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All right, now let's go to the case two. Remember,

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you will get the question again after looking at the case.

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This is a newborn baby who

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was born with multiple complications, preeclampsia,

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and is a full term baby

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who was suspected to have hypoxic ischemic encephalopathy.

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This patient got cooled and also got lipoprotein.

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And now we have the ultrasound superficial images of

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both the necks. This is just

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inferior to inferior to the subular region and above

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the supraclavicular region. You see this hyper echoic area

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with some small cis formation homogeneously,

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hyper eic, then esent muscles,

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same thing you can see on the left side.

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So on colored doctor images you can see,

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can you see my colored doctor images? Give me one second.

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On colored doctor images, there are, there is some internal vascularity.

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So can we share the questions? Okay.

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In a full term baby who has got an epo protean,

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what is the best possible diagnosis?

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Cool. 50% are correct.

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So HESIs Heman miosis is a correct answer.

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I'm going to show the most interesting case set here.

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Here is the post contrast study we did the twist protocol,

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as everyone knows, twist protocol includes using the radio, uh,

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using the gadolinium,

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which stays in the intravascular compartment for a very long time.

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I would like you to look at these images, which will, uh,

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definitely confirm that this is all hemangiomatosis. These are the superficial,

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um, soft tissue prominent areas we saw on the ultrasound,

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which homogeneously enhance

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on T2 bed images. However,

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the classic description of these emans,

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tiny superficial cutaneous emans,

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the book picture is cluster of, um,

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grapes or multiple cystic hyperintense, uh, foci.

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However,

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this is a brand new baby and he did not get enough time to develop that yet.

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You can see there is diffuse swelling of the subcutaneous tissues

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and there is vascularity as we saw in the post contrast study on the, um,

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Corona images. Again, these are the Excel images demonstrating the same.

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There is no

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Extension into the media sternum.

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There are a few pertinent negatives which we have to report.

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There is no in intermedia standard extent and also there is no intracranial

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extension.

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So this patient then got propranolol and got better.

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So this was diffuse hemangiomatosis,

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so diffuse hemangiomatosis, which was erythropoietin related.

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In this particular patient, uh,

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EPO receptors are usually found in the endothelial brain,

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cardiovascular and other tissues, and is used for neuroprotection.

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We know that it causes endothelial proliferation in addition to the cooling of

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the premature infants.

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That helps in protection of the brain in the patients who are suspected to have

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diffuse hypoxic ischemic injury. However,

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the side effects of this drug is abnormal proliferation of the tissues at

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different sites, and because there is proliferation of the endothelial cells,

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they can cause bleeding or congestive heart failure from over circulation.

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On radiology classic teaching on T2 weighted images, uh,

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we see multiple tiny hyperintense areas, uh, corresponding to,

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uh, multiple fluid spaces, uh, which look like bunch of grapes.

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Now, def diffuse heen angios,

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they are capillary hemangiomas,

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which are multiple and innumerable in number. Uh,

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they are slow flow lesions. Slow flow lesions are, uh,

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typically capillary heman, angiomas, renal lymphatic malformations, et cetera.

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The other types which are high flow lesions are AV fistula or

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AV malformation.

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The typical distribution of diffusing is,

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is along the long axis of the body. They can sometimes, uh,

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form heterogeneous masses because of internal bleeding and, uh,

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complex vascularity,

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but most of the times they will demonstrate homogeneous signal intensity and

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depending upon the fat component, we will see, um,

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hyperintensity on T1 weight images. And as we saw on ultrasound images,

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there was quite hyper echoic area, um,

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that was corresponding to the fatty component.

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So this case is a very good case of side effect of the EPO protein,

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which is, um,

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which is neuroprotective in a patient who has hypoxic ischemic injury. Uh,

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this patient responded very well to propranolol, which is,

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which does just the opposite of what erythropoietin does to the endothelial

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cells.