presentation1.pptx, ultrasound examination of the neonatal head
TRANSCRIPT
Dr ABD ALLAH NAZEER MD
Ultrasound examination of the neonatal head
ULTRASOUND OF THE NEONATAL HEAD PROTOCOLINDICATIONS
PrematuritySome people discriminate between the terms preterm and prematurePreterm refers to delivering prior to 37weeks whilst a premature infant is one that has not yet reached the level of fetal development that generally allows life outside the wombThe fine network of vessels (the germinal matrix) on the floor of the anterior horn of the lateral ventricles (the ependyma) are extremely fragileIf there is any hypoxic episode the reactive increase in blood pressure can result in a hemorrhage of these vesselsUsually assessed at day 1 and again at day 7
Increased head circumferencePersisting large fontanelleCraniosynostosis (premature closure of sutures)TraumaKnown hypoxiaFollow up of known pathologyFailure to thriveSuspected intracranial mass or infection
LIMITATIONSIf the anterior fontanel is very small or closed your visibility will be reduced or completely obscured Even with a large fontanelle the peripheral extremes of the brain are obscured from viewEQUIPMENT SELECTION AND TECHNIQUE
ProbesPrimarily a small footprint wide sector mid-frequency probe is essentialIdeally a specific 5-8MHz vector probe however a trans-vaginal probe also provides excellent imaging (A TV probe can be ergonomically difficult to use for some operators and awkward to ft in a humidicrib)You may also require a high frequency linear array to assess superficial structures and a curvilinear probe for axial trans-temporal imagesEnvironmentA warm room with warm gelIf still in high oxygen environment this should be maintained as much as possiblePatient positionIf still in a humidicrib as a high oxygen environment the baby must be scanned there You may need to place a cloth under andor beside the babys head to support and immobilize it for the scan
SCANNING TECHNIQUEUse sufficient gel to not require too much transducer pressureApproach is generally via the anterior fontanel The posterior fontanel can also be usedUsing the small footprint sector or TV probe
Begin in a coronal plane slowly sweeping from the anterior to the posteriorRotate 90o to perform sagittal and para-sagittal views
Using the high frequency linear probeGently scan through the anterior fontanelle in transverseYou should assess the superior sagittal sinus for patency and the sub-arachnoid spaceYou will usually be able to scan as deep as the 3rd ventricle
Using the 5mHz curvilinear probe scan through the temple in an axial plane particularly assessing the opposite subdural region
WHAT TO LOOK FORA solid grasp of the intracranial anatomy is vitalAlso a thorough understanding of the developmental evolution of the neonatal brain and how it changes between 28weeks and termEssentially the normal 10week premature brain is relatively smooth homogenous amp devoid of sulcigyrae
SAGITTALMidline (must include corpus callosum the 3rd and 4th ventricles and cerebellum)Parasagittal to show caudothalamic notch and detail of lateral venticlesFar lateral to show periventricular white matter
CORONALfrontalcaudate regionseries of images caudate to trigone of lateral ventriclesoccipital regionMEASUREMENTS
Coronal frontal horn of lateral ventricles at the foramen of Monroe (caudate nucleus)Sagittal trigone of lateral ventricles
ULTRASOUND OF THE NEONATAL HEAD - Normal
Normal sagittal at the 3rd
and 4th ventricles
Normal anterior coronal neonatal brain Scan angling forward of this point as far as possible to the bulls-horns of the sphenoid bone
Normal parasagittal at the lateral ventricles Normal mid-anterior coronal atthe sylvian fissures and 3rd ventricle
Normal far-posterior coronal Normal mid coronal view at the level of the brain stem
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
ULTRASOUND OF THE NEONATAL HEAD PROTOCOLINDICATIONS
PrematuritySome people discriminate between the terms preterm and prematurePreterm refers to delivering prior to 37weeks whilst a premature infant is one that has not yet reached the level of fetal development that generally allows life outside the wombThe fine network of vessels (the germinal matrix) on the floor of the anterior horn of the lateral ventricles (the ependyma) are extremely fragileIf there is any hypoxic episode the reactive increase in blood pressure can result in a hemorrhage of these vesselsUsually assessed at day 1 and again at day 7
Increased head circumferencePersisting large fontanelleCraniosynostosis (premature closure of sutures)TraumaKnown hypoxiaFollow up of known pathologyFailure to thriveSuspected intracranial mass or infection
LIMITATIONSIf the anterior fontanel is very small or closed your visibility will be reduced or completely obscured Even with a large fontanelle the peripheral extremes of the brain are obscured from viewEQUIPMENT SELECTION AND TECHNIQUE
