793

Echogenic Periventricular Halo: Normal Sonographic Finding
or Neonatal Cerebral Hemorrhage

Edward G. Grant1 Dieter Schellinger

James James

D. Richardson Mary Lee Coffey G. Smirniotopoulous

Intracranial sonographic evaluation of the normal neonate frequently reveals an echogenic halo about the lateral ventricles. This periventricular halo is seen to varying degrees when scanning in both semiaxial and parasagittal planes in almost all normal infants. Among 1 80 consecutive premature neonates scanned serially with real-time sonography, two were prospectively diagnosed as having a form of periventricular echogenicity that was abnormal and represented periventricular hemorrhage. This hemorrhage completely surrounded the lateral ventricles and was intensely echogenic, as echogenic as the choroid plexus. This abnormal periventricular echogenicity was reproducible from multiple scan planes and hemorrhage was confirmed by computed tomography (CT). By contrast, CT scans obtained on another 53 of the 1 80 premature infants failed to reveal evidence of any abnormality corresponding to the periventricular echogenicity. Both neonates with periventricular hemorrhage developed bilateral multiseptate areas of porencephaly as sequelae to their hemorrhages. The differentiation between normal periventricular echogenicity and periventricular hemorrhage therefore attains great significance to the sonographer.

Sonography intracranial ventricular hemorrhage

is now hemorrhage

established [i -3], are

as the and the

primary findings

method in the

for recognizing various forms

neonatal of cerebro-

hemorrhage is represented cerebral originate they
matrix

well known [4-6]. by areas of increased tissues in the

Specifically, echogenicity

mntraparenchymal within the nelahemorrhages in extend into neighareas contiguous which from is the

tively hypoechoic premature infants boring
with the

[7]. Most cerebroventnicular germinal matrix [8]. If they remain form localized of neonatal appearance in anatomic cerebral distinctly

brain paper and

tissue

usually
[7,

germinal

9].
hemorrhage, different

This rare common localized presented

addresses has

another a sonographic

which

intracerebral within one here had

hematoma described or two adjacent lobes a form of cerebral

above. While the of one hemisphere, where blood

latter is usually the two patients surrounded both

hemorrhage

lateral ventricles. This resulted in a sonographic image where one hemisphere represented a mirror image of the other with a broad band of high-level echoes surrounding
This
AJR.

the

ventricles.

article

appears
AJNR

in the January/February

In tandem

with this yet unreported

form

of neonatal

peniventnicular

hemorrhage
observed Methods on for

1 983 issue of
Received sion August

and the April 1983 issue of
1 982; accepted after revi-

we describe a periventnicular normal cerebral sonognams differentiating the two are

echogenic halo. This is frequently and may be mistaken for hemorrhage. discussed.

April
19,

28,
1982.

‘All authors: Department of Radiology, Georgetown University Hospital, 3800 Reservoir Rd., NW., Washington, DC 20007. Address reprint requests to E. G. Grant.

Materials
One of vision. and

and
hundred The

Methods
eighty premature neonates sector scanning were obtained scanner approach in every were with examined the was used using and an Advanced having of this sections Full details Technology a 90#{176} field scanning

AJR

I 40:793-796,

April

1983

Laboratories parasagittal

Mark

Ill real-time planes

5 MHz

transducer

0361 -803X/83/ 1404-0793 © American Roentgen Ray Society

transfontanelle

in the semicononal

examination.

