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different Doppler methods (with colour overlay) color Doppler Imaging power Doppler Imaging (PDI) (spectral Doppler) directional power Doppler ICV internal cerebral vein BVR basal vein of Rosenthal B Flow ® microflow Imaging ® SMI – superb microvascular Imaging ® optimisation of Doppler imaging gain in B mode to a low level -> no echogenicity within the vessels avoid blooming color Gain in Doppler mode adjusted so that the vessels are filled with color, but no color outside their wall -> to avoid „blooming“ Nicolaides et al. correction for the angle between the direction of blood flow and the ultrasound beam: ideal 0°, 1-40° reliable correction, > 60° high rate of error avoid aliasing adjust PRF according to the vessels you want to visualize (arteries: 20-200 cm/s; veins 2-20 cm/s) -> to avoid „aliasing“ ghost basilar artery colour box as small as possible -> to reduce artefacts mirror artifacts: when a highly reflective surface is distal to an object, a ghost can bee generated by multiple reflections of an object: ghosting can be avoided by scanning from a different angle ultrasound physics: postprocessing and velocities calculation of velocity of moving scatterers (amplitude coded) sound waves are compressed between a moving listener and/ or object; this compression shifts the returned sound frequency C=1560m/sec at 37°C, speed of sound in tissue V=(C x Fr)/(2 x F0 x cosø) Fr= shift in frequency F0= emitted frequency ø= angle between vessel and insonating beam the shift in frequency depends on reflector speed and on ultrasound frequency the angle of insonation with the vessel investigated must be as close to 0°as possible the cosine of the angle of insonation vis-a-vis the vessel flow direction, is applied to measure the correct velocity; with angles below 40°, a 5°-angulation error causes a velocity error of less than 10 % the maximum velocity detectable depends on - depth of the vessel - US frequency (in the diagram left the angle of insonation is zero) ultrasound energy and doppler: limitations of use - ultrasound travels through brain in 0,00006493506494 sec = in 0,065 msec thermal index < 0.7 only one % is reflected to the probe, the rest is lost in tissue by attenuation - ultrasound is attenuated by scattering, but the main attenuation is by absorption of the waves by tissue, which is then converted to heat recommended maximum time for transcranial and spinal scanning colour doppler power (spectral) doppler physical principle moving RBC shift doppler frequency moving scatterers between pulse trains angle dependency yes, unreliable velocities > 20° (> 6% error), no visualisation at angle 90° not unlimited 0,7 - 1 60 minutes 1 - 1.5 30 minutes 1.5 - 2 15 minutes 2 - 2.5 4 minutes 2.5 - 3 1 minute ≥3 not recommended caution - during contrast agent application thermal index above 0.7 not advised higher sound pressures energy TI value on machine may understimate biological temperature change TI of 1 means you heat the interrogated tissue up with 1°C after about 120 seconds artefacts heating effect is largest near bone 5 minutes in static B mode scanning may heat brain surface by up to 4 °C - practice: doppler scanning no longer than 15 minutes and not fixing a probe on one vessel continuously for more than 1 minute, especially during spectral doppler imaging - need for research with advancing technique; safety provided by limiting scan duration - caution in use of contrast agents (about double of colour doppler) more sensitive to low velocities but also to motion artefacts perfusion indices and vascular reactivity angle of insonation < 15° = reduction fault < 4% ø regional intracranial pressure pO2 pCO2 glycaemia haematocrit viscosity diameter flow flow velocity vessel wall strength platelet and (anti)coagulant function and