Neonatal Cranial Spinal Sonography
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Transcript of Neonatal Cranial Spinal Sonography
NEONATAL CRANIAL SONOGRAPHY
Joan K. Zawin, M.D.Cardinal Glennon Children’s Medical
Center
Saturday, April 21, 2012
Indications for HUS• Prematurity
• ↑ Head circumference
• Persistent large fontanelle
• Craniosynostosis
• ECMO
• Hypoxia
• FTT
• Mass
• Intracranial infection
• Trauma
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• Small acoustic window
• Cannot assess myelination
• Diffuse white matter injury
• Cerebellar lesions, infarctions, small isolated IVH - can be missed
Limitations of HUS
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Acoustic Windows• Anterior Fontanelle ( 9 - 15 mos)
• Posterior Fontanelle ( 3 mos)
• occipital horns, posterior white matter
• calcar avis
• Mastoid Fontanelle ( 24 mos)
• cerebellum, brainstem, cervical cord
• Transtemporal
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Choroid Plexus
• Thin in roof of III vent and in temporal horn
• “Split choroid” sign in trigone
• Present but not seen in roof of IV vent
• Never seen in occipital horn or anterior to foramen Monroe
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Choroid Plexus Cysts
• Common, 3% prevalence
• Glomus
• < 1 cm, unilateral = insignificant
• > 1cm, bilateral = ↑ assoc. with chromosomal abnormalities
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Midline Cystic Structures
• Communicate with each other
• Do not communicate with ventricular system or subarachnoid spaces
• Obliterated from posterior ➞ anterior
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Cavum Septum Pellucidum
• Between frontal horns
• Anterior to foramen of Monroe
• Usually closes 2-6 months after birth
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Cavum Septum Vergae
• Between bodies of lateral ventricles
• Posterior to foramen of Monroe
• Begins to close at 6 mos. gestation
• 97% closed at birth
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Cavum Veli Interpositi
• Posterior extension of CSV
• Posterior to quadrageminal plate cistern - pineal gland
• Only seen in very premature newborns
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Absent Septum Pellucidum
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Germinal Matrix
• Between ependyma lateral vent floor above and caudate nucleus below
• Roof of III and IV ventricles
• Involution begins at 3 mos gestation
• complete involution by 36 wks
• NOT seen unless there is a bleed
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ICH and PVL
• Most common CNS pathologies in premies
• Risk factors:
• < 1500 gm (20 - 25% incd)
• < 30 wks. gestation
• 67% < 32 wks. will have ICH
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Intracranial Hemorrhage
• 25 - 50% clinically silent
• Usually within first 3 days of life
• 50% Day 1
• 25% Day 2
• 80 - 90% occur by 3 - 4 days of age
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Intracranial Hemorrhage in
Premature Newborns
•Impaired autoregulation ➟ pressure passive circulation
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Causes of ICH in premies
• Systemic ↑ BP
• [↑P CO2, ↓Hb, ↑ intravascular vol]
• Increased CNS Venous Pressure
• asphyxia, tension PNTX, CHF, mechanical ventilation, tracheal suctioning
• Decreased CNS Perfusion
• ↓ Hb, ↓PO2, systemic hypotension43
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Screening
asx <1,000 gm
day 3-5 day 10-14
day 28
asx1,000 - 1250
gm
day 3-5day 28
asx1,251 - 1,500
gm
day 3-5Prior to discharge
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Papile Classification
Grade I 40% GMH only
Grade II 25% GMH + IVH
Grade III 20% GMH + IVH + ↑Vents
Grade IV 15%GMH + IVH +
parenchymal blood+/- ↑Vents
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Grade IV Hemorrhage
• Venous hemorrhagic infarction secondary to venous outflow compression
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Connatal Cysts
• Normal variant; incidence = 0.7%
• Superolateral to frontal horns
• Anterior to Foramen of Monroe
• “String of Pearls”
• Resolve spontaneously
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Caudothalamic Groove Cysts
• Congenital:
• Germinolytic
• chromosomal, metabolic, incidental
• Acquired:
• Subepdendymal
• post-hemmorahgic
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Periventricular Leukomalacia
• #1 ischemic brain injury in preemies
• <32 wks, <1500 g ; Hypocarbia
• ↑ echotexture periventricular white matter
• DDX:
• normal “flaring”
• transient edema
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Periventricular Leukomalacia
• Abnormal periventricular echotexture disappears in 2 - 3 wks
• 15% affected infants will then develop cysts
• 60 - 100% develop cerebral palsy
• visual and intellectual disabilities
