BYDR MUHAMMAD SALMAN KHAN

INFANT CRANIAL ULTRASOUND

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

SafeBedsideReliableEarly imagingSerial imaging:

Brain maturationEvolution of lesions

InexpensiveSuitable for screening

Aims of Neonatal Cranial Ultrasound

Exclude/demonstrate cerebral pathologyAssess timing of injuryAssess neurological prognosisHelp make decisions on continuation of

neonatal intensive careOptimise 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 lobe3. Skull4. 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 lobe5.Frontal horn of

lateral ventricle6.Caudate nucleus7.Basal ganglia8.Temporal lobe9.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 lobe5.Frontal horn6.Caudate neucleus8.Temporal lobe9.Sylvian fissure10.Corpus callosum11.Cavum septum

pellucidum12.Third ventricle13.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 lobe9.Sylvian fissure14.Body of lateral

ventricle15.Choroid plexus16.Thalamus17.Hippocampal fissure18.Aqueduct of Sylvius19.Brain stem20.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 lobe10.Corpus callosum15.Choroid plexus20.Parietal lobe21.Trigone of lateral

ventricle22.Cerebellum(a:

hemispheres; b: vermis)

23.Tentorium24.Mesencephalon

Sixth coronal plane (C6) through the parieto occipital lobes

Sixth coronal plane (C6) through the parieto occipital lobes

20.Parietal lobe25.Occipital lobe26.Parieto-occipital

fissure27.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 callosum11.Cavum septum pellucidum12.Third ventricle13.Cingulate sulcus16.Thalamus22b.Cerebellum(vermis)24.Mesencephalon26.Parieto-occipital fissure27.Calcarine fissure28.Pons29.Medulla oblongata32. Cisterna quadrigemina33. Interpeduncular fossa34. 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 lobe5. Frontal horn of lateral

ventricle6. Caudate nucleus8. Temporal lobe14. Body of lateral ventricle15. Choroid plexus16. Thalamus17. Hippocampal fissure20. Parietal lobe21. Trigone of lateral ventricle22a. Cerebellum(hemisphere)25. Occipital lobe36. 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 lobe8. Temporal lobe9. Sylvian fissure20. Parietal lobe25. Occipital lobe37. 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 lobe22. Cerebellum(a:

hemispheres; b: vermis)

23. Tentorium25. Occipital lobe27. Calcarine fissure29. Medulla oblongata36. Occipital horn of

lateral ventricle38. Falx

Parasagittal view using PF as an acoustic window

Parasagittal view using PF as an acoustic window

8. Temporal lobe15. Choroid plexus16. Thalamus20. Parietal lobe21. Trigone of

lateral ventricle22a. Cerebellum

(hemispheres)25. Occipital lobe27. 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

tentoriumInterdigitating 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 fissurePartially 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