Neonatalcranialusfromatoz 140223095544-phpapp01

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cranial USG technique

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Neonatalcranialusfromatoz 140223095544-phpapp01

  1. 1. DR. Muhammad Bin Zulfiqar PGR II FCPS RADIOLOGY SIMS/SHL
  2. 2. • Aims • Indications • Sonographic technique • Sonographic Anatomy • Doppler • Pathologies – Hemorrhage – PVL
  3. 3. Advantages of Cranial USG • Safe • Bedside- compatible • Reliable • Early imaging • Serial imaging: Brain maturation Evolution of lesions • Inexpensive • Suitable for screening
  4. 4. Aims of Cranial Ultrasound • Exclude/demonstrate cerebral pathology • Assess timing of injury • Assess neurological prognosis • Help make decisions on continuation of neonatal intensive care • Optimize treatment and support
  5. 5. Indications for Sonographic Exam  Cranial abnormality found on pre-natal sonogram  Increasing head circumference with or without increasing intracranial pressure  Acquired or Congenital inflammatory disease  Prematurity  Diagnosis of hypoxia, hypertension, hypercapnia, hypernaturemia, acidosis, pneumothorax, asphyxia, apnea, seizures, coagulation defects, patent ductus arteriosus, or elevated blood pressure  History of birth trauma or surgery  Suctioning of infant  Genetic syndromes and malformations
  6. 6. Anatomy of the Neonatal Skull  Fontanelles (“Soft Spots”)  Spaces between bones of the skull
  7. 7. Sonographic Technique What anatomy do you scan? Supratentorial Compartment  Both cerebral hemispheres  Basal Ganglia  Lateral & 3rd Ventricle  Interhemispheric fissure  Subarachnoid spaces  Views  Coronal  Modified Coronal (anterior fontanelle)  Sagittal (anterior fontanelle)  Parasagittal (anterior fontanelle)
  8. 8. Sonographic Technique Infratentorial Compartment  Cerebellum  Brain Stem  4th Ventricle  Basal Cisterns  Views  Coronal (mastoid fontanelle and occipitotemporal area)  Modified Coronal  Sagittal  Parasagittal (with increased focal depth & decreased frequency)
  9. 9. • Transducers : 5–7.5–10 MHz • Appropriately sized • Standard examination: use 7.5–8 MHz • Tiny infant and/or superficial structures: use additional higher frequency (10 MHz) • Large infant, thick hair, and/or deep structures: use additional lower frequency (5 MHz)
  10. 10. The Acoustic Windows Anterior Fontanel The Standard view window Posterior Fontanel Supplementary view window Mastoid Fontanel Supplementary view window Temporal Supplementary view window
  11. 11. Standard Views….Anterior Frontal • Coronal Views (at least 6 standard planes)
  12. 12. Standard Coronal Planes
  13. 13. First Coronal plane….Frontal Lobes 1. Interhemispheric fissure 2. Frontal lobe 3. Skull 4. Orbit
  14. 14. Second Coronal Plane….Frontal horns of Lateral Ventricle 2.Frontal lobe 5.Frontal horn of lateral ventricle 6.Caudate nucleus 7.Basal ganglia 8.Temporal lobe 9.Sylvian fissure
  15. 15. Third Coronal plane ….Foramen of Monro & 3rd Ventricle 2. Frontal lobe 5. Frontal horn of lateral ventricle 6. Caudate nucleus 8.Temporal lobe 9.Sylvian fissure 10. Corpus callosum 11. Cavum septum pellucidum 12. Third ventricle 13. Cingulate sulcus
  16. 16. Fourth coronal plane…. body of the lateral ventricle 1.Interhemispheric fissure 8.Temporal lobe 9.Sylvian fissure 14.Body of lateral ventricle 15.Choroid plexus 16.Thalamus 17.Hippocampal fissure 18.Aqueduct of Sylvius 19.Brain stem 20.Parietal lobe
