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Cranial Ultrasound Policy Yorkshire & Humber Neonatal ODN Clinical Guideline Title: Cranial ultrasound guideline Author: Dr Alan Sprigg, reviewed By Dr Iwan Roberts March 2017 Date written: October 2009, Updated March 2017 Review date: March 2020 This clinical guideline has been developed to ensure appropriate evidence based standards of care throughout the Yorkshire & Humber Neonatal Operational Delivery Network. The appropriate use and interpretation of this guideline in providing clinical care remains the responsibility of the individual clinician. If there is any doubt discuss with a senior colleague. A. Guideline summary 1. Aims To provide an approach to cranial ultrasound scanning that is likely to identify changes which would alter management and guide timely counselling. 2. Best Practice Recommendations Neonatal units should have a protocol for performing cranial ultrasound scans 3. Guideline Summary These are the recommendations. However, it is recognised that not all units will be able to access skilled sonographers at all times and this may results in some variation in the age at which infants are scanned. Gestational age Scan on Days <29/40 Days 0, 3,7,28 and at 36/40 CGA or if clinical concerns requiring cranial ultrasound scan 29-33/40 Around Day 7 and pre-discharge or if clinical concerns requiring cranial ultrasound scan > 33/40 Not required unless other clinical indication eg. thrombocytopaenia, HIE, abnormal neurology, CNS infection. B Full guideline and evidence 1. Background Cranial ultrasound scanning is widely used in neonates. There are many different approaches, from minimalistic through to obsessive. The network policy is derived from numerous sources and is a pragmatic approach that is likely to pick up changes that would alter management and guide timely counselling. Local clinical governance issues will dictate who performs scans, when, with what and image storage and interpretation. 2. Aim To provide an approach to cranial ultrasound scanning that is likely to identify changes which would alter management and guide timely counselling. 3. Areas outside remit Clinical management of cranial ultrasound findings Referral patterns of abnormal scans 4. Evidence 4.1 Who to scan and why The patient groups likely to need scanning are as diverse as the conditions that may require scanning. The table below is not an exhaustive list, but is likely to cover most situations. Patient Group Why scan them When to repeat Looking of intra cranial blood and development of Dictated by clinical condition Premature infants periventricular (see table below) leukomalacia Baby with abnormal Looking for structural Dictated by findings neurology lesions or blood In hypoxic ischaemic Looking for blood, midline encephalopathy every day in Following perinatal shift and/or cerebral the acute phase trauma/asphyxia oedema In others conditions dictated by findings Diagnosis of Looking for blood and/or coagulopathy or severe Dictated by findings midline shift thrombocytopaenia Suspected congenital Looking for associated Dictated by findings abnormality/syndrome structural lesions In meningitis at least once a Looking for intra cranial CNS infection – week until resolution. calcification, ventriculitis or congenital or acquired In others conditions dictated abscesses by findings Monitoring of a known Looking for changes Dictated by findings problem 4.2 Premature infants These are the recommendations. However, it is recognised that not all units will be able to access skilled sonographers at all times and this may results in some variation in the age at which infants are scanned. Patient Group First Scan When to repeat Any critically sick preterm Day 3, 7, 28 and at 36 weeks infant regardless of Within 24 hours of birth corrected gestational age gestation Preterm infant ≥33 weeks, None indicated Repeat not indicated no clinical concerns Preterm infant 29-33 Around 7 days old, but weeks; no clinical could be delayed to Just before discharge concerns second week of life Ideally at Day 3, 7, 28 and at Ideally within 24 hours Preterm infant<29 weeks 36 weeks corrected of birth gestational age. Scan daily until Preterm infant: clinical concerns/scan concerns or scan That day abnormality/clinical condition abnormality stabilised Static ventriculomegaly Already done Consider weekly scan Rapidly progressive ventriculomegaly or Already done Scan 2-3 times per week hydrocephalus 4.3 Technical considerations Appendix A covers the technical Standards required for neonatal cranial ultrasound scans of which there are several pertinent issues that are listed here: All images should have: two patient identity marks date, time and hospital which side is which labelled on each image the patient looking to the left in the saggital plane the