This document provides an overview of neonatal brain anatomy and common pathologies seen on ultrasound. It begins with a review of embryonic brain development and the anatomy of structures like the ventricles, basal ganglia, cerebellum and vascular system. Common indications for neonatal brain ultrasound are described. The technique involves scanning standardized coronal and sagittal views to evaluate the supratentorial and infratentorial compartments. Common abnormalities like Chiari malformation, holoprosencephaly, Dandy-Walker malformation, agenesis of the corpus callosum, ventriculomegaly and hydrocephalus are summarized with their characteristic ultrasound findings. Hemorrhagic pathologies such as intraventricular and

1. Dr/Ahmed Bahnassy
Consultant Radiologist
MBCHB-MSc-FRCR
Former:
Senior consultant Radiologist Riyadh Military hospital
AP Radiology -Qassim Univeristy-KSA

4. • Safe
• Bedside- compatible
• Reliable
• Early imaging
• Serial imaging:
Brain maturation
Evolution of lesions
• Inexpensive
• Suitable for screening

7. Embryology
• At the end of the 4th
week after conception,
the cranial end of the neural tube
differentiates into 3 primary brain vesicles
– Prosencephalon (Forebrain)
• Diencephalon
– Thalmus
– Hypothalmus
– Posterior Pituitary
• Telencephalon
– Cerebral hemispheres
– Cortex & Medullary Center
– Corpus Striatum
– Olfactory System
– Mesencephalon (midbrain)
• Cerebral Aqueduct
• Superior and inferior colliculi
(quadrigeminal body)
– Rhombencephalon (hindbrain)
• Myelencephalon
– Closed part of medulla oblongata
• Metencephalon
– Pons
– Cerebellum
– 3rd
, 4th,
and lateral ventricles
– Choroid Plexus

8. Anatomy of the Neonatal
Brain
Cerebrum
• 2 Hemispheres (Gray and White Matter)
• Lobes of the Brain
– Frontal
– Parietal
– Occipital
– Temporal
• Gyrus and Sulcus
– Gyrus: convulutions of the brain surface causing
infolding of the cortex
– Sulcus: Groove or depression separating gyri.

9. Anatomy of the Neonatal
Brain
Cerebrum• Fissures
– Interhemispheric
• Area of Falx Cerebri
– Sylvian
• Most lateral aspect of brain
• Location of middle cerebral artery
– Quadrigeminal
• Posterior and inferior from the cavum
vergae
• Vein of Galen posterior to fissure
• Falx Cerebri
– Fibrous structure separating the 2
cerebral hemispheres
• Tentorium Cerebelli
– “V” shaped echogenic extension of the
falx cerebri separating the cerebrum
and the cerebellum

10. Cerebrum
• Basal Ganglia
• collection of gray matter
– Caudate Nucleus & Lentiform
Nucleus
• Largest basal ganglia
• Relay station between the
thalmus and cerebral cortex
• Germinal Matrix includes
periventricular tissue and
caudate nucleus
– Thalmus
• 2 ovoid brain structures
• Located on either side of the 3rd
ventricle superior to the
brainstem
• Connects through middle of the
3rd
ventricle through massa
intermedia
– Hypothalmus
• “Floor” of 3rd
Ventricle
• Pituitary Gland is connected to
the hypothalmus by the
infundibulum

11. Anatomy of the Neonatal
Brain
• Meninges
– Dura Mater
– Arachnoid
– Pia Mater
• Cerebral Spinal Fluid (CSF)
– Surrounds and protects brain and spinal
cord.
– 40% formed by ventricles, 60%
extracellular fluid from circulation.

12. Ventricular System
• Lateral Ventricles: Largest of
the CSF cavities.
– Frontal Horn
– Body
– Occipital Horn
– Temporal Horn
• Trigone “Atrium”
• Foramen of Monro
• 3rd
Ventricle
• Aqueduct of Sylvius
• 4th
Ventricle
• Foramen of Luschka
• Foramen of Megendie
• Cisterns
– Cisterna Magna
• Spaces at the base of the
skull where the arachnoid
is widely separated from
the pia mater.