  17. 17. Fifth Coronal plane….Trigone of Lateral Ventricle 8.Temporal lobe 10.Corpus callosum 15.Choroid plexus 20.Parietal lobe 21.Trigone of lateral ventricle 22.Cerebellum(a: hemispheres; b: vermis) 23.Tentorium 24.Mesencephalon
  18. 18. Sixth Coronal Plane….Parieto Occipital Lobe 20.Parietal lobe 25.Occipital lobe 26.Parieto-occipital fissure 27.Calcarine fissure
  19. 19. • Sagittal Views (at least 5 standard planes) Standard Views…..Anterior Fontanelle
  20. 20. Midsagittal plane….3rd and 4th ventricles 10.Corpus callosum 11.Cavum septum pellucidum 12.Third ventricle 13.Cingulate sulcus 16.Thalamus 22b.Cerebellum(vermis) 24.Mesencephalon 26.Parieto-occipital fissure 27.Calcarine fissure 28.Pons 29.Medulla oblongata 31. Cisterna magna 32. Cisterna quadrigemina 33. Interpeduncular fossa 34. Fornix
  21. 21. Second and Fourth Parasagittal planes….right and left lateral ventricles 2. Frontal lobe 5. Frontal horn of lateral ventricle 6. Caudate nucleus 8. Temporal lobe 14. Body of lateral ventricle 15. Choroid plexus 16. Thalamus 17. Hippocampal fissure 20. Parietal lobe 21. Trigone of lateral ventricle 22a. Cerebellum(hemisphere) 25. Occipital lobe 36. Occipital horn of lateral ventricle Black arrow indicates Caudothalamic groove
  22. 22. First & Fifth Parasagittal planes….Insula 2. Frontal lobe 8. Temporal lobe 9. Sylvian fissure 20. Parietal lobe 25. Occipital lobe 37. Insula
  23. 23. Supplemental Acoustic Window
  24. 24. Coronal view, using the PF as an acoustic window 8. Temporal lobe 22. Cerebellum(a: hemispheres; b: vermis) 23. Tentorium 25. Occipital lobe 27. Calcarine fissure 29. Medulla oblongata 36. Occipital horn of lateral ventricle 38. Falx
  25. 25. Parasagittal view using PF as an acoustic window 8. Temporal lobe 15. Choroid plexus 16. Thalamus 20. Parietal lobe 21. Trigone of lateral ventricle 22a. Cerebellum (hemispheres) 25. Occipital lobe 27. Calcarine fissure
  26. 26. Upper Transverse view using left Temporal window
  27. 27. Upper Transverse view using left Temporal window 1. Interhemispheric fissure 8. Temporal lobe 12. Third ventricle 22. Cerebellum (a: hemispheres; b: vermis) 23. Tentorium 24. Mesencephalon 33. Interpeduncular fossa 41. Circle of Willis
  28. 28. Lower Transverse view using Left Temporal Window • 8. Temporal lobe • 22. Cerebellum (a: hemispheres; b: vermis) • 25. Occipital lobe • 28. Pons • 41. Circle of Willis • 42. Prepontine cistern
  29. 29. Coronal View…..Mastoid Fontanelle • 22. Cerebellum – a: hemispheres – b: vermis • 28. Pons • 30. Fourth ventricle • 31.Interpeduncular Fossa
  30. 30. Transverse View….Mastoid Fontanelle • 8. Temporal lobe • 22. Cerebellum – (a: hemispheres; b: vermis) • 25. Occipital lobe • 28. Pons
  31. 31. Doppler uses  Typical transcranial Doppler with imaging scan and recording from middle cerebral artery (MCA).  Doppler image shows circle of Willis.  A = anterior cerebral artery  M = middle cerebral artery  P = posterior cerebral artery  RI = resistive index  Demonstrates  Decreased blood flow/ischemia/infarction  Vascular abnormalities  Cerebral Edema  Hydrocephalus  Intracranial Tumors  Near-field structures
  32. 32. BLOOD FLOW VELOCITY • Changes in flow velocity occur when: • There is a change in vessel caliber • There is a change in volume flow
  33. 33. should we do doppler study vein of galen aneurysm
