Cranial Ultrasound

Dr Muhammad Jazib Shahid

Learning Objectives

 Introduction
 Aims
 Indications
 Sonographic Technique
 Sonographic Anatomy
 Doppler
 Pathologies
Introduction

 Cranial ultrasound (CUS) is an extremely valuable

tool for the evaluation of the brain during the
first year of life. It is used to look for hemorrhage
or a hypoxic-ischemic event in the neonate, to
exclude and monitor hydrocephalus, brain
malformations, etc.
Advantages

 Safe (lack of ionizing radiation, no need for

sedation)
 Inexpensive
 Portable and can be quickly performed
 Can be Repeated as many times as necessary
 Indications
 Abnormal increase in head circumference
 Hemorrhage or parenchymal abnormalities in preterm
and term infants
 Ventriculomegaly/hydrocephalus
 Vascular abnormalities
 Suspected hypoxic ischemic injury
 Patients on hypothermia, extracorporeal membrane
oxygenation (ECMO), and other support machines
 Congenital malformations
 Indications
 Signs or symptoms of a central nervous system disorder
(e.g., seizures, facial malformations, macrocephaly,
microcephaly, and intrauterine growth restriction)
 Congenital or acquired brain infection
 Suspected or known head trauma
 Craniosynostosis
 Follow-up or surveillance of previously documented
abnormalities, including prenatal abnormalities
 Screening before surgery.
Sonographic Technique

 Probe:
.The use of at least two types of transducers, convex and linear, is
recommended on every CUS.
.The convex to visualize deeper structures and the linear to characterize
structures closer to the probe.
 Frequency:
. 7.5 to 10 MHz are the adequate frequency for the initial scan of the entire
brain
.Tiny infants, Superficial structures: (10Mhz)
. Large infants, thick hairy deep structures: (5mhz)
Acoustic Windows
Views

 Coronal
 Sagittal
 Horizontal
Coronal view
Standard Coronal Planes

At least 6 standard
planes
1st Coronal Plane

 1.Interhemispheric

fissure
 2.Frontal lobe
 3.Skull
 4.Orbit
2nd Plane

2.Frontal lobe
5.Frontal horn of lateral ventricle
6.Caudate nucleus
7.Basal ganglia
8.Temporal lobe
9.Sylvian fissure
3rd Plane

2.Frontal lobe
5.Frontal horn of lateral ventricle
6.Caudate nucleus
7.Basal ganglia
8.Temporal lobe
9.Sylvian fissure
10. Corpus callosum
11. Cavum septum pellucidum
12. Third Ventricle
13. Cingulate Sulcus
4th Plane
1.Inter hemispheric fissure
8. Temporal lobe
9. Sylvian fissure
14.Body of lateral ventricle
15. Choroid plexus
16. Thalamus
17. Hippocampal fissure
18. Aqueduct of sylvius
19. Brain stem
20. Parietal lobe
5th Plane
8. Temporal Lobe
10.Corpus Callosum
15.Choroid plexus
20.Parietal lobe
21.Trigone of lateral ventricle
22.Cerebellum
(a: hemisphere b: Vermis)
23.Tentorium
24.Mesencephalon
6th plane

20.Parietal lobe
25.Occipital lobe
26.parieto-occipital fissure
27.Calcarine fissure
 Sagittal views

At least 5 planes
Midsagittal Plane
 10.Corpus callosum
 11.Cavum septum pellucidum
 12.Third ventricle
 13.Cingulate sulcus
 16.Thalamus
 22b.Cerebellum(vermis)
 24.Mesencephalon
 26.Parieto-occipital fissure
 27.Calcarine fissure
 28.Pons
 29.Medulla oblongata
 31. Cisterna magna
 32. Cisterna quadrigemina
 33. Interpeduncular fossa
 34. Fornix
2nd and 4th Sagittal plane
 2. Frontal lobe
 5. Frontal horn of lateral ventricle
 6. Caudate nucleus
 8. Temporal lobe
 14. Body of lateral ventricle
 15. Choroid plexus
 16. Thalamus
 17. Hippocampal fissure
 20. Parietal lobe
 21. Trigone of lateral ventricle
 22a. Cerebellum(hemisphere)
 25. Occipital lobe
 36. Occipital horn of lateral ventricle
1st and 5th Plane
 2. frontal lobe
 8. Temporal lobe
 9.Sylvian fissure
 20. Parietal lobe
 25.Occipital lobe
 37. Insula
Doppler
 Typical transcranial Doppler with imaging scan and recording from middle
cerebral artery (MCA).
 Doppler image shows circle of Willis.
 IA = anterior cerebral artery
 IM = middle cerebral artery
 P = posterior cerebral artery
 RI = resistive index (0.6-0.9)
 Demonstrates
 Decreased blood 'flow/ischemia/infarction
 Vascular abnormalities
 Cerebral Edema
 Hydrocephalus
 Intracranial Tumors
 Near-field structures
Pathologies
Intraventricular hemorrhage

 More common in premature infants

 Germinal matrix- highly vascular and vulnerable to
hemorrhage and ischemia
 Image is taken at 4-7 day of life
 90% of hemorrhage occur at first week
 Follow with weekly ultrasound to evaluate for
hydrocephalus
IVH Grading

 Grade I- Confined to germinal matrix

 Grade II- Intraventricular without ventricular
dilation
 Grade III- Intraventricular with ventricular dilation
 Grade IV-grade III with parenchymal haemorrhage
Grade I
Grade II
Grade III
Grade IV
Intraparenchymal Hemorrhage

 Brain parenchyma destroyed

 Originally considered an extension of IVH, but
may actually be a primary infarction of the
periventricular and sub cortical white matter with
destruction of the lateral wall of the ventricle
 Sonographic Finding :Zones of increased
echogenicity in white matter adjacent to lateral
ventricles
Periventricular leukomalacia
 Also known as Hypoxic-ischemic encephalopathy
 It likely occurs as a result of hypoxic-ischemic lesions
resulting from impaired perfusion at the watershed areas,
which in premature infants are located in a periventricular
location. It is likely that infection or vasculitis also play a
role in pathogenesis.
 Present as area of increased periventricular echogenicity.
 Effects:
 Cerebral palsy
 Intellectual problems
 Visual defects
Periventricular leukomalacia classification
 grade 1: areas of increased periventricular echogenicity
without any cyst formation persisting for more than 7 days
 grade 2: the echogenicity has resolved into small
periventricular cysts
 grade 3: areas of increased periventricular echogenicity,
that develop into extensive periventricular cysts in the
occipital and frontoparietal region
 grade 4: areas of increased periventricular echogenicity in
the deep white matter developing into extensive
subcortical cysts
Grade I
Grade II
Grade III
Grade IV
Hydrocephalus

 Hydrocephalus is an abnormal buildup of fluid in the

ventricles (cavities) deep within the brain
 CUS is really useful for the evaluation of children with
macrocephaly, rapid increase in head circumference or a
bulging fontanelle
 Can be due to obstruction to the CSF outflow, decreased
CSF absorption or CSF overproduction.
Dandy-Walker malformation
 Dandy-Walker malformation (DWM) is the most common posterior fossa
malformation, characterized by the triad of:
 hypoplasia of the vermis 
 cystic dilatation of the fourth ventricle extending posteriorly 
 enlarged posterior fossa
 Agenesis of Corpus Callosum

It is characterized by a
partial or complete
absence (agenesis) of
an area of the brain
that connects the two
cerebral hemispheres.
Thank you for your attention