Thalamic hemorrhage with intraventricular hemorrhage in the full term newborn

In a review of 19 full-term infants with intraventricular hemorrhage diag-nosed on computed tomography prior to 1 month of age, thalamic hemorrhage associated with the intraventricular

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1990;85;737

Pediatrics

Elke H Roland, Olof Flodmark and Alan Hill

Thalamic Hemorrhage With Intraventricular Hemorrhage in the Full-Term Newborn

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Thalamic Hemorrhage With Intraventricular

Elke H Roland, MD; Olof Flodmark, MD, PhD; and Alan Hill, MD, PhD

ABSTRACT. Intraventricular hemorrhage is an

uncom-mon problem in the full-term newborn In a review of 19

full-term infants with intraventricular hemorrhage

diag-nosed on computed tomography prior to 1 month of age,

thalamic hemorrhage associated with the intraventricular

hemorrhage was documented in 12 infants Thus,

tha-lamic hemorrhage appears to be the most common source

of intraventricular hemorrhage in this age group,

partic-ularly in infants who had uneventful birth histories and

in whom clinical abnormalities (signs of increased

intra-cranial pressure, seizures, altered level of consciousness)

developed after the first week of life The majority of

these infants had predisposing factors for cerebral venous

infarction such as sepsis, cyanotic congenital heart

dis-ease, and coagulopathy The clinical appearance and

out-come for infants with thalamic

hemorrhage/intraventric-ular hemorrhage were similar to those in infants with

intraventricular hemorrhage originating from other

sites, except for an increased incidence of cerebral palsy

in infants with thalamic hemorrhage/intraventricular

hemorrhage Definitive diagnosis was made on the basis

of characteristic radiologic abnormalities. Pediatrics

1990;85:737-742; thakimic hemorrhage, intraventricular

hemorrhage, newborn, cerebral infarction.

the premature infant as a result of rupture of fragile

vessels in the subependymal germinal matrix In

contrast, intraventricular hemorrhage occurs much

less frequently in the full-term newborn

infarc-tion Occasionally, intraventricular hemorrhage

may result from coagulopathy.”2

intra-ventricular hemorrhage, we identified an unusually

high incidence of thalamic hemorrhage in

study, we describe the clinical appearance, associ-ations, and radiologic features and sequelae at 18 months of age in this group of infants In addition,

we provide a review of the literature on the uncom-mon entity of thalamic

hemorrhage/intraventricu-lar hemorrhage in the full-term newborn

METHODS Study Population

1980 and May 1987 in whom intraventricular

only pediatric tertiary referral center for the

full-term deliveries per year Infants who had

intra-cerebral, subdural, subarachnoid, or posterior fossa

clinical and radiologic features as well as the

association with intraventricular hemorrhage

Radiologic Investigations

Received for publication May 2, 1988; accepted Jun 2, 1989.

Reprint requests to (A.H.) Division ofNeurology, British

Colum-bia’s Children’s Hospital, 4480 Oak St, Vancouver, British

Co-lumbia, Canada V6H 3V4.

American Academy of Pediatrics.

enhance-ment were performed on all infants, often at the

referring hospital at the time of onset of clinical

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enhance-738 THALAMIC HEMORRHAGE AND NEWBORN

original diagnosis of intraventricular hemorrhage

in an attempt to identify underlying

cerebrovascu-lar abnormalities Scans were performed with a

General Electric 8800 CT/T scanner Axial and

using a window width of 60 Hounsfield units and a

window level of 30 Hounsfield units.

Cerebral ultrasonography was not performed

rou-tinely at the onset of clinical abnormalities, either

because of lack of easy availability of the technique

at the referring hospitals during the initial years of

the study or because it was considered redundant

following diagnosis by CT Serial cranial ultrasound

posthemor-rhagic ventricular dilation Cerebral angiography

was performed in three of the infants with thalamic

obtained using a magnification technique

Neurologic Outcome

pe-diatric neurologist on all infants at 18 months of

age Developmental outcome was assessed

classified as follows: (1) normal; (2) mild/moderate

level, ie, impaired ambulation often associated with

The incidence of neurologic sequelae in infants with

thalamic hemorrhage/intraventricular hemorrhage

was compared with that of infants with

intraven-tricular hemorrhage from other sources

Statistical Analysis

The incidence of neurologic sequelae in infants

with thalamic hemorrhage/intraventricular

hem-orrhage as compared with those with

the Fisher exact test

RESULTS

Radiologic Features

Review of the CT scans of the 19 full-term infants

with intraventricular hemorrhage demonstrated

in-creased tissue attenuation in the region of the

hemor-rhage as the most probable source of

plexus

the infants with thalamic

of illness (Fig 2) Furthermore, increased attenua-tion in the region of the straight sinus (Fig 1) was

observed on noncontrast CT scans of two other

Fig 1. Noncontrast CT scan of brain of full-term

new-born with thalamic hemorrhage/intraventricular hemor-rhage Note increased attenuation in location of straight

sinus (arrow).

