Neonatal Head Protocol

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 infants RIGHT and LEFT sides before storing any images
Begin scanning in the coronal plane. Then proceed to sagittal - determine midline sagittal
first
The protocol is divided into 2 segmentsCORONAL and SAGITTAL

Scan Plane Probe Label Landmarks

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

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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
outlined
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

Tips
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
trauma)

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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

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Known as : Hydrocephalus or Ventriculomegaly

In general, terms may be used as synonyms. But there are underlying
differences.
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 cystsmall 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

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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

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