INFANT CRANIAL ULTRASOUND

BY DR MUHAMMAD SALMAN KHAN

 Cranial sonography (US) 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.

Advantages of Cranial Ultrasound

Safe Bedside Reliable

Early imaging
Serial imaging:

Brain maturation Evolution of lesions Inexpensive Suitable for screening

Aims of Neonatal Cranial Ultrasound

Exclude/demonstrate cerebral pathology Assess timing of injury Assess neurological prognosis

Help make decisions on continuation of neonatal

intensive care Optimise treatment and support

Indications
Premature infants - all <1500g or <32 weeks

gestation Low APGAR score Neurologic changes Cranial dysmorphism Seizures Follow-up of hemorrhage and periventricular leuokmalacia

Technique
Generally 5-10MHz sector transducer is used,

however do not limit yourself to only one transducer.

Generally the anterior fontanel is used as acoustic

window, posterior fontanel however is a good window to the occipital lobes.

Standard Views(Anterior Fontanel)

Coronal Views(at least 6 standard planes)

The Standard Coronal Planes

First coronal plane (C1) at the level of frontal lobes

First coronal plane (C1) at the level of frontal lobes

1. Interhemispheric fissure 2. Frontal lobe 3. Skull 4. Orbit

Second coronal plane (C2) at the level of frontal horns of the lateral ventricles

Second coronal plane (C2) at the level of frontal horns of the lateral ventricles
2.Frontal lobe 5.Frontal horn of lateral ventricle 6.Caudate nucleus 7.Basal ganglia 8.Temporal lobe 9.Sylvian fissure

Third coronal plane (C3) at the level of foramen of Monro and 3rd ventricle

Third coronal plane (C3) at the level of foramen of Monro and 3rd ventricle
2.Frontal lobe 5.Frontal horn 6.Caudate neucleus 8.Temporal lobe 9.Sylvian fissure 10.Corpus callosum 11.Cavum septum pellucidum 12.Third ventricle 13.Cingulate sulcus

Fourth coronal plane (C4) at the level of the body of the lateral ventricle

Fourth coronal plane (C4) at the level of the 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

Fifth coronal plane (C5) at the level of the trigone of the lateral ventricle

Fifth coronal plane (C5) at the level of the trigone of the 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

Sixth coronal plane (C6) through the parieto occipital lobes

Sixth coronal plane (C6) through the parieto occipital lobes

20.Parietal lobe 25.Occipital lobe 26.Parieto-occipital fissure 27.Calcarine fissure

Standard Views(Anterior Fontanel)

Sagittal Views (at least 5 standard planes)

Midsagittal plane(S3) through the 3rd and 4th ventricles

Midsagittal plane(S3) through the 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 32. Cisterna quadrigemina 33. Interpeduncular fossa 34. Fornix

Second and Fourth parasagittal planes(S2 ,S4) through right and left lateral ventricles

Second and Fourth parasagittal planes(S2 ,S4) through 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

First and Fifth parasagittal planes(S1,S5) through the insulae(right & left)

First and Fifth parasagittal planes(S1,S5) through the insulae(right & left)
2. Frontal lobe 8. Temporal lobe 9. Sylvian fissure 20. Parietal lobe 25. Occipital lobe 37. Insula

Posterior Fontanel as an acoustic window

Coronal view, using the PF as an acoustic window

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

Parasagittal view using PF as an acoustic window

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

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 Image 4-7 days after birth

90% of hemorrhages occur in first week of life Follow with weekly U/S to evaluate for hydrocephalus

 Grade I - Confined to germinal matrix Grade II - Intraventricular without ventricular

dilatation Grade III - Intraventricular with ventricular dilatation Grade IV - Periventricular hemorrhagic infarction

Periventricular Leukomalacia (PVL)

5-10% of premature infants Infarction of deep white matter Occurs in the watershed zone in infants, adjacent to

trigone of the lateral ventricles Seen as increased echogenicity (greater than choroid plexus)

 Often missed with ultrasound, serial exams increase

sensitivity May get cystic changes in 2-3 weeks Symptoms: spastic diplegia, intellectual deficits

Vein of Galen Malformation

Fistulous connection - cerebral arteries and midline

prosencephalic vein 2 types:

Choroidal - 90%, presents in neonate as CHF and intracranial bruit Mural - presents in infancy with developmental delay, seizures, and hydrocephalus

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 Probst bundles impress upon lateral ventricles

Chiari II Malformation
Batwing configuration of frontal horns Small posterior fossa with low-lying tentorium Interdigitating gyri

Large massa intermedia

Absence of corpus callosum Hydrocephalus Nearly 100% have myelomeningocele

Dandy Walker Malformation

Posterior fossa cyst which communicates with 4th

ventricle (arachnoid cyst and enlarged foramen magnum do not) Large posterior fossa Hypoplastic cerebellar vermis and laterally displaced cerebellar hemispheres Frequently associated with other anomalies

Temporal lobe arachnoid cyst

Most common intracranial congenital cystic lesion Can have mass effect and bony remodeling Same appearance as CSF on all imaging modalities

Corpus Callosum Lipoma

Associated with dysgenesis of the corpus callosum May involve any part of the corpus callosum or be

pericallosal in location

Semilobar Holoprosencephaly
Hypoplastic falx and interhemispheric fissure Partially separated thalamus Intermediate in severity between alobar and lobar

holoprosencephaly Can have associated facial anomaly

Lissencephaly
Lack of gyration and sulcation Thickened cortex Colpocephaly

Homogeneous or pseudoliver appearance to the

brain parenchyma Figure eight appearance due to shallow sylvian fissures Can result from intrauterine infection

Thanks