Periventricular Leukomalacia (PVL) and Birth Injury

“Periventricular” means “around the ventricles,” “leuko” means “white,” and “malacia” means “softening.” Therefore, periventricular leukomalacia (PVL) is a term that refers to damage (or softening) of the brain’s white matter around the ventricles, which are areas of the brain that are filled with cerebrospinal fluid (1). PVL is caused by oxygen deprivation around the time of birth (birth asphyxia). Other risk factors include brain bleeds and infections transmitted from mother to baby during birth (1, 2).

Like many birth injuries, PVL is more common in premature babies, because they are underdeveloped, fragile, and more susceptible to damage (1). However, PVL also can occur in  full-term infants. Especially when improperly managed, PVL can lead to permanent motor disorders such as cerebral palsy (CP). It may also cause intellectual and developmental disabilities (I/DDs), seizure disorders, vision and hearing deficits, and other complications (3, 4).


Periventricular Leukomalacia


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How do you pronounce periventricular leukomalacia?

Risk factors for periventricular leukomalacia (PVL)

The more premature a baby is, the more susceptible they are to developing PVL. Infants with the highest risk of PVL are those under 32 weeks gestational age (2). (PVL, however, can occur at any gestational age, including at term).

Besides prematurity, the following circumstances increase the likelihood that a baby will develop PVL:

Causes of periventricular leukomalacia (PVL)

hypoxic ischemic encephalopathy; HIE; birth asphyxia; neonatal encephalopathy; periventricular leukomalacia; PVL; white matter damage

Hypoxia Ischemia Due to Periventricular Leukomalacia (PVL)

PVL is typically caused by a lack of oxygenated blood flow to the brain around the time of birth, or an infection that is transmitted from mother to baby (6).

To learn more about pregnancy and birth-related complications that can restrict the flow of oxygenated blood to a baby’s brain, please see our page on causes of hypoxic-ischemic encephalopathy (HIE). Note that HIE is a broad term for brain damage caused by inadequate flow of oxygenated blood.

It is important to stress that oxygen deprivation and infection transmission are often preventable factors. If a physician or medical team’s negligence causes one of these issues, and the baby develops PVL, this constitutes medical malpractice. Families may be eligible for compensation through a birth injury lawsuit.

Signs and symptoms of periventricular leukomalacia (PVL)

Newborns with PVL do not always manifest obvious signs of this condition, but the following issues may emerge over time:

  • Motor control issues and tight/spastic muscles, especially in the legs (2)
  • Neonatal seizures
  • Intraventricular hemorrhages
  • Respiratory distress syndrome (RDS) (5)
  • Abnormalities in attention or behavior (6)

Often, signs and symptoms are not noticeable until the child begins to exhibit developmental delays. As the child ages and falls behind peers, the extent of problems caused by PVL becomes more apparent. However, as an infant, problems sucking or unusual stiffness should cause concern regarding PVL.

Diagnosing periventricular leukomalacia (PVL)

In diagnosing PVL, medical professionals should take a complete medical history and conduct a physical examination. Additionally, they may use the following tests:

  • Cranial ultrasound: This allows them to view the baby’s brain through the fontanelles, or soft spots between skull bones. Babies with PVL may show signs of cysts in the brain tissue.
  • Magnetic resonance imaging (MRI): This can show a detailed image of internal structures. It may reveal some of the early abnormalities in babies with PVL (1).

Prevention and treatment of periventricular leukomalacia (PVL)

Delaying premature birth, or preventing decreased oxygenation during an inevitable premature birth, is the most important step in decreasing the risk of PVL. Additionally, strategies that emphasize the maintenance of adequate blood supply and flow in the brain should be utilized to help prevent PVL.

While no specific cure exists for PVL, therapeutic hypothermia (brain/body cooling) has proven very effective in treating infants with hypoxic-ischemic encephalopathy at or near term. Hypothermia treatment works by cooling the brain and decreasing the amount of cellular death. When administered very shortly after birth (most guidelines say within six hours), the treatment can prevent or reduce the severity of neurological injury associated with HIE, such as PVL.

