Subependymal germinal matrix hemorrhage in full term neonates

1985;75;714Pediatrics House and Leonard E. Swischuk C. Keith Hayden, Jr, Karen E. Shattuck, C. Joan Richardson, Deborah K. Ahrendt, Ray Subependymal Germinal Matrix Hemorrhage in Full-Term Neonates http://pediatrics.aappublications.org/content/75/4/714 the World Wide Web at: The online version of this article, along with updated information and services, is located on ISSN: 0031-4005. Online ISSN: 1098-4275. PrintIllinois, 60007. Copyright © 1985 by the American Academy of Pediatrics. All rights reserved. by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, at Viet Nam:AAP Sponsored on February 10, 2014pediatrics.aappublications.orgDownloaded from at Viet Nam:AAP Sponsored on February 10, 2014pediatrics.aappublications.orgDownloaded from 714 PEDIATRICS Vol. 75 No. 4 April 1985 Subependymal Germinal Matrix Hemorrhage in Full-Term Neonates C. Keith Hayden, Jr, MD, Karen E. Shattuck, MD, C. Joan Richardson, MD, Deborah K. Ahrendt, MD, Ray House, MD, and Leonard E. Swischuk, MD From the Departments of Radiology and Pediatrics, The University of Texas Medical Branch, Galveston ABSTRACT. A population of healthy, full-term newborn infants was studied in order to obtain documentation of the prevalence of intracranial hemorrhage. Cerebral ultrasonography was performed within 72 hours of birth on 505 healthy newborn infants, 37 weeks of gestation or greater. Sonographic abnormalities were detected in 23 (4.6%) neonates. Bilateral subependymal germinal matrix hemorrhage occurred in 14 and unilateral hemorrhage in five infants. Other abnormalities detected included agenesis of the corpus callosum in two infants, a cyst involving the subependymal germinal matrix in one (presumably the result of a previous subependymal hemorrhage), and mild ventricular dilation of unknown etiol- ogy in one. Newborns with subependymal hemorrhage were compared with newborns without hemorrhage in order to determine whether any significant differences existed between the two populations. No significant differences existed between infants with and without subependymal hemorrhage with regard to gender, obstetrical presentation, use of forceps, birth trauma, Apgar scores, need for resuscitation, maternal age and parity, and neonatal clinical problems. Infants with subependymal hemorrhage were of significantly lower gestational age and birth weight; the overall difference in weight was attributable to lower weight in female infants with subependymal hemorrhage. Significantly more infants with subependymal hemorrhage were small for gestational age, vaginally delivered, and black. Pediatrics 1985;75:714- 718; intracranial hemorrhage, subependymal hemorrhage, premature infants. Spontaneous intracranial hemorrhage in the newborn infant is frequently associated with prematurity, trauma, and asphyxia;6 the very low- birth-weight infant of less than 1,500 g appears to Received for publication Aug 20, 1984; accepted Oct 16, 1984. Reprint requests to (C.K.H.) Department of Radiology, Child Health Center, The University of Texas Medical Branch, Gal- veston, TX 77550. PEDIATRICS (ISSN 0031 4005). Copyright © 1985 by the American Academy of Pediatrics. be the most vulnerable.7’8 The association between prematurity and intracranial hemorrhage has been strengthened by routine use of computed tomography,9’2 and more recently by ultrasonography.135 Using these newer modalities, intracranial hemorrhage has been demonstrated to occur in 40% to 83% of unselected preterm neonates!6’9 Intracranial hemorrhage in the full-term infant, however, appears to be much less common than in the premature infant. Several case reports and a few small series have recently appeared in the lit- erature,2031 but these have not been comprehensive studies and have not examined the prevalence of hemorrhage in the general newborn population. Thus, we studied prospectively a population of neonates, 37 weeks ofgestation or greater, to determine the prevalence of intraparenchymal and intraventricular hemorrhage. SUBJECTS AND METHODS Sonographic evaluation of the intracranial struc- tures was performed within 72 hours of birth on 505 neonates of 37 weeks of gestation or greater who were admitted during a 6-week