CHAPTER Neonatal Brain Imaging THOMAS L, SLOVIS, DOROTHY I. BULAS, and MARVIN , NELSON Neonatal hyposicischemie brain lesions (hypoxic. ischemic encephalopathy (HIE]) and. intracranial emorthage (GH) are unsgue becuse ofthe inmate anatomy and physiology of the premature infane Some Of thew lesions cam oecnr in term as well a preterm fntnts because of the difieaes that may transpire luring the tanstion from inutero to extrauterine frvironment These topic ate dkcied in this chapter fd the rest ofthe central actons stern abnormalities tte discussed in Section “The neonatal central nerves stem can be imaged by cranial uluasonography (US) magnetic resonance Indications for Neonatal Cranial Ultrasound Sen Tneracana hemorhage (c10901250 g 28 weeks eestor tpoichcmi sora inching foal whice tater acres) me ir numa infanswho cat be anspor for CT Prenat dewctedsboormsly Foloing rena snateo Hodrocepia ‘xara a collecon Sewct {Congeia abnomaliy pee ENS let ‘Shipected sgl sins tvonbis seanema eee ss Braluaon ofa sik neonate fo SNS sbmormaiy wen be ore cannot be transported fo MRI Macocepae ‘cir locaton —yein of Salen Inital een for congenial anomaie and sydcomes Paventon BMG = ‘ir aum—nfins who cna be eanpored foe CT Tloingprestaly detected abr Supe aga strona imaging (MRI) or computed tomography (CX). The indieatione for cranial US are Hed tn Table SI. CT ott tweful in acute siuations where inmncdai Information i necessary before surgery. MRI, including diffusionsweighted sequences and magnetic Tesonange spectroscopy (MB), has become extremely important it elucidating neonatal brain injury in the ac and chronic stages of neonatal brain injury (Table 813) ‘Theve modalities are important imaging tools for etl iter and should be used in an integrated comeflectig Approach without simecessry duplicate examination IMAGING TECHNIQUES. Ultrasonography Although US is examinerdependen, this disva fan be minimized unifore approach, wi ape Sequence of images, and modern equipment are There i increaing tne of softcopy readings + advent of picture archiving and comaunicaa ‘ystems. The interpreting physician dhrough th use ‘altime clipe can achiewe even greater oualizain Understanding ofthe examination, Tee nportal all examinations be checked so that question Findings ean be defined further, “The complete examination must meet the st ‘ofthe Amertcan Insite of Urasound in Medicine the American College of Radiology (ace the Arp tend ofthis chapter. This includes agit and cm Indications for Magnetic Resonance Imaging Fecha i IHF dere Encephalopathy rasa earpeed ee ed Encephalopathy ‘Unenpaned seswoh he anor font Fi 1 an Pee ie coer ote te Bios Serrano of pcos scale 19) Bese opr ean on ings th cei Bee asd St al he ers fates wee treo i 3.) vgs dee a Lead inh ty os ot ng eet upc or Dp ta a cies soe tin rcs oe in shang nthe seen ar Feri dale Doppler io pitely Pecan Gene cue cy cane Bit pa tly cn’ ce i Beara he Sop pags Fe ving cottons Bene ns Genin rt as i ahr hur porn nga ce nm Be Becta i ce irl pram D SoncTeanieinie 9) 4. nen ined oni agents may el a sng occa cl poet Bop aig seg tnt ag De ingen ic eral cough puso pony ad ret ye Ba ng ee coe, Meccan a, SS ah Eichmann ese th eneicer nd fy og Ti) ad cee me ean sen eqns eke a ga fom Hol cae std Tema a fee Sched ac til cae we ye ree Bical wie ace apy Bie te Paco spon of tae cic Biocenter aogh By sical ie en pedo i Ficcrdurastal Gases ining ie Besar tests pner anes Decanting yb eter Ste Nona Exar ne Vass Cranial UShelps define maturation (Table 3-3), normal toric stretores, and normal variants (Rig 31-7) Normal anatomic sructices that should be identified fn every examination are Usted in Table S14 and Appendices