Extensive Late-Onset
Primary
Subarachnoid
Hemorrhage in a
Preterm Infant
Sangkae Chamnanvanakij, MD and
Jeffrey M. Perlman, MB
Primary subarachnoid hemorrhage is a rare event in
the preterm infant and is most often diagnosed at the
postmortem examination. An extremely preterm infant
who developed septicemia from Staphylococcus aureus
infection in the second postnatal week and presented
with hypotension, metabolic acidosis, anemia, thrombocytopenia, and seizures is reported. Cranial ultrasound revealed a large extra-axial fluid collection
involving the left parietal cortex that at postmortem
examination was observed to be a large left-sided
primary subarachnoid hemorrhage. The subarachnoid
hemorrhage is most likely secondary to events associated with septic shock and probable disseminated
vascular coagulopathy. © 1999 by Elsevier Science
Inc. All rights reserved.
Chamnanvanakij S, Perlman JM. Extensive late-onset
primary subarachnoid hemorrhage in a preterm infant.
Pediatr Neurol 1999;21:735-738.

Introduction
Germinal matrix/intraventricular hemorrhage is the
most common form of bleeding in the very low– birthweight infant, affecting 40-60% of those infants weighing
less than 1,000 gm [1]. In contrast, severe or catastrophic
primary subarachnoid hemorrhage (SAH) is rarely observed in this patient population. When it occurs, SAH is
most often observed incidentally at postmortem examina-

From the Department of Pediatrics; University of Texas Southwestern
Medical School; Dallas, Texas.

© 1999 by Elsevier Science Inc. All rights reserved.
PII S0887-8994(99)00067-3 ● 0887-8994/99/$20.00

tion [2]. In general, SAH is considered a “benign intracranial lesion” [3]; however, when extensive in nature, the
risk of morbidity and mortality is markedly increased
[4,5]. We describe a case of extensive SAH in an extremely preterm infant with sepsis to illustrate the salient
clinical, radiologic, and pathologic features in this patient
population.
Case Report
The patient was a 646-gm, 25-week, appropriate for gestational age,
female infant, the second of a twin gestation, born to a 21-year-old
mother. The infant was delivered vaginally in the breech position. The
Apgar scores were 3, 6, and 8 at 1, 5, and 10 minutes, respectively. The
initial hospital course was complicated by hyaline membrane disease
requiring surfactant therapy, patent ductus arteriosus that was treated
with indomethacin, hyperglycemia, and hypernatremia. Cranial ultrasound scans at 3 and 7 days of age were normal. At 9 days of age, the
infant became lethargic and hypotensive and developed necrotizing
enterocolitis with pneumatosis, associated with a sudden fall in hematocrit from 35% to 19%. A hemogram revealed leukocytosis with a left
shift and a platelet count of 33,000/mm3. A C-reactive protein measurement was not obtained. A septic evaluation, including a spinal tap, was
performed. The cerebrospinal fluid revealed 79/mm3 erythrocytes, with
protein 105 mg/dL and glucose 171 mg/dL without evidence of meningitis. Antibiotics were initiated. On the following day, the infant
exhibited generalized tonic-clonic seizures that were treated with phenobarbital. A third cranial ultrasound scan obtained at that time revealed a
large extra-axial fluid collection in the left parieto-occipital region (Fig
1A). A second scan 24 hours later demonstrated a significant midline
shift (Fig 1B). The infant remained hypotensive and acidotic despite
aggressive medical treatment. Because of the unstable condition and
grave prognosis, no surgical intervention was attempted, and the infant
died at 11 days of age. The blood cultures were positive for methicillinresistant Staphylococcus aureus. Cultures for herpes simplex and other
viruses were negative.
The postmortem examination revealed a large, organized hematoma
confined to the subarachnoid space that compressed the left parietal lobe
with a midline shift of the hemisphere (Fig 2). There was minimal
evidence of acute neuronal necrosis within the cortex. A small hemorrhage was observed within the fourth ventricle. The cerebral vessels were
congested, and no aneurysm was identified. System findings included
evidence of necrotizing enterocolitis with terminal ileal perforation.
There was multifocal hemorrhage into the acinar spaces of the lungs and
hemorrhage at the corticomedullary junction within the kidneys.

Discussion
SAH is a relatively common intracranial hemorrhage
observed more often in term than in preterm infants [3].
Although most cases of SAH are asymptomatic, the
diagnosis in term infants is usually based on symptoms

Communications should be addressed to:
Dr. Perlman, Department of Pediatrics, University of Texas
Southwestern Medical Center, 5323 Harry Hines Boulevard,
Dallas, TX 75235-9063.
Received January 28, 1999; accepted May 28, 1999.

Chamnanvanakij and Perlman: Extensive Subarachnoid Hemorrhage 735

Figure 1. (A) Cranial ultrasound scan obtained on day 9. Observe the increased echogenicity extending inferiorly from within the left
sylvian fissure. (B) Coronal ultrasound scan
obtained 24 hours later. Observe the larger
appearing lesion with areas of hyperechogenicity interspersed with areas of hypoechogenicity.
A midline shift is also present.