13. Anatomy of the
Neonatal Brain
• Corpus Callosum
– Broad band of connective fibers between cerebral hemispheres.
– The “roof” of the lateral ventricles.
• Cavum Septum Pellucidum
– Thin, triangular space filled with CSF
– Lies between the anterior horn of the lateral ventricles.
– “Floor” of the corpus callosum
• Choroid Plexus
– Mass of specialized cells that regulate IV pressure by secretion/absorption of CSF
– Within atrium of the lateral ventricles
Choroid
Plexus
Cavum
Septum
Pellucidum

14. Anatomy of the Neonatal
Brain
Brain Stem
• Midbrain
• Pons
• Medulla
Oblongata

15. Anatomy of the Neonatal
Brain
Cerebellum
• Posterior cranial
fossa
• 2 Hemispheres
connected by
Vermis
• 3 Pairs of Nerve
Tracts
– Superior Cerebellar Peduncles
– Middle Cerebellar Peduncles
– Inferior Cerebellar Peduncles

16. Cerebrovascular
System
• Internal Cerebral
Arteries
• Vertebral Arteries
• Circle of Willis
– Middle Cerebral
Artery
• Longest branch in
Circle of Willis
that provides 80%
of blood to the
cerebral
hemispheres

17. Anatomy of the Neonatal Skull
• Fontanelles (“Soft Spots”)
– Spaces between bones of the skull

18. Indications for Sonographic
Exam
• Cranial abnormality found on pre-natal sonogram
• Increasing head circumference with or without
increasing intracranial pressure
• Acquired or Congenital inflammatory disease
• Prematurity
• Diagnosis of hypoxia, hypertension, hypercapnia,
hypernaturemia, acidosis, pneumothorax, asphyxia,
apnea, seizures, coagulation defects, patent ductus
arteriosus, or elevated blood pressure
• History of birth trauma or surgery
• Suctioning of infant
• Genetic syndromes and malformations

19. Sonographic Technique
• What anatomy do you scan?
– Supratentorial Compartment
• Both cerebral hemispheres
• Basal Ganglia
• Lateral & 3rd
Ventricle
• Interhemispheric fissure
• Subarachnoid space
– Views
» Coronal
» Modified Coronal (anterior fontanelle)
» Sagittal (anterior fontanelle)
» Parasagittal (anterior fontanelle)
– Infratentorial Compartment
• Cerebellum
• Brain Stem
• 4th
Ventricle
• Basal Cisterns
– Views
» Coronal (mastoid fontanelle and occipitotemporal area)
» Modified Coronal
» Sagittal
» Parasagittal (with increased focal depth & decreased frequency)

20. • Transucers : 5–7.5–10 MHz
• Appropriately sized
• Standard examination: use 7.5–8 MHz
• Tiny infant and/or superficial structures:
use additional higher frequency (10 MHz)
• Large infant, thick hair, and/or deep
structures: use additional lower frequency
(5 MHz)

22. Anterior
Fontanel
The Standard
view window
Posterior
Fontanel
Supplementary
view window
Mastoid
Fontanel
Supplementary
view window
Temporal
Supplementary
view window

23. • Coronal Views (at least 6 standard planes)

31. • Sagittal Views (at least 5 standard
planes)

42. 23. Tentorium
24. Mesencephalon
25. Occipital lobe
26. Parieto-occipital fissure
27. Calcarine fissure
28. Pons
29. Medulla oblongata
30. Fourth ventricle
31. Cisterna magna
32. Cisterna quadrigemina
33. Interpeduncular fossa
34. Fornix
35. Internal capsule
36. Occipital horn of lateral
ventricle
37. Insula
38. Falx
39. Straight sinus (sinus rectus)
40. Temporal horn of lateral
ventricle
41. Circle of Willis
42. Prepontine cistern
1. Interhemispheric fissure
2. Frontal lobe
3. Skull
4. Orbit
5. Frontal horn of lateral ventricle
6. Caudate nucleus
7. Basal ganglia
8. Temporal lobe
9. Sylvian fissure
10. Corpus callosum
11. Cavum septum pellucidum
12. Third ventricle
13. Cingulate sulcus
14. Body of lateral ventricle
15. Choroid plexus
(*: plexus in third ventricle)
16. Thalamus
17. Hippocampal fissure
18. Aqueduct of Sylvius
19. Brain stem
20. Parietal lobe
21. Trigone of lateral ventricle
22. Cerebellum
(a: hemispheres; b: vermis)

45. Doppler uses
• Typical transcranial Doppler with
imaging scan and recording from
middle cerebral artery (MCA).
• Doppler image shows circle of Willis.
– A = anterior cerebral artery
– M = middle cerebral artery
– P = posterior cerebral artery
– RI = resistive index
• Demonstrates
– Decreased blood
flow/ischemia/infarction
– Vascular abnormalities
– Cerebral Edema
– Hydrocephalus
– Intracranial Tumors
– Near-field structures

