ULTRASOUND CASE REVIEW

Associate Editor: Jennifer R. Marin, MD, MSc

An Infant Diagnosed With Hydrocephalus by

Point-of-Care Ultrasound
Susan K. Yaeger, MD and Jennifer R. Marin, MD, MSc

(CT) of the head at that time demonstrated hydrocephalus with

Abstract: Point-of-care ultrasound has become a valuable tool for pediatric
emergency physicians, with an increasing number of indications being
described. In this case presentation, we demonstrate the use of point-
of-care ultrasound in the pediatric emergency department to diagnose
ventriculomegaly in an infant presenting with a seizure.
Key Words: hydrocephalus, ventriculomegaly, point of care ultrasound
(Pediatr Emer Care 2017;33: 287–289)
CASE
A 10-week-old full-term female infant with a history of
salmonella meningitis and hydrocephalus was brought to the pedi-
atric emergency department (ED) after a seizure. The seizure was
described as 2 minutes of rapidly shifting eye movements, neck
extension, and full body stiffening that self-resolved. Parents
denied recent fevers, respiratory symptoms, vomiting, or diarrhea.
The patient was receiving her final week of cefotaxime therapy
through a peripherally inserted central catheter for meningitis.
At 6 weeks of age, she presented with status epilepticus and
was diagnosed with salmonella meningitis. A computed tomography
ventriculitis. An external ventricular drain was placed and then re-
moved 6 days later when magnetic resonance imaging (MRI)
demonstrated resolution of hydrocephauls.
On this presentation to the ED, the patient was well appearing
and smiling. She was afebrile with age-appropriate vital signs.
Her examination was normal, including a detailed neurologic
examination. Given concern for possible hydrocephalus but
without specific training in head ultrasound (US), the director
of pediatric emergency US, performed a point-of-care head
US examination, revealing hydrocephalus (Fig. 1A). A CT
confirmed dilated ventricles (Fig. 2).
ULTRASOUND FINDINGS
A point-of-care head US demonstrated the lateral ventricles
as symmetrically enlarged, anechoic spaces with well-defined bor-
ders and posterior acoustic enhancement.
TECHNIQUE
When performing the infant head US examination, a
high-frequency linear array transducer should be utilized. The

FIGURE 1. A, Transfontanellar point-of-care head US (coronal view) demonstrating ventriculomegaly of the lateral (LV) and third (TV)
ventricles. IF indicates interhemispheric fissure. B, Transfontanellar point-of-care head US (coronal view) in a normal 3-month-old. The IF and
normal-caliber LVs are demonstrated. In the absence of hydrocephalus, the TV is not always visualized sonographically.

transducer is placed over the anterior fontanel and by conven-

From the Division of Pediatric Emergency Medicine, Department of Pediatrics,
Children’s Hospital of Pittsburgh of the University of Pittsburgh Medical
Center, Pittsburgh, PA.
Disclosure: The authors declare no conflict of interest.
Reprints: Susan K. Yaeger, MD, Lehigh Valley Health Network, One City
Center, 9th Floor 707 Hamilton Street, Allentown, PA 18101
(e‐mail: Susan.Yaeger@lvhn.org).
Copyright © 2017 Wolters Kluwer Health, Inc. All rights reserved.
ISSN: 0749-5161
tion with the indicator toward the patient’s right. This results
in a coronal view through the brain with the patient’s right side
visualized on the left side of the screen. The depth can be ad-
justed to include the base of the skull. Fanning through the
brain from anterior to posterior, one can visualize the lateral
and third ventricles including the interhemispheric fissure
(Fig. 1B). By rotating the probe 90 degrees with indicator

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Yaeger and Marin Pediatric Emergency Care • Volume 33, Number 4, April 2017

pointed to the patient’s anterior, sagittal views are obtained by

fanning the transducer to the patient’s right and left, giving a
more complete view of the lateral ventricles (Fig. 3). If
abnormalities are suggested by the views obtained through
the anterior fontanel, additional views may be taken through
the posterior or mastoid fontanels or through any open suture,
burr hole, or craniotomy defect.1

REVIEW OF THE LITERATURE

Hydrocephalus is caused by the imbalance of production and
reabsorption of cerebrospinal fluid or obstruction to the flow of
cerebrospinal fluid. Computed tomography and MRI are
commonly performed for evaluation of hydrocephalus. There
are important considerations when selecting either modality,
particularly in infants. Computed tomography is rapid and
widely available; however, there is growing concern over ra-
diation exposure, particularly in patients who may require
multiple head CT scans throughout childhood.2 Magnetic res-
onance imaging demonstrates the anatomy in great detail;
however, the length of a full-brain MRI study can exceed FIGURE 3. Transfontanellar point-of-care head US (sagittal view) in
45 minutes and may require sedation in young children. In infants a normal 3-month-old demonstrating a lateral ventricle (LV).
with an open fontanel, US can be used quickly and safely to eval-
uate ventricular caliber.3
There are limitations to the head US examination worth
Case reports demonstrate point-of-care head US as a valuable
noting. As with all US examinations, success depends largely
diagnostic tool in the evaluation of life-threatening intracranial
on the skill and experience of the sonographer. However, many
processes affecting children. A 9-year-old girl with history of
publications, although not specific to head US, have estab-
congenital hydrocephalus and a ventriculoperitoneal shunt pre-
lished that with focused training pediatric emergency medicine
sented to an ED with headaches and vomiting. Point-of-care US
physicians can become skilled in point-of-care US.9–11 In addi-
was used to identify a discontinuity in the shunt tubing in the cer-
tion, the type of cranial US described here is appropriate only in
vical region with an adjacent fluid collection.4 In another case,
the young patient with an open fontanel. Finally, certain patholo-
point-of-care cranial US was used to diagnose intraventricular
gies, such as intracranial hemorrhage at the brain’s convexity, for
hemorrhage in a premature infant with fussiness and anemia.5
example, are not well visualized with US, and therefore, US is not
Several publications have highlighted the utility of point-of-care
a replacement for CT or MRI in some cases.12
US to identify pediatric skull fractures.6–8

CONCLUSIONS
Point-of-care cranial US may be a useful diagnostic tool in
the emergency evaluation of selected infants with neurologic
symptoms. In this case, point-of-care US was utilized to rapidly
and safely diagnose recurrent hydrocephalus.

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Pediatric Emergency Care • Volume 33, Number 4, April 2017
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