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27 1

C rib s id e N eu roson og rap hy :R ea l-T im e S on og raphy fo r In trac ran ia lIn ves tig a tion o f th e N eona te

M ary K . E dw ard s1D av id L . B row n1

Jan s M u lle r2C ha rle s B . G rossm an1G onza lo T . C hua1

R ece ive d April 10 , 1980 ; a ccep ted a fte r rev i-s ion Ju ly 8 , 1980 .

D epa rtm en t o f R ad io lo gy , M eth od is t H osp ita lGradua te Medical Center, 1604 N . C ap ito l A ve .,In d ia na po lis , IN 47206 . A ddres s rep rin t requ es tst o M . K . E dw ar ds .

2Depa rtm en t o f N eu rop a tho log y , Ind ian a U n i-ve rs ity S ch oo l o f M ed ic in e . Ind ian apo lis , IN46202.

T h is a r tic le ap pe ars in N ovem be r/D ecem be r1980 AJNR an d F eb ru ary 1 98 1 AJR .AJ R 136:271-276, Feb ru a ry 19 810361 - 8o3x/81 /1 362-0271 $0 0.00 Am er ica n Roen tg en R ay So c ie ty

A p ro sp ec tive s tud y w as m ad e o f 94 rea l-tim e so n o g rap h ic s ec to r s can s o f 56neona te s in a 6 m on th pe rio d . T he exam ina tio ns w ere pe rfo rm ed u s ing the an te rio rfo n tane lle a s an aco u st ic w in d o w . In 1 7 cases , co m pu ted to m o g rap h y (C T ) h ead scan sw ere ava ila b le fo r co m p ar iso n . In n o case d id th e C T an d so n o grap h ic e xam in a tio nd is agre e as to th e s ize o f th e la te ra l v en tr ic le s . A b n o rm a lit ie s d e te c ted b y so n o g rap hyin c lu d e ven tr icu lo m eg a ly , in tra ce reb ra l h em a to m as , a co n g en ita l g lio m a, and seve ra lc ys tic le s io n s . S o n o g rap h ic s ec to r s can n in g p rod u ces exce lle n t, d e ta iled im ag es o fd ila te d la te ra l a n d th ird ve n tric les , u ses no ion iz in g rad ia tio n , is less e xpen s iv e th a nC T , an d can b e per fo rmed in th e iso le tte , m in im iz ing th e risk o f h ypox ia and h ypo the r-m ia . A t M e th o d is t H o sp ita l G rad u a te M ed ic a l C en te r, so n o g rap h y h as rep lac ed C T asth e in it ia l m etho d o f in v es tig a tio n o f ven tr ic u la r s ize . C T p la ys a co m p lem en ta ry ro le inth e eva lua tio n o f th e p o ster io r fo s sa , in tra c ran ia l h em o rrh ag e , an d m ass le s io n s .

S in ce the firs t rep o rt o f th e c lin ic a l a pp lica tio n o f e choen cepha log ra ph y in1 956 [1 1. the re h a s been m uch in te res t in th e sonog ra ph ic d em ons tra tio n o fin tra c ra n ia l pa tho lo g y [2 , 3 ]. R ecen t a dvan ces in so nograph ic te ch no lo g y havep rodu ced h ig h reso lu tio n con ta c t sca nne rs a nd the O c ta son , a n au tom a ted w a te rd e lay scanne r [1 , 4 , 5 ]. T h ese in s tru m en ts p ro d u ce im ag es o f the neo n a ta lin tra c ra n ia l c on ten ts w ith su ffic ien t de ta il to pe rm it a ccu ra te e va lu a tion o f v en tri-cu lom ega ly a nd ce r ta in o the r in tra c ra n ia l les io ns [1 , 4 -6 ]. T he deve lo pm en t o f acom pac t tra nsdu ce r h ead fo r w id e -a ng le rea l-t im e sec to r s ca nn in g (ATL re a l-t im e d ig ita l s canner) ha s pe rm itte d the use o f th e an te rio r fon tan e lle a s ana cou s tic w ind ow . S in ce th e sonog ra ph ic b eam is n o t a tte nua te d b y th e sku ll, ac lea r d em ons tra tion o f in tra c ra n ia l a na tom y is a ch iev ed [6 -8 ]. In th is pape r, w edesc rib e ou r in it ia l e xpe rien ce w ith rea l-tim e sonog ra ph ic sec to r s cann in g in thein tra c ra n ia l in ves tiga tio n o f n eona tes and in fa n ts less th an 1 year o f ag e .

