We thank the nurses (appearing on film) for supporting the neonates. 
We thank J. Hagoort, MA, linguist, Department of Pediatric Surgery, Erasmus MC-Sophia Children&#8217;s Hospital, Rotterdam, the Netherlands, for reading and correcting the manuscript.

NOTA: Questo protocollo segue le linee guida del comitato etico della ricerca umana locale. 1. Considerazioni generali NOTA: Considerazioni generali relative ad apparecchiature, storage e sicurezza dati sono trattati nella discussione. <ol><li> Ottenere immagini utilizzando una ad alta risoluzione, in tempo reale, mobili macchina ad ultrasuoni 2D con più trasduttori con una banda di frequenze (vedi Discussione). Tipicamente, ottenere immagini di buona qualità utilizzando una sonda con una frequenza di 7,5 e 8,5 MHz. </li></ol> 2. Preparazione del Exam CUS <ol><li> Pianificare l&#39;esame CUS in modo che non coincida con altre procedure, come il prelievo di sangue. </li><li> Assicurarsi che un operatore sanitario o un genitore è disponibile per sostenere e / o il comfort del neonato durante l&#39;esame, utilizzando strategie come quelle secondo i principi di Newborn individualizzato Developmental Cura e Assessment Program 6 &lt;/ Sup&gt;. </li></ol> 3. Esame Attraverso anteriore Fontanel <ol><li> Installare la macchina ad ultrasuoni lungo l&#39;incubatore o culla. </li><li> Applicare gel trasduttore della sonda per assicurare un buon contatto tra la sonda e la pelle. Si consideri il riscaldamento il gel prima dell&#39;uso. </li><li> Avviare immagini attraverso la fontanella anteriore con una sonda convessa in B-mode. Posizionare la sonda nel mezzo della fontanella con il marcatore sulla sonda rivolto verso il lato destro del neonato. Il lato sinistro del cervello viene quindi visualizzato sul lato destro del monitor. NOTA: Imaging attraverso la fontanella anteriore può essere eseguita con il neonato in qualsiasi posizione 3. Per scopi di ricerca, può essere necessario lottare per una posizione di testa di serie. <ol><li> Registrare le immagini in almeno cinque coronale e sagittale cinque. Nella prima immagine regolare la profondità, le impostazioni di compensazione del guadagno di guadagno e di tempo per produrre un&#39;immagine riempire il settore, che contiene i contorni cranici, evitareing immagini troppo chiare o scure e puntando un equilibrio tra le riflessioni da strutture vicine e più profonde. </li><li> Piani coronali NOTA: Cercare di ottenere immagini perfettamente simmetrici. Quando si sospetta lesioni vicino lobo convessità frontale considerare registrazione specifiche sezioni coronali oblique, in modo che un emisfero viene visualizzato in maggior dettaglio (figura 1). <ol><li> Per l&#39;immagine prefrontale coronale, angolo la sonda in avanti per visualizzare i lobi frontali, anteriori alle corna frontali dei ventricoli laterali a livello dei solchi olfattiva. </li><li> Per l&#39;immagine coronale a livello di Monro, dell&#39;angolo la sonda di visualizzare la sezione anteriore coronale alla coroide tela per rappresentare le corna frontali dei ventricoli laterali, cavo del setto pellucido, corpo calloso, solco cinguli. Nota l&#39;ecogenicità di parti dei gangli basali. </li><li> Per l&#39;immagine coronale a livello del talamo, angolo all&#39;indietro la sonda per identificare la finefessure ral, tela coroide nel tetto del terzo ventricolo e lobi temporali. Nota l&#39;ecogenicità del talamo (soprattutto nuclei ventrolateral) in relazione ai gangli basali. Si noti che lesioni rete pulvinar può essere visualizzato in una sezione coronale extra solo fronte degli atri. </li><li> Per l&#39;immagine coronale a livello di atri, visualizzare i ventricoli laterali a livello del plesso coroide. Identificare i lobi temporali e emisferi cerebellari. Si noti la ecogenicità della sostanza bianca periventricolare rispetto al plesso coroideo. Confronta radiazione ottica con le normali aree iperecogene sopra e laterali per gli atri nei neonati pretermine. </li><li> Per l&#39;immagine parieto-occipitale coronale, angolo sonda all&#39;indietro al livello del solco parieto-occipitale per identificare i parietali e occipitali lobi. </li></ol></li><li> Sagittale <ol><li> Ruotare la sonda di 90 ° con il marcatore sulla sonda rivolto verso il viso del neonato. The parte anteriore del cervello viene visualizzato sul lato sinistro del monitor. Registra immagini a livello delle strutture seguenti (Figura 2). </li><li> Per l&#39;immagine mediosagittale, visualizza il corpo calloso, cavo del setto pellucido (CSP), terzo e quarto ventricolo, verme, cisterna magna, ponte e mesencefalo. Si noti la presenza di cavum Vergae e cavum veli interpositi 7. </li><li> Per l&#39;immagine parasagittale i ovoidale gangliothalamic (ad esempio, a destra), l&#39;angolo della sonda lateralmente per una vista parasagittale attraverso il ventricolo laterale. Identificare i plesso coroideo e notare la ecogenicità del talamo e nuclei della base. Il lato a scansione per gli aerei parasagittali deve essere indicata adeguatamente con strumenti di testo. </li><li> Per la parasagittale immagine insulare, l&#39;angolo della sonda ulteriormente laterale attraverso l&#39;insula. Identificare la fessura laterale e frontal-, temporo, parietal- e lobi occipitali. </li><li> Immagini parasagittali ripetere per tegli lato controlaterale (cioè, sinistra). </li></ol></li><li> Color Doppler <ol><li> Continuare immagini attraverso la fontanella anteriore con una sonda convessa con color Doppler. Considerare la valutazione velocità di flusso nelle arterie e vene cerebrali e ottenere indici derivati. NOTA: l&#39;indice resistivo (RI) è definita come velocità sistolica di picco - velocità diastolica end / velocità sistolica di picco. RI è l&#39;angolo-indipendente, i