47. Middle Cerebral Artery

48. Carotid Siphon - Genu

49. Anterior Cerebral Artery

50. Posterior Cerebral Artery – P1

51. Ophthalmic Artery

52. Basilar Artery

53. BLOOD FLOW VELOCITY
• Changes in flow velocity occur
when:
• There is a change in vessel caliber
• There is a change in volume flow

54. should we do doppler study
cyst=doppler
vein of
galen
aneurysm

56. Chiari Malformation
• Downward displacement of the cerebellar tonsils and
the medulla through the foramen magnum.
• Arnold-Chiari malformation shows a small displaced
cerebellum, absence of the cisterna magna,
malposition of the fourth ventricle, absence of the
septum pellucidum, and widening of the third
ventricle
– Commonly related
to meningomyelocele

57. Chiari Malformation
• Sonographic Features
– Small posterior fossa
– Small, displaced
Cerebellum
– Possible
Myelomeningocele
– Widened 3rd
Ventricle
– Cerebellum herniated
through enlarged foramen
magnum
– 4th
ventricle elongated
– Posterior horns enlarged
– Cavum Septum
pellucidum absent
– Interhemispheric Fissure
widened
– Tentorium low and
hypoplastic

58. Holoprosencephaly
• Common large central ventricle because prosencephalon
failed to cleave into separate cerebral hemispheres.
– Alobar Holoprosencephaly (Most Severe)
• Fused thalami anteriorly to a fused choroid plexus
• Single midline ventricle
• No falx cerebrum, corpus callosum, interhemispheric
fissure, or 3rd
ventricle
– Semilobar Holoprosencephaly
• Single ventricle
• Presents with portions of the falx and interhemispheric
fissure
• Thalmi partially separated
• 3rd
Ventricle is rudimentary
• Mild facial anomalies
– Lobar Holoprosencephaly (Least Severe)
• Near complete separation of hemipsheres; only anterior
horns fused
• Full development of falx and interhemispheric fissure

59. Holoprosencephaly
Alobar Holoprosencephaly Semilobar Holoprosencephaly

60. Dandy-Walker Malformation
• Congenital anomaly of the roof of the 4th
ventricle
with occlusion of the aqueduct of Sylvius and
foramina of Magendie and Luschka
• A huge 4th
ventricle cyst occupies the area where the
cerebellum usually lies with secondary dilation of the
3rd
ventricle; absent cerebellar vermis

61. Dandy-Walker Malformation

62. Agenesis of the Corpus
Callosum
• Complete or partial absence of the connection tissue between
cerebral hemispheres
– Narrow frontal horns
– Marked separation of lateral ventricles
– Widening of occipital horns and 3rd
Ventricle
• “Vampire Wings”

63. Agenesis of the Corpus Callosum

64. Ventriculmegaly
• Enlargement of the ventricles
without increased head
circumference
– Communicating
– Non-communicating
– Resut of cerebral atrophy
• Sonographic Findings
– Ventricles greater than
normal size first noted in the
trigone and occipital horn
areas
– Visualization of the 3rd
and
possibly 4th
ventricles
– Choroid plexus appears to
“dangle” within the
ventricular trium
– Thinned brain mantle in
case of cerebral atrophy

65. Hydrocephalus
• Enlargement of ventricles with increased
head circumference
– Communicating
– Non-communicating
• Sonographic Findings
– Blunted lateral angles of enlarged lateral
ventricles
– Possible intrahemispheric fissure
rupture
– Thinned brain mantle
• Aqueductal Stenosis
– Most common cause of congenital
hydrocephalus
– Aqueduct of Sylvius is narrowed or is a
small channel with blind ends;
occasionally caused by extrinsic lesions
posterior to the brain stem
– Sonographic Findings
• Widening of lateral and 3rd
ventricles
• Normal 4th
ventricle

66. Hydrancephaly
• Occlusion of internal carotid
arteries resulting in necrosis
of cerebral hemispheres
– Absence of both cerebral
hemispheres with presence
of the falx, thalmus,
cerebellum, brain stem, and
postions of the occipital and
temporal lobes
– Sonographic findings
• Fluid filled cranial vault
• Intact cerebellum and
midbrain

67. Cephalocele
• Herniation of a portion of the neural tube through a
defect in the skull
• Sonographic Findings
– Sac/pouch containing brain tissue and/or CSF and
meninges
– Lateral Ventricle Enlargement

68. Subarachnoid Cysts
• Cysts lined with arachnoid tissue and containing CSF
• Causes
– Entrapment during embryogenesis
– Residual subdural hematoma
– Fluid extravasation sectondary to meningeal tear or
ventricular rupture

