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Cerebral medullary veins: normal and abnormal pattern in fetal and pediatric patients.

Cerebral medullary veins: normal and abnormal pattern in fetal and pediatric patients. Tamara Feygin, Robert A. Zimmerman, Larissa T. Bilaniuk, Monica Epelman, Erin Simon-Schwartz, Avrum N. Pollock. Cerebral medullary veins. Fetal US Fetal MRI Neonatal MRI.

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Cerebral medullary veins: normal and abnormal pattern in fetal and pediatric patients.

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  1. Cerebral medullary veins: normal and abnormal pattern in fetal and pediatric patients. Tamara Feygin, Robert A. Zimmerman, Larissa T. Bilaniuk, Monica Epelman, Erin Simon-Schwartz, Avrum N. Pollock

  2. Cerebral medullary veins • Fetal US Fetal MRI Neonatal MRI

  3. Cerebral Medullary Veins Recent increased interest in imaging of medullary veins. New classification of unilateral periventricular infarction is based on precise anatomy of the affected vessels “Venous subtypes of preterm periventricular haemorrhagic infarction” by J. Dudnink et al,2007.Arch Dis Child Fetal Neonatal Ed 2008;93:F201-F206 doi:10.1136/adc.2007.118067

  4. Purpose: To characterize imaging features of normal and abnormal medullary veins. To define their role in the pathogenesis of certain cerebral disorders in fetal and pediatric brains

  5. Normal supratentorialmedullary veins • Superficial medullary veins: short channels in WM, drain to the cortical surface, variable in number and location • Deep medullary veins: longer channels, drain toward the ventricles, much less variation • Transcerebral (anastamotic) veins

  6. Deep Medullary Veins • ~ 2000-4000 very small (0.05-0.35 mm in caliber) veins drain periventricular WM and GM • 1936 First histological report of fan-shaped pattern of medullary veins thrombosis (H.Ehlers,et al) • 1986 Periventricular architecture is demonstrated by microvenography (S.Takashima,et al) • Run perpendicular to the long axis of the lateral ventricles on sagittal and converge on the corners of lat vent in a fan-shaped pattern

  7. Deep Medullary Veins • Pattern is not random • Strongly related to embryonic path of neurons migration • Unique arrangement and anatomic details may lead to predisposition for thrombosis

  8. Deep Medullary Veins • Normally seen in fetal brains from 18 to 32 wks • Not seen on conventional cross-sectional imaging or conventional angiogram, but may appear on SWI • When engorged appear in a spectrum of pathologies Fetal EPI T2WI

  9. Abnormal patterns • Apparent on conventional T1, T2,post contrast MRI, US • Primary pathology of medullary veins such as thrombosis or septic thrombophlebitis • Compensatory proliferation/engorgement (elevated intracerebral venous pressure, tumoral neovascularity, etc)

  10. Abnormal patterns: Thrombosis of medullary veins Periventricular hemorrhagic venous infarction (PVHVI) in the setting of prematurity and germinal matrix hemorrhage. Hemorrhagic periventricular leukomalacia (PVL) Perinatal venous infarction of uncertain etiology with Wallerian degeneration Diffuse hypoxic-ischemic injury to deep cerebral WM

  11. Ex 29 wks, 3 day old boy Periventricular hemorrhagic venous infarction in the setting of prematurity and germinal matrix hemorrhage/IVH. T2WI

  12. Sagittal US Ex-premature at 31 wks 11 day oldPeriventricular hemorrhagic venous infarction • MRI, T2WI

  13. FT with severe CHD (Ebstein anomaly), hemorrhagic PVL • Sagittal T1 Coronal T2 Axial GRE

  14. Abnormal patterns: Septic thrombophlebitis One of the key factors in pathogenesis of cerebral neonatal abscess Confined to cerebral medullary veins Occurs in the setting of neonatal meningitis caused by Gram negative microbes, such as Citrobacter species and Serratia Marcescens Complicated by deep WM abscesses

  15. Neonatal abscesses, Citrobacter meningitis T2WI DWI Post GD GRE

  16. Serratia Marcescens meningitis GRE Post Gd T2WI

  17. Abnormal patterns (engorgement): Primary pathology of dural venous sinuses Abnormal proliferation of medullary veins caused by elevated cerebral venous pressure (dural venous thrombosis) Vein of Galen malformation Dural AV fistula Some superficial arterio-venous malformations

  18. Superficial Arteriovenous Malformation T1WI, 3 Tesla

  19. 20wks fetus with numerous anomalies

  20. Conclusion: • Deep medullary veins are the smallest cerebral vessels, which can be recognized on MRI, US(linear probe) and conventional angiography. • These veins can be viewed as an important site for cascade of pathologic events in fetal/pediatric brain. • Early detection of abnormal appearance of medullary veins leads to more prompt diagnosis of serious cerebral injury.

  21. THANK YOU. THE END.

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