Disclosures. Imaging in the NICU. Neonatal Imaging. Objectives. Lines and Tubes. Endotracheal tube 4/18/2017. I have no disclosures

Transcription

1 Disclosures I have no disclosures Imaging in the NICU Adina Alazraki, FAAP, MD Special thanks to Sarah Sarvis Milla, FAAP, MD Assistant Professor of Radiology and Pediatrics Emory University School of Medicine Children s Healthcare of Atlanta Objectives Neonatal Imaging Identify normal and malpositioning of lines/tubes Discuss neonatal congenital and acquired lung and abdominal pathology Briefly review normal and abnormal cranial sonography Lines and Tubes Chest Airway Bones Cardiac Diaphragms Effusions Free Air Abdominal Gas Pattern Free air Pneumatosis Portal venous gas Mass Bones Stones/calcs Cranial Sonograms Anatomy Pathology Endotracheal tube Orogastric tube Central lines Umbilical arterial Umbilical venous Lines and Tubes Endotracheal tube Optimal position Mid thoracic trachea ~T2-4 1

2 C5 C6 C7 Orogastric Tube Optimal position Left upper quadrant Abnormal location Trachea or bronchi High in the proximal esophagus Esophageal atresia Mid esophagus or esophagogastric junction At risk for reflux and aspiration during OG feeds 2

3 Umbilical Venous Catheter Normal course Umbilical vein left portal vein ductus venosus middle hepatic vein IVC Optimal location IVC just at/below the right hemidiaphragm Abnormal Overlying the liver Hyperosmolar substances (TPN) can damage the liver parenchyma Requires removal and new catheter placement 3

4 Umbilical Arterial Line Normal course Umbilical artery internal iliac artery aorta Optimal location Aorta (between the T6- T10 vertebral bodies) Aorta (below L3) Abnormal Above T6 Near the ostia of the subclavian and carotid arteries Below T10 Near the ostia of the renal, celiac and superior mesenteric arteries Peripherally inserted central catheter (PICC) Upper and lower extremities Need to document tip location and course of catheter Beware of curls (particularly Left Inguinal) Complications Thrombosis Embolic phenomena Leakage if malposition 4

5 Neonatal Chest Respiratory Distress Syndrome (RDS) Pulmonary Interstitial Emphysema (PIE) Transient Tachypnea of Newborn (TTN) Meconium aspiration Pneumothorax Pneumomediastinum Neonatal Chest Neonatal Chest Congen Diaphragmatic Hernia (CDH) Congen Lobar Emphysema/Hyperinfla tion (CLE/CLH) Sequestration Congenital Pulmonary Airway Malformation (CPAM) Normal thymus PREMATURE BABY Respiratory distress syndrome Surfactant deficiency Alveolar instability and collapse Impaired oxygenation» Metabolic acidosis» Increased pulmonary vascular resistance right to left shunting through ductus Hyaline membrane disease Microscopic appearance of RDS» Homogeneous, eosinophilic membranes that line terminal bronchioles and alveolar ducts PREMATURE BABY RDS RDS Radiologic features reflect acinar collapse Hypoaeration Homogeneous reticulogranular appearance or groundglass opacity summation of collapsed alveoli transudation of fluid into the interstitium from capillary leak distension by air of innumerable bronchioles 5