quality of interaction with endothelium arteriole V=(CxFd)/(2xFtxcosø) vasopressin AT2 ACholine PGs pericyte function OSympathic nerves open ductus/steal parabolic flow prophile capillary venule C=1560m/sec at 37°C, speed of sound in tissue Fd= shift in frequency Ft= emitted frequency ø= angle between vessel and insonating beam artery indomethacin theofyllin cocaine barbiturates in ml/min V=average velocity in cm/sec R=radius of vessel in cm vein jugular pressure thoracic pressure (ventilation) mediators or Flow=SV x heartrate SV = stroke volume VTI= velocity time integral or stroke length subcallosal ACA flow profile and indices RI= S-D/S PI= S-D/Vmn S= Vp arterial indices D= EDV RI= resistance index (Pourcelot) = S-D/S is angle independent PI= pulsatility index (Gosling) = S-D/M is angle dependent FVI=AUVC velocity integral S M D average velocities in ICA in cm/sec average maximum velocity in internal carotid arteries 100 S 92 80 60 60 40 43 20 22 32 10 M 50 D 25 14 0 32w 40w 3mo S equals about 2M M equals about 2D RI lower (~0.6) and D closer to M in lateral striate arteries with S around 15 and M around 10 cm/sec for large arteries: RI drop from 0.8 to 0.7 between 32 and 40 weeks the major cerebral arteries and the circle of Willis olfactory nerve ACoA optic nerve anterior perforated substance ACA MCA MCA PCA SCA insula ACA AChA ICA basilar a. caudate tail PCoA AICA PICA PCA P1 PCA P2 ICA ASA SCA paramedian branches I basilar a. short circumferential branches I AICA vertebral a. vertebral a. anterior spinal communicating artery PICA posterior spinal a. anterior spinal a. adapted from Smith and van der Kooy 1985 cervical radiculomedullary a. large pial cerebral arteries 8 MCA middle cerebral artery (1) temporopolar a. (2) anterior temporal a. (3) lateral orbitofrontal a. (4) posterior trunk (5) anterior trunk (6) prefrontal a. (7) precentral a. (8) central a. (9) anterior parietal a. (10) posterior temporal a. (11) posterior parietal a. (12) angular a. 7 9 11 6 12 5 3 4 10 2 1 17 PCA posterior cerebral a. 1 perforators 2 quadrigeminal a. 3 thalamogeniculate aa. 4 lateral posterior choroidal a. 5 hippocampal aa. 6 medial posterior choroidal a. 7 temporopolar a. 8 anterior - middle - posterior inferior temporal aa. 9 posterior pericallosal a. 10 parieto-occipital a. 11 calcarine a. ACA arteria cerebri anterior 12 orbital a. 13 frontopolar a. 14 callosomarginal a. 15-17 anterior - middle - posterior internal frontal aa. 18 paracentral a. 19 pericallosal a. 20 anterior pericallosal a. 21-22 anterior - posterior internal parietal a. (precuneal a.) 23 Heubner’s artery 16 15 18 14 21 22 20 19 9 23 10 6 13 1 12 8 2 5 7 adapted from Smith and van der Kooy 1985 3 4 5 8 11 cerebral veins 10 cascades of venous confluence: A candelabra of medullary veins B palmate area of ependymal collector veins C ependymal veins at the transition from terminal to internal cerebral vein D internal cerebral and basal veins to great cerebral vein E straight and transverse sinus to superior sagittal sinus F deep and superfical Sylvian veins 13 SSS A 5 terminal vein from internal cerebral vein B 4 F 6 3 1 8 1 internal cerebral vein 2 basal vein 3 terminal (thalamo-striate) vein 4 septal vein 5 longitudinal caudate vein 6 middle- posterior caudate veins 7 superior thalamic vein 8 direct lateral vein 9 straight sinus 10 superior sagittal sinus 11 great cerebral vein 12 vein of Labbé 13 vein of Trolard 14 sigmoid sinus 7 2 D direct lateral vein from internal cerebral vein ICVs C inferior ventricle vein from basal vein 6 12 11 14 perfusion of para-ventricular white matter near the atrium (frontal view) 9 E 10 SMCV SSS DMCV connecting veins between SMCV (superficial middle cerebral veins) and deep middle cerebral (Sylvian) veins (DMCV) draining via the basal vein of Rosenthal BVR to BVR L SR R typical torcular