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Neonatal!
Cranial & Spinal
Sonography
Joan K. Zawin, M.D.
bariumqueen1@yahoo.com
Indications for HUS
• Prematurity	
• ↑ Head circumference	
• Persistent large
fontanelle	
• Craniosynostosis	
• ECMO	
• Hypoxia	
• FTT	
• Mass	
• Intracranial infection	
• Trauma
Limitations of HUS
• Small acoustic window	
• Cannot assess myelination	
• Diffuse white matter injury	
• Cerebellar lesions, infarctions, small isolated
IVH - can be missed
3
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	
4
5
6
Auckland District Health Board www.adhb.govt.nz/.../
NeonatalHUSSViews.htm
7
8
9
10
11
12
13
Normal Gray - White Matter
15
16
17
18
19
20
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
21
Choroid Plexus
Split Choroid Sign
Choroid Plexus Cysts
• Common, 3% prevalence	
• Glomus	
• < 1 cm, unilateral = insignificant	
• > 1cm, bilateral = ↑ assoc. with
chromosomal abnormalities
24
25
26
Midline Cystic
Structures
• Communicate with each other	
• Do not communicate with ventricular
system or subarachnoid spaces	
• Obliterated from posterior ➞ anterior	
• Can persist into adulthood
Cavum Septum
Pellucidum
• Between frontal horns	
• Anterior to foramen of
Monroe	
• Usually closes 2-6
months after birth
Cavum SeptumVergae
• Between bodies of
lateral ventricles	
• Posterior to foramen of
Monroe	
• Begins to close at 6 mos.
gestation	
• 97% closed at birth
30
CavumVeli Interpositi
• Posterior extension of
CSV	
• Posterior to
quadrageminal plate
cistern - pineal gland	
• Only seen in very
premature newborns	
• Helmut - shaped
32
33
Absent Septum
Pellucidum
35
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
36
Normal Caudothalamic
Groove
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
38
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
39
Intracranial
Hemorrhage in
Premature Newborns
• Impaired autoregulation ➟ pressure passive
circulation
40
Causes of ICH in
Premies
• Systemic ↑ BP 	
• [↑P CO2, ↓Hb, ↑ intravascular vol]	
• Increased CNSVenous Pressure	
• asphyxia, tension PNTX, CHF, mechanical
ventilation, tracheal suctioning	
• Decreased CNS Perfusion	
41
Screening
asx 	
<1,000 gm
day 3-5	
day 10-14	
day 28
asx	
1,000 - 1250
gm
day 3-5	
day 28
asx	
1,251 - 1,500
gm
day 3-5	
Prior to discharge
42
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
43
Grade IV Hemorrhage
• Venous hemorrhagic infarction secondary
to venous outflow compression
44
Grade I
Bilateral Grade I
Grade I vs. Normal
Grade I vs. Normal
Rt Grade II
Grade II vs. Normal
Grade III
Grade IV
Grade IV
Rt IV, Day 3
Left II, Right I Hemorrhages
Grade I vs. II?
Grade I vs. II?
58
59
61
62
63
64
65
Rt IV+ Lt II, Day 3
Rt IV + Lt II, Day 3
Rt IV + Lt II, 9 wks.
Rt IV + Lt II, Day 0
Rt IV + Lt II, Day 6
Rt IV + Lt II, Day 13
Day 13
Rt IV
Lt II
Rt IV + Lt II, 6 wks
Hemorrhagic Infarcts
Temporal Hemorrhage
Bilateral Cerebellar Bleeds
Bilateral Parietal Infarcts
Bilateral Parietal Infarcts
Bilateral Parietal Infarcts!
7 wks.
Bilateral Parietal Infarcts
80
Connatal Cysts
• Normal variant; incidence = 0.7%	
• Lateral to frontal horns	
• Anterior to Foramen of Monroe	
• “String of Pearls”	
• Resolve spontaneously
82
String of Pearls
Caudothalamic Groove
Cysts
• Congenital: 	
• Germinolytic	
• chromosomal, metabolic, incidental	
• Acquired: 	
• Subepdendymal	
• post-hemmorahgic
Germinolytic Cysts:!
Zellweger Syndrome
Zellweger Syndrome
• Cerebrohepatorenal Syndrome	
• Autosomal recessive leukodystrophy	
• Deficiency of peroxisomes	
• Life span ≤ 1 year
86
Zellweger Syndrome
Resolving Grade I
Germinolytic vs. Connatal
Cysts
Germinolytic vs. Connatal
Cysts
Colloid Cyst
Colloid Cyst
Periventricular
Leukomalacia
• #1 ischemic brain injury in preemies	
• <32 wks, <1500 g 	
• Vulnerable oligodendocyte precursors	
• Echogenic periventricular white matter: 	
• normal “flaring”	
• transient edema
93
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
94
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
95
PVL vs. Grade IV Bleed
• PVL: 	
• No mass effect	
• Multiple small cysts	
• Grade IV hemorrhage:	
• Mass effect	
• Larger porencephalic cysts
96
Normal Periventricular White
Matter
Normal Periventricular White
Matter
Bilateral PVL
PVL vs Normal
Bilateral PVL
Bilateral Cystic PVL
Periventricular Leukomalacia
Day 0 7 Weeks
Periventricular Leukomalacia
Periventricular Leukomalacia
Periventricular Leukomalacia
Periventricular Leukomalacia
Periventricular Leukomalacia
Periventricular Leukmalacia
Periventricular Leukomalacia
Cerebral Edema
• ↑ Parenchymal echogenicity	
• ↓ Sulcal/gyral differentiation	
• ↓Vascular pulsations
111
112
113
Ischemic Event, Day 22
Ischemic Event Day 22!
