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This is Pediatrics case 5 and the diagnosis were

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considering is periventricular leukomalacia.

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So you can see on your screen. We've got the earliest

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coronal image of a head ultrasound and

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head ultrasound is a very specialized study that we

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only perform in neonates by and

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large because they have incomplete Fusion of

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their sutures of their cranial sutures that happens later in

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the newborn first year of life really and

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so we can get a window a sonographic

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window through the anterior Fontanel. If it's a premature infant

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we can get a window through the posterior. Fontanelle. Oh, we

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also take images through the mastoid process before it's

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become completely.

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Well aerated and so what we're doing

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is we're trying to get a sense not just

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of the ventricles the size and

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here you can see lateral ventricles right and

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left.

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but we're also looking for any blood they

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could be in those ventricles and intraventricular Hemorrhage

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or sometimes called a

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germinal, Matrix Hemorrhage, and finally we're looking

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at

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The white matter the periventricular white matter.

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This is such an important area in the very young because

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of the risk of damage from hypoxia and

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ischemia. It's also an area we worry about in the very old

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as they develop a white matter degenerative disease of

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the tiniest vessels.

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So this is a high-risk area for ischemia.

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And what happens is when there's injury to

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this periventricular.

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white matter

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the brain starts to die all the different

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tissues of the body respond differently to ischemia and

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necrosis the brain response with liquefaction. So

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the brain actually dissolves away and

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creates empty space that sort of just

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Is subsumed Into The ventricle we call it xvacuodilitation of

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the lateral ventricles. So what we're looking at on this coronal

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image is we can see these lateral ventricles

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where a little closer to the frontal region than we are to the

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occipital.

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And you can see that they're a little bit enlarged on

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the earlier image. We had some measurements for five six

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millimeters, but we can also see that the

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brain tissue on either side of them is

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fairly homogeneous ecotexture, and that's reassuring but as

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we scroll back into the head we're seeing a

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couple of things happening one is we're seeing

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increased extra axial fluid

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sitting up here on top of the brain. It almost makes the brain look

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a little bit flatheaded and we're seeing these anechoic spaces.

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That are distinct from the lateral ventricles. There

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shouldn't be ventricles up here. These are the lateral ventricles. So

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what's going on here? And actually we're seeing some of it over here

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and maybe some tinier spaces here. This is the periventricular white

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matter. There's fluid in these

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defined spaces. And in this case quite extensive

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fluid almost up to the cortical surface of the brain and now

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we're starting to see areas here and notice what's going

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on around those anechoic fluid spaces. It's very

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echogenic. The white matter is not

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normal so you can see a much less echogenic

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appearance of white matter down here and as a rule of

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thumb here's our choroid plexus. So this

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white matter is about as echogenic

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as the choroid plexus this white

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matter down here not so echogenic. That's

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a more normal appearance down there.

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I'm going to keep scrolling back and you're going to just see even more

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extensive appearance of echogenicity of

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this white matter all of these focal areas of

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anechoic fluid and then this very large fluid

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space here.

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And as I scroll back to the back of the head you can see it's affecting

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both sides. It's quite extensive left a little

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bit more than right.

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And I also want you to pay attention to

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these extra axial fluid spaces outside the brain.

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This fluid up here. This is A sagittal view.

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So we're getting a kind of Antero posterior

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view of the brain here. You can see.

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the brain as it sweeps down we get a little bit of temporal and

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then

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we're also noticing the margin this is

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the

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margin of the brain this is that necrosis that

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Leukomalacia, which is become almost pure

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fluid and this is the extra axial fluid of the brain. I'm

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going to scroll all the way through those sagittal images and I'm

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going to go back. These are linear probe images

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so higher resolution and less depth and this is

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all fluid.

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That's a lot of fluid too much fluid sitting on top of

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this brain in a newborn. Now we have to ask ourselves. Where

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is that fluid? Is it subarachnoid that can

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be normal? Although this is a lot. Could it be subdural almost

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never normal could be the result of infection trauma hemorrhage.

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And in this case, we have both subarachnoid and

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subdural fluid. This is the margin

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right here. So we've got some subarachnoid fluid

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and some subdural fluid. So this patient is

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abnormal on multiple levels. They've got extracts you'll

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fluid too much in both spaces not normal, but

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also a large degree of periventricular

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leukomalacia. Why did this happen? Well, it's

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almost hypoxic almost always hypoxic ischemic injury

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to the brain that can occur at Birth with birth trauma can

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occur in premature neonates who have trouble oxygenating

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because their lungs aren't functioning properly and ultrasound

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can provide us with some very valuable information

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many times these patients are

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too ill to be transported down for MRI, of

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course MRIs the gold standard but ultrasound bedside exam

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very accessible non-invasive, very

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available and portable can show us the changes

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of the brain early changes with increased echogenicity

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and then later changes where we get.

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Equifact of necrosis of the brain and at some

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point this portion of the brain is just

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going to become subsumed into either the ventricles

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or the extracial space that X vacuodilitation I

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was talking about. I'm just going to take us all the way

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back to the initial images of the study and you can

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see on this coronal view. You've got bilateral Peri

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ventricular leukomalacia with subdural and

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subarachnoid extracts. You'll fluid

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that's the end of the case.