And B- ‘onal variant st be recognized to avold mise preston, Almost all premature infants have a eau pum peucdunand a cavum vergae- A small amount a extra i requenty seen in dhe Hist days uf lite after delve the lateral ventricles may’ e small fr completely effaced this shoul! not be mistaken fora Sign of cerebral edema (Fig, 8). Occasional, there fare 3 to Imm cyst adjacent to the, superolteral ‘margin of dhe Irotal hom (Fig 1-9). These may be found unilaterally oF tilserally in neonates without CGaMPTERS! — Nowra aRANINAGING 389 signs, plots, oF lboratory evidence of infection, SEbclage or ipporiaThele oy are soy and thon probably teprsent oarcaion of he frontal oma Srde incr conocer and should be considered Sora aint hogencenicuontae vents minerliig vase Iopaly or lentculnracewuclopathy with ealieation inne al ofthe lenoeatouate antes the mide ttrebral artery) maybe eter unter or ilateral and tre fou arous dsac, icing congerital ‘Econ, chromosomal sbmoreaises and pera brain injuyof ny caine (ce Big 314). The echogenic tRtugon ca Tepresentnonectie reponse to rsa in [Normal variants mut be recognized to avoid interpretation: + Cavum sepeum pellucidum and cavum vergae + faced lateral veneces in the frst days of ie + Comet of heft ors ofthe tera ‘Magnetic Resonance Imaging Increased ailablity and improved environmental factors (e, neonatal incubator specie neonaal head Crile, monitoring equipment) ‘have allowed MRI to ‘Secome 2 primatyIntaging modal in term and pre term neonites, I as changed our aby to make cay Aiagnonen The use ofS tesla MRI (37 wit its nereased Sglabornoise ratio has resulted in superbly dealed intges improving our howled of embryontedevlop- ment at teats to pathologie condisons. “The indications for Min neonate ae ted in ‘Table S12 Attention to the details of temperature ontol, stability of wal sign, ad adequate method of ‘Stacon is crucial in alnaining patent safey, The feonaalogss and their aff and nsres together with the MRI saffare responsible for patent preparation and Care dorng the examination. Neonates canbe sedated ‘wth chloral hydrate or midazolam and, 4 neces Tipplemented with Fentanyl All” MRcompadbe quipment for neonatal monitoring and rexwstation ‘oul be salable including pole oximety, heat rate, nd endile carbon dioxide etecor. Blood pressure Should be obaained as indicated. All of these factors become let ofan ise when 3 specie LST or ST MRE ompantle incubator wth iin MRI cil is used {immobistion besides season inclaes “wrapping” the neonate wih warming Blankets to maintain body emperaure and sng various sealable product to feablive the ifn’ hea win thee. ‘Most nconates are carrey imaged on the 1.5T units ‘becanse the specie abworption rte mits (SAR—a mew iremeat of fnternal heating) requit alteration of pro- tocol and compatible ventor ST provides ncremed Information, however, ands being used more frequenty at accesory equipment and ST units become aalable The techniques wed in neonatal MRE mus take na account the SAR fimis sn normal neresed ater ‘Content ofthe neonatal rain (about 10% greater thanauWTERs) — Sonata. meas AGING — 401‘ve i tn unasace laced pa Emperors canes vow kr ety eeu that of the adult brain) composing 959% oF the brain Solme-—especally nthe white matte. Views inal three planes inckade sequences using Tl-weighted Images (on the 31 TI iia stented inversion recovery ghtedinages (fast spin cho. wih case SAR), and iffasion weighted 1g apparent diffusion coeclent saps ld gradient recol, ana gradient echo seqence for blood: Spectroncopy tay be ‘Sefal in some neonates and tan optional sean, Future sequencer may include diffusion tensor and fiber tet Tetontrucion to define