0:00

So this was a patient who was a three month old,

0:03

former 34 week gestational age infant who was on ecmo.

0:08

So patients on extra corporeal membrane oxygenation,

0:13

also called extra corporeal life support,

0:16

are critically ill from either a cardiac standpoint and

0:19

or a pulmonary standpoint.

0:21

And I can't remember, or I don't know, uh,

0:23

why this patient was on ecmo,

0:25

but those patients undergo screening head ultrasound every

0:28

day because they're at increased risk, not only

0:31

of hemorrhage because they're anticoagulated

0:33

for the ECMO circuit, but they're also at increased risk

0:35

of thrombus and uh, ischemia.

0:38

So this patient, uh, underwent one

0:41

of our morning screening head ultrasounds on ecmo.

0:44

So we start with our baby head transducer,

0:46

that curved array, small footprint,

0:48

mid frequency transducer in the Corona plane

0:51

anterior to posterior to start.

0:53

This patient was left side down probably

0:55

because the ECMO circuit was in the right side.

0:57

Um, those very large cannula were in the right, uh,

1:00

neck in this infant.

1:02

So we're, uh, still imaging anterior to posterior.

1:05

And the first thing that is catching my eye are

1:07

that these extra axial spaces at the vertex are large.

1:11

Uh, the lateral ventricles look pretty normal in caliber.

1:15

This does look like, uh, at this point now a term infant.

1:18

We have lots of soci. Our YL fissure is nice and curvy.

1:22

Uh, we have appropriate sulfation, um,

1:24

for past term gestational age,

1:26

but we're gonna play close attention

1:27

to these extra axial spaces in this

1:29

infant on this right side.

1:31

Um, I do see nice normal vascular

1:34

structures on this left side.

1:35

I'm starting to see this linear structure that is, uh, sort

1:39

of paralleling the, the brain parenchyma on this left side.

1:43

So let's see if we have some more images here.

1:46

And as the attack is angling even more posteriorly

1:49

to show us the posterior extra axial spaces at the vertex,

1:52

the right side looks abnormal, as does the left.

1:55

So on the left side, we see this linear academic, uh,

1:59

structure that is parallel to the brain Parma,

2:02

and I'm concerned this is gonna be

2:03

displaced arachnoid monitor.

2:06

On these grayscale images,

2:07

I see these bridging vascular structures

2:09

and arachnoid granulations that stop at

2:12

that linear genic structure that displaced arachnoid matter.

2:16

On the right side, we have sort of similar findings,

2:19

but I don't see the displaced

2:20

arachnoid matter quite as well.

2:22

But I do see that there is displacement

2:24

of those normal bridging structures towards

2:27

the brain parenchyma.

2:28

So there's this, uh, hypo coic

2:30

or perhaps anti coic subdural collection

2:34

that is displacing those bridging structures down

2:36

towards the brain parenchyma.

2:38

This is showing us exactly the same thing.

2:41

So we don't see these normal bridging structures extending

2:44

all the way to the entertainment of the calvarium.

2:46

They're displaced towards the brain.

2:48

Parenchyma a little bit more pronounced posteriorly on the

2:51

right compared to the left, although I saw it.

2:52

We saw it together first on that left side.

2:56

Um, so let's keep looking at, uh, other images that the

2:58

Sonographer has gotten. She

2:59

has measured our frontal horn, lateral ventricles.

3:01

This is within normal limits.

3:03

Despite that there's a little bit of size asymmetry.

3:05

Uh, we don't have too much rounding

3:07

of our frontal horn, lateral ventricles.

3:09

Some might consider this to be at the upper limit of normal

3:11

or mildly dilated on that right side as we're angling off

3:16

to the right, I don't see any abnormal extra axial material

3:19

or any parenchymal abnormality on our off axis

3:22

coronal images towards the right.

3:24

We'll look at the same thing on the left to see

3:26

how far this, uh, subdural collection extends.

3:29

And I, I see it stopping here well

3:32

before it hits the middle cranial faucet inferiorly.

3:34

I don't see anything in the parenchyma that's abnormal.

3:37

Uh, importantly the tech has put on, uh,

3:40

color doppler imaging.

3:41

We see nice normal flow of our sagittal dural venous sinus.

3:45

We see normal structures in the subarachnoid

3:48

space filling in with color.

3:49

I don't see any, anything filling in

3:51

with flow in this subdural space.

3:53

Let's see if we have some better looks.

3:56

Oh, look how, unfortunately, a nice example

3:59

of a subdural collection on the sagittal plane.

4:03

So we see this sharp demarcation

4:05

of subarachnoid space closer to the brain, parenchyma,

4:09

arachnoid, modern, and then subdural space.

4:12

So this is a subdural collection on this right side.

4:16

We won't say that it's hemorrhage because it's not genic.

4:18

This must be a new finding that we saw on this infant

4:21

who is three months old.

4:23

Um, but it's not genic for us

4:24

to say this is subdural hemorrhage.

4:26

It's just a subdural collection.

4:28

Okay, here is where we're gonna see better detail.

4:31

We have switched to our linear high frequency transducer,

4:33

um, where we're gonna pay close attention

4:35

to these extra axial spaces.

4:38

Again, uh, right larger than left bilateral subdural

4:41

collections in this infant on ecmo.

4:44

So we'll just make sure that we call our clinicians

4:46

and tell them that there are some new subdural collections,

4:49

but they are, they're anti coic appearance.

4:51

And so we'll keep a close eye on what,

4:53

what these spaces look like over time.

4:56

I'm sure they'll follow this infant a little bit more

4:58

closely with head ultrasounds each day.

5:01

This is a gorgeous example

5:02

of a magnified linear high frequency, uh, transducer.

5:06

Look at the x extra axial spaces

5:07

where you can see sharp demarcation separated

5:11

by arachnoid moderate.

5:12

Uh, this side is subarachnoid space.

5:14

This side is subdural space, and we see that on both sides.

5:18

So bilateral subdural collections

5:20

where we see those bridging vessels stop in the subarachnoid

5:23

space, we don't see those bridging structures

5:26

in the subdural space.

5:28

A beautiful example of bilateral subdural collections.