Sub jects and M e thodsA p rospe c tiv e s tud y w as m ade o f 9 4 sonogram s in 5 6 neona te s and in fa n ts d u rin g a 6

m on th pe rio d . S e ve ra l n eona te s w ith a bnorm a l sc an s w e re re exam ined a t 1 w eek to 1m on th in te rv a ls to m on ito r ve n tricu la r s ize , p a r ticu la rly a fte r ve n tricu lop e rito nea l s hun tp lacem en t. T h e age o f the pa tie n ts w a s 1 da y to 1 1 m on th s . C om pu ted tom ogra phy (C T )scans we re ava ila b le fo r com par iso n in 1 7 cases . T he C T scanne r used was an EM I 1005ded ica te d head un it w ith a 60 sec scann in g tim e . T he sonog raph ic s canner w as an ATLrea l-t im e d ig ita l sc anne r w ith a 5 M H z tran sduce r p ro du c ing 900 sec to r im age s . T hecom pac t, 3 cm d iam e te r tra nsdu ce r head w as ea sy to m an ip u la te a nd th e scann in gte chn iqu e was re la tive ly e a sy to le a rn . M u ltip le v iew s o f th e ven tric les w ere ob ta in ed in theco rona l a n d sag itta l p ro jec tion s th rou gh th e an te rio r fon tan e lle . W hen po ss ib le , a dd ition a lv iew s th rou gh th e po s te rio r fo n ta ne lle w e re ob ta ine d to b e tte r dem ons tra te th e po s te rio rfo ssa . T he m ax im um tim e requ ire d fo r the e xam in a tion was 5 mm . The sonogram s we reob ta ine d in th e iso le tte , a n d w hen necessa ry , the scans w ere ob ta ine d by p la c in g th etran sduce r th rou gh th e a rm po rtho le o f the is o le tte p rese rv ing a cons ta n t tem pe ra tu re a ndo xy ge n c on ce ntra tio n.

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A B

F ig . 1 -S can n ing ang les in sag itta l (A ) co rona l (B ) p lanes.

A B

C

27 2 EDW ARDS E T AL. AJR:13 6, Februar y 1981

D

The scans we re in te rp re ted as pos itive fo r h yd rocepha lu s if thela te ra l v en tricu la r ra tio w as g rea te r th a n 0 .3 0 . T he la te ra l v en tricu la rra tio is d e fin e d a s the ra tio o f the w id th o f th e la te ra l v en tric les toth e g re a te s t in te rn a l d iam e te r o f th e c ra n ia l cav ity [2 ]. S e ve ra lau tho rs ha ve u sed th is m easurem en t to eva lu a te fe ta l an d neona ta lv en tricu la r s ize [2 , 5 , 6 , 9 , 1 0 ]. A lth ough th e se c to r sca n is lim itedto a 9O a rc , th e re w as no d ifficu lty m easuring the d iam ete r o f thecra n ia l ca v ity o r th e w id th o f the la te ra l ve n tric les . T he ave ra gela te ra l ve n tricu la r ra tio is re po rted a s 0 .25 a t te rm , the 99% upperlim it o f co n fide n ce m easu rem en t is 0.29 [2 ]. B ecau se the earlie s td ila ta tio n o f th e ven tr ic le fre quen tly ap pea rs in th e a tria o f th e la te ra lven tricles [5, 6], a scan was interpr eted a s cons is ten t w ith m in im a lo r b o rde rlin e ven tric u la r d ila tio n if th e a tria o f the la te ra l ve n tr ic le

w e re d ila te d even th ough th e fron ta l ho rn s o f th e la te ra l v en tric lesw e re no t.

S cans w e re ob ta ine d th ro u gh th e fo n ta ne lles a t v a riou s ang les toth e m idsag itta l a nd co ro na l p la ne s . F igu re 1 illu s tra te s the scann ingang le s u sed . B e cause s im ila rly a ng le d im ages ha ve no t b een re -p o r te d p rev iou s ly , sec tion s w ere ob ta ine d o f n o rm al ne ona ta l b ra in sfrom au to ps y spe c im en s fo r co rre la tio n w ith th e scan s . B e causeven tricu la r an a tom y is m ore c le a rly dem ons tra te d in scans o f in fa n tsw ith ven tric u la r d ila tio n tha n o f n o rm a l in fa n ts , la be led sca ns froman in fa n t w ith m ode ra te ven tricu lom ega ly a re com pare d w ith th enorm a l a u to ps y spec im ens in fig u res 2 and 3 .Resu l ts

