Post on 24-Feb-2016
description
Imaging the Misshapen Head
David Nielsen, MDPediatric Radiologist
Imaging the Misshapen Head
• Objective:
– Better understand how to image the most common causes of a misshapen head
Imaging the Misshapen Head
• Common causes:– Macrocephaly– Microcephaly– Craniosynostosis– Posterior plagiocephaly
Imaging the Misshapen Head
• Common causes:– Macrocephaly– Microcephaly– Craniosynostosis– Posterior plagiocephaly
Macrocephaly• Definition:
– Macrocephaly = Macrocrania
Macrocephaly• Definition:
– Macrocephaly = Macrocrania
– Head circumference > 2SD (> 95%) above the mean for age, sex, race, and gestation
What is the most common imaging finding in
macrocephaly?
A. B. C. D.
0% 0%0%0%
A. HydrocephalusB. Benign Enlarged
Subarachnoid Spaces (BESS)
C. Subdural HematomaD. Intracranial Mass
Macrocephaly• Ddx:
– #1: Benign Enlarged Subarachnoid Spaces (BESS)
– Also called:• Benign macrocrania• Benign extra-axial
collections• Benign external
hydrocephalus• Transient communicating
hydrocephalus
NL
BESS
Macrocephaly
• Benign enlarged subarachnoid spaces– Clinical:
Macrocephaly
• Benign enlarged subarachnoid spaces– Clinical:
• Macrocephaly presents between 3-6 months and peaks at about 7 months
Macrocephaly
• Benign enlarged subarachnoid spaces– Clinical:
• Macrocephaly presents between 3-6 months and peaks at about 7 months
• May have family history of macrocephaly
Macrocephaly
• Benign enlarged subarachnoid spaces– Clinical:
• Macrocephaly presents between 3-6 months and peaks at about 7 months
• May have family history of macrocephaly• Normal developmental/neurological exam
Macrocephaly
• Benign enlarged subarachnoid spaces– Clinical:
• Macrocephaly presents between 3-6 months and peaks at about 7 months
• May have family history of macrocephaly• Normal developmental/neurological exam• Stabilizes by 18 months along a curve paralleling the
95% curve
Macrocephaly
• Benign enlarged subarachnoid spaces– Clinical:
• Macrocephaly presents between 3-6 months and peaks at about 7 months
• May have family history of macrocephaly• Normal developmental/neurological exam• Stabilizes by 18 months along a curve paralleling the
95% curve• Spontaneously resolves by 24-36 months
Macrocephaly
• Benign enlarged subarachnoid spaces– Imaging:
Macrocephaly
• Benign enlarged subarachnoid spaces– Imaging:
• Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures
Macrocephaly
• Benign enlarged subarachnoid spaces– Imaging:
• Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures
• No mass effect
Macrocephaly
• Benign enlarged subarachnoid spaces– Imaging:
• Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures
• No mass effect• Same imaging characteristics as CSF
Macrocephaly
• Benign enlarged subarachnoid spaces– Imaging:
• Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures
• No mass effect• Same imaging characteristics as CSF• Cortical veins course through the fluid
Macrocephaly
• Benign enlarged subarachnoid spaces– Imaging:
• Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures
• No mass effect• Same imaging characteristics as CSF• Cortical veins course through the fluid• Ventricles are normal or mildly enlarged
Cortical veins
Benign enlarged subarachnoid spaces
Macrocephaly
Macrocephaly
Benign enlarged subarachnoid spaces
Cortical veins
Macrocephaly• Ddx:
– #1: Benign Enlarged Subarachnoid Spaces (BESS)
– Other:• Hydrocephalus (HC)• Subdural hematoma• Intracranial mass (rare)• Congenital/
syndromic/metabolic (rare)
Macrocephaly
Clinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT (or MRI)
Developmentally abnormal with open or closed fontanel
MRI
• Imaging is based on development and fontanel/age:
Macrocephaly
Clinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT (or MRI)
Developmentally abnormal with open or closed fontanel
MRI
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
• Normal neurological exam with open fontanel
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
• Normal neurological exam with open fontanel– Short-term clinical follow-up with serial head
circumference measurements with or without ultrasound
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
• Normal neurological exam with open fontanel– Short-term clinical follow-up with serial head
