Neonatal brain ultrasound - a practical guide for the young

radiologist

Poster No.: C-0527

Congress: ECR 2014
Type: Educational Exhibit
Authors: 1 2 2 1
N. Vainak , A. M. Calin , O. Fufezan ; Satu-Mare/RO, Cluj-
2

Napoca/RO
Keywords: Hemorrhage, Education and training, Screening, eLearning,
Education, Ultrasound-Power Doppler, Ultrasound-Colour Doppler,
Ultrasound, Pediatric, Neuroradiology brain, CNS
DOI: 10.1594/ecr2014/C-0527

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Learning objectives

To underline the importance of neonatal ultrasound of the brain

To show accurate examination techniques

To illustrate normal anatomy, normal variants and main pathological findings

Background

Neonatal US of the brain represents a very significant tool in the management of the
premature, high risk or symptomatic neonate.

Sonography is advantageous because it does not require use of ionizing radiation or

sedation, it is easily reproducible and portable.

This poster's aim is to demonstrate a step-by-step guide of how it's made and to describe
the most common findings, normal along with pathological ones.

Findings and procedure details

Ultrasound imaging technique

This examination is routinely performed through the anterior fontanel, which remains
patent in full-term infants until 9-18 months of age and serves as an acoustic window.

In premature infants and in those with increased intracranial pressure, the anterior
fontanel remains patent for a longer time.

Scanning is also possible through the posterior fontanel, in coronal, sagittal and oblique
planes, as well as through the squamosal suture, anterolateral, posterolatral fontanel and
even through bone windows in patients with closed fontanels.

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Fig. 1: The skull at birth, showing the anterior and posterior fontanels.

Page 3 of 62
References: www.wikipedia.org

Fig. 2: The skull at birth, showing the lateral fontanels.

References: www.wikipedia.org

The correct choice of the transducer depends on the size of the cranial vault and the
sonic windows:

For maximal resolution and depth penetration:

- 9-4 MHz curvilinear transducer is recommended for older babies

- 8-5 MHz small transducer for newborns

- 12-5, 17-5 and 15 MHZ linear transducer for superficial lesions and for the evaluation
of the internal content of meningocele or encephalocele.

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All the transducer allow the use of duplex/color Doppler imaging.

To scan as much of the intracranial contents as possible, a sequential scan is necessary:

- from anterior to posterior in the coronal plane

- from the midline to the later aspects in the sagittal plane, using the ventricular system
and the cerebrospinal fluid (CSF) as main references for the identification of anatomical
structures.

The parasagittal view of the brain includes the lateral ventricles, with the corresponding
frontal horns and bodies and the caudothalamic groove, a thin, echogenic band, located
between the caudate nucleus anteriorly and the thalamus posteriorly.

The highly vascular germinal matrix is found in preterm infants inferolateral to

the ependyma lining the floor of the lateral ventricle, anterior and superior to the
caudothalamic groove. The scan of the lateral ventricles also reaches the bodies and
temporal and occipital horns.

Within the atrium of the lateral ventricle, the choroid plexus can be seen.

Frequently, the lateral ventricles are asymmetric, with the occipital horns wider than the
frontal ones.

Posterior to the occipital horns, a periventricular blush of echogenity is found, supposedly

related to white matter fibers and vascular plexus.

Parasagittal views picture the brain in the periventricular region, the Sylvian fissure and
insula.

The midline sagittal scan of the brain is obtained with the transducer parallel to the
anteroposterior diameter of the cranial vault.

The cavum septum pellucidum is identified as a fluid-filled structure located between the
frontal horns of the lateral ventricles.

Above this midline fluid-filled structure is the corpus callosum, a thin, crescent-shaped,
hypoechoic structure with the main components - genu, body and splenium.

Superiorly to the corpus callosum, a broad, curvilinear hypoechoic band, representing

the cingulate gyrus is seen. It is separated from the more superficial gyri by the cingulate
sulcus, a thin hypoechoic line.

Vascular pulsations of the branches of the anterior cerebral arteries can also be seen
within the cerebral sulci, with real-time imaging.

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The third and fourth ventricles are pictured as hypoechoic structures on the midline, with
the bright area of the choroid plexus within the third ventricle. A dense band, representing
the quadrigeminal plate, lies behind the third ventricle.

