Pediatric Sonography

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					Pediatric Sonography

Pediatric Sonography
• Applicatons:
– – – – – – Neonatal Echoencephalography Evaluate jaundice Hypertrophic Pyloric Stenosis Urinary system evaluation Neonatal hip evaluation Neonatal spine

Neonatal Echoencephalography
• Ultrasound is the primary modality for the neonatal head
– – – – – Portable Readily available No radiation Non invasive Tolerated well by sick babies

Neonatal Echoencephalography
• Indications:
– – – – Abnormal findings in utero Premature infants Abnormal postnatal exam Difficult delivery – Hypoxia or Asphyxia

Neonatal Echoencephalography
• Premature infants:
– Brain damage is one of the primary concerns in a premature baby
• Intraventricular and subependymal hemorrhages occur in 40-70% of neonates under 34 weeks gestation

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Fontanelle
• Spaces between the bones of the skull • The fontanelles are not closed completely in a neonate

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Fontanelle
• The anterior fontanelle is easily felt as the “soft spot” • If hydrocephalus is present this fontanelle may be buldging • The transducer is placed
carefully on the anterior fontanelle to record multiple images of the brain in coronal, axial and sagital planes

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System
• The lateral ventricles are the largest of the cerebral spinal fluid cavities located within the cerebral hemispheres • They communicate with the third ventricle through the inerventricular foramen

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System
• There are two lateral ventricles • Each divided into 4 segments:
– – – – Frontal horn Body Occipital horn Temporal horn

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System
• Foramen of Monro – Connects the third ventricle with the lateral ventricles • Aqueduct of Sylvius – Connects the third and fourth ventricles • Foramen of Magendie – Continuous with the central canal of the spinal cord • Foramen of Luschka – Allows communication between the fourth ventricle and the subarachnoid space

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System – Cerebral Spinal Fluid
• Surrounds and protects the brain and spinal cord from physical impact • Approximately 40% of the CSF is formed by the choroid plexuses of the lateral, third and fourth ventricles • The rest is produced by the extracellular fluid movement from blood through the brain and into the ventricles

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System -CSF
• The fluid from the lateral ventricles passes through the foramen of Monro to the third ventricle • The fluid then passes through the aqueduct of Sylvius to the fourth ventricle • At that point the fluid may leave through the foramen of Magendie or the lateral foramen of Luschka

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System
• Cavum Septum Pellucidum
– Thin triangular space filled with CSF – Lies between the anterior horn of the lateral ventricles and forms the floor of the corpus callosum – The cavum spetum pellucidum is present at birth and closes within 3 to 6 months of life

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System
• Cavum Septum Pellucidum

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System
• Choroid Plexus
– Mass of special cells located in the atrium of the lateral ventricles – Regulate the intraventricular pressure by secretion of absorption of CSF – Glomus is the tail of the CP and a major site for bleeding

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Ventricular System
• Choroid Plexus

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Cisterns
• The narrow subarachnoid space surrounding the brain and spinal cord contains a small amount of fluid • The subarachnoid cisterns are the spaces at the base of the brain • The cisterna magna is one of the largest spaces located in the posterior fossa between the medulla oblongata, cerebeallar hemispheres and occipital bones

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Cisterns
• Cisterna Magna

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Cerebral Hemispheres
• Two hemispheres connected by the corpus collosum • Separated by a longitudinally by a longitudinal fissure

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Cerebrum
• Consists of gray and white matter • Cerebral cortex – outermost portion composed of gray matter • White matter is located within the cerebrum
– Largest and densest bundle of white matter is the corpus collosum

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Lobes
• Cortex is divided into four lobes • Lobes correspond to the cranial bones
– – – – Frontal Parietal Occipital Temporal

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Lobes

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Gyrus and Sulcus
• Gyri – convolutions on the surface of the brain caused by infolding of the cortex • Sulcus – groove or depression on the surface of the brain separating the gyri

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Corpus Callosum
• Forms broad bands of connecting fibers between the cerebral hemispheres • Forms the roof of the lateral ventricles

