Intracerebellar hemorrhage in premature infants: sonographic detection and outcome

Neurodevelopmental Consequences of Preterm Isolated Cerebellar Hemorrhage: A Systematic Review

CONTEXT

The effect of neonatal cerebellar hemorrhage on neurodevelopmental outcome (NDO) in the absence of supratentorial injury is still largely unknown.

OBJECTIVE

To evaluate the influence of isolated neonatal cerebellar hemorrhage on cognitive, motor, language, and behavioral NDOs and assess the effect of location and size on outcome.

DATA SOURCES

Embase, Medline, and Scopus were searched from inception to September 30, 2017.

STUDY SELECTION

Studies in which a diagnosis of isolated cerebellar hemorrhage was reported in preterm infants (<32 weeks' gestation) with a standardized NDO at ≥12 months of age were included.

DATA EXTRACTION

Patient characteristics, location, and size of bleeding and NDO (defined as severe [yes or no] on the basis of given cutoff points) in 4 domains were extracted.

RESULTS

Of the 1519 studies identified, 8 were included in final analyses. Of infants with isolated cerebellar hemorrhage, 128 were described (cumulative incidence: 2.3%). The incidence of severe delay in cognition, motor, language, and behavioral development was 38%, 39%, 41%, and 38%, respectively. The overall incidence of severe neurodevelopmental delay in ≥1 domain ranged from 43% to 75% and was most seen in infants with vermis involvement (87%-93%) and with large bleeds (46%-82%).

LIMITATIONS

Different neurodevelopmental scales lead to data heterogeneity, and reporting of data on a group level limited possibilities for an outcome description on an individual level.

CONCLUSIONS

Of infants with isolated cerebellar hemorrhage, 43% to 75% were severely delayed in cognition, motor, language, and/or behavioral development, with the highest incidence with vermis involvement and with large bleeds.

Systemic inflammation combined with neonatal cerebellar haemorrhage aggravates long-term structural and functional outcomes in a mouse model

BACKGROUND

Despite the increased recognition of cerebellar injury in survivors of preterm birth, the neurodevelopmental consequences of isolated cerebellar injury have been largely unexplored and our current understanding of the functional deficits requires further attention in order to translate knowledge to best practices. Preterm infants are exposed to multiple stressors during their postnatal development including perinatal cerebellar haemorrhage (CBH) and postnatal infection, two major risk factors for neurodevelopmental impairments.

METHODS

We developed a translational mouse model of CBH and/or inflammation to measure the short- and long-term outcomes in cerebellar structure and function.

RESULTS

Mice exposed to early combined insults of CBH and early inflammatory state (EIS) have a delay in grasping acquisition, neonatal motor deficits and deficient long-term memory. CBH combined with late inflammatory state (LIS) does not induce neonatal motor problems but leads to poor fine motor function and long-term memory deficits at adulthood. Early combined insults result in poor cerebellar growth from postnatal day 15 until adulthood shown by MRI, which are reflected in diminished volumes of cerebellar structures. There are also decreases in volumes of gray matter and hippocampus. Cerebellar microgliosis appears 24h after the combined insults and persists until postnatal day 15 in the cerebellar molecular layer and cerebellar nuclei in association with a disrupted patterning of myelin deposition, a delay of oligodendrocyte maturation and reduced white matter cerebellar volume.

CONCLUSIONS

Together, these findings reveal poor outcomes in developing brains exposed to combined cerebellar perinatal insults in association with cerebellar hypoplasia, persistence of microgliosis and alterations of cerebellar white matter maturation and growth.

Antenatal Exposure to Magnesium Sulfate Is Associated with Reduced Cerebellar Hemorrhage in Preterm Newborns

OBJECTIVE

To determine the association of antenatal magnesium sulfate with cerebellar hemorrhage in a prospective cohort of premature newborns evaluated by magnetic resonance imaging (MRI).

STUDY DESIGN

Cross-sectional analysis of baseline characteristics from a prospective cohort of preterm newborns (<33 weeks gestation) evaluated with 3T-MRI shortly after birth. Exclusion criteria were clinical evidence of a congenital syndrome, congenital infection, or clinical status too unstable for transport to MRI. Antenatal magnesium sulfate exposure was abstracted from the medical records and the indication was classified as obstetric or neuroprotection. Two pediatric neuroradiologists, blinded to the clinical history, scored axial T2-weighted and iron susceptibility MRI sequences for cerebellar hemorrhage. The association of antenatal magnesium sulfate with cerebellar hemorrhage was evaluated using multivariable logistic regression, adjusting for postmenstrual age at MRI and known predictors of cerebellar hemorrhage.

