Cerebrovascular Complications in Spinal Fusion Surgery: A Nationwide 8-year Follow-up Study in South Korea.

This retrospective study investigated the long-term incidence and risk of postoperative complications following spinal fusion. This study included 640,366 participants from a National Health Examination cohort in the Republic of Korea. Among them, 11,699 individuals underwent spinal fusion, and 56,667 individuals who underwent non-fusion spinal procedures served as controls. Propensity score matching was used to account for patient characteristics including demographic factors, comorbidities, and other relevant variables. The participants were followed for 8 years to assess the occurrence of cerebrovascular disease (CVD), hemorrhagic infarction (HA), ischemic infarction (II), occlusion and stenosis, and ischemic heart disease (IHD). The incidence rates of CVD and IHD were found to be 27.58 and 31.45 per 1,000 person-years in the spinal fusion group compared to 18.68 and 25.73 per 1,000 person-years in the control group (p < .001), respectively. Patients who underwent spinal fusion had a higher risk of CVD, HA, and IHD than those in the control group (all p < .001). In the subgroup analysis, thoracolumbar and noncervical spinal fusion were associated with a higher risk of CVD, II, and IHD (all p < .005). Patients undergoing thoracolumbar fusion may have an increased association with CVD, II in cerebral arteries, and IHD. This suggests a need for careful consideration of vascular risks in such patient populations.

Periventricular hemorrhagic infarction in preterm neonates: Etiology and time of development.

BACKGROUND: To find the obstetrical and delivery associated risk factors of antenatal and postnatal grade III intraventricular hemorrhage (IVH) or periventricular hemorrhagic infarction (PVHI) in preterm neonates. METHODS: A retrospective study of obstetric and delivery associated risk factors included neonates (<35 gestational weeks) with severe IVH/PVHI (n = 120) and a prospectively collected control group (n = 50). The children were divided into: (1) antenatal onset group (n = 27) with insult visible on cerebral ultrasonography within the first 12 hours of birth or periventricular cystic changes visible in PVHI within the first 3 days; (2) neonatal onset group (n = 70) with insult diagnosed after initial normal findings or I-II grade IVH, and (3) unknown time-onset group (n = 23) with insult visible at > 12 h of age. RESULTS: The mothers of the antenatal onset group had significantly more bacterial infections before delivery compared to the neonatal onset group: 20/27 (74.1%) versus 23/69 (33.3%), (odds ratio (OR) 5.7 [95% confidence interval 2.1-16]; p = 0.0008) or compared to the control group (11/50 (22%); OR 11 [2.8-42]; p = 0.0005). Placental histology revealed chorioamnionitis more often in the antenatal compared to the neonatal onset group (14/21 (66.7%) versus 16/42 (38.1%), respectively; OR 3.7 [1.18-11]; p = 0.025). Neonates with neonatal development of severe IVH/PVHI had significantly more complications during delivery or intensive care. CONCLUSIONS: Bacterial infection during pregnancy is an important risk factor for development of antenatal onset severe IVH or PVHI. In neonates born to mothers with severe bacterial infection during pregnancy, cerebral ultrasonography is indicated for early detection of severe IVH or PVHI.

Role of Decompressive Craniectomy in the Treatment of Malignant Cerebral Venous Sinus Thrombosis: A Single Center Consecutive Case Series Study in China.

OBJECTIVE: Patients with cerebral venous sinus thrombosis (CVST) may die during the acute phase due to increased intracranial pressure and cerebral herniation. The purpose of this study was to assess the role of decompressive craniectomy in the treatment of patients with malignant CVST. METHODS: Patients who underwent decompressive craniectomy and were consequently admitted to the Critical Care Unit, Department of Neurosurgery, at Capital Medical University Xuanwu Hospital from March 2010 to January 2021 were retrospectively examined with follow-up data at 12 months. RESULTS: In total, 14 cases were reviewed, including 9 female and 5 male patients, aged 23-63 years (42.7 ± 12.3 years). Prior to surgery, all patients had a GCS score <9. 6 patients had a unilateral dilated pupil, while 4 patients had bilateral dilated pupils. According to the head computed tomography (CT), all patients had hemorrhagic infarction, and the median midline shift was 9.5 mm before surgery. Thirteen patients underwent unilateral decompressive craniectomy, and 1 patient underwent bilateral decompressive craniectomy, among whom, 9 patients underwent hematoma evacuation. Within 3 weeks of surgery, 3 cases (21.43%) resulted in death, with 2 patients dying from progressive intracranial hypertension and 1 from acute respiratory distress syndrome (ARDS). Eleven patients (78.57%) survived after surgery, of whom 4 (28.57%) patients recovered without disability at 12-month follow-up (mRS 0-1), 2 (14.29%) patients had moderate disability (mRS 2-3), and 5 (35.71%) patients had severe disability (mRS 4-5). CONCLUSIONS: Emergent decompressive craniectomy may provide a chance for survival and enable patients with malignant CVST to achieve an acceptable quality of life (QOL).