ProbesPrimarily a small footprint wide sector mid-frequency probe is essentialIdeally a specific 5-8MHz vector probe however a trans-vaginal probe also provides excellent imaging (A TV probe can be ergonomically difficult to use for some operators and awkward to ft in a humidicrib)You may also require a high frequency linear array to assess superficial structures and a curvilinear probe for axial trans-temporal imagesEnvironmentA warm room with warm gelIf still in high oxygen environment this should be maintained as much as possiblePatient positionIf still in a humidicrib as a high oxygen environment the baby must be scanned there You may need to place a cloth under andor beside the babys head to support and immobilize it for the scan
SCANNING TECHNIQUEUse sufficient gel to not require too much transducer pressureApproach is generally via the anterior fontanel The posterior fontanel can also be usedUsing the small footprint sector or TV probe
Begin in a coronal plane slowly sweeping from the anterior to the posteriorRotate 90o to perform sagittal and para-sagittal views
Using the high frequency linear probeGently scan through the anterior fontanelle in transverseYou should assess the superior sagittal sinus for patency and the sub-arachnoid spaceYou will usually be able to scan as deep as the 3rd ventricle
Using the 5mHz curvilinear probe scan through the temple in an axial plane particularly assessing the opposite subdural region
WHAT TO LOOK FORA solid grasp of the intracranial anatomy is vitalAlso a thorough understanding of the developmental evolution of the neonatal brain and how it changes between 28weeks and termEssentially the normal 10week premature brain is relatively smooth homogenous amp devoid of sulcigyrae
SAGITTALMidline (must include corpus callosum the 3rd and 4th ventricles and cerebellum)Parasagittal to show caudothalamic notch and detail of lateral venticlesFar lateral to show periventricular white matter
CORONALfrontalcaudate regionseries of images caudate to trigone of lateral ventriclesoccipital regionMEASUREMENTS
Coronal frontal horn of lateral ventricles at the foramen of Monroe (caudate nucleus)Sagittal trigone of lateral ventricles
ULTRASOUND OF THE NEONATAL HEAD - Normal
Normal sagittal at the 3rd
and 4th ventricles
Normal anterior coronal neonatal brain Scan angling forward of this point as far as possible to the bulls-horns of the sphenoid bone
Normal parasagittal at the lateral ventricles Normal mid-anterior coronal atthe sylvian fissures and 3rd ventricle
Normal far-posterior coronal Normal mid coronal view at the level of the brain stem
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
LIMITATIONSIf the anterior fontanel is very small or closed your visibility will be reduced or completely obscured Even with a large fontanelle the peripheral extremes of the brain are obscured from viewEQUIPMENT SELECTION AND TECHNIQUE
ProbesPrimarily a small footprint wide sector mid-frequency probe is essentialIdeally a specific 5-8MHz vector probe however a trans-vaginal probe also provides excellent imaging (A TV probe can be ergonomically difficult to use for some operators and awkward to ft in a humidicrib)You may also require a high frequency linear array to assess superficial structures and a curvilinear probe for axial trans-temporal imagesEnvironmentA warm room with warm gelIf still in high oxygen environment this should be maintained as much as possiblePatient positionIf still in a humidicrib as a high oxygen environment the baby must be scanned there You may need to place a cloth under andor beside the babys head to support and immobilize it for the scan
SCANNING TECHNIQUEUse sufficient gel to not require too much transducer pressureApproach is generally via the anterior fontanel The posterior fontanel can also be usedUsing the small footprint sector or TV probe
Begin in a coronal plane slowly sweeping from the anterior to the posteriorRotate 90o to perform sagittal and para-sagittal views
Using the high frequency linear probeGently scan through the anterior fontanelle in transverseYou should assess the superior sagittal sinus for patency and the sub-arachnoid spaceYou will usually be able to scan as deep as the 3rd ventricle
Using the 5mHz curvilinear probe scan through the temple in an axial plane particularly assessing the opposite subdural region
WHAT TO LOOK FORA solid grasp of the intracranial anatomy is vitalAlso a thorough understanding of the developmental evolution of the neonatal brain and how it changes between 28weeks and termEssentially the normal 10week premature brain is relatively smooth homogenous amp devoid of sulcigyrae
SAGITTALMidline (must include corpus callosum the 3rd and 4th ventricles and cerebellum)Parasagittal to show caudothalamic notch and detail of lateral venticlesFar lateral to show periventricular white matter