RESULTS

Cerebellar hemorrhage was present in 27 of 73 newborns (37%) imaged at a mean ± SD postmenstrual age of 32.4 ± 2 weeks. Antenatal magnesium sulfate exposure was associated with a significantly reduced risk of cerebellar hemorrhage. Adjusting for postmenstrual age at MRI, and predictors of cerebellar hemorrhage, antenatal magnesium sulfate was independently associated in our cohort with decreased cerebellar hemorrhage (OR, 0.18; 95% CI, 0.049-0.65; P = .009).

CONCLUSION

Antenatal magnesium sulfate exposure is independently associated with a decreased risk of MRI-detected cerebellar hemorrhage in premature newborns, which could explain some of the reported neuroprotective effects of magnesium sulfate.

Cerebellar hemorrhagic injury in premature infants occurs during a vulnerable developmental period and is associated with wider neuropathology

BACKGROUND

Cerebellar hemorrhagic injury (CHI) is being recognized more frequently in premature infants. However, much of what we know about CHI neuropathology is from autopsy studies that date back to a prior era of neonatal intensive care. To update and expand our knowledge of CHI we reviewed autopsy materials and medical records of all live-born preterm infants (<37 weeks gestation) autopsied at our institution from 1999-2010 who had destructive hemorrhagic injury to cerebellar parenchyma (n = 19) and compared them to matched non-CHI controls (n = 26).

RESULTS

CHI occurred at a mean gestational age of 25 weeks and involved the ventral aspect of the posterior lobe in almost all cases. CHI arose as a large hemorrhage or as multiple smaller hemorrhages in the emerging internal granule cell layer of the developing cortex or in the nearby white matter. Supratentorial germinal matrix hemorrhage occurred in 95% (18/19) of CHI cases compared to 54% (14/26) of control cases (p = 0.003). The cerebellar cortex frequently showed focal neuronal loss and gliosis (both 15/19, 79%) in CHI cases compared to control cases (both 1/26, 4% p < 0.0001). The cerebellar dentate had more neuronal loss (8/15, 53%) and gliosis (9/15, 60%) in CHI cases than controls (both 0/23, 0%; p < 0.0001). The inferior olivary nuclei showed significantly more neuronal loss in CHI (10/17, 59%) than in control cases (5/26, 19%) (p = 0.0077). All other gray matter sites examined showed no significant difference in the incidence of neuronal loss or gliosis between CHI and controls.

CONCLUSIONS

We favor the possibility that CHI represents a primary hemorrhage arising due to the effects of impaired autoregulation in a delicate vascular bed. The incidences of neuronal loss and gliosis in the inferior olivary and dentate nuclei, critical cerebellar input and output structures, respectively were higher in CHI compared to control cases and may represent a transsynpatic degenerative process. CHI occurs during a critical developmental period and may render the cerebellum vulnerable to additional deficits if cerebellar growth and neuronal connectivity are not established as expected. Therefore, CHI has the potential to significantly impact neurodevelopmental outcome in survivors.

Cerebellar hemorrhage in very low birth weight premature infants: the advantage of the posterolateral fontanelle view

OBJECTIVE

The purpose of this study was to determine the prevalence of cerebellar hemorrhage in very low birth weight infants using the posterolateral fontanelle for ultrasound (US) examination.

METHODS

The study included 125 very low birth weight premature infants (defined as equal or less than 1500 grams at birth) hospitalized in the premature or neonatal intensive care departments that had at least one head US examination including both anterior and posterolateral fontanelle scans.

RESULTS

On US performed through the posterolateral fontanelle, four (3.2%) infants had echogenic posterior fossa lesions interpreted as hemorrhages. None of these lesions were initially or retrospectively observed through the standard anterior fontanelle scan. Two infants died at age 4 and 39 days, respectively. All survivors are being followed up in the hospital's neurodevelopment outpatient clinic.

CONCLUSIONS

Cerebellar hemorrhage may be overlooked on standard anterior fontanelle views. The posterolateral approach may assist in diagnosing these lesions.

Cerebellar haemorrhage in the extremely preterm infant

AIM

The aim of this study was to investigate the incidence, risk factors and developmental outcomes of cerebellar haemorrhage in the extremely preterm infant.

METHODS

Over a 4-year period from January 2004, all patients with cerebellar haemorrhage born at 24-27 weeks gestation or with a birthweight < 1000 g were identified from database review. All patients had cranial ultrasound scans including views from the mastoid fontanelle. To verify the incidence, a review of all reports over the 4-year period and a review of all cranial imaging over a 2-year period were carried out.

