Topic: Brain and Heart Ultrasound

Group 1 Members:
Alipio, Mark
Revilla, Devin
Abaya, Roie
Salcedo, Shaw
Abarca, Anna
Sedillo, Francisco
Banzon, Ma. Aizza

October 6, 2016
53B
Leonila P. Felizate, RRT, MAEd

Brain USD
I. Anatomy
The brain is the largest and most complex part of the nervous system.
The brain includes two cerebral hemispheres, the diencephalon, the brainstem, and the
cerebellum.
The brainstem connects the brain and spinal cord and allows two-way communication between.
A. Introduction
1. The brain contains nerve centers associated with sensory functions.
and is responsible for sensations and perceptions.
2. The other functions of the brain include control of motor functions and higher
mental functions such as memory; it also provides characteristics such as
personality.
B. Structure of the Cerebrum
1. The cerebrum is the largest part of the adult brain.
2. The cerebrum consists of two hemispheres.
3. The corpus callosum is a bridge of nerve fibers that connects the two cerebral
hemispheres.
4. Sulci are grooves between ridges.
5. The 5 lobes of the cerebral hemispheres are frontal, parietal, occipital,
temporal and insular.
C. Diencephalon
1. The diencephalon is located between the cerebral hemispheres and above the
brainstem.
2. The various parts of the diencephalon are thalamus, hypothalamus, optic tracts,
the infundibulum, posterior pituitary gland, mammillary bodies and the pineal
gland.
3. The hypothalamus regulates heart rate, arterial blood pressure, body
temperature, water and electrolyte balance, control of hunger and body weight,
control of movements and glandular secretions of the stomach and intestine,
produces hormones, and controls sleep and wakefulness.
4. The limbic system consists of portions of the cerebral cortex, thalamus,
hypothalamus, basal nuclei, and other deep nuclei and controls emotional
experience and expression and can modify the way a person acts.
E. Brainstem
1. Introduction
a. The brain stem connects the brain and spinal cord.
b. The brain stem consists of the midbrain, pons, and medulla oblongata.
2. Midbrain
a. The midbrain is between the diencephalon and the pons.

b. The cerebral aqueduct is a connection between the third ventricle and

fourth ventricle.
c. Corpora quadrigemina are two pairs of rounded knobs on the superior
surface of the midbrain.
3. Pons
a. The pons is located on the underside of the brainstem between the
midbrain and medulla oblongata.
4. Medulla Oblongata
a. The medulla oblongata is located between the spinal cord and pons.
F. Cerebellum
1. The cerebellum is located inferior to the occipital lobes of the cerebrum and
posterior to the pons and medulla oblongata.
2. Overall, the cerebellum functions to integrate sensory information concerning
the position of body parts and coordinated skeletal muscle activity and maintains
posture
G. Ventricles and Cerebrospinal Fluid
1. Ventricles are interconnected cavities and are located within the cerebral
hemispheres and brainstem.
2. The ventricles are continuous with the central canal of the spinal cord
and are filled with cerebrospinal fluid.
3. The largest ventricles are the lateral ventricles which are located in the cerebral
hemispheres.
4. The third ventricle is located in the midline of the brain beneath the corpus
callosum.
5. The fourth ventricle is located in the brainstem just in front of the cerebellum.
6. The cerebral aqueduct is a connection between the third and fourth ventricles.
7. The choroids plexus is specialized mass of capillaries and functions to secrete
cerebrospinal fluid.
8. Most of the cerebrospinal fluid arises in the lateral ventricles
and circulates into the third ventricle, fourth ventricle, the central canal of the
spinal cord, and the subarachnoid space.
9. Cerebrospinal fluid is continuously absorbed into the blood.
10. Arachnoid granulations are tiny, fingerlike structures that project from the
subarachnoid space into the dural sinuses.
11. Cerebrospinal fluid is different from blood in that it contains a greater concentration
of sodium and lesser concentrations of glucose and potassium.

