Structure and evolution of echo dense lesions in the neonatal brain. A combined ultrasound and necropsy study.

Abstract

SUMMARY Sixty seven of 216 infants weighing less than 2 kg at birth had cerebral lesions on ultrasonic scanning. Eight of 17 who had periventricular leukomalacia, with or without subependymal or intraventricular haemorrhage, or both, died. These and one larger baby were the subject of a combined ultrasound, and where appropriate, necropsy study. There was excellent correlation between the ultrasound and necropsy findings, only some of the earlier lesions of periventricular leukomalacia being missed by ultrasound. The data suggest it is now possible to distinguish periventricular leukomalacia and subependymal/intraventricular haemorrhage by ultrasound, that both lesions may be present in the same brain, that apparent parenchymal extension of an intraventricular haemorrhage is more probably the result of haemorrhage into ischaemic periventricular tissue, and that the term 'periventricular haemorrhage' should be abandoned since it confuses two lesions of differing aetiology and differing clinical importance. Future advances in neonatal brain ultrasound depend on accurate assessment of both the nature and site of lesions within the cerebral hemispheres and ventricular system since the interpretation of these parameters is of critical importance.The periventricular regions of the brain of the preterm neonate are known to be particularly susceptible to circulatory disturbances. Two major groups of lesions are recognised, the subependymal haemorrhage (or germinal matrix haemorrhage) /intraventricular haemorrhage complex, simplistically related to hyperperfusion of the brain, and periventricular leukoencephalomalacia related to hypoperfusion.l There is growing evidence from follow up studies that the prognosis of the former disorder is good whereas it is frequently very poor with periventricular leukomalacia.2The advent of techniques to show lesions of the neonatal brain during life has greatly extended knowledge about the genesis and natural history of these disorders but their exact inter-relation remains controversial.3 The relatively low resolution of early scanning instruments combined with ignorance of the natural history of the lesions prevented distinction between subependymal/intraventricular haemorrhage and periventricular leukomalacia, the term periventricular haemorrhage being introduced to describe all echo dense lesions related to the walls of the lateral ventricles. Subsequent discussion of periventricular haemorrhage as a single entity has obscured the differences and associations between the lesions. In 1983 we described the ultrasound appearance of early periventricular leukomalacia before the cystic phase had developed.4 Other authors have confirmed our observations, though some stress the haemorrhagic nature of these lesions.i7 Improved techniques now allow the distinction between these two groups of lesions, yet there are few combined ultrasonic and necropsy studies of either subependymal/intraventricular haemorrhage8 or periventricular leukomalacia.9The present study endeavours to distinguish betwe...

Periventricular leucomalacia and intraventricular haemorrhage in the preterm neonate.

“…In many infants intraventricular clot is seen within the ventricle and accompanies this parenchymal appearance. The triangular parenchymal appearance has been recently described by Rushton et al, 8 and we refer to it as 'PVL' (Fig. 2).…”

Maternal Receipt of Magnesium Sulfate Does Not Seem to Reduce the Risk of Neonatal White Matter Damage

“…16 -20 IVH and ventriculomegaly are correlates of white matter damage. [21][22][23][24][25][26][27] For this reason we sought, but did not find, an inverse relationship between maternal magnesium sulfate receipt and risk of IVH and ventriculomegaly in the newborn. Our failure to find a reduced risk of IVH in association with maternal receipt of magnesium sulfate is in keeping with the observation of some investigators 28,29 but not of others.…”

Ultrasonographic Differential Diagnosis and Neurodevelopmental Outcome of Cerebral White Matter Lesions in Premature Infants

“…2 This association has led to the hypothesis that the IVH compresses the terminal vein draining the periventricular white matter resulting in a venous infarction. [3][4][5] PVL is a bilateral, nonhemorrhagic cystic white matter lesion commonly associated with subsequent spastic motor and cognitive deficits. 6,7 The pathogenesis of PVL has been attributed to arterial hypotension, which causes focal ischemia and ensuing development of cysts at arterial "watershed" areas.…”