V en tricu la r e n la rgem en t w a s d iag nosed in 2 1 neona te s .CT co rre la tio n was a va ila b le in 1 7 ca se s and in no ca se d idso nography and C T d isag re e as to th e deg ree o f ven tric u -lom ega ly . G ene ra lly , s onogra ph y dem ons tra te d g re a te r d e -ta il o f th e v en tricu la r s ys tem than d id C T . In th e p re sen ce o fve n tricu la r e n la rgem en t, m any s tru # {2 28 }tu res p rev io us ly u nde -tec te d o r p oo rly v is ua lize d by sonog ra ph y o r C T can rou -tine ly b e seen , in c lu d in g th e an te rio r rece sses o f the th irdv en tric le , th e m assa in te rm ed ia , the fo ram in a o f M on ro , ite r,an d the sup ra p ine a l re ce ss . In th e no rm a l n e ona te th even tric le s a re fre quen tly s lit like s truc tu re s and less ana tom icd e ta il is d em ons tra ted [4 ]. T h e dem ons tra tion o f po s te rio rfoss a s tru c tu res and the b ra in s tem is le ss s a tis fa c to ry , a ndth e fo u rth ven tric le is ra re ly s een even in th e p re sence o fv en tricu la r d ila tio n .

F ig . 2 .-A , M id lin e sa g itta l sc an o fm odera te ly h yd rocep ha lic ne on a te . B ,Sag itta l b ra in sectio n o f n o rm a l ne ona te .a = c in gu la te su lcu s , b = co rp us ca l-lo sum , c = m assa in te rm ed ia , d = an -te no r rece sses o f th ird ven tric le . Sa g it ta lscan (C) and brain section (D) ang ledla te ra lly . a = cho ro id p lexus, b = t em -p o ra l h o rn , c = a trium , d = occ ip i ta lhorn .

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CR IBS ID E N EUROSONOGRAPHY 273

4 5A 5BFig . 4 .-V en tric u la r ban d ( a r r ow ) in bo dy o f la t-

e ra l v e nt ri cl e.

TA BLE 1 : S onog ra ph ic F ind in gs

F ig . 5 .-A , La rge re trosy lv ia n co llec tion o f so lid echoes ( a r r ow ) be lie ve d to rep resen t in tra ce reb ra lhem atom a in in fan t w ith d is sem ina ted in tra vas cu la r co ag u lo pa thy . B , La rge hem atom a fo und a t au top sy .

Abnorma l i ty (n NO .

No rma l 33Ven tr icu lomega ly . . . 21Ven tr icu la r b a nd . . 2Po re ncepha lic c ys t . . . 2In tra ve ntricu la r he ma tom a . . . . . 2Subara chno id cys t . 1Gl ioma .. . ... 1I nt ra ce re br al h em at om a . . 1

To ta l . 63

A lth o ugh th e p r im a ry a im o f so nography w as th e e va lua -tion o f ve n tricu la r s iz e , o the r abno rm a lit ie s w e re oc cas io n -a lly reco gn ized (tab le 1 ). The se inc lu de subarachno id cys t,po re ncepha lic cys t, an d ven tricu la r ba nds (fig . 4 ). In th re epa tie n ts la rg e co lle c tio ns o f so lid ec hoes w ere dem ons tra te din th e ce reb ra l hem isphe res .

The firs t, a ch ild w ith d issem ina ted in trav ascu la r co agu-lo pa thy and a rap id ly de te rio ra tin g cou rse w as fo u nd toha ve a la rg e le ft p a rie too cc ip ita l c o lle c tio n o f so lid echoes(fig . 5 ). Th e les io n was in te rp re te d a s an in trace re b ra l he -m a tom a . A m id lin e sh ift to the rig h t w as dem ons tra ted a sw e ll a s m a rke d d ila tio n o f the rig h t la te ra l ven tric le . A t

A JR :1 36 , F eb ru ary 1981

Fig . 3 .-C orona l scan (A ) a nd b ra inse ction (B ) a t leve l o f fo ram ina o f M onro .a = tha lam us , b = th ird ven tric le , c =c in gu la te su lc us , d = c orp us ca llo su m,e = se p tum pe lluc id ium , f = cauda tenuc leu s , g = s y lv ian fissu re . C o ro na lsca n (C ) a nd bra in se c tio n (D ) a t lev e l o fmassa in te rm ed ia . a = l at er al v en tr ic le ,b = m as sa i nt er me di a, c = h ippocam-pus .