12. The functions of cerebrospinal fluid are to help maintain a stable ionic concentration
in the CNS, and provides a pathway to the blood for wastes.
13. Because cerebrospinal fluid completely surrounds the brain and spinal cord, it
protects them by absorbing forces that might otherwise jar and damage them.
II. Materials
Gown and gloves
Coupling gel
Transducer
3MHz (infants)
5MHz (6- 18th months)
7 .5 MHz (preterm and term newborns)
III. Patient Preparation
Keeping the infant warm is of utmost importance
Gown and gloves are recommended
Coupling gel should be at body temperature
Quiet environment must be maintained
IV. Basic Scanning Protocol
Patient Position:
Supine with head facing upwards
Prone with head lying on either side
CORONAL SCAN
Place the transducer over the anterior fontanels with the scanning plane aligned with the long
axis of the head and now rotate the transducer by 90 degrees. The scan plane is now aligned
transversally, and angles the beam forward and then backward.
SAGITTAL SCAN
Centre the transducer over the anterior fontanel with scanning plane aligned with the long axis
of the head. Angle the transducer to first right, to the see the right ventricle, right temporal lobe
and the sylvian fissure. The transducer is similarly angled towards the left side.
V. Indications
Choroid plexus cysts (CPCs) are cysts that occur within choroid plexus of the brain. The brain
contains pockets or spaces called ventricles with a spongy layer of cells and blood vessels called
the choroid plexus. This is in the middle of the fetal brain. The choroid plexus has the important
function of producing cerebrospinal fluid. The fluid produced by the cells of the choroid plexus
fills the ventricles and then flows around the brain and the spinal cord to provide a cushion of
fluid around these structures.CPCs can form within this structure and come from fluid trapped
within this spongy layer of cells, much like a soap bubble or a blister. CPCs are often called "soft
signs" or fetal ultrasound "markers" because some studies have found a weak association
between CPCs and fetal chromosome abnormalities.It is believed that many adults have one or
more tiny CPCs.The fetal brain may create these cysts as a normal part of development. They are

temporary and usually are gone by the 32nd week of pregnancy.CPCs are a rare cause of
intermittent hydrocephalus. This is caused by a blockage of foramina within the ventricular
drainage system of the central nervous system (CNS), which can lead to expansion of the
ventricles, compressing the brain (the cranial cavity cannot expand to accommodate the increase
in fluid volume) and possibly causing damage.
Agenesis of the corpus callosum (ACC) is a rare birth defect (congenital disorder) in which
there is a complete or partial absence of the corpus callosum. It occurs when the corpus
callosum, the band of white matter connecting the two hemispheres in the brain, fails to develop
normally, typically during pregnancy. The fibers that would otherwise form the corpus callosum
become longitudinally oriented within each hemisphere and form structures called Probst
bundles.In addition to agenesis of the corpus callosum, other callosal disorders include
hypogenesis (partial formation), dysgenesis (malformation) of the corpus callosum, and
hypoplasia (underdevelopment) of the corpus callosum. Agenesis of the corpus callosum is
caused by disruption to development of the fetal brain between the 3rd and 12th weeks of
pregnancy. In most cases, it is not possible to know what caused an individual to have ACC or
another callosal disorder. However, research suggests that some possible causes may include
chromosome errors, inherited genetic factors, prenatal infections or injuries, prenatal toxic
exposures, structural blockage by cysts or other brain abnormalities, and metabolic disorders.
Hydrocephalus is a condition in which there is an abnormal accumulation of cerebrospinal fluid
(CSF) within the brain.This typically causes increased pressure inside the skull. Older people
may have headaches, double vision, poor balance, urinary incontinence, personality changes, or
mental impairment. In babies there may be a rapid increase in head size. Other symptoms may
include vomiting, sleepiness, seizures, and downward pointing of the eyes.Hydrocephalus can
occur due to birth defects or be acquired later in life. Associated birth defects include neural tube
defects and those that result in aqueductal stenosis. Other causes include meningitis, brain
tumors, traumatic brain injury, intraventricular hemorrhage, and subarachnoid hemorrhage. There
are four types of hydrocephalus: communicating, non-communicating, ex-vacuo, and normal
pressure. Diagnosis is typically by examination and medical imaging.
Cerebral atrophy is a common feature of many of the diseases that affect the brain. Atrophy of
any tissue means a decrement in the size of the cell, which can be due to progressive loss of
cytoplasmic proteins. In brain tissue, atrophy describes a loss of neurons and the connections
between them. Atrophy can be generalized, which means that all of the brain has shrunk; or it
can be focal, affecting only a limited area of the brain and resulting in a decrease of the functions
that area of the brain controls. If the cerebral hemispheres (the two lobes of the brain that form
the cerebrum) are affected, conscious thought and voluntary processes may be impaired.Some
degree of cerebral shrinkage occurs naturally with age; after the brain completes growth and
attains its maximum mass at around age 25[citation needed], it gradually loses mass with each
decade of life, although the rate of loss is comparatively tiny until the age of 60, when
approximately .5 to 1% of brain volume is lost per year. By age 75, the brain is an average of
15% smaller than it was at 25. Some areas of the brain such as short-term memory are affected
more than others and men lose more brain mass overall than women.
VI. Contraindication

No absolute contraindications for head are recognized; however, it should not be performed if it
delays definitive care in an emergent situation.

