Objective:To investigate the clinical and cranial ultrasound (CUS) characteristics of moderate-to-severe (Grade Ⅲ–Ⅳ) neonatal intracranial hemorrhage (ICH), with the aim of providing a scientific basis for clinical diagnosis, treatment, and prognostic evaluation.Methods:We retrospectively collected clinical data from 64 neonates diagnosed with Grade Ⅲ or Ⅳ ICH by cranial ultrasound at Suzhou Municipal Hospital between January 2023 and August 2025. The data included perinatal baseline characteristics, CUS imaging features, and clinical outcomes. Based on outcomes at discharge, patients were divided into a good outcome group and a poor outcome group to analyze risk factors for adverse prognosis. The χ2 test was used to compare differences in clinical characteristics between the two groups, and multivariate binary logistic regression analysis was performed to identify independent factors associated with poor prognosis in neonates with ICH.Results:Among the 64 included neonates with moderate-to-severe ICH, 39 (60.9%) had a gestational age of ≤ 28 weeks, and 43 (67.2%) had a birth weight of ＜1500 g. At the initial CUS diagnosis, 43 cases (67.2%, 43/64) had Grade III ICH and 21 (32.8%, 21/64) had Grade IV ICH. During follow-up, 36 infants (56.3%, 36/64) developed progressive ventricular dilation (hydrocephalus), and 18 (28.1%, 18/64) developed periventricular leukomalacia (PVL). The poor outcome group comprised 40 cases (62.5%, 40/64), while the good outcome group comprised 24 cases (37.5%, 24/64). The rates of Grade Ⅳ hemorrhage and PVL were significantly higher in the poor outcome group than in the good outcome group (χ2=4.021 and 5.21, respectively; both P＜0.05). Multivariate logistic regression analysis, after adjustment for confounding factors, indicated that very low birth weight (VLBW) was an independent risk factor for poor prognosis (OR=4.37, 95%CI: 1.47-12.99, P＜0.05).Conclusion:Neonates with moderate-to-severe ICH have a poor prognosis with a high rate of adverse outcomes. Grade IV hemorrhage, PVL formation, and VLBW are closely associated with poor prognosis. Cranial ultrasound can accurately diagnose early intracranial hemorrhage and dynamically monitor disease evolution, providing imaging evidence to guide clinical treatment plans and improve patient outcomes.