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Hello and welcome to Noon Conference, hosted by Modality

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and previous noon conferences by creating a free account.

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Today we're honored to welcome Dr. Harris Cohen

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for a lecture entitled Perinatal Neuros Sonography.

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Dr. Cohen completed his radiology residency at SUNY

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Downstate and a pediatric radio radiology fellowship at

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Children's National Medical Center.

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He's held leadership roles at several institutions,

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is active in major radiology societies,

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like A-C-R-S-P-R-S-R-U-R-S-N-A-A-I-U-M,

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and his authored textbooks focus on ultrasound perinatal OB

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GYN and pediatric imaging.

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At the end of the lecture, please join him in a q

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and a session where he will address questions you may have

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on today's topic.

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Please remember to use that q

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and a feature to submit your questions so we can get to

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as many as we can before our time is up.

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With that, we are ready to begin today's lecture.

1:07

Dr. Cohen, please take it from here.

1:11

Um, again, I'm Harris Cohen, um,

1:14

and, uh, the title is Perinatal Neuros Sonography.

1:18

We're gonna be talking about, uh, aspects of, uh,

1:22

perinatal brain with, uh, concentration on neonatal brain.

1:26

Uh, I have nothing to disclose

1:31

in about 40 minutes of time.

1:33

We will discuss a few methods in head ultrasound technique,

1:37

review some intracranial ultrasound anatomy,

1:40

and review some teaching points regarding evaluation

1:43

of some anomalies versus mimics concerns in the premature

1:48

and particular intracranial hemorrhage IVH

1:51

and inter parenchymal hemorrhage, intraventricular

1:53

and inter parenchymal hemorrhage.

1:54

And, um, paraventricular leukomalacia.

1:59

There is a lot to these topics,

2:02

and this is just a mere, um, uh,

2:06

small, uh, portion of it.

2:08

The, um, windows to the brain

2:12

and they had the decision on how to, uh,

2:15

ultrasound the brain was actually very confusing

2:18

to the early, uh, fathers and mothers of ultrasound.

2:21

And, uh, in 1979, a couple

2:23

of articles came out about the anterior fontanel being the

2:28

source for intonation of the fontanel since ultrasound

2:31

was not particularly, uh, good at the time to, uh, go

2:35

through a curved object

2:37

and go through the brain through bone.

2:39

So the anterior fontanel is an easy way

2:41

to place a transducer and, uh, look at what the contents are

2:46

and we'll talk about all the other openings within

2:48

the skull that can be used.

2:50

Um, this is just an example, two drawings, um,

2:54

that show you basic exams in the neonate.

2:58

Um, so if we were looking at

3:01

what a sagittal image looks like,

3:02

even though the kid's in coronal position, uh, we see

3:06

that the midline image is important to get the, um,

3:11

interhemispheric fisure, the corpus Callum,

3:13

the third ventricle, um, the ca septum lucidum,

3:17

and then angling to the right or to the left.

3:21

One of the key goals is to look at the brain

3:24

between the corde Anth thalamus,

3:25

where the sub penal area is,

3:27

which is a concern for bleeding.

3:29

And then as one sweeps across from, uh, through the right

3:33

or through the left, one will extend out to the Sylvie

3:36

and Fisher where middle cerebral artery tributaries

3:39

are readily seen.

3:41

And then if we look at this image of a, um,

3:45

kid in sagittal position, this is to show you

3:47

what the coronal imaging of the brain

3:50

through the anterior fontanel is like.

3:53

And one can take images of the frontal area in the beginning

3:58

of one's sweep anterior to the ventricles.

4:01

And then as one goes posteriorly, one is able to see, uh,

4:05

all aspects of the, uh, lateral ventricles

4:09

and, uh, the third ventricle

4:11

and the fourth ventricle that sits anterior

4:13

to the verus of the cerebellum.

4:15

And the act of aductive, Sylvia, between the third

4:18

and the fourth, uh, ventricles,

4:23

uh, key to evaluating the abnormal is

4:26

to know what normal is.

4:28

And, uh, here's an example of a, uh, ultrasound

4:30

of a brain done through an anterior fontanel, which, uh,

4:35

I'm showing you some anatomical points even though there is,

4:39

um, an abnormality here.

4:41

But, um, if I'm to teach someone about head ultrasound,

4:45

I'm gonna say, and the goal is

4:48

to make sure there's no severe anomaly.

4:51

Uh, one of the easiest things is

4:52

to make sure there's an inter atmospheric fisure, uh,

4:55

that separates the, um, uh, frontal, uh, brain,

5:01

uh, the frontal lobe so that you can have a feel

5:05

that there's been diverticulitis of the brain

5:07

and you at least the worst form

5:09

of holo pros cephalic doesn't exist.

5:11

The alo bar, holo pro cephalic, um,

5:14

if one goes further down.

5:17

So this line is the spheric fissure,

5:19

the echoic area over here is the corpus callosum.

5:24

So some people call that the anchor sign.

5:27

And the gray area

5:32

pointed out by the yellow arrow is the corpus callosum.

5:36

It's present. This is the anterior portion of it

5:38

where the frontal horns are.

5:40

'cause these are the frontal horns.

5:42

And, um, there the visualization

5:45

of corpus callosum there goes against complete agenesis

5:48

of the corpus callosum

5:57

green, the arrows point, um, the echogenicity

6:01

that's seen in the subependymal area on a coronal view,

6:05

which aren't normally there.

6:06

And those echogenicity are not within the frontal horns,

6:09

but they are within the subependymal area showing the

6:13

simplest form of hemorrhage that we look

6:15

for in premature neonates in particular.

6:19

Uh, and we'll talk about the grading system.

6:27

So knowing this is strange, knowing

6:32

what anomalies look like,

6:33

if not picked up antenatally is important.

6:36

Um, I spend, um, there's been tremendous, uh,

6:40

growth in the ability to pick up things.

6:42

Antenatally ultrasound is the great tool

6:45

for antenatal analysis, although fetal MR has helped us.

6:50

And if someone wasn't picked up there

6:52

and was first seen in neonatal life, uh,

6:55

the same anomalies exist.

6:57

Um, there are nuances to picking it up, antenatally

7:01

and nuances to picking it up.

7:03

Um, postnatally.

7:06

So this is an example of a, um,

7:10

anterior fontella approach showing a brain.

7:13

Uh, one sees the brain, uh, here, uh,

7:16

one sees the in atmospheric fissure.

7:18

Uh, so I don't have a, um, complete

7:22

a low bar hollow proli.

7:24

I see the frontal horns, but they are wide apart.