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F ig . 6 .-A , La rge fron ta l m ass w ith ce n tra l f lu id e cho es (ar row) . B , H e m o rr h ag e wIth in mass (ar row) . F ig . 7 .-La rge so lid hem a tom as (ar rows) inGlioma was rem oved a t s u rg e ry . la te ra l and th ird ven tric les. H ippocam pus ( a r r ow -

head ) .

27 4 EDW ARDS ET AL . AJR:1 36, Februar y 1981

au topsy 2 days la te r a m ass ive in tra ce reb ra l hem a tom a wasfou nd as w e ll a s d ila ta tion o f th e righ t la te ra l v en tric le . T h esecond pa tien t, an in fan t w ith fo ca l se izu res bu t appa ren tlyo the rw ise no rm a l, w as fo u nd to h ave a la rg e so lid m ass inthe le ft fron ta l reg ion w ith a m id line sh ift to the r igh t (fig . 6 ).T he m ass con ta ined cen tra l flu id echoes . N o hyd rocepha lusw as dem onstra ted . A t su rge ry a la rge hem o rrhag ic g liom aw ith a necro tic cen te r w as rem oved . A co llec tion o f so lidechoes was found in the la te ra l v en tric le s o f a th ird in fan tco rre spond ing to la rge in tra ven tricu la r hem a tom as (fig . 7 ).

Discuss ionM any au tho rs h ave rec en tly dem ons tra te d th e va lue o f

sonog raphy in the eva lua tion o f neona ta l in tra c ran ia l pa -tho logy [4 -6 , 8 ]. T he O ctason scann ing sys tem us ing awa te r tank and an a rray o f e igh t sonog raph ic transduce rscan p roduce c lea r im ages o f the in tra cran ia l c on ten ts inseve ra l ang le s as w e ll a s the usua l CT p lane [4 ]. T heneona tes m ust be transpo rted to the rad io logy depa rtm en tand rem oved from the ir is o le tte s fo r the ir O ctason exam i-na tion . C on tac t sonog raph ic s cann ing has been fo rm e rlylim ited by the poo r transm is s ion o f the sonog raph ic beamth rough the sku ll and the d ifficu lty ob ta in ing good trans -duce r coup ling to the irregu la r ly shaped su rfa ce o f the head[4 , 6 ]. The deve lopm en t o f a com pac t transduce r headp rim arily de s ign ed fo r re a l-t im e ca rd ia c scann ing has per-m itted the use o f the fon tane lle s as acous tic w indow s in theneona te . T he scans a re lim ited to a 90 0 p ie -shaped im age ,bu t th is is no t a se r ious d isadvan tage s in ce the transduce rcan eas ily be ang led to im age the en tire ce reb ra l convex ity .

In tra ven tricu la r and suba rachno id hem o rrhage is a com -m on p rob lem in p rem a tu re in fan ts , and has been repo rtedin one -th ird to one -ha lf o f in fan ts we igh ing le ss than 2 ,000g a t b irth [4 , 11 ]. B ecause a ll flu id co lle c tions appea r ass im ila r cy s tic spaces on sonog raphy , hem o rrhage in to theflu id -fi lle d ven tr ic le s canno t be de tec ted un less the hem o r-rhage has deve loped in to a so lid hem a tom a . Tw o in fan ts inou r se r ie s w ith no rm a l sonog ram s w e re found to have in tra -c ran ia l hem o rrhage on C T . T he re fo re , C T is m o re accu ra te

th an sonog raph y in th e de tec tion o f re ce n t in trac ran ia l hem -o rrhage [1 1 ]. C omm un ica ting hyd rocepha lus , a frequen tcom p lica tion of in tra c ran ia l hem o rrhage , can be m onito redw ith accu racy by e ithe r CT o r sonog raphy , bu t sonographyis p re fe rre d a t ou r in s titu tio n in the fo llow -up o f in tra c ra n ia lhem o rrhage [1 2 ].

