An Atlas of Neonatal Brain Sonography, 2nd Edition

Springer.

PART I

NORMAL ANATOMY

1

SULCI AND GYRI

OVERVIEW

Sulci are linear structures separating gyri. Most develop in a particular sequence well before the 28th week of gestation and constitute a good indicator for gestational age (Chi et al 1977, Feess-Higgins and Larroche 1987). Their echogenicity on ultrasound is brought about by the presence of collagen and blood vessels in the pia mater, contrasting with the watery brain parenchyma. Antenatal sonography clearly shows the interhemispheric fissure at the 10th week and the lateral fissure at the 19th week. The frontal parts of the cingulate, central and calcarine sulci show echographically shortly before the 26th week. The cingulate sulcus develops fully between the 28th week and the 31st week, as well as the inferior temporal sulcus and the circular sulcus of the insula. The latter comes to full development with most ramifications of the cingulate sulcus and the tertiary sulci after the 31st week (Slagle et al 1989). The postcentral sulcus develops around the 30th week and constitutes a boundary with the postcentral gyrus. Gyral development is asymmetrical even at 32 weeks gestation, when the right gyral pattern is already slightly in advance. The left planum temporale is bigger at this stage, a prelude to language development. Twins develop gyri at a standard pace minus about two weeks. A 10 MHz ultrasound scanhead is recommended for evaluation of sulci and gyri along the convexity of the cerebrum. Knowledge of the normal maturation of sulci and gyri is necessary to identify abnormal insular gyration in polymicrogyria and hemimegalencephaly. Lesions in the posterior frontal or parietal parenchyma must be situated in relation to primary cortex in front of the central sulcus; the latter can be located in parasagittal sections through recognition of the cingular sulcus and its supramarginal branch at the caudal end of the paracentral lobule. The central sulcus has an omega-shape because of a posterior bend around midlevel between sinus and insula, the ‘hand-knob’.

Fig. 1.1 Mesial surface at 29 weeks gestation.

Fig. 1.2 Mesial surface at term.

Fig. 1.3 The main gyri and their first anatomical appearance (in weeks postconceptional age) (sc = central sulcus; sca = calcarine sulcus; sci = cingulate sulcus; scoll = collateral sulcus; sip = intraparietal sulcus; sl = lateral sulcus; spc = precentral sulcus; spo = parieto-occipital sulcus; spoc = postcentral sulcus; ssp = subparietal sulcus; st = temporal sulcus). The central sulcus reaches the superior cerebral convexity around 30 weeks; the corpus callosum is completely shaped into its definitive form by around 16 weeks. (Based on Smith and van der Kooy 1985.)

Fig. 1.4 The primary sulci and fissures are highlighted on these drawings; the top images are lateral (left) and mesial (right) views of the brain of an infant born at 28 weeks gestation; the bottom images are from an infant with a postconceptional age of 37 weeks. Between 30 weeks and term the secondary and tertiary sulci appear; the gyral complexity at term resembles that of the adult. (Based on Feess-Higgins and Larroche 1987.)

TABLE 1.1

Anatomical development: gyri and sulci, corpus callosum, cerebellum

(PARA)SAGITTAL SECTIONS

Bordering the midline and above the level of the ventricles the following can be seen:

The cingulate sulcus and the sulcus of the corpus callosum bordering superior frontal gyrus, cingulate gyrus and corpus callosum.

The craniocaudal course of the precentral, the cingulate and the parieto-occipital sulcus, which constitute a boundary with, respectively, the superior frontal gyrus, the paracentral lobule and precuneus.

The subparietal sulcus continues the course of the cingulate sulcus.

The mesial end of the central sulcus, rostral to the perpendicularly curved marginal and cingulate sulci; between the precentral and cingulate sulcus is the paracentral lobule.

The calcarine sulcus forms a boundary with the cuneus and the medial occipitotemporal gyrus.

The insular anatomy can be easily related to the central groove (Fig. 1.6). Insular lobe anatomy is discussed in Chapter 5 on normal anatomy of lobar parenchyma. Developmental aspects of the insular area are discussed under disorders of neuronal migration.

Fig. 1.5 Immediate parasagittal section at 37 weeks gestation (7.5 MHz). Recognition of the main mesial sulci and the areas they border.

Figs 1.6 and 1.7 Outer parasagittal section at 29 weeks gestation (top) and at term (bottom). Recognition of the insular triangle and its relation to the central sulcus.

FRONTAL SECTIONS

These sections show how sulci penetrate the brain cortex over a short distance. The cingulate and corpus callosum sulci are perpendicular to the interhemispheric fissure. Laterally in the brain parenchyma, on a level with the middle cranial fossa, one can see Y-shaped echodense lines. They are from the sylvian or lateral sulci. The extremities of the upward and downward branches of this Y correspond to the circular sulcus of the insula. Originally wide open, the insula closes later on (after the 31st week) (Figs 1.11 and 1.12). The lower arm of the sylvian fissure is particularly long in frontal echosections whereas it is shorter at the level of the hippocampus. More ventrally the lateral sulcus constitutes the cranial boundary of the temporal lobe. The middle cerebral artery M1 part courses from medial to lateral in the lateral sulcus. The parahippocampal gyrus lies medial to the temporal horn of the lateral ventricle: this is the most medial gyrus of the temporal lobe, bordered by the collateral sulcus. In (near) term infants the omega-shape of the central sulcus (a caudal bulge between insula and superior sagittal sinus) can be appreciated.

Figs 1.8, 1.9 and 1.10 Frontal sections at 34 postmenstrual weeks (sc = cingulate sulcus).

Figs 1.11 and 1.12 Maturation of the insula and its coverings (opercula) at 25, 32 and 40 weeks of gestation. The left set of coronal images are behind the foramen of Monro and the right set are at insular level, through the insular gyri. Between 26 and 32 weeks the opercula start to meet and hide the insular cortex. On coronal images this produces a recumbent Y, the limbs of which lengthen with increasing gestational age. On parasagittal section the open triangular space (island) of 25 weeks turns into a covered triangular area with complex linear echodensities representing short and long gyri fanning out from the limen insulae.

