Background <p>Hyperechoic ependyma is a known ultrasound finding in preterm infants with intraventricular hemorrhage but its prognostic implications remain uncertain.</p> Objective <p>To evaluate whether hyperechoic ependyma identified on head ultrasound in preterm neonates is associated with intraventricular hemorrhage severity, post-hemorrhagic hydrocephalus of prematurity, multiloculated hydrocephalus, and other complications.</p> Materials and methods <p>This retrospective single-center study included 184 preterm neonates (&lt;37&#xa0;weeks’ gestation) who underwent early (≤10&#xa0;days) and/or late (&gt;10&#xa0;days) head ultrasound in the neonatal intensive care unit (NICU). Hyperechoic ependyma was identified by consensus between two radiologists. Logistic regression was used to assess associations with intraventricular hemorrhage grade, ventriculomegaly, shunt-dependent hydrocephalus, multiloculated hydrocephalus, and periventricular leukomalacia, including magnetic resonance imaging (MRI) correlation.</p> Results <p>Hyperechoic ependyma was observed in 14/184 neonates (7.6%), more often on late ultrasound. It was strongly associated with intraventricular hemorrhage, particularly high-grade intraventricular hemorrhage (<i>P</i>&lt;0.0001). While linked to higher rates of shunt dependency and periventricular leukomalacia, it was an independent predictor only for multiloculated hydrocephalus (OR≈11.3, <i>P</i>=0.021), after adjusting for intraventricular hemorrhage grade.</p> Conclusion <p>Hyperechoic ependyma is associated with high-grade intraventricular hemorrhage and is an independent risk factor for multiloculated hydrocephalus. This sonographic finding may reflect underlying ependymal inflammation or injury and could serve as an early imaging marker for complex hydrocephalus in preterm infants.</p> Graphical Abstract <p></p>