Ultrasound of the Neonatal Head and Spine | GE Healthcare

Summary

This webinar, facilitated by Claire and presented by neonatologist Cheryl Rogerson, delves into neonatal head and spine ultrasound. Covering anatomy, scanning techniques, and pathology, it provides insights into optimal imaging, ventricular measurements, and conditions like interventricular hemorrhage and periventricular leukomalacia. The discussion also touches on the significance of the cerebellum, the importance of acoustic windows, and the implications of various findings for long-term outcomes in neonatal care.

Takeaways

• 🌟 The webinar, facilitated by Claire, focuses on neonatal head and spine ultrasound, featuring Cheryl Rogerson, a consultant neonatologist with extensive experience in the field.
• 🔍 Cheryl Rogerson has a passion for ultrasound and has contributed to its use and education globally, particularly in Malawi, and has published research on neonatal brain and spine conditions.
• 📚 The anatomy and windows for cranial ultrasound scanning are crucial for optimal imaging of the neonatal brain, including the anterior fontanelle and other sutures, as well as the foramen magnum for brainstem views.
• 👶 The routine scanning of neonates is recommended at specific time intervals post-birth, varying based on the infant's gestational age and clinical indications such as hemorrhage or leukomalacia.
• 📉 Ventricular measurements are vital for assessing the health of neonatal brains, with specific guidelines for measuring the anterior horn width, the third ventricle, and the fourth ventricle.
• 🩺 The presentation highlighted the importance of differentiating between various grades of interventricular hemorrhage and their implications for long-term outcomes in neonates.
• 🧊 The webinar discussed the significance of identifying and monitoring conditions like periventricular leukomalacia, which can be associated with cerebral palsy and developmental delays.
• 🌐 The use of pulse-doppler in ultrasound is instrumental in assessing blood flow, which can indicate conditions like raised intracranial pressure or intrauterine asphyxia.
• 🔊 The mastoid fontanel view is emphasized as essential for examining the posterior fossa and identifying cerebellar hemorrhages that may be missed with other views.
• 🤔 The script raises awareness about conditions that may not be pathological, such as lenticular straight artery echogenicity, which is commonly seen in preterm infants and not associated with adverse outcomes.
• 🔍 Spinal ultrasounds are a key aspect of neonatal care, particularly for infants with sacral dimples, and the webinar provides insights into when and how to perform these scans effectively.

Q & A

What is the main focus of the webinar presented by Cheryl Rogerson?

The webinar focuses on ultrasound scanning of the head and spine in neonates, covering topics such as anatomy, pathology, and the use of ultrasound in clinical settings.

How long is the webinar scheduled to run?

The webinar is scheduled to run for approximately 60 minutes.

What is Cheryl Rogerson's professional background in relation to the webinar topic?

Cheryl Rogerson is a consultant neonatologist with over 20 years of experience in ultrasound scanning of neonates, including work in Malawi and involvement with the neonatal SIPUC.

What are the standard scanning planes used in neonatal ultrasound?

The standard scanning planes include five coronal, five sagittal, a mastoid fontanel view, and additional optional images such as those of the cerebellum.

What is the significance of measuring the cerebellar diameter in relation to gestation?

The cerebellar diameter is measured to help determine the gestational age of an infant when it is uncertain, as there are published guidelines relating cerebellar diameter to gestation.

How is the long-term outcome for neonates being assessed using ultrasound?

Long-term outcomes are being assessed through serial ultrasounds that individualize a person's prognosis, moving away from percentages to more personalized predictions.

What is the importance of the mastoid fontanel view in neonatal ultrasound?

The mastoid fontanel view is crucial for examining the posterior fossa, as it is the only way to adequately visualize structures like the cerebellum and the fourth ventricle.

What is the role of pulse Doppler in neonatal ultrasound scans?

Pulse Doppler is used to assess blood flow in the cerebral arteries, which can indicate conditions such as raised intracranial pressure or intrauterine asphyxia.

How is the corpus callosum related to the agenesis of the corpus callosum condition?

In agenesis of the corpus callosum, the fibers that normally cross from left to right in the corpus callosum instead turn upward and form bundles of procce, leading to a high-riding third ventricle and a typical 'staghorn' appearance on imaging.

What are the implications of finding a sacral dimple in neonatal spinal ultrasound?

A sacral dimple may indicate an underlying spinal problem, but only if it is greater than 2.5 centimeters away from the anus, has associated hair or skin pigmentation, or is raised and cystic. Otherwise, it is considered a simple dimple and not associated with underlying spinal dysraphism.

How can the presence of a small anterior fontanelle in a neonate be assessed with ultrasound?

If a small anterior fontanelle is associated with concerns about suture fusion or overlapping, an ultrasound can be performed to examine the sutures and determine if they are open or closed, and to assess the head shape and size.

Outlines

00:00

🎓 Introduction to Neonatal Head and Spine Ultrasound Webinar

The script begins with an introduction to a webinar on neonatal head and spine ultrasound, facilitated by Claire. The session is to be recorded for later viewing and will last approximately 60 minutes. Participants are informed about the muting of the conference line and the process for submitting questions. Cheryl Rogerson, a consultant neonatologist with extensive experience in ultrasound scanning of neonates, is introduced as the main speaker. Her background includes work in Malawi and contributions to medical education and research. The webinar will cover various topics including anatomy, ultrasound scanning techniques, and pathology identification in neonatal patients.

05:00

🧠 Anatomy and Ultrasound Windows for Neonatal Brain Imaging

This paragraph delves into the importance of understanding the anatomy and acoustic windows for optimal neonatal brain ultrasound imaging. It discusses the significance of the non-fused cranial sutures and fontanelles in creating an ultrasound window. The speaker explains the anatomical landmarks, including the frontal, central, and postcentral gyri, as well as the parietal, occipital, and cerebellar regions. The paragraph also addresses the routine scanning protocols for neonates, including the timing and planes used for scanning, and the importance of identifying pathology in the anterior frontal and posterior regions of the brain.

