Neonatal cranial USG by Dr. Prashant Gupta

1. CRANIAL SONOGRAPHY OF
INFANT
Dr. Prashant Gupta
NAMS

2. • Neonatal sonography of the brain is an essential
part of newborn care, particularly in high-risk and
unstable premature infants.
• Current ultrasound (US) technology allows for
rapid evaluation of infants in the intensive care
nursery with virtually no risk.
• Color and spectral Doppler ultrasound of cranial
blood flow may prove valuable, particularly for
cystic lesions when the differential diagnosis
includes a vascular lesion, or for possible
subdural hematomas, and to separate normal
vascular structures from clot.

3. Advantage of cranial US (CUS)
• Bedside- compatible
• Reliable
• Early imaging
• Serial imaging:
Brain maturation
Evolution of lesions
• Inexpensive
• Suitable for screening
• no ionizing radiation
• no sedation.

4. EQUIPMENT
• Transducers : 5–10 MHz
• Appropriately sized
• Standard examination: use 7.5–8
MHz
• Small 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)

5. THE ACOUSTIC WINDOWS
Anterior Fontanel
The Standard view
window
Posterior Fontanel
Supplementary
view window
Mastoid Fontanel
Supplementary
view window
Temporal
Supplementary
view window

6. SONOGRAPHIC TECHNIQUE
• Every effort should be made to maintain normal
body temperature in premature infants when
performing ultrasound
• Handwashing and cleansing of the transducer
between patients are of paramount importance
to avoid the spread of infection in the intensive
care nursery.
• Standard brain scanning includes
 sagittal and coronal view from anterior
fontanelle
 axial view from posterior and mastoid fontanel

7. Coronal brain ultrasound planes through anterior fontanelle. A through F correspond to front to back. CC,
Cerebral cortex; BV, body of lateral ventricle; FH, frontal horn; OH, occipital horn; CN, caudate nucleus;
M, massa intermedia; PR, pineal recess; 3, third ventricle; TH, temporal horn; SR, supraoptic recess; IR,
infundibular recess; CP, choroid plexus; 4, fourth ventricle; CB, cerebellum.
Coronal view
•Coronal images are obtained by
placing the scan head of the transducer
transversely across the anterior
fontanelle
•The plane of the ultrasound beam
should then sweep in an anterior-to-
posterior direction, completely
through the brain.
•At least six standard coronal images
should be obtained during this anterior
to posterior sweep.

8. Standard Views(Anterior Fontanel)
• Coronal Views(at least 6 standard planes)

9. The Standard Coronal Planes

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

11. First coronal plane (C1) at the level of
frontal lobes
1. Interhemispheric
fissure
2. Frontal lobe
3. Skull
4. Orbit

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

13. 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

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

15. 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

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

17. 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

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

19. 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

20. Sixth coronal plane (C6) through the
parieto occipital lobes

21. Sixth coronal plane (C6) through the
parieto occipital lobes
20.Parietal lobe
25.Occipital lobe
26.Parieto-
occipital fissure
27.Calcarine
fissure

22. Coronal brain ultrasound images: normal full-term infant. Anterior to posterior corresponds to sections A to
F - A, FL, Frontal lobes; black arrow, interhemispheric fissure. B, P, Putamen; C, caudate nucleus; f,
frontal horns of lateral ventricles; TL, temporal lobe; arrowhead, corpus callosum; closed arrow, sylvian
fissure; open arrow, bifurcation of internal carotid artery. (On images A and B black arrow represents
interhemispheric fissure.) C, B, Brainstem; 3, location of third ventricle (third and fourth ventricles are
difficult to see in normal patients on coronal cuts). D, S, Centrum semiovale; b, body of lateral ventricle; c,
choroid plexus; T, thalamus; V, vermis of cerebellum; curved arrow, tentorium cerebelli; straight white
arrow, cingulate sulcus.

23. E, PL, Parietal lobe; G, glomus of choroid plexus; CB, cerebellum. F, OL, Occipital lobe.

24. Sagittal Imaging
•The sagittal images are obtained by
placing the transducer longitudinally
across the anterior fontanelle and
angling it to each side.
•The midline is first identified through
the interhemispheric fissure by
recognition of the curving line of the
corpus callosum above the cystic
cavum septi pellucidi and cavum
vergae, the third and fourth ventricles,
and the highly echogenic cerebellar
vermis.

