Download
imaging the misshapen head n.
Skip this Video
Loading SlideShow in 5 Seconds..
Imaging the Misshapen Head PowerPoint Presentation
Download Presentation
Imaging the Misshapen Head

Imaging the Misshapen Head

329 Views Download Presentation
Download Presentation

Imaging the Misshapen Head

- - - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript

  1. Imaging the Misshapen Head David Nielsen, MD Pediatric Radiologist

  2. Imaging the Misshapen Head • Objective: • Better understand how to image the most common causes of a misshapen head

  3. Imaging the Misshapen Head • Common causes: • Macrocephaly • Microcephaly • Craniosynostosis • Posterior plagiocephaly

  4. Imaging the Misshapen Head • Common causes: • Macrocephaly • Microcephaly • Craniosynostosis • Posterior plagiocephaly

  5. Macrocephaly • Definition: • Macrocephaly = Macrocrania

  6. Macrocephaly • Definition: • Macrocephaly = Macrocrania • Head circumference > 2SD (> 95%) above the mean for age, sex, race, and gestation

  7. What is the most common imaging finding in macrocephaly? • Hydrocephalus • Benign Enlarged Subarachnoid Spaces (BESS) • Subdural Hematoma • Intracranial Mass

  8. Macrocephaly • Ddx: • #1: Benign Enlarged Subarachnoid Spaces (BESS) • Also called: • Benign macrocrania • Benign extra-axial collections • Benign external hydrocephalus • Transient communicating hydrocephalus BESS NL

  9. Macrocephaly • Benign enlarged subarachnoid spaces • Clinical:

  10. Macrocephaly • Benign enlarged subarachnoid spaces • Clinical: • Macrocephaly presents between 3-6 months and peaks at about 7 months

  11. Macrocephaly • Benign enlarged subarachnoid spaces • Clinical: • Macrocephaly presents between 3-6 months and peaks at about 7 months • May have family history of macrocephaly

  12. Macrocephaly • Benign enlarged subarachnoid spaces • Clinical: • Macrocephaly presents between 3-6 months and peaks at about 7 months • May have family history of macrocephaly • Normal developmental/neurological exam

  13. Macrocephaly • Benign enlarged subarachnoid spaces • Clinical: • Macrocephaly presents between 3-6 months and peaks at about 7 months • May have family history of macrocephaly • Normal developmental/neurological exam • Stabilizes by 18 months along a curve paralleling the 95% curve

  14. Macrocephaly • Benign enlarged subarachnoid spaces • Clinical: • Macrocephaly presents between 3-6 months and peaks at about 7 months • May have family history of macrocephaly • Normal developmental/neurological exam • Stabilizes by 18 months along a curve paralleling the 95% curve • Spontaneously resolves by 24-36 months

  15. Macrocephaly • Benign enlarged subarachnoid spaces • Imaging:

  16. Macrocephaly • Benign enlarged subarachnoid spaces • Imaging: • Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures

  17. Macrocephaly • Benign enlarged subarachnoid spaces • Imaging: • Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures • No mass effect

  18. Macrocephaly • Benign enlarged subarachnoid spaces • Imaging: • Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures • No mass effect • Same imaging characteristics as CSF

  19. Macrocephaly • Benign enlarged subarachnoid spaces • Imaging: • Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures • No mass effect • Same imaging characteristics as CSF • Cortical veins course through the fluid

  20. Macrocephaly • Benign enlarged subarachnoid spaces • Imaging: • Symmetrical enlargement over the frontoparietal convexities and within the interhemispheric fissure, cortical sulci, and sylvian fissures • No mass effect • Same imaging characteristics as CSF • Cortical veins course through the fluid • Ventricles are normal or mildly enlarged

  21. Macrocephaly Cortical veins Benign enlarged subarachnoid spaces

  22. Macrocephaly Cortical veins Benign enlarged subarachnoid spaces

  23. Macrocephaly • Ddx: • #1: Benign Enlarged Subarachnoid Spaces (BESS) • Other: • Hydrocephalus (HC) • Subdural hematoma • Intracranial mass (rare) • Congenital/syndromic/metabolic (rare)

