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Neonatal cranial US.pdf
- 1. Neonatal Cranial and Neonatal Cranial and Spine Ultrasound Spine Ultrasound Ana Maria Gaca, MD Ana Maria Gaca, MD Pediatric Radiology Pediatric Radiology Duke University Medical Center Duke University Medical Center Durham, North Carolina Durham, North Carolina
- 5. 5 5 Cranial Ultrasound Cranial Ultrasound Standard Images Standard Images „ „ CORONAL PLANE CORONAL PLANE Frontal Horns Frontal Horns Foramen of Monroe Foramen of Monroe Posterior 3 Posterior 3rd rd Ventricle Ventricle Quadrigeminal Cistern Quadrigeminal Cistern Ventricular Trigones Ventricular Trigones Periventricular White Periventricular White Matter Matter „ „ SAGITTAL PLANE SAGITTAL PLANE Midline Midline Caudothalamic groove Caudothalamic groove Ventricular trigones Ventricular trigones Sylvian Fissure Sylvian Fissure
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- 16. 16 16 Neonatal Intracranial Neonatal Intracranial Pathology Pathology „ „ Preterm Infant Preterm Infant – – Germinal matrix hemorrhage Germinal matrix hemorrhage – – Periventricular Periventricular leukomalacia leukomalacia (PVL) (PVL) „ „ Term Infant Term Infant – – Parenchymal hemorrhage Parenchymal hemorrhage – – Diffuse cerebral edema Diffuse cerebral edema
- 17. 17 17 Germinal Matrix Germinal Matrix „ „ Source of immature neural tissue Source of immature neural tissue – – Largest at 23 Largest at 23- -24 wks gestation 24 wks gestation – – Essentially involutes by 36 wks Essentially involutes by 36 wks gestation gestation „ „ Most common site of intracranial Most common site of intracranial hemorrhage in the preterm infant hemorrhage in the preterm infant (20% of infants < 1500 g) (20% of infants < 1500 g) – – 80 80- -90% by 96 hours of life 90% by 96 hours of life „ „ Venous Venous hemorrhage hemorrhage
- 18. 18 18 Intracranial Hemorrhage Intracranial Hemorrhage - - Screening Screening „ „ Who? Who? – – < 32 weeks gestation < 32 weeks gestation – – Weight < 1500 g Weight < 1500 g „ „ When? When? – – 4 4- -7 days after birth 7 days after birth - - 90% of 90% of hemorrhages occur in first week of life hemorrhages occur in first week of life – – Weekly to evaluate for hydrocephalus Weekly to evaluate for hydrocephalus
- 19. 19 19 Intracranial Hemorrhage Intracranial Hemorrhage - - Imaging Imaging „ „ Germinal matrix bleed Germinal matrix bleed – – ovoid echogenic mass in the ovoid echogenic mass in the caudothalamic caudothalamic groove groove „ „ Intraventricular hemorrhage Intraventricular hemorrhage – – Lateral, 3 Lateral, 3rd rd and 4 and 4th th ventricles ventricles – – May fill ventricle, layer dependently or May fill ventricle, layer dependently or adhere to adhere to choroid choroid
- 20. 20 20 Grading of Germinal Grading of Germinal Matrix Hemorrhage Matrix Hemorrhage „ „ I I - - Subependymal Subependymal „ „ II II - - Subependymal Subependymal with blood in with blood in nondilated nondilated ventricles ventricles „ „ III III - - Subependymal Subependymal with blood in with blood in dilated ventricles dilated ventricles „ „ IV IV - - Subependymal Subependymal, intraventricular , intraventricular and and intraparenchymal intraparenchymal* * * * Formerly referred to as parenchymal extension Formerly referred to as parenchymal extension
- 21. 21 21 Grade I
- 22. 22 22 Grade I
- 23. 23 23 Grade II
- 24. 24 24 Grade II
- 25. 25 25 Grade III
- 26. 26 26 Grade III
- 27. 27 27 Grade IV
- 28. 28 28 Grade IV
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- 31. 31 31 Periventricular Periventricular Leukomalacia Leukomalacia „ „ 25 25- -40% of very low birth wt babies 40% of very low birth wt babies „ „ Focal necrosis of deep white matter Focal necrosis of deep white matter „ „ Watershed ischemic infarction Watershed ischemic infarction „ „ US sensitivity 28 US sensitivity 28 – – 50% 50% „ „ Early Early – – normal normal → → increased increased echogenicity echogenicity „ „ Late Late – – cystic cystic encephalomalacia encephalomalacia (2 (2- -6 6 wks) wks)
- 32. 32 32 Early PVL
- 33. 33 33 Later PVL
- 34. 34 34 Hemorrhage in Term Hemorrhage in Term Infants Infants „ „ Rarely germinal matrix hemorrhages, Rarely germinal matrix hemorrhages, often venous bleeds often venous bleeds „ „ Site of hemorrhage Site of hemorrhage – – Choroid Choroid plexus plexus – – Thalamus Thalamus – – Subpial region Subpial region „ „ Infants often severely stressed Infants often severely stressed
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- 36. 36 36 Hypoxic/Ischemic Injury Hypoxic/Ischemic Injury „ „ 36 wks gestation 36 wks gestation – – watershed moves watershed moves to periphery to periphery „ „ US : US : – – Increased echogenicity Increased echogenicity – – Loss of gyral Loss of gyral- -sulcal interfaces sulcal interfaces – – Slit Slit- -like ventricles like ventricles „ „ DDx DDx – –cerebritis cerebritis, edema, hemorrhage , edema, hemorrhage