A Case of Two-stage Surgery Using Intracranial Pressure Monitoring for Hemorrhagic Infarction during Direct Oral Anticoagulant Medication.

Direct oral anticoagulants (DOACs) are considered to cause a few hemorrhagic complications, including hemorrhagic infarction; these are administered in the acute phase of cerebral infarction for secondary prevention of cerebral embolism. Hemorrhagic infarction with cerebral herniation requires urgent decompressive craniectomy and can become fatal. Perioperative management is challenging because patients are often on antithrombotic therapy. In this study, we report on a case of a 61-year-old man with left-sided hemiparesis and impaired consciousness; he suffered from a hemorrhagic infarction with cerebral herniation during oral DOAC treatment after endovascular recanalization for the middle cerebral artery occlusion. As the patient was on apixaban for <3 h, performing decompressive craniectomy was considered difficult to stop hemostasis. We then opted to perform a small craniotomy to remove the hematoma, control the intracranial pressure (ICP), and administer fresh frozen plasma. We waited for the effect of apixaban to diminish before performing decompressive craniectomy. Gradually, his level of consciousness was noted to improve. Hemorrhagic cerebral infarction while on DOAC medications can be safely treated with small craniotomy and ICP monitoring followed by decompressive craniectomy. Thus, this case highlights the value of staged surgery under ICP monitoring in the absence of an immediate administration of DOAC antagonists.

Timing of Antithrombotic Secondary Prevention in Patients with Intracranial Hemorrhage after Stroke Thrombolysis and Thrombectomy.

In patients with acute ischemic stroke, hemorrhagic transformation (HT) of infarcted tissue frequently occurs after reperfusion treatment. We aimed to assess whether HT and its severity influences the start of secondary prevention therapy and increases the risk of stroke recurrence. In this retrospective dual-center study, we recruited ischemic stroke patients treated with thrombolysis, thrombectomy or both. Our primary outcome was the time between revascularization and the start of any secondary prevention therapy. The secondary outcome was ischemic stroke recurrence within three months. We compared patients with vs. without HT and no (n = 653), minor (n = 158) and major (n = 51) HT patients using propensity score matching. The delay in the start of antithrombotics or anticoagulants was median 24 h in no HT, 26 h in minor HT and 39 h in major HT. No and minor HT patients had similar rates of any stroke recurrence (3.4% (all ischemic) vs. 2.5% (1.6% ischemic plus 0.9% hemorrhagic)). Major HT patients had a higher stroke recurrence at 7.8% (3.9% ischemic, 3.9% hemorrhagic), but this difference did not reach significance. A total of 22% of major HT patients did not start any antithrombotic treatment during the three-month follow-up. In conclusion, the presence of HT influences the timing of secondary prevention in ischemic stroke patients undergoing reperfusion treatments. Minor HT did not delay the start of antithrombotics or anticoagulants compared to no HT, with no significant difference in safety outcomes. Major HT patients remain a clinical challenge with both a delayed or lacking start of treatment. In this group, we did not see a higher rate of ischemic recurrence; however, this may have been censored by elevated early mortality. While not reaching statistical significance, hemorrhagic recurrence was somewhat more common in this group, warranting further study using larger datasets.

ADC measurement relevance to predict hemorrhage transformation after mechanical thrombectomy.

