1. DR/Ahmed Bahnassy
Consultant radiologist
PSMMC

2. Safe
 Bedside- compatible
 Reliable
 Early imaging
 Serial imaging:
Brain maturation
Evolution of lesions
 Inexpensive
 Suitable for screening


4. Exclude/demonstrate cerebral pathology
 Assess timing of injury
 Assess neurological prognosis
 Help make decisions on continuation of neonatal
intensive care
 Optimise treatment and support


6. Embryology

At the end of the 4th week after conception,
the cranial end of the neural tube
differentiates into 3 primary brain vesicles
 Prosencephalon (Forebrain)
 Diencephalon



Thalmus
Hypothalmus
Posterior Pituitary
 Telencephalon
 Cerebral hemispheres
 Cortex & Medullary Center
 Corpus Striatum
 Olfactory System
 Mesencephalon (midbrain)
 Cerebral Aqueduct
 Superior and inferior colliculi
(quadrigeminal body)
 Rhombencephalon (hindbrain)
 Myelencephalon

Closed part of medulla oblongata
 Metencephalon
 Pons
 Cerebellum
 3rd, 4th, and lateral ventricles
 Choroid Plexus

7. Anatomy of the Neonatal Brain
Cerebrum
 2 Hemispheres (Gray and White Matter)
 Lobes of the Brain
 Frontal
 Parietal
 Occipital
 Temporal
 Gyrus and Sulcus
 Gyrus: convulutions of the brain surface
causing infolding of the cortex
 Sulcus: Groove or depression separating gyri.

8. Anatomy of the Neonatal Brain
Cerebrum

Fissures
 Interhemispheric
 Area of Falx Cerebri
 Sylvian
 Most lateral aspect of brain
 Location of middle cerebral artery
 Quadrigeminal
 Posterior and inferior from the cavum
vergae
 Vein of Galen posterior to fissure
Falx Cerebri
 Fibrous structure separating the 2
cerebral hemispheres
 Tentorium Cerebelli
 “V” shaped echogenic extension of the
falx cerebri separating the cerebrum
and the cerebellum


9. Cerebrum

Basal Ganglia
 collection of gray matter
 Caudate Nucleus & Lentiform
Nucleus
 Largest basal ganglia
 Relay station between the
thalmus and cerebral cortex
 Germinal Matrix includes
periventricular tissue and
caudate nucleus
 Thalmus
 2 ovoid brain structures
 Located on either side of the 3 rd
ventricle superior to the
brainstem
 Connects through middle of the
3rd ventricle through massa
intermedia
 Hypothalmus
 “Floor” of 3rd Ventricle
 Pituitary Gland is connected to
the hypothalmus by the
infundibulum

10. Anatomy of the Neonatal Brain
 Meninges
 Dura Mater
 Arachnoid
 Pia Mater
 Cerebral Spinal Fluid (CSF)
 Surrounds and protects brain and spinal cord.
 40% formed by ventricles, 60% extracellular
fluid from circulation.

11. Ventricular System
 Lateral Ventricles: Largest of
the CSF cavities.
 Frontal Horn
 Body
 Occipital Horn
 Temporal Horn
 Trigone “Atrium”
 Foramen of Monro
 3rd Ventricle
 Aqueduct of Sylvius
 4th Ventricle
 Foramen of Luschka
 Foramen of Megendie
 Cisterns
 Cisterna Magna
 Spaces at the base of the
skull where the arachnoid
is widely separated from
the pia mater.

12. Anatomy of the
Neonatal Brain
Cavum
Septum
Pellucidum



Choroid
Plexus
Corpus Callosum
 Broad band of connective fibers between cerebral hemispheres.
 The “roof” of the lateral ventricles.
Cavum Septum Pellucidum
 Thin, triangular space filled with CSF
 Lies between the anterior horn of the lateral ventricles.
 “Floor” of the corpus callosum
Choroid Plexus
 Mass of specialized cells that regulate IV pressure by secretion/absorption of CSF
 Within atrium of the lateral ventricles

13. Anatomy of the Neonatal Brain
Brain Stem
 Midbrain
 Pons
 Medulla
Oblongata

14. Anatomy of the Neonatal Brain
Cerebellum
 Posterior cranial
fossa
 2 Hemispheres
connected by
Vermis
 3 Pairs of Nerve
Tracts
 Superior Cerebellar
Peduncles
 Middle Cerebellar
Peduncles
 Inferior Cerebellar
Peduncles

