NEONATAL CRANIAL                      SONOGRAPHY                                   Joan K. Zawin, M.D.                    ...
Indications for HUS                      • Prematurity        • Hypoxia                      • ↑ Head             • FTT   ...
Limitations of HUS                      • Small acoustic window                      • Cannot assess myelination          ...
Acoustic Windows                      • Anterior Fontanelle ( 9 - 15 mos)                      • Posterior Fontanelle ( 3 ...
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Choroid Plexus                      • Thin in roof of III vent and in temporal                           horn             ...
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Choroid Plexus Cysts                      • Common, 3% prevalence                      • Glomus                      • < 1...
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Midline Cystic                                 Structures                      • Communicate with each other              ...
Cavum Septum                                    Pellucidum                      • Between frontal                         ...
Cavum Septum Vergae                      • Between bodies of                           lateral ventricles                 ...
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Cavum Veli Interpositi                      • Posterior extension                           of CSV                      • ...
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Absent Septum                             PellucidumSaturday, April 21, 2012
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Germinal Matrix                      • Between ependyma lateral vent floor above                           and caudate nucl...
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ICH and PVL                      • Most common CNS pathologies in premies                      • Risk factors:            ...
Intracranial                               Hemorrhage                      • 25 - 50% clinically silent                   ...
Intracranial                   Hemorrhage in                Premature Newborns                      •    Impaired autoregu...
Causes of ICH in                                  premies                    • Systemic ↑ BP                           • [...
Screening                                                 day 3-5                               asx                       ...
Papile Classification                           Grade I     40%            GMH only                           Grade II    2...
Grade IV Hemorrhage                      • Venous hemorrhagic infarction                           secondary to venous out...
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Connatal Cysts                      • Normal variant; incidence = 0.7%                      • Superolateral to frontal hor...
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Caudothalamic Groove                           Cysts                      • Congenital:                       • Germinolyt...
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Periventricular                              Leukomalacia                      • #1 ischemic brain injury in preemies     ...
Periventricular                                 Leukomalacia                      • Abnormal periventricular echotexture  ...
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Cerebral Edema                    • ↑ Parenchymal echogenicity                    • ↓ Sulcal/gyral differentiation        ...
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Perivascular                             Mineralization                      • TORCH                      • Trisomies(21 a...
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Vein of Galen                                 Malformation                      • Venous ectasia due to AVM               ...
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Posterior Fossa                      • Cerebellar vermis = midline/echogenic                      • Cerebellar hemispheres...
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Classic Dandy Walker                      • Vermian hypoplasia                      • Cystic dilatation posterior fossa   ...
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Dandy Walker                                 Continuum                      • Variant with vermis present and less        ...
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Benign Hygroma of                                 Infancy                      • Children 6 mos. - 2 yrs.                 ...
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Hydrocephalus                   • Obstructive: (non-communicating)                    • most common                    • C...
Hydrocephalus                      • Non-obstructive: (communicating)                       • impaired CSF resorption     ...
Hydrocephalus                      • Levene Index:                       • ≤ 40 wks.                       • COR image jus...
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Normal Ventricular                            Measurements                      • COR Images:                       • Fron...
Spinal UltrasoundSaturday, April 21, 2012
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Spinal Ultrasound                      • ≤ 4 months of age                      • Anatomic Variants:                      ...
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Filar Cysts                      • fusiform                      • anachoic                      • thin wall, well defined ...
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Tethered Cord                      • Findings:                       • conus below L2-L3                       • long thin...
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Pilonidal Sinus                      • aka sacral dimple; incd= 2-9%                      • < 5 mm diameter, <2.5 cm from ...
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Dorsal Dermal Sinus                      • Incomplete separation neural and                           cutaneous ectoderm➝ ...
Dorsal Dermal Sinus                      • Tract hypoechoic relative to SQ fat                           hyperechoic in CS...
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Caudal Regression                                   161Saturday, April 21, 2012
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Diastematomyelia                                  163Saturday, April 21, 2012
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Interesting Cases                                   165Saturday, April 21, 2012
Twin - Twin Transfusion                            Recepient                                166Saturday, April 21, 2012
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ECMO                            177Saturday, April 21, 2012
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Abnormal Prenatal                           Renal Ultrasound                                   185Saturday, April 21, 2012
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Zellweger Syndrome                      • Cerebrohepatorenal Syndrome                      • Autosomal recessive leukodyst...
Birth Trauma                                192Saturday, April 21, 2012
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Caput Succandeum                      • Serosanguinous subcutaneous fluid                           collection             ...
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Contact                      • http://www.slideshare.net/lembark/                           neonatal-cranial-spinal-sonogr...
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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.

Published in: Health & Medicine, Technology

Neonatal Cranial Spinal Sonography

  1. 1. NEONATAL CRANIAL SONOGRAPHY Joan K. Zawin, M.D. Cardinal Glennon Children’s Medical CenterSaturday, April 21, 2012
  2. 2. Indications for HUS • Prematurity • Hypoxia • ↑ Head • FTT circumference • Mass • Persistent large fontanelle • Intracranial infection • Craniosynostosis • Trauma • ECMOSaturday, April 21, 2012
  3. 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. 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. 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. 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. 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. 29. Cavum Septum Pellucidum • Between frontal horns • Anterior to foramen of Monroe • Usually closes 2-6 months after birthSaturday, April 21, 2012
  30. 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. 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. 35. Absent Septum PellucidumSaturday, April 21, 2012
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  37. 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. 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. 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. 42. Intracranial Hemorrhage in Premature Newborns • Impaired autoregulation ➟ pressure passive circulation 42Saturday, April 21, 2012
  43. 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. 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. 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. 46. Grade IV Hemorrhage • Venous hemorrhagic infarction secondary to venous outflow compression 46Saturday, April 21, 2012
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  68. 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. 72. Caudothalamic Groove Cysts • Congenital: • Germinolytic • chromosomal, metabolic, incidental • Acquired: • Subepdendymal • post-hemmorahgicSaturday, April 21, 2012
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  76. 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. 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. 83. Cerebral Edema • ↑ Parenchymal echogenicity • ↓ Sulcal/gyral differentiation • ↓ Vascular pulsations 83Saturday, April 21, 2012
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  86. 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. 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. 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. 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. 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. 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. 119. Hydrocephalus • Obstructive: (non-communicating) • most common • CSF cannot enter subarachnoid space • Aqeductal stenosis, Chiari Malformation, Dandy - Walker 119Saturday, April 21, 2012
  120. 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. 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. 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. 129. Spinal UltrasoundSaturday, April 21, 2012
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  133. 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. 139. Filar Cysts • fusiform • anachoic • thin wall, well defined • immediately distal to conus 139Saturday, April 21, 2012
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  144. 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. 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. 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. 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. 161. Caudal Regression 161Saturday, April 21, 2012
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  163. 163. Diastematomyelia 163Saturday, April 21, 2012
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  165. 165. Interesting Cases 165Saturday, April 21, 2012
  166. 166. Twin - Twin Transfusion Recepient 166Saturday, April 21, 2012
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  177. 177. ECMO 177Saturday, April 21, 2012
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  185. 185. Abnormal Prenatal Renal Ultrasound 185Saturday, April 21, 2012
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  191. 191. Zellweger Syndrome • Cerebrohepatorenal Syndrome • Autosomal recessive leukodystrophy • Deficiency of peroxisomes • Life span ≤ 1 year 191Saturday, April 21, 2012
  192. 192. Birth Trauma 192Saturday, April 21, 2012
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  196. 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. 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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