Below this cistern, the brightly echogenic cerebellar vermis is seen, indented anteriorly
by the triangular fourth ventricle.

The cisterna magna, with an anechoic appearance, is located inferior to the cerebellum
and communicates with the fourth ventricle.

The moderately echoic brain stem lies anterior to the fourth ventricle and posterior to
the clivus.

Fig. 22: Ultrasound neonatal brain scan - sagittal view

References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Coronal plane imaging begins anteriorly and shifts posteriorly.

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A first, far anterior view of the frontal hemispheres should depict the anterior tips of the
frontal horns of the lateral ventricles, the interhemispheric fissure, and the orbits.

A second image is acquired at the level of the frontal horns or bodies of the lateral
ventricles, anterior to the foramina of Monroe. The anterior horns of the lateral ventricles
appear as anechoic, crescent, paramedian, fluid-filled structures. The roof of this portion
of the lateral ventricle is formed by the corpus callosum, the medial walls by the
cavum septi pellucidi and the lateral walls, which normally are concave, by the heads
of the caudate nuclei. The superior aspect of the corpus callosum is separated from
the hypoechoic cingulate gyrus by the brightly hyperechoic pericallosal sulcus. The
putamen and globus pallidus are located lateral and inferior to the caudate nucleus. The
hypoechoic frontal and temporal lobes are imaged at this level. Vascular pulsations may
also be observed with real-time imaging- those of the anterior cerebral arteries in the
interhemispheric fissure and those of the middle cerebral arteries in the Sylvian fissure.

The next section is obtained slightly posteriorly at the level of the foramen of Monroe,
where the lateral and third ventricles communicate. Because of its small size, the normal
third ventricle is not visualized. Vascular pulsations from the anterior and middle cerebral
arteries can also be observed on this scan. In extension, the relatively echogenic brains
stem - pons and medulla - is observed on this image. The choroid plexus is seen in the
roof of the third ventricle and in the groove between the ventricle and the thalamus.

The next image is acquired at the level of the quadrigeminal plate cistern and the
cerebellum. On this view, a midline pie-shaped area of bright echogenicity, occupying
the lower third of the brain with the
anechoic cisterna magna posteriorly and inferiorly, represents the cerebellar vermis. The
bodies of the lateral ventricles are seen superiorly and the temporal horns inferiorly.
On this image, the pulsations of the middle cerebral and pericallosal arteries can be
observed.

On the next scan, at the posterior aspects of the lateral ventricles, at the level of the
trigone, the choroid plexus is depicted. The splenium of the corpus callosum separates
the lateral ventricles, as they diverge. Also, the previously described periventricular blush
is seen lateral to the posterior horns of the lateral ventricles. Inferiorly, the posterior part
of the cerebellum is observed.

The final image is the most posterior view of the brain parenchyma
in the coronal projection and it is important for evaluation of the parenchyma. It includes
the more superficial sulci and gyri of the occipital lobes and the echogenic areas located
superior to the atria of the lateral ventricles, representing white matter.

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Fig. 23: Ultrasound neonatal brain scan - coronal view
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

The extra-axial fluid space can be most easily visualized ultrasonographically in the
midline. For the assessment of the extracerebral spaces, a high-frequency - 12-15
MHz - transducer is the most suitable. With this technique, the extra-axial spaces,
cerebral convexities and extra-axial vessels are accessible to the examiner. Normal
measurements include: sinocortical width - 0.4 to 3.3 mm, craniocortical width - 0.3 to
6.3 mm, interhemispheric width - 0.5 to 8.2 mm.

Posterior fontanel

Posterior fontanel imaging is recommended for examining posterior fossa abnormalities,

for a greater accuracy in detecting intraventricular hemorrhage (IVH), for the
differentiation between clot and choroid and a better depiction of the occipital and
temporal horns.

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Fig. 3: Cranial sutures shown from top of head.
References: www.wikipedia.org

Mastoid fontanel

When using the mastoid fontanel as an acoustic window, for assessment of the posterior
fossa and brain stem, a high-frequency transducer is positioned 1 cm posterior to the ear
and 1 cm above the tragus. Images obtained this way are useful in detecting hemorrhage
involving the brain stem, cerebellum and subarachnoid cisterns, in detection of clot

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within the fourth ventricle and cisterna magna and in demonstration of posterior fossa
malformations.

