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By
Dr: Rabab Hashim
 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.
Advantages of Cranial Ultrasonography
 Safe
 Bedside
 Reliable
 Early imaging
 Serial imaging:
Brain maturation
Evolution of lesions
 Inexpensive
 Suitable for screening
Equipment
What is the optimum time for CUS
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
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.
Anatomical points
Cranial ultrasnography, by dr Rabab hashem
Cranial ultrasnography, by dr Rabab hashem
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
Anterior
Fontanel
The Standard
view window
Posterior
Fontanel
Supplementary
view window
Mastoid
Fontanel
Supplementary
view window
Temporal
Supplementary
view window
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.
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
Well-fitting ultrasound probe, positioned on the anterior fontanel. Arrow
indicates the marker on the probe
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.
Probe positioning for obtaining sagittal planes. Arrow indicates marker
Normal CUS Scan
Coronal Planes
Coronal Views
1st coronal plane at the level of the
frontal lobe
Anterior horns of the lateral Ventricles
The Third Ventricle
Post cronal(Trigone)
Sagittal Views
Midline Sagittal
Lateral (RT &LT)Angled Parasagittal
Normal variant
Cavum septum pellcidum
Chorioïd plexus cyst
Abnormal Scans
Congenital infectDWV&VOGV
PVLPHVDIVH
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
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
Germinal matrix haemorrhage
G1 IVH
G1 IVH
IVH GII
IVH III
IVH III
Cranial ultrasnography, by dr Rabab hashem
Cranial ultrasnography, by dr Rabab hashem
Post Hemorrhagic hydrocephalus
PHVD
PHVD
Cranial ultrasnography, by dr Rabab hashem
PHH
Ventricular index
Ventricular index and HC chart(Levene)
Ventricular reservoir
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
Periventricular Leukomalacia(PVL)
Cranial ultrasnography, by dr Rabab hashem
Periventricular Leukomalacia G I
PVL II
Periventricular Leukomalacia G II
Periventricular Leukomalacia G III
PVL IV
Periventricular Leukomalacia G IV
Congenital malformation
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
Vein of Galen Malfomatiorn
Congenital infection
Calcifications
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
Our patient
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.
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.

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Cranial ultrasnography, by dr Rabab hashem

  • 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
  • 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.
  • 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
  • 21. 1st coronal plane at the level of the frontal lobe
  • 22. Anterior horns of the lateral Ventricles
  • 27. Lateral (RT &LT)Angled Parasagittal
  • 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
  • 40. PHVD
  • 42. PHH
  • 44. Ventricular index and HC chart(Levene)
  • 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
  • 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
  • 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
  • 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.