This is an Emergency – See a Neonatologist Immediately
A 32-week preterm infant with bilateral periventricular flaring requires urgent neonatology evaluation and should not wait one week. This infant falls into the high-risk category requiring Level III neonatal intensive care unit (NICU) capabilities, and the imaging findings suggest potential white matter injury that demands immediate specialist assessment and serial monitoring.
Why This Cannot Wait
Gestational Age Alone Mandates Urgent Specialist Care
Infants born at <32 weeks' gestation should be cared for at a Level III facility with continuously available neonatologists, as they are at significantly increased risk for perinatal complications including intraventricular hemorrhage (IVH), periventricular leukomalacia (PVL), and progressive neurological deterioration 1.
Approximately 15-20% of infants weighing <1500g at birth develop IVH, and this infant's gestational age places them squarely in this high-risk category 1.
Periventricular Flaring Signals Active White Matter Injury
Bilateral periventricular flaring (echogenicity) represents active white matter injury that can evolve into cystic PVL or diffuse white matter damage, both of which are major precursors for cerebral palsy, cognitive impairment, and attention deficit disorders 2.
The critical window for intervention is NOW – periventricular white matter injury in preterm infants can progress rapidly, and early neonatology involvement allows for:
- Serial cranial ultrasound monitoring to detect progression
- Assessment for developing hydrocephalus
- Identification of concurrent IVH (which co-occurs in 43% of PVL cases) 2
- Neuroprotective strategies if clinically indicated
Clinical Deterioration Can Be Rapid or Silent
Many IVHs and white matter injuries are clinically silent, meaning the infant may appear stable while significant brain injury is occurring or progressing 1.
The "saltatory" pattern of deterioration can evolve over hours to days with decreased alertness, hypotonia, abnormal eye movements, and respiratory difficulties – waiting one week risks missing the window for early intervention 1.
Immediate Actions Required
Urgent Neonatology Consultation
- Transfer to or consultation with a Level III NICU is mandatory for infants <32 weeks with suspected brain injury, as these facilities have continuously available neonatologists, specialized nurses, respiratory therapists, and advanced imaging capabilities 1.
Serial Ultrasound Monitoring Protocol
Immediate baseline cranial ultrasound with specific measurements including anterior horn width (AHW) and Levene ventricular index must be obtained, with normal AHW being <3mm and concerning values being 3-5mm 3.
Serial ultrasounds should be performed at least weekly (or more frequently if abnormalities progress) to monitor for ventricular dilation, as AHW >6mm or ventricular index >97th percentile + 4mm indicates abnormal expansion requiring potential intervention 3.
Clinical Surveillance for Symptomatic Hydrocephalus
- Daily assessment for signs of increased intracranial pressure including progressive splaying of sagittal suture width, fontanel fullness, increasing head circumference, apnea, bradycardia, lethargy, or decreased activity in close coordination with the neonatology team 3.
The Cavum Septum Pellucidum Finding
This is a Normal Variant in Preterm Infants
The cavum septum pellucidum (CSP) is present in 100% of infants at 25-26 weeks' postconceptual age and in 61% of premature infants overall – this is a normal developmental structure that typically closes by 36-40 weeks' postconceptual age 4, 5, 6, 7.
At 32 weeks' gestation, the presence of CSP is expected and not concerning in itself – the highest incidence (52%) is found in infants of very low gestational age (≤33 weeks) within the first seven days of life 5.
However, Monitor for Pressure-Related Changes
While CSP is normal, increases in ventricular pressure from developing hydrocephalus can cause premature closure (approximation of the septal laminae), which may paradoxically make the CSP disappear earlier than expected 7.
The neonatologist needs to correlate CSP appearance with ventricular measurements to distinguish normal developmental closure from pressure-related changes 7.
Long-Term Implications Requiring Early Intervention
Periventricular Flaring Predicts Neurodevelopmental Risk
Bilateral periventricular flaring, even without cystic changes, significantly increases risk for motor impairment – infants with PVF show poor muscle power regulation in shoulders and trunk by 3 months' corrected age, which predicts impairment at 18 months 8.
Early identification allows for immediate referral to early intervention services and physical therapy, which can improve outcomes when started promptly 3, 9.
Term-Equivalent MRI is Essential
- Cranial ultrasound significantly underdetects cerebellar hemorrhage and diffuse white matter injury – the neonatologist will arrange for MRI with diffusion-weighted imaging at term-equivalent age for comprehensive prognostic assessment 3.
Common Pitfall to Avoid
Do not be falsely reassured by a clinically stable-appearing infant – the absence of obvious symptoms does not exclude significant ongoing brain injury or the risk of rapid deterioration. The combination of extreme prematurity (32 weeks) and bilateral periventricular flaring mandates immediate specialist evaluation regardless of current clinical appearance 1.