CONTINUING MEDICAL EDUCATION

Neonatal Cranial
Sonography: Modern
Strategies and Applications
By Roee S. Lazebnik, M.D., Ph.D. and Laura J. Varich, M.D.

Upon completion of this

activity, participants should
be able to:
Describe modern sonographic
acquisition techniques and
protocols.
Distinguish the benefits and
limitations of different acoustic
windows.
Describe many clinical
applications for sonographic
anatomic and functional
evaluation.
Outline the potential role for the
latest technologies, including 3D
sonography.
Who will benefit:
Radiologists, sonographers,
physicians, physician assistants,
nurses, and referring physicians
interested in body imaging will
benefit from the information in
this educational activity and can
receive Continuing Medical
Education credit by completing
the post-test and evaluation
provided.

June 2007

oth logistical and clinical factors make the

imaging of newborn infants a challenging
task. The newborn is an (understandably)
uncooperative patient, incapable of following
directions such as hold your breath or
remain still. Thus, cross-sectional modalities such as CT or MRI that require cooperation for optimal image quality are difficult to
apply. Even low-dose ionizing radiation is
potentially harmful for neonates, particularly
when serial exams are required. Finally, transportation of sick newborns to an imaging
suite, particularly those infants requiring
intensive care and isolette housing, is often
very difficult, if not impossible.
Sonography overcomes these challenges
and provides several advantages. While many
neonatal organ systems are amenable to
sonographic evaluation, brain imaging is a
particularly attractive application. Not only is

Earn 1.0 hours of AMA PRA

Category 1 Credit(s) through
June 2009

Dr. Lazebnik is a resident physician and Dr.

Varich is a clinical assistant professor, both in
the radiology department at Stanford University School of Medicine.
Neither Dr. Lazebnik nor Dr. Varich has any
significant financial arrangement or affiliation with any manufacturer of any pharmaceutical or medical device and neither is affiliated in any manner with any provider of any
commercial medical or healthcare professional
service.

the neonatal head uniquely configured to

facilitate ultrasound scanning through fontanelles, but the most common clinical indications for head imaging, such as hemorrhage or congenital anomalies, are readily
evaluated. Further, the real-time nature,
portability, and safety of this modality allow
clinicians to perform rapid, frequent (serial),
bedside exams as clinically indicated, even for
hemodynamically unstable neonates.
The first widespread application of ultrasound technology to the neonatal head
occurred sometime in the late 1970s, with
2D real-time studies. The introduction of
Doppler technology into clinical practice in
the late 1980s dramatically expanded the
diagnostic capabilities. The most recent generation of ultrasound devices, first introduced
in the 1990s, allows for dynamic 3D (4D)
imaging. Parallel to these developments,
advances in image processing have further
improved image quality and the clinicians
ability to interact with a sonographic data set.
A more comprehensive review of neonatal
head sonography is available in the text by
Siegel.1
STANDARD EXAM
Modern sonographic examination of newborns is typically performed with a sector
transducer using 5 MHz or higher frequency. Standard images are acquired through
three acoustic windows: anterior fontanelle

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NEONATAL CRANIAL SONOGRAPHY:

MODERN STRATEGIES AND APPLICATIONS
(AF), posterior fontanelle (PF), and mastoid fontanelle (MF). Each of these windows is optimal for a different subset of
anatomy that must be evaluated.
Historically, the AF, which closes by age
nine to 15 months, was the primary
imaging window. The PF may provide
improved sensitivity for intraventricular
hemorrhage, however, particularly when
the lateral ventricles are not dilated, and
it allows improved visualization of the
occipital periventricular white matter, an
area of particular concern in periventricular leukomalacia. The PF and MF are particularly useful in evaluating the posterior
fossa for hemorrhage or anomalies such
as Chiari malformation.2,3
While subtle variations exist, and every
exam must be tailored to the individual
patients indications, the exam typically
includes at least six coronal images (at the
levels of the frontal horns anterior to the
foramen of Monro, thalami, quadrigeminal plate cistern, atria of lateral ventricles,
and posterior to the lateral ventricles) and
five sagittal images (midline and two
parasagittal views on each side). An axial
plane demonstrating the cerebellum is
often obtained using the MF window.
Neonatal intracranial sonography is
used for common and emerging applications as well as modern imaging
strategies:
Intracranial hemorrhage. Evaluation
for intracranial hemorrhage (ICH) is a
common indication for sonography.
Most cases occur during the first few days
after birth, particularly within the first 24
hours. Ultrasound is more observerdependent than CT or MRI for detection of intraventricular hemorrhage, and
CT and MRI are more sensitive for
detecting intraparenchymal hemorrhage.4 In the context of critically ill
neonates who often require serial exams,
however, sonography is the modality of
choice. An example is the neonate requiring extracorporeal membrane oxygenation who is evaluated daily for ICH due
to anticoagulation.
Hemorrhage in the acute or subacute
setting is most commonly identified as a

June 2007

FIGURE 1. Intracranial hemorrhage. A: Sagittal view of intraventricular hemorrhage (grade III) demonstrates ventricular dilatation secondary to hyperechoic blood volume. B: Coronal view from another study demonstrates
hyperechoic foci in parenchyma adjacent to lateral ventricles (grade IV).