period to the normal newborn nursery at the University of Texas Medical Branch, Galveston. The study was ap- proved by the Institutional Review Board; written, informed parental consent was obtained for all ha- bies who participated. Examination was performed in the nursery using a commercially available Technicare real-time sec- tor scanner with a 5 MHz, 13-mm head with an optimal focal depth of 2 to 6 cm. Patients were scanned in the coronal, sagittal, and parasagittal planes, using the anterior fontanel as an acoustic window. The study population consisted of 265 male and 240 female infants. Birth weight was 3,321 ± 459 g at Viet Nam:AAP Sponsored on February 10, 2014pediatrics.aappublications.orgDownloaded from ARTICLES 715 (mean ± SD) and gestational age was 39.3 ± 1.2 weeks (mean ± SD). Route of delivery was vaginal in 383 (75.8%) infants and cesarean section in 122 (24.2%). When classified according to established standards of intrauterine growth,32 404 (80%) infants were appropriate for gestational age, nine (1.8%) were small for gestational age, and 92 (18.2%) were large for gestational age. The group included 274 (54.3%) Anglo-Americans, 121 (24%) blacks, 105 (20.8%) Mexican-Americans, and five (1.0%) Asians. RESULTS Of 505 infants studied, 480 (95%) had normal findings on sonogram. Two infants had sonograms that were inadequate for proper interpretation, and 23 had abnormal findings on sonogram. The follow- ing abnormalities were found: mild lateral ventricular dilation in one infant; agenesis of the corpus callosum in two infants; subependymal germinal matrix hemorrhage in 19 infants (bilateral in 14, left unilateral in four, right unilateral in one); and a cyst of the left subependymal germinal matrix in one infant. This latter infant apparently had an old subependymal hemorrhage with complete cystic degeneration, and this infant is included in the group with subependymal hemorrhage. Three other infants with subependymal hemorrhage also showed evidence of cystic degeneration within the area of hemorrhage. Bilateral subependymal hemorrhage is shown in the Figure. None of the 20 newborn infants with unilateral or bilateral subependymal hemorrhage demonstrated direct evidence of intraventricular bleeding as manifested by an echogenic clot or cast forma- tion within the ventricular system. However, two infants, both with bilateral subependymal hemorrhages, demonstrated indirect evidence suggesting some degree of intraventricular extension. Both infants had lateral ventricular dilation, and one demonstrated third ventricular dilation as well. These findings would suggest the possibility of intraventricular extension causing ventricular or ex- traventicular hydrocephalus. Infants with subependymal hemorrhage were compared with the 480 newborns with normal findings on sonogram in order to determine any significant differences between the two populations (Table). No differences existed between infants with and without hemorrhage with regard to gender, obstetrical presentation (vertex v breech), use of forceps, one- and five-minute Apgar scores, need for resuscitation, and maternal age and parity. There was a significant difference with regard to birth weight and gestational age. Babies with subependymal hemorrhage were of lesser gestational age and lower birth weight. The difference in weight, however, was attributable to lower weight in female infants and black infants with subependymal hemorrhage. As shown in the Table, female infants with hemorrhage were of significantly lower birth weight than female infants without hemorrhage. Blacks with hemorrhage had lower birth weight than blacks without hemorrhage. Significantly more babies with subependymal hemorrhage were small for gestational age, were delivered vaginally, and were black. The three infants who were small for gestational age and who had hemorrhage were black and female. All infants were examined for evidence of birth trauma and were monitored during their nursery stay for the occurrence of clinical problems. Neither trauma nor clinical problems were more frequent or more severe in the group of infants who had subependymal hemorrhages. None ofthe babies had clinical symptoms suggesting the presence of hemorrhage. DISCUSSION The