Cranial Ultrasound Case

by Kaynan Doctor
Children's National

2 month old previously healthy male presenting to the ED with altered mental status.

For the past 2 days his mother has noticed “eye rolling” with reduced tracking as well as increased fatigue. On the day prior to arriving his mother noted that he slept for 23 hours.

No recent illness or trauma. Review of symptoms is negative for fevers, vomiting or seizure like activity. Birth history:  Full term, normal pregnancy and scans with normal neonatal course. Patient has continued to have had head circumferences within the normal range.

Vital signs – T 35.7 HR 164 RR 28 BP 112/57 Sats 100% RA

Physical exam is pertinent for

A well nourished infant who has prominent downward gaze, anterior fontanelle full but soft with splayed sutures. Patient otherwise has normal findings on CVS Respiratory and Abdominal examination.

Prior to obtaining neuroimaging you obtain the following images via bedside ultrasound.

Bedside cranial ultrasound use in the emergency department can be very useful for visualizing the ventricles and brain parenchyma in infants and toddlers where the fontanelles have not closed (posterior fontanelle normally closes at 1-3 months and the anterior fontanelle normally closes at 9-18 months unless there is underlying pathology). Using a linear array transducer or neonatal probe positioned over the anterior fontanelle with lateral-facing probe marker a coronal view allows the user to see the frontal lobes, lateral ventricular horns through to the occipital lobes in significant detail. Turning the probe 90º provides a sagittal view starting with the corpus callosum and septum cavum pellucidum. The indications for bedside cranial ultrasound outside the realms of the NICU may be for emergently identifying acute bleeds or ventriculomegaly prior to further neuroimaging.

In this case, a cystic structure was identified which was later confirmed on MRI as a thin walled 3^rd ventricular cyst measuring 16x12x18mm which was obstructing the free flow of CSF between the anterior and posterior portions of the 3^rd ventricle (see MRI images below). This was successfully neurosurgically managed.