7:28

And if I look here at

7:30

what some people call an uplifted third ventricle, um,

7:34

this is the widely separated frontal horns,

7:37

the Texas Longhorn sign.

7:39

It's one of the signs of agenesis, of the corpus callosum.

7:43

And if you go further back, you'll see

7:45

that the two lateral ventricles parallel each other

7:48

and they do not meet normally, uh, the ventricles

7:52

go toward each other anteriorly and meet

7:55

or they meet at the, uh, area, which is the cave.

8:00

Um, so these are, uh, two lines

8:04

that if I have ventricles that I can make a line

8:07

that goes straight and they never meet, then I have

8:10

to worry about a genesis of the alosi.

8:14

And here's another example of a coronal image of a patient

8:19

with agenesis of the corpus coum showing a non-specific sign

8:22

that is oftentimes seen with, uh,

8:26

agenesis of the corpse coum.

8:27

And that is, um, colpocephaly colpocephaly, uh,

8:32

is a teardrop shape lateral ventricle.

8:35

So you can see that it appears non dilated anteriorly,

8:39

but posteriorly it appears, um, like a teardrop

8:44

of interest in this one particular image, uh,

8:47

which is something you don't necessarily see, is

8:49

that there's a large cystic area within the echogenic area

8:53

of the choroid.

8:54

You can see the choroid on the right.

8:56

You can see the choroid on the left has this large cystic

8:58

area within it, which is a large choroid plexus cyst.

9:01

And there are two smaller choroid plexus cys here.

9:04

Choroid plexus cysts are very commonly seen.

9:07

Uh, they're seen in one to 3% of normals.

9:10

Uh, obstetrical individuals will say

9:13

that they are found in one to 3%, um,

9:16

pointing more toward 1% in the, uh, second trimester.

9:21

Um, classic teaching is

9:24

that they disappear somehow in the third trimester,

9:26

but I'm always confused by that

9:28

because choroid plexus are seen in one to 3%

9:31

of normal neonates.

9:33

Um, there had been a linkage in the past about Chorio Plexus

9:38

cysts, an association with Trisomy 21,

9:41

which has been disproven.

9:42

It is still related to trisomy 18.

9:45

Uh, some individuals have said, well, the worrisome cases

9:48

for trisomy 18 are very large cysts, or very as,

9:52

or an asymmetry of cyst one side to the other.

9:56

But, um, articles have proven that

10:00

trisomy 18 patients may have Horry plexus cyst

10:03

that are regular in size, whether

10:04

that's the statistical norm of the one to 3%

10:07

of normal people having it,

10:09

or it's related to the tri to trisomy 18 is unknown.

10:13

And one can look at the remainder of the body

10:16

to see if there's anything in particular

10:18

that suggests Trisomy 18.

10:21

One of the easiest things for me is I look at the hand,

10:23

if the hand is open, uh, that's atypical of trisomy 18,

10:27

in which there are usually overlapping fingers.

10:30

Uh, and there are other ways of figuring it out, including,

10:32

uh, uh, karyotyping if you need it.

10:36

Uh, but merely on the basis of Horri plexus cyst,

10:39

nobody should believe that the patient is a trisomy 18.

10:43

One has to have other findings.

10:46

Uh, this is a sagittal image of a normal individual.

10:50

This is a normal individual who has, um, gyre

10:54

and ssci indicating

10:55

that they're certainly older than 32, 34 week.

10:59

Um, you can see the Gyre

11:01

and Ssci, the sci are the

11:02

echogenic lines that you're seeing.

11:04

The Gyre are the gray lines.

11:06

This is, um, area of corpus callosum.

11:10

Burma is seen here with a small black area suggesting

11:14

that the fourth ventricle, which is there,

11:15

is normal in size.

11:17

But I don't really show you that, um,

11:21

for any these images

11:22

for anything other than saying the gyral pattern of a person

11:26

who does not have agenesis of a corpus Callum parallels the,

11:30

um, the, uh, corpus callosum itself.

11:34

While if there's no corpus Callum,

11:36

as in the image on your right, uh, the Gyre sci

11:41

extend toward the third ventricle.

11:44

So this is sometimes called the sunburst sign on the

11:47

mesial aspect of the brain.

11:49

Gyre do not parallel the corpus callosum,

11:51

which is not present, but appear

11:53

to extend into the third ventricle.

11:55

And you'll see my amazing lines coming through, showing you

11:59

that, uh, this is a sign that's not in the literature.

12:04

It's a sign I use, uh, when I teach some things.

12:07

Uh, you don't have to learn this sign by heart.

12:10

Uh, it's just the image. So I call this to sign.

12:13

If I look at the brain on a coronal image,

12:16

and the kid is very young, I

12:19

very young means low gestational age.

12:22

So let's say it's a 22 weeker, 24 weeker.

12:26

I'm gonna see two things. What I'm gonna see,

12:28

which you don't see here, uh, Sylvie

12:31

and Fisher, that's wider than normal.

12:33

And I'm going to see, uh, few, if any, gyre.

12:39

So if I was reading this image,

12:42

I say there's no ventricular magaly,

12:43

maybe the frontal horn's a little bit full on the left.

12:46

There's no extra AAL collection.

12:48

Really, I'm looking at the edges.

12:50

There's a little bit of fluid here.

12:51

Seen extra actually, um, few ra slash sci noted,

12:56

uh, which is a normal finding for lesser gestational edges.

12:59

So let's say this kid was 26 weeks gestation.

13:02

This is completely normal.

13:03

I'm gonna show you dini hyphen cyst, uh,

13:06

published specimens, uh, which you can see that point.

13:10

Uh, because if somebody says to you,

13:11

I don't know if the kid has lissencephaly

13:13

or not lissencephaly, um,

13:17

I cannot call the four 30 weeks gestation

13:19

or even 32 weeks gestation because I'm not gonna see gyri.

13:24

But if I'm, if the kid is in an age where gyri

13:26

or readily seen

13:28

and I don't see them, then I have

13:29

to worry about lissencephaly.

13:31

Uh, so here is, uh, some of those pathology images.

13:34

And you can see at 22 weeks,

13:36

you're not seeing gyri and sci really.

13:38

Um, you got something here, you got, uh,

13:42

little bit seen at 24 weeks,

13:43

and that's quite in contradistinction.

13:46

And her work shows, um, the brains in

13:51

multiple weeks, you know, every two weeks.

13:53

But I just show, I'm just showing you 22 and 24 weeks

13:56

and compared the 36

13:58

and 38 weeks with all the gyri, um, there in

14:02

what is a brain without lissencephaly.

14:09

And here's another image of a brain, uh,

14:13

interhemispheric Interhemispheric Fisher is seen corpus

14:17

close seen ventricles are frontal horns are normal.

