153
Unilateral Thalamic Haemorrhage in the Pre-Term and FullTerm Newborn* By L. S. De Vries 1, M. Smet2, N. Goemans 1, G. Wilms 2, H. Devlieger1 and P. Casaer1 1Department of Paediatrics and Neonatal Medicine, University Hospital, Gasthuisberg, Leuven, Belgium, Present address L. S. De Vries: Department of Neonatalogy; Wilhelmina Childrens Hospital, Utrecht, 2Department of Radiology, University Hospital Gasthuisberg, Leuven, Belgium
One fuII-term and three premature newborns with a unilateral thalamic haemorrhage are reported. The lesion was diagnosed using cranial ultrasonography and confirmed in three using magnetic resonance imaging. Severe perinatal asphyxia occurred in all infants. The neonatal clinical history, subsequent neuro-developmental outcome and neuroimaging findings are discussed. As the prognosis appears to be much better than for infants with bilateral thalamic densities, it is important that this tyPe of lesion is recognised as aseparate entity.
Methods Cranial ultrasound was performed using a mechanical sector scanner with a 7.5 MHz transducer (Ultramark 4). MRI was obtained using a 1.5 Tesla supraconductive imaging system (Siemens) with a relaxation time (TR) of 2.5 sec and echo time (TE) of 90 msec for T2 weighted spinecho sequence (SE) and a TR of 0.52 sec and TE of 15 msec for Tl weighted SE sequence.
Keywords Haemorrhage - Thalamus - Newborn - Imaging
Introduction Haemorrhage and/or necrosis in the thalami have been described in fuII-term infants who suffered severe birth asphyxia (2, 3, 7, 9). Shen et al (7) coined the term "bright thalamus" as the lesion appears as an area of increased echogenicity, using ultrasonography. This lesion tends to be bilateral and should not be confused with a unilateral thalamic haemorrhage, reported in fuII-term infants, who were initially weH, but presented with abnormal neurological signs during the first (4, 5) or second week of life (5, 8). The unilateral thalamic haemorrhage diagnosed so far in the fuII-term infant was always associated with an intraventricular haemorrhage. We report four infants, three of whom were premature, in whom a unilateral thalamic haemorrhagic lesion,
Case reports
Case 1 This male infant was born at 33 weeks gestation by an emergency Caesarean section because of fetal distress following a car accident in which the mother was involved. The infant was in poor condition at birth with an Apgar score of 4 at one and 6 at 5 and 10 minutes in spite of intubation and assisted ventilation. At 7 hours of age he was referred to our neonatal intensive care unit. Mechanical ventilation was required for 7 days, because of respiratory distress syndrome and persistent fetal circulation for which he received Tolazoline, dopamine and dobutamine. His subsequent recovery was uneventful. At 40 weeks postmenstrual age he was still hypotonie but alert. At 5 months of age he was sociable, able to grasp objects with both hands but still hypotonie. At 11 months he was no longer hypotonie, was ahle to sit without support and was noted to have a transient asymmetry in tone. At 15 months he was found to have anormal development. On his initial ultrasound scan, performed on day 2, a large echogenie lesion was noted in the left thalamus, which was separate from the lateral ventricle (Fig. 1). This le-
ReceivedJune 10,1990; acceptedJanuary 10,1991 Neuropediatrics 23 (1992) 153-156 © Hippokrates Verlag Stuttgart
* This study is part of The Developmental Neurology Research Project, K. U. Leuven. At present this research project is mainly supported by the Medical Research Council, Belgium (F.G.W.G.) and by the Janssen Research Foundation, Beerse, Belgium
Downloaded by: University of British Columbia. Copyrighted material.
Abstract
without any evidence of an associated intraventricular haemorrhage, was diagnosed in the neonatal period using real-time ultrasound. In three of them Magnetic Resonance Imaging (MRI) was performed to confirm the diagnosis.