RESULTS

From the data analysed on 339 neonates, five cases of cerebellar haemorrhage were identified, four on ultrasound scan (1.2%) and one on magnetic resonance imaging (1.5% total). Two cases were associated with grade III peri-intraventricular haemorrhage. The cases had diverse maternal, antenatal and post-natal risk factors. The two with associated peri-intraventricular haemorrhage have developmental delay. The cases with isolated cerebellar haemorrhage had good neurodevelopmental outcomes.

CONCLUSIONS

A low incidence of cerebellar haemorrhage identified from the mastoid fontanelle was demonstrated. The neurodevelopmental outcome was better than that described in previous reports.

Myth: cerebral palsy cannot be predicted by neonatal brain imaging

There is controversy in the literature about the value of brain imaging in neonates regarding the prediction of cerebral palsy (CP). The aim of this review was to unravel the myth that CP cannot be predicted by neuroimaging in neonates. Major intracranial lesions in the preterm infant should be recognized with sequential cranial ultrasound and will predict those with non-ambulatory CP. Magnetic resonance imaging (MRI) at term-equivalent age will refine the prediction by assessment of myelination of the posterior limb of the internal capsule. Prediction of motor outcome in preterm infants with subtle white matter injury remains difficult, even with conventional MRI. MRI is a better tool to predict outcome in the term infant with hypoxic-ischaemic encephalopathy or neonatal stroke. The use of diffusion-weighted imaging as an additional sequence adds to the predictive value for motor outcome. Sequential and dedicated neuroimaging should enable us to predict motor outcome in high risk newborns infants.

Cerebellar hemorrhage on magnetic resonance imaging in preterm newborns associated with abnormal neurologic outcome

OBJECTIVE

To investigate the relationship between cerebellar hemorrhage in preterm infants seen on magnetic resonance imaging (MRI), but not on ultrasonography, and neurodevelopmental outcome.

STUDY DESIGN

Images from a cohort study of MRI in preterm newborns were reviewed for cerebellar hemorrhage. The children were assessed at a mean age of 4.8 years with neurologic examination and developmental testing using the Wechsler Preschool and Primary Scale of Intelligence, Third Edition.

RESULTS

Cerebellar hemorrhage was detected on both ultrasonography and MRI in 3 of the 131 preterm newborns evaluated, whereas smaller hemorrhages were seen only on MRI in 10 newborns (total incidence, 10%). Adjusting for gestational age at birth, intraventricular hemorrhage, and white matter injury, cerebellar hemorrhage detectable solely by MRI was associated with a 5-fold increased odds of abnormal neurologic examination compared with newborns without cerebellar hemorrhage (outcome data in 74%). No association with the Wechsler Preschool and Primary Scale of Intelligence, Third Edition score was found.

CONCLUSIONS

Cerebellar hemorrhage is not uncommon in preterm newborns. Although associated with neurologic abnormalities, hemorrhage seen only on MRI is associated with much more optimistic outcomes than that visible on ultrasonography.

The clinical presentation of preterm cerebellar haemorrhage

The objective of this study was to evaluate clinical symptoms and findings on cranial ultrasound (CUS) in preterm infants with cerebellar haemorrhage through retrospective analysis of all preterm infants with a postnatal CUS or MRI diagnosis of cerebellar haemorrhage admitted in a tertiary care centre between January 2002 and June 2009. Fifteen infants were identified; median gestational age was 25 2/7 weeks and median birth weight 730 g. We discerned six types of haemorrhage: subarachnoid (n = 3), folial (n = 1), lobar (n = 9, of which 4 bilateral), giant lobar (n = 1, including vermis) and contusional (n = 1). Especially in infants with lobar cerebellar haemorrhage, CUS showed preceding or concurrent lateral ventricle dilatation, mostly without intraventricular haemorrhage (IVH). Thirteen infants suffered from notable, otherwise unexplained motor agitation in the days preceding the diagnosis. In conclusion, motor agitation may be a presenting symptom of cerebellar haemorrhage in preterm infants. Unexplained ventriculomegaly can be a first sign of cerebellar haemorrhage and should instigate sonographic exploration of the cerebellum.