2A and 26). The peniventnicular in both cases and could CT scanning surrounding mild be identified the are highly plexus.‘P. contain rhages duced similar relatively were well from dense little defined blood. 3 weeks of which agnosed phy and of age was Case with 2.‘: ‘. . areas of hemorrhage relatively infants. and focal areas of extremely high echogenicity were scattered through the peniventniculan hemorrhage in case 2 In normal noted The that thin neonates the peniventnicular chonoid areas are hypenechoic ventricles plexus. corresponded pulmonary neonates as having peniventnicular exhibited zones of intense hemorrhage echogenicity Results Normal Periventricular Echogenicity ventricles (figs. they seemed hemorbe reprorevealed both lateral to between panasagittal gions less area.794 GRANT ET AL. a boy. i. Semiaxial (A) and parasagittal . tnigones. less of fluid is always to parallel normal of the on semiaxial echogenicity The defined 1 A). planes. 1 0.‘ . separated their outer ventricular from the bonders echodense choroid by a rim of anechoic CSF and are usually irregular. The normal penhalo is also homogeneously are plane. This which can in axial is distinct between weeks) evaluations clinical discharge sonography children rhage. a well prominent were diat sonograaround the at from to were Correlative two be cases identified the peniventniculan halo some diagnosed of increased as having were echogenicity all cases. 1 -Normal subject.__. Both 1 . T = thalamus. of increased scans seen echogenicity on the semiaxial about the appearance internal septations in a perpendicular echogenicity 2E). poorly defined borders. degree to discontinue further suspected sonographic before peniventnicular in several scan be identified sonogram the Periventricular at Hemorrhage peniventnicular age by menstrual and was hemorrhage history. of peniventniculam (figs. Two second intervals consecat later “normal” 1-2 for infant’s were below surrounding reproduce non bonder tnigones. In the other seen on presumably 53 cases normal no abnormality to or otherwise sonograms. Separation from hyperechoic choroid plexus (C) by thin line of anechoic CSF (arrows). and anechoic hemorrhage. 2C). Follow-up sonograms were all neonates stay (first scans with in the abnormal Intensive days pathology did In this undergo pool scans Care 1 and was a final of neonates at 1 week Nursery. These areas were of higher reflectivity than that seen around the ventricles in normal infants. This CSF reappeared separated areas as the where is always bonders there and lateral hypenechoic In the anechoic the may so line chonoid sections representing plexus in the that chonoid cerebrospinal and areas the hyperechoic above the (CSF) On ne- the ventricles alone could be identified. by CT.. AJR:140. g at birth several CT scans of bilateral that would on a total hemorrhage of 55 patients. scan not The will echoreadily pennot ventricles (fig. echogenicity One area The cannot lateral same to the is true the yenof the supe- All neonates neonates examined obtained during utive the normal 1 750 g at birth and less than 33 weeks age. reappear tnicles normal sponding superior on as a definite the parasagittal peniventnicular of the hyperechoic scan. Follow-up scans revealed ventricular dilatation in both anechoic regions developed which had the sonographic porencephalic cysts with posthemomrhagic multiseptate lateral ventricles. poorly areas are scans frequently (fig.-:-‘ . still the clinically most were of Case 1. 2D and Eventually genic throughout These areas identified ventricular if one (fig. Normal periventricular echogenic halo (arrowheads). April 1983 . than echogenic.148 girl. Irregular. bilateral obtained was peniventniculan observed only hemorthe diag- in virtually while two 30 Both neonates with weeks gestational weighed 1. In the were reasons. The the anechoic the normal the ventricles and choroid original scans demarcations peniventniculam expanded peniventnicular of both neonates showed loss of between the chonoid plexus and echogenicity. peniventniculan have age 5 months. weighed problems. technique gestational are available in recent publications [5. when scanning occiput. 3). believed unless Most the sufficient intracranial infants nursery. disease. These areas but always should be any scanning angle. Fig.:L’ r__1- #{149} 1 (B) sonograms.300 g and died at nosis could explained was confirmed echo-halo. 1 1]. 1 B). 3. a comeplanes from easily on area of echogenicity to the tnigone and hemorrhage. Scanning was performed on ‘inborn’ ‘ premature within 72 hr of birth and ‘ outborn’ ‘ infants were generally within 48 hr of admission. than these a (fig.

AJR:140. April 1983 ECHOGENIC PERIVENTRICULAR HALO IN NEONATES 795 Fig. in eliminating them by chang- ing gain Because of our inability to convincingly demonstrate these echogenic areas in several scan planes. (Cyst on left appears to communicate with ventricle [V] while on right a membrane separates the two. 1 i ]. 6 weeks of age. relate it to the dense the lateral ventricles this echogenicity may The high-level penivenon horizontal sonoplanes. Peniventrlcular hemorrhage. E. Inhomogeneous hemorrhagic echo pattern. Bilateral peniventnicular hemorrhage confirmed. observed echo-halo 9. displayed in sagittal present mismatched echo zones clearly are not reproducible may be unmistakably or topographically settings We have not been Semiaxial successful or transducers. represent a scanning artifact. echogenicity was pres- Discussion ent from sonographic anatomy hemorrhage any scanning diffuse. Sylvian fissure (arrows). but on horizontal planes.-Case 2. A. common peniventnicular echogenicity described cle has not been discussed previously. One might be tempted to vascular plexus normally surrounding in the fetus [8]. been investigated by a number of authors [7. Parasagittal sonogram. 6 weeks of age. 3 days of age. that we have hemorrhage of intraparenchymal opposed . CT scan. Large penventricular anechoic areas bilaterally (A).-Case 1 . On the other hand. 3. in two cases with verified peniventnicular hemorrhage. bilateral peniventnicular may represent primary to the more common hemorrhage white matter germinal Normal and in the sonographic neonatal findings brain have This rare. merely tnicular grams they absent sonogram. described as angle. D. The in this artiits similarity hemorrhage The actual remains spec- ulative. some areas are extremely echogenic (E). C. Modventricular enlargement (L).) C = choroid plexus. Conversely. Hemorrhage is isoechoic with areas of choroid plexus forming continuous echogenic complex (PV). On the other hand. Subarachnoid blood (arrowheads) outlines falx. others less echogenic (L). 3 days of age. on sagittal images. 2. Bilateral periventricular hemorrhage (arrowheads). Internal septation (arrow). Large with periventricular internal erate lateral anechoic areas (A) septations (arrows). Semiaxial sonogram. 3 days of age. we tend to believe they are artifactual. B. Fig. 2 days of age. Semiaxial sonogram. though to a severe yet unusual gives it great importance cause of this frequently form of intracranial to the sonographer. Parasagittal sonogram.