6 PREMATURE BABY RDS Management Prenatal administration of corticosteroids Accelerates structural and biochemical lung maturity Antenatal administration of exogenous surfactant Delivered into the tracheobronchial tree as a liquid bolus» Uneven or asymmetric distribution PREMATURE BABY Profoundly premature babies Initial radiograph appears relatively normal Subtle haziness or interstitial thickening Structurally immature lungs Paucity of alveoli Over several days to weeks radiographic changes manifest to diffuse haziness coarse, irregular pattern PREMATURE BABY Bronchopulmonary dyspasia (BPD) Term introduced by Northway et al in 1967 Chronic lung disease Prolonged positive-pressure mechanical ventilation and supplemental oxygen Etiology Combination of barotrauma and oxygen toxicity (due to inadequate concentrations of antioxidant enzymes) Introduction of surfactant replacement therapy BPD in very premature neonates Due to the inhibition of acinar and vascular growth during a vulnerable stage of lung development (rather than barotrauma and oxygen toxicity) PREMATURE BABY Bronchopulmonary dyspasia (BPD) Radiologic features Northway 4 developmental stages» Stage I: (2-3 days after birth); typical granular opacities of RDS» Stage II: (4-19 days); nearly complete opacification of the lungs» Stage III: (10-20 days); small round cystic lucencies alternating with regions of irregular opacity» Stage IV: (beyond 1 month); bubbly lungs Surfactant replacement era coarse interstitial opacities without cystic lucencies 6

7 BPD PREMATURE BABY Air leak phenomena Pulmonary interstitial emphysema (PIE) Rupture of terminal airways or alveoli Predisposes to pneumothorax Imaging findings Linear and serpentine lucencies radiating out from hila Treatment Reduce ventilatory pressures High-frequency ventilation (oscillator) Selective intubation away from affected side Decubitus position with affected side down PIE PREMATURE BABY Pulmonary hemorrhage Usually secondary to severe hypoxia or capillary damage, as can be seen in RDS, meconium aspiration, patent ductus arteriosus or neonatal pneumonia Typically manifests clinically as blood within ET tube Radiographic findings Acute onset of large areas of airspace consolidation 7

8 6 hours later PREMATURE BABY Patent ductus arteriosus Ductus closes within 24 hrs triggered by high oxygen tensions Hypoxia prevents closure of the ductus Radiographic findings Hyperaerated lungs Cardiomegaly Increased perihilar pulmonary vascularity Bilateral consolidation secondary to edema RDS FULL TERM NEONATES Amniotic fluid aspiration Transient tachypnea Neonatal pneumonia/sepsis Meconium aspiration RDS Severe systemic abnormalities Congenital heart disease RDS-PDA 8

9 FULL TERM NEONATES Transient tachypnea of the newborn (TTN) Secondary to delayed clearance of fetal pulmonary fluid C-section babies and precipitous deliveries Maternal sedation or diabetes Respiratory distress evidenced by tachypnea, retractions and nasal flaring Begins ~6 hrs of life, peaks 1 day, resolves 2-3 days Radiographic findings Hyperaeration Airspace opacification Increased interstitial markings Prominent/indistinct pulmonary vascularity Pleural effusion FULL TERM NEONATES Amniotic fluid aspiration Occurs during or just prior to birth Usually related to stress No meconium present Radiographic findings Hyperaeration Mildly coarse increased markings FULL TERM NEONATES Meconium aspiration If released in utero into the amniotic fluid Often aspirated during fetal respirations Usually occurs in full-term or post-term newborns Aspirated meconium causes Obstruction of small airways Chemical pneumonitis Radiographic findings Hyperaeration- asymmetric and patchy Asymmetric coarse, nodular lung densities Pleural effusions may be present Pneumothorax in 20 40% of cases 9

10 FULL TERM/PRETERM NEONATES Neonatal pneumonia (sepsis) Often associated with maternal rupture of membranes Infection can occur in utero, during passage through birth canal or shortly after birth Usual bacteria E. coli Group B Streptococcus Radiographic findings are variable Hyperinflated, hypoinflated or normally aerated lungs Coarse patchy asymmetric infiltrates Fine, reticular changes Mimicking edema or RDS Group B Strep FULL TERM NEONATES Chylothorax Most common cause of large pleural effusion in the newborn Due to traumatic tear of thoracic duct during delivery Right sided chylothorax tear below T7 Left sided chylothorax tear above T7 Radiographic findings Pleural effusion ranging from small to complete opacification of the hemithorax with contralateral shift of mediastinal structures Treatment Thoracentesis Chest tube placement 10

