ASA 2022 Melbourne Conference - Neonatal Neurosonography

Summary

In this informative lecture, Henry delves into neonatal neural sonography, covering the essentials of technique, anatomy, and pathology. He highlights the importance of probe selection and scanning approaches, then transitions into a detailed exploration of neonatal brain pathologies, including hemorrhage grading, hydrocephalus, and various congenital anomalies. The presentation is a valuable resource for medical professionals seeking to enhance their understanding of neonatal brain ultrasounds.

Takeaways

• 🌟 Neonatal neural sonography is divided into two main sections: basic technique and anatomy, and pathology.
• 🔍 High-frequency transducers are essential for neonatal neural sonography to ensure good image resolution, with micro-convex array transducers being the speaker's preferred choice.
• 👶 Indications for neonatal cranial ultrasound include prematurity, low Apgar scores, neurological changes, cranial dysmorphisms, and follow-up for known hemorrhages or other pathologies.
• 📚 Key sonographic features to learn include the inter-hemisphere fissure, sylvian fissures, cavum septum pellucidum, corpus callosum, basal ganglia, ventricular system, and cerebellum.
• 🧠 The cavum septum pellucidum is a fetal neural developmental marker that is normally present and can be associated with CNS anomalies if absent.
• 🔑 The corpus callosum is the largest white matter structure, connecting both hemispheres of the brain and playing a role in eye movement, cognition, and tactile localization.
• 🚫 Germinal matrix hemorrhages typically occur in the sub-ependymal region and are a significant concern due to their potential to cause severe neurological deficits.
• 🌐 The ventricular system, consisting of the lateral, third, and fourth ventricles, is essential for the circulation of cerebrospinal fluid and can be affected by various pathologies.
• 💉 The extra-axial spaces are important for identifying collections such as subdural or epidural hemorrhages, and benign enlargement of the arachnoid spaces.
• 🔍 Scanning techniques involve using the anterior fontanelle for obtaining coronal and sagittal views, with attention to detail to avoid missing critical findings.
• 🩸 Intraventricular hemorrhage (IVH) is a primary concern in neonatal brain ultrasounds, especially in extremely premature infants, and is graded from one to four, with grade four being the most severe.

Q & A

What are the two main sections covered in Henry's lecture on neonatal neural sonography?

The two main sections covered in Henry's lecture are the basics of neonatal neural sonography, which includes technique, anatomy, and the second section on pathology.

What type of transducer does Henry recommend for neonatal neural sonography?

Henry recommends using a high-frequency transducer for good resolution in neonatal neural sonography, with a preference for micro-convex array transducers that usually range from three to ten megahertz.

What are the primary indications for neonatal cranial ultrasound?

The primary indications for neonatal cranial ultrasound include prematurity, low Apgar scores, any neurological changes upon or during admission, cranial dysmorphisms such as macrocephaly or microcephaly, craniosynostosis, and follow-up for known hemorrhages or other pathologies.

What is the cavum septum pellucidum and why is it significant in neonatal sonography?

The cavum septum pellucidum is a midline cystic structure between the anterior horns of the lateral ventricles and is a fetal neural developmental marker. It is present in normal brains and its absence has been associated with central nervous system anomalies like septo-optic dysplasia, holoprosencephaly, and agenesis of the corpus callosum.

What is the significance of the corpus callosum in the brain and what does it consist of?

The corpus callosum is a horizontal bundle of nerve fibers that connects both hemispheres of the brain and is the largest white matter structure, consisting of over 200 million axons. It plays a crucial role in eye movement, cognition, and tactile localization.

What is the germinal matrix, and why is it important in neonatal brain scans?

The germinal matrix is a highly vascularized thin membrane located in the sub-ependymal region of the cytothalamic groove. It is important because it is the starting point for germinal matrix hemorrhages, which can occur in premature infants.

What are the key features of the ventricular system in the brain, and why are they important in neonatal sonography?

The ventricular system consists of the lateral ventricles, the third ventricle, and the fourth ventricle. These are chambers filled with cerebrospinal fluid and contain the choroid plexus, which creates the fluid. They are important in neonatal sonography to check for abnormalities such as hydrocephalus or hemorrhages.

What is the significance of the extra axial spaces in neonatal sonography?

The extra axial spaces are important in neonatal sonography because they can have collections from benign enlargement of the arachnoid spaces, which is a common cause of microcephaly, up to and including subdural or epidural hemorrhages.

Can you explain the grading system for intraventricular hemorrhages (IVH) in neonatal patients?

The grading system for IVH consists of four grades. Grade one is the least severe, with bleeding contained within the germinal matrix. Grade two indicates bleeding has broken into the ventricle but occupies less than 50% of the ventricular space without ventricular dilatation. Grade three involves bleeding occupying more than 50% of the ventricle or causing ventricular enlargement. Grade four is the most severe, characterized by intraparenchymal or periventricular hemorrhage within the brain tissue itself.

What are some risk factors for intraventricular hemorrhage in neonatal patients?

Risk factors for intraventricular hemorrhage include prematurity (less than 32 weeks, especially if extreme, and less than 1500 grams), rapid fluctuations in blood pressure or blood volume, transfer from outside facilities, coagulopathy or blood clotting disorders, respiratory distress, and hypoxic ischemic events.

Outlines

00:00

📚 Introduction to Neonatal Neural Sonography

Henry begins the lecture by expressing gratitude to the ASA for the opportunity to speak and introduces the topic of neonatal neural sonography. The lecture is divided into two sections: basic technique, anatomy, and a subsequent pathology section. The objectives include a detailed overview of neuroanatomy, techniques, probe selection, and scanning approaches. Henry emphasizes the importance of using a high-frequency transducer for better resolution in neonatal sonography and discusses the advantages of micro-convex array transducers over sector probes for imaging detail. Indications for neonatal cranial ultrasound are also outlined, such as prematurity, low Apgar scores, neurological changes, and cranial dysmorphisms. Key sonographic features to observe include various brain structures and fissures, with a diagram provided for clarity.

05:02

🔍 Probe Selection and Neonatal Cranial Ultrasound Indications

This paragraph delves into the specifics of probe selection for neonatal neural sonography, highlighting the use of high-resolution linear probes for detailed imaging. Henry discusses the challenges of imaging as babies grow and their fontanels decrease in size. Indications for neonatal cranial ultrasound are expanded upon, with a focus on the importance of monitoring for hemorrhages, especially in premature infants. Key sonographic features are described in detail, including the interhemispheric fissure, sylvian fissures, cavum septum pellucidum, corpus callosum, basal ganglia, ventricular system, and cerebellum. A diagram is used to illustrate the brain lobes and corresponding bones, providing a visual aid for understanding the anatomy.

10:02

🧠 Detailed Exploration of Brain Structures and Pathology

Henry provides an in-depth look at various brain structures, including the germinal matrix, a critical area for the development of hemorrhages, and the ventricular system, which comprises chambers filled with cerebral spinal fluid. He explains the importance of the choroid plexus, a network of cells that produce and filter cerebrospinal fluid. Scanning techniques are discussed, with a focus on the anterior fontanelle as the primary scanning window, and the importance of obtaining clear, angled images to avoid missing critical details. The paragraph concludes with a detailed explanation of how to perform a comprehensive scan, including the order and technique for obtaining coronal and sagittal views.

