1.

Normal lung anatomy

The anteroposterior (AP) diameter of the neonatal chest is almost as great as

its transverse diameter, giving the chest a cylindrical configuration.
The degree of rotation is best assessed by comparing the length of the
anterior ribs visible on both sides.
As newborn chest radiographs are taken in the AP projection, the normal CTR
can be as large as 0.6.
The thymic size is variable and may alter with the degree of lung inflation.
It may blend with the cardiac silhouette, may have an undulating boarder due
to indentation by the adjacent ribs or may exhibit the classic ‘sail sign’ more
commonly seen on the right side.
Thymic tissue may involute rapidly with prenatal or postnatal stress: for
example, in severe illnesses such as hyaline membrane disease (HMD),
infections, or following corticosteroid treatment.
There are some well-recognised artefacts on a newborn chest radiograph.
The hole in the incubator top may be confused with a pneumatocele; and skin
folds may overlie the chest wall mimicking a pneumothorax (although these
can usually be seen to extend beyond the lateral edge of the lung).

2. Normal lung development

During the embryonic phase of gestation (from 26 days to 6 weeks) the lung
bud develops from the primitive foregut and divides to form the early
tracheobronchial tree.
During the pseudoglandular phase (6–16 weeks) there is airway development
to the level of the terminal bronchioles, with a deficient number of alveolar
saccules.
Multiple alveolar ducts develop from the respiratory bronchioles during the
canicular or acinar phase (16–28 weeks).
These ducts are lined by type II alveolar cells that can produce surfactant, and
which differentiate into thin type I alveolar epithelial cells.
At the end of this phase, primitive alveoli form.
Progressive thinning of the pulmonary interstitium allows gas exchange via
approximation of the proliferating capillaries with the type I cells.
During the saccular phase (28–34 weeks) there is an increase in the number
of terminal sacs, further thinning of the interstitium, continuing proliferation of
the capillary bed and early development of the true alveoli.
The alveolar phase extends from approximately 36 weeks’ gestation until 18
months of age. While most alveoli have formed by 5 to 6 months of age, late
alveolarisation continues well into early adulthood.

3. Imaging anatomy of liver

The neonatal liver is hypoechoic relative to the kidneys. This reverses during
infancy. The umbilical vein and the ductus venosus are patent in the
premature and early newborn child (<48 hours), and in two-thirds up to 1 week
of age.
Patency beyond 2 to 3 weeks is abnormal. The ductus venosus is seen as a
vascular channel between the left portal branch and the left hepatic
vein/inferior vena cava.
There is considerable variation in the size of normal livers, and measurements
are difficult to standardise.
Portal vein sonographic diameter—after 1 to 3 hours of fasting—in the supine
position was found to range, in mm, from 3 to 5 mm (at birth), 4 to 8 mm (1
year), 6 to 8 mm (5 years), 6 to 9 mm (10 years) and 7 to 11 mm (15 years).
Similar findings were done in a more recent cohort, supine, after at least 2
hours of fasting, where the 5 to 95 centiles in mm were 3.0 to 6.4 (0 to 12
months of age), 4.3 to 8.3 (1 to 5 years) and 5.0 to 10.8 (5 to 10 years).

4. Imaging anatomy of biliary system

The suggested upper limit of normal for the common bile duct diameter is
approximately 2 mm in infants, 4 mm in children and 7 mm in adolescents; the
gall bladder length should be at least 1.5 cm in neonates.

5. Pancreas imaging anatomy

Pancreatic size is variable, volumetric references unavailable, and

sonographic measurements have unknown reliability.
The pancreas is large relative to the size of the child, and hypoechoic.
Suggested anteroposterior dimensions on US are (infants to teenagers, cm) 1
to 2 cm (head and tail) and 0.6 to 1.1 cm (body) with standard deviations of
around 0.4 cm.
Suggested normal pancreatic duct diameters are 1.1 mm in toddlers to 2.1
mm in late teens with standard deviations of about 0.2 mm.