  34. 34. Hemorrhagic Pathology  Risk Factors  Pre term infants  Less than 1500 grams birth weight  Grading  Grade I - Confined to germinal matrix  Grade II - Intraventricular without ventricular dilatation  Grade III - Intraventricular with ventricular dilatation  Grade IV - Periventricular hemorrhagic infarction
  35. 35. Germinal Matrix Hemorrhage  Far more common in premature infants  Germinal matrix - highly vascular and vulnerable to hypoxemia and ischemia, only present 24-32nd week gestation more common site  Image 4-7 days after birth  90% of hemorrhages occur in first week of life  Follow with weekly U/S to evaluate for hydrocephalus
  36. 36. Subependymal-Intraventricular Hemorrhage (SEH-IVH)  Caused by capillary bleeding in the germinal matrix  Continued subependymal (SEH) bleeding pushes into the ventricular cavity (IVH) & continues to follow CSF pathways causing obstruction  Since 70% of hemorrhages are asymptomatic, it is necessary to scan babies routinely  Small IVH’s may not be seen from the anterior fontanelle because blood tends to settle out in the posterior horns  Risk Factors  Pre term infants  Less than 1500 grams birth weight
  37. 37. Grade I Hemorrhage
  38. 38. Grade II Hemorrhage
  39. 39. Grade III Hemorrhage
  40. 40. Grade IV Hemorrhage
  41. 41. Intraparenchymal Hemorrhage  Brain parenchyma destroyed  Originally considered an extension of IVH, but may actually be a primary infarction of the periventricular and sub cortical white matter with destruction of the lateral wall of the ventricle.  Sonographic Finding  Zones of increased echogenicity in white matter adjacent to lateral ventricles
  42. 42. Intracerebellar Hemorrhage  Types  Primary  Venous Infarction  Traumatic Laceration  Extension from IVH  Sonographic Findings  Areas of increased echogenicity within cerebellar parenchyma  Coronal views through mastoid fontanelle may be essential to differentiate from large IVH in the cisterna magna
  43. 43. Epidural Hemorrhages and Subdural Collections  Best diagnosed with CT because the lesions are located peripherally along the surface of the brain. an echogenic layer of clotted blood (arrow) is seen between the cortex and the skull. five hours after the image the clot has started to lyse, and the layer is now hypoechoic. a parasagittal view demonstrates the fluid around the cortical mantle and the paucity of gyri due to the
  44. 44. Periventricular Leukomalacia (PVL) or White Matter Necrosis (WMN)  Also known as Hypoxic-Ischemic Encephalopathy (HIE).  Affects the periventricular zones.  watershed zone between deep and superficial vessels.  Causes:  Ischemia  Infection  Vasculitis
  45. 45. Periventricular Leukomalacia (PVL) or White Matter Necrosis (WMN)  PVL presents as areas of increased periventricular echogenicity.  Premature infants born at less than 33 weeks gestation (38% PVL) and less than 1500 g birth weight (45% PVL).  Effects  cerebral palsy,  intellectual impairment  visual disturbances
  46. 46. Periventricular Leukomalacia (PVL) or White Matter Necrosis (WMN) Grade 1. Persisting more than 7 days Grade 2. Developing into small periventricular cysts Grade 3. Developing into extensive periventricular cysts, occipital and frontoparietal Grade 4. In deep white matter developing into extensive subcortical cysts
  47. 47. PVL or WMN 1 2 Sagittal image of a child with PVL grade 1 Transverse and sagittal image of a child with PVL grade 2.
