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This was an 11 day old,

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former 32 week gestational age infant who presented

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for screening head ultrasound

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after a clinical diagnosis of necrotizing enteritis.

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So the clinical team was worried about either germinal

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matrix hemorrhage or white matter injury

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prematurity in this infant.

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So we're starting with our curved array,

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small footprint baby head transducer in the coronal plane

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going from anterior to posterior.

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Um, we have nice normal sized,

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although symmetrically, diminutive

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frontal horn, lateral ventricles.

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We have a normal Calum septum lucidum.

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This infant does have a little bit of genic,

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bilateral thalami.

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There is a little bit of abnormal hyper coic

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material at the left anterior, uh,

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germinal matrix at the coth thalamic groove.

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We'll make sure we look at that on the sagittal plane

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to confirm if that's a real versus not finding.

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Um, the other thing that's catching my eye

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as we're going from anterior to posterior is this abnormal,

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asymmetric, patchy focus of hyper echogenicity.

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Um, at, at the superior aspect of the, of the, um,

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per ventricular white matter here.

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This infant still does have

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some normal looking posterior germinal matrix.

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This hypoechoic linear structure paralleling the lateral

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ventricles and we're just coming more posterior.

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We do have a little bit of hyper echogenicity, um,

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posteriorly, but let's go look on the sagittal plane

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to see if that finding persists.

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On our, on our off axial coronal plane imaging,

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there's no abnormal hyper, hyper coic

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or collections along the middle cranial

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fossa on either side.

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Left looked okay, right, also looks okay to me.

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Our superior sagittal dural venous sinus fills in normally

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with collar dopper imaging in both the coronal

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and sagittal planes.

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Uh, we have a nice normal looking anterior

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cerebral artery coming around.

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We have our uh, uh, basal artery vertebral artery.

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We see part of, uh, circle wills structures here

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on the sagittal images.

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We have nice normal looking midline structures.

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So normal corpus callum, normal calum septic lucidum normal,

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uh, midbrain, pons, medulla ble, normal looking cerebellum.

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Let's go find that periventricular white

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matter that caught our eye.

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So here we are coming off to the right side.

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I don't see anything abnormal at

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that right coth themic groove.

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Um, on the right side, the per ventricular white

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matter looks okay.

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It's less genic than the adjacent choroid plexus.

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Um, coming over, let's look at that left side

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actually, I'm gonna change my mind.

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There's some abnormal patchy material here, um, at the,

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like sort of prior to occipital region of

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that periventricular white matter.

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Um, let's go find that left side that caught our eye on the,

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on the coronal plane

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and it sort of has a similar appearance to that white

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to that right side.

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Um, but it's more conspicuous on this

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Left side. So do you see

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these abnormal echogenic foci here, um,

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at the prial parietal occipital region

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of the per ventricular white matter.

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So white matter of in of prematurity is a watershed type

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of an insult and it occurs at the frontal parietal region

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in the parietal occipital region of the,

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of the lateral ventricles.

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So this to me is concerning

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for white matter injury of prematurity.

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Um, we switched to our coronal coronal, um, we switched

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to our linear high frequency transducer

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and we basically repeat the same study over again.

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So, um, we're going coronal anterior to posterior.

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We can get another look at this.

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Uh, peri ventricular white matter.

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There's a little bit of abnormal hyper genicity on

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that right side and that left side.

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Let's go back and look at the, um, coth thalamic groove

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to see if we believe that

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that germinal matrix hyper coic foci was real.

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And I do think we have a little bit

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of asymmetry on this left side compared to the right side.

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Um, so let's go confirm that on the sagittal plane,

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the tech has measured nice normal ventricle sizes for us.

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Thank you. Um, let's go to the left.

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Caught at the limit groove on the sagittal plane

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and I do think there's a little bit

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of abnormal genic material sitting here.

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So this is our caudate head.

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This is the thalamus

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and there's abnormal epigenic material sitting right on top

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of that coth thalamic groove.

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So this is gonna be grade one germinal matrix hemorrhage in

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this infant on the left side.

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And again that abnormal, uh, kind

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of patchy hyper coic period ventricular white matter.

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So this is concerning for white matter injury

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of prematurity in this infant.

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Our cinematic images are gonna show us similar findings.

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Um, our small footprint, uh, baby head transducer

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as we go anterior to posterior.

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We see that genic focus at the anterior uh,

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germal matrix on the left.

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And as we go posterior,

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we see some patchy periventricular white matter bilaterally,

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but left more pronounced than right on the um,

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uh, sagittal plane as we're going from the midline.

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So midline towards the right.

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Um, a little bit

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of patchy hyper coic periventricular white matter.

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This is gonna be the CNA going from

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midline towards the left.

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And we already saw that it's a little bit more conspicuous

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on the left side compared to the right.

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So some abnormal per ventricular hyper genicity concerning

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for white matter injury of prematurity on this ultrasound.

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So the good news is we can confirm this on an MRI.

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So this is a screening head ultrasound.

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Once the infant is clinically stable enough

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to be transported to the magnet to undergo MRI imaging,

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we can confirm all of these findings that we were, um,

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worried about on this head ultrasound.

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Okay, so this infant, uh,

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after that screening ultrasound came to MRI

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to more definitively evaluate the brain.

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So we're gonna start with this sagittal T one weighted image

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in this top left hand screen.

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And um, this is a motion degraded study.

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Unfortunately, we do not sedate infants, um,

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to undergo brain MRI

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unless we absolutely have to at our institution,

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we'll do a feed and bundle technique of imaging.

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So we'll make the baby fat happy, ready for nappy,

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and then put them in the magnet.

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Um, so we feed them, we make them warm, we swaddle them,

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and we have them take a nap in our magnet.

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Um, sometimes that can take a while.

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So the um, pertinent uh,

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positive findings in this in this head ultrasound are these

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subtle T one hyperintense signal foci in the per

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ventricular, uh, regions

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that correspond nicely unfortunately to that, uh,

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those patchy hyper coic foci that we saw on the ultrasound.

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So that was the left side.

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On the right side, we actually have

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similar abnormal findings.

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So these low signal foci of T one hyperintensity

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in the, uh, parietal occipital parietal regions

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of the per ventricular white matter.

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So this is white matter injury of prematurity.

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Um, I will scroll through.

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This is our axial T two weighted image

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and then this is our susceptibility weighted MR sequence.

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Um, axial on on this lower, uh,

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bottom left hand screen

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and we can see the correlate for

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that epigenic focus we saw at the anterior germinal matrix

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at the CODO thalamic groove on

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that screening head ultrasound.

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So we have a little bit of hemorrhage grade one germinal

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matrix hemorrhage on that left side of this infant as well.

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Last but not least, we'll scroll

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through our diffusion weighted imaging just

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to make sure we don't see any evidence of acute infarction

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and there's no, no abnormal areas of diffusion restriction.

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We do see some low signal foci of that, uh, of

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that germinal matrix hemorrhage.

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So this is left grade one germinal matrix hemorrhage

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with white matter injury of prematurity.