Pediatric Sonography: Neonatal heads Flashcards

hemorrhages around lateral ventricle

intraventricular and subependymal hemorrhages

40 to 70% in neonates under 34 weeks

Periventricular leukomalacia

multifocal white matter necrosis

when blood vessels burst, blood clots can collect in the white matter

Cerebral palsy

12 to 20% in infants weighing less than 2000g

frontal

parietal

temporal

occipital

cerebellum

anterior

posterior

lateral

commonly around 6 months

Aqueduct of Sylvius

Foramen of Magendie

foramen of Luschka

corpus callosum

Cavum septum pellucidum

CSP

trigone/atrium region

Foramen of Monroe

Messa intermedius

hypothalamus.

Cistern

cisterna magna

CSF

Cavum Vergae

caudate nucleus

head, body and tail

head

midbrain

pons

medulla oblongata

communication between cerebellum and the sensory nerves

thalami and cerebellum

into two cerebral peduncles

...

the two vertebral arteries come together to form the basilar artery

the basilar divides posterior cerebral artery

the internal carotid artery turns into the middle cerebral artery

the posterior communicating artery connects the posterior cerebral and the middle cerebral arteries

the anterior cerebral artery branches off the middle cerebral artery

the anterior communicating artery connects the two anterior cerebral arteries

into the sylvian fissure Y

portable

inexpensive

non-invasive

requires no sedation

5 MHz to 10 MHz phased array is optimal

small linear array may also be used

toward the patients nose

top - superior - superficial

bottom - inferior - deep

right - anterior

left - posterior

top - superior - superficial

bottom - inferior - deep

right - left

left - right

slowly angle through the coronal plane

beginning rostrally at the frontal lobes angle posteriorly

The infant should be disturbed as little as possible. The exam should be done in the neonatal unit. Transducer gel should be body temperature.

If the parents or guardians are available the sonographer should explain the exam is being performed to visualize the structures of the cranium for possible defects or problems that might arise in the premature infant.

Keep the infant as warm as possible.

7.5 MHz sector is a good choice but a curve linear transducer may also be used.

3 – 5 MHz sector is a good choice but a curve linear transducer may also be used.

Begin doing a full sweep through the anterior fontanelle. Starting perpendicularly with a coronal view, slowly angle the transducer toward the face, scanning through the anterior horns and through the frontal lobes. Then slowly angle toward the occipital lobes and the posterior portion of the cranium and back to perpendicular. Change to a sagittal view, once again beginning perpendicular sweep the transducer toward the right lateral horn and through the temporal lobe and back to perpendicular. Repeat on the left side through the left lateral horn and temporal lobe. Finish back at a perpendicular position.

Look for:

• Hemorrhage
• Defects
• Size
• Vascularity
• Fluid
• Masses

After scanning through the brain start taking images.

Document the normal anatomy and any pathology found, including measurements and vascularity if indicated

Sex

Gestational Age

Weight

Family History

Anomalies previously found

Supine with the head facing up

Prone with head facing the side may be used as necessary

Coronal & Sagittal

Begin perpendicular to the anterior fontanelle, angle the transducer toward the face return midline and sweep the posterior.

Begin perpendicular to the anterior fontanelle, Angle the transducer to the right return midline and sweep the left

Scanning a baby while they sleep is easier on the patient and easier for scanning

After the fourth week after conception the neural tube separates into three main structures that will form the brain. These structures include the prosencephalon (forebrain) , mesencephalon (midbrain) and rhombencephalon (hindbrain).

The forebrain consists of the cerebrum, thalamus, hypothalamus and the diencephalon. The midbrain will develop into ventricles and the cerebral peduncles. The hindbrain will develop into the cerebellum and the brain stem including the medulla oblongata and pons

Four ventricles circulate cerebral spinal fluid around the brain.

divided into the frontal, occipital and temporal temporal horns. All horns converge at the trigone region. They are filled with cerebral spinal fluid.

The third ventricle is a midline structure containing cerebral spinal fluid. It is connected with the lateral ventricles by the foramen of Monroe and to the forth ventricle by the aqueduct of sylvius.

The fourth ventricle is also filled with cerebral spinal fluid.

Lies midline and consists of connective fibers connecting the two hemispheres. It creates the roof of the lateral ventricles and sits superior to the cavum septum.

A midline structure that creates the floor of the corpus callosum. It is filled with cerebral spinal fluid. It sits between the lateral ventricles. It is present at birth but closes around 4 months.

The thalamus is an egg-shaped structure. It sits within the 3^rd

The cerebellum takes up most of the posterior fossa. The connection between each lobe is called the vermis.

Lies posteroinferior to the cerebellum.

