Transfontanelar Ultrasound Technique, Normal Anatomy, Anatomic Variants and Classification Review

Transcription

1 Transfontanelar Ultrasound Technique, Normal Anatomy, Anatomic Variants and Classification Review Poster No.: C-2615 Congress: ECR 2013 Type: Educational Exhibit Authors: S. E. Vazquez, R. E. Ochoa Albíztegui ; Mexico, DF/MX, Mexico City/MX Keywords: Education and training, Normal variants, Education, Diagnostic procedure, Ultrasound, Pediatric, Neuroradiology brain DOI: /ecr2013/C-2615 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 25

2 Learning objectives Learn the suggested technique for transfontanelar ultrasound scanning. Identify normal anatomy and variants in new-born patients. Review Papile's and Volpe's Classifications of intracranial hemorrhage. Background In Mexico about a 6% of newborn babies are preterm (<37 weeks of gestation). Of these preterm babies a 10% develop intracranial hemorrhage visible by ultrasound. Ultrasound is a convenient method to identify and follow new born intracranial hemorrhage because of portability, accessibility and low cost. For preterm babies ultrasound should be obtained in the 1st, 3rd and 7th day after birth and/or if neurological deterioration or metabolic acidosis is diagnosed (G.Tinajero, 2012). Since 1970, cranial ultrasound examinations have been performed on preterm infants to provide information about perinatal brain injury for the prediction of long term outcomes (Sauve, 2001). Screening Programme NICU and/or 32 weeks GA and/or birth High care and #32 weeks GA and # 1,500 weight <1,500 g g <24h after birth rd On the 3 day On the 3rd day Biweekly until the second week Weekly until discharge Weekly until discharge Around term More frequently in the case of (suspected) More frequently in the case of (suspected) abnormalities abnormalities Taken from (Wezel-Meijler, 2007). The assessment includes: Page 2 of 25

3 Anatomy Maturation Distinction of cortex/white matter Echogenicity of cortex Echogenicity/homogeneity of white matter Echogenicity/homogeneity of deep grey matter Ventricular system: size, lining, echogenicity if dilated: perform serial measurements Width of subarachnoid spaces Midline shift Taken from (Wezel-Meijler, 2007). Early ultrasound examinations allow diagnosis of hemorrhagic lesions, and later ultrasound examinations can detect cystic lesions or ventriculomegaly (Sauve, 2001). The major advantages of the technique include high-resolution capability, portable instrumentation, lack of ionizing radiation, and relative affordability. The most important of which are prior hypoxic-ischemic insults, posthemorrhagic hydrocephalus, and periventridar hemorrhagic infarction (Volpe, 1989). The American Academy of Neurology suggests that all infants younger than 30 weeks' gestation be screened by cranial ultrasonography at 7-14 days postnatal life and at weeks postmenstrual age. (David J Annibale, 2012) The vascular structure of the cerebral white matter in mid-to-late gestation includes long penetrating arteries that originate from the anterior, middle or posterior cerebral artery. The end zones of these arteries are especially prone to hypoperfusion and ischemia, and, thus, there is an increased likelihood of ischemic necrotic damage along the course or end zones of the arteries, or in the periventricular area (Sauve, 2001). Periventricular hemorrhagic infarction is a serious complication of germinal matrixintraventricular hemorrhage, with adverse neurodevelopmental sequelae approaching 90% in earlier reports. The impact of this lesion is best appreciated when one considers that approximately 20% of the 55,000 premature infants born with birth weight < 1500 g. in the United States each year develop germinal matrix-intraventricular hemorrhage (Bassan H & al., 2006) Page 3 of 25

4 Imaging findings OR Procedure details Imaging Findings For an appropriate evaluation 5 sagittal and 6 coronal images should be obtained through the anterior fontanel. Additional images through posterior fontanel and temporal window may aid in diagnose. Evaluation includes standard views in coronal and sagittal planes. The acoustic windows, used are the temporal window, anterior, posterior and mastoid fontanel (Wezel-Meijler, 2007). The examinations are performed with a 5 MHz or 7.5 MHz transducer through the anterior fontanelle. ANATOMY (Fig.4-Fig. 15) NORMAL ANATOMIC VARIANTS ( Fig.16- Fig. 22) Volpe Grading of Severity of Intraventricular Hemorrhage by Ultrasound Scan Severity Description Grade I Germinal matrix hemorrhage with no or minimal intraventricular hemorrhage (<10% of ventricular area on parasagital view) Grade II Intraventricular hemorrhage (10 to 50% of ventricular area on parasagittal view) Grade III Intraventricular hemorrhage (> 50% of ventricular area on parasagittal view; usually distends lateral ventricle) Separate notation Periventiruclar echodensity location and extent) (indicate Taken from (Volpe, 1989). Page 4 of 25

5 Papile et al. Grade Severity Description 1 Subependymal matrix) 2 Intraventricular hemorrhage ventricular dilatation 3 Intraventricular hemorrhage ventricular dilatation with 4 Intraventricular hemorrhage parenchymal hemorrhage with hemorrhage (germinal without Taken from (Richard A. Bowerman, 1984). Images for this section: Page 5 of 25

6 Fig. 4: Frontal lobes, also first coronal plane. 1 (Interhemipheric fissure); 2 (eyes/orbits), 3 (fontal lobe). Fig. 2: Coronal Section Page 6 of 25

7 Fig. 3: 6 coronal planes Page 7 of 25

8 Fig. 5: Parietal lobes, second coronal plane. 1 (interhemispheric fissure), 2 (frontal horn or lateral ventricle), 3 (caudate nucleus), 4 (Temporal Lobe), 5 (basal Ganglia), 6 (Sylvian Fissure) Page 8 of 25

