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2016-07-06  Intracranial hemorrhage  © Nguyen T. Ha  www.TheFetus.net

Intracranial hemorrhage

Long H Nguyen1, Trang Thu T. Nguyen2Nguyen T. Ha3

1. Hue University of Medicine and Pharmacy, Vietnam.
2. Imaging diagnostic Department, Tu Du Maternal Hospital, Vietnam.
3. Director of Imaging diagnostic Department, Tu Du Maternal Hospital, Vietnam.



Case report

A 27-year old nulliparous pregnancy was referred to our department at 36 weeks because of an abnormal scan in another centre. She had a normal obstetrical history.

Our ultrasound and MRI examinations suggest the diagnosis of intracranial hemorrhage. 

Images 1-4: 2D axial views of the head show an inhomogeneous and unclearly border mass displacing medially the left cerebral hemisphere, and connected to the subdural space. The normal landmarks of left cerebral hemisphere was disordered. The left cerebral hemisphere was enlarged and pushing the midline to the right side. (images 1 and 2).  BPD was at 99% and HC at 98% of percentile, respectively.

  



Images 5 and 6: 2D coronal images of the head showing the outer border of the left lateral ventricle was not clear compared with contralateral side. The normal landmards of left cerebral hemisphere seem ill-defined.

 


Images 7: 2D sagital image of the fetal head s
hows normal corpus callosum.





Images 8: spectral doppler analysis of the middle cerebral artery. S/D: 11, RI: 0.9, PI: 1.8 and i
ncreased peak systolic velocity: 108 cm/s. Fetal heart rate was 167 beats/minute.





Image 9: multiplanar
 T2 weighted views of the fetal head showing a large chronic subdural hematoma from the left frontal to occipital lobe. It compressed the underlying left cerebral parenchyma resulting in midline shift of 7mm and contralateral ventricular dilatation (14 mm)





Video 1: 2D images showing the abnormal mass in the left cerebral hemisphere.

 


Outcome: the fetus died spontaneously one week later. The parent refused the autopsy.



Intracranial hemorrhage


Definition

- Bleeding within fetal cranium.

- An intracranial hemorrhage (ICH) is a collection of extravasated blood occurring in the fetal brain, usually affecting the lateral ventricles, although it can occasionally be found in other parts of the brain.


Synonymous: germinal matrix hemorrhage, intraventricular  hemorrhage, intraparenchymal hemorrhage and subdural hematoma.


Prevalence: Overall  estimated  incidence  of  1:10,000 pregnancies.


Etiology


- Alterations in maternal-fetal blood pressure:

            + Maternal seizure disorder-acute abdomen

            + Drug use: Cocain, aspirin

            + Maternal  hemorrhagic disorders,  maternal  hypotension, HELLP syndrome.

            + Complications of monochorionic twin pregnancies

 

- Trauma: fetal subdural hematomas can be caused by trauma

 

 - Maternal thrombocytopenia-coagulation disorders:

            + Immune thrombocytopenic purpura, alloinmune thrombocytopenia, and hidden antiplatelet

autoantibodies.

            + Factor V or X deficiency, coumadin therapy


- Bacterial/viral infection

 

-Abnomalies of umbilical cord, placenta, amniocentesis complication



Pathogenesis: postnatally, most intraventricular hemorrhages originate in the subependymal germinal matrix region. In the premature brain, the germinal matrix contains thin-walled friable vessels supported by a delicate matrix that is easily injured by any elevation of the cerebral blood pressure, as in fetal hypoxia  or  thrombosis. It  is  unclear  whether  the  pathophysiology is the same in intrauterine hemorrhage.


Ultrasound diagnosis:


- Hemorrhage usually extensive when diagnosed in utero: normal intracranial landmarks often obscured

- Intraparenchymal

            + Hyperechoic mass within parenchyma

            + Porencephaly develops with time

- Subependymal

            + Same appearance/grading as neonatal GMH

- Intraventricular

            + Hyperechoic intraventricular clot

            + Irregular bulky choroid plexus

            + Echogenic, irregular ependyma

            + Hydrocephalus

- Subdural

            + Hyperechoic material outlining cortex

            + Separates Sylivian fissure from calvarium: normal distance cortex to skull vault ≤ 4mm.


Classification: ICH is commonly classified by severity into four grades, as follows:


- Grade I: limited to the subependymal matrix

- Grade II : clear  spillover  to  the  ventricles  but  filling less  than  50%  of  the  lateral  ventricle  (without  acute ventriculomegaly)

- Grade III: spillover  to  the  ventricles  with  filling  more than  50%  of  the  lateral  ventricle  (with  acute ventriculomegaly)

- Grade IV: characteristics of grades I to III with destruction of periventricular parenchyma
 

Differential diagnosis:

- Intracranial tumor

            + Large, heterogeneous, rapid growth

            + Caution: intracranial tumors may bleed, look for blood flow in periphery of mass with color Doppler.                Clot is not perfused, tumor will show flow

            + Macrocephaly common

            + Choroid plexus papilloma is a potential mimic for intraventricular clot

- Infection

            + May cause detructive brain lesions

            + Intracranial/liver calcifications, hydrops.

- Ischemia

            + Periventricular leukomalacia


Prognosis: the prognosis for ICH largely depends on the severity of the condition, which ranges from mild neurologic deficits to neonatal death. A 50% perinatal death rate and 50% neurologic compromise in survivors have been reported, and the grade of hemorrhage correlates with the severity of the prognosis. The risk of recurrence depends on the underlying cause. Patients with alloimmune thrombocytopenia carry a very high (85% to 90%) recurrence risk of ICH.


Management: the management options are mainly based on timely termination of pregnancy in severe cases, and conservative approaches including early postnatal neurological evaluation, shunting operation, and implementing special rehabilitation program in milder cases.

 
 
Referrences:

           1. Joshua A. Copel et al (2012), Obstetric Imaging, Intracranial Hemorrhage, p. 236 – 237.

2. Paula J. Woodward, Anne Kennedy, Roya Sohaey, Janice L.B. Byrne, Karen Y. Oh, Michael D. Puchalski (2005), Diagnostic Imaging Obstetrics, Intracrainal Hemorrage, p. 2-64 – p.2-68

 

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