Detection Of Intracranial Hemorrhage Research Articles

Pituitary apoplexy: evaluation, management, and prognosis

To review the current standard of care in the diagnosis and treatment of pituitary apoplexy and to determine any updated clinical management strategies. Pituitary apoplexy is a rare but life-threatening medical emergency. Presenting signs and symptoms often include severe headache, visual loss, ophthalmoplegia, altered consciousness, and impaired pituitary function. Common predisposing factors include closed head trauma, blood pressure alterations, history of pituitary irradiation, cardiac surgery, anticoagulation, treatment with dopamine agonists, pituitary stimulation testing, and pregnancy. MRI imaging is the most sensitive sequence for the detection of acute and old intracranial hemorrhage. Patients often require emergent intravenous fluids, blood transfusions, and high-dose corticosteroids. Patients who remain clinically and neurologically unstable require urgent transsphenoidal surgical decompression as definitive treatment. In patients with pituitary apoplexy, improvement in visual field defects, visual acuity, and diplopia is typically observed after emergent application of therapy, often including medical and surgical treatment. Some patients may require long-term hormonal therapy after surgery.

Neuroimaging of traumatic brain injury

In this article, the neuroradiological evaluation of traumatic brain injury is reviewed. Different imaging strategies in the assessment of traumatic brain injury are initially discussed, and this is followed by a review of the imaging characteristics of both primary and secondary brain injuries. Computed tomography remains the modality of choice for the initial assessment of acute head injury because it is fast, widely available, and highly accurate in the detection of skull fractures and acute intracranial hemorrhage. Magnetic resonance imaging is recommended for patients with acute traumatic brain injury when the neurological findings are unexplained by computed tomography. Magnetic resonance imaging is also the modality of choice for the evaluation of subacute or chronic traumatic brain injury. Mild traumatic brain injury continues to be difficult to diagnose with current imaging technology. Advanced magnetic resonance techniques, such as diffusion-weighted imaging, magnetic resonance spectroscopy, and magnetization transfer imaging, can improve the identification of traumatic brain injury, especially in the case of mild traumatic brain injury. Further research is needed for other advanced imaging methods such as magnetic source imaging, single photon emission tomography, and positron emission tomography.

Effect of a Computer-aided Diagnosis System on Clinicians’ Performance in Detection of Small Acute Intracranial Hemorrhage on Computed Tomography

To analyze the effect of a computer-aided diagnosis (CAD) system on clinicians' performance in detection of small acute intracranial hemorrhage (AIH) on computed tomography (CT). The authors have developed a CAD scheme that used both image processing techniques and anatomic knowledge based classification system to improve diagnosis of small AIH on CT. A multiple-reader, multiple-case receiver operating characteristic (ROC) study was performed. Twenty clinicians, including seven emergency physicians, seven radiology residents, and six radiology specialists were recruited as readers of 60 sets of brain CT, including 30 cases that show AIH smaller than 1 cm, and 30 controls. Each reader read the same 60 cases twice, first without, then with the prompts produced by the CAD system. The clinicians ranked their confidence in diagnosing a case of showing AIH, which produced the ROC curves. Significantly improved performance is observed in emergency physicians, average area under the ROC curve (Az) increased from 0.8422 to 0.9294 (P = .0107) when they make the diagnosis without and with the support of CAD. Az for radiology residents increased from 0.9371 to 0.9762 (P = .0088). Az for radiology specialists increased from 0.9742 to 0.9868, but was statistically insignificant (P = .1755). CAD can improve the clinicians' performance in detecting AIH on CT. In particular, emergency physicians can benefit most from the CAD and improve their performance to a level approaching that of the average radiology residents.

