Overview of anatomy and common abnormalities of the neonatal head, brain, and spine.

1. NEONATAL CRANIAL
SONOGRAPHY
Joan K. Zawin, M.D.
Cardinal Glennon Children’s Medical
Center
Saturday, April 21, 2012

2. Indications for HUS
• Prematurity • Hypoxia
• ↑ Head • FTT
circumference
• Mass
• Persistent large
fontanelle • Intracranial infection
• Craniosynostosis • Trauma
• ECMO
Saturday, April 21, 2012

3. Limitations of HUS
• Small acoustic window
• Cannot assess myelination
• Diffuse white matter injury
• Cerebellar lesions, infarctions, small isolated
IVH - can be missed
3
Saturday, April 21, 2012

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
• Transtemporal
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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
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25. Choroid Plexus Cysts
• Common, 3% prevalence
• Glomus
• < 1 cm, unilateral = insignificant
• > 1cm, bilateral = ↑ assoc. with
chromosomal abnormalities
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26. 26
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28. Midline Cystic
Structures
• Communicate with each other
• Do not communicate with ventricular
system or subarachnoid spaces
• Obliterated from posterior ➞ anterior
Saturday, April 21, 2012

29. Cavum Septum
Pellucidum
• Between frontal
horns
• Anterior to foramen
of Monroe
• Usually closes 2-6
months after birth
Saturday, April 21, 2012

30. Cavum Septum Vergae
• Between bodies of
lateral ventricles
• Posterior to foramen
of Monroe
• Begins to close at 6
mos. gestation
• 97% closed at birth
Saturday, April 21, 2012

31. 31
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32. Cavum Veli Interpositi
• Posterior extension
of CSV
• Posterior to
quadrageminal plate
cistern - pineal gland
• Only seen in very
premature newborns
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35. Absent Septum
Pellucidum
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37. 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
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40. 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
40
Saturday, April 21, 2012

41. 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
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Saturday, April 21, 2012

42. Intracranial
Hemorrhage in
Premature Newborns
• Impaired autoregulation ➟
pressure passive circulation
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43. 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
• ↓ Hb, ↓PO2, systemic hypotension
43
Saturday, April 21, 2012

44. Screening
day 3-5
asx
day 10-14
<1,000 gm
day 28
asx
day 3-5
1,000 - 1250
day 28
gm
asx
day 3-5
1,251 - 1,500
Prior to discharge
gm
44
Saturday, April 21, 2012

45. Papile Classification
Grade I 40% GMH only
Grade II 25% GMH + IVH
Grade III 20% GMH + IVH + ↑Vents
GMH + IVH +
Grade IV 15% parenchymal blood
+/- ↑Vents
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46. Grade IV Hemorrhage
• Venous hemorrhagic infarction
secondary to venous outflow
compression
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68. Connatal Cysts
• Normal variant; incidence = 0.7%
• Superolateral to frontal horns
• Anterior to Foramen of Monroe
• “String of Pearls”
• Resolve spontaneously
Saturday, April 21, 2012

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72. Caudothalamic Groove
Cysts
• Congenital:
• Germinolytic
• chromosomal, metabolic, incidental
• Acquired:
• Subepdendymal
• post-hemmorahgic
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76. Periventricular
Leukomalacia
• #1 ischemic brain injury in preemies
• <32 wks, <1500 g ; Hypocarbia
• ↑ echotexture periventricular white matter
• DDX:
• normal “flaring”
• transient edema
76
Saturday, April 21, 2012

77. Periventricular
Leukomalacia
• Abnormal periventricular echotexture
disappears in 2 - 3 wks
• 15% affected infants will then develop cysts
• 60 - 100% develop cerebral palsy
• visual and intellectual disabilities
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83. Cerebral Edema
• ↑ Parenchymal echogenicity
• ↓ Sulcal/gyral differentiation
• ↓ Vascular pulsations
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86. Perivascular
Mineralization
• TORCH
• Trisomies(21 and 13)
• Twin-twin transfusion
• Fetal ETOH or cocaine exposure
• Neonatal asphyxia
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95. Vein of Galen
Malformation
• Venous ectasia due to AVM
• Superior to cerebellum - quadrageminal
plate cistern
• SX: CHF, seizures, hydrocephalus,
hemorrhage( in older kids)
• RX = embolization
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100. 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
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105. Classic Dandy Walker
• Vermian hypoplasia
• Cystic dilatation posterior fossa
communicating with IV vent
• Enlarged posterior fossa
• Tocular-lambdoid inversion
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109. Dandy Walker
Continuum
• Variant with vermis present and less
posterior fossa enlargement
• Persistent Blake Pouch Cyst
• looks like non-specific posterior fossa
cyst
• Mega Cisterna Magna
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114. Benign Hygroma of
Infancy
• Children 6 mos. - 2 yrs.
• Head circumference > 97th percentile
• Cause unknown, familial?
• Subarachnoid spaces > 3.3mm
• +/- slight ventricular enlargement
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119. Hydrocephalus
• Obstructive: (non-communicating)
• most common
• CSF cannot enter subarachnoid space
• Aqeductal stenosis, Chiari Malformation,
Dandy - Walker
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120. Hydrocephalus
• Non-obstructive: (communicating)
• impaired CSF resorption
• infection, hemorrhage, congenital abs.
arachnoid villi
• Ex Vacuo:
• loss of brain parenchyma → ↑ CSF
spaces
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121. Hydrocephalus
• Levene Index:
• ≤ 40 wks.
• COR image just posterior to
Foramen of Monroe
• 3 Dot sign
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128. 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)
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129. Spinal Ultrasound
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133. Spinal Ultrasound
• ≤ 4 months of age
• Anatomic Variants:
• Ventriculus Terminalis
• Filar Cysts
• Pseudomass due to clumped nerve
roots
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139. Filar Cysts
• fusiform
• anachoic
• thin wall, well defined
• immediately distal to conus
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144. Tethered Cord
• Findings:
• conus below L2-L3
• long thin conus
• posterior position of cord/filum
• ↓nerve root pulsations
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153. 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
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156. 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
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Saturday, April 21, 2012

157. Dorsal Dermal Sinus
• Tract hypoechoic relative to SQ fat
hyperechoic in CSF
• Associated Findings:
• cutaneous hemangiomata, hairy nevi
• low conus
• intraspinal lipomas, epidermoids/
dermoids
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161. Caudal Regression
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163. Diastematomyelia
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165. Interesting Cases
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166. Twin - Twin Transfusion
Recepient
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177. ECMO
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185. Abnormal Prenatal
Renal Ultrasound
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191. Zellweger Syndrome
• Cerebrohepatorenal Syndrome
• Autosomal recessive leukodystrophy
• Deficiency of peroxisomes
• Life span ≤ 1 year
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192. Birth Trauma
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196. Caput Succandeum
• Serosanguinous subcutaneous fluid
collection
• Below scalp and superficial to
periosteum
• Associated with moulding and over-
riding sutures
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199. Contact
• http://www.slideshare.net/lembark/
neonatal-cranial-spinal-sonography
• Joan K. Zawin
<bariumqueen1@yahoo.com>
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Saturday, April 21, 2012