15:02

📘 Sagittal and Parasagittal Views in Neonatal Sonography

The lecture continues with a focus on sagittal and parasagittal views in neonatal sonography. Henry describes the process of scanning, starting with the midline and moving to the right and left, highlighting the importance of obtaining six images to cover all necessary areas. He provides detailed descriptions of what can be observed in these views, such as the corpus callosum, thalamic adhesion, third ventricle, cerebellar vermis, and fourth ventricle. The use of different probes is discussed, with a preference for linear transducers for their ability to reveal subtle structures. The paragraph concludes with an overview of the vascular anatomy, including the circle of Willis and the blood flow in major cerebral arteries.

20:03

🩸 Neonatal Neuropathology and Hemorrhage Grading

Henry transitions to the second part of the lecture, focusing on neonatal neuropathology, particularly the prevalence and significance of hemorrhage in neonatal brain ultrasounds. He explains that hemorrhage is the primary reason for conducting these ultrasounds, especially in extremely premature infants. The lecture covers the grading system for hemorrhages, ranging from grade one to grade four, with each grade indicating increasing severity and potential outcomes. Risk factors for hemorrhage are discussed, including prematurity, blood pressure fluctuations, and coagulopathy. The paragraph concludes with a visual representation of hemorrhage grades and their typical locations within the brain.

25:04

🛑 Advanced Imaging of Neonatal Hemorrhages and Outcomes

This paragraph provides a detailed examination of the progression and outcomes of neonatal hemorrhages. Henry discusses how grade one hemorrhages can progress to higher grades and the potential for cystic degeneration over time. He describes the process of blood clot retraction and the formation of cystic spaces, which may eventually lead to subependymal cysts. The paragraph also covers the evolution of grade two hemorrhages, which involve blood breaking into the ventricles without causing ventricular dilatation, and the potential long-term effects, such as calcified plaques and the development of hydrocephalus in more severe cases like grade three hemorrhages.

30:05

🧊 Cystic Degeneration and Hydrocephalus in Neonatal Pathology

Henry discusses the process of cystic degeneration following hemorrhages and the development of hydrocephalus, a condition characterized by abnormal accumulation of cerebrospinal fluid in the ventricles. He explains that hydrocephalus can result from various causes, including post-hemorrhagic obstruction. The paragraph details the imaging findings in hydrocephalus, including the dilation of the trigone and occipital horn, and the potential need for a VP shunt or reservoir to manage the condition. Henry emphasizes the importance of early diagnosis and intervention to prevent complications such as encephalomalacia and brain damage due to increased pressure.

35:05

🧬 Congenital Anomalies and Their Sonographic Features

The lecture shifts focus to congenital anomalies, with Henry providing an overview of various conditions, including agenesis of the corpus callosum, holoprosencephaly, hydranencephaly, and schizencephaly. He describes the sonographic features of these anomalies, such as the 'moose head' appearance in agenesis of the corpus callosum and the monoventricle in holoprosencephaly. The paragraph also touches on the risk factors and prognosis associated with these conditions, highlighting the importance of accurate diagnosis and the potential impact on patient outcomes.

40:07

🦄 Advanced Congenital Anomalies and Neuropathology

Henry concludes the lecture with a discussion on additional congenital anomalies and their impact on neonatal neuropathology. He describes conditions such as schizocephaly, lissencephaly, and pachygyria, emphasizing their unique imaging characteristics and the importance of recognizing these features in sonography. The paragraph also covers the Walker-Warburg syndrome, which is associated with cobblestone lissencephaly, and its typical presentation, including hydrocephalus and cerebellar malformations. The lecture ends with a reminder of the vast range of pathologies that can be encountered in neonatal neuroanatomy and neuropathology.

Keywords

💡Neonatal Neural Sonography

Neonatal Neural Sonography is an ultrasound technique used to examine the brain structure and function in newborns. It is a crucial diagnostic tool for identifying congenital abnormalities, hemorrhages, and other neurological conditions in infants. In the video, it is the central theme, with the speaker discussing various aspects of the technique, including the basics, anatomy, and pathology.

💡Transducer

A transducer in the context of sonography refers to the device that sends and receives ultrasonic waves to create images. The speaker mentions the importance of using a high-frequency transducer for neonatal neural sonography to achieve good resolution and details the different types of probes, such as sector, micro-convex array, and linear probes, which are used for specific imaging purposes.

💡Interhemisphere Fissure

The interhemisphere fissure is a deep groove in the brain that separates the two cerebral hemispheres. It is an important anatomical landmark in sonography, as it helps in distinguishing between the cerebrum and cerebellum. The script describes it as an invagination of the dura mater and tentorium, which is a key feature to identify during neonatal brain scans.

💡Corpus Callosum

The corpus callosum is a bundle of nerve fibers that connects the two cerebral hemispheres and plays a role in interhemispheric communication. It is a significant structure in neuroanatomy and is discussed in the script as a key component to visualize during neonatal sonography, with its components, the rostrum, genu, body, and splenium, being highlighted.

💡Cavum Septum Pellucidum

The cavum septum pellucidum (CSP) is a midline cystic structure found between the anterior horns of the lateral ventricles. It is a normal developmental marker in fetal scans and is mentioned in the script as a structure that is often observed in neonatal sonography, with its absence sometimes associated with central nervous system anomalies.

💡Germinal Matrix

The germinal matrix is a highly vascularized thin membrane located in the sub-ependymal region, which is significant because it is the site where many brain bleeds in neonates begin. The script explains its importance in identifying potential hemorrhages, particularly in premature infants, and how bleeds can occur due to its delicate nature.

💡Intraventricular Hemorrhage (IVH)

Intraventricular Hemorrhage refers to bleeding within the ventricles of the brain, a common and serious condition in premature infants. The script discusses the grading system for IVH, its risk factors, and the potential outcomes and complications associated with different grades of hemorrhage, emphasizing its significance in neonatal pathology.

💡Hydrocephalus

Hydrocephalus is a condition characterized by an abnormal accumulation of cerebrospinal fluid within the brain's ventricles, leading to ventricular enlargement. The video script describes it as a common finding in neonatal sonography, which may result from various pathological conditions, including post-hemorrhagic hydrocephalus.

💡Holoprosencephaly

Holoprosencephaly is a congenital anomaly where the prosencephalon (forebrain) fails to divide into two hemispheres. The script describes different types of holoprosencephaly, such as alobar, semilobar, and lobar, and discusses the associated features and poor prognosis of this condition, highlighting its importance in the context of congenital brain malformations.

💡Lissencephaly

Lissencephaly is a neuronal migration disorder characterized by a smooth brain surface without the normal gyri and sulci. The video script explains that it results in a brain that lacks the typical folding patterns, which is a significant finding in neonatal brain sonography and is associated with various genetic syndromes and developmental outcomes.

💡Doppler Ultrasound

Doppler ultrasound is a technique used to assess blood flow and has applications in neonatal sonography for evaluating conditions like hypoxic-ischemic injury. The script mentions using Doppler to examine the cerebral arteries for resistive indices, which can indicate the presence of hypoxic ischemic injury in the brain.

