医学专题一新生儿颅脑超声.pptx

新生儿颅脑新生儿颅脑(l no)超声影像超声影像汪元芳MD,ARDMS,ARVT第一页，共四十六页。Neurosonography 1Neurosonography 1 Technique,Indication,AnatomyTechnique,Indication,Anatomy ProtocolProtocol IVH&PVLIVH&PVL Spinal SonographySpinal Sonography第二页，共四十六页。Technique and IndicationTechnique and IndicationRoutinely for premature infants at 6 days and 4 weeks and as needed to rule out Intraventricular Hemorrhage and Periventricular Leukomalacia,as well as other abnormalitiesTypically up to 9 months or as long as fontanelle is openUse anterior fontanelle mostly,also transmastoid and posterior for better visualization of the posterior fossa and 4th ventricleHighest frequency transducer to allow sufficient penetration and resolution(curved or vector),linear images to define superficial structures第三页，共四十六页。AnatomyAnatomyCorpus CollosumCSPCavum VergaeVelum InterpositumVentriclesChoroid PlexusCerebellumCaudate NucleusThalamusSylvian FissuresCircle of WillisCerebral HemispheresBrain CoveringLobes of Cerebrum第四页，共四十六页。Lobes of CerebrumLobes of CerebrumTemporalTemporalParietalParietalFrontalFrontalOcciptalOcciptal第五页，共四十六页。VentriclesVentriclesLateral Ventricle-Frontal Horn-Body-Occipital Horn-Temporal Horn第六页，共四十六页。第七页，共四十六页。AnatomyAnatomy CSF PathwayCSF Pathway-Choroid Plexus-Lateral Ventricles-Foramina of Monro-3rd Ventricle-Aqueduct of Sylvius-4th Ventricle-Foramina of Magendie and Luschka-Foramen Magnum 第八页，共四十六页。AnatomyAnatomy Covering of BrainCovering of BrainSubdural Subdural VsVsSubarachnoidSubarachnoidSubarachnoidSpaceSubduralSpace第九页，共四十六页。BESSIBESSI(Benign Enlargement of the Subarachnoid Benign Enlargement of the Subarachnoid Spaces of Infancy)Spaces of Infancy)-Enlargement of frontal,temporal extracerebral CSF spaces,enlargement of the frontal horns,and macrocephaly-Will show bridging cortical veins(to distinguish between subdural collections which are never benign)Subarachnoid Subarachnoid VsVsSubduralSubdural第十页，共四十六页。Subarachnoid Subarachnoid VsVsSubduralSubdural第十一页，共四十六页。ProtocolProtocolCoronal Images(frontal occipital)Frontal at level of orbitsOrbital BonesFrontal horns Anterior to Foramen of MonroMCA Region(Measure Lat.Vents.)Foramen of MonroPosterior aspect of 3rd ventricle through thalamiCerebellum and Lateral Vents.BodiesTentoriumLaertal Vents.Including Choroid PlexusCortex of occipital lobes and posterior Interhemispheric Fissure(periventricular white matter)第十二页，共四十六页。ProtocolProtocolCoronalCoronalMCARegion of Circle of WillisMCAMeasure Lat.VentsMeasure Lat.Vents3rd VentSylvian Fissures第十三页，共四十六页。ProtocolProtocolCoronalCoronalThalami第十四页，共四十六页。ProtocolProtocolCoronalCoronalCerebellumTentoriumCerebellar Vermis第十五页，共四十六页。ProtocolProtocolCoronalCoronalChoroid Plexus in Lat.Vents.Periventricular White MatterInterhemispheric Fissure(Falx)第十六页，共四十六页。ProtocolProtocol ParasagittalMidline including corpus callosum,cavum,3rd and 4th vents,vermis,cisterna magnaCaudothalamic grooveFrontal horn of lat.VentBody of lat.Vent including temporal and occipital hornsSylvian fissueSulci/Gyri lateral第十七页，共四十六页。ProtocolProtocolParasagittalParasagittal3rd Vent.4th Vent.Cerebellar VermisAqueduct ofSylvius Corpus CollosumMidlineMidline第十八页，共四十六页。ProtocolProtocolParasagittalParasagittalCavum VergaeCisterna MagnaVelum InterpositumCavum SeptumPellucidumMidlineMidline第十九页，共四十六页。ProtocolProtocolParasagittalParasagittalThalamusCaudothalamic GrooveCaudate Nucleus第二十页，共四十六页。ProtocolProtocolParasagittalParasagittalTemperal Horn of Lat.VentSylvian FissureFrontal Horn of Lat.VentPeriventricularWhite Matter第二十一页，共四十六页。ProtocolProtocolParasagittalParasagittalPremature Smooth BrainSulcationTerm第二十二页，共四十六页。ProtocolProtocolTransmastoidView of cerebellum,4th ventricle,foramen magnumCerebellar hemisphere closer to transducer will have best resolution,thus we image the cerebellum from both the right and left mastoid fontanellesPosterior fontanelleImage the occipital horns of the lateral ventricles第二十三页，共四十六页。ProtocolProtocolPosteriorPosteriorOccipital Horn of Lat.Vent4th Vent.Cisterna MagnaTransmastoidTransmastoidCerebellum第二十四页，共四十六页。Interventricular HemorrhageInterventricular Hemorrhage(IVH)(IVH)Complications of prematurity:IVH and PVLGerminal matrix consists of proliferating cells that give rise to neuroblasts which migrate out to form the neurons of the cerebral cortex and the basal gangliaHighly vascular,consisting of network of thin-walled capillaries,veins and arteriolesEarly in gestation,germinal matrix forms subependymal lining of entire ventricular system.Maximizes in size at 23-24wks,then slowly regresses,involuting 3rd vent and occipital and temporal horns firstDuring end of gestation,only small area remains over caudate nucleus.By 36 weeks,almost completely gone.Germinal matrix hemorrhage in infants is usually venous in origin第二十五页，共四十六页。