Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Germinal Matrix Hemorrhage Imaging

  • Author: Omar Islam, MD, FRCPC; Chief Editor: Eugene C Lin, MD  more...
 
Updated: Nov 24, 2015
 

Overview

Germinal matrix hemorrhage (GMH) and intraventricular hemorrhage (IVH) are the most common and most important neurologic injuries in preterm neonates. The brain of a premature infant lacks the ability to autoregulate cerebral blood pressure; thus, fluctuations in cerebral blood pressure and flow can rupture the primitive germinal matrix vessels or lead to infarction of the metabolically active germinal matrix. The damage can extend into the periventricular white matter, resulting in significant neurologic sequelae, including cerebral palsy, mental retardation, and seizures. Injury to the germinal matrix has substantial mortality and morbidity rates.

A common lesion that characterizes the neuropathology of GMH/IVH is bleeding into the subependymal germinal matrix, with or without subsequent rupture into the lateral ventricle (see the images below). Sequelae of GMH/IVH include germinal matrix destruction, periventricular hemorrhagic infarction with subsequent encephalomalacia, and posthemorrhagic hydrocephalus.[1, 2, 3, 4]

Axial nonenhanced computed tomography scan. The im Axial nonenhanced computed tomography scan. The image shows bilateral grade 2 subependymal and intraventricular germinal matrix hemorrhage without hydrocephalus.
Coronal ultrasonogram of a 1-day-old neonate. The Coronal ultrasonogram of a 1-day-old neonate. The image demonstrates a bilateral grade 2 subependymal hemorrhage. Note the echogenic clot in the left temporal horn (arrow, right side).

Ultrasonography is the primary imaging modality for the screening and diagnosis of GMH/IVH, and computed tomography (CT) scanning and magnetic resonance imaging (MRI) are used as supplementary tools (see the images above).

Intraventricular hemorrhage grading system

The IVH grading system created by Burstein et al in 1979 relies on the detection of blood in the subependymal germinal matrix and the ventricles, as follows[5] :

  • Grade 1: Hemorrhage that is confined to the germinal matrix
  • Grade 2: Extension of the hemorrhage into the lateral ventricles without hydrocephalus
  • Grade 3: Ventricular hemorrhage with the presence of associated hydrocephalus
  • Grade 4: Parenchymal hemorrhage

Preferred examination

Ultrasonography is the preferred screening and diagnostic tool for GMH.[6, 7] The portability of this modality allows imaging in the nursery with minimal disturbance of the infant. Ultrasonography also depicts GMHs that are larger than 5 mm, with a sensitivity of nearly 100% and specificity of 91%. Smaller GMHs, however, are more difficult to identify. Power and pulsed-wave Doppler ultrasonography can be used to identify preterm neonates who are at risk for GMH and IVH during their first week of life. Using this modality, clinicians can detect autoregulatory fluctuations in the preterm neonate's cerebral blood flow with examination of the lenticulostriate arteries; measurements of the peak velocity, resistive index, and coronal vascular cross-sectional area; and product of the peak velocity and vascular cross-sectional area.[8, 9, 10]

CT scanning and MRI are also used and have better interobserver agreement.[11] Because these modalities more readily depict small GMHs, CT scanning and MRI have a higher sensitivity than that of ultrasonography. However, these 2 imaging modalities require that the infant be moved from the nursery; there is also the possibility that sedation would be required.[12, 13]

Limitations of techniques

All imaging modalities have relatively low negative predictive values (NPVs). In a 2000 study, Blankenberg et al found negative predictive values of 53% at 2-month follow-up and 59% at 2-year follow-up, irrespective of the modality.[14] However, the absence of neuroimaging abnormalities in the infant does not exclude the possibility of later neurodevelopmental problems.

Differential diagnosis

Periventricular leukomalacia is included in the differential diagnosis.

Special concerns

Normal imaging findings must be viewed with caution. Ultrasonography, CT scanning, and MRI all have low negative predictive values of approximately 60%.

With fetal ultrasonography and fetal MRI, GMH/IVH can be identified in utero, remote in time from delivery.[15]

Next

Computed Tomography

Intraventricular hemorrhage (IVH) evolves in a predictable pattern. Acutely, it appears to hyperattenuate. After 7-10 days, the hemorrhage becomes isoattenuating relative to the brain parenchyma. Later, with clot retraction, a subependymal hematoma may develop into a fluid-filled cyst. The affected brain parenchyma may undergo atrophy and gliosis (see the following image below).