Highlights

Introduction to neonatal neural sonography, covering basics, technique, anatomy, and pathology.

Use of high-frequency transducers for better resolution in neonatal neural sonography.

Explanation of probe selection, including micro-convex array transducers and linear probes for high-resolution imaging.

Indications for neonatal cranial ultrasound, such as prematurity, low Apgar scores, and cranial dysmorphisms.

Key sonographic features to observe, including inter-hemisphere fissure, sylvian fissures, and cavum septum pellucidum.

Importance of the corpus callosum in neonatal brain imaging and its components.

Significance of the germinal matrix in hemorrhage occurrence and its relation to the cytothalamic region.

Description of the ventricular system, including the lateral, third, and fourth ventricles.

Scanning techniques and windows for neonatal brain ultrasound, emphasizing the anterior fontanelle.

Overview of neonatal neuropathology, focusing on hemorrhage as the primary reason for brain ultrasounds.

Grading system for intraventricular hemorrhages and their respective severities and outcomes.

Risk factors associated with hemorrhages, including prematurity and fluctuations in blood pressure.

Discussion on the progression and outcomes of hemorrhage grades, from grade one to grade four.

Identification and differentiation of core plexus cysts and their association with trisomy 18.

Overview of hypoxic-ischemic injury in neonates and its sonographic markers.

Presentation of periventricular leukomalacia (PVL) and its impact on white matter.

Discussion on hydrocephalus, its causes, and the importance of monitoring ventricular size.

Overview of extra-axial spaces in neonatal brain imaging and their clinical significance.

Brief on congenital anomalies such as agenesis of the corpus callosum and holoprosencephaly.

Conclusion summarizing the extensive range of pathologies covered in neonatal neuroanatomy and neuropathology.