variations: SSS draining preferentially to the right is most common SR straight sinus (sinus rectus) SSS superior sagittal sinus motor and language areas in relation to convexity veins and arteries SSS premotor cortex sensorimotor Trolard v. cortex variations of convexity pial veins Wernicke speech sensory area frontal eye field Broca speech motor area MCA Labbé v. SMCV SMCV= superficial middle cerebral vein(s) typical SSS * contralateral isolated arm/hand motor symptoms due to parasagittal cortical injury near SSS thrombosis T L T vein of Trolard L vein of Labbé SSS superior sagittal sinus pial large anastomosing veins drain with an acute angle in SSS (*) visualisation of both veins of Labbé deep cerebral veins in superolateral 3D view and the pericentral circulatory loop from MCA and central artery to terminal and internal cerebral vein 8 6 7 8 6 5 8 2 10 1 3 5 17 1 9 11 8 16 2 4 9 15 1 2 3 4 5 6 7 internal cerebral vein basal vein terminal (thalamo-striate) vein septal vein middle- posterior13caudate veins superior thalamic vein superior sagittal sinus 8 great cerebral vein 9 vein of Trolard 10 ICA 11 MCA 12 ACA A2 13 thalamic perforator 14 pial medullary centripetal artery 7 17 4 9 12 14 2 14 12 16 5 4 13 11 3 1 6 2 15 PG 1 2 3 4 5 6 7 8 9 internal cerebral vein basal vein terminal (thalamo-striate) vein medial atrial vein superior choroidal vein septal vein longitudinal caudate vein middle- posterior caudate veins superior thalamic vein 13 10 11 12 13 14 15 16 17 anterior thalamic vein direct lateral vein sigmoid sinus superior sagittal sinus inferior sagittal sinus vein of Trolard vein of Labbé Sylvian veins 8 10 flow visualisation depends on sampling frequency (prf)(spectral Doppler) 2 1 internal cerebral (1) and terminal vein (2) with stepping up prf transverse sinus flow in a preterm with stepping up prf large vessels with high velocity are depicted with a convex low frequency probe (spectral Doppler) sagittal sagittal parasagittal at insula 2 10 5 7 3 8 12 9 4 1 10 11 coronal axial sagittal 2 14 6 4 6 1 4 3 15 1 internal carotid artery 2 anterior cerebral artery 3 anterior choroidal artery 4 basilar artery 5 Heubner’s artery 6 posterior communicating artery 7 internal cerebral vein 8 great cerebral vein of Galen 9 straight sinus 10 central artery (of insula and cerebrum) 11 posterior trunk of the middle cerebral artery 12 tuberothalamic artery 13 lateral striate MCA perforator artery 14 middle cerebral artery M1 15 posterior cerebral artery 13 12 14 1 small vessels with low velocity are depicted with a linear high frequency probe (spectral Doppler, low pulse repetition frequency) 1 pial vein 2 pial artery 3 periventricular vein 1 cm 1 0.7 cm 2 0.5 cm 1 cm 3 frontal power doppler posterior temporal power doppler broader periventricular deep venous drainage in frontal than posterior temporal lobe 2 2 2 1 1 a. centralis 1,9 mm regular spacing of branches of the central artery in microdoppler mode 1 1 1 parasagittal pareventricular vascular detail 1 palmate zone: lateral ependymal collectors 2 candelabra zone perforators from anterior MCA and ACA (1) mixed with inferior striate veins (2) Doppler images of large pial arteries coronal axial via temporosquamosal suture: circle of willis sagittal carotid arteries MCA ACA PCA ICV ACA ACA PCA MCA ICA basilar artery basilar artery posterior communicating artery MCA and branches PCoA with x-flow Esaote my lab twice MCA MCA perforators MCA PCoA axial approach MCA MCA ICA mastoid view: superior cerebellar artery PCoA and PCA perforators to thalamus (angio mode spectral Doppler) anterior coronal tuberothalamic a. posterior coronal P2 PCA medial posterior choroidal a. P1 PCA perforator a. P2 PCA thalamogeniculate aa. ICV ICV P1 PCA perforator a. P2 PCA thalamogeniculate aa. parasagittal ACA and MCA perforators (spectral Doppler) Heubner’s