Fig 2. Noncontrast CT scan of brain of full-term

new-born with thalamic hemorrhage/intraventricular hemor-rhage Note decreased tissue attenuation (arrow) in

thai-amus adjacent to hemorrhage in thaiamus.

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patients with thalamic

hemorrhage/intraventricu-lar hemorrhage In one patient, failure of

opacifi-cation of the ipsilateral internal cerebral vein

suggestive of venous occlusion was shown in

of Galen, inferior sagittal sinus, and straight sinus

other infants

scans obtained at least 3 weeks after the initial

was normal filling of major cerebral venous sinuses

with contrast material

Clinical Features

sudden onset of dramatic neurologic abnormalities

Prior to this presentation, 16 infants appeared

nor-mal Of the 7 infants in whom intraventricular

Clini-cal features were nonspecific for the site of origin

apnea, lethargy, irritability, bulging fontanel, and

Fig 3. Cerebral angiogram, venous phase, demonstrates

nonopacification of internal cerebral vein at time of

visualization of inferior sagittal sinus (arrow) These two

vascular structures are normally visualized

simultane-ously.

TABLE 1. Time of Onset of Clinical Abnormalities in Full-Term Infants With Intraventricular Hemorrhage

Intraventricular

Residual germinal matrix 3 0 Unknown (possibly choroid 2 2 plexus)

jitteriness

patients in our series are listed in Table 1 The .clinical and radiologic features of the 12 infants in

this series who had thalamic

hemorrhage/intraven-tricular hemorrhage as well as 8 additional infants

abnor-malities occurred early, ie, prior to 48 hours of age,

ma-trix in 3 infants, and most probably originated from

abnor-malities during the first 2 days of life In 3 infants

in whom symptoms developed early, including 1

infant with thalamic hemorrhage/intraventricular

sugges-tive of acute birth asphyxia, eg, Apgar scores of less

delivery

In 12 infants, the birth histories were

in this group Predisposing factors for cerebral ye-nous thrombosis in this group (sepsis, congenital

dis-turbance) were identified in 5 of the 10 infants with

(patients 1, 2, 6, 10, 11)

Neurologic Outcome The neurologic sequelae at 18 months of age are

incidence of developmental delay, hydrocephalus,

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hemor-TABLE 2. Clinical Features of Full-Term Infants With Thalamic Hemorrhage/Intraventricular Hemorrhage

(g)

Complications

Present study

1 M, 3000 12 Vomiting, lethargy, sei- LTH/IVH, nonopaci- Urinary tract

in-zures fication of internal fection

cerebral vein (by

angiogram)

in-zures attenuation in thal- fection

amus

3 F, 2970 6 Opisthotonus, seizures RTH/IVH, normal None

angiogram

tense fontanelle hypertension

7 F, 3140 0.5 Apnea, focal seizures LTH/IVH, decreased None

attenuation in

thal-amus

scores

9 M, 3870 2 Seizures, respiratory Bilateral TH/IVH Asphyxia, cyanotic

disease

11 F, 3170 8 Vomiting, coma RTH/IVH, increased Sepsis

attenuation in straight sinus

12 M, 2970 5 Seizures, apnea LTH/IVH, decreased None

attenuation in thal-amus

Palma et al#{176}

normal Apgar scores

14 M, 3500 26 Opisthotonus, tense LTH/IVH Prolonged rupture

Mitchell and O’Tuama3

15 F, 3850 12 Vomiting, dehydration, LTH/IVH None

tense fontanelle

Trounce et a14

16 F, 3110 11 Vomiting, dehydration, LTH/IVH None

tense fontanelle

ity

tonus, sunsetting

eyes

opisthotonus, abnor-mal eye movements

Primhak and Smith#{176}

20 M, 3340 1.5 Focal seizures, apnea, LTH/IVH Prolonged labor

feeding problems

* Abbreviations: R, right; L, left; TH, thalamic hemorrhage; IVH, intraventricular hemorrhage

hem-infants with intraventricular hemorrhage from orrhage compared with infants with

740 THALAMIC HEMORRHAGE AND NEWBORN

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TABLE 3. Neurologic Outcome at 18 Months of Age*

Intraventricular Hemorrhage and Choroid Plexus!