Transcripts

hello everyone i'm henry and thank you

for joining me i want to thank the asa

for giving me the opportunity to speak

it is quite the honor today i'm going to

be talking about neonatal neural

sonography and it's going to be broken

down into two sections the first section

is just going to be the basics technique

anatomy and then the second video will

be on pathology so lecture objectives

like i said already anatomy we're going

to a detailed overview of the

neuroanatomy techniques probe selection

scanning approaches and then in the

second video pathology all right so

probe choice now when you're doing

neonatal neural sonography you want to

use a

high measure transducer to get good

resolution and we have small probes that

are just for that like this sector that

goes up to 10 megahertz uh my favorite

are these little curved ones the micro

convex array transducers uh they're

usually from three to ten megahertz they

take very very good images much better

than the sector probes in my opinion and

then finally linear probes to get those

really nice high resolution uh images

here you can see the difference from a

sector probe in a parasagital view

and the linear you can see so much more

detail with the linear obviously

the older the baby gets the bigger the

baby's brain gets or their head gets and

the smaller their fontanels get using a

linear is less feasible

all right so indications for neonatal

cranial ultrasound prematurity is

probably the number one reason to do

these exams uh any premature infant less

than 32 weeks or less than 15

100 grams is at an increased risk for

hemorrhage

low abgar scores any neurological change

upon admission or during admission

cranial dysmorphisms so macrocephaly

microcephaly craniosynostosis

uh and follow-up for known hemorrhages

or other pathology

key sonographic features that you want

to pay attention to and learn are the

inter hemisphere fissure

the sylvian fissures also known as the

lateral sulcus

cavum septa lucidum

corpus callosum

basal ganglia especially the

cytothalamic region

the ventricular system so the ventricles

and the cerebellum so here is the

diagram i made of the lobes pretty

simple

yellow is frontal

green is a parietal lobe purple is a

temporal lobe and orange is the

occipital lobe each lobe is has its

corresponding bone

and then you have the cerebellum and

brain stem

so let's begin with the inter hemisphere

fissure

the inter hemisphere fissure is an

invagination or a deep groove

of the dura mater and the tentorium is

also an invagination of the dural matter

that separates the cerebrum to the

cerebellum

the intra-hemispheric fissure is also

called false cerebri and it separates

both hemispheres of the brain

once it goes down it eventually meets up

with the corpus callosum

all right

sylvian fissures are lateral grooves

their deep lateral grooves are on the

temporal region they separate the

frontal occipital lobes to the temporal

lobes they look like sideways wise i

always tell my students and the insula

is buried deep to it

let's go back real quick so here you

have the temporal

temporal lobes

cavim septum pellucidum or cavum septi

pellucidai is a midline cystic structure

in between the anterior horns of the

lateral ventricles it is a fetal neural

developmental marker so when you're

doing fetal scans it's one of the things

we look for

uh it's present in normal brains

people who do fetal scans are very well

familiar with with the structure

absence of this structure has been

associated with central nervous system

anomalies like septo-optic dysplasia

holoprosencephaly and corpus callosum a

genesis

it usually fuses by six months

uh it is present in a lot of newborn

infants we see it quite a lot it's a

normal structure and it persists in 15

of adults

it is not that it really obliterates is

that just as you grow up and your grain

bags gets bigger

the lateral you know all the structures

get kind of closer together and you

can't really make it out like you can in

fetuses and in neonates

so here we have a sagittal and a coronal

view and that's the cavum septum

pellucidum right there and in corona and

then we have a gross pathology example

in coronal also showing the anterior

horns of the lateral ventricles

and the caveman septum pellucidum

so kevin vergie

is one that not everyone is familiar

with um if you do a lot of brain

ultrasounds you will be familiar with

this but it's a continuation of the the

csp

it's usually

posterior and beneath the splenium and

body of the corpus callosum here you can

see the csp and cavenfree

it is present 30 in infants and present

in less than one percent of adults here

you can see the normal csp

with

without the cavendriki in this patient

then we have the cavin veli

interpositive or cavan vellum

interpositum

it is a supercententorial cystic

structure

it is antero inferior to the splenium of

the corpus callosum so it's more

inferior more posterior than the cave

and fergie

um there's no associated congenital

anomalies

and here is its structure right here

anytime you do see this it's good to put

color doppler because this is an area

where you can have a regular cysts quite

commonly and also a vein of galen

aneurysm could be present in this

portion here

so you can put color doppler to rule

that out

all right so the corpus callosum very

important structure it's a horizontal

bundle of nerve fibers that connects

both hemispheres of the brain

it is the largest white matter structure

consists of over 200 million axons

its components are the rostrum the genu

the body and the splenium from anterior

to posterior

it is important for eye movement

cognition and tactile localization

and it is reportedly larger in females

maybe that's why women are more smarter

so here you have a coronal view of the

corpus callosum

and here's a sagittal zoomed up view

there you can see the rostrum is like a

little beak portion right there and then

you got the genu which was right here

the whole body and then the splenium

splenium is towards the back it's

posterior i use i usually remind the

students that think uh when you're

trying to scan the spleen

sometimes you gotta scan more posterior

to get a good spleen image

and splenium is posterior to the back

all right so the germinal matrix very

important structure that is highly

vascularized thin membrane and it's

important for us because this is where

the

germinal matrix hemorrhages begin so the

bleeds it is located in the

sub-ependymal region of the cytothalamic

groove so where the cardiac nucleus and

the thalamus meet it is a source for

neuronal precursors that constitute

brain parenchyma which what that means

is primitive nerve cells begin here and

then they migrate outwards and here is

that counterthylamic groove so

parasagittal you got the cauday nucleus

here

the thalamus and then this portion right

here that's where the catothalamic

groove is germinal matrix is

and if you do have a bleed that's where

it's going to be so it'll be a germinal

matrix hemorrhage or a sub ependymal

hemorrhage which subappendable meaning

under the lining of the ventricle

here is with a diagram

and it's important to note

that the echogenicity of the chlorate

plexus is going to be very similar to

great wood bleeds

but the location is important the cory

plexus usually begins about

one third to halfway

of the thalamus and then it tapers

there

so if you have this there a lot of

people when they first start scanning

they confuse that with blood that's not

blood that's the core plexus so the

location here if you have a little hump

there that's echogenic then nothing then

the core plexus that part is the blood

all right so now let's go to the

ventricular system so the ventricles are

just a series of chambers inside the

brain that are filled with cerebral

spinal fluid they contain the core

plexus as well which create that

cerebral spinal fluid there's the

prepared lateral ventricles

the third ventricle and the fourth

ventricle so here's a diagram of the

ventricular system in a parasagittal

view and a coronal view so here you got

the lateral ventricles which would be

anterior horn occipital horn temporal

horn and then you have the third

ventricle

this little structure is where the

thalamic adhesion or massa intermediate

is so pretty much the midline of the

thalamus

and then you have several foramen and

channels that connect the ventricles

like the foramen of monroe

and the aqueduct of silvius or the

cerebral aqueduct that goes down into

the fourth ventricle

and here is a diagram of a parasagital

view of the lateral ventricle so again

anterior horn

posterior horn or occipital horn

temporal horn and the cory plexus

and here's a coronal view

showing the anterior horns of the

lateral ventricles the foramen of

mineral on each side and the third

ventricles the larger the baby is the

less you're gonna be able to see these

structures

so here we have the third ventricle in

midline sagittal so let's go back

in corona the third ventricle is like a

slit

and then in sagittal it looks broader

obviously and more premature uh infants

you're gonna see it easier in larger

kids you're not gonna see it as well

so is this structure right here

that's the third ventricle this is the

masa intermedia or the thalamic adhesion

which would go right there

and then from here you have the cerebral

aqueduct or the aqueduct the silvius

which goes into the fourth ventricle

then the posterior fossa and then into

the spinal cord

so that's aqueduct silvius and the

fourth ventricle which is always

triangular shaped and anterior to the

cerebellum midline of the cerebellum

which would be the vermis

so extra axial spaces are important

because you can have collections there

from benign enlargement of the arachnoid

spaces which is common and common cause

of microcephaly

up to and including

um subdural hemorrhages or

epidural hemorrhages

and here you can see the layers so this