Fig. 1.13 Anterior coronal section (29 weeks). The straight gyri are separated from each other by the interhemispheric fissure, and laterally from the orbital gyri by the olfactory sulci.

PARTICULAR SULCI

Several planes of section are presented below to illustrate the olfactory sulci, the hippocampal layering, the collateral sulcus, the lateral fissure and the cingulate sulcus.

Figs 1.14 and 1.15 Axial section at 32 weeks showing the straight gyri, the uncus and the optic tract (rostral end at the top). Coronal T2 MR (right) at the level of the straight gyrus and olfactory sulcus.

Figs 1.16, 1.17, 1.18 and 1.19 Axial (middle left), coronal (middle right) and parasagittal (below right) sections to demonstrate the collateral sulcus (arrows). (Schematic drawing based on Nieuwenhuys et al 1988.)

Fig. 1.20 Parasagittal section (29 weeks) through the uncus. The fissure of Bichat separates the basal ganglia and thalamus from the hippocampus. Within the latter the hippocampal sulcus is the dividing line between subiculum and dentate gyrus.

Fig. 1.21 Parasagittal section at 29 weeks showing the lateral fissure under and behind the insular dome.

Fig. 1.22 Some aspects of development of the cingulate sulcus shown against the mesial surface of the right hemisphere at 29 weeks gestation. (Published with permission, Slagle et al 1989.)

Figs 1.23, 1.24, 1.25, 1.26 The central sulcus (central sulcus of Rolando) is the large and deep sulcus in front of the supramarginal sulcus ascending on the mesial surface from the cingulate sulcus. On the cerebral convexity it is the sinuous groove with a constant knob to the back (the omega of the hand representation in the motor homunculus). From the primary motor cortex in front of the central sulcus, the corticospinal fibres descend into the posterior limb of the internal capsule (PLIC); Fig. 1.26 is a superior view of the brain with a three-dimensional ultrasound scan.

FURTHER READING

Bernard C, Droullé P, Didier F, Gérard H, Larroche JC, Plénat F, Bomsel F, Roland J, Hoeffel JC (1988) Aspects echographiques des sillons cérébraux à la période anté et péri-natale. Journal de Radiologie 69: 521–532.

Chi JG, Dooling EC, Gilles FH (1977) Gyral development of the human brain. Ann Neurol 1: 86–93.

Feess-Higgins A, Larroche J-C (1987) Le développement du cerveau foetal humain. Atlas anatomique. Paris: Masson.

Huang C-C (1991) Sonographic cerebral sulcal development in premature newborns. Brain Dev 13: 27–31.

Murphy NP, Rennie J, Cooke RWI (1989) Cranial ultrasound assessment of gestational age in low birthweight infants. Arch Dis Child 64: 569–572.

Naidich TP, Grant JL, Altman N, Zimmerman RA, Birchansky SB, Braffman B, Daniel JL (1994) The developing cerebral surface. Neuroimaging Clin N Am 2: 201–224

Nieuwenhuys R, Voogd J, van Huijzen C (1988) The Human Central Nervous System, 3rd edn. Berlin: Springer-Verlag.

Slagle TA, Oliphant M, Gross SJ (1989) Cingulate sulcus development in preterm infants. Pediatr Res 26: 598–602.

van der Knaap MS, van Wezel-Meijler A, Barth PG, Barkhof F, Ader HJ, Valk J (1996) Normal gyration and sulcation in preterm and term neonates: appearance on MR images. Radiology 200: 389–396.

2

LATERAL VENTRICLES

OVERVIEW

The lateral ventricles are cavities filled with cerebrospinal fluid (CSF), seen on ultrasound as echofree zones. They are found on both sides under the falx and are inferolaterally bordered by the head of the caudate nucleus. Their shape resembles a horseshoe curled round the caudate nucleus, thalamus and cerebral peduncles. The lateral ventricles each consist of a body (corpus), an atrium and three horns. On a cross-section, the corpus is seen as a triangle pointing laterally upwards, with a slight convex bulge towards the vertex. On its floor there is vascular tissue resting on thalamic nuclei, while medially the fornix borders the ventricular floor. The frontal horn has an elliptical slit-shaped lumen, partly covered by the corpus callosum and situated laterally to the septum pellucidum. The temporal or sphenoidal horn ends in the ventricular atrium. Medially the temporal horn is bordered by the pes of the hippocampus; its existence can be detected echographically via the plexus that hangs in it. The occipital horn is not always well visualized from the anterior fontanelle, its dimensions differing from one individual to another. Inspection from the posterior fontanelle is useful to confirm mild intraventricular haemorrhage (IVH). The choroid plexus projects horizontally in the direction of the occipital lobe. The choroid plexus of the lateral ventricle, found on the floor of the body of the ventricle, continues into the roof of the temporal horn. Frontal and occipital horns do not contain plexus.

Fig. 2.1 The ventricular cavities from above (v = ventricle). (Based on Paturet 1964.)

The foramen of Monro is the connecting passage between the third ventricle and the frontal horn of the right or left lateral ventricle. In the absence of ventriculomegaly it is not always visible. It can be localized as the place where the third ventricle plexus curves into the lateral ventricle in the foramen’s upper caudal margin.

Figs 2.2, 2.3 and 2.4 7.5 MHz scans of a healthy term infant: (a) coronal view just in front of the foramen of Monro; (b) coronal view through choroid glomus (both sections indicated on a parasagittal section). These images demonstrate normal lateral ventricle cavities at term with an equal width of frontal and parietal size; asymmetry in volume is not uncommon, but is abnormal if the difference is marked. These differences are discussed in detail in the Chapter 15 on unilateral hydrocephalus.