14:20

Cystic area between them is the Cajun septum lucidum, the

14:24

potential space that's seen in perhaps 60%

14:29

of newborns who are full term

14:31

and 90% of newborns who are premature.

14:34

So normally you see Cape Septum lucidum, the obstetricians,

14:37

and doing their fetal exams at 18 to 21 weeks

14:41

or beyond, um, are going to strictly make sure

14:46

that they see the cave from septum lucidum.

14:48

Uh, just as an example, here is a Sylvie

14:50

and fisher, which is somewhat wide in this younger kid.

14:53

And this is the cerebellum, which we can see better if we go

14:56

through a trans mastoid view.

14:58

But you see the cerebellum here and the ci sternum magna.

15:01

And you look at the ci sternum magna,

15:02

because you want the cisterna magnum be less than 10

15:05

millimeter, and you want it

15:06

to not extend to the fourth ventricle.

15:07

This is normal. Some people call this a peanut

15:10

shaped, uh, cerebellum.

15:19

The cave of septum lucin is pointed out by that green arrow.

15:25

Uh, so again, as I noted,

15:27

an obstetrical concern is a case in which you don't

15:31

see a cave of septum lucin.

15:32

So here is a fetal Mr.

15:35

Um, you are seeing frontal horn, frontal horn,

15:38

and cavem septum lucidum.

15:40

You also can see gyre.

15:43

Um, so this would be a normal image.

15:46

If on the other hand, you're an obstetrician

15:48

and you're looking at this kid and this is an ultrasound,

15:51

and you don't see sep iid, you see frontal horn,

15:53

frontal horn, but no sept pellucid eye, then you have

15:56

to worry, um, as just a,

16:00

um, a point of information.

16:02

This is a normal cerebellum, peanut shaped

16:05

and normal ci sternum magna on this, um, uh,

16:11

image, uh, axial image.

16:14

So an absent septi, if you don't see the septi,

16:17

it could be just absent septi,

16:19

or it could be part of Dier syndrome.

16:21

And d morsi syndrome is associated with hypothalamic

16:24

and pituitary dysfunction.

16:26

Uh, there, uh, uh, have the kids have problems with vision,

16:30

with smell, with coordination and intelligence?

16:33

Um, there are, there's some imaging you can do via Mr, um,

16:38

after the kid is born, uh,

16:41

to look at the optic tracts to see if they're small.

16:44

But, um, the major

16:49

information you wanna know is uc, eptide lucid eye.

16:52

So if I don't see Eptide lucid eye,

16:54

and I think maybe I have the more Ca syndrome, uh, then I,

16:59

uh, look at this neonatal image.

17:01

This is a Corona image.

17:03

And you might say to me, I don't see Septi lucid eye

17:07

because here is very dilated frontal horn,

17:09

dilated frontal horn, no septic ide.

17:11

There are no two lines going down here,

17:12

but there is residua from at least one of those lines.

17:16

This happens to be a third ventricle that's full.

17:18

This is a large temporal horn tip in this person with, uh,

17:23

hydrocephalus or dilated ventricles.

17:26

And the grayish debris in here probably relates

17:29

to hemorrhage that the kid has.

17:32

Um, in the, that you can see in the dependent area,

17:34

it's probably older hemorrhage

17:36

and maybe there's some residual here.

17:39

Um, this is a dilated third ventricle.

17:42

So one of the things I have to remember is that

17:47

sometimes a person with long-term hydrocephalus,

17:51

and you can have it all throughout fetal life,

17:52

you have long-term hydrocephalus.

17:55

They, that pressure from the hydrocephalus can break the

18:01

thin septic, lucid eye fenestrated them.

18:03

And you might have a situation like this patient,

18:06

which luckily we see this, this little bit of, uh,

18:10

residua from the fenestrated septic hallide,

18:13

there might have been nothing here

18:14

and the patient would've had a diagnostic workup

18:17

for something other than what they have

18:19

or in addition to what they have.

18:20

So it can simulate absent septum lucidum.

18:26

This is, um, a,

18:30

uh, lucky image.

18:32

This is a person who has hydrocephalus.

18:35

Um, you can tell that the very,

18:36

there's a very dilated third ventricle.

18:38

This is the mass intermedia,

18:39

but this is a really lucky shot, an en phos view

18:43

of the thin septum lucidum on one of the sides.

18:46

I don't remember if it was right or left,

18:48

in which we can see an actual defect in it as part

18:52

of the fenestration.

18:54

So we've had these fenestrations,

18:55

we followed them over time,

18:56

and we've seen, uh, them enough to confirm that, uh,

19:00

you can develop fenestration

19:02

and could eventually result in an image in which you don't

19:06

see sep Lucite.

19:09

Um, something else I've learned from antenatal, Mr.

19:13

Uh, so again, I get a number of these patients sent

19:15

to me for fetal Mr.

19:17

Um, and they sometimes use the term box ca them, uh,

19:23

or absent septum lucidum,

19:25

but they're using the term box cm, uh,

19:27

and it requires a search for something else.

19:29

So this is, uh, box cm. There's no septum lucidum.

19:33

The obstetrician has asked me to do a fetal Mr

19:35

because they're worried.

19:37

Uh, this happens to be a different image of a neonate with

19:42

what might be the equivalent of this boxed, um,

19:46

k uh, area of km and, uh, no SEP five lucid ic.

19:55

So we've done a number of these

19:57

and, uh, we've seen three patients on,

20:00

we haven't reported this yet,

20:02

but I've said it in a national meetings.

20:05

Uh, we've seen three patients in which we're working it up.

20:09

We do the mr a very adequate

20:15

obstetrical neuro sonogram has been performed.

20:19

And yet, uh, the readers have missed the fact that,

20:24

um, there is a connection between the ventricular system

20:26

and the extra axial space.

20:28

So you can see here this is somewhat dilated frontal horns.

20:32

And you can see this little line over here extending

20:34

to the extra axial space.

20:36

And, uh, you can see this Mr this is a neonate

20:39

who had similar thing in which there was a smo.

20:44

The normal ventricle is very smooth in its margins.

20:47

Here's this little dizel extending out.

20:50

And in both these cases, the patient has no,

20:56

uh, this is, this is an axial cut of it.

20:59

Same thing. Ventricle,

21:00

not particularly dilated in this individual, extending out

21:03

to an extra axial space.

21:05

And this is an example of thin lip schizo celi.

21:09

There's a schizo celi, but

21:11

because it's thin lip as opposed to, um, uh,

21:16

wide lip schizo celi, um, it's easier for the

21:22

imager, whether an obstetrician or a radiologist to miss.

