Neonatal Cranial & Spinal Ultrasound

transcript

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

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

Auckland District Health Board www.adhb.govt.nz/.../NeonatalHUSSViews.htm

Normal Gray - White Matter

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

Choroid Plexus

Split Choroid Sign

Choroid Plexus Cysts

• Common, 3% prevalence

• Glomus

• < 1 cm, unilateral = insignificant

• > 1cm, bilateral = ↑ assoc. with chromosomal abnormalities

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 Septum Vergae

• Between bodies of lateral ventricles

• Posterior to foramen of Monroe

• Begins to close at 6 mos. gestation

• 97% closed at birth

Cavum Veli Interpositi

• Posterior extension of CSV

• Posterior to quadrageminal plate cistern - pineal gland

• Only seen in very premature newborns

• Helmut - shaped

Absent Septum Pellucidum

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

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

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

Intracranial Hemorrhage in

Premature Newborns

• Impaired autoregulation ➟ pressure passive circulation

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

Screening

asx <1,000 gm

day 3-5 day 10-14

day 28

asx1,000 - 1250

day 3-5day 28

asx1,251 - 1,500

day 3-5Prior to discharge

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

Grade IV Hemorrhage

• Venous hemorrhagic infarction secondary to venous outflow compression

Grade I

Bilateral Grade I

Grade I vs. Normal

Rt Grade II

Grade II vs. Normal

Grade III

Grade IV

Rt IV, Day 3

Left II, Right I Hemorrhages

Grade I vs. II?

Rt IV+ Lt II, Day 3

Rt IV + Lt II, Day 3

Rt IV + Lt II, 9 wks.

Rt IV + Lt II, Day 13Day 13 Rt IV Lt II

Rt IV + Lt II, 6 wks

Hemorrhagic Infarcts

Temporal Hemorrhage

Bilateral Cerebellar Bleeds

Bilateral Parietal Infarcts

Bilateral Parietal Infarcts! 7 wks.

Bilateral Parietal Infarcts

Connatal Cysts

• Normal variant; incidence = 0.7%

• Lateral to frontal horns

• Anterior to Foramen of Monroe

• “String of Pearls”

• Resolve spontaneously

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

Zellweger Syndrome

Resolving Grade I

Germinolytic vs. Connatal Cysts

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

• 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

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

PVL vs. Grade IV Bleed

• PVL:

• No mass effect

• Multiple small cysts

• Grade IV hemorrhage:

• Mass effect

• Larger porencephalic cysts

Normal Periventricular White Matter

Bilateral PVL

PVL vs Normal

Bilateral PVL

Bilateral Cystic PVL

Periventricular LeukomalaciaDay 0 7 Weeks

Periventricular Leukmalacia

Cerebral Edema

• ↑ Parenchymal echogenicity

• ↓ Sulcal/gyral differentiation

• ↓ Vascular pulsations

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

Perivascular Mineralization

• Lenticulostriate arteries

• Can develop and progress after birth

• Unilateral or bilateral

• Punctate or linear

Lenticulostriate Vasculopathy

Agenesis Corpus Callosum

Agenesis Corpus Callosum vs. Normal

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

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

Classic Dandy Walker

• Vermian hypoplasia

• Cystic dilatation posterior fossa communicating with IV vent

• Enlarged posterior fossa

• Tocular-lambdoid inversion

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

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

Prominent Subarachnoid Spaces

Hydrocephalus

• Obstructive: (non-communicating)

• most common

• CSF cannot enter subarachnoid space

• Aqeductal stenosis, Chiari Malformation, Dandy - Walker

Hydrocephalus

• Non-obstructive: (communicating)

• impaired CSF resorption

• infection, hemorrhage, congenital abs. arachnoid villi

• Ex Vacuo:

• loss of brain parenchyma → ↑ CSF spaces

Hydrocephalus

• Levene Index:

• ≤ 40 wks.

• COR image just posterior to Foramen of Monroe

• 3 Dot sign

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)

Zika: Prenatal

Summary

• Invaluable for evaluation of brain in NICU

• portable

• no radiation

• Bleeds, strokes, PVL, structural abnormalities - calcifications

• Hydrocephalus - monitoring

Spinal Ultrasound

• ≤ 4 months of age

• Anatomic Variants:

• Ventriculus Terminalis

• Filar Cysts

• Pseudomass due to clumped nerve roots

Filar Cysts

• Fusiform

• Anachoic

• Thin wall, well defined

• Immediately distal to conus

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

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

Dorsal Dermal Sinus

• Tract hypoechoic relative to SQ fat hyperechoic in CSF

• Associated Findings:

• cutaneous hemangiomata, hairy nevi

• low conus

• intraspinal lipomas, epidermoids/dermoids

Tethered Cord

• Findings:

• conus below L2-L3

• long thin conus

• posterior position of cord/filum

• ↓nerve root pulsations

Caudal Regression

Diastematomyelia

Birth Trauma

Cephalohematoma

Caput Succandeum

• Serosanguinous subcutaneous fluid collection

• Below scalp and superficial to periosteum

• Associated with moulding and over-riding sutures

Interesting Cases

Chiari II + Cervicothoracic Meningomyelocele

Cervicothoracic Meningomyelocele

Chiari II + Cervicothoracic Meningomyelocele

Terminal Myelocystocele L4 - S3 Spinal Dysraphism

Terminal Myelocystocele!L4 - S3 Spinal Dysraphism

Low conus + syrinx + meningocele + bony defect, syrinx

Omphalocele, Cloacal extrophy, Imperforate anus, 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

Abnormal Prenatal Renal Ultrasound

Zellweger Syndrome

• Cerebrohepatorenal Syndrome

• Autosomal recessive leukodystrophy

• Deficiency of peroxisomes

• Life span ≤ 1 year

Birth Trauma

Cephalohematoma

Caput Succandeum

• Serosanguinous subcutaneous fluid collection

• Below scalp and superficial to periosteum

• Associated with moulding and over-riding sutures

Contact

• http://www.slideshare.net/lembark/neonatal-cranial-spinal-sonography

• Joan K. Zawin <bariumqueen1@yahoo.com>

Neonatal Cranial & Spinal Ultrasound

Health & Medicine