Assessment of Hemorrhage in Pituitary Macroadenoma by T2*-Weighted Gradient-Echo MR Imaging

Intratumoral hemorrhage occurs frequently in pituitary macroadenoma and manifests as pituitary apoplexy and recent or old silent hemorrhage. T2*-weighted gradient-echo (GE) MR imaging is the most sensitive sequence for the detection of acute and old intracranial hemorrhage. T2*-weighted GE MR imaging was used to investigate intratumoral hemorrhage in pituitary macroadenomas. Twenty-five consecutive patients who underwent total or subtotal resection of pituitary macroadenoma with heights from 17 to 53 mm, including 1 patient with classic pituitary apoplexy, underwent MR imaging before surgery, including T2*-weighted GE MR imaging. For histologic assessment of the hemorrhage in whole surgical specimens, we used hematoxylin-eosin staining. T2*-weighted GE MR imaging detected various types of dark lesions, such as "rim," "mass," "spot," and "diffuse" and combinations, indicating clinical and subclinical intratumoral hemorrhage in 12 of the 25 patients. The presence of intratumoral dark lesions on T2*-weighted GE MR imaging correlated significantly with the hemorrhagic findings on T1- and T2-weighted MR imaging (P < .02 and <.01, respectively), and the surgical and histologic hemorrhagic findings (P < .001 and <.001, respectively). T2*-weighted GE MR imaging could detect intratumoral hemorrhage in pituitary adenomas as various dark appearances. Therefore, this technique might be useful for the assessment of recent and old intratumoral hemorrhagic events in patients with pituitary macroadenomas.

Overnight Preliminary Head CT Interpretations Provided by Residents: Locations of Misidentified Intracranial Hemorrhage

Our aim was to determine the patterns of error of radiology residents in the detection of intracranial hemorrhage on head CT examinations while on call. Follow-up studies were reviewed to determine if there was any adverse effect on patient outcome as a result of these preliminary interpretations. Radiology residents prospectively interpreted 22,590 head CT examinations while on call from January 1, 2002, to July 31, 2006. The following morning, the studies were interpreted by staff neuroradiologists, and discrepancies from the preliminary report were documented. Patients' charts were reviewed for clinical outcomes and any imaging follow-up. There were a total of 1037 discrepancies identified, of which 141 were due to intracranial hemorrhage. The most common types of intracranial hemorrhage that were missed were subdural and subarachnoid hemorrhage occurring in 39% and 33% of the cases, respectively. The most common location for missed subdural hemorrhage was either parafalcine or frontal. The most common location of missed subarachnoid hemorrhage was in the interpeduncular cistern. There was 1 case of nontraumatic subarachnoid hemorrhage that was not described in the preliminary report. Fourteen patients were brought back to the emergency department for short-term follow-up imaging after being discharged. We did not observe any adverse clinical outcomes that resulted from a discrepant reading. Discrepancies due to intracranial hemorrhage are usually the result of subdural or subarachnoid hemorrhage. A more complete understanding of the locations of the missed hemorrhage can hopefully help decrease the discrepancy rate to help improve patient care.

Early detection of life-threatening intracranial haemorrhage using a portable near-infrared spectroscopy device

To determine whether infrared spectroscopy allows early recognition of epidural and subdural haematomas among trauma patients. Injured people admitted to two trauma units were enrolled in a prospective multicentre observational study, and infrared spectroscopy was performed before computed tomography of the head as a part of their initial evaluation. Subsequent CT findings suggestive of epidural or subdural haematoma served as controls. Over 12 months, 110 patients were enrolled; 64 (58.1%) were men and 46 (41.9%) were women. Mean age was 56.2 years, and mean Glasgow Coma Scale on admission was 12.6. Infrared spectroscopy was 90.5% sensitive and 95.5% specific for epidural and subdural haematoma. Positive and negative predictive values were 82.6% and 97.7%, respectively. Infrared spectroscopy allows early recognition of epidural and subdural haematomas in trauma cases. Further studies are needed to evaluate whether immediate confirmation or exclusion of epidural and subdural haematomas with portable near-infrared spectroscopy devices improves the decision-making process in the treatment of severely injured people.

