Parasagittal Scans Research Articles

Quantitative Evaluation of White Matter Injury by Cranial Ultrasound to Detect the Effects of Parenteral Nutrition in Preterm Babies: An Observational Study.

Nutrition in early life has an impact on white matter (WM) development in preterm-born babies. Quantitative analysis of pixel brightness intensity (PBI) on cranial ultrasound (CUS) scans has shown a great potential in the evaluation of periventricular WM echogenicity in preterm newborns. We aimed to investigate the employment of this technique to objectively verify the effects of parenteral nutrition (PN) on periventricular WM damage in preterm infants. Prospective observational study including newborns with gestational age at birth ≤32 weeks and/or birth weight ≤1500 g who underwent CUS examination at term-equivalent age. The echogenicity of parieto-occipital periventricular WM relative to that of homolateral choroid plexus (RECP) was calculated on parasagittal scans by means of quantitative analysis of PBI. Its relationship with nutrient intake through enteral and parenteral routes in the first postnatal week was evaluated. The study included 42 neonates for analysis. We demonstrated that energy and protein intake administered through the parenteral route positively correlated with both right and left RECP values (parenteral energy intake vs. right RECP: r = 0.413, p = 0.007; parenteral energy intake vs. left RECP: r = 0.422, p = 0.005; parenteral amino acid intake vs. right RECP: r = 0.438, p = 0.004; parenteral amino acid intake vs. left RECP: r = 0.446, p = 0.003). Multivariate linear regression analysis confirmed these findings. Quantitative assessment of PBI could be considered a simple, risk-free, and repeatable method to investigate the effects of PN on WM development in preterm neonates.

Quantitative ultrasonographic examination of cerebral white matter by pixel brightness intensity as marker of middle-term neurodevelopment: a prospective observational study

Non-cystic white matter (WM) injury has become prevalent among preterm newborns and is associated with long-term neurodevelopmental impairment. Magnetic resonance is the gold-standard for diagnosis; however, cranial ultrasound (CUS) is more easily available but limited by subjective interpretation of images. To overcome this problem, we enrolled in a prospective observational study, patients with gestational age at birth < 32 weeks with normal CUS scans or grade 1 WM injury. Patients underwent CUS examinations at 0–7 days of life (T0), 14–35 days of life (T1), 370/7–416/7 weeks’ postmenstrual age (T2), and 420/7–520/7 weeks’ postmenstrual age (T3). The echogenicity of parieto-occipital periventricular WM relative to that of homolateral choroid plexus (RECP) was calculated on parasagittal scans by means of pixel brightness intensity and its relationship with Bayley-III assessment at 12 months’ corrected age was evaluated. We demonstrated that: (1) Left RECP values at T1 negatively correlated with cognitive composite scores; (2) Right RECP values at T2 and T3 negatively correlated with language composite scores; (3) Left RECP values at T1 and T2 negatively correlated with motor composite scores. Thus, this technique may be used as screening method to early identify patients at risk of neurodevelopmental issues and promptly initiate preventive and therapeutic interventions.

Рентгеноанатомия гипоплазированных клиновидных пазух

The degree of pneumatization of the sphenoid sinus varies in different individuals, including the absence of air cavities in the body of the bone or their hypoplasia. Such options are quite rare, they should be considered when planning and choosing a method of surgical treatment. Objective. To classify sphenoid sinuses of unusual size and shape. Patients and methods. The data of cone-beam computed tomography of 16 patients aged 22 to 70 years with dental and ENT pathology, who had an unusual size and shape of the sphenoid sinuses, were studied in order to classify them. On axial scans, the maximum transverse size (width, diameter) of the sinus was measured. On parasagittal scans, the position of the posterior wall of each sphenoid sinus relative to the sella turcica was assessed, and the distance to the plane drawn through the anterior wall of the sella turcica was also measured. Results. There were 13 cases of unilateral and 3 cases of bilateral hypoplasia of the sphenoid sinus. Bilateral hypoplasia is a rare variant of individual variability. With unilateral hypoplasia, the contralateral air cavity may not extend beyond the body of the sphenoid bone or extend into other parts of it or adjacent structures. Conclusion. When diagnosing unilateral hypoplasia of the sphenoid sinus, one should not only consider its distance from the anterior wall of the Turkish saddle but also correlate the absolute dimensions of the two air cavities.

