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Table of Contents
REVIEW ARTICLE
Year : 2020  |  Volume : 13  |  Issue : 2  |  Page : 66-68

Neonatal cranial ultrasound: A review article


Department of Pediatric, Hatta Hospital, DHA, Dubai, United Arab Emirates

Date of Web Publication9-May-2020

Correspondence Address:
Ammar Mohammed Haidar Shehadeh
Hatta Hospital, DHA, Dubai
United Arab Emirates
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/HMJ.HMJ_63_19

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  Abstract 


Cranial ultrasound (CUS) is a bedside, safe and reliable imaging procedure. It can assist in the early diagnosis, management and prognostication of most preterm and full-term prenatal, perinatal and postnatal neurological insults. Moreover, it is a cost-effective procedure that gives a very high accuracy not far from that of the more sophisticated procedures such as computed tomography and magnetic resonance imaging. However, continuous training and competency assurance are needed, as CUS is operator-dependent imaging that needs a considerable training for the best results. In this article, we reviewed the advantages, applications and accuracy of CUS. In addition, we shed light on the benefit of having CUS in house before exposing the newborn infant to the risks of the other more complicated imaging techniques.

Keywords: Cranial ultrasound, head ultrasound, intraventricular haemorrhage, periventricular leukomalacia, preterm infant


How to cite this article:
Haidar Shehadeh AM, Sammak AK. Neonatal cranial ultrasound: A review article. Hamdan Med J 2020;13:66-8

How to cite this URL:
Haidar Shehadeh AM, Sammak AK. Neonatal cranial ultrasound: A review article. Hamdan Med J [serial online] 2020 [cited 2021 Sep 27];13:66-8. Available from: http://www.hamdanjournal.org/text.asp?2020/13/2/66/284051




  Introduction Top


Cranial ultrasound (CUS) is the simplest and safest bedside procedure for neonatal brain imaging. Its applicability had increased hand in hand with the improvement of the modern sophisticated neonatology practice. Recent advances in neonatal care had significantly improved preterm survival rate reaching 55%, 72% and 84% at 24, 25 and 26 weeks, respectively.[1] At the same time, it also exposed more preterms to neurological complications such as intraventricular haemorrhage (IVH) (26%, 21% and 14% at 24, 25 and 26 weeks, respectively),[2] post-haemorrhagic ventricular dilation (PHVD) (25% of infants with IVH[2]) and periventricular leucomalacia (PVL) (1%–2%).[3] Moreover, other serious neurological complications like neonatal encephalopathy that affects 3/1000 live term infants,[4] have a significant impact on the neurological outcome of the newborn.

Consequently, a safe, reproducible, reliable, bedside procedure to assess and follow that bulk of neonatal neurological complications is needed. CUS is the best procedure to serve that purpose. It is easy, safe, portable, readily available, radiation-free and the least expensive imaging modality used in paediatric.[5]


  Materials and Methods Top


Databases including Medline, google scholar and Embase were searched. Randomised, observational trials and literature reviews were included. While animal and model studies excluded. Cranial ultrasound advantages, disadvantages and applications summarized and discussed in view of the available evidence.


  Discussion Top


Cranial ultrasound advantages

CUS can be performed bedside, even in the incubator, without much manipulation. It is a very safe radiation-free procedure, without evidence of any harm to patients in the four decades that it has been in use, although with theoretical thermal and non-thermal hazards if used imprudently.[6]

It can be carried out any time after birth and repeated safely as frequent as required. Hence, brain maturation, brain lesions evolution and the timing of brain damage could be followed closely.[7] CUS allows detection of most ischaemic and haemorrhagic brain lesions, cerebral malformations and major brain anomalies such as IVH, PVL and hypoxic ischaemic encephalopathy (HIE). Furthermore, the cost of CUS is very low compared with other imaging modalities.[7]


  Applications of Cranial Ultrasound Top


Intraventricular haemorrhage

Cranial ultrasound should be performed routinely in all preterm babies <32 weeks who has a high rate of IVH.[8] However, after 32 weeks the incidence of IVH is <5%, and brain ultrasound is not routinely indicated.[9]

In one-third of the cases, IVH presents with echodensities in the first hour after birth indicating a very early onset of IVH. By the 3rd day, majority of IVH will be evident on CUS leaving only few cases to present later up to the age of 2 weeks.[10] Therefore, performing CUS at 2 weeks of age provide the most accurate diagnosis. However, the earlier the onset of IVHs the worse the prognosis.[11] Hence, earlier repeated ultrasound imaging is advisable.