10:02

📐 Techniques and Measurements in Neonatal Ultrasound

The paragraph focuses on the techniques used in neonatal ultrasound, including the measurement of the cerebellar diameter to estimate gestational age and the use of Doppler to assess blood flow in the arteries. It details the standard planes for cranial ultrasound scanning and the significance of serial ultrasounds for determining long-term outcomes. The speaker also describes the coronal and sagittal scan techniques, providing insights into the structures visualized at different levels of the scan, such as the lateral ventricles, corpus callosum, and the temporal and cerebellar regions.

15:03

🔍 Advanced Ultrasound Techniques for Neonatal Brain Assessment

This section discusses advanced ultrasound techniques for assessing the neonatal brain, including the use of parasagittal views to examine the lateral ventricles and white matter. It highlights the importance of Doppler waveform analysis for detecting conditions like raised intracranial pressure and the use of pulse Doppler to visualize blood flow in arteries. The paragraph also covers the identification of abnormalities such as hemorrhages, edema, and hydrocephalus, and the impact of external factors like patent ductus arteriosus on blood flow.

20:04

🦴 Posterior Fossa and Ventricular Measurements in Neonatal Ultrasound

The paragraph discusses the importance of the mastoid fontanel view in examining the posterior fossa and the challenges of measuring the cerebellar diameter in relation to gestational age. It provides a detailed explanation of ventricular measurements, including the anterior horn width, the occipital horn, and the third and fourth ventricles. The speaker emphasizes the use of these measurements in assessing conditions like hydrocephalus and the normal values for these measurements in neonatal patients.

25:05

👶 Gestational Assessment and Hemorrhage Identification in Neonates

This section focuses on the assessment of gestational age through ultrasound, particularly the evaluation of goal development and the identification of interventricular hemorrhage using the Graf classification system. The speaker discusses the reliability of ultrasound in detecting hemorrhages and the importance of classifying them accurately. The paragraph also covers the use of ultrasound to monitor changes in hemorrhage grade and the significance of post-hemorrhagic hydrocephalus.

30:06

🩺 Diagnosis and Monitoring of Periventricular Leukomalacia

The paragraph discusses the diagnosis and monitoring of periventricular leukomalacia (PVL), a serious condition associated with a high risk of cerebral palsy and developmental delay. It describes the use of ultrasound to identify cystic changes in the brain's parenchyma and the importance of timing in detecting these cysts. The speaker also differentiates between significant and insignificant cysts based on their location and long-term implications.

35:07

🧊 Understanding and Differentiating Extra-Axial Bleeds in Neonates

This section addresses the challenges of identifying extra-axial bleeds, such as epidural, subdural, and subarachnoid hemorrhages, using ultrasound. The speaker emphasizes the importance of careful investigation and the use of MRI for confirmation. The paragraph also discusses the incidence of these bleeds in relation to birth trauma and the signs to look for in ultrasound, such as midline shift and increased epidural thickness.

40:09

🌟 Identification of Aqueductal Stenosis and Other Neonatal Abnormalities

The paragraph discusses the identification of aqueductal stenosis and other abnormalities like venous malformations and agenesis of the corpus callosum in neonatal ultrasound. It highlights the importance of using color flow Doppler to differentiate between cystic structures and pathological conditions. The speaker also addresses the significance of echogenic findings and the need for further investigation to rule out serious conditions.

45:11

👶🏻 Clinical Indications for Neonatal Ultrasound and Suture Assessment

This section covers the clinical indications for neonatal ultrasound, particularly in cases of small anterior fontanelles and concerns about suture fusion. The speaker discusses the importance of assessing sutures for signs of compression or molding and the potential association with craniosynostosis. The paragraph also touches on the value of ultrasound in identifying cases where further investigation may be necessary.

50:11

📚 Conclusion and Q&A Session of the Neonatal Ultrasound Webinar

The final paragraph wraps up the webinar with a Q&A session. The speaker addresses questions about the recording of the webinar, the distribution of the recording, and specific clinical inquiries related to neonatal ultrasound. The facilitator thanks the participants for joining and the speaker for her presentation, emphasizing the value of the information shared and the opportunity for further learning.

Keywords

💡Ultrasound

Ultrasound refers to a medical imaging technique that uses high-frequency sound waves to create images of structures within the body. In the context of this video, ultrasound is the primary tool for examining the head and spine of neonates, providing insights into their anatomical and physiological conditions. The script discusses the use of ultrasound for neonatal brain and spine imaging, highlighting its importance in detecting various conditions such as hemorrhages and developmental abnormalities.

💡Neonatal

Neonatal pertains to the period shortly after birth, typically up to the first 28 days of a newborn's life. The video's theme revolves around neonatal care, specifically the use of ultrasound to assess the health of newborns' heads and spines. The script mentions the unique considerations for neonatal ultrasound scanning, such as the non-fused cranial sutures and the developmental stages of the brain.

💡Cranial Ultrasound

Cranial ultrasound is a type of imaging specifically used to examine the skull and brain of infants. The script describes the procedure and significance of cranial ultrasound in identifying issues like interventricular hemorrhage and periventricular leukomalacia in neonates, which are critical for timely medical intervention.

💡Interventricular Hemorrhage

Interventricular hemorrhage is a type of brain bleed that occurs within the ventricles of the brain. The script discusses the grading of this condition (Grade 1 to Grade 4) and how ultrasound can be used to detect and monitor such hemorrhages in neonates, which is crucial for their prognosis and treatment planning.

💡Posterior Fontanelle

The posterior fontanelle is one of the soft spots on an infant's skull, located at the back of the head. The script mentions the importance of the posterior fontanelle in ultrasound imaging, as it provides an acoustic window for visualizing the brain, particularly for detecting hemorrhages within the occipital horn.

💡Ventricles

Ventricles are the fluid-filled cavities within the brain that are part of the ventricular system. The script discusses the measurement of ventricle widths as part of the ultrasound examination, which can indicate conditions such as hydrocephalus or post-hemorrhagic ventricular dilation.

💡Cerebellum

The cerebellum is a region of the brain that plays a key role in motor control and coordination. The script mentions the importance of examining the cerebellum during neonatal ultrasound, as it can reveal hemorrhages or other abnormalities that may impact the child's motor development.

💡Spinal Ultrasound

Spinal ultrasound is an imaging technique used to examine the spinal column and cord. The script discusses the indications and techniques for performing spinal ultrasound in neonates, particularly in cases where there are concerns about a sacral dimple or other potential spinal abnormalities.