circumference measurements with or without ultrasound• If head stabilizes (i.e. measurements again parallel the normal
curve), the likely diagnosis is BESS:
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
• Normal neurological exam with open fontanel– Short-term clinical follow-up with serial head
circumference measurements with or without ultrasound• If head stabilizes (i.e. measurements again parallel the normal
curve), the likely diagnosis is BESS:– No imaging (or no additional imaging) is recommended
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
• Normal neurological exam with open fontanel– Short-term clinical follow-up with serial head
circumference measurements with or without ultrasound• If head stabilizes (i.e. measurements again parallel the normal
curve), the likely diagnosis is BESS:– No imaging (or no additional imaging) is recommended
• If head continues to enlarge disproportionate to the child’s growth (i.e. measurements do not again parallel the normal curve) and clinical exam is still otherwise normal:
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
• Normal neurological exam with open fontanel– Short-term clinical follow-up with serial head
circumference measurements with or without ultrasound• If head stabilizes (i.e. measurements again parallel the normal
curve), the likely diagnosis is BESS:– No imaging (or no additional imaging) is recommended
• If head continues to enlarge disproportionate to the child’s growth (i.e. measurements do not again parallel the normal curve) and clinical exam is still otherwise normal:
– Ultrasound to screen for severe hydrocephalus or large mass
Benign enlarged subarachnoid spaces
Macrocephaly
Macrocephaly
Choroid plexus papilloma
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT (or MRI)
Developmentally abnormal with open or closed fontanel
MRI
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT (or MRI)• Normal neurological exam with closed fontanel
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT (or MRI)• Normal neurological exam with closed fontanel
– Case-by-case risk/benefit assessment of short-term clinical follow-up with serial head circumference measurements versus imaging with CT (radiation risk) or MRI (sedation risk)
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT (or MRI)• Normal neurological exam with closed fontanel
– Case-by-case risk/benefit assessment of short-term clinical follow-up with serial head circumference measurements versus imaging with CT (radiation risk) or MRI (sedation risk)
– Each modality also has advantages for the clinical question to be answered (e.g. CT is preferred for bones)
Macrocephaly
Benign enlarged subarachnoid spaces
6 mo 11 mo
Macrocephaly
Pilocytic Astrocytoma
MRI - Benign enlarged subarachnoid spaces
Macrocephaly
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT (or MRI)
Developmentally abnormal with open or closed fontanel
MRI
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT or MRI
Developmentally abnormal with open or closed fontanel
MRI• Abnormal developmental/neurological exam with open or closed fontanel
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT or MRI
Developmentally abnormal with open or closed fontanel
MRI• Abnormal developmental/neurological exam with open or closed fontanel– MRI to evaluate brain parenchyma, extra-axial spaces
Macrocephaly
Non-communicating hydrocephalus
Macrocephaly
Anaplastic medulloblastoma
MacrocephalyClinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo)
Ultrasound
Developmentally normal with closed fontanel (>6 mo)
CT (or MRI)
Developmentally abnormal with open or closed fontanel
MRI• This approach to imaging macrocephaly reduces both unnecessary imaging and radiation exposure
References:Smith, MR, JC Leonidas, J Maytal. The Value of Head Ultrasound in Infants with Macrocephaly. Pediatric Radiology 1998; 28:143-146.Wilms G, Vanderschueren G, et al. CT and MR in infants with pericerebral collections and macrocephaly: benign enlargement of the subarachnoid spaces versus subdural collections. American Journal of Neuroradiology 1993; 14:855-860.Hudgins, R, Boydston WR. All Heads Great and Small, Macrocephaly. Children’s Healthcare of Atlanta. http://www.choa.org/default.aspx?id=921. Accessed June 15, 2008.
12-month-old male with macrocephaly and
developmental delay. What study is indicated?
