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Cranial ultrasound by neonatologists

Pediatric Research (2020) 87:1–2; https://doi.org/10.1038/s41390- A systematic review, “Diagnostic and predictive value of
020-0779-8 Doppler ultrasound for evaluation of the brain circulation in
preterm infants”,2 deals with the value of estimating arterial flow
indices in preterm infants. The, not unexpected, salient finding is
that this is an area where research did not offer strong evidence
This seminar is written by a group of neonatologists with a of anything. On the other hand, it is a paper that should
passion for cranial ultrasound (CUS) in the newborn. In many encourage the reader to reconsider the future of CUS in studying
European neonatal intensive care units, CUS has been in the brain perfusion, both at the macro- (arteries and veins) and
hands of the neonatologist for a few decades now. Although this microvascular level. The prognostic value of perfusion indices is a
gradually produced clinical knowledge and scientific production, completely open field.
apart from lecturing at symposia there is no formal transnational “Preterm germinal matrix hemorrhage, sequelae and outcome”
education with quality control in our group. This seminar, was one of the next unavoidable topics. This is one of the injuries
together with other efforts to transfer knowledge by bedside that remains prevalent. The paper by Parodi et al.3 discusses
teaching (eurUS.brain), is part of a strive for formal guidelines grading of the extent of this lesion paradigm. We should strive to
and intercollegial assessment. It is greatly appreciated that this completely prevent GMH after birth and to find ways of limiting
journal, together with the European Society of Pediatric evolving venous infarction near affected matrix areas. Given that
Research, endorses support for education and science in the the subventricular protomap of neuronal and glial progenitors is
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field of neonatology. present in viable preterm infants, one can predict that the
The brain of the newborn is not an organ where treatment location and extent of matrix hemorrhage will correlate with
options are actually abundant. Cooling has opened the box of specific dysfunctions. If we can predict such specificity, we will
possibilities, and several neuroprotective strategies are under also find ways of mitigating dysfunction in survivors. MRI and
investigation: the following decades will introduce strategies CUS will be complementary in this topic.
aiming at prevention and treatment of acquired brain lesions. Since we realized—by scanning via het mastoid fontanelle—that
To change management means we have to follow strict extremely low birthweight infants are at risk of cerebellar
diagnostic rules both for inclusion in clinical trials and for hemorrhage, “Ultrasound of acquired posterior fossa abnormalities
individual care. That is one goal of this seminar. The second is to in the newborn”4 became very actual. High-frequency linear probes
offer suggestions for research by challenging some outdated provide access to many relevant lesions in the cerebellar hemi-
views on CUS. Throughout the work we carefully point to spheres, but also to understanding transverse sinus thrombosis, the
concepts that need validation. Cutting-edge technical opportu- thrombotic heel of Achilles in preterms. Measurement of cerebellar
nities are not included, because the aim was to summarize state- size will be an important item in the prospective analysis of
of-the-art CUS for common types of perinatal brain injury. This imperfect postnatal brain growth with CUS; this may define a subset
does not mean we do not hunger for attention by ultrasound of preterm infants’ candidate for targeted neuroprotection in a
vendors for the brain of the newborn. When appropriate, distant future. Not surprisingly, several other posterior fossa findings
statements on CUS are compared with postmortem and MR have caught our attention and are compared with MR findings.
findings of the disease at hand. These papers are produced in Next to injury of germinal matrix (by germinolysis or hemor-
the regular fashion with a first author and co-authors, but rhage) a prevalent type of injury is to white matter, both in preterm
members of eurUS.brain have contributed to all papers by final and term infants. “Preterm white matter injury: ultrasound diagnosis
reading and correcting. and classification”5 tackles the grading of white matter injury by
CUS is relatively complex because several windows to the CUS. As a group we felt this was perhaps the biggest challenge,
brain can be used and different probes with variable settings are because for years the acclaim has been that MRI was in fact the only
in vogue. The technical aspects of scanning, the natural part of reliable tool to study preterm white matter injury. In this chapter we
training of radiologists, need to be brought under the attention demonstrate how specific injury types can be ascertained with CUS,
of clinicians and this is done in the paper by Dudink et al.1. A and when combined with measurement of brain growth, how CUS
complete careful scan in a fragile preterm infant is a piece of studies can be planned that will offer prognostic insight, even in the
medical art, the action itself takes time and the report must be absence of MR correlation. The periventricular white matter is
carefully written. Clinicians tend to conclude what diagnosis is also, because it is near the anterior fontanel, the area where
most likely and what further diagnostic actions are potentially we may expect improved diagnostic accuracy by technical
useful. Redirection of care is in their hands, often only upon advances of CUS, especially by the study of microvascular behavior.
careful evaluation of the extent of damage. A witticism of use This is where vendors should embrace clinical research and offer
here is that any CUS image or video framed should be of such bedside tools for objective measurement of tissue alteration with
quality to be usable in publications. Standard planes are CUS. White matter perfusion monitoring with CUS is a direct
indicated, avoiding to curtail the sonographer to so-called research goal.
standard imaging, but encouraging exploration of additional The original paper, “The development and validation of a cranial
views of any lesion or structure of interest. Routine scanning of a ultrasound scoring system for infants with hypoxic-ischemic
few sectional planes, as performed by lay people because it is encephalopathy”,6 concludes this seminar. It reviews the limited
part of the standard scheme, should become obsolete. yet essential role of CUS in the diagnosis of perinatal asphyxia and