21:25

So in these cases, they were, they did not see it.

21:29

And um, this was an ans uh, an example

21:33

of closed lip schizo cephalic schizo celi.

21:36

There's a trans mantle column

21:38

of ray matter crossing cerebra from P to append

21:41

as per the handbook of clinical neurology in 2020.

21:45

So I am a little bit more leery to look for this.

21:49

And here's an example of a, uh, axial view,

21:54

uh, in obstetrical life in which there is a normal

21:58

appearing ventricle here.

22:00

And this is a portion of a ventricle.

22:01

Maybe I don't see it here because of my technique

22:04

or the technique of the person who did it,

22:05

but I see this extension from there.

22:07

And if I see this, I gotta worry about there being a schizo

22:11

Eli, which I might be able to prove only

22:13

after the kid's born

22:14

or with a, a fetal MRI

22:18

or via neonatal MRI.

22:24

And this is another example. This is an older neonate.

22:28

So this could be a 39 40 week gestation.

22:30

It was the older gyr.

22:32

And you can also see

22:33

that whoever was doing this case had some difficulty

22:35

penetrating either 'cause of a small, uh, anterior fontanel,

22:39

or they were somewhat limited in their technique.

22:42

'cause the brain is, uh, more complex at this time.

22:45

Uh, whatever it is, this is at least somewhat dilated,

22:50

um, ventricle.

22:52

And then there's an extension over here going beyond it, uh,

22:56

which led to an individual who, uh,

23:00

another images could be proven to have a schizo.

23:05

So I look at neonatal neuros, neuros sonograms now with a,

23:09

uh, more jaded eye.

23:11

Um, other things that I consider important, uh,

23:16

as peripheral things that maybe you don't go over.

23:19

And basic neuros sonogram lectures, it's important

23:22

to see the brain borders.

23:24

So, uh, I call something the too easy to see,

23:27

brain border sign.

23:29

Uh, if you see the brain's border,

23:32

usually it's some extra aio fluid.

23:34

You better worry about the extra aio fluid

23:36

and figure out whether it's normal or not.

23:38

It could be something simple like desi benign,

23:41

extra axial spaces of infancy.

23:43

They may have changed the wording a little bit

23:45

that kids have.

23:47

Uh, it could be because of something else, a hemorrhage.

23:51

Uh, for example. Um, as an aside,

23:54

I also have a term I use too easy to see brain sign.

23:58

If I look at an ultrasound

23:59

and I see the brain exceptionally well, this is more,

24:02

this is truer in obstetrical life, then I gotta worry

24:05

that there might be some calvarial mineralization problem.

24:09

Osteogenesis and perfecta in particular hypophosphatasia.

24:13

And in rare cases, if I see the brain too easily,

24:16

then you gotta make sure that there actually is ossification

24:18

around it because you could have, um, extension of brain

24:22

beyond calvarium.

24:25

Um, so anyway, uh, here's an example.

24:29

This is an extremely old case.

24:30

It's the first case I ever saw this.

24:32

Um, I think this is, this is from the,

24:35

uh, mid to late eighties.

24:37

Uh, there's an individual head ultrasound.

24:39

Nobody knows anything that's going on.

24:42

We see the brain border very well, but we see it.

24:45

There's this large extra axial gray stuff,

24:48

echogenic material.

24:50

Um, the frontal horn on the left side is a little full.

24:53

This might be the ca lucidum.

24:55

And there's some impression probably

24:57

because of mass on the right side,

25:01

on the lateral ventricle on the right.

25:02

And here's another example,

25:03

pointing a little more posteriorly in which we see

25:06

dilated left lateral ventricle, not

25:08

as dilated right lateral ventricle.

25:11

But um, there appears to be a midline shift

25:14

because there is this prominent extra axial collection.

25:19

And when it's echogenic like that,

25:21

my first choice is that it's hemorrhage.

25:24

And so here's another image of it.

25:26

And this was actually a mother who stated

25:30

after we saw this,

25:31

that she had been hit in the abdomen at some point

25:32

during her pregnancy.

25:34

And this was what I labeled fetal abuse.

25:38

Um, but it's important to know that.

25:40

So I show you an old film.

25:41

Part of the reason I show you an old film is

25:43

'cause old films are important.

25:45

And, um, within the last five years, we've had another one

25:47

of these cases here in uh, Tennessee.

25:51

Uh, so anyway, Bessie, I mentioned it.

25:53

Benign enlargement of the subarachnoid spaces of infancy.

25:57

What can I say about it?

25:59

Uh, it's idiopathic prominence

26:00

of the subarachnoid space filled

26:02

with fluid overlying cerebral convexes,

26:04

especially in the frontal region,

26:06

which you see on the coronal imaging.

26:08

Uh, it can be in the interhemispheric fissure separating the

26:11

two, uh, frontal lobes.

26:13

Uh, but you also see it both in cts when they perform it on

26:17

neonates and in ultrasounds.

26:18

If they could get good sagittal images of neonates,

26:21

seeing large amount of fluid that's more readily seen

26:24

above the entire brain, uh, it's not that uncommon.

26:29

It's thought to be due to arachnoid VII immaturity probably

26:32

in CSF resorption.

26:34

Um, there some people will call it abnormal if they see four

26:39

millimeter cranial cortical measurement, uh,

26:42

or six millimeter

26:44

or greater, uh, in atmospheric fissure width, which is said

26:48

to be greater than two standard deviations of normal.

26:52

And suggesting that there is more fluid than you expect.

26:55

But if you have more fluid than you expect

26:57

and it's bessy, it's benign, it's self limited,

26:59

it'll resolve by two years.

27:01

Now, how do you prove it's Bessie?

27:03

Because I oftentimes say

27:06

to the people here,

27:09

I don't understand why this is having trouble coming down.

27:11

There's an image, it's a closeup

27:13

of the frontal brain there gyr,

27:16

and there's this large CSF collection that is, um,

27:21

ideally Bessie, a benign thing

27:24

that is a subarachnoid space filled

27:26

with fluid on the other hand.

27:30

Uh, so what you do is you color the, um, brain

27:34

and as long as you see vessels within the fluid space,

27:38

then you know that it is, um, subarachnoid space

27:42

and it's non worrisome.

27:45

Uh, you can see the inter atmospheric fisure is not widened

27:47

here, but this is, uh, benign.

27:50

Uh, they may watch the kid

27:51

but uh, maybe measure the head on follow-up visits

27:55

to the pediatrician.

27:57

Uh, but this is of no concern.

28:00

On the other hand, subdural hemorrhage subdural collection

28:04

may indicate non-accidental or other trauma.