CORONALfrontalcaudate regionseries of images caudate to trigone of lateral ventriclesoccipital regionMEASUREMENTS
Coronal frontal horn of lateral ventricles at the foramen of Monroe (caudate nucleus)Sagittal trigone of lateral ventricles
ULTRASOUND OF THE NEONATAL HEAD - Normal
Normal sagittal at the 3rd
and 4th ventricles
Normal anterior coronal neonatal brain Scan angling forward of this point as far as possible to the bulls-horns of the sphenoid bone
Normal parasagittal at the lateral ventricles Normal mid-anterior coronal atthe sylvian fissures and 3rd ventricle
Normal far-posterior coronal Normal mid coronal view at the level of the brain stem
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
SCANNING TECHNIQUEUse sufficient gel to not require too much transducer pressureApproach is generally via the anterior fontanel The posterior fontanel can also be usedUsing the small footprint sector or TV probe
Begin in a coronal plane slowly sweeping from the anterior to the posteriorRotate 90o to perform sagittal and para-sagittal views
Using the high frequency linear probeGently scan through the anterior fontanelle in transverseYou should assess the superior sagittal sinus for patency and the sub-arachnoid spaceYou will usually be able to scan as deep as the 3rd ventricle
Using the 5mHz curvilinear probe scan through the temple in an axial plane particularly assessing the opposite subdural region
WHAT TO LOOK FORA solid grasp of the intracranial anatomy is vitalAlso a thorough understanding of the developmental evolution of the neonatal brain and how it changes between 28weeks and termEssentially the normal 10week premature brain is relatively smooth homogenous amp devoid of sulcigyrae
SAGITTALMidline (must include corpus callosum the 3rd and 4th ventricles and cerebellum)Parasagittal to show caudothalamic notch and detail of lateral venticlesFar lateral to show periventricular white matter
CORONALfrontalcaudate regionseries of images caudate to trigone of lateral ventriclesoccipital regionMEASUREMENTS
Coronal frontal horn of lateral ventricles at the foramen of Monroe (caudate nucleus)Sagittal trigone of lateral ventricles
ULTRASOUND OF THE NEONATAL HEAD - Normal
Normal sagittal at the 3rd
and 4th ventricles
Normal anterior coronal neonatal brain Scan angling forward of this point as far as possible to the bulls-horns of the sphenoid bone
Normal parasagittal at the lateral ventricles Normal mid-anterior coronal atthe sylvian fissures and 3rd ventricle
Normal far-posterior coronal Normal mid coronal view at the level of the brain stem
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
WHAT TO LOOK FORA solid grasp of the intracranial anatomy is vitalAlso a thorough understanding of the developmental evolution of the neonatal brain and how it changes between 28weeks and termEssentially the normal 10week premature brain is relatively smooth homogenous amp devoid of sulcigyrae
SAGITTALMidline (must include corpus callosum the 3rd and 4th ventricles and cerebellum)Parasagittal to show caudothalamic notch and detail of lateral venticlesFar lateral to show periventricular white matter
CORONALfrontalcaudate regionseries of images caudate to trigone of lateral ventriclesoccipital regionMEASUREMENTS
Coronal frontal horn of lateral ventricles at the foramen of Monroe (caudate nucleus)Sagittal trigone of lateral ventricles
ULTRASOUND OF THE NEONATAL HEAD - Normal
Normal sagittal at the 3rd
and 4th ventricles
Normal anterior coronal neonatal brain Scan angling forward of this point as far as possible to the bulls-horns of the sphenoid bone
Normal parasagittal at the lateral ventricles Normal mid-anterior coronal atthe sylvian fissures and 3rd ventricle
Normal far-posterior coronal Normal mid coronal view at the level of the brain stem
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
ULTRASOUND OF THE NEONATAL HEAD - Normal
Normal sagittal at the 3rd
and 4th ventricles
Normal anterior coronal neonatal brain Scan angling forward of this point as far as possible to the bulls-horns of the sphenoid bone
Normal parasagittal at the lateral ventricles Normal mid-anterior coronal atthe sylvian fissures and 3rd ventricle
Normal far-posterior coronal Normal mid coronal view at the level of the brain stem
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Normal parasagittal at the lateral ventricles Normal mid-anterior coronal atthe sylvian fissures and 3rd ventricle
Normal far-posterior coronal Normal mid coronal view at the level of the brain stem
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Normal far-posterior coronal Normal mid coronal view at the level of the brain stem
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Normal coronal view of the lateral ventricles and caudao-thalamic groove
Normal posterior coronal using a linear array transducer Zoomed at the level of the trigone of the lateral venticles visualizing the body of the choroid plexii
