# Intracranial hemorrhage identified after initiating therapeutic hypothermia: two case reports of neonatal hypoxic-ischemic encephalopathy due to hypovolemic shock with anemia: a case report

## TL;DR

Two newborns with hypoxic-ischemic encephalopathy developed undetected intracranial hemorrhage before therapeutic hypothermia, highlighting the need for more accurate imaging.

## Contribution

Highlights the risk of undetected intracranial hemorrhage in neonates undergoing therapeutic hypothermia for hypoxic-ischemic encephalopathy.

## Key findings

- Intracranial hemorrhage was not detected by cranial ultrasonography before therapeutic hypothermia initiation.
- Computed tomography or MRI later revealed subdural hematomas in both cases.
- One infant required discontinuation of hypothermia and surgical intervention due to persistent bleeding.

## Abstract

Therapeutic hypothermia for moderate-to-severe hypoxic-ischemic encephalopathy in neonates effectively improves neurological outcomes when initiated within 6 hours of birth. However, coagulopathy is a potential side effect of therapeutic hypothermia and requires careful monitoring for signs of hemorrhage. Uncontrolled hemorrhage is the primary exclusion criterion for therapeutic hypothermia. Herein, we report two cases of intracranial hemorrhage that, despite being massive enough to cause hypovolemic shock with anemia, could not be detected by cranial ultrasonography before the initiation of therapeutic hypothermia for hypoxic-ischemic encephalopathy.

One of the two Japanese newborn cases (one male and one female, 0 years old) was delivered by vacuum extraction and the other by forceps. Both infants presented with hypoxic-ischemic encephalopathy symptoms due to hypovolemic shock with anemia, without evidence of umbilical cord rupture or ultrasonographic evidence of ongoing bleeding such as intracranial or intraabdominal hemorrhage. Therapeutic hypothermia was initiated 5 hours after birth in both cases, alongside blood transfusion. One infant (male) presented with recurrent hypotension, while the other (female) developed hydrocephalus. Subsequent computed tomography or magnetic resonance imaging revealed a subdural hematoma. In one case (the male newborn), hypothermia was discontinued due to persistent bleeding, and a craniotomy was performed for hematoma evacuation.

These cases show that even in massive intracranial hemorrhage causing hypovolemic shock, subdural hematoma may be undetectable on bedside imaging such as cranial ultrasonography. Therefore, when therapeutic hypothermia is considered for neonates with hypoxic-ischemic encephalopathy secondary to hypovolemic shock with anemia, clinicians should be cautious and not rely solely on ultrasonography to rule out intracranial hemorrhage. Early and proactive computed tomography imaging should be performed to investigate the cause of neonatal hypoxic-ischemic encephalopathy due to hypovolemic shock with anemia.