Cranial Ultrasound Is an Important Tool in the Recognition of Life-Threatening Infratentorial Hemorrhage in Newborns.

Timely detection of severe infratentorial hemorrhage in neonates is crucial, especially in case of life-threatening brain stem compression and/or acute obstructive hydrocephalus, which need lifesaving neurosurgical intervention. Although the detection of infratentorial hemorrhage by ultrasound scanning is often considered as difficult, the use of additional acoustic windows and recognition of characteristic ultrasound features facilitate early diagnosis. In this case series, we report on newborns with severe, symptomatic infratentorial hemorrhage detected primarily by cranial ultrasound. We demonstrate the characteristic ultrasound features present in all cases and discuss how ultrasound diagnosis contributed to early diagnosis and treatment.

Single fetal demise in monochorionic pregnancies: incidence and patterns of cerebral injury.

OBJECTIVE: To evaluate the incidence, type and severity of cerebral injury in the surviving monochorionic (MC) cotwin after single fetal demise in twin pregnancies. METHODS: All MC pregnancies with single fetal demise that were evaluated at the Leiden University Medical Center between 2002 and 2013 were included. Perinatal characteristics, neonatal outcome and the presence of cerebral injury, observed on neuroimaging, were recorded for all cotwin survivors. RESULTS: A total of 49 MC pregnancies with single fetal demise, including one MC triplet, were included in the study (n = 50 cotwins). Median gestational age at occurrence of single fetal demise was 25 weeks and median interval between single fetal demise and live birth was 61 days, with a median gestational age at birth of 36 weeks. Severe cerebral injury was diagnosed in 13 (26%) of the 50 cotwins and was detected antenatally in 4/50 (8%) and postnatally in 9/50 (18%) cases. Cerebral injury was mostly due to hypoxic-ischemic injury resulting in cystic periventricular leukomalacia, middle cerebral artery infarction or injury to basal ganglia, thalamus and/or cortex. Risk factors associated with severe cerebral injury were advanced gestational age at the occurrence of single fetal demise (odds ratio (OR), 1.14 (95% CI, 1.01-1.29) for each week of gestation; P = 0.03), twin-twin transfusion syndrome developing prior to single fetal demise (OR, 5.0 (95% CI, 1.30-19.13); P = 0.02) and a lower gestational age at birth (OR, 0.83 (95% CI, 0.69-0.99) for each week of gestation; P = 0.04). CONCLUSIONS: Single fetal demise in MC pregnancies is associated with severe cerebral injury occurring in 1 in 4 surviving cotwins. Routine antenatal and postnatal neuroimaging, followed by standardized long-term follow-up, is mandatory.

Renal failure after single fetal demise in monochorionic twins: incidence and description of a case.

Single intrauterine fetal demise in monochorionic (MC) twins may result in acute exsanguination from the surviving twin into the low-pressure circulation of the demised co-twin through the vascular anastomoses. This may lead to severe hypoxic-ischemic injury in the surviving twin due to hypovolemia, hypotension and anemia, resulting in multiorgan damage. Most studies in single fetal demise in MC twin pregnancies have reported on the risk of cerebral injury. The aim of our study was to explore the incidence and severity of renal damage in surviving MC twins after intrauterine co-twin death. We reviewed all cases of MC twins with single fetal demise presented over a 10-year period at our center. One of the 44 (2.3%) surviving co-twins was diagnosed with severe renal damage. We describe this case in detail, as it provides valuable insights into the pathogenesis of renal and other organ failure after MC co-twin death.

Perinatal asphyxia in monochorionic versus dichorionic twins: incidence, risk factors and outcome.

OBJECTIVE: To estimate the incidence, risk factors, severity and outcome after perinatal asphyxia in monochorionic (MC) versus dichorionic (DC) twins. METHODS: We included all consecutive near-term MC and DC twins with perinatal asphyxia admitted to our neonatal ward between 2004 and 2013 and compared the perinatal characteristics and neonatal outcome between both groups. RESULTS: The incidence of perinatal asphyxia in MC and DC twin infants was 4.0 (11/272) and 4.0% (8/200; p = 1.00). In contrast to DC twins, asphyxia in MC twins was strongly associated with acute exsanguination and anemia at birth; 64% (7/11) in MC twins and 0% (0/8) in DC twins (p < 0.01). Median hemoglobin level at birth in the MC and DC groups was 11.5 and 18.6 g/dl, respectively (p < 0.01). CONCLUSIONS: Perinatal asphyxia in MC twins is often associated with severe anemia at birth due to acute hemorrhage through the placental vascular anastomoses.

Double fatal outcome after ruptured vasa previa in monochorionic twins: case report and review of the literature.

Vasa previa is a condition in which one or more fetal blood vessels run through the amniotic membranes and cross or run near the external orifice of the uterus. Rupture of membranes can lead to tearing of these vessels and cause acute fetal exsanguination. In monochorionic twin (MC) pregnancies, acute exsanguination in one twin can lead to severe complications in the co-twin due to the presence of inter-twin placental vascular connections. We report a MC pair with severe perinatal asphyxia due to acute exsanguination after prenatally undetected ruptured vasa previa. This resulted in severe hemorrhagic shock in both twins with double fatal outcome. Antenatal detection of vasa previa is of paramount importance to prevent severe morbidity and mortality, especially in MCs. A review of the literature is presented.

Lenticulostriate vasculopathy in very preterm infants.

OBJECTIVE: To assess for lenticulostriate vasculopathy (LSV) on cranial ultrasound (cUS) scans of very preterm infants: incidence and aetiology, evolution during neonatal period, association with clinical parameters, and MRI equivalent. DESIGN: Prospective study. SETTING: Tertiary neonatal referral centre. PATIENTS: Very preterm infants (<32 weeks) underwent sequential cUS throughout the neonatal period and MRI around term age. cUS were evaluated for LSV and other changes, and MRI for changes in signal and myelination in deep grey matter. LSV was divided into early-onset (7 postnatal days). Perinatal clinical parameters were collected for all infants and compared between groups. RESULTS: In 22/111 (20%) infants LSV was detected: early-onset in 5 and late-onset in 17. LSV mostly presented some weeks after birth and persisted for several months. There were no associations between LSV and other changes on cUS or deep grey matter changes on MRI. Infants with late-onset LSV were younger and smaller at birth than infants with early-onset LSV. Postmenstrual age at first detection was comparable for both LSV groups. There were no associations between LSV and perinatal clinical parameters, but infants with LSV had less episodes of hypotension than infants without LSV. CONCLUSIONS: LSV is a frequent finding on cUS in very preterm infants, but does not show on MRI. The postmenstrual age, rather than gestational and postnatal age, seems important in LSV development. LSV is not associated with clinical parameters. When encountered in otherwise healthy preterm infants, LSV is probably a benign temporary phenomenon.