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
The superior sagittal sinus and other vascular channels can be readily assessed with power Doppler Normal far-posterior coronal
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal images for neonatal brain C (caudate) T (thalamus)F (foramen of Monro) m (midbrain) 3 (third ventricle) q(quadrigeminal plate cistern) CB(cerebellar hemispheres
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Sagittal images for neonatal brain 3 (third ventricle) mi(mass intermedia) p(pellyof pons) 4 (fourth ventricle) cv (cerebellar vermis) C(caudate nucleus) t(thalamus)
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Germinal Matrix Hemorrhage
Germinal matrix hemorrhage (GMH) is also known as periventricular hemorrhage or preterm caudothalamic hemorrhage These germinal matrix hemorrhages occur in the highly vascular but also stress sensitive germinal matrix which is located in the caudothalamic groove This is the subependymal region between the caudate nucleus and thalamusThe germinal matrix is only transiently present as a region of thin-walled vessels migrating neuronal components and vessel precursorsIt has matured by 34 weeks gestation such that hemorrhage becomes very unlikely after this ageMost GMHs occur in the first week of lifeMost common in infants These hemorrhages start in the caudothalamic groove and may extend into the lateral ventricle and periventricular brain parenchymaMost infants are asymptomatic or demonstrate subtle signs that are easily overlooked These hemorrhages are subsequently found on surveillance sonography
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Grade 1 intracranial hemorrhage Sagittal and coronal US of subependymalhemorrhage located in the groove between the thalamus and the nucleus caudatus
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal section - grade I - subependymal germinal matrix hemorrhage (blue arrows)
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Sagittal and coronal US of a grade 2 hemorrhage
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal section - grade II - GMH and IVH without ventricular dilation (blue arrow)
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
LEFT Coronal image green arrow indicating grade 3 hemorrhage RIGHT Sagittal image yellow arrow indicating venous infarction
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Sagittal section - grade III - GMH and IVH with ventricular dilation (white arrows)
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Intracranial hemorrhage grade 4
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Peri Ventricular Leukomalacia (PVL)PVL is also known as Hypoxic-Ischemic Encephalopathy (HIE) of the pretermIt is a white matter disease that affects the periventricular zonesIn prematures this white matter zone is a watershed zone between deep and superficial vesselsUntil recently ischemia was thought to be the single cause of PVL but probably other causes (infection vasculitis) play an additional rolePVL presents as areas of increased periventricular echogenicityNormally the echogenicity of the periventricular white matter should be less than the echogenicity of the choroid plexus PVL occurs most commonly in premature infants born at less than 33 weeks gestation (38 PVL) and less than 1500 g birth weight (45 PVL)Detection of PVL is important because a significant percentage of surviving premature infants with PVL develop cerebral palsy intellectual impairment or visual disturbancesMore than 50 of infants with PVL or grade III hemorrhage develop cerebral palsy
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Sagittal image of a child with PVL grade 1
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Transverse and sagittal image of a child with PVL grade 2
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Sagittal and coronal images demonstrating extensive PVL grade 3
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal and transverse images demonstrating PVL grade 4
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal and transverse images demonstrating PVL grade 4
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Aneurysm of vein of Galen
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Gray-scale and Doppler coronal USG demonstrating a cystic midline structure in the region of posterior third ventricle with mass effect (A) Typical swirl effect is noted on Doppler (B) Findings are highly suggestive of aneurysmal malformation of the vein of Galen The corresponding axial and sagittal T2W images of MR examination confirming large aneurysmal dilatation of the vein of Galen (C and D)
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal section - Absent corpus callosum widely separated frontal horns of lateral ventricles dilation and posterosuperior displacement of third ventricle Partial agenesis corpus callosum