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NEONATAL CRANIAL SONOGRAPHY:

MODERN STRATEGIES AND APPLICATIONS
hyperechoic focus. The location and
extent of bleeding have prognostic value
and are often graded using the Papile system.5 The vascular-rich subependymal
germinal matrix, deep to the thalamus
and caudate head (caudothalamic notch),
is often the first location at which bleeding is identified (grade I). Extension to
the lateral ventricle (grade II), subsequent ventricular dilatation due to large
volume intraventricular hemorrhage
(grade III), and associated parenchymal
involvement (grade IV), must be documented (Figure 1).
The sonographic appearance of cerebellar hemorrhage, a possible complication of extreme preterm birth, includes
unilateral or bilateral hyperechoic lesions
in the cerebellar hemispheres or vermis.
This appearance is distinct from a posterior fossa subarachnoid hemorrhage, in
which echogenic areas may surround the
cerebellum. Parenchymal architecture distortion including central hypoechogenicity or peripheral echogenicity may also be
present.6
Hemorrhage evaluation is enhanced
by imaging through the PF window. This
accentuates subtle differences in echogenicity between clot and a choroid glomus and improves delineation of clots
extending into the occipital and temporal
horns. Additional information may be
obtained using the MF window, particularly for detecting hemorrhage involving
the brain stem, cerebellum, and subarachnoid cisterns. The MF window is
also useful for evaluation of the fourth
ventricle and cisterna magna, which are
surrounded by echogenic structures.7
Ischemic brain injury. Periventricular
leukomalacia (PVL) is the most common
consequence of neonatal ischemic brain
injury, particularly for premature infants.
This process typically affects white matter
adjacent to the lateral ventricles, often
watershed areas supplied by deep penetrating arteries. Diagnosis of PVL is
important because of its association with
cerebral palsy, developmental abnormalities, and visual dysfunction. The sonographic features of PVL include periven-

June 2007

FIGURE 2. Alobar holoprosencephaly. A: Midline sagittal view demonstrates dilated ventricle and dorsal sac. B:
Coronal view demonstrates single midline ventricle (monoventricle).

tricular hyperechoic foci or later-appearing cysts. Serial examination is often

required, as these findings may become
apparent only over a time span of several weeks. Features such as symmetry and
well-defined borders help differentiate

PVL from hemorrhage.

A related application of sonography is
acute delineation of the infarcted
parenchyma following ischemic brain
injury. Imaging may show vessels that
increase in size (luxury perfusion) at the

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NEONATAL CRANIAL SONOGRAPHY:

MODERN STRATEGIES AND APPLICATIONS

Figure 3: Dandy-Walker malformation. Midline sagittal view demonstrates retrocerebellar fluid-filled cystic structure communicating with fourth ventricle.

periphery of the affected area. This may

be due to degradation of the blood-brain
barrier and subsequent release of vasoactive substances, causing local vasodilatation.8,9 A potential caveat is that while
major intracranial arteries are easily and
rapidly identified, absolute flow velocity
is not a sensitive or accurate measure of
actual cerebral blood flow.10
Vascular applications. Doppler imaging of intracranial vasculature is gaining
popularity for evaluation of neonatal
cerebral perfusion abnormalities. Such
imaging often involves estimation of the
resistive index (RI), defined by the difference between peak systolic and lowest
diastolic velocities divided by the peak
systolic velocity of the interrogated arterial vessel. The RI eliminates the need for
accurate angle estimation to correct
absolute velocity measurements. Decreased RI may result from impairment
of cerebral autoregulation. This must be
interpreted, however, in the context of
physiologic RI decrease with age.