SIZE OF THE LATERAL VENTRICLE

In healthy children and neonates the lateral ventricles are often asymmetrical (i.e. the diagonals of the right and left lateral ventricle differ at least 2 mm in a frontal section at the level of the foramen of Monro). Different types of asymmetry have been described depending on the place where mild asymmetrical dilatation is most clear (body and/or occipital horn). The left ventricle tends to be larger, a predilection that is not related to head presentation at vaginal delivery. There is no significant difference between underlying and upper ventricle in case of lateral head position. Dilatation of the lateral ventricles often begins in the occipital horns. If they are not clearly seen, this is an argument against the presence of dilatation. In cases of obvious ventriculomegaly, the concavity that characterizes the floor of the frontal horn disappears, whereby the normal boomerang shape is gradually lost. If one can clearly see the whole ventricle in one parasagittal section, including temporal and occipital horns, ventriculomegaly must be present.

Most studies prefer to define lateral ventricle width as a function of cranial width (the cella media index). This produces indices which, under normal circumstances, tend to remain constant during the first months of life. They are good tools for recognition of hydrocephalus. In term neonates the following data are found:

Fig. 2.5 From rostral to caudal, the contours (black) of the lateral ventricle cavity in coronal section.

On an axial section through the body of the lateral ventricle the ratio [midline to lateral wall of the ventricle]/[midline to internal table of the skull] varies between 0.25 and 0.35 (0.22–0.33 according to Helmke and Winkler 1987).

On a frontal section through the head of the caudate nucleus the ratio [laterolateral diameter between the points of the frontal horns]/[distance between the left and right internal table on that section] averages 0.32 (95 per cent reliability margin 0.23–0.42).

Slightly higher ratios have been found in preterm (0.32–0.36) than in term infants (0.25–0.30). Term values are achieved around 36 weeks gestation. Such a ratio measured behind the foramen of Monro, at the level of the corpus of the lateral ventricle, tends to be 0.35 at or around term. It has been customary to talk about ventriculomegaly for values between 0.36 and 0.40, and about hydrocephalus for values above 0.40. The ventricular diameter can be followed serially on axial sections by measuring the distance between the falx and the external wall of the body of the opposite ventricle: 97th centile measurements for Levene’s lateral ventricle index are 10 mm around 26 weeks, 13 mm around 33 weeks and 14 mm around 40 weeks. The diagonal width of the lateral ventricle in a frontal section rarely exceeds 3 mm at the foramen of Monro. One speaks of ‘ballooned’ frontal horns when this diagonal measure exceeds 6 mm.

Fig. 2.6 Several indices of lateral ventricular size in an axially reconstructed sonogram (Kretz 3D technique). RF = roof to floor, LVI = Levene’s lateral ventricle index (notice site dependence, larger LVI expected towards the atrium coming from the foramen of Monro), LVS = Saliba’s lateral ventricle surface, CMI = cella media width.

Fig. 2.7 Levene’s lateral ventricle index. gestational age (weeks) index (mm)

Fig. 2.8 Saliba’s lateral ventricle surface measurement.

Another method consists of measuring the surface of the body of the lateral ventricle on a cross-section behind the foramen of Monro, through the base of the pons (Saliba et al 1990):

In preterm infants with a gestational age of 27 to 36 weeks, normal values show a broad range: around birth the surface varies between 5 and 15 mm², with an average value of about 8 mm².

Values of more than 15 mm² during the first week of life and more than 20 mm² during the first month of life appear to exceed the normal range. Any such value must be compared with the child’s head circumference and subarachnoid space width, to determine whether ventricular dilatation is due to obstruction of liquor flow or to loss of brain tissue.

In fetal life, the ventricle opposite the scanhead clearly shows its lateral wall as an echoic line; at the level of the corpus of the lateral ventricle, this line parallels the falx; the lateral ventricle width is represented by the distance between midline and far ventricle wall, identical to the lateral ventricle index after birth (Johnson et al 1980: mean width 8 mm at 16 weeks postmenstrual age, 9 mm at 26 weeks, 11 mm at 33 weeks and 12 mm at 40 weeks). Atrial width is constant in the third trimester.

Fig. 2.9 In the third fetal trimester the width of the atrium measured in an axial section through the choroid glomus is remarkably constant at between 6 and 9 mm (average 7.6 mm) (Cardoza et al 1988).

ASPECTS OF THE WALL OF THE LATERAL VENTRICLE

Fig. 2.10 Frontal coronal 7.5 MHz section compared with a detail of an anatomy specimen (Leonhardt et al 1947): the anterior commissure (*) is part of the floor of the frontal horns, but not always clearly seen with ultrasound; the fornical columns are poorly echoic nodules in the laminae of the septum pellucidum.

Figs 2.11 and 2.12 Matrix tissue, hypointense on this T2-weighted fetal MR image of a fetus of 20 weeks, cannot be differentiated from surrounding tissue with ultrasound (coronal 8.5 MHz scan at 26 weeks).

Fig. 2.13 Parietal coronal 7.5 MHz section in an infant of 30 weeks gestation (anatomical drawing from Leonhardt et al 1987); the floor of the ventricle is formed – from lateral to medial – by caudate body (1), terminal stria, the lateral dorsal thalamic nucleus (2) and choroid plexus (3); none of these can be recognized with ultrasound except for the indentation of the floor at the terminal stria.

FURTHER READING

Cardoza JD, Goldstein RB, Filly RA (1988) Exclusion of fetal ventriculomegaly with a single measurement: the width of the lateral ventricular atrium. Radiology 169: 711–714.

Davies MW, Swaminathan M, Chuang SL, Betheras FR (2000) Reference ranges for the linear dimensions of the intracranial ventricles in preterm neonates. Arch Dis Child Fetal Neonatal Ed 82: F218–F223.

Helmke K, Winkler P (1987) Sonographisch ermittelte Normwerte des intrakraniellen Ventrikelsystemes im ersten Lebensjahr (Ultrasonic measurements of the normal intracerebral ventricular system in the first year of life). Monatsschrift für Kinderheilkunde 135: 148–152.

Johnson ML, Dunne MG, Mack LA (1980) Evaluation of fetal intracranial anatomy by static and real time ultrasound. J Clin Ultrasound 8: 311–318.