28:06

Seeing normal cortical veins, again,

28:08

traversing the fluid suggest besi.

28:11

But if you don't see any fluid, you have

28:12

to worry about subdural hemorrhage.

28:14

So here's an example of somebody

28:15

that we saw within the last couple of years, um,

28:18

that has this large fluid area.

28:21

So you say, well, okay, that might be Bessie,

28:23

except if you look at it closely,

28:25

there is the brain parenchyma.

28:27

There is a subarachnoid space mashed down by

28:31

this fluid, and when you color it,

28:34

you see color in the brain vessels

28:35

and you see color in vessels in the subarachnoid space,

28:38

but no color at all in this subdural hemorrhage.

28:42

And so this was problematic

28:44

and had to be, uh, dealt with subarachnoid flow compressed

28:48

by subdural without vascular flow and require surgery.

28:52

So there are other helpful windows to the brain

28:55

and they include the posterior fontanel.

28:58

Um, uh, New Zealand article, a number of years ago,

29:02

perhaps late nineties, early two thousands, discussed

29:05

how you could pick up a greater amount

29:06

of hemorrhage if you look posteriorly as well as anteriorly.

29:10

And in the late nineties

29:11

and early two thousands,

29:12

people started discussing the mastoid

29:14

fontanel, which is seen here.

29:16

It's an area equivalent to behind the child's ear

29:20

that you could see sub tentorial area real well.

29:23

But any skull opening, including the atopic suture, uh,

29:27

in the forehead, uh, can be used to see what's going on.

29:30

And off the record, well on the record,

29:33

if I have a six month old that comes to me

29:36

and they say, the kid is a big head, we want you

29:38

to evaluate the brain,

29:39

but uh, the parents are afraid of of radiation,

29:41

they don't wanna do a ct, you can actually, um,

29:45

in the relatively thin squamous brain take a transducer

29:49

sometimes of lower transducer, uh, lower frequency.

29:52

So typically your head ultrasounds done in the

29:54

equivalent of about seven five.

29:56

Uh, but you could take a three, um,

30:00

and send it across the head and you can penetrate

30:03

and see at least the middle one third

30:05

so you can figure out if there's ventricular magaly or not.

30:07

Oftentimes when they tell me

30:08

that there's a kid they want

30:10

evaluated the kid's head is funny.

30:12

Um, I would ask if they had a relative

30:14

that had a funny looking head

30:15

and everyone always had an uncle with a funny head,

30:19

he couldn't get hats on.

30:20

And uh, I mean, we still look at the kid,

30:23

but at least we feel more comfortable

30:25

that there isn't a significant problem,

30:27

particularly the kid has normal milestones.

30:29

Anyway, mastoid fontanel view, am I gonna talk about it?

30:34

Uh, so I've just talked about lower frequency transcranial,

30:37

not through a fontanel can help.

30:40

Uh, but these are posterior fontanel views.

30:42

So again, this is, um, Choal had written about going

30:46

through the posterior fontanel.

30:47

Here's an image going through the posterior fontanel.

30:50

So posterior is up top and anterior is down low.

30:55

And you're seeing choroid plexus in, uh,

30:58

without any CSF in a dilate.

31:00

There's a little bit of CSF, there's no dilation,

31:03

so there's no ventriculomegaly

31:05

and there was no concern in this case for hemorrhage.

31:08

And at the same time, they did a methodology through the,

31:12

uh, posterior, uh, posterior fontanel in which they saw CSF.

31:17

The CSF continued toward the fourth ventricle

31:20

and the cere cerebellar hemispheres,

31:23

which looked pretty good, are still separated.

31:26

And this is a concern for dandy walker malformation

31:29

or dandy walker spectrum malformation.

31:31

So the chorea work chorea.

31:34

Now, the doctor, uh, published their work in 2004

31:37

and they said there was a 32% increase in grade two

31:41

interventricular hemorrhage diagnosis

31:44

because they added the

31:46

posterior review with the anterior review.

31:53

And this is just the first dandy walker

31:56

I ever ultrasounded posteriorly,

31:59

also from the early eighties.

32:01

And you can see the hemispheres widely separated,

32:03

the large cystic area extending

32:06

to the fourth ventricle using a posterior

32:08

approach way before chorea.

32:10

And then again, the uh, Eli area here, a relatively

32:15

area here is Desi.

32:18

So let's see, mastoid views.

32:20

So we in, when I came to University of Tennessee,

32:24

we were not doing, uh, routine mastoid views.

32:27

And since then we have, uh, made it a requirement

32:30

and it has helped us, uh, see things.

32:33

One of the reasons the mastoid view was created was to look

32:37

for cerebellar hemorrhages,

32:39

which occur in the same prematures that can have, um,

32:44

other hemorrhages, the subependymal hemorrhages.

32:47

Uh, it also allowed us

32:48

to see the dandy walkers a little bit better.

32:51

It allows us to figure out gestational age,

32:54

which is something we're, uh, we've created a chart on

32:57

and we're submitting to the literature.

32:59

Um, and it allows analysis of subarachnoid cysts,

33:03

particularly when they're sub tentorial.

33:05

And it actually allows you

33:06

to see the transverse sinus in case you're looking

33:08

for clot within sinuses in, uh, in very dehydrated kids,

33:13

oftentimes sagittal sinus will have clot in it.

33:16

Um, you can actually look over here on a, on a mastoid view

33:21

and that'll tell you what's happening with the, um,

33:25

transverse sinuses.

33:26

So here is a normal, um, cerebellum.

33:30

There's a line inside the cisterna magna, which is residua,

33:35

uh, from Blake's pouch cyst.

33:36

We'll talk about it. And this is a different patient

33:39

with large echogenic area looking like hemorrhage

33:43

and some echogenic debris

33:44

and a distended posterior aspect lateral ventricle.

33:47

But this is the cerebellum with eye, right, right, is

33:51

what they put it on the right ear.

33:52

So this is the right side, this is left side.

33:54

There was a left cerebellar hemisphere hemorrhage.

34:04

Uh, this is normal. Um, what do you see?

34:07

You see two cerebellar hemispheres. You see a vermis.

34:10

The vermis prevents communicate its existence,

34:12

prevents communication between the cisterna magna normal

34:15

size, that less than 10 millimeters.

34:17

And uh, fourth ventricle, which is not seen on this image.

34:21

And the line, uh, which used to be called um, dural folds,

34:25

is actually residual Blakes pouch cyst,

34:28

which the green arrow was pointing at the residua

34:31

because, um, in order to have adequate flow

34:36

from the fourth ventricle out, um, Blake's pouch,

34:41

which is a normal structure, has to fenestrated

34:44

to allow a formation of an open foramen of magdi.