A. B. C. D.
0% 0%0%0%
A. UltrasoundB. CTC. MRID. Brain PET scan
Imaging the Misshapen Head
• Common causes:– Macrocephaly– Microcephaly– Craniosynostosis– Posterior plagiocephaly
Imaging the Misshapen Head
• Common causes:– Macrocephaly– Microcephaly– Craniosynostosis– Posterior plagiocephaly
Microcephaly• Definition:
– Head circumference < 2SD (< 5%) below the mean for age, sex, race, and gestation
Microcephaly• Ddx:
– Congenital malformation
– Infection (TORCH)– Hypoxia-Ischemia – Old trauma– Toxic/Metabolic
Microcephaly• Clinical:
– Abnormal developmental or neurological exam
• Imaging:– MRI
Polymicrogyria
Imaging the Misshapen Head
• Common causes:– Macrocephaly– Microcephaly– Craniosynostosis– Posterior plagiocephaly
Imaging the Misshapen Head
• Common causes:– Macrocephaly– Microcephaly– Craniosynostosis– Posterior plagiocephaly
Craniosynostosis
• Definition:– Premature fusion of
cranial sutures• Synonyms:
– Craniostenosis, sutural synostosis, cranial dysostosis
• M:F = 3:1
Craniosynostosis
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly
Craniosynostosis
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly
Craniosynostosis
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly– Coronal – 26% (1/7700)
• Brachycephaly
Craniosynostosis
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly– Coronal – 26% (1/7700)
• Brachycephaly
Craniosynostosis
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly– Coronal – 26% (1/7700)
• Brachycephaly– Metopic – 8% (1/25,000)
• Trigonocephaly
Craniosynostosis
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly– Coronal – 26% (1/7700)
• Brachycephaly– Metopic – 8% (1/25,000)
• Trigonocephaly
Craniosynostosis
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly– Coronal – 26% (1/7700)
• Brachycephaly– Metopic – 8% (1/25,000)
• Trigonocephaly– Lambdoid – 5% (1/40,000)
• Brachycephaly (bilateral) or Trapezoid skull (unilateral)
1
Craniosynostosis
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly– Coronal – 26% (1/7700)
• Brachycephaly– Metopic – 8% (1/25,000)
• Trigonocephaly– Lambdoid – 5% (1/40,000)
• Brachycephaly (bilateral) or Trapezoid skull (unilateral)
– Other /syndromic – 5%
1
• Incidence: 3-5 cases per 10,000 live births– Sagittal – 56% (1/3600)
• Scaphocephaly– Coronal – 26% (1/7700)
• Brachycephaly– Metopic – 8% (1/25,000)
• Trigonocephaly– Lambdoid – 5% (1/40,000)
• Brachycephaly (bilateral) or Trapezoid skull (unilateral)
– Other /syndromic – 5%
1
Craniosynostosis
Posterior Plagiocephaly
• Posterior plagiocephaly:
Posterior Plagiocephaly
• Posterior plagiocephaly:– Synonyms:
• positional plagiocephaly, deformational plagiocephaly, positional molding, postural flattening
Posterior Plagiocephaly
• Posterior plagiocephaly:– Synonyms:
• positional plagiocephaly, deformational plagiocephaly, positional molding, postural flattening
– Commonly seen since “Back to Sleep” began in the 1990’s
Posterior Plagiocephaly
• Posterior plagiocephaly:– Synonyms:
• positional plagiocephaly, deformational plagiocephaly, positional molding, postural flattening
– Commonly seen since “Back to Sleep” began in the 1990’s– Asymmetrical flattening of the posterior skull due to
recumbent/sleep position
Posterior Plagiocephaly
• Posterior plagiocephaly:– Synonyms:
• positional plagiocephaly, deformational plagiocephaly, positional molding, postural flattening
– Commonly seen since “Back to Sleep” began in the 1990’s– Asymmetrical flattening of the posterior skull due to
recumbent/sleep position – Does not usually require imaging
Posterior Plagiocephaly
• Posterior plagiocephaly:– Synonyms:
• positional plagiocephaly, deformational plagiocephaly, positional molding, postural flattening
– Commonly seen since “Back to Sleep” began in the 1990’s– Asymmetrical flattening of the posterior skull due to
recumbent/sleep position – Does not usually require imaging– Must distinguish from lambdoid synostosis
Otherwise normal child with posterolateral flattening
Normal sutures/positional plagiocephalySagittal Lambdoid Coronal
Posterior Plagiocephaly
Otherwise normal child with posterolateral flattening
Posterior Plagiocephaly
NL
Normal sutures/ positional
plagiocephaly
CraniosynostosisLambdoid synostosis
Craniosynostosis
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• When imaging is required, it depends on the risk category as determined by history/physical:
Craniosynostosis
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• When imaging is required, it depends on the risk category as determined by history/physical:
CraniosynostosisRisk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
• Plain films:
CraniosynostosisRisk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
• Plain films: • Lowest radiation dose
