Intraventricular hemorrhage with hydrocephalus - Grade III

Case contributed by Tito Alfredo Atencia Rincón


Newborn premature 33.5 weeks, (1500Kg) high risk pregnancy product in 18 year old teenager. No history of maternal diseases. They request transfontanellar ultrasound for presenting respiratory distress data with refractory desaturations despite having oxygen by nasal cannula.

Patient Data

Age: Newborn
Gender: Female



In ultrasound dynamics, severe supratentorial dilatation of the ventricles is seen in the coronal and sagittal sections, associated with the occupation of the caudothalamic grooves by hyperechogenic structures in keeping of hemorrhagic component.



Dilation at supratentorial level. The ventricles are measured at maximum thickness in the coronal cuts 19 mm the right ventricle and 24 mm the left ventricle. Occupation of the caudothalamic grooves by echogenic structures suggestive hyperechogenic images of the hemorrhagic component. It measures 20 x 6 mm in the right ventricle and 4 mm in the left ventricle. Depending on the ultrasound findings it is interpreted as grade III hemorrhage.

Case Discussion

Transontanellar ultrasound plays a fundamental role in the detection and management of brain neonatal pathology, especially in high-risk premature infants.
The main risk factors for its development are: a gestational age of 32-33 weeks, birth weight less than 1500 gm or both. The most frequent brain complications are subependymal hemorrhage that affects the germinal matrix.

Clinical signs include: decreased level of consciousness, abnormal postures, hypotonia, crisis, apnea, coma and low hematocrit. 50% are silent. Ultrasound is the most effective method for diagnosis and follow-up, being its sensitivity and specificity to detect intraventricular hemorrhage of 90% and 85% respectively.

Screening ultrasound is usually done between the first and second week for a first cerebral evaluation. For gradation of its severity, the Bustein and Papile classification is used. 

In this case, it is a grade III hemorrhage: Intraventricular hemorrhage without objectifying hydrocephalus by the Evans index. Grade III hemorrhage can form a mold of the entire ventricle (ventricle inside the ventricle). An expansion of one or both ventricular cavities and blood levels is observed in the occipital horn.

In its evolution, the clot resolves completely or persists as linear bands or septa. Hydrocephalus stops or disappears in most patients (65-75%). The rest develop mild hydrocephalus that requires referral in less than 10% of cases.

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