6 wk. F/U
Perivascular
Mineralization
• TORCH	
• Trisomies(21 and 13)	
• Twin-twin transfusion	
• Fetal ETOH or cocaine exposure	
• Neonatal asphyxia	
• Chronic hypoxia - cardiopulmonary
116
Perivascular
Mineralization
• Lenticulostriate arteries	
• Can develop and progress after birth	
• Unilateral or bilateral	
• Punctate or linear
117
118
119
120
Lenticulostriate
Vasculopathy
Agenesis Corpus Callosum
Agenesis Corpus Callosum
vs. Normal
Agenesis Corpus Callosum
vs. Normal
Agenesis Corpus Callosum
Agenesis Corpus Callosum
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
128
129
130
Vein of Galen Malformation
Vein of Galen Malformation
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
133
134
Classic Dandy Walker
• Vermian hypoplasia	
• Cystic dilatation posterior fossa
communicating with IV vent	
• Enlarged posterior fossa	
• Tocular-lambdoid inversion
136
137
138
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
140
141
Retro-cerebellar Arachnoid
Cyst
Retro-cerebellar Arachnoid
Cyst
Benign Hygroma of
Infancy
• Children 6 mos. - 2 yrs.	
• Head circumference > 97th percentile	
• Cause unknown, familial?	
• Subarachnoid spaces > 3.3mm	
• +/- slight ventricular enlargement
144
145
146
Prominent Subarachnoid
Spaces
Hydrocephalus
• Obstructive: (non-communicating)	
• most common	
• CSF cannot enter subarachnoid space	
• Aqeductal stenosis, Chiari Malformation,
Dandy - Walker
148
Hydrocephalus
• Non-obstructive: (communicating)	
• impaired CSF resorption	
• infection, hemorrhage, congenital abs.
arachnoid villi	
• ExVacuo:	
• loss of brain parenchyma → ↑ CSF
spaces
149
Hydrocephalus
• Levene Index:	
• ≤ 40 wks.	
• COR image just posterior to Foramen of
Monroe	
• 3 Dot sign
150
151
152
153
154
155
NormalVentricular
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)
156
Zika: Prenatal
Zika: Prenatal
Summary
• Invaluable for evaluation of brain in NICU	
• portable	
• no radiation	
• Bleeds, strokes, PVL, structural
abnormalities - calcifications	
• Hydrocephalus - monitoring
159
Spinal Ultrasound
161
162
163
Spinal Ultrasound
• ≤ 4 months of age	
• AnatomicVariants:	
• Ventriculus Terminalis	
• Filar Cysts	
• Pseudomass due to clumped nerve roots
164
165
166
167
168
Filar Cysts
• Fusiform	
• Anachoic	
• Thin wall, well defined	
• Immediately distal to conus
169
170
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
171
172
173
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
174
Dorsal Dermal Sinus
• Tract hypoechoic relative to SQ fat
hyperechoic in CSF	
• Associated Findings:	
• cutaneous hemangiomata, hairy nevi	
• low conus	
• intraspinal lipomas, epidermoids/
dermoids	
175
176
177
178
179
180
181
182
Tethered Cord
• Findings:	
• conus below L2-L3	
• long thin conus	
• posterior position of cord/filum	
• ↓nerve root pulsations
183
184
185
186
187
188
189
190
191
Caudal Regression
192
193
Diastematomyelia
194
195
Birth Trauma
196
197
Cephalohematoma
199
200
201
Caput Succandeum
• Serosanguinous subcutaneous fluid
collection	
• Below scalp and superficial to periosteum	
• Associated with moulding and over-riding
sutures
202
Interesting Cases
204
Chiari II + Cervicothoracic
Meningomyelocele
Cervicothoracic
Meningomyelocele
Chiari II + Cervicothoracic
Meningomyelocele
Chiari II + Cervicothoracic
Meningomyelocele
Chiari II + Cervicothoracic
Meningomyelocele
Chiari II + Cervicothoracic
Meningomyelocele
Chiari II + Cervicothoracic
Meningomyelocele
Terminal Myelocystocele
L4 - S3 Spinal Dysraphism
Terminal Myelocystocele!
L4 - S3 Spinal Dysraphism
214
Low conus + syrinx + meningocele + bony
defect, syrinx
Omphalocele, Cloacal extrophy,
Imperforate anus, Terminal Myelocystocele
OEIS - Terminal
Myelocystocele
OEIS - Terminal
Myelocystocele
OEIS - Terminal
Myelocystocele
OEIS - Terminal
Myelocystocele
Summary
• Portable, no radiation
• Static and dynamic information
• Limited window of opportunity
• < 4 months of age
Joan K. Zawin, MD!
bariumqueen1@yahoo.com
Twin - Twin Transfusion
Recepient
222
223
224
225
226
227
228
229
230
231
ECMO
232
233
234
235
236
237
238
239
Abnormal Prenatal
Renal Ultrasound
240
241
242
243
244
245
Zellweger Syndrome
• Cerebrohepatorenal Syndrome	
• Autosomal recessive leukodystrophy	
• Deficiency of peroxisomes	
• Life span ≤ 1 year
246
Birth Trauma
247
248
249
Cephalohematoma
251
252
Caput Succandeum
• Serosanguinous subcutaneous fluid
collection	
• Below scalp and superficial to periosteum	
• Associated with moulding and over-riding
sutures
253
Contact
• http://www.slideshare.net/lembark/
neonatal-cranial-spinal-sonography	
!
• Joan K. Zawin
<bariumqueen1@yahoo.com>
255

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