6. Spleen imaging anatomy

Accessory spleens are common and of no real clinical importance. In the
neonate the spleen is hypointense both on T1W & T2Wimages.
With increasing white pulp to red pulp ratio, its MRI appearance is similar to
that in adults by 8 months of age.
High-frequency US may demonstrate the spotted appearance of a reactive
spleen, and this should not be mistaken for multifocal infection.

7. Normal gonadal imaging of girls

Normal pelvic structures can be difficult to visualise in children: visualisation of

the ovaries by US depends on their location, size and the age of the girl—they
are more easily seen in the first few months of life.
Ovarian volume is usually under 1 mL in the neonate, and 2 to 4 mL in the
prepubertal child. Ovaries typically look heterogeneous due to the presence of
follicles, and larger follicles can appear as small ovarian ‘cysts’ which are
normal at all ages .
After puberty, ovarian volumes of 5 to 15 mL are normal, with normal
primordial follicles less than 10 mm in diameter, and stimulated follicles 10 to
30 mm in diameter.
The normal uterus also changes dramatically with hormonal changes, and is
the most useful guide to pubertal staging.
The neonatal uterusm is prominent due to circulating maternal oestrogens,
typically measuring 2 to 4.5 cm in length, with thickened and clearly visible
endometrial lining.
By 1 year of age it becomes smaller, has changed to the prepubertal tubular
appearances: the fundus and cervix are the same size and the endometrium
is no longer visible.
At puberty, the fundus starts to enlarge, becomes up to three times the size of
the cervix, with a total uterine length of 5 to 7 cm and the typical adult pear-
like shape.
The endometrial appearances will clearly vary with the phase of the menstrual
cycle.
The vagina may be visualised by US if air-filled (shown as a linear bright
echo), or if fluid filled.
On MRI the vagina is best seen on sagittal T2 weighted spin-echo sequences.
As with the uterus, the appearance and the thickness of the vaginal epithelium
and the signal from the vaginal wall change with the age and the phases of
the menstrual cycle.
US genitography with saline filling of the vagina, or 3D US can be used for
uterine anomalies, and perineal US for vaginal and urethral problems.

8. Normal gonadal imaging in boys

The prostate has an ellipsoid homogeneous appearance, but is difficult to see

in newborns, as are the normal seminal vesicles.
As the processus vaginalis remains open for some time after birth (and may
never close completely), hydroceles are considered a normal physiological
finding in the newborn. Cryptorchidism is discussed later in this chapter. The
normal testis changes in appearance during childhood.
It hasa homogeneous hypoechoic echotexture and is spherical/oval in shape
during the neonatal period, measuring less than 10 mm in diameter.
The epididymis and mediastinum testis are usually not seen at this point, but
are clearly identified by puberty.
Testicular size in adolescence ranges from 3 to 5 cm in length and from 2 to 3
cm in depth and width (2 to 4 mL in total).
Testicular flow, as measured by Doppler US, also changes with age.
The testis in infants shows very low-velocity colour flow, which can be difficult
to see despite optimised slow-flow settings, and even normal prepubertal
testes may not demonstrate low-velocity flow even on power Doppler US.
Technically it may be difficult to identify abnormalities in a single testis given
the wide range of normal values, and thus a side-by-side comparison can be
useful.

9. Normal renal anatomy

The neonatal kidneys lack renal sinus fat in the first 6 months of life, and the
medullary pyramids are typically large and hypoechoic relative to the cortex
(the opposite to that found in older children and adults), which may be
mistaken for pelvicalyceal dilatation (PCD) or ‘cysts’
The normal neonatal renal cortex is also hyper- to iso-echoic relative to the
adjacent normal liver, which again can often be reversed in adults.
The neonatal renal pyramids may be echogenic, a transient physiological
appearance in up to 5% of newborns, and should not be mistaken for
nephrocalcinosis, although it can be seen in older infants with dehydration.
The average newborn kidney is approximately 4.5 cm in length.
As the paediatric kidney is more spherical than the ellipsoid adult kidney, renal
volumes may be a better assessment using the equation:
10. Normal myelination of brain

Most of the changes associated with myelination occur in the first 2 years of
life
Myelination is the process by which brain oligodendrocytes produce layers of
myelin that wrap around the neuronal axons and act as a layer of insulation for
the transmission of electric action potentials down the neuronal axon.
Axonal transmission is facilitated at the junctions between these myelin
sheaths or nodes of Ranvier by a process known as saltatory conduction.
The extent of myelination of the infant brain can be assessed by magnetic
resonance imaging (MRI) according to specific milestones which are
analogous to the normal milestones of clinical development.