A Lancet Issue Devoted to Stroke

Marc Fisher MD Kennedy Lees MD Section Editors: The dominant theme of the January 27, 2007 issue of Lancet is stroke. In a new editorial policy the Lancet decided to publish themed issues of particular interest to both general clinicians and specialist researchers. Stroke is undoubtedly a disease that requires special attention: approximately 1% of the 6.5 billion people living on our planet—twice the population of Canada or 8 times the population of Switzerland—will die each year of stroke. Many of these strokes are either preventable or could be delayed to a more advanced age. Considering such figures, the Lancet editors have to be congratulated for their decision, which is an important step in the struggle to reduce the burden of stroke in our societies. They have carefully selected original articles, seminars, and reviews on stroke. In the following we will comment on the 4 original articles. ### Wahlgren N, Ahmed N, Davalos A, Ford GA, Grond M, Hacke W, Hennerici MG, Kaste M, Kuelkens S, Larrue V, Lees KR, Roine RO, Soinne L, Toni D, Vanhooren G, for the SITS-MOST investigators. Thrombolysis with alteplase for acute ischemic stroke in the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST): an observational study. Lancet. 2007;369:275–282. The European Agency for the Evaluation of Medicinal Products (EMEA) mandated a postlicensing observational registry of thrombolysis use in Europe as a condition of licensing. The web-based SITS-MOST registry was launched in response to this need and collected more than 6000 patients from nearly 300 European centers. #### Methods Any European center was eligible as long as they agreed to enter all consecutive patients and agreed to site monitoring and aggregrate data reporting. Both experienced and inexperienced thrombolysis sites were eligible. The primary outcomes were safety outcomes: symptomatic ICH and death at 3 months from treatment. #### Results Patients enrolled in the registry were typically similar to those enrolled in prior trials and stroke thrombolysis registries. The mortality rate was 11.3% and symptomatic ICH rate 7.3%. Excellent functional outcome was achieved in 39% of patients. #### Interpretation This experience represents the largest stroke thrombolysis registry globally. It documents the safety and effectiveness of alteplase for stroke in routine clinical …

Detection of unanticipated intracranial hemorrhage during intraoperative magnetic resonance image–guided neurosurgery

The authors report unanticipated intraoperative intracranial hemorrhaging in two pediatric neurosurgical patients. Both children were undergoing elective craniotomies with the aid of intraoperative magnetic resonance (iMR) imaging. In both cases, the ability of iMR imaging to aid in diagnosis allowed prompt and definitive treatment of potentially life-threatening complications. These cases illustrate the ability of iMR imaging to aid in differentiating unexpected and/or unexplained intraoperative events in pediatric neurosurgery.

Computer aided detection of small acute intracranial hemorrhage on computer tomography of brain

Introduction Detection of acute intracranial hemorrhage (AIH) is a primary task in image interpretation of computer tomography (CT) of brain for patients suffering from acute neurological disturbance or head injury. Although CT readily depicts AIH, interpretation can be difficult especially when the lesion is inconspicuous or the reader is inexperienced. Objective To develop a computer aided detection system that improves diagnostic accuracy of small AIH on brain CT. Materials and methods Intracranial contents are first segmented by thresholding and morphological operations, which are then subjected to denoising and adjustment for CT cupping artifacts. The brain is then automatically realigned into normal position. AIH candidates are extracted based on top-hat transformation and left–right asymmetry. AIH candidates are registered against a normalized coordinate system such that the candidates are rendered anatomical information. True AIH is differentiated from mimicking normal variants or artifacts by a knowledge-based classification system incorporating rules that make use of quantified imaging features and anatomical information. A total of 186 clinical cases, including 62 CT studies showing small (<1 cm) AIH, and 124 controls, were retrospectively collected. Forty positive cases and 80 controls were used for the training of the CAD. Twenty-two positive cases and 44 controls were used in the validation of the CAD system. Regions of AIH identified by two experienced radiologists were used as gold standard. The size of individual AIH volume was also recorded. Results On a per patient basis, the system achieved sensitivity of 95% (38/40) and specificity of 88.8% (71/80) in the training dataset. The sensitivity and specificity were 100% (22/22) and 84.1% (37/44) respectively for the diagnosis of AIH in the validation cases. Individual cases contained variable number of AIH volumes. There were 77 lesions in the 40 training cases and 46 lesions in the 22 validation cases. On a per lesion basis, the sensitivities were 84.4% (65/77) and 82.6% (38/46) for all lesions 10 mm or smaller for the training and validation datasets, respectively. False positive rates were 0.19 (23/120) and 0.29 (19/66) false positive lesion per case for the training and validation datasets, respectively. Conclusion This study demonstrated that CAD is valuable for detection of small AIH on brain CT.