valori di velocità assoluti non sono 8-10. RI non è simile nelle arterie di diverso calibro. Misurazioni seriali sono utili solo se eseguito nella stessa esatta posizione dello stesso vaso. </li></ol></li><li> Registrare le immagini su piani coronali delle seguenti navi (Figura 3): <ol><li> Visualizzare i seni trasversali a livello del cervelletto. Se solo uno o nessuno seni trasverso viene visualizzato, provare a ridurre la frequenza di ripetizione (PRF). Se allora ancora solo uno o nessuno dei seni trasversipossono essere identificati attraverso il fontanella anteriore, utilizzare una sonda ad alta frequenza lineare per la visualizzazione attraverso la fontanella mastoide (vedi paragrafo 4.4.2). </li><li> Visualizza il cerchio di Willis con arterie carotidi interne, arterie cerebrale media e anteriore arterie cerebrali a livello delle corna frontali dei ventricoli laterali. Distinguere le arterie cerebrali anteriori destro e sinistro è spesso difficile, ma di solito è inutile. Identificare i candelabri striatale delle arterie. </li><li> Angolo della sonda indietro per visualizzare l&#39;arteria basilare con le vene giugulari adiacenti. </li><li> Angle ancora più indietro per visualizzare le vene cerebrali e thalamostriate interne. </li></ol></li><li> Registrare un&#39;immagine nel piano sagittale di una cerebrale anteriore (Figura 4). Valutare la velocità del flusso e RI ad una parte specifica di questo vaso (di solito sotto il ginocchio del corpo calloso). Vicino le velocità della linea mediana della vena cerebrale interna possono esserefacilmente misurata. </li><li> Usando una sonda lineare ad alta frequenza in un piano coronale nella fontanella anteriore, identificare il seno sagittale superiore. Se ciò dovesse fallire, ridurre la quantità di pressione applicata con la sonda al fontanella. NOTA: La sonda lineare può essere utilizzato per la visualizzazione dettagliata delle strutture superficiali (meningi, spazio aracnoide e subdurale, corteccia). Navi tangenziale sono nello spazio subaracnoideo. Idealmente, Doppler come descritto nella procedura precedente sarà eseguita durante il primo esame CUS del neonato. Durante l&#39;esame di follow-up alcuni dei passi possono essere saltati. In caso di sospetta cerebrale sinovenous immagini trombosi Doppler come descritto nei punti 3.3.5.1, 3.3.7 e 4.4.2 devono essere eseguite. </li></ol></li></ol> 4. Esame Attraverso Alternative Acoustic di Windows <ol><li> Avanti, proseguire l&#39;esame attraverso le finestre acustiche alternative. </li><li> Considerare la registrazione di immagini attraverso il lambdoidea (posTERIOR) Fontanel utilizzando una sonda convessa (Figura 5). La fontanella posteriore si trova all&#39;incrocio delle suture sagittale e lambdoid 3,11. Immagine attraverso la fontanella posteriore ponendo il neonato in decubito laterale. NOTA: In molti neonati prematuri immagini soddisfacenti possono essere ottenuti anche attraverso l&#39;aspetto posteriore della sutura sagittale con il bambino in posizione supina 3. <ol><li> Posizionare la sonda nel mezzo della fontanella posteriore per una vista sagittale. Angle sonda leggermente fuori linea mediana di identificare il corpo del ventricolo laterale e il corno occipitale. Girare la sonda di circa 90 ° per ottenere una visione coronale. Identificare le corna occipitale dei ventricoli laterali. </li></ol></li><li> Si consideri la registrazione di immagini attraverso il (temporale) finestra laterale che utilizza una sonda convessa o lineare sopra l&#39;orecchio (Figura 6). <ol><li> Se necessario, ottenere immagini attraverso la finestra laterale per consentirevista dettagliata del tronco cerebrale 12. Posizionare la sonda orizzontalmente sopra e leggermente di fronte all&#39;orecchio. Spostare la sonda fino a quando i peduncoli cerebrali vengono visualizzati. NOTA: altre strutture che possono essere identificati sono il terzo ventricolo, acquedotto e lobi temporali. Utilizzando color Doppler, il circolo di Willis può essere visualizzato. </li></ol></li><li> Registrare le immagini attraverso la fontanella mastoide (Figura 7). La fontanella mastoide si trova dietro l&#39;orecchio, allo svincolo di temporale, parietale e occipitale ossa 4. Immagine attraverso la fontanella mastoide ponendo il neonato in una posizione di decubito laterale 3. NOTA: Nella nostra esperienza, i neonati spesso mostrano segni di disagio quando si ottengono immagini attraverso la fontanella mastoide. Pertanto, sarebbe meglio farlo dopo l&#39;imaging attraverso la fontanella anteriore e altre finestre acustiche. Noi ipotizziamo che questo disagio potrebbe essere causato dal meccanismo di risposta uditiva a pulses di radiofrequenza energia 13. <ol><li> Immagine attraverso mastoid fontanella con una sonda convessa. Posizionare la sonda in parallelo per l&#39;orecchio per ottenere una visione coronale. Spazzare la sonda avanti e indietro per individuare gli emisferi cerebellari, verme, terzo e quarto ventricolo, ponte e cisterna magna. Nei piccoli prematuri dell&#39;emisfero cerebellare controlaterale può essere ben rappresentato. </li><li> Immagine attraverso mastoid fontanella utilizzando una sonda lineare. Se (uno dei) seni trasversali non possono essere identificati attraverso la fontanella anteriore, utilizzare una sonda ad alta frequenza lineare per la visualizzazione attraverso la fontanella mastoide. Posizionare la sonda parallela al lobo dell&#39;orecchio per ottenere una vista coronale. <ol><li> Identificare l&#39;emisfero cerebellare e quarto ventricolo. Utilizzando color Doppler, identificare la trasversale e sigma seno, seno tentoriale e vene emissario. </li></ol></li></ol></li><li> Considerare la visualizzazione ulteriore fossa posteriore attraverso forame magnum 14. </li></ol>

