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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5774_Библиотеки_им_академика_М_И_Перельмана.pdf
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In mild cases, the echo of the lesion is lower than that of
the choroid plexus; in a moderate degree, the echo of the
lesion area is equal to that of the choroid plexus; in severe
cases, the echo of lesion area is stronger than that of the choroid plexus.
Special Tips
1. Cranial ultrasound is the rst choice for the diagnosis of
neonatal HIE. CT is sensitive to early cerebral hemorrhage. MRI is an important supplement to ultrasound and
CT, especially for the evaluation of mild HIE (Fig.2.195).
Fig. 2.195 CT and MRI ndings of HIE. (a, b). CT shows intraventricular hemorrhage and subarachnoid hemorrhage. (c, d). MRI manifestations
of the acute phase, a wide area of brain edema
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2. HIE can be accompanied by intracranial hemorrhage,
especially subarachnoid hemorrhage.
3. The lesions persist for 3 to 4weeks in dynamic observation, and the prognosis is poor.
2.9.4.2 Intracranial Hemorrhage
Basic Concepts
Intracranial hemorrhage (IH), common in birth injury,
hypoxia, hemorrhagic diseases, and so on, is the most common neonatal brain disease, especially in premature infants.
Severe cases may cause death or neurological sequelae.
Clinical manifestations: Mild IH may be asymptomatic,
and the prognosis is good. Severe IH with the following
symptoms has a poor prognosis: irritability, convulsion,
reduced reaction, low muscle tension, disturbance of consciousness, coma, and apnea.
Bleeding sites are subependymal, choroid plexus, brain
parenchyma, subdural, subarachnoid space, and cerebellum.
The morbidity and mortality of severe hemorrhage are high.
IH is generally divided into 4 grades: Grade I, subependymal hemorrhage; grade II, intraventricular hemorrhage; grade
III, intraventricular hemorrhage with ventricular dilatation;
grade IV, ventricular dilatation and intracerebral hemorrhage.
Ultrasonic Diagnosis
1. Subependymal hemorrhage.
(a) Sonogram shows a focal hyperechoic mass under the
anterior horn of lateral ventricle, unilateral, or
bilateral.
(b) Combine the abnormalities on the coronal and sagit-
tal views for further diagnosis.
(c) Subependymal cyst is formed after the hemorrhage is
absorbed (Fig.2.196).
2. Intraventricular hemorrhage.
(a) Intraventricular hemorrhage is caused by subependy-
mal hemorrhage broke into the lateral ventricle, or
choroid plexus hemorrhage owed into the lateral
ventricle.
(b) Sonogram shows hyperechoic masses in the ventricle
with irregular distribution; the choroid plexus is
thickened, enlarged, and lengthened, with a rough
surface (Fig.2.197).
Fig. 2.196 Subependymal hemorrhage. (a). The coronal view of the
neonatal head shows subependymal hemorrhage under the anterior horn
of bilateral ventricles (grade I). (b). The coronal view of the neonatal
head shows the formation of the left ependymal cyst in the late stage of
hemorrhage (arrow). (c). The sagittal view of the neonatal head shows
the left ependymal cyst in the later stage of hemorrhage (arrow). (d).
Coronal view of the neonatal head shows the right ependymal cyst in
the late stage of hemorrhage (arrow)
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Fig. 2.197 Intraventricular hemorrhage. (a). On the sagittal view, the
right ventricle is lled with irregular hyperechoic mass, combining with
lateral ventricular dilatation. (b). In the sagittal view, lateral ventricular
dilatation and irregular hyperechoic mass at thalamic sulcus of the caudate nucleus are shown. (c). Lateral ventricular dilatation and hyperechoic mass (arrow) at the choroid plexus are visible in the sagittal
section. (d). The coronal view shows bilateral ventricular dilatation and
bilateral intraventricular hyperechoic mass (arrow). (e). The transverse
view shows bilateral ventricular dilatation and hyperechoic mass in the
right ventricle (arrow), indicating intracranial hemorrhage (grade III).
(f). The coronal view shows the bilateral ventricular dilatation, and a
mass with relatively hyperechoic edge (arrow), which is formed by the
liqueed blood clot in the late stage of hemorrhage. (g). The transverse
view shows the dilated bilateral ventricles, shifted midline, and a mass
with relatively hyperechoic edge (arrow), which is formed by the liqueed blood clot in the late stage of hemorrhage. (h, i). The coronal view
shows the dilated bilateral ventricles, and a mass with relatively hyperechoic edge (arrow), which is formed by the liqueed blood clot in the
late stage of hemorrhage
2 Application ofDiagnostic Ultrasound inthePerinatal Period
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g
h
i
Fig. 2.197 (continued)
(c) In the late stage of hemorrhage, the echo intensity
gradually become weakened or absorbed to form a
cyst.
3. Hemorrhage of cerebral parenchyma.
1. Hemorrhage of cerebral parenchyma is the most serious
type of intracranial hemorrhage, and the mortality rate is
as high as 75%. Survivors often have neurological
sequelae, such as cerebral palsy, epilepsy, growth retardation, mental or motor disorders. It happens in the frontal
lobe, occipital lobe, or parietal lobe, especially in premature cases.
2. Sonogram shows the focal increased echogenicity or
complex echoic mass in the cerebral parenchyma, regular
or irregular, with a conspicuous boundary. When the mass
is large, the cerebral midline will be shifted to the healthy
side (Fig.2.198).
4. Subdural hemorrhage: Subdural hemorrhage is caused by
the rupture of the tentorium cerebelli or falx cerebri. The
distance between the skull and brain tissue increases, representing an anechoic area with scattered points echo
inside. If a large clot forms, it could be hyperechoic
(Fig.2.199).