is the dermis this is the skin

then you have the dura mater

then the arachnoid space

and the pia mater around the brain so

these three layers are the meninges and

i use dap as a mnemonic to remember dap

dura arachnoid pia i'll go over some

more detailed images of these spaces

later on so the corey plexus very

important it is a network of epithelial

cells

capillaries and connective tissue that

creates the cerebral spinal fluid it

also filters wastes it is located in the

lateral ventricles as you can see here

it is also located in the third

ventricle on the roof of the third

ventricle and the fourth ventricle and

they're hyperechoic

so now let's go into scanning windows so

the standard windows that we scan is the

most important is anterior fontanelle so

here we have a a fetal neonatal skull

and you can see the parietal bones the

frontal bones the parietal bones and

then what would become the sutures and

the anterior fontanelle so if you put

the transducer right there

and just

right there and rocket anterior to

posterior you can get all the coronal

images you want the notch or the

indicator of the transducer to be on the

patient's right side

and then when you're sagittal you want

the notch facing anterior and then same

rocking motion side to side you can get

your sagittal and parasagital views

so we begin our exam with six coronal

views from interior to posterior as you

can see doing that fanning motion

oftentimes you don't even have to move

the transducer just

tilting it and fanning like that you can

get all the images you need obviously

also pivoting and rotating to get your

image as straight as possible because if

the baby's moving or if you're angled or

you're off axis you're not gonna have

you're gonna have a very tilted image

which is not

you know it's not as aesthetically

pleasing and you might miss something as

well so all the way anterior is where we

begin and you can see the frontal horns

the periventricular white matter inter

hemisphere fissure

the cranium

which kind of looks like a bird swooping

down that's why they you know they

trained me i don't or top me and then

the orbits

but i like to know i like to prefer to

know the real anatomy

so again intermittent fissure and the

frontal lobes

and there you can see that

that bird swooping down i guess it's

like a dove or something i don't know

all right so more posteriorly you'll

start to begin to get the little

temporal horns the cave and septum

pollution you see how this is a term

baby and how tiny the lateral ventricles

are antihermosphere fissure and corpus

callosum

so corpus callosum looks like a blue

macaroni into hemispheric fissure

caveman septum pellucidum the lateral

ventricles frontal lobes and the

temporal lobes and one of the sylvian

fissures seen relatively clearly this is

with the sector probe like i said before

with the with the

the micro curve the ray probe the images

are just fantastic this one's with a

linear see how much prettier so again

sylveon fissures this is just slightly

more posterior back

you got the supercellular cistern right

here

thalamus cutting nucleus

so bleeds would start around here in

coronal

temporal lobes midbrain

cingulate sulcus

and then the sylvian fissures which

already said

and then that blue

macaroni

corpus callosum

slightly posterior back

again you have the lateral ventricles

earlier i mentioned that the third the

third ventricle has cory plexus and the

roof of the third ventricle and you can

see that pretty clearly there

so third ventricle

lateral ventricles corpus callosum

very clear with a nine megahertz

transducer

frame of mineral on both sides

there's more angling more posterior now

you start to get a tentorium

so you have cerebellum tentorium

lateral ventricles with a little bit of

cory plexus in it and this is important

to note because when you first start

scanning these you might go here and if

you're inexperienced you'll see that and

you're like oh no that's is that a bleed

but you got to know your position um

this is more posterior

the caudate groove is anterior to this

and the bleeds usually be a little bit

bigger than that

so again civilian figures or lateral

sulcus

then slightly more posterior to the

level of the cory plexus so you got your

lateral ventricles here corey plexus

into hemispheric fissure

a piece of the corpus callosum and

finally

all the way posterior so here you've got

your interim for your fissure occipital

lobe and periventricular white matter

so those are the coronal views next are

the sagittal views

so the way we scan we usually begin

sagittal midline then go to the right

and then go to the left also six images

um

kind of duplicating the midline when you

come back from the right now some places

some people start in the right and

they'll sweep all the way through every

place is a little bit different but you

want to get

these images

so beginning sagittal midline again you

have the corpus callosum right here

thalamic adhesion third ventricle

cerebellar vermicus

fourth ventricle and here's with the

labeling

corpus callosum again rostrum genu body

and splenium csp carbon cave and fergie

here is the cerebral aqueduct or

aqueduct of silvius

this part here is known as a fornix

this is with a linear transducer again

you got the corpus callosum the ecogenic

fornix right here above the thalamus and

then you also see the pons the medulla

oblongata midbrain and brain stem

sometimes it's very hard to make out

these structures

uh in bigger babies and uh more

premature and neonates you can

definitely see it here you got the

cerebellum again and the fourth

ventricle always triangular shaped

so then you begin parasagittal to the

right

parasitical to the left so your first

stop is the caudate nucleus or

catathalamic groove which we saw this

image earlier

focus on this part for bleeds

then you got the

lateral ventricle again enter your horn

body occipital horn and temper horn with

cor uh corey plexus

this is a good part sometimes blood

collects here that's another good parts

to view

and then all the way lateral you're

gonna get the periventricular white

matter the sylvian fissure or lateral

sulcus in parasagittal separating the

frontal occipital lobes to the temporal

lobes and here's the view of the extra

axial space again you see there's some

some fluid here which is normal this is

the

superior sagittal sinus and you can see

there's like little echogenic lines here

those are vessels those are perforating

vessels in the arachnoid matter and

that's normal so again it would be dura

mater arachnoid space and then pia mater

on the brain

so another view is the posterior

fontanelle

and that's where i said earlier you can

use that view if there's any blood

collecting in the occipital horn you

might not be able to see it from the

anterior fontanelle this is a good view

to check there

here you got two views corey plexus

lateral ventricle and the occipital horn

right here

then you have the temporal window which

is going to give you a bipartial

diameter type view like the one you

would get in a fetus

obviously whatever you're approaching

from is the side that's closest to the

face of the transducer so this is the

baby's left side

so this would be the left side of the

head but obviously on this exam this is

right temporal so i usually approach

from the right temporal unless a baby

has some dressings or something like

that

so you can see the sylvian fissures

right here the lateral sulcus

here you got the csp lateral ventricles

intra-hemispheric fissure

a little bit of the cerebellum and

midbrain

and you got a little bit of third

ventricle as

well then you have the mastoid view

this is good for looking at the

cerebellum and posterior fossa so if you

have any posterior phosphates or you

know cerebellar

hemorrhages or anything like that this

is a good view and here's the the gross

anatomy view of the cerebellum you see

the fourth ventricle right there fourth

ventricle cerebellar vermis right in the

middle

very nice view

lastly we'll do a basic overview of the

of the vascular anatomy so this is

through that same temporal window you're

going to get the circle of willis this

is in a in an infant and you got the

middle cerebral artery anterior cerebral

arteries on both sides and the posterior

cerebral arteries which is usually

subdivided into segments p1 and p2 so

circle of willis

and the blood flow or the arterial

velocity in these arteries usually go

highest from mca to pca so mca then aca

then pca and velocity ascending to

descending the normal resistive index is

greater than 0.6 which is important

because in

patients that have

hypoxia or hypoxic ischemic

encephalopathy they'll normally have

lower resistive indices due to

brain-sparing effects so they're going

to be receiving a lot more blood flow so

that's an indicator of hypoxia

and here's a transverse view with the

circle of willis again middle cerebral

arteries right there posterior arteries

basilar artery and then the two

vertebral arteries

so here we have sagittal midline

and coronal

so this is very nice you can see the

internal carotid artery you can almost

see maybe the ophthalmic artery coming

off of there then that goes the ica goes

up into the brain bifurcates into aca

and mca so in sagittal midline you see

the aca

which then goes on to become the

pericalosa artery so here your corpus

callosum periclosal artery

then you have your internal cerebral

vein and your vein of galen so vanilla

and very important also four aneurysms

and then you got the straight sinus and

here you have corona again circle of

willis middle cerebral arteries

anterior cerebral arteries and the

terminal internal carotid arteries

in that view if you angle posteriorly

you'll be able to see the the basilar

artery going into the circle of willis

so that pretty much concludes the

anatomical and technical aspect of this

talk welcome to the second portion of

