Introduction
Ultrasound is a fast and bedside examination which makes it ideal for premature
infants. Try to get all the information you can. Do not limit yourself to only one
transducer or only one acustic window. Generally the large fontanel is used as
acoustic window. The small fontanel however is a good window to the occipital
lobes. This can be usefull in patients with borderline hyperechogenicity in these
areas.
Disadvantages of US are:
• Limited overview in posterior fossa and convexity of the brain
• Absence of US-signs in ischemia in full-terms in first 24 hours
• Difficulty in detecting migration disorders, cortical dysplasia
Indications for neonatal cranial ultrasound:
1. Hydrocephalus (a large head).
2. Intracranial bleeding.
3. Hypoxaemic damage.
4. Meningocele and other congenital anomalies.
5. Convulsions.
6. A small head (microcephaly).
7. Bulging fontanelles (raised intracranial pressure).
8. Trauma.
9. Intrauterine infection.
10. After meningitis, to exclude aqueduct stenosis or other sequelae.
Scanning technique:
Use a 7.5 MHz transducer if available; otherwise, use a 5 MHz transducer.
Sagittal scan: Center the transducer over the anterior fontanelle with the
scanning plane aligned with the long axis of the head. Angle the transducer first
to the right, to see the right ventricle, and then to the left to see the left
ventricle.
Coronal scan: Rotate the transducer 90° so that the scan plane is aligned
transversally, and angle the beam forward and then backward.
Axial scan: Center the transducer is used above the ear and angle the beam
up towards the vault and down towards the base of the skull. Repeat on the
other side.
Normal midline anatomy: In 80% of neonates, the fluid-filled cavum septi
pellucidi will be seen as a midline structure. Below the cavum will be the
triangular fluid-filled third ventricle, and surrounding these structures will be
normal brain tissue of varying echogenicity.
Sagittal section: Angled sagittal sections on each side of the brain will show
the lateral ventricles shaped like an inverted "U". It is important to visualize the
solid thalamus and the caudate nucleus below the ventricles because this is the
region of the brain in which haemorrhage is most frequent
By angling the transducer, the entire ventricular system can be examined. The
echogenic choroid plexus will be seen mainly within the atria and the temporal
horns.
Coronal section: Multiple scans should be performed at different angles,
depending on the individual patient, to image the whole ventricular system and
the adjacent brain. Most suitable angle for the particular part of the brain to be
examined.
Axial section: The first, most inferior, section will demonstrate the heart-
shaped pedicles and show arterial pulsation in the circle of Willis.
The next section above this will show the thalamus and the central echo of the
falx cerebri.
The top (superior) section will show the walls of the lateral ventricles. The
ventricle and the corresponding hemisphere can then be measured
Ventricular dilatation: It is easy to recognize ventricular dilatation and
asymmetry with ultrasound. If in doubt, re-examination after an interval is
essential. One of the common causes of dilatation is congenital aqueduct
stenosis.
Agenesis of the corpus callosum is another congenital cause of hydrocephalus.
This causes marked lateral displacement of the lateral ventricles and upward
movement of the third ventricle.
Agenesis of the corpus callosum is another congenital cause of hydrocephalus.
This causes marked lateral displacement. The lateral ventricles and upward
movement of the third ventricle.
Intracranial bleeding
1. Subependymal bleeding appears as one or more hyperechogenic areas
just below the lateral ventricle, best seen in a transverse plane adjacent to the
frontal horn. Confirm this with a sagittal scan: the haemorrhage may be
bilateral. This is a grade I haemorrhage.
2. Intraventricular bleeding into normal size ventricles. Additional echoes from
the normally echo-free ventricles (as well as from the hyperechogenic choroid
plexus) indicate thrombus (clot) in the ventricles. If there is no ventricular
dilatation, this is a grade II haemorrhage.
3. Intraventricular bleeding into dilated ventricles. When there is intraventricular
haemorrhage with ventricular dilatation, this is a grade III haemorrhage.
4. Intraventricular bleeding accompanied by bleeding into the brain substance
appears as areas of increased echogenicity within the brain. This is a grade IV
haemorrhage, the most severe form.
5. Sequelae of bleeding. In grades I and II, the blood is Lisually reabsorbed
during the first week of life, but more severe bleeding (grades III and IV) can
cause posthaemorrhagic hydrocephalus as well as loss of brain tissue
(porencephalic cysts). Developmental retardation with abnormal neurological
findings may result.
Neonatal cerebral abnormalities:
• Necrosis of brain tissue results in a poorly delineated region of
hypoechogenicity, usually lateral to the lateral ventricles (peri-ventricular
leukomalacia).
• Cerebral oedema can result in obliteration of the ventricle and of the cranial
sulci. The brain is generally more echogenic than normal.
• Cerebral infections cause changes in echogenicity, including punctate
hyperechogenic regions due to calcification.