cranial USG technique

1. DR. Muhammad Bin Zulfiqar
PGR II FCPS RADIOLOGY SIMS/SHL

2. • Aims
• Indications
• Sonographic technique
• Sonographic Anatomy
• Doppler
• Pathologies
– Hemorrhage
– PVL

3. Advantages of Cranial USG
• Safe
• Bedside- compatible
• Reliable
• Early imaging
• Serial imaging:
Brain maturation
Evolution of lesions
• Inexpensive
• Suitable for screening

5. Aims of Cranial Ultrasound
• Exclude/demonstrate cerebral pathology
• Assess timing of injury
• Assess neurological prognosis
• Help make decisions on continuation of
neonatal intensive care
• Optimize treatment and support

6. Indications for Sonographic Exam
 Cranial abnormality found on pre-natal sonogram
 Increasing head circumference with or without
increasing intracranial pressure
 Acquired or Congenital inflammatory disease
 Prematurity
 Diagnosis of hypoxia, hypertension, hypercapnia,
hypernaturemia, acidosis, pneumothorax, asphyxia,
apnea, seizures, coagulation defects, patent ductus
arteriosus, or elevated blood pressure
 History of birth trauma or surgery
 Suctioning of infant
 Genetic syndromes and malformations

7. Anatomy of the Neonatal Skull
 Fontanelles (“Soft Spots”)
 Spaces between bones of the skull

8. Sonographic Technique
What anatomy do you scan?
Supratentorial Compartment
 Both cerebral hemispheres
 Basal Ganglia
 Lateral & 3rd
Ventricle
 Interhemispheric fissure
 Subarachnoid spaces
 Views
 Coronal
 Modified Coronal (anterior fontanelle)
 Sagittal (anterior fontanelle)
 Parasagittal (anterior fontanelle)

9. Sonographic Technique
Infratentorial Compartment
 Cerebellum
 Brain Stem
 4th
Ventricle
 Basal Cisterns
 Views
 Coronal (mastoid fontanelle and
occipitotemporal area)
 Modified Coronal
 Sagittal
 Parasagittal (with increased focal depth &
decreased frequency)

10. • Transducers : 5–7.5–10 MHz
• Appropriately sized
• Standard examination: use 7.5–8 MHz
• Tiny infant and/or superficial structures: use
additional higher frequency (10 MHz)
• Large infant, thick hair, and/or deep structures:
use additional lower frequency (5 MHz)

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

13. Standard Views….Anterior Frontal
• Coronal Views (at least 6 standard planes)

14. Standard Coronal Planes

15. First Coronal plane….Frontal Lobes
1. Interhemispheric
fissure
2. Frontal lobe
3. Skull
4. Orbit

16. Second Coronal Plane….Frontal horns of Lateral
Ventricle
2.Frontal lobe
5.Frontal horn of lateral
ventricle
6.Caudate nucleus
7.Basal ganglia
8.Temporal lobe
9.Sylvian fissure

17. Third Coronal plane ….Foramen of Monro & 3rd
Ventricle
2. Frontal lobe
5. Frontal horn of lateral
ventricle
6. Caudate nucleus
8.Temporal lobe
9.Sylvian fissure
10. Corpus callosum
11. Cavum septum pellucidum
12. Third ventricle
13. Cingulate sulcus

18. Fourth coronal plane…. body of the lateral
ventricle
1.Interhemispheric fissure
8.Temporal lobe
9.Sylvian fissure
14.Body of lateral ventricle
15.Choroid plexus
16.Thalamus
17.Hippocampal fissure
18.Aqueduct of Sylvius
19.Brain stem
20.Parietal lobe

19. Fifth Coronal plane….Trigone of Lateral
Ventricle
8.Temporal lobe
10.Corpus callosum
15.Choroid plexus
20.Parietal lobe
21.Trigone of lateral ventricle
22.Cerebellum(a: hemispheres; b:
vermis)
23.Tentorium
24.Mesencephalon

