1. Cranial Sonography:
Techniques and Image
Interpretation
Lisa H. Lowe
Zachary Bailey

2. OBJECTIVE
• To discuss the modern approach for cranial
ultrasound of grey scale technique and
interpretation
• Use of linear imaging and use of multiple
fontanels and screening doppler techniques

3. Cranial ultrasound technique
• Performed using linear array transducer via anterior
fontanel in coronal and sagittal planes
• 6 to 8 coronal images from frontal lobes ant to
frontal horns of lateral ventricle to occipital lobes
posterior to lateral ventricle trigones
• Sagittal midline view of corpus callosum and
cerebellar vermis and bilateral parasagittal images

4. • Four doppler images for screening vascular structures,
arterial system for patency and resistance to flow by
obtaining color doppler images of circle of Willis
obtained via anterior or temporal fontanel to localize
MCA or ICA and obtain spectral tracing with PSV, EDV
and RI
• Venous system is evaluated for patency by obtaining
color doppler images of sagittal sinus and vein of Galen
• Areas of hyper or hypovascularity for vascular ischemia
or infarction
• CD via posterior fontanel or foramen magnum used for
screening for patency of transverse sinuses
• Linear transducer via anterior fontanel allow detailed
interrogation of convexity of subarachnoid space and
superficial cortex and deep brain matter.

5. Cranial ultrasound interpretation
GREY SCALE IMAGING
CORONAL VIEWS

6. SAGITTAL VIEW
PARASAGITTAL VIEW

7. DOPPLER IMAGING

8. Conclusion
• With modern protocols used in cranial
sonography is highly accurate in detection of
cranial abnormalities

9. discussion
• Coronal brain scans of skull with transducer
held along anterior fontanalle six standard
frozen images are acquired
1. Most anterior scan is anterior to frontal horn of
lateral ventricle contains
• Frontal lobes of cerebral cortex
• Orbits deep to internal floor of skull base

11. Orbital ridges
Frontal
lobes
Interhemispheric fissure
INTERHEMISPHERIC
FISSURE
CHOROID
PLEXUS
FRONTAL LOBES

12. • Next is section through frontal horns of lateral
ventricle : symmetric anechoic and comma shaped
– Structures from superior to inferior in midline are
1. Interhemispheric fissure
2. Cingulate sulcus
3. Genu and anterior body of corpus callosum
4. Septum pellucidum
5. Lateral to putamen is the echogenic septum pellucidum
6. Inferiorly the ICA bifurcates to form ACA and MCA which
appear echogenic

13. INTERHEMISPHERIC FISSURE
CINGULATE SULCUS
GENU AND BODY OF
CORPUS CALLOSUM
SEPTUM PELLUCIDUM
FRONTAL HORNS OF
LATERAL VENTRICLE
TEMPORAL LOBES
ICA BIFURCATION TO ACA AND MCA

14. • More posteriorly the body of lateral ventricles and
either cavum septum pellucidum are noted
• Other structures are
1. Thalami on either side of 3rd ventricle
2. Deep to thalami is the brainstem
3. Lateral to lentiform nucleus is the deep white matter of
brain called the centrum semiovale

15. THALAMUS
CAUDATE NUCLEUS
SYLVIAN FISSURE
3RD VENTRICLE
CAVUM SEPTUM PELLUCIDUM
BODY OF LATERAL
VENTRICLE
BRAINSTEM
(PONS)
INTERNAL CAPSULE

16. • More posteriorly the body of lateral ventricle
becomes more rounded and size of caudate nucleus
decreased in size posterior to foramen of Monroe
• Echogenic matter in floor is choroid plexus
• Prominent thalami
• Posterior fossa contain echogenic vermis
• If cavum septum pellucidum is cystic posteriorly it
is labelled as cavum vergae
• Temporal horns of lateral ventricle are seen only in
case of hydrocephalus

17. BODY OF LATERAL
VENTRICLE
CHOROID
PLEXUS
THALAMUS POSTERIOR
FOSSA WITH
VERMIS
CAVUM VERGAE

18. • Posterior sections reveal :-
– Trigone or atrium of lateral ventricle is visualised
– Echogenic glomus of choroid plexus obscures lumen of
CSF

19. GLOMUS
PARIETAL
LOBE
CENTRUM
SEMIOVALE

20. • Most posterior section :-
1. Occipital lobe
2. Occipital horns of lateral ventricle angled posterior to
cerebellum

21. SAGITTAL BRAIN SCANS
1. Midline
– Curving line of corpus callosum
– Cystic cavum septum pellucidum
– Cerebellar vermis

24. • Shallow angulation 10 to either sides :-
– Normal lateral ventricles
– Anterior sector medial and posterior sector lateral
– Caudate nucleus and thalamus with in arms of ventricle
– Caudothalamic groove area to recognise germinal matrix
hemorrhage
– Normal hyperechoic blush posterior and superior to
ventricular trigones on parasagittal views
– Normal peritrigonal echogenity

