Neurosonography Essay Example & Outline

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Neurosonography


What is Neurosonography?

Neurosonography refers to a branch of medicine that is dedicated to taking of ultrasound scans on patients’ brains, as well as their nervous systems. This field is also referred to as neuroimaging or neurosonology . The primary motives of this highly specialized field are aimed at monitoring and diagnosing the flow of blood through the blood vessels of the patient located within the Central nervous System or the CNS as it is commonly referred to. Just like many other medical fields with sub-branches, neonatal Neurosonography is a sub-branch of this field. This branch specializes in the imaging of infants’ nervous systems. The open fontanelles of the neonate make it possible to fully analyze the neurological state of the neonate.

Many of the neonates subjected to this imaging are born either premature or preterm. This imaging is intended to investigate and determine the existence of any neurological disorders, or disorders of the nervous system. This field makes use of highly specialized equipment that is designed to image the brain of the neonate based on ultrasound technology to provide a detailed view of the neonate brain and nervous system. In this way, doctors are able to detect any abnormalities in the brain and nervous system. Neurosonography is also widely used in laminectomy procedures to assess the state of the spine.

Proper Instrumentation

Neurosonographic examinations are facilitated by the use of linear array transducers. These transducers can be either sector or curved. To generate images, these transducers emit an intense pulse of extremely high frequency into the tissue to be imaged. The arrival time and intensity of the acoustic echoes generated by the tissue enables the imaging of the tissue. The tissue acts as ‘reflectors’ hence enable imaging. The high frequencies used are responsible for developing high resolution images .

To assess the superficial structures such as the superior sagittal sinus, linear array transducers are the objects of choice. In cases where the anterior fontanelle has already fused, medics are forced to use low frequency transducers that have the ability of penetrating through the fused bone. In terms of instrumentation use, premature neonates demand the use of high frequencies while infants and full term neonates use lower frequencies. To ensure safety, Doppler power output of the instruments is regulated by the ALARA principle. This principle dictates that the Doppler power output should be As Low As Reasonably Achievable. In this way, instruments guarantee both safety and accurate high resolution results.

Guidelines

In order to regulate the practice of Neurosonography, and facilitate safe and accurate procedures, AIUM (American Institute of Ultrasound in Medicine) has put in place guidelines that all practitioners must follow. The first and most vital is that Neurosonography shall be performed on infants only in the existence of valid medical reasons. This goes on to add that the lowest possible ultrasonic exposure setting is to be used during the procedure .

The guidelines assert that Neurosonography in term and pre-term neonates is used for reasons such as to assess for hydrocephalous, presence of congenital malfunctions, to screen for parenchymal abnormalities and hemorrhage in pre-term neonates, to determine the presence of hypoxic ischemic encephalopathy and as follow-ups on previously documented problems.

However, AIUM understands that restricting medics to these golden rules can in itself be harmful. The variant nature of abnormalities and conditions make it virtually impossible to treat one patient like the other. In such cases where additional information is a prerequisite of the diagnosis and healing process, practitioners are allowed not to break, but instead to circumvent these rules in pursuit of medical explanations. Although such procedures are incapable of detecting every possible abnormality, they prove to be highly effective in detecting most of them. It is for this sole reason that AIUM permits the ‘skirting’ of the law insofar as Neurosonography guidelines are concerned.

Standard Protocols

The need to provide quality ultrasound services demands the use of standard protocols to dictate the operation of the industry. In order to perform diagnostic medical ultrasounds, all individuals are required to be medical practitioners that are accredited and reviewed by AIUM. In this way, quality is guaranteed in terms of conducting the procedure, as well as interpretation of the results. All physicians are required to hold a valid state license and to undergo re-accreditation procedures by AIUM every three years. The need to remain afloat in the rapidly evolving world of medical technology demands that all physicians involved in conducting and interpreting ultrasounds are retrained in terms of use of new machinery and techniques.

Sonographers are required to be certified in their specialties, and must remain so in order to achieve AIUM accreditation. Sonographs are given a time limit of two business days to be read and their findings given to the patient. Mechanisms are also in store to ensure that patients are contacted as soon as results are released and that emergency findings can be addressed immediately while paying attention to patient safety. Seeing that it is a branch of medicine, medical ethics laws apply to sonographers, as well. Maintaining doctor-patient confidentiality, filing of reports, prevention of infectious diseases and the application of the ALARA principle all rank highly in the ethics codes on the practice of Neurosonography.

Normal Anatomy of the Neonatal Brain

A normal neonate that was carried to term has fully developed neonatal features. The cortical folding of the brain of a normal neonate is similar to that of an adult. The folds are fully developed, and all the sulci have already been formed by the time of birth. In healthy neonates, small remnants of the germinal matrix can be seen in the caudothalamic notch. They can also be spotted on the posterior end of the thalami, almost at the junction formed together with the optic radiation.