Color Doppler images

Color Doppler images may be acquired for the screening of the vascular structures.

An image obtained through the anterior or temporal fontanel will provide a picture of
the circle of Willis. Patency and resistance to flow will be appreciated, but also spectral
tracing with measurements of peak systolic velocity (PSV), end-diastolic velocity (EDV)
and resistive index (RI) is possible.

A color Doppler image of the sagittal sinus and vein of Galen, obtained in the sagittal
plane will provide information about the patency of the venous system.

Power-Doppler is useful in areas of hyper- or hypovascularity, as may occur in vascular

occlusion, ischemia and infarction.

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Fig. 5: Coronal section - Willis circle - color Doppler. ACA = anterior cerebral artery,
ACM = middle cerebral artery.
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

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Fig. 21: Sagittal section - Doppler measurements
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Normal variants:

- asymmetry in size of the lateral ventricles, the left being more often

larger than the right and most pronounced in the most posterior portion of the occipital
horn

- coarctation of the lateral ventricles, unilateral or bilateral, may have the appearance of
a germinal matrix cyst or periventricular leukomalacia (PVL)

- split choroid - cleft or lobular appearance of the ventricular atrium, may be confused
with choroidal hemorrhage

- truncated choroid plexus - flattening of the rounded lower portion of the plexus

- choroid cyst, may be single or multiple, variable in size

Pathological findings

Intracranial hemorrhage

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Intracranial hemorrhage represents a leading cause of morbidity and mortality in
newborns, especially in preterm infants.

Risk factors:

- prematurity (less than 32 weeks' gestation)

- low birth weight (less than 1500 g)

- sex (males 2:1)

- multiple gestations

- trauma at delivery

- prolonged labor

- hypocoagulation

- pneumothorax

- patent ductus arteriosus

- factors associated with increased or decreased cerebral blood flow

ICH in the premature neonate has been divided into four grades, the most widely
accepted classification being modified from that of Papile et al:

grade I - subependymal germinal matrix hemorrhage (GMH);

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Fig. 6: Coronal section - grade I - subependymal germinal matrix hemorrhage (blue
arrows).
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

grade II - GMH and IVH without ventricular dilation;

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Fig. 7: Coronal section - grade II - GMH and IVH without ventricular dilation (blue
arrow).
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

grade III - A. mild GMH and IVH with ventricular dilation;

B. moderate GMH and IVH with ventricular dilation

C. severe GMH and IVH with ventricular dilation

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Fig. 8: Sagittal section - grade III - GMH and IVH with ventricular dilation (white
arrows).
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

grade IV - intraparenchymal hemorrhage (IPH) with IVH.

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Fig. 9: Coronal section - grade IV- intraparenchymal hemorrhage (blue arrow).
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Ultrasound findings:

The germinal matrix represents a highly cellular, richly vascular, and metabolically active
area, which lies beneath the ependyma of the lateral ventricles and represents the usual
initial site of ICH in the premature brain.

Germinal matrix hemorrhage (GMH):

- appears in the first week of life

- uniformly echogenic mass inferolateral to the frontal horns at a level just posterior to
the foramen of Monroe

- may be unilateral or bilateral

- if large, it can cause focal compression of the inferolateral margin of the ventricle

- typical appearance: round region of asymmetric hyperechogenity.

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- if the hemorrhage resolves, the focal lesion decreases in size an echogenity and
frequently results in a subenepndymal cyst.

Intraventricular hemorrhage (IVH):

- may represent the intraventricular extension of GMH

- may be unilateral or bilateral

- bright echoes within the ventricular lumen.

- if the ventricles are not dilated (i.e., grade II IVH), the clot may be difficult to identify and
to separate from the choroid plexus

- in grade III IVH with ventricular dilation, the clot is easily detected.

- with severe hemorrhage, the entire ventricle is filled with blood, forming a cast of the
ventricle.