💡Corpus Callosum

The corpus callosum is a broad band of nerve fibers that connects the two hemispheres of the brain, facilitating communication between them. The script discusses agenesis of the corpus callosum, a condition where this structure is underdeveloped or absent, and how it can be identified through ultrasound imaging.

💡MCA Doppler

MCA Doppler refers to the Doppler ultrasound assessment of the middle cerebral artery. The script touches on the use of MCA Doppler to evaluate blood flow in the brain, which can be particularly relevant in cases of hypoxic ischemic encephalopathy or other conditions affecting cerebral perfusion.

💡Sacral Dimple

A sacral dimple is a small indentation in the lower back, near the buttocks. The script discusses the role of sacral dimples as potential indicators for spinal ultrasound scanning to rule out underlying spinal abnormalities, with specific criteria provided for when such scans are warranted.

Highlights

Introduction to the webinar on ultrasound of the head and spine for neonates by facilitator Claire.

Cheryl Rogerson's expertise in neonatal ultrasound scanning and her involvement in teaching and research presented.

Importance of a good ultrasound window for optimal imaging of the neonatal brain emphasized.

Anatomy and windows for cranial ultrasound scan, including the anterior fontanelle and the mastoid fontanel, discussed.

Routine scanning of neonates proposed for different gestational ages and clinical indications.

Significance of ventricular measurements in assessing long-term outcomes for neonates.

Use of coronal and sagittal scans to identify and assess various brain structures and potential pathology.

Doppler waveform analysis for evaluating blood flow and detecting increased intracranial pressure.

Mastoid fontanel view's importance in examining the posterior fossa and detecting cerebellar hemorrhages.

Ventricular measurements techniques and their relevance to normal and abnormal findings.

Identification of interventricular hemorrhage grades according to the Papile classification.

Differentiation between cystic periventricular leukomalacia and other cystic lesions in the brain.

Assessment of extra-axial bleeds and their challenges in ultrasound diagnostics.

Agenesis of the corpus callosum identification and its differentiation from lipomas.

Guidelines for spinal ultrasound in neonates, especially in cases of sacral dimples.

Techniques for scanning the neonatal spine and identifying normal and abnormal findings.

Conclusion and opening the floor for questions, highlighting the educational value of the webinar.

