Neonatal Head Protocol

  Only use warm gel - infants should be kept warm at all times
  Do not put pressure on probe while scanning
  Wash hands and clean probe between each infant
  If an alarm sounds during the examination, notify the nurse immediately
 DO NOT move the infant - ask the nurse for assistance
 Determine the infant’s RIGHT and LEFT sides before storing any images
 Begin scanning in the coronal plane. Then proceed to sagittal - determine midline sagittal
 The protocol is divided into 2 segments—CORONAL and SAGITTAL

Scan Plane Probe Label Landmarks
 Orbits
Extreme Angle COR ANT
 Frontal lobe with blushing
 Anterior horns of lateral ventricles
Anterior Angle COR ANT  Cavum septum pellucidum
 Corpus Callosum
 Sylvian Fissure
 Bodies of lateral ventricles
 3rd Ventricle/Thalami
True  Cavum septum pellucidum
Coronal/Mid  Corpus callosum
 Brainstem
 Hippocampi Gyri
 Sylvian Fissure
 Choroid Plexus
Slight Posterior
COR POST  Cerebeullm
 Thalami
 Sylvian Fissure
 Choroid Plexus
 Quadrigeminal cistern
Posterior Angle COR POST
 Tentorium
 Cerebellum & Cisterna Magna
 Sylvian Fissure
Posterior Angle COR POST  Glomus of Choroid plexus
 Sylvian Fissure
Extreme Angle  IHF
Posterior  Periventricular Blush

Neonatal Head Protocol

Scan Probe Label Landmarks Identified
Plane Position
 Cavum septum pellucidum
 Corpus callosum
 Aqueduct of Sylvius
True Midline SAG ML
 Cerebellar vermis & 4th ventricle
 Cisterna Magna

 Caudothalmic groove
Slight Oblique  Thalami
Angle to the SAG RT  Caudate nucleus
Sagittal Right  Lateral ventricle

*The fetal  Lateral ventricle
Oblique Angle
SAG RT  Choroid plexus
skull to the Right
should be
Extreme  Sylvian fissure
Oblique Angle SAG RT
as a true
to the Right
profile on
 Caudothalmic groove
the screen Slight Oblique  Thalami
Angle to the SAG LT  Caudate nucleus
Left  Lateral ventricle

 Lateral ventricle
Oblique Angle
SAG LT  Choroid plexus
to the Left
Extreme  Sylvian fissure
Oblique Angle SAG LT
to the Left

It is extremely important to make sure you have the RIGHT and LEFT sides labeled correctly
Exposure to cold will cause increased stress on the infant
Utilize other fontanelles to add information to the examination (posterior, mastoid, etc.)
 Perform extreme angled coronal views to visualize fluid under the skull (associated with

Neonatal Head Protocol

Types of Common Pathologies

 Intracranial Hemorrhage
 Most common reason to perform neurosonography as it is the most common cause of
neurological morbidity and mortality
 In premature neonates, most hemorrhages arise in the germinal matrix
 Most hemorrhages are caused by mechanical stress and/or increases in cerebral blood
flow to fragile vessels
 Areas of hemorrhages include: subdural, subarachnoid, subependymal, germinal
matrix, cerebellum, etc.
 Most hemorrhages are divided into types or grades of bleeds and each bleed can
develop into the next grade

Grade I-Subependymal Hemorrhage (SEH)
 Found in the area of the caudothalamic groove
 Multiple fragile thin-walled vessels are located here and are very
sensitive to increased pressure, leading to rupture & hemorrhage
 Sonographically:
 Echogenic area in caudothalamic groove
 If it resolves, cystic replacement (subependymal cyst) may be seen

Grade II- SEH and Intraventricular Hemorrhage (IVH)
 Sonographically:
 Abnormal echogenicity within the lateral ventricle
 Smooth borders
 Asymmetrical to other side
 Clot may change over time

Grade III –S EH, IVH, & ventricular dilatation
 Sonographically:
 Dilated ventricle
 Abnormal echogenicities within the ventricle
 May have aqueductal stenosis from blood clot
 Clot may change over time

Grade IV-Intraparenchymal hemorrhage (IPH) with or without IVH
 IVH that has extended from the ventricle into the brain parenchyma
 Undergo reabsorption
 Sonographically:
 Abnormal echogenicities located in:
o lateral ventricles
o cerebral hemispheres
 Ventriculomegaly

 Enlarged Ventricles

Neonatal Head Protocol

 Known as : Hydrocephalus or Ventriculomegaly
 In general, terms may be used as synonyms. But there are underlying
 Classified as Communicating or Non-communicating
 Non-communicating (intraventricular obstructive hydrocephaly)
 Obstruction of flow w/in ventricular system
 No cerebrospinal fluid flow is going to subarachnoid space
 Communicating (extraventricular obstructive hydrocephaly)
 Obstruction is extraventricular
 Cerebrospinal fluid flow is going to subarachnoid space
 Sonographically:
 Dilatation of lateral ventricles
 Bilateral or unilateral dilatation
 Dilatation of 3rd and/or 4th ventricles
 Decreased brain parenchyma
 Abnormal placement of choroid plexus (CHP)
 Monitored growth of ventricles

 Periventricular Leukomalacia
 Most significant pathological injury to the brain of premature infants
 Softening and eventually cystic necrosis of white matter
 Associated with cerebral wasting
 Caused by infarction
 the infarcted or hemorrhaged area undergoes necrosis leaving a cyst—small to
large and some may communicate with the ventricles
 Associated with severe cardio-respiratory compromise leading to hypotension, severe
hypoxia, and ischemia
 Sonographically:
 Typically bilateral
 More variable in timing in cerebrum around ventricles
 Increased echogenicity first 10 days
 Echogenicity resolves in 2 weeks
 Cysts appear 2-6 weeks after echogenic phase
 Cysts resolve resulting in ventriculomegaly 3-4 months

Measurements – site specific

• Midline to lateral dimension
– Midline to lateral dimension should be 12 mm or less

Neonatal Head Protocol

• Ventricular depth
– Widest line perpendicular to the longest axis should be 4 mm or less

• Lateral ventricular width ratio (LVR)
– Ventricular width divided by the hemispheric width
– % of the cerebral hemisphere occupied by the lateral ventricle
– Ratio of the distance between the lateral sides of the ventricles and BPD or
– Can be done individually per side (measure from midline to lateral dimension and
midline to skull)
– Normal LVR should not exceed .33 or lateral ventricle should not exceed 33% of the
hemispheric width
• Mild hydrocephalus .35 to .40
• Moderate hydrocephalus .41-.50
• Severe hydrocephalus over .50