Intraventricular Hemorrhage (n = 7)

Thalamic Hemorrhage!

Intraventricular Hemorrhage (n = 12)

Values

Developmental delay

* Germinal matrix/intraventricular hemorrhage + choroid plexus/intraventricular hemorrhage and thalamic hemor-rhage/intraventricular hemorrhage were compared using the two-tailed version of Fisher’s exact test.

1 P < 05 denotes statistically significant difference between groups.

hemorrhage/intraventricular hemorrhage (2

pa-tients) appeared normal neurologically at

follow-up In the majority (10 patients), there was at least

mild or moderate developmental delay

DISCUSSION

problem in the full-term newborn In contrast to

the premature newborn, in whom intraventricular

sub-ependymal germinal matrix, the origin of

diverse.13 According to our data, extension of

of intraventricular hemorrhage in the full-term

newborn, an observation that has not been reported

previously in this age group

The pathogenesis of thalamic

not clear Hemorrhage into thalamus and basal

full-term newborn in association with coagulation

disorders1 and hypoxic-ischemic cerebral injury.47

intraventricular hemorrhage Several isolated cases

have been reported of unilateral thalamic

hemor-rhage associated with intraventricular hemorrhage

in full-term newborns who appeared otherwise

healthy.2’3’8’9 In these instances, because of the close

proximity of large venous channels to the

con-sidered to represent a secondary phenomenon

re-sulting from extension of the thalamic hemorrhage

adults and older children in the context of chronic

hypertension.10” Similarly, in studies in both

suggested for intermittent episodes of hypertension

in the genesis of intraventricular hemorrhage in the

patients, however Furthermore, although thalamic

hypoxic-ischemic cerebral injury,47 a role for birth

scores, lack of other evidence of perinatal asphyxia,

in our patients (cerebral angiography was not per-formed in all infants because of its potential mor-bidity in this age group) The absence of vascular

how-ever

The clinical appearance of thalamic hemorrhage!

intraventricular hemorrhage was characterized by

sudden onset of marked neurologic abnormalities

in all patients The clinical features, with the ex-ception of timing of onset of problems, were

gen-erally nonspecific and did not permit diagnosis of

the location of hemorrhage Thus, the clinical

infants with intraventricular hemorrhage of other origin and consisted principally of signs of

in-creased intracranial pressure, seizures, and

dimin-ished level of consciousness In a recent report8 of

4 full-term newborns with thalamic hemorrhage! intraventricular hemorrhage, persistent downward

may be pathognomonic of hemorrhage in this

patients with thalamic

abnormalities, ie, often after 4 days of age, in as-sociation with an uneventful birth history occurred

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742 THALAMIC HEMORRHAGE AND NEWBORN

in the majority of cases of thalamic hemorrhage!

intraventricular hemorrhage (17 of 20 patients).

that thalamic hemorrhage/intraventricular

hemor-rhage may be a result of postnatal causes

Predis-posing factors for venous thrombosis (sepsis,

con-genital heart disease, and hematologic

disturb-ances) were documented in 6 of the 12 infants with

in our study

Although the diagnosis of thalamic hemorrhage!