Leonhardt H, Tillmann B (1987) Anatomie des Menschen: Lehrbuch und Atlas. Band 3: Nervensystem, Sinnesorgane. Stuttgart: Thieme.

Levene MI (1981) Measurement of the growth of the lateral ventricles in preterm infants with realtime ultrasound. Arch Dis Child 56: 900–904.

McArdle CB, Richardson CJ, Nicholas DA, Mirfakhrace M, Hayden CK, Amparo EC (1987) Developmental features of the neonatal brain: MR imaging. Part II. Ventricular size and extracerebral space. Radiology 162: 230–234.

Perry RNW, Bowman ED, Roy RND, de Crespigny LCH (1985) Ventricular size in newborn infants. J Ultrasound Med 4: 475–477.

Poland RL, Slovis TL, Shankaran S (1986) Normal values for ventricular size as determined by real time sonographic techniques. Pediatr Radiol 15: 12–14.

Saliba E, Bertrand P, Gold F, Vaillant MC, Laugier J (1990) Area of lateral ventricles measured on cranial ultrasonography in preterm infants: reference range. Arch Dis Child 65: 1029–1032.

Shen EY, Huang FY (1989) Sonographic finding of ventricular asymmetry in neonatal brain. Arch Dis Child 64: 730–744.

3

THIRD VENTRICLE

SAGITTAL SECTION

The third ventricle is a slit-shaped rectangular cavity filled with CSF. It is situated in between the thalami and above the bony sella turcica. On a sagittal section the sonogram shows a clearly delineated echolucent zone of rounded triangular shape. Ventrocranially and slightly laterally, one finds the interventricular foramen of Monro. Ventrocaudally there is the pointed anterior recess around the optic chiasm, and dorsocranially there is the pineal recess. In fact, the anterior recess consists of a supra-optic recess and an infundibular recess, sonographically inseparable. Often one can see the aqueduct emerge in the space between the pineal and anterior recesses. Sometimes one suspects an indentation of the ventricular floor by the mamillary bodies. Echoic linear choroid plexus is found superiorly. Ventrally the latter bifurcates and, via the interventricular foramina, it courses on as plexus from right and left lateral ventricles. The echolucent interpeduncular cistern is visible under the third ventricle. Behind it one can find the particularly dense bifurcation of the basilar artery and, further dorsally, the echolucent cerebral peduncles. The anterior wall of the third ventricle, between the interventricular foramina and optic chiasm, is formed by the mildly echoic lamina terminalis and its commissures.

CORONAL SECTION

In the healthy term infant it is difficult to recognize the third ventricle on a coronal view because it is narrow and because its lateral walls course parallel to the direction of the sound waves. For this reason it is better to approach measurement of this ventricle through the lateral fontanelles, as in axial view both thalamic walls appear as bright lines with a dark space in between. On both sides of the ventricle one suspects (sub)thalamic and ventrocaudally hypothalamic nuclei, both not amenable to discrete sonographic documentation. The middle commissure is a cylindrical echoic structure in the third ventricle, interconnecting the lateral walls. The size of this commissure is variable.

Figs 3.1, 3.2 and 3.3 Perfect sagittal 7.5 MHz sonograms of two infants: (bottom) a healthy 29 weeks infant; and (middle) a 32 weeks infant with leukomalacia and callosal thinning (and mild ventriculomegaly that permits recognition of the otherwise virtual lumen of the third ventricle); in some children the hypothalamic sulcus can be clearly seen between the foramen of Monro and aqueduct, dividing the wall of the third ventricle in thalamic (dorsal) and hypothalamic portions. Compare with the scheme above.

Figs 3.4 and 3.5 In the healthy infant the third ventricle cannot be seen with 7.5 MHz coronal sonographic examination just behind the foramen of Monro; the ventrolateral thalamic nuclei are mildly echoic in contrast with the darker posterior limb of the internal capsule, itself bordered by the mildly echoic pallidum; sonographic diagnosis of lesions in subthalamus, substantia nigra or mamillary bodies has not been accomplished so far.

AXIAL SECTION

On axial sections the width of the third ventricle normally averages 2.8 mm and 3.8 mm respectively for age groups 0–3 and 9–12 months. In the early neonatal period the third ventricle is no wider than 2 mm. When its anatomical boundaries are clearly distinguishable in the sagittal plane, the ventricle is already dilated.

Figs 3.6 and 3.7 Only in the axial (transsphenoidal) plane can one reliably measure mild dilatation of the third ventricle, because its walls are seen as very echoic lines due to perpendicular insonation, even if not dilated (left: a term infant with 7.5 MHz; right: an infant of 29 weeks gestation with 8.5 MHz).

FURTHER READING

Helmke K, Winkler P (1987) Sonographisch ermittelte Normwerte des intrakraniellen Ventrikelsystemes im ersten Lebensjahr. Monatsschrift für Kinderheilkunde 135: 148–152.

4

CHOROID PLEXUS

Figs 4.1, 4.2 and 4.3 Coronal 7.5 MHz sections through the choroid glomus: the fatter part of the glomus is the deeper occipitotemporal portion; in some children the glomus slightly bulges laterally (left, 29 weeks, middle, 24 weeks, right, at term). The appearance that plexus is more abundant in preterm infants is only relative to the smaller cerebral mantle.

The choroid plexus is a highly vascularized organ producing cerebrospinal fluid. Sonographically, plexus tissue shows up as a hyperreflective structure with micropulsations. This organ courses from the roof of the third ventricle via the interventricular foramina to corpora and temporal horns of the lateral ventricles. The plexus of the lateral ventricles forms the lateral borders of the transverse fissure; from the vein of Galen both internal cerebral veins are derived as they cover the roof of the third ventricle and its tela choroidea; the anterior choroidal veins drain lateral ventricle plexus to the U-turn of the internal cerebral vein as it continues as thalamostriate (terminal) vein. Its echoic potential is caused by frequent liquid–solid transitions in the villous crypts and is also due to its high vascularity. The choroid plexus develops in the seventh conceptual week. The tela choroidea and plexus of the third ventricle constitute one single echoic sickle-shaped strip, covered by both internal cerebral veins and above them the fornix. As the plexus courses dorsally in the lateral ventricle, its diameter increases. In the body of the lateral ventricle it lies against the lateral fornical wall. On a frontal section the plexus in the temporal horn shows as a recumbent elliptical density. Near the trigone, dorsal to the posterior nucleus of the thalamus, the plexus widens into the choroid glomus, in the atrium of the lateral ventricle. The glomus is seen as a laterolateral bulge on posterior parietal coronal sections through the atrium.

