REVIEW ARTICLE

Neonatal Head Ultrasound

A Review and Update—Part 1: Techniques and Evaluation of the
Premature Neonate
Vijetha V. Maller, MD* and Harris L. Cohen, MD†

imagers began using other approaches to brain evaluation

Abstract: Ultrasound of the infant brain has proven to be an important
via other US windows to the skull. Technical improvements
diagnostic tool in the evaluation of neonatal brain morphology and pa-
in US and Doppler software and hardware over the last 3 decades
thology since its introduction in the late 1970s and early 1980s. It is a
and greater experience with US as well as other modalities
relatively inexpensive examination that can be performed in the
analyzing the prenatal and postnatal brain have increased our
isolette in the neonatal intensive care unit. There is no radiation expo-
ability to diagnose infant brain abnormalities.
sure and no need for sedation. This article will discuss gray scale and
Doppler techniques and findings in normal head ultrasounds of pre-
mature neonates. It will discuss intracranial pathologies noted in such NEUROSONOGRAPHIC TECHNIQUE
neonates and their neurodevelopmental outcome. Neonatal neurosonography is performed in coronal and
sagittal planes with transducer frequencies of 7.5 MHz or
Key Words: neurosonography, transducer, fontanelle, mastoid, higher. Sector transducers have made way for higher frequency
intraventricular hemorrhage, germinal matrix, caudothalamic groove, curved linear array transducers that ideally fit into the anterior
periventricular leukomalacia, ventriculomegaly fontanelle. Transducers should operate at the highest frequency
(Ultrasound Quarterly 2019;35: 202–211) needed for optimal near field resolution realizing that there is a
trade-off between the better resolution of higher frequencies and
the better penetration of lower frequencies. Coronal planes ob-
HISTORY tained via the anterior fontanelle are visualized with anterior to
The history of modern neurosonography in the United States posterior angulation (Fig. 1). Sagittal imaging examinations
was limited until the late 1970s and early 1980s. In the early use a midline view as well as leftward and rightward angulated
1960s, Brinker and Taveras from Columbia used a commercial parasagittal views (Fig. 2) that extend from midline to each of
metal flaw detector to evaluate the brain midline.1 In 1965, the Sylvian fissures. Additional imaging may be performed
Brinker developed a water-immersion ultrasound (US) scanner through any skull opening particularly the posterior fontanelle
to potentially evaluate the brain but was unsuccessful because and the mastoid fontanelle (Fig. 3). Posterior fontanelle imaging
of the difficulty of transmitting the US beam through the bones has been shown to improve identification of hemorrhage in in-
of the skull.1 Ultrasound investigations through the infant skull conclusive anterior fontanelle imaging because of better evalua-
performed by Johnson et al2 with static gray-scale imaging and tion of the atria and occipital horns of the lateral ventricles.7–9
by Pape et al using a linear array real-time scanner were reported The mastoid fontanelle approach has allowed excellent visuali-
in 1979.3,4 In 1980, the first descriptions of infant head US im- zation of posterior fossa structures such as the cisterna magna,
ages using the anterior fontanelle, which bypassed the need to fourth ventricle, cerebellar hemispheres, and the cerebellar
penetrate bone, were reported by 2 groups, Ben-Ora et al5 and vermis as well as the atrial and occipital portions of the lateral
Babcock et al,6 using static B mode US scanners. The first use ventricles. The addition of mastoid views to routine anterior
of real-time imaging for head US in multiple planes using the fontanelle head US imaging improves the detection of cere-
anterior fontanelle as an US window was reported by Grant bellar injury in preterm infants.10 It can be used to evaluate
et al.4 With the development of real-time gray scale imaging, subtentorial anomalies such as Dandy Walker spectrum
the era of real time evaluation of the neonatal head truly began. and rhombencephalosynapsis.
With the success of anterior transfontanelle imaging, clinical
ANTERIOR FONTANELLE VIEWS
Received for publication November 15, 2018; accepted January 31, 2019.
*Department of Radiology, Le Bonheur Children's Hospital; and †Department of Sagittal Midline Plane
Radiology, University of Tennessee Health Science Center, Memphis, TN. The midline sagittal plane provides excellent visualization
The authors declare no conflict of interest. of the corpus callosum (CC) (Fig. 4). The echogenic pericallosal
Address correspondence to: Vijetha V. Maller, MD, Department of Radiology, sulcus, which contains the pericallosal arteries, surrounds the CC
Le Bonheur Children's Hospital, 848 Adams Ave, Radiology G216,
Memphis, TN 38103 (e‐mail: vijethamaller@gmail.com). superiorly. The pericallosal sulcus is surrounded superiorly by
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved. the cingulate gyrus. Color Doppler of the anterior cerebral artery
DOI: 10.1097/RUQ.0000000000000439 will show it crossing over and paralleling the CC when the CC is