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal section - Dandy - Walker malformation - dilation of thefourth ventricle (blue star) hypoplastic cerebellar hemispheres
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Porencephalic cyst Large foci of intraventricularintraparenchymal bleed
could lead to a cavitating destructive lesion in the brain parenchyma After resolution and evacuation of the hematoma the cavity of the lesion communicates with the ventricular system leading to the formation of a porencephalic cyst Porencephalic cysts which are often a sequel of grade 4 hemorrhages are usually associated with higher neurodevelopmental defects
Coronal USG and the high-resolution parasagittal view demonstrating a large porencephalic cyst communicating with the left lateral ventricular cavity
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Choroid plexus cystsCommon 3 prevalenceGlomuslt 1cm unilateral = insignificantgt 1cm bilateral = increase associated with chromosomal abnormalities
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Midline cystic structuresCommunicate with each otherDo not communicate with ventricular system or subarachnoid spacesObliterated from posterior to anterior
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Cavum septum pellucidum and vergue
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Connatal CystsNormal variant incidence = 07Superolateral to frontal hornsAnterior to Foramen of MonroeString of pearlsResolve spontaneously
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Choroid plexus cyst
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Caudothalamic Groove Cysts
Congenital GerminolyticChromosomal metabolic incidentalAcquiredSubependymalPost-hemorrahgic
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Benign Hygroma of infancyChildren 6 months to 2 yearsHead circumference gt 97th percentileCause unknown FamilialSubarachnoid spaces gt 33 mm+_ slight ventricular enlargement
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Benign Hygroma
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Hydrocephalus
Obstructive non-communicating)Most commonCSF cannot enter subarachnoid spaceAqueductal stenosis Chiari Malformation Dandy-WalkerNon-obstructive communicating)Impaired CSF resorptionInfection hemorrhage congenital absence arachnoid villiEx VacuoLoss of brain parenchyma lead to increase CSF spaces
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Mild to moderate Hydrocephalus
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Mild Hydrocephalus Moderate to marked Hydrocephalus
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal section - Hydrocephalus with little ventricular dilation (blue stars)
Coronal section ndash Largehydrocephalus (blue star)
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Aqueductal stenosis causing obstructive hydrocephalus
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal and parasagittal USG demonstrating colpocephaly in a patient with agenesis of corpus callosum Also there is hypoplasia of the cerebellum mainly involving the right lobe
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Holoprosencephaly
Ultrasound may also show a snake under the skull sign in some situationsHoloprosencephaly is a rare congenital brain malformation resulting from incomplete separation of the two hemispheres
Alobar holoprosencephalyIn alobar holoprosencephaly the thalami are fused and there is a single large posteriorly located ventricle Most commonly associated with facial abnormalities such as cyclopia ethmocephaly cebocephaly and median cleft lipFor more details see the article on alobar holoprosencephaly
Semilobar holoprosencephalyHere the basic structure of the cerebral lobes are present but are fused most commonly anteriorly and at the thalami The olfactory tracts and bulbs are usually not present and there is agenesis or hypoplasia of the corpus callosumFor more details see the article on semilobar holoprosencephaly
Lobar holoprosencephalyThis is the least affected subtype Patients demonstrate more subtle areas of midline abnormalities such as fusion of the cingulate gyrus and thalami The olfactory tracts are absent or hypoplastic There may be hypoplasia or absence of the corpus callosum
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Semilobar holoprosencephalyAlobar holoprosencephaly
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal section - Alobar holoprosencephaly - large horseshoe-shaped single ventricular cavity (blue arrow) and fused thalami (pink star)
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Hydranencephaly is a rare encephalopathy that occurs in-utero It is characterised by destruction of the cerebral hemispheres with transformation of the same into a membranous sac containing cerebrospinal fluid and the remnants of cortex and white matter
