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

Fellows’ Journal Club

Subpial hemorrhage with underlying infarction is a recognizable condition with unique MR imaging and sonographic features. Improved recognition may advance understanding of risk factors and outcomes.

Abstract

Figure 1 from Assis et al
MR imaging of 2 preterm neonates who did not survive to discharge from the neonatal unit. The first patient (A–C) was born at 27 weeks 3 days’ gestation and had a large subpial hemorrhage and a large underlying hemorrhagic infarct. The second patient (D–F) was born at 28 weeks 1 day of gestation. She had a relatively small subpial hemorrhage and underlying hemorrhagic infarct but had engorged deep medullary veins in the bilateral cerebral hemispheres that may have had small thrombosis (not shown).

BACKGROUND AND PURPOSE

Neonatal subpial hemorrhage with underlying cerebral infarct is a previously described but poorly understood clinicoradiographic syndrome. We sought to further characterize the cranial ultrasound and MR imaging characteristics and associated outcomes of this condition across the full range of gestational ages, including extreme and very preterm neonates.

MATERIALS AND METHODS

This was a single tertiary pediatric center retrospective case series. Brain MR imaging and cranial ultrasound of neonates with subpial hemorrhage with underlying cerebral infarct were identified from a population-based radiology registry (2006–2020). Original images were reviewed by 2 neuroradiologists blinded to history and outcome. Clinical presentation, course, and outcome at >12 months were abstracted from medical records. The diagnostic utility of cranial ultrasound was compared with that of MR imaging.

RESULTS

Sixteen patients were included (median gestational age, 36.5 weeks; range, 27–41 weeks; 31% premature). MR images were obtained acutely at the time of presentation between days 0 and 9 of life. On T2WI and DWI, a consistent presence of a hypointense subpial bleed and an underlying hyperintense cerebral cortex were recognized, which created a distinct MR imaging pattern resembling the yin-yang symbol. Findings of all the MRAs and MRVs were normal. Cranial ultrasound detected 6 of 7 MR imaging lesions with sonographic features correlating well with MR imaging. The 3 extreme or very preterm neonates did not survive. The remainder survived with relatively mild neurologic deficits.

CONCLUSIONS

Subpial hemorrhage with underlying infarction is a recognizable condition with unique MR imaging and sonographic features. Improved recognition may advance understanding of risk factors and outcomes.

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