BACKGROUND: ADC (apparent coefficient diffusion) value has been known to predict hemorrhage transformation (HT) after thrombolysis and recently, after mechanical thrombectomy (MT). We aimed to evaluate that utility separately in basal ganglia and superficial territory. We used HT occurrence with or without NIHSS change as primary outcome measures. METHODS: This single-center retrospective study included consecutive stroke patients receiving MT for internal carotid artery (ICA) or middle cerebral artery (M1 or M2) occlusion. In patient with or without HT, using the Heidelberg Bleeding Classification, on follow-up CT scan at 24-48 h, we assessed the ADC value separately in basal ganglia and superficial territory on MRI before MT to search for the correlation. Multivariable analysis was performed using variables with significant differences between the HT group and non-HT group. RESULTS: One hundred seventeen patients were included in the final analysis. HT distribution was as follows: 9 patients (7.69%) HI1 or 2; 14 patients (11.97%) PH1; 21 patients (17.95%) PH2; 29 patients (24.79%) subarachnoid hemorrhage; and 21 patients (17.95%) symptomatic intracranial hemorrhage (sICH). Mean ADC minimal value in basal ganglia in the HT group was significantly lower than in the non-HT group (377.6 × 10-6 mm2/s [± 52.4] vs 413.3 × 10-6 mm2/s [± 72.5]; p = 0.0229) with an area under the curve (AUC) of 0.6622 (95% CI: 0.5-0.8; p = 0.014). MRI-MT time was significantly longer in the HT group (p = 0.0002), but there was no association between ADC value and onset-MRI or MRI-MT times (Spearman's coefficients <0.7, p > 0.05). Glycemia at admission (>1.5 g/L) (OR = 4.2; 95% CI [1.611; 10.961]) and carotid occlusion (OR = 2.835; 95% CI [1.134; 7.091]) were independently associated with HT. CONCLUSIONS: ADC value in basal ganglia, unlike brain superficial territory, are correlated to HT risk after MT.

Multiple Cerebral Hemorrhages and White Matter Lesions Developing after Severe hMPV Pneumonia in a Patient with Trisomy 13: A Case Report and Review of the Literature.

Human metapneumovirus (hMPV) is a common cause of upper and lower respiratory tract infections in children. A few case reports have described hMPV encephalitis or encephalopathy. Neuroimaging data on patients with hMPV encephalitis are scarce. We report a patient with trisomy 13 who developed severe hMPV pneumonia, multifocal cerebral and cerebellar hemorrhagic infarctions and extensive cerebral white matter demyelination. Although adult respiratory distress syndrome and disseminated intravascular coagulation contributed to the devastating central nervous system (CNS) lesions, endothelial dysfunction of the CNS caused by hMPV infection probably also played a pathophysiological role in this case.

Epidemiology and pathogenesis of stroke in preterm infants: A systematic review.

BACKGROUND: Perinatal stroke is one of the principal causes of cerebral palsy (CP) in preterm infants. Stroke in preterm infants is different from stroke in term infants, given the differences in brain maturation and the mechanisms of injury exclusive to the immature brain. We conducted a systematic review to explore the epidemiology and pathogenesis of periventricular hemorrhagic infarction (PVHI), perinatal arterial ischemic stroke (PAIS) and cerebral sinovenous thrombosis (CSVT) in preterm infants. METHODS: Studies were identified based on predefined study criteria from MEDLINE, EMBASE, SCOPUS and WEB OF SCIENCE electronic databases from 2000 -2019. Results were combined using descriptive statistics. RESULTS: Fourteen studies encompassed 546 stroke cases in preterm infants between 23 -36 weeks gestational ages and birth weights between 450 -3500 grams. Eighty percent (436/546) of the stroke cases were PVHI, 17%(93/546) were PAIS and 3%(17/546) were CSVT. Parietal PVHI was more common than temporal and frontal lobe PVHI. For PAIS, left middle cerebral artery (MCA) was more common than right MCA or cerebellar stroke. For CSVT partial or complete thrombosis in the transverse sinus was universal. All cases included multiple possible risk factors, but the data were discordant precluding aggregation within a meta-analysis. CONCLUSION: This systematic review confirms paucity of data regarding the etiology and the precise causal pathway of stroke in preterm infants. Moreover, the preterm infants unlike the term infants do not typically present with seizures. Hence high index of clinical suspicion and routine cUS will assist in the timely diagnosis and understanding of stroke in this population.

Primary jejunogastric intussusception: A case report and review of the literature.