69. Hemorrhagic Pathology
• Subependymal-Intraventricular Hemorrhage (SEH-IVH)
– Caused by capillary bleeding in the germinal matrix
– Most frequent location is the thalamic-caudate groove
– Continued subependymal (SEH) bleeding pushes into the
ventricular cavity (IVH) & continues to follow CSF pathways
causing obstruction
– Treatment: Ventriculoperitoneal Shunt
– Since 70% of hemorrhages are asymptomatic, it is necessary
to scan babies routinely
– Small IVH’s may not be seen from the anterior fontanelle
because blood tends to settle out in the posterior horns
• Risk Factors
– Pre term infants
– Less than 1500 grams birth weight

70. Hemorrhagic Pathology
• Grades
– Based on the extension of the hemorrhage
– Ventricular measurement
• Mild dilation: 3-10 mm
• Moderate dilation: 11-14 mm
• Large dilation: greater than 14mm
• Grade I
– Without ventricular enlargement
• Grade II
– Minimal ventricular enlargement
• Grade III
– Moderate or large ventricular enlargement
• Grade IV
– Intraparenchymal hemorrhage

71. Hemorrhagic Pathology
• Grade I

72. Hemorrhagic
Pathology
• Grade II

73. Hemorrhagic Pathology
• Grade III

74. Hemorrhagic Pathology
• Grade IV

75. Intraparenchymal Hemorrhage
• Brain parenchyma
destroyed
• Originally considered an
extension of IVH, but
may actually be a
primary infarction of the
periventricular and
subcortical white matter
with destruction of the
lateral wall of the
ventricle.
• Sonographic Finding
– Zones of increased
echogenicity in white
matter adjacent to
lateral ventricles

76. Intracerebellar Hemorrhage
• Types
– Primary
– Venous Infarction
– Traumatic Laceration
– Extension from IVH
• Sonographic Findings
– Areas of increased
echogenicity within
cerebellar parenchyma
• Coronal views through
mastoid fontanelle may
be essential to
differentiate from large
IVH in the cisterna
magna

77. Epidural Hemorrhages and
Subdural Collections
• Best diagnosed with CT because the
lesions are located peripherally along
the surface of the brain.

78. Ischemic-Hypoxic Lesions
• Hypoxia: Lack of adequate oxygen to the brain
• Ischemia: lack of adequate blood flow to the brain
– Types
• Selective neuronal necrosis
• Status marmoratus
• Parasagittal cerebral injury
• Periventricular leukomalacia (PVL), white matter
necrosis (WMN), or cerebral edema
• Focal brain lesions (occurs when lesions are distributed
within large arteries)
– Sonographic Findings
• Areas of increased echogenicity in subcortical and deep
white matter in the basal ganglia

79. Ischemic-Hypoxic Lesions
Periventricular Leukomalacia (PVL) or White
Matter Necrosis (WMN)
• Most important cause of abnormal neurodevelopment
in preterm infants
• Early chronic stage
– Multiple cavities develop in necrotic white matter
adjacent to frontal horns
• Middle chronic Stage
– Cavities resolve and leave gliotic scars and diffuse
cerebral atrophy
– Increased Echogenicity
• Late chronic stage
– Echolucencies develop in the echolucent lesions
corresponding to the cavitary lesions in the white
matter (cysts)

80. PVL or WMN
1 2
3
4

81. Brain Infections
• Common infections referred to by TORCH
– T: Toxoplasma Gondii
– O: Other (Syphilis)
– R: Rubella Virus
– C: Cytomegalovirus
– H: Herpes Simplex Type 2
• Consequences
– Mortality
– Mental Retardation
– Developmental Delay

82. Ependymitis and Ventriculitis
• Ependymitis
– Irritation from hemorrhage within
the ventricle
– Occurs earlier than ventriculitis
• Sonographic Features
– Thickened, hypoechoic ependyma
(epithelial lining of the ventricles)
• Ventriculitis
– Common complication of purulent
meningitis
• Sonographic Findings
– Thin septations extending from the
walls of the lateral ventricles.

83. Questions to be answered during
exam

87. Why US spines ?
Spinal ultrasound (SUS) is becoming
increasingly accepted as a first line
screening test in neonates suspected of
spinal dysraphism .