Magnetic resonance imaging and computed tomography in emergency assessment of patients with suspected acute stroke: a prospective comparison

Although the use of magnetic resonance imaging (MRI) for the diagnosis of acute stroke is increasing, this method has not proved more effective than computed tomography (CT) in the emergency setting. We aimed to prospectively compare CT and MRI for emergency diagnosis of acute stroke. We did a single-centre, prospective, blind comparison of non-contrast CT and MRI (with diffusion-weighted and susceptibility weighted images) in a consecutive series of patients referred for emergency assessment of suspected acute stroke. Scans were independently interpreted by four experts, who were unaware of clinical information, MRI-CT pairings, and follow-up imaging. 356 patients, 217 of whom had a final clinical diagnosis of acute stroke, were assessed. MRI detected acute stroke (ischaemic or haemorrhagic), acute ischaemic stroke, and chronic haemorrhage more frequently than did CT (p<0.0001, for all comparisons). MRI was similar to CT for the detection of acute intracranial haemorrhage. MRI detected acute ischaemic stroke in 164 of 356 patients (46%; 95% CI 41-51%), compared with CT in 35 of 356 patients (10%; 7-14%). In the subset of patients scanned within 3 h of symptom onset, MRI detected acute ischaemic stroke in 41 of 90 patients (46%; 35-56%); CT in 6 of 90 (7%; 3-14%). Relative to the final clinical diagnosis, MRI had a sensitivity of 83% (181 of 217; 78-88%) and CT of 26% (56 of 217; 20-32%) for the diagnosis of any acute stroke. MRI is better than CT for detection of acute ischaemia, and can detect acute and chronic haemorrhage; therefore it should be the preferred test for accurate diagnosis of patients with suspected acute stroke. Because our patient sample encompassed the range of disease that is likely to be encountered in emergency cases of suspected stroke, our results are directly applicable to clinical practice.

Lesions identified on T2*-weighted gradient echo images in two patients with suspected diffuse axonal injury that resolved in less than ten days

T2*-weighted gradient echo (GE) imaging is useful for detection of intracranial hemorrhage in the patients with diffusion axonal injury (DAI). However, the temporal changes in the DAI-related lesions on T2*-weighted GE images are not clear. We report two very rare cases with DAI in which lesions identified on T2*-weighted GE images resolved in less than ten days.

Comparison of Five MR Sequences for the Detection of Acute Intracranial Hemorrhage

Purpose: To evaluate the respective value of 5 MR sequences to distinguish between stroke patients with and without acute intracerebral hemorrhage (ICH). Methods: MR images obtained ≤6 h after stroke onset of 86 patients (43 ICH, 43 non-ICH) were reviewed by 3 observers who looked for signs of acute ICH on each image set [T₁ and T₂ gradient echo (GRE), FLAIR, T₂-EPI and DWI], presented separately. Results: For the identification of ICH, intraobserver and interobserver concordance were at least ĸ = 0.95 for all sequences. Of all interpretations, 7 (0.4%) were erroneous, with sensitivity and specificity of FLAIR, T₂-EPI and DWI reaching 100%; GRE sensitivity and specificity were 100% and 95–97.5%, respectively; T₁ sensitivity and specificity were 97.3–100% and 97.4–100%, respectively. All 4 patients misclassified on one pulse sequence were correctly classified on all the other sequences. Conclusion: In the setting of acute stroke, each of the 5 studied sequences enables ICH and non-ICH patients to be distinguished with high sensitivity and specificity.