<ol>
	<li>Plaisier, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+of+routine+early+MRI+in+preterm+infants.">Safety of routine early MRI in preterm infants.</a> Pediatric Radiology. 42 (10), 1205-1211 (2012).</li><li>Raets, M. M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Serial+Cranial+US+for+Detection+of+Cerebral+Sinovenous+Thrombosis+in+Preterm+Infants.">Serial Cranial US for Detection of Cerebral Sinovenous Thrombosis in Preterm Infants.</a> Radiology. 269 (3), 879-886 (2013).</li><li>Di Salvo, D. N. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=A+new+view+of+the+neonatal+brain:+Clinical+utility+of+supplemental+neurologic+US+imaging+windows.">A new view of the neonatal brain: Clinical utility of supplemental neurologic US imaging windows.</a> Radiographics. 21 (4), 943-955 (2001).</li><li>Enriquez, G., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Mastoid+fontanelle+approach+for+sonographic+imaging+of+the+neonatal+brain.">Mastoid fontanelle approach for sonographic imaging of the neonatal brain.</a> Pediatric Radiology. 36 (6), 532-540 (2006).</li><li>Luna, J. A., Goldstein, R. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonographic+visualization+of+neonatal+posterior+fossa+abnormalities+through+the+posterolateral+fontanelle.">Sonographic visualization of neonatal posterior fossa abnormalities through the posterolateral fontanelle.</a> AJR Am J Roentgenol. 174 (2), 561-567 (2000).</li><li>Als, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Individualized+Behavioral+and+Environmental+Care+for+the+Very-Low-Birth-Weight+Preterm+Infant+at+High-Risk+for+Bronchopulmonary+Dysplasia+-+Neonatal+Intensive-Care+Unit+and+Developmental+Outcome.">Individualized Behavioral and Environmental Care for the Very-Low-Birth-Weight Preterm Infant at High-Risk for Bronchopulmonary Dysplasia - Neonatal Intensive-Care Unit and Developmental Outcome.</a> Pediatrics. 78 (6), 1123-1132 (1986).</li><li>Govaert, P., de Vries, L. S. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=.">.</a> An Atlas of Neonatal Brain Sonography. , (2010).</li><li>Gray, P. H., Griffin, E. A., Drumm, J. E., Fitzgerald, D. E., Duignan, N. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Continuous+Wave+Doppler+Ultrasound+in+Evaluation+of+Cerebral+Blood-Flow+in+Neonates.">Continuous Wave Doppler Ultrasound in Evaluation of Cerebral Blood-Flow in Neonates.</a> Archives of Disease in Childhood. 58 (9), 677-681 (1983).</li><li>Seibert, J. J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Duplex+Pulsed+Doppler+Ultrasonography+Versus+Intracranial-Pressure+in+the+Neonate+-+Clinical+and+Experimental+Studies.">Duplex Pulsed Doppler Ultrasonography Versus Intracranial-Pressure in the Neonate - Clinical and Experimental Studies.</a> Radiology. 171 (1), 155-159 (1989).</li><li>Volpe, J. J., Perlman, J. M., Hill, A., Mcmenamin, J. B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cerebral+Blood-Flow+Velocity+in+the+Human+Newborn+-+the+Value+of+Its+Determination.">Cerebral Blood-Flow Velocity in the Human Newborn - the Value of Its Determination.</a> Pediatrics. 70 (1), 147-152 (1982).</li><li>Correa, F., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Posterior+fontanelle+sonography:+An+acoustic+window+into+the+neonatal+brain.">Posterior fontanelle sonography: An acoustic window into the neonatal brain.</a> American Journal of Neuroradiology. 25 (7), 1274-1282 (2004).</li><li>Helmke, K., Winkler, P., Kock, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonographic+examination+of+the+brain+stem+area+in+infants.+An+echographic+and+anatomic+analysis.">Sonographic examination of the brain stem area in infants. An echographic and anatomic analysis.</a> Pediatric Radiology. 17 (1), 1-6 (1987).</li><li>Elder, J. A., Chou, C. K. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Auditory+response+to+pulsed+radiofrequency+energy.">Auditory response to pulsed radiofrequency energy.</a> Bioelectromagnetics. , S162-S173 (2003).</li><li>Brennan, C. M., Taylor, G. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Sonographic+imaging+of+the+posterior+fossa+utilizing+the+foramen+magnum.">Sonographic imaging of the posterior fossa utilizing the foramen magnum.</a> Pediatric Radiology. 40 (8), 1411-1416 (2010).</li><li>Rutherford, M. A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Magnetic+resonance+imaging+of+white+matter+diseases+of+prematurity.">Magnetic resonance imaging of white matter diseases of prematurity.</a> Neuroradiology. 52 (6), 505-521 (2010).</li><li>Wezel-Meijler, G., Steggerda, S. J., Leijser, L. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Cranial+Ultrasonography+in+Neonates:+Role+and+Limitations.">Cranial Ultrasonography in Neonates: Role and Limitations.</a> Seminars in Perinatology. 34 (1), 28-38 (2010).</li><li>Leijser, L. M., de Vries, L. S., Cowan, F. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+cerebral+ultrasound+effectively+in+the+newborn+infant.">Using cerebral ultrasound effectively in the newborn infant.</a> Early Human Development. 82 (12), 827-835 (2006).</li><li>Houston, L. E., Odibo, A. O., Macones, G. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+safety+of+obstetrical+ultrasound:+a+review.">The safety of obstetrical ultrasound: a review.</a> Prenatal Diagnosis. 29 (13), 1204-1212 (2009).</li><li>Torloni, M. R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+of+ultrasonography+in+pregnancy:+WHO+systematic+review+of+the+literature+and+meta-analysis.">Safety of ultrasonography in pregnancy: WHO systematic review of the literature and meta-analysis.</a> Ultrasound in Obstetrics &amp; Gynecology. 33 (5), 599-608 (2009).</li></ol>