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Ultrasound Quarterly • Volume 35, Number 3, September 2019 Neonatal Head US - Technique and Premature

caudothalamic groove, which is at the junction of the head of

the caudate nucleus and the thalamus. It is here where the
neuroblasts and single-celled vessels remain at 28 to 32 weeks
and subependymal hemorrhage (SEH) may develop (Fig. 7).
Routine parasagittal imaging continues with angulation to the
brain periphery and the Sylvian fissure.

Coronal Plane
The transducer should be angled from front to back, im-
aging the brain parenchyma beginning from a plane through
the region of the orbit and frontal lobe to the occipital and
subtentorial area. Lateral ventricles can be evaluated for size
at the frontal horns, bodies, atria (the first area to dilate in hydro-
cephalus), and occipital horns. On coronal view, the genu of the
CC is seen in front of and superior to the frontal horns. The
cavum septi pellucidi (the term preferred to cavum septum
pellucidum) is a potential space between the septi pellucidi.18
It is seen inferior to the genu of the CC in at least 90% of all pre-
term neonates and 60% of full-term infants. It usually closes at

FIGURE 1. Head US imaging technique. Coronal planes

obtained via anterior fontanelle imaging with the transducer
angled from front to back and imaging the brain parenchyma
from the orbit to subtentorium. (Reprinted from Cohen HL,
Blitman NM, Sanchez J. Neurosonography of the infant: the
normal examination. In: Timor-Tritsch I, Monteagudo A, Cohen
HL, eds. Ultrasonography of the Prenatal and Neonatal Brain. 2nd
ed. New York: Mc-Graw-Hill; 2001:413, with permission).

present, in a midline sagittal view. When the CC is absent, the an-

terior cerebral artery will rise superiorly and anterior to where the
genu of the CC would be expected to be. The third ventricle is
seen inferior to the CC and cavum septi pellucidi. Normal
echogenic choroid plexus can be seen within the roof of the third
ventricle.11 It does not extend anterior to the foramina of Monro
or into the occipital horns. The choroid plexus is well seen on
parasagittal views within the lateral ventricles. At times, choroid
plexus cysts can be seen in the usually homogenously echogenic
choroid plexus. Such cysts are seen in 1% to 3% of fetuses as well
as neonates.6,12,13 Their presence has no clinical significance in
otherwise normal neonates (Fig. 5).14 Choroid plexus cysts have
been associated with trisomy 18 and their presence, particularly if
large (>1 cm) and bilateral requires review of the fetus for any
possible associated finding of trisomy 18.15,16