Detection of intracranial hemorrhage: Comparison between gradient-echo images and b0 images obtained from diffusion-weighted echo-planar sequences on 3.0T MRI

In this study, we compared the effectiveness of b0 echo-planar MR images (EPI) imaging with gradient recalled echo (GRE) in detecting acute hemorrhage. Brain images in 69 patients who suffered from acute infarction were reviewed. Nine of them had suffered from acute hemorrhage. Comparing b0EPI and GRE images side-by-side, we found no significant different effectiveness in detecting hemorrhage ( P = .522, ≥.05). We concluded that b0EPI imaging could detect hemorrhagic lesions as effectively as GRE can without additional acquisition time.

Evaluation of personal digital assistants as an interpretation medium for computed tomography of patients with intracranial injury.

The objective of the study was to assess the feasibility of using a personal digital assistant (PDA) as a medium for the interpretation of cranial CT scans of trauma patients. Twenty-one noncontrast cranial CT scans were transferred in their entirety to a PDA from the picture archiving and communications system (PACS) utilizing General Electric (GE) PathSpeed PACS Web Server interface and synchronization. All CT scans had been interpreted by board-certified radiologists prior to the study. Seven of the scans demonstrated subarachnoid hemorrhage, seven demonstrated subdural hematomas, and the remaining scans were normal. After transfer to the PDA, all images were separately reviewed in a blinded manner by a radiologist and a neurosurgeon. Images were graded for their quality and diagnostic utility in the evaluation of intracranial hemorrhage. Image quality was categorized as excellent, very good, acceptable for diagnosis, or not acceptable for diagnosis. Based on the radiologic diagnosis, recommendation for surgical management was made by the reviewing neurosurgeon. The accuracy rate for both the radiologist and the neurosurgeon in the detection of intracranial hemorrhage was 95%. There was one false negative which was attributed to error in judgment rather than poor image quality. This diagnostic error did not affect patient management. The sensitivity and specificity for detection of intracranial hemorrhage were 93% and 100%, respectively. Image quality was judged to be excellent in 90% of the cases and very good in the remaining 10%. Our results suggest that the PDA is a robust medium for interpretation of CT scans in patients with suspected hemorrhage following intracranial injury. In this setting, the PDA should be considered for teleradiology purposes.

MF plant provides accurate test results

To analyze the effect of a computer-aided diagnosis (CAD) system on clinicians’ performance in detection of small acute intracranial hemorrhage (AIH) on computed tomography (CT).The authors have developed a CAD scheme that used both image processing techniques and anatomic knowledge based classification system to improve diagnosis of small AIH on CT. A multiple-reader, multiple-case receiver operating characteristic (ROC) study was performed. Twenty clinicians, including seven emergency physicians, seven radiology residents, and six radiology specialists were recruited as readers of 60 sets of brain CT, including 30 cases that show AIH smaller than 1 cm, and 30 controls. Each reader read the same 60 cases twice, first without, then with the prompts produced by the CAD system. The clinicians ranked their confidence in diagnosing a case of showing AIH, which produced the ROC curves.Significantly improved performance is observed in emergency physicians, average area under the ROC curve (Az) increased from 0.8422 to 0.9294 (P = .0107) when they make the diagnosis without and with the support of CAD. Az for radiology residents increased from 0.9371 to 0.9762 (P = .0088). Az for radiology specialists increased from 0.9742 to 0.9868, but was statistically insignificant (P = .1755).CAD can improve the clinicians’ performance in detecting AIH on CT. In particular, emergency physicians can benefit most from the CAD and improve their performance to a level approaching that of the average radiology residents.

Utility of an initial D-dimer assay in screening for traumatic or spontaneous intracranial hemorrhage.