artery coronal parasagittal medial striate MCA coronal lateral striate MCA parasagittal lateral posterior choroidal artery perforators from PCA parasagittal anterior MCA and ACA perforators coronal inferior striate vein to basal vein of Rosenthal spectral Doppler impression of the deep arterial perforators and medullary vessels not directional sensitive spectral microdoppler: deep medullary venous cnfluence V A A V “watershed” area between deep perforators and centripetal pial arteries A A upper maximum reach of perforator arteries A artery V vein stenosis and flow velocity change in the great cerebral vein normal aspect via the anterior fontanelle high resolution images via the posterior fontanel 4 2 1 5 3 6 1 tectum 2 splenium 3 sulcus parieto-occipitalis 4 internal cerebral vein 5 great cerebral vein (Galen) 6 straight sinus basal vein proximal to stenosis at stenosis developing brain veins transverse sinus middle plexus internal cerebral vein and superior choroidal vein posterior plexus pineal gland straight sinus mesencephalic vein superior sagittal sinus basal vein of Rosenthal in formation anterior plexus marginal sinus (primitive transverse sinus) tentorial sinus inferior striate vein jugular foramen superior petrosal sinus dorsal metencephalic vein (posterior cerebellar vein) superficial middle cerebral vein petrosquamosal sinus anterior cerebral vein primary head vein trigeminal nerve ophtalmic vein superior petrosal sinus and great anterior cerebellar vein tentorial sinus 15 mm stage (~day 42) sigmoid sinus ventral diencephalic vein, inferior choroidal vein prootic sinus occipital vein middle meningeal sinus emissary veins (mastoid, condyloid) straight sinus superior sagittal sinus anterior plexus supraorbital vein posterior auricular vein internal cerebral vein transverse sinus opthalmic veins jugular vein tentorial sinus posterior plexus superior petrosal sinus cavernous sinus, pterygoid plexus, sphenoid emissary vein common facial vein vertical deep cervical vein facial veins emissary vein superior petrosal sinus transverse deep cervical vein lingual vein, superficial temporal vein ophtalmic vein cavernous sinus inferior petrosal sinus 50 mm stage (early fetal period, week 9) adapted from Streeter 1915 jugular foramen cephalic vein left innominate vein inferior petrosal sinus and ventral myelencephalic vein 80 mm stage, early second trimester external jugular vein lateral thoracic vein adapted from Padget 1957 axillary vein subclavian vein superior intercostal vein developing brain arteries 1 anterior division 2 posterior division 3 ventral aorta 4 dorsal aorta 5 ICA (internal carotid artery) 6 c … cervical segmental arteries 7 trigeminal artery 8 suboccipital (proatlantal) artery 9 vertebral artery 10 basilar artery 11 midbrain plexus 12 external carotid artery 13 longitudinal neural artery 14 posterior communicating artery 15 middle cerebral artery 16 anterior cerebral artery 17 posterior cerebral artery 18 superior cerebellar artery 19 hypoglossal artery 11 2 otic placode n. V 11 13 13->10 5 1 17 7 19 1 1 19 12 c1 3 11 15 10 16 c1 12 18 14 8 5 3 9 c6 24d 28d 29-33d 54d variation of the circle of Willis (with Doppler ultrasound) embryonic type (large) PCoA high prf term equivalent preterms 50 % adulthood 10-40 % A1 hypoplasia PCoA normal caliber 4 preterms now at PMA 37w coronal axial axial, linear high frequency probe RICA ACA RPCA MCA RICA mesencephalon LPCA LICA LICA bilateral infraoptic low origin of both A1 parts vessel from left ICA to “interrupted basilar a.” inserts ecccentric (below the sagittal plane) asymmetric caliber PCoA antenatal diagnosis: vein of Galen malformation confirmed by day 1 ultrasound enlarged carotid arteries enlarged basilar artery large, patent falx sinus circle of Willis, axial feeding ACA vein of Galen malformation with progressive