Pediatric Periventricular Leukomalacia Workup
- Author: Terence Zach, MD; Chief Editor: Ted Rosenkrantz, MD more...
Cranial ultrasonography is the modality of choice for the initial evaluation of hypoxic-ischemic damage of the CNS in premature infants. Ultrasonography may be performed in the NICU without the need to transport fragile infants.
The earliest ultrasonographic appearance of periventricular leukomalacia (PVL) is abnormal increased echotexture in the periventricular white matter. This is a nonspecific finding that must be differentiated from the normal periventricular halo and mild periventricular edema that may not result in permanent injury.
The abnormal periventricular echotexture of periventricular leukomalacia usually disappears at 2-3 weeks. Approximately 15% of infants experiencing periventricular leukomalacia demonstrate periventricular cysts first appearing at 2-3 weeks after the initial increased echodensities.
The severity of periventricular leukomalacia is related to the size and distribution of these cysts. Initial cranial ultrasonographic findings may be normal in patients who go on to develop clinical and delayed imaging findings of periventricular leukomalacia. Examples of cranial ultrasonography in periventricular leukomalacia are shown in the images below.
Computed Tomography Scanning
CT scanning is not a first-line modality in evaluating these fragile premature infants in the first weeks of life. CT scanning may be helpful to better evaluate the extent and severity of periventricular leukomalacia.
Findings include ventriculomegaly involving the lateral ventricles with irregular margins of the ventricles and loss of deep white matter. Examples of CT scanning in periventricular leukomalacia are shown in the images below.
Magnetic Resonance Imaging
As with CT scanning, MRI does not play a major role in the early evaluation of periventricular leukomalacia. MRI is most helpful in detecting infants with non-cystic periventricular leukomalacia or evaluating infants who develop clinical signs suggestive of periventricular leukomalacia.
MRI demonstrates the loss of white matter, abnormal signal intensity of the deep white matter, and ventriculomegaly; it also reveals thinning of the posterior body and splenium of the corpus callosum in severe cases of periventricular leukomalacia.
In a study of MRIs at term-equivalent age from 3 cohorts of 325 very preterm infants, Kidokoro et al found 33% (n=107) had some grade of brain injury (eg, periventricular leukomalacia, intraventricular/cerebellar hemorrhage) and 10% (n=33) had severe brain injury. The investigators noted severe brain injury and impaired growth patterns were independently associated with perinatal risk factors and delayed cognitive development.
Volumetric MRI scanning is also helpful in determining the extent of injury to the descending corticospinal tracts.
A relationship between the degree of injury to the descending corticospinal tracts as assessed by MRI and the severity of diplegia has been reported.
Examples of MRI in periventricular leukomalacia are shown in the images below.
Obtain electroencephalography (EEG) studies in preterm infants for early detection of periventricular leukomalacia. Changes in hypoxic-ischemic encephalopathy and EEG wave patterns may change over time and indicate the severity of the brain injury. EEG abnormalities may be apparent before anomalies seen on ultrasonography.
Spectral-domain optical coherence tomography (SD-OCT) shows promise in the evaluation of prematurity on early optic nerve development and of central nervous system development and anomalies.
On histologic examination, periventricular leukomalacia lesions demonstrate widespread loss of oligodendrocytes and an increase in astrocytes.
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