To evaluate the sensitivity of a D-dimer assay as a screening tool for possible traumatic or spontaneous intracranial hemorrhage. If adequately sensitive, the D-dimer assay may potentially permit omission of a more expensive computed tomography (CT) scan of the head when such hemorrhage is clinically suspected. Prospective, consecutive, blinded study of patients (age > 16 years) requiring a CT scan of the head for suspected intracranial hemorrhage over a five-month period at a university, Level I trauma center. All study patients had a serum D-dimer assay obtained prior to their CT scans. Sensitivity and specificity, with 95% confidence intervals (95% CIs), of the enzyme-linked immunosorbent assay (ELISA) D-dimer assay for the detection of intracranial hemorrhage were calculated. Of the 319 patients entered in the study, 25 (7.8%) had a CT scan positive for intracranial hemorrhage. Patients with intracranial hemorrhage were more likely to have a positive D-dimer assay (chi-square = 13.075, p < 0.001). The D-dimer assay had 21 true-positive and four false-negative tests, resulting in a sensitivity of 84.0% (95% CI = 63.7% to 95.5%) and a specificity of 55.8% (95% CI = 55.5% to 55.9%). The four false-negative cases included one small intraparenchymal hemorrhage, one small subarachnoid hemorrhage, one moderate-sized intraparenchymal hemorrhage with mid-line shift, and one large subdural hematoma requiring emergent surgery. Due to the catastrophic nature of missing an intracranial hemorrhage in the emergency department, the D-dimer assay is not adequately sensitive or predictive to use as a screening tool to allow routine omission of head CT scanning.

Subsequent intracranial haemorrhage following open heart surgery

Intracranial haemorrhage (ICH) is an uncommon but lethal complication of open heart surgery. The aim of the present paper is to analyse studies of ICH subsequent to open heart surgery and further to discuss the risk factors and strategies. Articles were obtained from Index Medicus/MEDLINE database of the National Library of Medicine USA from 1966 to present, and the Chinese Biomedical Literature Database (CBMDISC) of the Institute of Medical Information of Chinese Academy of Medical Sciences from January 1982 to December 2000. Search terms included cardiopulmonary bypass, cardioplegia, neurosurgery, craniotomy, sphenotresia, ICH, intracranial haematoma, haemorrhagic stroke/infarct and craniocerebral injury. Information obtained from the cited literature helped complete the collection of the documents. In total 35 reports covering 179 cases are reviewed. Of the 182 ICHs of 179 patients after open heart surgery, intracerebral haemorrhage was the most frequent (41.21%), subdural haematoma was the second (22.53%) and epidural haematoma was the third (12.64%). Of the 77 sites of ICHs that can be traced, the frontal region was involved the most (23.34%) and the parietal, occipital and temporoparietal regions second (each was 12.99%). It occurred most often on the right (55.84%), more often on the left (31.77%), and the least often on bilateral (12.99%) sides of the brain. Haemorrhage in intracerebral was most common (40.66%), sudural the second (22.53%), then epidural (12.64%) and subarachnoid (3.85%) and the least common in multiple sites. Sixty‐eight (37.36%) of the patients were treated by craniotomy for haematoma evacuation, 30 (16.48%) by conservative treatment, 27 (14.84%) were not treated in time and died, and the other 57 (31.32%) treatment methods are unknown. Forty‐two patients (23.08%) survived, one of whom (0.55%) was in a vegatative state, 103 (56.59%) died and 37 (20.33%) have unknown outcomes. ICH following open heart surgery is rare but risky and always life threatening. Any factors leading to cerebrovascular injury or fluid shifts with fluctuations in cerebral volume during pre‐, intra‐ or postoperation of open heart surgery may cause ICH. Computed tomography scan optimizes the detection of ICH. Miscellaneous prophylactic approaches are mandatory for patients vulnerable to ICH following open heart surgery. Therapeutic approaches as either antibiotics or early operations should be determined on a substantial basis of prosthetic endocarditis patients with ICHs.

