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AIUM Practice Parameter for the Performance of

Neurosonography in

Neonates and Infants

© 2014 by the American Institute of Ultrasound in Medicine

Parameter developed in conjunction with the American College of Radiology (ACR),

the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU).

neurosonography.qxp_1115 12/1/15 3:22 PM

The American Institute of Ultrasound in Medicine (AIUM) is a multidis-

ciplinary association dedicated to advancing the safe and effective use

of ultrasound in medicine through professional and public education,

research, development of parameters, and accreditation. To promote

this mission, the AIUM is pleased to publish, in conjunction with the

American College of Radiology (ACR), the Society for Pediatric

Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU),

this AIUM Practice Parameter for the Performance of Neurosonography

in Neonates and Infants. We are indebted to the many volunteers who

contributed their time, knowledge, and energy to bringing this docu-

ment to completion.

The AIUM represents the entire range of clinical and basic science

interests in medical diagnostic ultrasound, and, with hundreds of vol-

unteers, the AIUM has promoted the safe and effective use of ultra-

sound in clinical medicine for more than 50 years. This document and

others like it will continue to advance this mission.

Practice parameters of the AIUM are intended to provide the medical

ultrasound community with parameters for the performance and

recording of high-quality ultrasound examinations. The parameters

reflect what the AIUM considers the minimum criteria for a complete

examination in each area but are not intended to establish a legal stan-

dard of care. AIUM-accredited practices are expected to generally fol-

low the parameters with recognition that deviations from these param-

eters will be needed in some cases, depending on patient needs and

available equipment. Practices are encouraged to go beyond the

parameters to provide additional service and information as needed.

14750 Sweitzer Ln, Suite 100

Laurel, MD 20707-5906 USA

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www.aium.org

©2014 American Institute of Ultrasound in Medicine


I. Introduction

The clinical aspects contained in specific sections of this parameter (Introduction,Specifications of the Examination, and Equipment Specifications) were developed collabora-tively by the American Institute of Ultrasound in Medicine (AIUM), the American College ofRadiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologistsin Ultrasound (SRU). Recommendations for physician requirements, written requests forthe examination, documentation, and quality control vary among the organizations and areaddressed by each separately.

This parameter has been developed to assist physicians performing sonographic studies of thebrain in neonates and infants. For the purpose of this parameter, infants are defined primarilyas those in whom the anterior fontanelle remains open. Neurosonography should be per-formed only when there is a valid medical reason, and the lowest possible ultrasonic exposuresettings should be used to gain the necessary diagnostic information. In some cases, addi-tional or specialized examinations may be necessary. Although it is not possible to detect everyabnormality, adherence to the following parameter will maximize the detection of most abnor-malities of the brain in neonates and infants that can be imaged with ultrasound.

II. Indications/Contraindications

Indications for neurosonography in preterm or term neonates and infants include but are notlimited to:

• Evaluation for hemorrhage or parenchymal abnormalities in preterm and terminfants.1–5

• Evaluation for hydrocephalus.1–5

• Evaluation for the presence of vascular abnormalities.2–8

• Evaluation for possible or suspected hypoxic ischemic encephalopathy.2–5,9–12

• Evaluation and follow-up of patients on hypothermia, extracorporeal membrane oxy-genation, and other support machines.

• Evaluation for the presence of congenital malformations.2–5

• Evaluation of signs and/or symptoms of central nervous system disorders (eg,seizures, facial malformations, macrocephaly, microcephaly, and intrauterine growthrestriction).2–5,13

• Evaluation of congenital or acquired brain infections.2–5

• Evaluation of trauma (eg, complications of falls, cephalohematoma, and subgalealhematoma, including fractures, subdural hematoma, and/or subarachnoid hemor-rhage).2–5,14,15

• Evaluation for craniosynostosis.16

• Follow-up or surveillance of previously documented abnormalities, including prenatalabnormalities.2–5

• Screening before surgical procedures.

There are no contraindications to neurosonography.

2014—AIUM PRACTICE PARAMETER—Neurosonography in Neonates and Infants

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III. Qualifications of Personnel

See www.aium.org for AIUM Official Statements including Standards and Guidelines for theAccreditation of Ultrasound Practices and relevant Physician Training Guidelines.