Transcripts

good evening everyone and welcome to

today's webinar ultrasound of the

head and spine my name is Claire and

I'll be facilitating the webinar today

the webinar is scheduled to run for

approximately 60 minutes and will be

recorded so the benefit of everyone the

conference line has been muted for all

participants we will open up for

questions in the last ten minutes please

note if you do have any questions during

the webinar you can submit them via the

questions pane on your control panel and

they will be answered at the end cheryl

Rogerson is a consultant neonatologist

at the Royal Women's Hospital Melbourne

and a lecturer with the University of

Melbourne she has been involved in

ultrasound scanning of neonates for over

20 years her passion for ultrasound

found her working in Malawi for four

years using ultrasound as a part of the

care of patient and teaching point of

care ultrasound scanning she has heard

edu and is a founding board member of

the neonatal SI CPU and has been

teaching on the courses for eight years

she has published on ventricular

dilation and long term outcome the

cerebellum and on point-of-care

echocardiography thank you so much for

your time today Cheryl I'll now hand the

webinar over to you and thank you very

much Claire thank you for everyone for

dialing in at this late hour it's really

exciting to be talking about neonatal

head and spine ultrasound

I'm sure Rogerson but first I would also

like to acknowledge my colleagues Lisa

Fox grant Foster and Caroline garlic

who've also participated and providing

me with some slides the outline of the

talk will be the anatomy in the windows

for the cranial ultrasound scan viral

development interventricular hemorrhage

the posterior fontanelle pathology extra

axial bleeds spinal ultrasound scans and

pathology an acoustic window to further

the optimal imaging of the neonatal

brain it requires a good ultrasound

window which includes mainly the non

fused cranial sutures of the fontanel we

have the anterior fontanelle which is

here the mastoid fontanel the posterior

fontanelle the sphenoid and the frame

Magnum and we also talked about getting

views of the spine and the brainstem

through the foramen magnum see Anatomy

it's really important to remember that

your ultrasounds window is actually over

the posterior frontal lobe and the

central gyrus and the thoughts focus and

the post central gyrus is behind your

actual ultrasound probe the parietal

lobe is more parietal is more posterior

than you generally think and then we

have the occipital lobe the cerebellum

the pons and the medulla cutting through

the center of the brain we have the

corpus callosum we have the cerebrum we

have the matter intermedia we have the

third ventricle the pons the medulla the

fourth ventricle the vestigial point of

the fourth ventricle which is used quite

extensively for measuring the cerebellum

and the cerebellum height and thermal

height we have the parietal occipital

sulcus the occipital lobe

so putting this in to where is the area

of pathology when we see periventricular

lesions and parenchymal lesions

this is anterior frontal in the sagittal

plane this is posterior frontal so below

your actual ultrasound probe is the

posterior frontal area behind that is

the parietal then we have occipital

temporal and then the thalamus this will

become a little bit more clearer as we

go through some of the slides routine

scanning of the neonate is generally

done in different ways but this is a

proposed way for the Australian system

we tend to try and do a scan in the

first 1 2 3 days

then at 7 to 10 days and then at 28 days

and then monthly until discharged if the

children are 28 weeks or less at 28

weeks but less than 32 weeks we just

tend to do one in the first week and

then monthly afterwards after an infant

is 32 weeks gestation the indication for

cranial ultrasound scanner purely

clinical intraventricular hemorrhage and

the periventricular echogenicity and

periventricular leukomalacia really does

not occur in infants the standard

general well infant after 32 weeks the

standard scanning planes you generally

do five coronal five sagittal a mastoid

fontanel view and then there's further

optional images coming into play now as

most people are looking at the

cerebellum and looking for cerebellar

hemorrhages so they measure the transfer

Abela diameter and there are published

guidelines as to the cerebellar diameter

in relation to gestation and this is

frequently used when people aren't sure

of the gestation of an infant many

people measure the air and their artery

resistive index some people measure the

middle cerebral artery resistive index

and then there is measuring of the

ventricle width and ventricular

measurements looking at the anterior

horn width the phalam occipital distance

is now actually being really heavily

researched and in using ultrasound to

determine the long term outcome for

particular instant so really trying to

get their long-term outcome away from

these are the percentages trying to

actually individualize a person's

long-term outcome and there's more and

more research being done on ultrasound

serial ultrasounds being used to

determine an individual's long-term

outcome the coronal scan the anterior

fontanelle as we've seen is a diamond

shape and the beam is that is swept from

the orbit through to the posterior area

through to the occipital lobe

conventionally the right side of the

patient is displayed on the left side of

the screen and the beam is swept

anterior to posterior so this is a 30

week infant in the coronal plane to

looking here at the insular the calcify

is the interpreter the lateral ventricle

this is the root of the third ventricle

with the car takes us in a third

ventricle this is the cicada and let

them loose alone scintilla and this is

the capillary so internally anterior to

frontally so these are the anterior

frontal lobes so you're looking at the

orbits here the roof of the orbit and

these are the two frontal lobes of the

inter Hemmer fissure then you go to the

next plane which is at the level of the

thalamus you have the anterior horns of

the lateral ventricles should not really

be completely visible you have a little

bit of the corpus callosum and you have

the start of the Sylvian fissure you

then go back into the level of the

Circle of Willis so you will see pulse'