The authors have nothing to disclose.

Descriviamo e dimostrare un approccio state-of-the-art per neonatale Doppler CUS. In mani esperte, questo è un ottimo strumento per la sicurezza, comodino seriale imaging cerebrale neonatale. In molti NICUs non sono utilizzati in modo ottimale le possibilità descritte. Aggiunta di studi Doppler consente per lo screening di pervietà delle arterie intracraniche e vene. Velocità di flusso possono essere valutati e gli indici ottenuti. Doppler CUS consente il rilevamento di trombosi sinovenous cerebrale in una fase iniz...

Since its clinical introduction in the late 1970&#8217;s cranial ultrasound (CUS) has been widely used for detecting congenital anomalies and acquired brain lesions during the neonatal period. In many neonatal intensive care units (NICUs), CUS has become indispensable in the care for critically ill neonates. Major advantages are its relatively low cost and the fact that it can be performed at bedside, even when a patient is unstable. In addition it is radiation-free and allows for serial imaging. Another technique often used for neuroimaging in critically ill neonates is magnetic resonance imaging (MRI). MRI provides excellent image quality, but its clinical use in NICU&#8217;s is currently limited because of logistic and safety issues1. 
Over time, quality of CUS has drastically improved, with advancing technique leading to higher resolution, faster image processing and digital display and back-up. Important brain structures can be adequately visualized using optimal settings. Traditionally, images are obtained through the anterior fontanel. This approach is less suitable for evaluation of infratentorial structures because they are located far away from the transducer and the highly echoic tentorium impedes their assessment. Use of high-frequency linear transducers through alternative acoustic windows and adapted settings also provides access to these brain regions. Examples of these supplemental acoustic windows are the lambdoid (posterior), mastoid and lateral (temporal) fontanels. So far, however, only few NICUs use these additional acoustic windows routinely2-5. Doppler techniques can be used for screening patency of intracranial vessels. Flow velocities and indices in cerebral arteries can also be obtained. Some manufacturers now provide hardware to visualize flow around 2 cm/sec (Raets, et al., unpublished data). Small vessels are well displayed: medullary trunks and channels, subependymal veins tributing to the thalamostriate veins, and perforator arteries. 
We present our approach of neonatal CUS, focusing on the use of different transducers, multiple acoustic windows and Doppler techniques. Neonatologists and radiologists use this approach in daily clinical practice but is also suitable for research purposes. In the practical part of the video we demonstrate bedside use in the NICU.