HEART USD
I. Anatomy
Echocardiography is a dynamic assessment and it is important to examine structures through the
entire cardiac cycle. The normal heart sits in the left chest with its base anchored by the great
vessels: the aorta, superior vena cava, and main pulmonary artery. The cardiac apex points
anterior inferior and about 60 degrees to the left. The heart consists of two thicker walled
ventricles, two thinner walled atria and four valves that separate flow between the chambers.
The left heart is filled by 4 pulmonary veins draining into the left atrium. Blood flows between
the anterior and posterior leaflets of the mitral valve into the thick walled left ventricle.
The left ventricle (LV) is thicker walled and is the largest of the four chambers in the normal
heart. The LV is by far the main focus in echocardiography and learning nuances of its
appearance aids the experienced sonographer. The cardiac apex provides a distinctive landmark
from which to orient the image. In the longitudinal (long) parasternal (LPS) view the cardiac
apex is on the left side of the screen while the apex is on the right side of the screen in the
subxiphoid (SUX) view.
From the LV, blood flows into the tubular ascending aorta and into the systemic circulation. The
ascending aorta, otherwise known as the Left Ventricular outflow tract (LVOT), is shaped like a
tube on long axis. The aortic valve can be seen in this plane as two of the three aortic leaflets
(typically the non coronary cusp and right coronary cusp) mark diastole (closed) and systole
(open). Occasionally the left coronary cusp is seen in this imaging plane. In the short axis
parasternal view, tilting the probe cephalad can image the aortic valve in cross section. This is
the so-called Mercedes Benz sign where all three valves are displayed at the ascending aortic
root.
Superior and inferior vena cava drain into the right atrium and can help orient the sonographer.
These structures lead the operator to the right side of the heart. In the subxiphoid view of the
heart, the left lobe of the liver is used as an acoustic window to image the three hepatic veins
draining into the IVC as it passes through the diaphragm and drains into the right atrium. From
there, blood flows through the tricuspid valve into the triangular shaped right ventricle. The right
ventricle size is determined by forces influencing preload (e.g. intravascular volume, right atrial
and tricuspid function) and afterload (e.g. pulmonary artery pressure). It can assume many
shapes depending on the disease state. The pulmonary arteries are difficult to see yet can be
visualized in the short axis parasternal view. The right heart normally carries deoxygenated
blood to the lungs and is separated from the left heart by the interatrial septum and the thick
walled interventricular septum.
Cardiac Tissues
Outermost = Pericardium and Epicardium
Middle = Myocardium

Innermost = Endocardium
Lines Cardiac Chambers
II. Materials
Patient Gown
Table
Fresh linen/towels
Acoustic Gel
ECG lead wires
Electrodes
Medical Tape
III. Patient Preparation
There is no special preparation required for a heart ultrasound.
You should come as you are and eat or drink as you normally do.
If you take medications, you should continue to take them as normal unless your doctor specifies
otherwise.
You should plan on being at the echocardiography lab for about 45 minutes to one hour.
IV. Basic Scanning Protocol
Probe selection: Typically, cardiac imaging requires the use of intercostal acoustic windows.
This necessitates the use of probes with small footprints. Phased or micro convex arrays are
utilized for this reason. Imaging in adults requires the use of lower frequencies (typically 2-4
MHz). Curvilinear probes can be used to image the heart, especially in the subxiphoid view.
However, rib shadows impede the use of these larger footprint probes with transthoracic
imaging.
Orientation: To image the heart utilizing ultrasound, one must approach the acquisition and
interpretation of the heart from various orthogonal planes based on the hearts position within the
chest. Traditional imaging planes for anatomic structures are transverse (short axis) and sagittal
(long axis) planes. The picture on the monitor is essentially a displayed version of the ultrasound
beam that emanates from the transducer face. Structures closest to the transducer are
displayed at the top of the image deemed the near field. The deeper structures are displayed at
the bottom of the screen in the far field. The focal zone is that area of greatest resolution
(usually marked with a caret) that indicates the transition from the near to far field. All probes
have an indicator that demarcates the leading edge of the beam that corresponds to a mark on the
monitor. This orientation in cardiac imaging has created much controversy on how to position
the probe on the chest wall to obtain the necessary standard images of the heart. Standard
cardiology teaching positions the probe pointing to the right shoulder in the long parasternal
view or to the left shoulder in the short parasternal view with the indicator on the right side of
the monitor. Other methods have been described such as rotating the probe 180 degrees and
reversing the image on the monitor so the indicator is on the left side of the image (standard for
abdominal presets). The confusion in the cardiac display is best explained and clarified at the
bedside by touching one side of the probe and watching the resultant image on the display.
Standard display of cardiac anatomy in the long and short axis, subxiphoid and apical views are
the goal for cardiac imaging.
Scanning Methods: Scanning the patient incorporates the 3 Ps, Patient, Probe and Picture. The
anatomy of the patient is interrogated with an ultrasound probe that then displays the returning