left on the right in the coronal plane (just like an x-ray) Take at least 5 coronal images: Anterior to frontal horns of lateral ventricles Thorough the anterior horns of lateral ventricles at Sylvian fissure Through the 3rd ventricle and thalami Posterior horns and choroids Posterior to choroids in occipital lobes Ventricular index should be measured at level of 3rd ventricle Take at least 5 saggital images: Midline, 3rd ventricle, cavum septum pellucidum and corpus callosum Each lateral ventricle showing anterior and posterior horns Brain parenchyma in each hemisphere outside the ventricles Other oblique and axial images can be obtained 4.4 Frequency of scans This is often dictated by the clinical conditions. However, in premature infants a balance needs to be struck between scanning many low risk babies and the poor predictive value of scans. Depending on the research group cranial ultrasound has a positive predictive value between 50 to 75% for abnormal outcome depending on the nature and timing of the scans. Additionally, the positive predictive value of a normal scan is only between 90 to 95% for future normality depending on the research group and your definition of normal. Therefore, we have decided upon an incremental approach to scanning. This should allow babies at high risk of intraventricular haemorrhage to be found. It should also detect those who go on to get cystic periventricular leukomalacia. It will also detect early catastrophic changes that could assist with timing of insults. Additionally, babies with early changes associated with appalling neurological outcomes can be offered early palliative care as a valid treatment option. In the moderate preterm infant 29-33 weeks with no clinical concerns, there may be a cost effectiveness argument for delaying the scan until the second week of life, as it reduces the number of scans performed in total, without affecting the clinical management. However, this is based on American data and cost analysis making generalisability to the English health care system difficult. There is little evidence to support effectiveness of the routine screening of near-term premature infants who are well. In many instances around the region these babies are on the postnatal wards or in transitional care wards. 5. Audit criteria Cranial ultrasound scans performed as protocol in the preterm infant 6. References Jessop Wing cranial ultrasound guidelines Liverpool Women’s Hospital cranial ultrasound guidelines American Academy of Paediatrics’ cranial ultrasound standards of care University College Hospital of London’s cranial ultrasound guidelines Cerebral ultrasound presentation at Royal College of Paediatrics and Child Health 20th April 2005 by Alan Sprigg and Janet Rennie Optimal cost-effective timing of cranial ultrasound screening in low-birth-weight infants. Boal D K, Watterberg K L, Miles S, Gifford K L: http://www.crd.york.ac.uk/crdweb/ShowRecord.asp?View=Full&ID=21995000975 Appendix A Technical Standards (Dr Alan Sprigg Jan 2003) Background: Cranial ultrasound scans (US) are an essential part of routine investigation during neonatal intensive care. Sequential scans are now standard, and the results are used to assist in diagnosis (e.g. hypoxic ischaemic encephalopathy, stroke), to aid decision making in possible withdrawal of intensive care and to monitor complications and interventions (e.g. ventriculo- peritoneal shunts). Medical and non-medical personnel of various specialities perform cranial US scans. There are no supporting professional standards. Clinical governance directs that a competency in cranial US is an important aspect of training and service provision. This document was produced after wide consultation with neonatologists, radiologists and sonographers across the UK. The aim of this document is to provide a basic framework to provide a consistent standard achievable in all units. Some units may have to adapt their practice in order to meet the minimum standards proposed which should apply to a professional service for neonatal US scans. THE MACHINE: A high resolution real-time 2D machine with dedicated settings for cranial US. (Such a machine could be also used for cardiac imaging on the Neonatal Unit but would also need Doppler and colour flow capability). Probe requirements: High frequency transducer(s) (5-7 MHz) having a small footprint to match the size of the fontanelle, e.g. an electronic phased array or sector scanner. Depending on manufacturer, two probes may be needed, one of 5 MHz and one of 7.5 MHz (for large and small babies). Ideally a high frequency (7-10MHz) linear probe should also be available to scan the extra- cranial fluid spaces, and superior sagittal sinus. Quality assurance (QA): The scan machine should be checked (at least)
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