Myelination of the ventro-lateral nucleus of the thalamus (VLNT), the globus pallidus (GP) and the brain stem is evident at birth, as well. Unmyelinated white matter can also be seen in the hemispheres. The corpus callosum is also unmyelinated in a healthy neonate carried to term. At birth, the thalami and basal ganglia of a normal neonate are large and outrightly divided by the internal capsule. The brain stem of a healthy neonate is also well articulated. The decussation of the superior cerebellar peduncles, the quadrigeminal plate, the medial lemnisci and medial longitudinal fascicule are all clearly seen. The developmental stages in which many of these parts are in at birth form the basis of determining whether the child is normal or abnormal.

Abnormalities in the Neonatal Brain

Acquired

These are abnormalities that neonates acquire after their birth. The causes may vary from injury to infection of the neonate, but they are not passed down through parent-child relationship via birth or genetic inheritance (6). The fragile state of the neonate exposes it to an array of dangers, seeing that one can easily inflict injury upon it. Such injury can expose the neonate to diseases such as lymphoblastic leukemia, cardiomyopathy and myocarditis. These diseases can also be influenced by the environment in which the neonate is placed. The presence of pathogens that are capable of infecting the neonate with diseases plays a central role these diseases. However, Neurosonography can also be used to detect such diseases in neonates.

Congenital

There are also a number of diseases that many people inherit genetically from their parents. Neonates are no exception to this rule, seeing that they too are sufferers of abnormalities such as congenital heart disease and asphyxia among other diseases. Unlike the acquired abnormalities, these are purely genetic and are passed down from parents to children. Neonates particularly suffer a lot from this disadvantage.

Most Frequent Pathologies

Neonates are fragile in nature, and many of them have been known to suffer from different kinds of pathologies. One of the most common and fatal pathologies is hydrocephalus (4). This refers to the enlargement of the ventricular system and is a very painful experience for the neonate. It can be either obstructive or communicating hydrocephalus. Another pathology common in neonates is hemorrhagic. This refers to subependymal intraventricular bleeding. As a form of pathology, it is most common in pre-term neonates (1). Such neonates weigh in at less than 1500 grams birth weight and are less than 32 weeks.

The caudothalamic groove proves to be the most common location. This pathology is classified into four categories, Grades I, II, III and IV. Periventricular leukomalacia is another common pathology. It is characterized by the necrosis of the white matter usually near the lateral ventricles. Being an ischemic lesion, it is the most frequent one on the immature brains of neonates. It can be diagnosed as either acute or chronic.

Another form of pathology is holoprosencephaly. This pathology is the result of a disturbed ventral induction process in the early stages of development in which the brain fails to form bilateral cerebral hemispheres (4). Agenesis of the Corpus Callosum is also a common pathology. It can refer to either the presence of narrow frontal horns coupled with an absent CSP, or the absence of the Corpus Callosum.

Applications of Neurosonography

strong>In the Ultrasound Room

In the ultrasound room, Neurosonography has a number of applications. First and foremost, it can be used to determine the presence of neurological abnormalities in neonates (2). The use of this approach in scanning the brains of the infants is able to indicate any brain abnormalities. Though it may fail to expose every abnormality, it succeeds in exposing a large number of them. Secondly, the use of sonographs to determine the locations of tumors in laminectomy procedures to assess any abnormalities in the spines is another fort relying on Neurosonography.

In the OR

The Operating Room (OR) has its fair share of uses for Neurosonography. In Turkey, for instance, three dimensional Neurosonography has been used to treat tumors located along the spine. Through the use of Neurosonography, the doctors were able to map out the location and position of the tumor, and proceed to successfully remove it (4). The use of intra-operative 3D Neurosonography has been used to remove 6 intra-medullary and 22 extra-medullary tumors from patients in Turkey. The possibilities of this method becoming the standard measure insofar as neurological surgery is concerned only serve to raise the profile of Neurosonography.

References

1. Edwards, M. K., Brown, D. L., Muller, J., Grossman, C. B., & Chua, G. T. (1981). Cribside neurosonography: real-time sonography for intracranial investigation of the neonate. American Journal of Roentgenology, 136(2), 271-275.
2. Fischer, A. Q. (1985). Pediatric neurosonography: Clinical, tomographic, and neuropathologic correlates.New York: Wiley.
3. Girard, N., Gire, C., Sigaudy, S., Porcu, G., d'Ercole, C., Figarella-Branger, D., ... & Confort- Gouny, S. (2003). MR imaging of acquired fetal brain disorders. Child's Nervous System, 19(7-8), 490-500.
4. Graziani, L. J., Mitchell, D. G., Kornhauser, M., Pidcock, F. S., Merton, D. A., Stanley, C., & McKee, L. (1992). Neurodevelopment of preterm infants: neonatal neurosonographic and serum bilirubin studies. Pediatrics, 89(2), 229-234.
5. LaRusso, S., Goss, S. E., Jackson, M. L., & Society of Diagnostic Medical Sonographers (U.S.). (2009). NCER National Certification Exam Review: Neurosonography. Plano,
Tex:Society of Diagnostic Medical Sonography.
6. Proctor, M. R., & Black, P. M. L. (2005). Minimally invasive neurosurgery. Totowa, N.J: Humana Press.