echoes (ultrasound beam) on a picture display according to the probes orientation. The chest
can be imaged from a series of acoustic windows and tissue planes. First of all, make sure to
document the right patient and medical record number. Ensure that there is a recording device
(analog-thermal paper, Super VHS, or digital- Picture Archiving Communication System-PACS)
and set the correct cardiac preset application. Cardiac settings enhance the image for optimal
motion detection. Scan the patient from the patients right and hold the probe comfortably as a
pen or gently in a cupped hand. Apply generous amount of warm gel and position the patient in
left lateral decubitus if tolerated. The heart sits in the chest at an angle and can be approached
through the intercostal muscles. These intercostals and structures such as the liver (gray or black
structures in the near field) act as acoustic windows to allow sound waves to penetrate to the
underlying heart and chest cavity. Comparatively, strong reflectors such as ribs or gas in the
stomach obscure visualization into the far field. The ribs obscure the beam from penetrating,
therefore it is important to rotate the cardiac probe to align the beam parallel to the ribs in the
space and eliminate rib shadows.
Long Axis Parasternal: The heart sits obliquely in the left chest with the apex pointing
toward the left hip. To obtain the long parasternal view, begin to sweep the probe across
the parasternal area in the third or fourth intercostal space. If the mark on the monitor is
on the left, than point the probe to the left hip, if the mark on the monitor is on the right,
point the probe to the right shoulder. Either way the image is displayed in the same
manner for convenience with the curved apex on the left side of the monitor. Look for
the landmark mitral valve and rotate the probe to image the aortic and mitral valve in the
same long axis plane.
Short Axis Parasternal: The short axis is in plane ninety degrees from the long axis and
points the probe toward 8 oclock or the left shoulder. After adjusting the probe to obtain
a circular short axis view of the left ventricle, the structures along the endocardial border
help to determine the segmental position of the heart.
The short axis focuses on obtaining an image of the LV in a circular pattern and then
angling through the various positions to interrogate the respective wall segments.
Angling through the short axis views allows the operator to visualize the LV from the
smaller caliber apex past the base to the aortic valve in the superior mediastinum. The
short axis beam can be aimed cephalad to image the aortic valve in cross section. This
image can provide insight into the right ventricular outflow tract, as it is oriented anterior
to the aorta.
Subxiphoid: A common approach to critically image the heart is the subxiphoid view.
Unlike other cardiac views, this view is dependent on the left lobe of the liver as an
acoustic window in the near field. With the probe aimed to the right, angle cephalad
toward the thorax and then center the heart onto the screen with a rock and slide
maneuver. The operator should first identify the starry sky appearance to the liver.
Next the anechoic IVC in the far field abuts the hyperechoic diaphragm. As the operator
angles up into the chest, the IVC will transition into the right atrium. Measurements
taken at this IVC/RA junction have been described as rough estimates of central venous
pressure.
Apical: On physical exam the point of maximal intensity on the chest wall demarcates
the cardiac apex. An ultrasound probe can be placed lateral to the nipple line there and
rotated between the three apical views (Apical four chamber, apical two chamber, apical
long). The apical four-chamber view displays the ventricular septum in the middle with