intraventricular hemorrhage in our patients was

may also be established by cranial

hem-orrhage was less extensive, there was decreased

tissue attenuation in the thalamus adjacent to the

hemorrhage in the CT scans, which is consistent

atten-uation in the region of the straight sinus on CT

scans of two infants with thalamic hemorrhage/

intraventricular hemorrhage performed without

contrast enhancement (Fig 1), as well as the

ab-sence of opacification of the ipsilateral internal

cerebral vein during cerebral angiography in one

patient (Fig 3), raises the possibility that venous

hemorrhagic thalamic infarction.15’16 An

demonstrated previously by neuropathologic

stud-ies in young infants Intraventricular hemorrhage

was not uncommon, presumably because of the

proximity of the larger venous channels to the

ventricular walls.17

cerebral palsy in infants with thalamic

hemor-rhage/intraventricular hemorrhage, the outcome of

these patients did not differ significantly from that

suggested in previous reports3’8’9 of infants with

unilateral thalamic hemorrhage/intraventricular

hemorrhage In contrast, infants with bilateral

tha-lamic hemorrhage following birth asphyxia have

uniformly poor prognosis and have either died or

developed severe neurologic sequelae.47 According

to our data, neurologic sequelae, eg, hydrocephalus,

seizures, and cerebral palsy (especially hemiplegia),

are common following thalamic

of cases Only a minority of infants appeared

neu-rologically and developmentally normal at 18

months of age

hem-orrhage is suggested by our data as a cause of intraventricular hemorrhage in the full-term new-born This is seen especially in infants with Un-eventful birth histories and infants in whom clinical abnormalities develop after 1 week of age Both the clinical appearance during the newborn period and neurologic outcome appear similar to that of full-term infants with intraventricular hemorrhage originating from other sites Thus, although tha-lamic hemorrhage/intraventricular hemorrhage may be suspected on the basis of clinical features, definitive diagnosis is based on radiologic abnor-malities observed either on CT scans, cranial

ultra-sonography, or cerebral angiography.

REFERENCES

1 Volpe JJ. Neurology of the Newborn. Philadelphia, PA: WB Saunders Co; 1987

2 Palma PA, Miner ME, Morriss FH, et al Intraventricular hemorrhage in the neonate born at term. Am J Dis Child.

1979;133:941-944

3. Mitchell W, O’Tuama L Cerebral intraventricular hemor-rhages in infants: a widening age spectrum. Pediatrics.

1980;65:35-39

4 Kotagal 5, Toces 5, Kotagal P, Archer C Symmetric hi-thalamic and striatal hemorrhage following perinatal

1983;17:353-355

5 Voit T, Lemburg P Damage of thalamus and basal ganglia

in asphyxiated full-term neonates. Neuropediatrics. 1987;

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6 Kreusser KL, Schmidt RE, Shackelford GD, Volpe JJ Value

of ultrasound for identification of acute hemorrhagic necro-sis of thalamus and basal ganglia in an asphyxiated term infant. Ann Neurol. 1984;16:361-363

7 Donn SM, Bowerman RA, DiPietro MA, Gebarski S Son-ographic appearance of neonatal thalamic-striatal hemor-rhage. J Ultrasound Med. 1984;3:231-233

Levene MI Primary thalamic haemorrhage in the newborn:

a new clinical entity. Lancet. 1985;1:190-192

9 Primhak RA, Smith MF Primary thalamic hemorrhage in first week of life. Lancet. 1985;1:635

10 Waishe TM, David KR, Fisher CM Thalamic hemorrhage:

a computed tomographic-clinical correlation. Neurology.

1977;27:217-’222

11 Livingston JH, Brown JK Intracerebral haemorrhage after the neonatal period. Arch Dis Child. 1986;61:538-544

12 Goddard J, Lewis RM, Armstrong DL, Zeller RS Moderate, rapidly induced hypertension as a cause of intraventricular hemorrhage in the newborn beagle model. ,J Pediatr.

1980;96:1057-1060

13 Wimberley PD, Lou HC, Pedersen H, et al Hypertensive peaks in the pathogenesis of intraventricular hemorrhage in the newborn: abolition by phenobarbitone sedation. Acta Pediatr Scand. 1982;71:537-542

14 Young RSK, Liberthson RR, Zalneraitis EL Cerebral hem-orrhage in neonates with coarctation of the aorta. Stroke.

1982;13:491-494

15 Wendling LR Intracranial venous sinus thrombosis: diag-nosis suggested by computed tomography. Am J Roentgenol.

1978;130:978-980

16 Rao KC, Knipp HC, Wagner EJ Computed tomographic findings in cerebral sinus and venous thrombosis. Radiology.

1981;140:391-398

17 Ehlers H, Courville CB Thrombosis of internal cerebral veins in infancy and childhood: Review of literature and

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1990;85;737

Pediatrics

Elke H Roland, Olof Flodmark and Alan Hill

Thalamic Hemorrhage With Intraventricular Hemorrhage in the Full-Term Newborn

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Copyright © 1990 by the American Academy of Pediatrics All rights reserved Print ISSN: 0031-4005 American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007 has been published continuously since 1948 PEDIATRICS is owned, published, and trademarked by the PEDIATRICS is the official journal of the American Academy of Pediatrics A monthly publication, it

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