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 LEFT and RIGHT side 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
Position

Label

Extreme Angle
Anterior

COR ANT

Anterior Angle

COR ANT

True
Coronal/Mid

COR ML

Slight Posterior
Angle

COR POST

Posterior Angle

COR POST

Posterior Angle

COR POST

Extreme Angle
Posterior

COR POST

Coronal

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Landmarks

Orbits
Frontal lobe with blushing
IHF
IHF
Anterior horns of lateral ventricles
Cavum septum pellucidum
Corpus Callosum
Sylvian Fissure
IHF
Mid Lateral ventricles
3rd Ventricle/Thalami
Cavum septum pellucidum
Corpus callosum
Brainstem
Hippocampi Gyri
Sylvian Fissure
IHF
Choroid Plexus
Cerebeullm
Thalami
Sylvian Fissure
IHF
Choroid Plexus
Quadrigeminal cistern
Tentorium
Cerebellum & Cisterna Magna
Sylvian Fissure
IHF
Glomus of Choroid plexus
Sylvian Fissure
IHF
Periventricular Blush

Neonatal Head Protocol

Scan
Plane

Probe
Position

True Midline

Sagittal
*The fetal
skull
should be
outlined
as a true
profile on
the screen

Slight Oblique
Angle to the
Right

Label

SAG ML

SAG RT

Oblique Angle
to the Right

SAG RT

Extreme
Oblique Angle
to the Right

SAG RT

Slight Oblique
Angle to the
Left

SAG LT

Oblique Angle
to the Left

SAG LT

Extreme
Oblique Angle
to the Left

Landmarks Identified

Cavum septum pellucidum

Corpus callosum
Aqueduct of Sylvius
Cerebellum vermis & 4th ventricle
Cisterna Magna

Caudothalmic groove
Thalami
Caudate nucleus
Lateral ventricle

Lateral ventricle
Choroid plexus

Sylvian fissure

Caudothalmic groove
Thalami
Caudate nucleus
Lateral ventricle

Lateral ventricle
Choroid plexus

Sylvian fissure

SAG LT

Tips
It is extremely important to make sure you have the RIGHT and LEFT sides labeled correctly
Exposure to cold will cause increase stress on the infant
For superficial structure imaging use highest frequency available and possibly a linear
transducer with lots of gel on the fonatelle
Utilize other fontanelles to add information to the examination (posterior, mastoid, etc.)
Pathologies

Perform extreme angled coronal views to visualize fluid under the skull
(associated with trauma)
Documentation must include
o Gray scale sagittal and transverse images including images with 3 measurements
(length, width & height)
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Neonatal Head Protocol

o
o

Color Doppler image document the presence of blood flow (a cystic mass may be an
aneurysm)
Spectral Doppler image document type and velocity of blood flow

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

Undergo reabsorption
Sonographically:
Abnormal echogenicities located in some or all of the following:
o lateral ventricles
o cerebral hemispheres

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Neonatal Head Protocol

Ventriculomegaly

Enlarged Ventricles

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 intraventricular 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

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Neonatal Head Protocol

Measurements

Midline to lateral dimension

Midline lateral dimension should be 12 mm or less

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 to the lateral ventricle
Ratio of the distance between the lateral sides of the ventricles and BPD
May only measure one side to determine % of hemisphere vs ventricle
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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