Review of ultrasound images of the cranium and spine in neonatal patients with a variety of specific conditions.

1. Neonatal!
Cranial & Spinal
Sonography
Joan K. Zawin, M.D.
bariumqueen1@yahoo.com

2. Indications for HUS
• Prematurity
• ↑ Head circumference
• Persistent large
fontanelle
• Craniosynostosis
• ECMO
• Hypoxia
• FTT
• Mass
• Intracranial infection
• Trauma

3. Limitations of HUS
• Small acoustic window
• Cannot assess myelination
• Diffuse white matter injury
• Cerebellar lesions, infarctions, small isolated
IVH - can be missed
3

4. 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
4

5. 5

6. 6
Auckland District Health Board www.adhb.govt.nz/.../
NeonatalHUSSViews.htm

7. 7

8. 8

9. 9

10. 10

11. 11

12. 12

13. 13

14. Normal Gray - White Matter

15. 15

16. 16

17. 17

18. 18

19. 19

20. 20

21. 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
21

22. Choroid Plexus

23. Split Choroid Sign

24. Choroid Plexus Cysts
• Common, 3% prevalence
• Glomus
• < 1 cm, unilateral = insignificant
• > 1cm, bilateral = ↑ assoc. with
chromosomal abnormalities
24

25. 25

26. 26

27. Midline Cystic
Structures
• Communicate with each other
• Do not communicate with ventricular
system or subarachnoid spaces
• Obliterated from posterior ➞ anterior
• Can persist into adulthood

28. Cavum Septum
Pellucidum
• Between frontal horns
• Anterior to foramen of
Monroe
• Usually closes 2-6
months after birth

29. Cavum SeptumVergae
• Between bodies of
lateral ventricles
• Posterior to foramen of
Monroe
• Begins to close at 6 mos.
gestation
• 97% closed at birth

30. 30

31. CavumVeli Interpositi
• Posterior extension of
CSV
• Posterior to
quadrageminal plate
cistern - pineal gland
• Only seen in very
premature newborns
• Helmut - shaped

32. 32

33. 33

34. Absent Septum
Pellucidum

35. 35

36. 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
36

37. Normal Caudothalamic
Groove

38. 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
38

39. 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
39

40. Intracranial
Hemorrhage in
Premature Newborns
• Impaired autoregulation ➟ pressure passive
circulation
40

41. Causes of ICH in
Premies
• Systemic ↑ BP
• [↑P CO2, ↓Hb, ↑ intravascular vol]
• Increased CNSVenous Pressure
• asphyxia, tension PNTX, CHF, mechanical
ventilation, tracheal suctioning
• Decreased CNS Perfusion
41

42. Screening
asx
<1,000 gm
day 3-5
day 10-14
day 28
asx
1,000 - 1250
gm
day 3-5
day 28
asx
1,251 - 1,500
gm
day 3-5
Prior to discharge
42

43. 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
43

44. Grade IV Hemorrhage
• Venous hemorrhagic infarction secondary
to venous outflow compression
44

45. Grade I

46. Bilateral Grade I

47. Grade I vs. Normal

48. Grade I vs. Normal

49. Rt Grade II

50. Grade II vs. Normal

51. Grade III

52. Grade IV

53. Grade IV

54. Rt IV, Day 3

55. Left II, Right I Hemorrhages

56. Grade I vs. II?

57. Grade I vs. II?

58. 58

59. 59

61. 61

62. 62

63. 63

64. 64

65. 65

66. Rt IV+ Lt II, Day 3

67. Rt IV + Lt II, Day 3

68. Rt IV + Lt II, 9 wks.

69. Rt IV + Lt II, Day 0

70. Rt IV + Lt II, Day 6

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

72. Rt IV + Lt II, 6 wks

73. Hemorrhagic Infarcts

74. Temporal Hemorrhage

75. Bilateral Cerebellar Bleeds

76. Bilateral Parietal Infarcts

77. Bilateral Parietal Infarcts

78. Bilateral Parietal Infarcts!
7 wks.

79. Bilateral Parietal Infarcts

80. 80

81. Connatal Cysts
• Normal variant; incidence = 0.7%
• Lateral to frontal horns
• Anterior to Foramen of Monroe
• “String of Pearls”
• Resolve spontaneously