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			<td height="42" style="height:42px;width:216px;">Name of Material/ Equipment</td>
			<td style="width:191px;">Company</td>
			<td style="width:119px;">Catalog Number</td>
			<td style="width:167px;">Comments/Description</td>
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			<td height="21" style="height:21px;width:216px;">MyLab 70</td>
			<td style="width:191px;">Esaote (Genoa, Italy)</td>
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			<td>Ultrasound system</td>
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state of the art cranial ultrasound imaging in neonates

Cranial ultrasound (CUS) is a reputable tool for brain imaging in critically ill neonates. It is safe, relatively cheap and easy to use, even when a patient is unstable. In addition it is radiation-free and allows serial imaging. CUS possibilities have steadily expanded. However, in many neonatal intensive care units, these possibilities are not optimally used. We present a comprehensive approach for neonatal CUS, focusing on optimal settings, different probes, multiple acoustic windows and Doppler techniques. This approach is suited for both routine clinical practice and research purposes. In a live demonstration, we show how this technique is performed in the neonatal intensive care unit. Using optimal settings and probes allows for better imaging quality and improves the diagnostic value of CUS in experienced hands. Traditionally, images are obtained through the anterior fontanel. Use of supplemental acoustic windows (lambdoid, mastoid, and lateral fontanels) improves detection of brain injury. Adding Doppler studies allows screening of patency of large intracranial arteries and veins. Flow velocities and indices can be obtained. Doppler CUS offers the possibility of detecting cerebral sinovenous thrombosis at an early stage, creating a window for therapeutic intervention prior to thrombosis-induced tissue damage. Equipment, data storage and safety aspects are also addressed.

Esempi di immagini realizzato secondo il protocollo descritto sono presentati nelle Figure 1 - 7. Le immagini devono essere interpretati con cautela da parte di un osservatore esperto. Imaging simmetrico è necessario per un&#39;adeguata interpretazione delle immagini coronali effettuate attraverso la fontanella anteriore (Figura 1). Qualsiasi lesione sospetta deve essere visualizzato sia in una e (metà) piano sagittale coronale o visualizzazione attraverso una finestr...

Watch this Scientific Journal Video about State of the Art Cranial Ultrasound Imaging in Neonates at JoVE.com

State of the Art Cranial Ultrasound Imaging in Neonates

Cranial ultrasound (CUS) is a valuable tool for brain imaging in critically ill neonates. This video shows a comprehensive approach for neonatal (Doppler) CUS for both clinical and research purposes, including a bedside demonstration of the technique.

Stato dell&#39;arte cranica Ultrasound Imaging in neonati

Cranial ultrasound (CUS) is a reputable tool for brain imaging in critically ill neonates. It is safe, relatively cheap and easy to use, even when a ...

state-of-the-art-cranial-ultrasound-imaging-in-neonates

Research

JoVE Journal

Medicine

23.8K Views.  Erasmus MC-Sophia Children's Hospital. Cranial ultrasound (CUS) is a valuable tool for brain imaging in critically ill neonates. This video shows a comprehensive approach for neonatal (Doppler) CUS for both clinical and research purposes, including a bedside demonstration of the technique. 

Video: State of the Art Cranial Ultrasound Imaging in Neonates

Dual-mode Imaging of Cutaneous Tissue Oxygenation and Vascular Function

Accurate assessment of cutaneous tissue oxygenation and vascular function is important for appropriate detection, staging, and treatment of many health disorders such as chronic wounds. We report the development of a dual-mode imaging system for non-invasive and non-contact imaging of cutaneous tissue oxygenation and vascular function. The imaging system integrated an infrared camera, a CCD camera, a liquid crystal tunable filter and a high intensity fiber light source. A Labview interface was programmed for equipment control, synchronization, image acquisition, processing, and visualization. Multispectral images captured by the CCD camera were used to reconstruct the tissue oxygenation map. Dynamic thermographic images captured by the infrared camera were used to reconstruct the vascular function map. Cutaneous tissue oxygenation and vascular function images were co-registered through fiduciary markers. The performance characteristics of the dual-mode image system were tested in humans.

A dual-mode imaging system was developed for non-contact assessment of cutaneous tissue oxygenation and vascular function.

Dual-mode Imaging di ossigenazione dei tessuti cutanei e di funzione vascolare

Accurate assessment of cutaneous tissue oxygenation and vascular function is important for appropriate detection, staging, and treatment of many health ...

Ricerca

Medicina

Murine Echocardiography and Ultrasound Imaging

Rodent models of cardiac pathophysiology represent a valuable research tool to investigate mechanism of disease as well as test new therapeutics.1 Echocardiography provides a powerful, non-invasive tool to serially assess cardiac morphometry and function in a living animal.2 However, using this technique on mice poses unique challenges owing to the small size and rapid heart rate of these animals.3 Until recently, few ultrasound systems were capable of performing quality echocardiography on mice, and those generally lacked the image resolution and frame rate necessary to obtain truly quantitative measurements. Newly released systems such as the VisualSonics Vevo2100 provide new tools for researchers to carefully and non-invasively investigate cardiac function in mice. This system generates high resolution images and provides analysis capabilities similar to those used with human patients. Although color Doppler has been available for over 30 years in humans, this valuable technology has only recently been possible in rodent ultrasound.4,5 Color Doppler has broad applications for echocardiography, including the ability to quickly assess flow directionality in vessels and through valves, and to rapidly identify valve regurgitation. Strain analysis is a critical advance that is utilized to quantitatively measure regional myocardial function.6 This technique has the potential to detect changes in pathology, or resolution of pathology, earlier than conventional techniques. Coupled with the addition of three-dimensional image reconstruction, volumetric assessment of whole-organs is possible, including visualization and assessment of cardiac and vascular structures. Murine-compatible contrast imaging can also allow for volumetric measurements and tissue perfusion assessment.