IV. Written Request for the Examination

The written or electronic request for an ultrasound examination should provide sufficientinformation to allow for the appropriate performance and interpretation of the examination.

The request for the examination must be originated by a physician or other appropriatelylicensed health care provider or under the provider’s direction. The accompanying clinicalinformation should be provided by a physician or other appropriate health care provider famil-iar with the patient’s clinical situation and should be consistent with relevant legal and localhealth care facility requirements.

V. Specifications of the Examination

(Also see section VII, Equipment Specifications.)

Standard Imaging Examination of the Neonate and Infant2–5

The coronal view, by convention, should have the patient’s right side on the left side of theimage. Representative coronal views should be obtained by sweeping through the entire brainfrom anterior to posterior using the anterior fontanelle as a sonic window and should include,sequentially:

• Frontal lobes anterior to the frontal horns of the lateral ventricles with orbits visualizeddeep to the skull base.

• Frontal horns or bodies of the lateral ventricles and interhemispheric fissure.• Lateral ventricles at the level of the lateral and third ventricles. • Include interhemispheric fissure, cingulate sulcus (if developed), corpus callosum,

septum pellucidum or cavum septi pellucidi, caudate nuclei, putamina, globi pallidi,and sylvian fissures. The foramina of Monro should also be depicted, outlining thecourse of the choroid plexus from the lateral into the third ventricle.

• Lateral ventricles slightly posterior to the foramina of Monro where the lateral andthird ventricles communicate. Include the pons and medulla, thalami, and choroidplexus in the roof of the third ventricle and in the caudothalamic grooves.

• Level of the quadrigeminal plate cistern and cerebellum. Include the cerebellar vermis,cisterna magna posteriorly and inferiorly, bodies of the lateral ventricles bordered bycaudate nuclei and thalami, and temporal horns.

• Echogenic glomi of choroid plexuses at the posterior aspect of the lateral ventricles atthe level of trigones. Include the splenium of the corpus callosum at divergence of thelateral ventricle, periventricular white matter lateral to posterior horns of the lateralventricles.

• Area posterior to the occipital horns. Include parietal and occipital lobes and the pos-


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terior interhemispheric fissure.• Extra-axial fluid spaces as needed. Use linear high-frequency (≥9 MHz) transducers to

obtain a coronal magnification view of the extra-axial fluid space, including only peripheralbrain structures (superior sagittal sinus at the level of the frontal horns; measure thesinocortical distance, craniocortical distance, and width of the interhemispheric fissure).17

The transducer may be tilted from side to side to image as much of the superficial peripheralsurfaces of the cerebral hemispheres as possible. The appropriate frequency of the transducershould be selected to ensure that the superficial and deep structures are well depicted. In somelater-term or older infants, more than one transducer frequency may be needed for optimalevaluation of the supratentorial and infratentorial structures.

The sagittal view, by convention, should place the anterior aspect of the brain on the left sideof the image. The right or left side should be clearly annotated. Sequential representative sagittalviews are obtained with appropriate degrees of left and right transducer angulation because thefrontal horns are somewhat more medial than the bodies of the lateral ventricles. These viewsshould include:

• Right and left parasagittal to demonstrate the insula.• Right and left parasagittal to demonstrate the sylvian fissure.• Right parasagittal to image the deep white matter (periventricular regions).• Right and left parasagittal views of the lateral ventricles, including the caudothalamic groove.• Right and left parasagittal views of the lateral ventricles showing the choroid plexus.• Additional parasagittal views to include all parts of the lateral ventricles.• Midline sagittal views to include the corpus callosum, cavum septi pellucidi and cavum

vergae if present, third and fourth ventricles, aqueduct of Sylvius, brain stem, cerebellarvermis, cisterna magna, and sulci (if present). The branches of the anterior cerebralartery (pericallosal artery and callosomarginal artery) may be visualized.

• Pulsed Doppler assessment of the midline anterior cerebral artery resistive index, asneeded.