15. Cerebrovascular System
 Internal Cerebral
Arteries
 Vertebral Arteries
 Circle of Willis
 Middle Cerebral
Artery
 Longest branch in
Circle of Willis that
provides 80% of
blood to the
cerebral
hemispheres

16. Anatomy of the Neonatal Skull
 Fontanelles (“Soft Spots”)
 Spaces between bones of the skull

17. Function and Physiology
 Cerebellum
 Controls Skeletal Muscle
Movement
 Cerebral Hemispheres
 Frontal
 Voluntary muscles,
speech, emotions,
personality, morality, and
intellect
 Parietal
 Pain, temperature, and
spatial ability
 Occipital
 Vision
 Temporal
 Auditory and Olfactory

18. Indications for Sonographic Exam
 Cranial abnormality found on pre-natal sonogram
 Increasing head circumference with or without






increasing intracranial pressure
Acquired or Congenital inflammatory disease
Prematurity
Diagnosis of hypoxia, hypertension, hypercapnia,
hypernaturemia, acidosis, pneumothorax, asphyxia,
apnea, seizures, coagulation defects, patent ductus
arteriosus, or elevated blood pressure
History of birth trauma or surgery
Suctioning of infant
Genetic syndromes and malformations

19. Sonographic Technique

What anatomy do you scan?
 Supratentorial Compartment
 Both cerebral hemispheres
 Basal Ganglia
 Lateral & 3rd Ventricle
 Interhemispheric fissure
 Subarachnoid space
 Views
 Coronal
 Modified Coronal (anterior fontanelle)
 Sagittal (anterior fontanelle)
 Parasagittal (anterior fontanelle)
 Infratentorial Compartment
 Cerebellum
 Brain Stem
 4th Ventricle
 Basal Cisterns

Views




Coronal (mastoid fontanelle and occipitotemporal area)
Modified Coronal
Sagittal
Parasagittal (with increased focal depth & decreased frequency)

20. Transucers : 5–7.5–10 MHz
 Appropriately sized
 Standard examination: use 7.5–8 MHz
 Tiny infant and/or superficial structures: use
additional higher frequency (10 MHz)
 Large infant, thick hair, and/or deep structures:
use additional lower frequency (5 MHz)


22. Anterior
Fontanel
The Standard
view window
Temporal
Supplementary
view window
Posterior
Fontanel
Supplementary
view window
Mastoid
Fontanel
Supplementary
view window

23. 
Coronal Views (at least 6 standard planes)

31. 
Sagittal Views (at least 5 standard planes)

42. 1. Interhemispheric fissure
2. Frontal lobe
3. Skull
4. Orbit
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
14. Body of lateral ventricle
15. Choroid plexus
(*: plexus in third ventricle)
16. Thalamus
17. Hippocampal fissure
18. Aqueduct of Sylvius
19. Brain stem
20. Parietal lobe
21. Trigone of lateral ventricle
22. Cerebellum
(a: hemispheres; b: vermis)
23. Tentorium
24. Mesencephalon
25. Occipital lobe
26. Parieto-occipital fissure
27. Calcarine fissure
28. Pons
29. Medulla oblongata
30. Fourth ventricle
31. Cisterna magna
32. Cisterna quadrigemina
33. Interpeduncular fossa
34. Fornix
35. Internal capsule
36. Occipital horn of lateral
ventricle
37. Insula
38. Falx
39. Straight sinus (sinus rectus)
40. Temporal horn of lateral
ventricle
41. Circle of Willis
42. Prepontine cistern

43. Questions to be answered
during exam

46. Doppler uses
 Typical transcranial Doppler with
imaging scan and recording from
middle cerebral artery (MCA).
 Doppler image shows circle of Willis.
 A = anterior cerebral artery
 M = middle cerebral artery
 P = posterior cerebral artery
 RI = resistive index
 Demonstrates
 Decreased blood
flow/ischemia/infarction
 Vascular abnormalities
 Cerebral Edema
 Hydrocephalus
 Intracranial Tumors
 Near-field structures