tation here from the middle cerebral

artery if you put colored dots are on

Cavin septum pellucidum and you're

starting to now look at the temporal

lobe then you go further back and you're

at the level of the basilar artery

you have the cave and septum pellucidum

the caudate nuclei which is this

inferior circular area at the base

inferior margin of the lateral vent

of course and you have the echogenic

brain stem pons and medulla then you go

back further to the level of the

cerebellum and you tend to have the 3.5

which is their choroid plexus and the

roof of the third ventricle the insula

and then you have the choroid fishes so

the choroid fishes are the joining

plates of the choroid into the inferior

margin of the lateral ventricles you

have the vermis of the cerebellum and

you have a little bit of the sister and

a Magnus

then you keep going back further and

you're looking at the tentorium you must

remember that you're floating back now

from the anterior fontanelle and in fact

your ultrasound beam is going from the

cerebellum up towards the tentorium you

have the quadrigemina plate cistern the

cerebellum and the bodies of the lateral

ventricles you're not out coming up now

to the paraventricular white matter

you're having the choroid plexus which

is in the atria of the ventricles and

the occipital lobes just above the

tentorium and then you go as far back as

possible so that you can define that

there is no assisting periventricular

leukomalacia the sagittal plane is done

also through the anterior fontanelle and

it's 90 degrees to the coronal plane the

beam is swept through the intracranial

structures laterally to the right and to

the left of the midline

that is the parasagittal plane and this

is the true surgical plan images are

taken to show comparable planes on each

side so this is the sagittal midline

this is the corpus callosum this is the

cingulate focus this is the corpus

callosum this is the cerebellar vermis

so you put your superior vermis the

vestigial point of the fourth ventricle

and your inferior verma you have the

Kavon septum pellucidum evident here

fourth ventricle so this is the

parasagittal view and for the

parasagittal view it's really important

to remember that the ventricles don't

run parallel to the inter hemispheric

fissure they run at a slight angle that

is going from

but for the right ventricle it's going

from the midline a little bit more

laterally to the right so when you're

sweeping out to get the parasagittal

view you need to move the posterior part

of your probe just a little bit more

lateral than the anterior part of your

probe and you will see the lateral

ventricle at the frontal horn you'll see

the occipital horn you'll see the atria

you'll see the periventricular white

matter which is particularly important

in their notes looking for

periventricular echogenicity and

periventricular leukomalacia you'll see

the caudate nucleus which is outlined by

a thin more echogenic rim and it's an

inferior semicircular structure in the

inferior margin of the lateral ventricle

will see the choroid plexus you'll see

the temporal lobe then you go right out

to the lateral as far lateral as you can

and you'll get the chandelier view

sometimes what you need to do to get

this view is to move further in the

anterior fontanelle to the opposite side

so that you can get the beams to sweep

to the Sylvian fissure to get this sort

of chandelier on the quarter economic

cruise is actually here so here's the

caudate nucleus here's the thalamus and

then you see this is the germinal matrix

which is noted within the quarter

ceramic groove it's one of the most

important areas you really want to know

how much echogenicity there is and

sometimes you need to do a little bit of

a medial and oblique angle innate

angulation to actually get the quarter a

ceramic groove in display the next thing

is to look at the cerebral post waves

and the anterior cerebral artery so you

place the Doppler and you should trace

out the Doppler waveform and the live

index should be somewhere between point

six and point eight superior

Lari that's your anterior cerebral

artery been coming in is your basilar

artery

this is looking at the Circle of Willis

so this is your right middle cerebral

artery because the image is labeled

showing that we're now imaging through

the right mastoid fontanel you there are

the anterior cerebral arteries this is

part of the brainstem the cerebral

peduncles and this is the left middle

cerebral artery and the posterior

cerebral artery you do a post spectral

Doppler through the middle cerebral

artery and that is also helpful looking

at the resistive index which we will go

through late in further slides if you've

got very low blood flow you can often

see very nice pictures of low blood flow

by turning on the pulse doppler and you

can define where your arteries are and

their wits and their files

the corpus callosum and then you're

going into cave and septum pellucidum

cetera colossal artery and the marginal

clothes luxury and the anterior cerebral

artery so these become more clear in

pulse-doppler because sometimes in a

very preterm infant it's very low

velocity flow this is an area of infant

with a raised intracranial pressure and

as you can see this is an abnormal

spectral doppler for an infant so you

have forward flow in systole and then

reverse flow in diastole and this is

consistent with quite significant raised

intracranial pressure factors that

change the waveform and increased

resistive indexes due to increased

vascular resistant that reduces flow

during diastole which is what we've just

seen raised intracranial pressure the

patent ductus arteriosus is also steals

blood from the carotid if it's very

large and you can get absent end

diastolic flow in the anterior cerebral

artery intracranial processes such as

hemorrhages edema and hydrocephalus and

if the operator puts pressure on the

transducer you can often induce reversed

flow and that is also suggested that

there's some increased intracranial

pressure a decreased RI which is due to

generally due to high diastolic flow is

through two integer on a 6e of growth

retardation elevated heart rate and

decreased cardiac output so intrauterine

asphyxia is thought to show this very

high diastolic flow which would be

evidenced by a high diastolic flow

across here and thats related to

cerebral reperfusion after the asphyxia

insult so the mastoid fontanel view

which is extremely important to do

because it's really the only way where

you can really look at the posterior

fossa the fontanel is located at the

junction of the square square Mosel

lambdoidal and occipital sutures so it's

just here the probe is hold with the

point going through

period and the other point going

inferior so this is the posterior fossa

view here is your cerebellum here is

your sister and a magnet and if you

angle the beam more towards the eyes you

will see the fourth ventricle come into

play and if you angle it more inferior

lis you'll see the folio of the

cerebellar hemispheres many people

measure the cerebellar trans cerebellar

distance and you take the maximal point

just posterior to the fourth ventricle

where you get nice clear margins of the

cerebellum and the measurement should be

almost consistent with their gestation

up to about 32 weeks and there are

well-recognized nomograms that you can

use to relate their cerebellar diameter

to their gestation

just looking at the cerebellum and

looking at the transfer Abela diameter

these are the atria of the ventricles

which you can see in this mastoid

functional view ventricular measurements

have been used and there is generally a

standard way of measuring them so the

anterior horn width is measured at the

level of the insula where it is

completely equal and you measure at the

post at the parallel area of the

anterior horn width at the level of the

roof of the third ventricle with the

corpus callosum then you can do the

SoLoMo occipital distance which you

should have the full ventricle as a si

and you measure from the area that is

perpendicular to the line that goes

through the maximal bit of the occipital

horn to the thalamus including the

choroid plexus the third ventricle is

measured in the trans fontanel lateral

fontanel view where this is Philomath

this is thalamus and then you measure

from internal margin to internal margin

and it should be less than two

millimeters and the fourth ventricle is

measured in the fat mastoid fontanel

view measuring base and the height and

that should be less than ten millimeters

in all views so ventricular measurements

we're at the level of the interior we're

at the level of the roof of the third

ventricle with the choroid plexus and

we're measuring from the most parallel

margins of the anterior horns and this

is where you measure the anterior horn

width at the level of the corpus

callosum obviously this baby's a little

bit got a small corpus callosum

the fellow occipital distance we

generally try and make a mark to try and

get a parallel a perpendicular line to