Fig. 4.4 Parasagittal (right) 7.5 MHz scan of one hemisphere in an infant of 25 weeks gestation: relatively abundant choroid plexus fills the atrium in the form of a globular structure (glomus); one often perceives lamination in the glomus because of the presence of a hypoechoic layer between two more echoic outer parts.

Fig. 4.5 The entire ventricular system and arterial supply of choroid plexus:

(1) anterior choroidal artery from the middle cerebral artery near its origin in the internal carotid artery: to lateral ventricle plexus up to the glomus;

(2) medial posterior choroidal artery from the posterior cerebral artery: to third ventricle plexus;

(3) lateral posterior choroidal artery from the posterior cerebral artery: to lateral ventricle plexus from foramen of Monro to glomus.

(Adapted from Nieuwenhuys et al 1988.)

FURTHER READING

Riebel T, Nasir R, Weber K (1992) Choroid plexus cysts: a normal finding on ultrasound. Pediatr Radiol 22: 410–412.

5

LOBAR PARENCHYMA

TRACTS

In the normal brain a difference in echogenicity is noticed between cerebral cortex and underlying white matter. The latter is slightly more echoic, probably because vessels are relatively more numerous. Myelination, which is mainly a postnatal phenomenon, is not accompanied by an increase in echogenicity. The relation between echoic properties and fibre tracts is described for the optic radiation in the section on leukomalacia (see p. 361). The internal capsule in its posterior limb is insonated more or less tangentially and appears as a hypoechoic band, increasingly so with maturation. The anterior limb on the other hand is insonated perpendicularly and is variably hyperechoic.

CORTEX–WHITE MATTER DIFFERENTIATION

It is possible to observe in different locations pia mater separated from white matter by cortex, especially on parasagittal 7.5 MHz sections through the cingulate sulcus. The thickness of the cortex seen with ultrasound does not exceed a few millimetres. A frontal section with a 7.5 to 10 MHz transducer offers a good view of the cortico-medullary difference. Venous congestion and leukomalacia enhance this difference by rendering white matter more echoic (see Chapter 47 on asphyxia). A tangential view of a sulcus or fissure may create the impression of an echoic focus in the parenchyma. Subtle rotations of the scanhead allow differentiation of this normal variant from lesions such as infarction with sinus thrombosis, lobar haemorrhage and laminar necrosis in asphyxia.

Figs 5.1, 5.2, 5.3, 5.4 and 5.5 Different aspects of the echoic difference between cortex and white matter. Both term and preterm infants often have almost equal cortex and white matter brightness (left: preterm; bottom: term). Congestion and white matter injury increase the echoic property of the white matter and thus demarcate the darker cortical ribbon: this increase in contrast is shown for the watershed areas caught in the angle in the bottom middle picture, for the entire cerebrum with selective leukomalacia in the term infant of the bottom right picture.

TEMPORAL LOBE AND HIPPOCAMPUS

ANATOMICAL STRUCTURES

The mesial part of the temporal lobe (with the hippocampus and inferior horn of the lateral ventricle) can be examined both with parasagittal and with frontal sections through the anterior fontanelle. In a parasagittal section through the pes hippocampi and the choroid fissure, the amygdaloid nucleus, the inferior horn, the pes hippocampi and the hippocampal sulcus produce a typical layered picture. The hippocampus is located above the choroid plexus and below the echoic hippocampal fissure and the pulvinar. On a section through the limen of the insula one can sometimes see the echopoor inferior horn underneath plexus, which is echodense, and the hippocampal structures. The collateral groove limits the parahippocampal gyrus.

Figs 5.6, 5.7 and 5.8 Above: structures in an axial section through the basal ganglia, and in a coronal section through the left hippocampal formation (top right). (Adapted with permission from Paturet 1964.) Below: the parahippocampal gyrus and its bordering collateral sulcus in a preterm infant at 34 weeks postconceptional age.

ECHOGRAPHIC SECTIONS

Generally two echodense lines appear in the poorly echoic mesial temporal lobe. The upper line corresponds to the hippocampal fissure of Bichat and laterally to the plexus of the temporal horn. The lower, a fine echoline, corresponds to the floor of the ventricle and medially and anteriorly to the hippocampal sulcus. This layered constellation varies according to depth and direction of section. The amygdaloid nucleus can be seen above the inferior horn in the temporal uncus, which shows as the curled tip of a Moor slipper. Further towards the posterior fossa, the parahippocampal gyrus, the collateral sulcus and the middle occipitotemporal gyrus can be seen. Temporal, collateral and occipitotemporal sulci divide the temporal lobe into five gyri, two of which are situated laterally, one basally and two mesially.

Figs 5.9 and 5.10 Term infant with birth asphyxia: (left) coronal view behind the foramen of Monro; (right) parasagittal view; both 7.5 MHz. Neuronal injury is the cause of thalamic and striatal echogenicity; some hippocampal structures are well delineated in both coronal and parasagittal sections; it is not always easy to distinguish between the layers of hyperdense reflections from plexus, the hippocampal fissure (f) and sulcus (s), and the floor of the temporal horn (h) of the lateral ventricle. Poorly echoic regions alternate with echodense lines. The fimbria and dentate gyrus are small, echopoor and hard to distinguish. The hippocampal sulcus is seen as a small, echodense line.

Figs 5.11 and 5.12 Coronal 10 MHz section (left) just behind the foramen of Monro in preterm infant of 25 weeks gestation, scanned on day 1. Visualization of the hippocampal formation is better than at term (right).