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Cerebral Edema
• ↑ Parenchymal echogenicity
• ↓ Sulcal/gyral differentiation
• ↓ Vascular pulsations
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Perivascular Mineralization
• TORCH
• Trisomies(21 and 13)
• Twin-twin transfusion
• Fetal ETOH or cocaine exposure
• Neonatal asphyxia
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Vein of Galen Malformation
• Venous ectasia due to AVM
• Superior to cerebellum - quadrageminal plate cistern
• SX: CHF, seizures, hydrocephalus, hemorrhage( in older kids)
• RX = embolization
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Posterior Fossa
• Cerebellar vermis = midline/echogenic
• Cerebellar hemispheres= hypoechoic
• Cisterna magna - posterior/ inferior to vermis
• communicates with IV vent via vallecula
• ↑ in Dandy Walker, ↓ with Chiari
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Classic Dandy Walker
• Vermian hypoplasia
• Cystic dilatation posterior fossa communicating with IV vent
• Enlarged posterior fossa
• Tocular-lambdoid inversion
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Dandy Walker Continuum
• Variant with vermis present and less posterior fossa enlargement
• Persistent Blake Pouch Cyst
• looks like non-specific posterior fossa cyst
• Mega Cisterna Magna
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Benign Hygroma of Infancy
• Children 6 mos. - 2 yrs.
• Head circumference > 97th percentile
• Cause unknown, familial?
• Subarachnoid spaces > 3.3mm
• +/- slight ventricular enlargement
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Hydrocephalus
• Obstructive: (non-communicating)
• most common
• CSF cannot enter subarachnoid space
• Aqeductal stenosis, Chiari Malformation, Dandy - Walker
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Hydrocephalus
• Non-obstructive: (communicating)
• impaired CSF resorption
• infection, hemorrhage, congenital abs. arachnoid villi
• Ex Vacuo:
• loss of brain parenchyma → ↑ CSF spaces
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Hydrocephalus
• Levene Index:
• ≤ 40 wks.
• COR image just posterior to Foramen of Monroe
• 3 Dot sign
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Normal Ventricular Measurements
• COR Images:
• Frontal horn: ≤ 13 mm (2.9 mm)
• III ventricle: ≤ 10 mm (2.6 mm)
• Subarachnoid space: ≤ 4 mm
• SAG Images:
• TOD ≤ 24.7mm (12mm)
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Spinal Ultrasound
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Spinal Ultrasound
• ≤ 4 months of age
• Anatomic Variants:
• Ventriculus Terminalis
• Filar Cysts
• Pseudomass due to clumped nerve roots
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Filar Cysts
• fusiform
• anachoic
• thin wall, well defined
• immediately distal to conus
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Tethered Cord
• Findings:
• conus below L2-L3
• long thin conus
• posterior position of cord/filum
• ↓nerve root pulsations
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Pilonidal Sinus
• aka sacral dimple; incd= 2-9%
• < 5 mm diameter, <2.5 cm from anus
• No cutaneous abnormalities
• Do not extend to neural structures
• Short hypoechoic tract from skin to coccyx
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Dorsal Dermal Sinus
• Incomplete separation neural and cutaneous ectoderm➝ epithelial-line tract
• Connects skin to cord/cauda equina/arachnoid space
• ↑ incd. meningitis/abscesses
• Superior to coccyx
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Dorsal Dermal Sinus
• Tract hypoechoic relative to SQ fat hyperechoic in CSF
• Associated Findings:
• cutaneous hemangiomata, hairy nevi
• low conus
• intraspinal lipomas, epidermoids/dermoids
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Caudal Regression
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Diastematomyelia
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Interesting Cases
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Twin - Twin TransfusionRecepient
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ECMO
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Abnormal Prenatal Renal Ultrasound
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Zellweger Syndrome
• Cerebrohepatorenal Syndrome
• Autosomal recessive leukodystrophy
• Deficiency of peroxisomes
• Life span ≤ 1 year
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Birth Trauma
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Caput Succandeum
• Serosanguinous subcutaneous fluid collection
• Below scalp and superficial to periosteum
• Associated with moulding and over-riding sutures
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Contact
• http://www.slideshare.net/lembark/neonatal-cranial-spinal-sonography
• Joan K. Zawin <[email protected]>
Saturday, April 21, 2012