Timing of intracranial hemorrhage during extracorporeal life support.

This study was conducted to determine the timing of intracranial hemorrhage (ICH) in patients on extracorporeal life support (ECLS) to improve the use of the head ultrasound in the detection of ICH. A review was conducted of all neonatal ECLS patients at the neonatal intensive care nursery at Kosair Children's Hospital in Louisville, Kentucky, from May, 1985 through November, 1994 to establish a study group of infants in whom an ICH developed while on ECLS. Thirty infants who had an ICH (excluding subarachnoid hemorrhage and infarction) on ECLS were included in the study. Data were collected that included patients demographics, age at initiation of ECLS, duration of ECLS, type of ECLS support (venoarterial or venovenous), oxygenation index and last arterial blood gas before ECLS, hours of ECLS before ICH, and grade of ICH. ICH occurred in 9.9% of the neonatal patients requiring ECLS. These included 8 infants with a Grade I bleed, 1 infant with a Grade II, 4 infants with a Grade III, and 17 infants with a Grade IV. Ten of the 30 patients had sepsis as their primary diagnosis, and these infants were more likely to have an ICH while on ECLS compared to nonseptic infants (p < 0.02). The Kaplan-Meier curve showed that 50% of ICHs occurred in the first 24 hours of ECLS, 75% by 48 hours, and that 85% of ICHs occurred within 72 hours of initiation of bypass. There was no difference in timing of ICH in the septic infants compared to the nonseptic infants. The late occurring bleeds (> 72 hours) were all associated with significant neurologic changes or with multiorgan failure. It is concluded that daily head ultrasounds should be performed during the first 3 days of ECLS because most ICHs (85%) occur in the first 72 hours of cardiopulmonary bypass. In this era of cost containment, subsequent head ultrasounds should be obtained with changes in the infant's neurologic status or with the development of multiorgan failure.

Fetal Intracranial Haemorrhage

Achiron, R.; Pinchas, O. Hamiel; Reichman, B.; Heyman, Z.; Schimmel, M.; Eidelman, A.; Mashiach, S. Author Information

Fetal intracranial haemorrhage: clinical significance of in utero ultrasonographic diagnosis

To review in utero detection of fetal intracranial haemorrhage. Retrospective survey of pregnant women presenting to the ultrasonographic unit in whom the diagnosis of fetal intracranial haemorrhage was reached. The Chaim Sheba Medical Center in Ramat Gan, and Shaare Zedek Medical Center in Jerusalem; two large district general hospitals, each with 6000 maternity patients per year. Five fetuses with gestational ages ranging from 26 to 36 weeks. Maternal complications, fetal monitoring, prenatal Doppler ultrasound studies, postnatal imaging studies, neonatal morbidity and mortality. Transabdominal sonography showed hyperechoic lesions in the brain parenchyma, and the lateral ventricle in three of five fetuses. In the remaining two fetuses, transvaginal sonography enhanced the visualisation of ventriculomegaly with intraventricular haemorrhage in one and periventricular leukomalacia was identified in the second. Three fetuses were appropriate for gestational age, and two were severely growth retarded. In one woman severe pre-eclamptic toxaemia may explain intracranial haemorrhage. Abnormal nonstress test and abnormal flow velocity waveforms in the umbilical and cerebral arteries were present in the two growth retarded fetuses, and in one who was appropriate for gestational age. The two growth retarded fetuses died shortly after birth. Of the three surviving infants, two had normal long term development, and one developed hydrocephalus with subsequent severe neurodevelopmental retardation, dying at the age of seven months. This small series shows that intracranial haemorrhage has a broad spectrum of manifestations with diverse prognosis. Following an antenatal diagnosis of intracranial haemorrhage, the obstetrician must give special consideration to electronic fetal heart monitoring and Doppler velocity waveforms. The prenatal diagnosis of intracranial haemorrhage has medico-legal implications suggesting that neurological outcome may not necessarily be due solely to intrapartum events and management.