Focal Nervous System Lesions

The previously described scheme may avoid the need for ventriculoperitoneal shunting in some patients (Figure 254.1). Stabilization of head growth and decreased ventricular size are signs that serial lumbar punctures with or without medication are effective.

Figure 255.1.— Ultrasonographic findings in a patient with resolution of progressive hydrocephalus treated with serial lumbar punctures. Sizes of the head circumference are at the top or the bottom of each ultrasound. Days of age are in the corners of each study. The first lumbar puncture was done at 14 days and the last at 32 days.

Failure of serial lumbar punctures is usually reflected by an increase in ventricular size and increased head growth (Figure 255.2). An increase in head circumference alone is not a good indication of progressive ventriculomegaly because the head circumference of a healthy neonate may grow at a rate of 1 cm per week shortly after the general condition improves.

Figure 255.2.— Ultrasonographic findings in a patient with progressive hydrocephalus that required ventroperitoneal shunting despite serial lumbar punctures and medication. Sizes of the head circumference are at the top or the bottom of each ultrasound. Days of age are in the corner of each ultrasound. The first lumbar puncture was done at 16 days and the last at 38 days.

Progression of ganglionic germinal matrix bleed to periventricular hemorrhagic infarction

Germinal matrix bleed may progress to periventricular hemorrhagic infarction (Figure 255.3). Periventricular hemorrhagic infarction may be confined to the area drained by the medullary veins or may involve a wider distribution.

Figure 255.3.— Progression of germinal matrix hemorrhage.

Periventricular hemorrhagic infarction is usually asymptomatic during the neonatal period. Longterm neurological sequela are spastic hemiparesis (or asymmetrical quadriparesis) and intellectual deficits. The diagnosis of periventricular hemorrhagic infarction is made by ultrasonography. (Figure 255.4).

Figure 255.4.— Ultrasonographic findings in a patient with periventricular hemorrhagic infarction. Brain ultrasound at 7 days of age (7 D) is normal; at 14 days of age (14 D) shows a left germinal matrix hemorrhage (L GMH); at 20 days of age (20 D) shows bilateral germinal matrix hemorrhages and a left periventricular hemorrhagic infarction (PVHI); at 34 days of age shows a cyst in the area of the left germinal matrix hemorrhage and resolution of the periventricular hemorrhagic infarction.