Neonatal Cranial POCUS Teaching Tools

Curvilinear probe (preferred for neonatal brain imaging)
In radiology, they will often re-perform the full exam using the Linear probe for superficial structures.

Mode / System Setup

Select the Cranial / Neuro preset on your ultrasound machine.
Adjust depth and gain for optimal visualization of ventricular structures.

Landmarks & Imaging Planes

- Cranial ultrasound is performed through the anterior fontanelle, using two standardized imaging planes:

Image Acquisition Requirements

To ensure accuracy and uniformity, the following sequences must be obtained for every scan.
Identification of the right side should be made on every still image.
For each plane do a full sweep from front to back or from midline to the right and midline to the left.
There are standardized 6 coronal plane images and 5 sagittal plane images, however for POCUS you are answering specific clinical questions. Appropriate images taken after a full sweep in both planes showing clinical question replies are adequate.

Sagittal Plane Acquisition

A. Midline Sagittal Image

Identify:
- Corpus callosum
- Fourth ventricle
- Cerebellum

B. Parasagittal Sweeps

After capturing midline:
- Sweep to the right until the lateral ventricle disappears
- Return to midline and sweep to the left with the same technique
At each parasagittal level identify:
- Lateral ventricles
- Thalamus
- Head of caudate nucleus
- Choroid plexus
End of sweep: last parasagittal image where the lateral ventricle is no longer visible.

Coronal Plane Acquisition

A. Frontal Coronal Image

Identify:
- Interhemispheric fissure
- Lateral ventricles
- Caudate nuclei
- Uncus of the temporal horn

B. Coronal Sweeps (Anterior → Posterior)

As you sweep posteriorly, evaluate:
- Lateral ventricles (size, symmetry)
- Full extent of the choroid plexus
- Any echogenic material suggesting hemorrhage
- Ventricular enlargement

Hydrocephalus Assessment

Hydrocephalus must be confirmed using standardized measurements in the coronal plane at the level of the Foramen of Monro (3rd ventricle level):

Ventricular Index (VI)
Anterior Horn Width (AHW)
Compare measurements to gestational age reference values. Use abnormal values to determine need for neurosurgical evaluation.

Image Interpretation Principles

Confirm Findings in Two Planes any suspected:

Intraventricular hemorrhage
Ventriculomegaly
Parenchymal bleed
These must be visualized in both coronal and sagittal planes to avoid misinterpretation from oblique images.

Clinical Scope of Cranial POCUS

Cranial POCUS is intended to identify:

Acute intracranial bleeding
Acutely new-onset or progressive hydrocephalus
Important: Before altering clinical care, review images with a Pediatric Radiologist.

In comparison with cranial POCUS, a full cranial/head ultrasound (HUS) performed by radiologist experts is far more exhaustive and granular in the information it provides. A comprehensive HUS includes numerous standardized coronal and sagittal cuts that require years of dedicated training and experience to interpret accurately, particularly when assessing subtle abnormalities in ventricular configuration, parenchymal echogenicity, and evolving white-matter injury. Beyond grayscale imaging, a full HUS also incorporates Doppler assessment (arteries and veins) and systematic visualization of the posterior fossa, including dedicated views (mastoid or posterior fontanelle windows) to evaluate the cerebellum (among other reasons, to detect cerebellar hemorrhages). In contrast, the scope of cranial POCUS is intentionally focused and problem-oriented: it is designed to screen for major intracranial pathology (such as significant intraventricular hemorrhage or marked ventriculomegaly), monitor known abnormalities over time, support bedside clinical decision-making, and provide rapid, repeatable assessments that complement—but do not replace—formal radiology studies. In radiology, extremely preterm infants benefit from posterior and lateral imaging because of their heightened risk of periventricular leukomalacia. Ultimately, reproducibility and diagnostic reliability depend less on the absolute number of images acquired than on consistent technique, standardized landmarks, and expert interpretation.

Coronal views (via anterior fontanelle) - Radiology HUS