Neuropediatrics 23 (1992)
L. S. De Vries et al
Case2
a
This female infant was born at 34 weeks gestation by emergency Caesarean seetion because of placental abruption. The infant was in poor condition at birth with an Apgar score of 2 at 1 minute. Following intubation and assisted ventilation she showed a slow recovery. At 3 hours of age she was referred to our neonatal intensive care unit. Mechanical ventilation was required for aperiod of 5 days, because of respiratory distress syndrome. This was complicated by persistent fetal circulation, for which she received Tolazoline. Her neonatal course was further complicated by a pneumothorax and pneumomediastinum on day two, which were drained successfully. She was extubated on day 5 and her subsequent recovery was uneventful. At 40 weeks postmenstrual age she was very hypotonie. At 5 months she was alert and sociable but showed very poor head control and was still severely hypotonie. At 14 months, however, she was developmentally normal and no longer hypotonie. On her initial ultrasound scan performed on day two there was no evidence of a haemorrhage, but a slight increase in echogenicity was noted in the periventricular region. A repeat scan on day 18 showed a resolving lesion in the right thalamus. At 5 months of age this lesion could no longer be identified, but a slight asymmetry was noted in ventricular size.
b
Fig. 1
Cranial ultrasound performed on day 3 (Case 1), showing in a coronal (a) and parasagittal (b) view an area of increased echogenicity in the left thalamus (arrow), which is separate from the lateral ventricle.
sion resolved over the next two weeks and only a few small cystic lesions were still noted in this region at 40 weeks postmenstrual age.
MRI performed at 4 weeks of age showed an area of low signal intensity, both on Tl as well as T2 weighted spinecho sequence, suggestive of a resolving haemorrhage. The second study performed at 5 months still showed evidence of haemoglobin breakdown products.
Table 1
Case 3 This female infant was born at 31 weeks' gestation by an emergency Caesarean section because of severe fetal distress. The infant was in good condition at birth with an Apgar score of 6 at one and 8 at five minutes and had no problems following delivery. At 40 weeks postmenstrual age she was hypotonie but alert. At 9 months of age her tone had normalised and her development was normal, when corrected for prematurity. A routine ultrasound scan, performed on day one showed a right germinallayer haemorrhage and aseparate
Four infants with an unilateral thalamic lesion. Gestation (wks)
Birth weight (g)
33
2120
2
34
2320
3
31
1100
4
38
2200
Patient no.
MRI performed at 3 weeks of age showed a marked lesion in the posterior part of the right thalamus (Fig. 2). An increase in signal intensity was noted on Tl weighted spinecho sequence. On T2 weighted spinecho sequence a rirn of low signal intensity surrounded the area of high signal intensity, suggestive of an old haemorrhage (> 2 weeks). A repeat scan at 5 months of age still showed evidence of haemoglobin breakdown products.
RDS = respiratory distress syndrome; GLH = germinallayer haemorrhage
Neonatal problems
Ultrasound
MRllmaging
Outcome
fetal distress RDS-PFCS fetal distress RDS-PFCS pneu mothorax feta I distress
It thalamic lesion rt thalamic lesion
It thalamic haemorrhagic lesion rt thalamic haemorrhagic lesion
transient asymmetry in tone. Normal at 15 mo normal at 14 mo
rt GLH rt thalamic lesion rt thalamic lesion
not done
normal at 9 mo
rt thalamic haemorrhagic lesion
asym metry in tone at9 mo
fetal distress meconium aspiration
PFCS = persistent fetal circulation syndrome;
Downloaded by: University of British Columbia. Copyrighted material.
154
Unilateral Thalamic Haemorrhage in the Pre- Term and Full- Tenn Newborn
Neuropediatrics 23 (1992)
155
a
b
Fig.2
MRI performed on day 21 (Case 2). An area of inerease in signal intensity is noted in the right thalamus on a eoronal Tl weighted SE sequenee (a), while a rim of low signal intensity surrounds an area of high signal intensity on the axial T2 weighted image (b).
b
area of inereased eehogenieity in the right thalamus. With serial ultrasound examinations this lesion was noted to beeome smaller and eould no longer be seen at 40 weeks postmenstrual age.