Serial CUS measurements of the lateral ventricles after IVH are essential to follow its progress and complications, and for the early recognition, therapeutic and prognostic evaluation of PHVD.[12] Neurological development correlate significantly with the measurements of parenchymal lesions on CUS. Intraventricular echodensity area is a very important prognostic factor for motor development in infants with Grade 4 IVH and for the ventriculoperitoneal shunt requirement.[13]

Periventricular leucomalacia

PVL is the predominant form of hypoxic brain injury and the leading known cause of cerebral palsy (CP) and cognitive deficits in premature infants, most often diagnosed with CUS.[14] Evidence of PVL onset can be suggested by CUS. While antenatal cystic PVL is evident by 2 weeks of age.[15] Postnatal onset PVL development may not be completed until 3 months of age or later. However, most cysts are evident within 60 days of birth.[16]

Therefore, any critically ill preterm or low birth weight neonate should be screened by a CUS to search for perinatal insults such as hemorrhage, hypoxic-ischemic injury, intrauterine infection, congenital malformation and other lesions.[5]


  Perinatal Hypoxia Top


Early CUS should be performed before starting hypothermia therapy to exclude cerebral haemorrhage or structural abnormalities and presence of calcifications, cysts or atrophy. However, asphyxial brain injury becomes evident only after the age of 24 and 72 h.[17] Sequential CUS is helpful for assessing the evolution of hypoxic injury, and for defining the pattern and the timing of their onset of lesions. In neonates affected by severe forms of encephalopathy, CUS can detect cortex and basal ganglia lesions.[18]


  Other Applications Top


Furthermore, routine scanning is suggested in all neonates (terms and preterms) with macrocephaly, dysmorphic features, seizures and in infants whose Apgar scores <7 at 1 and 5 min.[19] In addition, CUS is indicated in any newborn with a neurologic clinical symptom that range from hypotonia to seizures.[5]

CUS is the preferred imaging technique before neonatal extracorporeal membrane oxygenation (ECMO). CUS is indicated to detect associated intracranial haemorrhage which is a contraindication for ECMO. Moreover, as ECMO hold a high risk for brain injury, multiple CUS imagings should be done before, during and after ECMO.[20]


  Cranial Ultrasound Accuracy and Prognostic Value Top


CUS is a sensitive predictor of later neurodevelopment. CUS findings and mental developmental index are strongly correlated, especially with Grade 3 and 4 germinal matrix haemorrhage.[21] There was a fourfold increase in the risk of psychomotor delay and threefold increase in the risk of mental delay in infants with moderate/severe ventriculomegaly.[22] Notably, echolucencies were also associated with a significant risk of delayed mental and psychomotor development.[22] On the other hand, children without CUS abnormality had low probability (23% and 26%) of delayed mental or psychomotor development.

In two other studies looking at CUS accuracy in detecting IVH, CUS had high sensitivity and specificity for detecting IVH Grade III. While for Grade I–II CUS accuracy is much less with only (60%) sensitivity. Nevertheless, both studies were retrospective with a relatively small number of patients included. However, given the low cost, safety and advantages of bedside evaluation, CUS should continue to be the first-line bedside imaging procedure for the evaluation of babies with suspected IVH.[23]

The specific location of cystic PVL has been reported to be of a prognostic value in some studies.[24],[25] Spastic CP is commonly associated with leucomalacia at the level of the optic radiations adjacent to the trigone and at the level of the frontal white matter near the foramen of Monro. Measuring the anteroposterior dimension of cystic PVL in the parasagittal section may predict which infants will develop CP, and more severe sensory and cognitive impairments.[24] Moreover, infants with IVH and white matter damage are prone for psychiatric abnormalities, including disruptive disorders, attention deficit/hyperactivity disorder, anxiety disorder or tics.[26]

In infants with perinatal hypoxia, the strong correlation between CUS and CT brain lesions is well-recognised.[27] In addition, CUS findings are well correlated with magnetic resonance imaging (MRI) when both techniques were used at the same time.[28] In one study, the consistency rate between CUS and MRI was 88%.[21]

While CUS is a very useful imaging modality and generally the first choice for initial imaging, MRI provides greater resolution and is preferred where very detailed brain parenchymal anatomy is required.[29] Moreover, computed tomography is the preferred first-line imaging modality in the acute trauma setting.[30]


  Conclusion Top


CUS is a reliable imaging procedure for the early detection and follow-up of prematurity neurological complications, especially IVH, PVL and HIE. It has a reliable diagnostic, therapeutic and prognostic value in preterm neurologic evaluation.

In addition, early CUS in perinatal asphyxia is essential before hypothermia therapy to detect intracranial haemorrhage and other neurological pathologies. Thereafter, CUS is highly reliable in detecting s hypoxic brain changes.

