Paediatric Radiology · Neonatal neuroimaging · Papile 1978 and Volpe ultrasound grading

Papile and Volpe Grading of Germinal Matrix–Intraventricular Haemorrhage

Comparison of the historical Papile classification and the cranial ultrasound-based Volpe grading system for germinal matrix–intraventricular haemorrhage in preterm neonates.

Purpose

To grade germinal matrix–intraventricular haemorrhage by its location, intraventricular extent and associated ventricular distension, while separately identifying periventricular haemorrhagic infarction.

System	Grade	Imaging criteria	Key reporting point
Papile	Grade I	Subependymal germinal matrix haemorrhage without definite intraventricular extension.	Usually centred at the caudothalamic groove.
Papile	Grade II	Intraventricular haemorrhage without ventricular dilatation.	Blood is present within the ventricular system, but the ventricles are not distended.
Papile	Grade III	Intraventricular haemorrhage with ventricular dilatation.	Distinguish acute distension by clot from subsequent post-haemorrhagic ventricular dilatation.
Papile	Grade IV	Intraventricular haemorrhage with parenchymal haemorrhagic involvement.	Historical category; the parenchymal lesion is now generally regarded as periventricular haemorrhagic infarction rather than direct extension of IVH.
Volpe	Grade I	Germinal matrix haemorrhage with no or minimal IVH occupying less than 10% of the ventricular area on the parasagittal view.	Includes isolated germinal matrix haemorrhage and only minimal ventricular blood.
Volpe	Grade II	IVH occupying 10–50% of the ventricular area on the parasagittal view.	The ventricle is not substantially distended by haemorrhage.
Volpe	Grade III	IVH occupying more than 50% of the ventricular area on the parasagittal view, usually distending the lateral ventricle.	Represents extensive IVH; document associated ventricular dilatation.
Volpe	Separate lesion: PVHI	Periventricular haemorrhagic infarction is recorded separately by side, location and extent.	PVHI replaces the misleading concept of Papile grade IV as simple parenchymal extension of IVH.

How to use it

Papile grading was developed from CT appearances, whereas the Volpe system is adapted to cranial ultrasound and quantifies the proportion of the lateral ventricle occupied by blood.
Volpe grades I and II are separated at 10% ventricular involvement; grade III occupies more than 50% and usually distends the ventricle.
Grade each side separately when the haemorrhage is asymmetric and describe the distribution of intraventricular blood.
Report periventricular haemorrhagic infarction, ventricular dilatation and additional white-matter injury separately rather than relying on the grade alone.

Common mistake

Do not describe the parenchymal lesion historically labelled Papile grade IV as direct extension of intraventricular blood. It usually represents venous infarction caused by obstruction of medullary venous drainage and should be reported as periventricular haemorrhagic infarction.

Exam pearl

Volpe grading: less than 10% is grade I, 10–50% is grade II and more than 50% with usual ventricular distension is grade III; periventricular haemorrhagic infarction is recorded separately.

Viva questions

What does the Papile classification grade?: It grades germinal matrix–intraventricular haemorrhage according to subependymal haemorrhage, ventricular involvement, ventricular dilatation and historical parenchymal involvement.
Enumerate the four Papile grades.: Grade I is subependymal germinal matrix haemorrhage; grade II is IVH without ventricular dilatation; grade III is IVH with ventricular dilatation; and grade IV historically denotes IVH with parenchymal haemorrhagic involvement.
How does Volpe grade germinal matrix–intraventricular haemorrhage?: Grade I has no or minimal IVH occupying less than 10% of the ventricular area, grade II occupies 10–50%, and grade III occupies more than 50% and usually distends the lateral ventricle.
What is the principal difference between Papile grade II and grade III?: Papile grade II is IVH without ventricular dilatation, whereas grade III is IVH associated with ventricular dilatation.
Why is the term Papile grade IV potentially misleading?: The parenchymal lesion is not usually caused by direct extension of intraventricular blood. It generally represents periventricular haemorrhagic venous infarction caused by impaired medullary venous drainage.
How should periventricular haemorrhagic infarction be reported?: Report it separately from the IVH grade and describe its side, anatomical location, extent and whether it is unilateral or bilateral.