IVHIVHRisk Factors for IVH-premature infantInstability of Cardiovascular system leading to sudden increases in blood pressureAbsence of autoregulatory mechanism which maintains constant blood flow to brainMechanics of ventilation,tracheal suctioning,pnuemothorax,patent ductus arteriosus,and high inspired oxygen content because they all increase systemic pressure flow to brain第二十六页，共四十六页。IVHIVHClinical FindingsDiminished consciousness,apnea,decreased hematocrit,coma,seizures50%silent,detected by imaging80-90%of IVH occurs within first 4 days of life第二十七页，共四十六页。IVHIVHGrade I HemorrhageCoronally,echogenic mass inferolateral to floor of frontal horns and medial to head of caudate nucleusParasagitally,increased echogenicity anterior to caudothalamic grooveUnilateral or bilateral,subependymal,normal ventricle sizesResolving clot undergoes central liquefaction and may form tiny subependymal cyst第二十八页，共四十六页。IVHIVH第二十九页，共四十六页。IVHIVHGrade 2 HemorrhageIVH,hemorrhage ruptures through subependymal lining into lat.VentsEchogenic material fills part or all of NON-dilated ventricular system,may adhere to choroid and be difficult to distinguishDecreases in size and echogenicity over several weeksSubependymal lining of vents may develop echogenic lining due to chemical ventriculitis第三十页，共四十六页。IVHIVH第三十一页，共四十六页。IVHIVHGrade 3 HemorrhageIVH with ventricular enlargement of one or both lat.VentsMay extend into 3rd,4th vents,and cavumUsually resolves over 5-6 weeksMay resolve completely or persist as bands or septationsPost-hemorrhagic hydrocephalus in more than 2/3,usually remains mild-mod,few need shunt placement(10%)第三十二页，共四十六页。IVHIVH第三十三页，共四十六页。IVHIVHGrade 4 HemorrhageIVH with extension into the brain parenchyma adjacent to one or both lat.Vents,ventricular dilationCan cause mass effect with midline shiftTypically frontal or parietal,and unilateral(same side as IVH)If bilateral,usually assymetric-helping to differentiate from nonhemorrhagic ischemic lesions(PVL)which tend to be bilaterl,symmetricalBy 2-3 months,area of encephalomalacia develops,can communicate with ipsilateral lat.Vent which is often dilated第三十四页，共四十六页。IVHIVH第三十五页，共四十六页。Periventricular LeukomalaciaPeriventricular Leukomalacia(PVL)(PVL)In premature infant,same risk factors as for IVH.Systemic hypotension causes fall in cerebral perfusion,leading to ischemia,then infarction and ultimately PVLPVL is an ischemic lesion affecting the deep white matter adjacent to trigones of lat.vents and frontal horns near foramen of MonroClinically,hypotonia,seizures,apneic or bradycardiac episodes.25-40%of very low bw infants(1000g)Increased echogenicity of white matter seen sonographically第三十六页，共四十六页。PVLPVLSymmetric or assymetric2-3 weeks after ischemic insult,cystic changes occur cystic encephalomalaciaLarger area of PVL,great likelihood of hemorrhagicLarger area of PVL,more likely to have cystic formationCerebral atrophy later result of PVL shows as prominent interhemispheric fissures,cerebral sulci,and lat.VentsSpastic diplegia of both legs is classic neurologic sequela of PVL.In severe cases,may affect arms.Also,intellectual and visual deficits can occur.第三十七页，共四十六页。PVLPVL第三十八页，共四十六页。Spinal SonographySpinal SonographyMultiple images are obtained of the entire length of the spine in both sagittal and transverse scanning planesSpecial attention paid to area of question(dimple)to ensure no connection with spinal canalSpecific images needed to document cord positioning,Conus Medullaris,motion of the Filum Terminale and Nerve Roots,termination of the Thecal Sac第三十九页，共四十六页。Spinal SonographySpinal SonographyThe normal conus terminates above L3(usually L1-L2)The normal thecal sac terminates at S1-S2The normal cord and Cauda Equina should demonstrate vascular pulsations and should be demonstrated via m-mode as well as a cine第四十页，共四十六页。Spinal SonographySpinal SonographyConus Medullaris 第四十一页，共四十六页。Spinal SonographySpinal SonographyFilum TerminalisTermination of Thecal SacCauda Equina/Nerve Roots第四十二页，共四十六页。Spinal SonographySpinal Sonography第四十三页，共四十六页。Spinal SonographySpinal Sonography第四十四页，共四十六页。Spinal SonographySpinal SonographyTethered CordTethered Cord第四十五页，共四十六页。内容(nirng)总结新生儿颅脑(l no)超声影像。汪元芳MD,ARDMS,ARVT。Technique,Indication,Anatomy。in Lat.Vents.。Interhemispheric Fissure(Falx)。Tethered Cord第四十六页，共四十六页。