Parasagittal Plane
Parasagittal views of each side of the brain are obtained
by angling the transducer laterally from the midline. Peritrigonal
echogenicity, also known as the peritrigonal halo or blush, can FIGURE 2. Head US imaging technique. Median and
be seen as increased echogenicity in the parenchyma in the paramedian sagittal planes obtained via anterior fontanelle
imaging. Plane 1 extends through the Sylvian fissure, plane 2
periatrial area, posteriorly. Although it may suggest white mat-
runs through the head of caudate (C) and thalamus (T), and
ter abnormality, such as echogenic periventricular leukomalacia plane 3 extends through the midline. (Reprinted from Cohen HL,
(PVL), the prominent echogenicity is due to anisotropic effect Blitman NM, Sanchez J. Neurosonography of the infant: the
caused by the US beam from the anterior fontanelle striking ex- normal examination. In: Timor-Tritsch I, Monteagudo A, Cohen
actly perpendicular to the periatrial white matter tracts (Fig. 6).17 HL, eds. Ultrasonography of the Prenatal and Neonatal Brain. 2nd
It is important to evaluate the germinal matrix region at the ed. New York: Mc-Graw-Hill; 2001:406, with permission).

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Maller et al Ultrasound Quarterly • Volume 35, Number 3, September 2019

FIGURE 3. Infant skull showing normal open sutures, which can serve as sonographic windows to the brain. (Reprinted from Cohen HL,
Blitman NM, Sanchez J. Neurosonography of the infant: the normal examination. In: Timor-Tritsch I, Monteagudo A, Cohen HL,
eds. Ultrasonography of the Prenatal and Neonatal Brain. 2nd ed. New York: Mc-Graw-Hill; 2001:404, with permission).

2 to 6 months after birth.19 Its absence in fetal workups is at vergae with the latter obliterating first. A further extension, the
times concerning for agenesis of the septum pellucidum (and cavum velum interpositum, can be present and is noted between
Demorsier syndrome).18 Cavum vergae is the extension of the the fornicial fibers superior to the roof of the third ventricle.20
echoless cavum septi pellucidi posterior to the fornices, bounded
posteriorly by the splenium of the CC, and superiorly by the body
of the CC. It is rarely seen without a cavum septi pellucidi.18 Typ-
ically, the cavum septi pellucidi communicates with the cavum

FIGURE 4. Normal head US in a preterm in sagittal plane

through the midline. The echoless cavum septum pellucidum FIGURE 5. Choroid plexus cyst. Head US parasagittal plane in
(CSP) extends posteriorly as the cavum vergae and further a term neonate shows a choroid plexus cyst seen as an anechoic
posteriorly and inferiorly as the cavum velum interpositum. It sits thin walled round structure posteriorly in the body of the
below the CC (arrowheads). 4, fourth ventricle; 3. third ventricle; left lateral ventricle (arrow). Such cysts can be seen in 1% to 3%
V, cerebellar vermis. of normal neonates.

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Ultrasound Quarterly • Volume 35, Number 3, September 2019 Neonatal Head US - Technique and Premature

the frontal brain. The Sylvian fissures imaged at the periphery

of the brain (Fig. 8) will have a wider rectangular shape (on
coronal view) in the young premature infant compared with a
classic echogenic Y shape in a term infant with greater brain
development.21,22 Normal developmental changes with an in-
crease in the number of gyri and sulci seen occur between 24
and 40 weeks. Preterm infants (or fetuses) cannot be diagnosed
confidently as having lissencephaly when less than 28 to
32 weeks because at that time the cerebral cortex is normally
relatively smooth.21

Transmastoid Imaging
The mastoid fontanelle located at the junction of the squa-
mous, lambdoid, and occipital sutures does not fuse until 2 years
of age. Ultrasound imaging through this fontanelle allows excel-
lent visualization of the cerebellar vermis and hemispheres. The
US transducer is placed about 1 cm behind the helix and 1 cm
above the tragus of the ear. Transmastoid views will also show
FIGURE 6. Peritrigonal echogenicity due to anisotropy. Head the fourth ventricle and cisterna magna. Some supratentorial
US parasagittal plane in preterm neonate demonstrates an structures can be seen as well including the posterior portion
echogenic area in the peritrigonal region (arrowheads), which of the ventricular system and at times the third ventricle as well
may simulate echogenic PVL. It is caused by normal white matter as the thalamus, cerebral peduncles, and basal cisterns. The
fibers insonated at a 90-degree angle to the sound sent from cerebellar hemispheres are symmetrical ovoid structures con-
the transducer placed in the anterior fontanelle. taining linear bright folial echogenicities. The cerebellar vermis
appears as an echogenic midline structure between the hemi-
At times, limited seating of the transducer within the pos- spheres and posterior to the fourth ventricle.21 The cisterna
terior fontanelle will obscure the anterolateral portions of the magna is an anechoic structure posterior to the vermis and
frontal brain. Pointing the transducer from the extreme right
and/or left side of the anterior fontanelle across to the contralat-
eral side may provide adequate evaluation of the periphery of