the widest edge of the occipital horn

and then you measure to the thalamus

including the choroid plexus so this is

the fella mo occipital distance this is

the third ventricular measurement which

is taken through the lateral fontanel

which is a found above the ear in a

parallel plane along the line from the

eye to the ear and then you will see

Salamis thalamus foramen of Monro and

this is the third ventricle and then the

third ventricle should be less than two

millimeters if it is normal

I've chosen a dilated one here to

demonstrate how to measure the third

ventricle the foramen magnum view is

frequently used when you want to look at

the cisterna Magna and see if there's

any cord compression

so we're basically we're trying to look

up through this hole in the base of the

skull so the neck needs to be flexed a

little bit obviously not enough to

occlude their airway and you slide an

angle towards the anterior fontanelle so

that you can see the pons the medulla

the sister and a Magnus and the

cerebellum so these are 4mm here will be

final in Atlantis cause we can be the

vertebra and we can start doing the

rubella and looking at the pons and we

can see a generous piston and manner

this isn't trying to define the anatomy

of the sister and a magnet here we've

got despite the survival cord you have

the inferior vermis of the brainstem in

this particular image this is the

vestigial point the fourth ventricle

this is the superior vermis this is the

foramen magnum this is the medulla and

then you're going up to the pons thyroid

is also very important for neonatal

ultrasound scan because viral

development post growth is not as

equivalent to it is in the fetus it is

about two weeks behind so you can often

look at an infant and you can get some

assessment as to their gestation so the

goal development is generally looking at

the how how many features of goal

development primary tertiary and

secondary branching so it tends to be

featureless at 24 weeks unless unless

it's widely gazing calcarine insuline

and post occipital fissures 28 to 30

weeks you get primary you're branching

and 36 weeks you get secondary branching

and 38 weeks you get tertiary branching

I tend to just look at the singular

focus and so it should be discontinuous

at 24 weeks continuous line at 26 weeks

the first branch of the primary focus at

32 weeks multiple branches at 34 weeks

and then you get this cobblestone

appearance at 38 weeks so this is

looking at the cingulate sulcus this is

pretty discontinuous this is an infant

who's 24 weeks or less then you start to

see the cingulate Falk is showing some

branching so this is primary branching

and perhaps a little bit of secondary

branching so we're now looking at an

infant who's 32 to 34 weeks and then

this is your terminus of multiple

branching of the cingulate sulcus

interventricular hemorrhage who

interventricular hemorrhage is generally

been classified in the for fuel

classification of grade 1 2 3 & 4 whilst

this is not a perfect classification I

thought it best to sort of use this

classification because I think it's the

one that most people use but there is

some plans for the ended in end near

natal database collection group to

actually move away from this very simple

classification of hemorrhages but until

that becomes universally accepted I

think we'll just go through the usual

for pure classification do you have a

grade 1 which is confined to the solder

tender mall and the germinal matrix a

grade 2 there should be blood noted

within the ventricular lumen and the

best way of seeing this is by using the

posterior

fontanelle who grade 3 is an

intervention to the hemorrhage with

ventricular dilatation under grade 4 is

interventricular hemorrhage with

parenchyma hemorrhagic infarction how

cool is ultrasound at looking at

hemorrhages well it's pretty good for a

germinal matrix hemorrhage it's about

61% and specificity of 78% this is

compared to MRI and CT scans the

diagnosis of interventricular hemorrhage

when you're talking about a grade 2 you

get highest sensitivity and specificity

and parenchymal hemorrhage there's a

reasonably high sensitivity and

specificity so it's pretty good it's not

perfect but it's reliable you can repeat

it easily and you have a reasonable

sensitivity and specificity okay so this

is the germinal matrix it's bulky

there's an increased area of echo to

Nyssa T

there's bulging into the hemorrhage into

the ventricle this is a great one this

is a north also a grade one in the

coronal plane you've got some bulging

into the ventricle but the ventricle is

not dilated it's only four millimeters

this is also a grade one this is a an

infant with an interventricular

hemorrhage and then when you look down

below you can see there's a large amount

of occipital horn hemorrhage so this is

a grade two it looks like a grade one on

the coronal but if you go to the fudge

little plane it's a grade two this is

another way of looking at grade twos and

you can see the the hemorrhage in the

occipital horn this is the posterior

fontanelle view so you come into the

posterior fontanelle and you can

actually see that there's a hemorrhage

that has layered and fallen into the

occipital lobe this is a Grade three you

have been tricked to the dilatation and

you have hemorrhage that is generally

filling up more than 50% of the

ventricle this is a Grade three you have

been tricular dilatation these

ventricles are dilated this is always

really difficult it was a grade three

hemorrhage or was it a grade two and I

think it's really important to say is

this ER what is the initial point of

hemorrhage though the initial

Ridge is what the hemorrhage should be

classified and then if you have post

hemorrhagic hydrocephalus I think you

should say it's a grade two with post

hemorrhagic hydrocephalus or it's a

grade three with post hemorrhagic

hydrocephalus

so this infant we felt had a grade three

MS now develop gone on to develop post

hemorrhagic hydrocephalus so this is

measuring the Laveen measurement so you

measure the widest point of the verb for

the invictus this measure of the fishery

horn method and including all that

emerge so this is an infant who's

actually having interventricular

hemorrhage in the stands nation can see

the blood is moving on to it by

prescribing and you see in the streaming

of ourselves as their pain is crying and

the pressure with changing within the

ventricle when we have too much filler

for everything that people frequently do

if they want to do lumber punctures to

see if they can reduce the ventricular

dilation one of the things that you can

use is you can use pulse doppler to see

is there CSF flow so if you look here

you've got arterial flow but if you look

very carefully at the third ventricle

going into the fourth ventricle when the

baby cries or a little bit of pressure

is exerted on the anterior fontanelle

you can actually see low flow coming

through the third ventricle into the

fourth ventricle and so we use this to

help us decide whether lumber punches

aren't likely to be successful

this is obviously a grade four so you've

got a large grade three on the right and

you've got parenchymal extension in this

fan-shaped area in the parenchymal this

is also per ventricular

echogenicity and so this is in a

sagittal plane extensive periventricular

fo Jennison is not as bright as bone but

as we watch that that will develop into

cystic periventricular leukomalacia this

is an arterial in fact it's quite wide

it's in a circular area and the MRI

confirmed that it was actually an

arterial in fact there's no Associated

interventricular hemorrhage this is an

isolated parenchymal echogenicity

associated with infertile area and so

therefore it's a natural in fact not a

parametric learning lesson in fact for

grateful the thought to be related to

obstruction of the terminal veins of the

terminal Vanquish while i eat that

occasion though is in fear van causes

the vena in but so once again you have a

large hemorrhage with a connectedness T

and this fear a grasp or we will march

or a halt I'm pregnant returned McClure

Malaysia so this is breakdown of the

parenchyma secondary to complete in fact

and you gradually see all these cysts

forming and this is a gradual meltdown

of the whole brain extensive statistic

proven tricular leukomalacia bilateral

periventricular leukomalacia is

associated with a 60 to 70 percent

chance of cerebral palsy and a 50%

chance of developmental delay less than

an IQ of 80 so it's a really important

thing to diagnose and obviously if this

does Grose's this is quite easy but

sometimes it's relatively small and

these cysts appear six weeks after the

injury that has caused them and then

they disappear later on

you

okay so now going into other sisters you

can see in the brain I think this is the

one that causes a lot of people quite a

bit of problem this is the right

periventricular cyst so these are now

actually called con natal sister the old

terminology for them was periventricular

cyst

if these cysts are in the inferior

