technique, anatomy and common pathology seen in transcranial ultrasound

2. Neonatal sonography of the brain is now an essential
part of newborn care, particularly in high-risk and unstable
premature infants.

3. Portability, lower cost, speed, no ionizing radiation, and no
sedation.

5. Evaluation for hemorrhage or parenchymal abnormalities in
preterm and term infants.
Evaluation for hydrocephalus.
Evaluation for the presence of vascular abnormalities
Evaluation for the presence of congenital malformations.
Evaluation of signs and/or symptoms of central nervous system
disorders.
Evaluation of congenital or acquired brain infections
Evaluation of trauma
Follow-up or surveillance of previously documented
abnormalities, including prenatal abnormalities

6. a 7.5-MHz or higher transducer is recommended to obtain the
highest resolution possible. (phased array transducer)
5-MHz transducer may be necessary to allow for
adequate sound penetration of a larger infant head.

7. Acoustic windows:
Standard
• Anterior fontanel
Supplement
• Temporal
• Posterior
• Mastoid

8. Coronal plane
Sagittal plane

9. six to eight coronal
images are obtained

11. Very useful view to evaluate the occipitals horns for the
diagnosis of intraventricular hemorrhage
The choroid glomus will be seen with extensions into the
ventricular body and temporal horn.
The occipital horn does not contain choroid plexus and should
be completely anechoic.

13. The caudothalamic
groove at the junction
of these two structures
is an important area to
recognize, because this
is the most common
site of germinal matrix
hemorrhage in the
subependymal region
of the ventricle.

14. Brain perfusion patterns
Vascular supply changes with maturation
and affect the pattern of brain injury in
HIE
Premature neonatal brain:
Has a ventriculopetal vascular pattern
and hypo perfusion results in a
periventricular border zone of white
matter injury

15. In term neonatal brain
Ventriculofugal vascular pattern
develops as the brain matures
and the border zone during hypo
perfusion is more peripheral with
subcortical white matter and
parasagittal cortical injury

16. Documentation of Doppler
imaging of the circle of Willis
and the region of vein of Galen
is an essential part of the
assessment.
Spectral tracing with peak
systolic velocity (PSV),
end-diastolic velocity (EDV),
and resistive index (RI) need to
be recorded for evaluation of
ischemia

17. There is a large range of ventricular size both antenatally and in
the newborn. Reliable measurements are needed to:
● Define enlargement of the ventricles
● Monitor hydrocephalus
● Minimize interobserver variations
● Provide proper and adequate documentation.

18. It is important to have a standard technique and measurement
within a department so that it is consistently reproducible
between sonographers undertaking the examinations and so
that the clinicians clearly understand the figures produced
Still no consensus as to which is best, but the most widely
accepted measure is the ventricular index as described by
Levene

19. Chart is for preterm infants.
Index measures the distance
from the falx to the lateral
border of the lateral ventricle.
This is measured coronally in
the plane of the third ventricle
posterior to the foramen of
Monro
The only problem with
Levene’s ventricular index
occurs when there is midline
shift.

24. One of the most important indications of neurosonography is
the demonstration of intracranial hemorrhage in a premature
infant.
Routine screening cranial USG should be performed in all
infants of under 30 weeks gestation, once between 7 and 14
days of age
Should be optimally repeated between 36 and 40 weeks
postmenstrual age

33. Periventricular Leukomalacia:
the principal ischemic lesion of the premature infant, is infarction
and necrosis of the periventricular white matter.
PVL the white matter most affected is in the arterial border zones
at the level of the optic radiations adjacent to the trigones of the
lateral ventricles and the frontal cerebral white matter near the
foramina of Monro.

34. Initial sonographic examination in PVL may be normal
Within 2 weeks of the initial insult, however, the
periventricular white matter increases in echogenicity
until it is greater than the adjacent choroid plexus
Two to 4 weeks after the insult, cystic changes may develop in
the area of abnormal echogenic parenchyma
can be single or multiple and are parallel to the ventricular
border in the deep white matter and often lateral and/or
superior to the top of the ventricles

39. is a common result of hypoxic-ischemic events in full-term
infants
Initially, the brain edema will cause slitlike ventricles in a
diffusely echogenic brain with poorly defned sulci.
This echogenicity may cause silhouetting of the sulci so that the
sulci seem to disappear.
brain parenchyma appears echogenic in the distribution of the
injury, and the sulci are difficult to appreciate because of
surrounding echogenic edematous brain

41. Doppler examination of the intracranial vessels and circle of
Willis is helpful in evaluating the severity of intracranial ischemia.
Diastolic flow, reflected in Resistive Index (RI) is a measure that
will indicate the hemodynamic status of intracranial flow.

47. Cystic intracranial lesions are
quite common, and
ultrasound is the best method
for evaluating such lesions
most cystic masses of the
brain are quite benign, so it is
important to recognize them
for what they are

50. 11% of children with brain neoplasms present before 2 years of
age.
Tumors that do present before 2 years are usually congenital.
Brain tumors can be difficult to diagnosis in the neonate
MRI or CT is generally the imaging modality of choice in these
infants.

52. Neonatal hydrocephalus is easily
recognized by routine coronal and
sagittal imaging.
Ventricular size is slightly larger in
newborns than in older children

53. The entire ventricular system should be evaluated to identify the
level
at which a transition occurs from a large to a small ventricle.
Dilation of the lateral and third ventricles indicates an aqueduct
of Sylvius obstruction, most often
Most common causes of intraventricular obstructive
hydrocephalus (IVOH) include infection or hemorrhage (causing
obstruction to the exiting foramina of the third or fourth
ventricle), congenital anomalies (e.g., aqueductal stenosis

54. The most common causes of extraventricular obstructive
hydrocephalus (EVOH) are hemorrhage and infection with
fibrosis at the basal cisterns, incisura, convexity cisterns, or
parasagittal region
Ventricular enlargement does not always mean obstruction.
Severe cases of hypoxic-ischemic injury result in large ventricles
due to brain atrophy 2 to 4 weeks after the insult rather than
obstructive hydrocephalus