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by the American Institute of Ultrasound in Medicine J Ultrasound Med 29:151-156 • 0278-4297
AIUM Practice Guideline for the Performance of Neurosonography in Neonates and Infants
I. Introduction The clinical aspects contained in specific sections of this guideline (Introduction, Specifications of the Examination, and Equipment Specifications) were developed collaboratively by the American Institute of Ultrasound in Medicine (AIUM), the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU). Recommendations for physician requirements, the written request for the examination, documentation, and quality control vary among these organizations and are addressed by each separately. This guideline has been developed to assist physicians performing sonographic studies of the brain in neonates and infants. For the purpose of this guideline, infants are defined primarily as those in whom the anterior fontanelle remains open. Neurosonography should be performed only when there is a valid medical reason, and the lowest possible ultrasonic exposure settings should be used to gain the necessary diagnostic information. In some cases, additional or specialized examinations may be necessary. While it is not possible to detect every abnormality, adherence to the following guideline will maximize the detection of most abnormalities of the brain in neonates and infants that can be imaged with ultrasound. II. Indications/Contraindications Indications for neurosonography in preterm and term neonates and infants include but are not limited to the following:
There are no contraindications to neurosonography. III. Qualifications of Personnel See the AIUM Official Statement Training Guidelines for Physicians Who Evaluate and Interpret Diagnostic Ultrasound Examinations and the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. IV. Written Request for the Examination The written or electronic request for an ultrasound examination should provide sufficient information to allow for the appropriate performance and interpretation of the examination. The request for the examination must be originated by a physician or other appropriately licensed health care provider or under their direction. The accompanying clinical information should be provided by a physician or other appropriate health care provider familiar with the patient’s clinical situation and should be consistent with the relevant legal and local health care facility requirements. V. Specifications of the Examination (Also see VII. Equipment Specifications)
Standard Imaging Examination of the Neonate and Infant
The transducer may be tilted from side to side to image as much of the superficial peripheral surfaces of the cerebral hemispheres as possible. The frequency of the transducer should be selected to ensure that the superficial and deep structures are well depicted. This may necessitate using more than 1 frequency setting, a linear transducer, or a standoff pad to aid in imaging of the superior sagittal sinus and superficial central cerebral structures. The sagittal view, by convention, should place the anterior aspect of the brain on the left side of the image. The right side, midline, or left side should be clearly annotated. Sequential representative sagittal views are obtained with appropriate degrees of left and right transducer angulation. On each side, these views should include the caudothalamic groove, the lateral ventricle with demonstration of the occipital horn and its choroid plexus, the periventricular white matter, the sylvian fissure, and the middle cerebral artery branches (angiographic sylvian triangle equivalent). A midline sagittal view should include the corpus callosum, the cavum septum pellucidum and cavum vergae extension (if present), the third ventricle, the area of the aqueduct of Sylvius, the fourth ventricle, the vermis of the cerebellum, and the cisterna magna. Additional views, if necessary, may be taken through the posterior or mastoid fontanelles, the foramen magnum, any open suture, or thin areas of the temporoparietal bone. The transtemporal approach may also be used to visualize the circle of Willis and its major branches. Cine loop software, when available, can be useful in demonstrating real-time information. When clinically indicated, spectral, color, and/or power Doppler imaging may be useful for evaluating vascular structures through any fontanelle or via the transcranial technique. VI. Documentation Adequate documentation is essential for high-quality patient care. There should be a permanent record of the ultrasound examination and its interpretation. Images of all appropriate areas, both normal and abnormal, should be recorded. Variations from normal size should be accompanied by measurements. Images should be labeled with the patient identification, facility identification, examination date, and side (right or left) of the anatomic site imaged. An official interpretation (final report) of the ultrasound findings should be included in the patient’s medical record. Retention of the ultrasound examination should be consistent both with clinical needs and with relevant legal and local health care facility