short presentation for indian medical graduate

1. Neonatal cranial sonography:
A concise review for clinicians
Dr Rekha Khare
MD Radiology
Prof and HOD
Hind institute of medical sciences Barabanki

2. Neonatal head– my study
• Ultra sonographic study of children suspected
of hydrocephalus at Queen Elizabeth Central
Hospital Blantyre Malawi
East African Medical Journal 1997.74,4:
267-270
Prof Adeloye ---neurosurgeon
Dr Rekha khare---consultant radiologist

3. My babies for study…..

4. Observation of our study
Hydrocephalus
HI injury
Porencephalic cyst
TORCH syndrome (mother HIV+)
Cerebral dysplasia/ hydrancephaly
Congenital anomaly prominent cisterna magna septum
pellucidum cyst etc.

5. Conclusion of our study
Neonatal head sonography
• All big heads were
not hydrocephalus

6. Neonatal sonography
• It is an important part of neonatal care in
general, high risk and unstable premature
infants

7. Why to choose USG
• Rapid evaluation in intensive care unit
• No need of sedation and virtually no risk
• Ideal imaging modality due to it’s portability,
Can be done in incubator
• Low cost, and No radiation
• Can be repeated and do follow up
• No preparation and no discomfort to patient

8. USG versus CT or MRI
• CT is the imaging with radiation
• MRI takes long time compare to other imaging
• Both are not cost effective
• Can’t repeat quite often
** CT is better to see hemorrhage and calcification
MRI is better for ischemic injury

9. Indication of USG
• Most useful for detection and follow up of
intracranial hemorrhage
• Hydrocephalus/ increased head circumference
• Periventricular leukomalacia
• Hypoxia/ HI injury
• CNS malformations, infection and masses
• Trauma
* However MRI scores over cranial sonography when
major anomalies are suspected

10. Probe selection
• Primarily a small footprint, (5-8MHz)
• If it is non available trans-vaginal probe also
provides excellent imaging
• A high frequency linear probe to assess
superficial structures, cephalohematoma etc.

11. Environment
• A warm room with warm gel.
• If neonate is in high oxygen environment, this should
be maintained as much as possible or it can be done
in incubator
• Patient position
• Put a cloth under and/or beside the baby's head to
support and immobilize it for the scan.
• Clean hands

12. SCANNING TECHNIQUE
• Use sufficient gel to not require too much transducer pressure.
• Approach is generally via the anterior fontanel. The posterior
fontanel can also be used.
• Using the small footprint sector or TV probe:
– Begin in a coronal plane slowly sweeping from the anterior to
the posterior.
– Rotate 90 degree to perform sagittal and para-sagittal views.
• Using the high frequency linear probe:
– Gently scan through the anterior fontanelle in transverse.
– Assess the superior sagittal sinus for patency, and the sub-
arachnoid space.

13. Technique

14. Sagittal and Coronal

15. Brain on USG

16. Pathologies
what to see on neonatal head
sonography

17. Understanding of normal anatomy
• A solid grasp of the intracranial anatomy is
vital.
• How it changes between 28weeks and term
• Essentially, the normal 10week premature
brain is relatively smooth, homogenous &
devoid of sulci/gyrae

18. Hypoxia and hemorrhage
USG is highly accurate in detecting hemorrhage and resulting
ventricular dilatation
• In term infant–
* hypoxic ischemic
encephalopathy
and intracranial
hemorrhage
• In pre term infant-
GMH
( germinal matrix hemorrhage)
Intraventricular hemorrhage
PVL

19. Preterm and Prematurity and
hemorrhage
– Preterm refers to delivering prior to 37weeks whilst
– a premature infant is one that has not yet reached the
level of fetal development that generally allows life outside
the womb
– The fine network of vessels on the floor of the anterior
horn of the lateral ventricles are extremely fragile.
– If there is any hypoxic episode, the reactive increase in
blood pressure can result in a hemorrhage of these
vessels.
– Usually assessed at day 1 and again at day 7.

20. Hypoxia– Cerebral edema
Brain swelling/HIE
• Abnormally diffuse brain parenchymal
echogenicity
• Slit like ventricle
• Loss of visualization of normal sulci

21. Hypoxia & hemorrhage on USG
Germinal matrix hemorrhage intraventricular hemorrhage

22. CNS infection---
• Any kind of infection is diagnosed clinically and on
lab test but role of USG is for complication
• In utero infection during
first two trimester --- congenital malformation
while in third trimester---- destructive lesion

23. Meningitis –USG versus MRI
dilated ventricle , ventriculitis ,septation and debris better seen on USG

24. TORCH syndrome
• TORCH syndrome refers to infection of a developing fetus or
newborn by any of a group of infectious agents.
• It is an acronym meaning---
T– toxoplasmosis
O- other agent
R- rubella(German measles)
C- cytomegalovirus
H- herpes simplex

25. Congenital TORCH infection
diagnosed clinically but role of USG is for complication
• Microcephaly
• Periventricular calcification is most significant
• Brain atrophy
• Hydrocephalus
• Subependymal cyst
• Complication like ---subdural effusion,infarction ,
cerebritis or abscess