further early changes i abpormal fiber Was. The Suggested Readings ge {formation on current techniques wwe at various fel "The imaging appearance ofthe normal neonatal MR Jmage depends on maturational age (Fig: 31-10). Ax noted in’ Chapter 20, neuronal migration is moa ‘Complete By 24 weeks. The brain remsine mainly gyre ‘xcept fr infldingof the lateral suns (ean fre) before 20 weeks of development Suleation then begins ina predictable orderly fash ty term the sl Becavee 9 ml o aro i be crea iphon. rosa oeTitsosound Landmarks of Cortial Maturation jecs of Gentton Ultrasound Landmahs Matted alin eas ‘Whole cingulate cs nna Covered complet 2 Secondary cingulate sl Stengel neler J (ed: Texsok of Neonatal Uiraound ith maturation a the cells migrate fom this region 19 The periphery. The second marker the migrating cell. ‘he ate noted low signal smametic Bands of the antrum semovale on TEveighted images and high Signal, although less defined on TI-weighted images fig S12). "The thie marker i MRS, which rele. fhe maturation process becuse the normal specs of precrn infants ifr from the spectra of term ints Tig 3113), The multiude of metabolic processes Geciring nly or to 2 greater extent in neonates is Stcountale forthe differences on MRS. 8 CGONITERS! — NEONATAL ARAN IMAGING 405: "Normal Anatomic Structures Frontal born nerd ences {eral ales (oan ate ae Bestension ot pio an pe es Cerebelc hempheres ‘wscoan sraucTURs(CoLok Dorman ATION) Perillo artery and alos marginal branches Nile cereal series shown ign dn an ‘ercra sty Invern carpe oreicsin he roe poe “Stpesor gia sis andi draining ene In ee ne Tater snes ‘Great cerebral ein in of Galen) Dring tein Of herr, acading terminal vla ‘dhe hed ofthe caudate mle Pou 213. Fora nots ln 2 t20 wens grata, hoon tn shown nt pwc, tapered406 SecrioN i — mRNA AND NEONATAL IMAGING Difasonsveighted images show dhat the ADC in the normal white matter decreases with increasing gestation from es than 8 weeks to term, This occurs wis he ls fa water and the beginning of mjelination. The ADG Spear impart joing HIE Brain MRI of a preterm aeonate imaged at term equivalent ages quantiatvey diferent from brain MIL {tlanormal erm teonate, ADC alae are higher in the a ‘central white matter and in the posterior limb of the pos tenor cape There abo are changes ofthe dalam find conte gray matter. Although there i tle Brain Sulume diferente in the lermegulvalent former pre nature infant from tha of fuller int a 8 yea age there maybe igiieant deereaed volume Ih whi sna gray mater prematuely born children who wer thought o be "arta Computed Tomography Although in mos instances US and NR are equal of more sense in detecting neonatal brain disease, CT ‘demand urgent singieal care. CT ean quickly confirm theestent of hemonthage and severe HIP and is super'e sith its large Bld of ew in the evaluation of extras Collections compared wth US. Patients who are note {pile for MRI are neonates on extracorporeal membrane ‘Siygetaion. If significant brain injury i stapected i these infants Glecan quick confirm the extent of injury, which is crucial when making critica clinical imitations ofthis examination include the radiation dose {approninatey 9 rad) and dhe nee to tsteport an Ainstable infant to the CT scanner Te preterm Infant {unmyelinated white mater low in attenuation making ieifelt st testo differentiate white mater jy from immature white matter Advantages of CT incde the rapid ime to complete the sud pally withow te eed for sedation, 8408 SAcHHON — PRENSTAL AND NEONATAL BAGING ‘Gestational Age When Primary Fissures and Sulci Become Visible at Anatomic, Ultrasound, and ‘Magnetic Resonance Imaging Examinations ‘Parietoaccipital