This video demonstrates use of a rail-mounted high-frequency ultrasound probe to perform echocardiography on an anesthetized mouse. The methods describe both conventional two-dimensional and M-mode measurements of cardiac function in addition to newer, more powerful tools such as color Doppler, strain analysis, as well as general and targeted contrast imaging.

L&#39;ecocardiografia murini e imaging a ultrasuoni

Rodent models of cardiac pathophysiology represent a valuable research tool to investigate mechanism of disease as well as test new therapeutics.1  ...

MRI-guided Disruption of the Blood-brain Barrier using Transcranial Focused Ultrasound in a Rat Model

Focused ultrasound (FUS) disruption of the blood-brain barrier (BBB) is an increasingly investigated technique for circumventing the BBB1-5. The BBB is a significant obstacle to pharmaceutical treatments of brain disorders as it limits the passage of molecules from the vasculature into the brain tissue to molecules less than approximately 500 Da in size6. FUS induced BBB disruption (BBBD) is temporary and reversible4 and has an advantage over chemical means of inducing BBBD by being highly localized. FUS induced BBBD provides a means for investigating the effects of a wide range of therapeutic agents on the brain, which would not otherwise be deliverable to the tissue in sufficient concentration. While a wide range of ultrasound parameters have proven successful at disrupting the BBB2,5,7, there are several critical steps in the experimental procedure to ensure successful disruption with accurate targeting. This protocol outlines how to achieve MRI-guided FUS induced BBBD in a rat model, with a focus on the critical animal preparation and microbubble handling steps of the experiment.

Microbubble-mediated focused ultrasound disruption of the blood-brain barrier (BBB) is a promising technique for non-invasive targeted drug delivery in the brain1-3. This protocol outlines the experimental procedure for MRI-guided transcranial BBB disruption in a rat model.

MRI-guidato Interruzione della barriera emato-encefalica transcranica con ultrasuoni focalizzati in un modello murino

Focused ultrasound (FUS) disruption of the blood-brain barrier (BBB) is an increasingly investigated technique for circumventing the BBB1-5. The BBB is a ...

Multi-modal Imaging of Angiogenesis in a Nude Rat Model of Breast Cancer Bone Metastasis Using Magnetic Resonance Imaging, Volumetric Computed Tomography and Ultrasound

Angiogenesis is an essential feature of cancer growth and metastasis formation. In bone metastasis, angiogenic factors are pivotal for tumor cell proliferation in the bone marrow cavity as well as for interaction of tumor and bone cells resulting in local bone destruction. Our aim was to develop a model of experimental bone metastasis that allows in vivo assessment of angiogenesis in skeletal lesions using non-invasive imaging techniques.
For this purpose, we injected 105 MDA-MB-231 human breast cancer cells into the superficial epigastric artery, which precludes the growth of metastases in body areas other than the respective hind leg1. Following 25-30 days after tumor cell inoculation, site-specific bone metastases develop, restricted to the distal femur, proximal tibia and proximal fibula1. Morphological and functional aspects of angiogenesis can be investigated longitudinally in bone metastases using magnetic resonance imaging (MRI), volumetric computed tomography (VCT) and ultrasound (US).
MRI displays morphologic information on the soft tissue part of bone metastases that is initially confined to the bone marrow cavity and subsequently exceeds cortical bone while progressing. Using dynamic contrast-enhanced MRI (DCE-MRI) functional data including regional blood volume, perfusion and vessel permeability can be obtained and quantified2-4. Bone destruction is captured in high resolution using morphological VCT imaging. Complementary to MRI findings, osteolytic lesions can be located adjacent to sites of intramedullary tumor growth. After contrast agent application, VCT angiography reveals the macrovessel architecture in bone metastases in high resolution, and DCE-VCT enables insight in the microcirculation of these lesions5,6. US is applicable to assess morphological and functional features from skeletal lesions due to local osteolysis of cortical bone. Using B-mode and Doppler techniques, structure and perfusion of the soft tissue metastases can be evaluated, respectively. DCE-US allows for real-time imaging of vascularization in bone metastases after injection of microbubbles7.
In conclusion, in a model of site-specific breast cancer bone metastases multi-modal imaging techniques including MRI, VCT and US offer complementary information on morphology and functional parameters of angiogenesis in these skeletal lesions.

In the pathogenesis of bone metastasis, angiogenesis is a crucial process and therefore represents a target for imaging and therapy. Here, we present a rat model of site-specific breast cancer bone metastasis and describe strategies to non-invasively image angiogenesis in vivo using magnetic resonance imaging, volumetric computed tomography and ultrasound.

Multi-modal Imaging di angiogenesi in un modello di ratto Nudo di metastasi ossee cancro al seno utilizzando la risonanza magnetica, tomografia computerizzata volumetrica e Ultrasuoni

Angiogenesis is an essential feature of cancer growth and metastasis formation. In bone metastasis, angiogenic factors are pivotal for tumor cell ...