  24. Macrocephaly • Imaging is based on development and fontanel/age:

  25. Macrocephaly

  26. Macrocephaly • Normal neurological exam with open fontanel

  27. Macrocephaly • Normal neurological exam with open fontanel • Short-term clinical follow-up with serial head circumference measurements with or without ultrasound

  28. Macrocephaly • Normal neurological exam with open fontanel • Short-term clinical follow-up with serial head circumference measurements with or without ultrasound • If head stabilizes (i.e. measurements again parallel the normal curve), the likely diagnosis is BESS:

  29. Macrocephaly • Normal neurological exam with open fontanel • Short-term clinical follow-up with serial head circumference measurements with or without ultrasound • If head stabilizes (i.e. measurements again parallel the normal curve), the likely diagnosis is BESS: • No imaging (or no additional imaging) is recommended

  30. Macrocephaly • Normal neurological exam with open fontanel • Short-term clinical follow-up with serial head circumference measurements with or without ultrasound • If head stabilizes (i.e. measurements again parallel the normal curve), the likely diagnosis is BESS: • No imaging (or no additional imaging) is recommended • If head continues to enlarge disproportionate to the child’s growth (i.e. measurements do not again parallel the normal curve) and clinical exam is still otherwise normal:

  31. Macrocephaly • Normal neurological exam with open fontanel • Short-term clinical follow-up with serial head circumference measurements with or without ultrasound • If head stabilizes (i.e. measurements again parallel the normal curve), the likely diagnosis is BESS: • No imaging (or no additional imaging) is recommended • If head continues to enlarge disproportionate to the child’s growth (i.e. measurements do not again parallel the normal curve) and clinical exam is still otherwise normal: • Ultrasound to screen for severe hydrocephalus or large mass

  32. Macrocephaly Benign enlarged subarachnoid spaces

  33. Macrocephaly Choroid plexus papilloma

  34. Macrocephaly

  35. Macrocephaly • Normal neurological exam with closed fontanel

  36. Macrocephaly • Normal neurological exam with closed fontanel • Case-by-case risk/benefit assessment of short-term clinical follow-up with serial head circumference measurements versus imaging with CT (radiation risk) or MRI (sedation risk)

  37. Macrocephaly • Normal neurological exam with closed fontanel • Case-by-case risk/benefit assessment of short-term clinical follow-up with serial head circumference measurements versus imaging with CT (radiation risk) or MRI (sedation risk) • Each modality also has advantages for the clinical question to be answered (e.g. CT is preferred for bones)

  38. Macrocephaly 11 mo 6 mo Benign enlarged subarachnoid spaces

  39. Macrocephaly Pilocytic Astrocytoma

  40. Macrocephaly MRI - Benign enlarged subarachnoid spaces

  41. Macrocephaly

  42. Macrocephaly • Abnormal developmental/neurological exam with open or closed fontanel

  43. Macrocephaly • Abnormal developmental/neurological exam with open or closed fontanel • MRI to evaluate brain parenchyma, extra-axial spaces

  44. Macrocephaly Non-communicating hydrocephalus

  45. Macrocephaly Anaplastic medulloblastoma

  46. Macrocephaly • This approach to imaging macrocephaly reduces both unnecessary imaging and radiation exposure References: Smith, MR, JC Leonidas, J Maytal. The Value of Head Ultrasound in Infants with Macrocephaly. Pediatric Radiology 1998; 28:143-146. Wilms G, Vanderschueren G, et al. CT and MR in infants with pericerebral collections and macrocephaly: benign enlargement of the subarachnoid spaces versus subdural collections. American Journal of Neuroradiology 1993; 14:855-860. Hudgins, R, Boydston WR. All Heads Great and Small, Macrocephaly. Children’s Healthcare of Atlanta. http://www.choa.org/default.aspx?id=921. Accessed June 15, 2008.

  47. 12-month-old male with macrocephaly and developmental delay. What study is indicated? • Ultrasound • CT • MRI • Brain PET scan

  48. Imaging the Misshapen Head • Common causes: • Macrocephaly • Microcephaly • Craniosynostosis • Posterior plagiocephaly

  49. Imaging the Misshapen Head • Common causes: • Macrocephaly • Microcephaly • Craniosynostosis • Posterior plagiocephaly

  50. Microcephaly • Definition: • Head circumference < 2SD (< 5%) below the mean for age, sex, race, and gestation