Case 4 This male infant was born at 38 weeks gestation by an emergeney Caesarean seetion beeause of loss of fetal movements and meeonium stained liquor. The infant did not cry immediately and was ventilated using bag and mask. Because of an inerease in oxygen requirement he was referred to our neonatal intensive eare unit. He was meehanieally ventilated during transfer, but managed weIl with endotraeheal CPAP following admission and eould be extubated on day two. Roving eye movements and jerky movements of arms and legs were noted on day three. His neurologieal behaviour gradually improved but he was still noted to be hypotonie at diseharge at 3 weeks of age. At 9 months of age he was alert and able to sit without support. A slight asymmetry in tone was noted, being slightly inereased on the left side. His initial ultrasound study performed on day 5 showed a slight inerease in eehogenieity in the right thalamus (Fig. 3a). A cr sean at nine days of age did not show any abnormalities in the right thalamus (Fig. 3b).
c Fig. 3 Cranial ultrasound (a) on day 5 (Case 4), showing an area of inereased eehogenieity in the right thalamus (arrow). A CT performed on day 9 shows areas of deereased attenuation in the periventrieular white matter, but no lesion in the right thalamus (b). On day 11, however, the thalamie lesion is seen as an area of high signal intensity (arrow) on a eoronal Tl weighted MRI image (e).
Downloaded by: University of British Columbia. Copyrighted material.
a
L.
Neuropediatrics 23 (1992)
MRI performed on day 11 clearly showed a lesion in the right thalamus (Fig. 3c). The presence of an increased signal intensity on both T 1- as weIl as T2-weighted spinecho sequence, was suggestive of arecent haemorrhage.
Discussion Using real-time ultrasound, a unilateral thalamic lesion was identified in four newborns, three of whom were premature. Using ultrasonography it was not possible to make a distinction between ischaemia and haemorrhage. Using MRI we were able to show the presence of blood within the lesion (6), but were still unable to distinguish between a thalamic haemorrhage and a haemorrhagic infarction. Thalamic lesions can be difficult to identify using ultrasonography, as was best illustrated in the full-term infant. In this infant a CT scan was unable to identify the thalamic lesion, while this lesion was clearly identified using MRI. The unilateral thalamic lesion described here should be distinguished from the unilateral thalamic haemorrhage associated with an intraventricular haemorrhage, reported in full-term infants (4, 5, 8) and from bilateral thalamic densities, usually referred to as "the bright thalamus", as has been reported in severely asphyxiated full-term infants (2, 3, 8, 9). In the full-term infant with a unilateral thalamic haemorrhage there is an acute clinical deterioration. The infants present with seizures and signs of raised intracranial pressure and in the study of Trounce et al (8) downwards deviation of the eyes. In the infants reported in the present study, the thalamic lesion was never associated with an intraventricular haemorrhage. The lesion occurred within the first few days of life and no clinical deterioration was noted in any of these infants. The neurodevelopmental outcome in the fullterm infants with the bilateral bright thalamus is known to be uniformly poor (7, 9). Ten of the 12 infants reported by Roland et al (5) with a unilateral thalamic haemorrhage and intraventricular haemorrhage developed cerebral palsy, mostly hemiplegia, and in 9 cases a mild to moderate developmental delay was noted. Neurological examination at 40 weeks postmenstrual age of the four infants reported in this study showed severe hypotonia and this appeared to persist during the first six months, but subsequently resolved. As only two of the four infants have reached the age of one year, no definite data are available as yet about their long-term outcome, but the short-term outcome appears to be favourable. The pathophysiology of the isolated unilateral thalamic haemorrhage remains unclear. The four infants re-
s. De Vries et al
ported in this study suffered severe asphyxia, two antenatally and the other two around the time of delivery. Two of the premature infants were severely hypotensive and hypoxaemic and required inotropic drugs to sustain their blood pressure and tolazoline to treat the persistent fetal circulation syndrome. This type of unilateral thalamic haemorrhage has, to our knowledge not yet been diagnosed using ultrasonography. A postmortem study of apremature infant with a Listeria septicaemia did reveal a small unilateral haemorrhage similar to the lesion reported here (1). Whether this type of lesion is indeed rare or is not always identified is difficult to tell. Although our infants are still young, the prognosis appears to be much better than in those suffering bilateral thalamic densities or a unilateral thalamic haemorrhage associated with an intraventricular haemorrhage and it is therefore important that this type of lesion is recognised as aseparate entity.