Appareti KE. To differentiate the two forms of peniventnicular echogenicity. as would loss of the anechoic line of CSF separating the chonoid plexus and the normal peniventnicular halo before the onset of 11. time ultrasonography of the head in infancy. The white paucity matter of intraventnicular hematoma in the sively for presence into peninatal of widespread. Real-time sonography of the infant and neonatal head. neonates.2:349-356 Armstrong 1 2. 1 39 : 687-691 DC. AJNR 1980. and hypoxia may also be a predisposing factor toward this type of hemorrhage. : 367-375 leukomalacia Arch Dis in Child . peniventnicular a plausible explanation for Armstrong and Norman with severe birth bilateral peniventniculan hemorrhage. Ultrasonic evaluation of neonatal intracranial hemorrhage and its complications. Grant EG. Smith Y. Detection of neonatal intracranial hemorrhage utilizing real-time and static ultrasound. London DA. Mack LA.1 :295-300 5. nosis all scans should be obtained in two planes. bradycardia. AJR 1981 137:245-250 phaly [9]. Both infants with peniventnicular hemorrhage eventually developed mild ventricular dilatation and an array of adjacent porencephalic neonates beyond cysts. Normal peniventnicular echogenicity should also never be as neflective as the choroid plexus. Wigglesworth JS: Haemorrhage. Norman MG. Apparently. 1 974. Schellinger D. Sauerbrei EE. Peniventricular Complications and sequelae. et al. suggests and bilateral is known bleeding hemorrhage etiology. real changes should be reproducible in all scan planes. Borts FT. Mack LA. Grant EG. Philadelphia: Lippincott. Rogers JV. I 979 9. Borts FT et al. which may produce a similar image. the sonographic 4. AJNR 1981. an ischemic excluThe posthemomrhagic We conclude. Johnson ML. Sonographic findings in cerebral intraparenchymal hemorrhage in neonates. AJNR 1981. The sonographic findings were identical with the late changes observed in the two cases described above. Evolution of porencephalic sonographic 1 0. 1 39 : 677-685 7. Radiology 1981 139:667-676 Shuman WP. We assume that the bleeding had occurred after these initial scans and thus remained undetected. Borts F. Christie DP. Mannes EJ. The accuracy of high resolution. Carroll BA. Enzmann DR. Smith Y. Internal inhomogeneity of the echogenic halo would support hemorrhage. For diagof peniventniculan hemorrhage. Grant EG. AJR:140.3 : 47-50 DS. McCullough manian KN. Pape and Wigglesworth [8] decnibe similar white matter hemorrhage occurring in association with bacterial and viral meningoencephalitis.49 D.1 :487-492 6. that recognition halo attains from the of this diagnostic unusual normal signifiform of a different into peniventniculan infarcted this type white ischemia. Digney M. Cooperberg PL. et al. Radiology 1 981 . Hirsch JH. Alford EC. Pape KE. Rumack CM. AJNR 1980. ischemia and the perinatal brain. Previous sonograms at 2 and 8 days of life were normal. various electrolyte inbalances. The absence of these late changes in the rest of our patient sample would lend credence to the notion that the usually observed peniventniculan halo is indeed a normal finding. Intracranial hemorrhage in premature infants: accuracy of sonographic evaluation. [i 2] connect hemorrhage asphyxia. Kerner M.2:129-132 8. Radiology 1 981 . Babcock cysts from evidence intraparenchymal hemorrhage in neonates: AJNR I 982. Schellinger D. echogenic enlargement. Sonography of ventnicular size and germinal matrix hemorrhage in premature infants. McCullough DC. Grant EG. Schellinger D. with its associated apnea. Harrison PB. JCU 1981 9:427-433 3. Han BK. Real time sonographic sector scanning of the neonatal cranium: technique and normal anatomy. Prematurity then. Schellinger D. Real time ultrasonography intraventnicular hemorrhage and comparison tomography. We previously reported that all premature hemorrhage who experienced the germinal matrix intraparenchymal develop porence- REFERENCES 1 . Wright K. also presented here. April 1983 matrix bleed. We have to infer that this patient also suffered peniventniculan hemorrhage. matter to be a preferred site or be differentiated territory would present of cerebral hemorrhage. A third case of multiseptate peniventnicular porencephaly was encountered in another 5-week-old premature infant on a pnedischarge sonognam. this unusual form of peniventnicular hemorrhage follows the same pattern.796 GRANT ET AL. peniventnicular cance and must ventricular therefore. Sivasubraof neonatal with computed 2.

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