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Sylke SteggerdaLeiden University Medical Center
Leiden, the Netherlands
Cranial ultrasound
posterior fossa lesionsPosterior fossa lesions in NICU
• Increasingly recognized• Mainly in preterm but also full term• Consequences for outcome
Introduction
Limperopoulos, Pediatrics 2005 & 2007; Limperopoulos Pediatr neurol 2009Volpe, J Child Neurol 2009; Brossard-Racine, Cerebellum 2015; Hortensius Pediatrics 2018
Anterior fontanel
Routine CUS windowPosterior fossa often poor
Meijler and Steggerda Neonatal Cranial Ultrasonography 2019
Ultrasound of posterior fossa
Posterior fontanel
Correa AJNR 2004; Steggerda, EHD 2009; Meijler and Steggerda Neonatal Cranial Ultrasonography 2019
Better detection small IVH and occipital WMIAlso visualization cerebellum (vermis)
Mastoid fontanel
Improves visualizationBetter detection abnormalities
Enriquez Eur Rad 2006; Steggerda, Seminars FN Med 2016 Meijler and Steggerda Neonatal Cranial Ultrasonography 2019
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Mastoid fontanelAxial (transverse) plane
28 weeks
Mastoid fontanelCoronal plane
28 weeks
33 weeks
• Preterm cerebellar injury
• Hypoxic ischemic injury
• Infections
• Other hemorrhagic lesions
Posterior fossa abnormalities
• Most hemorrhagic (CBH)
• Incidence 3-20% (large and punctate)
• Often clinically silent
• Associated with
low GA and BW
supratentorial IVH (same risk factors)
unexplained ventricular dilatation (!)
Preterm cerebellar injury
Limperopoulos, Pediatrics 2005; Volpe, J Child Neurol 2009; Steggerda, Radiology 2009; Parodi, ADC FN ed. 2015
CBH Classification
Grade 1
punctate (≤ 4mm) lesion(s)
Grade 2
limited CBH (< 1/3 hemisphere)
often lateral/inferior convexity
Grade 3
extensive CBH (>1/3 hemisphere)
often destruction and atrophy
Meijler and Steggerda, Neonatal Cranial Ultrasonography 2019; Boswinkel, Cerebellum 2019; Parodi, ADC FN ed. 2015
(MF) CUS
Grade 1 CBH
MRI at term
SWI
Early CUS
3
L
LL
Grade 2 CBH
CUS day 3 acute stage
CUS 2 wks, same patient subacute stage
R
Grade 2 CBH
Ventricular dilatation, agitation (*)
CUS 30 wks
(*) Ecury-Goossen 2010
Grade 3 CBH
CBH and subdural hemorrhage
L
*
T
MRI at termMRI 30 wks
RR
CUS 4 wks, subacute stage large CBH
Subacute CBH
Fetal CBH Rh alloimmunization
post IUT bilateral fetal CBH
delivery term age
GA 22 wks
Term age
Fetal CBH can present as
cerebellar hypoplasia
Motor and non motor (cognition, behavior, social)
Depends on size, location
• Large CBH high risk impaired outcome
• Intermediate CBH do better
• Bilateral and/or vermis, less favorable
• Punctate no effect on outcome at 2 yrs
Outcome preterm CBH
Boswinkel, Cerebellum 2019; Hortensius, Pediatrics 2018Limperopoulos, Pediatrics 2007; Brossard-Racine, Cerebellum 2015; Steggerda, Cerebellum 2013
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Perinatal asphyxia
Ischemic cerebellar and brain stem injury
GBS meningitis
Normal
Congenital CMV
Cerebellar hypoplasia
Candida
Term baby, uncomplicated delivery
Hypotonic, apnea 6 hrs pp
Subdural PF hemorrhage (often echolucent) -> emergency intervention
L
RR
Term, uncomplicated delivery, irritated, apnea
PF hemorrhage, acute hydrocephalus -> Decompresion, shunt placement
R R
5
Important diagnostic tool
• Preterm CBH
• Other conditions (HIE, infection, PF hemorrhage)
• Antenatal injury, malformations
Diagnostic performance can be optimized
• Additional windows, settings, awareness
Large, relevant abnormalities
• Majority diagnosed on (MF) CUS
Posterior fossa CUS Indications MF CUS
Infants “at risk”
• <32 weeks
• IVH (at any GA)
• Unexplained ventricular dilatation, agitation
• Perinatal asphyxia
• Suspected congenital, infectious, metabolic disorder
• Abnormal AF view
At least once in first week, repeat on indication
• Evolution of lesions, monitor cerebellar growth
All members
EurUS.brain group
Monica Fumagalli
Alessandro Parodi
Paul Govaert
[email protected]
Thanks to