Canine Neonatal Transcranial Ultrasonography From Birth Until Closure of Bregmatic Fontanelle

Ultrasonography is a valuable diagnostic tool that has been used for diagnosis of neonatal brain diseases. The purpose of the present study was to describe the sequential ultrasonographic appearance of the normal canine neonatal brain from birth till closure of the bregmatic fontanelle. In total, 16 clinically normal neonates of mixed breed dogs were used. The bregmatic fontanelle was used as an acoustic window to record 5 transcranial scans (3 transverse, 1 sagittal, and 1 parasagittal scans) at 3, 10, 20, and 30 days of age. The appearance, echogenicity, and developmental differentiation of the structures within the cranium were described. Good images were obtained at 10 and 20 days of age. At 30 days of age, the obtained images presented poor details, as the fontanelle was small. Data obtained from this study represent the basis of brain ultrasound in neonates until 30 days of age, which could be beneficial in diagnosing congenital brain diseases.

Porcine carcass phantom for ultrasound imaging and hands-on practice in needle insertion in the thoracic paravertebral space

To the Editor, Thoracic paravertebral block (PVB) provides excellent surgical anesthesia as well as postoperative analgesia for thoracic surgeries. Several ultrasound-guided PVB techniques have been described using either a transverse scan or a parasagittal scan in both the in-plane and the out-of-plane needle insertion approaches. The different approaches rely on the identification of one of two landmarks: 1) the superior costotransverse ligament (SCTL) or 2) the internal intercostal membrane (IICM). Learning to scan and identify the SCTL and IICM is possible on volunteers or patients, but, ideally, proficiency of hands-on needle insertion skills is acquired on phantoms prior to patient care given the potential risks of epidural or intrathecal spread, accidental pleural puncture, and pneumothorax associated with thoracic PVB. It is well known that phantom practice can shorten the learning curve, reduce complications, and result in changes in clinical practice. We have designed a pig carcass phantom which can be used to practice ultrasound-guided PVB. A pig weighing 50-60 kg is purchased from a local abattoir, sacrificed, shaved, decapitated, eviscerated, and washed as per regulations for human consumption. The carcass is then stored in the abattoir fridge at 4 C until use (not frozen). The carcass is placed prone for scanning and needle practice. Ultrasound images of the paravertebral space can be obtained using a 12 MHz transducer, and real-time longitudinal parasagittal views show the sonoanatomy of the transverse processes, pleura, and SCTL (Figs. 1, 2). Transverse views show the sonoanatomy of the transverse process, pleura, external intercostal muscle, and internal intercostal membrane. The phantom is useful not only for scanning but also for hands-on practice in needle insertion involving a particularly realistic tactile experience and practice in hand-eye coordination. A successful needle insertion and injection is indicated by downward displacement of the parietal pleura (a hyperechoic line visualized on ultrasound). The addition of methylene blue dye to the injectate permits localization of dye spread along the thoracic paravertebral space after injection, shown by viewing the pleura from the front (Figs. 3, 4). Unintentional pleural puncture is indicated by dye leakage beyond the parietal pleura when inspected from the front. Also, needle track marks are not seen in the flesh after repeated needle insertions. We recommend the pig carcass phantom for teaching and learning ultrasound-guided thoracic PVB because of the remarkable anatomical similarity of paravertebral space structures in pigs and humans. This is a potentially useful training model to gain competency in scanning and needle insertion for this technique as well as for ultrasound-guided intercostal blocks. F. W. Abdallah, MD V. W. Chan, MD (&) Toronto Western Hospital, University Health Network, University of Toronto, Toronto, ON, Canada e-mail: Vincent.Chan@uhn.on.ca

