1 / 114

Imaging the Misshapen Head

Imaging the Misshapen Head. David Nielsen, MD Pediatric Radiologist. Imaging the Misshapen Head. Objective: Better understand how to image the most common causes of a misshapen head. Imaging the Misshapen Head. Common causes: Macrocephaly Microcephaly Craniosynostosis

wright
Download Presentation

Imaging the Misshapen Head

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

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

More Related