Subpial Hemorrhage of the Neonate

Abstract

Background and Purpose— Subpial hemorrhage of the neonate is a rare stroke subtype reported in few case series. Birth trauma and coagulopathy are commonly proposed etiologies. We evaluated our subpial hemorrhage of the neonate patient cohort to expand current understanding Methods— Cases of subpial hemorrhage of the neonate were identified by keyword searches of the institutional database. The medical records and magnetic resonance imagings were reviewed. Results— Seventeen cases were identified. Assisted delivery occurred in 12% of cases, and acute coagulation abnormalities occurred in 77%. Subpial hemorrhage of the neonate was located in the temporal lobe in 82%, with cytotoxic edema and medullary vein congestion and thrombosis subjacent to the hemorrhages in 100% and 76% of cases, respectively. Neurological disability was present in 44% of survivors. Three patients had chronic coagulation abnormalities. Conclusions— In our cohort, clinical findings supporting a potential relationship with birth trauma were infrequent. The imaging findings suggest a nonarterial, deep venous pattern of hemorrhagic ischemia.

Idiopathic Neonatal Subpial Hemorrhage with Underlying Cerebral Infarct: Imaging Features and Clinical Outcome

“…Third, we further analyzed the MR imaging features of the subpial hemorrhage and underlying infarct. We found that the underlying infarcted brain parenchyma often has concurrent hemorrhage, observed in 11 of 15 scans, which is similar to the reported 76% incidence of concurrent hemorrhage by Cain et al 5 (Fig 2). In addition, we recognized the consistent combination of a bright, hyperintense appearance of the cerebral cortex with the dark, hypointense overlying subpial hemorrhage on T2WI and DWI, which creates a distinct imaging pattern that resembles the yin-yang symbol in Chinese philosophy (Fig 3).…”

“…Unfortunately, even though the imaging pattern of the subpial hemorrhage with underlying infarct described here and in previous reports 4,5 is characteristic, the pathophysiology remains unknown. Subpial hemorrhages have been described using various terminologies in the literature, including leptomeningeal hemorrhage, superficial lobar hemorrhage, pial hemorrhage, extraaxial bleed with underlying infarct, and so forth.…”

“…In First, our cohort of patients included 3 either extremely preterm (# 28 weeks' gestation) or very preterm (28-32 weeks' gestation) neonates, all of whom did not survive to discharge. In the case series of Huang and Robertson 4 and that of Cain et al, 5 the patients were either term or late-preterm, and all survived with relatively minor neurologic deficits. Our sample size is small, preterm neonates are already at high risk of mortality, and the direct cause of death may not be attributable to the intracranial abnormalities.…”

“…4 In their report of 7 term neonates who had spontaneous superficial parenchymal and leptomeningeal hemorrhage on CT and MR imaging, 4 had short-term clinical follow-up and were neurologically normal. Recently, Cain et al 5 reported 17 neonates who had subpial hemorrhage with underlying intraparenchymal cytotoxic edema on MR imaging shortly after birth. All of these term or late-preterm neonates survived except for one who succumbed to complications of congenital heart disease.…”

Neuroimaging in Perinatal Stroke and Cerebrovascular Disease

“…Some genetic arteriopathies associated with both fetal and neonatal hemorrhagic stroke include collagen IVA and JAM3 mutations, which can appear identical to hemorrhagic venous infarctions (77)(78)(79)(80)(81)(82)(83)(84). In addition to hemorrhages occurring later in life, fetal and neonatal patients may present with subpial hemorrhages (Figure 8), which may be related to local venous thrombosis or birth trauma (85)(86)(87). In these cases, blood is seen between the pia mater and the displaced brain parenchyma, often accompanied by venous infarction and subarachnoid or parenchymal blood.…”