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Get PDF Neonatal Cranial Ultrasonography: Guidelines for the Procedure and Atlas of Normal Ultrasound Anatomy

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Learning Ultrasound. Textbook of Diagnostic Sonography. Ultrasound: The Requisites. More ultrasound eBooks Report a problem. DOI: On April 5, In Volume 14 Number 1 , Original articles. Hypoxic-ischemic encephalopathy HIE is a leading cause of disability in full-term newborns.

Long-term consequences of HIE, even when treated by hypothermia, are not easily predictable. To assess the potential role of electroencephalography and neuroimaging parameters as early predictors of neurodevelopmental outcome in HIE newborns treated with hypothermia.

INTRODUCTION

We retrospectively evaluated 13 HIE patients treated with hypothermia in January September Early instrumental evaluations, in particular aEEG and US, seem to predict neurodevelopmental outcome at months in HIE newborns treated with hypothermia. Key words : asphyxia, hypoxic-ischemic encephalopathy, hypothermia, newborn.

Hypoxic-ischemic encephalopathy HIE , following neonatal asphyxia, is a leading cause of neurological disability in newborns: 1 it can result in serious consequences such as death, cerebral palsy, epilepsy, cognitive, behavioural and developmental deficits. Hypothermic treatment limits brain damage, reducing mortality and disability at months of life. Therefore, the aim of this study was to assess the potential role of amplitude-integrated electroencephalography a-EEG background patterns, cranial ultrasonography US and cerebral magnetic resonance imaging MRI findings as early predictors of neurodevelopmental outcome at 18 months in neonates undergoing therapeutic hypothermia for HIE.

Hypothermic treatment was performed according to the current national guidelines for the management of HIE. A trained nurse or technician applied surface electrodes at C3-C4 locations according to the international 10 —20 system. A severity score, based on the classification reported by Murray et al. All US images were blindly reviewed by a single neonatologist G. For each patient different anatomical sites were evaluated: basal ganglia, periventricular and subcortical white matter, cortical grey matter, and the severity of injuries was classified according to the severity score proposed by DeVries.

INTRODUCTION

The basal ganglia were classified as: normal in the absence of ultrasound abnormalities, slightly altered in the presence of focal hemorrhage or hyperechogenicity of the lateral thalamus, moderately altered in the case of hyperechogenicity of the thalamus and putamen, seriously altered if the caudate and the entire thalamus were involved. The white and cortical substance were classified as: normal in the absence of ultrasound abnormalities, slightly altered in the case of focal hemorrhage of the periventricular white matter or widespread hyperechogenicity predominant in the paraventricular and parasagittal areas, moderately altered in the absence of cortical profile in one or both cerebral hemispheres, severely impaired in the case of diffuse hyperechogenicity of the white matter with greater involvement of the subcortical substance.

Brain MRI was performed between 7 and 28 days of life and different anatomical sites were evaluated: posterior limb of the internal capsule PLIC , basal ganglia, periventricular white matter and subcortical and cortical grey matter. The severity of injuries was classified according to the severity score proposed by Cheong JL et al. For all patients, a development evaluation was performed between 18 and 24 months of life by a pediatric neurologist R.

Differences between subjects with positive and negative neurodevelopmental outcome were evaluated by chi-square test or Fischer test as appropriate for categorical variables and by Mann-Whitney U test for continuous variables. Statistical analysis was performed using SPSS version Out of 13 enrolled patients, 8 Characteristics of enrolled patients for the four items included in the definition of neurodevelopmental outcome MDI score, motor, hearing and visual impairment are shown in table 1.

Mean MDI score at months was The a-EEG severity scores at 6, 12 and 24 hours were not different in subjects with positive and negative neurodevelopmental outcomes. Globally, there was an improving trend from 6 to 24 hours, with an increase in slight alterations at the expense of severe ones table 2. In regard to the cranial US, the two groups of subjects with positive and negative neurodevelopmental outcomes did not differ in severity of alterations in any anatomical site and at any time table 3.

