Purpose or Case Report: Ultrasound is frequently utilized to screen for intracranial pathologies in neonates, including intracranial hemorrhage. There are several risk factors that predispose to neonatal intracranial hemorrhage including prematurity and bleeding diathesis (Tan 2018). Intracranial hemorrhage typically appears hyperechoic on ultrasound, although very rare cases of hypoechoic hemorrhage have been reported in patients receiving anticoagulation in the setting of ECMO (Bulas 1991, Svrckova 2020). Here we present a case of multifocal hypoechoic acute intracranial hemorrhages in a premature neonate with thrombocytopenia of unclear etiology. Though a connection between anticoagulation and echogenicity of hemorrhage has not been firmly established, this raises the question of how coagulation status can affect the ultrasound characteristics of hemorrhage.

Our patient is a premature female infant born at 35w1d via uncomplicated cesarean delivery to a 30-year-old G1P0 mother with routine prenatal care. Gestation was complicated by intrauterine growth restriction. Mother also had Covid-19 during the pregnancy and exposure to Zika virus without confirmed infection. After birth, APGAR scores were 8 and 8. A head ultrasound performed on the first day of life was unremarkable. Initial labs were notable for a platelet count of 13k requiring seven platelet transfusions. On day of life 12 the infant was found to have an increasing head circumference with full fontanelles. Follow up head ultrasound at this time revealed multifocal hypoechoic lesions in the brain parenchyma but no hyperechoic hemorrhage. On MRI obtained the same day those hypoechoic foci demonstrated heterogenous T1 isointensity and increased susceptibility consistent with intraparenchymal hemorrhage. Platelets at that time were 69k. Delayed head ultrasound 5 weeks later revealed significant cystic encephalomalacia with parenchymal volume loss and ventriculomegaly.
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