Neonatal extra-axial hemorrhage

A 37 weeks gestation male neonate was born to a 25 year old G3P2002 mother.  The mother has a history of urinary retention due to Fowler's syndrome requiring self-catheterization.   Later in the pregnancy, there were concerns regarding IUGR.   Delivery was via elective repeat cesarean section.  There was meconium stained amniotic fluid.  Birth weight was 2070 grams and OFC 33 cm.  Apgar scores were 8 and 9.  Initially he breastfed but then seemed less vigorous in his attempts.  Lethargy and apneic spells ensued.  He was noted as having “dots on the face.”  He was transferred to the NICU.

In the NICU, he manifested poor respiratory effort and there was intermittent bradycardia.  He was intubated.  A cranial ultrasound showed extensive intracranial hemorrhage with a right-to-left midline shift.  Platelet count was 5,000 and hemoglobin 8.1.  PT was 19.6 (INR 1.9), PTT 36.4 and fibrinogen 69.  A cranial CT scan showed a very large extra-axial  hemorrhage in the right hemicranium with some evidence of entrapment of the left lateral  ventricle and right temporal horn.   With blood products, including platelet transfusion, the platelet count rose to 129,000.  PT was 15.1 (INR 1.4), PTT 32 and fibrinogen 321.

Neurosurgery, in view of the massive hemorrhage with midline shift, which did produce anisocoria, and the coagulopathy declined intervention.  There was initial discussion regarding whether or not to otherwise limit care.  The mother decided to proceed with medical management.

Seizures were treated with levetiracetam.  An  MRI showed again extensive right hemisphere extra-axial hemorrhage with midline shift, uncal herniation and downward transtentorial herniation.  There was extensive edema and restricted diffusion in the right cerebral hemisphere and, to a lesser extent, in the left cerebral hemisphere.  MRA showed considerable mass effect on the circle of Willis with leftward shift.  Initially, the neonate was flaccid.

 

Subsequently, the neonate became more active.  Respiratory assistance ceased to be necessary.  No motor asymmetry was evident.  He fed orally, but did so taking inadequate intake.  A gastrostomy was placed.  Anisocoria was still present.  The etiology of his thrombocytopenia and coagulopathy was deemed unclear.  Hematology consultation could not define this as neonatal alloimmune thrombocytopenia.  Maternal antiplatelet antibody testing was negative. He was discharged from the newborn hospitalization at 33 days of age.

The most recent cerebral imaging study, a cranial CT, showed encephalomalacia involving the majority of the right cerebral hemisphere. There was a relatively high attenuation seen predominantly along the peripheral aspect of encephalomalacia, relating to evolving residual blood products. Mass effect had improved. There was no evidence for new or progressive hemorrhage. There was an interval decrease in the size of the lateral ventricles compared to the most recent MRI done a month earlier. There was mild to moderate ex vacuo dilation of the right lateral ventricle and residual dilation of the temporal horn of the left lateral ventricle.

At 2 ½ months of age he will breastfeed by day, but receives gastrostomy feeding overnight.  Visual attentiveness has not been established.   He is perceived as utilizing his extremities symmetrically, but examination shows slightly increased tone and reflexes on the left.  Therapy with levetiracetam continues with no seizures appreciated.