Neurosonography: State of the art
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1 Neurosonography: State of the art Lisa H Lowe, MD, FAAP Professor and Academic Chair, University MO-Kansas City Pediatric Radiologist, Children s Mercy Hospitals and Clinics
2 Learning objectives After this talk, the listener should be able to: Describe modern screening head US Update their own practice protocols Perform modern head US with Doppler
3 Outline - Discuss Modern head US technique: Anatomy Anterior fontanel Posterior fontanels Screening Doppler & RI s Linear Normal variants/pitfalls Compare normal vs pathology
4 Screening head US Old way Gray scale only Modern way Doppler screening Arterial & Venous Resistive index Posterior fontanels Linear 12-4 mhz Cortex and basal ganglia
5 RULES OF NORMAL ANATOMY: White matter should look like white matter Gray Matter should look like gray matter
6 RULES OF NORMAL ANATOMY: 1. Normal is symmetric, but symmetric is NOT always normal 2. US can screen anatomy, vessel patency & resistance
7 Normal Anatomy Modern basics..
8 Screening coronal US: 3 parts Via anterior fontanel: 1. Gray scale 2. Doppler Color Spectral 3. Linear }
9 6-8 Coronal gray scale views 1. Frontal lobes: Orbital Cones Interhemispheric fissure
10 Gray scale coronal 2. Frontal horns: Corpus callosum Cavum septum pellucidum Subarachnoid space Subarachnoid space Corpus callosum Cavum
11 Gray scale coronal 3. Thalami: Thalamus Foramen of Monro Third ventricle Caudate nucleus Midbrain (M) M Caudate nucleus
12 Gray scale coronal 4. Body lateral ventricles: Lateral Ventricles Lateral ventricles 4 th ventricle Cerebral peduncle (CP) Sylvian fissure (SF) CP 4th CP SF
13 Gray scale coronal 5. Cisterna magna: Cisterna magna Cerebellum (CB) Quadrigeminal plate cistern (Q) Lateral ventricles Q Lateral Ventricles CB CB Cisterna Magna
14 Gray scale coronal 5. Cisterna magna: Dancing lady Always has a clean dress NO spots! MCA Q MCA CB CB Spot on the lady s dress! Circle CM of Willis
15 Gray scale coronal 6. Choroid plexus: Rule: White matter always < echogenic than choroid plexus White matter Choroid Plexus
16 Gray scale coronal: Cortex Rule: 3 layers Pia -echogenic Gray matterhypo White matterhyper Pia Gray matter White matter
17 Gray scale coronal 7. Occipital lobes: Interhemispheric Fissure Occipital lobes Interhemispheric fissure Occipital Lobes
18 7 Gray scale sagittal MI 4th 1. Midline Sagittal: Cavum septum pellucidum Corpus callosum Massa intermedia (MI) 3rd ventricle Aqueduct 4th ventricle Vermis (V) MI V 4th V
19 Gray scale sagittal 2. Right CT groove: Caudatethalamic groove Thalamus T
20 Gray scale sagittal 3. Right lat vent: Entire lateral ventricle Choroid plexus Temporal lobe Occipital lobe Thalamus Caudate C T Lateral ventricle Choroid plexus Temporal Lobe Occipital Lobe
21 Gray scale sagittal 4. Right Sylvian fissure: Sylvian fissure Sylvian fissure Note echogenicity of pia, cortex and white matter
22 Gray scale sagittal 5. Left CT groove: Caudate(C) Thalamus(T) C T
23 Gray scale sagittal 6. Left ventricle: Entire ventricle Lateral Ventricle Choroid Temporal lobe Occipital lobe C T Choroid plexus Caudate Thalamus Temporal Lobe Occipital Lobe
24 Gray scale sagittal 7. Left Sylvian fissure: Temporal lobe Sylvian fissure Temporal Lobe
25 Standard sagittal views Posterior fossa: Cisterna magna Cerebellum (C) Midbrain Midbrain C Cisterna magna C
26 Posterior fossa views Cerebellum: Side ways dancing lady Cisterna magna 3rd
27 Posterior fossa views Posterior fossa: Rotate 90 degrees Dancing lady 3rd C C Cisterna magna
28 Screening Doppler US Doppler MCA RI s Anterior fontanel - 1. Coronal arterial- RI (Normal) Sagittal venous Sagittal sinus Vein of Galen MCA RI 0.79