5. Subarachnoid hemorrhage: The widened horizontal or
vertical part of the lateral ssure or the enlarged cistern is
visible in the sonogram.
6. Cerebellar hemorrhage: Sonogram shows abnormal area
of increased echogenicity in the cerebellum, with irregular margins.
Special Tips
1. Meningitis, brain tumor, and brain abscess may also
exhibit t areas of increased echogenicity, enlarged ventricular, echo enhanced choroid plexus, anechoic, and
complex echo areas. It is necessary to combine the history and clinical manifestations for further diagnosis.
2. Under ultrasound examination, it is difcult to show
small subdural hemorrhage, subarachnoid hemorrhage,
and cerebellar hemorrhage.
3. Generally, ultrasound is the rst choice for routine screening of neonatal intracranial hemorrhage. When there are
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Fig. 2.198 Parenchymal hemorrhage. (a). The transverse view shows
the enhanced echo in the right brain parenchyma and midline deviation.
(b). The coronal view shows the enhanced echo in bilateral parenchyma. (c). The coronal view shows the enhanced echo in bilateral
parenchyma, mainly on the right side. (d). The coronal view shows the
Fig. 2.199 Subdural hemorrhage. (a). The coronal view shows the right subdural hemorrhage (arrow). (b). The lateral transverse view shows the
subdural hemorrhage (arrow)
enhanced echo in the right brain parenchyma (arrow). (e). The sagittal
view shows the dilated lateral ventricle and the hyperechoic mass in the
thalamus. (f). The sagittal view shows the enhanced echo in the left
parenchyma, indicating intracranial hemorrhage (grade IV)
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no positive ndings by ultrasound while highly suspected
abnormal in clinical, CT, or MRI is recommended to
detect subdural hemorrhage, hemorrhage in posterior
fossa and other marginal locations, and brain parenchyma
point hemorrhage. If the condition of neonate keeps stable and accessible to MRI, it is better to choose MRI than
CT.MRI is superior to CT and ultrasound in assessing the
prognosis (Fig.2.200).
2.9.4.3 Periventricular Leukomalacia
Basic Concepts
Periventricular leukomalacia (PVL) refers to the ischemic
coagulation necrosis of periventricular white matter, which
mostly involves the optic radiation area of the lateral ventricular triangle and the white matter area outside the anterior
horn. PVL often occurs in premature infants, and can be
divided into four stages: ① enhanced echo phase; ② relatively
normal phase; ③ cyst formation phase; and ④ cyst disappearance phase.
Ultrasonic Diagnosis
1. In the early stage of PVL, sonogram shows the enhanced
echo around the ventricle, manifested as bilaterally symmetrical and rough echo enhanced areas (Fig.2.201).
2. At the late stage (2–3weeks), cysts are formed around the
ventricles, accompanied by ventricular enlargement
caused by white matter atrophy.
Fig. 2.200 CT and MRI manifestations of neonatal intracranial hemorrhage. (a). CT shows extensive hemorrhage in the right ventricle. (b). MRI
(T1WI) shows hyperintense hemorrhage near the anterior horn of the left ventricle
Fig. 2.201 Periventricular leukomalacia. (a). The coronal view shows bilateral periventricular echo enhancement (arrow). (b). The sagittal view
shows periventricular echo enhancement (arrow)
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Special Tips
1. The sensitivity of ultrasonography in the diagnosis of
PVL is low.
2. MRI is of poor specicity in the diagnosis of early
lesions of focal PVL, but it is more valuable in the diagnosis of late PVL. In MRI images, PVL represents
decreased white matter volume, enlarged ventricle,
irregular ventricle wall, gliosis, and delayed myelination (Fig.2.202).
2.9.4.4 Neonatal Hydrocephalus
Basic Concepts
Neonatal hydrocephalus refers to the ventricular dilatation or
accumulation because of the excessive increase of cerebrospinal uid and accumulation in the ventricular system,
caused by the obstruction of cerebrospinal uid circulation,
excessive secretion of cerebrospinal uid, or disorder of
cerebrospinal uid absorption. The cerebrospinal uid
circulation is affected by midbrain aqueduct stenosis, intracranial hemorrhage, and infection.
Generally, ventriculomegaly is characterized by an
enlarged ventricle without head circumference enlargement.
In contrast, enlarged ventricular with head circumference
enlargement is hydrocephalus.
Ultrasonic Diagnosis
1. Sonogram shows ventricular enlargement or hydrocepha-
lus (Fig.2.203).
2. According to the size of the lateral ventricle, hydrocepha-
lus is divided into mild, medium, and severe degrees. The
width of the lateral ventricle is 4–6mm in mild cases,
7-10 mm in moderate cases, and more than 10 mm in
severe cases.
3. It may be accompanied by brain tissue compression and
atrophy.
Fig. 2.202 MRI ndings of PVL
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c
d
e
Fig. 2.203 Neonatal hydrocephalus. (a, b). The coronal view shows
massive hydrocephalus in bilateral ventricles (severe). (c). The sagittal
view shows massive hydrocephalus in left ventricle (severe). (d, e). The
coronal view shows the dilation of bilateral anterior horn of ventricles
with remote blood clots in the right ventricle
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Special Tips
It is easy to diagn’ose ventricular dilatation and hydrocephalus.
1. Dynamic observation shows that most of the progressive
ventricle expansion cases are hydrocephalus.
2. In some brain atrophy cases, the ventricles are also
enlarged, but the sulcus, cistern, and hemispheric ssure
are widened signicantly.
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