margin of the lateral ventricle and

their anterior to the foramen of Monro

these have been followed up in long-term

studies and they are not associated with

any long-term disability and they are

insignificant finding in terms of

long-term outcome they gradually

disappear by the time the child is six

months a natural etiology of them is not

completely known but there are small

cysts that are found in the inferior

margin of their ventricle are they

related to perhaps a small hemorrhage

that now resolving that happened unusual

I don't think that's likely I think it's

most likely related to germinal matrix

lysis and loss of the germinal matrix

which in the fetus is actually in the

anterior horn then going on to the

mastoid fontanel view you can actually

see quite significant hemorrhage and

this is really the best way of seeing

posterior fossa hemorrhage in the

cerebellum so the there are many studies

which have looked at the anterior

fontanelle view versus the mastoid front

of you mill view and Kathryn improv

lists are shown quite clearly that

unless you use the mastoid fontanel view

you are really going to miss quite a few

cerebellar hemorrhages so this is a

cerebellar hemorrhage it's generally

circular and it's best seen by using the

mastoid fontanel view everything that

echogenic is not a hemorrhage so this is

once again using the mastoid fontanel

view and this is an echogenic lesion

which was found to be in the fourth

ventricle and it actually has blood flow

and MRI confirmed that this was a

hemangioma that was growing and so

obviously the concern was that there

would be an obstructive hydrocephalus

developed

okay this is the MRI and it confirmed

that it was a camera hemangioma

I think extra axial bleeds extra SEO

bleeds are really difficult on

ultrasound and I think it's often very

difficult to be clear whether it's an

epidural or subdural or a subarachnoid

hemorrhage but they can be seen and with

careful investigation and squeezing to

the side of the skull she can actually

see extracted but gently and requested

in MRI there are looking to extract your

beds but we will just go through them

again every through bleeding memory

causes from trauma and it's lengthy form

with the convex surface away from the

girl the subdural and the subarachnoid -

occurs within normal deliveries about

3-4 18 and of all deliveries according

to CT scans that were done in the late

80s and obviously most of these are

asymptomatic and then you can get quite

symptomatic subarachnoid hemorrhages as

resulting from birth trauma okay I think

the most important thing is to see is

there midline shift is there a

generalised increase in epigenesis of

the franca mo suggesting that there is

hypoxic injury associated with this

extract you'll bleed so things to look

for so this is an extract you'll bleed I

think it's very difficult to appreciate

here but this side is not the same as

the other and there is a hemorrhage

located in the temporal horns this is

also an extract he'll bleed you've got

an increased epigenesis II the cortex

has been pushed away from the bone and

you've got a thickening of the

hippocampal gyri so this is blood

layering around the bone and on the

temporal horn this one here is also very

difficult to see but this is a détente

Oriole bleed it's quite a circular area

best seen in the mastoid fontanel view

and this was also confirmed on MRI to be

a 10 toriel blade agenesis of the corpus

callosum

is quite frequently seen and it is

important I think the reason to talk

about it is that sometimes you can be

confused with a lipoma and think that

the corpus callosum is there so the

fibers of the corpus callosum arise from

the superficial layers of the cerebral

cortex and they are meant to cross from

the left to the right with the with

agenesis of the corpus callosum these

five is instead of crossing from left to

right go longer tuna Li and they form

the bundles of procced okay so this is a

genesis of the corpus callosum so you've

got the Sun race line you've got the

gyri coming all the way to the midline

coming all the way to the textual plate

and then you have a small lipoma that is

in the area where the corpus callosum

would normally be you often have a high

writing third ventricle associated with

agenesis of the corpus callosum and then

you sometimes can have this typical

staghorn appearance with an inter

hemispheric cyst and here's your third

ventricle that's also associated with

the agenesis of the corpus callosum

everything that cystic is not assessed

or filled with just fluid as we can see

this is natural venous malformation so

it's important whenever you see anything

cystic in the brain to put on color flow

to confirm what the flow is doing and

everything that echogenic is not always

pathological so this is lenticular

straight artery echogenicity and this is

of unknown origin it's really not clear

what causes this it's very commonly seen

in the preterm infant when they're

gradually getting towards term and I

think the most important thing to know

is that lenticular straight artery air

continuity is really not associated with

any significant long-term outcome issues

for the preterm infant it has no good

correlation with long term development

in utero when you see lenticular

straight artery echogenicity people are

concerned that it's related to in utero

infection and it's always checked for

but when it's seen postnatally in the

day 30 day 60 scan it is of less

significance you can confirm that this

is an artery by putting on your pulse

doppler and you can see that this is

filled with law

flow low amplitude low velocity flow and

you can confirm that this is lenticular

straight artery echogenicity and that

the flow is still occurring in those

vessels okay I think that's all about

Haslam we'll go on to the final

ultrasound spinal ultrasound I was

mainly going to focus on the fact that

there are many infants that are born

with a sacral dimple and constants

frequently we are asked to scan infants

for this sacral dimple and so reading

the literature it became quite clear

that a lot of the circled imports do not

need to be scanned and are not

associated with final abnormalities I

think with the increasing advent of

antenatal scans the use of folic acid

antenatal e the the value of skin

pigmentation and this simple fateful

dimple as an indicator of an underlying

or called spinal problem is becoming

less so important as rottener into a

simple people is less than 2.5

centimeters away from me

- there's no Associated hair or skin

pigmentation these patients do not need

to be spared this reference for next

slide for that is greater than 2.5

centimeters away from their anus has got

a pigmented spinal lesion or this raised

fatty cystic lesion well yeah those

visions do need to be scanned and these

are the people who have looked at of

course final dis racism in relation to

sacral dimples that have come out with

this new recommendation but that simple

coccygeal dimple that 2.5 centimeters or

more or less from the anus is a simple

to do dimple or simple statement in

full and it's really not associated with

underlining or caught spinal disk racism

okay the technique obviously you want

the neonate to be comfortable or prone

on the side a linear array of the

highest frequency available should be

used

and using that field-of-view scanning

can really give you a nice long image of

the spine it's you can count by two ways

you can identify 12 and then count down

or you can identify s1 and then count up

the cord should finish at l2 which is

the conus don't meddle RS and then you

should villa visualize the filament

terminally and you tend to use em mo to

document movement of the cord okay so

this is called finishing it l1 l2 so

it's important to label your spine

here's your your CONUS and here's your

terminal filler filler Marlin so this is

a normal cord so here's your clone is

filling and here's your terminus and

this is a way of counting so you can

count from your sacrum at 5 4 3 2 1 so

this is s1 and then the next one bill 5

and you can count back and you see it by

the angulation that is caused from the

sacrum back to the

lumber spine this is using M mode to see

movement of your spine

and this is a final chord which is

showing nor movement whatsoever is the

epidemic Center and there is no movement

with breathing and so therefore this

infant has a fixed low life for their

accomplices and sling is finished below

okay and so these available body this is

your color and experiment and it allows

image of a lower life for some people

look at the circle dimples see if

there's a city connection that there can

follow down to the tumor and it turns

the fun board see a transit of a low

line cord you put the Inca genic center

and then the final chord yes your

surgery will say and that is

and book mentor in before or five

disputing with long serve you and I see

anything since there is a sister at the

end of the turf at the end see our

course for these formally through

lowlier needed healing on TVs 100 K so

I'm thank you very much missing these

