Diagnostic ultrasound ( PDFDrive )

CHAPTER 45 Neonatal and Infant Brain Imaging 1545
A B C
D
E
FIG. 45.39 Intraventricular Hemorrhage: Anterior and Posterior Fontanelle in Two Neonates. Neonate 1: (A) Sagittal sonogram through
the anterior fontanelle shows intraventricular hemorrhage within the occipital horn. (B) Occipital horn hemorrhage better visualized through the
posterior fontanelle. Neonate 2: (C) Sagittal sonogram through the anterior fontanelle vaguely shows clot in occipital horn. (D) Sagittal sonogram
through the posterior fontanelle clearly shows hemorrhage (H) and choroid plexus (C) better than the previous image. (E) Hemorrhage seen separate
from the choroid plexus. Note how the echogenicity of the clot is lower than that of the choroid plexus in neonate 2, suggesting older hemorrhage
than that seen in neonate 1.
Signs of Intraventricular Hemorrhage
Hyperechoic material ills portion of ventricular system
Clot forms a cast of the ventricle
May obscure ventricle because lumen completely illed
Thick, echogenic choroid plexus
Echolucent centrally later, as clot matures
Low-level echoes loating in a ventricle
Cerebrospinal luid–blood luid levels
Blood in the third or fourth ventricle may be missed and is
much more clearly identiied on posterior fossa ultrasound with
mastoid views. If the blood extends into the subarachnoid space
and cisterna magna, there is an increased risk for posthemorrhagic
hydrocephalus 105,106 (Fig. 45.40, Video 45.11 and Video 45.12).
Cisterna magna clot is a better predictor of posthemorrhagic
hydrocephalus than initial hydrocephalus. Early-onset IVH, in
the irst 6 hours of life, is uncommon and is associated with a
higher risk for both cognitive and motor impairment, including
cerebral palsy. 107 Neurodevelopmental outcomes in extremely
premature infants have shown increased rates of neurosensory
impairment, developmental delay, cerebral palsy, blindness, and
deafness at 2 to 3 years corrected age in an Australian cohort
study, 108 even when the original injury was grade 1 or II IVH.
Intraventricular Hemorrhage With
Hydrocephalus (Grade III Hemorrhage)
he ventricular enlargement that occurs ater IVH allows for
clear visualization of clot, which oten assumes a dependent
location but may be adherent to ventricular walls and/or choroid
plexus (Figs. 45.41 and 45.42, Video 45.13, Video 45.14, Video
45.15). Change in position may lead to change in location of
mobile clot. Posterior fontanel le images may show IVH in the
occipital horn in subtler cases. As with SEH, in time the echogenic
clot will become more echolucent centrally and may eventually
resolve. A chemical ventriculitis as a response to blood in the
CSF typically causes thickening and increased echogenicity of
the subependymal lining of the ventricle. Posthemorrhagic
hydrocephalus may require shunting if it is progressive. Follow-up
scans should be obtained weekly unless the head grows rapidly
or another crisis intervenes. Typically, the most severe degree
of hydrocephalus occurs ater several weeks. As the blood clears
from the ventricles, particularly with a block at the aqueduct,
the ventricular size may return to normal. In one series, posthemorrhagic
ventricular dilation required surgical treatment
with a ventriculoperitoneal reservoir or shunt in only 34% of
very-low-birth-weight infants with hydrocephalus. 109 Another
series reported a marked decrease in both temporary and permanent
shunts in extremely low-gestational-age newborns, such
that only 16% of these infants required a permanent shunt ater