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| REVIEW ARTICLE |
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| Year : 2020 | Volume
: 9
| Issue : 4 | Page : 122-126 |
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Bed side neurosonogram – As essential tools in neonatal intensive care units
Nakul Kothari
Consultant, Critical Care and Neonatology, NH SRCC Children's Hospital, Mumbai, India
| Date of Submission | 09-Dec-2020 |
| Date of Decision | 25-Jan-2021 |
| Date of Acceptance | 08-Feb-2021 |
| Date of Web Publication | 22-Dec-2021 |
Correspondence Address:
Nakul Kothari
NH SRCC Children's Hospital, Mumbai, Maharashtra
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/jpai.jpai_31_20
In neonatal intensive care units (NICUs), almost all babies have one or more risk factors for the development of intracranial abnormalities or intracranial bleeds. Early identification of any such lesion is very important in treatment, prognostication, and directing further therapy in such high-risk babies. As NICU care in India is advancing, we should evolve and adapt the new strategies to help us serve our babies better. Neurosonogram is one such tool, which now is essential in any tertiary NICU. Neurosonogram is an ideal tool for the primary screening of the neonatal brain. It can demonstrate many unsuspected cranial abnormalities. It has to be emphasized about its use as a screening modality for preterm and birth asphyxia neonates influencing their neurodevelopmental outcome. This is particularly important in the anticipation of potential preventive, protective, and rehabilitative strategies for the management of critically ill newborn infants.
Keywords: Intraventricular hemorrhage, neonatal intensive care unit, neurosonogram, periventricular leukomalacia, ultrasound
How to cite this article:
Kothari N. Bed side neurosonogram – As essential tools in neonatal intensive care units. J Pediatr Assoc India 2020;9:122-6 |
How to cite this URL:
Kothari N. Bed side neurosonogram – As essential tools in neonatal intensive care units. J Pediatr Assoc India [serial online] 2020 [cited 2023 Oct 2];9:122-6. Available from: http://www.jpai.in//text.asp?2020/9/4/122/333372 |
| Bedside Neurosonogram, an Essential in Neonatal Intensive Care Unit | |  |
Ultrasound is now an essential tool in your neonatal intensive care unit (NICU), which will give you plenty of information. It can screen the extent of brain injury, cardiac function, presence of different intracardiac shunts, lung expansions, real-time response of surfactant replacement, air leaks, and many more.[1]
It is very important to incorporate bedside ultrasound in our daily practice and upskill ourselves to make it more useful for us. It can be extremely valuable to prognosticate and help us with difficult decision-making. This information can also be used to understand physiology better and further enhance our understanding of the baby's illness.[2]
| Before You Start | | |
- Familiarize yourself with your machine, know where the knobs are
- Inform parents preferably before or if in emergency, then after the scan
- Aseptic precautions (wash hands, clean probe)
- Position the baby according to the scan (Machine at the head end or on the right of the baby for heart scans) before commencing the scan
- Minimal handling and minimize time at the bedside
- Documentation of your findings.
| Holding the Probe | | |
- Marker to right for the head, abdomen, vascular
- Mark to baby's left for heart scans
- Always have the side of the hand in contact with the baby for stabilization
- Probe to have good contact with skin rather than pressure on the probe/baby.
| Which Babies to Scan | | |
- All babies <34 weeks gestation should have a routine neurosonogram to detect periventricular hemorrhage, ischemia, and/or ventricular dilatation.[3],[4]
In addition, scans are done in other cases, specifically in:
- Abnormal increase in head circumference
- Hemorrhage or parenchymal abnormalities in preterm and term infants
- Ventriculomegaly (hydrocephalus)
- Twin-to-Twin Transfusion Syndrome
- In-utero demise of sibling
- Vascular abnormalities
- Suspected hypoxic-ischemic injury (hypoxic-ischemic encephalopathy)
- Patients on therapeutic hypothermia, extracorporeal membrane oxygenation, and other support machines
- Congenital malformations
- Signs or symptoms of a central nervous system disorder (eg, seizures, facial malformations, macrocephaly, microcephaly, and intrauterine growth restriction)
- Congenital or acquired brain infection
- Suspected or known head trauma
- Craniosynostosis
- Follow-up or surveillance of previously documented abnormalities, including prenatal abnormalities
- Screening before surgery.
There are no contraindications to neurosonography.
Previous scans if done, should be re-assessed before a new scan is done.
| The Different Views | | |
- Anterior fontanelle (3 planes)
- Coronal
- Sagittal
- Para-sagittal.
- Posterior fontanelle
- Axial
- Temporal
- Post-auricular/mastoid.
| Standardized Imaging | | |
All images acquired should be standardized images for comparative study and appropriate references. They should be appropriately stored in accordance with the hospital's policy and reproducible when required.
Coronal view should have patient's right on the left side of the image. Typical coronal views can be attained by sweeping through, from anterior to posterior, using the anterior fontanelle window.
