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Neonatal Cranial Spinal Sonography

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Overview of anatomy and common abnormalities of the neonatal head, brain, and spine.

Overview of anatomy and common abnormalities of the neonatal head, brain, and spine.

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  • 1. NEONATAL CRANIAL SONOGRAPHY Joan K. Zawin, M.D. Cardinal Glennon Children’s Medical CenterSaturday, April 21, 2012
  • 2. Indications for HUS • Prematurity • Hypoxia • ↑ Head • FTT circumference • Mass • Persistent large fontanelle • Intracranial infection • Craniosynostosis • Trauma • ECMOSaturday, April 21, 2012
  • 3. Limitations of HUS • Small acoustic window • Cannot assess myelination • Diffuse white matter injury • Cerebellar lesions, infarctions, small isolated IVH - can be missed 3Saturday, April 21, 2012
  • 4. 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 4Saturday, April 21, 2012
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  • 21. 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 21Saturday, April 21, 2012
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  • 25. Choroid Plexus Cysts • Common, 3% prevalence • Glomus • < 1 cm, unilateral = insignificant • > 1cm, bilateral = ↑ assoc. with chromosomal abnormalities 25Saturday, April 21, 2012
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  • 28. Midline Cystic Structures • Communicate with each other • Do not communicate with ventricular system or subarachnoid spaces • Obliterated from posterior ➞ anteriorSaturday, April 21, 2012
  • 29. Cavum Septum Pellucidum • Between frontal horns • Anterior to foramen of Monroe • Usually closes 2-6 months after birthSaturday, April 21, 2012
  • 30. Cavum Septum Vergae • Between bodies of lateral ventricles • Posterior to foramen of Monroe • Begins to close at 6 mos. gestation • 97% closed at birthSaturday, April 21, 2012
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  • 32. Cavum Veli Interpositi • Posterior extension of CSV • Posterior to quadrageminal plate cistern - pineal gland • Only seen in very premature newbornsSaturday, April 21, 2012
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  • 35. Absent Septum PellucidumSaturday, April 21, 2012
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  • 37. 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 37Saturday, April 21, 2012
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  • 40. 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 40Saturday, April 21, 2012
  • 41. 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 41Saturday, April 21, 2012
  • 42. Intracranial Hemorrhage in Premature Newborns • Impaired autoregulation ➟ pressure passive circulation 42Saturday, April 21, 2012
  • 43. 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 hypotension 43Saturday, April 21, 2012
  • 44. Screening day 3-5 asx day 10-14 <1,000 gm day 28 asx day 3-5 1,000 - 1250 day 28 gm asx day 3-5 1,251 - 1,500 Prior to discharge gm 44Saturday, April 21, 2012
  • 45. Papile Classification Grade I 40% GMH only Grade II 25% GMH + IVH Grade III 20% GMH + IVH + ↑Vents GMH + IVH + Grade IV 15% parenchymal blood +/- ↑Vents 45Saturday, April 21, 2012
  • 46. Grade IV Hemorrhage • Venous hemorrhagic infarction secondary to venous outflow compression 46Saturday, April 21, 2012
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  • 68. Connatal Cysts • Normal variant; incidence = 0.7% • Superolateral to frontal horns • Anterior to Foramen of Monroe • “String of Pearls” • Resolve spontaneouslySaturday, April 21, 2012
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  • 72. Caudothalamic Groove Cysts • Congenital: • Germinolytic • chromosomal, metabolic, incidental • Acquired: • Subepdendymal • post-hemmorahgicSaturday, April 21, 2012
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  • 76. Periventricular Leukomalacia • #1 ischemic brain injury in preemies • <32 wks, <1500 g ; Hypocarbia • ↑ echotexture periventricular white matter • DDX: • normal “flaring” • transient edema 76Saturday, April 21, 2012
  • 77. 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 77Saturday, April 21, 2012
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  • 83. Cerebral Edema • ↑ Parenchymal echogenicity • ↓ Sulcal/gyral differentiation • ↓ Vascular pulsations 83Saturday, April 21, 2012
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  • 86. Perivascular Mineralization • TORCH • Trisomies(21 and 13) • Twin-twin transfusion • Fetal ETOH or cocaine exposure • Neonatal asphyxia 86Saturday, April 21, 2012