9 Fig. 15: Echogenic choroid plexus in boomerang shape, never to be seen in frontal horn, because it may be hemorrhage. No splash images should be seen, since this may be clots. Page 9 of 25

10 Fig. 16: 3 (Cavum septum pelucidum), 4 (Vergae), 5 (bone molding, because of vaginal bith), 6 Calcar Avis) if hemorrhage doubt, calcar avis in posterior fosa is seen as an inverted monticle. Pitfall: it's not seen when ventricles are collapsed as in the first hrs, also a normal finding). Page 10 of 25

11 Fig. 17: Fig. 17 Coronal plane, 7 (lobulated choroid plexus), 8 (choroid plexus notch). Fig ventricular asymmetry. Page 11 of 25

12 Fig. 18: 11 (Collapsed ventricles) in the first hrs, 12 (ventricular horns prolonged to convexity). Page 12 of 25

13 Fig. 19: 13 (frontal emergency of choroid plexus). Page 13 of 25

14 Fig. 20: 14 (Wide subarachnoid space) only it can only be evaluated in premature Fig. 14: 1st and 5th parasagittal planes through the insulae, 1 (frontal lobe), 2 (temporal lobe), 3 (Sylvian fissure), 4 (parietal lobe), 5 (occipital lobe), 6 (insula). Page 14 of 25

15 Fig. 13: 2nd and 4th parasagittal planes (right and left), 1 (frontal lobe), 2 (frontal horn of lateral ventricle), 3 (caudate nucleus), 4 (temporal lobe), 5 (hippocampal fissure), 6 (parietal lobe), 7 (body of lateral ventricle) 8(choroid plexus in third ventricle)9 (cerebellum), 10 (occipital lobe), 11 (occipital horn of lateral ventricle), 12 (thalamus). Periventricular halo, variant in premature, important because it can be confused with parenchymal hemorrhage. *Normal variant # 2. Page 15 of 25

16 Fig. 12: 3rd section plane, midsagittal plane, through 3rd and 4th, 1 (corpus callosum), 2 (cavum septum pellucidum), 3 (third ventricle), 4 (cingulate sulcus), 5 (thalamus), 6 (cerebellum (a: vermis), 7 (mesencephalon), 8 (pons), 9 (medulla oblongata), 10 (cisterna magna), 11 (cisterna quadrigemina), 12 (Interpeduncular fossa), 13 (fornix). Page 16 of 25

17 Fig. 11: 5 standard sagittal planes Page 17 of 25

18 Fig. 10: Sagittal Section Page 18 of 25

19 Fig. 9: Sixth coronal plane, through the parieto-occipital lobes 1 (parietal lobe), 2 (occipital lobe), 3 (parieto-occipital fissure), 4 (Calcarine fissure). Note how the cortical foldings are barely visible because of prematurity*. *Normal variant # 1. Page 19 of 25

20 Fig. 8: Fifth coronal plane at level of the trigone of the lateral ventricles, 1 (temporal lobe), 2 (corpus callosum), 3 (choroid plexus), 4 (third ventricle), 5 (parietal lobe), 6 (Trigone of lateral ventricle), 7 (tentorium), 8 (Mesencephalon), 9 (cerebellum a: hemispheres; b: vermis). Page 20 of 25

21 Fig. 1 Page 21 of 25

22 Fig. 7: Fourth coronal plane, 1 (interhemispheric fissure), 2 (Temporal lobe), 3 Sylvian Fissure, 4 (Body of lateral ventricle), 5 (Choroid plexus), 6 (Plexus in 3rd ventricle), 7 (thalamus), 8 Hippocampal fissure), 9 (Mesencephalic aqueduct), 10 (Brain stem), 11 (Parietal lobe). Page 22 of 25

23 Fig. 6: Foramen of Monro leve, third coronal plane, 1 (interhemispheric fissure), 2 (frontal lobe), 3 (Cingulate sulcus), 4 (Corpus callosum), 5 (Cavum septum pelucidum), 6 (Third ventricle), 7 (temporal lobe), 8 (Caudate nucleus). Narrow lateral ventricles (Normal finding) Page 23 of 25

24 Fig. 21: 15 mega cerebral cistern. Page 24 of 25

25 Conclusion Transfontanelar ultrasound is a simple, noninvasive and low cost method to determine early intracranial pathology in new born patients. Identifying normal anatomy, variants and adequate scanning technique will assess radiologist in pathology detection. References Bassan H, F. H., & al., e. (2006). Perventricular Hemorrhagic Infarction: Risk Factors and Neonatal Outcome. Pediatr Neurol, 35: David J Annibale, J. H. (26 de June de 2012). Medscape Reference. Recuperado el 25 de 01 de 2013, de article/ workup#showall G.Tinajero, A. (25 de Junio de 2012). Ultrasonido Transfontanelar en el INPER. (E. O. Albíztegui, Entrevistador) Medscape. (s.f.). Recuperado el 25 de 01 de 2013, de emedicine.medscape.com/article/ workup#showall Richard A. Bowerman, S. M. (1984). Natural History of Neonatal Periventricular/Intraventricular Hemorrhage and Its Complications: Sonographic Observations. AJR, 143: Sauve, R. (2001). Routine screening cranial ultrasound examinations for the prediction of long term neurodevelopmental outcomes in preterm infants. Paediatr Chid Health, Vol 6, No1: Volpe, J. J. (1989). Intraventricular Hemorrhage in the Premature InfantCurrent Concepts. Part I1. Ann Neurol, 1989;25: Wezel-Meijler, G. v. (2007). Neonatal Cranial Ultrasonography. Verlag Berlin Heidelberg : Springer. Personal Information Page 25 of 25