Consists of two curved structures that wrap around the thalamus. It is responsible for absorbing cerebral spinal fluid.

channels that connects the 3^rd and 4^th ventricle

channels connecting the lateral ventricle with the 3^rd ventricle

Consists of the midbrain, pons and medulla oblongata. This structure connects the spinal cord to the brain.

A midline structure where the falx lies between the two hemispheres.

A pea-shaped structure within the 3^rd

spiral-like fold covering the temporal horns.

Column like structures connected to the pons and the thalamus

fissures of the brain that separate the folds.

echogenic covering that separates the cerebellum from the cerebral. It is part of the dura mater.

A fissure located laterally between the temporal and frontal lobes. The middle cerebral artery lies in this fissure.

located within the concavity of the lateral angles of each ventricle.

A vascular network located near the caudate nucleus. This is a common site for hemorrhage in the neonate infant.

Immediately superior to the superior aspect of the tentorium.

Evaluate the cranial anatomy of a neonate infant for pathology including: anomalies, intracranial hemorrhage, and ventricular dilation

Premature Delivery

Abnormal posturing

Low birth weight

Seizers

Apnea

coma

Anterior: orbits

Anterior: anterior horns and lateral ventricles

Middle: lateral ventricles, cavum septum pellucidum, 3^rd ventricle, and corpus callosum

Posterior: ambient wings of the cisterna magnum

Posterior: tentorium and cisterna magnum

Posterior: choroid plexus

Posterior: glomus of choroids

Posterior: occipital lobe

Midline: cavum septum pellucidum, corpus callosum, 3^rd ventricle and foramen of Monroe, aquaduct of slyvius, 4^th ventricle, tentorium, cisterna magna

Left Thalamus

Left Caudothalamic groove

Left Lateral ventricle: anterior, body, and occipital (temporal is hydrocephalic

Left Angle slightly lateral from lateral ventricle to show the white matter

Left very lateral: Sylvain fissure/ middle cerebral artery

Repeat on left side

Two Lateral Ventricles: filled with cerebral spinal fluid and appear as echogenic slits.

Third Ventricle: Midline structure, echogenic walls and the center appears anechoic.

Forth Ventricle: Midline structure inferior to the third ventricle, echogenic walls and the center appears anechoic.

midline, echogenic structure, midgray and has medium to low level echoes.

appears anechoic, fluid filled structure. Anterior to the corpus callosum

midline, echogenic structure within the 3^rd ventricle

vermis is echogenic and the surrounding parenchyma appears midgray

fluid filled, anechoic structure lays posteroinferior to the cerebellum

echogenic structures that wrap around the thalamus

rarely seen during ultrasound unless dilated

channels connecting the lateral ventricle with the 3^rd ventricle

appears midgray with low echogenicity

echogenic area separating the two hemispheres

mid-gray, best seen with ventricular dilatation

echogenic, spiral-like fold coving the temporal horn.

Column like structures connected to the pons and the thalamus

echogenic spider- like fissures of the brain that separate the folds.

echogenic covering that separates the cerebellum from the cerebral.

A fissure located laterally between the temporal and frontal lobes. It appears as a Y shape. The middle cerebral artery lies in this fissure.

appears midgrey

small echogenic area at the junction of the caudate and the thalamus . hemorrhages are common here.

echogenic area superior to the tentorium.

Congenital anomaly associated with spina bifida. The brain stem and cerebellum are pulled toward the spinal cord, secondary hydocephus develops.

Small posterior fossa

Myelomeningocele decompression of the ventricle

Small cerebellum

Absence of the cisterna magna

4^th ventricle in low position

Absence of the septum pellucidum

Widening of the 3^rd ventricle

Cerebellar tonsil herniation into enlarged foramen magna

Displacement of pons and medulla

Elongation of 4^th ventricle

Enlarged massa intermedia

3^rd ventricle slightly larger

Small anterior horns

Enlargement of posterior horns

Wide interhemispheric fissure

Small posterior fossa

Low tentorium

Hydrocephalus

40 to 75% aqueductal stenosis

Partial or complete agenesis is often seen with heterotopias and polymicrogyria.

Narrow frontal horns

Separation of the anterior horns

Widening of the occipital horns

Widening of the 3^rd ventricles

3^rd ventricles have pointed upper corners (bat-wings)

poor muscle tone

porencephaly

hydrocephalus

microgyria

Arnold-Chiari

fusion of the hemispheres.

A congenital anomaly in which a 4^th ventricle cyst occupies the cerebellar space.

Hydroplasia of cerebellar vermis

Enlarged 4^th ventricle

Cysts in posterior fossa

Small brain stem

Hydrocephalus

Atresia of the Luschka and Magendie

4^th ventricle communicates directly to cysts

Obstruction above and below 4^th ventricle

Absence of Corpus Callosum

hydrocephalus

agenesis of the corpus callosum

encephalocele

holoprosencephaly

microcephaly

infundibular hamartomas

brain stem lipomas.