25. Standard Views(Anterior Fontanel)
• Sagittal Views (at least 5 standard planes)

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

27. Midsagittal plane(S3) through the 3rd
and 4th ventricles10.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

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

29. 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

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

31. 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

32. Posterior Fontanel as an acoustic
window

33. Coronal view, using the PF as an acoustic
window

34. 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

35. Parasagittal view using PF as an acoustic
window

36. •The transducer is placed over
posterior fontanelle and angled
slightly off midline with the
anterior portion of the probe
directed slightly medially, to
demonstrate the lateral
ventricular trigone with its
occipital horn in the near field.
•Angling the transducer into
the left and right parasagittal
planes will display each
occipital horn
Posterior fontanelle scan

37. 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

38. Occipital horn: posterior fontanelle images. A, Occipital horn with lobular choroid,
sagittal plane. B, Occipital horns, axial plane (turned 90 degrees clockwise)

39. Mastoid fontanelle images at fourth ventricle level in posterior fossa. A, Normal cerebellar
hemispheres (C), cerebellar vermis (V), fourth ventricle (4), and cisterna magna (CM).
•The ultrasound transducer is
placed about 1 cm behind the
helix of the ear and 1 cm above
the tragus.
•The mastoid fontanelle allows
assessment of the brainstem
and posterior fossa, which are
not well demonstrated in the
standard planes through the
anterior fontanelle.
Mastoid Fontanelle scan

40. Normal variants
• Frontal horn cyst.
• Cavum septum pellucidum and
cavum verge
• Cavum velum interpositum
• Calcar avis
• Mega cisterna magna

41. Frontal horn cysts, coronal and sagittal sonogram shows uncommon normal
cystic variants, also called frontal horn coarctation or connatal cysts. Frontal
horn cysts appear to be septations in the ventricles (arrow) but are thought to
be caused by folding of the frontal horn on itself.
Frontal horn cysts
•coarctation of the frontal horn
or connatal cysts
•exactly parallel (not above or
below) and adjacent to the frontal
horns.
•caused by folding of the frontal
horn on itself, resulting in kinking
(seen as a septation).
•typically bilateral and have
septations between the cyst and
the frontal horns

42. • continuous cystic midline structure in the septum
pellucidum during fetal life. The septum contains
the cavum septi pellucidi anterior to the foramen
of Monro and the cavum vergae posteriorly.
• Both parts are normally present early in
gestation, but they close from back to front,
starting at approximately 6 months’ gestation.
• By full term, closure has occurred posteriorly in
97% of infants so that there is only a cavum septi
pellucidi at birth.
Cavum Septi Pellucidum and Cavum Vergae

43. Normal premature infant brain. Sagittal. A, 25 weeks. No sulci; corpus callosum lies above
completely cystic cavum septi pellucidi and cavum vergae. Arrow, Occipitoparietal fissure. B, 27
weeks. Cingulate sulcus (arrow) is just developed, and cavum septi pellucidi (C) and cavum
vergae (V) are readily visible.

44. C, 30 weeks. Cingulate sulcus (short arrow) has a few branches. Long arrow, Cavum velum
interpositum.
•represents a potential space
above the choroid in the roof of
the third ventricle and below the
columns of the fornices.
•may appear as an anechoic,
inverted, helmetlike space
just inferior and posterior to the
splenium in the pineal region
Cavum velum interpositum

45. B, Calcar avisv(CA) can be averaged into the occipital horn and imitate
hemorrhage. Note continuity with the adjacent brain identifies this structure.
Calcar avis
•On posterior fontanelle views, a
normal gyrus, the calcar avis,
frequently protrudes into the
medial aspect of the lateral
ventricle at the junction of the
trigone and occipital horn.
•It can be recognized due to a
central echogenic sulcus (calcarine
fissure), its continuity with the
adjacent brain, and normal
vascularity on color Doppler
ultrasound.

46. Mega cisterna magna. A and B, Sagittal and coronal sonograms show an enlarged cisterna
magna (C) behind the vermis on A and below the tentorium on B, with no communication to
the fourth ventricle and no hydrocephalus.
Mega cisterna magna

47. Ventricular measurement
• Measurement of the ventricular system should be done in an easy
reproducable sonographic plane.
• Coronal section is used through the lateral ventricles slightly posterior to
the foramen of Monro.
• Two methods
1)Levine index- Up to 40 weeks of gestational age
2)Ventricular index-After 40 weeks
Levine index
•the absolute distance between the
falx and the lateral wall of the
anterior horn in the coronal plane at
the level of the third ventricle.
•This is performed for the left and
right side.
•measurements can be compared to
the reference curve and are quite
useful for further follow-up.