requirements. Reporting should be in accordance with the AIUM Practice Guideline for Documentation of an Ultrasound Examination. VII. Equipment Specifications Neurosonographic examinations should be conducted with sector or curved linear array transducers that can fit within and image through the anterior fontanelle. Linear array transducers are useful in evaluating superficial structures such as the superior sagittal sinus. If the anterior fontanelle is not available, imaging may be performed through available sutural openings or by using a transcranial approach via the thinner squamosal portion of the temporal bone. This approach may require a lower-frequency transducer to penetrate through the bone. The transducer should be adjusted to operate at the highest clinically appropriate frequency, realizing that there is a trade-off between resolution and beam penetration. Higher frequencies are used in younger premature neonates and lower frequencies in older and full-term neonates and infants. Doppler power output should be as low as reasonably achievable (ALARA) to answer the diagnostic question. VIII. Quality Control and Improvement, Safety, Infection Control, and Patient Education Policies and procedures related to quality control, patient education, infection control, and safety should be developed and implemented in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. Equipment performance monitoring should be in accordance with the AIUM Standards and Guidelines for the Accreditation of Ultrasound Practices. IX. As Low as Reasonably Achievable Principle The potential benefits and risks of each examination should be considered. The ALARA principle should be observed when adjusting controls that affect the acoustic output and by considering transducer dwell times. Further details on ALARA may be found in the AIUM publication Medical Ultrasound Safety, Second Edition. Acknowledgments This guideline was developed by the American Institute of Ultrasound in Medicine (AIUM) in collaboration with the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU) according to the process described in the AIUM Clinical Standards Committee Manual. Collaborative Committees AIUM Harris L. Cohen, MD Michael DiPietro, MD Harriet Paltiel, MD ACR Lori L. Barr, MD, Chair Lynn A. Fordham, MD Laurence Needleman, MD SPR Marta Hernanz-Schulman, MD Beth Kline-Fath, MD Vesna Martich Kriss, MD SRU Dorothy I. Bulas, MD Brian D. Coley, MD AIUM Clinical Standards Committee David M. Paushter, MD, Chair William Middleton, MD, Vice Chair Susan Ackerman, MD Lisa Allen, BS, RDMS, RDCS, RVT Mert O. Bahtizar, MD Jude Crino, MD William L. Diacon, MD, RDMS Judy Estroff, MD Kimberly D. Gregory, MD, MPH Barbara S. Hertzberg, MD Charles Hyde, MD Joan M. Mastrobattista, MD Jon W. Meilstrup, MD Christopher Moore, MD, RDMS, RDCS Carl Reading, MD Leslie Scoutt, MD Daniel Skupski, MD Jay Smith, MD Joseph Wax, MD Lami Yeo, MD Comments Reconciliation Committee Edward I. Bluth, MD, Chair Lori L. Barr, MD Dorothy I. Bulas, MD Harris L. Cohen, MD Brian D. Coley, MD Michael DiPietro, MD Kate A. Feinstein, MD Lynn A. Fordham, MD Mary C. Frates, MD Donald P. Frush, MD Marta Hernanz-Schulman, MD Alan D. Kaye, MD Beth Kline-Fath, MD Vesna M. Kriss, MD David C. Kushner, MD Paul A. Larson, MD Deborah Levine, MD Lawrence A. Liebscher, MD Laurence Needleman, MD Harriet Paltiel, MD David M. Paushter, MD Michael I. Rothman, MD Carol M. Rumack, MD Robert M. Sinow, MD
Footnotes The American Institute of Ultrasound in Medicine (AIUM) is a multidisciplinary association dedicated to advancing the safe and effective use of ultrasound in medicine through professional and public education, research, development of guidelines, and accreditation. To promote this mission, the AIUM is pleased to publish, in conjunction with the American College of Radiology (ACR), the Society for Pediatric Radiology (SPR), and the Society of Radiologists in Ultrasound (SRU), this AIUM Practice Guideline for the Performance of Neurosonography in Neonates and Infants. We are indebted to the many volunteers who contributed their time, knowledge, and energy to bringing this document to completion. The AIUM represents the entire range of clinical and basic science interests in medical diagnostic ultrasound, and, with hundreds of volunteers, the AIUM has promoted the safe and effective use of ultrasound in clinical medicine for more than 50 years. This document and others like it will continue to advance this mission. Practice guidelines of the AIUM are intended to provide the medical ultrasound community with guidelines for the performance and recording of high-quality ultrasound examinations. The guidelines reflect what the AIUM considers the minimum criteria for a complete examination in each area but are not intended to establish a legal standard of care. AIUM-accredited practices are expected to generally follow the guidelines with recognition that deviations from these guidelines will be needed in some cases, depending on patient needs and available equipment. Practices are encouraged to go beyond the guidelines to provide additional service and information as needed. References
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