FIGURE 7. Normal parasagittal plane. Head US parasagittal FIGURE 8. Normal Sylvian fissure in a premature neonate.
plane through the germinal matrix region in a preterm neonate. Head US coronal plane in a preterm neonate born at 24 weeks
The arrow points to the caudothalamic groove between the gestational age demonstrates Sylvian fissures, which appear
caudate head (C) and the thalamus (T). This area must be squared with echoless cerebrospinal fluid within and lateral to
reviewed for germinal matrix hemorrhage particularly in them. Arrowheads point to the right Sylvian fissure. Only a few
preterm neonates. An arrowhead points to choroid plexus in the gyri and sulci are seen consistent with the neonate's early
lateral ventricle. 24-week gestational age. We have called this the toast sign.

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Maller et al Ultrasound Quarterly • Volume 35, Number 3, September 2019

cerebellar hemisphere (Fig. 9).23 The foramen of Magendie

can sometimes be visualized at the inferior portion of the cere-
bellum, as a linear or tubular echoless area, extending between
the fourth ventricle and the cisterna magna. This is seen most
often in younger premature neonates.
Color Doppler Imaging of the Head
Color Doppler imaging of the intracranial vessels can as-
sess cystic masses as vascular or not. It can be used to assess the
patency of the arterial and the venous system. The circle of
Willis and its branches can be assessed through the anterior fon-
tanelle usually in the coronal plane but can be seen with other
approaches including transcranial imaging through the thinner
temporal bone, although at times needing a lower frequency
transducer. The middle cerebral artery can be better analyzed
via a transtemporal approach (Fig. 10).24 The superior sagittal si-
nus can be evaluated through an open sagittal suture (Fig. 11A).
The transmastoid view is useful for the evaluation of the trans-
verse sinus, sigmoid sinus, and the torcula (Fig. 11B).25

IMAGING IN PRETERM INFANTS

FIGURE 10. Normal color Doppler image of circle of Willis via
Head US in Preterm Neonates transcranial image. The white arrows point to middle cerebral
Neonates of less than 32 weeks of gestational age and less arteries; the white arrowheads point to anterior cerebral arteries.
than 1500 g are at risk for intraventricular hemorrhage (IVH).26 Black arrowheads point to the posterior cerebral arteries.
Guidelines for the recommended timing of head US exams have
been developed to detect the maximal number of abnormal stud- studies of IVH if examined in the first couple of days of life. In
ies among asymptomatic newborns. There can be false-negative an asymptomatic premature infant, an initial scan should be per-
formed between days 3 and 7 of life to best capture all cases of
IVH in the first week of life. A second scan between days 10 and
14 is thought to identify most clinically and developmentally
important findings.22,27,28 The rationale behind this second scan
is also the desire to further identify other cases of IVH. Whereas
75% of cases are identified in the first week of life, at least 84%
are noted by days 10 to 14. The 10- to 14-day examination al-
lows identification of any early posthemorrhagic hydrocephalus
as well as the identification of echogenic periventricular white
matter consistent with echogenic PVL.27 A third scan usually
performed at 4 to 6 weeks of age helps exclude PVL by the sep-
aration of normal periventricular echogenicity of white matter
from echogenic (early) PVL which by 4 to 6 weeks would be
cystic. Posthemorrhagic hydrocephalus can be also noted, usu-
ally seen 1 to 3 weeks after the initial IVH.22,27
Obviously in symptomatic neonates (eg, dropping hemat-
ocrit, seizures) or in neonates with abnormal fetal examinations,
a head US should be performed as soon as possible. Magnetic
resonance imaging is the imaging modality of choice for hyp-
oxic ischemic encephalopathy in the acute phase, but US even
with its lower sensitivity for the detection of early ischemic
changes is an important triaging tool.29,30

