1 West Virginia Medical Journal — OA WVMJ OA Case Report and Review of Literature | Charles Marcus, MD Abdul Tarabishy, MD Lana Winkler, MD Department of Diagnostic Radiology, West Virginia University Hospital Corresponding Author: Lana Winkler, MD, Assistant Professor, Department of Diagnostic Radiology, WVU Hospital, 1 Medical Center Drive, Morgantown, WV 26506 Email: lwinkler@hsc.wvu.edu Abstract Symptomatic spontaneous intracranial hemorrhage is rare in term neonates and the literature available on this subject is limited. In this case report, we present the clinical presentation, imaging fndings and clinical course of a term neonate with neonatal seizures who was found to have intracranial hemorrhage. The available literature on this has been briefy reviewed and imaging fndings and management of these newborns has been discussed in brief. Case Presentation A frstborn male child of a 31 year old healthy female with unremarkable prenatal course and ultrasounds who presented with multiple apneic episodes associated with cyanosis. The pregnancy was unremarkable except for a viral gastroenteritis one month prior to delivery requiring a one day hospital stay and intravenous fuids. The labor progressed normally and the baby was delivered vaginally at 39 weeks and 2 days of gestation without instrumentation at a community hospital. Mild meconium staining was present at birth. The baby was normal on examination without evidence for cephalohematoma. Birth weight was 3.23 kilograms, APGAR (Appearance, Pulse, Grimace, Activity, and Respiration) scores were 9 at one and fve minutes and child received Vitamin K injection. The baby was nursed within the frst few hours without diffculty. Approximately 10 hours after delivery, parents noted multiple episodes where the baby turned blue, appeared to stop breathing and returned to normal with gentle stimulation. The episodes gradually increased in frequency and duration. Oxygen was administered, and baby was intubated and transferred to a tertiary care center with a neonatal intensive care unit (NICU). The baby was loaded with phenobarbital and further investigations were performed. A computed tomography (CT) of the brain revealed right temporal intraparenchymal hemorrhage extending along the tentorium cerebelli (Figure 1). Magnetic Resonance Imaging (MRI) of the brain confrmed the fndings with extension of the right temporal intraparenchymal hemorrhage into the right lateral ventricle with associated restricted diffusion thought to be due to the hemorrhage itself, and not underlying infarct (Figure 2). Intracranial and Extracranial Magnetic Resonance Angiography (MRA) revealed no underlying vascular anomalies. An Intracranial Magnetic Resonance Venography (MRV) revealed venous anatomic variants with a hypoplastic right transverse sinus and a small sized right sigmoid sinus. No obstruction to the venous drainage or thrombus was identifed (Figure 3). Lumbar puncture demonstrated frank xanthochromia, borderline decreased glucose (49mg/dL) and elevated protein (215mg/ dL). Cerebrospinal fuid (CSF) and blood cultures were negative. CSF amino acid profle, Herpes Simplex Virus 1 and 2 assays Intracranial Hemorrhage resulting in Apneic Seizures in a Full-term infant: A Case Report and Review of Literature WVMJ OA Figure 1. Unenhanced axial CT images (A and B) and coronal CT image (C) demonstrate ill-defned hyperdensity in the right temporal region (white arrows) representing intraparenchymal hemorrhage with blood also tracking along the tentorium cerebelli.