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ARTICLES: Elise Roze, Koenraad N. J. A. Van Braeckel, Christa N. van der Veere, Carel G. B. Maathuis, Albert Martijn, and Arend F. Bos Functional Outcome at School Age of Preterm Infants With Periventricular Hemorrhagic Infarction Pediatrics 2009; 123: 1493-1500 [Abstract] [Full text] [PDF]

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Periventricular hemorrhagic infarction in preterm infants: the importance of size and location

Jeroen Dudink, Maarten Lequin, Sandra Horsch, Paul Govaert   (11 September 2009)

Periventricular hemorrhagic infarction in preterm infants: the importance of size and location 11 September 2009
Jeroen Dudink, Neonatologist Sophia Childrens Hospital, ErasmusMC, Maarten Lequin, Sandra Horsch, Paul Govaert Send letter to journal: Re: Periventricular hemorrhagic infarction in preterm infants: the importance of size and location j.dudink{at}erasmusmc.nl Jeroen Dudink, et al.	Roze E et al. reported motor, cognitive, and behavioral outcome at school age in preterms with periventricular hemorrhagic infarction (PHI).They set out to identify risk factors for adverse outcome and conclude that size and location of PHI did not correlate with functional motor outcome and intelligence. In our opinion the size (extent) and location (involvement of anatomical structures) of neonatal focal brain injury play an important role in determining neurodevelopmental outcome. We believe that proper understanding of lesion anatomy is imperative for parent counselling and for early intervention studies. An example is the spatial relationship between preterm brain lesions such as PHI and the corticospinal tract: the existence of PHI in the area of the corticospinal tract predicts the development of a hemisyndrome (Rademaker et al. 1994, De Vries et al. 2001, Dudink et al. 2008). It is (neuro)logical to approach PHI associated with germinal matrix hemorrhage (GMH) from the angle of vascular anatomy, as infarction follows occlusion of medullary veins draining into the internal cerebral vein near the foramen of Monro (Gould et al. 1986). Conventional (T1- and T2-weighted) MRI on top of sonographic detection allows fine description of size and location of the lesion and of structures involved, like the corticospinal tract (Dudink et al. 2008). When describing outcome in relation to ultrasound, correct anatomical definition of the lesion is paramount. To our surprise the Roze et al. paper reports 16 infants of 23 where the occipital lobe is involved. Occipital medullary veins are not involved in previous papers (deVries et al. 2001, Dudink et al. 2008) or their frequency of involvement cannot be ascertained (Bassan et al. 2006). Typical extensive PHI extends to midatrial level, important when comparing lesions due to leukomalacia often extending deep into the occipital lobe. In our experience the variants of venous infarction are: prefrontal (along caudate head), posterior frontal, frontoparietal, atrial (posterior temporal) and temporal. The latter two variants are rare and occur not within the drainage area of the internal cerebral vein but instead of the basal vein of Rosenthal. The veins draining the lateral atrial and occipital wall drain directly into the internal cerebral vein, basal vein or great cerebral vein in their course through the quadrigeminal cistern, so they do not course through matrix areas in the caudothalamic groove where there is a high risk of GMH (Ono et al. 1984). In conclusion, given the small number of patients in the Roze et al. report and given the uncertainty about anatomical descriptions of the infarcts studied, the conclusion that sonographic size and location do not seem to bear on outcome is, in our opinion, unsupported. Roze E, Van Braeckel KN, van der Veere CN, Maathuis CG, Martijn A, Bos AF. Functional outcome at school age of preterm infants with periventricular hemorrhagic infarction. Pediatrics. 2009 Jun;123(6):1493- 500 Rademaker KJ, Groenendaal F, Jansen GH, Eken P, de Vries LS. Unilateral haemorrhagic parenchymal lesions in the preterm infant: shape, site and prognosis. Acta Paediatr. 1994 Jun;83(6):602-608 de Vries LS, Roelants-van Rijn AM, Rademaker KJ, Van Haastert IC, Beek FJ, Groenendaal F. Unilateral parenchymal haemorrhagic infarction in the preterm infant. Eur J Paediatr Neurol. 2001;5(4):139-149 Dudink J, Lequin M, Weisglas-Kuperus N, Conneman N, van Goudoever JB, Govaert P. Venous subtypes of preterm periventricular haemorrhagic infarction. Arch Dis Child Fetal Neonatal Ed. 2008 May;93(3):201-206 Bassan H, Benson CB, Limperopoulos C, Feldman HA, Ringer SA, Veracruz E, Stewart JE, Soul JS, Disalvo DN, Volpe JJ, du Plessis AJ (2006) Ultrasonographic features and severity scoring of periventricular hemorrhagic infarction in relation to risk factors and outcome. Pediatrics 117:2111-2118 Gould SJ, Howard S, Hope PL, Reynolds EOR (1986) Periventricular intraparenchymal cerebral haemorrhage in preterm infants: the role of venous infarction. J Pathol 151:197-202 Ono M, Rhoton AL, Peace D, Rodriguez RJ (1984) Microsurgical anatomy of the deep venous system of the brain. Neurosurgery 15:621-657 Conflict of Interest: None declared