Skip to main content

Thank you for visiting You are using a browser version with limited support for CSS. To obtain the best experience, we recommend you use a more up to date browser (or turn off compatibility mode in Internet Explorer). In the meantime, to ensure continued support, we are displaying the site without styles and JavaScript.

Degree of ventriculomegaly predicts school-aged functional outcomes in preterm infants with intraventricular hemorrhage



Greater ventriculomegaly in preterm infants with intraventricular hemorrhage (IVH) has been associated with worse neurodevelopmental outcomes in infancy. We aim to explore the relationship between ventriculomegaly and school-age functional outcome.


Retrospective review of preterm infants with Grade III/IV IVH from 2006 to 2020. Frontal–occipital horn ratio (FOHR) was measured on imaging throughout hospitalization and last available follow-up scan. Pediatric Cerebral Performance Category (PCPC) scale was used to assess functional outcome at ≥4 years. Ordinal logistic regression was used to determine the relationship between functional outcome and FOHR at the time of Neurosurgery consult, neurosurgical intervention, and last follow-up scan while adjusting for confounders.


One hundred and thirty-four infants had Grade III/IV IVH. FOHR at consult was 0.62 ± 0.12 and 0.75 ± 0.13 at first intervention (p < 0.001). On univariable analysis, maximum FOHR, FOHR at the last follow-up scan, and at Neurosurgery consult predicted worse functional outcome (p < 0.01). PVL, longer hospital admission, and gastrotomy/tracheostomy tube also predicted worse outcome (p < 0.05). PVL, maximum FOHR, and FOHR at consult remained significant on multivariable analysis (p < 0.05). Maximum FOHR of 0.61 is a fair predictor for moderate–severe impairment (AUC 75%, 95% CI: 62–87%).


Greater ventricular dilatation and PVL were independently associated with worse functional outcome in Grade III/IV IVH regardless of neurosurgical intervention.


  • Ventriculomegaly measured by frontal–occipital horn ratio (FOHR) and periventricular leukomalacia are independent correlates of school-age functional outcomes in preterm infants with intraventricular hemorrhage regardless of need for neurosurgical intervention.

  • These findings extend the known association between ventriculomegaly and neurodevelopmental outcomes in infancy to functional outcomes at school age.

  • FOHR is a fair predictor of school-age functional outcome, but there are likely other factors that influence functional status, which highlights the need for prospective studies to incorporate other clinical and demographic variables in predictive models.

This is a preview of subscription content

Access options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.

Fig. 1: Study population.
Fig. 2: Percentage of stacked bar plots of functional outcome scores.


  1. 1.

    Cizmeci, M. N. et al. Assessment of brain injury and brain volumes after posthemorrhagic ventricular dilatation: a nested substudy of the randomized controlled Elvis Trial. J. Pediatr. 208, 191.e2–197.e2 (2019).

    Article  Google Scholar 

  2. 2.

    Vassilyadi, M., Tataryn, Z., Shamji, M. F. & Ventureyra, E. C. Functional outcomes among premature infants with intraventricular hemorrhage. Pediatr. Neurosurg. 45, 247–255 (2009).

    Article  Google Scholar 

  3. 3.

    Dorner, R. A. et al. Early neurodevelopmental outcome in preterm posthemorrhagic ventricular dilatation and hydrocephalus: Neonatal ICU Network Neurobehavioral Scale and imaging predict 3-6-month motor quotients and Capute Scales. J. Neurosurg. Pediatr. (2019).

  4. 4.

    Srinivasakumar, P. et al. Posthemorrhagic ventricular dilatation-impact on early neurodevelopmental outcome. Am. J. Perinatol. 30, 207–214 (2013).

    Google Scholar 

  5. 5.

    de Vries, L. S. et al. Treatment thresholds for intervention in posthaemorrhagic ventricular dilation: a randomised controlled trial. Arch. Dis. Child. Fetal Neonatal Ed. 104, F70–F75 (2019).

    Article  Google Scholar 

  6. 6.

    Cizmeci, M. N. et al. Randomized controlled Early versus Late Ventricular Intervention Study in posthemorrhagic ventricular dilatation: outcome at 2 years. J. Pediatr. 226, P28.E3–P35.E3 (2020).

    Article  Google Scholar 

  7. 7.

    Lai, G. Y. et al. Timing of temporizing neurosurgical treatment in relation to shunting and neurodevelopmental outcomes in post-hemorrhagic ventricular dilatation of prematurity: a meta-analysis. J. Pediatr. (2021).

  8. 8.

    Radhakrishnan, R. et al. Frontal occipital and frontal temporal horn ratios: comparison and validation of head ultrasound-derived indexes with MRI and ventricular volumes in infantile ventriculomegaly. AJR Am. J. Roentgenol. 213, 925–931 (2019).

