0:00

So this is a two day old former premature infant who came

0:04

to screening head ultrasound.

0:05

This patient was transferred from an outside institution,

0:08

and so our, our images are gonna

0:10

be just a little bit different.

0:11

They used a sector transducer rather than

0:13

that curved small footprint baby head

0:16

transducer, but that's okay.

0:17

We can still see some of the same abnormalities,

0:20

so they start sagittal at midline.

0:22

We have a normal corpus callosum.

0:24

They are, uh, coming off to the right.

0:26

We see a normal variant septal vein in this

0:29

calum septum lucidum.

0:31

But there is some abnormal epigenic material

0:33

that we are starting to see in the germinal matrix here,

0:37

not just confined to the, uh,

0:39

anterior co themic groove region.

0:41

Um, coming off to the left side now, uh,

0:44

we also have some abnormal genic material on the

0:48

left side as well.

0:49

So let's go find that in the coronal plane next.

0:53

So we have that abnormal genic material is confirmed

0:57

in the paral plan as well.

0:58

So right, we have this abnormal academic focus, um, filling

1:03

that right frontal horn, lateral ventricle on the left side.

1:07

Um, a our ventricle is, uh, just mildly enlarged

1:10

with rounding of that frontal horn lateral ventricle.

1:13

We see that hemorrhage in the left ventricle a little bit

1:16

more posteriorly in the coronal plane.

1:18

Um, filling and expending both of the lateral ventricles,

1:22

right more so than left but abnormal bilaterally.

1:26

This white matter is at the upper limit of normal.

1:29

Um, for me, I'm,

1:30

I'm wondering if there's gonna be a little bit

1:32

of white matter injury if prematurity in this infant.

1:35

Um, let's go back to the, um, sagittal plane.

1:38

We'll look at the cinematic images to see if we think

1:40

that's a real finding or not,

1:43

and that that per ventricular white matter on the right side

1:47

in the uh, parietal posterior paral region is at

1:49

the upper limit of normal.

1:50

So this, this would be an infant that I would say, um,

1:53

borderline hyper coic per ventricular white matter,

1:57

which could be seen with, um,

1:59

white matter injury prematurity.

2:00

And we would follow up what that does over time.

2:03

It does look asymmetric compared to that left side.

2:06

Um, we'll go to the Corona Sase to, uh, see

2:09

that one more time and it's just a little bit asymmetric on

2:12

that right side compared to the left.

2:13

So there, there are definitely bilateral grade three

2:17

germinal matrix hemorrhages with ventriculomegaly

2:20

and questionable, uh, white matter injury

2:23

of prematurity on that right side.

2:26

So we'll see what this patient does at follow up.

2:29

So then this patient was transferred to our institution,

2:32

to our NICU and we repeated head ultrasound.

2:35

So this is 10 days after that initial head ultrasound.

2:39

So we're using our baby head transducer in the coronal plane

2:42

going from anterior to posterior.

2:44

The ventricle caliber is pretty similar to that first study.

2:47

We still see abnormal hyper coic material filling

2:52

and expanding both of those, uh,

2:55

lateral ventricles posteriorly. It's challenging

2:58

To tell for me where is posterior germinal matrix

3:02

and what is intraventricular material.

3:04

So let's go to the sagittal plane to see if we can, uh, tell

3:08

what is happening there while

3:11

we're still in the coronal plane.

3:12

Unfortunately that, uh,

3:14

abnormal hyper coic material in the per ventricular white

3:17

matter does persist and is actually more pronounced here.

3:21

So, um, this is actually going to be, uh,

3:24

per ventricular hemorrhagic venous infarction

3:27

on this right side.

3:28

Um, maybe a little bit of white matter injury prematurity on

3:32

that left side as well.

3:33

Let's go to the sagittal plane to get a better look at that.

3:38

Unfortunately, on these off axis images first, um,

3:42

we have enlargement of our atria of the temporal horn

3:45

of our right lateral ventricle.

3:47

So posteriorly we have ventricular mely

3:49

that looks more pronounced than that first study we had

3:51

of this infant, less so on the right,

3:54

but definitely bilateral, uh,

3:56

ventricular mely right worse than left

3:58

with right-sided per ventricular

4:00

hemorrhagic venous infarction.

4:02

Our superior sagittal dur venous sinus is patent.

4:06

As we come to our, uh, sagittal plane, we get again,

4:09

get a look that these superior sagittal dur

4:11

venous sinus patent.

4:12

We see our anterior cerebral artery coming

4:14

around the collosal branch here, um, filling in nicely

4:17

with color as we're going to that right side.

4:21

Um, we can definitely see uh,

4:23

ventricular mely on this right side.

4:25

So this is kind of a complex case

4:27

where we'll be descriptive.

4:29

So we have, uh, germinal matrix hemorrhage filling

4:32

and expanding the, uh, lateral ventricle on that right side

4:36

with, um, more conspicuous per ventricular

4:39

hemorrhagic venous infarction.

4:41

And we're also developing some post

4:42

hemorrhagic hydrocephalus.

4:44

So the lateral ventricle is enlarging in size over time.

4:48

So this will be an infant that, uh,

4:50

unfortunately will be imaged at multiple time points over

4:54

the course of the weeks and months of this infant's life.

4:57

As this hemorrhage evolves

4:59

and as these ventricles most likely will become larger in

5:02

size over time to follow up this post hemorrhagic

5:05

hydrocephalus to see if

5:08

and when they need to place a, uh,

5:10

ventricular drainage catheter to be able to drain some of

5:14

that CSF from those dilated ventricles.

5:16

The left is less dilated than the right in this infant.

5:20

On our trans mastoid images,

5:22

we have a nice normal looking cerebellum,

5:24

nice normal heart shaped cerebellum.

5:25

We do get another look at this blood in the occipital horn,

5:29

lateral ventricles bilaterally, uh, right more so than left.

5:33

This is a nice example of normal color doppler fillin

5:37

of our transverse dural venous sinuses bilaterally.

5:40

We might be at the level

5:41

of the sigmoid sinus on this left side,

5:43

but nice normal color Doppler fillin of both sides

5:46

of the poster phos venous sinuses.

5:49

We switched to our coronal linear high frequency transducer

5:52

image to get, uh, just a little bit more detail

5:54

of the same findings.

5:55

And actually I'm

5:57

Noticing that the, uh, peri ventricular white matter is

5:59

abnormally hyper coic on this left side as well.

6:02

Um, so that could be peri ventricular

6:04

hemorrhagic venous infarction.

6:06

It could be white matter injury of prematurity that is hard

6:09

to tell at an ultrasound.

6:10

This patient needs to go undergo MRI screening as soon as he

6:14

or she is clinically well enough to be transported

6:17

and, uh, kept warm in the magnet to,

6:20

to better evaluate that over time.

6:23

So this is a case of lots going on,

6:25

but the main learning point here is over time,

6:28

post germinal matrix hemorrhage.

6:30

Uh, you wanna be careful to look

6:32

for post hemorrhagic hydrocephalus

6:35

and be sure that you're comparing ventricle size over time

6:38

between studies to, uh, see if

6:41

and when an infant might need, uh,

6:43

ventricular drainage catheter placed

6:45

by our neurosurgery colleagues.

6:47

And that's probably why that infant was transferred

6:49

to our institution to undergo, uh, for

6:53

VP placement.