29 Anatomy: Screening Doppler Normal RI s: highest in premies & decrease up to age 2 RI s NOT accurate in cardiac disease General approximation: Premie (+/- 0.05) Term (+/- 0.05) 1 year (+/- 0.05) 2+ years (+/- 0.05) ballpark all infants
30 Screening Doppler: Arterial MCA or ICA RI s Lt MCA Rt ICA RT ICA LT ICA RI=0.71
31 Screening Doppler: Transtemporal (TCD) Circle of Willis: ICAs harder to see Closed anterior fontanel Sickle cell posthemorrhage vasospasm Lt MCA Lt PCA Midbrain
32 Screening Doppler: Venous Via anterior fontanel, Sagittal plane Vein of Galen Sagittal sinus Sup Sag Sinus VOG
33 Screening Doppler: Venous Via posterior fontanel Transverse sinus cerebellum Transv sinus Midbrain
34 Screening Doppler: Power Normal Hyperemia Hypoxic injury
35 Screening linear: Layers of cortex Pia Cortex/gray matter White matter Routine Subarachnoid Many vessels Symmetric Linear
36 Normal Variants Vs. Pathology
37 Normal Variants: Immature Sulcation >24 weeks, Sylvian fissure is present SMOOTH cortex Occipitoparietal fissure seen at 24 weeks
38 Term Sulcation Cingulate Sulcal branching gyrus forms occurs at 28 > weeks 30 weeks
39 Abnormal: Lack of sulcation No cingulate gyrus Agenesis Corpus Callosum Choroid plexus
40 Normal Variants: Cavum Septum Pellucidum Fluid between leaves of septum pellucidum Cavum Septum Pellucidum closes by 3-6 months
41 Normal Cisterna Magna Cavum septum pellucidum Choroid plexus Normal cisterna magna 7 mm 3 rd } V Normal Cisterna Magna: 3-8 mm sagittal
42 Mega Cisterna Magna vs. Arachnoid cyst MCM < 8mm Arachnoid cyst - mass effect? Significance? Retrocerebellar cyst DDx: Dandy Walker malformation
43 Normal Variants: Asymmetric Ventricles 20-40% infants Lateral ventricles - smaller as infant matures Normal =<10 mm transverse
44 Abnormal: Ventriculomegaly Vents > 10mm Colpocephaly Ddx: Chiari 2, PVL or Agenesis Corpus Callosum Agenesis corpus callosum
45 Normal Abnormal: Variants: Germinal Choroid matrix Plexus hemorrhage Variants Bulbous glomus Echoes anterior to caudothalamic groove = germinal matrix hemorrhage C T
46 Normal Variants: Choroid Plexus Cysts Isolated variant 1% pregnancies Round, < 1 cm? chromosomal aneuploidy if > 2 cm, multiple, and/or bilateral
47 Normal Variants: Connatal cysts Synonyms: subfrontal or frontal horn cysts Bilateral, symmetric, multiple, "string of pearls
48 Periventricular cysts summary A=Periventricular leukomalacia Abnormal B= Connatal cysts Normal C=Subependymal cysts Abnormal Image courtesy of radiology resident artist, Reza Zinati, MD
49 Normal Variants: Subependymal Cysts Congenital (germinolytic) vs acquired (posthemorrhagic) Congenital (germinolytic) -? cause hypoxia, hemorrhagic, infection, genetic, metabolic
50 Normal Variants: Hyperechoic Pseudolesions? Normal Rotation Lesion of must the be transducer seen in TWO 90 degrees planes to lesion be resolves, abnormal thus. normal
51 Abnormal: Periventricular WM WM=echogenic 90 degrees still echogenic 3 wk follow up
52 Normal Variants: Periventricular Halo Periventricular white matter - normally hyperechoic Normal echogenicity < adjacent choroid plexus Asymmetric or heterogeneous WM - abnormal
53 Abnormal: Asymmetric white matter Infant on ECMO 24 hr f/u Blood
54 Normal Variants: Lenticulostriate Vasculopathy Nonspecific association with TORCH infections, chromosomal Unilateral abnormalities, or bilateral; malformations, Branching, linear and hypoxic or punctate ischemic echogenicity states
55 Conclusions: Age of radiation awareness, high quality US is more important than ever US technology has advanced greatly Radiologists must use updated US techniques
56 peds/neuro/index.htm
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