26. TORCH on USG
• Intracranial calcification or
periventricular calcification
(hyperechogenic foci),
considered the commonest
of features
• fetal hydrocephalus
• Heterogeneous brain
parenchyma
• Microcephaly
• Intraventricular adhesion

27. What is hydrocephalus
• Hydrocephalus is a condition in which an accumulation of CSF
occurs within the ventricles
• Hydrocephalus mainly two types---
communicating and non-communicating
Both could be congenital and acquired
Congenital like ----birth defects as neural tube defect or aqueduct atresia
Acquired--- post meningitis( increased formation of CSF),
tumors (obstruction to flow of CSF)
Communicating hydrocephalus ---- normal pressure hydrocephalus like
cerebral atrophy inconsistent for age-- cerebral palsy
Hydrocephalus ex-vacuo---post traumatic or mature infarction or hemorrhage

28. Hydrocephalus on USG
Dilated ventricles

29. Normal size of the lateral ventricle
Hanging choroid plexus
•
– <1 cm = normal.
– 1-1.2 cm = borderline
ventriculomegaly
– >1.2-1.5 cm = mild
ventriculomegaly
– >1.5 cm = marked
ventriculomegaly

30. How to measure lateral ventricle

31. Assessment of hydrocephalus
LV: Marginal cortex
• LV: marginal cortex :: 1:4---normal
• If it is 2:3 ---may need shunt
and treat underlying cause(infection/sol)
• If it is 3: 2--- good for shunt
• If it is 4:1--- shunt not effective

32. Can we diagnose hydrocephalus
during antenatal check-up
• During a prenatal ultrasound between 15 and
35 weeks gestation,ventricles could be seen
whether enlarged
• But sometimes, the hydrocephalus is not
discovered until after the baby is born

33. Periventricular leukomalacia
• PVL is a ischemic injury involving watershed
area of preterm/premature infants
• PVL involves the death of white matter in
periventricular brain tissue

34. Acute PVL
• comparatively
hyperechoic or
echogenic
periventricular area

35. Chronic PVL ventricular ballooning with periventricular
hemorrhage
• ventriculomegaly,
periventricular cystic
change, loss of deep
white matter
* MRI has better sensitivity
and specificity in chronic
PVL

36. Hydranencephaly on USG
• Hydranencephaly or cerebral dysplasia is a rare
encephalopathy that occurs in-utero.
• It is characterized by destruction of the cerebral tissue or
whole hemisphere which are replaced into a membranous
sac of CSF
• Porencephaly is considered a less severe degree of the same
pathology
• However, it may present in neonates with seizures, respiratory failure,
flaccidity or decerebrate posturing with a vegetative state
*The condition may be diagnosed prenatally using
ultrasound or fetal MRI.

37. Hydrancephaly on USG

38. Subdural hemorrhages CT is better
• Due to stretching and tearing of
bridging cortical veins as they
cross the subdural space to drain
into an adjacent dural sinus
• These veins rupture due to
shearing forces when there is a
sudden change in the velocity of
the head
• Suspected USG picture with
clinical presentation always
ask CT scan---may need
surgical intervention

39. Controversy about SDH
• Some controversy, for academic interest only, exists as to the
exact location of a subdural hematoma.
• Classical teaching is that it is located in the potential space
between the arachnoid layer and inner layer of the dura;
• however, no such space really exists. Rather the arachnoid-
dura junction is composed of "avascular tissue with flake-like
cells stacked in several layers with narrow intercellular clefts" .
Bleeding occurs within this multicellular layer
• This possibly accounts for why some acute hematomas
appear to have multiple compartments, usually ascribed to
intermittent bleeding

40. Cerebral atrophy
cranial ultrasound in the neonatal intensive care unit can predict cerebral palsy—the
types and severity of motor dysfunction esp. in low birth wt. . babies
• Brain damage in the
first few months or
years of life.
• Infections, such as
meningitis or
encephalitis lesions
detected or HI injury

41. Limitation of USG
• If the anterior fontanelle is very small or
closed, visibility will be reduced or completely
obscured
• If the fontanelle is large, the peripheral
extremes of the brain are obscured from view.

42. Role of brain Doppler
• Doppler plays an important
role in diagnosis and follow
up of brain damage
secondary to ischemia,
hemorrhage,
infection,tumour or any
type of developmental
anomaly
• Resistive index of major
intracranial arteries ranges
from 0.6-0.8

43. Summary
• Hemorrhage– whether the term or preterm neonate
or whether it is GMH or IVH or ICH----we need to
treat the baby
• Hydrocephalus--- assess the LV: marginal cortex
whether it is post infective or due to mass
• PVL/ cerebral dysplasia/ GCA—we need to counsel
the parents and explain the outcome

44. Summary
• Head USG is must for preterm or premature neonates
• Hemorrhage– whether in term or preterm neonate
whether it is GMH or IVH or ICH----Treat it
• Hydrocephalus--- assess the LV: marginal cortex
if it is post infective lesion or mass lesion—treat the cause
and or ask for shunt
• If it is PVL or cerebral dysplasia or GCA—counsel the parents
and explain the outcome