CraniosynostosisRisk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
• Plain films: • Lowest radiation dose• Adequate screening for all craniosynostosis
Otherwise normal child with posterolateral flattening
Normal sutures/positional plagiocephalySagittal Lambdoid Coronal
Posterior Plagiocephaly
Craniosynostosis
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
Craniosynostosis
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
CraniosynostosisRisk Category ImagingIntermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
• Low-dose head CT:
CraniosynostosisRisk Category ImagingIntermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
• Low-dose head CT: • ~80% less radiation than standard head CT
CraniosynostosisRisk Category ImagingIntermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
• Low-dose head CT: • ~80% less radiation than standard head CT• Optimized for evaluation of the bones/sutures
Craniosynostosis – Intermediate Risk
Standard CT Low Dose CT
Standard CT Low Dose CT
Craniosynostosis – Intermediate Risk
Child with mild developmental delay and right
parieto-occiptal flattening
NLNormal sutures/ positional
plagiocephaly
Craniosynostosis – Intermediate Risk
Child with developmental delay and left posterior
flattening
Normal sutures/ posterior
plagiocephaly
Craniosynostosis – Intermediate Risk
NL
CraniosynostosisRisk Category ImagingIntermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
• Low-dose head CT: • ~80% less radiation than standard head CT• Optimized for evaluation of the bones/sutures• Only at CMH
Why you send patients here!
Low Radiation CT at CMH
• Dedicated low-dose pediatric protocols for:– Paranasal sinuses– Scoliosis spines– Cranial dermoid cysts– Facial bones– Cleft palate– Etc.
Craniosynostosis
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
Craniosynostosis
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull x-ray study
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
CraniosynostosisRisk Category ImagingHigh risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• Standard head CT:
CraniosynostosisRisk Category ImagingHigh risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• Standard head CT: • Higher radiation dose
CraniosynostosisRisk Category ImagingHigh risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• Standard head CT: • Higher radiation dose
• Infants are significantly more affected by radiation (cancer risk)• Infants have a longer lifespan to manifest the effects (cancer risk)
CraniosynostosisRisk Category ImagingHigh risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• Standard head CT: • Higher radiation dose
• Infants are significantly more affected by radiation (cancer risk)• Infants have a longer lifespan to manifest the effects (cancer risk)
• Use to evaluate skull and brain
CraniosynostosisRisk Category ImagingHigh risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• Standard head CT: • Higher radiation dose
• Infants are significantly more affected by radiation (cancer risk)• Infants have a longer lifespan to manifest the effects (cancer risk)
• Use to evaluate skull and brain• Used by the surgeon for pre-surgical planning
• This is NOT a prerequisite for a plastic surgery consultation
CraniosynostosisRisk Category ImagingHigh risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• Standard head CT: • Higher radiation dose
• Infants are significantly more affected by radiation (cancer risk)• Infants have a longer lifespan to manifest the effects (cancer risk)
• Use to evaluate skull and brain• Used by the surgeon for pre-surgical planning
• This is NOT a prerequisite for a plastic surgery consultation• Do not use as a screening exam for craniosynostosis
Craniosynostosis – High Risk
History: clinical exam suggesting coronal synostosis
NL
Craniosynostosis – High Risk
History: pre-operative coronal synostosis repair
Craniosynostosis – High Risk
History: pre-operative sagittal synostosis repair
Craniosynostosis – High Risk
History: pre-operative sagittal synostosis repair
3D Surface Rendering Max Intensity Projection Intracranial Superior View
Craniosynostosis – High Risk
History: pre-operative sagittal synostosis repair111111111111111111111111111111111111111111111111111111111111111111
Craniosynostosis – High Risk
History: pre-operative lambdoid synostosis repair
111111111111111111111111111111111111111111
NL
NL
CraniosynostosisRisk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull (plain films)
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
• This approach to imaging craniosynostosis and posterior plagiocephaly reduces both unnecessary imaging and radiation exposure
6-month-old infant with flat posterior skull & normal development. Which study is indicated?