brain damage due to recurrent steal of flow before embolisation pial artery with steal after embolisation pial artery without steal MCA steal MCA without steal SSS with intermittent backflow normal forward SSS flow readmission pial vein with arterialised flow destruction within MCA territory, mainly posterior trunk area pulsatile backflow in superior sagittal sinus AVM proximal to the vein of Galen, dilated inferior sagittal sinus coronal dilated inferior sagittal sinus dilated vein of Galen ACA PCA ICA sagittal dilated inferior sagittal sinus dilated ICA and ACA as well as PCA dilated vein of Galen enlarged circle of Willis arteries infratentorial AVM with arterial fistula from the posterior inferior cerebellar artery term infant with “asphyxia” day 3 MRI large transverse sinus mastoid view large straight sinus characteristic Doppler findings of rare neonatal vascular anomalies : dural AVM and choroidal AVM sagittal antenatal cavity in the back of the brain (no doppler images): dural AVM with spontaneous postnatal regression without sequelae coronal relatively high flow in a sigmoid sinus posterior interhemispheric “cavity” T1 T2 MRV visualisation of arteries feeding a choroidal AVM at very high prf (only high velocity arteries visible) term, day one apnoe and seizures; one artery of the AVM was embolised in early infancy, the other artery regressed spontaneously cavernoma coronal mastoid mastoid PMA 30w day 21 day 60 ELBW 26w, unchanging asymptomatic findings up to term age coronal parasagittal axial temporal T1 T2 hydrocephalus due to brainstem vascular anomaly, courtesy E Valverde, Madrid T1 + contrast enhancement may suggest haemangioma rather than cavernoma frontal paracingular developmental venous anomaly (DVA) the draining vein anterior coronal coronal power doppler coronal high freq. detail R L the draining vein coronal @ Monro coronal micro doppler parasagittal coronal SSWI the caput medusae parasagittal micro doppler 35w no RDS, mild IUGR, asymptomatic posterior temporal developmental venous anomaly (DVA) with haemorrhage power doppler, non-directional neonatal MRI day 5 18 months control MRI sinus pericranii MRV term infant with pulsatile mass overlying the anterior fontanel: sinus pericranii with scalp to intracranial drainage T1 MRI mass mass MRV large transverse sinus mass arterial feeder (facial artery) coronal sagittal sagittal mass enlarged superior sagittal sinus sagittal normal velocities in adjacent ACA branch high flow velocity in superior sagittal sinus mass focal vascular dysplasia with adjacent cortical anomalies coronal parasagittal coronal T2 asymmetrical insular gyration L vascular haemorrhagic type of lesion R conspicuous right internal cerebral vein with high velocity flow (normal < 10 cm/sec) normal aspect of carotid arteries and basilar artery multiple prenatal brain lesions, images day 1 and 2 after term delivery wide superior sagittal sinus at the posterior fontanelle wide right transverse sinus abnormal Doppler findings in unusual vascular conditions aneurysm subarachnoid haematoma after coiling 1 month old, seizures, anaemia and retino-subarachnoid haemorrhage prenatal hydrocephalus with plexus papilloma preterm 35w, chance finding of plexus carcinoma PHACES syndrome lenticulostriate arteriopathy asymmetric cerebellar hypoplasia courtesy dr Steggerda; LUMC Leiden asymmetric cerebellar hypoplasia smaller left MCA and supraclinoid ICA absence of left posterior communicating artery; left PCA elongated and tortuous courtesy dr Blesia; Hospital Sant Joan de Déu, Barcelona genetic small artery disorders infant with progressive microcephaly, psychomotor retardation, spasticity and feeding problems, recurrent seizures; normal platelet count, normal liver enzymes: Aicardi-Goutières syndrome disseminated hnyperechoic lesions newborn with persistent