48. Ventricular index
•the ratio of the distance
between the lateral sides
of the ventricles and the
biparietal diameter.

50. CLASSICIFICATION OF
CONGENITAL BRAIN MALFORMATIONS

51. DISORDERS OF NEURAL TUBE CLOSURE
Chiari Malformations
Chiari I malformation
• simply the downward displacement of the cerebellar
tonsils, without displacement of the fourth ventricle or
medulla.
Chiari II malformation
• the most common and of greatest clinical importance
because of its almost universal association with
myelomeningocele.
Chiari III malformation
• a high cervical encephalomeningocele in which the
medulla, fourth ventricle, and virtually the entire
cerebellum reside.

53. Chiari II malformation. A, Lateral parasagittal sonogram, and B, MR image, show pointing of
frontal horn(curved arrow) and colpocephaly; O, occipital horn; T, trigone of lateral ventricle.

54. Chiari II malformation. C, Midline sagittal sonogram, and D, midline sagittal MR image, show
enlargement of massa intermedia (M) and tonsillar herniation through foramen magnum
(arrow).

55. Agenesis of Corpus Callosum
•depending on the timing of the intrauterine insult,
development of corpus callosum may be partially or
completely arrested . If partial, the genu is usually
present, and the dorsal splenium or the anterior
rostrum is absent.
•associated anomalies include
Chiari II and Dandy-Walker malformations,
holoprosencephaly, encephaloceles, lipomas,
arachnoid cysts, migrational abnormalities, and
Aicardi syndrome

57. Agenesis of the corpus callosum, isolated anomaly. A, Tiny frontal horns are widely
separated. B, Starburst sulci radiate above the third ventricle. C and D, Occipital horns are
larger than frontal horns and widely separated.

58. Agenesis of the corpus callosum.
A and B, Sagittal and coronal sonograms show marked tapering of the frontal
horns with larger occipital horns (colpocephaly).

59. Dandy-Walker Malformation
• Characterised by cystic dilatation of the fourth
ventricle and an enlarged posterior fossa with
upward displacement of lateral sinuses,
tentorium and torcula herophili associated with
varying degree of vermian aplasia or hypoplasia.
• Due to failure of development of anterior
medullary velum( embryonic roof of 4th
ventricular) atresia of fourth ventricular outlet
foramina, and delayed opening of foramen
magendie.

61. Dandy-Walker malformation: classic isolated malformation. A and B, Coronal and
sagittal sonograms. C, Dandy-Walker posterior fossa cyst; 3, third ventricle; 4, fourth
ventricle; L and LV, dilated lateral ventricles

62. Dandy-Walker malformation: classic isolated malformation C, Coronal ultrasound shows Dandy-Walker
malformation after ventriculoperitoneal shunt. Lateral and third ventricles have decompressed, but Dandy
Walker cyst (D) remains dilated. Frequently, posterior fossa cysts require additional shunts for
decompression.

63. Dandy Walker Variant
Dandy-Walker variant. Axial posterior fossa ultrasound shows a wide continuity between the
fourth ventricle and the cisterna magna, where the cerebellar vermis is hypoplastic and
separated behind the fourth ventricle.
•There is mild vermian hypoplasia with
a variable sized cystic space caused by
open communication of posteroinferior
4th ventricle and cisterna magna
through enlarged vallecula.
•4th ventricle is often slightly to
moderately enlarged but posterior
fossa is typically normal size.
•Brain stem is usually normal.
•Although hydrocephalus may be
present, 3rd and lateral ventricles are
usually normal.

64. DISORDERS OF DIVERTICULATION AND CLEAVAGE
Holoprosencephaly
• results from a failure of diverticulation when the primitive
prosencephalon does not divide into the telencephalon
and the diencephalon between the fourth and eighth
weeks of gestation.
• represents a spectrum of malformations that form a
continuum from most severe, with no separation of the
telencephalon into hemispheres (alobar
holoprosencephaly), to least severe, with partial
separation of the dorsal aspects of the brain (lobar
holoprosencephaly)
• The septum pellucidum is absent in all forms of
holoprosencephaly

65. Alobar
Holoprosencephaly
-the most severe form of
disorder.
Infants with this defect usually
die within the first months of
life or are stillborn.
-Facial features may include
cebocephaly , cyclopia, and
ethmocephaly (cyclopia or
hypotelorism) with a midline
proboscis above the eyes.