82. 82

83. String of Pearls

84. Caudothalamic Groove
Cysts
• Congenital:
• Germinolytic
• chromosomal, metabolic, incidental
• Acquired:
• Subepdendymal
• post-hemmorahgic

85. Germinolytic Cysts:!
Zellweger Syndrome

86. Zellweger Syndrome
• Cerebrohepatorenal Syndrome
• Autosomal recessive leukodystrophy
• Deficiency of peroxisomes
• Life span ≤ 1 year
86

87. Zellweger Syndrome

88. Resolving Grade I

89. Germinolytic vs. Connatal
Cysts

90. Germinolytic vs. Connatal
Cysts

91. Colloid Cyst

92. Colloid Cyst

93. Periventricular
Leukomalacia
• #1 ischemic brain injury in preemies
• <32 wks, <1500 g
• Vulnerable oligodendocyte precursors
• Echogenic periventricular white matter:
• normal “flaring”
• transient edema
93

94. Periventricular
Leukomalacia
• 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
94

95. 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
95

96. PVL vs. Grade IV Bleed
• PVL:
• No mass effect
• Multiple small cysts
• Grade IV hemorrhage:
• Mass effect
• Larger porencephalic cysts
96

97. Normal Periventricular White
Matter

98. Normal Periventricular White
Matter

99. Bilateral PVL

100. PVL vs Normal

101. Bilateral PVL

102. Bilateral Cystic PVL

103. Periventricular Leukomalacia
Day 0 7 Weeks

104. Periventricular Leukomalacia

105. Periventricular Leukomalacia

106. Periventricular Leukomalacia

107. Periventricular Leukomalacia

108. Periventricular Leukomalacia

109. Periventricular Leukmalacia

110. Periventricular Leukomalacia

111. Cerebral Edema
• ↑ Parenchymal echogenicity
• ↓ Sulcal/gyral differentiation
• ↓Vascular pulsations
111

112. 112

113. 113

114. Ischemic Event, Day 22

115. Ischemic Event Day 22!
6 wk. F/U

116. Perivascular
Mineralization
• TORCH
• Trisomies(21 and 13)
• Twin-twin transfusion
• Fetal ETOH or cocaine exposure
• Neonatal asphyxia
• Chronic hypoxia - cardiopulmonary
116

117. Perivascular
Mineralization
• Lenticulostriate arteries
• Can develop and progress after birth
• Unilateral or bilateral
• Punctate or linear
117

118. 118

119. 119

120. 120

121. Lenticulostriate
Vasculopathy

122. Agenesis Corpus Callosum

123. Agenesis Corpus Callosum
vs. Normal

124. Agenesis Corpus Callosum
vs. Normal

125. Agenesis Corpus Callosum

126. Agenesis Corpus Callosum

127. 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

128. 128

129. 129

130. 130

131. Vein of Galen Malformation

132. Vein of Galen Malformation

133. 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
133

134. 134

135. Classic Dandy Walker
• Vermian hypoplasia
• Cystic dilatation posterior fossa
communicating with IV vent
• Enlarged posterior fossa
• Tocular-lambdoid inversion

136. 136

137. 137

138. 138

139. 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

140. 140

141. 141

142. Retro-cerebellar Arachnoid
Cyst

143. Retro-cerebellar Arachnoid
Cyst

144. Benign Hygroma of
Infancy
• Children 6 mos. - 2 yrs.
• Head circumference > 97th percentile
• Cause unknown, familial?
• Subarachnoid spaces > 3.3mm
• +/- slight ventricular enlargement
144

145. 145

146. 146

147. Prominent Subarachnoid
Spaces

148. Hydrocephalus
• Obstructive: (non-communicating)
• most common
• CSF cannot enter subarachnoid space
• Aqeductal stenosis, Chiari Malformation,
Dandy - Walker
148

149. Hydrocephalus
• Non-obstructive: (communicating)
• impaired CSF resorption
• infection, hemorrhage, congenital abs.
arachnoid villi
• ExVacuo:
• loss of brain parenchyma → ↑ CSF
spaces
149