48. Middle Cerebral Artery

49. Carotid Siphon - Genu

50. Anterior Cerebral Artery

51. Posterior Cerebral Artery – P1

52. Ophthalmic Artery

53. Basilar Artery

54. BLOOD FLOW VELOCITY
• Changes in flow velocity occur
when:
• There is a change in vessel caliber
• There is a change in volume flow

55. should we do doppler study
vein of
galen
aneurysm
cyst=doppler

58. Chiari Malformation
 Downward displacement of the cerebellar tonsils and
the medulla through the foramen magnum.
 Arnold-Chiari malformation shows a small displaced
cerebellum, absence of the cisterna magna,
malposition of the fourth ventricle, absence of the
septum pellucidum, and widening of the third
ventricle
 Commonly related
to meningomyelocele

59. Chiari Malformation
 Sonographic Features
 Small posterior fossa
 Small, displaced
Cerebellum
 Possible
Myelomeningocele
 Widened 3rd Ventricle
 Cerebellum herniated
through enlarged foramen
magnum
 4th ventricle elongated
 Posterior horns enlarged
 Cavum Septum
pellucidum absent
 Interhemispheric Fissure
widened
 Tentorium low and
hypoplastic

60. Holoprosencephaly

Common large central ventricle because prosencephalon
failed to cleave into separate cerebral hemispheres.
 Alobar Holoprosencephaly (Most Severe)
 Fused thalami anteriorly to a fused choroid plexus
 Single midline ventricle
 No falx cerebrum, corpus callosum, interhemispheric
fissure, or 3rd ventricle
 Semilobar Holoprosencephaly
 Single ventricle
 Presents with portions of the falx and interhemispheric
fissure
 Thalmi partially separated
 3rd Ventricle is rudimentary
 Mild facial anomalies
 Lobar Holoprosencephaly (Least Severe)
 Near complete separation of hemipsheres; only anterior
horns fused
 Full development of falx and interhemispheric fissure

61. Holoprosencephaly
Alobar Holoprosencephaly
Semilobar Holoprosencephaly

62. Dandy-Walker Malformation
 Congenital anomaly of the roof of the 4th ventricle
with occlusion of the aqueduct of Sylvius and
foramina of Magendie and Luschka
 A huge 4th ventricle cyst occupies the area where the
cerebellum usually lies with secondary dilation of the
3rd ventricle; absent cerebellar vermis

63. Dandy-Walker Malformation

64. Agenesis of the Corpus Callosum
 Complete or partial absence of the connection tissue between
cerebral hemispheres
 Narrow frontal horns
 Marked separation of lateral ventricles
 Widening of occipital horns and 3rd Ventricle
 “Vampire Wings”

65. Agenesis of the Corpus Callosum

66. Ventriculmegaly
 Enlargement of the ventricles
without increased head
circumference
 Communicating
 Non-communicating
 Resut of cerebral atrophy
 Sonographic Findings
 Ventricles greater than
normal size first noted in the
trigone and occipital horn
areas
 Visualization of the 3rd and
possibly 4th ventricles
 Choroid plexus appears to
“dangle” within the
ventricular trium
 Thinned brain mantle in
case of cerebral atrophy

67. Hydrocephalus


Enlargement of ventricles with increased
head circumference
 Communicating
 Non-communicating
Sonographic Findings
 Blunted lateral angles of enlarged lateral
ventricles
 Possible intrahemispheric fissure
rupture
 Thinned brain mantle
 Aqueductal Stenosis
 Most common cause of congenital
hydrocephalus
 Aqueduct of Sylvius is narrowed or is a
small channel with blind ends;
occasionally caused by extrinsic lesions
posterior to the brain stem
 Sonographic Findings
 Widening of lateral and 3rd ventricles
 Normal 4th ventricle

68. Hydrancephaly
 Occlusion of internal carotid
arteries resulting in necrosis
of cerebral hemispheres
 Absence of both cerebral
hemispheres with presence
of the falx, thalmus,
cerebellum, brain stem, and
postions of the occipital and
temporal lobes
 Sonographic findings
 Fluid filled cranial vault
 Intact cerebellum and
midbrain

69. Cephalocele
 Herniation of a portion of the neural tube through a
defect in the skull
 Sonographic Findings
 Sac/pouch containing brain tissue and/or CSF and
meninges
 Lateral Ventricle Enlargement