true incidence of intracranial and/or intraventricular hemorrhage in the term newborn has not been established. Intracranial hemorrhage in term neonates was once thought to be primarily subdural or subarachnoid, and to be related to birth trauma. Hemorrhage into the ventricles was almost exclusively considered a problem of the premature infant, although such hemorrhages were described in term infants examined at autopsy by Craig3 and others.34’35 More recently, other reports203’ of term infants with intraventricular hemorrhage demonstrated by computed tomography and ultrasonography have emerged. Term infants who sustain intracranial hemorrhage often have other associated problems including coagulation defects, severe asphyxia, or significant birth trauma.25’’3637 These patients typically are symptomatic at birth and may die shortly there- after.2125,3435m,39 More recently,26’2931 other term infants with intracranial hemorrhage who have no evidence of asphyxia, trauma, or coagulopathy have been described. Although most of these infants develop clinical symptoms such as apnea or sei- zures, virtually all survive their hemorrhage.26’3’ The infants in our study differed form those pre- viously described in that they were all asymptomatic. Intraventricular hemorrhage in the term neonate has been reported to arise primarily from the cho- roid plexus.35’39 Hemorrhage arising from the subependymal germinal matrix has also been docu- mented.242629’38 The area of the germinal matrix is most extensive early in gestation and decreases in at Viet Nam:AAP Sponsored on February 10, 2014pediatrics.aappublications.orgDownloaded from :: _:4 #{163} 716 SUBEPENDYMAL GERMINAL MATRIX HEMORRHAGE r w 13 ‘I 13 Figure. Bilateral subependymal hemorrhage. Top, Coronal scan demonstrating bilateral subependymal hemorrhages (arrows) with slight dilation of lateral ventricles (V). Bottom, Parasagittal scan demonstrating subependymal hemorrhage (arrows) with small cystic area in center. at Viet Nam:AAP Sponsored on February 10, 2014pediatrics.aappublications.orgDownloaded from ARTICLES 717 TABLE. Characteristics of Neonates With and Without Subependymal Hemorrhage (SEH) No SEH SEH Significance Gender Male 252 (52.5)* 10 (50) NS Female - 228 (47.5) 10 (50) NS Gestational age (wk) 39.4 ± 1.2t 38.8 ± 1.1 .02 Birth weight (g) 3,327 ± 448 3,078 ± 539 .02 By gender Male 3,397 ± 441 3,270 ± 516 NS Female 3,249 ± 445 2,886 ± 515 .01 By race/ethnicity Anglo-American 3,360 ± 435 3,509 ± 316 NS Black 3,199 ± 415 2,780 ± 510 .003 Mexican-American 3,378 ± 488 2,804 NS Asian 3,293 ± 692 2,892 NS Classification Appropriate for gesta- 386(80.4) 16 (80) NS tional age Small for gestational age 6 (1.3) 3 (15) <.005 Large for gestational age 88 (18.3) 1 (5) NS Race/Ethnicity Anglo-American 264 (55.0) 8 (40) NS Black 109 (22.7) 10 (50) .0005 Mexican-American 103 (21.5) 1 (5) NS Asian 4 (0.8) 1 (5) NS Delivery Vaginal 362 (75.4) 19 (95) .04 Cesarean section 118 (24.6) 1 (5) * Values in parentheses are percents. t Values are mean ± SD. :1:Student’s t test. §x2test. size after 32 weeks.7’8 However, remnants of the germinal matrix are present at term. It persists longest in the perivascular tissue, and at term, there are scattered islands of matrix cells in the ventricular wall with a thick cushion in the region of the caudate nucleus and thalamus.4#{176} In this study, 20 of 505 newborns had evidence of asymptomatic, localized subependymal germinal matrix hemorrhage. This underscores the importance of the subependymal germinal matrix in the region of the caudate nucleus as a potential site of hemorrhage in the term newborn. The factors predisposing to the hemorrhages in the infants we studied are not known. When compared with the group of infants without hemorrhage, the 20 infants with evidence of germinal matrix bleeding were smaller and of slightly lower gestational age. The overall difference in weight was attributable to lower weight in female infants and in black infants who had hemorrhage, and was primarily accounted for by three small-for-gestational-age black female infants in the group with hemorrhage. Proportionally more infants with hemorrhage were black, were small for gestational age, and were delivered vaginally. Although these differences