Non-Surgical Management of Advanced Cardiac Lymphoma

Non-Surgical Management of Advanced Cardiac Lymphoma

Integrated backscatter of the brain of preterm infants

We measured integrated backscatter (IBS) in the brain of preterm infants using acoustic ultrasound. The study group consisted of 25 preterm infants (gestational age, 32.4+/-2.5 weeks; birth weight, 1488+/-422 g). In parasagittal scans through the posterior horn of the lateral ventricle, regions of interest (ROI) were positioned in the cerebral white matter near the posterior horn (P), anterior horn (A) of the lateral ventricle, and the thalamus (T). IBS of the ROI was measured and IBS of P minus T (P-T) and IBS of A minus T (A-T) were calculated. A-T was greater than P-T. A-T and P-T decreased with increasing gestational age and birth weight. These changes may represent maturation of the cerebrum. A-T or P-T may be useful parameters of cerebral tissue characterization.

P15.10: An anatomic fetal brain structure and a normal variant mimicking anomalies on routine neurosonographic studies. Report of two cases

Fetal cranial anatomic structures that were not visualized previously are now perfectly delineated using transvaginal neurosonographic planes. Familiarity with these structures and their normal variants is essential for proper interpretation of prenatal ultrasound studies. Here we present two cases in which a bifidus choroid plexus (a normal variant) and a normal calcar avis (an anatomic fetal structure) mimicked abnormalities on routine ultrasound evaluation of the fetal brain. The first case simulated an intraventricular hemorrhage or a choroid plexus malformation in second-trimester fetal neurosonographic study and the normal variant has been confirmed posteriorly by a neonatal cranial sonography. The second one mimicked an intraventricular clot located within the occipital horn of the lateral ventricle in a third-trimester fetal cerebral study (parasagittal scans). By changing the angulation of the transducer the configuration of the calcar avis could be well recognized. These potential pitfalls have been already reported in the neonates. As far as we know, there are no similar cases described in the fetus.

Prenatal disturbance alters the size of the corpus callosum in young monkeys.

Many factors during fetal life and early infancy have been found to affect the development of the brain. The following study investigated whether maternal stress during pregnancy would influence the size and shape of one sensitive brain region, the corpus callosum, in infant monkeys. For 30% of the gestation period, from Days 90 to 140 postconception, gravid females were disturbed using an acoustical startle protocol for 10 min per day. Magnetic resonance imaging was then employed to obtain sagittal and coronal scans of their infants' brains. Morphometric measures of the corpus callosum were compared in 16 monkeys (5 controls and 11 from disturbed pregnancies). Prenatal conditions altered the corpus callosum, but in a differential manner for male and female monkeys. Based on the midsagittal and parasagittal scans, prenatally disturbed male offspring showed a decrease in overall size of the corpus callosum whereas the prenatal disturbance resulted in an increased area in females. An evaluation of callosal height from the coronal images suggested that the volumetric change was associated with a shift in anterior-to-posterior shape from the genu back toward the splenium. These findings concur with observations in other animals and humans, which have indicated that prenatal and postnatal factors can influence the development of the corpus callosum, possibly affecting communication between the hemispheres.

Multiplanar Reconstructed Computed Tomography Images Improves Depiction and Understanding of the Anatomy of the Frontal Sinus and Recess