During earliest brain development none of the brain is myelinated.

By term, key structures such as the ventrolateral thalami, dorsolateral
putamina, posterior limb of the internal capsule, inferior colliculi, medial
longitudinal fasciculus and dorsal brainstem nuclei are already myelinated.
As the brain matures, there is progressive T1 and T2 shortening of the white
matter due to an increase in the lipid content and reduced water content of
developing myelin and packing of myelinated white matter tracts.
This follows a centrifugal posteriorto-anterior and caudal-to-cranial pattern and
is virtually complete by the age of 2 years.
Advanced MRI techniques show progressive reduction in free water diffusion,
increased fractional anisotropy (assessed by diffusion tensor imaging) and
increased magnetisation transfer.
Brain myelination is detected in grey matter earlier on T2 weighted fast
spinecho (FSE) and in the white matter tracts earlier on T1 weighted spin-
echo (SE) or short tau inversion recovery (STIR) sequences.
Most myelination occurs post term in the first 8 months of life, although the
final parts of this process may extend into adulthood.
The brain should appear virtually fully myelinated on T2 weighted sequences
by 2 years, with almost an adult appearance on T1 weighted sequences by 10
months

The newborn has limited motor function but a well-developed sensory system.
Thus the myelination pattern seen at birth at full term is primarily in the
sensory tracts. During the first 6 months of life, the process of myelination is
easiest to follow on T1
weighted images, where the myelinated areas appear bright. T2 weighted
images are less sensitive, and it takes much more myelin to produce a
hypointense signal within the white matter.
During this period, T2 weighted images show only subtle myelination.
At full term, T1weighted images should show high signal in the dorsal medulla
and brainstem, the cerebellar peduncles, a small part of the cerebral
peduncles, approximately a third of the posterior limb of the internal capsule,
the central corona radiata and the deep white matter in the region of the pre-
and post-central gyrus.
Progression of myelination is seen in the optic radiations during the first
months of life.
The internal capsule will demonstrate T1 shortening within the anterior limb by
3 months, whereas on T2 weighted images the hypointensity due to myelin is
not seen until approximately 8 months of age.
The splenium of the corpus callosum on T2 weighted images becomes
hypointense at 3 months of age.
The hypointense signal extends anteriorly along the body and genu, and the
complete corpus callosum is myelinated at 6 months.
After 6 months the signal pattern on T1 weighted images becomes less
precise, and after 10 months the brain is fully myelinated by T1 criteria.
T2 weighted images are then used to assess the myelination from 6 months to
24 months of age, when the signal pattern generally is fully mature and has a
completely adult pattern, although the milestones of myelination are much
more imprecise than during the first 6 months of life.
On T2 weighted images the first signs of mature subcortical white matter are
found around the calcarine fissure at 4 months and in the pre- and post-
central gyri at 8 months.
By 10 months the occipital subcortical white matter appears isointense with
the overlying grey matter and finally shows mature hypointense signal around
1 year of age.
This process proceeds anteriorly and by 18 months has finally reached the
most frontal parts and the frontal poles of the temporal lobes.
Regions of persistent hyperintensity on T2 weighted sequences known as the
‘terminal myelination zones’ may be seen within the peritrigonal areas well into
adulthood.
They can be distinguished from white matter disease by the presence of a rim
of normal myelinated brain between these areas and the ventricular margin,
and no evidence of white matter volume loss such as ventricular enlargement
or irregularity of the ventricular margins.
Other areas may also persist as regions of signal hyperintensity beyond 2
years (e.g. in the frontotemporal subcortical white matter and peritrigonal
white matter) and should not be mistaken for disease

