0:00

Okay, so, um, HIE uh, ultrasounds can have a variety of,

0:05

uh, appearances, right?

0:06

So here's some kind of, you see

0:07

that gray white interface, it's kind of blurred.

0:09

And you've got slit ventricles. So this is a diffusely

0:11

edematous brain, but the location's pretty good

0:14

'cause we're now term, right?

0:15

Here's one of the central injuries.

0:17

So very echogenic basal ganglia compared

0:19

to like the white matter.

0:21

And then here's another one

0:22

where you actually have almost like a super scan.

0:24

So like you have diffuse kinda white matter injury here.

0:28

Uh, and then it's actually kind of exaggerated contrast

0:31

with the, the more ous gray matter.

0:33

So you can have either decreased or increased contrast,

0:37

but both are abnormal, right?

0:38

And obviously you have to correct

0:39

for ultrasound artifacts and gain and things.

0:41

But again, like I think the clinical picture

0:43

and then being able to really look at that gray,

0:45

white distinction and so forth is helpful.

0:48

Okay, so watershed

0:49

injury, you know, just like adults, right?

0:50

So these kinda like A-C-A-M-C, A PCA border zones, right?

0:52

So the cortex, the white matter kind

0:54

of paralleling the lateral ventricles

0:56

here, restricted diffusion.

0:58

You can see that the, the T two is, is sort of appreciable,

1:02

uh, edema on top of an already watery brain,

1:04

but it's not as easy to appreciate.

1:06

So having, it's all about timing, right?

1:09

Um, and then late, so this is called dula gyus.

1:12

So, uh, the medullary arteries are penetrating in, uh,

1:16

to the, um, you know, to these kind of like deep, deep sci.

1:20

And so it's kind of a watershed area if, if you're getting

1:23

that, um, uh, you know, low flow, uh, from cerebral artery.

1:26

So basically you get the selective kind of injury

1:28

to the deep ssci with relative span of surface of gyre.

1:31

So it's like, uh, Latin from mushroom gyre.

1:34

And so we're not talking like your American mushrooms.

1:36

It's like, uh, not, not the straw mushrooms.

1:38

It's like those Asian oyster mushrooms

1:40

that have like really long stems and like tiny little tops.

1:43

So that's what this eulo gyre is.

1:44

And this is, this is a risk factor

1:46

for seizures, for example.

1:47

So you can see the border zone appearance, uh,

1:50

on follow-up can be, uh, bilateral,

1:53

but it can also often be asymmetric, right?

1:55

So these, all of these cases, uh, uh, have some level

1:58

of asymmetry, but there is actually bilateral

2:00

involvement watershed.

2:02

And this is, this just shows you that, you know,

2:04

although watershed injuries usually partial hypoxia

2:06

of its prolonging, you actually have pretty severe sequelae.

2:10

Okay? The central injury here, uh, so this is, uh, the a DC,

2:14

and you're seeing the restriction in

2:16

these critical areas, right?

2:17

High flow areas. So the corticospinal tracts,

2:19

the basal ganglia, um, classically the areas

2:22

that are selectively vulnerable

2:24

and the term infant are gonna be the, um, the, uh,

2:27

posterior pertamina right here.

2:29

And then the, uh, ventral lateral thalami.

2:31

So like these part of the thalami.

2:32

So when you see that pattern, that's pretty specific

2:35

for term HIE.

2:37

And so here, this is a little tricky,

2:38

but see, uh, the clicks, uh,

2:41

they're a little bit like, they're a little bit faded.

2:43

You're not seeing that T two darkness

2:45

for like a third to a half of it.

2:46

It's kind of blurred out.

2:48

There's maybe a little bit too much edema here.

2:50

And then the vent lateral thal line,

2:52

the posterior peri are actually a bit too T one, right?

2:55

So they're approaching the level of the clicks, right?

2:57

So something's not quite right

2:59

In this whole central area.

3:00

And then the a SL perfusion, she says that we have, uh,

3:04

re like essentially a reactive hyperperfusion in those same

3:07

injured areas because basically they have the ischemia now

3:09

they're trying to rebound, but you see

3:10

that they're actually stealing

3:12

blood from the rest of the brain.

3:13

The rest of the brain has pretty slow flowing.

3:14

You have excessive perfusion to these injured areas.

3:16

So that's that secondary energy failure

3:19

and it steals from the rest of the brain.