INTRACRANIAL HEMORRHAGE IN
PRETERM NEONATES
FIGURE 9. Normal transmastoid view. Head US. Transducer on The germinal matrix is an area of neuronal and glial
left mastoid area. There are 2 cerebellar hemispheres (C) with proliferation with many neuroblasts and a rich array of single-
the normal echogenic vermis (V) seen between them. The vermis cell-thick vessels, which appears at the seventh week of gesta-
is seen between the more anterior fourth ventricle (4) and the tion in the subependymal layer of the ventricles. The cells of
posterior cisterna magna (arrowhead). the germinal matrix migrate toward the periphery (cortex)

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Ultrasound Quarterly • Volume 35, Number 3, September 2019 Neonatal Head US - Technique and Premature

FIGURE 11. Head US (A) midline sagittal color Doppler image. Black arrows point to color flow in a patent superior sagittal sinus.
B, Right transmastoid fontanelle color Doppler image. The black arrowhead points to a patent right transverse sinus. The black arrow
points to a patent right sigmoid sinus.

during fetal brain development.31,32 The germinal matrix lines defined as an intraventricular extension of the SEH. Grade 3
the entire ventricular system, early in gestation, reaching its IVH is intraventricular hemorrhage with ventricular dilation
greatest size at 23 weeks of gestation. It then begins to involute (Fig. 14). Grade 4 IVH was once thought to be due to intraven-
in the area of the third ventricle followed by involution at the tricular blood, with or without ventricular dilation extending
temporal and occipital horns of the lateral ventricles by the into the brain parenchyma. The definition has evolved since
end of second trimester. Only a small amount of germinal ma- Volpe31 described the periventricular abnormality as due to
trix remains by 28 to 32 weeks of gestation as a focal area at the periventricular venous hemorrhagic infarction and stated that
caudothalamic groove. By 35 to 36 weeks, the germinal matrix it was not from direct extension from the ventricular cavity
involutes completely.33 (Fig. 15). Patients with grade I or grade II hemorrhages have a
Preterm neonates with a gestational age of less than low morbidity and mortality. Grade III and grade IV hemor-
32 weeks have immature autoregulation of their blood pressures. rhages have higher morbidity and mortality rates, and survivors
The lack of baroreceptors that adults have to keep pressures have a higher risk for both cognitive and motor impairment.34
normal in the brain despite hypotension or hypertension puts The choroid plexus in a very premature infant can
the neonatal brain at risk. Elevations in blood pressure will di- normally have a lumpy bumpy appearance with prominent
late the neonatal intracranial vessels with the potential rupture echogenicity, but this should not be confused with an acute
of the fragile vessels at the germinal matrix. Episodes of hypo- intraventricular clot. Differentiation between echogenic choroid
tension lead to decreased flow into the brain and can result in plexus and hemorrhage can be made. First, choroid plexus is not
hemorrhage from hypoxia and reperfusion injury.26 Hemor- found in the frontal horns anterior to the foramina of Monro or
rhage is seen as echogenic with fibrin deposition, that is, clot the occipital horns. Echogenic masses seen anterior to the
formation. Papile et al32 classified germinal matrix hemorrhage foramina of Monro or in the occipital horns are clots until
into 4 grades. Grade 1 is limited to the subependymal region disproven. Doppler evaluation can help note flow in the normal
(Fig. 12). It can be diagnosed when there is focal echogenicity vascular choroid plexus, which would be absent within hem-
or with older hemorrhage, heterogeneity, or cyst formation in orrhagic clot. Tincture of time may help the differentiation
the caudothalamic groove, near the foramen of Monro. At times, because hemorrhage evolves as clot lyses and retracts. As the
such SEH may be symmetric. Grade 2 IVH (Fig. 13) is when clot dissolves, it becomes more echopenic, which early in its