20. Sixth Coronal Plane….Parieto Occipital
Lobe
20.Parietal lobe
25.Occipital lobe
26.Parieto-occipital fissure
27.Calcarine fissure

21. • Sagittal Views (at least 5 standard planes)
Standard Views…..Anterior Fontanelle

22. Midsagittal plane….3rd
and 4th
ventricles
10.Corpus callosum
11.Cavum septum pellucidum
12.Third ventricle
13.Cingulate sulcus
16.Thalamus
22b.Cerebellum(vermis)
24.Mesencephalon
26.Parieto-occipital fissure
27.Calcarine fissure
28.Pons
29.Medulla oblongata
31. Cisterna magna
32. Cisterna quadrigemina
33. Interpeduncular fossa
34. Fornix

23. Second and Fourth Parasagittal
planes….right and left lateral ventricles
2. Frontal lobe
5. Frontal horn of lateral ventricle
6. Caudate nucleus
8. Temporal lobe
14. Body of lateral ventricle
15. Choroid plexus
16. Thalamus
17. Hippocampal fissure
20. Parietal lobe
21. Trigone of lateral ventricle
22a. Cerebellum(hemisphere)
25. Occipital lobe
36. Occipital horn of lateral
ventricle
Black arrow indicates Caudothalamic
groove

24. First & Fifth Parasagittal planes….Insula
2. Frontal lobe
8. Temporal lobe
9. Sylvian fissure
20. Parietal lobe
25. Occipital lobe
37. Insula

25. Supplemental Acoustic Window

26. Coronal view, using the PF as an acoustic
window
8. Temporal lobe
22. Cerebellum(a:
hemispheres; b: vermis)
23. Tentorium
25. Occipital lobe
27. Calcarine fissure
29. Medulla oblongata
36. Occipital horn of lateral
ventricle
38. Falx

27. Parasagittal view using PF as an acoustic
window
8. Temporal lobe
15. Choroid plexus
16. Thalamus
20. Parietal lobe
21. Trigone of lateral
ventricle
22a. Cerebellum
(hemispheres)
25. Occipital lobe
27. Calcarine fissure

28. Upper Transverse view using left
Temporal window

29. Upper Transverse view using left
Temporal window
1. Interhemispheric fissure
8. Temporal lobe
12. Third ventricle
22. Cerebellum
(a: hemispheres; b: vermis)
23. Tentorium
24. Mesencephalon
33. Interpeduncular fossa
41. Circle of Willis

30. Lower Transverse view using Left Temporal
Window
• 8. Temporal lobe
• 22. Cerebellum
(a: hemispheres; b: vermis)
• 25. Occipital lobe
• 28. Pons
• 41. Circle of Willis
• 42. Prepontine cistern

31. Coronal View…..Mastoid Fontanelle
• 22. Cerebellum
– a: hemispheres
– b: vermis
• 28. Pons
• 30. Fourth ventricle
• 31.Interpeduncular Fossa

32. Transverse View….Mastoid Fontanelle
• 8. Temporal lobe
• 22. Cerebellum
– (a: hemispheres; b: vermis)
• 25. Occipital lobe
• 28. Pons

34. Doppler uses
 Typical transcranial Doppler with
imaging scan and recording from
middle cerebral artery (MCA).
 Doppler image shows circle of Willis.
 A = anterior cerebral artery
 M = middle cerebral artery
 P = posterior cerebral artery
 RI = resistive index
 Demonstrates
 Decreased blood
flow/ischemia/infarction
 Vascular abnormalities
 Cerebral Edema
 Hydrocephalus
 Intracranial Tumors
 Near-field structures

35. BLOOD FLOW VELOCITY
• Changes in flow velocity occur
when:
• There is a change in vessel caliber
• There is a change in volume flow

36. should we do doppler study
vein of
galen
aneurysm

38. Hemorrhagic Pathology
 Risk Factors
 Pre term infants
 Less than 1500 grams birth weight
 Grading
 Grade I - Confined to germinal matrix
 Grade II - Intraventricular without ventricular dilatation
 Grade III - Intraventricular with ventricular dilatation
 Grade IV - Periventricular hemorrhagic infarction