this video we're gonna go over neonatal

neuropathology

so the number one reason to do neonatal

brain ultrasounds is hemorrhage

particularly interventricular or

intraventricular hemorrhage

now 45 of extreme premature infants so

as infants below 28 weeks or under a

thousand grams

develop intraventricular hemorrhages

it is thought to be caused from impaired

or autoregulation so these patients they

have these germinal matrices

that are very delicate

any change in pressure pressure or blood

volume can cause those little

capillaries and blood vessels to rupture

leading to hemorrhage fifty percent of

bleeds usually happen on the first day

and by the fourth day ninety percent of

all beliefs that are going to happen

have already happened

so the prevalence of intraventricular

hemorrhage

by grade is grade one seventeen 17

grade 2 12

grade 3 3

and grade 4 3 or 3.8 percent now

obviously the the lower the grade the

better it is for the baby and the more

common it is

so this privileges of all bleeds

all right so risk factors are

prematurity so less than 32 weeks

especially if you're extreme premature

and less than 1500 grams

rapid fluctuations in blood pressure or

blood volume

transfer from outside facilities has

been known to uh correlate with

increased risk of hemorrhages

any type of coagulopathy or blood

clotting disorders

respiratory distress

and hypoxic ischemic events

now the grading system of bleeds

consists of four grades grade one

through grade four grade one being the

less severe and grade four being the

most severe

grade one through grade three

are thought to begin in the

subappendible region and then break into

the ventricles whereas grade four is

thought to be from venous infarction in

the parenchyma itself

so we're gonna go over them all this is

a quick overview so this is a normal

brain

this is not to be confused with blood

this is the

the

cory plexus and the roof of the third

ventricle then you have a grade one

which is just containing

blood within the germinal matrix or the

sub-ependymal region you see this side

there's two bleeds and here's the

corresponding image

and then here's a grade two

so the bleeds a little larger is broken

into the ventricle it's taking up less

than fifty percent of the ventricular

space

and there is no ventricular dilatation

or ventricular megaly

so grade 3 is also a intraventricular

hemorrhage

with

greater than 50 of the vegetable being

taken up by blood

and or ventricular ventriculomegaly

and then grade four which is an

intraparenchymal or periventricular

hemorrhage is just blood within the

parenchyma

so grade one here's a gross anatomy view

or gross pathology view you see the

blood right here this is the ladder of

ventricles septum pellucidum

so it is limited to the sub-ependymal or

germinal matrix region it's usually less

than a centimeter um if no progression

the outcome of this condition is as if

they never had a bleed so great ones

usually have pretty good outcomes pretty

good prognosis

um 80 of grade ones can uh progress into

higher grades

so here's that same image bilateral

grade one and it's good to see it in

coronal and sagittal earlier i mentioned

that the corey plexus begins about one

third or halfway to the thalamus so this

is choreoplexus and this is in a grade

one bleed you can see that geneticity is

very similar

here's another example of a left-sided

grade one bleed so here's your thalamus

caude nucleus so you see this little

groove right here that's where the blood

is

and it's right there sometimes it's a

little harder to see in coronal and

easier to see in sagittal

so this is a 30 wing a 31 week

premature infant

measuring about 1500 grams

over time the bleeds can involute and

undergo degeneration so if they

don't progress to grade two or grade

three they just stay there and

eventually the blood clot starts to

retract and you have these little cystic

spaces and that's just cystic

degeneration over time there may be a

sub-ependymal cyst that's left over in

his place

in fact sometimes when you scan infants

you'll notice a subappendable cyst which

is different from a choriplexist and

that could be maybe that this p the baby

had or the fetus had a bleed or grade

one in utero that just has resolved and

what's left over is a sub ependymal cyst

all right so grade two

once the blood has gone from the general

matrix and broken into the ventricle

you have a grade two

so

you're not gonna have ventricular megaly

so the vegetables are not gonna be very

large they're gonna be normal sized

and the blood can make a cast of the

portion of the ventricle that it's in

as you can kind of see right here this

but it's taking up some space here

and this is a great too

right there is within the ventricle and

you can see here

it's taking up a good portion of the

ventricle

but the ventricles are not enlarged this

is that same patient the initial exam

you see the blood within the ventricle

without ventricular dilatation and then

you can see the blood clot involuting

and contra retracting over a period of

two weeks

and undergoing cystic degeneration as

well and then finally two months later

all that was left was this calcified

plaque here attached to the corey plexus

no ventricular megaly the ventricles are

very small slit like

as you'd expect

grade three

grade 3 is much more severe

it's going to be taking up a lot of the

ventricle and also causing ventricular

enlargement

so it's ivh with ventricular megaly

the ventricular lining can become

echogenic

that's considered ventriculitis over

time the blood products can cause

irritation and cause the

ventricular lining to become more

egogenic and thicker

there's a 20 increase in mortality once

a patient gets at grade three

and a 35 percent increase in

neurological deficits things like

cerebral palsy uh developmental delay

so here you go you got blood right here

here's your thalamus here's your cory

plexus there's a nice

chunk of blood right there and you can

see the entire ventricle is filled with

echogenic material that is

coagulating blood that hasn't coagulated

completely yet

and there's also ventricular dilatation

and then this is the same patient six

months later

and this patient was 34 weeks

gestational age and they weighed

uh 19 27 grams when they were born so

six months later

see the ventricles are kind of prominent

and there's no more blood but there's

good development of the brain there's

gyra and sulci everywhere

and then grade four is intraparenchymal

so a grade four is can happen

just in the parenchyma or involve the

ventricles and the parenchyma so

intraparamob bleed

white matter venous infarct is what they

believe is what causes it

eventually once that blood uh

you know resolves a fluid-filled cavity

will be left in its place

that's a process called encephalomalacia

and the cavity that's left is usually

called a pore encephalic cyst

grade four bleeds have a 50 chance of

mortality

and 90

increase in neurological deficits

so it is the most severe of all the

bleeds

and carries a lot of morbidity and

mortality

here's a very you could tell 27 weeks

gestational age so extreme preemie

you see this is very there's no sulky or

gyrite pretty much

immature brain you see this large

amount of blood within the parenchyma

there's also blood within the ventricle

and there's midline shift so the midline

is being shifted to the left that's

caused from increased pressure which

causes further cerebral tissue damage so

here you see the blood within the

parenchyma and then blood within the

ventricle

here's another one on the opposite side

so you got all this blood here in the

parenchyma

right there here's a perpendicular white

matter region

and then over time you can see it start

to undergo cystic degeneration

and there's also ventricular megaly now

this is two weeks after there's blood

within the ventricle as well

and then over time once the patient's

healed four month interval you can see

there's a large cystic space that's a

poor encephalitis cyst the cystic space

usually connects to the ventricular

system

and it's just filled with cerebral

spinal fluid

here's another one very premature infant

you see the soviet fissures here other

than that not much gyri or sulci

enter hemispheric fissure here and you

can see day one

day two and by day three those are bleed

so remember earlier usually fifty

percent of bleeds happen on the first

day

by the third or fourth day almost all

the bleeds have happened so here's the

blood

on the right side

here you can see it extending from the

ventricle and into the tissue so there's

blood within the ventricle and blood

within the tissue this is cory plexus

not to be mistaken with blood

and over time day 7 and then day 28 you

can see it undergoing cystic

degeneration this one will also have a

pore encephalic cyst like the other

like the other case

this is a patient that presented with

hypoxia

at the very first exam their initial

exam there's no gray white matter

differentiation you can't really make

out any of the structures

this is caused from edema

over time they developed a large

parenchymal hemorrhage on the left

right here all this you can see there's

also midline shift

here's a parenchymal bleed that begins

around the area of the cerebellum in

between the tentorium and the brain or

cerebrum

you see the the structure right here

and transverse

and then in sagittal and you can also

see it is causing

hydrocephalus or ventricular megaly

because it's obstructing the flow of

cerebral spinal fluid

all right so corey plexus cysts

very common

they occur within the chlorine plexus

they are not true cis as they don't have

an epithelial lining

they're pretty commonly seen prenatally

and also in neonates

there has been some association with

trisomy 18

but if no other abnormality is found on

the the fetal ultrasound there's about a

one percent chance that that's that