- as the hemorrhage resolves, the interior becomes hypoechoic, surrounded by a

echogenic rim

- residual intraventricular septation may persist and a week after the event

- other possible consequences: ventricular enlargement, posthemorrhagic

hydrocephalus, inflammatory ependimitis

Intraparenchymal hemorrhage (IPH):

- the most severe grade of ICH in the premature infant

- hemorrhage into areas that are already damaged by periventricular leucomalakia (PVL)

- associated with IVH in 80% of cases

- occurs on the side of the cerebral hemisphere with the more severe IVH

- brightly echogenic appearance

- frontoparietal distribution and

- often causes a mass effect.

- resolves in a similar manner with the other types of inctracranial hemorrhage and a
porencephalic cyst may form

Page 18 of 62
Other, much less common sites of ICH in the neonate are subarachnoid hemorrhage
(SAH) and intracerebellar hemorrhage (CBH).

Subarachnoid hemorrhage (SAH):

- increased echogenity and widening of the horizontal portion of the Sylvian fissure

- subtle changes, only detectable with large quantities of blood

- Ct is the preferred imaging modality

Intracerebellar hemorrhage (CBH):

- the use of the mastoid fontanel improves diagnosis

- poor prognosis

- echodense area within the cerebellum

- 4th ventricle not visualized

- on sagittal scans - loss of normal differentiation of the brain stem structures

Subdural and epidural hemorrhages:

- usually occur in term infants secondary to trauma

- enlarged craniocortical distance

- widening of the interhemispheric fissure

- a linear or elliptical fluid collection between the brain and the skull

- mass effect

- CT and magnetic resonance imaging (MRI) are the preferred imaging modalities

Hypoxic-ischemic encephalopathy

Perinatal hypoxic-ischemic injury of the brain induces major neurologic and

developmental deficits in infants and young children. GMH-IHV is the most frequent
consequence of a hypoxic brain injury in the preterm infant. If the ischemic component
is also significant, infarct may occur, resulting in PVL and periventricular hemorrhagic
infarction (PVHI) in the premature infants.

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Periventricular leukomalacia (PVL):

- coagulation necrosis of the white matter

- occurs at the external angle of the frontal horns near the foramen of Monroe and at the
level of the optic radiations adjacent to the trigone

- bilateral, coarse, globular, or broad bands of echogenity in the periventricular white

matter

- bilateral and symmetric pattern

- usually in the first 10 days of life

- evolves to multiple tiny cysts or porencephalic cysts

- white-matter gliotic scars

- ventricular enlargement

- MRI represents a useful diagnostic adjunct

Page 20 of 62
Fig. 10: Coronal section - Periventricular leukomalacia (red arrow) - cystic
transformation.
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Periventricular hemorrhagic infarction (PVHI):

- area of hemorrhagic necrosis in the periventricular white matter

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- dorsal and lateral to the external angle of the lateral ventricle

- unilateral or bilateral

- asymmetric, globular or triangular fan-shaped echogenic lesion, radiating from the

external angle of the lateral ventricle

- localized or extensive in the periventricular white matter

- evolves into cystic cavities, usually single and large and progress to porencephaly

- poor prognosis

Fig. 11: Coronal section - Periventricular hemorrhagic infarction with cystic

transformation (blue arrows).
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Perinatal asphyxia:

- term infant

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- tiny slit-like ventricles

- obliteration of the extra-axial fluid spaces

- hazy increased parenchymal echogenicity

Cerebral cortical infarction:

- rare condition

- risk factors: prematurity, asphyxia, congenital heart disease, polycythemia and

hyperviscosity, trauma, meningitis, and thromboembolism

- common involvement of the middle cerebral artery distribution

- absence of gyral definition

- absence of vascular pulsations

- altered parenchymal echogenicity

Congenital anomalies

Hydrocephalus:

- the most common congenital anomaly in neonates

- increased volume of fluid within the ventricular

- can be either obstructive or nonobstructive

- obstructive hydrocephalus can be classified as noncommunicating, in which the point

of obstruction occurs within the ventricular system and communicating, in which the
obstruction occurs beyond the ventricular system, the arachnoid granulations.

