CASE 1102 Published on 13.08.2001
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Germinal matrix related intraventricular hemorrhage of the premature infant

Section

Neuroradiology

Case Type

Clinical Cases

Authors

S. Cakirer

Connected authors
Patient

2 days, male

Categories
No Area of Interest ; Imaging Technique MR
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Clinical History
A 2-day-old baby boy, was referred for MRI because of increasing head circumference. The baby was born prematurely, at 31 weeks gestation, via normal vaginal delivery.
Imaging Findings
A 2-day-old baby boy, was referred for MRI because of increasing head circumference. The baby was born prematurely, at 31 weeks gestation, via normal vaginal delivery. The Apgar score was low (9). An MRI examination of the brain was performed on a 1.5 T system, using SE T1 and FSE T2-weighted sequences in three orthogonal imaging planes. The examination revealed a small subependymal hematoma located at the left thalamo-caudate notch.There was also intraventricular blood (with hemorrhagic sedimentation levels), and triventricular hydrocephalus. Additionally, the myelination process was immature (consistent with premature birth), and the amount of white matter appeared decreased. The baby died on the next day.
Discussion
Germinal matrix (GM) is a highly vascular subependymal tissue. GM is located adjacent to lateral ventricles and to roof of third and fourth ventricles. GM has its largest volume around 26 weeks of gestation, and it involutes usually by 32-34 weeks of gestation. The rich capillary network of the germinal matrix consists of persisting immature vessels, and it does not contain any supporting connective tissue. GM bleeding usually occurs in premature neonates who are less than 32 weeks of age. Most of the GM bleeds occur on the first day of life (36 %). Almost 91 % of GM bleeds occur by the sixth day of life. The most common risk factor for GM bleeding is the prematurity. Other risk factors are low birth weight, male gender, multiple gestations, trauma at delivery, prolonged labor, hyperosmolarity, hypocoagulation, pneumothorax. GM bleeds are most commonly located at the region of the caudate nucleus and thalamostriate groove, so called caudothalamic notch. Papile classification divides GM bleeds into four grades. Grade I is characterized by subependymal hemorrhage confined to germinal matrix; grade II by subependymal hemorrhage ruptured into nondilated ventricle; grade III by intraventricular hemorrhage with ventricular enlargement; and grade IV by extension of germinal matrix hemorrhage into brain parenchyma. The patients clinically may present with seizures, dystonia, obtundation, intractable acidosis, bulging anterior fontanel, drop in hematocrit level, bloody cerebrospinal fluid. Ultrasonography, computed tomography and MRI detect the definite site of GM bleeding, extension of the hemorrhage into the parenchyma and ventricular compartment, and areas of ischemic damage, with high sensitivity and specificity rates. Complications are posthemorrhagic hydrocephalus in 30-70 % of the patients, porencephalic cyst formation, mental retardation, cerebral palsy, and death in 25% of the patients.
Differential Diagnosis List
1. Germinal matrix hemorrhage in a premature infant. 2. Intraventricular hemorrhage.
Final Diagnosis
1. Germinal matrix hemorrhage in a premature infant. 2. Intraventricular hemorrhage.
Case information
URL: https://www.eurorad.org/case/1102
DOI: 10.1594/EURORAD/CASE.1102
ISSN: 1563-4086
Figure 1

Figure 1

Figure 1
Axial SE T1-weighted image shows that bilateral lateral ventricles are enlarged with intraventricular posterior layering of hemorrhagic elements of intracellular methemoglobin, seen as hyperintense layering (arrows). Note that both the amount and the myelination of the white matter have seriously decreased. Septum pellucidum is also absent.
Figure 1
Sagittal SE T1-weighted image shows marked enlargement of the lateral ventricles. Hemorrhagic sedimentation levels are observed in the occipital horns (arrows). Note that both the amount and the myelination of the white matter are decreased.
Figure 1
Coronal FSE T2-weighted image shows enlargemend of the lateral ventricles and of the third ventricle. The volume of the cerebral white matter is decreased with hyperintense signal intensity changes, presumably representing undermyelination of the white matter. A small subependymal hypointense area (arrow) is seen within the left caudate nucleus, consistent with a germinal matrix hemorrhage.