CUS could exclude or demonstrate cerebral pathology in term and preterm babies. It helps in demonstrating the cause of the neurological symptoms, assessing timing of injury and neurological prognosis, and helps in making decisions on continuation of neonatal intensive care and optimisation of treatment and support.

Recommendations

  • CUS is a cost-effective machine, need to be provided in every Neonatal unit (NU)
  • Training courses for the operators (either neonatologists or radiologists) are essential
  • Competency assurance is a must, as it is a high operator-dependent device
  • Restricted privileges only for the trained staff are paramount.


Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

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8.
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Paneth N, Pinto-Martin J, Gardiner J, Wallenstein S, Katsikiotis V, Hegyi T, et al. Incidence and timing of germinal matrix/intraventricular hemorrhage in low birth weight infants. Am J Epidemiol 1993;137:1167-76.  Back to cited text no. 10
    
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Jary S, Kmita G, Wroblewska J, Whitelaw A. Quantitative cranial ultrasound prediction of severity of disability in premature infants with post-haemorrhagic ventricular dilatation. Arch Dis Child 2012;97:955-9.  Back to cited text no. 13
    
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17.
Rutherford MA, Pennock JM, Dubowitz LM. Cranial ultrasound and magnetic resonance imaging in hypoxic-ischaemic encephalopathy: A comparison with outcome. Dev Med Child Neurol 1994;36:813-25.  Back to cited text no. 17
    
18.
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19.
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20.
von Allmen D, Babcock D, Matsumoto J, Flake A, Warner BW, Stevenson RJ, et al. The predictive value of head ultrasound in the ECMO candidate. J Pediatr Surg 1992;27:36-9.  Back to cited text no. 20
    
21.
Zhang XH, Qiu SJ, Chen WJ, Gao XR, Li Y, Cao J, et al. Predictive value of cranial ultrasound for neurodevelopmental outcomes of very preterm infants with brain injury. Chin Med J (Engl) 2018;131:920-6.  Back to cited text no. 21
    
22.
O'Shea TM, Allred EN, Dammann O, Hirtz D, Kuban KC, Paneth N, et al. The ELGAN study of the brain and related disorders in extremely low gestational age newborns. Early Hum Dev 2009;85:719-25.  Back to cited text no. 22
    
23.
Intrapiromkul J, Northington F, Huisman TA, Izbudak I, Meoded A, Tekes A. Accuracy of head ultrasound for the detection of intracranial hemorrhage in preterm neonates: Comparison with brain MRI and susceptibility-weighted imaging. J Neuroradiol 2013;40:81-8.  Back to cited text no. 23
    
24.
Rogers B, Msall M, Owens T, Guernsey K, Brody A, Buck G, et al. Cystic periventricular leukomalacia and type of cerebral palsy in preterm infants. J Pediatr 1994;125:S1-8.  Back to cited text no. 24
    
25.
Weiss HE, Goldstein RB, Piecuch RE. A critical review of cranial ultrasounds: Is there a closer association between intraventricular blood, white matter abnormalities or cysts, and cerebral palsy? Clin Pediatr (Phila) 1999;38:319-23.  Back to cited text no. 25
    
26.
Whitaker AH, Van Rossem R, Feldman JF, Schonfeld IS, Pinto-Martin JA, Tore C, et al. Psychiatric outcomes in low-birth-weight children at age 6 years: relation to neonatal cranial ultrasound abnormalities. Arch Gen Psychiatry 1997;54:847-56.  Back to cited text no. 26
    
27.
Hill A, Martin DJ, Daneman A, Fitz CR. Focal ischemic cerebral injury in the newborn: Diagnosis by ultrasound and correlation with computed tomographic scan. Pediatrics 1983;71:790-3.  Back to cited text no. 27
    
28.
Miller E, Daneman A, Doria AS, Blaser S, Traubici J, Jarrin J, et al. Color Doppler US of normal cerebral venous sinuses in neonates: A comparison with MR venography. Pediatr Radiol 2012;42:1070-9.  Back to cited text no. 28
    
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Roelants-van Rijn AM, Groenendaal F, Beek FJ, Eken P, van Haastert IC, de Vries LS. Parenchymal brain injury in the preterm infant: Comparison of cranial ultrasound, MRI and neurodevelopmental outcome. Neuropediatrics 2001;32:80-9.  Back to cited text no. 29
    
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  In this article
Abstract
Introduction
Materials and Me...
Discussion
Applications of ...
Perinatal Hypoxia
Other Applications
Cranial Ultrasou...
Conclusion
References

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