Fig. 5.13 Parasagittal section through hippocampus at 28 weeks gestation. Notice the Moor slipper tip with amygdala (a) and the fine line of the fimbria hippocampi between the fissure of Bichat (f) and the floor of the lateral ventricle (h).

FURTHER READING

Sasaki M, Nakasato T, Goto H, Yanagisawa T, Suzuki T, Matsuda I, Fujiwara M, Hashimoto S, Saito K (1989) Normal sonographic findings of the infant temporal lobe in coronal sections. Brain Dev 11: 230–235.

THE INSULA OF REIL

NORMAL INSULAR ANATOMY

(Nieuwenhuys et al 1988)

The mature insula lies hidden in the sylvian fissure, and can only be seen when the lips of that fissure are widely separated. The insular opercula are separated from each other by the three branches of the lateral fissure, and are named the orbital, frontal, frontoparietal, and temporal operculum. The orbital operculum lies below the anterior horizontal branch of the fissure, the frontal operculum between this and the anterior ascending branch, the parietal operculum between the anterior ascending branch and the upturned end of the posterior branch, and the temporal operculum below the posterior branch. The insula is surrounded by a deep circular groove. When the opercula have been removed, the insula is seen as a triangular eminence, the apex (limen) of which is directed toward the anterior perforated substance. It is divided into a larger anterior and a smaller posterior part by a central groove, which runs backward and upward from the apex of the insula. The anterior part is subdivided by shallow sulci into three or four short gyri, while the posterior part is formed by one long gyrus, which is often bifurcated at its upper end. The limen insulae connects the insular pole to orbital olfactory cortex.

Fig. 5.14 Insular anatomy in the adult: 1 = central sulcus; 2 = lateral fissure ascending branch; 3 = lateral fissure posterior branch; 4 = circular sulcus; 5 = lateral fissure anterior branch; 6 = central sulcus of the insula; 7 = limen insulae. Inset below: lateral view of the insula at 18, 25 and 29 weeks gestation. (Adapted with permission, Nieuwenhuys et al 1988.)

NORMAL SONOGRAPHIC DEVELOPMENT OF THE INSULA OF REIL

Three planes are discerned during screening of the insula in parasagittal view:

1  Opercular view: at term the different opercula meet and leave open an unopercularized space rostrally. The lateral fissure also gives off a short anterior and an ascending branch.

2  Insular view: more medially two to three sulci between the short insular gyri become visible together with the circular sulcus. A dense undulating line, the lateral fissure, continues under the insula from front to back as a border with the temporal lobe. In parasagittal section this fissure seems to blend with the posterior margin of the insular lobe. Also visible are the superior temporal sulcus and anterior branch of the circular sulcus.

Fig. 5.15 Parasagittal sonogram: development of insular gyration in opercular, insular and fissural plane. (Published with permission, Govaert et al 2004.)

Fig. 5.16 Development of insular gyration in coronal sections at atrial level. (Published with permission, Govaert et al 2004.)

3  Fissural view: nearer the midline one can detect only the lateral fissure posterior branch and the anterior margin of the circular sulcus, both converging on the limen.

Opercularization of the insula begins on a sonogram around the 24th gestational week and progresses cranially. On coronal section through the choroid glomus at atrial level the insular space forms a shallow groove at 24 weeks, which becomes a slit (partially opercularized insula) at 28 weeks, which grows longer and develops branches – at first linear, later curved – after 32 weeks. At 28 weeks the ascending anterior part of the circular sulcus and the lateral fissure at the bottom of the insula are seen in parasagittal section. Subsequent change consists of undulation and bifurcation of the lateral fissure, together with discrete elongation of the anterior branch. Secondary gyri become visible in the insular dome between 28 and 34 weeks. At 34 weeks opercular anatomy is maturing with visible anterior and ascending branches of the lateral fissure.

FURTHER READING

Govaert P, Swarte R, De Vos A, Lequin M (2004) Sonographic appearance of the (ab)normal insula of Reil. Dev Med Child Neurol 46: 610–616.

Nieuwenhuys R, Voogd J, van Huizen C (1988) The Human Central Nervous System 3rd edn. Berlin: Springer.

CALCAR AVIS

The calcar avis is a piece of cortex and subcortical white matter underneath the incurved calcarine sulcus. The calcarine sulcus is formed around the 16th postconceptional week. Between the 32nd and the 40th week it stretches, thus shifting a piece of cortex and white matter into the occipital horn. The calcar avis will be more or less prominent dependent upon the depth of the gyri. An echogram through the posterior fontanelle clearly shows this structure. It needs to be distinguished from haemorrhage in the occipital horn, which shows as dense reflections from the lower margin of the occipital horn rather than its lateral and superior wall. The use of Doppler imaging to illustrate the absence of vessels in a clot can be helpful to make this distinction, especially if viewed from the posterior fontanelle.

Figs 5.17, 5.18, 5.19 and 5.20 Parasagittal (top left), posterior parasagittal (through the posterior fontanelle), postmortem (coronal at 30 weeks) and T1 MRI parasagittal (term) aspect of calcar avis. The calcar avis appears as a soft echogenicity in the mesial wall of the occipital horn of the lateral ventricle. The incumbent calcarine sulcus (arrow) is best seen in the top right image of an infant with colpocephaly due to callosal agenesis.

Fig. 5.21 Parasagittal insonation from the posterior fontanelle, showing Doppler flow in plexus but not in the clot attached to it that points towards the occipital horn.

FURTHER READING

DiPietro MA, Brody BA, Teele RL (1985) The calcar avis: demonstration with cranial US. Radiology 156: 363–364.

Fig. 5.22 Calcarine sulcus (Ca) and parietooccipital sulcus (PO) in the sagittal plane at term.

Fig. 5.23 Coronal section through the atrium: between the inner end of the lateral fissure and the upper part of the atrium one can observe elongated hyperechoic areas representing the optic radiation.