89. Challenging MRI
The advantages of SUS are not only a diagnostic sensitivity
equal to MRI but that, unlike MRI, SUS can be
performed portably, without the need for sedation or
general anaesthesia.
In addition, MRI is highly dependent on factors affecting
resolution, including patient movement, physiological
motion from cerebral spinal fluid (CSF) pulsation and
vascular flow, factors that do not affect SUS .
New generation high frequency ultrasound machines
with extended field of view capability now permit
imaging of high diagnostic quality in young
babies.

90. When to perform ?
SUS is possible in the neonate owing to a lack
of ossification of the predominantly cartilaginous
posterior arch of the spine . The quality of
ultrasound assessment decreases after the first
3–4 months of life as posterior spinous elements
ossify, and in most children SUS is not possible
beyond 6 months of age. However, the persisting
acoustic window in children with posterior spinal
defects of SD enables ultrasound to be performed
at any age

91. When to request US spines ?
Current RCR guidelines are that
all neonates with a hairy patch or sacral
dimple should undergo SUS . However,
while more than 90% of patients with occult
SD have a cutaneous abnormality over the
lower spine , a cutaneous marker may have
a low yield in predicting the presence of a
clinically significant abnormality. In a recent
review of 200 SUS examinations performed
over an 11-year period, SD was found in
less than 1% of cases when a cutaneous
marker was the only clinically detected
abnormality .

92. Gastrulation stage

93. Neurulation stage

94. Retrogressive differentiation and
relative cord ascent
Formation of the
ventriculus terminalis, the
caudal portion of the
conus medullaris, and the
filum terminale through the
processes of canalization
and retrogressive
differentiation.

96. Sonographic examination of the neonatal spine
is performed with the infant in a warm room lying
in a prone, lateral decubitus, or semi-erect
position.
Feeding the infant before examination helps him
or her to relax.
Placing a towel under the infant’s pelvis will flex
the spine enough to separate the midline
posterior arches .
.

98. A high frequency (7- to 15-MHz) linear-
array transducer should be used .. higher
frequency transducers are beneficial for
optimization of superficial structures such
as skin lesions and sinus tracts.
Extended field-of-view (EFOV) imaging is
an additional feature that can demonstrate
the whole neonatal spine from T12 to the
coccyx

99. • Mark T 12 in
transverse
plane
(presence of
ribs
witnessing)
• Then count
downwards to
end of cord.

100. Alternatively by
Locating the last lumbar vertebra, L5, by
evaluating the lumbosacral junction. Then
count cephalad to the conus medullaris.
Locating the last ossified vertebral body,
the first coccygeal segment. Then count the
five sacral segments cephalad into the
lumbar vertebra.

101. The spinal cord lies in the spinal canal within anechoic
CSF of the subarachnoid space. Surrounding
the canal is the dura mater, which is shown by
anechogenic line dorsal and ventral to the canal. The
cord is lined with the arachnoid sheet, which exhibits an
echogenic line parallel to the cord’s surface.
Caudally, the lumbar enlargement tapers, forming the
conus medullaris, which extends and becomes the filum
terminale.

102. Filum teminale
The filum terminale images as an echogenic
cordlike structure that is surrounded by
echogenic nerve roots of the cauda
equina. For that reason, separation of the two is
difficult.
However, the filum terminale is commonly more
echogenic than the surrounding cauda equina.
The filum terminale normally measure less than
or equal to 2 mm.

103. Cord
On a sagittal image, the spinal cord appears as
a hypoechoic cylindrical structure with two echogenic
complexes centrally. These represent the
central echo complex. The normal cord lies one
third to one half of the way between the dorsal and
ventral walls of the spinal canal
On a transverse image, the cervical spinal cord
appears as an oval shape, whereas the thoracic and
lumbar portions are more circular.

104. Conus level
The level of the conus usually ends between
T12 and L1 or L2 .If it ends at the L2-L3 disk space or
lower, it is abnormal, and one should explore for any
tethering masses. However, it must be noted that a
normal cord may lie around L3, mainly in preterm infants.
The normal position of the cord should be central
in the spinal canal. The spinal cord is held in place
by echogenic dentate ligaments passing laterally
from each side of the cord.
The normal spinal cord produces a rhythmic movement

105. • Standard views

107. Cystic ventriculus terminalis
(normal variant)

108. Cystic distension of distal spinal
canal (normal variant )
Size smaller
than
5 mm and
stability over
time
distinguish this
normal variant
from small
syrinx.

109. Filar cyst (normal variant)
criteria for filar
cyst:
location just below
conus medullaris,
fusiform shape,
well defined, thin
walled, and
hypoechoic.