34:49

Um, this is just, um, sometimes you see in the very young,

34:53

some communication with the fourth ventricle only on the

34:56

inferior aspect of the cerebellum.

34:58

Um, I'm confused about whether this is part

35:01

of a Danny Walker spectrum or what I've been saying is,

35:04

and the literature has said in part, um,

35:10

uh, if you see the verus that it might be some

35:15

hypoplasia and very young neonates, uh, due

35:18

to incomplete development of the cerebellum,

35:20

particularly its inferior neo cerebellum.

35:23

I think this is controversial

35:25

and I don't necessarily know if it's true.

35:26

There's some interesting work, uh, done by one

35:30

of our former neuro radiologists, um, Dr. Whitehead

35:35

and others with regard to cerebellum.

35:37

And um, hopefully I'll get smarter, uh, over time

35:41

with a lot of people's information.

35:44

It certainly is not a classic dandy walker malformation.

35:49

Um, so if we go to some of the basics on head ultrasound,

35:52

if you look at Kathy's 11th edition,

35:54

which the 12th edition in the 13th edition say as well, um,

36:00

indications for neonatal cranial ultrasound include

36:02

screening intracranial hemorrhage is, uh,

36:06

more common in less than 32 weeks and less than 1500 grams.

36:09

That was the old, uh, story.

36:11

Different neonatologists are saying they're more worried

36:14

at 1250 grams.

36:15

They're more worried at a thousand grams.

36:17

They're more worried at 30 weeks.

36:19

They're more worried at 28 weeks.

36:20

Certainly the younger you are.

36:21

And the less you weigh, the greater the possibility.

36:24

You'll have a subependymal hemorrhage

36:25

and an interventricular hemorrhage.

36:27

Hypoxic ischemic encephalopathy, including PVL,

36:30

which is focal white matter necrosis, is a reason to do it.

36:33

Birth trauma, another reason to do it.

36:36

And prenatally detected abnormality.

36:38

Another reason to look with head ultrasound,

36:43

uh, this can be an initial evaluation.

36:45

Procedures congenital anomaly, macrocephaly CNS infection,

36:50

suspected sagittal sinus thrombosis.

36:53

Uh, it allows follow up for intercranial hemorrhage,

36:56

hydrocephalus, and extra axial collections.

36:58

So again, a great concern for the premature,

37:02

for the premature infant in particular is subependymal

37:05

hemorrhage or, or, uh, interventricular hemorrhage

37:09

or grade four hemorrhage, which we'll discuss.

37:12

Uh, and again, less than 1500 grams

37:14

and less than 32 weeks were the key

37:17

areas they used to look at.

37:18

Uh, why is IBH of concern, uh, in that specific group?

37:22

Because it's bleeding in the sub penal germinal matrix area,

37:25

which is highly cellular rich vascularized area

37:29

with active cell proliferations neuroblast destined

37:32

for the cerebral cortex

37:34

and vessels that are only a cell thick.

37:37

The brain of premature infants cannot change vascular inflow

37:41

pressure to protect itself from changes in neonatal blood

37:44

pressure and such premature infant brains are pressure

37:47

passive and therefore greater risk for injury.

37:49

Whether the pressure is high

37:50

or the pressure is low, um,

37:56

for some reason this doesn't move well.

37:58

Um, Pappi 1979 created classification

38:03

for hemorrhage and then people disagreed with some of it.

38:06

So it's evolved somewhat in their people

38:07

who say they don't like the classification,

38:09

but it's what exists now.

38:11

Grade one is hemorrhage limited

38:12

to the subependymal area in the germinal matrix region.

38:15

Grade two is intraventricular hemorrhage without dilation.

38:18

Grade three is intraventricular extension

38:21

with ventricular dilation.

38:22

And then you might say, well if there's something in the

38:25

ventricle, how you say it's not dilated for grade two?

38:28

So they changed the ruling

38:31

and said, well if it's greater than 50% dilation,

38:34

which is an odd statement then,

38:37

and I gested mostly, uh, you can call it grade three IVH

38:40

and grade four IVH many years ago was thought

38:42

to be intraventricular hemorrhage

38:45

with associated extension into the parenchyma.

38:47

But it was proven of vi volpi etal in the late 1980s

38:52

that it was due to, um, a, a more delayed,

38:57

uh, venous infarction that occurred with the hemorrhage.

39:01

Um, I think, uh,

39:02

Dr. Taylor showed some interesting work in the early two

39:06

thousands with regard

39:07

to vessels feeding the subependymal area

39:09

and perhaps they being pressed on by the hemorrhage

39:13

and then leading to some of the periventricular,

39:16

particularly in the frontal area.

39:18

Um, infarction.

39:26

So here's a grade one you sing.

39:30

Actually the first picture I showed you was better echogenic

39:32

area, not within the ventricle,

39:34

although there might be a.in here.

39:35

It could be artifactual or it could be a grade two.

39:37

But this is evidence of grade one.

39:39

And this is a para sagittal image in which

39:42

you see the head of the CO eight.

39:43

The thalamus and sub penal area has the hemorrhage

39:46

because it's not pure white, it's probably subacute

39:48

or older when

39:53

sub penal hemorrhage resolves cysts are typically seen in

39:56

their place between the head of the CO eight, uh,

39:58

nucleus and the thalamus.

39:59

So here is somewhat older grade one hemorrhage

40:02

and you see cysts over here

40:04

and you see a cyst here between the head

40:06

of the chord eight and the thalamus.

40:11

Now that is in contradistinction to a specific, um,

40:17

variation called al cysts,

40:19

which simulate grade one hemorrhage.

40:21

And this is an example

40:23

of it's cystic area here, cystic area here.

40:25

They're lateral to the frontal horns,

40:28

but they have a very classic image on para sagittal view

40:31

and in which it looks like some people say a string

40:33

of pearls to me it looks like, uh, links of sausage.

40:38

Um, this is a 27 weeker, 910 grams seven day old.

40:44

Um, the Canadian cyst is also known as coarctation

40:48

of lateral ventricles or frontal horn cysts.

40:51

And these are cystic areas lateral to the frontal horns.

40:53

They're found in 0.7% of low birth weight infants.

40:57

Um, ultrasound, uh, shows thin walled cyst

41:00

that can look like string of pearls

41:02

and they're said to regress, uh, this is a grade

41:07

two, but you might, someone might argue it's a three.

41:09

Uh, there is big clot filling the left frontal horn a little

41:13

bit in the right frontal horn, maybe some residual here,

41:16

clot within the third ventricle.