In regard to the brain MRI, the two groups did not differ in severity of alterations in any anatomical site. Severe anomalies were recorded at all sites in one patient belonging to the group with a negative outcome table 4. This study aimed to analyse the presence of early anomalies detected by a-EEG, cranial US and brain MRI, in neonates undergoing therapeutic hypothermia for HIE, and to assess their potential prognostic value with respect to neurodevelopmental outcomes at 18 months.

The first instrumental parameter taken into account was a-EEG recorded at 6, 12 and 24 hours of birth. No difference was found in the a-EEG severity scores at each time point between subjects with positive and negative neurodevelopmental outcomes. An improving trend from 6 to 24 hours was also globally found, with an increase of the slight alterations at the expense of the severe ones, that, however, tended to persist into the negative outcome group.

Flaring persisting beyond the first week of life is by definition PVL garde 1. The term flaring is used to describe the slightly echogenic periventricular zones, that are seen in many premature infants in the first week of life. During this first week it is not sure if this is a normal variant or a sign of PVL grade 1.

Flaring persisting beyond the first week of life is by definition PVL grade 1. Follow up is needed to differentiate flaring from PVL grade I. The case on the left shows a premature infant with flaring.

Fetal MRI - General Information

At follow up no cyst formation was found and after the first week a normal periventricular white matter was seen. Germinal matrix hemorrhage GMH is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage. These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix, which is located in the caudothalamic groove.

This is the subependymal region between the caudate nucleus and thalamus. Most infants are asymptomatic or demonstrate subtle signs that are easily overlooked. These hemorhages are subsequently found on surveillance sonography. Grade 1 intracranial hemorrhage On the left an intracranial hemorrhage confined to the caudothalamic groove. It is staged as grade 1 hemorrhage. Grade 2 intracranial hemorrhage On the left a grade 2 intracranial hemorrhage. On the coronal image only the cavum septi pellucidi is seen. Both lateral ventricles are filled with blood, but there is no ventricular dilatation.

On the left the same patient after 3 days.

Neonatal brain ultrasound

The ventricles are dilated and clot formation is seen. Secondary hydrocephalus occuring several days after a grade 2 bleed should not be mislabeled as grade 3 hemorrhage. Grade 3 intracranial hemorrhage On the left a grade 3 intracranial hemorrhage filling the left lateral ventricle. Also note the wedge shaped hyperechoic area on the laterosuperior side of the ventricle.

This represents a small venous infarction. Same patient as above. Two weeks later the venous infarction has developed into a hypoechoic area with cyst formation. Grade 4 intracranial hemorrhage Originally these grade 4 hemorrhages were thought to result from subependymal bleeding into the adjacent brain. Today however most regard these grade 4 hemorrhages to be venous hemorrhagic infartions, which are the result of compression of the outflow of the veins by the subependymal hemorrhage. On the left a grade 4 hemorrhage. There is a large subependymal bleeding but also a large area with increased echogenicity in the brain parenchyma lateral to the ventricle.

This is probably the result of a venous infarct. These venous infarctions resolve with cyst formation. These cysts can merge with the lateral ventricle, finally resulting into a porencephalic cyst. On the left a different patient with a grade 4 hemorrhage at a later stage with extensive cyst formation. Grade 1 and 2 bleeds generally have a good prognosis. Grade 3 and 4 bleeds have variable long-term deficits, but outcome in grade 3 hemorrhages is usually good when no parenchymal injury has occurred.

Hydrocephalus is a common complication and many infants require ventriculoperitoneal shunting. The mechanisms by which hydrocephalus develop include:. Well known variants are the cavum of the septum pellucidum and the cavum vergae. The more premature the baby, the more frequently these cavities are present. They can persist until adulthood.

A less frequently seen variant is the cavum of the velum interpositum.