are statistically significant, their clinical importance is not clear. These findings produce some intriguing associations but provide no real clues to causation. All of our patients were studied within 72 hours of birth and most within 24 to 48 hours of birth. This did not permit us to time the occurrence of the hemorrhage as has been done in studying the premature infant.41 However, in four of the 20 infants, hemorrhage most probably occurred in utero. In one infant, a cyst involving the region of the left subependymal germinal matrix area was demonstrated. Although such cysts have been described in association with intrauterine infections, cerebrohepatorenal syndrome, and ventriculitis,42 this infant had no evidence of any of these problems. Thus, we conclude that the cyst resulted from a subependymal germinal matrix hemorrhage that occurred in utero. Three other infants with subependymal hemorrhage also demonstrated cystic degeneration of the hemorrhagic area; this finding suggested that the hemorrhages were older, were in stages of resolution, and most probably occurred in utero. Hemorrhage into the subependymal germinal matrix is primarily a problem of the premature infant. This study demonstrates, however, that at Viet Nam:AAP Sponsored on February 10, 2014pediatrics.aappublications.orgDownloaded from 718 SUBEPENDYMAL GERMINAL MATRIX HEMORRHAGE such hemorrhages occur with relative frequency (4%) in the term newborn and the hemorrhages may be clinically silent. Although the cause of the hemorrhage is unknown, infants who appeared at greatest risk were black, vaginally delivered, and small for gestational age. ACKNOWLEDGMENTS This work was supported by grant NS 07377-14 from the National Institute of Neurological and Communica- tive Disorders and Stroke, National Institutes of Health. The authors thank Nancy Bertolino, RN, and Lela Thomas, RN, for their help with this project. REFERENCES 1. Cole VA, Durbin GM, Olaffson A, et al: Pathogenesis of intraventricular haemorrhage in newborn infants. Arch Dis Child 1974;49:722-728 2. Hambleton J, Wigglesworth JS: Origin of intraventricular haemorrhage in the preterm infant. Arch Dis Child 1979;51:651-659 3. Kenny JD, Garcia-Prats JA, Hilliard JL, et al: Hypercarbia at birth: A possible role in the pathogenesis of an intraventricular hemorrhage. Pediatrics 1978;62:465-467 4. Moriette G, Relier JP, Larroche J: Intraventricular hemorrhage during the course of hyaline membrane disease. Arch Fr Pediatr 1979;34:492-504 5. Towbin A: Central nervous system damage in the human fetus and newborn infant. Am J Dis Child 1970;1 19:529-542 6. Tsiantos A, Victorin L, Relier JP, et al: Intracranial hemorrhage in the prematurely born infant. J Pediatr 1974;85:854-859 7. Volpe JJ: Neonatal intracranial hemorrhage: Pathophysiol- ogy, neuropathology, and clinical features. Clin Perinatol 1977;4:77-102 8. Volpe JJ: Neonatal periventricular hemorrhage: Past, present, and future. J Pediatr 1978;92:693-696 9. Lee BCP, Grassi AE, Schechner 5, et al: Neonatal intraventricular hemorrhage: A serial computed tomography study. J Comput Assist Tomogr 1979;3:483-490 10. Rumack CM, McDonald MM, O’Meara OP, et al: CT de- tecting in course of intracranial hemorrhage in premature infants. AJR 1978;131:493-497 11. Burstein J, Papile LA, Burstein R: Subependymal germinal matrix and intraventricular hemorrhage in premature newborns: Diagnosis by CT. AJR 1977;128:971-976 12. Burstein J, Papile LA, Burstein R: Intraventricular hemorrhage and hydrocephalus in premature newborns: A prospective study with CT. AJR 1979;132:613-635 13. London DA, Carroll BA, Enzmann DR: Sonography of yen- tricular size and germinal matrix hemorrhage in premature infants. AJR 1980;135:559-564 14. Grant EJ, Schellinger D, Borts FT, et al: Real time sonography of the neonatal and infant head. AJR 1981;136:265- 270 15. Sauerbrei EE, Digney M, Harrison PB, et al: Ultrasono- graphic evaluation of neonatal intracranial hemorrhage and its complications. Radiology 1981;139:677-685 16. Papile LA, Burstein J, Burstein R, et al: Incidence and evaluation of subependymal intraventricular hemorrhage: A study of infants with birth weights less than 1500 grams. J Pediatr 1978;92:529-534 17. Ahmann PA, Lazzara A, Dykes