coreplex assist would be associated with

trisomy 18. if there's other anomalous

features or other markers there's a

about a four percent chance increase of

association with trisomy but still not

very much the increased risk is

essentially the same whether there is a

single choroplex assist or multiple

cysts so if we see a coriplex with two

cysts that doesn't shouldn't raise

concern for anomalies

however

fit up to 15

50 of patients with trisomy 18 have

coreplex assist

but that's a causation versus

correlation issue

and here's a small example of a

choriplex assist

on the right coryplexus very common all

right so cory plexus papilloma

is a rare neuroectodermal tumor

it is a benign tumor does have some

malignant potential but very low

malignant potential

it is most commonly seen in patients

under five years

and is most commonly seen in infants

uh presenting symptoms could be or

science can be macrocephaly

hydrocephalus alter mental status

it is the third most common after or the

third most common brain tumor after

teratoma and it represents about one

percent of all brain tumors

and two to six percent of all pediatric

brain tumors

so here we have a newborn that

presented with microcephaly

and you can see here there's ventricular

megaly and this large

tumor

coming off of the corey plexus and it

turned out to be a choroid plexus

papilloma so here we have her sagittal

and your coronal views and it's on the

left side

it's very big

and as such it's also causing

obstruction which leads to hydrocephalus

so hypoxic ischemic injury it's a very

important condition that happens when

babies are born and they are lacking

oxygen for whatever reason uh they

usually have apogas scores of zero to

three

greater than five minutes

they often present with seizures coma

and or hypohypotonia

associated material conditions are

pre-eclampsia

fetal infections drug and alcohol abuse

maternal drug and alcohol abuse severe

fetal anemia cardiac disease lung

malformations or problems with blood

flow to the placenta

it is estimated prevalence of one to

three per 1 000 life births

redistribution of blood to the brain may

lead to multi-organ failure

initially the sonograms look normal but

it's important to look uh and doppler

the cerebral arteries the anterior

cerebral artery and the middle cerebral

artery and look for the resistive

indices if they're equal or less than

0.55 in the first 72 hours that

indicates

hypoxic ischemic injury of the brain

sometimes you can also see echogenic

lesions within the basal ganglia like

the thalamus or the cardia nucleus but

you might need to use a linear

transistor to see those times i've done

patients that have hypoxic ischemic

injuries

and the brain looks normal with the

curved probe of the microcurve probe and

you use the linear and it shows some

echogenic lesions within the basal

ganglia

you can also develop little echogenic

lesions in the periventricular white

matter too these are usually due to

infarcts and they definitely present

after they are going to be there

all right so this was a

newborn with cardiac arrest and you can

see the initial

dopplers were of low resistive indices

and eventually the baby went on to have

brain death and those reversal of flow

in the cerebral arteries and you can see

the edema in the sylvian fissure

now when you're doppling the

cerebral arteries it's important to know

the patient's cardiac status because if

they have a pain inductive arteriosis

that might change the waveform and cause

some some reversal of flow in some cases

but this one they obviously had good

diastolic flow

with low resistance indices which is

usually due to brain sparing effect and

then they developed reversal flow

which means that the capillary beds of

the of the brain are closed

here's a 32-week gestational age uh

uh baby who had a biophysical profile

uh low score biophysical profile and

then had a cardiac arrest at birth

and here you see the echogenic lesions

around the ventricles ventricles are

prominent and then they became very

enlarged and you see how those echogenic

lesions eventually start to become

cystic those are infarcts

here's another baby with

hypoxia

at birth and you see again

there's no differentiation between the

green and white matter the brain looks

smudgy

that's a sign of edema and then three

months later you see just how much

brain damage there was there's cystic

encephalomatia all over the brain

increase subdural fluid

increased fluid in the centaurium

just a lot of cerebral damage

all right onto periventricular

leukomalacia or pvl our povl is a white

matter disease usually caused from white

matter infarctions

the the periventricular white matter is

normally echogenic as you can see here

um it's less echogenic than the cory

plexus and this is also called the

periventricular blush

now early on in the stages of

ventricular leukomalacia

it can be a little hard to tell

obviously the more premature the infant

is the higher risk they got

and that's why we do serial ultrasounds

if this is expected you know if the

echogenicity of the ventricular white

matter is a little increased they can do

serial ultrasounds to see if they do

eventually end up developing cystic

spaces within the periventricular white

matter which is what would be pvl

typically cystic changes appear about

two to six weeks after the vascular

insult

and these patients also have significant

significant neuromotor impairments

here you have a patient that whose

initial exam looked much like the other

ones very smudgy brain

echogenic

sulci

then

brain stayed looking edematous

with ventricular enlargement and then

eventually they developed

periventricular leukomalacia two months

later you see all these cystic spaces

here's another one

25-week gestational age 720 grams

extremely premature

the initial exams were normal

perivecular white matter looked pretty

decent and the serial exams immediately

started to get some echogenicity

increased echogenicity in the

periventricular white matter

which ended up developing into cystic

spaces which is

pvl or periventricular leukomalacia so

you see out here it's normal and

parasagittal then you start to have all

these little electrogenic spaces

which then become cystic spaces

all right hydrocephalus hydrocephalus is

pretty common uh is an abnormal

accumulation of cerebral spinal fluid

in the ventricles with ventricular

ventricular megaly so the ventricles get

enlarged

there are four types communicating

non-communicating ex vacuole and normal

pressure

uh depending on the severity they may

require a vp shunt or a reservoir to be

placed in to reduce

that uh ventricular megaly which then

puts pressure on the brain which can

lead to brain damage

another cause of hydrocephalus is post

hemorrhagic hydrocephalus and it results

from mechanical obstruction by blood

within the lower parts of the

ventricular system

the trigone and the occipital horn are

the first to dilate

the incidence in surviving infants

that's infants have had

ivh is estimated to be around 15 percent

so around 50 of babies who develop

intraventricular hemorrhage go on to

develop post hemorrhagic hydrocephalus

and 10 to 20 of those patients require a

ventro ventricular peritoneal shunt or a

reservoir to reduce that fluid

here we've got a piece of a case of very

large ventricles so ventricular megaly

and this is important why we need to

you know

get these hydrocephalus cases treated

because the increased blood pressu

because the increased pressure on the

brain can lead to cystic encephalon

encephalomalacia as well so here you see

you've got very large ventricles and the

parenchyma of the brain is very cystic

so lots of white matter disease

here's another case of hydrocephalus

very large ventricles

you can see how thin the parenchyma is

this isn't transverse you can see the

cory plexus oftentimes depending on the

position of the head you can see the the

coreplex is actually dangling

and here's the same patient with a

reservoir

so we went over the extract scale

species real quickly in the other video

but it's good to know again we also

observe and monitor the extra axial

spaces

for increased fluid or blood

this is with the 24 megahertz transducer

off the new ge logic e10 and you can see

the the skin

this is a cranium here cranium here from

here to here is anterior fontanelle this

is a superior sagittal sinus and this is

the arachnoid space so arachnoid space

and then pia mater and then the dura

so if you had fluid above this it would

be subdural but since there's fluid

below this is within the arachnoid space

it's normal and that is a tiny amount so

tiny that you can't even see it this is

with the 9l

you can't even see that fluid

accumulation but with the 24 makers

transducer you can see it

this is the patient we went over on the

other slides and you see the vessels

within the arachnoid matter

and then this is the dura right here

so this is this one is these are normal

and these are benign enlargement of the

subarachnoid spaces this probably

wouldn't even be considered that it's

usually a little bit more than that

here we have

fluid collections on both parietal lobes

right

and then with the 18 megahertz

transducer

you can see

the pia mater

you could also see the arachnoid space

because he has echogenic and he's got

these little vessels when you put the

colored upper you can see the blood

vessels within the arachnoid space and

then this anechoic region here this is

the subdural space so this is subdural

fluid it's usually most likely a

subdural hygroma

sometimes you if there if there's

echogenic fluid there it could be a

subdural hematoma and here's your

superior sagittal sinus again

here's another case with very very large

extra axial space

compression of the brain

this is a subdural hygroma

and due to the increased intracranial

pressure from this extra fluid

you can see that there's some cystic or