Hydranencephaly
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Hydranencephaly
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Anencephaly is the most severe form of cranial neural tube defect
(NTD) and is characterised by absence of cortical tissue (although brainstem and cerebellum may be variably present) as well as absence of the cranial vault Morphological spectrum within anencephaly ranges from holocrania (severest form) to merocrania (mildest form)
Antenatal ultrasoundAnencephaly may be sonographically detectable as early as 11 weeks Ultrasound can be a non invasive cost effective and fast method to detect anencephaly and has an accuracy of approximating 100 at 14 weeksno parenchymal tissue is seen above the orbits and calvarium is absent parts of the occipital bone and mid brain may be present if a small amount of neural tissue is present it is then termed exencephaly
this may be seen at an earlier stageless than expected value for crown rump length (CRL)a frog eye or mickey mouse appearance may be seen when seen in the coronal plane due to absent cranial bonebrain and bulging orbitsmay show evidence of polyhydramnios due to impaired swallowing
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Anencephaly
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Encephalocele (also known as meningoencephalocele) are a type of cephalocoele where brain tissue herniates out through a defect in the cranium
Antenatal ultrasoundAn encephalocoele may be seen as a purely cystic mass or may contain echoes from herniated brain tissue if the mass appears cystic the meningocele component predominates while a solid mass indicates predominantly an encephalocele Larger encephalocoeles may show accompanying microcephaly
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Occipital meningocele with encephalocele
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Coronal section - periventricular calcifications (white arrows) in a patient with CMV infection
Sagittal and coronal views - Tuberous sclerosis - marked echogenous
intracerebral foci
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Fetal intracranial hemorrhage may occur either within the cerebral
ventricles subdural space or infratentorial fossa
Antenatal ultrasoundThe sonographic appearance of fetal intracranial hemorrhage is extremely variable depending on its location and age of the hemorrhage A massive intraparenchymal hemorrhage can sometimes be seen as an irregular hyperechoic mass As the hemorrhage matures porencephalic cyst formation or fetal intracranial calcification may be seen
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
USG images demonstrating a grade 4 left intracranial hemorrhage Note extensive ill-defined intraparenchymal component with relatively less mass effect indicating hemorrhagic venous infarct
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Large right tempo-occipital and cerebellar hemorrhage shown as the hyperechoic area in the coronal and parasagittal images
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Acute ischemia Evaluation of diffuse brain edema is technically challenging on
neurosonography As the size of the ventricles varies considerably ventricular size is unreliable as a parameter in assessing the mass effect The usual observation in the cases of ischemia is a combination of diffuse increase in the echogenicity of ganglionic areas with associated obliteration of cisterns and small capacity of the ventricles CT andor magnetic resonance imaging (MRI) still remain as superior techniques in assessing diffuse intracranial ischemia Serial Doppler examination of the intracranial vessels and circle of Willis is helpful in evaluating the severity of intracranial ischemia Diastolic flow reflected in Resistive Index (RI) is a measure that will indicate the hemodynamic status of intracranial flow
Coronal USG at two levels demonstrating the subtle increase in the cerebral parenchymal echoes in a patient with acute ischemia (secondary to meconium aspiration) Note the small-capacity ventricles and obliterated cisternal spaces
Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
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Cerebral edemaIncreased parenchyma echogenicityDecreased sulcalgyral differentiationDecrease vascular pulsations
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Perivascular Mineralization
TORCHTrisomies(21 and 13)Twin-twin transfusionNeonatal asphyxia
TORCH infection
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
TORCH infection
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
High-resolution images of the subarachnoid spaces normal high-convexity subarachnoid space is demonstrated (yellow arrows) (B) Shows a dilated subarachnoid space with
internal echoes in a patient with pyogenic meningitis (black arrows)
Thank You
Thank You