FIGURE 12. Bilateral grade 1 SEHs. Head US (A) coronal plane in a 3-day-old male neonate born at 34 weeks of gestational age
shows echogenicity (arrowheads) posterior and medial to the frontal horns of both lateral ventricles. The homogenously bright
echogenicity is consistent with early hemorrhage in the subependymal area between the caudate head and thalamus. B, Parasagittal
plane in the same neonate at 7 days of age shows echogenicity in the right germinal matrix with an echopenic focus (arrow). This
parasagittal image is in the orthogonal plane to the coronal view. It confirms hemorrhage in the germinal matrix region between
the head of caudate (C) and thalamus (T). The cystic area is consistent with aging and partial dissolution of the clot.

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Maller et al Ultrasound Quarterly • Volume 35, Number 3, September 2019

FIGURE 13. Grade 2 IVH on left. Head US in a 4-day-old neonate born at 26 weeks of gestation age. A, Coronal plane through the
frontal horn shows echogenic clot (arrow) in a nondilated frontal horn of the left lateral ventricle. An echogenic hemorrhagic focus
(arrowhead) on readers' right is seen in the left subependymal area. An arrowhead on the readers left points to somewhat more
echogenic material in the right subependymal region consistent with a newer grade 1 germinal matrix hemorrhage. B, Left parasagittal
plane. An arrow points to clot within a relatively nondilated anterior portion of the left lateral ventricle.

lysis, may appear as an echopenic structure with a highly often result in echogenicity lining the ependyma, the inner
echogenic periphery. ventricular wall, because of the irritant blood products and
In the case of grade 1 SEH, the caudothalamic clot may the development of a chemical ventriculitis. Grade 4 peri-
develop subependymal cysts. In grade 2, 3, or 4 hemorrhages, ventricular venous infarction may cavitate resulting in a
when the clot dissolves, echogenic debris will be seen within porencephalic cyst (Fig. 16).
the dependent portions of the ventricles. When a neonate is
in supine position, it can be seen in the occipital horns of the
lateral ventricles. Clot position will change with change in
the neonate's head position. Intraventricular hemorrhage will

FIGURE 15. Grade 4 hemorrhage on right. Head US coronal

plane in an 8-day-old preterm neonate born at 28 weeks of
FIGURE 14. Grade 3 IVH on left. Head US coronal image in a gestational age. The white arrows point to a large echogenic area
3-day-old neonate born at 25 weeks of gestation age shows consistent with hemorrhage dilating the ventricle. The echogenic
echogenic clot (arrow) distending the body of left lateral ventricle material seen extending well beyond the expected superior
consistent with grade 3 IVH. An arrowhead points to the extent of the right frontal horn is due to associated venous
echogenic clot in the nondilated body of right lateral ventricle infarction. The right frontal hemorrhagic infarction creates an
consistent with grade 2 IVH. It can be seen as less echogenic than impression on the cavum septum pellucidum (white arrowhead).
the imaged right choroid plexus. There is clot in the right temporal horn tip (black arrow).

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Ultrasound Quarterly • Volume 35, Number 3, September 2019 Neonatal Head US - Technique and Premature

Cerebellar Hemorrhage
The germinal zones that exist within the external granule
cell layer of the cerebellar hemispheres and in the subependymal
layer of the fourth ventricle can bleed in preterm infants, es-
pecially in infants less than 750 g of birth weight.35–37 Acute
cerebellar hemorrhage appears (with clot development)
homogenously echogenic. Over time, the clot becomes hetero-
geneous and eventually hypoechoic. Mastoid fontanelle views
are helpful in detecting cerebellar hemorrhage (Fig. 17).