FD, et al: Intrayentricular hemorrhage in the high risk preterm infant: Incidence and outcome. Ann Neurol 1980;7:118-124 18. Bejar R, Curbelo V, Coen RW, et al: Diagnosis and follow- up of intraventricular and intracerebral hemorrhages by ultrasound studies of infant’s brain through the fontanelles and sutures. Pediatrics 1980;66:661-673 19. Palma PA, Morriss FH, Miner ME, et al: Prospective survey of intraventricular hemorrhage in infants less than 1800 grams. Pediatr Res 1980;14:635 20. Chaplin ER Jr, Goldstein GW, Norman D: Neonatal sei- zures, intracerebral hematoma, and subarachnoid hemorrhage in full-term infants. Pediatrics 1979;63:812-815 21. Palma PA, Miner ME, Morriss FH, et al: Intraventricular hemorrhage in the neonate born at term. Am J Dis Child 1979;133:941-944 22. Cartwright DW, Culbertson K, Schreiner RL, et al: Changes in clinical presentation of term infants with intracranial hemorrhage. Dev Med Child Neurol 1979;21:730-737 23. Leblanc R, O’Gorman AN: Neonatal intracranial hemorrhage: A clinical and serial computerized tomographic study. J Neurosurg 1980;53:642-651 24. Guekos-Thoni U, Boltshauser E, Mieth D, et al: Intracranial hemorrhage in the term infant confirmed by computed tomography. Helv Paediatr Acta 1980;35:531-544 25. Baleriaux D, Ticket L, Dony D, et al: The contribution of CT to perinatal intracranial hemorrhage including that ac- companying apparently uncomplicated delivery at full term. Neuroradiology 1980;19:273-277 26. Ludwig B, Brand M, Brockerhoff P: Postpartum CT examination of the heads of full term infants. Neuroradiology 1980;20:145-154 27. Flodmark 0, Scotti G, Hardwood-Nash DC: Clinical significance of ventriculomegaly in children who suffered perinatal asphyxia with or without intracranial hemorrhage: An 18 month follow-up study. J Comput Assist Tomogr 1981;5:633-673 28. Guekos-Thoeni U, Boltshauser E, Willi UB: Intraventricu- lar hemorrhage in full-term neonates. Dev Med Child Neurol 1982;24:704-705 29. Mackay P1J, Crespigny L, Murton U, et al: Intraventricular hemorrhage in term neonates: Diagnosis by ultrasound. Aust Paediatr J 1982;18:205-207 30. Scher NS, Wright FS, Lockman LA, et a!: Intraventricular hemorrhage in the full-term neonate. Arch Neurol 1982;39:769-783 31. Meidell R, Marinelli PE, Randall V, et al: Intracranial parenchymal hemorrhage in a full-term infant: An unusual clinical presentation with ultrasonographic diagnosis. Clin Pediatr 1983;22:780-783 32. Lubchenco LO, Hansman C, Dressier M, et al: Intrauterine growth as estimated from live born birth weight data at 24 to 42 weeks of gestation. Pediatrics 1966;37:403-408 33. Craig WS: Intracranial hemorrhage in the newborn. Arch Dis Child 1983;13:89-123 34. Fedrick J, Butler NR: Certain causees of neonatal death: II. Intraventricular hemorrhage. Biol Neonate 1970;15:257-290 35. Lacey DJ, Terplan K: Intraventricuiar hemorrhage in full term neonates. Dev Med Child Neurol 1982;24:332-337 36. Lorber J, Lilleyman JS, Peile EF: Acute infantile thrombo- cytosis and vitamin K deficiency associated with intracranial hemorrhage. Arch Dis Child 1979;54:471-472 37. McCarthy JW, Coble LL: Intracranial hemorrhage and sub- sequent hydrocephaius in a neonate with classical hemo- philia. Pediatrics 1973;51:122-124 38. Maki Y, Shirai 5: Angiographic findings in intraventricular hemorrhage in newborn infants. Acta Radio! 1975;347:167- 174 39. Donat JF, Okazaki H, Kleinberg F, et al: Intraventricular hemorrhage in full-term and premature infants. Mayo Clin Proc 1978;53:437-441 40. Friede RL: Developmental Neuropathology. New York, Springer-Verlag, 1974, pp 7-8 41. Partridge JC, Babcock DS, Steichen JJ, et al: Optimal timing for diagnostic cranial ultrasound in low birth weight infants: Detection of intracranial hemorrhage and ventricular dilatation. J Pediatr 1983;102:281-287 42. Shackelford GD, Fulling KH, Glasier CM: Cysts of the subependymal germinal matrix: Sonographic demonstration with pathologic correlation. Radiology 1983;149:1 17-121 at Viet Nam:AAP Sponsored on February 10, 2014pediatrics.aappublications.orgDownloaded from 1985;75;714Pediatrics House and Leonard E. Swischuk C. Keith Hayden, Jr, Karen E. Shattuck, C. Joan Richardson, Deborah K. 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