Neonatal cranial ultrasound report template
A structured neonatal cranial ultrasound report template used for paediatric cranial ultrasound. It covers 9 sections and 25 fields, and includes a one-click normal preset.
Technique
Transfontanelle ultrasound through the anterior fontanelle in coronal and sagittal planes, with supplementary mastoid views as required.
Sample normal neonatal cranial ultrasound report
This is the text SonoTez generates when the doctor applies the template's normal preset. Measurements are left for the doctor to enter.
Technique
Transfontanelle ultrasound through the anterior fontanelle in coronal and sagittal planes, with supplementary mastoid views as required.
Findings
Right lateral ventricle
The right lateral ventricle is normal in size.
No germinal matrix or intraventricular haemorrhage on the right.
Left lateral ventricle
The left lateral ventricle is normal in size.
No germinal matrix or intraventricular haemorrhage on the left.
Third / fourth ventricles and midline
The third and fourth ventricles are normal in size.
Midline structures including the corpus callosum and cavum septi pellucidi are normal.
Periventricular white matter
Periventricular white matter echogenicity is normal with no cystic change.
Extra-axial spaces
Extra-axial spaces are not widened.
Posterior fossa
The posterior fossa appears normal.
Impression
Normal neonatal cranial ultrasound. No intracranial haemorrhage or periventricular white matter injury is seen.
What to include: sections and measurements
Age at scan
- Corrected gestational age (weeks)
- Day of life (days)
Right lateral ventricle
- Ventricular index (mm)
- Anterior horn width (mm)
- Thalamo-occipital distance (mm)
- Size: normal · mildly dilated · moderately dilated · severely dilated · slit-like
- Germinal matrix / IVH (doctor-assessed): no haemorrhage · grade i - germinal matrix only · grade ii - intraventricular, no dilatation · grade iii - intraventricular with dilatation · periventricular haemorrhagic infarction
Left lateral ventricle
- Ventricular index (mm)
- Anterior horn width (mm)
- Thalamo-occipital distance (mm)
- Size: normal · mildly dilated · moderately dilated · severely dilated · slit-like
- Germinal matrix / IVH (doctor-assessed): no haemorrhage · grade i - germinal matrix only · grade ii - intraventricular, no dilatation · grade iii - intraventricular with dilatation · periventricular haemorrhagic infarction
Third / fourth ventricles and midline
- Third ventricle width (mm)
- Third and fourth ventricles: normal · dilated
- Corpus callosum, cavum septi pellucidi, falx: normal · abnormal
- Description
Periventricular white matter
- Periventricular echogenicity: normal · increased (flare)
- Duration of increased echogenicity (days)
- Cystic PVL (doctor-assessed): no cystic change · small localised fronto-parietal cysts (grade ii) · extensive periventricular cysts (grade iii) · cysts extending into subcortical white matter (grade iv)
Extra-axial spaces
- Extra-axial spaces: not widened · prominent · collection
- Description
Posterior fossa
- Cerebellum / posterior fossa: normal · abnormal
- Description
Doppler
- ACA resistive index
Other findings
- Other findings
Writing the impression
Answer the clinical question first, list the remaining findings in order of importance, and keep anything new out of the impression. If a structure was not fully seen, say so and give the reason. See how to write an ultrasound report for wording and certainty terms.