OCCIPITAL LOBE

This is echographically the lobe least accessible from the anterior fontanelle. It is usually not possible to recognize the calcarine sulcus, but the experienced sonographer may suspect its presence on a parasagittal section. Apart from that this lobe shows up as a hypoechoic zone behind the parieto-occipital sulcus. Recognition of the optic radiation in coronal section through the atrium is discussed in the section on leukomalacia (see p. 361).

FRONTAL LOBE

The frontal lobe is bordered posteriorly by the central sulcus and by the lateral fissure along the external part of the hemisphere.

Fig. 5.24 The sonographic window of the anterior fontanelle shown against the mesial arterial vasculature (of the anterior and posterior cerebral artery). The frontal lobe extends to the central groove and is the parenchymal part of the cerebrum that really fills the ultrasound image (darker sector).

Figs 5.25 and 5.26 Parasagittal sections at 29 weeks and at term (right) illustrating the extent of the frontal lobe within the sonographic window: the frontal lobe ends with primary motor cortex just anterior to the central groove.

Mesially the posterior border is the central sulcus encircled by the paracentral lobule. The frontal lobe extends mesially below the cingulate gyrus. An anterior coronal section displays a number of sulci and gyri against the orbital roof: the gyrus rectus is situated against the falx, with the olfactory sulcus just beside it (a short linear density rising from below the midline, upwards and laterally away from it, on which rests the olfactory tract, see Chapter 1 on sulci and gyri). The external orbital sulcus will be found laterally at the base of this lobe. It is difficult to provide a more detailed description of the gyrational pattern in the apex of the frontal lobe via transfontanellar sonography.

PARIETAL LOBE

The parietal lobe on the lateral hemispheric wall extends from the central sulcus to the indentation of the parieto-occipital sulcus. The intraparietal sulcus starts at the postcentral sulcus, penetrating the parietal lobe behind the lateral sulcus. In between lies the supramarginal gyrus. The angular gyrus is situated between the intraparietal sulcus and the superior temporal sulcus. Some of those anatomical landmarks can be located by means of extremely lateral scans using a 10 MHz transducer. On the mesial hemisphere wall the parietal lobe consists only of the cuneus, hemmed in between the calcarine and parieto-occipital sulci.

Fig. 5.27 Parasagittal section at 36 weeks showing the insula and two important sulci in the parietal lobe.

6

MIDLINE STRUCTURES

Fig. 6.1 Development of midline structures at 8, 12 and 18 weeks gestation. (Based on O’Rahilly and Müller 1994.)

The development of midline commissures is complex. Aspects related to malformation are discussed under callosal agenesis.

CORPUS CALLOSUM

During sonography this structure is almost completely visible from the anterior fontanelle except for the splenium which is often partially visible. A sagittal section shows corpus callosum as a thin, longitudinal, echopoor structure arching from front to back. It is located on the floor of the longitudinal cerebral fissure. The frontal curved part is the genu. The genu courses anteriorly down into the rostrum, which becomes narrower and touches the upper part of the lamina terminalis. Posteriorly the genu continues into the middle part. This part bends towards the back and slightly upwards, to course through in the splenium, which is the thicker and most rounded dorsal part of the corpus callosum. The upper boundary is the pericallosal cistern, also containing the pericallosal arteries. The cingulate gyrus rests on the pericallosal cistern. Under the corpus callosum there are two leaflets of the septum pellucidum, containing the cavum. In a sagittal section one observes how the laminae of the septum pellucidum touch the concave surface of the middle part, the genu, the rostrum and the fornix. An immediate parasagittal section shows the corpus callosum as the roof of the lateral ventricle. Upwards the splenium is in touch with the falx cerebri and the inferior sagittal sinus. Towards the back the splenium touches the border of the tentorium near the great vein of Galen. The vein itself courses in the transverse fissure, a horizontal echodense band under the splenium laterally ending in the choroidal fissures of the temporal horns. In a frontal section, the corpus callosum is a thin, narrow echopoor plate. At the front it is slightly curved, concave on the upper side, and it forms the roof of the lateral ventricles.

Fig. 6.2 Sagittal (top) and coronal (bottom) 7.5 MHz images through the foramen of Monro in a preterm infant with posthaemorrhagic hydrocephalus. Midline structures are accentuated by mild ventricular dilatation and ventricular wall hyperechogenicity due to haemorrhagic remnants; fornical reflections can only be seen separately when the ventricles are somewhat dilated; otherwise their reflections are mixed with those from plexus and ventricular walls.

Figs 6.3, 6.4 and 6.5 Mid-sagittal section at 29 weeks (8.5 MHz) displaying the entire corpus callosum. Compare with an anatomical specimen of the midline 2 months after term birth (cot death) and a sagittal T1 MRI at full term.

CAVUM OF THE SEPTUM PELLUCIDUM AND VERGA’S VENTRICLE

Both cavities are lined by glia and not ependyma. They are situated between the fornix and corpus callosum. The cavum of the septum pellucidum is almost always easily recognizable in the perinatal period. Its diameter rarely exceeds 8 mm. Around the sixth postnatal month, and for the rest of life, it can on average be identified in one person out of six. The walls of the cavum consist of two septal leaflets, which during infancy gradually tend to merge into one single membrane from back to front. There is no well defined transition area towards Verga’s ventricle. Verga’s ventricle runs into the posterior side of the cavum of the septum pellucidum, above the choroid plexus and underneath the splenium of the corpus callosum. Laterally this cavum is bordered by the crura of the fornix, which end in the alveus and fimbria of the hippocampus. The cavum of Verga and the cavum of the velum interpositum are subcallosal cavities that have to be differentiated from an aneurysm of the great vein of Galen.

Fig. 6.6 Sagittal (top) and coronal (bottom, plane of section in top image) 7.5 MHz sections of a preterm infant (gestational age 29 weeks) without brain injury. The cavum of the septum pellucidum and Verga’s ventricle may be relatively large in preterm infants.

Fig. 6.7 12 MHz sagittal section at 26 weeks: notice the foramen of Monro (M), the cavum septi pellucidi and within it a septal trabecula (arrow, possibly with a small vein).

Fig. 6.8 Hyperechoic stage of postnatal germinolysis, bordering the leaflets of the cavum septi pellucidi (arrow indicates right septal leaflet).