Imaging Glioma Initiation In Vivo Through a Polished and Reinforced Thin-skull Cranial Window

Glioma is the one of the most lethal forms of human cancer. The most effective glioma therapy to date-surgery followed by radiation treatment-offers patients only modest benefits, as most patients do not survive more than five years following diagnosis due to glioma relapse 1,2. The discovery of cancer stem cells in human brain tumors holds promise for having an enormous impact on the development of novel therapeutic strategies for glioma 3. Cancer stem cells are defined by their ability both to self-renew and to differentiate, and are thought to be the only cells in a tumor that have the capacity to initiate new tumors 4. Glioma relapse following radiation therapy is thought to arise from resistance of glioma stem cells (GSCs) to therapy 5-10. In vivo, GSCs are shown to reside in a perivascular niche that is important for maintaining their stem cell-like characteristics 11-14. Central to the organization of the GSC niche are vascular endothelial cells 12. Existing evidence suggests that GSCs and their interaction with the vascular endothelial cells are important for tumor development, and identify GSCs and their interaction with endothelial cells as important therapeutic targets for glioma. The presence of GSCs is determined experimentally by their capability to initiate new tumors upon orthotopic transplantation 15. This is typically achieved by injecting a specific number of GBM cells isolated from human tumors into the brains of severely immuno-deficient mice, or of mouse GBM cells into the brains of congenic host mice. Assays for tumor growth are then performed following sufficient time to allow GSCs among the injected GBM cells to give rise to new tumors-typically several weeks or months. Hence, existing assays do not allow examination of the important pathological process of tumor initiation from single GSCs in vivo. Consequently, essential insights into the specific roles of GSCs and their interaction with the vascular endothelial cells in the early stages of tumor initiation are lacking. Such insights are critical for developing novel therapeutic strategies for glioma, and will have great implications for preventing glioma relapse in patients. Here we have adapted the PoRTS cranial window procedure 16and in vivo two-photon microscopy to allow visualization of tumor initiation from injected GBM cells in the brain of a live mouse. Our technique will pave the way for future efforts to elucidate the key signaling mechanisms between GSCs and vascular endothelial cells during glioma initiation.

Imaging Glioma Initiation In Vivo Through a Polished and Reinforced Thin-skull Cranial Window

By combining a polished and reinforced thin-skull (PoRTS) cranial window and glioblastoma (GBM) cell injection, we can observe glioma initiation and growth from injected GBM cells in the brain of a live mouse longitudinally.

Imaging Glioma Iniziazione<em&gt; In Vivo</em&gt; Attraverso un lucido e sottile rinforzato cranio finestra craniale

Glioma is the one of the most lethal forms of human cancer. The most effective glioma therapy to date-surgery followed by radiation treatment-offers ...

A Novel Application of Musculoskeletal Ultrasound Imaging

Ultrasound is an attractive modality for imaging muscle and tendon motion during dynamic tasks and can provide a complementary methodological approach for biomechanical studies in a clinical or laboratory setting. Towards this goal, methods for quantification of muscle kinematics from ultrasound imagery are being developed based on image processing. The temporal resolution of these methods is typically not sufficient for highly dynamic tasks, such as drop-landing. We propose a new approach that utilizes a Doppler method for quantifying muscle kinematics. We have developed a novel vector tissue Doppler imaging (vTDI) technique that can be used to measure musculoskeletal contraction velocity, strain and strain rate with sub-millisecond temporal resolution during dynamic activities using ultrasound. The goal of this preliminary study was to investigate the repeatability and potential applicability of the vTDI technique in measuring musculoskeletal velocities during a drop-landing task, in healthy subjects. The vTDI measurements can be performed concurrently with other biomechanical techniques, such as 3D motion capture for joint kinematics and kinetics, electromyography for timing of muscle activation and force plates for ground reaction force. Integration of these complementary techniques could lead to a better understanding of dynamic muscle function and dysfunction underlying the pathogenesis and pathophysiology of musculoskeletal disorders.

We describe a new ultrasound-based vector tissue Doppler imaging technique to measure muscle contraction velocity, strain and strain rate with sub-millisecond temporal resolution during dynamic activities. This approach provides complementary measurements of dynamic muscle function and could lead to a better understanding of mechanisms underlying musculoskeletal disorders.

Una applicazione Novel di muscoloscheletrico Ultrasound Imaging

Ultrasound is an attractive modality for imaging muscle and tendon  motion during dynamic tasks and can provide a complementary methodological  approach ...

Diagnostic Ultrasound Imaging of Mouse Diaphragm Function

Function analysis of rodent respiratory skeletal muscles, particularly the diaphragm, is commonly performed by isolating muscle strips using invasive surgical procedures. Although this is an effective method of assessing in vitro diaphragm activity, it involves non-survival surgery. The application of non-invasive ultrasound imaging as an in vivo procedure is beneficial since it not only reduces the number of animals sacrificed, but is also suitable for monitoring disease progression in live mice. Thus, our ultrasound imaging method may likely assist in the development of novel therapies that alleviate muscle injury induced by various respiratory diseases. Particularly, in clinical diagnoses of obstructive lung diseases, ultrasound imaging has the potential to be used in conjunction with other standard tests to detect the early onset of diaphragm muscle fatigue. In the current protocol, we describe how to accurately evaluate diaphragm contractility in a mouse model using a diagnostic ultrasound imaging technique.