hyperplastic vitreum, cerebral arteriopathy: Norrie disease protein mutations excluded calcified pial artery 12 choroid plexus hyperplasia near term, mild hypothermia, chance finding PRF 4.0 KHz PRF 1.0 KHz PRF 1.0 KHz anaplastic glioma high velocities in ICA R strong right TS drainage abnormal perfusion in tumor margin normal velocities in ICA L and basilar a. internal carotid artery thrombosis coronal axial total occlusion right ICA normal ICA images normal patency in both ICAs partial occlusion right ICA lower velocities preterm infant, incidental finding three ECMO patients, all different aspects of the ICA after the procedure arterial ischaemic stroke: absence of flow, luxury perfusion or normal anatomic Doppler signal no flow in affected lateral striate perforator artery large draining vein near left posterior truncal MCA stroke bilateral MCA stroke with large arteries patent MCA MCA stroke areae stroke area DW MRI: double embolic stroke thalamic arterial stroke types tuberothalamic (polar) a. MCA AChA PCA ICA thalamogeniculate a. PCoA PCA P1 perforator a. medial posterior choroidal a. basilar a. left thalamic stroke near perforator from PCA P1, Doppler profiles preterm 34w, umbilical venous catheter only risk factor coronal coronal unaffected preterm of similar PMA parasagittal lenticulostriate arteriopathy ichtyosis/prematurity/eosinophilia syndrome postnatal onset arteriopathy in a preterm of 28w GA convex probe linear probe perforator arteries unaffected inferior striate vein, in direction of the basal vein superior sagittal sinus thrombosis; recanalisation in sagittal colour Doppler images day 5 day 11 day 15 2 months primary in utero thrombosis of the internal cerebral vein (dysfibrinogenaemia) and posthaemorrhagic hydrocephalus subacute clot on SWI at level of superior thalamus posthaemorrhagic hydrocephalus on admission on admission 18 days after birth day 25 reappearing right ICV left ICV in TOF MRA MIP projection left ICV return of flow in the right ICV Tajdar et al. 2018 screening for transverse sinus patency from the anterior fontanelle ICVs jugular vein typical right transverse sinus dominance (different machines) head rotated left for 90°, supine on back atypical left transverse sinus dominance face neutral up, supine on back codominance head again rotated left for 90°, supine on back effect of neck rotation on visualisation of the sigmoid sinus (preterm 30w PMA) VLBW transverse sinus thrombosis asymptomatic at 24w GA, postnatal day 5 posterior caudate vein terminal vein ICVs central clot in transverse sigmoid sinus sinus normal aspect transverse sinus patency or thrombosis near temporal lobe haematoma right TS left TS patent ICVs left TS and sigmoid sinus term, caesarean section after failed vacuum traction, apnoea day 1: both transverse sinus are patent lesion temporal lesion pointing to TS limited flow in partially thrombosed left TS term, spontaneous vaginal delivery, apnoeic seizures day 1: partial thrombosis in the ipsilateral transverse sinus normal right TS normal right transverse sinus phase-contrast MRV a Willis’ cord is not a thrombus term, pneumothorax coronal coronal bridging vein SSS SSS SSS bridging vein entering venous lacuna Willis’ cord 34w GA at 38w PMA, high blood pressure skin and fontanelle parasagittal Willis’ cord SSS anterior SSS brain SSS Willis’ cord gates on arteries: caliber of the vessel matters ACA pial MCA perforator ACA ICA basilar a. basilaris pial insular a. ACA MCA perforator a. significant PDA: clinical relevance only when steal is important Text reflow in ACA ICV not pulsatile decreasing resistance index in term birth asphxyia: poor correlation with lesion pattern normal arterial flow pattern RI low for RI values in ACA a negative correlation (r= -0.48, p = 0.019) exists between lowest RI on day 2 or 3 and (subsequent) hyperechoic