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Basal Ganglia
• Collection of gray matter that includes the caudate nucleus, claustrum and thalamus

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Brain Stem
• Part of the brain connecting the forebrain and the spinal cord • Contains the midbrain, pons and medulla oblongata

Neonatal Echoencephalography
• Anatomy of the neonatal brain
– Cerebellum
• Composed of two hemispheres that have the appearance of cauliflower • Lies in the posterior cranial fossa

Neonatal Echoencephalography
• Exam Protocol
– Exam is done in the NICU/nursery at bedside – Sonographer should contact the nurse to find out the status of the neonate before the examination – Warm gel should be used – If baby is in an isolette, keep in mind that the baby’s body temperature will decrease if the isolette is open for an extended amount of time – Wash your hands before and after the exam – Clean transducer between patients

Neonatal Echoencephalography
• Exam Protocol
– Coronal Plane

Neonatal Echoencephalography
• Exam Protocol
– Coronal Plane
• Transducer is placed on the anterior fontanelle with the scanning plane following the coronal suture • Critical that symmetrical images are obtained • Transducer is angled from the anterior to the posterior skull to completely visualize the lateral and third ventricles, the deep subcortical white matter and the basal ganglia

Neonatal Echoencephalography
• Exam Protocol
– Coronal Plane
• Angled anteriorly

Neonatal Echoencephalography
• Exam Protocol
– Coronal Plane
• Mid

Neonatal Echoencephalography
• Exam Protocol
– Coronal Plane
• Angled posteriorly
Last image: Page 592 Figure 21-17 F

Neonatal Echoencephalography
• Exam Protocol
– Sagittal Plane/Parasagittal plane

Neonatal Echoencephalography
• Exam Protocol
– Sagittal/Parasagittal Plane
• Rotated 90 degrees from the coronal plane • Transducer is placed on the anterior fontanelle and scanning plane follows the sagittal suture • Sagittal images provide the most extensive visualization of the brain
– Begin midline – perpendicular to the skull and then scan to the right and left

Neonatal Echoencephalography
• Exam Protocol
– Sagittal/Parasagittal Plane
• Midline

Neonatal Echoencephalography
• Exam Protocol
– Sagittal/Parasagittal Plane
• Right

Neonatal Echoencephalography
• Exam Protocol
– Sagittal/Parasagittal Plane
• Left

Pediatric Considerations
• Warm Gel – but not too much since it cools off quickly (remove gel as soon as possible) • Keep babies safe, secure and warm – wrap in blankets and only uncover area being scanned • Pacifiers • Bottles (if doing an abdomen exam – if surgery isn’t anticipated, examine gallbaldder and pancreas first and then give baby bottle) • Allow parents in the exam room • Distractions – toys, stickers, music, movies • Explain exam to parents of babies • Get help from other sonographers or enlist a parent to help

Pediatric Considerations
• • • • Take a break if child becomes restless Have parent hold child or lay down with child Explain procedure to older children Let older children touch gel and transducer so they know it doesn’t hurt • Work quickly

Pylorus
• Pyloric canal
– Located between the stomach and duodenum – In some infants the pyloric muscle can become hypertrophied, resulting in significantly delayed gastric emptying – Hypertrophy of the circular muscle of the pylorus is an acquired condition that narrows the pyloric canal

Pylorus
• Pyloric canal

Pylorus
• Pyloric canal
– Hypertrophic pyloric stenosis
• Appears most commonly in male infants between 2 and 6 weeks of age • Projectile vomiting is common due to the thickened pyloric muscle obstructing the stomach • Dehydration and weight loss may occur • An “olive shaped” mass is often felt in the RUQ

Pylorus
• Pyloric canal
– Hypertrophic pyloric stenosis
• Exam protocol
– If the stomach is empty then an oral feeding may be necessary to visualize the pyloric area » Water or Pedialyte – Exam is done in supine and RLD positions – A preliminary survey is done to exlude other abnormalities – Linear transducer