Desenvolvimento cerebral em recém-nascidos prematuros

OBJETIVO:Rever a literatura atual que aborda o crescimento e o desenvolvimento cerebral de crianças prematuras e as alterações cognitivas e motoras que podem decorrer da prematuridade. FONTES DE DADOS: Foram utilizadas as bases de dados Medline e Lilacs, selecionados artigos publicados entre os anos de 2000 e 2007 e livros-texto com conteúdo relevante. SÍNTESE DOS DADOS: A evolução do recém-nascido pré-termo diferencia-se da evolução apresentada pela população a termo. Estudos têm demonstrado que ex-prematuros apresentam alterações anatômicas cerebrais que se associam a prejuízos cognitivos. Várias regiões do sistema nervoso central (substância cinzenta, substância branca, corpo caloso, núcleo caudado, hipocampo e cerebelo) têm seus volumes avaliados por neuroimagem e, apesar de resultados controversos, parecem ter desenvolvimento alterado nessa população. Diante disso, espera-se haver repercussão funcional e/ou cognitiva em crianças, adolescentes e adultos nascidos prematuramente. Ex-prematuros avaliados na infância tardia e na adolescência demonstram alterações de quociente de inteligência, memória, capacidade para cálculos e função cognitiva global. Déficits motores, na capacidade de planejamento e de associação, na coordenação motora e na atenção também foram relatados na literatura. CONCLUSÕES: A prematuridade pode levar a alterações anatômicas e estruturais do cérebro devido à interrupção das etapas de desenvolvimento pré-natal. Tais alterações podem causar déficits funcionais, tornando os ex-prematuros sujeitos a problemas cognitivos e motores, assim como suas repercussões nas atividades de vida diária, mesmo na adolescência e idade adulta.

Cerebellar injury in preterm infants: incidence and findings on US and MR images

PURPOSE

To investigate the incidence and characteristics of cerebellar injury in a cohort of very preterm infants by using the mastoid fontanelle (MF) and posterior fontanelle (PF) approach in addition to routine cranial ultrasonography (US) through the anterior fontanelle (AF), with magnetic resonance (MR) imaging as the reference standard.

MATERIALS AND METHODS

The institutional review board approved this prospective study and informed consent was obtained. A cohort of 77 preterm infants (< 32 weeks) was examined with serial cranial US throughout the neonatal period by using the AF, PF, and MF views. MR imaging was performed around term-equivalent age in 59 of 77 infants. Sensitivity, specificity, positive predictive value, and negative predictive value of routine cranial US and cranial US with additional views were calculated.

RESULTS

At cranial US performed through the MF, seven (9%) of 77 infants were identified to have posterior fossa hemorrhage. In only two of seven infants, the lesions were seen on routine AF views. The PF approach did not increase the detection rate of posterior fossa hemorrhage. MR images confirmed cranial US findings in all cases. MR images showed punctate hemorrhage in the cerebellum in six infants with normal cranial US findings. Among the 59 infants examined with both cranial US and MR imaging, cerebellar injury was diagnosed in 11 (19%).

CONCLUSION

Cerebellar injury is a frequent finding in very preterm infants. Cranial US through the MF can demonstrate injury missed by using the routine AF approach. Punctate hemorrhagic lesions may remain undetected even when the MF approach is used; the prognostic implications of these smaller lesions need further attention.

Top of the basilar artery embolic stroke and neonatal myoclonus

Cerebellar stroke has been virtually unreported in the living newborn infant. A term newborn male weighing 3380g at birth suffered myoclonic seizures within 24 hours of birth by spontaneous vaginal delivery. Apgar scores were 3 and 4 at 1 and 5 minutes. Myoclonus persisted for 9 days, responding poorly to step-up anticonvulsant treatment including lidocaine, midazolam, and clonazepam. Imaging documented arterial ischaemic stroke within the left posterior cerebral and both superior cerebellar arteries, compatible with top of the basilar artery stroke. There was no electrographic correlate for the seizures. Disturbed oscillation within the dentato-rubro-olivary circuitry was the likely mechanism. The probable cause was embolism from an in-utero-onset inferior caval vein thrombosis. At 22 months the child was sitting unsupported. Scores on the Bayley Scales of Infant Development II were equivalent to those of a 12-month/year-old. He showed ataxic motor behaviour. Embolism can cause neonatal top of the basilar artery stroke, which may present with myoclonus due to cerebellar injury.

Neonatal cranial ultrasonography: how to optimize its performance

Cranial ultrasonography (CUS) is an excellent and non invasive tool for brain imaging during the neonatal period. It is traditionally performed through the anterior fontanel. Although the advantages of CUS are numerous, there are also diagnostic limitations. Alternative imaging techniques including the use of different transducer types and frequencies and of additional acoustic windows can improve image quality and the diagnostic accuracy of CUS. This review will focus on techniques to be applied for optimizing the performance of CUS in the newborn infant.