Fetal intracerebral hemorrhage: review of the literature and practice considerations

Abstract

Fetal intracerebral hemorrhage is increasingly recognized on prenatal imaging. In this review, we discuss clinically relevant aspects of fetal intracerebral hemorrhage, including germinal matrix-intraventricular hemorrhage, as well as intraparenchymal hemorrhage. We discuss current clinical practice for prenatal counseling and postnatal management of fetal intracerebral hemorrhage, and offer practical recommendations for clinicians. We propose standardized terminology for classification of fetal intracerebral hemorrhage to be used in future research. We also highlight gaps in the literature and priorities for future research, namely the need for prospective large-scale studies to better understand underlying etiologies and neurodevelopmental outcomes in fetal intracerebral hemorrhage. IMPACT STATEMENT: We discuss the diverse etiologies and outcomes of fetal intracerebral hemorrhage, and propose standardized terminology for classification. We outline current practice and offer practical recommendations for management and counseling of fetal intracerebral hemorrhage, recognizing the need for capacity-building in the newly emerging subspecialty of fetal neurology. We highlight gaps in the literature and research priorities in fetal intracerebral hemorrhage to promote collaborative research, and the development of interventions to improve pregnancy and child outcomes.

Fig. 1. Fetal intracerebral hemorrhage discussed in this guideline.

a–c Intraventricular Hemorrhage (IVH); d–f Intraparenchymal Hemorrhage (IPH) without intraventricular hemorrhage. a Isolated intraventricular hemorrhage such as germinal matrix hemorrhage (GMH-IVH; arrow). b Intraventricular hemorrhage (solid arrow) with subsequent periventricular hemorrhagic infarction (PVHI; dotted arrow). c Intraventricular hemorrhage (solid arrow) with separate area of intraparenchymal hemorrhage (dotted arrow). d Intraparenchymal hemorrhage (dotted arrow) associated with a cerebral sinovenous thrombosis (CSVT), also known as a dural venous sinus thrombosis (DVST; solid open arrow). e Intraparenchymal hemorrhage (dotted arrow) in an arterial distribution suspicious for hemorrhagic transformation of an arterial infarct (Fetal Arterial Ischemic Stroke; FAIS). f intraparenchymal hemorrhage not associated with IVH, clot, nor consistent with hemorrhagic transformation of an arterial infarct suspected to be an idiopathic hemorrhage (Fetal Hemorrhagic Stroke; FHS). Illustrations are meant to reflect anatomy at ~25 gestational weeks. Refer to Fig. 2 for the corresponding proposed classification flowchart.

Fig. 2. Proposed classification flowchart of fetal intracerebral hemorrhage.

CSVT cerebrosinovenous thrombosis, FAIS fetal arterial ischemic stroke, FHS fetal hemorrhagic stroke, GMH-IVH germinal matrix hemorrhage-intraventricular hemorrhage, IPH intraparenchymal hemorrhage, PVHI periventricular hemorrhagic infarction.

Fig. 3. Intracerebral hemorrhage on fetal MRI.

Coronal T2-weighted MRI (a) at 33 gestational weeks showing mild ventriculomegaly with cysts at the bilateral caudothalamic grooves, and postnatal axial T2-weighted MRI in this case (b) showing small germinal matrix hemorrhage, septation in the right lateral ventricle and white matter hyperintensities due to congenital CMV. Axial echoplanar imaging (EPI) at 22 gestational weeks (c) in monochorionic twin showing bilateral germinal matrix-intraventricular hemorrhage (GMH-IVH), with cerebellar hemorrhage (d) on coronal T2-weighted MRI. GMH-IVH with right periventricular venous hemorrhagic infarction (e) at 31 gestational weeks due to COL4A2 variant, and postnatal axial T2-weighted MRI showing chronic changes (f). Twin with ventriculomegaly on coronal T2-weighted MRI (g) at 22 weeks and bilateral GMH confirmed on EPI (not shown), with postnatal follow-up MRI at 8 months (h) showing persistent severe ventriculomegaly despite ventriculoperitoneal shunting for post-hemorrhagic hydrocephalus with parenchymal volume loss and periventricular nodular heterotopia.