Germinal matrix hemorrhage

Germinal matrix haemorrhages,also know as periventricular-intraventricular haemorrhages (PVIH), correspond to are the most commoncommonest type of intracranial haemorrhage in neonates and are related to a perinatal stress affecting the highly vascularised subependymal germinal matrix. The majority of cases occur in premature births within the first week of life. They are a cause of significant morbidity and mortality in this population. 

Epidemiology

Germinal matrix haemorrhage can only occur when the germinal matrix is present and is therefore only seen in premature infants. Haemorrhages can be identified in 67% of infants born prematurely at 28-32 weeks ¹ and 80% of infants born between 23 and 24 weeks of gestation ². The majority of haemorrhages (90%) are identified within 4 days of birth, and 40% within the first 5 hours ⁴.

Clinical presentation

Clinical presentation for grade I and II bleeds is vague. These are usually found on routine ultrasound performed on premature neonates. With grade III and IV bleeds respiratory depression or apnoea, abnormal posturing, seizures and bulging fontanelles may be seen ².

Pathology

The germinal matrix is formed early during embryogenesis and is the site of glial and neuronal differentiation. From here cells migrate peripherally to form the brain. It is densely cellular and, not surprisingly, also densely vascular ².

The blood vessels of the germinal matrix are weak walled-walled and predisposed to haemorrhage. A significant stress experienced by a premature infant after birth may cause these vessels to rupture. The bleeding occurs initially in the periventricular areas causing a periventricular haemorrhage (PVH). If this bleeding persists, the expanding volume of blood dissects into the adjacent lateral ventricles leading to an intraventricular haemorrhage (IVH).

There areis a direct relation between prematurity, germinal matrix and thus the number of capillaries in this region: at 32 weeks germinal matrix is only present at the caudothalamic groove. By 35-36 weeks gestation the germinal matrix has essentially disappeared and thus the risk of haemorrhage is markedly reduced.

Risk factors

• low birthweight
• cyanotic congenital heart disease
• prolonged labour
• multifetal pregnancy

Classification

See: gradingGrading of neonatal intracranial haemorrhage.

Radiographic features

Ultrasound

This is the investigation of choice since it is portable and does not require sedation. Germinal matrix haemorrhages appear as echogenic regions close to the caudothalamic groove extending along the floor of the frontal horn of the lateral ventricle.

It is important to distinguish haemorrhage from the normal choroid plexus which is also echogenic. The caudothalamic groove acts as a convenient landmark: echogenicity anterior to the groove represents blood as the choroid finishes at the groove ⁴.

CT

CT may demonstrate high attenuating regions in keeping with haemorrhage which may or may not also be seen dependently within the ventricles.

With grade IV bleeds, large confluent regions of low density (venous infarction) and patchy regions of hyperdensity (haemorrhage) are seen in the periventricular regions. They are typically flame-shaped ⁴.

MRI

The appearance of the haemorrhage will vary according to the age of the bleed (see ageing blood on MRI).

Treatment and prognosis

IdealThe ideal treatment is the prevention of premature delivery. Antenatal dexamethasone administered to the mother, or indomethacin administered to the infant also decrease the incidence, although the exact mechanism by which this occurs is uncertain ². 

If hydrocephalus is present, CSF drainage may be necessary.

Prognosis depends on the extent of haemorrhage and presence of hydrocephalus (see germinal matrix haemorrhage grading). Grade I and II haemorrhages have a good prognosis, whereas grades III and IV have a poor prognosis, with a 90% mortality for grade IV bleeds ¹.

In grade IV bleeds significant areas of cerebral tissue may be lost, forming porencephalic cysts.

Complications

• post haemorrhagic hydrocephalus
• blockage of villi
• obliterative fibrosing arachnoiditis
• periventricular leukomalacia
• cyst formation
  • cavitation of haemorrhage
  • subependymal cyst
  • unilocular porencephalic cyst

Differential diagnosis

Differential considerations on antenatal ultrasound includesinclude:

• normal choroid plexus: does not extend anterioranteriorly to the caudothalamic groove/foramen of Monro
• Intraventricular haemorrhage of the newborn: within the subependymal region, rather than the germinal matrix
• early periventricular leukomalacia: when echogenicity is increased, common in preterm
• hypoxic ischemic-ischemic brain injury: involves subcortical cerebral or basal ganglia injury; common in term babies
• TORCH CNS infection: commonly seen with periventricular calcifications

See also

• patterns of neonatal hypoxic–ischaemic-ischaemic brain injury
• fetal intracranial haemorrhage