change to cortex compatible with laminar cortical necrosis RI normal ACA resistance Index < 0,55 • • • term birth asphyxia with leukomalacia HIE stroke hypoglycaemia MCA RI = 0,69 RI normal term birth asphyxia with thalamic injury after cooling ICV velocity 12 cm/sec severe increase of intracranial pressure term birth asphyxia: hyperechoic change to cortex compatible with laminar cortical necrosis blue colour due to reversed diastolic flow in ACA ICA ACA extreme swelling with reflow in diastole in ICA and ACA high systolic and low diastolic flow velocity in ACA plexus papilloma of the third ventricle with hydrocephalus Doppler visualisation of CSF in motion in third ventricle and aqueduct video CSF returns into ventricles: best depicted in the aqueduct velocities from -10 to +10 cm/sec mastoid view to and fro v3 aqueduct abnormal vessels near a lesion bilateral GMH, abnormal oblique small vessel in the left matrix area with pulsatile character high lateral atrial vein near atrial venous infarct TV TV ? BVR 54 venous signal in a horizontal vessel near the unvisualised left basal vein (BVR) TV = terminal vein medullary veins and venous infarction 1 2 3 4 5 6 7 8 internal cerebral vein terminal vein anterior thalamic vein superior striate vein septal vein palmate convergence area candelabra convergence area subcortical convergence area SSS 8 8 ependymal collector in palmate area not occluded by GMH 7 7 7 5 7 6 1 3 ven t ricl e ma rgin 6 2 4 preterm 32w PMA, parasagittal preterm 25w PMA, day 14, coronal based on Okudera et al. 1999 venous infarction GMH/IVH GMH/IVH venous infarct interlacing deep and superficial veins at the candelabra zone explain the feathered outer appearance of a venous infarct tributaries of the thalamostriate (terminal) vein and infarct types anterior terminal vein longitudinal caudate vein terminal vein medullary veins medullary veins superior choroidal vein anterior infarction above caudate head internal cerebral vein thalamo-striate (terminal) vein infarction transverse caudate vein striatal vein infarction superior thalamic veins striatal veins para-atrial vein infarction inferior thalamic vein inferior striatal vein temporal matrix infarction lateral atrial vein great cerebral vein hippocampal venous complex straight sinus inferior choroidal vein PG deep middle cerebral vein inferior ventricle vein PG sigmoid sinus basal vein transverse sinus 5 4 6 1 2 3 1 2 3 4 5 6 internal cerebral vein terminal (thalamo-striate) vein medial atrial vein longitudinal caudate vein middle and posterior caudate veins superior striate vein 5 1 inverted parasagittal sonogram coronal doppler 2 anatomy of deep veins is relevant to onset of GMH in the caudothalamic groove normal symmetrical deep venous anatomy with visualisation of the U-turn coronal coronal GMH/IVH 3 2 3 2 1 1 coronal 4 1 2 3 4 internal cerebral vein posterior caudate vein terminal vein U-turn from terminal vein to internal cerebral vein 4 3 1 1 2 3 4 internal cerebral vein direct lateral vein terminal vein medial atrial vein right parasagittal preterm IVH following GMH in the presence of a left direct lateral vein coronal atypical terminal vein atypical vein terminal vein posterior caudate vein drop in flow velocity and reversed direction over the acute angle between posterior caudate and terminal vein high drainage by lateral atrial vein to basal vein on the right typical terminal vein conspicuous middle and posterior caudate veins TCV PCV PCV TCV PCV 6.5 mm terminal vein receiving posterior caudate vein, different examples posterior caudate vein (PCV) position and angle Monro venous fan TCV PCV 6,1 mm posterior caudate vein distance to foramen of Monro obtuse, over right to acute angle between medullary vein and terminal vein PCV = posterior caudate vein TCV = transverse (middle) caudate vein venous