The use of multiplanar reconstructed computed tomography (CT) images of frontal recess and sinuses was assessed with regard to depiction and understanding of anatomy and effect on surgical approach. Three otorhinolaryngologists and one radiologist read CT scans of 43 patients referred for routine paranasal sinus scans. Spiral (helical) CT scans were obtained and coronal and parasagittal reconstructions were imaged. Three hundred forty-two readings were analyzed. The scans were assessed in the coronal plane and then in the parasagittal plane. The images were assessed for (i) Bent and Kuhn classification of frontal ethmoidal sinus air cells, (ii) size of frontal sinus ostium (assessed as unsure, normal, small, or large), (iii) use of parasagittal scans regarding additional understanding of the anatomy with particular reference as to how the agger nasi cell and frontal ethmoidal cells were arranged in a three-dimensional space, and (iv) if the parasagittal scan and subsequent three-dimensional picture created altered the surgical approach. The first two criteria were assessed in the coronal plane and then in the parasagittal plane. There was no statistically significant difference between the Bent and Kuhn classification of frontoethmoidal cells on coronal and reconstructed parasagittal images (t-test; p > 0.05). The parasagittal scans were significantly better than the coronal scans for identifying and assessing the size of the frontal sinus ostium (p < 0.001; chi-square test). Assuming an intraobserver change rate (repeat error) of 10% on CT scan observations, an exact binomial test was performed on S-PLUS, which showed that there was a significant (p < 0.001) proportion of observers who changed their rating after looking at the parasagittal scan. There also was significant improvement in observers' abilities to identify and classify the size of the frontal ostium as reflected by the number of observers who changed from being unsure on the coronal scans to sure on the parasagittal scans. Observers felt that the parasagittal scans improved their three-dimensional understanding of the anatomy of the frontal recess by 58% on a 10-point Lickert scale. In 55% of these observations, the surgical plan was altered by a mean of 70.2% on a 10-point Lickert scale based on additional information obtained by viewing the parasagittal scans. The three-dimensional understanding of the frontal recess is improved greatly by using both coronal and parasagittal reconstructed images as compared with coronal images alone. This had important implications on the planning of the surgery in the frontal recess.

The Choroid Plexus in Normal Full-term Neonate: A Study of Morphological Variety on Sonography

Purpose : The purpose of this study was to evaluate the sonographic features of normal choroid plexus, thushelping avoid misinterpretations such as intraventricular hemorrhage or abnormality. Materials and Methods :Posterior coronal, parasagittal, and oblique sagittal scans of 400 choroid plexus in normal full-term neonates(100girls, 100 boys) were reviewed with special attention to coronal configuration, glomus patterns, and the shape of anterior ends. Sonographic features were classified as follows ; tubular(type 1), posterior clubbing(type 2),mid-bulging(type 3), or double choroidal pattern(type 4), as seen on posterior coronal scans; crescent(type1),superior notching(type 2), dorsal bulging(type 3), or inferior notching(type 4), as seen on parasagittal scans; and anterior tapering(type 1) and clubbing shape (type 2) on oblique parasagittal scans. Maximal diameters of the choroid plexus on posterior coronal scan and the glomus on parasagittal scan were measured. All sonographic measurements of normal choroid plexus were statistically analysed according to gender and side. Results : Four hundred normal choroid plexus were classified as 293 cases(73%) of tubular pattern(type 1), 50 cases(13%) ofposterior bulging(type 2), 44 cases (11%) of mid-bulging(type 3) and 13 cases(3%) of double choroidal pattern(type 4) as seen on posterior coronal scans ; 263 cases(66%) of crescent shape(type 1), 70 cases(17%) of superiornotching (type 2), 38 cases(9%) of dorsal bulging(type 3), and 29 cases(7%) of inferior notching(type 4), as seenon parasagittal scans; and 233 cases(58%) of anterior tapering(type 1) and 167 cases(42%) of anterior clubbing(type 2), as seen on oblique parasagittal scans. Maximal diameters of the choroid plexus on posterior coronal scanwere (95% confidence interval [CI]) on the right side and (95% CI) on the left side, and (95% CI) mm on the right and on the left side glomus on parasagittal scan. There were no significant statistical differences with regard to gender and side. Conclusion : We have observed the morphological variety of the choroid plexus in normal full-term neonates on ultrasonograms and believe that a knowledge of the various sonographic patterns involved can help differentiating normal choroid plexus from intraventricular hemorrhage or choroidal abnormality.

A leaking laparoscopy wound

A 34-year-old Bahrainian woman presented to the Accident and Emergency Department complaining of fluid leaking from a recent laparoscopy scar. She spoke very little English so no further history was available. Examination of the abdomen was unremarkable. She was referred for an ultrasound examination of the abdomen to exclude an intra-abdominal collection or urinoma. A midline sagittal scan of the pelvis and a parasagittal scan to the left are shown (Figs 1 &amp; 2). What is the diagnosis? What were the likely indications for the laparoscopy? The ultrasound examination revealed a moderate amount of ascites, later confirmed to be the source of the leaking fluid. The uterus was normal in size but had a very thickened endometrial echo (16–18 mm anteroposterior diameter).