References De Vries, L. 5.,]. C. Larroche, M. 1. Levene: Intraeranial haemorrhage. In: Fetal and Neonatal Neurology and Neurosurgery. Eds. Levene, M. 1., Bennett, M.]., Punt,]. Churehill Livingstone (1988) 308 2 Kotagal, 5., S. S. Toce, P. Kotagal, C. R. Archer: Symmetrie bithalamie and striatal haemorrhage following perinatal asphyxia in a term infant. J. Comput. Assist. Tomogr. 7 (1983) 353-355 3 Kreusser, K. L., R. E. Schmidt, G. D. Shackelford,].]. Volpe: Value of ultrasound for identifieation of aeute haemorrhagie neerosis of thalamus and basal ganglia in an asphyxiated term infant. Ann. Neurol. 16 (1984) 361-363 4 Primhak, R. A., M. F. Smith: Primary thalamie haemorrhage in first week of life. Laneet (letter) 1 (1985)635 5 Roland, E. H., O. Flodmark, A. Hill: Thalamie haemorrhage with intraventrieular haemorrhage in the fuH-term newborn. Pediatr. 85 (1990) 737-742 6 Seidenwurm, D., T.-K. Meng, H. Kowalski,]. C. Weinreb, 1. 1. Kricheff: Intraeranial hemorrhagie lesions: evaluation with spin-echo and gradientrefoeused MR imaging at 0.5 and 1.5 T. Radiology 172 (1989) 189-194 7 Shen, E. Y., C. C. Huang, S. C. Chyou, H. Y. Hung, C. H. Hsu, F. Y. Huang: Sonographie finding of the bright thalamus. Areh. Dis. Child. 61 (1986) 1096-1099 8 Trounce,]. Q., C. 1. Fawer, ]. Punt, K. L. Dodd, A. R. Fielder, M. 1. Levene: Primary thalamie haemorrhage in the newborn: a new clinieal entity. Laneet 1 (1985) 190-192 9 Voit, T., P. Lemburg: Damage of thalamus and basal ganglia in asphyxiated full-term neonates. Neuropediatrics 18 (1987) 176-181 1
Professor Paul Casaer Paediatrie Neurology Seetion Department of Paediatries and Neonatal Medieine University Hospital Gasthuisberg B-3000 Leuven, Belgium
Downloaded by: University of British Columbia. Copyrighted material.
156
Unilateral Thalamic Haemorrhage in the Pre-Term and FullTerm Newborn* By L. S. De Vries 1, M. Smet2, N. Goemans 1, G. Wilms 2, H. Devlieger1 and P. Casaer1 1Department of Paediatrics and Neonatal Medicine, University Hospital, Gasthuisberg, Leuven, Belgium, Present address L. S. De Vries: Department of Neonatalogy; Wilhelmina Childrens Hospital, Utrecht, 2Department of Radiology, University Hospital Gasthuisberg, Leuven, Belgium
One fuII-term and three premature newborns with a unilateral thalamic haemorrhage are reported. The lesion was diagnosed using cranial ultrasonography and confirmed in three using magnetic resonance imaging. Severe perinatal asphyxia occurred in all infants. The neonatal clinical history, subsequent neuro-developmental outcome and neuroimaging findings are discussed. As the prognosis appears to be much better than for infants with bilateral thalamic densities, it is important that this tyPe of lesion is recognised as aseparate entity.
Methods Cranial ultrasound was performed using a mechanical sector scanner with a 7.5 MHz transducer (Ultramark 4). MRI was obtained using a 1.5 Tesla supraconductive imaging system (Siemens) with a relaxation time (TR) of 2.5 sec and echo time (TE) of 90 msec for T2 weighted spinecho sequence (SE) and a TR of 0.52 sec and TE of 15 msec for Tl weighted SE sequence.