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  • 95. Vein of Galen Malformation • Venous ectasia due to AVM • Superior to cerebellum - quadrageminal plate cistern • SX: CHF, seizures, hydrocephalus, hemorrhage( in older kids) • RX = embolizationSaturday, April 21, 2012
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  • 100. 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 100Saturday, April 21, 2012
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  • 105. Classic Dandy Walker • Vermian hypoplasia • Cystic dilatation posterior fossa communicating with IV vent • Enlarged posterior fossa • Tocular-lambdoid inversionSaturday, April 21, 2012
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  • 109. 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 MagnaSaturday, April 21, 2012
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  • 114. Benign Hygroma of Infancy • Children 6 mos. - 2 yrs. • Head circumference > 97th percentile • Cause unknown, familial? • Subarachnoid spaces > 3.3mm • +/- slight ventricular enlargement 114Saturday, April 21, 2012
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  • 119. Hydrocephalus • Obstructive: (non-communicating) • most common • CSF cannot enter subarachnoid space • Aqeductal stenosis, Chiari Malformation, Dandy - Walker 119Saturday, April 21, 2012
  • 120. Hydrocephalus • Non-obstructive: (communicating) • impaired CSF resorption • infection, hemorrhage, congenital abs. arachnoid villi • Ex Vacuo: • loss of brain parenchyma → ↑ CSF spaces 120Saturday, April 21, 2012
  • 121. Hydrocephalus • Levene Index: • ≤ 40 wks. • COR image just posterior to Foramen of Monroe • 3 Dot sign 121Saturday, April 21, 2012
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  • 128. 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) 128Saturday, April 21, 2012
  • 129. Spinal UltrasoundSaturday, April 21, 2012
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  • 133. Spinal Ultrasound • ≤ 4 months of age • Anatomic Variants: • Ventriculus Terminalis • Filar Cysts • Pseudomass due to clumped nerve roots 133Saturday, April 21, 2012
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  • 139. Filar Cysts • fusiform • anachoic • thin wall, well defined • immediately distal to conus 139Saturday, April 21, 2012
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  • 144. Tethered Cord • Findings: • conus below L2-L3 • long thin conus • posterior position of cord/filum • ↓nerve root pulsations 144Saturday, April 21, 2012
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  • 153. 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 153Saturday, April 21, 2012
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  • 156. 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 156Saturday, April 21, 2012
  • 157. Dorsal Dermal Sinus • Tract hypoechoic relative to SQ fat hyperechoic in CSF • Associated Findings: • cutaneous hemangiomata, hairy nevi • low conus • intraspinal lipomas, epidermoids/ dermoids 157Saturday, April 21, 2012
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  • 161. Caudal Regression 161Saturday, April 21, 2012
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  • 163. Diastematomyelia 163Saturday, April 21, 2012
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  • 165. Interesting Cases 165Saturday, April 21, 2012
  • 166. Twin - Twin Transfusion Recepient 166Saturday, April 21, 2012
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  • 177. ECMO 177Saturday, April 21, 2012
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  • 185. Abnormal Prenatal Renal Ultrasound 185Saturday, April 21, 2012
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  • 191. Zellweger Syndrome • Cerebrohepatorenal Syndrome • Autosomal recessive leukodystrophy • Deficiency of peroxisomes • Life span ≤ 1 year 191Saturday, April 21, 2012
  • 192. Birth Trauma 192Saturday, April 21, 2012
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  • 196. Caput Succandeum • Serosanguinous subcutaneous fluid collection • Below scalp and superficial to periosteum • Associated with moulding and over- riding sutures 196Saturday, April 21, 2012
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  • 199. Contact • http://www.slideshare.net/lembark/ neonatal-cranial-spinal-sonography • Joan K. Zawin <bariumqueen1@yahoo.com> 199Saturday, April 21, 2012

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