S onog raphy has been success fu l in the d iagnos is o f cys ticle s ion s such a s D and y-W a lke r cys t, p o re n cepha lic cys t,su bdu ra l h em atom a , subdura l h yg rom a , and hem o rrh age[4 ]. O u r s er ie s in c lu d es severa l in fan ts w ith s im ila r ab n o r-m a lit ie s , inc lud in g tw o in fa n ts w ith po re ncepha lic cy s t, tw ow ith ven tr ic u la r bands , and one w ith a suba rachno id cys t.T he use fu lness o f the sonog raphy is no t lim ited to theeva lua tion o f flu id co lle c tions , w h ich is illu s tra ted by theth ree in fan ts w ith la rge in tra ce reb ra l co lle c tions o f so lidechoes .

In summ ary , c ribs ide sonog raph ic sec to r scann ing o ffe rsm any advan tages in the eva lua tion o f neona ta l in tra cran ia lpa tho logy . B ecause sonog raphy p roduces c lea r, de ta iledim ages o f the d ila ted th ird and la te ra l v entr ic le s , a ccu ra teeva lua tion o f ven tr ic u la r s iz e can be pe rfo rm ed qu ick ly a tthe cr ib s ide w ithou t ion iz ing rad ia tion and a t le ss expensethan C T . A t ou r in s titu tion sonog raphy has been used as thep rocedu re o f cho ice in the screen ing o f neona tes w ithsuspec ted ven tricu la r en la rgem en t, pa rticu la r ly those w ithan en la rg ed o cc ip ita l fro n ta l c irc um fe re nce . If ve n tricu la ren la rgem en t is de tec ted w ith sonog raphy , and the in fan tscond ition pe rm its , the ch ild is usua lly then taken to therad io logy depa rtm en t fo r a C T scan in an attem p t to de te r-m ine the e tio logy o f the ven tr ic u la r en la rgem en t. S onog ra -phy is gene ra lly used fo r subsequen t exam ina tions .

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c om p lica tio ns fo llow in g head in ju ry . A cta C h ir S cand1956 ;110 :301 -315

2 . D enkhaus H , W insbe rg F . U ltrason ic m easu rem en t o f the fe ta lv en tric ula r s ys te m. Rad io logy 1 97 9; 1 3 1: 78 1- 78 7

3 . K os so ff G , G a rre tt W J , R ada vano v ic h G . U ltra so n ic a tla s o fn o rm al b ra in o f in fa n t. U ltraso und M ed B io l 1 9 7 4;1 :2 59 -2 66

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4 . H abe r K , W ach ter AD , C h ris tenson PC , V auche r Y , S ahn DJ ,Sm ith JR . U ltra son ic eva lua tion o f in tra cran ia l pa tho logy inin fa nts : a n ew te ch niq ue . Rad io logy 1980 ;1 34 :173 -178

5 . John son M L , M ack LA , A um ack CM , F ro s t M , R ashbaum C . B -m ode echoencepha log raphy in the no rm a l and h igh risk in fan t.AJR 1979 ;133 :375 -381

6 . S ko ln ick M L, R o senbaum AE , M a tz uk T , G u thke lch AN , H e in zE R . D e te c tio n o f d ila te d ven tric les in in fa n ts ; a co rre la tive s tu dybe tween u ltra sound and com pu ted tom og raphy . Rad io logy1 97 9;13 1 :4 47 -4 51

7 . B en-O ra A , E ddy L , H a tch G , S o lida B . The an te rio r fon tane lleas an a cous tic w in dow to th e neona ta l ve n tricu la r sys tem . JC UI 980 ;8 :65 -67

8 . B abco ck DS , H an B K , LeQ uesne GW . B -m ode g re y sca le

u ltras ound o f th e head in the new born and young in fa n t. A JR1980 ;1 34 :457 -468

9 . Hahn FJ, R im K . F ron ta l ven tricu la r d im ens ions on no rm a lc om pu te d to m og ra ph y. AJR 1 9 7 6 ;1 2 6: 59 3- 59 6

10 . G a rre tt W J, K osso ff G . G rey sca le exam ina tion o f the b ra in inch ild ren . In : W hite D , B row n RE , eds . U ltras ound in m ed ic in e ,vo l 3A . c lin ica l a sp ec ts . N ew Y ork : P lenum , 1977 :821 -828

11 . Pevsne r PH , G a rc ia -B unue l A , Leeds N , F inke ls te in M . S ub -epend ym al a nd in tra ve n tric u la r h em orrha ge in n eona tes . R a-d io logy 1976;119 :111 -114

12 . G arre tt W J, K osso ff G , Jones AF . U ltra son ic c ross-sec tiona lvisualization o f hyd rocepha lus in in fan ts . Neuro rad io logy1975;8 :279 -288