11. Normal gyral development

Gyral and sulcal development mainly occurs in utero or in the premature brain
Gyration is the process by which the individual gyri and sulci of the cerebral
hemispheres form.
The MRI appearances lag behind the extent of gyral formation seen at the
same age at postmortem.
The surface of the cerebral hemispheres is initially smooth, with the
interhemispheric fissure and Sylvian fissures having already formed by 16
weeks’ gestation.
Other primary sulci, such as the callosal sulcus and parieto-occipital fissure,
are recognisable at 22 weeks’ gestation, followed by the cingular and
calcarine sulci.
The central sulcus is seen in most infants by 27 weeks.
Gyration then continues into the postterm period in a standardised and
consistent sequence, beginning with the sensorimotor regions and visual
pathways, areas that are also myelinating at the same time.
The slowest regions of gyration are also those with the slowest myelination,
such as the frontal and temporal poles.
By term the gyral pattern is nearly the same as the appearance in adults, with
further deepening of the sulci occurring post term.
The Sylvian fissures are also wider and vertically oriented, and these continue
to mature
post term.

12. Postnatal maturational changes

Development of the corpus callosum begins with the posterior genu, body and
splenium and then the anterior genu and rostrum.
All these components are present by 20 weeks’ gestation; however, it
continues to grow in length and thickness through the rest of the fetal period
and post term.
The adult appearance with full thickness of the corpus callosum is achieved by
8 to 10 months of age, and bulking up of the splenium as the visual pathways
mature occurs by 4 to 6 months.
In the adult there are several regions where there is relative T2 hypointensity,
considered to be due to the normal deposition of iron; these are the basal
ganglia, particularly the globus pallidus, substantia nigra and red nucleus.
In the infant the basal ganglia begin to appear relatively T2 hypointense to
cortex by approximately 6 months of age due to myelination, but the putamen
and globus pallidus are isointense to each other and the internal capsule.
They then become relatively bright with respect to white matter as this begins
to myelinate. By 9 or 10 years there is a second stage of T2 shortening in the
globus pallidus, substantia nigra and red nucleus, which reduces further
during the second decade.
The dentate nuclei show similar though less marked changes by
approximately age 15 years. This phase is due to iron deposition, which
continues throughout adult life.
In normal infants up to the age of 2 months the anterior pituitary gland has a
convex upper border and is of relatively high T1 weighted signal.
From 2 months the pituitary gland has a flat surface and is isointense with
grey matter.
It slowly grows during childhood and ranges from 2 to 6 mm in vertical
diameter until puberty, when it enlarges again

13. Normal development of spinal cord

The spinal cord forms during three embryological stages known as

gastrulation (at 2 to 3 weeks of gestation), primary neurulation (3 to 4 weeks)
and secondary neurulation (5 to 6 weeks).
During gastrulation the embryonic bilaminar disc consisting of epiblast and
hypoblast is converted to a trilaminar disc by migration of cells from the
epiblast through Hensen node, a focal region of thickening occurring at the
cranial end of the midline ‘primitive streak’ of the disc.
This results in the midline notochord and a layer that will form the future
mesoderm.
During primary neurulation the notochord induces the overlying ectoderm to
become neurectoderm and form the neural plate.
Subsequent folding and bending occurs until the margins unite to form the
neural tube.
The cranial end closes at day 25, whereas the caudal end closes a couple of
days later.
Finally the caudal cell mass arises from the primitive streak and undergoes
retrogressive differentiation with cavitation.
This is the origin of the fetal neural tissue and vertebrae distal to S2 and will
become the conus medullaris.
A focal expansion of the fetal canal known as the terminal ventricle occurs as
a result of incomplete retrogressive differentiation.
This may be seen as a normal asymptomatic finding in young children and
may persist in a small minority into adulthood.
It is seen on all postmortem studies but is bigger in those detectable on MRI.
Spinal dysraphisms can result from abnormalities occurring during any of
these periods.

The normal level of the spinal cord termination has a normal or Gaussian
distribution.
It is a popular misconception that the spinal cord lies lower in the neonate and
continues to rise as the vertebral column grows during childhood.
In fact, most authors agree that it has already reached its adult position by
term and in 98% lies above L2/3, the majority lying between T11/12 and L1/2.
The spinal cord termination should be considered unequivocally abnormal if
seen at or below L3.