Diagnostic ultrasound imaging has proven to be effective in diagnosing various respiratory diseases in human and animal subjects. We demonstrate a comprehensive ultrasound protocol utilized by Dr. Zuo's lab to analyze diaphragm kinetics specifically in mouse models. This is also a non-invasive research technique which can provide quantitative information on mouse respiratory muscle function.

Diagnostic Ultrasound Imaging di funzione mouse Diaframma

Function analysis of rodent respiratory skeletal muscles, particularly the diaphragm, is commonly performed by isolating muscle strips using invasive ...

High-frequency Ultrasound Imaging of Mouse Cervical Lymph Nodes

High-frequency ultrasound (HFUS) is widely employed as a non-invasive method for imaging internal anatomic structures in experimental small animal systems. HFUS has the ability to detect structures as small as 30 &#181;m, a property that has been utilized for visualizing superficial lymph nodes in rodents in brightness (B)-mode. Combining power Doppler with B-mode imaging allows for measuring circulatory blood flow within lymph nodes and other organs. While HFUS has been utilized for lymph node imaging in a number of mouse&#160; model systems, a detailed protocol describing HFUS imaging and characterization of the cervical lymph nodes in mice has not been reported. Here, we show that HFUS can be adapted to detect and characterize cervical lymph nodes in mice. Combined B-mode and power Doppler imaging can be used to detect increases in blood flow in immunologically-enlarged cervical nodes. We also describe the use of B-mode imaging to conduct fine needle biopsies of cervical lymph nodes to retrieve lymph tissue for histological&#160; analysis. Finally, software-aided steps are described to calculate changes in lymph node volume and to visualize changes in lymph node morphology following image reconstruction. The ability to visually monitor changes in cervical lymph node biology over time provides a simple and powerful technique for the non-invasive monitoring of cervical lymph node alterations in preclinical mouse models of oral cavity disease.

This protocol describes the application of high-frequency ultrasound (HFUS) for imaging mouse cervical lymph nodes. This technique optimizes visualization and quantification of cervical lymph node morphology, volume and blood flow. Image-guided biopsy of cervical lymph nodes and processing of lymph tissue for histological evaluation is also demonstrated.

Ad alta frequenza di Ecografia del mouse cervicali Linfonodi

High-frequency ultrasound (HFUS) is widely employed as a non-invasive method for imaging internal anatomic structures in experimental small animal ...

Transcutaneous Microcirculatory Imaging in Preterm Neonates

Microcirculatory imaging (MI) is a relatively new research tool mainly used in the intensive care setting. MI provides a clear view of the smallest capillaries, arterioles and venules. The magnifying effect visualizes the flow pattern of erythrocytes through these vessels.
It's non-invasive character makes it suitable to apply in (preterm) neonates, even in cardiorespiratory unstable patients. In adults and children, MI is mainly performed sublingually, but this is not possible in preterm infants as these cannot cooperate and the size of the probe is problematic. In preterm infants, MI is therefore performed transcutaneously. Their thin skin makes it possible to obtain high quality images of peripheral microcirculation. 
In this manuscript we will demonstrate the method of transcutaneous MI in preterm infants. We will focus on the different techniques and provide tips to optimize image quality. The highlights of software settings, safety and offline analysis are also addressed.

Microcirculatory imaging (MI) is used to monitor peripheral perfusion in critically ill or preterm neonates. This manuscript and video demonstrates the optimal approach for obtaining high-quality images.

Transcutanea microcircolatoria Imaging in pretermine neonati

Microcirculatory imaging (MI) is a relatively new research tool mainly used in the intensive care setting. MI provides a clear view of the smallest ...

Ultrasound Imaging of the Thoracic and Abdominal Aorta in Mice to Determine Aneurysm Dimensions

Contemporary high-resolution ultrasound instruments have sufficient resolution to facilitate the measurement of mouse aortas. These instruments have been widely used to measure aortic dimensions in mouse models of aortic aneurysms. Aortic aneurysms are defined as permanent dilations of the aorta, which occur most frequently in the ascending and abdominal regions. Sequential measurements of aortic dimensions by ultrasound are the principal approach for assessing the development and progression of aortic aneurysms in vivo. Although many reported studies used ultrasound imaging to measure aortic diameters as a primary endpoint, there are confounding factors, such as probe position and cardiac cycle, that may impact the accuracy of data acquisition, analysis, and interpretation. The purpose of this protocol is to provide a practical guide on the use of ultrasound to measure the aortic diameter in a reliable and reproducible manner. This protocol introduces the preparation of mice and instruments, the acquisition of appropriate ultrasound images, and data analysis.

Ultrasound imaging has become a common modality to determine the luminal dimensions of thoracic and abdominal aortic aneurysms in mice. This protocol describes the procedure to acquire reliable and reproducible two-dimensional ultrasound images of the ascending and abdominal aorta in mice.

Formazione immagine di ultrasuono dell'Aorta toracica ed addominale in topi per determinare le dimensioni di Aneurysm

Contemporary high-resolution ultrasound instruments have sufficient resolution to facilitate the measurement of mouse aortas. These instruments have been ...