Basic Training. ISUOG Basic Training Distinguishing Between Normal & Abnormal Appearances of the Skull & Brain
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1 ISUOG Distinguishing Between Normal & Abnormal Appearances of the Skull & Brain
2 Learning objectives At the end of the lecture you will be able to: Describe how to obtain the 3 planes required to assess, including measuring, the fetal head correctly Recognise the differences between the normal & most common abnormal ultrasound appearances of the 3 planes of the fetal brain
3 Three basic axial planes of the head TRANS VENTRICULAR Skull, Falx, CSP, LV TRANS THALAMIC BIOMETRY BPD, OFD, HC TRANS CEREBELLAR BIOMETRY- TCD Cerebellum/ vermis
4 Imaging the Head The three planes technique 1. Identify cervical spine and occipital junction in sag plane 2. Rotate probe 90 0 & identify the cranial vault 3. Gently angulate probe to identify trans ventricular plane and trans thalamic plane 4. Gently rotate probe towards occiput for trans cerebellar plane ensure CSP is also seen anteriorly
5 From plane 4 to 5 (rotate &) slide minimally Planes 4, 5 & 6 From plane 4 to 6 - rotate from plane 1 or 2 to 4 - rotate through 90 0 From plane 1 or 2 to 4 Identify junction of cervical spine & occiput - rotate through 90 0
6 The trans ventricular plane plane 4/20 The most cephalad of the three planes Integrity: Intactness of skull 2.Bone density : Poor visualization of near field 3.Falx : Interrupted by CSP Occipital / posterior horn of lower lateral ventricle 5.Frontal horns of BOTH lateral ventricles
7 Lateral ventricles - Technique of measurement: Symmetrical axial view / Optimal zoom Atrium measured at the level of the glomus of choroid plexus, opposite the parieto occipital sulcus Calipers placed touching the inner edge of the ventricle wall at its widest part, aligned perpendicular to the long axis of the ventricle +
8 Measurement of lateral ventricles Normal Occipital horn of lateral ventricle < 10mm Refer if LV size is > 10mm
9 The transthalamic plane 5/20 - anatomical landmarks 1. Midline falx 2. Cavum septum pellucidum Both thalami in apposition separated by the falx 4 4. Hippocampal gyri 5 5. The lateral sulcus
10 Cranial biometry BPD & head circumference 1. Trans thalamic plane 2. Angle of insonation 90 deg to midline echoes 3. Symmetric hemispheres 4. Falx with CSP & thalamus CALIPERS: Outer to inner Cerebellum NOT to be visualised Use appropriate charts
11 Cranial biometry BPD & head circumference BPD/ OFD CEPHALIC INDEX - BPD/OFD X Normal < 75 - Dolicocephaly >85 - Brachycephaly HC
12 Head circumference chart Use standard reference charts Refer if HC outside normal range for period of gestation
13 Cranial biometry cerebellar diameter Key points Ensure complete visualization of CB Ensure anatomical landmarks avoid steep angulation
14 The trans cerebellar plane 6/ Frontal horns of both LV 2. Cavum septum pellucidi 3.Thalami 4.Cerebellum 5. Cisterna magna
15 Trans cerebellar plane biometry Trans cerebellar diameter Maximum Diameter in the correct plane Cisterna magna vermis to inner edge of occipital bone (normal range mm) Refer if : TCD < 5 th centile for period of gestation, Cisterna magna > 10mm Two cerebellar hemispheres appear separated
16 Common abnormalities to be excluded in the three planes ( 4, 5,6)
17 The cranial vault ANENCEPHALY
18 The cranial vault lemon sign of open ntd
19 Other head shapes Dolicocephaly Strawberry Clover leaf Brachycephaly
20 OSTEOGENESIS IMPERFECTA POOR MINERALISATION OF SKULL REDUCED BONE DENSITY NORMAL SKULL POOR NEAR FIELD VISIBILITY
21 The cranial vault- skull integrity Cephaloceles Can occur anywhere Most common in the occipital regaion Meningocele / meningo encephalocele Varying sizes
22 Trans thalamic & ventricular planes ventriculomegaly mm 16 mm Post horn >10mm Refer if LV size is >10 mm Ventricular shape tear drop in ACC Tear drop
23 Holoprosencephaly Several types Alobar most severe Associated anomalies may be present Refer if Midline Falx is not visualized and ventricles are fused
24 Trans cerebellar plane anomalies Banana shaped cerebellum in Spina Bifida Cisterna Magna > 10 mm Mega cisterna magna
25 Trans cerebellar plane anomalies Dandy walker Malformation
26 Trans cerebellar plane anomalies Cystic hygroma Edema hydrops
27 Key features of planes 4, 5 and 6 Plane 4 TRANS VENTRICULAR Plane 5 TRANS THALAMIC Plane 6 TRANS CEREBELLAR Skull, Falx, CSP, LV BIOMETRY BPD, OFD, HC BIOMETRY- TCD Cerebellum/ vermis Anencephaly, Cephalocele Alobar holoprosencephaly Ventriculomegaly Post fossa cyst Mega cisterna Magna Cystic hygroma Scalp Edema
28 Key Take Home Points Head is imaged in three planes Lateral ventricular plane, Trans thalamic plane & Trans cerebellar plane It is important to identify the specific landmarks Any variation in the appearances should raise suspicion of an anomaly Lateral ventricle > 10mm, Cisterna magna > 10mm refer Head circumference < 5 th centile / > 95 th Centile refer Trans cerebellar diameter < 5 th centile or altered shape refer
29 THANK YOU
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