ULTRASOUND CRANIUM

Dr. Ali Yikilmaz

McMaster Children’s Hospital
Diagnostic Imaging, Hamilton, ON, Canada
yikilmaz@hhsc.ca

15th Asian and Oceanian Congress of Child Neurology (AOCCN) 2019, in

conjunction with the 41st Malaysian Paediatric Association (MPA) Annual Congress
No disclosures
 OUTLINE
• Introduction

• Technique

• Normal variants

• Hypoxic-ischemic encephalopathy
 Why Ultrasound ?
• Inexpensive
• Does not require sedation
• Reproducible
• No ionizing radiation
• Suitable for screening
• Bed-side application***
 Technique
• Stabilization of patient
• Cleaning and disinfection of the
probes
• Anterior and mastoid fontanels are
routinely used
– additional fontanels if needed

Sonographer Sarah Zuccolo

 Technique

Higher
Lower Resolution
Resolution
 When to perform?
• Term (≥37 weeks)
– Whenever necessary

• Preterm (<37 weeks) - Screening

– First: 10-14. days (especially for GMH)

– Second: 4. week (especially for PVL)

 Indications

CC agenesis Meningitis Abscess Hydrocephalus

Hemangioblastoma Vein of Galen PDA

Lipoma
malformation
 Anterior
fontanel Posterior
Fontanel

Pterion

Mastoid
Squamous fontanel
Suboccipital
 6
1
3 4 5
2

1 2 3 4 5 6
 1 5

2 4
3

1 2 3 4 5
RT RT ML LT LT
1

MRI
Trans-temporal Approach
Trans-temporal Approach
Posterior Fontanel
Mastoid Fontanel
 Advanced age

4-month-old
Immature white matter
 Connatal Cysts

1 day of life 7 week old

MRI
Germinolytic cyts
Choroid plexus
 Pons

MRI
 Internal Cerebral Veins

MRI MRV
US
Mineralizing Vasculopathy
Lenticulostriate
arteries
 Hypoxic-Ischemic Injury

Preterm Term
Intraventricular Parenchymal
/Periventricular hemorrhage
hemorrhage (GMH)

Periventricular Parasaggital injury

leukomalacia (PVL)

Stroke

Premature infants are NOT small infants!

 Germinal Matrix
Lateral
Lateral ventr. vent.

KN
T

KN

T
T
 Germinal Matrix Hemorrhage (GMH)

–Grading*
• Grade I: GMH
• Grade II: GMH + IVH
• Grade III: GMH + IVH + ventricular dilatation
• Grade IV: (+) Periventricular hemorrhagic infarction

–Grade I: No clinical significance

–Grade IV: Poor prognosis, usually with neurological sequela

*Burstein J, Papile LA, Burstein R. Intraventricular hemorrhage and hydrocephalus in premature newborns: a prospective study with CT. AJR 1979;132:631-5.
GMH– Grade I

Grade I
GMH
 Evolution of GMH

Day 4 Day 10 3 week 6 week

9 week
GMH- Grade II

Grade II
GMH- Grade III

Grade III
 GMH- Grade IV
Medullary
Vein

Subepandymal
Vein

Terminal
Vein

Grade IV
 GMH- Grade IV =
Periventricular Hemorrhagic Infarction

Day 3 4 week 9 week

10 week 12 week 12 week

Parenchymal Hemorrhage
 Periventricular Leukomalacia (PVL)=
White matter injury of prematurity
• Most common cause of cerebral palsy

• Main hypoxic-ischemic injury pattern in the premature infant

• Liquefaction phagocytosis cavitation gliosis

 White matter injury of prematurity

2 days 2 weeks
4 weeks
 White matter injury of prematurity

4 day 4 weeks 3-month-old

Hypoxic-Ischemic Injury - Term

Parasagittal injury
Hypoxic-Ischemic Injury - Term

Multicystic Encephalomalacia
Stroke - MCA

2-month-old with dilated

cardiomyopathy 6 days after
Sinus Thrombosis
Venous Infarction

Day 0
 Conclusion
• Cranial US is essential in the evaluation of neonates with
the main advantage of portable application.

• It is the best screening tool for the complications of

prematurity.
THANK YOU! Toronto from Niagara