Fig. 6.9 Sagittal section, showing a small cavum septi pellucidi and a septal vein in one leaflet (arrow).

A sagittal section shows the cavum as an echolucent zone with concave rims towards the base of the brain. Under normal circumstances it is sometimes possible to see fenestrations in the partitions of the septum pellucidum on a near-sagittal section. A frontal view nearly always shows a triangular or trapezoid echolucent space with its base under the corpus callosum and its apex against the fornix. Pointed and short linear densities in the septal walls are normal reflections from the medial subependymal veins. Occipitally directed coronal sections show Verga’s ventricle as a cavity between the choroid glomera.

FURTHER READING

Anderson NG, Laurent I, Cook N, Woodward L, Inder TE (2005) Growth rate of corpus callosum in very premature infants. Am J Neuroradiol 26: 2685–2690.

Babcock DS (1984) The normal, absent, and abnormal corpus callosum: sonographic findings. Radiology 151: 449–453.

Farruggia S, Babcock DS (1981) The cavum septi pellucidi: its appearance and incidence with cranial ultrasonography in infancy. Radiology 139: 147–150.

Gebarski SS, Gebarski KS, Bowerman RA, Silver TM (1984) Agenesis of the corpus callosum: sonographic features. Radiology 151: 443–448.

Mott SH, Bodensteiner JB, Allan WC (1992) The cavum septi pellucidi in term and preterm newborn infants. J Child Neurol 7: 35–38.

Shaw C-M, Alvord EC (1969) Cava septi pellucidi et Vergae: their normal and pathological states. Brain 92: 213–224.

7

CISTERNS

Cisterns are accumulations of liquid between brain structures and the skull. Normally they rarely show up on sonograms. Their existence can be suspected because the walls, consisting of leptomeninges and blood vessels, are strongly echogenic. An enlarged cistern looks like an irregularly rimmed cavity and generally indicates a proximally located obstruction to the circulation of CSF. The cisterna magna and the prepontine cistern normally show as a cavity. It follows that they play an important part when looking for subarachnoid haemorrhage in a sagittal ultrasound section (extensively illustrated by Paneth et al 1994).

Basal (suprasellar) cistern: this comprises the chiasmatic and interpeduncular cisterns.

Cisterna magna (cerebellomedullary cistern): this cistern, located under the echogenic vermis above the occipital bone, is of variable size. If large, it will be viewed as an accumulation of liquid in the posterior fossa, around the cerebellum. In this cistern are found the postero-inferior cerebellar artery, cranial nerves IX–XII and the cerebellar tonsils.

Pontine cistern: this is a hypoechoic zone ventrally above the pons, in front of the cerebral peduncles, under and behind the anterior recess of the third ventricle. The particularly echodense zone with arterial pulsations in this cistern corresponds with the bifurcation of the basilar artery. It ends in the interpeduncular cistern.

Quadrigeminal cistern: this is an echofree area (1–3 mm wide) behind an echogenic line between the plexus of the third ventricle and the vermis. A cyst of the quadrigeminal cistern thus lies behind this ventricle. This cistern contains the posterior cerebral and posterior choroidal arteries, cranial nerve IV and the great vein of Galen. There is a direct lateral communication with the retrothalamic cistern behind the pulvinar. The thickness of the echoic zone overlying the colliculi (normally no more than 3 mm) often increases in cases of subarachnoid haemorrhage.

Ambient cistern: this constitutes the lateral connection between the prepontine and interpeduncular cisterns in front, and the quadrigeminal cistern behind. In this cistern we find the posterior cerebral artery, superior cerebellar artery, mesencephalic vein, cranial nerve IV and the optic tract. On a frontal section through the hippocampus the ambient cistern shows as the vertical part of a C, encircling the brainstem on both sides. The upward curve of the C corresponds to the hippocampal fissure and the plexus of the temporal horn, whereas the lower curve corresponds to the tentorium. This echoic curve is 1–3 mm wide in preterm infants around 26 weeks postconceptional age.

Chiasmatic cistern: this is a pentagonal echodense zone around the optic chiasm. Its angles correspond to the arteries of the circle of Willis: in front, the anterior cerebral arteries; laterally, the carotid siphon with the origin of the middle cerebral arteries; and at the back, the posterior cerebral arteries. Sideways the cistern ends, together with the middle cerebral artery, in the lateral cistern which fills out the sylvian fossa.

Fig. 7.1 Sagittal scheme of the important cisterns. (Adapted with permission, Nieuwenhuys et al 1988.)

Fig. 7.2 Top, 7.5 MHz sagittal images zoomed in on the posterior fossa from the anterior fontanelle; bottom, 10 MHz sagittal images through the neck, with the spinal cord to the right; both subjects were healthy term infants. Nuchal echography permits visualization of structures within the posterior fossa if the cisterna magna is patent; a small cisternal size makes recognition of the rear brainstem wall difficult.

Fig. 7.3 Axial section in a preterm infant at pontine level. Notice the basilar artery (arrow) against the pons and behind the prepontine cistern.

Fig. 7.4 Sagittal Doppler image to illustrate a large cavum veli interpositi (arrow) underneath the splenium and above the quadrigeminal cistern (arrowhead). The large vessel is one of the internal cerebral veins.

FURTHER READING

Paneth N, Rudelli R, Kazam E, Monte W (1994) Brain Damage in the Preterm Infant. Clinics in Developmental Medicine No. 131. London: Mac Keith Press.

8

BASAL GANGLIA AND THALAMUS

ANATOMY OF DEEP GREY NUCLEI

A parasagittal section through the caudothalamic groove is the best way of showing the thalamus, the lentiform nucleus, the internal capsule and their mutual relationship. It shows the thalamus and basal ganglia as an egg-shaped structure bordered by: at the upper front, the frontal horn of the lateral ventricle; at the upper back, the rest of the lateral ventricle; below in front, the rostral corpus callosum; and below at the back, the ambient cistern and choroidal fissure. In the floor of the lateral ventricle,