110. Pseudo-masses
• Clumped nerve
roots..
• Use 2
planes..to see
the whole
length of nerve
root.

111. Dysmorphic coccyx
• Cartilagenous
angulated
lesion.
• Not dermal
sinus track.

112. Three processes can lead to
congenital anomalies:
First, premature separation of the skin
ectoderm from the neural tube
can lead to entrapment of
mesodermal elements, such as
fat.
Second, failed neurulation leads to
dysraphisms,
such as myelomeningocele(overt
or closed )

113. Last ,anomalies of the
filum terminale, such as
fibrolipomas and caudal
regression syndrome
caused by
disembryogenesis of the
caudal cell mass

114. Classification
Congenital spinal dysraphisms can be classified on the
basis of the presence or absence
of a soft-tissue mass and skin covering .
Those without a mass include tethered cord,
diastematomyelia, anterior sacral meningocele,
and spinal lipoma.
Those with a skin covered soft-tissue mass include
lipomyelomeningocele and myelocystocele.
And those with a back mass but without skin covering
include myelomeningocele and myelocele

117. Lipoma

118. Dorsal dermal sinus track

119. Tethered cord
Sonographically, tethered cord is diagnosed
in neonates by the presence of a low-lying
conus (below the L2–L3 disk space) and
lack of normal nerve root motion during realtime
sonography
Search for cause

120. Intradural lipoma
• Hyperechoic
dural mass..
• Tethered cord.

121. Thick filum terminale

122. Fatty filum

123. Lipoma of filum terminale
Tethered cord
L3

124. Diastematomyelia
• Echogenic spur
between two
hemicords in
transverse
image.

125. Caudal regression syndrome
• Blunted conus
medullaris.
• Fatty filum
• Absence of sacral
vertebrae and
coccyx .

126. Myelomeningocele
• Cystic mass
(CSF)
• +tethered
cord
• +neural
elements.
• +soft tissue
mass

127. Unilocular meningocele

128. Lipomyelomenimgeocyle

129. Trauma evaluation
haematoma

130. Spinal cord compression
craniocervical narrowing in bone dysplasia

132. Neuroblastoma

133. Sacrococcygeal teratoma

139. Conclusion
• Spinal ultrasound (SUS) is becoming
accepted as a first line screening test in
neonates with high sensitivity and
specificity.
• Recognizing normal anatomy ,variants
and congenital anomalies early in life help
in futur planning of management .

141. • Echostructure.
• Size.
• Variations.
• Congenital anomalies.
• Renal abnormality.

142. RENAL ANATOMY
RENAL
CORTEX
MEDULLA
MAJOR
CALYCES
RENAL
PELVIS
RENAL
MEDULLARY
PYRAMID
RENAL
CAPSULEURETER
MINOR
CALYX
RENAL
COLUMN

143. NORMAL RENAL
SONOGRAPHY
• Paired retroperitoneal organs
• Renal sinus- dense central echoes
due to renal fat
– Contains:
• Collecting system: calyces, infundibula, &
part of renal pelvis
– bifid system seen as two separate lobulations
• Renal vessels: renal hilium
• Lymphatics
• Fat
• Fibrous tissues

144. RENAL SINUS
• Central area of the kidney
from the medial border
• Bounded by fat
– anteriorly and posteriorly by
fibrous sheath known as
Gerota’s fascia
– laterally by the laterocoronal
fascia which becomes
continuous with peritoneum
& abdominal wall

145. RENAL SONOGRAPHY
• Renal parenchyma - 2 parts cortex & medulla
– thickest at the renal poles
• Cortex located between capsule & medulla
– low level uniform echoes
– less echogenic than liver & spleen
– Columns of Bertin = columns of cortical tissue located between
pyramids
» can enlarge & mimic a mass
» normal variant
• medulla
– renal volume is estimated bywater displacement
• V = 0.49 x length x width x anterior posterior dimension

146. RENAL SONOGRAPHY
• Renal parenchyma - 2 parts cortex & medulla
– Medulla
• Pyramids - triangular or rounded hypoechoic areas
• Rounded zones of decreased echogenicity between
cortex & renal sinus
• Specular echoes interspersed at the junction of the
cortex & medulla represents arcuate arteries & veins
(known as corticomedullaryjunction)

147. Dysplastic kidney
renal parenchymal thickness
compared to normal
cortico-
medullary
ratio
larger volume of medulla in the neonatal kidney
results in a ratio of cortex to medulla of 1.64:1 in the
neonate as compared with a ratio of 2.59:1 in the
adult.

