0:00

So this was a one day old infant

0:02

who was a former 35 week gestational age premature infant

0:06

who came to screening head ultrasound.

0:09

Um, I actually don't have a great history

0:11

for why we imaged this infant on Day

0:13

of life one instead of day of life seven.

0:15

So there must have been some clinical concern either based

0:17

on exam or laboratory wise.

0:21

So on this ultrasound, we again start

0:23

with our baby head transducer in the coronal plane going

0:26

anterior to posterior.

0:28

As we are going anterior to posterior,

0:29

we immediately see some abnormalities.

0:31

So we have abnormal epigenic hemorrhage in the

0:34

bilateral lateral ventricles.

0:36

Um, ventricle caliber is just within normal limits,

0:39

so at least grade to germinal matrix hemorrhages,

0:43

not a normal study.

0:45

Um, uh, certainly on day of life one,

0:48

the per ventricular white matter can be

0:50

challenging to evaluate.

0:52

So, uh, we'll look on this sagittal plane

0:53

to see if we think this echogenicity

0:55

of the periventricular white matter is within normal limits

0:58

or not so posteriorly.

1:00

Um, and then we go to our angled off access coronal images.

1:04

Looking along the peripheral aspect of the brain

1:06

and especially the middle cranial fossa looks normal on the

1:10

right on the left side, it looks pretty normal.

1:12

This white matter keeps catching my eye.

1:14

On the left side,

1:16

the tech has measured the frontal hor lateral ventricles.

1:19

They are just within normal limits for size,

1:21

so could be grade two.

1:23

Um, if we think they're dilated,

1:24

we would call these grade three germinal matrix hemorrhages.

1:27

Going to our sagittal plane images, we start off midline

1:30

and we're going to the right.

1:31

We have a nice normal looking corpus Callum,

1:34

normal looking cerebellum so far.

1:37

We have our anterior cerebral artery, um, filling in

1:39

with color doppler image.

1:41

As we're going to the right.

1:42

We see this abnormal echogenic material in the uh,

1:46

right lateral ventricle, not just confined

1:48

to the um, germal matrix.

1:50

Um, the paraventricular white matter I think looks

1:52

okay on this image.

1:54

Coming off to the left side, we again see hemorrhage filling

1:57

that uh, left lateral ventricle.

2:01

So probably just grade two at this point.

2:03

Um, if we thought they were dilated it would be grade three

2:06

and this per ventricular white matter probably just within

2:09

normal limits for genicity.

2:12

Um, so in this patient it would be important

2:14

to follow up with this infant.

2:15

Does over time, um, again,

2:17

we're just seeing images showing us nice normal color

2:20

doppler fill in of our superior cyral dur venous sinus.

2:23

We switched to our linear high frequency transducer

2:25

to get a little bit better detail

2:27

of not only this hemorrage,

2:28

but um, any other abnormalities we might see.

2:32

Um, so I think this is just gonna be

2:34

anisotropy this abnormal.

2:35

What I was wondering if it's normal

2:37

or abnormal per ventricular, uh, white matter genicity

2:40

'cause we have these nice lines going through the area.

2:42

So with antrop it is an artifact

2:45

that we see at ultrasound when we have perpendicular

2:48

epigenic, linear foci that we're hitting

2:50

with our transducer.

2:52

So I think this is gonna be just within normal limits

2:54

for day of life.

2:56

One imaging we see on the right, it has this nice normal,

2:58

Uh, linear appearance

3:01

and on the left it's been excluded unfortunately from view

3:04

on this left side, but I think

3:05

that's probably gonna be within normal limits.

3:07

Our cerebellum does look normal, so nice,

3:08

normal heart shape, normal looking verus no abnormal

3:11

hyper coic material.

3:13

But this infant's gonna be important to follow up as long

3:16

as there's no other need

3:17

for imaging sooner than in one week at one week of life.

3:20

We'll get a look at what this infant looks like

3:22

to follow up not only the blood

3:24

but see what that white matter does.