Axial nonenhanced computed tomography scan. The im Axial nonenhanced computed tomography scan. The image shows bilateral grade 2 subependymal and intraventricular germinal matrix hemorrhage without hydrocephalus.

Blankenberg et al found that CT scanning had nearly twice the sensitivity of ultrasonography in the detection of germinal matrix hemorrhage (GMH) and IVH; interobserver agreement with this modality was also improved relative to ultrasonography.[14]

A normal CT scan finding for GMH and IVH does not exclude abnormal neurodevelopment; the negative predictive value is 50-60% at age 2 years.

Previous
Next

Magnetic Resonance Imaging

In the first 3 days after intraventricular hemorrhage (IVH), subependymal hematomas are isointense to slightly hypointense on T1-weighted MRIs (T1WIs) and markedly hypointense on T2-weighted MRIs (T2WIs). In the early subacute stage during days 4-7, the signal intensity increases on T1WIs. In the late subacute stage during days 7-14, the signal intensity increases on T2WIs. Over the next several months, the hemorrhage becomes hypointense on images obtained with both sequences, and ferromagnetic effects secondary to hemosiderin and ferritin predominate (see the images below in Multimedia).[12]

Sagittal spoiled gradient-recalled echo (SPGR) mag Sagittal spoiled gradient-recalled echo (SPGR) magnetic resonance image (MRI) of a fetus at 34 weeks' gestation in a 29-year-old woman. The MRI was performed to investigate fetal tachycardia; the image demonstrates intraventricular hemorrhage and parenchymal hematoma.
Sagittal spoiled gradient-recalled echo (SPGR) mag Sagittal spoiled gradient-recalled echo (SPGR) magnetic resonance image (MRI) of a fetus at 34 weeks' gestation in a 29-year-old woman (same patient as in the previous image). An ultrasonogram was initially performed to investigate fetal tachycardia and revealed hydrocephalus. Subsequent SPGR MRI demonstrated a grade 4 germinal matrix hemorrhage in utero.
Sagittal spoiled gradient-recalled echo magnetic r Sagittal spoiled gradient-recalled echo magnetic resonance image of a fetus. The image demonstrates a grade 4 germinal matrix hemorrhage in utero.
Axial single-shot, fast spin-echo, T2-weighted mag Axial single-shot, fast spin-echo, T2-weighted magnetic resonance image of a fetus. The image demonstrates a grade 4 germinal matrix hemorrhage in utero.
Coronal single-shot, fast spin-echo, T2-weighted m Coronal single-shot, fast spin-echo, T2-weighted magnetic resonance image of a fetus. The image demonstrates a grade 4 germinal matrix hemorrhage in utero.
Axial diffusion-weighted magnetic resonance image Axial diffusion-weighted magnetic resonance image (MRI) of a fetus. The MRI demonstrates no evidence of an acute infarct. Abnormal parenchymal signal intensity seen on MRIs obtained with other sequences is most compatible with hemorrhage.

As with CT scanning, Blankenberg et al found that MRI had nearly twice the sensitivity of ultrasonography in the detection of germinal matrix hemorrhage (GMH) and intraventricular hemorrhage (IVH), and interobserver agreement with this modality was also improved relative to ultrasonography.[14]  A normal image finding for GMH/IVH does not exclude abnormal neurodevelopment. The negative predictive value is 50-60% at age 2 years.

Previous
Next

Ultrasonography

Neurosonography is the primary modality for both screening and follow-up of germinal matrix hemorrhage (GMH) and intraventricular hemorrhage (IVH) in neonates. Ultrasonography is portable, allowing imaging in the comfortable environment of the neonatal intensive care unit (NICU), this modality has negative predictive values similar to those of CT scanning and MRI. Current screening protocols recommend performing ultrasonographic studies on days 7-14 of life and between the fourth and sixth weeks of life. Many centers offer more frequent screening.[16, 8, 9]

On ultrasonograms, acute subependymal hemorrhage appears as a homogeneous echogenic mass, often in the caudothalamic groove (see the image below).

Coronal ultrasonogram of a 1-day-old neonate. The Coronal ultrasonogram of a 1-day-old neonate. The image demonstrates a bilateral grade 2 subependymal hemorrhage. Note the echogenic clot in the left temporal horn (arrow, right side).

The hematoma becomes less echogenic over time, beginning with the central portion. Subsequent to eventual clot retraction, a subependymal cyst may develop, or a linear echo may result (see the following image).