Another neuroprotective agent shows promise. Some research has found that when a mother is given the steroid betamethasone during pregnancy, it can reduce the risk of PVL in the baby (7). Further research is needed in this area. Magnesium sulfate can also confer neuroprotective effects on babies likely to be born prematurely and may prevent PVL (8).

Babies with PVL should be monitored for the development of disorders such as cerebral palsy, intellectual impairment, visual problems, and epilepsy.

Outlooks for babies with periventricular leukomalacia (PVL)

Once children with PVL are older, they are likely to miss certain developmental milestones due to motor problems and intellectual disabilities.  Visual-motor dysfunction is common and many children with PVL are diagnosed with spastic cerebral palsy.

Periventricular leukomalacia (PVL) and medical malpractice

Areas of negligence that may lead to PVL include the following:

  • Failure to properly monitor the baby and recognize fetal distress
  • Failure to diagnose and treat disorders that can lead to premature birth
  • Failure to prevent issues that can cause hypoxic-ischemic injury
  • Improper use of forceps or vacuum extractors
  • Failure to obtain adequate informed consent, which includes advising the mother of the risks and alternatives of delivery methods, medication usage, etc.
  • Failure to properly deliver the baby and follow standards of care when performing a C-section or vaginal delivery
  • Over-ventilation of the newborn, causing hypocarbia
  • Failure to timely and appropriately resuscitate.  

When underlying conditions are not properly diagnosed and treated, it is negligence.  When conditions like hypoxic-ischemic encephalopathy and PVL result from this negligence, it constitutes medical malpractice.


Birth injury attorneys helping children with periventricular leukomalacia (PVL)
Reiter & Walsh, PC | Birth Trauma Attorneys

At ABC Law Centers, our award-winning lawyers represent victims of birth injury every day. We are dedicated to helping clients obtain compensation for medical expenses and care to secure the future of their children. If your loved one was diagnosed with periventricular leukomalacia (PVL), we encourage you to reach out today for a free consultation. In fact, you would pay nothing throughout the entire legal process unless we win your case.

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Video: our periventricular leukomalacia (PVL) attorneys discuss HIE and birth injury


Sources

  1. Children’s Hospital. (2014, August 24). Periventricular Leukomalacia (PVL). Retrieved February 12, 2019, from https://www.chop.edu/conditions-diseases/periventricular-leukomalacia-pvl
  2. Periventricular leukomalacia: MedlinePlus Medical Encyclopedia. (n.d.). Retrieved February 12, 2019, from https://medlineplus.gov/ency/article/007232.htm
  3. Periventricular Leukomalacia Information Page. (n.d.). Retrieved February 12, 2019, from https://www.ninds.nih.gov/Disorders/All-Disorders/Periventricular-Leukomalacia-Information-Page
  4. Ekici, B., Aydınlı, N., Aydın, K., Çalışkan, M., Eraslan, E., & Özmen, M. (2013). Epilepsy in children with periventricular leukomalacia. Clinical neurology and neurosurgery, 115(10), 2046-2048.
  5. Hatzidaki, E., Giahnakis, E., Maraka, S., Korakaki, E., Manoura, A., Saitakis, E., … & Giannakopoulou, C. (2009). Risk factors for periventricular leukomalacia. Acta obstetricia et gynecologica Scandinavica, 88(1), 110-115.
  6. Pathology of Periventricular Leukomalacia. (2019, February 01). Retrieved February 12, 2019, from https://emedicine.medscape.com/article/1961885-overview
  7. Ahya, K. P., & Suryawanshi, P. (2018). Neonatal periventricular leukomalacia: current perspectives. Research and Reports in Neonatology, 8, 1-8.
  8. Magnesium Sulfate to Prevent Brain Injury in Premature Infants – Full Text View. (n.d.). Retrieved February 12, 2019, from https://clinicaltrials.gov/ct2/show/NCT00065949