3:20

And that's what we're trying to blunt with the cooling.

3:24

So late findings, so here you see the cystic degeneration.

3:26

So now like very, very bright, uh, posterior pertamina

3:30

and ventral lateral alm I with some cystic degeneration,

3:32

very specific for, uh, neonatal HIE.

3:35

And then here, uh, this is older, uh, patient,

3:38

but you see again that posterior

3:39

pertamina ventral later thalami.

3:40

So if you see this in an adult or an older child

3:43

or whatever, and there's no history you can call it, right?

3:46

Because nothing else does this.

3:48

Um, and you can have as asymmetric, right?

3:50

So hemiplegia, uh,

3:51

you can have asymmetric central injury as well.

3:53

So this person, you know, uh, right hemisphere involvement,

3:55

they're gonna have more left-sided symptoms, okay?

3:59

You can have large, uh, large artery infarcts,

4:02

uh, in term babies.

4:03

Um, it's not too common, not like adults,

4:06

right, who have strokes all the time.

4:07

But again, on the MCA stroke,

4:09

on the ultrasound restricted diffusion edema, again,

4:12

edema on top of a watery brain can be

4:14

hard to see if it's more subtle.

4:16

Um, interestingly, we usually don't find a, a clot, right?

4:20

Like there's nothing for neural ir to do.

4:21

It's usually the theory is

4:23

that maybe there's some placental emboli.

4:24

They kinda like flicked off and occluded

4:26

and then they kind of cleared out.

4:27

So we usually don't find the actual clot,

4:29

but you see there's restricted diffusion,

4:31

but on the a SL, there's actually a, a luxury perfusion,

4:34

and that mc is actually more hyperemic.

4:36

So again, that's that secondary energy failure.

4:38

So that's flooding the area with free radicals

4:41

and causing additional injury on top

4:42

of the original ischemia.

4:44

And so again, in the late phase, you can get, you know,

4:47

porn cephalic and eulogy in those mc distributions.

4:50

And so again, if you're seeing eLog gyri, that's pretty,

4:53

that's quite specific.

4:54

That pattern. Uh, those mushroom gyri

4:56

or cystic porn cephalic, it means

4:58

that they had a pretty early insulin,

4:59

not necessarily perinatal,

5:01

but at least in the, you know,

5:02

first one max two years of life, right?

5:04

When they didn't have mature astrocytes.

5:07

So you can, you can, again, you can call it,

5:09

this is not an adult mc in far, this is definitely,

5:11

even if you had no priors,

5:12

you'd know this was earlier in life and then global injury.

5:17

Um, so, uh, these are tricky, right?

5:19

Because, uh, this, uh, here are some cases

5:21

where I think they were out outside the hypothermic window,

5:24

like they got transferred in, it was more than six hours.

5:26

So there was no point in starting the hypo in this

5:28

heart, starting the cooling.

5:30

But you do see there's some restricted diffusion centrally,

5:32

but there's some little spots peripherally too.

5:35

This is a little too emini.

5:36

And then you're losing the clicks, you're getting

5:38

that bright basal ganglia.

5:40

Too much edema here. So on follow up,

5:42

it's actually bloomed, right?

5:43

So this was like one or two days, this was five days.

5:46

And so you see that doing it too early, right?

5:49

Doing the imaging too early can actually really

5:50

underestimate the degree of, of, uh, end stage injury.

5:54

So here, yes, there's central pattern,

5:55

but there's really diffuse

5:56

Diffusion restriction.

5:58

Profound basal ganglia, really diffuse edema.

6:00

You lose that gray, white distinction.

6:02

Here's another example with a SL.

6:03

So again, you see some central restriction,

6:05

but it's a little too emus out here as well.

6:08

So it's really both central and peripheral patterns.

6:10

You see that rebound hyperperfusion

6:12

of the injured basal ganglia,

6:13

and then it's stealing from the surrounding brain.

6:16

You're losing the clicks.

6:18

And then here, uh, so you know, at day four or five, right?

6:21

You have profound blooms. So the entire brain is restricted.

6:24

The profusion actually is,

6:25

is more consistent between the two.

6:27

So it's been a better prognostic factor, right?

6:29

So you're still getting a, a ton

6:30

of rebound hyperperfusion, right?

6:32

Um, and, and then in the end stage right,

6:34

you essentially have this like cystic HIE, right?

6:37

Very swollen and it all shrinks down.