Sagittal ultrasonogram. The image demonstrates a g Sagittal ultrasonogram. The image demonstrates a grade 3 germinal matrix hemorrhage and shows a subependymal focus of hyperechogenicity (arrow) that represents hemorrhage, as well as intraventricular hemorrhage and hydrocephalus.

Acutely, IVH also appears echogenic. Cerebrospinal fluid (CSF)–blood fluid levels may be observed. When large, the clot forms a cast of the ventricle (see the image below) and may break up in the ventricle, resulting in low-level echoes that float in the CSF.

Sagittal ultrasonogram. The image shows intraventr Sagittal ultrasonogram. The image shows intraventricular hemorrhage; the clot forms a cast of the ventricle.

The clot may also move when the patient's head position changes. With clot evolution, the hematoma becomes echolucent, starting centrally (see the following images). Scanning through the posterior fontanelle may optimize visualization of occipital horn clots.

Sagittal neurosonogram. The image demonstrates a g Sagittal neurosonogram. The image demonstrates a grade 3 germinal matrix hemorrhage with an intraventricular clot and hydrocephalus.
Coronal neurosonogram. The image demonstrates (rig Coronal neurosonogram. The image demonstrates (right) grade 4 germinal matrix and intraventricular hemorrhage and (left) grade 1 germinal matrix hemorrhage.

Intraparenchymal hemorrhage is usually located in the frontal and parietal lobes and appears acutely as an echogenic homogeneous mass. As the hemorrhage evolves, an echogenic rim with a sonolucent center forms. After 2-3 months, a porencephalic cyst (if the lesion communicates with a ventricle) or encephalomalacia may develop (see the image below).

Sagittal ultrasonogram. The images shows cystic en Sagittal ultrasonogram. The images shows cystic encephalomalacia as a sequela of previous germinal matrix hemorrhage. In a region of an earlier parenchymal hemorrhage, a cerebrospinal fluid-filled cyst has formed (arrow).

Power and pulsed-wave Doppler ultrasonography may be useful in identifying preterm neonates who are at risk of GMH/IVH during their first week of life. The ultrasonograms may depict autoregulatory fluctuations in cerebral blood flow. Neurosonography depicts GMHs that are larger than 5 mm with a sensitivity of 100% and a specificity of 91%. IVH may blend imperceptibly with the choroid plexus, which has a similar echo texture; thus, asymmetric thickness of the choroid plexus should be viewed with suspicion. The lack of abnormality with ultrasonography does not exclude the possibility of later neurodevelopmental problems.

Previous
 
Contributor Information and Disclosures
Author

Omar Islam, MD, FRCPC Assistant Professor of Radiology, Queen's University Faculty of Health Sciences; Consulting Staff, Department of Imaging Services, Section Head, Division of Neuroradiology and Head and Neck Imaging, Kingston General Hospital and Hotel Dieu Hospital, Canada

Omar Islam, MD, FRCPC is a member of the following medical societies: Canadian Medical Association, Ontario Medical Association, American Society of Neuroradiology, Radiological Society of North America

Disclosure: Nothing to disclose.

Coauthor(s)

Andrew Leung, MD 

Andrew Leung, MD is a member of the following medical societies: College of Physicians and Surgeons of Ontario

Disclosure: Nothing to disclose.

Specialty Editor Board

Bernard D Coombs, MB, ChB, PhD Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand

Disclosure: Nothing to disclose.

Kieran McHugh, MB, BCh Honorary Lecturer, The Institute of Child Health; Consultant Pediatric Radiologist, Department of Radiology, Great Ormond Street Hospital for Children, London, UK

Kieran McHugh, MB, BCh is a member of the following medical societies: American Roentgen Ray Society, Royal College of Radiologists

Disclosure: Nothing to disclose.

Chief Editor

Eugene C Lin, MD Attending Radiologist, Teaching Coordinator for Cardiac Imaging, Radiology Residency Program, Virginia Mason Medical Center; Clinical Assistant Professor of Radiology, University of Washington School of Medicine

Eugene C Lin, MD is a member of the following medical societies: American College of Nuclear Medicine, American College of Radiology, Radiological Society of North America, Society of Nuclear Medicine and Molecular Imaging

Disclosure: Nothing to disclose.

Additional Contributors

Charles M Glasier, MD Professor, Departments of Radiology and Pediatrics, University of Arkansas for Medical Sciences; Chief, Magnetic Resonance Imaging, Vice-Chief, Pediatric Radiology, Arkansas Children's Hospital

Charles M Glasier, MD is a member of the following medical societies: American College of Radiology, American Society of Neuroradiology, Radiological Society of North America, Society for Pediatric Radiology

Disclosure: Nothing to disclose.

