhages within 14-21 days, there remains a cystic defect with or without progressive dilation of the ventricles. It seems that posthemorrhagic hydrocephalus is more likely to occur with increased severity of hemorrhage. Of the cystic defects, only lesions in the pyramidal tract region lead to clear-cut neurological syndromes, e.g. hemiparesis. In our study, there is a positive relationship between the severity of intraventricular hemorrhage and mortality in premature neonates, a finding consistent with those of Krishnamoorthy et al. [3], Fitzhardinge et al. [4] and Williamson et al. [5]. In addition, we found mortality to be very high for grade III and total for grade IV IVH. On the other hand IVH grades I and II are overcome as a rule - if additional complications are absent (Table I). There was also a correlation between the degree of intraventricular hemorrhage and subsequent outcome in our study (Table II).
IVH grades I and II did not have a negative influence on the course of the infants development. The hemorrhage was resolved without dilation of the ventricles and the children show a development equally favourable to that of preterm neonates without hemorrhage. Poorest outcome is related to grade III. But the number of such cases in our investigation is small. The two babies, having survived IVH grade III, developed a posthemorrhagic hydrocephalus. These results differ from those of Fitzhardinge et al. [4], who could demonstrate a higher percentage of handicapped children both in former preterm neonates with IVH grades I and II and in preterm neonates without hemorrhage. This difference may be caused by the greater number of preterm infants with birthweights below 1000 g in Fitzhardinge’s study. The children under 1000 g examined by Williamson et al. [5] did not show any correlation between outcome and degree of intraventricular hemorrhage either. The incidence of abnormal outcome in these children was high. On the other hand, abnormal outcome for infants with birthweights greater than 1000 g appeared to be more directly related to grade of hemorrhage than to birthweight. Williamson’s study is consistent with our own in the case of IVH grades III and IV, but differs in IVH grades I and II. We believe that many of the infants in this study with IVH grades I and II were under 1000 g, whereas in the case of those of IVH grades III and IV, weight becomes a relatively unimportant factor. In our study there are almost exclusively infants weighing over 1000 g. This could account for the divergences in the results of our two studies. In our clinic, we try to keep up-to-date: as concerns the proof of hemorrhages, we have replaced the classical CT-method with the more elegant ultrasound imaging. This fact may explain why we have only a small number of infants with intracranial hemorrhages documented by CT-scan. References 1. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and evolution of subependymal and intraventricular hemorrhage; a study of infants with birthweights less than 1,500 gm. J Pediatr 1978; 92: 529-534. 2. Kotlarek F. Computertomographische Befunde bei natalen Enzephalopathien und ihre Wertigkeit fiir die Nah- und Langzeitprognose. Habilitationsschrift, Aachen 1981. 3. Krishnamoorthy KS, Shannon DC, DeLong GR et al. Neurologic sequelae in the survivors of neonatal .intraventricular hemorrhage. Pediatrics 1979; 64: 233-237. 4. Fitzhardinge PM, Flodmark 0, Fitz CR, Ashby S. The prognostic value of computed tomography of the brain in asphyxiated premature infants. J Pediatr 1982; 100: 476-481. 5. Williamson WD, Desmond MM, Wilson GS, Andrew L, Garcia-Prats JA. Early neurodevelopmental outcome of low birthweight’ infants surviving neonatal intraventricular hemorrhage. J Perinat Med 1982; 10: 34-41.
Treatment and outcome of intracranial hemorrhage P.M. Fitzhardinge, Department of Pediatrics, Unioersity of Toronto, Mount Sinai Hospital, 600 University Avenue, Toronto, Ontario MSG 1X5, Canada Computed tomography (CT) and ultrasound (U/S) surveys of the brains of very low. birthweight infants have shown a remarkably consistent incidence of germinal layer (GLH) and intraventricular hemorrhage (IVH). Most studies report such