June 2007

Increased RI due to loss of forward diastolic flow may result from sustained
asphyxia with subsequent development
of intracranial hemorrhage or diffuse
cerebral edema.11
Another Doppler-derived metric is the
Vm ratio, defined as mean velocity in the
right and left middle cerebral arteries
divided by mean velocity in the right and
left internal carotid arteries. This ratio,
when measured at birth, may help estimate the likelihood of cerebral palsy neurologic outcome, especially for neonates
without the diagnosis of hypoxicischemic encephalopathy.12
Other applications for Doppler imaging include monitoring of neonatal
seizures. Such events produce a detectable
increase in flow velocity even if not associated with an increase in blood pressure.13
Ultrasound is also useful for defining vessels around tumors and showing tumor
recurrence at an early stage. For solid or
cystic craniopharyngiomas, several characteristics have been described: a sellar

echogenic or anechoic tumor mass associated with rim echogenicity (encapsulated),

hyperechogenicity (calcified capsule), or
spot echogenicity (calcific spots).14 A nonvascular application of Doppler imaging is
examination of cerebrospinal fluid flow
dynamics where high and pulsatile flow is
correlated with meningitis.9
Anatomic abnormalities. A common
application of sonography is characterization of intracranial congenital abnormalities. In hydranencephaly, the result of
occlusion of the bilateral internal carotid
arteries, for example, ultrasound can
demonstrate absence of both cerebral
hemispheres. The interhemispheric fissure, or falx, is typically present but may
be deviated. For holoprosencephaly, an
anterior midline defect associated with
facial and central nervous system abnormalities, sonography may be useful in
classification into one of three forms,
each with varying prognoses. The most
severe form, alobar holoprosencephaly,
features a single ventricle with dorsal cyst,
complete thalamic fusion, and absence of
the interhemispheric fissure (Figure 2).
The semilobar form of holoprosencephaly features partially formed interhemispheric fissures and partially fused
thalami. Lobar holoprosencephaly is considered the mildest form and demonstrates absence of the anteroinferior portion of the interhemispheric fissure.
Ventriculomegaly is an easily appreciated finding with a large differential diagnosis that includes both acute and developmental causes. Sonography allows the
clinician to document the progression of
ventricle enlargement, typically from the
occipital horns (colpocephaly) to the
temporal and, finally, the frontal horns.
Ultrasound also allows identification of
associated features, such as properties of
the CSF and other anatomic features that
help narrow the diagnostic possibilities.
The sonographic features of ventriculitis,
for example, include ventriculomegaly,
intraventricular echogenic material, and
echogenic ependyma. In contrast, aqueductal stenosis, a common cause of
hydrocephalus, demonstrates enlarged

DIAGNOSTIC IMAGING: CONTINUING MEDICAL EDUCATION

NEONATAL CRANIAL SONOGRAPHY:

MODERN STRATEGIES AND APPLICATIONS
lateral and third ventricles without
enlargement of the fourth ventricle or
the presence of intraventricular debris.
Ultrasound is also particularly useful
for evaluation of various intracranial cystic structures, including normal variants
(cavum septum pellucidum), developmental lesions (Dandy-Walker continuum disorders [Figure 3]), cysts due to
perinatal injury, cystlike vascular structures, hemorrhagic cysts, and abscess. A
review by Epelman et al offers a summary of differential specific features.15
FUTURE DIRECTIONS
Presently, most neonatal cranial sonography is performed using a standard 2D
probe, resulting in a series of independent cross-sectional images or cine clips.
Three-D sonography is an emerging
technology that uses either a specialized
3D probe for volumetric acquisition or
image processing techniques that account for the spatial location of related
2D images to construct a 3D imaging
volume. In a typical 3D acquisition, the
sonographer scans the anatomic region
of interest with a single sweep of a volumetric transducer. This precludes acquisition of multiple independent images
through the organ of interest, greatly
reducing scan time.
This technique may also reduce the
variability of image quality among different sonographers. In contrast to conventional sonography, the resulting volumetric data may be processed retrospectively
to obtain custom imaging planes (Figure
4). This also allows more direct, spatially
coregistered comparison with cross-sectional modalities such as CT and MRI.
Further, comparison of serial imaging
studies over time is facilitated, as multiple
corresponding anatomic landmarks are
present in all data sets. Three-D surface
visualization is feasible by manual or
automated segmentation of the volumetric data set.
Many specific applications of 3D
sonography exist for imaging of the
neonatal head. In evaluation of hemor-

June 2007

Figure 4: Multiplanar reformatting of volumetric acquisition. Data set acquired using 3D technique may be retrospectively reformatted into continuous slices of arbitrary orientation.

