Neonatal neurosonography

USG

1. NEONATAL
NEUROSONOGRAPHY

2. •Most widely used neuro imaging procedure in pre-terms
•Helps in assessing the neurological status of the child ,since clinical
examination and symptoms are non-specific
•It is safe ,reliable ,inexpensive, suitable for screening ,provides easy imaging
and can be done bedside

3. INDICATIONS :
•Asphyxia and birth trauma, prematurity (screening, i.e.
third and seventh day).
•Macro-or hydrocephalus and (fetally) suspected
cerebral malformations.
•Suspicion of brain haemorrhage.
•Clinical neurologic symptoms.
•Disease potentially associated with cerebral
manifestations (e.g. septicemia with brain abscess,
tuberous sclerosis and other syndromic disease),
meningeal empyema, meningoencephalitis, etc.
•Some centers perform screening neonatal brain US.
•US may play a role in suspected inflicted/non-
accidental (NAI).

4. Requirements
•Generally high frequency phased
array transducer (5-8MHZ) with a
small foot print probe
•For standard examination 7.5-8
MHZ
•Tiny infant /superficial structures:
additional higher frequency (10
MHZ)
•Large infant /thicker hair/deep
structures: low frequency (5MHZ)

5. Imaging windows

6. Standard coronal planes

8. Sagittal views

9. COLOUR DOPPLER IMAGING
•Mostly useful in demonstrating circle of Willis and region of vein of
Galen
•Easily accessible vessels
•ACA
•MCA

10. Doppler imaging
•Imaging of circle of Willis and region of vein of Galen is essential
•Transfontanellar
•Anterior cerebral artery (ACA) and its branches (particularly the pericallosal) and basilar
artery (BA)—best seen in sagittal sections
•Circle of Willis with its major feeding arteries and draining veins—best seen in coronal
section
•Internal carotid artery (ICA)—in parasagittal or coronal section

11. Transtemporal Dopplersonography
•Most vessels of circle of Willis are visible, particularly:
•Middle cerebral artery (MCA), proximal part of ACA (A1-segment).
•Proximal part of posterior cerebral artery (PCA), posterior and anterior
communicating arteries.
•Depiction of (proximal) ICA, distal ACA and BA difficult or impossible.
•This view used for transcranial flow evaluation

12. Normal variants

13. Immature
sulcation
•Infants born before 24
weeks posses smooth
cerebral cortex. Exhibiting
only Sylvian fissures

14. Choroid plexus
variant
•Generally does not extend past the
caudo-thalamic groove in the frontal
horns or past the ventricular atria in
occipital horns
•Lobular or bulbous variants –occur
frequently in the glomus with in
ventricular atria and lateral ventricles

15. Choroid plexus cysts

16. Pseudo cysts
•These are also called coarctation of
the lateral ventricle.
They are often bilaterally and have no
neurological sequelae

17. Germinolytic cysts
•Are located at the caudothalamicgroove.
They are tear shaped.
There are no signs of intracerebralhemorrhageand these children have no
neurological sequelae.
The etiologyis not known.

18. Persistent fetal
fluid filled spaces
•Common finding in healthy neonates include :
cavum septi pellucidi,
cavum vergae,
Cavum veli interpositi
The more premature the baby, the more frequently these
cavities are present.
A less frequently seen variant is the cavum of the velum
interpositum.
This presents as a cyst-like structure in the region of the tectum

19. Periventricular
Echogenicities
•Flaring is the term used
•Physiologically reduced differentiation
between grey and white matter due to
immaturity; central nonmyelinated white
matter can be relatively echogenic,
particularly in periventricular areas.
•During this first week it is not sure if this is a
normal variant or a sign of PVL grade 1.

20. Ventricular
Asymmetry
•Normal ventricles measure
less than 10mm in transverse
diameter with 60 %of full
term and 30%of premature
infants having ventricles
smaller than 2-3mm
•Asymmetry of ventricles has
been observed In 20-40 %
of infants

21. Cisterna
magna
•Size -quite variable
•Typically less than 8mm
•>8mm-MEGA CISTERNA MAGNA
(1%)
•Normal variant should be
distinguished from arachnoid cyst and
dandy walker malformation

22. Mineralizing
vasculopathy
•Seen in the thalamostriatal and
lenticulostriatal arteries and is
caused by calcification of the
arterial wall.
A wide range of perinatal, acquired,
and nonspecific clinical conditions
may result in this sonographic
finding.