References
  1. Simard JM, Castellani RJ, Ivanova S, Koltz MT, Gerzanich V. Sulfonylurea receptor 1 in the germinal matrix of premature infants. Pediatr Res. 2008 Dec. 64(6):648-52. [Medline].

  2. Roze E, Kerstjens JM, Maathuis CG, ter Horst HJ, Bos AF. Risk factors for adverse outcome in preterm infants with periventricular hemorrhagic infarction. Pediatrics. 2008 Jul. 122(1):e46-52. [Medline].

  3. Xu H, Hu F, Sado Y, Ninomiya Y, Borza DB, Ungvari Z, et al. Maturational changes in laminin, fibronectin, collagen IV, and perlecan in germinal matrix, cortex, and white matter and effect of betamethasone. J Neurosci Res. 2008 May 15. 86(7):1482-500. [Medline].

  4. Yang LT, Li WY, Kaartinen V. Tissue-specific expression of Cre recombinase from the Tgfb3 locus. Genesis. 2008 Feb. 46(2):112-8. [Medline].

  5. Burstein J, Papile LA, Burstein R. Intraventricular hemorrhage and hydrocephalus in premature newborns: a prospective study with CT. AJR Am J Roentgenol. 1979 Apr. 132(4):631-5. [Medline].

  6. Parodi A, Morana G, Severino MS, Malova M, Natalizia AR, Sannia A, et al. Low-grade intraventricular hemorrhage: is ultrasound good enough?. J Matern Fetal Neonatal Med. 2013 Aug 23. [Medline].

  7. Intrapiromkul J, Northington F, Huisman TA, Izbudak I, Meoded A, Tekes A. Accuracy of head ultrasound for the detection of intracranial hemorrhage in preterm neonates: comparison with brain MRI and susceptibility-weighted imaging. J Neuroradiol. 2013 May. 40(2):81-8. [Medline].

  8. O'Dell MC, Cassady C, Logsdon G, Varich L. Cinegraphic versus Combined Static and Cinegraphic Imaging for Initial Cranial Ultrasound Screening in Premature Infants. Pediatr Radiol. 2015 Oct. 45 (11):1706-11. [Medline].

  9. Intrapiromkul J, Northington F, Huisman TA, Izbudak I, Meoded A, Tekes A. Accuracy of head ultrasound for the detection of intracranial hemorrhage in preterm neonates: comparison with brain MRI and susceptibility-weighted imaging. J Neuroradiol. 2013 May. 40 (2):81-8. [Medline].

  10. Parodi A, Morana G, Severino MS, Malova M, Natalizia AR, Sannia A, et al. Low-grade intraventricular hemorrhage: is ultrasound good enough?. J Matern Fetal Neonatal Med. 2015 Nov. 28 Suppl 1:2261-4. [Medline].

  11. Fumagalli M, Bassi L, Sirgiovanni I, Mosca F, Sannia A, Ramenghi LA. From germinal matrix to cerebellar haemorrhage. J Matern Fetal Neonatal Med. 2013 Aug 23. [Medline].

  12. Martino F, Malova M, Cesaretti C, Parazzini C, Doneda C, Ramenghi LA, et al. Prenatal MR imaging features of isolated cerebellar haemorrhagic lesions. Eur Radiol. 2015 Oct 16. [Medline].

  13. Fumagalli M, Bassi L, Sirgiovanni I, Mosca F, Sannia A, Ramenghi LA. From germinal matrix to cerebellar haemorrhage. J Matern Fetal Neonatal Med. 2015 Nov. 28 Suppl 1:2280-5. [Medline].

  14. Blankenberg FG, Loh NN, Bracci P, et al. Sonography, CT, and MR imaging: a prospective comparison of neonates with suspected intracranial ischemia and hemorrhage. AJNR Am J Neuroradiol. 2000 Jan. 21(1):213-8. [Medline]. [Full Text].

  15. Morioka T, Hashiguchi K, Nagata S, et al. Fetal germinal matrix and intraventricular hemorrhage. Pediatr Neurosurg. 2006. 42(6):354-61. [Medline]. [Full Text].

  16. Yikilmaz A, Taylor GA. Cranial sonography in term and near-term infants. Pediatr Radiol. 2008 Jun. 38(6):605-16; qiuz 718-9. [Medline].