sulcus Cena ic us PATHOPHYSIOLOGY OF NEONATAL BRAIN DISEASE Much research remains to be done inthe pathophyso- ‘ogy of sequired neonatal brain injury. Curent areas of CGnokines are chemical signaling molecules produced by seite blood eels in response tos wide satiety of imi CChorioamnionit has been implied a one factor that ‘cute the telease of tyokines, witch case prestaan irl verre sack aro BS wet geno oh, in reeate to aimulate wterine contractions (he = the fee born prematurely) and has been implica in causing white matter injury in te, fetus, OM Detiewe impalrment of cerebral blood flow init complex serier of interrelated events that lea Iyposielschemie brain damage (Fig 3I-L). The pal ofan iar pends om satraon of he developing oligodendrocytes and neurons of the plate cortex (are Chapter 28) when an behemicsan nthe serum semisrle orca Pr Seas apn ccs early in gestation. In a term neonate, neurons i the deep gray matter and in the perirolandic cortex are Ios vulerable to ny Ts preterm infant, periventricular white mater isthe nos yinerabl to oxidative stress, Thesvitch to anaero- Ue gcolye(Fig. 31-15), high concentrations of tty Aci, high oxygen consumption, lesser concentrations ofantoxidant and saat of redox-aetve won place the white mater at highest Fk of injury. The excess Acacion of gitamate and its neutotansmitrs such a3 Ametiypaspartte is process called ito. In thi process, atc oxide is produced in excenve amotants Gout — NeONsTAL ARAN IMAGING — 409 8 mpeg ta rs leading ta fee radials, which damage the oligodendo- ‘ote Ferrero states that immature oligodendrocytes and their progencrator are vulnerable te ke depletion of noaidantand/or exposure to exogenous free radicals” Oxidative tres, exeltotxieny and inflammation suc choroamsoaltispreeiptate brain injury. All lead foaccelerated cellular death or apoptosis (ce Fig 51-13) The rato of apoptosis an active proces in an orderly programed fashion without sflammation) to necrost Fe pasve proces in which cell death sa reaction to ‘umation) tn te reparative proces maybe important fnminimiring the effec of brain injury4410 sterion n — PRENATAL AxD NEONATAL IMAGING Mersze INAss wom gL Ln ALA ‘plane of te bran Metabolites iertted are locate (La) ap [ep Macey sapere NA, lame on giao cine ronson ine Satsmus: Wi whe mati. Sct van Naina Pera Msn bho Pus, ary 2008807 NOS. =] ee] Peas a ‘Shu ura ry. Pom Sno, Patan I epee rr Gan uy em neared eon Ea oe ‘death begins nmodtely andl cortinons for days to weeks Te ‘silat phnarypechenge rom ans neste SSuholgy tow fulogy eomoing sponta This lion ‘riod maroateapoptons conn [See oor a) fan forme baton tar ehey NE et ‘Major Neuropathologic Varieties of Neonatal Hypoxiclschemic Brain Injury Selective neuronal necro Fang crea ijury—waterhed injures, vel Trrder 200 injrer, Peshencr estonia congution necro oral (a mull heerlen necrosis et an pe Nera fhe Nevo he. ‘Oxidative sre exctotonc and inflammation precipitate neonatal rai nr. IMAGING HYPOXIC-ISCHEMIC BRAIN INJURY TIE is siguficant problem in the neonatal period ive term birth 1-100 to 21000 incur such rain i nd 03:1000 live er bid have significant neuro Scquciae. In term infant with eran hyposic chet injury approximately 30% have other oF ‘anileaatlons Yenventnesiar white matter sur, snc lesions and dice extenshely high signal int (DEHSI) lesions of the white mater, are mest found in premature ian The major neuropaOk tarietis OF Iyposicasehemic injury are Tse 0 SE (Figs. 3116 and 3-17, yponiciachemic brn injury i frequent "pean problem i the neboaal petiod Asexplained by the pathophysiology of fee Dan injury, miletomoderte injry ro the pre ‘rain damages the germinal matee and pert