Keywords Haemorrhage - Thalamus - Newborn - Imaging
Introduction Haemorrhage and/or necrosis in the thalami have been described in fuII-term infants who suffered severe birth asphyxia (2, 3, 7, 9). Shen et al (7) coined the term "bright thalamus" as the lesion appears as an area of increased echogenicity, using ultrasonography. This lesion tends to be bilateral and should not be confused with a unilateral thalamic haemorrhage, reported in fuII-term infants, who were initially weH, but presented with abnormal neurological signs during the first (4, 5) or second week of life (5, 8). The unilateral thalamic haemorrhage diagnosed so far in the fuII-term infant was always associated with an intraventricular haemorrhage. We report four infants, three of whom were premature, in whom a unilateral thalamic haemorrhagic lesion,
Case reports
Case 1 This male infant was born at 33 weeks gestation by an emergency Caesarean section because of fetal distress following a car accident in which the mother was involved. The infant was in poor condition at birth with an Apgar score of 4 at one and 6 at 5 and 10 minutes in spite of intubation and assisted ventilation. At 7 hours of age he was referred to our neonatal intensive care unit. Mechanical ventilation was required for 7 days, because of respiratory distress syndrome and persistent fetal circulation for which he received Tolazoline, dopamine and dobutamine. His subsequent recovery was uneventful. At 40 weeks postmenstrual age he was still hypotonie but alert. At 5 months of age he was sociable, able to grasp objects with both hands but still hypotonie. At 11 months he was no longer hypotonie, was ahle to sit without support and was noted to have a transient asymmetry in tone. At 15 months he was found to have anormal development. On his initial ultrasound scan, performed on day 2, a large echogenie lesion was noted in the left thalamus, which was separate from the lateral ventricle (Fig. 1). This le-
ReceivedJune 10,1990; acceptedJanuary 10,1991 Neuropediatrics 23 (1992) 153-156 © Hippokrates Verlag Stuttgart
* This study is part of The Developmental Neurology Research Project, K. U. Leuven. At present this research project is mainly supported by the Medical Research Council, Belgium (F.G.W.G.) and by the Janssen Research Foundation, Beerse, Belgium
Downloaded by: University of British Columbia. Copyrighted material.
Abstract
without any evidence of an associated intraventricular haemorrhage, was diagnosed in the neonatal period using real-time ultrasound. In three of them Magnetic Resonance Imaging (MRI) was performed to confirm the diagnosis.
Neuropediatrics 23 (1992)
L. S. De Vries et al
Case2
a
This female infant was born at 34 weeks gestation by emergency Caesarean seetion because of placental abruption. The infant was in poor condition at birth with an Apgar score of 2 at 1 minute. Following intubation and assisted ventilation she showed a slow recovery. At 3 hours of age she was referred to our neonatal intensive care unit. Mechanical ventilation was required for aperiod of 5 days, because of respiratory distress syndrome. This was complicated by persistent fetal circulation, for which she received Tolazoline. Her neonatal course was further complicated by a pneumothorax and pneumomediastinum on day two, which were drained successfully. She was extubated on day 5 and her subsequent recovery was uneventful. At 40 weeks postmenstrual age she was very hypotonie. At 5 months she was alert and sociable but showed very poor head control and was still severely hypotonie. At 14 months, however, she was developmentally normal and no longer hypotonie. On her initial ultrasound scan performed on day two there was no evidence of a haemorrhage, but a slight increase in echogenicity was noted in the periventricular region. A repeat scan on day 18 showed a resolving lesion in the right thalamus. At 5 months of age this lesion could no longer be identified, but a slight asymmetry was noted in ventricular size.
b
Fig. 1
Cranial ultrasound performed on day 3 (Case 1), showing in a coronal (a) and parasagittal (b) view an area of increased echogenicity in the left thalamus (arrow), which is separate from the lateral ventricle.
sion resolved over the next two weeks and only a few small cystic lesions were still noted in this region at 40 weeks postmenstrual age.
MRI performed at 4 weeks of age showed an area of low signal intensity, both on Tl as well as T2 weighted spinecho sequence, suggestive of a resolving haemorrhage. The second study performed at 5 months still showed evidence of haemoglobin breakdown products.
Table 1
Case 3 This female infant was born at 31 weeks' gestation by an emergency Caesarean section because of severe fetal distress. The infant was in good condition at birth with an Apgar score of 6 at one and 8 at five minutes and had no problems following delivery. At 40 weeks postmenstrual age she was hypotonie but alert. At 9 months of age her tone had normalised and her development was normal, when corrected for prematurity. A routine ultrasound scan, performed on day one showed a right germinallayer haemorrhage and aseparate
Four infants with an unilateral thalamic lesion. Gestation (wks)
Birth weight (g)
33
2120
2
34
2320
3
31
1100
4
38
2200
Patient no.
