A term (37 weeks) newborn baby boy with suspicion for coarctation of the aorta on prenatal ultrasound had a head ultrasound performed to evaluate for structural anomalies. The head ultrasound revealed grade 1 germinal matrix hemorrhage and areas of hemorrhage in the left temporal/occipital region. A follow-up brain MRI revealed blood products expanding the subpial potential space with displacement of the adjacent sulci and extension along the calvarium over the left occipital lobe demonstrated on T1-weighted imaging (A), T2-weighted imaging (B), and gradient echo (C). There was an associated hematocrit level (B, C) within the hematoma. Diffusion-weighted imaging demonstrated cytotoxic edema in the adjacent left temporal lobe (D). The patient had no family history of bleeding disorders, prolonged umbilical bleeding, coagulation abnormalities, or birth trauma. The patient had an echocardiogram, which demonstrated a normal aortic arch without coarctation, which confirmed a false-positive prenatal ultrasound.
Subpial hemorrhage is a rare type of intracranial extra-axial hemorrhage with unclear mechanism and incidence.1,2 It classically presents on imaging as hemorrhage, which courses along the surface of the brain but still has a confined appearance differentiating it from subarachnoid hemorrhage. Subpial hemorrhage is most common in the temporal lobes and close to suture lines.1 Most cases demonstrate restricted diffusion within the adjacent brain parenchyma.1
Spontaneous subpial hemorrhage may occur in otherwise healthy term neonates but may also be related to birth trauma or coagulopathy.2 The etiology remains unknown but may be related to thrombosis or compression of medullary veins along the surface of the brain.1,2 Patients often present with apnea or seizures shortly after birth.1
Alhyari L, Cornwell BO. JAOCR at the Viewbox: Subpial Hemorrhage in a Newborn. J Am Osteopath Coll Radiol. 2021;10(2):27.