(e.g., seizure, apnea), abnormal neurologic signs (e.g.,
lethargy, tense anterior fontanel), or bloody cerebrospinal
fluid without clearing during drainage [3,6]. The diagnosis
is most frequently confirmed by cranial computed tomography. The etiology of SAH in term infants is presumed to
be related to the processes of delivery in most cases. Less
common causes include hemophilia [7], saccular aneurysm [8-11], mycotic aneurysm [12], and arteriovenous
malformation [13]. In these circumstances, the subarachnoid blood usually extends from the primary site of
bleeding (i.e., intraventricular, cerebellar, or subdural). In
preterm infants, SAH is more difficult to diagnose clinically because the symptoms are often nonspecific or

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related to other primary disease processes [3]. Most
commonly, it is incidentally diagnosed at postmortem
examination [2,3]. SAH in most cases involving the
preterm infant is secondary to intraventricular hemorrhage, with extension of blood through the foraminae of
Luschka and Magendie into the subarachnoid space [3].
Primary SAH is much less common. The distribution of
small-to-moderate SAH is usually over the cerebral hemisphere or within the sylvian fissure [2]. When severe, SAH
may present as a circumscribed blood coagulum or subarachnoid hematoma. In one large postmortem examination series the hematoma mostly involved the temporal
lobe, with a left-sided predominance [2]. The pathogenesis

Figure 2. Brain specimen from the infant from the postmortem examination. Observe the large organized hematoma
involving the left posterior parietal cortex. The hematoma
was confined to the subarachnoid space.

of primary SAH remains unclear. Factors considered
important include previous hypoxia, fragility of blood
vessels within the subarachnoid space, and elevations in
venous pressure [2].
The sonographic diagnosis of SAH is less well described than that of germinal matrix/intraventricular hemorrhage. SAH presents as an extra-axial fluid collection
that is difficult to distinguish from that observed with a
subdural hematoma. Computed tomography is often used
to reveal the characteristic findings of sulci and fissures
filled with blood [14]. In the present report the extra-axial
fluid collection observed on the sonogram was initially
interpreted as representing a large subdural hematoma.
However, the location of blood within and extending
beyond the sylvian fissure was more consistent with SAH,
which was confirmed at postmortem examination. The late
development of the unilateral subarachnoid hematoma in
the absence of marked bleeding within the germinal matrix
Table 1.

Reference

or intraventricular system was unanticipated. Although the
unilateral involvement was somewhat unusual, it is consistent with the previous postmortem examination findings
of Larroche [2]. There are three previous case reports of
similar late hemorrhage in preterm infants (Table 1). In
two of the cases the blood was confined to the subdural
space [15], and it was confined to the subarachnoid space
in one infant [4]. All three infants were extremely premature (i.e., birth weight less than 1,000 gm) and had
evidence of Gram-negative septicemia (i.e., Escherichia
coli and Klebsiella pneumoniae). In the authors’ patient,
evidence of multiorgan hemorrhage at postmortem examination supports the role of sepsis and probable disseminated intravascular coagulopathy in the genesis of the
SAH. Bleeding from bridging veins is a less likely
possibility. Interestingly enough, Staphylococcus aureus,
the organism identified in this case, has been previously
associated with mycotic aneurysms [12,16]. However,

Characteristics of subarachnoid and subdural hematomas in preterm infants

GA, BW

Primary
Diagnosis

Postnatal
Age (day)

4

32 wk, 2,100 gm

Septicemia,
K. pneumoniae

11

15

33 wk, 935 gm

Septicemia, DIC,
E. coli

6

27 wk, 795 gm

Septicemia, DIC,
K. pneumoniae

8

Abbreviations:
BW ⫽ Birth weight
CT ⫽ Computed tomography
DIC ⫽ Disseminated intravascular coagulopathy
E. ⫽ Escherichia
GA ⫽ Gestational age

Radiologic Findings
HUS (day 11): large extra-axial fluid collection over left
temporal lobe, small GMH CT scan (day 11): large
subarachnoid hematoma
HUS (day 6): large extra-axial fluid collection with
midline shift CT scan (day 15): large SDH over left
cerebral hemisphere, hydrocephalus
HUS (day 8): large extra-axial fluid collection over right
cerebral hemisphere CT scan (1 mo): resolving SDH,
hydrocephalus, porencephalic cyst

Postmortem
Examination
Findings
—

—

Same

GMH ⫽ Germinal matrix hemorrhage
HUS ⫽ Cranial ultrasound
K.
⫽ Klebsiella
SDH ⫽ Subdural hematoma

Chamnanvanakij and Perlman: Extensive Subarachnoid Hemorrhage 737

aneurysmal dilatation of any vessel was not identified at
postmortem examination.
The authors described the unusual and late appearance
of massive unilateral SAH in a preterm infant diagnosed
by cranial ultrasound scan with postmortem examination
correlation. The SAH in this patient was most likely
secondary to events associated with septic shock and
probable disseminated intravascular coagulopathy.

References
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