INTRODUCTION: Jejunogastric intussusception following gastric surgery is a rare complication that, if not diagnosed early, can have catastrophic outcomes. PRESENTATION OF CASE: We have reported a case, never described previously, of an acute spontaneous retrograde JGI, presenting with obstruction and hematemesis, in a 70-year-old woman who has never, previously, undergone abdominal surgery. DISCUSSION: As in all cases of intestinal intussusception, early diagnosis is important for acute JGI as mortality rates increase from 10% when the intervention occurs within 48 h. to 50% if treatment is delayed for 96 h. The diagnosis of JGI can be determined with many imaging studies, such as endoscopy, ultrasonography (US), barium stadium and CT scan. Although JGI, up to now, has been described as a rare complication after any type of gastric surgery, this disease must, however, be suspected also in patients who have never undergone abdominal surgery, if they present with non-sedable abdominal pain associated with signs of high intestinal obstruction and hematemesis. CONCLUSION: Our hope is to add to the available literature to aid physicians in their diagnostic work-up and in developing management plans for similar cases occurring in the future.

Cerebral hemorrhagic infarction was diagnosed subsequently after high-amplitude slow waves detected on processed electroencephalogram during sedation: a case report.

BACKGROUND: Continuous electroencephalogram (EEG) monitoring is useful for assessing the level of sedation and detecting non-convulsive epileptic seizures and cerebral ischemia in the intensive care unit. This report describes a case of cerebral hemorrhagic infarction diagnosed after the detection of high-amplitude slow waves on processed EEG during sedation. CASE PRESENTATION: A 68-year-old man who underwent cardiac surgery was sedated in the intensive care unit following an invasive procedure. High-amplitude slow waves appeared on processed EEG monitoring before the detection of anisocoria. Computed tomography revealed a cerebral hemorrhagic infarction. CONCLUSIONS: In the management of critically ill patients, continuous EEG monitoring with forehead electrodes may be useful in the early detection of brain lesions.

Ileal hemorrhagic infarction after carotid artery stenting: A case report and review of the literature.

BACKGROUND: Ileal hemorrhagic infarction after carotid artery stenting (CAS) is a fatal complication. The prognosis of ileal hemorrhagic infarction after CAS is very poor if not treated in a timely manner. We describe a rare case of ileal hemorrhagic infarction due to acute embolism of the mesenteric artery after CAS. CASE SUMMARY: A 67-year-old man with acute ischemic stroke underwent CAS via the right femoral artery approach 21 d after intensive medical treatment. On the first day after surgery, the patient had abdominal distension and abdominal pain. Abdominal enhanced computed tomography revealed intestinal obstruction, severe stenosis of the superior mesenteric artery, and poor distal angiography. An exploratory laparotomy was performed, and pathological examination showed hemorrhagic ileal infarction. It was subsequently found that the patient had intestinal flatulence. With the guidance of an ultrasound scan, the patient underwent abdominal puncture, drainage, and catheterization. After 58 d of treatment, the patient was discharged from hospital with a National Institutes of Health Stroke Scale score of 2 points, and a Modified Rankin Scale score of 1 point. At the 6-mo follow-up, the patient had an excellent functional outcome without stroke or mesenteric ischemia. Furthermore, computed tomography angiography showed that the carotid stent was patent. CONCLUSION: Ileal hemorrhagic infarction is a fatal complication after CAS, usually caused by mesenteric artery embolism. Thus, more attention should be paid to the complications of embolism in the vascular system as well as the nervous system after CAS, and the complications should be identified and treated as early as possible.

Clinical and Radiological Characteristics of Acute Cerebrovascular Diseases Among Egyptian Patients With COVID-19 in Upper Egypt.