3:26

So this patient came back for imaging two days later.

3:30

Um, so they were clinically very worried

3:31

that something else was going on with this infant.

3:33

So we didn't wait one week of life

3:36

to do screening head ultrasound.

3:38

We image them only, only two days later.

3:40

So again, we're starting with our baby head transducer in

3:42

the coronal plane going anterior to posterior.

3:45

This patient was left side down rather than supine

3:48

for clinical care purposes.

3:50

Um, but the good news is we can angle our transducer

3:53

however we want to try to get those normal anatomic planes.

3:56

So as we go anterior to posterior, we're gonna look

3:59

for any changes of that hemorrhage

4:01

that we saw in that prior study.

4:02

And we can again see

4:03

that there's hemorrhage filling both lateral ventricles.

4:07

It's important to note that our right side is gonna be up in

4:10

this infant who is left side down.

4:12

And so the blood is going

4:13

to go dependently towards the left side

4:16

of the lateral ventricle on this right side.

4:18

So that's why it has that sort of funny appearance

4:20

where it looks like it's medial.

4:22

As I'm looking at these images, there is something else

4:25

that is newly wrong with this infant.

4:27

So remember on that first study, uh,

4:30

we had normal looking extra AAL spaces at the vertex.

4:33

We had normal color doppler fill in when we were looking at

4:36

our superior sagittal dur venous sinus.

4:38

But this doesn't look like a normal dur venous sinus to me.

4:41

This looks like a, a triangle that is full

4:43

of genic expansile material.

4:46

So we'll uh, play close attention to

4:48

what our color Doppler images look like,

4:50

but this looks like thrombosis

4:52

of the superior sagittal dur venous sinus to me.

4:55

Um, so we have a little bit

4:56

of evolving intraventricular hemorrhage,

4:58

but a new finding of dur venous sinus thrombosis.

5:01

But let's go find the color Doppler image that's gonna show

5:03

that a little bit better for us.

5:04

We continue from anterior posterior looking at the per

5:08

ventricular white matter.

5:09

This infant is still less than one week of of life,

5:12

but this periventricular white matter is at the upper limit

5:15

of normal genicity.

5:17

Um, but again, this superior duro venous sinus is

5:20

continuing to catch my eye.

5:21

It is too echogenic, too expansile.

5:24

Um, I don't see anything along the, um, peripheral aspects

5:27

of the brain on either side.

5:30

Um, okay, so here's where we're gonna pay close attention.

5:32

So we see our anterior cerebral artery coming around.

5:35

We see part of the per collosal branch.

5:38

I'm not seeing fill in

5:39

of the superior sagittal dur venous sinus just yet.

5:42

Let's see if the stenographer gave us more images.

5:44

Trying to, trying to show that again,

5:47

I don't see any color Doppler fill in

5:49

of the superior sagittal dural venous sinus.

5:51

Let's see if she gave us some magnified images at

5:54

that vertex to show us that a little bit better.

5:57

Again, we have nice normal fillin of circle

5:59

of vous structures, anterior cerebral artery

6:02

and deep venous structures, no fillin.

6:04

I see one little draining cortical vein

6:06

that I don't see my superior sagittal venous

6:08

sinus filling in with color.

6:11

Okay, so our machines have a microvascular imaging technique

6:15

where our texts can press a button to,

6:18

they will use both color doppler, power doppler

6:21

and then they will turn on a microvascular

6:23

imaging technique.

6:25

It's not a doppler technique,

6:26

but it's looking for very slow flow.

6:28

I see a couple of little, uh,

6:30

superficial draining cerebral veins,

6:32

but I only see a tiny little thread like amount

6:35

of flow in the anterior aspect

6:37

of the superior sagittal sinus.

6:39

A little bit of thread like flow posteriorly.

6:42

So this is an unfortunate case

6:43

of superior sagittal dural venous sinus thrombosis.

6:47

I see the same findings on this linear high

6:49

frequency transducer image.

