Anesth Pain Med.  2024 Oct;19(Suppl 1):S25-S35. 10.17085/apm.24106.

Intraoperative transfontanelle ultrasonography for pediatric patients

• Kim EH
• Park JB
• Kim JT

• KMID: 2563584
• DOI: http://doi.org/10.17085/apm.24106

Abstract

Cerebral blood flow (CBF) plays a vital role in delivering cerebral oxygen, and the accurate assessment of CBF is crucial for the intraoperative management of critically ill infants. Although the direct measurement of CBF is challenging, CBF velocity (CBFV) can be assessed using transcranial Doppler. Recent advances in point-of-care ultrasound have introduced brain ultrasound as a feasible intraoperative option, in which transfontanelle ultrasonography (TFU) has been applied to measure the CBFV through the anterior fontanelle. However, the intraoperative application of TFU in pediatric patients remains limited. The present review highlights the procedural aspects and clinical applications of TFU for anesthetic and intensive care management in pediatric patients. TFU facilitates the visualization of cerebral vessels and allows a noninvasive assessment of cerebral hemodynamics. The clinical significance of TFU involves its usefulness in various clinical scenarios, including monitoring CBF during cardiac surgery, assessing fluid responsiveness, and estimating intracranial pressure. TFU also enables the detection of cerebral emboli and the evaluation of anatomical abnormalities such as hydrocephalus or intracranial hemorrhage. TFU has demonstrated potential as an invaluable tool in pediatric care, despite limited familiarity among anesthesiologists. Additional research is needed to explore the associations between CBF and clinical outcomes, focusing on autoregulation, the impact of physiological changes, the associations of TFU findings with other brain monitoring tools such as electroencephalography, cerebral oximetry, and the implications of microemboli. TFU is a significant advancement and valuable tool for noninvasively assessing cerebral hemodynamics and CBF in pediatric patients with open fontanelles.

Keyword

Anesthesia; Blood flow velocities; Cerebral arteries; Cranial fontanelle; Doppler ultrasonography, transcranial; Newborn infants

Figure

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  Fig. 1. Missing diastolic flow because of left to right shunting (“diastolic steal”) through an open PDA in the left internal carotid artery (A) and recovered diastolic blood flow after PDA closure (B). PDA: patent ductus arteriosus.

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  Fig. 2. Coronal section. (A) Probe placement on the anterior fontanelle of the infant during cardiac surgery, (B) the coronal frontal image, (C) the coronal image at the level of Monro, and (D) the coronal section of the ACA, MCA, and both ICAs. ACA: anterior cerebral artery, MCA: middle cerebral artery, ICA: internal carotid artery.

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  Fig. 3. Sagittal section of the anterior cerebral and pericallosal arteries.

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  Fig. 4. Diastolic reverse flow with the absence of forward flow at the left internal carotid artery because of a kink in the proximal left common carotid artery (A) and recovered forward flow at the left internal carotid artery after aortopexy (B).

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  Fig. 5. Respiratory variation in transfontanelle internal carotid artery blood flow velocity (A) and aorta blood flow velocity (B).

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  Fig. 6. HITS in the Doppler spectrum. HITS: high-intensity transient signals.

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