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Fig. 12: Coronal section - Hydrocephalus with little ventricular dilation (blue stars).
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Page 24 of 62
Fig. 13: Coronal section - Large hydrocephalus (blue star).
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Disorders of closure

Skull defects, also known as "cranium bifidum," are often associated with congenital
malformations of the brain, meninges, or both. These
defects most often present as a midline occipital mass.

Meningocele:

- small defect

- only meninges herniate

Encephalomeningocele:

- the defect is large

- the meninges and part of the brain herniate

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Meningohydroencephalocele:

- the brain tissue herniates along with a portion of the ventricle and meninges

Fig. 4: Illustration of a child with encephalocele

References: www.wikipedia.org

The corpus callosum is the largest structure which connects the two hemispheres.

Primary agenesis:

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- occurs around the 12th gestational week

- associates lipoma, encephalocele, arachnoid cyst or migrational abnormality

Secondary dysgenesis:

- occurs later, due to destruction of previously formed corpus callosum - associates

microcephaly, Dandy-Walker syndrome, Arnold-Chiari malformation, holoprosencephaly,
cyclopia, septo-optic dysplasia, porencephaly or aqueductal stenosis.

Ultrasound findings:

- absence of sonolucent band in location of corpus callosum

- widely separated frontal horns and bodies of lateral ventricles

- colpocephaly

- concave medial borders of lateral ventricles

- dilation and posterosuperior displacement of third ventricles

- radial arrangement of medial cerebral sulci.

Page 27 of 62
Fig. 14: Coronal section - Absent corpus callosum, widely separated frontal horns of
lateral ventricles, dilation and posterosuperior displacement of third ventricle.

Page 28 of 62
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Dandy-Walker cysts:

- cystic dilation of the fourth ventricle

- hypoplastic cerebellar hemispheres

- absent or rudimentary vermis

- large posterior fossa continuous with the fourth ventricle

- variable degrees of hydrocephalus

- associated with encephalocele, agenesis of the corpus callosum, holoprosencephaly,

gyral anomalies, heterotopias, cleft palate, polysyndactylism.

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Fig. 15: Coronal section - Dandy - Walker malformation - dilation of the fourth ventricle
(blue star), hypoplastic cerebellar hemispheres.
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Arnold- Chiari type I:

- inferior displacement of the tonsils and cerebellum

- no displacement of the fourth ventricle or the medulla

Arnold-Chiari type II:

- the most common type seen in neonates and infants

- small posterior fossa

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- downward displacement of medulla, forth ventricle, cerebellum

- obliteration of cisterna magna

- elongation of pons and fourth ventricle

- hydrocephalus

- colpocephaly

- dilation of the third ventricle

- partial or complete absence of septum pellucidum.

Disorders of diverticulation

Septo-optic dysplasia:

- agenesis of septum pellucidum

- dilation of lateral ventricles with flattened roofs

- hypoplastic optic chiasm, nerves, and infundibulum

- dilation of chiasmatic and suprasellar cisterns

- expansion of optic recess of third ventricles

Holoprosencephaly:

- alobar, representing no division of the cerebral hemispheres, with a large, horseshoe-

shaped single ventricular cavity, thin, anteriorly placed cerebrum and fused thalami

- semilobar, with normal formation of dural, interhemispheric fissure and falx, partially
separated thalami, the presence of a rudimentary third ventricle and a possible presence
of the splenium of corpus callosum.

- lobar, consisting in the fusion of frontal lobes, hypoplastic frontal horns of the lateral
ventricles, interhemispheric fissure missing rostrally but with the presence of body and
splenium of corpus callosum and a hypoplastic aspect of the falx.

Page 31 of 62
Fig. 16: Coronal section - Alobar holoprosencephaly - large, horseshoe-shaped single
ventricular cavity (blue arrow) and fused thalami (pink star).
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Aventricular cerebrum indicates the absence of the ventricles.

Disorders of sulcation

Lissencephaly:

- also known as smooth brain, agyria or pachygyria

- failure of development of sulci and gyri

- increased depth of gray matter

- widened subarachnoid space

- minimal or no visible indentations

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- Sylvian fissures shorter and more oblique

- absent pulsation of MCA in Sylvian groove

- mild-to-moderate ventricular dilation

- increased periventricular echogenicity

- no normal gray-white interdigitation.