Complex abnormality from failure of cleavage of the prosencephalon

*Must obtain modified coronal studies of the whole frontal lobe to determine if frontal horns are present

The most severe form of Holoprosencephaly

Single midline ventricle

Thin, primitive cerebral cortex

Fused Thalami and hemispheres , hyper echogenic choroid plexus

Absent corpus callosum & interhemiphermic fissure, 3^rd ventricle

Large dorsal cyst

Multiple facial abnormalities

• cebocephaly
• cyclopia
• ethmocephaly

Characterized by the abnormal storage and collection of glycogen in the tissue of the liver and kidneys.

Single ventricle

More brain parenchyma present

Posterior faux and interhemispheric fissure

Splenium and genu seen midline

3rd ventricle is small

Mild facial

• hypotelorism
• cleft lip

Least severe form

Nearly complete separation of hemispheres

Faux and interhemispheric fissure development

Some front lobe fusion

Absent septum pellucidum

Anterior horns fused

Occipital horns separation

3^rd ventricle separates the thalami

Absent genu

mild facial abnormalities

Lesions in the midline that induce malformations of the telencephalon

Single ventricle cavity

Absent corpus callosum

* Presence frontal horns helps differentiate between Holoprosencephaly

Gastrointestinal bleeding

blood in the stools

vomiting of blood

Encephalopathy

Also known as porencephaly, is a cyst filled with cerebral spinal fluid. May be caused by hemorrhage , infarction, trauma, inflammation of the nervous system.

Cyst without mass

Reduction of hemisphere

Midline shift

Contralateral ventricular enlargement

Brain development is destroyed and preplaced with cerebral spinal fluid. May be caused by bilateral occlusion of the internal carotid

Midbrain, basal ganglia, choroid plexus, and thalamus sparing

Presence of cerebral spinal fluid

Absent Doppler flow in carotid

Possible absent falx cerebri

An imbalance of production and absorption of cerebral spinal fluid. There are three types: obstruction to outflow, decreased absorption, or rarely overproduction.

Blunting of the lateral angles of the lateral ventricle

Widening of the ventricle system

Rare choroid plexus cyst

enlargement of head, bulging fontanelles

interference of cerebral flow

Enlargement of proximal ventricle cavity

pathway of cerebral fluid are open but there is a decrease in absorption. The ventricular system becomes uniformly distended. The most common cause is aquaduct stenosis.

Narrow aqueduct of Slyvius may be replaced by small network

Widening of lateral ventricles

Normal size 4^th ventricle

Small posterior fossa

Cerebellum displaced posteriorly

Absent cisterna magna

lined by arachnoid tissue and contain cerebral spinal fluid.

Normal vermis (Not Dandy- Walker)

Sonolucent

Verify with color Doppler

Interhemispheric cysts

Suprasellar cysts

Cerebral convexity cysts

A hepatic cyst is usually a solitary, non-parasitic cyst of the liver. solitary or multiple.

Common and single

Well-defined

Anechoic mass

Unilateral

Left larger than right

4 to 7 mm

*Rare Multiple cysts larger than 10 mm associated with trisomy 18

Discrete in the lining of the ventricle. Commonly the result of sequel of germinal matrix

Smooth walled

Spherical

Located in lateral ventricle

Dilation of the vein of Galen, caused by vascular malformation off the posterior cerebral.

Anechoic cystic

Between lateral ventricles

Calcification

Hydrocephaly with possible thrombus

Most common hemorrhage in preterm, affecting 30 to 50% of infants born before 32 weeks. The most common site is the interthalmic groove. Can cause obstruction in the choroid plexus.

Fluid

Echogenic structure in white matter

Become cystic and are absorbed leaving cavity

Complicate Subependymal hemorrhage, meaning brain tissue has been

Difficult to find in live infants. Primmary: intracerebellar, venous infarction, traumatic laceration – resulting from occipital diastasis, extension to the cerebellum of a large SHE-IVH

Echogenic structures

Within the less echogenic cerebellar parenchyma

Become cystic with time leaving cavity lesions

Better diagnosed with CT. located peripherally along the surface of the brain.

Nonechogenic spaces

Between the echogenic calvarium and the cortex

persistent

Also called Multifocal White Matter Necrosis, most common ischemic lesion in the immature brain. Highly echogenic areas in the white matter.

echolucencies in white matter

Associated with Cerebral Palsy

occur within large arteries. Early on cause destruction of cerebral tissue and leave cavitary lesions. These lesions correspond to cerebral infarction.

Echogenic localized lesions

Sonolucencies appear after few days

A common complication of purulent meningitis. This is probably caused by infection spreading to the choroid plexus. Stents and other objects placed the body can cause this infection. Can lead to hydrocephalon

Thin septations extending from lateral ventricles.

Septations thicken