Wednesday, February 10, 2016

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.



  1. At 4 months of age (he has moved out of state): He is doing ok. Growing slowly but growing!! Lots is going on. We are doing PT 2x a week because he is a bit delayed. We will hopefully find out on 4/11 what he can see through those beautiful eyes of his. We saw craniofacial doctor last week and was told we may need to do a surgery to fix his bones because he has a unique form of craniosynostosis. He wants to wait two more months to officially decide but he says he is pretty sure he will need the surgery. (Mama is not looking forward to that) We still haven't been able to see the neurologist. Which in a way I'm ok with that but then I'm also upset because I would like to wean him off the diazepam but can't see a doctor til June. He doesn't have much twitching anymore so I would like to wean him so that he doesn't have to be too dependent on it.

    He still hasn't smiled so we are patiently waiting for that day to come and for him to look at me purposefully! But I have hope it will come one day!! He is eating great and have speech help with it! We are teaching him to touch toys purposefully which is going great but lots of work ahead!

  2. At 20 months of age, he was admitted for status epilepticus. His levetiracetam maintenance dosage was increased,

    "He is nonverbal. He coos and grunts. He is right-hand dominant. He can grab toys purposefully and play with them. He will not grab with his left hand, unless the right arm is constrained. He is able to Army crawl in a circle and rolls a lot.”

    MRI showed interval evolution of the previously seen right cerebral hemorrhagic infarct with progression of cystic
    encephalomalacia in the right cerebral hemisphere and secondary ex vacuo ventricular dilatation.

    EEG showed continuous focal attenuation in the right hemisphere, maximal in the right frontal and temporal regions, occasional central midline sharps. and asymmetric sleep architecture.