148. RENAL SONOGRAPHY
• Vascular exchange
– renal arteries
• come off of aorta - can be multiple
• right renal artery (RRA) - seen posterior to IVC in
sagittal plane
– renal veins
• come off of IVC
• left renal vein (LRV) - seen between SMA & aorta
in the transverse plane

149. RENAL ARTERY

150. RENAL SIZE

151. Normal renal size
Normal Liver, Spleen,
and Kidney
Dimensions in
Neonates, Infants,
and Children:
Evaluationwith
Sonography..
AJR:171,December19
98

152. Development

153. Anomalies and variations
• Congenital variations
– fetal lobulations
– dromedary hump.
– Fusion anomalies :horseshoe -
isthmus of tissue that connects
both kidneys
– Ascent anomalies: pelvic kidney
fails to migrate from pelvic area
during embryology

154. Renal pyramids ..The
normal and abnormal

155. principle
Focused sonographic
evaluation of the
pyramids with high-
frequency
transducers produces
the most detailed
images of the
pyramids

156. This improved
resolution is best
achieved with
lineararray
transducers
functioning at a high
megahertz range
(even up to 17 MHz)

157. warning
Those unfamiliar with this normal neonatal
appearance,
the relatively large, normal, hypoechoic
pyramids may be misinterpreted as dilated calices
or renal cystic disease and the relatively thinner
hyperechoic cortex may be misinterpreted as
cortical scarring or even ischemic changes.

159. normal variant
was beleived due to tamm horsfall protein

160. Obstruction

161. Ischaemia

162. Infection-candidiasis
parenchymal
or collecting system
fungus ball

163. Renal vein thrombosis

164. ARPKD

165. Spectrum

166. Beckwith-Wieldmann syndrome
dysplastic
tubules

167. Nephrocalcinosis
early late
hyperechoic cortex and medulla

168. Linear pattern

169. Punctate pattern

170. progress to cyst

171. lesson of presentation

172. Lesch Nyhan Syndrome
urate crystal
deposition

173. Glycogen storage disease

174. Sickle cell anaemia

175. • Normal neonatal kidney should be
evaluated according to:
• Normal echotexture.
• Normal size for age.
• Normal development.
• Excluding normal variants.
• Diagnosing congenital anomalies ..and
lastly evaluating a diseased kidney
accordingly .

177. Importance of the finding
• Most common congenital condition
discovered by antenatal US.
• ultrasonography enables us to detect the
correctable cause of hydronephrosis, such
as ureteropelvic junction obstruction.
• Failure of recognizing those needing
surgical intervention will result in
permanent loss of the kidney.

178. Fetal hydronephrosis Detection
• Grignon et al developed a grading system for hydronephrosis in
fetuses of 20 weeks gestation or greater in relation to their postnatal
findings.
• Grade I dilatations (AP renal pelvic diameter up to 1.0 cm) were
described as normal and physiologic because none of the affected
patients required surgery after birth.
• Grade II (>1.0–1.5 cm) and grade III (>1.5 cm with slight dilatation of
calices) dilatation was termed intermediate hydronephrosis; 50%
required postnatal surgical intervention.
• All patients with grade IV dilatation (>1.5-cm pelvis, moderate
dilatation of calices, no cortical atrophy) or grade V hydronephrosis
(>1.5-cm pelvis, severe caliceal dilatation, atrophic renal cortex)
required surgery.
• Their work suggests that one should be concerned with pelvic
dilatations greater than 10 mm particularly if there is associated
calyceal dilatation and loss of cortex.

179. • Clinically significant disease is more likely
if:
• (1) a grade 3 or 4 hydronephrosis is
present;
• (2) the renal pelvis diameter is > 10 mm;
• (3) the renal pelvis/kidney ratio is > 0.5.

180. Incidence:
• Pre-natal ultrasound
–detects fetal anomaly in 1% of
pregnancies, of which 20-30%
are genitourinary in origin and
50% manifest as hydronephrosis

181. Grading of Severity of
Hydronephrosis
Grade Central Renal
Complex
Renal
Parenchymal
Thickness
0 Intact Normal
1 Slight splitting Normal
2 Evident splitting Normal
3 Wide splitting Normal
4 Further dilatation Thin

182. Pathophysiology:
• Anatomic and functional processes
interrupts the flow of urine.
• There is a rise in ureteral pressure
causing stretching and dilation; if
pressures continue to rise, leads to
decline in renal blood flow and GFR.
• When significant obstruction is
persistent, it affects nephrogenic tissue
and results in varying degrees of cystic
dysplasia and renal impairment.