66. Alobar holoprosencephaly. A, Coronal sonogram shows single central ventricle (V) and
fused thalami (T). No falx or interhemispheric fissure is present. B, MR image, and C, pathology
specimen, show single central ventricle and fused thalami. D, Autopsy specimen shows
cebocephaly (severe hypotelorism and malformed nose).

67. Septo-optic Dysplasia
Septo-optic dysplasia. A and
B, Coronal and
sagittal sonograms; C,
pathology specimen.
Although the cavum septum
pellucidum is absent, the
corpus callosum is present.
-mildest form of lobar
holoprosencephaly
-absence of the septum
pellucidum and optic
nerve hypoplasia
-About two thirds of these
infants have hypothalamic-
pituitary dysfunction.
-may have visual
symptoms and growth
restriction.

68. DISORDERS OF SULCATION AND
CELLULAR MIGRATION
Schizencephaly
• Split brain
• a gray matter lined CSF filled cleft that extends from the
ependymal surface of the brain through the white matter
to the pia
• caused by a primary neuronal migration malformation in
utero
• Two types-
closed lip – cleft walls are in apposition
open lip- cleft walls are separated.
• Cleft may be unilateral or bilateral, symmetrical or
asymmetric

69. Schizencephaly. A, Coronal sonogram, and B, coronal MR image, of open-lip schizencephaly
show bilateral clefts (c) with wide openings to the ventricular (v) system. C, Sonogram, and D,
CT image, show closed-lip schizencephaly with calcification from in utero infection.

70. DESTRUCTIVE LESIONS
Porencephalic Cyst
• After 26 weeks’ gestation, a porencephalic cyst will develop
in an area of normally developed brain that has been
damaged and heals with scarring because of a lining of
gliotic white matter.
• By definition, porencephalic cysts always connect with the
ventricular system but do not extend to the surface cortex.
• usually occur after birth secondary to intraparenchymal
hemorrhage (IPH), infection (focal vasculitis, abscess), or
trauma.

71. Hydranencephaly
• believed to be caused by bilateral occlusion of
the internal carotid arteries during fetal
development, but it may result from any of
several intracranial destructive processes.
• It is the severest form of porencephaly in that
there is almost total destruction of the
cerebral cortex.
• These infants may appear surprisingly normal
at birth but are developmentally delayed from
an early age and frequently die within the first
year of life.

72. • USG findings:
-calvarium filled with CSF
-Structures that receive their blood supply
from the posterior cerebral artery and vertebral
artery, such as the thalamus, cerebellum,
brainstem, and posterior choroid plexus are
spared
• Blood flow will not be appreciated by color or
spectral Doppler in the carotid arteries.
• The presence of the falx helps differentiate this
lesion from alobar holoprosencephaly, in which
the falx does not form.

73. Hydranencephaly in two full-term
newborns. A, Coronal anterior; B, midline
sagittal; and C, coronal posterior
sonograms. Note that only anechoic
cerebrospinal fluid is seen above
thalamus (T), which at first looks like
holoprosencephaly, but the definitive
diagnosis is made because there is a falx
seen in the midline on all three views.
Note the echogenic falx on the midline
view.

74. Cystic Encephalomalacia
• Encephalomalacia is an area of focal brain damage that
pathologically has astrocytic proliferation and glial septations.
• In diffuse brain damage, there may be large areas of cystic
encephalomalacia
Cystic encephalomalacia. A , coronal ; B, sagittal , Severe hypoxic ischemic
encephalopathy has resulted in diffuse infarction, particularly severe in the
cerebral cortex, leading to multiple cystic areas in necrotic brain.

75. HYDROCEPHALUS
• Hydrocephalus occurs in 5 to 25 per 10,000
births and results from an imbalance between
CSF production and its drainage by the
arachnoid villi.
• Neonatal hydrocephalus is easily recognized
by routine coronal and sagittal imaging.
• Sonography is also helpful in following
ventricular decompression in patients shunted
for hydrocephalus.

