JOURNAL OF THE LOUISIANA STATE MEDICAL SOCIETY
REFERENCES
between normal variants and pathologies.⁴ Netanyahu et al. found that prominent choroid plexuses on ultrasound appear large, usually irregular, and lobulated. Anterior portions of the choroid plexus often appear large and extend laterally toward the wall of the lateral ventricle on coronal images. An unusual configuration of a long stalk arising from the glomus extending posteriorly and terminating in a small nodule is seen in some cases. These benign appearances of a prominent choroid plexus are similar and may appear identical to what is seen in intraventricular hemorrhage, causing the two entities to be easily confused. The stalk and nodule configuration may be misinterpreted as a clot attached to the glomus or as a free- floating clot in the ventricle.5 Ultrasound images obtained through the posterior fontanelle can rule out the presence of clots or fresh blood from an intraventricular hemorrhage within the ventricle.⁶ It is important to distinguish echogenic-appearing hemorrhage from the choroid plexus, which also appears echogenic. The caudothalamic groove acts as a convenient landmark, with echogenicity anterior to the groove representing blood as the choroid plexus terminates at the groove.⁷ Sagittal projection of the caudothalamic groove area is prone to give a misleading appearance of GMH secondary to strong echo production from the lateral ventricle if the head of the caudate nucleus is not well visualized and the scan plane is oblique. This misleading appearance is corrected with a proper scan plane alignment, including the head of the caudate nucleus, the caudothalamic groove and the thalamus.⁷ The appearance of a hemorrhage will vary according to the stage of the blood on MR imaging. Blood products are initially isointense but become hyperintense after approximately three days on T1W sequence. GMH may show chronic hemorrhage, presenting on MRI as a hypointense irregular rim or small foci on T2-weighted imaging, compatible with evolving blood products and associated with focal decrease of cerebellar hemisphere volume.⁸ Intrapiromkul et al. found that cranial ultrasound has high sensitivity and specificity in detecting grade III GMH using MR Susceptibility Weighted Imaging (SWI) as a reference, but decreased sensitivity in detecting grade II GMH in preterm neonates. It was also determined that ultrasound was not sensitive in detecting either small cerebellar or extra-axial hemorrhage.³
1. deBijl-MarcusKA, BrouwerAJ, deVriesLS, et al.Theeffectof headpositioning and head tilting on the incidence of intraventricular hemorrhage in very preterm infants: a systematic review. Neonatology. 2016; 111: 267-79. 2. McCrea HJ, Ment LR. The diagnosis, management and postnatal prevention of intraventricular hemorrhage in the preterm neonate. Clin Perinatol. 2008;35: 777-92. 3. Intrapiromkul J, Northington F, Huisman T, et al. Accuracy of head ultrasound for the detection of intracranial hemorrhage in preterm neonates: Comparison with brain MRI and susceptibility-weighted imaging. J Neuroradiol . 2013; 40(2): 81-8. 4. Madhukar M, Choudhary A, Boal D, et al. Choroid plexus: normal size criteria on neuroimaging. Surgical and Radiologic Anatomy. 2012; 34 (10):887-95. 5. Netanyahu I, Grant EG. Prominent choroid plexus in meningomyelocele: sonographic findings. AJNR. 1986; 7: 317-21. 6. Enríquez G, Correa F, Lucaya J, et al. Potential pitfalls in cranial sonography. Pediatr Radiol. 2003; 33: 110-7. 7. Browie J, Kirks D, Rosenberg E. et al. Caudothalamic groove: value in identification of germinal matrix hemorrhage by sonography in preterm neonates. AJR 1983; 141:1317-1320. 8. Martino F, Malova M, Cesaretti C, et al. Prenatal MR imaging findings of isolated cerebellar hemorrhagic lesions. European Radiology . 2016; 26 (8): 2685-96. Nancy Emelife, MD, Adam Blanchard, MD, Juan Gomez, MD, Millie Yu, MS, Enrique Palacios, MD , and Jeremy Nguyen, MD are affiliated with Tulane University Department of Radiology in NewOrleans, Louisiana. DonaldOlivares is a Digital Imaging Specialist and Graphic Designer for Department of Radiology at Tulane University Health Sciences Center in New Orleans, Louisiana.
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