Cranial computed tomography and real-time sonography in full-term neonates and infants

Identifying infant hydrocephalus in the emergency department with transfontanellar POCUS

Hydrocephalus carries significant morbidity in the infant population. Although clinical symptoms are often nonspecific, hydrocephalus is easily identified using transfontanellar sonography. In this review, we provide the emergency physician with a succinct overview of infant hydrocephalus and the point-of-care ultrasound (POCUS) technique for identification of this pathology.

Intracranial hemorrhage in term newborns: management and outcomes

Child neurology is frequently a late player in the management of the term newborn with intracranial hemorrhage in the first neonatal week. It is crucial, however, that the child neurologist undertake a comprehensive evaluation by investigating etiology and management of the hemorrhage. Intracranial hemorrhage is usually associated with premature newborns. The literature on intracranial hemorrhage in term newborns is largely in the form of isolated case reports or a small series of cases, and mostly nonsystematic. Presented here is an evidence-based review of the incidence, risk factors, etiologies, and clinical management of intracranial hemorrhage in the first week after birth, with discussion of the role of neuroimaging and hematologic investigation. Consideration of these investigations along with documentation of every intervention or its explanation will reduce parental anxiety and will assure the best possible neurologic as well as legal outcomes of term newborns with intracranial hemorrhage.

Cranial sonography in term and near-term infants

Sonographic patterns of brain injury in the term and near-term infant are quite different from those in the premature infant. Although periventricular leukomalacia and germinal matrix hemorrhage are rarely seen in term infants, selective neuronal injury, parasagittal infarction, focal stroke, diffuse hypoxic-ischemic injury, and deep parenchymal hemorrhages are more common lesions. In addition, congenital brain tumors, hamartomatous lesions, such as hemimegalencephaly, and tuberous sclerosis can mimic ischemic and hemorrhagic injury. Sonography remains an important tool in the initial evaluation of intracranial abnormalities in critically ill term and near-term infants. An understanding of the differences in etiology, sonographic patterns, and limitations of sonography in the term infant is essential for accurate and effective diagnoses in this age group.

Sonographically detected subarachnoid hemorrhage: an independent predictor of neonatal posthemorrhagic hydrocephalus?

Blood from an intraventricular hemorrhage (IVH) can collect in the basilar cisterns and cause ventriculomegaly and eventual need for ventriculoperitoneal (VP) shunt. We looked for sonographic evidence of subarachnoid hemorrhage (SAH) in three basal cisterns and in the Sylvian fissure of 82 infants with IVH, 30 of whom had ventriculomegaly. We found that ultrasonographically diagnosed SAH and measurement of ventricular blood volume predict ventriculomegaly and need for VP shunt.

The predictive value of head ultrasound in the ECMO candidate

Cranial ultrasound (US) examination is the screening technique of choice for assessing preexisting neurological damage in potential neonatal extracorporeal membrane oxygenation (ECMO) candidates. Currently, US evidence of intracranial hemorrhage greater than grade I in severity is a contraindication to ECMO at this ECMO center. In the current study, radiological findings were reviewed in 129 consecutive neonatal ECMO cases in an attempt to identify which pre-ECMO US findings were associated with the development of subsequent intracranial complications while on ECMO. Pre-ECMO head US, post-ECMO head US, and head computed tomography (CT) scans were reviewed retrospectively by one radiology team. Ventricular, parenchymal, and extraaxial fluid abnormalities were recorded for each case. Pre-ECMO US findings were then correlated with the subsequent development of significant intracranial radiological abnormalities noted on post-ECMO studies as well as with clinical data regarding ECMO course and outcome. Results showed that infants with evidence of severe edema or periventricular leukomalacia on pre-ECMO imaging had a 63% incidence of subsequent major intracranial complications. This represents a significantly higher risk than in candidates with a normal examination or evidence of grade I intracranial hemorrhage, subependymal cysts, or mild edema. These results suggest that infants with sonographic evidence of ischemic or anoxic damage on pre-ECMO US are at high risk for the development of significant intracranial complications if ECMO therapy is instituted.

Infantile hydrocephalus: brain sonography as an effective tool for diagnosis and follow-up

Infantile hydrocephalus is a common disease. In most affected children the process starts before the age of 2 when the bregmatic fontanel is still open. Brain sonography has emerged as an effective tool in diagnosing progressive ventricle dilation and may be used for continuous follow-up. It gives such important information as: (a) cortical thickness, an expression of proper shunt function and of prognostic value concerning neuropsychological development; (b) position of the tip of the catheter, which is considered by some to be a predictive factor of shunt failure; (c) other complications such as subdural collections, isolated IV ventricle, and slit ventricles. This methodology permits frequent examinations and allows better comprehension of the pathological process by the parents and medical staff.

Cerebral blood flow velocity pattern in healthy and asphyxiated newborns: a controlled study

In a controlled study serial determinations of cerebral blood flow velocity using Doppler ultrasound and repeated real-time ultrasonographic- or computerized axial tomographic studies of the brain were performed in 17 (nearly) full-term newborns who experienced perinatal asphyxia and in 17 healthy matched controls during the first week of life. A higher cerebral blood flow velocity was found during the first 4 days of life, indicating a lower cerebrovascular resistance in the asphyxiated infants compared to the control infants. These haemodynamic changes coincided with cerebral oedema and neurological abnormalities. It is speculated that the changes in the cerebral circulation in asphyxiated infants are at least partly caused by cerebral oedema-induced increase of intracranial pressure due to severe perinatal asphyxia. Serial Doppler ultrasound investigations of the brain may be a useful non-invasive method for early detection and follow-up of the consequences of severe perinatal asphyxia.

Real time ultrasound, arterial pulsation and neonatal cerebral infarction

This paper describes an infant whose cranial ultrasound scan showed marked unilateral cerebral arterial pulsation and enlargement without other abnormality. Subsequent computerized tomogram showed extensive cortical infarction in an area not readily accessed by ultrasound. It is concluded that the real time dimension of cranial ultrasound is of diagnostic value in the absence of demonstrable parenchymal or intraventricular abnormality.

Neurosonography of hydrocephalus in infants

Transfontanel cranial ultrasonography reliably delineates ventricular size and anatomy in small infants. In these children, it is an excellent primary imaging technique for evaluation of the many clinical problems related to ventricular dilatation. Sonography can be useful for: detecting ventriculomegaly, differentiating nonobstructive ventricular dilatation from obstructive enlargement (hydrocephalus), determining the cause of hydrocephalus; aiding in the temporary management of patients with hydrocephalus; and aiding in the management of patients with permanent ventricular shunts.

Posthaemorrhagic hydrocephalus in newborn term infants

Intraventricular haemorrhage may occur de novo in previously well, term newborn infants. In a group of six neonates a high incidence of posthaemorrhagic hydrocephalus was found. Posthaemorrhagic hydrocephalus may be more common in full term newborn infants than previously recognised.

Transfontanellar ultrasound of term infants

Transfontanellar ultrasound scans were performed on 96 term infants admitted to a special care baby unit. Thirty infants had abnormal scans; abnormalities detected included intracranial haemorrhage, hydrocephalus and fluid collections. Intracranial haemorrhage is less common in term than in pre-term infants but is generally associated with a worse prognosis. Clinically asymptomatic infants were demonstrated to have significant abnormalities. It is suggested that ultrasound scanning should be the initial neuroradiological investigation in this age group and all term infants in a special care unit should be routinely scanned.