| Coronal Views | | |
Coronal views should include the following, sequentially as shown in [Figure 1]:
- Coronal section 1: Frontal lobes anterior to the frontal horns of the lateral ventricles with orbits visualized deep to the skull base [Figure 2]
- Coronal section 2: Frontal horns or bodies of lateral ventricles and interhemispheric fissure. Include lateral ventricles at the level of the foramina of Monro (outlining the course of the choroid plexus from the lateral into the third ventricle), interhemispheric fissure, cingulate sulcus (if developed), corpus callosum, septum pellucidum or cavum septi pellucidi, caudate nuclei, putamina, globi pallidi, and Sylvian fissures [Figure 3]
- Coronal section 3: Lateral ventricles slightly posterior to the foramina of Monro, the point at which the lateral and third ventricles communicate. Include the pons and medulla, thalami, and choroid plexus in the roof of the third ventricle and in the caudothalamic grooves [Figure 4]
- Coronal section 4: Level of the quadrigeminal plate cistern and cerebellum. Include the cerebellar vermis and cisterna magna [Figure 5]
- Coronal section 5: Echogenic glomi of choroid plexuses at the posterior aspect of the lateral ventricles at level of trigones. Include the splenium of the corpus callosum at divergence of the lateral ventricle and periventricular white matter lateral to the posterior horns of lateral ventricles [Figure 6]
- Coronal section 6: Posterior to occipital horns. Include parietal and occipital lobes and the posterior interhemispheric fissure [Figure 7]
- Midline sagittal views [Figure 8] to include the corpus callosum, cavum septi pellucidi, and cavum vergae, if present, third and fourth ventricles, aqueduct of Sylvius, brain stem, cerebellar vermis, cisterna magna, and sulci, if present. The branches of the anterior cerebral artery, [Figure 9] (pericallosal artery and callosomarginal artery) may be visualized as needed.
 | Figure 3: Coronal section view, through septum pellucidum and corpus callosum
Click here to view |
 | Figure 4: Coronal section view, through the foramen of Monro and third ventricle
Click here to view |
 | Figure 8: Midline sagittal view, showing various structures as identified in the image
Click here to view |
 | Figure 9: PW doppler through the anterior cerebral artery, calculating the RI
Click here to view |
The sagittal view, [Figure 8], by convention, should also include the following:
- Right and left parasagittal views to show the insula, Sylvian fissure
- Right and left parasagittal view to image the deep white matter (periventricular regions)
- Right and left parasagittal views of lateral ventricles, including the caudothalamic groove and choroid plexus
- Additional parasagittal views [Figure 10] to include all parts of lateral ventricles
- Midline anterior cerebral artery pulsed Doppler assessment of the resistive index, as needed, especially for infants with suspected hypoxic ischemic encephalopathy
Resistive index = (Peak systolic– end-diastolic)/peak systolic
Run-off situation: Low diastolic velocity RI > 0.80 reliably predicts rapid run-off (usually after 24 h if PDA)
The mastoid view is primarily used to visualize the cerebellum and may be obtained from both the right and left mastoid fontanelles as needed [Figure 11]. | Figure 11: Mastoid view, showing cerebellar hemisphere and fourth ventricle
Click here to view |
Additional views, if necessary, maybe taken through the posterior fontanelle, any open suture, burr hole, craniotomy defect, or thin areas of the temporal and parietal bones. The axial view can be useful to see the blood flow in the “Circle of Willis,” as shown in [Figure 12].
The Doppler power output should be as low as reasonably achievable (ALARA) to answer the diagnostic question.
| Some Important Measurements in Neurosonogram | | |
These values should always be interpreted with the gestational age-wise normal values.[5]
Some important measurements that can be useful are anterior horn width, ventricular index, thalamo-occipital distance, 3rd ventricular diameter, 4th ventricular dimensions, and trans-cerebellar diameter, as depicted in [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17].
| Documentation | | |
Accurate and complete documentation is essential for high-quality patient care. Written reports and ultrasound images/video clips that contain diagnostic information should be obtained and archived, with recommendations for follow-up studies if clinically applicable, in accordance with the local policy.
| Infection Control | | |
Transducer preparation, cleaning, and disinfection should follow manufacturer's recommendations and be consistent with the local infection control policy.
| Conclusion | | |
Neurosonogram is critical as an investigatory modality in NICU for early, safe and easy diagnostic tool for predicting the neurological damage for management in NICU and predicting outcome. Expected outcomes from NICU has moved from “survival” to “intact survival” of the high-risk infant, prompting initiation of strategies to identify neurological abnormality at the earliest. Neurosonogram is an ideal tool for the primary screening of the neonatal brain. It can demonstrate many unsuspected cranial abnormalities. It has to be emphasized about its use as a screening modality for preterm and birth asphyxia neonates influencing their neurodevelopmental outcome. This is particularly important in the anticipation of potential preventive, protective, and rehabilitative strategies for the management of critically ill newborn infants.[6]
Acknowledgment
I am thankful to Dr. Jan Klimek, my mentor and guide, who introduced me to the world of bedside ultrasounds. He taught me how this skill can help me manage babies in the NICU. I will be forever indebted to him for his time, efforts and patience towards amateur trainees like me.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Leijser LM, Cowan FM. State-of-the-art neonatal cranial ultrasound. Ultrasound 2007;15:6-17.  |
| 2. | Maria A, Gupta A, Aggarwal R, Sreenivas V, Paul VK, Deorari AK. Incidence of periventricular leucomalacia among a cohort of very low birth weight neonates (<1500 g). Indian Pediatr 2006;43:210-6. |
| 3. | van Houten JP, Rothman A, Bejar R. High incidence of cranial ultrasound abnormalities in full-term infants with congenital heart disease. Am J Perinatol 1996;13:47-53. |
| 4. | Van Wezel-Meijler G. Cranial Ultrasonography: Advantages and Aims Part 1, Neonatal Cranial Ultrasonography. 1 st ed. Berlin: Springer; 2007. p. 3-4. |
| 5. | Leijser LM, Cowan FM. State-of-the-art neonatal cranial ultrasound. Ultrasound 2007;15:6-17. |
| 6. | Veyrac C, Couture A, Saguintaah M, Baud C. Brain ultrasonography in the premature infant. Pediatr Radiol 2006;36:626-35. |
[Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5], [Figure 6], [Figure 7], [Figure 8], [Figure 9], [Figure 10], [Figure 11], [Figure 12], [Figure 13], [Figure 14], [Figure 15], [Figure 16], [Figure 17]
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