porophilic cyst or cystic

encephalomalacia of the of the cerebral

tissue

all right so arachnoid cysts are fluid

filled

sacs with arachnoid lining

they're common they're more common in

males to females at a two to one ratio

and they're often seen prenatally

incidentally and often they are

asymptomatic this is one of the

more normal locations for them

and you can see this is these are

prenatal images in our place we do is

pediatrics but we do women that come for

fetal mris we do their the fetal

ultrasound before they get the mri so

this is the same patient with the mri

so that's an arachnoid cyst

all right so congenital anomalies

there's a very very long list of

congenital anomalies i'm gonna go over a

few

due to the time constraints

so beginning with a genesis of the

corpus callosum

it is rare about one in four thousand

individuals and with a male to female

ratio of two to one

now you can have a genesis of the corpus

callosum which is no corpus callosum at

all it doesn't develop or you can have a

hypoplastic

uh part of the of the corpus callosum

this is called this genesis

usually we have a genesis of the corpus

callosum you're going to have an

enlarged third ventricle or more

prominent appearing third ventricle

it happens usually between the 12th and

the 16th to 20th weeks of gestation

posteriorly you're going to have

copocephali which is enlargement of the

lateral ventricles in a teardrop shaped

fashion

and in coronal you're gonna have a

bullhorn

or a mousse head appearance of the

anterior horns of the lateral ventricles

they look like a u and this because

they're more separate than than usual

there's also another sign called the

race car sign

for that separation of the lateral

ventricles as well

maternal alcohol consumption is a risk

factor

so here we have a sagittal view with the

normal corpus normal corpus callosum

and then we have a sagittal view with

the corpus callosum agenesis so you see

there's a third ventricle and no corpus

callosum and also the gyrite they raid

they radiate instead of going peri

colossal and then lateral or horizontal

they radiate in this fashion

here's a cro here's a coronal view

showing the core uh corpus callosum

right there so into hemispheric fissure

corpse callosum and then here you have

inter hemisphere fissure norco no corpus

callosum

dilated third ventricle and you see the

the two anterior horns the lateral

ventricles are very separated here's

another case where the anterior portion

so the rostrum and genu of the corpus

callosum seem pretty well formed and

then the posterior aspect of it the

splenium

and body

don't see very don't seem very well

formed

it's very thin

and here we have an example of that same

case

so we see the moose head appearance or

the race car sign

and then more posterior you can see

the copulcephaly or the teardrop shaped

ventricles

and here's a side-by-side view of the

ultrasound and mri

you see a teardrop shaped ventricles

there

all right so next up is hollow

procencephaly it is rare there's an

incidence of one per ten thousand to

sixteen thousand light births and a zero

point two percent incidence rate

um the prosencephalon fails to develop

into two hemispheres in this condition

and there's three types there's lobar

semilobar and a lobar

and here you can see the continuum from

normal

to a low bar a low bar being the most

severe one

so a low bar holoprosencephaly i said is

the most severe form it is often

associated with cyclopia

so you have one eye or two eyes fused in

one to one socket proboscis which is a

you know usually protrusion onto the

forehead or around the nose

so it is considered a mono ventricle in

all three cases just in a low bar is

very prominent

there's no cerebral hemispheres there's

no mid lane there's no uh inter

hemispheric fissure

the thalamus

is fused and all the midline structure

are are also fused and the prognosis is

poor

next up is semilobar holoprosencephaly

it is the middle subtype

you can have agenesis or hypoplasia of

the corpus callosum

you have fusion of the frontal and

parietal lobes with separation of the

occipital lobes the prognosis is better

than a lobar so again you have thalamic

fusion and you know the midline

structures will be fused you do have a

bit of an inter-hemispheric fissure

not a clearly seen corpus callosum maybe

some there in the splenium and body

all right and you see the anterior

portion of the brain is completely fused

there's no inter hemisphere fissure

separating the lobes

and then the most common is low bar

holoprosencephaly so less severe type

the fox is present all the way down up

to the up to the corpus callosum you

won't have a caveman septum to plucidum

the anterior horns are fused

you can't have a hypoplastic corpus

callosum as well

and here's a prenatal example of lobar

holoprosencephaly there you can see

there's no certain pellucidum

the anterior horns are fused

but there is a hemispheric fissure

present so the fox is present and there

is corpus callosum

and posteriorly the ventricles do divide

into two separate structures

following up is hydron encephalin

also rare with the 0.2 rate of incidence

it results in a vascular insult after

the 12th week usually of the internal

carotid arteries

you can't have a falx midbrain and below

will be present so you have membrane you

can have basal ganglia you can have

brain stem pons but you're not going to

have any cerebral hemispheres you can

have a fox with just an empty sac fill

the cerebral spinal fluid it is not to

be mistaken with hydrocephalus or

anencephaly there are cases of

hydrocephalus that are so severe that it

appears

that there is a hydranencephaly but even

in those cases you can see a sliver of

cerebral tissue

of the either right or left cerebral

lobe

um and in anencephaly there is no

cranium and it's just flat there's no

brain and the

the head is flat

uh the prognosis is poor and many babies

are still born with hydrogen encephalin

so here we have a case and here you see

the centaurium

and below the centaurium you can see

not very clear structure but you can see

there's mid-brain structures there and

you see there's no cerebral hemispheres

at all you see some maybe thalamic

structures there

and there is cerebellum

and here you can see the falx and just

fluid

so here you see cerebellum

uh pons midbrain fourth ventricle but no

cerebral hemispheres whatsoever

next up is schizocephaly

another rare condition with about 1.5

per 100 000 life births

it is a cortical malformation that

creates a cleft that's lined with gray

matter from the ependyma to the pia

mater there's two types open lipped and

closed-lipped

here's a fetal view showing

these areas here

and this cleft shaped area here that's

schizocephaly

here's a postnatal ultrasound showing

this area here which is schizocephaly

and you see it's on the right lateral

part so here's into hemisphere fissure

and you can see

the split right here

and here's a prenatal example of

holoprosencephaly and schizocephaly so

here you can see the monoventricle

right no hemispheres and then all this

is schizoincephaly so next up is

licincephaly pachygeria complex

now listencephaly is a neuronal

migration disorder resulting in a smooth

brain so there's no gyrite or sulci

aegeria would be no gyrae whatsoever

pachygeria would be broad gyrate and

then less encephalitis is just a smooth

brain surface

now when babies are born very very very

premature their brains almost look like

they have less encephalitis but you can

see as they develop their brain will

start to

create gyri and sulci whereas somebody

who has less encephali

they'll be full term and their brain

will look very smooth so there's two

types which is type one is classically

encephality but it's rare about 11.7

per million births

uh presenting symptoms and signs are

usually hypotonia seizures and

microcephaly usually develops uh by one

year of age

and then type two is cobblestoneless

encephalin which

the smooth brain but the cortical of

tissue has a bumpy surface and it's

associated with walker water break

syndrome and muscle eye brain disease

so here's a full term baby for two weeks

2950 grams they have a grade one bleed

but if you notice their brain is very

smooth so this is the appearance of a

brain of a very premature infant but

they're 40 weeks full term and full

weight and you see there's just no

gyrations

or sulci

and here's another one that on first

on first appearances might give the

appearance of absent cave and septum

pelucidum which it is there is no cave

in something to blossom or so maybe uh

you know mono ventricles so maybe

holoprosencephaly but as you can see

here cavemcet and pellucidum a genesis

there's also some third ventricular

enlargement

and

from the posterior occipital view you

can see that there's a cystic structure

here

that connects right here so there's

vermin hypoplasia or a genesis and a

posterior phosphate extending outwards

which is a posterior encephalocele and

also if you look this is a full term

baby you can see that the brain is very

smooth

it lacks gyri and sulci

so this is a case of walker warburg

syndrome

which is sometimes known as heart

syndrome it is a lethal form of

congenital muscular dystrophy they

typically have hydrocephalus

neuronal migration anomalies are present

so algeria or lysocephaly most likely

cobblestone listens heavily

they'll have a dandy walker continuum

they also have retinal dysplasia a

posterior encephalocele and cerebellar

malformations

all right so that concludes this

presentation

the list of pathologies that can be

found in neuroanatomy and neuropathology

are very very vast

i just hope i can covered a good amount

of pathology maybe some stuff that you

guys haven't seen before and again i

want to thank the asa for inviting me to

speak it has been quite the honor you

guys can follow me on

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much and take care