11 PNEUMOMEDIASTINUM Can occur spontaneously in both premature and full-term neonates Radiographic signs Elevation of the thymus ( spinnaker sign ) Radiolucency outlining superior mediastinum, sometimes cardiac silhouette Pneumopericardium Air outlines the heart on the AP and lateral views Retropharyngeal air Subcutaneous emphysema in the neck Continuous diaphragm sign Air in the mediastinum beneath the heart Spontaneously resolve PNEUMOTHORAX Common in both premature and full-term neonates Spontaneous or secondary to barotrauma Radiographic findings Hyperlucency adjacent to the heart borders or diaphragms In the supine position, pleural air tends to accumulate anteriorly and medially Relative hyperlucency of the entire hemithorax May see faint lungs markings Air collects anteriorly Cross-table lateral Look for displacement of the ventral surface of the lung 11

12 DIFFERENTIAL DIAGNOSIS DIFFERENTIAL DIAGNOSIS HYPOAERATION HYPERAERATION FINE INCREASED MARKINGS COARSE INCREASED MARKINGS RDS TRANSIENT TACHYPNEA RDS TRANSIENT TACHYPNEA SEPSIS (Group B Strep) AMNIOTIC FLUID ASPIRATON SEPSIS AMNIOTIC FLUID ASPIRATON MECONIUM ASPIRATION MECONIUM ASPIRATION NEONATAL PNEUMONIA SEPSIS CONGENITAL LYMPHANGIECTASIA 28 wk preemie- RDS Neonatal Pneumothorax Look for neonatal pneumo along mediastinal border 12

13 Pulmonary Interstitial Emphysema Fullterm infant with respiratory distress- Meconium aspiration Congenital diapragmatic hernia Incidental Morgagni hernia Often diagnosed prenatally; Liver (left lobe) position and lung volume help predict outcome Follow stomach and small bowel to help make diagnosis Congenital lobar hyperinflation Chronic left lower lobe PNA or prenatally diagnosed chest masssequestration Look for aortic feeder to lung and note drainage: intralobar is into pulmonary venous drainage 13

14 Hyperinflation from Pulmonary sling Shunt vascularity Common Left-right shunts: ASD, VSD, PDA Remember this appearance on UGI Neonatal Abdomen (Bowel) Be familiar with normal appearances of the thymus NEC/pneumoperitoneum Esophageal atresia (TE fistula) Pyloric stenosis Malrotation (+/- volvulus) Duodenal atresia/stenosis/web Jejunal atresia Meconium ileus/peritonitis Colonic atresia Small left colon/immature colon/mec plug Hirschsprung If you think pneumatosis, look for portal venous gas and free air 14

15 Pneumoperitoneum Beneath the diaphragm Outlining the liver Anteriorly over the abdomen/falciform (football) Outlining bowel (Rigler s sign) 86 Esophageal atresia Prenatal diagnosis or newborn with feeding intolerance Look for distal gas to suggest presence of distal TE fistula (most common form) Double bubble of duodenal atresia- no distal bowel gas Newborn with bilious emesis Complete obstruction from volvulus Malrotation with midgut volvulustruly life threatening 15

16 Malrotation and midgut volvulus Malrotation, no volvulus Gastroschisis Omphalocele Lower bowel obstruction Meconium ileus Colonic atresia Small left colon syndrome (aka meconium plug) Hirschsprung Water soluble contrast enema Omphalocele is often associated with chromosomal and associated congenital anomalies Hirschsprung Rectum should be bigger than sigmoid Functional immaturity of colon risk factors: diabetic moms, mag sulfate 16

