Subpial hemorrhages in neonates: imaging features, clinical factors and outcomes

Neonatal subpial hemorrhage: Padua experience and systematic review

Subpial hemorrhage (SPH) is a rare subtype of intracranial hemorrhage, predominantly affecting term neonates and often associated with cortical-subcortical infarction. We described the epidemiology of SPH by analyzing cases referred to our hospital and concurrently conducting a systematic review of the cases reported in the literature. We also illustrated factors associated with adverse outcomes. A retrospective study was conducted on neonates with SPH referred to our hospital from 2013 to 2023 (cohort 1). Additionally, a systematic literature review on neonatal SPH was performed using PubMed, Scopus, Cochrane, and Web of Science up to April 2024 (cohort 2). Cohorts 1 and 2 were pooled for combined analysis. A total of 173 cases were analyzed, 10 original cases (cohort 1) and 163 literature cases (cohort 2). Ninety-two percent was term/late preterm neonates (59% male). Clinical presentations included seizures (36%), apnea (36%), and encephalopathy (18%). Ninety-four percent was diagnosed with brain magnetic resonance imaging and/or cranial ultrasound. Lesions were located in the temporal lobe in 60%, with infarctions adjacent to SPH in 90%. Sixteen percent died, 53% was diagnosed with neurological impairment, and 8% with epilepsy. In a subcohort of 67 patients (cohort 3) with available individual data (10/10 from cohort 1, 57/163 from cohort 2), low birth weight (LBW), seizures, neonatal infections, and parenchymal hemorrhage were significantly associated with adverse outcomes.

CONCLUSION

Neonatal SPH is rare, predominantly located in the temporal lobe, and frequently presents with seizures and apneas. Neurologic sequelae are common, and parenchymal hemorrhage was strongly associated with neurological impairment in our study.

WHAT IS KNOWN

• Subpial hemorrhage is a rare subtype of intracranial extra-axial bleeding, often associated with cortical-subcortical infarction in the adjacent parenchyma, predominantly affecting male term neonates. The temporal lobe is the most commonly involved area, frequently exhibiting the "yin-yang sign" on brain MRI.

WHAT IS NEW

• This is the first systematic review of neonatal subpial hemorrhage, emphasizing a distinctive clinical presentation marked by seizures and apneas (potentially of ictal origin), consistent with a high prevalence of temporal lobe involvement. Prognostically, a significant incidence of neurological impairment was observed, and the occurrence of parenchymal hemorrhage adjacent to subpial hemorrhage was strongly associated with adverse outcomes.

Neonatal subpial hemorrhage: clinical presentation, neuroimaging findings and outcome

PURPOSE

Subpial hemorrhage is a rare form of intracranial hemorrhage (ICH) in neonates that remains underreported and inadequately understood. The aim of this study is to characterize the neuroimaging patterns of subpial hemorrhage, assess changes in the underlying brain parenchyma, and examine its clinical features and outcomes.

METHODS

We reviewed the medical records and neuroimaging data of neonates with subpial hemorrhage admitted to our hospital between January 2010 and December 2023. Cases of subpial hemorrhages were identified through keywords searches within the hospital´s electronic database.

RESULTS

Twenty-eight patients were included in this retrospective study, 82% of whom were born at term. The most common clinical indication for imaging was a combination of apneas and seizures, ocurring in 50%. Hematologic abnormalities were present in 58% of patients. Magnetic resonance imaging (MRI) was performed acutely at the time of presentation between days 1 and 9 of life in 85% of cases. Subpial hemorrhages were unilateral in 86% of neonates, most commonly located in the temporal lobe (44%), and associated with other type of intracranial hemorrhage in 96% of cases, most often parenchymal (86%) and subdural (64%) hemorrhages. We identified three imaging patterns of subpial hemorrhage and two patterns of changes in the underlying brain parenchyma. Additionally, the hyperintense pia mater sign (HPm-sign) was observed on time-of-flight MR angiography (TOF-MRA) in 12 of 18 patients. Neurologic sequelae were noted in 28% of survivors.

CONCLUSION

Subpial hemorrhage has a distinctive MR pattern, often accompanied with cortical infarction and in most cases underlying parenchymal hemorrhage. In this study, we identified the HPm-sign that may be used to differentiate subpial hemorrhage from other types of hemorrhages. Additionally, we found a correlation between prominent medullary veins (PMV) and intraparenchymal hemorrhage (IPH).

