Sonography of the Infant Brain-Intracranial Hemorrhage In the Term Infant - SD

Intracranial Hemorrhage in Term Infants

Intracranial hemorrhage in the term baby is far less common than in premature infants.

It generally is associated with asphyxia birth trauma, apneic episodes, seizures and coagulation defects.

The distribution of blood is quite different than the pattern that we've described with premature infants.

Example of Infant Treated with Heparin

Here's an example of an infant who had been treated with heparin for a complication of an umbilical artery catheter that resulted in occlusion of the aorta and a renal artery.

We see a very bright area of increased echogenicity overlaying the region of the right lateral ventricle as well as the thalamus.

Diagnosis Considerations

One might question, how do we know this is hemorrhage?

We know that this particular baby was treated with heparin and was at risk for bleeding, but tumor could look like this.

Non shadowing calcification, early abscess formation with tightly compacted purulent material could have the same appearance.

The most important thing is to understand the baby's gestational age and the clinical history as one comes to a conclusion as to what the underlying etiology is.

Intracranial hemorrhage in the term infant may be clinically asymptomatic.

It is more likely to be involving the cerebral hemispheres, the cerebellum, the subarachnoid space, the subdural space, as well as the epidural space.

It's more common in infants who are small for gestational age.

There's a higher incidence in vaginal deliveries and a higher incidence in infants of color.

Cerebellar Hemorrhage

Cerebella hemorrhage is an uncommon event.

It is associated with germinal matrix hemorrhage and intraventricular hemorrhage in preemies.

It's associated with traumatic delivery and coagulation defects.

In full term neonates, there is generally a very poor prognosis for cerebella hemorrhage as it is frequently fatal.

Here's an example.

This is a an occipital mastoid view where we see the cerebellum and we see this bright area of echogenicity that is in involving the right cerebella hemisphere.

Little bit easier to see on the view when we turn the baby's head on the film in the direction that we would like to see the cerebellum.

This has a very poor prognosis.

Subependymal Hemorrhage

Saba penal hemorrhage in term infants can be difficult to diagnose with Ultrasound.

Ultrasound is less accurate for the diagnosis of subependymal hemorrhage.

Not so much anymore for cerebella hemorrhage because of the fact that we use the occipital mastoid views.

The reason it's difficult to see the subependymal hemorrhage is that often it's not possible with ultrasound to see entirely over the convexity of the brain.

Subependymal hemorrhage is associated with asphyxia trauma and disseminated intravascular coagulation.

Typically, we'll see increased echoes and widening of the horizontal portions of the Sylvie and fissure.

Subdural and Epidural Hemorrhage

Subdural and epidural hemorrhage is usually secondary to trauma.

In term infants, it is difficult to detect with ultrasound.

We can use a standoff pad, a high frequency transducer, and we may use axial transtemporal views to aid in the diagnosis.

CT and MRI are the preferred imaging modalities for evaluation of extra axial hemorrhage and fluid collections.

Extra-Axial Fluid Spaces and Case Example

We talked earlier on about how to measure the extra axial fluid spaces, and this is the ultrasound correlation in a baby who has an increase in the extra axial fluid spaces suspicious for hemorrhage.

This is Sano cortical, cranial cortical and interhemispheric fissure.

This baby came in to the ultrasound lab because of an enlarged head circumference was the child of two lawyers who had adopted the baby and had no clinical findings that they reported to the pediatrician, but the pediatrician was concerned that the baby's head circumference had grown outta proportion to the size of the baby's body.

While the coronal view shows that there is a separation of the outer margin of the brain from the inner margin of the cranial vault.

There's increase in the extra axial fluid space, more so on the left than on the right, and there's some brighter echogenicity in the fluid around the right cerebral hemisphere.

Suspicious for hemorrhage.

Note too that there is dilatation of the right and the left lateral ventricles, and we don't see the septum lucidum here.

This is choroid plexus at the farter of Monroe bilaterally, and here we see dilatation of the third ventricle.

As we scan more posteriorly in this coronal view, again, we see the bilateral enlargement of the extra axial fluid spaces left larger than right, but right more echogenic than left.

This is choroid plexus coming around the areas of the atria of the lateral ventricles.

This area here looks somewhat unusual in that there is less echogenicity.

Para sagittal view shows the frontal horn, the body, the atrium of the lateral ventricle, temporal horn, choroid plexus, and this large area that's devoid of echogenicity suspicious for apor cephalic cyst.

Here's the opposite side, notice the increased extra axial fluid space.

Same thing here and more echogenic.

We have a ventricle that is mildly dilated compared to this, which is mild to moderately dilated.

Here's the CT scan.

We see that there is a importance cephalic cyst communicating with the occipital horn of this lateral ventricle that there is dilatation of the occipital horn.

The ventricle is relatively larger on the right side than the left, that there is a loss of brain parenchyma in the occipital region and that there are bilateral subdural collections.

Plain film of the skull documented the presence of multiple fractures.

This baby actually was a victim of unsuspected child abuse until the physician noted the enlarged head circumference and sent the baby for imaging.

Case of Infant with Seizures

Here's another infant who came in because of seizures with a large head circumference greater than the 97th percentile.

We see on the left side that there is a normal extra axial fluid space, but here we see that there is a subdural collection that is quite hyper coic.

Here's another view looking at the same area.

Remember with sono, look at the extra axial fluid spaces they can be visualized.

Here we can see on the sagittal view that on the right side there is a large echogenic collection, which is thought to be hemorrhage.

Cephalohematoma

Cephalohematoma is a bleed under the periosteum that is confined by the sutures.

As we look at this axial view of the skull, we can see the midline and the lateral ventricles, and there is this collection that is confined by the sutures outside the cranial vault.

Very commonly we see a mirror image artifact, which again we see with this cone down view.

This was scanned through a gel pad.

Subgaleal Hematoma

Subgaleal hematoma is a collection that is basically seen around the entire scalp of the baby's head.

As we look at the coronal as well as the sagittal views, we see that there is a hyper coic collection in the soft tissues around the cranial vault with no underlying abnormality.

At times we will actually identify bony abnormalities in the region of a subgaleal hematoma or a cephalohematoma.

In this axial view, we see the cranial vault and we see this large collection around the cranial vault in this baby with a subgaleal hematoma.

In addition, we could see that there is a fracture of the underlying bone.