Schizencephaly:

- clefts in brain, often bilateral

- clefts lined by gray matter, often along axis of normal fissure development.

- associated with ventricular dilation, heterotopia, polymicrogyria.

The disorders of size include microcephaly and macrocephaly, which can be either
familiar or associated with neurofibromatosis. Hydrocehpalus may be an underlying
cause of macrocephaly.

The destructive lesions which cause congenital anomalies of the brain include:

-hydranencephaly - in which the cerebral hemispheres are replaced by thin sacs of CSF,
with intact cranial vault, meninges and falx

-porencephaly - representing an area of cavitation within the cerebral hemisphere caused

by a periventricular hemorrhage, a hypoxic-ischemic lesion, infection, trauma or surgery
resulting in cystic structures

-hypoxia

-toxicosis

-inflammatory disease such as rubella, cytomegalic inclusion disease, toxoplasmosis and

herpes simplex virus

Disorders of histiogenesis

- tuberous sclerosis - hereditary disorder characterized by epilepsy, mental retardation

and hamartomatous foci in the cerebrum, cerebellum and spinal cord.

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Fig. 17: Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci.
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

- neurofibromatosis - characterized by the presence of neurofibromas, cutaneous

pigmentary changes (many café-au-lait spots), skeletal abnormalities, a predilection for
certain tumors, particularly within the central nervous system (optic pathway gliomas and
astrocytomas), vascular and endocrine abnormalities.

- Sturge-Weber syndrome (encephalotrigeminal angiomatosis)

- vascular lesions - Galen vein malformations, arteriovenous malformations, prediction of

the risk for IVH and PVL, evaluation of hydrocephalus - assessed with duplex and color
Doppler, transfontanellar and transcranial views.

Intracranial tumors:

- uncommon in children younger than two years

- supratentorial tumors are more common in infants

Page 34 of 62
- neurologic criteria: macrocranium, tumor erosion of the vault or clinical signs of
increased intracranial pressure

- neuroectodermal origin

- teratoma is the most frequent type

- other tumors: glioma, astrocytoma, lipma of the corpus callosum, primitive

neuroectodermal tumor, choroid plexus papilloma, ependymoma and ganglioglioma.

Fig. 18: Coronal section - Intracranial tumor (blue star - glioma).

References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Ultrasound is not able to differentiate between the various cell types, but the size and
location of the masses can give clues that can limit the differential diagnosis.

Page 35 of 62
Intracranial teratomas:

- large echogenic lesions

- contain cystic spaces and echogenic areas with acoustic shadowing, given by
calcifications

- located mainly in the pineal region, but also in the suprasellar and posterior fossae

- may obstruct the ventricular system or erode the skull

- uniformly fatal.

Gliomas:

- lesions in the brain stem

- hyperechoic compared with the cerebral hemispheres

- difficult to recognize in the normal hyperechoic cerebellum

Intracranial arachnoid cysts:

- the most common congenital cystic abnormality of the brain.

- fluid-filled cavities

- primary cyst caused by abnormal leptomeningeal formation or secondary caused by

arachnoid adhesions

- may communicate with the subarachnoid space

- supratentorial or infratentorial

- most often located in the Sylvian fissure or temporal region.

- produce mass effect and hydrocephalus.

Intracranial infection

Common causative organisms for brain infections:

- group B streptococcus

- Escherichia coli

Page 36 of 62
After the neonatal period:

- Haemophilus influenzae

- Streptococcus pneumoniae

- Neisseria meningitides

Ventriculitis is a common complication, because of hte entrance of the organisms at the

level of the choroid plexus.

Perinatal intracranial infections may also be secondary to viral or protozoan agents:

- cytomegalovirus (CMV)

- Toxoplasma gondii

- rubella

- herpes simplex virus type 2

Ultrasound findings:

Meningitis:

- increase in echogenity of the cortical sulci

- widening of the sulcal echoes

- small fluid collections

- ventricular enlargement in late stages

Ventriculitis:

- its presence increases mortality and morbidity.

- dilated ventricles, with thickened, irregular, hyperechoic ependyma

- irregular, hyperchoic choroid plexus

- intraventricular septations may develop

- better seen on US than on CT

Page 37 of 62
- vasculitis and venous thrombosis may occur

Meningoencephalitis:

- increased parenchymal echogenity

- multiple, patchy pattern

- increased gyral echogenity

- decreased vascular pulsations are noted.