© The Author(s) 2020

 Editorial
2
propagates a scoring system that could be useful in situations Monica Fumagalli, https://orcid.org/0000-0002-0186-0710
where easy access to (repeated) MR scanning is not available. Paul Govaert, https://orcid.org/0000-0002-2011-4529
As a network of neonatal CUS specialists, we realize that we Sandra Horsch, https://orcid.org/0000-0002-2412-7319
have only just started. We are open to constructive suggestions Alessandro Parodi, https://orcid.org/0000-0002-3463-3004
Adelina Pellicer; https://orcid.org/0000-0001-8109-4958
from the pediatric as well as radiological community.
Luca Ramenghi
Charles Roehr, https://orcid.org/0000-0001-7965-4637
Paul Govaert1, Charles C. Roehr2,3 and Pierre Gressens4 Sylke Steggerda, https://orcid.org/0000-0002-5603-5697
1
ZNA Middelheim, Antwerp, Belgium; 2Newborn Services, John Eva Valverde, https://orcid.org/0000-0002-2598-9172
Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust,
Oxford, UK; 3Medical Sciences Division, Nuffield Department of
Population Health, National Perinatal Epidemiology Unit, University REFERENCES
of Oxford, Oxford, UK and 4Université de Paris, NeuroDiderot, Inserm, 1. Dudink, J., Steggerda, S.J., Horsch, S., on behalf of the eurUS.brain group. State of
Paris, France the art neonatal cerebral ultrasound: technique and reporting. Pediatr. Res. (2020).
Correspondence: Paul Govaert (govaert@icloud.com) https://doi.org/10.1038/s41390-020-0776-y.
2. Camfferman, F.A. et al. Diagnostic and predictive value of Doppler ultrasound for
evaluation of the brain circulation in preterm infants: a systematic review. Pediatr.
Res. (2020). https://doi.org/10.1038/s41390-020-0777-x.
ACKNOWLEDGEMENTS 3. Parodi, A., Govaert, P., Horsch, S., Bravo, M.C., Ramenghi, L.A., on behalf of the
Members of eurUS.brain are listed in the Appendix. The members have read and eurUS.brain group. Cranial ultrasound findings in preterm germinal matrix hae-
approved this issue. Funding for this publication was provided by the European morrhage, sequelae and outcome. (2020). https://doi.org/10.1038/s41390-020-
Society for Paediatric Research (ESPR). 0780-2.
4. Fumagalli, M., Parodi, A., Ramenghi, L., Limperopoulos, C., Steggerda, S., on behalf
of the eurUS.brain group. Ultrasound of acquired posterior fossa abnormalities in
ADDITIONAL INFORMATION the newborn. Pediatr. Res. (2020). https://doi.org/10.1038/s41390-020-0778-9.
Competing interests C.C.R. serves as a Corresponding Editor and PG serves as an 5. Agut, T. et al. Preterm white matter injury: ultrasound diagnosis and classification.
Associate Editor for Pediatric Research. C.C.R. has received lecture fees from various Pediatr. Res. (2020). https://doi.org/10.1038/s41390-020-0781-1.
pharmaceutical and medical devices companies on matters unrelated to the topic in 6. Annink, K.V. et al. The development and validation of a cranial ultrasound scoring
this supplement, and received grant funding from Chiesi Pharmaceutical Grant for system for infants with hypoxic-ischemic encephalopathy. Pediatr. Res. (2020).
investigating specific pharmacodynamics in newborn infants, also unrelated to the https://doi.org/10.1038/s41390-020-0782-0.
manuscripts in this supplement.

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APPENDIX: MEMBERS OF EURUS.BRAIN material in this article are included in the article’s Creative Commons license, unless
Thais Agut, https://orcid.org/0000-0002-5673-0016 indicated otherwise in a credit line to the material. If material is not included in the
Ana Alarcon, https://orcid.org/0000-0001-7223-2028 article’s Creative Commons license and your intended use is not permitted by statutory
Roberta Arena, https://orcid.org/0000-0002-8603-4206 regulation or exceeds the permitted use, you will need to obtain permission directly
Marco Bartocci, https://orcid.org/0000-0002-2454-6847 from the copyright holder. To view a copy of this license, visit http://creativecommons.
Mayka Bravo, https://orcid.org/0000-0002-2917-4288 org/licenses/by/4.0/.
Fernando Cabañas, https://orcid.org/0000-0002-1578-0703
Nuria Carreras, https://orcid.org/0000-0002-8770-2755
Olivier Claris © The Author(s) 2020
Jeroen Dudink, https://orcid.org/0000-0003-0446-3646

Pediatric Research (2020) 87:1 – 2