77. Aqueductal stenosis. A Coronal and midline sagittal ultrasound images; B, Sagittal T1-
weighted MR scan. Marked lateral and third (arrow) ventricular dilation demonstrated, but
fourth ventricle is normal (best seen anterior to the cerebellar vermis on sagittal MRI).
A B

78. Germinal Matrix Hemorrhage
• GMH is a common event occurring primarily in
premature infants less than 32 weeks’ gestational age.
• Infants at greatest risk are those at gestational ages of
less than 30 weeks, with birth weight less than 1500 g,
or both.
• GMH originates predominantly as hemorrhage in the
germinal matrix below the subependymal layer and
may be contained by the ependyma or may rupture
into the ventricular system or less often into the
adjacent parenchyma.
• Sonography is the most effective method for detecting
this hemorrhage in the newborn period and for follow-
up in the subsequent weeks.

79. Germinal Matrix Hemorrhage

80. Sequelae of subependymal
hemorrhage
(SEH). SEH may resolve, leaving a
normal scan; may resolve, leaving a
small subependymal cyst; or may
progress, rupturing into the ventricle,
causing intraventricular hemorrhage
(IVH), or extending into the
parenchyma, causing
intraparenchymal hemorrhage (IPH).
Hydrocephalus (HC) and porencephaly
(PC) are common sequelae of SEH.

81. Sagittal and coronal US of subependymal hemorrhage located
in the groove between the thalamus and the nucleus caudatue.
Grade I

83. Coronal and Sagittal US Both lateral ventricles are filled with blood,
but there is no ventricular dilatation.
Grade II

85. Coronal and sagittal sonograms show aging clot has become less echogenic
than choroid, lateral ventricle is dilated
Grade III

87. Coronal US, a large subependymal bleeding but also a large area with increased
echogenicity in the brain parenchyma lateral to the ventricle.
Grade IV

89. Peri Ventricular Leukomalacia (PVL)
• PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE)
of the preterm.
• It is a white matter disease that affects the periventricular
zones.
• In prematures this white matter zone is a watershed zone
between deep and superficial vessels.
• PVL presents as areas of increased periventricular
echogenicity.
• Normally the echogenicity of the periventricular white matter
should be less than the echogenicity of the choroid plexus.
• PVL occurs most commonly in premature infants born at less
than 33 weeks gestation (38% PVL) and less than 1500 g birth
weight (45% PVL).

90. • Detection of PVL is important because a significant
percentage of surviving premature infants with PVL develop
cerebral palsy, intellectual impairment or visual disturbances.
• More than 50% of infants with PVL or grade III hemorrhage
develop cerebral palsy.
• Grading

92. Transverse and sagittal image of a child with
PVL grade 2.
-small periventricular cysts.
Sagittal image of a child with PVL grade 1
-Increased periventricular echogenicity

93. Sagittal image demonstarting extensive
PVL grade 3
-areas of increased periventricular
echogenicity, that develop into extensive
periventricular cysts in the occipital and
fronto-parietal region.
Coronal and transverse images demonstrating
PVL grade 4
-areas of increased periventricular echogenicity
in the deep white matter developing into
extensive subcortical cysts.

94. Post traumatic injury
Subdural and Epidural Hematomas
• these hematomas present as unilateral or
bilateral hypoechoic fluid collections
surrounding the brain parenchyma.
• Small amounts of fluid may be difficult to
detect secondary to the nearfield artifact
inherent in every transducer. In such case a
high-frequency transducer (10-12 MHz) is
used or lower-frequency transducer,
interposing an acoustic gel pad between the
transducer and the fontanelle.

95. Coronal and sagital view- hypoechoic fluid surrounding the brain parenchyma

96. Galenic Venous Malformations
• represent dilation of the vein of Galen caused by a vascular
malformation that is fed by large arteries off the anterior or
posterior cerebral artery circulation.
• Infants with large shunts usually present in the first month of
life with congestive heart failure. In later childhood, smaller
shunts present with seizure, cranial bruit, hydrocephalus,
and cardiomegaly.
• Sonographically, a galenic venous malformation appears as
an anechoic cystic mass between the lateral ventricles ,
posterior to the foramen of Monro, superior to the third
ventricle, and primarily in the midline.
• Differentiated from other cystic masses by identification of a
large feeding vessel on Doppler USG.

97. Enlarged vein of Galen

99. Reference:
Diagnostic ultrasound, 4Th Edition: Carol M.
Rumac