Date post: | 07-May-2015 |
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BYDR MUHAMMAD SALMAN KHAN
INFANT CRANIAL ULTRASOUND
Cranial sonography (US) is the most widely used neuroimaging procedure in premature infants.
US helps in assessing the neurologic status of the child, since clinical examination and symptoms are often nonspecific
It gives information about immediate and long term prognosis.
Advantages of Cranial Ultrasound
SafeBedsideReliableEarly imagingSerial imaging:
Brain maturationEvolution of lesions
InexpensiveSuitable for screening
Aims of Neonatal Cranial Ultrasound
Exclude/demonstrate cerebral pathologyAssess timing of injuryAssess neurological prognosisHelp make decisions on continuation of
neonatal intensive careOptimise treatment and support
Indications
Premature infants - all <1500g or <32 weeks gestation
Low APGAR score Neurologic changes Cranial dysmorphism Seizures Follow-up of hemorrhage and periventricular
leuokmalacia
Technique
Generally 5-10MHz sector transducer is used, however do not limit yourself to only one transducer.
Generally the anterior fontanel is used as acoustic window, posterior fontanel however is a good window to the occipital lobes.
Standard Views(Anterior Fontanel)
Coronal Views(at least 6 standard planes)
The Standard Coronal Planes
First coronal plane (C1) at the level of frontal lobes
First coronal plane (C1) at the level of frontal lobes
1. Interhemispheric fissure
2. Frontal lobe3. Skull4. Orbit
Second coronal plane (C2) at the level of frontal horns of the lateral ventricles
Second coronal plane (C2) at the level of frontal horns of the lateral ventricles
2.Frontal lobe5.Frontal horn of
lateral ventricle6.Caudate nucleus7.Basal ganglia8.Temporal lobe9.Sylvian fissure
Third coronal plane (C3) at the level of foramen of Monro and 3rd ventricle
Third coronal plane (C3) at the level of foramen of Monro and 3rd ventricle
2.Frontal lobe5.Frontal horn6.Caudate neucleus8.Temporal lobe9.Sylvian fissure10.Corpus callosum11.Cavum septum
pellucidum12.Third ventricle13.Cingulate sulcus
Fourth coronal plane (C4) at the level of the body of the lateral ventricle
Fourth coronal plane (C4) at the level of the body of the lateral ventricle
1.Interhemispheric fissure
8.Temporal lobe9.Sylvian fissure14.Body of lateral
ventricle15.Choroid plexus16.Thalamus17.Hippocampal fissure18.Aqueduct of Sylvius19.Brain stem20.Parietal lobe
Fifth coronal plane (C5) at the level of the trigone of the lateral ventricle
Fifth coronal plane (C5) at the level of the trigone of the lateral ventricle
8.Temporal lobe10.Corpus callosum15.Choroid plexus20.Parietal lobe21.Trigone of lateral
ventricle22.Cerebellum(a:
hemispheres; b: vermis)
23.Tentorium24.Mesencephalon
Sixth coronal plane (C6) through the parieto occipital lobes
Sixth coronal plane (C6) through the parieto occipital lobes
20.Parietal lobe25.Occipital lobe26.Parieto-occipital
fissure27.Calcarine fissure
Standard Views(Anterior Fontanel)
Sagittal Views (at least 5 standard planes)
Midsagittal plane(S3) through the 3rd and 4th ventricles
Midsagittal plane(S3) through the 3rd and 4th ventricles
10.Corpus callosum11.Cavum septum pellucidum12.Third ventricle13.Cingulate sulcus16.Thalamus22b.Cerebellum(vermis)24.Mesencephalon26.Parieto-occipital fissure27.Calcarine fissure28.Pons29.Medulla oblongata32. Cisterna quadrigemina33. Interpeduncular fossa34. Fornix
Second and Fourth parasagittal planes(S2 ,S4) through right and left lateral ventricles
Second and Fourth parasagittal planes(S2 ,S4) through right and left lateral ventricles
2. Frontal lobe5. Frontal horn of lateral