39. Germinal Matrix Hemorrhage
 Far more common in premature infants
 Germinal matrix - highly vascular and
vulnerable to hypoxemia and ischemia, only
present 24-32nd
week gestation more common
site
 Image 4-7 days after birth
 90% of hemorrhages occur in first week of life
 Follow with weekly U/S to evaluate for
hydrocephalus

40. Subependymal-Intraventricular Hemorrhage
(SEH-IVH)
 Caused by capillary bleeding in the germinal matrix
 Continued subependymal (SEH) bleeding pushes into the
ventricular cavity (IVH) & continues to follow CSF pathways
causing obstruction
 Since 70% of hemorrhages are asymptomatic, it is necessary
to scan babies routinely
 Small IVH’s may not be seen from the anterior fontanelle
because blood tends to settle out in the posterior horns
 Risk Factors
 Pre term infants
 Less than 1500 grams birth weight

41. Grade I Hemorrhage

42. Grade II Hemorrhage

43. Grade III Hemorrhage

44. Grade IV Hemorrhage

45. Intraparenchymal Hemorrhage
 Brain parenchyma destroyed
 Originally considered an
extension of IVH, but may
actually be a primary
infarction of the
periventricular and sub
cortical white matter with
destruction of the lateral wall
of the ventricle.
 Sonographic Finding
 Zones of increased
echogenicity in white
matter adjacent to lateral
ventricles

46. Intracerebellar Hemorrhage
 Types
 Primary
 Venous Infarction
 Traumatic Laceration
 Extension from IVH
 Sonographic Findings
 Areas of increased echogenicity
within cerebellar parenchyma
 Coronal views through
mastoid fontanelle may be
essential to differentiate from
large IVH in the cisterna
magna

47. Epidural Hemorrhages and Subdural
Collections
 Best diagnosed with CT because the lesions are
located peripherally along the surface of the brain.
an echogenic layer of clotted
blood (arrow) is seen between
the cortex and the skull.
five hours after the image the clot
has started to lyse, and the layer is
now hypoechoic.
a parasagittal view
demonstrates the fluid around
the cortical mantle and the
paucity of gyri due to the

48. Periventricular Leukomalacia (PVL) or
White Matter Necrosis (WMN)
 Also known as Hypoxic-Ischemic Encephalopathy
(HIE).
 Affects the periventricular zones.
 watershed zone between deep and superficial
vessels.
 Causes:
 Ischemia
 Infection
 Vasculitis

49. Periventricular Leukomalacia (PVL) or
White Matter Necrosis (WMN)
 PVL presents as areas of increased periventricular
echogenicity.
 Premature infants born at less than 33 weeks
gestation (38% PVL) and less than 1500 g birth
weight (45% PVL).
 Effects
 cerebral palsy,
 intellectual impairment
 visual disturbances

50. Periventricular Leukomalacia (PVL) or
White Matter Necrosis (WMN)
Grade 1. Persisting more than 7 days
Grade 2. Developing into small periventricular
cysts
Grade 3. Developing into extensive
periventricular cysts, occipital and
frontoparietal
Grade 4. In deep white matter developing into
extensive subcortical cysts

51. PVL or WMN
1
2
Sagittal image of a child with
PVL grade 1
Transverse and sagittal image of a child
with PVL grade 2.

52. PVL or WMN
Coronal and transverse images
demonstrating PVL grade 4
Sagittal image demonstrating
extensive PVL grade 3

53. THANX

54. Chiari Malformation
 Sonographic Features
 Small posterior fossa
 Small, displaced
Cerebellum
 Possible
Myelomeningocele
 Widened 3rd
Ventricle
 Cerebellum herniated
through enlarged
foramen magnum
 4th
ventricle elongated
 Posterior horns enlarged
 Cavum Septum
pellucidum absent
 Interhemispheric Fissure
widened
 Tentorium low and
hypoplastic