184. Proper evaluation protocol

186. I-Mild (Grade II)
• These images shows mild dilatation of the pelvis as well
as the calyces of the right kidney

187. II-Moderate (III)
• The above ultrasound images show cupping of the calyces with moderate dilation
(Right kidney) of the pelvis and calyces. Despite the hydronephrosis the renal
parenchyma is still preserved.

188. III-severe (IV)
• The above sonographic images show marked dilatation of the
pelvicalyces with sever thinning of the renal parenchyma. note
almost total absence of normal renal tissue (cortex).

190. VU reflux

191. PUJ obstruction..early

192. PUJ obstruction ..too late

193. What is this ?

195. Posterior urethral valve

199. choosing the probe

200. Assesment of DDH
• The technique for performing an infant hip
sonogram may vary depending upon one's belief
as to pathophysiology.
• Initial focus of hip sonography by Graf was on
acetabular morphology, using a single static
sonographic view.
• Harcke et al, on the other hand, emphasized
assessment of instability in addition to
morphology and advocated a dynamic
sonographic technique.

201. • The current recommendation for
sonographic examination of the infant hip
incorporates assessment of both instability
and morphology so the pathophysiology
issue is resolved with respect to
performance of the sonographic
examination .

202. Hip sonography
TABLE 1 -- HIP SONOGRAPHY FOR DEVELOPMENTAL DYSPLASIA OF THE HIP
View Key Feature Comment
Coronal neutral* A
Acetabular morphology Measurement optional
Coronal flexion A
Acetabular morphology Measurement optional
Stability (if stressed) Stress optional
Used with Pavlik harness
Transverse flexion A
Stability Stress required (except during treatment)
Used with Pavlik harness
Transverse neutral Femoral head position Optional view
Data from Harcke HT, Grissom LE: Performing dynamic sonography of the infant hip. AJR Am J Roentgenol 155:837-844, 1990;
with permission.

203. Correct coronal view

204. Correct transverse view

205. I-Morphological assesment
• This system is based upon the
appearance of the acetabulum in a
coronal neutral position and describes
measurement of acetabular slope (alpha
angle) and position of the acetabular
labrum (beta angle).

206. How to make good
exam
• The proper coronal view, whether the femur is in
neutral or in flexion, contains three elements .
• (1) The echoes from the bony ilium should be in
a straight line parallel to the surface of the
transducer.
• (2) The transition from the os ilium to the
triradiate cartilage must be seen definitively.
• (3) Finally, the echogenic tip of the cartilage
labrum needs to be present in the same plane
that contains the other two elements.

207. Model view

208. Take your measurements

210. • Graf classification of infant hips based on the depth and shape
of the acetabulum as seen on coronal ultrasonograms.
• Type I: normal; characterized by a well-formed acetabular cup
with the femoral head beneath the acetabular roof.
• Type II: immature in infants less than three months of age and
mildly dysplastic in infants older than three months;
characterized by a shallow acetabulum with a rounded rim.
• Type III: subluxated; characterized by a very shallow
acetabulum with some displacement of the femoral head.
• Type IV: dislocated; characterized by a flat acetabular cup and
loss of contact with the femoral head.

212. II- Stability assesment
• The assessment of instability incorporates
dynamic technique in two views that
include application of stress.
• Both views are performed with the hip
flexed: the transducer orientation is
coronal for one view and axial for the
other.

213. Relax your patient
• Assessing the hip when the infant is not
relaxed masks the presence of instability.
• To ensure a cooperative infant, it is
recommended that a sonogram be
performed in a quiet, semidarkened
environment with a parent present and
visible to the child.
• Bottle feeding the infant during the
examination is helpful.

214. • Examination by ultrasound is modeled
after the clinical examination and is based
upon the provocative test for dislocation of
an unstable hip (Barlow test) or the
reduction of a dislocated hip (Ortolani
test).

215. • With subluxation and lesser degrees of
instability, the flexed hip tends to seat with
abduction.
• Displacement is noted during adduction
and stress.

216. • The key feature of instability is the lateral
movement (toward the transducer) of the
femoral head along the ischium. This results in
increased echogenic soft tissue medially.
• Whereas a normal hip shows slight changes in
the appearance of the medial tissues between
abduction and adduction, with instability, the
thickness more than doubles

217. Dynamic testing
• At rest :Normal.
• With stress
subluxation occurs
and B angle
increases.

221. Capsule distension

222. Compare the 2 sides in difficult
cases

223. Transient synovitis versus septic
arthritis

227. where to scan ?

228. Obtaining the image

229. Cervix sign-Hamburger sign

230. Donut sign

231. Measurements

232. Gastric contents effect