6:51

I'm not ignoring this, uh, blood in both of the ventricles

6:54

with a little bit of dilation.

6:56

Now I would call this, so still grade two

6:59

germ matrix hemorrhage.

7:00

Um, and now we're developing mild ventricular mely.

7:03

So we're developing post hemorrhagic hydrocephalus.

7:06

But again, the most important finding is this new finding of

7:09

superior sagittal dro venous sinus thrombosis.

7:13

Um, let's see if we have any other, um, images of

7:15

that area or any sinus.

7:17

And I don't have any color doppler sinus to evaluate

7:20

that better, but we're gonna recommend an MRI with MRV

7:24

for this infant to better delineate, uh, all

7:26

of the abnormalities, including the extent

7:29

of the dur venous sinus thrombosis again,

7:32

when this patient is clinically well enough

7:33

to be transported to the magnet.

7:36

So later that same day actually the infant had underwent

7:39

the, uh, follow-up head ultrasound later

7:41

that same day came to MRI.

7:43

So this image on the top left-hand corner is a T one

7:47

sagittal weighted image,

7:49

and we see a little bit of linear, uh,

7:52

T one signal hyperintensity in a draining cortical vein.

7:55

We see T one signal hyperintensity corresponding

7:58

to the hemorrhage in the dependent aspect of the,

8:01

um, lateral ventricle.

8:03

Not sure if this is left or right,

8:04

but we have bilateral intraventricular hemorrhage.

8:07

The other important finding is this abnormal T one signal

8:11

hyperintensity along basically the entire aspect

8:14

of the superior sagittal dural venous sinus all

8:17

the way to the toula.

8:18

Some of this intrinsic T one hyperintensity may be a little

8:21

bit of hemorrhage also along the tentorium,

8:24

but let's look at the axial.

8:25

So this is an axial T two weighted image where we see, um,

8:29

expansile, low TTU signal clot, um, in the toula,

8:33

um, at the inferior aspect.

8:35

Now we're going into our superior sagittal dur

8:37

venous sinus superiorly.

8:39

We see low signal hemorrhage in both

8:41

of our ventricles on the left larger than right.

8:45

Uh, so bilateral grade two germinal matrix hemorrhages

8:48

with ventricular magaly

8:49

and that low signal of clot extends all the way

8:52

to the vertex of the superiors dur

8:54

Venous sinus.

8:55

And we see these little squid like low signal foci in

8:59

the draining cortical vein.

9:00

So we have some superficial, uh, vein thrombosis

9:03

as well in this infant.

9:05

Going over here to our susceptibility weighted series at the

9:09

bottom left here, we see unfortunately some very

9:13

pronounced blooming

9:14

or susceptibility artifact related to all

9:17

of these areas of thrombosis.

9:19

So in these, uh,

9:20

superficial draining cortical veins in the superior sagittal

9:23

dur venous sinus extending all the way down to the toula

9:26

and probably into both of the, uh, transverse

9:30

dur venous sinuses as well in the posterior fossa.

9:33

Just looking at our diffusion weighted image here on the

9:36

bottom right hand side, we have some, uh, associated, uh,

9:39

high signal or diffusion restriction corresponding

9:42

to the areas of blood.

9:44

Um, but to me the, uh,

9:45

para ventricular white matter looks okay on these images.

9:49

I don't see any like intrinsic hyperintensity.

9:51

So I think this T one signal hyperintensity we could see in

9:55

that sulcus was probably one

9:56

of these little draining cortical veins that was,

9:58

that was thrombus maybe.

10:00

Um, and I don't, I don't see anything else.

10:03

This is a little bit of a suboptimal signal to noise ratio

10:07

sagittal T one image,

10:09

but, uh, I don't see any, uh, definite evidence

10:11

of white matter injury of prematurity in this infant,

10:14

but definitely intraventricular hemorrhage bilaterally

10:16

and extensive dual venous sinus thrombosis.

10:19

A new finding compared to day of life, one a few days later.

10:23

Um, imaging the same infant.