Subcortical leukomalacia

Case:

The male patient was born at 32 weeks gestation, with Apgar scores 1 and 3. After initial stabilization the child was transferred to the NICU and after 3 weeks eventually discharged from the perinatal center. During the outpatient follow-up the patient presented with the complaints including poor feeding and weak suck.The infant was referred to a pediatric neurologist.  A cranial ultrasound was ordered to assess for brain injury.

Here are the main loops from this patient’s brain US exam:

Prevalence and Etiology:

Leukomalacia is the most common form of white matter injury in preterm infants, with a prevalence inversely related to gestational age. In infants born before 32 weeks, the incidence of significant white matter injury can range from 4% to 15%, though mild "flares" are much more frequent. The etiology is primarily rooted in the vulnerability of "pre-oligodendrocytes"—the cells responsible for building myelin—which are highly sensitive to hypoxia-ischemia and inflammation. In your case, the infant’s low Apgar scores (1 and 3) suggest a significant perinatal hypoxic event that likely triggered this "watershed" injury in the deep white matter.

Prognosis:

The prognosis of subcortical leukomalacia depends heavily on the extent of the lesions and whether they evolve into cysts. When the injury extends into the subcortical white matter (SCL), there is a high risk of long-term neurodevelopmental deficits. Patients commonly present with "spastic diplegia" (stiffness in the legs) because the motor tracks for the lower extremities run closest to the ventricles. Beyond motor issues, infants are at risk for "cerebral visual impairment" (CVI) and cognitive delays. Early intervention with physical and occupational therapy is crucial, as the brain’s plasticity in the first year can help optimize functional outcomes despite the permanent structural loss.

Learn more in our previous blog posts on sonoanatomy with a focus on midline structures and subependymal pseudocysts.