150. Hydrocephalus
• Levene Index:
• ≤ 40 wks.
• COR image just posterior to Foramen of
Monroe
• 3 Dot sign
150

151. 151

152. 152

153. 153

154. 154

155. 155

156. NormalVentricular
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)
156

157. Zika: Prenatal

158. Zika: Prenatal

159. Summary
• Invaluable for evaluation of brain in NICU
• portable
• no radiation
• Bleeds, strokes, PVL, structural
abnormalities - calcifications
• Hydrocephalus - monitoring
159

160. Spinal Ultrasound

161. 161

162. 162

163. 163

164. Spinal Ultrasound
• ≤ 4 months of age
• AnatomicVariants:
• Ventriculus Terminalis
• Filar Cysts
• Pseudomass due to clumped nerve roots
164

165. 165

166. 166

167. 167

168. 168

169. Filar Cysts
• Fusiform
• Anachoic
• Thin wall, well defined
• Immediately distal to conus
169

170. 170

171. 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
171

172. 172

173. 173

174. 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
174

175. Dorsal Dermal Sinus
• Tract hypoechoic relative to SQ fat
hyperechoic in CSF
• Associated Findings:
• cutaneous hemangiomata, hairy nevi
• low conus
• intraspinal lipomas, epidermoids/
dermoids
175

176. 176

177. 177

178. 178

179. 179

180. 180

181. 181

182. 182

183. Tethered Cord
• Findings:
• conus below L2-L3
• long thin conus
• posterior position of cord/filum
• ↓nerve root pulsations
183

184. 184

185. 185

186. 186

187. 187

188. 188

189. 189

190. 190

191. 191

192. Caudal Regression
192

193. 193

194. Diastematomyelia
194

195. 195

196. Birth Trauma
196

197. 197

198. Cephalohematoma

199. 199

200. 200

201. 201

202. Caput Succandeum
• Serosanguinous subcutaneous fluid
collection
• Below scalp and superficial to periosteum
• Associated with moulding and over-riding
sutures
202

204. Interesting Cases
204

205. Chiari II + Cervicothoracic
Meningomyelocele

206. Cervicothoracic
Meningomyelocele

207. Chiari II + Cervicothoracic
Meningomyelocele

208. Chiari II + Cervicothoracic
Meningomyelocele

209. Chiari II + Cervicothoracic
Meningomyelocele

210. Chiari II + Cervicothoracic
Meningomyelocele

211. Chiari II + Cervicothoracic
Meningomyelocele

212. Terminal Myelocystocele
L4 - S3 Spinal Dysraphism

213. Terminal Myelocystocele!
L4 - S3 Spinal Dysraphism

214. 214
Low conus + syrinx + meningocele + bony
defect, syrinx

215. Omphalocele, Cloacal extrophy,
Imperforate anus, Terminal Myelocystocele

216. OEIS - Terminal
Myelocystocele

217. OEIS - Terminal
Myelocystocele

218. OEIS - Terminal
Myelocystocele

219. OEIS - Terminal
Myelocystocele

220. Summary
• Portable, no radiation
• Static and dynamic information
• Limited window of opportunity
• < 4 months of age

221. Joan K. Zawin, MD!
bariumqueen1@yahoo.com

222. Twin - Twin Transfusion
Recepient
222

223. 223

224. 224

225. 225

226. 226

227. 227

228. 228

229. 229

230. 230

231. 231

232. ECMO
232

233. 233

234. 234

235. 235

236. 236

237. 237

238. 238

239. 239

240. Abnormal Prenatal
Renal Ultrasound
240

241. 241

242. 242

243. 243

244. 244

245. 245

246. Zellweger Syndrome
• Cerebrohepatorenal Syndrome
• Autosomal recessive leukodystrophy
• Deficiency of peroxisomes
• Life span ≤ 1 year
246

247. Birth Trauma
247

248. 248

249. 249

250. Cephalohematoma

251. 251

252. 252

253. Caput Succandeum
• Serosanguinous subcutaneous fluid
collection
• Below scalp and superficial to periosteum
• Associated with moulding and over-riding
sutures
253

255. Contact
• http://www.slideshare.net/lembark/
neonatal-cranial-spinal-sonography
!
• Joan K. Zawin
<bariumqueen1@yahoo.com>
255