  17. Blankenberg FG, Norbash AM, Lane B, et al. Neonatal intracranial ischemia and hemorrhage: diagnosis with US, CT, and MR imaging. Radiology. 1996 Apr. 199(1):253-9. [Medline].

  18. Boal DK, Watterberg KL, Miles S, Gifford KL. Optimal cost-effective timing of cranial ultrasound screening in low-birth-weight infants. Pediatr Radiol. 1995. 25(6):425-8. [Medline].

  19. Carson SC, Hertzberg BS, Bowie JD, Burger PC. Value of sonography in the diagnosis of intracranial hemorrhage and periventricular leukomalacia: a postmortem study of 35 cases. AJNR Am J Neuroradiol. 1990 Jul-Aug. 11(4):677-83. [Medline].

  20. Ghazi-Birry HS, Brown WR, Moody DM, et al. Human germinal matrix: venous origin of hemorrhage and vascular characteristics. AJNR Am J Neuroradiol. 1997 Feb. 18(2):219-29. [Medline]. [Full Text].

  21. Pinto-Martin JA, Riolo S, Cnaan A, et al. Cranial ultrasound prediction of disabling and nondisabling cerebral palsy at age two in a low birth weight population. Pediatrics. 1995 Feb. 95(2):249-54. [Medline].

  22. Taylor GA. New concepts in the pathogenesis of germinal matrix intraparenchymal hemorrhage in premature infants. AJNR Am J Neuroradiol. 1997 Feb. 18(2):231-2. [Medline]. [Full Text].

  23. Townsend SF, Rumack CM, Thilo EH, Merenstein GB, Rosenberg AA. Late neurosonographic screening is important to the diagnosis of periventricular leukomalacia and ventricular enlargement in preterm infants. Pediatr Radiol. 1999 May. 29(5):347-52. [Medline].

 
Previous
Next
 
Axial nonenhanced computed tomography scan. The image shows bilateral grade 2 subependymal and intraventricular germinal matrix hemorrhage without hydrocephalus.
Coronal ultrasonogram of a 1-day-old neonate. The image demonstrates a bilateral grade 2 subependymal hemorrhage. Note the echogenic clot in the left temporal horn (arrow, right side).
Sagittal spoiled gradient-recalled echo (SPGR) magnetic resonance image (MRI) of a fetus at 34 weeks' gestation in a 29-year-old woman. The MRI was performed to investigate fetal tachycardia; the image demonstrates intraventricular hemorrhage and parenchymal hematoma.
Sagittal spoiled gradient-recalled echo (SPGR) magnetic resonance image (MRI) of a fetus at 34 weeks' gestation in a 29-year-old woman (same patient as in the previous image). An ultrasonogram was initially performed to investigate fetal tachycardia and revealed hydrocephalus. Subsequent SPGR MRI demonstrated a grade 4 germinal matrix hemorrhage in utero.
Sagittal spoiled gradient-recalled echo magnetic resonance image of a fetus. The image demonstrates a grade 4 germinal matrix hemorrhage in utero.
Axial single-shot, fast spin-echo, T2-weighted magnetic resonance image of a fetus. The image demonstrates a grade 4 germinal matrix hemorrhage in utero.
Coronal single-shot, fast spin-echo, T2-weighted magnetic resonance image of a fetus. The image demonstrates a grade 4 germinal matrix hemorrhage in utero.
Axial diffusion-weighted magnetic resonance image (MRI) of a fetus. The MRI demonstrates no evidence of an acute infarct. Abnormal parenchymal signal intensity seen on MRIs obtained with other sequences is most compatible with hemorrhage.
Sagittal ultrasonogram. The image demonstrates a grade 3 germinal matrix hemorrhage and shows a subependymal focus of hyperechogenicity (arrow) that represents hemorrhage, as well as intraventricular hemorrhage and hydrocephalus.
Sagittal ultrasonogram. The image shows intraventricular hemorrhage; the clot forms a cast of the ventricle.
Sagittal neurosonogram. The image demonstrates a grade 3 germinal matrix hemorrhage with an intraventricular clot and hydrocephalus.
Coronal neurosonogram. The image demonstrates (right) grade 4 germinal matrix and intraventricular hemorrhage and (left) grade 1 germinal matrix hemorrhage.
Sagittal ultrasonogram. The images shows cystic encephalomalacia as a sequela of previous germinal matrix hemorrhage. In a region of an earlier parenchymal hemorrhage, a cerebrospinal fluid-filled cyst has formed (arrow).
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.