sign in sign up
<<
Home , Fontanelle

UNIVERSITY OF WASHINGTON MEDICAL CENTER DIAGNOSTIC ULTRASOUND DEPARTMENT PROTOCOL NEONATAL

Pt. Prep –No prep

Exams are usually done in the NICU, where there are strict disinfection guidelines. All personnel entering the NICU must use good hand washing technique along with use of disinfecting gel/lotion. Please read the signs on the patient doors and if patient is in isolation follow the instructions. If there is a sign that says 72, that means that they baby is in it’s first 72 hours of life and you need to contact the RN before going in. You must gel or wash your hands and arms up to your elbow. If the patient is in isolation then the sonographer should wear a blue plastic gown. Please let the RN know that you are coming up or that you have arrived before starting the exam.

Clean the transducer with the same wipes that we use for all our probes, between each patient. Individual gel packs must be used to minimize any spread of infection.

Transducer selection: Scanning is to be performed with dedicated neonatal head probes - multiple-foci 8.0 - 5.0-MHz or higher transducers. Ultrasound widows: The drawing below, illustrates the neonatal scull (lateral view) with the major sutures to illustrate the posterior, anterior and mastoid fontanelle. Technique - Access • – open until 9 to 18 months • Open longer – Premature infants – Increased ICP

Technique - Access • , • Squamosal suture, • Anterolateral or • Posterolateral fontanelles.

Normal anatomy:

Normal anatomy

Preferred imaging order and technique:

Document coronal views of the with the patients right side located on the left hand of the ultrasound screen with specific images as mentioned below.

1. Document coronal views of the brain with specific images as mentioned below.

Demonstrate brain anatomy in the coronal plane through anterior fontanel; scanning from anterior to the frontal horns through the brain to posterior to the atria of the brain:

1. Anterior to the frontal horns 2. Through the frontal horns 3. Level of MCA’s 4. Foramen of Monroe (3rd ventricle) 5. Body of the lateral ventricles 6. Atria 7. Posterior to atria

Standard views CORONAL 1. Anterior to frontal horns (frontal lobe parenchyma)

2. Anterior horns / sylvian fissure

3. 3rd ventricle / thalami

4. Posterior horns / choroid plexus

5. Parietal parenchyma

British Society of Paediatric Radiologists 2003

2. Document sagittal views of the brain with specific images as mentioned below.

Demonstrate the anatomy in the following sagittal planes (through anterior fontanel): 1. Midline through CSP, 3rd ventricle, and brainstem 2. Long axis of each ventricle, demonstrating the thalamo-caudate notch 3. Right and left periventricular parenchyma

Standard views • SAGITTAL

• Midline (3rd / 4th ventricles, CSP, cerebellum) • Caudo-thalamic groove • Ventricle (anterior, body, posterior, temporal) • Lateral to ventricle to image deep white matter

British Society of Paediatric Radiologists 2003

Identify and document any of the following:

• /Ventriculomegaly • Subependymal Hemorrhage (with or without ventricular invasion) • Subependymal hemorrhage with ventricular dilatation • Intraventricular hemorrhage with intraparenchymal invasion • Periventricular areas of parenchymal cysts/infarct

3. Document images of the cerebellum by scanning through the mastoid fontanelle.

Demonstrate the anatomy of the posterior fossa in the following planes:

1. Axial – US transducer positioned almost parallel to the orbito-meatal line and above the tragus, slightly separating the external auricle. 2. Coronal – US transducer placed along the and moved slightly from the tragus to a retro-auricular position. White arrows indicate the orientation of the transducer.

Axial images:

1. Superior anterior view through the cerebral peduncles

2. Middle view through the superior vermis

3. Inferior–posterior view through fourth ventricle and inferior vermis and cisterna magna

Coronal images: 1. Through the mid-brain

2. Through the anterior cerebellar hemispheres

3. Through the vermis

4. Through the posterior cerebellar hemispheres

Cine clips should be used to further document any suspected pathology.

Intracranial hemorrhage Classification according to Papille Grade 1- Hemorrhage limited to subependymal matrix. Grade 2- Hemorrhage extending into ventricular system, < 50%. Grade 3- Hemorrhage extending into ventricular system, 50% or more of one or both lateral ventricles. Grade 4- Hemorrhage grade 1, 2 or 3 with extension into brain tissue.

1) If the infant has a Grade II bleed or higher and ventriculomegaly please take these extra measurements, in addition to the normal neonatal head protocol.

2) Abnormal Normal

3) Image to be taken at the foramen of Monroe – best seen when you see the temporal horns and midbrain 4) The widest distance across the ventricular walls of frontal horns (A): ___cm 5) The widest distance across the ventricular walls of the temporal horns (B): ___cm 6) The widest internal diameter at the foramen of Monroe (C): ___cm 7) Calculate the FTHR: Frontal temporal horn ratio (A+B/2*C) 8) Abnormal Normal 9) The widest bioccipital horn diameter (D): ____cm 10) The widest biparetal diameter (E): ___cm 11) Calculate the FOR: Fronto occipital ratio (A+D/2*E) Cut offs - Normal =0.4, Mild=0.55, Moderate=0.60, Severe=0.7 for both FOR and FTR. Shunt needed when the ratio is greater than 0.55

8/17