The mastoid view is primarily used to visualize the cerebellum. On an anterior axial image at thelevel of the brain stem, the third ventricle, cerebral peduncles, thalamus, and basilar cisterns canalso be demonstrated. A more posterior axial image shows the fourth ventricle, posterior ver-mis, and folia of the cerebellar hemispheres, tentorium, and cisterna magna.18,19

Additional views, if necessary, may be taken through the posterior or mastoid fontanelle, theforamen magnum, any open suture, the Burr hole, a craniotomy defect, or thin areas of the tem-poral and parietal bones.20 The transtemporal approach may also be used to visualize the cir-cle of Willis and its major branches.

Posterior fontanelle, axial, and sagittal views may be used, as necessary, to clarify abnormalitiessuspected in the occipital areas, posterior horns of the lateral ventricles, and cerebellum.20

For patients with ventricular shunt tubes, additional oblique views via the anterior fontanelle and/oraxial views may be obtained when a shunt tube and its tip are not visualized on routine scans.

When clinically indicated, spectral, color, and/or power Doppler imaging may be useful toevaluate vascular structures through a fontanelle or a transcranial approach.


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VI. Documentation

Adequate documentation is essential for high-quality patient care. There should be a perma-nent record of the ultrasound examination and its interpretation. Images of all appropriateareas, both normal and abnormal, should be recorded. Variations from normal size should beaccompanied by measurements. Images should be labeled with the patient identification, facil-ity identification, examination date, and side (right or left) of the anatomic site imaged. An officialinterpretation (final report) of the ultrasound findings should be included in the patient’s medicalrecord. Retention of the ultrasound examination should be consistent with both clinical needsand relevant legal and local health care facility requirements.

Reporting should be in accordance with the AIUM Practice Parameter for Documentation of anUltrasound Examination.

VII. Equipment Specifications

Neurosonographic examinations should be conducted with sector or curved linear transducersthat can fit within and image through the anterior fontanelle.2–5 Linear transducers are usefulin evaluating superficial structures such as the superior sagittal sinus. If the anterior fontanelleis not available, imaging may be performed through available sutural openings or by using atranscranial approach via the thinner squamosal portion of the temporal bone. This approachmay require a lower-frequency transducer to penetrate through the bone. The transducershould be adjusted to operate at the highest clinically appropriate frequency, realizing thatthere is a trade-off between resolution and beam penetration. Higher frequencies are used inneonates and young infants and lower frequencies in older infants.

The Doppler power output should be as low as reasonably achievable (ALARA) to answer thediagnostic question.

VIII. Quality Control and Improvement, Safety, Infection Control,and Patient Education

Policies and procedures related to quality control, patient education, infection control, and safety should be developed and implemented in accordance with the AIUM Standards andGuidelines for the Accreditation of Ultrasound Practices.

Equipment performance monitoring should be in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices.


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IX. ALARA Principle

The potential benefits and risks of each examination should be considered. The ALARA prin-ciple should be observed when adjusting controls that affect the acoustic output and by con-sidering transducer dwell times. Further details on ALARA may be found in the AIUM publi-cation Medical Ultrasound Safety, Third Edition.

Acknowledgments

This parameter was revised by the AIUM in collaboration with the American College ofRadiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologistsin Ultrasound (SRU) according to the process described in the AIUM Clinical StandardsCommittee Manual.

Collaborative Committees Members represent their societies in the initial and final revision of this parameter.

ACRHenrietta Kotlus Rosenberg, MD, ChairBeverly E. Hashimoto, MD

AIUMTeresita Angtuaco, MDLynn Fordham, MDRob Goodman, MD

SPRCarol E. Barnewolt, MDJudy A. Estroff, MDHarriet J. Paltiel, MD

SRUDorothy I. Bulas, MDHarris L. Cohen, MDBrian D. Coley, MD

Original copyright 1995; revised 2014, 2009, 2006, 1999Renamed 2015


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AIUM Clinical Standards CommitteeJoseph Wax, MD, ChairJohn Pellerito, MD, Vice ChairBryann Bromley, MDPat Fulgham, MDCharlotte Henningsen, MS, RT, RDMS, RVTAlexander Levitov, MDVicki Noble, MD, RDMSAnthony Odibo, MD, MSCEDavid Paushter, MDDolores Pretorius, MDKhaled Sakhel, MDShia Salem, MDJay Smith, MDPaula Woodward, MD


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