    Article  Google Scholar 

  9. 9.

    Wellons, J. C. 3rd et al. Shunting outcomes in posthemorrhagic hydrocephalus: results of a hydrocephalus clinical research network prospective cohort study. J. Neurosurg. Pediatr. 20, 19–29 (2017).

    Article  Google Scholar 

  10. 10.

    Papile, L. A., Burstein, J., Burstein, R. & Koffler, H. Incidence and evolution of subependymal and intraventricular hemorrhage: a study of infants with birth weights less than 1,500 gm. J. Pediatr. 92, 529–534 (1978).

    CAS  Article  Google Scholar 

  11. 11.

    Fiser, D. H. Assessing the outcome of pediatric intensive care. J. Pediatr. 121, 68–74 (1992).

    CAS  Article  Google Scholar 

  12. 12.

    Pollack, M. M. et al. Relationship between the functional status scale and the pediatric overall performance category and pediatric cerebral performance category scales. JAMA Pediatr. 168, 671–676 (2014).

    Article  Google Scholar 

  13. 13.

    Leijser, L. M. et al. Posthemorrhagic ventricular dilatation in preterm infants: when best to intervene? Neurology 90, e698–e706 (2018).

    Article  Google Scholar 

  14. 14.

    van Zanten, S. A., de Haan, T. R., Ursum, J. & van Sonderen, L. Neurodevelopmental outcome of post-hemorrhagic ventricular dilatation at 12 and 24 months corrected age with high-threshold therapy. Eur. J. Paediatr. Neurol. 15, 487–492 (2011).

    Article  Google Scholar 

  15. 15.

    de Vries, L. S. et al. Early versus late treatment of posthaemorrhagic ventricular dilatation: results of a retrospective study from five neonatal intensive care units in the Netherlands. Acta Paediatr. 91, 212–217 (2002).

    Article  Google Scholar 

  16. 16.

    Bassan, H. et al. Timing of external ventricular drainage and neurodevelopmental outcome in preterm infants with posthemorrhagic hydrocephalus. Eur. J. Paediatr. Neurol. 16, 662–670 (2012).

    Article  Google Scholar 

  17. 17.

    Lo, M., Kishimoto, J., Eagleson, R., Bhattacharya, S. & de Ribaupierre, S. Does ventricular volume affect the neurodevelopmental outcome in infants with intraventricular hemorrhage? Childs Nerv. Syst. 36, 569–575 (2020).

    Article  Google Scholar 

  18. 18.

    Cizmeci, M. N. et al. Periventricular hemorrhagic infarction in very preterm infants: characteristic sonographic findings and association with neurodevelopmental outcome at age 2 years. J. Pediatr. 217, 79–85 (2020). e71.

    Article  Google Scholar 

  19. 19.

    Obeid, R. et al. The utility of the fronto-temporal horn ratio on cranial ultrasound in premature newborns: a ventriculomegaly marker. Pediatr. Res. (2021).

  20. 20.

    Jary, S., Kmita, G., Wroblewska, J. & Whitelaw, A. Quantitative cranial ultrasound prediction of severity of disability in premature infants with post-haemorrhagic ventricular dilatation. Arch. Dis. Child. 97, 955–959 (2012).

    Article  Google Scholar 

  21. 21.

    Shankaran, S. et al. Outcomes following post-hemorrhagic ventricular dilatation among infants of extremely low gestational age. J. Pediatr. (2020).

  22. 22.

    Norooz, F. et al. Decompressing posthaemorrhagic ventricular dilatation significantly improves regional cerebral oxygen saturation in preterm infants. Acta Paediatr. 104, 663–669 (2015).

    CAS  Article  Google Scholar 

  23. 23.

    Vesoulis, Z. A., Whitehead, H. V., Liao, S. M. & Mathur, A. M. The hidden consequence of intraventricular hemorrhage: persistent cerebral desaturation after IVH in preterm infants. Pediatr. Res. 89, 869–877 (2021).

  24. 24.

    Klebermass-Schrehof, K. et al. Can neurophysiological assessment improve timing of intervention in posthaemorrhagic ventricular dilatation? Arch. Dis. Child. Fetal Neonatal Ed. 98, F291–F297 (2013).

    Article  Google Scholar 

  25. 25.

    Jary, S., De Carli, A., Ramenghi, L. A. & Whitelaw, A. Impaired brain growth and neurodevelopment in preterm infants with posthaemorrhagic ventricular dilatation. Acta Paediatr. 101, 743–748 (2012).

    Article  Google Scholar 

  26. 26.