70. Subarachnoid Cysts
 Cysts lined with arachnoid tissue and containing CSF
 Causes
 Entrapment during embryogenesis
 Residual subdural hematoma
 Fluid extravasation sectondary to meningeal tear or
ventricular rupture

71. Hemorrhagic Pathology
 Subependymal-Intraventricular Hemorrhage (SEH-IVH)
 Caused by capillary bleeding in the germinal matrix
 Most frequent location is the thalamic-caudate groove
 Continued subependymal (SEH) bleeding pushes into the
ventricular cavity (IVH) & continues to follow CSF pathways
causing obstruction
 Treatment: Ventriculoperitoneal Shunt
 Since 70% of hemorrhages are asymptomatic, it is necessary
to scan babies routinely
 Small IVH’s may not be seen from the anterior fontanelle
because blood tends to settle out in the posterior horns
 Risk Factors
 Pre term infants
 Less than 1500 grams birth weight

72. Hemorrhagic Pathology
 Grades
 Based on the extension of the hemorrhage
 Ventricular measurement
 Mild dilation: 3-10 mm
 Moderate dilation: 11-14 mm
 Large dilation: greater than 14mm
 Grade I
 Without ventricular enlargement
 Grade II
 Minimal ventricular enlargement
 Grade III
 Moderate or large ventricular enlargement
 Grade IV
 Intraparenchymal hemorrhage

73. Hemorrhagic Pathology
 Grade I

74. Hemorrhagic
Pathology
 Grade II

75. Hemorrhagic Pathology
 Grade III

76. Hemorrhagic Pathology
 Grade IV

77. Intraparenchymal Hemorrhage
 Brain parenchyma
destroyed
 Originally considered an
extension of IVH, but
may actually be a
primary infarction of the
periventricular and
subcortical white matter
with destruction of the
lateral wall of the
ventricle.
 Sonographic Finding
 Zones of increased
echogenicity in white
matter adjacent to
lateral ventricles

78. Intracerebellar Hemorrhage
 Types
 Primary
 Venous Infarction
 Traumatic Laceration
 Extension from IVH
 Sonographic Findings
 Areas of increased
echogenicity within
cerebellar parenchyma
 Coronal views through
mastoid fontanelle may
be essential to
differentiate from large
IVH in the cisterna
magna

79. Epidural Hemorrhages and Subdural
Collections
 Best diagnosed with CT because the lesions
are located peripherally along the surface of
the brain.

80. Ischemic-Hypoxic Lesions
 Hypoxia: Lack of adequate oxygen to the brain
 Ischemia: lack of adequate blood flow to the brain
 Types
 Selective neuronal necrosis
 Status marmoratus
 Parasagittal cerebral injury
 Periventricular leukomalacia (PVL), white matter
necrosis (WMN), or cerebral edema
 Focal brain lesions (occurs when lesions are distributed
within large arteries)
 Sonographic Findings
 Areas of increased echogenicity in subcortical and deep
white matter in the basal ganglia

81. Ischemic-Hypoxic Lesions
Periventricular Leukomalacia (PVL) or White
Matter Necrosis (WMN)
 Most important cause of abnormal neurodevelopment
in preterm infants
 Early chronic stage
 Multiple cavities develop in necrotic white matter
adjacent to frontal horns
 Middle chronic Stage
 Cavities resolve and leave gliotic scars and diffuse
cerebral atrophy
 Increased Echogenicity
 Late chronic stage
 Echolucencies develop in the echolucent lesions
corresponding to the cavitary lesions in the white
matter (cysts)

82. PVL or WMN
1
2
4
3

83. Brain Infections
 Common infections referred to by TORCH
 T: Toxoplasma Gondii
 O: Other (Syphilis)
 R: Rubella Virus
 C: Cytomegalovirus
 H: Herpes Simplex Type 2
 Consequences
 Mortality
 Mental Retardation
 Developmental Delay

84. Ependymitis and Ventriculitis
 Ependymitis
 Irritation from hemorrhage within
the ventricle
 Occurs earlier than ventriculitis
 Sonographic Features
 Thickened, hypoechoic ependyma
(epithelial lining of the ventricles)
 Ventriculitis
 Common complication of purulent
meningitis
 Sonographic Findings
 Thin septations extending from the
walls of the lateral ventricles.