are the references the other spinal cord

references words it's physically and do

you have any questions

for me to you Claire

Felipe

see that so will now open up to any

questions the famous so just a reminder

if you do have any questions you can

submit that I have questions pane the

first question we pop what would you

name the parents again so that is pooled

comment natal v co n - n a tal comment

Lisa basically the next question was

other normal measurements for this

interstellar system I'm further the

success I have investigated that or

sudden amazement to the supersize

I'm sorry I'd need to - I doubt that

question is fun in that

oh man all their normal measurements

sisters when assessing frightening old

tank response option

I need to have treatment and look for

just so really you want in tinnitus

three so forth great feet and over ten

millimeters it's party being saying that

you need treatment to relieve this in

enrich the dilation famila when you get

a preterm infant that is 60 to 90 days

of age people also measure the anterior

on which and what they have found is if

your anterior horn is greater than six

millimeters made a business trip

associated we disagrees

post here education catalyst but these

vegetables are just getting bigger to

fill up the space of brain that has not

been growing the bigger and bigger the

ventricles are over six millimeters

their higher incidence of long-term

neurological motion at the core and your

new department will delay so you have

these two things millimeters the

ventricular dilation accumulated the

hemorrhage or is it related to X vacuo

dilation of which once again three

millimeters is normal six millimeters is

not thought to show any three to six

millimeters is not really associated

with poorer long-term outcome but once

you get greater than six millimeters its

associated with poorer long-term outcome

in the X preterm infant and is thought

to be you know X vacuo dilatation in the

infant who's got poor cortical growth

great thanks for that Cheryl the next

question we have for you is why would

you assess MCA

versus ACA I think that it's a there's

no difference in which one you choose

I think the anterior cerebral artery

tends to be easier to teach so that's

why I tend to use the anterior cerebral

artery versus versus the middle cerebral

artery so it's a matter of preference

which one you find easiest to get the

middle cerebral artery is where most

people have done the research in looking

at in in for instance who have got

hypoxic ischemic encephalopathy and

looking for that high diastolic flow and

the main reason they've used that is

when you actually get good at getting it

you can actually get a as the almost

zero degree doppler angle so the middle

cerebral artery you are more likely to

get repetitive results with less intra

op interoperative and interoperative

error

I think the anterior cerebral artery is

easier for people learning but it is

most probably less repeatable if you're

going to be using it for research and

for using diagnostic as a diagnostic

criteria so the middle cerebral artery

is it's better it's easier to get zero

degree angle I think that's why most

people like to use it alright we've got

another question for you what are your

thoughts on newborn flash infant

ultrasound for increased head

circumference right okay I think that if

the baby has crossed the central and

they still have open sutures I think a

cranial ultrasound scan would be is the

best way to assess those infants most of

those infants just have a

constitutionally enlarged head and when

you do the cranial ultrasound scan what

you just see is normal ventricles no

post hemorrhagic hydrocephalus no

dilated ventricles no big subarachnoid

spaces you just just see a normal brain

and if there

and I think that it's a good screening

tool but you know obviously if the

infant continues to cross the Centaurs

you then want to go on and do through

the scanning but I think as a primary

investigation for infants with a large

head that people are concerned about I

think that it's quite a valuable tool up

up to the time when the suture is closed

and you can no longer get good windows

it it's quite a reasonable tool up to

three months

great thanks for that so the next one

that's come through is the PV L is an

isolated entity or related to hemorrhage

okay

so TCP VL is not an isolated and entity

but you can see cysts within the pre

ventricular reasons region for other

reasons than associated with hemorrhage

so cystic ppl traditionally is

associated with an intraventricular

hemorrhage and you've got this per

ventricular

echogenicity which is related to

infarction and you get this breakdown of

the parenchymal you can also see cystic

PVL related to other entities where it

is thought to be secondary to a

watershed poor perfusion whilst in utero

so infant to have got severe introducer

and growth restriction can also get

super ventricular leukomalacia which is

unrelated to an interventricular

hemorrhage so you can sort of get the

the entities with a hemorrhage or the

entities not related to a hemorrhage so

it's not always associated with

intraventricular hemorrhage yeah

wonderful

the next one that come through is more

of a request they are asking please show

references for spinal us again oh sure

so these are the references for the barn

wall dis racism correct next question

we've got fine fist as described in your

talk

are they a significant abnormality sorry

say that again

fine fist as described in your talk

are they a significant abnormality um

yeah so these seeds these cysts that you

see at the base of the spine generally

associated with a low-lying spine and

tethering of the cord and they are

associated with lower motor neuron

disorders later on in life and then they

should be followed up with MRIs thought

up a new neurological mobile tech

support is there any merit I don't think

there's any value I mean the value of

middle sensory Doppler is the main use

of it is in babies at hypoxic ischemic

and Carol Odyssey so using things with

these diffusion injury sustained way in

the middle cerebral arteries is if you

think that you have an infant with

asteroid and people have documented in

poor middle cerebral artery flows Omni

society you might be in a MRA the third

reason for king at the middle cerebral

artery would be looking for rare

interest cranial pressure and I think if

there is no clinical indication or

clinical signs for that you may choose

not to look for middle cerebral artery

Doppler in an infant if the infinite is

coming to you because they've got

big head but it's not really crossing

cent Isles and there's no other clinical

science with it

I wouldn't have thought that it was an

essential thing to do

I'm not quite sure what information it

would help you with okay great

next question is it true that the CSP

has often disappeared by three months

yes yep so the Kempton pellucidum can

can disappear and it's not always

visible all the time

next question have you ever seen an

indication for small Imperial Frontale

for a two-day-old baby sorry so I think

you're asking would you actually do an

ultrasound because there's a small

anterior fontanelle well certainly if

the if these small anterior fontanelle

is associated with the concern are these

sutures overlying or are these sutures

fused

yes you would be reasonable to do an

ultrasound for that and that would be

one of the times that I would actually

look at the sutures because you can

actually tell other sutures open or

close you might not be able to define

how far open now are in terms of

millimeters but you can tell them of

they're open or closed and you can often

actually tell whether they're

overlapping because there's been

compression and molding during the

delivery especially they had a vaginal

delivery versus ridging which would be

associated with craniosynostosis but if

they've got a small anterior fontanelle

and a normal head shape normal head size

you would be here it's not unreasonable

to do an ultrasound to to look at that

but you'd want to have perhaps a little

bit more of an indication than just a

small anterior fontanelle you want to

have concern that the sutures were

overlapping or overlying or that there

was a small head circumference in

association with the small anterior

fontanelle but you know you get requests

to do ultrasounds for lots of unusual

reasons and sometimes you think god why

am i doing this i don't really you and

then you do it and you find something so

it's often hard if someone's asked you

to do it often find it hard to say no

I'm not going to do it or there's no

indication great just as a that we're

getting a lot of questions about the

recording and a copy of the webinar so

just to let everyone know in one go that

the webinar is being recorded and will

be distributed

so they'll know for the questions I

would like to thank you for joining us

today and thank you again Cheryl for the

presentation we hope you will enjoy the

remainder of your evening thank you

thanks Claire