MRI performed at 3 weeks of age showed a marked lesion in the posterior part of the right thalamus (Fig. 2). An increase in signal intensity was noted on Tl weighted spinecho sequence. On T2 weighted spinecho sequence a rirn of low signal intensity surrounded the area of high signal intensity, suggestive of an old haemorrhage (> 2 weeks). A repeat scan at 5 months of age still showed evidence of haemoglobin breakdown products.
RDS = respiratory distress syndrome; GLH = germinallayer haemorrhage
Neonatal problems
Ultrasound
MRllmaging
Outcome
fetal distress RDS-PFCS fetal distress RDS-PFCS pneu mothorax feta I distress
It thalamic lesion rt thalamic lesion
It thalamic haemorrhagic lesion rt thalamic haemorrhagic lesion
transient asymmetry in tone. Normal at 15 mo normal at 14 mo
rt GLH rt thalamic lesion rt thalamic lesion
not done
normal at 9 mo
rt thalamic haemorrhagic lesion
asym metry in tone at9 mo
fetal distress meconium aspiration
PFCS = persistent fetal circulation syndrome;
Downloaded by: University of British Columbia. Copyrighted material.
154
Unilateral Thalamic Haemorrhage in the Pre- Term and Full- Tenn Newborn
Neuropediatrics 23 (1992)
155
a
b
Fig.2
MRI performed on day 21 (Case 2). An area of inerease in signal intensity is noted in the right thalamus on a eoronal Tl weighted SE sequenee (a), while a rim of low signal intensity surrounds an area of high signal intensity on the axial T2 weighted image (b).
b
area of inereased eehogenieity in the right thalamus. With serial ultrasound examinations this lesion was noted to beeome smaller and eould no longer be seen at 40 weeks postmenstrual age.
Case 4 This male infant was born at 38 weeks gestation by an emergeney Caesarean seetion beeause of loss of fetal movements and meeonium stained liquor. The infant did not cry immediately and was ventilated using bag and mask. Because of an inerease in oxygen requirement he was referred to our neonatal intensive eare unit. He was meehanieally ventilated during transfer, but managed weIl with endotraeheal CPAP following admission and eould be extubated on day two. Roving eye movements and jerky movements of arms and legs were noted on day three. His neurologieal behaviour gradually improved but he was still noted to be hypotonie at diseharge at 3 weeks of age. At 9 months of age he was alert and able to sit without support. A slight asymmetry in tone was noted, being slightly inereased on the left side. His initial ultrasound study performed on day 5 showed a slight inerease in eehogenieity in the right thalamus (Fig. 3a). A cr sean at nine days of age did not show any abnormalities in the right thalamus (Fig. 3b).
c Fig. 3 Cranial ultrasound (a) on day 5 (Case 4), showing an area of inereased eehogenieity in the right thalamus (arrow). A CT performed on day 9 shows areas of deereased attenuation in the periventrieular white matter, but no lesion in the right thalamus (b). On day 11, however, the thalamie lesion is seen as an area of high signal intensity (arrow) on a eoronal Tl weighted MRI image (e).
Downloaded by: University of British Columbia. Copyrighted material.
a
L.
Neuropediatrics 23 (1992)
MRI performed on day 11 clearly showed a lesion in the right thalamus (Fig. 3c). The presence of an increased signal intensity on both T 1- as weIl as T2-weighted spinecho sequence, was suggestive of arecent haemorrhage.