infarction within the terminal vein area: collector veins occluded or distended d82 d4 d82 R sc L d26 sc L R GMH sc infarction right terminal vein (GA 25w) sc asymmetry in sulcus centralis (sc) porencephaly normal posterior caudate vein GMH GMH GMH enlarged middle caudate vein persistent flow in displaced posterior caudate vein venous infarction: empty venous space and enlarged pial draining veins parasagittal parasagittal TCV coronal empty venous space PCV early porencephaly 4,9 mm superior striate vein bigger upward pial veins above limited infarct affected PCV ? coronal parasagittal limited infarct, early porencephaly infarct area normal downward drainage caudal to lesion parasagittal PCV = posterior caudate vein TCV = transverse (middle) caudate vein sequence from carotid injury to medial striate perforator stroke to GMH to venous infarction 27w difficult vaginal breech, neck traction and carotid injury parasagittal coronal 3 3 3 2 2 1 1 coronal 3 coronal 4 axial 6 3 5 7 1 medial striate perforator stroke 2 GMH 3 venous infarction 4 terminal vein not visualised 5 carotid artery occluded 6 ACA A1 flow reversal toward unperfused right carotid artery 7 internal cerebral vein patent porencephaly forms independent of affected vein in GMH with venous infarction preterm 25w 6d, caesarean section for fetal distress, pneumothorax and low initial blood pressure day 3 3 3 3 2 1 2 3 4 GMH IVH venous infarction (later porencephaly) subependymal collector vein implicated in venous infarction (with flow) 5 site of porencephaly formation 2 1 day 17 3 3 3 2 2 4 4 relation between gliotic leukomalacia and deep venous anatomy juxtaventricular medullary veins gliotic PVL anterior terminal vein caudate terminal vein striatum hypoperfusion of deep white matter thalamus leukomalacia basal vein internal cerebral vein venous fan sits medial to gliotic PVL (arrow) unstable perfusion of germinal matrix matrix haemorrhage medullary vein disorders (hyperechoic white matter) in term infants: congestion, medullary vein thrombosis and polycythaemia/hyperviscosity thrombosis of superior sagittal and straight sinus with deep venous congestion leading to white matter ischaemia unexplained white matter haemorrhage with patent superior sagittal sinus: medullary vein thrombosis ? term, SGA, grunting, mild hypoglycaemia, low platelet count and venous hematocrit 75 % parasagittal bilateral subcortical orbitofrontal haemorrhagic ischaemia no flow in SSS normal flow in SSS sagittal escape drainage via tentorial sinus to transverse sinus details of injury near the superior sagittal sinus brain doppler imaging: achondroplasia at 2 months: venous congestion leading to distended lacunae lacuna Willis’ cord microV Doppler patent superior sagittal sinus under a thick hyperechoic dural membrane: intradural haematoma bilateral subdural haematoma overlying sulcus calcarinus abnormal echoes near calcar sketch sulcus calcarinus sulcus calcarinus posterior fontanel coronal dissection of the aorta with reversed flow in both carotid arteries normal downstream flow in both ICVs upstream flow in basilar a downstream flow in both carotids downstream flow in both carotids and upstream in both A1s of ACA term, PPHN, inotropes, anuria reduced arterial flow in cortex adjacent to GMH with medullary venous infarction: spasm ? before GMH with GMH reduced flow in white matter prior to venous infarction infarct non-directional spectral microdoppler (Esaote MyLab twice) GMH ependymal vein not visualised reduced flow in white matter with venous infarction present term, heart failure, PPHN and NO, major inotropic use, not on oscillator, not on ECMO: unexplained rate observation in a deep vein internal cerebral vein at 379 bpm off inotropics after 1week: normal flow profile ACA at 180 bpm SSS sigmoid sinus suspicion of injury to left pulvinar