ECHOCARDIOGRAPHY FOR THE NEONATOLOGIST PDF

Corresponding author. Abstract One of the major challenges of neonatal intensive care is the early detection and management of circulatory failure. Routine clinical assessment of the hemodynamic status of newborn infants is subjective and inaccurate, emphasizing the need for objective monitoring tools. An overview will be provided about the use of neonatologist-performed echocardiography NPE to assess cardiovascular compromise and guide hemodynamic management. Different techniques of central blood flow measurement, such as left and right ventricular output, superior vena cava flow, and descending aortic flow are reviewed focusing on methodology, validation, and available reference values.

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October 29, Ultrasound is the preferred modality in neonates with suspected occult spinal dysraphism OSD. OSD implies the presence of one or more spinal cord anomalies, which can cause tethering of the spinal cord and possible neurological and bladder or bowel function deficits.

Ultrasound is easy to perform, since the posterior arch of the vertebra is not yet ossified, providing a perfect acoustic window. Especially the lumbosacral part of the spinal canal with the conus medullaris and the cauda equina can be beautifully depicted with a high resolution linear array probe. Classification of Spinal dysraphism Spina bifida aperta Spinal dysraphism or spina bifida is a congenital anomaly resulting in a defective closure of the neural arch.

It is classified into open spina bifida aperta and closed dysraphism spina bifida occulta. Open dysraphism presents with a swelling over the back which is noticed at birth and may contain meninges and CSF, called meningocele or contain parts of the spinal cord or nerves, called myelomeningocele.

Ultrasound should not be used to image open spinal dysraphism at the lesion itself. It does not add much and can lead to infection. Ultrasound can be used to examine more cranial parts of the vertebral column, searching for additional anomalies and is useful to measure the size of the ventricles of the brain after closure of the myelomeningocele.

Spina bifida occulta In closed or occult spinal dysraphism, also called spina bifida occulta, there is an intact covering of the skin. The anomaly is suspected when there are skin changes like hair tufts, hemangiomas, pigmented spots, cutaneous dimples or a subcutaneous mass.

Another reason to perform ultrasound is when there is a congenital anomaly that is associated with OSD like anal atresia.

The terms thickened or fatty filum terminale, spinal lipomas, split cord malformations, dermoid cyst, and syringohydromyelia are all different forms of OSD. Normal anatomy Click to enlarge The spinal cord is depicted as a very hypoechoic structure with a central echogenicity.

This central echogenicity is supposed to represent the interface between the anterior commissure and the median anterior fissure, and not the central canal. Axial image of the spinal cord with central echogenicity. Axial image of the cauda equina. The lower end of the cord is thickened, which is the lumbar intumescence. The cord tapers in a sharp cone blue arrow. The cauda equina is seen as a bunch of moving strands. If the baby is lying in the decubitus position, the strands will gravitate to the dependent posterior side.

If the baby is examined in the prone position with a pillow under the abdomen, the stands will move ventrally. The filum terminale can be seen as a thin echogenic thread. The dural sac ends at approximately S2. More distally fatty tissue is present. Video of the normal sagittal anatomy. Always obtain axial views.

The movement of the nerve roots is better seen in the transverse plane compared to the sagittal plane and it is easier to assess intraspinal pathology like a thickened filum. Film in right decubitus position. The nerve roots are clustered in the dependent side, but move freely. When the nerve roots do not move freely, it can be a sign of OSD. Position of the conus medullaris The normal position of the conus is at L!.

It should not be below L2. The best way to determine the position of the conus medullaris is by identifying the lumbosacral junction at the lordotic angle between the lumbar and sacral vertebrae arrow. It can be helpful to flex and extend the pelvis to see the point of motion of the sacrum. In this newborn the lumbosacral junction is less clearly seen because there is no acute angle. If one is uncertain, make a panoramic or dual image of the lumbosacral vertebral column and compare the vertebral count from below upwards with a lateral plain film.

Sagittal view of a normal "kyphotic" coccyx in a 2-day-old girl The coccyx, if not yet ossified, is composed of hypoechoic cartilage.

It usually has a kyphotic shape. On transverse views it should not be confused with a fluid collection or an abscess. Normal variants Two-week-old girl with a sacral simple.

There is a slight hydromyelia white arrow and a cyst in the filum terminale yellow arrow , both are normal variants. Central canal In this image the central canal is visible as a thin anechoic line in the spinal cord white arrow. Although this is sometimes associated with pathology it is frequently seen as a normal finding. Ventriculus terminalis A small cyst is seen in the proximal filum terminale.

This is called a ventriculus terminalis or fifth ventricle. Sometimes it is seen in the conus medullaris. It is formed during embryogenesis and usually regresses completely during early childhood. If it stays persistent, it typically measures less than 2 cm in craniocaudal dimension and 2 mm in transverse dimension and is detected as an asymptomatic and incidental finding in adults. Here a sagittal image of a three-months-old girl who was imaged because of a skin discoloration of the lower back.

The spinal anatomy was normal and there was no sign of OSD. There is a straight coccyx, which is a normal variant.

Usually the coccyx has a anteriorly bent tip, but sometimes it is straight or even dorsally bent, which is also a normal variant. Pathology In many cases occult spinal dysraphism may not cause any symptoms. However in some cases there may develop neurological problems due to tethering of the cord. A tethered cord is a pathologic fixation of the spinal cord in an abnormal caudal location, so that the cord suffers mechanical stretching, distortion and ischemia with growth and development.

In these cases ultrasound is well suited to image the contents of the spinal canal and to look for findings that are associated with a tethered cord Table. Low conus medullaris Newborn girl with a cloacal malformation. The conus medullaris is at L5.

No lipoma visible. Findings were confirmed at MR imaging which was acquired at the age of 9 months. Continue with the MR. MR image at the age of 9 months. The conus medullaris is now seen at L4. Thickened filum terminale.

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Persistent PDA has been suggested as an independent risk factor for increased risk of intraventricular hemorrhage IVH , necrotizing enterocolitis NEC , bronchopulmonary dysplasia BPD , acute pulmonary hemorrhage, and a fold increase in mortality [20]. However, studies on PDA treatment have failed to demonstrate any benefit on the long-term outcomes [21]. Certainly there is a clear trend towards treating less number of infants with PDA [22]. However, safety of the conservative approach has not been established. Secondly, while some infants with an hsPDA may need intervention, others may need only careful observation [22].

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Echocardiography for the Neonatologist

The most important cardiac heart disease in neonatology is the diagnosis of a persistent ductus arteriosus and the estimation of its haemodynamic relevance. Another important pathophysiologic situation in neonatology is the diagnosis of pulmonary hypertension. Last but not least is echocardiography helpful for the diagnosis of cardiac failure, hypotension and shock. Structural heart diseases have to be confirmed or excluded.

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Neonatal spine - Ultrasound

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