By dr Rabab Hashem, MRCPCH, pediatrician at El Nasr hospital Port said. Cranial sonography is the most widely used neuroimaging procedure in premature infants. US helps in assessing the neurologic status of the child, since clinical examination and symptoms are often nonspecific. It gives information about immediate and long term prognosis.

1. By
Dr: Rabab Hashim

2.  Cranial sonography is the most widely used
neuroimaging procedure in premature infants.
 US helps in assessing the neurologic status of the
child, since clinical examination and symptoms are
often nonspecific
 It gives information about immediate and long term
prognosis.

3. Advantages of Cranial Ultrasonography
 Safe
 Bedside
 Reliable
 Early imaging
 Serial imaging:
Brain maturation
Evolution of lesions
 Inexpensive
 Suitable for screening

4. Equipment

5. What is the optimum time for CUS

6. How images are assessed by cranial US?
 Anatomy
 Maturation
 Distinction of cortex/white matter
 Echogenicity/homogeneity of white matter
 Ventricular system: size, lining, and if dilated to
perform serial measurements
 Midline shift

7. Performing Cranial Ultrasound Examinations
Preterm neonates and sick full-term neonates are
examined in their incubator while maintaining monitoring.
 performed while only the incubator windows are open
Manipulation of the infant (with the exception of minor
adjustments) is rarely necessary while scanning
through the anterior fontanel.
 Older infants and full-term neonates can be examined in
their cot or car seat or on an adult’s lap.

8. Anatomical points

11. Ventricular System
 Lateral Ventricles: Largest
of the CSF cavities.
 Frontal Horn
 Body
 Occipital Horn
 Temporal Horn
 Trigone “Atrium”
 Foramen of Monro
 3rd Ventricle
 Aqueduct of Sylvius
 4th Ventricle
 Foramen of Luschka
 Foramen of Megendie

12. Anterior
Fontanel
The Standard
view window
Posterior
Fontanel
Supplementary
view window
Mastoid
Fontanel
Supplementary
view window
Temporal
Supplementary
view window

13. Standard Views
 Allow optimal visualisation of the supratentorial structures.
 the anterior fontanel is used as the acoustic window.
 Images are recorded in 6 coronal and 5 sagittal planes.
 In addition to the standard planes, the whole brain can be
scanned to obtain an overview of the brain’s appearance.
This allows assessment of the anatomical structures and
detection of subtle changes and small and/or superficially
located lesions.

14. Coronal Planes
 The anterior fontanel is palpated, and the transducer is
positioned in the middle, with the marker on the probe
turned to the right side of the baby
 The probe is angled sufficiently far forwards and
backwards to scan the entire brain from the frontal
lobes at the level of the orbits to the occipital lobes

15. Well-fitting ultrasound probe, positioned on the anterior fontanel. Arrow
indicates the marker on the probe

16. Sagittal Planes
 The transducer in the middle of the anterior fontanel.
 the marker is now pointing towards the baby’s mid-face.
 The anterior part of the brain will thus be projected on
the left side of the monitor
 First, a good view of the midline is obtained.
 The transducer is subsequently angled sufficiently to the
right and the left to scan out to the Sylvian fissures on
both sides.

17. Probe positioning for obtaining sagittal planes. Arrow indicates marker

18. Normal CUS Scan

19. Coronal Planes

20. Coronal Views

21. 1st coronal plane at the level of the
frontal lobe

22. Anterior horns of the lateral Ventricles

23. The Third Ventricle

24. Post cronal(Trigone)

25. Sagittal Views

26. Midline Sagittal

27. Lateral (RT &LT)Angled Parasagittal

28. Normal variant
Cavum septum pellcidum

29. Chorioïd plexus cyst

30. Abnormal Scans
Congenital infectDWV&VOGV
PVLPHVDIVH

31. Intraventricular Haemorrhage
 More common in premature infants
 Germinal matrix - highly vascular and vulnerable
to hypoxemia and ischemia.
 Image 4-7 days after birth
 90% of hemorrhages occur in first week of life
 Follow with weekly U/S to evaluate for hydrocephalus

32. IVH grading
 Grade I - Confined to germinal matrix
 Grade II - Intraventricular without ventricular
dilatation
 Grade III - Intraventricular with ventricular
dilatation
 Grade IV - Periventricular hge and hemorrhagic
infarction

33. Germinal matrix haemorrhage
G1 IVH
G1 IVH

34. IVH GII

35. IVH III

36. IVH III

39. Post Hemorrhagic hydrocephalus
PHVD

40. PHVD

42. PHH

43. Ventricular index

44. Ventricular index and HC chart(Levene)

45. Ventricular reservoir

46. Periventricular Leukomalacia (PVL)
 5-10% of premature infants
 Infarction of deep white matter
 Seen as increased echogenicity (greater than choroid plexus)
 Often missed with ultrasound, serial exams increase
sensitivity( grade I)
 May get cystic changes in 2-3 weeks
 Symptoms: spastic diplegia, intellectual deficits

47. Periventricular Leukomalacia(PVL)

49. Periventricular Leukomalacia G I

50. PVL II

51. Periventricular Leukomalacia G II

52. Periventricular Leukomalacia G III

53. PVL IV
Periventricular Leukomalacia G IV

54. Congenital malformation

55. Dandy-Walker Variant
Posterior fossa cyst which
communicates with 4th
ventricle
Large posterior fossa
Hypoplastic cerebellar
vermis and laterally
displaced cerebellar
hemispheres
Frequently associated with
other anomalies

56. Vein of Galen Malfomatiorn

57. Congenital infection
Calcifications

58. Congenital Absence of the Corpus
Callosum
80% have associated
anomalies
Parallel lateral
ventricles
Elevated 3rd ventricle
Absent cingulate
gyrus and sulcus
“Sunburst sign” -
radially arranged
sulci

59. Our patient

60. Limitations of Cranial Ultrasonography
 Image quality can be affected by small acoustic windows, thick hair or
hats used for ventilatory support systems
 Brain’s convexity is not well visualized, cortical infarctions may be
overlooked, especially in the first days after the event.
 extracerebral haemorrhage located at the convexity of the cerebral
hemispheres (subdural, epidural, and subarachnoid haemorrhages not be
reliably assessed)
 Hypoglycaemic parenchymal injury, often involving the occipital lobes,
may not be recognized.
 Some lesions resulting from infection, such as (micro-) abscesses and
encephalitis, may not be recognized by cUS.

61. Take home message
 cUS plays an important role in predicting neurological prognosis in
the high-risk newborn.
 Standard cUS is performed using the anterior fontanel.
 Optimal timing and frequency of serial cUS examinations is essential
 in the high-risk neonate ischaemic lesions may develop at any time
during the neonatal period and may change in appearance over a
variable period of time.
 MRI is recommended in the case of (suspected) parenchymal brain
injury and in very preterm neonates, neonates with neurological
symptoms, congenital malformations and miscellaneous disorders.