IS Case 364: Grade IV intracranial hemorrhage

Lisa Siripun, MD

2009 URMC Imaging Sciences
Publication Date: 2010-03-02


Patient is a 9-day-old 24 weeks pre-term infant on an oscillator.


There is left intraventricular hemorrhage which extends from the germinal matrix into the lateral ventricle and also involves the parenchyma in the frontal and parietal regions.


Grade IV intracranial hemorrhage


Germinal matrix hemorrhage occurs in the germinal zone, a highly vascular region in the caudothalamic groove that is extremely sensitive to oxygenation changes. Most germinal matrix hemorrhages occur in the first week of life. It is related to perinatal stress such as labile blood pressure, hypoxia and hypercarbia, etc. It is most commonly seen in infants < 32 weeks gestation and weighing less than 1000 grams.

Grades of Intracranial hemorrhage:

I - Confined to caudothalamic groove

II - Extends into the ventricle but does not expand it

III - Fills and distends the adjacent ventricle causing post-hemorrhagic hydrocephalus

IV - Parenchymal hemorrhage

Ultrasound is the best imaging tool through the anterior frontanelle. Findings:

* Acute blood is echogenic. Later clot retracts and becomes iso- to hypoechoic

* Fluid-debris levels maybe seen in the ventricle

* Secondary hydrocephalus may occur

* If hemorrhage extends into the ventricle, chemical ventriculitis/ependymitis may occurs in 2-3 days (Ependymal lining become thick and echogenic)


  1. Leung A, Islam O. Germinal matrix hemorrhage. Emedicine. December 22, 2008.
  2. Donnelly LF. Germinal matrix hemorrhage. IN: Fundamentals of Pediatric Radiology. Saunders. 2001; 223-224.

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