Discussion Using real-time ultrasound, a unilateral thalamic lesion was identified in four newborns, three of whom were premature. Using ultrasonography it was not possible to make a distinction between ischaemia and haemorrhage. Using MRI we were able to show the presence of blood within the lesion (6), but were still unable to distinguish between a thalamic haemorrhage and a haemorrhagic infarction. Thalamic lesions can be difficult to identify using ultrasonography, as was best illustrated in the full-term infant. In this infant a CT scan was unable to identify the thalamic lesion, while this lesion was clearly identified using MRI. The unilateral thalamic lesion described here should be distinguished from the unilateral thalamic haemorrhage associated with an intraventricular haemorrhage, reported in full-term infants (4, 5, 8) and from bilateral thalamic densities, usually referred to as "the bright thalamus", as has been reported in severely asphyxiated full-term infants (2, 3, 8, 9). In the full-term infant with a unilateral thalamic haemorrhage there is an acute clinical deterioration. The infants present with seizures and signs of raised intracranial pressure and in the study of Trounce et al (8) downwards deviation of the eyes. In the infants reported in the present study, the thalamic lesion was never associated with an intraventricular haemorrhage. The lesion occurred within the first few days of life and no clinical deterioration was noted in any of these infants. The neurodevelopmental outcome in the fullterm infants with the bilateral bright thalamus is known to be uniformly poor (7, 9). Ten of the 12 infants reported by Roland et al (5) with a unilateral thalamic haemorrhage and intraventricular haemorrhage developed cerebral palsy, mostly hemiplegia, and in 9 cases a mild to moderate developmental delay was noted. Neurological examination at 40 weeks postmenstrual age of the four infants reported in this study showed severe hypotonia and this appeared to persist during the first six months, but subsequently resolved. As only two of the four infants have reached the age of one year, no definite data are available as yet about their long-term outcome, but the short-term outcome appears to be favourable. The pathophysiology of the isolated unilateral thalamic haemorrhage remains unclear. The four infants re-
s. De Vries et al
ported in this study suffered severe asphyxia, two antenatally and the other two around the time of delivery. Two of the premature infants were severely hypotensive and hypoxaemic and required inotropic drugs to sustain their blood pressure and tolazoline to treat the persistent fetal circulation syndrome. This type of unilateral thalamic haemorrhage has, to our knowledge not yet been diagnosed using ultrasonography. A postmortem study of apremature infant with a Listeria septicaemia did reveal a small unilateral haemorrhage similar to the lesion reported here (1). Whether this type of lesion is indeed rare or is not always identified is difficult to tell. Although our infants are still young, the prognosis appears to be much better than in those suffering bilateral thalamic densities or a unilateral thalamic haemorrhage associated with an intraventricular haemorrhage and it is therefore important that this type of lesion is recognised as aseparate entity.
References De Vries, L. 5.,]. C. Larroche, M. 1. Levene: Intraeranial haemorrhage. In: Fetal and Neonatal Neurology and Neurosurgery. Eds. Levene, M. 1., Bennett, M.]., Punt,]. Churehill Livingstone (1988) 308 2 Kotagal, 5., S. S. Toce, P. Kotagal, C. R. Archer: Symmetrie bithalamie and striatal haemorrhage following perinatal asphyxia in a term infant. J. Comput. Assist. Tomogr. 7 (1983) 353-355 3 Kreusser, K. L., R. E. Schmidt, G. D. Shackelford,].]. Volpe: Value of ultrasound for identifieation of aeute haemorrhagie neerosis of thalamus and basal ganglia in an asphyxiated term infant. Ann. Neurol. 16 (1984) 361-363 4 Primhak, R. A., M. F. Smith: Primary thalamie haemorrhage in first week of life. Laneet (letter) 1 (1985)635 5 Roland, E. H., O. Flodmark, A. Hill: Thalamie haemorrhage with intraventrieular haemorrhage in the fuH-term newborn. Pediatr. 85 (1990) 737-742 6 Seidenwurm, D., T.-K. Meng, H. Kowalski,]. C. Weinreb, 1. 1. Kricheff: Intraeranial hemorrhagie lesions: evaluation with spin-echo and gradientrefoeused MR imaging at 0.5 and 1.5 T. Radiology 172 (1989) 189-194 7 Shen, E. Y., C. C. Huang, S. C. Chyou, H. Y. Hung, C. H. Hsu, F. Y. Huang: Sonographie finding of the bright thalamus. Areh. Dis. Child. 61 (1986) 1096-1099 8 Trounce,]. Q., C. 1. Fawer, ]. Punt, K. L. Dodd, A. R. Fielder, M. 1. Levene: Primary thalamie haemorrhage in the newborn: a new clinieal entity. Laneet 1 (1985) 190-192 9 Voit, T., P. Lemburg: Damage of thalamus and basal ganglia in asphyxiated full-term neonates. Neuropediatrics 18 (1987) 176-181 1
Professor Paul Casaer Paediatrie Neurology Seetion Department of Paediatries and Neonatal Medieine University Hospital Gasthuisberg B-3000 Leuven, Belgium
Downloaded by: University of British Columbia. Copyrighted material.
156
