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The
study of choice to diagnose a germinal matrix bleed is a brain ultrasound.
On the coronal view, the germinal matrix hemorrhage appears as an area
of increased echogenicity just below the frontal horn of the lateral
ventricles (Figure 252.1). Germinal matrix bleeds require no treatment.
Figure 252.1.— Germinal matrix hemorrhages (GMH) appear as an area of increased echogenicity just below the frontal horn. L: left; D: days; PVHI: periventricular hemorrhagic infarction; B: bilateral.
The
evolution of germinal matrix hemorrhages varies. Ganglionic germinal matrix
bleeds may resolve or progress (Figure 252.2) to intraventricular hemorrhages,
periventricular infarctions, or parenchymal hemorrhage.
Germinal matrix bleeds may
resolve, leading to disappearance of the ultrasonographic abnormality
in the area of the bleed or the appearance of a cyst in the same area.
Most cysts ultimately disappear.
Intraventricular hemorrhage
is probably the most frequent complication of germinal matrix bleeding
(Figure 252.2). It occurs when blood from the germinal matrix tears
the ependymal layer and spills into the ventricles. Intraventricular
hemorrhage may resolve, produce an acute hemorrhagic hydrocephalus,
or lead to post-hemorrhagic hydrocephalus.
Figure 252.2.— Progression of germinal matrix hemorrhage.
Resolution
of intraventricular hemorrhage
Intraventricular
hemorrhages resolve in a significant number of premature neonates.
When the amount of
intraventricular bleeding is small, the blood clears and no hydrocephalus
develops. The diagnosis of a resolved intraventricular bleed should
be delayed for at least 2 months and neonates with even small intraventricular
bleeds should be followed for at least 3 months because of the possibility
of developing post-hemorrhagic hydrocephalus.
Acute
hemorrhagic hydrocephalus
Acute hemorrhagic
hydrocephalus is usually associated with a sudden clinical deterioration.
The usual presentation is that of a previously healthy premature neonate
who suddenly develops blood pressure and heart rate instability and
a bulging fontanelle. Acute hydrocephalus results from obstruction
of the cerebrospinal fluid pathway at the aqueduct of Sylvius or foramina
of Monro (Figure 252.3). There only treatment for acute hydrocephalus
is supportive.
Figure 252.3.— Ultrasound studies demonstrating progression of germinal matrix hemorrhage to intraparenchymal hemorrhage and the development of acute hydrocephalus. GMH: germinal matrix hemorrhage; D: days; IPH: intraparenchymal hemorrhage.
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