41:19

And then on para sagittal view, clot is a cast

41:22

frontal horn area and temporal horn tip area.

41:27

And um, a central area

41:34

interventricular, no interventricular

41:41

Interventricular hemorrhage with less than 50%

41:42

ventricular dilation.

41:43

So this will be called a grade two.

41:46

And there's clot in the third ventricle

41:48

and then you see them as clot ages.

41:50

Initially it's echogenic just like choroid,

41:53

but as it ages it becomes gray.

41:55

So if you had a big choroid plexus

41:57

and you didn't know if the patient had hemorrhage

41:58

or not, you could wait a week or two

42:00

and see, uh, the um, grayness.

42:04

You can also see status post bleeding

42:06

that there's a residual event

42:07

that some people call ventriculitis.

42:09

But this white stuff at the periphery

42:11

of the ventricle is evidence of old bleed.

42:14

And you can see back here that there is

42:18

a dependent clot within the system that is older

42:21

'cause it's not as white as choroid plexus, uh, when older.

42:25

Again, clot is less echogenic, uh, clot looks like choroid

42:29

after fibrin deposition.

42:30

Initially it can be separated by knowing that.

42:34

So if you don't know, if you see epigenic area

42:35

and you say, gee, I don't know if

42:37

that's choroid plexus versus um, clot.

42:41

If you color it, you put do color doppler on it.

42:44

Um, choroid plexus, which is a living structure,

42:46

will have vascular flow in it while clot will not.

42:53

And this is just another example of

42:57

vascular flow within the choroid proving that it's choroid

43:00

grade three hemorrhage, dilated ventricular system.

43:02

You can see this large amount of older hemorrhage, uh,

43:05

within the dependent surface.

43:07

This is the, uh, temporal horn typic occipital horn here.

43:17

Also here, if you thought this was purely choroid plexus,

43:20

if you make a line at the foramen

43:22

and Monroe, which is the place

43:24

where lateral ventricle meets third ventricle, the uh,

43:27

exit site, um,

43:29

choroid should never be anterior the foramen and Monroe.

43:32

So in this case, this suggests it's clot.

43:42

And then grade four hemorrhage.

43:45

This is an individual whose lateral ventral doesn't look

43:47

terrible here, but it's probably not seen that well.

43:49

There's a large echogenic area

43:52

with some ePen area intimating subacute or older clot.

43:56

But it's much more extensive than let's say the most

44:01

anterior position of the frontal horn here, suggesting

44:04

that this is brain parenchyma that is negatively impacted

44:08

and that is white matter infarction.

44:13

Um, which would make this a grade four hemorrhage.

44:16

Sometimes if you look at it on a paraag

44:18

and see these little lines extending from the white

44:21

material, to me that is an indicator

44:23

that it's white matter infarction.

44:24

And I know that it's not the, um, I know that it's not,

44:29

um, the clot within the ventricle

44:31

in this case you're fortunate.

44:32

You can see the upper portion of the ventricle

44:34

with this little bit of CSF.

44:38

And eventually the uh, it'll resolve

44:41

and you'll see a cystic area going beyond the ventricle

44:43

that is, uh, po and pha cyst.

44:46

And again, here is echogenic infarc

44:48

and the per ventricular white matter be wary of asymmetry

44:51

because there's normally some echogenic

44:52

periventricular white matter.

44:54

But if one side is much wider than the other,

44:57

be wary if there's a regularity to shape,

45:00

be wary If on a paraag you see lines extending from it,

45:03

be wary, that's infarction

45:08

and we're going to end soon, eventually two to three weeks.

45:11

If you're unsure of what you're seeing two

45:13

to three weeks down the road, it'll become cystic

45:15

and readily seen.

45:16

It was an area of concern, but I wouldn't

45:18

have had a concern here.

45:19

But there are more subtle cases

45:22

and there's clot within a ventricle.

45:26

But you, the cystic area is residual from a, um,

45:32

the, the infarction of a grade four hemorrhage

45:34

and older hemorrhage, again looks like,

45:39

um, ePen material surrounded by echogenic material.

45:42

So this is old clot that we're looking in,

45:44

this very dilated person

45:47

and one has to know that about a third of people

45:50

who develop IVH will go on to, uh,

45:54

post hemorrhagic hydrocephalus.

45:56

So it's good to look at them post first visualization.

46:02

And we obviously follow people day.

46:04

The first week of life, probably day three to seven is best

46:07

for early, um, S-E-H-I-V-H diagnosis.

46:11

And then we always look at them at three weeks

46:13

to see if they develop any post hemorrhagic hydrocephalus

46:16

or if there was a missed amount of PVL.

46:21

And again, these are common at the watershed areas.

46:24

And one of the watershed areas is

46:25

at the frontal lorn region.

46:27

This is an individual who has these cystic areas due

46:30

to periventricular leukomalacia who developed seizures.

46:33

Um, neonatal hypo, hypo hypoxic ischemic brain disease.

46:37

We won't be talking much about 'cause we've run outta time.

46:41

Cerebral white matter disease is a better predictor

46:43

of poor neurologic outcome than is

46:45

intraventricular hemorrhage.

46:47

Insults are not truly periventricular since the discrete

46:49

foal I of coagulation necrosis are found throughout the

46:52

white matter of the brain, better called focal

46:54

necrosis of white matter.

46:56

I think it's easier picked up on Mr.

46:57

And MR has been a valuable help be it particularly

47:00

'cause most remain solid areas of coagulation necrosis.

47:05

PVL is seen predominantly in prematures ultrasound may show

47:09

acute necrosis that appears echogenic

47:12

and become cystic in one

47:13

to three weeks, which is what I said.

47:15

Uh, unhappily ultrasound misses

47:17

what is more readily seen at autopsy.

47:19

Hopefully the patient doesn't go to autopsy.

47:22

And then this is the feared status Marti, uh,

47:26

in which there is highly echogenic basal ganglia in a

47:30

kid with hypoxia.

47:31

That is, uh, one of the signs of HIE.

47:36

So this was a brief review

47:37

of some neonatal neuros sonography teaching points.

47:40

Ultrasound is a fine tool for the analysis

47:42

of the premature brain within the safe

47:44

confines of the ol isolate.

47:45

And NICU some techniques

47:47

and diagnostic axioms were reviewed.

47:49

A few pearls and pitfalls were noted.

47:51

IVH and to a lesser extent PVL were discussed

47:54

and I left out a lot, a lot about the neuros, sonography

47:58

and doppler, HIE, other CNS anomalies,

48:01

infections, et cetera, et cetera.

48:03

Um, so I'm turning this back

48:05

to the moderator in case there are any questions.

