[Intrauterine cerebral hemorrhage as a cause of hydrocephalus]

Intrauterine grade IV intraventricular hemorrhage in a full-term infant leading to hydrocephalus

INTRODUCTION

Peri/intraventricular hemorrhage (PIVH) is more often seen in premature neonates and can lead to posthemorrhagic hydrocephalus, characterized by high mortality rate and neurodevelopmental delay.

CASE REPORT

We report a case of in utero PIVH in a full-term neonate, which led to hydrocephalus. The infant developed at 8 months of gestational age intracerebral/intraventricular hemorrhage at the regions of the left basal ganglia and thalamus with significant intraventricular extension and ventriculomegaly, which was diagnosed with fetal MR scan, and progressed post partum to active multiloculated hydrocephalus. At the age of 3 months, the infant was operated on with endoscopic fenestration of the ventricular septations at the left side and ventriculoperitoneal shunt insertion at the right side. A follow-up MR scan after 4 months showed improvement of the ventriculomegaly and the multiloculated hydrocephalus. Up to a period of 6 months follow up, there have been no shunt-related problems.

DISCUSSION

The complications of a grade IV intraventricular hemorrhage are well documented in premature infants. It is difficult to know to what extent these apply equally to full-term infants with intraventricular hemorrhage. Ventricular hemorrhage is very rarely reported in full-term neonates, and even more rarely in the intrauterine period.

Connatal (fetal) hydrocephalus: an acquired pathology?

We investigated the etiology of hydrocephalus present at birth, i.e. of fetal hydrocephalus. Both inherited and dysraphic major malformations are very rare. Intraventricular hemorrhages and viral infections during pregnancy are among the proposed etiologies; they are supported more by anatomical, physiopathological and experimental findings than by clinical evidence. Cases of fetal intraventricular hemorrhages cited in the literature are anecdotical, and the reports fail to identify maternal or fetal predisposing factors. The role of viruses in the etiology of connatal hydrocephalus has been postulated on the basis of epidemiological considerations in human pathology and of a considerable amount of experimental studies in animals. Investigations were generally focused on aqueduct ependyma, but research should also address other structures involved in the genesis of hydrocephalus (choroid plexus, extraventricular CSF pathways, including arachnoid villi). Furthermore, experimental evidence has emerged concerning a number of toxins and of drugs administered during pregnancy, which are thought to be involved in the genesis of hydrocephalus: once more, the conclusions reached in these experimental trials lend further credence to the human epidemiological data linking pregnancy disturbances with fetal hydrocephalus. Since most of these toxic agents are also thought to induce major malformations, we could assume the degree of their effect to depend on the embryonal stage affected: the earlier the action, the worse the malformation.