17 Microcolon--Meconium ileus test for CF Meconium peritonitis and periorchitis in utero bowel perforation and patent processus Neonatal CNS Imaging Neonatal sono Anatomy Germinal Matrix hemorrhage Periventricular leukomalacia (PVL) Macrocephaly Congenital malformation Tethered cord Preterm infants Screen/follow IC Hemorrhage (< g, <30 wk) PVL Hydrocephalus Extra-axial fluid collections Symptoms Seizures CNS infection Who gets head US? Near term/term Too sick to be moved for head CT or MRI Macrocephaly On ECMO Follow finding detected in utero/syndromic Screening Standard views and anatomy < 32 weeks, 1500 g Majority of bleeding identified within the first week < 28 weeks, < 1000 g Most at risk 1 st screen in asymptomatic infant Between 7 and 14 days If normal, follow-up at term (36-40 w) If abnormal, tailor follow-up individually 17

18 Corpus callosum Cingulate gyrus Frontal white matter Frontal White Matter Circle of Willis Cavum septum pellucidum Cerebellar vermis Belly of Pons Cerebral peduncles Quadrigeminal plate 4V Cisterna magna Quadrigeminal plate cistern Choroid plexus Centrum semiovale Intracranial hemorrhage Premature Term Choroid in atrium of LV Caudothalamic groove Centrum semiovale GMH IVH Intraparenchymal Venous infarct periventricular Hypoxic-ischemic PVL Intracerebellar Subarachnoid IVH Intraparenchymal Subdural Intracranial hemorrhage Grade I: subependymal (GMH) 75% of total Grade II: intraventricular (IVH) without ventricular dilatation 25% develop Post hemorrhagic hydrocephalus (PHH) Grade III: IVH with ventricular dilatation 50% PHH 20% mortality Grade IV: parenchymal hemorrhage 5% of total with gestational age > 50% mortality 90% major motor deficits 70% cognitive dysfunction Germinal Matrix Hemorrhage Germinal matrix Cellular region of caudate Source of neuronal and glial precursors Involutes by 36 weeks Fetus has poor autoregulation of CBF Immature, complex vascular feeders of GM Poor response to changes in cerebral blood flow Hypo/hypertension Elevated cerebral venous pressure Bleeds on caudate Extension into ventricles IVH 18

19 Periventricular infarct ICH Grade IV GMH venous congestion and back pressure Causes venous hemorrhagic infarct Not bleeding from GM leaking into brain Sequelae PH Hydrocephalus Acute obstruction by clot Obliterative arachnoiditis Malfunction of pacchionian granulation Clot in cisterna magna increases risk Mastoid view Motor defect Developmental delay Acquired subependymal cyst from evolving hemorrhage ICH grade 2 Lateral ventricles full of blood without dilatation Grade 2 IVH 3 day follow up Dilated ventricles, clot Post hemorrhagic hydrocephalus NOT evolution to grade 3 Prognostically important L R L R ICH Grade 3 ICH grade 4 Dilated, clot filled ventricle Wedge of echogenicity Venous infarct Evolves to small cyst IVH 3 on left and 4 on right 19

20 Porencephalic cyst Cystic resolution of venous infarct Here has wide communication with lateral ventricle Periventricular Leukomalacia Periventricular Leukomalacia Acute Echogenic region of necrosis 1-3 weeks WM cysts End stage Ventriculomegally Loss of PVWM GM impingement on vents Lobulated ventricular walls US relatively insensitive Detects 30-50% MRI Diffusion images show extent Need image early in course CT not sensitive Grade 1 increased PV echogenicity > 7 days Asymmetric, coarse, globular or more hyperechoic than the choroid plexus Normal periventricular halo Hyperechoic 'blush' posterosuperior to the ventricular trigones Grade 2 small PV cysts Grade 3 extensive occipital and frontoparietal PV cysts Grade 4 deep WM subcortical cysts Grade 1 PVL vs. flaring PVL grade 2 Normal flaring of PV white matter Not more echogenic than choroid Grade 1 PVL Resolves on follow up 20

21 PVL grade 3 PVL grade 2 PVL grade 4 21