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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.

Resolution of ganglionic germinal matrix hemorrhages

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.

Progression of ganglionic germinal matrix bleed to intraventricular hemorrhage

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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