  48. 48. PVL or WMN Coronal and transverse images demonstrating PVL grade 4 Sagittal image demonstrating extensive PVL grade 3
  49. 49. THANX
  50. 50. Chiari Malformation  Sonographic Features  Small posterior fossa  Small, displaced Cerebellum  Possible Myelomeningocele  Widened 3rd Ventricle  Cerebellum herniated through enlarged foramen magnum  4th ventricle elongated  Posterior horns enlarged  Cavum Septum pellucidum absent  Interhemispheric Fissure widened  Tentorium low and hypoplastic
  51. 51. Holoprosencephaly  Common large central ventricle because Prosencephalon failed to cleave into separate cerebral hemispheres.  Alobar Holoprosencephaly (Most Severe)  Fused thalami anteriorly to a fused choroid plexus  Single midline ventricle  No falx cerebrum, corpus callosum, Interhemispheric fissure, or 3rd ventricle  Semilobar Holoprosencephaly  Single ventricle  Presents with portions of the falx and Interhemispheric fissure  Thalami partially separated  3rd Ventricle is rudimentary  Mild facial anomalies  Lobar Holoprosencephaly (Least Severe)  Near complete separation of hemispheres; only anterior horns fused  Full development of falx and interhemispheric fissure
  52. 52. Holoprosencephaly Alobar Holoprosencephaly Semilobar Holoprosencephaly
  53. 53. Dandy-Walker Malformation  Congenital anomaly of the roof of the 4th ventricle with occlusion of the aqueduct of Sylvius and foramina of Magendie and Luschka  A huge 4th ventricle cyst occupies the area where the cerebellum usually lies with secondary dilation of the 3rd ventricle; absent cerebellar vermis
  54. 54. Dandy Walker Malformation
  55. 55. Agenesis of the Corpus Callosum  Complete or partial absence of the connection tissue between cerebral hemispheres  Narrow frontal horns  Marked separation of lateral ventricles  Widening of occipital horns and 3rd Ventricle  “Vampire Wings”
  56. 56. Agenesis of the Corpus Callosum
  57. 57. Ventriculmegaly  Enlargement of the ventricles without increased head circumference  Communicating  Non-communicating  Result of cerebral atrophy  Sonographic Findings  Ventricles greater than normal size first noted in the trigone and occipital horn areas  Visualization of the 3rd and possibly 4th ventricles  Choroid plexus appears to “dangle” within the ventricular trium  Thinned brain mantle in case of cerebral atrophy
  58. 58. Hydrocephalus  Enlargement of ventricles with increased head circumference  Communicating  Non-communicating  Sonographic Findings  Blunted lateral angles of enlarged lateral ventricles  Possible interhemispheric fissure rupture  Thinned brain mantle  Aqueductal Stenosis  Most common cause of congenital hydrocephalus  Aqueduct of Sylvius is narrowed or is a small channel with blind ends; occasionally caused by extrinsic lesions posterior to the brain stem  Sonographic Findings  Widening of lateral and 3rd ventricles  Normal 4th ventricle
  59. 59. Hydrancephaly  Occlusion of internal carotid arteries resulting in necrosis of cerebral hemispheres  Absence of both cerebral hemispheres with presence of the falx, thalamus, cerebellum, brain stem, and positions of the occipital and temporal lobes  Sonographic findings Fluid filled cranial vault Intact cerebellum and midbrain
  60. 60. Cephalocele  Herniation of a portion of the neural tube through a defect in the skull  Sonographic Findings  Sac/pouch containing brain tissue and/or CSF and meninges  Lateral Ventricle Enlargement
  61. 61. Arachnoid Cysts  Cysts lined with arachnoid tissue and containing CSF  Causes  Entrapment during embryogenesis  Residual subdural hematoma  Fluid extravasation secondary to meningeal tear or ventricular rupture
  62. 62. Brain Infections  Common infections referred to by TORCH  T: Toxoplasma Gondii  O: Other (Syphilis)  R: Rubella Virus  C: Cytomegalovirus  H: Herpes Simplex Type 2  Consequences  Mortality  Mental Retardation  Developmental Delay
  63. 63. Ependymitis and Ventriculitis  Ependymitis  Irritation from hemorrhage within the ventricle  Occurs earlier than ventriculitis Sonographic Features  Thickened, hypoechoic ependyma (epithelial lining of the ventricles)  Ventriculitis  Common complication of purulent meningitis Sonographic Findings  Thin septations extending from the walls of the lateral ventricles.

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