Intracranial hemorrhage in term neonates

BACKGROUND: Intracranial hemorrhage (ICH) is an uncommon but important cause of morbidity and mortality in term neonates; currently, ICH is more frequently diagnosed because of improved neuroimaging techniques. PURPOSE: The study aims to evaluate the clinical characteristics and neuroimaging data (pattern, size, distribution) of neonatal ICH. METHODS: We reviewed MRI data from July 2004 to June 2015 for 42 term neonates with ICH who were less than 1 month old. We recorded clinical data and manifestations, mode of delivery, Apgar score at 1 and 5 min, associated hypoxic insult, birth trauma, neurological symptoms, EEG results, extent and site of hemorrhage, neurosurgical intervention, and developmental outcomes. The clinical outcome was determined for 27 neonates. Risk factors were assessed in relation to ICH. RESULTS: A total of 42 neonates who presented with ICH underwent MR imaging 2 to 22 days postnatally (mean age 9.3 days). The majority of clinical symptoms were present in patients within the first 24 h of life (n = 31), but symptoms appeared until day 10 postnatally (mean 4.9 days, n = 11). Seizure or seizure-like activity was the most common presenting symptom (17/42, 40.5%), with apnea seen in another seven infants (7/42, 16.7%). The majority of infants had a normal prenatal course. Two patients had antenatally detected hydrocephalus. Ten had infratentorial hemorrhage, and two had supratentorial hemorrhage. A total of 30 infants had a combination of infratentorial and supratentorial hemorrhage. Subdural hemorrhage (SDH) was the most common type of hemorrhage (40/42, 95.2%), followed by nine cases of parenchymal hemorrhage, seven of subarachnoid hemorrhage, three of germinal matrix hemorrhage (GMH), and one of epidural hemorrhage (EDH). A total of 16 infants had two or more types of hemorrhage. SDH was identified along the tentorium (n = 38) as well as over the cerebellar hemispheres (n = 39), along the interhemispheric fissure (n = 10), and over the occipital (n = 13) or parietooccipital (n = 11) lobes. Intraparenchymal hemorrhage involved either the frontal (n = 4), parietal (n = 3), or cerebellar (n = 2) lobes. Traumatic delivery was suspected in 20 patients (47.6%), and perinatal asphyxia was present in 21 patients (50.0%). A low Apgar score at 5 min and a history of perinatal asphyxia were the factors that most predicted poor clinical outcomes (n = 12/27). Logistic regression analysis revealed that a history of perinatal asphyxia resulted in poor outcomes. No patients died. One infant required burr hole drainage of a right parietal EDH, one infant needed a subcutaneous reservoir, and three infants required a ventriculoperitoneal shunt for obstructive hydrocephalus. CONCLUSION: SDH was the most common type of ICH in term infants. Combined supratentorial and infratentorial hemorrhage was more common than isolated infratentorial hemorrhage in these infants. A total of 44.4% of patients had poor outcomes, with perinatal asphyxia the most common statistically significant cause.