48:09

Thank you Dr. Cohen. That was awesome.

48:11

It was an awesome lecture.

48:12

Appreciate you sharing it with us.

48:14

Uh, at this time we will take questions.

48:16

So if you've got any, go ahead and put those into that q

48:19

and a feature so we can get through as many as we can

48:23

before we close today.

48:24

And you're gonna tell me what the questions are, right?

48:27

I sure am. I'm gonna do my best

48:28

with some of these words, right?

48:29

Thanks. Um, we've got one in there right now

48:32

and it asks for grade two and three hemorrhages.

48:35

Mm-hmm. It's only interventricular hemorrhage,

48:39

not associated sub epidermal.

48:43

Well, no, if you have a grade two to three, statistically

48:46

what you had is you had a subependymal hemorrhage

48:49

that went into the ventricle

48:51

and then either was a lot in the

48:52

ventricle, a little bit in the ventricle.

48:53

So I believe it's, i i, I kind of like believe like

48:57

what Pappi said in 1979, that one leads to two,

49:01

leads to three.

49:03

Um, but uh, four is unrelated to

49:06

what their original thought was.

49:07

That one led to two that led to three,

49:10

then three burst out into the brain parenchyma.

49:12

And they've proven that that's related to, um, uh,

49:16

infarction, white matter infarction unrelated

49:18

to the actual movement of the blood.

49:21

So I would think that if I have a grade two kid

49:24

that there was a p there was a ental hemorrhage.

49:28

Uh, but it doesn't really, you know,

49:29

it's kind of like a moot point.

49:31

I see it within the ventricle. It's a grade two.

49:33

I see it within dilated ventricle.

49:35

It's grade three since ones and twos do well clinically,

49:38

and threes and fours do less well.

49:41

My major concern is to worry about the threes and fours

49:44

and worry about, um, some of the consequences of threes

49:48

and fours, particularly fours which are associated

49:50

with cerebral palsy.

49:55

Thank you. How do you differentiate mild periventricular

49:59

flares from normal mild per ventricular hyperintensities,

50:06

Uh, meaning normal, uh,

50:08

echogenicity in the periventricular white matter?

50:10

I kind of like look at one versus the, I look at right side

50:14

and left side and look for symmetry.

50:16

If I see symmetry and it's not particularly white

50:18

and some of this is me gestalt it,

50:21

then I'll say I'm not worried about it.

50:23

Let's say there was something at the borderline

50:25

of me worrying, then I would say to the clinician, you know,

50:28

I see something, it's a little bit worrisome.

50:30

I'm not sure it's more echogenic.

50:32

I can look myself today

50:34

and if we don't want me to look today,

50:37

what I can do is we can wait two to three weeks.

50:39

You follow the kid, you do right by the kid.

50:41

And in two to three weeks, if this is abnormal,

50:43

it'll develop cystic areas within it statistically,

50:47

or if you wanna go mr, you could always go mr.

50:49

But in most instances you don't want

50:51

to do an mr when the kid is at risk going

50:54

outside the isolette.

50:58

What are the most frequent chronic complications

51:01

and when will you see it in weeks or months

51:04

Of PVL?

51:06

I'm not sure if, if the

51:07

Person has that. Well, so

51:08

if you're, i, the wastebasket term

51:11

of cerebral palsy is what people say occur.

51:13

I mean, you can have seizures, you can have this, you can,

51:16

seizures is a concern that you might see early.

51:18

But um, it's, it's a better, better for a neonatologists

51:23

who want, who follows people.

51:25

And one of the problems in societies, we don't have people

51:28

that I know that follow them from birth on.

51:31

I mean, one of my interests is in following things from

51:34

obstetrical life into neonatal life.

51:37

But, um, uh, neurologists

51:40

who see these kids in clinic can give you some information

51:43

as to, uh, what exactly is the,

51:49

um, changes clinically in follow up.

51:53

And some people who have what you think is

51:57

very bad may actually have decent, um, um, outcomes.

52:02

Um, there's a certain amount I'm not allowed.

52:05

I have no idea if as a physician I'm allowed to say

52:07

that there's certain luck involved.

52:10

Um, but, um, I would be asking that of, uh,

52:14

neurologists who follow them and, uh, and pediatricians.

52:21

All right, this question, can I,

52:24

so can I confidently call IVH If

52:27

what looks like choroid plexus goes a little bit into the

52:30

frontal horns, sometimes I fear I may be over calling.

52:33

So sometimes I fear I may be over calling.

52:36

So it matters how much is there?

52:38

You see it in frontal horn, it's hemorrhage

52:40

until this proven, in my opinion,

52:42

you see something a tiny bit

52:44

and they're angling the beam,

52:46

then you can go take a transducer, re-look yourself,

52:49

make a decision whether you see it there or not.

52:52

If truly it's anterior, the M

52:53

and Monroe as per orthodox teaching,

52:56

it should be considered hemorrhage.

52:58

If I said, well, you know,

52:59

I'm not really sure I can wait on it

53:01

because if I wait on it, I wait a week

53:04

or two, it will become less echogenic.

53:07

If it's hemorrhage, if it's choroid, it won't.

53:10

But if I see it in there, I call it,

53:12

I say rule out grade two, let's look in two to three weeks.

53:15

You know, uh, I will,

53:17

I would rather the clinician know I'm concerned about

53:20

something than not.

53:22

Uh, it's a very difficult role for the radiologist

53:25

because you one know errors that occur

53:28

and two, everyone thinks you're God-like

53:30

and know everything exactly that you are the true answer.

53:33

And I philosophically believe that 50%

53:37

of the time the radiologist is of great help

53:39

to the clinician and 50% of the time may be less.

53:42

So the clinician, if they talk to you,

53:45

'cause I liked it when people talk to each other,

53:47

the clinician gives you some information

53:48

that makes you better at your next exam.

53:51

It makes you better the next time you see something.

53:54

So it's truly a marriage between clinical imager,

53:58

the radiologist, and the clinical caregiver of the,

54:03

uh, clinician, the doctor.

54:05

But that's my philosophy.

54:08

Love that. Okay, Dr. Cohen,

54:11

I don't think we have any other questions.

54:12

So we are okay to wrap.

54:15

Good. Thank you so much for being here and,

54:17

and giving this lecture and answering those questions

54:20

Fine by me. I'm

54:21

happy if I've helped anyone.

54:25

Thanks for everyone else

54:26

for participating in our noon conference

54:28

and asking such great questions.

54:29

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54:32

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54:33

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54:35

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54:38

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54:40

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54:44

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54:47

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54:50

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54:54

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54:56

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