Neonatal Cranial & Spinal Ultrasound
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Transcript of Neonatal Cranial & Spinal Ultrasound
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Indications for HUS• Prematurity
• ↑ Head circumference
• Persistent large fontanelle
• Craniosynostosis
• ECMO
• Hypoxia
• FTT
• Mass
• Intracranial infection
• Trauma
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Limitations of HUS
• Small acoustic window
• Cannot assess myelination
• Diffuse white matter injury
• Cerebellar lesions, infarctions, small isolated IVH - can be missed
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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
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Auckland District Health Board www.adhb.govt.nz/.../NeonatalHUSSViews.htm
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Normal Gray - White Matter
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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
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Split Choroid Sign
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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
• Can persist into adulthood
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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
• Helmut - shaped
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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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Normal Caudothalamic Groove
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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
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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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Grade I
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Bilateral Grade I
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Grade I vs. Normal
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Grade I vs. Normal
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Rt Grade II
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Grade II vs. Normal
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Grade III
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Grade IV
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Grade IV
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Rt IV, Day 3
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Left II, Right I Hemorrhages
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Grade I vs. II?
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Grade I vs. II?
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Rt IV+ Lt II, Day 3
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Rt IV + Lt II, Day 3
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Rt IV + Lt II, 9 wks.
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Rt IV + Lt II, Day 0
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Rt IV + Lt II, Day 6
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Rt IV + Lt II, Day 13Day 13 Rt IV Lt II
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Rt IV + Lt II, 6 wks
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Hemorrhagic Infarcts
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Temporal Hemorrhage
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Bilateral Cerebellar Bleeds
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Bilateral Parietal Infarcts
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Bilateral Parietal Infarcts
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Bilateral Parietal Infarcts! 7 wks.
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Bilateral Parietal Infarcts
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Connatal Cysts
• Normal variant; incidence = 0.7%
• Lateral to frontal horns
• Anterior to Foramen of Monroe
• “String of Pearls”
• Resolve spontaneously
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String of Pearls
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Caudothalamic Groove Cysts
• Congenital:
• Germinolytic
• chromosomal, metabolic, incidental
• Acquired:
• Subepdendymal
• post-hemmorahgic
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Germinolytic Cysts:!Zellweger Syndrome
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Zellweger Syndrome
• Cerebrohepatorenal Syndrome
• Autosomal recessive leukodystrophy
• Deficiency of peroxisomes
• Life span ≤ 1 year
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Zellweger Syndrome
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Resolving Grade I
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Germinolytic vs. Connatal Cysts
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Germinolytic vs. Connatal Cysts
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Colloid Cyst
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Colloid Cyst
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Periventricular Leukomalacia
• #1 ischemic brain injury in preemies
• <32 wks, <1500 g
• Vulnerable oligodendocyte precursors
• Echogenic periventricular white matter:
• 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
• 2 - 6 wks.
• 60 - 100% develop cerebral palsy
• visual and intellectual disabilities
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PVL Grading!
• I. ↑ Echogenicity > 7 days without cysts
• II. Small periventricular cysts
• III. Extensive periventricular cysts - frontoparietal and parieto-occipital
• IV. Cysts appearing subcortical due to loss of white matter
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PVL vs. Grade IV Bleed
• PVL:
• No mass effect
• Multiple small cysts
• Grade IV hemorrhage:
• Mass effect
• Larger porencephalic cysts
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Normal Periventricular White Matter
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Normal Periventricular White Matter
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Bilateral PVL
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PVL vs Normal
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Bilateral PVL
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Bilateral Cystic PVL
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Periventricular LeukomalaciaDay 0 7 Weeks
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Periventricular Leukomalacia
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Periventricular Leukomalacia
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Periventricular Leukomalacia
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Periventricular Leukomalacia
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Periventricular Leukomalacia
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Periventricular Leukmalacia
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Periventricular Leukomalacia
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Cerebral Edema
• ↑ Parenchymal echogenicity
• ↓ Sulcal/gyral differentiation
• ↓ Vascular pulsations
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Ischemic Event, Day 22
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Ischemic Event Day 22!6 wk. F/U
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Perivascular Mineralization
• TORCH
• Trisomies(21 and 13)
• Twin-twin transfusion
• Fetal ETOH or cocaine exposure
• Neonatal asphyxia
• Chronic hypoxia - cardiopulmonary
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Perivascular Mineralization
• Lenticulostriate arteries
• Can develop and progress after birth
• Unilateral or bilateral
• Punctate or linear
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Lenticulostriate Vasculopathy
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Agenesis Corpus Callosum
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Agenesis Corpus Callosum vs. Normal
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Agenesis Corpus Callosum vs. Normal
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Agenesis Corpus Callosum
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Agenesis Corpus Callosum
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Vein of Galen Malformation
• Congenital AV shunts - persistant prosencephalic vein of Markowski
• Superior to cerebellum - quadrageminal plate cistern
• SX: CHF, seizures, hydrocephalus, hemorrhage( in older kids)
• RX = embolization
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Vein of Galen Malformation
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Vein of Galen Malformation
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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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Posterior Fossa Cysts
• 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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Retro-cerebellar Arachnoid Cyst
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Retro-cerebellar Arachnoid Cyst
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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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Prominent Subarachnoid Spaces
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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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Zika: Prenatal
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Zika: Prenatal
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Summary
• Invaluable for evaluation of brain in NICU
• portable
• no radiation
• Bleeds, strokes, PVL, structural abnormalities - calcifications
• Hydrocephalus - monitoring
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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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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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173
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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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Tethered Cord
• Findings:
• conus below L2-L3
• long thin conus
• posterior position of cord/filum
• ↓nerve root pulsations
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Caudal Regression
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Diastematomyelia
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Birth Trauma
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Cephalohematoma
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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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Interesting Cases
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Chiari II + Cervicothoracic Meningomyelocele
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Cervicothoracic Meningomyelocele
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Chiari II + Cervicothoracic Meningomyelocele
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Chiari II + Cervicothoracic Meningomyelocele
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Chiari II + Cervicothoracic Meningomyelocele
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Chiari II + Cervicothoracic Meningomyelocele
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Chiari II + Cervicothoracic Meningomyelocele
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Terminal Myelocystocele L4 - S3 Spinal Dysraphism
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Terminal Myelocystocele!L4 - S3 Spinal Dysraphism
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Low conus + syrinx + meningocele + bony defect, syrinx
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Omphalocele, Cloacal extrophy, Imperforate anus, Terminal Myelocystocele
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OEIS - Terminal Myelocystocele
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OEIS - Terminal Myelocystocele
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OEIS - Terminal Myelocystocele
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OEIS - Terminal Myelocystocele
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Summary
• Portable, no radiation
• Static and dynamic information
• Limited window of opportunity
• < 4 months of age
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Twin - Twin Transfusion Recepient
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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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Cephalohematoma
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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]>
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