E1837. Acute Surgical Chest in the Neonate: What the Radiologist Needs to Know
  1. Nadia Sultan; University of Rochester
  2. Nina Klionsky; University of Rochester
  3. Deepa Biyyam; Phoenix Children's Hospital
  4. Mitchell Chess; University of Rochester
  5. Apeksha Chaturvedi; University of Rochester
Acute surgical chest in the neonate can arise secondary to a wide spectrum of conditions ranging from congenital diaphragmatic hernias, cystic thoracic malformations, esophageal atresias, congenital and postsurgical chylothoraces and ventral chest wall defects. Preceding the era of sophisticated prenatal diagnosis, several of these conditions resulted in fetal/neonatal loss. Improved prenatal diagnosis and prognostication of these conditions has vastly improved perinatal management, which has thereby resulted in increased neonatal survival and reduced morbidity. Since imaging is so central to surgical decision-making, it is important for radiologists to familiarize themselves with imaging findings and imaging-defined prognostic criteria for these entities that are relevant to the pediatric surgeon. Cardiac conditions are outside the scope of this review and will not be addressed.

Educational Goals / Teaching Points
To review perinatal imaging findings for surgical chest in the neonate on an illustrative, case-based template. To emphasize details obtainable on imaging relevant to surgical decision-making. To outline imaging-defined prognostic indicators specific to each entity. To overview clinical scenarios where surgery may be required in the neonatal period for entities that are more often operated later in infancy or childhood.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques
Antenatal ultrasound, fetal MRI and postnatal chest radiographs, fluoroscopy, ultrasound, CT and MRI aid diagnosis, and in several cases, prognostication of conditions leading to acute surgical chest in the neonate. Congenital diaphragmatic hernias, ventral thoracic wall defects, cystic thoracic malformations, esophageal atresias, congenital chylothorax and neonatal tumors such as teratomas may first be detected on the 18-20 -week ultrasound scan. Fetal MRI may be helpful in differentiating congenital diaphragmatic hernia from other cystic lung lesions. Assessment of lung-to-head ratio on ultrasound and lung volumes on fetal MR can aid prognostication, since lung hypoplasia is the main cause of dismal survival in these patients. Similarly, cystic thoracic malformation volume ratios (CVR) assessed by antenatal imaging can predict the risk of complications and the need for surgery in the neonatal period. Post-natal imaging confirms antenatal findings, adding greater detail to the prenatal morphological evaluation and detecting associated findings.

Concurrent use of antenatal ultrasound and fetal MRI results in early detection and characterization of surgical chest lesions and help guide pediatric surgeons in appropriate post-natal management. Prenatal imaging aids prognostication of several of these entities.