Background and Purpose: There is little information on the acute cerebrovascular complications of coronavirus disease 2019 (COVID-19) in Egypt. The aim of this study was to estimate the proportion of acute cerebrovascular disease (CVD) among COVID-19 patients and evaluate their clinical and radiological characteristics in comparison with non-COVID-19 CVD. Materials and Methods: In a retrospective study, COVID-19 patients whom presented with CVD in Assiut and Aswan University Hospitals were compared with non-COVID-19, CVD patients, admitted to Qena University Hospital, prior to the pandemic. The following data were collected: clinical history and presentation, risk factors, comorbidities, brain imaging (MRI or CT), chest CT, and some laboratory investigations. Results: Fifty-five (12.5%) of the 439 patients with COVID-19 had acute CVD. Of them, 42 (9.6%) had ischemic stroke while 13 patients (2.9%) had hemorrhagic CVD. In the 250 cases of the non-COVID-19 group, 180 had ischemic stroke and 70 had hemorrhagic stroke. A large proportion of patients with COVID-19 who presented with ischemic stroke had large vessel occlusion (LVO), which was significantly higher than in non-COVID-19 patients with CVD (40 vs. 7.2%, P < 0.001). Comorbidities were recorded in 44 (80%) cases. In COVID-19 ischemic stroke patients, risk factors [hypertension and ischemic heart disease (IHD)] and comorbidities (hepatic and renal) were significantly higher than those in non-COVID-19 patients. In addition, 23.5% had hemorrhagic CVD, and six patients with LVO developed hemorrhagic transformation. Conclusion: Acute CVD among patients with COVID-19 was common in our study. LVO was the commonest. Hypertension, IHD, and anemia are the most common risk factors and could contribute to the worsening of clinical presentation. Comorbidities were common among patients with CVD, although a large number had elevated liver enzymes and creatinine that were partially due to COVID-19 infection itself. The current results begin to characterize the spectrum of CVD associated with COVID-19 in patients in Upper Egypt. Registration ID: The ID number of this study is IRB no: 17300470.

Surgical management of cerebral venous sinus thrombosis: Case series and literature review.

BACKGROUND: Cerebral venous sinus thrombosis (CVST) is not a common type of stroke (5%) but still hazardous to be misdiagnosed or mistreated. Aggressive medical treatment is usually failed to hinder increase intracranial tension. Therefore, decompressive craniectomy (DC) is the final measure to mitigate the deleterious effect of supratentorial herniation. The purpose of the study is to illustrate our experience with the surgical treatment of CVST and reviewing the previous works of literature. METHODS: Forty-two patients were admitted to Kasr Al-Ainy University Hospital from June 2019 to March 2020. The admission was either to the neurology department or intensive care unit or neurosurgery department. Every patient who was diagnosed with CVST received an emergency neurosurgery consultation. Seven patients were operated on with DC according to the criteria mentioned above. Therapeutic heparin was given in addition to intracranial pressure lowering measures. RESULTS: The mean and standard deviation of the age was (25.14 ± 10.1) years. There were five females (71.45%) in our series. The mean and standard deviation of clinical manifestations are (8.5 ± 7.77) weeks with range (3- 14 weeks). Most of the cases were presented by a decreased level of consciousness (6/7) and anisocoria (6/7), followed by fits (3/7). Four cases out of seven had the previous history of oral contraceptive administration. CONCLUSION: DC provides an urgent last arm for intractable increased intracranial tension. Patients with CVST need urgent consultation for neurosurgical intervention.

Pioglitazone Prevents Hemorrhagic Infarction After Transient Focal Ischemia in Type 2 Diabetes.

Pioglitazone (PGZ), a PPARγ agonist, has been used for diabetic patients as an insulin-sensitizing agent. Recent studies have demonstrated that PGZ increases adiponectin (APN) levels and provides vascular protection in ischemic conditions. This study was designed to assess the neuroprotective effects of PGZ against cerebral ischemia-reperfusion injury via an APN-related mechanism. Type 2 diabetic leptin-deficient mice (db/db) were administered PGZ for 1 week, and plasma insulin and APN levels were measured. These mice received a middle cerebral artery occlusion and reperfusion injury, and they were evaluated for the infarct volume and by immunohistochemistry and western blotting analysis at several time points after ischemia. PGZ-administered db/db mice showed improved insulin sensitivity, and the hemorrhagic rate and infarct volume were decreased (P < 0.05). In the PGZ-administered group, plasma APN levels increased compared with the vehicle group. In the db/db group, PGZ administration significantly suppressed inflammatory reactions and oxidative stress after reperfusion (P < 0.05). PGZ may be applicable for acute cerebral ischemia treatment in metabolic syndrome patients as well as antidiabetic agents.