POSTHEMORRHAGIC VENTRICULAR DILATION

AND POSTHEMORRHAGIC HYDROCEPHALUS
Premature infants may develop ventricular dilation after
IVH. Dilation due to obstruction is termed hydrocephalus. Post-
hemorrhagic hydrocephalus may occur owing to obstruction
from the blood clots within or outside the ventricular system
or reactive ventriculitis from hemorrhage particularly at the
level of the aqueduct of Sylvius. Clot outside the brain may ob-
struct the ventricular system as well. Key, however, is the post-
hemorrhagic development of hydrocephalus from inflammation
of the arachnoid granulations at the surface of the brain preventing
adequate resorption of cerebrospinal fluid into the lymphatic FIGURE 17. Cerebellar hemorrhage. Head US right transmastoid
system (Fig. 18). Volpe's38 textbook refers to a 2002 Murphy approach shows a prominent echogenic area (arrow) in the left
et al39 study, which noted that only 7% of infants with grades cerebellar hemisphere. The lateral ventricles are dilated and
1 and 2 IVH developed progressive posthemorrhagic ventricu- contain clot. A, anterior; P, posterior.
lar dilation, whereas 75% of infants with grade 3 and grade 4
IVH who survived to more than 14 days old developed progres- shunt, whereas 25% to 35% of infants with grades 3 and 4
sive posthemorrhagic ventricular dilation. About 1% of infants IVH needed VP shunting. Sometimes, obstruction can occur
with grades 1 and 2 IVH required a ventriculoperitoneal (VP) at both the aqueduct of Sylvius and the outlets of the fourth

FIGURE 16. Porencephalic cyst as residua of right side grade 4

hemorrhage. Head US coronal plane in premature neonate at FIGURE 18. Posthemorrhagic ventricular dilation and aging clot.
25 days of age. There is a large cystic area (arrow) extending from Head US coronal plane in a 3-week-old neonate born at 25 weeks
the frontal horn to the superior aspect of the frontal brain. Aging of gestational age shows dilated lateral ventricles containing
clot and debris (arrowheads) are seen within the right lateral older blood clot (arrowheads) now seen as echopenic except
ventricle. This right sided cystic area extends far superior to the most for a thin peripheral echogenicity. The temporal horns are
superior extent of the left frontal horn suggesting porencephaly dilated. Echogenic clot is also seen within the dilated third
as residua of the original right grade 4 venous infarction. ventricle (arrow).

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Maller et al Ultrasound Quarterly • Volume 35, Number 3, September 2019