A specular reflection arising from the ventricular wall: a potential pitfall in the diagnosis of germinal matrix hemorrhage.

Reflection artifacts may complicate the diagnosis of intracranial hemorrhage in preterm neonates. A linear focus of bright echoes in the region of the germinal matrix at or anterior to the caudothalamic grooves, often seen on parasagittal scans, may be mistaken for a germinal matrix hemorrhage but is actually a reflection of the ultrasound beam at the wall of the lateral ventricle. Cranial sonograms of 100 preterm infants were retrospectively analyzed and categorized with regard to presence and size of specular reflection. Eight cases demonstrated a bright echogenic focus; seven of these potentially could have been mistaken for hemorrhages.

Improved visualization of choledocholithiasis by sonography

During a 20 month period, real-time sonography performed on 26 patients achieved an overall sensitivity of 75% for detecting choledocholithiasis. Although previous publications have stressed very low sensitivities for diagnosing choledocholithiasis (13%-55%), it was postulated that the reasons for these disappointing results are primarily related to technique. Most laboratories evaluate the distal common bile duct (where most calculi are located) by obtaining parasagittal scans. Detection of choledocholithiasis can be substantially improved by scanning the intrapancreatic part of the bile duct in a transverse fashion with the patient in an erect position. Advantages of the transverse view include the ability to demonstrate the distal common bile duct in a high percentage of patients and to differentiate shadowing caused by duodenal gas from ductal calculi. The proximal duct is best imaged by obtaining parasagittal scans with the patient in a supine left posterior oblique position. Using these scanning techniques, eight (89%) of nine proximal and 16 (70%) of 23 distal calculi were visualized.

Cerebral structure and intraventricular haemorrhage in the neonate: a real-time ultrasound study.

A method for systematic scanning of the neonatal brain with real-time ultrasound is described, and the linear array is compared with mechanical sector scanners. Anatomical landmarks recognised on axial, coronal, and parasagittal scans are verified by comparison with brain slices at necropsy. A prospective study of 50 infants admitted consecutively to the neonatal unit at this hospital showed intraventricular haemorrhage in 18 (36%). These 18 infants included 10 (43%) out of 23 of birthweight less than or equal to 1500 g, and 3 (27%) out of 11 of birthweight 1501-2000 g. An unexpected feature was the recognition of intraventricular haemorrhage in 5 of the 13 infants greater than 2000 g birthweight. On sequential daily scans intraventricular haemorrhage was diagnosed most often in the first 2 days of life and abnormal ventricular echoes persisted for up to 12 days thereafter. Late development of hydrocephalus was recorded in 2 infants. Real-time ultrasound provides the neonatologist with a practical method for diagnosis and monitoring of intracranial lesions in the ill neonate and is a valuable, non-invasive, and safe tool for studying the pathophysiology of neurological handicap in infancy.

Ultrasonography of the Diaphragmatic Crura

The diaphragmatic crura are being recognized with increasing frequency on routine sonograms. In a study of 100 random patients the right crus was seen in parasagittal scans in 50% of patients and in transverse scans in approximately 90%. The left crus was not specifically identified on parasagittal scans, but was visible in about 50% of patients on transverse scans. Longitudinal coronal approaches can significantly improve visualization of the crura.

Ultrasonic detection of pericardial effusions adjacent to the right atrium during routine examination of the upper abdomen

Pericardial effusions are usually detected on ultrasound by examining the heart with time--motion (T/M) or real-time equipment through a left chest intercostal space. Since fluid within the pericardium also accumulated around the right atrium, effusions can also be diagnosed by observing fluid separating the right atrium from hemidiaphragm on parasagittal scans of the right upper abdomen. In order to be certain that this space represents pericardial rather than pleural fluid, the inferior vena cava must be identified along the lower margin of the fluid space as a tubular structure traversing from the diaphragm into the right atrium. Our procedure is proposed as an ancillary approach for detecting clinica-ly unsuspected effusions during the routine examination of the upper abdomen rather than as a replacement for the usual method of visualising pericardial effusions.