- meningeal thickening - more than 1.3 mm over a gyrus or more than 2 mm over a sulcus

Fig. 19: Coronal section - increase in echogenity of the cortical sulci (blue arrow) in a
case of meningitis.
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca

Abscess:

- caused by Proteus mirabilis or Citrobacter diversus

Page 38 of 62
- well-circumscribed lesion with a hypoechoic center, fluid-debris level and thick,
echogenic wall

- may compress the ventricles or cause midline shift

Cytomegalovirus:

- gyral abnormalities: agyria, poly-microgyria, focal microgyria, calcification (usually

periventricular), hypoplastic cerebellum

Fig. 20: Coronal section - periventricular calcifications (white arrows) in a patient with
CMV infection

Page 39 of 62
References: Department of Radiology, 3rd Pediatric Clinic, Cluj - Napoca
Toxoplasmosis:

- calcification (periventricular and cortical),

- microcephaly

- hydrocephalus

- atrophy

- porencephaly

Herpes simplex virus:

- diffuse cerebral edema,

- diffuse cerebral atrophy

- multicystic encephalomalacia

- punctate or gyriform calcification

- cerebellar involvement

Rubella:

- areas of ischemic necrosis

- scattered calcifications (basal ganglia, white matter, and periventricular)

- ventriculomegaly

Cephalohematoma:

- the most common injury of the skull in the newborn period

- appears after birth trauma as a soft-tissue lesion

- located mostly in the parietal and occipital regions

- bound by the sutures

- elliptical hypoechoic collection with areas of increased echogenity, representing blood

in different states

- does not cross the suture, which can be observed with sonography.

Page 40 of 62
Images for this section:

Fig. 22: Ultrasound neonatal brain scan - sagittal view

Page 41 of 62
Fig. 23: Ultrasound neonatal brain scan - coronal view

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Fig. 3: Cranial sutures shown from top of head.

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Fig. 5: Coronal section - Willis circle - color Doppler. ACA = anterior cerebral artery, ACM
= middle cerebral artery.

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Fig. 21: Sagittal section - Doppler measurements

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Fig. 6: Coronal section - grade I - subependymal germinal matrix hemorrhage (blue
arrows).

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Fig. 7: Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow).

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Fig. 8: Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows).

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Fig. 9: Coronal section - grade IV- intraparenchymal hemorrhage (blue arrow).

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Fig. 10: Coronal section - Periventricular leukomalacia (red arrow) - cystic transformation.

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Fig. 11: Coronal section - Periventricular hemorrhagic infarction with cystic
transformation (blue arrows).

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Fig. 12: Coronal section - Hydrocephalus with little ventricular dilation (blue stars).

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Fig. 13: Coronal section - Large hydrocephalus (blue star).

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Fig. 14: Coronal section - Absent corpus callosum, widely separated frontal horns of
lateral ventricles, dilation and posterosuperior displacement of third ventricle.

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Fig. 15: Coronal section - Dandy - Walker malformation - dilation of the fourth ventricle
(blue star), hypoplastic cerebellar hemispheres.

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Fig. 16: Coronal section - Alobar holoprosencephaly - large, horseshoe-shaped single
ventricular cavity (blue arrow) and fused thalami (pink star).

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Fig. 17: Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci.

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Fig. 18: Coronal section - Intracranial tumor (blue star - glioma).

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Fig. 19: Coronal section - increase in echogenity of the cortical sulci (blue arrow) in a
case of meningitis.

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Fig. 20: Coronal section - periventricular calcifications (white arrows) in a patient with
CMV infection

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Conclusion

Properly executed and with appliance of modern protocols, US becomes highly

accurate for detection of cranial abnormalities, providing the great advantage of a short
examination time.

Accompanied by video tutorials and suggestive images, a radiologist can easily learn
how to perform and interpret an US of the brain and include it as a first-line examination
for a risk patient.

Personal information

References

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Healthcare; 2008.

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4) Riccabona M. Pediatric Imaging Essentials. Georg Thieme Verlag 2013.

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