Congenital Oropouche in Humans: Clinical Characterization of a Possible New Teratogenic Syndrome

Oropouche fever is caused by the Oropouche virus (OROV; Bunyaviridae, Orthobunyavirus), one of the most frequent arboviruses that infect humans in the Brazilian Amazon. This year, an OROV outbreak was identified in Brazil, and its vertical transmission was reported, which was associated with fetal death and microcephaly. We describe the clinical manifestations identified in three cases of congenital OROV infection with confirmed serology (OROV-IgM) in the mother-newborn binomial. One of the newborns died, and post-mortem molecular analysis using real-time RT-qPCR identified the OROV genome in several tissues. All three newborns were born in the Amazon region in Brazil, and the mothers reported fever, rash, headache, myalgia, and/or retro-orbital pain during pregnancy. The newborns presented with severe microcephaly secondary to brain damage and arthrogryposis, suggestive of an embryo/fetal disruptive process at birth. Brain and spinal images identified overlapping sutures, cerebral atrophy, brain cysts, thinning of the spinal cord, corpus callosum, and posterior fossa abnormalities. Fundoscopic findings included macular chorioretinal scars, focal pigment mottling, and vascular attenuation. The clinical presentation of vertical OROV infection resembled congenital Zika syndrome to some extent but presents some distinctive features on brain imaging and in several aspects of its neurological presentation. A recognizable syndrome with severe brain damage, neurological alterations, arthrogryposis, and fundoscopic abnormalities can be associated with in utero OROV infection.

A Case of Neonatal Cytotoxic Lesions of the Corpus Callosum With Subpial Hemorrhage

Subpial hemorrhage is a rare type of birth-related brain hemorrhage in neonates that can manifest with symptoms such as apnea and seizures. On brain magnetic resonance imaging (MRI), subpial and parenchymal hemorrhages are typically observed but often resolve without lasting sequelae. Cytotoxic lesions of the corpus callosum (CLOCCs) are not as common in neonates as they are in adults and children. We present a rare case of a term neonate with subpial hemorrhage accompanied by CLOCCs who experienced a favorable clinical course. A full-term female infant was delivered via emergency cesarean section. At 18 hours post-birth, the infant experienced recurrent seizures. Following phenobarbital administration and the initiation of respiratory support, a brain MRI performed on day 6 revealed hematomas in the subpial and subcortical regions, leading to a diagnosis of subpial hemorrhage. Additionally, diffusion restriction was noted in the corpus callosum and optic radiation extending to the posterior limb. Follow-up MRI on day 14 of life showed the resolution of most of the lesions, confirming the diagnosis of CLOCCs. The infant was discharged on day 22 without further seizures and has shown normal growth and development for 18 months post-discharge. Thus, this case reports a neonatal patient with typical radiological features and clinical progression of subpial hemorrhage and CLOCCs, leading to a favorable outcome. The positive outcome underscores the importance of understanding the unique radiological features and progression of these conditions. In neonates presenting with splenial lesions associated with brain hemorrhage, it is crucial to monitor the resolution of symptoms and lesions to rule out alternative diagnoses. Furthermore, continued developmental monitoring is recommended to ensure optimal outcomes.

Imaging of Hemorrhagic Stroke in Children

Hemorrhagic stroke (HS) is an important cause of neurologic morbidity and mortality in children and is more common than ischemic stroke between the ages of 1 and 14 years, a notable contradistinction relative to adult stroke epidemiology. Rapid neuroimaging is of the utmost importance in making the diagnosis of HS, identifying a likely etiology, and directing acute care. Computed tomography and MR imaging with flow-sensitive MR imaging and other noninvasive vascular imaging studies play a primary role in the initial diagnostic evaluation. Catheter-directed digital subtraction angiography is critical for definitive diagnosis and treatment planning.

Neuroimaging of Neonatal Stroke: Venous Focus

Perinatal venous infarcts are underrecognized clinically and at imaging. Neonates may be susceptible to venous infarcts because of hypercoagulable state, compressibility of the dural sinuses and superficial veins due to patent sutures, immature cerebral venous drainage pathways, and drastic physiologic changes of the brain circulation in the perinatal period. About 43% of cases of pediatric cerebral sinovenous thrombosis occur in the neonatal period. Venous infarcts can be recognized by ischemia or hemorrhage that does not respect an arterial territory. Knowledge of venous drainage pathways and territories can help radiologists recognize characteristic venous infarct patterns. Intraventricular hemorrhage in a term neonate with thalamocaudate hemorrhage should raise concern for internal cerebral vein thrombosis. A striato-hippocampal pattern of hemorrhage indicates basal vein of Rosenthal thrombosis. Choroid plexus hemorrhage may be due to obstruction of choroidal veins that drain the internal cerebral vein or basal vein of Rosenthal. Fan-shaped deep medullary venous congestion or thrombosis is due to impaired venous drainage into the subependymal veins, most commonly caused by germinal matrix hemorrhage in the premature infant and impeded flow in the deep venous system in the term infant. Subpial hemorrhage, an underrecognized hemorrhage stroke type, is often observed in the superficial temporal region, and its cause is probably multifactorial. The treatment of cerebral sinovenous thrombosis is anticoagulation, which should be considered even in the presence of intracranial hemorrhage. ©RSNA, 2024 Test Your Knowledge questions in the supplemental material and the slide presentation from the RSNA Annual Meeting are available for this article.