    McClugage, S. G. et al. Functional outcomes at 2 years of age following treatment for posthemorrhagic hydrocephalus of prematurity: what do we know at the time of consult? J. Neurosurg. Pediatr. (2020).

  27. 27.

    Dorner, R. A. et al. The relationship between clinical imaging and neurobehavioral assessment in posthemorrhagic ventricular dilation of prematurity. Front. Physiol. 10, 64 (2019).

    Article  Google Scholar 

  28. 28.

    Brouwer, A. et al. Neurodevelopmental outcome of preterm infants with severe intraventricular hemorrhage and therapy for post-hemorrhagic ventricular dilatation. J. Pediatr. 152, 648–654 (2008).

    Article  Google Scholar 

  29. 29.

    Fiser, D. H. et al. Relationship of pediatric overall performance category and pediatric cerebral performance category scores at pediatric intensive care unit discharge with outcome measures collected at hospital discharge and 1- and 6-month follow-up assessments. Crit. Care Med. 28, 2616–2620 (2000).

    CAS  Article  Google Scholar 

  30. 30.

    Abecassis, I. J. et al. Toward a comprehensive assessment of functional outcomes in pediatric patients with brain arteriovenous malformations: the pediatric quality of life inventory. J. Neurosurg. Pediatr. 18, 611–622 (2016).

    Article  Google Scholar 

  31. 31.

    Rohlwink, U. K. et al. Imaging features of the brain, cerebral vessels and spine in pediatric tuberculous meningitis with associated hydrocephalus. Pediatr. Infect. Dis. J. 35, e301–e310 (2016).

    Article  Google Scholar 

  32. 32.

    Lichenstein, R. et al. Presentations and outcomes of children with intraventricular hemorrhages after blunt head trauma. Arch. Pediatr. Adolesc. Med. 166, 725–731 (2012).

    Article  Google Scholar 

  33. 33.

    Raymond, T. T. et al. Outcomes among neonates, infants, and children after extracorporeal cardiopulmonary resuscitation for refractory inhospital pediatric cardiac arrest: a report from the National Registry of Cardiopulmonary Resuscitation. Pediatr. Crit. Care Med. 11, 362–371 (2010).

    PubMed  Google Scholar 

  34. 34.

    Whittemore, B. A., Swift, D. M., Thomas J. M. & L. F. Chalak, L. F. A neonatal neuroNICU collaborative approach to neuromonitoring of posthemorrhagic ventricular dilation in preterm infants. Pediatr. Res. (2021).

  35. 35.

    Cizmeci, M. N. & de Vries, L. S. Fronto-temporal horn ratio: yet another marker of ventriculomegaly? Pediatr. Res. 10.1038/s41390-021-01379-9 (2021).

  36. 36.

    Brouwer, M. J. et al. New reference values for the neonatal cerebral ventricles. Radiology 262, 224–233 (2012).

    Article  Google Scholar 

  37. 37.

    Beijst, C. et al. Two-dimensional ultrasound measurements vs. magnetic resonance imaging-derived ventricular volume of preterm infants with germinal matrix intraventricular haemorrhage. Pediatr. Radiol. 50, 234–241 (2020).

    Article  Google Scholar 

  38. 38.

    Leijser, L. M. et al. Post-hemorrhagic ventricular dilatation: inter-observer reliability of ventricular size measurements in extremely preterm infants. Pediatr. Res. (2020).

  39. 39.

    Benavente-Fernandez, I., Siddiqi, A. & Miller, S. P. Socioeconomic status and brain injury in children born preterm: modifying neurodevelopmental outcome. Pediatr. Res. 87, 391–398 (2020).

    Article  Google Scholar 

  40. 40.

    Wang, L. W. et al. Isolated cystic periventricular leukomalacia differs from cystic periventricular leukomalacia with intraventricular hemorrhage in prevalence, risk factors and outcomes in preterm infants. Neonatology 111, 86–92 (2017).

    Article  Google Scholar 

Download references

Author information




G.Y.L. contributed to the concept and design, acquisition of data, analysis and interpretation of the data, and drafting the article. S.A. contributed to the acquisition of data. M.L.V.D. and S.K.L. were involved in the concept and design of the study. M.L.V.D., S.K.L., R.-A.O.D.R., and D.G.-S. contributed to the interpretation of the data. All authors contributed to critically revising the article for important intellectual content and approved the final version of the article.

Corresponding author

Correspondence to Grace Y. Lai.

Ethics declarations

Competing interests

The authors declare no competing interests.


No consent was required for retrospective review of the anonymized data.

Additional information

Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Lai, G.Y., Abdelmageed, S., DeRegnier, RA.O. et al. Degree of ventriculomegaly predicts school-aged functional outcomes in preterm infants with intraventricular hemorrhage. Pediatr Res (2021).

Download citation


Quick links