Published on February 25, 2014
INFANT CRANIAL ULTRASOUND BY DR MUHAMMAD SALMAN KHAN
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 Safe Bedside Reliable Early imaging Serial imaging: Brain maturation Evolution of lesions Inexpensive Suitable for screening
Aims of Neonatal Cranial Ultrasound Exclude/demonstrate cerebral pathology Assess timing of injury Assess neurological prognosis Help make decisions on continuation of neonatal intensive care Optimise 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 lobe 3. Skull 4. 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 lobe 5.Frontal horn of lateral ventricle 6.Caudate nucleus 7.Basal ganglia 8.Temporal lobe 9.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 lobe 5.Frontal horn 6.Caudate neucleus 8.Temporal lobe 9.Sylvian fissure 10.Corpus callosum 11.Cavum septum pellucidum 12.Third ventricle 13.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 lobe 9.Sylvian fissure 14.Body of lateral ventricle 15.Choroid plexus 16.Thalamus 17.Hippocampal fissure 18.Aqueduct of Sylvius 19.Brain stem 20.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 lobe 10.Corpus callosum 15.Choroid plexus 20.Parietal lobe 21.Trigone of lateral ventricle 22.Cerebellum(a: hemispheres; b: vermis) 23.Tentorium 24.Mesencephalon
Sixth coronal plane (C6) through the parieto occipital lobes
Sixth coronal plane (C6) through the parieto occipital lobes 20.Parietal lobe 25.Occipital lobe 26.Parieto-occipital fissure 27.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 callosum 11.Cavum septum pellucidum 12.Third ventricle 13.Cingulate sulcus 16.Thalamus 22b.Cerebellum(vermis) 24.Mesencephalon 26.Parieto-occipital fissure 27.Calcarine fissure 28.Pons 29.Medulla oblongata 32. Cisterna quadrigemina 33. Interpeduncular fossa 34. 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 lobe 5. Frontal horn of lateral ventricle 6. Caudate nucleus 8. Temporal lobe 14. Body of lateral ventricle 15. Choroid plexus 16. Thalamus 17. Hippocampal fissure 20. Parietal lobe 21. Trigone of lateral ventricle 22a. Cerebellum(hemisphere) 25. Occipital lobe 36. 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 lobe 8. Temporal lobe 9. Sylvian fissure 20. Parietal lobe 25. Occipital lobe 37. 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 lobe 22. Cerebellum(a: hemispheres; b: vermis) 23. Tentorium 25. Occipital lobe 27. Calcarine fissure 29. Medulla oblongata 36. Occipital horn of lateral ventricle 38. Falx
Parasagittal view using PF as an acoustic window
Parasagittal view using PF as an acoustic window 8. Temporal lobe 15. Choroid plexus 16. Thalamus 20. Parietal lobe 21. Trigone of lateral ventricle 22a. Cerebellum (hemispheres) 25. Occipital lobe 27. 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 tentorium Interdigitating 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 fissure Partially 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
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