ventricle, the foramina of Luschka and Magendie. Such a situ- between the ventriculopetal and ventriculofugal branches of the
ation can result in a trapped fourth ventricle. When this oc- deep penetrating arteries and the subsequent reperfusion of
curs, the patient will need an additional ventriculostomy to these areas. Periventricular leukomalacia is most commonly ob-
fully decompress the ventricular system because a VP shunt served adjacent to the frontal horns and foramen of Monro as
into the lateral ventricle will only decompress the lateral well as the trigone of the lateral ventricles. The cerebral white
and third ventricles. matter of an immature brain is populated predominantly by
the preoligodendrocytes, which are more susceptible to hypoxic
Hypoxic Ischemic Injury in Preterm Neonates injury as opposed to the mature oligodendrocytes of the mature
brain.41,44 The long-term sequelae of PVL may be visual, audi-
Hypoxic ischemic injury (HII) is more common in the
tory, and motor deficits with spastic diplegia or quadriplegia.
preterm than the term neonate. The ischemic injury can be
Such findings fall loosely within the broader term of cerebral
antepartum, intrapartum, or postpartum. As discussed, the rela-
palsy. The cerebral cortex in premature neonates is typically un-
tively poor autoregulatory mechanism (passive pressure) in the
affected because of the collateral blood supply from meningeal
preterm neonates is responsible for an inability of the neonate
intra-arterial anastomoses, which involute at term.45
to correct increased or decreased pressures presented to their
On head US, within the first 2 weeks of a HII, increased
brain. This is particularly true in the case of hypotension, an
echogenicity is seen in the periventricular white matter predom-
important factor in the pathogenesis of hypoxic injury. A se-
inantly in the peritrigonal region, which represents white matter
vere hypoxic event will result in injury to areas of advanced
edema or hemorrhage. This initial finding should be differen-
myelination, which have the highest metabolic activity. These
tiated from the normal periventricular flare or halo, which is
include the thalamus, globus pallidus, hippocampus, dorsal
thought due to anisotrophy from US hitting the periatrial white
brainstem, and the cerebellum.40–42 The caudate nucleus, puta-
matter fibers at a 90-degree angle from an anterior fontanelle
men, and the perirolandic cortex tend to be spared in premature
approach. It is helpful therefore to try to evaluate the corre-
infants when compared with term infants because these myelinate
sponding area of echogenicity with a different approach or a
at the older age of 33 to 35 weeks. In cases of HII, a head US can
different US window to avoid the artifactual increased
demonstrate increased echogenicity in the thalami by 48 to
echogenicity due to anisotropy. The echogenicity of an area
72 hours of life. The thalami may appear normal in the first
of PVL is typically greater than that of the adjacent choroid.46
2 days of life. Magnetic resonance imaging is helpful to diag-
Concern is greatest when the echogenicity is asymmetric.
nose this type of injury because US is less sensitive in the early
Symmetry may suggest normalcy if not particularly echogenic.
stages of HII, but the use of magnetic resonance imaging is lim-
A 2- to 3-week follow-up will allow cyst development to be
ited at times because of patient condition and the desire to not
seen if there is true abnormality. Some patients may show in-
move them outside the neonatal intensive care unit.43 In cases
creased periventricular echogenicity and periventricular cysts.
of HII of only mild to moderate severity, thalamic abnormality
Such an image has been described as a “Swiss cheese appear-
may be seen, but reperfusion injury may create the more com-
ance” (Fig. 19).22 At around 3 to 6 months of age, if not earlier,
monly noted germinal matrix–IVHs. All HII patients are at risk
the cystic areas may fill in with fibrous and glial cells and no
for developing PVL.
longer be seen sonographically despite the replacement of nor-
mal brain cells by gliosis and periventricular volume loss.47–49
Periventricular Leukomalacia It is at this time when the abnormality if not already seen may
Periventricular leukomalacia is infarcted periventricular be missed. Eventually, generalized cerebral atrophy occurs
white matter. It occurs secondary to decreased blood flow to with widening of cerebral sulci, interhemispheric fissure,
the periventricular white matter at the watershed areas typically and ventriculomegaly.50

FIGURE 19. Cystic PVL. Head US (A) parasagittal plane in a 3-week-old preterm neonate. Cystic areas (arrowheads) are seen within
echogenic white matter (arrows) in the periphery of the left brain consistent with cystic PVL. B, Coronal plane. Arrowheads point to
cystic areas within the echogenic white matter (arrows) adjacent to the frontal horns of the lateral ventricles on coronal head US
consistent with cystic PVL.

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Ultrasound Quarterly • Volume 35, Number 3, September 2019 Neonatal Head US - Technique and Premature

SUMMARY 24. D'Andrea A, Conte M, Scarafile R, et al. Transcranial Doppler ultrasound:

physical principles and principal applications in neurocritical care unit.
Neurosonography is a useful and at times the only neces- J Cardiovasc Echogr. 2016;26(2):28–41.
sary diagnostic imaging tool for the assessment of the neonatal 25. Huisman T, Poretti A. Duplex sonography of the neonatal and infant brain.
brain. Proper techniques and knowledge of normal anatomy and In: Rumack CM, Levine D, eds. Diagnostic Ultrasound. 5th ed.
variations for this tool can improve diagnosis. Its use is of key im- Philadelphia: Elsevier; 2018.
26. O'Leary H, Gregas MC, Limperopoulos C, et al. Elevated cerebral pressure
portance in the analysis of the premature particularly because of passivity is associated with prematurity-related intracranial hemorrhage.
the ease of bedside analysis in the neonatal intensive care unit. Pediatrics. 2009;124(1):302–309.
27. Perlman JM, Rollins N. Surveillance protocol for the detection of
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