rhage, 3D imaging both demonstrates

hemorrhage and allows for more accurate
differentiation of its location, magnitude,
volumetric quantification, and serial progression.16 Interpolation of an axial plane
is particularly useful for distinguishing
subependymal hemorrhage from choroid
plexus.17 For evaluation of ventriculomegaly and hydrocephalus, 3D imaging allows increased accuracy in ventricular volume measurements. Acquisition of
a 3D Doppler volume allows detailed
evaluation of vascular structures such as
vein of Galen aneurysm, arteriovenous
malformations, and other pathology.
Finally, sonographic 3D visualization is
particularly useful for neurosurgical planning and, unlike modalities such as CT or
MRI, allows real-time intraoperative
guidance in almost any operating room.
CONCLUSION
Intracranial imaging of the neonate is a
logistically challenging task. Ultrasound
is simultaneously efficient, effective, and
safe modality for this application, and it is
particularly appropriate for many com-

mon clinical scenarios such as intracranial

hemorrhage and ventriculomegaly. Sonographic technology has undergone
tremendous evolution over the past 40
years, from 2D depictions of basic anatomy to high-resolution 3D real-time visualizations of structure and function.
Future iterations will likely continue this
trend of yielding improved, more versatile clinically relevant evaluation.
References
1. Siegel MJ. Pediatric sonography, 3rd ed. Philadelphia:
Lippincott Williams & Wilkins, 2002.
2. Correa F, Enriquez G, Rossello J, et al. Posterior fontanelle
sonography: an acoustic window into the neonatal brain. AJNR
2004;25(7):1274-1282.
3. Merrill JD, Piecuch RE, Fell SC, et al. A new pattern of cerebellar hemorrhages in preterm infants. Pediatrics 1998;102(6):E62.
4. Blankenberg FG, Loh NN, Bracci P, et al. Sonography, CT, and
MR imaging: a prospective comparison of neonates with suspected
intracranial ischemia and hemorrhage. AJNR 2000;21(1):213-218.
5. Papile LA, Burstein J, Burstein R, Koffler H. Incidence and
evolution of subependymal and intraventricular hemorrhage: a
study of infants with birth weights less than 1,500 gm. J Pediatr
1978;92(4):529-534.
6. Limperopoulos C, Benson CB, Bassan H, et al. Cerebellar hemorrhage in the preterm infant: ultrasonographic findings and risk
factors. Pediatrics 2005;116(3):717-724.
7. Di Salvo DN. A new view of the neonatal brain: clinical utility
of supplemental neurologic US imaging windows. Radiographics
2001;21(4):943-955.
8. Steventon DM, John PR. Power Doppler ultrasound appearances of
neonatal ischaemic brain injury. Pediatr Radiol 1997;27(2):147-149.
9. Tatsuno M, Hasegawa M, Okuyama K. Ventriculitis in infants:
diagnosis by color Doppler flow imaging. Pediatr Neurol
1993;9(2):127-130.

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MODERN STRATEGIES AND APPLICATIONS
10. Van Bel F, Schipper J, Guit GL, Visser MO. The contribution
of colour Doppler flow imaging to the study of cerebral haemodynamics in the neonate. Neuroradiology 1993;35(4):300-306.
11. Chao CP, Zaleski CG, Patton AC. Neonatal hypoxic-ischemic
encephalopathy: multimodality imaging findings. Radiographics
2006;26 Suppl 1:S159-172.
12. Fukuda S, Kato T, Kuwabara S, et al. The ratio of flow velocities in the middle cerebral and internal carotid arteries for the pre-

diction of cerebral palsy in term neonates. J Ultrasound Med

2005;24(2):149-153.
13. Boylan GB, Panerai RB, Rennie JM, et al. Cerebral blood flow
velocity during neonatal seizures. Arch Dis Child Fetal Neonatal
Ed 1999;80(2):F105-110.
14. Lin KL, Wang HS, Lui TN. Diagnosis and follow-up of craniopharyngiomas with transcranial Doppler sonography. J
Ultrasound Med 2002;21(7):801-806.

15. Epelman M, Daneman A, Blaser SI, et al. Differential diagnosis of intracranial cystic lesions at head US: correlation with CT
and MR imaging. Radiographics 2006;26(1):173-196.
16. Riccabona M. Pediatric three-dimensional ultrasound: basics
and potential clinical value. Clin Imaging 2005;29(1):1-5.
17. Salerno CC, Pretorius DH, Hilton SW, et al. Three-dimensional
ultrasonographic imaging of the neonatal brain in high-risk neonates:
preliminary study. J Ultrasound Med 2000;19(8):549-555.

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Reference #: A07019062
Release Date: JUN 2007
Expiration Date: JUN 2009
Number of AMA PRA Credits Designated
for this Activity: 1.0

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