Pylorus
• Pyloric canal
– Hypertrophic pyloric stenosis
• Exam protocol
– Longitudinaly images are obtained by placing the transducer transversely across the RUQ just below the level of the xiphoid process – The transducer is then rotated obliquely until the pyloric muscle is visualized in its long axis

Pylorus
• Pyloric canal
– Hypertrophic pyloric stenosis
• Exam protocol
– Longitudinal image

Pylorus
• Pyloric canal
– Hypertrophic pyloric stenosis
• Exam protocol
– Transverse images are obtained from the coronal plane – After identifying the gallbladder the transducer can be angled medially until the bulls eye or target appearance is seen

Pylorus
• Pyloric canal
– Hypertrophic pyloric stenosis
• Exam protocol
– Transverse image

Pylorus
• Pyloric canal
– Hypertrophic pyloric stenosis
• Exam protocol
– RLD images and evaluation may be done for better visualization – Fluid may be give through a bottle if the stomach is empty

Pylorus
• Pyloric canal
– Hypertrophic pyloric stenosis
• Exam protocol
– Measurements » A diagnosis of HPS can be made when: » A muscle thickness of 3.5mm or greater on the long axis view » A channel length of 17mm or greater » Muscle length of 20mm or greater

Neonatal Hip
• Applications
– Rule out developmental displacement of the hip – Septic arthritis and/or joint effusion – Proximal focal femoral deficiency

Neonatal Hip
• Hip joint
– The hip joint is formed by the articulation of the head of the femur with the acetabulum of the hip bone

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Ultrasound imaging allows the fine details of the hip to be evaluated • The size, shape and position of the femoral head can be assessed sonographically well before the bones are ossified enough to see on radigraphs – Sonography can be used until femoral ossification occurs (begins around 2-8 months of age and is complete around 1 year of age • The motion of the femoral head in the acetabulum under stress can be tested

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Linear transducer is used • The femoral head appears hypoechoic because it is cartilaginous and contains a focal echogenic ossification nucleus • The femoral head sits within the acetabulum which is echogenic and has a deep concave configuration

Neonatal Hip
• Hip joint
– Sonographic evaluation

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Protocol includes four different views
– – – – Transverse – neutral Transverse – flexion Coronal – neutral Coronal – flexion

– Primary objective is to determine the position and stability of the femoral head and the development of the acetabulum

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Transverse – neutral
– Leg is brought down to a neutral position – Transducer is horizontal to the acetabulum

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Transverse – neutral
– Sonolucent femoral head is positioned against the bony acetabulum – “Flower” – femoral head is the flower and the echoes from the ischium and pubis anteriorly represent the leaves at its base » “Golf ball on tee”

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Transverse – neutral

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Transverse – flexion
– Transducer is moved posteriorly over the hip joint

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Transverse – flexion
– The bony shaft of the femur gives off bright reflected echoes anteriorly adjacent to the femoral head – The echoes from the bony acetabulum appear posteriorly to the femoral head – The normal hip produces a “U” configuration

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Transverse – flexion

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Transverse – flexion
– Abduction and adduction maneuvers are done » Deep “U” is produced with maximum abduction » “V” is produced with adduction – Barlow maneuver is done to asses stability » In a normal hip the femoral head will remain deeply within the acetabulum

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Graf’s alpha and beta angles
– A series of lines and angle measurements used to evaluate the morphology of the acetabulum

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Coronal – neutral
– Supine – Transducer positioned coronally with the hip joint

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Coronal – neutral
– The midportion of the acetabulum with the straight iliac line superiorly and the inferior tip of the os ilium medially within the acetabulum

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Coronal – neutral

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Coronal – neutral • Alpha and beta angles

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Coronal – flexion
– Transducer position is maintained – Hip is moved into a 90 degree angle of flexion

Neonatal Hip
• Hip joint
– Sonographic evaluation
• Coronal – flexion
– To check for instability » Push and pull maneuver » Barlow maneuver

» These maneuvers are usually performed by an orthopedist or a radiologist » May be done by an experienced pediatric sonographer in some departments

Reference
• The Textbook of Diagnostic Ultrasonography 6th edition. HagenAnsert.