The clinical study of the correlation between different types of hemorrhage transformation and serum uric acid in patients with acute cerebral infarction / 中国医师进修杂志

Objective:To investigate the relationship between different types of hemorrhagic transformation and serum uric acid in patients with acute cerebral infarction.Methods:The clinical data of 365 patients with acute cerebral infarction in Jinhua Central Hospital of Zhejiang Province from June 2018 to December 2020 were retrospectively analyzed. The clinical data and the serum uric acid level at the time of admission were recorded, and the occurrences of hemorrhagic infarction (HI) and cerebral parenchymal hematoma (PH) were counted. The risk factors of HI and PH in patients with acute cerebral infarction were analyzed by multivariate Logistic regression analysis.Results:Among 365 patients, 328 cases had no hemorrhagic transformation (control group); 37 cases (10.1%) had hemorrhagic transformation, with 20 cases of HI (HI group) and 17 cases of PH (PH group). The uric acid in PH group was significantly lower than that in control group and HI group: (243.59 ± 61.49) μmol/L vs. (307.84 ± 80.12) and (305.45 ± 94.99) μmol/L, and there was statistical difference ( P<0.05); there was no statistical difference in uric acid between control group and HI group ( P>0.05). The patients was divided into 3 groups according to the tertiles of serum uric acid, uric acid ≤ 264.9 μmol/L was in 121 cases (Ⅰ group), 265.0 to 338.8 μmol/L was in 122 cases (Ⅱ group) and ≥338.9 μmol/L was in 122 cases (Ⅲ group). The rate of PH in Ⅲ group was significantly lower than that in Ⅰ group: 0.8% (1/122) vs. 8.3% (10/121), and there was statistical difference ( P<0.05). Taking patients without hemorrhage transformation as a reference, multivariate Logistic regression analysis result showed that diabetes, atrial fibrillation and large-area infarction were independent risk factors of HI in patients with acute cerebral infarction ( P<0.01); the age, large-area cerebral infarction, thrombolytic therapy, platelet count and uric acid were independent risk factors of PH in patients with acute cerebral infarction ( P<0.05 or <0.01). Conclusions:In patients with acute cerebral infarction, higher serum uric acid is independently correlated with lower PH, and has no correlation with HI. Serum uric acid level has certain value in predicting PH.

Differentiation of hemorrhagic infarction from primary intracerebral hemorrhage in the chronic period.

Regarding incidentally found old hemorrhagic foci on gradient-echo magnetic resonance imaging (GRE), it is difficult to distinguish whether the foci are the consequence of hemorrhagic infarction (HI) or primary intracerebral hemorrhage (PICH). We analyzed the radiological characteristics of patients with a definite history of HI or PICH by reviewing long-term follow-up GRE. We retrospectively enrolled patients with HI or PICH, verified by clinical history and radiological findings, who had undergone follow-up GRE at least 3 months after the first imaging. The shape of the hemorrhagic lesion was classified as "cavitation" or "no cavitation." The shape of the hemosiderin rim was classified as total dark rim and partial dark rim. Hyperintense perilesional signal was determined when an obvious hyperintensity on T2-weighted image was present. Further, we compared the radiological characteristics between HI and PICH. In total, 69 patients (38 with HI and 31 with PICH) were enrolled, of whom 45 (65%) were men. The mean patient age was 65.5 ± 12.7 years. The mean time interval from the initial stroke onset to the follow-up image was 56.2 months. Hyperintense perilesional signal was observed in 38 patients; it was associated with HI (33/38 vs. 5/31, p < 0.001). Furthermore, partial dark rim was associated with HI (34/40 vs. 4/29, p < 0.001). Cavitation was more frequently observed in patients with HI than in those with PICH (36/60 vs. 2/9, p = 0.068). Presence of hyperintense perilesional signal and partially encasing dark hemosiderin rim suggest that chronic hemorrhagic foci are the sequelae of HI, not PICH.

Routine imaging of the preterm neonatal brain.

Routine brain imaging to detect injuries affecting preterm infants is used to predict long-term outcomes and identify complications that might necessitate an intervention. Although magnetic resonance imaging may be indicated in some specific cases, head ultrasound is the most widely used technique and, because of portability and ease of access, is the best modality for routine imaging. Routine head ultrasound examination is recommended for all infants born at or before 31+6 weeks gestation. For preterm neonates born between 32+0 to 36+6 weeks gestation, routine head ultrasound is recommended only in presence of risk factors for intracranial hemorrhage or ischemia. Brain imaging in the first 7 to 14 days postbirth is advised to detect most germinal matrix and intraventricular hemorrhages. Repeat imaging at 4 to 6 weeks of age is recommended to detect white matter injury.