A. B. C. D.
0% 0%0%0%
A. 3D CTB. MRIC. UltrasoundD. No imaging
Imaging the Misshapen Head
• Common causes:– Macrocephaly– Microcephaly– Craniosynostosis– Posterior plagiocephaly
Clinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo) UltrasoundDevelopmentally normal with closed fontanel (>6 mo) CT (or MRI)Developmentally abnormal with open or closed fontanel
MRI
How to Image Macrocephaly:
How to Image Craniosynostosis/Posterior Plagiocephaly:
Imaging the Misshapen Head
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull (plain films)
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
Clinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo) UltrasoundDevelopmentally normal with closed fontanel (>6 mo) CT (or MRI)Developmentally abnormal with open or closed fontanel
MRI
How to Image Macrocephaly:
How to Image Craniosynostosis/Posterior Plagiocephaly:
Imaging the Misshapen Head
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull (plain films)
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
Clinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo) UltrasoundDevelopmentally normal with closed fontanel (>6 mo) CT (or MRI)Developmentally abnormal with open or closed fontanel
MRI
How to Image Macrocephaly:
How to Image Craniosynostosis/Posterior Plagiocephaly:
Imaging the Misshapen Head
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull (plain films)
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
Clinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo) UltrasoundDevelopmentally normal with closed fontanel (>6 mo) CT (or MRI)Developmentally abnormal with open or closed fontanel
MRI
How to Image Macrocephaly:
• (
How to Image Craniosynostosis/Posterior Plagiocephaly:
Imaging the Misshapen Head
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull (plain films)
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformations
Clinical Presentation & Fontanel/Age ImagingDevelopmentally normal with open fontanel (<6 mo) UltrasoundDevelopmentally normal with closed fontanel (>6 mo) CT (or MRI)Developmentally abnormal with open or closed fontanel
MRI
How to Image Macrocephaly:
How to Image Craniosynostosis/Posterior Plagiocephaly:
Imaging the Misshapen Head
Risk Category ImagingLow risk – developmentally normal and posterior or posterolateral flattening only
No imaging, or 4-view skull (plain films)
Intermediate risk – children who don’t clearly fit into the low or high risk group
Low-dose head CT
High risk – developmentally abnormal and/or obvious head deformity almost certainly needing surgery
Standard head CT with 3D reformationsHow to Image Children in KC!
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parameters used by Pediatric Radiologists.” AJR 2008; 191: 611-617.2. Brenner DJ, Hall EJ. Computed tomography: an increasing source of radiation exposure. N Engl J Med
2007; 357:2277-2284.3. Brenner, DJ Estimating cancer risks from pediatric CT: going from the qualitative to the quantitative.
Pediatric Radiology 2002: 32: 228-2314. Brenner DJ, Elliston CD, Hall EJ, and WE Berdon. Estimated risks of radiation-induced fatal cancer
from pediatric CT. AJR 2001;176: 289-296 5. Cohen, MM Jr. Epidemiology of Craniosynostosis. In: Cohen, MM Jr, ed Craniosynostosis:
diagnosis, evaluation, and management, 2nd ed. New York: Oxford University Press, 2000: 112-118.6. Goske MJ, et. al. The ‘Image Gently’ campaign: increasing CT radiation dose awareness through a
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Thanks/Contributed:
Julianne Dean, MDTiffany Lewis, DO
Lisa Lowe, MDTrent Phan, DO
Cindy Taylor, MD