24. Pathologies

25. Corpus
Callosum
Malformations
•Dysgenesis of partial
•or total agenesis of corpus callosum.
•Associated malformations, for example: arachnoid cyst, Arnold–Chiari and various
syndromes (Trisomia 8, 13, etc.)

26. Hydrocephalus
•dilatation of internal and/or external CSF spaces.
•Task of US
•Depiction of dilatation/widened ventricles or external CSF spaces.
•Potentially recognise cause of dilatation.
•Find signs that indicate elevated intracranial pressure.

27. On usg

28. Role of CDS in Increased Intracranial Pressure

29. VEIN OF GALEN
MALFORMATION
•The most common intracranial vascular anomaly
presenting in the neonatal period. Multiple
abnormal feeding vessels or an arteriovenous
fistula with few feeding vessels drain into the vein
of Galen, which becomes massively enlarged.

30. Temporal lobe arachnoid cyst
Most common intracranial
congenital cystic lesion

31. Holoprosencephaly
•Rare severe malformation based on lack of hemispheric
differentiation of early foetal brain
•Several forms:
•Alobar Holoprosencephaly
•Semilobar Holoprosencephaly
•Lobar Holoprosencephaly
•De Morsier Syndrome: Septo-Optic Dysplasia–mild form of holo
prosencephaly

32. Septo-Optic Dysplasia
•Syndrome consisting of hypopituitarism, hypotelorism and blindness
due to hypoplasia of optic discs

33. Dandy–Walker
Malformations/Spectrum
•Variable cystic malformation in posterior
fossa, associated with atypical shape and
size of posterior fossa + cerebellar
hypoplasia.

34. Lissencephaly
•Lack of gyration and sulcation
•Can be completely missing (agyria)
•or altered, showing many tiny gyri(polymicrogyria),
•few unusually flat gyri (pachygyria)
•or enlarged gyri(macrogyria).

36. Megalencephaly
•Regional disturbance of brain
development, can be generalized or
focal/unilateral (hemimegalencephaly)
and may be associated with metabolic
disturbances.

37. Schizencephaly
•Gap in brain parenchyma
connecting ventricle to extra-axial
CSF system.
•If filled with CSF—open lip
schizencephaly.
•No fluid separating the lips—
closedlipschizencephaly.
•DDx:Any kind of porencephalic
or cystic defect connecting with
ventricle, heterotopia.

38. Germinal matrix
haemorrhage
•One of the most common indications
of neurosonography in preterm
infants
•Routine screening –in all infants of
under 30 weeks gestation, once
between 7 and 14 days of age and
should be optimally repeated between
36 and 40 weeks postmenstrual age.

41. Peri ventricular leukomalacia
•also known as Hypoxic-Ischemia Encephalopathy (HIE) of the preterm.
•PVL occurs most commonly in premature infants born at less than 33
weeks gestation (38% PVL) and less than 1500 g birth weight (45% PVL).
•It is a white matter disease that affects the periventricular zones.
•Causes: ischemia, infection,vasculitis

45. ACUTE
ISCHEMIA
•As the size of the ventricles varies
considerably, ventricular size is
unreliable as a parameterin assessing
the mass effect.
•The usual observation in the cases of
ischemia is a combination of diffuse
increase in the echogenicity of
ganglionic areas with associated
obliteration of cisterns and small
capacity of the ventricles

46. Inflammation
•US only shows indirect changes or complications
•Final diagnosis always needs other tests (lumbar puncture, blood
samples, MRI, etc.).
•Common causes for prenatal CNS infections are cytomegalovirus,
herpes, toxoplasma, HIV and rubella (TORCH).

47. Postnatal
US Findings
•Hydro-, micro-and macrocephalus.
•Intracerebral calcifications, band-like or
stippled—most commonly in area of
basal ganglia
•Non-calcifying vasculopathy as
remnant of vascular involvement
•Hemispheric calcification occurs, can
be large
•Porencephalic defects, multi-cystic
encephalopathy and atrophy.

48. Meningitis

49. Ependymitis and
ventriculitis
•Ependymitis occur from
irritation from
haemorrhage with in
ventricle
•Occurs earlier than
ventriculitis
•Ventriculitis is common
complication of purple
that meningitis