25. FRONTAL LOBE
CAUDOTHALAMIC
GROOVE
CAUDATE
NUCLEUS
THALAMUS
CHOROID PLEXUS

26. SYLVIAN FISSURE
INSULAR CORTEX
TEMPORAL LOBE

27. Through posterior fontanalle
• AFFORDED GREATER ACCURACY IN DETECTION OF
INTRAVENTRICULAR HEMORRHAGE THAN
ANTERIOR FONTANALLE IMAGING WHEN
VENTRICLES ARE NOT DILATED
• POSTERIOR FONTANALLE IMAGING ALSO HELPED IN
DETERMINING POSTERIOR FOSSA MALFORMATIONS

28. LATERAL VENTRICLE

29. THALAMUS
OCCIPITAL LOBE
CHOROID

30. TRIGONE OF LATERAL
VENTRICLE

31. Doppler sonography

32. SYLVIAN FISSURE
THALAMUS
MCA
BRAINSTEM

33. CORPUS CALLOSUM
PONS
BRANCH OF
PERICALLOSAL ARTERY
CEREBELLUM
OCCIPITAL
LOBE
4TH VENTRICLE
CINGULATE GYRUS

34. CIRCLE OF WILLIS MCA

35. CEREBELLUM VERMIS
BRAINSTEM

36. CIRCLE OF WILLIS
MCA
TEMPORAL
LOBES

37. Normal variants and pitfalls that
mimics pathologic abnormalities
• Immature sulcation in premature infants
• Persistent fetal fluid filled spaces
• Mega cisterna magna
• Asymmetric ventricular size
• Choroid plexus variants
• Periventricular cystic lesions
• Hyperechoic white matter pseudolesions or
periventricular halo
• Lenticulostriate vasculopathy

38. • Immature sulcation
– Infants born before the 24th week possess a
smooth cerebral cortex exhibiting only the sylvian
fissures.
– a diagnosis of lissencephaly should not be made
in patients younger than 24 weeks’ gestational age

39. • Persistent fetal fluid filled spaces
– Persistent fetal fluid–filled spaces, a common
finding in healthy neonates, include the cavum
septi pellucidi (CSP), cavum vergae, and cavum veli
interpositi.
– The CSP is the most anterior and the most
common of the fetal fluid–filled spaces.
– Persistent fetal fluid–filled spaces occasionally
persist into adulthood and are a normal variant of
no significance

40. • Mega cisterna magna
1. The typical cisterna magna is less than 8 mm in both the
sagittal and axial planes
2. A mega cisterna magna, which some believe is due to
cerebellar damage and volume loss, measures greater
than 8 mm and is seen in 1% of postnatally imaged brains
3. A mega cistern magna is a normal variant distinguished
from an arachnoid cyst by its lack of mass effect and
from a DandyWalker malformation by the presence of the
cerebellar vermis

41. • Assymetric ventricles
1. Normal ventricles measure less than 10 mm in
transverse diameter, with 60% of full term and
30% of premature infants having ventricles
smaller than 2–3 mm
2. Asymmetry between the sizes of the ventricles
has been observed in 20–40% of infants

42. • Choroid Plexus Variants
1. It does not extend past the caudothalamic grooves into
the frontal horns or past the ventricular atria into the
occipital horns.
2. Echogenic material anterior to the caudothalamic groove
or in the dependent portions of the occipital horns
suggests germinal matrix and intraventricular hemorrhage
3. Lobular or bulbous variants of the choroid plexus occur
most frequently in the glomus within the ventricular atria
and lateral ventricles
4. Choroid cysts smaller than 1 cm are incidentally noted in
1% of infants at autopsy

43. • Periventricular Cystic Lesions
1. Cystic lesions in the periventricular region include
connatal cysts, subependymal cysts,and white matter
cysts due to periventricular leukomalacia
2. Connatal (or subfrontal) cysts are seen most often during
the early postnatal period and may regress spontaneously
3. The sonographic appearance includes bilateral symmetric
cysts located adjacent to the frontal horns, just anterior to
the foramina of Monro. The cysts frequently appear in
multiples and take on a classic appearance that has been
likened to a string of pearls

44. 4. Two indistinguishable cysts are located at the
caudothalamic groove, including a subependymal
cyst due to germinal matrix hemorrhage and a
germinolytic cyst due to metabolic disorders such
as Zellweger syndrome

45. 5. cysts found in the white matter adjacent to
lateral ventricles are typically the result of
periventricular leukomalacia,which is caused by
hypoxic ischemic injury in the premature infant

46. • Hyperechoic White Matter Pseudolesion or Periventricular
Halo
1. Hyperechoic white matter pseudolesions, or
periventricular halos, may appear as artifacts due to
anisotropic effect
2. Additional images obtained at a 90° angle resolve the
finding and prevent misinterpretation
3. periventricular white matter pseudolesions and halos are
normally less echogenic than the adjacent choroid plexus

47. • Lenticulostriate Vasculopathy
1. thought to be due to thickening of the lenticulostriate
artery walls secondary to a variety of pathologic
conditions and infections
2. lenticulostriate vasculopathy often occurs without a
specific cause being identified and thus remains a
nonspecific finding seen on sonography as unilateral or
bilateral branching,linear, or punctate increased
echogenicity within the thalami