55. Holoprosencephaly
 Common large central ventricle because Prosencephalon
failed to cleave into separate cerebral hemispheres.
 Alobar Holoprosencephaly (Most Severe)
 Fused thalami anteriorly to a fused choroid plexus
 Single midline ventricle
 No falx cerebrum, corpus callosum, Interhemispheric
fissure, or 3rd
ventricle
 Semilobar Holoprosencephaly
 Single ventricle
 Presents with portions of the falx and Interhemispheric
fissure
 Thalami partially separated
 3rd
Ventricle is rudimentary
 Mild facial anomalies
 Lobar Holoprosencephaly (Least Severe)
 Near complete separation of hemispheres; only anterior
horns fused
 Full development of falx and interhemispheric fissure

56. Holoprosencephaly
Alobar Holoprosencephaly Semilobar Holoprosencephaly

57. Dandy-Walker Malformation
 Congenital anomaly of the roof of the 4th
ventricle
with occlusion of the aqueduct of Sylvius and
foramina of Magendie and Luschka
 A huge 4th
ventricle cyst occupies the area where the
cerebellum usually lies with secondary dilation of the
3rd
ventricle; absent cerebellar vermis

58. Dandy Walker Malformation

59. Agenesis of the Corpus Callosum
 Complete or partial absence of the connection tissue between
cerebral hemispheres
 Narrow frontal horns
 Marked separation of lateral ventricles
 Widening of occipital horns and 3rd
Ventricle
 “Vampire Wings”

60. Agenesis of the Corpus Callosum

61. Ventriculmegaly
 Enlargement of the ventricles without
increased head circumference
 Communicating
 Non-communicating
 Result of cerebral atrophy
 Sonographic Findings
 Ventricles greater than normal size
first noted in the trigone and occipital
horn areas
 Visualization of the 3rd
and possibly 4th
ventricles
 Choroid plexus appears to “dangle”
within the ventricular trium
 Thinned brain mantle in case of
cerebral atrophy

62. Hydrocephalus
 Enlargement of ventricles with increased head
circumference
 Communicating
 Non-communicating
 Sonographic Findings
 Blunted lateral angles of enlarged lateral
ventricles
 Possible interhemispheric fissure rupture
 Thinned brain mantle
 Aqueductal Stenosis
 Most common cause of congenital
hydrocephalus
 Aqueduct of Sylvius is narrowed or is a
small channel with blind ends;
occasionally caused by extrinsic lesions
posterior to the brain stem
 Sonographic Findings
 Widening of lateral and 3rd
ventricles
 Normal 4th
ventricle

63. Hydrancephaly
 Occlusion of internal carotid
arteries resulting in necrosis
of cerebral hemispheres
 Absence of both cerebral
hemispheres with presence
of the falx, thalamus,
cerebellum, brain stem, and
positions of the occipital and
temporal lobes
 Sonographic findings
Fluid filled cranial vault
Intact cerebellum and
midbrain

64. Cephalocele
 Herniation of a portion of the neural tube through a
defect in the skull
 Sonographic Findings
 Sac/pouch containing brain tissue and/or CSF and
meninges
 Lateral Ventricle Enlargement

65. Arachnoid Cysts
 Cysts lined with arachnoid tissue and
containing CSF
 Causes
 Entrapment during embryogenesis
 Residual subdural hematoma
 Fluid extravasation secondary to
meningeal tear or ventricular
rupture

66. Brain Infections
 Common infections referred to by TORCH
 T: Toxoplasma Gondii
 O: Other (Syphilis)
 R: Rubella Virus
 C: Cytomegalovirus
 H: Herpes Simplex Type 2
 Consequences
 Mortality
 Mental Retardation
 Developmental Delay

67. Ependymitis and Ventriculitis
 Ependymitis
 Irritation from hemorrhage within
the ventricle
 Occurs earlier than ventriculitis
Sonographic Features
 Thickened, hypoechoic ependyma
(epithelial lining of the ventricles)
 Ventriculitis
 Common complication of purulent
meningitis
Sonographic Findings
 Thin septations extending from the
walls of the lateral ventricles.