Ultrasound of the Neonatal Head and Spine | GE Healthcare
Summary
TLDRThis 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
🎓 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.
🧠 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.
📐 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.
🔍 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.
🦴 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.
👶 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.
🩺 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.
🧊 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.
🌟 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.
👶🏻 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.
📚 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.
Mindmap
Keywords
💡Ultrasound
💡Neonatal
💡Cranial Ultrasound
💡Interventricular Hemorrhage
💡Posterior Fontanelle
💡Ventricles
💡Cerebellum
💡Spinal Ultrasound
💡Corpus Callosum
💡MCA Doppler
💡Sacral Dimple
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
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