Neonatal Cranial UltrasoundsRADY 401 Case Presentation

Male infant born at 26w 3d and 815g was admitted to the NICU for extreme prematurity, currently stable with mechanical ventilation.

This patient requires screening for neonatal intraventricular hemorrhage (IVH) with cranial ultrasound.

Routine screening cranial ultrasound examinations are recommended for all infants born at 32 weeks’ gestation or earlier. Germinal matrix is more durable after 32w

Timing of cranial ultrasound: Recommended at 7-10 days of life to screen for hemorrhage

▪ First screen can be completed earlier if clinically indicated (generalized seizures, altered consciousness, deterioration, decreased spontaneous movements, etc.)

Second scan recommended at 6 weeks of life to monitor for ventriculomegaly, cystic lesions, and periventricular leukomalacia.

Afterwards, patient can be followed with cranial ultrasounds as needed per clinical course

Coronal R Sagittal L Sagittal

Okay… so how do I read this and what does it mean?

Grade 1: Germinal matrix hemorrhage

Grade 2: Intraventricular hemorrhage without dilatation

Grade 3: Intraventricular hemorrhage with dilatation

Grade 4: Parenchymal hemorrhage

Grade 1: Germinal matrix hemorrhage

Grade 2: Intraventricular hemorrhage without dilatation

Grade 3: Intraventricular hemorrhage with dilatation

Grade 4: Parenchymal hemorrhage

Normal choroid plexus

Grade 1: Germinal matrix hemorrhage

Grade 2: Intraventricular hemorrhage without dilatation

Grade 3: Intraventricular hemorrhage with dilatation

Grade 4: Parenchymal hemorrhage

Grade 1: Germinal matrix hemorrhage

Grade 2: Intraventricular hemorrhage without dilatation

Grade 3: Intraventricular hemorrhage with dilatation

Grade 4: Parenchymal hemorrhage

Grade 1: Germinal matrix hemorrhage

Grade 2: Intraventricular hemorrhage without dilatation

Grade 3: Intraventricular hemorrhage with dilatation

Grade 4: Parenchymal hemorrhage

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60

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Grade 1 Grade 2 Grade 3 Grade 4

Per

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f p

atie

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Complications from IVH by Grade

Progressive Venticular Dilation Neurological Sequelae

Grade 1: Germinal matrix hemorrhage

Grade 2: Intraventricular hemorrhage without dilatation

Grade 3: Intraventricular hemorrhage with dilatation

Grade 4: Parenchymal hemorrhage

Coronal R Sagittal L Sagittal

Coronal R Sagittal L Sagittal

Bilateral Grade 2 GM/IVH with ?mild dilation

1. Who requires screening for IVH with cranial ultrasound?

2. Where is the germinal matrix located?

3. At what grade do neonatal IVHs become clinically significant?

1. Who requires screening for IVH with cranial ultrasound?

Premature infants born prior to 32w gestation

2. Where is the germinal matrix located?

At the caudothalamic groove

3. At what grade do neonatal IVHs become clinically significant?

Grades 3-4

1. Routine screening cranial ultrasound examinations for the prediction of long term neurodevelopmental outcomes in preterm infants. Paediatr Child Health. 2001;6(1):39-52.

2. L. R. Ment, H. S. Bada, P. Barnes, et al. Practice parameter: Neuroimaging of the neonate: Report of the Quality Standards Subcommittee of the American Academy of Neurology and the Practice Committee of the Child Neurology Society. Neurology. 2002; 58: 1726-1738

3. Intraventricular Hemorrhage (IVH) . Intensive Care Nursery House Staff Manual at UCSF Children’s Hospital. 2004. https://www.ucsfbenioffchildrens.org/pdf/manuals/49_IntraventricularHem.pdf

4. Bhat V, Bhat V. Neonatal neurosonography: A pictorial essay. Indian J Radiol Imaging. 2014.5. Germinal Matrix Hemorrhage Grade 1. University of Virginia. 2013. https://www.med-

ed.virginia.edu/courses/rad/peds/neuro_webpages/b15.html6. Lall N, WeerakkodyY, et al. Germinal matrix haemorrhage (grading). Radiopaedia.

https://radiopaedia.org/articles/germinal-matrix-haemorrhage-grading-27. De Vries L, Leijser L. Germinal matrix hemorrhage and intraventricular hemorrhage (GMH-IVH) in the

newborn: Pathogenesis, clinical presentation, and diagnosis. UpToDate. July 2018. 8. De Vries L, Leijser L. Germinal matrix hemorrhage and intraventricular hemorrhage (GMH-IVH) in the

newborn: Prevention, management, and complications. UpToDate. June 2018. 9. Standard Neonatal Cranial Ultrasound Views. Ministry of Health, New Zealand Government. Accessed

online December 2018. http://www.adhb.govt.nz/newborn/TeachingResources/Radiology/HUSS/ NeonatalHUSSViews.htm