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Washington University Experience | VASCULAR | Hemorrhage - Neonatal | 21A0 Case 21 History
Case 21 History ---- The patient was a 68-day-old, former 29-4/7-week twin A infant, transferred from an OSH to treat his chronic lung disease. The pregnancy was complicated by di-di twin gestation, preeclampsia, and IUGR. Procardia was required for blood pressure control during the pregnancy and treatment with magnesium sulfate was initiated when the mother presented with worsening preeclampsia, treated by C-section delivery and surfactant replacement therapy after delivery. Over the course of the next 2 months, he was intubated/extubated multiple times and received surfactant & dexamethasone courses. He had three negative head ultrasounds to 9/14. He was then transferred to SLCH on 10/20 and had frequent episodes of desaturation. There were several witnessed episodes of seizure-like behavior which were associated with desaturations and transient bradycardia. Head ultrasound showed multiple cystic areas in the periventricular region bilaterally thought to be frontoparietal white matter infarcts. A CT showed extensive bilateral periventricular leukomalacia involving the frontal and parietal lobes, as well as left occipital lobes. There were also small foci of likely intraparenchymal hemorrhage noted in the left occipital and left parietal lobes, as well as area of low attenuation with peripheral hyperdensity in the left frontal lobes, which was thought to represent hemorrhage or early calcification. The family made the decision to discontinue life-sustaining treatment on 10/22. ---- At autopsy the brain was slightly small at 285g (normal for age = 337g), but otherwise developmentally normal. Coronal sections showed intraventricular hemorrhage with an adjacent intraparenchymal component in the left frontal lobe as well as a possible hemorrhagic infarct. There was diffuse white matter softening in the cerebrum with formation of cysts in the periventricular region (bilaterally) with thinning of the corpus callosum. ---- Microscopic examination showed widespread pallor in the white matter with the periventricular regions, cavitation secondary to volume loss and marked reactive astrocytosis. The left periventricular region showed hemorrhage composed of fresh blood as well as containing hemosiderin laden histiocytes and few foamy histiocytes and intraventricular extension of the hemorrhage; the surrounding brain parenchyma showed hypoxic-ischemic changes and focal periventricular leukomalacia with cyst formation. Rare neurons were mineralized. ---- This case demonstrates the neuropathologic complexity of individual cases in which pale ischemic and hemorrhagic lesions may coexist.