ventricle6. Caudate nucleus8. Temporal lobe14. Body of lateral ventricle15. Choroid plexus16. Thalamus17. Hippocampal fissure20. Parietal lobe21. Trigone of lateral ventricle22a. Cerebellum(hemisphere)25. Occipital lobe36. Occipital horn of lateral
ventricle
First and Fifth parasagittal planes(S1,S5) through the insulae(right & left)
First and Fifth parasagittal planes(S1,S5) through the insulae(right & left)
2. Frontal lobe8. Temporal lobe9. Sylvian fissure20. Parietal lobe25. Occipital lobe37. Insula
Posterior Fontanel as an acoustic window
Coronal view, using the PF as an acoustic window
Coronal view, using the PF as an acoustic window
8. Temporal lobe22. Cerebellum(a:
hemispheres; b: vermis)
23. Tentorium25. Occipital lobe27. Calcarine fissure29. Medulla oblongata36. Occipital horn of
lateral ventricle38. Falx
Parasagittal view using PF as an acoustic window
Parasagittal view using PF as an acoustic window
8. Temporal lobe15. Choroid plexus16. Thalamus20. Parietal lobe21. Trigone of
lateral ventricle22a. Cerebellum
(hemispheres)25. Occipital lobe27. Calcarine fissure
Germinal Matrix Hemorrhage
Far more common in premature infants Germinal matrix - highly vascular and
vulnerable to hypoxemia and ischemia, only present 24-32nd week gestation
Image 4-7 days after birth 90% of hemorrhages occur in first week of life Follow with weekly U/S to evaluate for hydrocephalus
Grade I - Confined to germinal matrix Grade II - Intraventricular without ventricular
dilatation Grade III - Intraventricular with ventricular
dilatation Grade IV - Periventricular hemorrhagic
infarction
Periventricular Leukomalacia (PVL)
5-10% of premature infants Infarction of deep white matter Occurs in the watershed zone in infants,
adjacent to trigone of the lateral ventricles Seen as increased echogenicity (greater than
choroid plexus)
Often missed with ultrasound, serial exams increase sensitivity
May get cystic changes in 2-3 weeks Symptoms: spastic diplegia, intellectual
deficits
Vein of Galen Malformation
Fistulous connection - cerebral arteries and midline prosencephalic vein
2 types: Choroidal - 90%, presents in neonate as CHF
and intracranial bruit Mural - presents in infancy with developmental
delay, seizures, and hydrocephalus
Congenital Absence of the Corpus Callosum
80% have associated anomalies Parallel lateral ventricles Elevated 3rd ventricle Absent cingulate gyrus and sulcus “Sunburst sign” - radially arranged sulci Probst bundles impress upon lateral
ventricles
Chiari II Malformation
Batwing configuration of frontal horns Small posterior fossa with low-lying
tentoriumInterdigitating gyri Large massa intermedia Absence of corpus callosum Hydrocephalus Nearly 100% have myelomeningocele
Dandy Walker Malformation
Posterior fossa cyst which communicates with 4th ventricle (arachnoid cyst and enlarged foramen magnum do not)
Large posterior fossa Hypoplastic cerebellar vermis and laterally
displaced cerebellar hemispheres Frequently associated with other anomalies
Temporal lobe arachnoid cyst
Most common intracranial congenital cystic lesion
Can have mass effect and bony remodeling Same appearance as CSF on all imaging
modalities
Corpus Callosum Lipoma
Associated with dysgenesis of the corpus callosum
May involve any part of the corpus callosum or be pericallosal in location
Semilobar Holoprosencephaly
Hypoplastic falx and interhemispheric fissurePartially separated thalamus Intermediate in severity between alobar and
lobar holoprosencephaly Can have associated facial anomaly
Lissencephaly
Lack of gyration and sulcation Thickened cortex Colpocephaly Homogeneous or “pseudoliver” appearance
to the brain parenchyma “Figure eight appearance” due to shallow
sylvian fissures Can result from intrauterine infection
Thanks