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- 42. 42 42 Case #1
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- 46. 46 46 Sagittal Coronal Dandy Walker Variant
- 48. Agenesis of the Corpus Agenesis of the Corpus Callosum Callosum
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- 52. 52 52 Case #2
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- 55. 55 55 Vein of Galen Vein of Galen Malformation Malformation „ „ Persistent embryologic venous Persistent embryologic venous drainage drainage „ „ Complications: Complications: – – Strokes Strokes – – Steal phenomena Steal phenomena – – Can lead to progressive hemiparesis Can lead to progressive hemiparesis
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- 63. Neonatal Spine US Neonatal Spine US
- 64. 64 64 Spine Ultrasound Spine Ultrasound - - Technique Technique „ „ Screening exam Screening exam „ „ Sagittal and axial planes Sagittal and axial planes „ „ Linear transducer Linear transducer „ „ Patient imaged prone Patient imaged prone „ „ Can image from craniocervical junction Can image from craniocervical junction to sacrum to sacrum
- 65. 65 65 Spine Ultrasound Spine Ultrasound - - Indications Indications „ „ Multiple congenital anomalies Multiple congenital anomalies „ „ Complicated sacral dimple Complicated sacral dimple – – Above the Above the gluteal gluteal crease crease – – Bottom of pit not seen Bottom of pit not seen – – Possible drainage from dimple Possible drainage from dimple – – Skin stigmata ( Skin stigmata (hemangioma hemangioma, cutis , cutis aplasia aplasia, hairy patch and skin tags) , hairy patch and skin tags) „ „ Soft tissue mass suggesting Soft tissue mass suggesting spina spina bifida bifida occulta occulta
- 66. 66 66 Spine Ultrasound Spine Ultrasound „ „ Conus medullaris Conus medullaris – – Normally between L1 and L2 Normally between L1 and L2 – – Should not be below L2 Should not be below L2- -L3 L3 „ „ Filum terminale Filum terminale – – Cordlike, echogenic structure Cordlike, echogenic structure – – May be hard to differentiate from nerve May be hard to differentiate from nerve roots of cauda equina roots of cauda equina
- 67. 67 67 Central echo complex Arachnoid and pia mater Dura mater Conus medullaris
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- 71. 71 71 Normal Variants Normal Variants Ventriculus Ventriculus Terminalis Terminalis „ „ Ependyma Ependyma lined lined „ „ Distal cord Distal cord „ „ DDx DDx – – – – Syrinx Syrinx – – Transient dilation of Transient dilation of central canal central canal Reprinted with permission from the American Journal of Roentgenology (AJR:188, March 2007)
- 72. 72 72 Normal Variants Normal Variants Transient dilation of Transient dilation of central canal central canal „ „ Healthy newborns Healthy newborns „ „ Usually disappears Usually disappears in first weeks of life in first weeks of life
- 73. 73 73 Normal Variants Normal Variants Filar Filar cyst cyst „ „ Within Within filum filum (vs. (vs. conus conus medullaris medullaris of of terminal ventricle) terminal ventricle) „ „ Midline Midline „ „ Just below Just below conus conus „ „ Well defined Well defined „ „ Simple cyst Simple cyst
- 74. 74 74 Normal Variants Normal Variants Prominent Prominent Filum Filum „ „ Normal: <2 mm Normal: <2 mm thick thick
- 75. 75 75 Tethered cord Tethered cord „ „ Incomplete/failed regression distal Incomplete/failed regression distal cord cord „ „ Low Low conus conus: below L2 : below L2- -L3 disk space, L3 disk space, lack of normal nerve root motion lack of normal nerve root motion „ „ Tight Tight filum filum syndrome syndrome – – conus conus at at normal level, but still tethered normal level, but still tethered – – US US - - ↓ ↓ or absent nerve root movement or absent nerve root movement
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- 77. 77 77 Case #3
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- 82. 82 82 Dorsal Dermal Sinus Dorsal Dermal Sinus „ „ Tract: skin to canal Tract: skin to canal „ „ Dimple or ostium Dimple or ostium „ „ Midline or Midline or paramedian paramedian „ „ Complications Complications – – meningitis, abscess meningitis, abscess
- 83. 83 83 Pseudosinus Pseudosinus Tract Tract „ „ Pilonidal Pilonidal sinus sinus „ „ Hypoechoic Hypoechoic tract tract from skin from skin → → coccyx coccyx „ „ Check carefully for Check carefully for mass or fluid along mass or fluid along or originating from or originating from tract tract