the right heart displayed on the left side of the screen and the larger left heart on the right
of the screen. The atria are seen in the far field.
V. Indications and Contraindications
Mitral stenosis is a narrowing of the mitral valve opening. Mitral stenosis restricts blood flow
from the left atrium to the left ventricle. Mitral stenosis causes blood flow through the narrowed
valve opening from the left atrium to the left ventricle to be reduced. As a result, the volume of
blood bringing oxygen from the lungs is reduced, which can make you feel tired and short of
breath. The volume and pressure from blood remaining in the left atrium increases which then
causes the left atrium to enlarge and fluid to build up in the lungs. Mitral stenosis almost always
results from rheumatic fever, a childhood illness that sometimes occurs after untreated strep
throat or scarlet fever. Rheumatic fever is very rare in this country due to the use of effective
antibiotics to prevent infections.
Hypoplastic left heart syndrome (HLHS) is a birth defect that affects normal blood flow
through the heart. As the baby develops during pregnancy, the left side of the heart does not form
correctly. Hypoplastic left heart syndrome is one type of congenital heart defect. Congenital
means present at birth.
Hypoplastic left heart syndrome affects a number of structures on the left side of the heart that do
not fully develop, for example:
The left ventricle is underdeveloped and too small.
The mitral valves is not formed or is very small.
The aortic valve is not formed or is very small.
The ascending portion of the aorta is underdeveloped or is too small.
Often, babies with hypoplastic left heart syndrome also have an atrial septal
defect, which is a hole between the left and right upper chambers (atria) of the heart.
Cardiomyopathy refers to diseases of the heart muscle. These diseases have many causes, signs
and symptoms, and treatments.In cardiomyopathy, the heart muscle becomes enlarged, thick, or
rigid. In rare cases, the muscle tissue in the heart is replaced with scar tissue.As cardiomyopathy
worsens, the heart becomes weaker. It's less able to pump blood through the body and maintain a
normal electrical rhythm. This can lead to heart failure or irregular heartbeats called arrhythmias.
In turn, heart failure can cause fluid to build up in the lungs, ankles, feet, legs, or abdomen.The
weakening of the heart also can cause other complications, such as heart valve problems.
A heart murmur is an extra or unusual sound heard during a heartbeat. Murmurs range from
very faint to very loud. Sometimes they sound like a whooshing or swishing noise. The two types
of heart murmurs are innocent (harmless) and abnormal.Innocent heart murmurs aren't caused by
heart problems. These murmurs are common in healthy children. Many children will have heart
murmurs heard by their doctors at some point in their lives.People who have abnormal heart
murmurs may have signs or symptoms of heart problems. Most abnormal murmurs in children
are caused by congenital heart defects. These defects are problems with the heart's structure that
are present at birth.In adults, abnormal heart murmurs most often are caused by acquired heart
valve disease. This is heart valve disease that develops as the result of another condition.
Infections, diseases, and aging can cause heart valve disease.

Pericardial effusion is an abnormal accumulation of fluid in the pericardial cavity. Because of

the limited amount of space in the pericardial cavity, fluid accumulation leads to an increased
intrapericardial pressure which can negatively affect heart function. A pericardial effusion with
enough pressure to adversely affect heart function is called cardiac tamponade. Pericardial
effusion usually results from a disturbed equilibrium between the production and re-absorption
of pericardial fluid, or from a structural abnormality that allows fluid to enter the pericardial
cavity.
Normal levels of pericardial fluid are from 15 to 50 mL.
Infective endocarditis is a form of endocarditis. It is an inflammation of the inner tissues of the
heart, the endocardium, usually of the valves. It is caused by infectious agents, or pathogens,
which are largely bacterial but a few other organisms can also be responsible. Before the age of
modern antibiotics it was almost universally fatal.The valves of the heart do not receive any
dedicated blood supply. As a result, defensive immune system mechanisms (such as white blood
cells) cannot directly reach the valves via the bloodstream. If an organism (such as bacteria)
attaches to a valve surface and forms a vegetation, the host's immune response is blunted. The
lack of blood supply to the valves also has implications for treatment, since drugs also have
difficulty reaching the infected area.Normally, blood flows smoothly through these valves. If
they have been damaged from rheumatic fever, for example the risk of bacterial attachment
is increased.
Pulmonary hypertension (PH) is high blood pressure in the arteries to your lungs. It is a serious
condition. If you have it, the blood vessels that carry blood from your heart to your lungs become
hard and narrow. Your heart has to work harder to pump the blood through. Over time, your heart
weakens and cannot do its job and you can develop heart failure.