1. Utilization of cine MRI technique in CNS, Head & Neck and beyond in fetuses and children. L. Nagae, T. Feygin, L. T. Bilaniuk, R. A. Zimmerman The Children’s Hospital of Philadelphia University of Pennsylvania School of Medicine University of Pennsylvania School of Medicine

2. PURPOSE : Real time cine MRI in evaluation of: - functional impairment of fetal organ systems, especially, in head & neck pathology -various pathologic entities causing alteration of cerebro-spinal fluid (CSF) flow in children Upper GI and more

3. Evaluation of fetal pathology: More than 7,000 referrals to CHOP in 10 years with a variety of pathology: ( CONGENITAL HEART DISEASE, NEUROLOGIC MALFORMATIONS, NECK MASSES, CONGENITAL DIAPHRAGMATIC HERNIA, UROPATHY, etc ) Ultrasound (US): Primary obstetric imaging tool MRI: Further assessment of sonographic findings

4. FETAL MRI : MORPHOLOGY

5. FETAL MRI CINE :Dynamic processes

6. FETAL MRI CINE TECHNIQUE: 1.5 Tesla Superconducting Siemens Avanto short bore magnet Parallel imaging with 2D True FISP TR: 3.66; TE: 1.83; Flip angle:90; matrix 179 x 256 No breath holding, acquisition time 30- 35 sec No breath holding, acquisition time 30- 35 sec

7. Real time cine MRI in evaluation of functional impairment of fetal organs systems Various pathologic entities causing alteration of cerebro-spinal fluid (CSF)flow ( myelomemingocele, Chiari II malformation, Dandy-Walker malformation, aqueductal stenosis) Swallowing function (head& neck masses, cleft lip& palate, micrognatia) Cardiomyopathy, uropathy Diaphragmatic excursions, etc

8. INDICATIONS FOR CINE, fetal CNS pathology :  Chiari II malformation  Dandy-Walker malformation,  Aqueductal stenosis  Head and Neck Masses  Cerebral arachnoid cyst  Cleft lip and palate  And more…

9. Normal pattern of CSF flow

10. MMC, CHIARI 2 malformation, “two hits” hypothesis

11. Myelomeningocele,CINE

12. CINE: Swallowing function Head and neck masses Cleft lip and palate Brain stem anomaly

13. Normal pattern of fetal swallowing

14. Soft palate movements

15. Epidermoid cyst: abnormal tongue movement

16. Venolymphatic malformation: hypopharyngeal pooling

17. Craniofacial teratoma

19. Cleft lip and palate

20. Cleft lip and palate: Velopharyngeal incompetence ? Cleft lip Normal

21. Normal left ventricular outflow

22. Aorta coarctation

23. Postnatal Real time MR techniques: True FISP Cine Cine phase contrast The acquisition plane depends on the particular CSF flow being evaluated.

24. Endoscopic neurosurgical procedures Obstructive hydrocephalus, 3d ventriculostomy (ETV) Arachnoid cyst fenestration

25. INDICATIONS: Evaluation of CEREBRAL CSF FLOW and p atency of - Sylvian aqueduct -Foramina of MONRO -Fenestration site of arachnoid cyst -Fenestration site of ETV And more

26. True FISP IPAT Cine 1.5 or 3.0 Tesla Superconducting Siemens Magnet Parallel imaging with 2D True FISP TR: 3.66; TE: 1.83; Flip angle:90; matrix 179 x 256 No breath holding 35 sec acquisition time

27. Cine: Normal pattern

28. Cine: Periventricular leukomalacia (PVL)

29. Cine:Foramina of Monroe, SA

30. Cine Phase-contrast Imaging Low velocity encoding(VENC) parameter (5cm/sec) to sensitize the sequence to slow CSF flow 1.45 min acquisition time Requires Pox or ECG gaiting

31. Ex-premie at 29 wks, congenital hydrocephalus, s/p ETV MRI PC MRI cine

32. Arachnoid cyst fenestration

33. 10 m.o. boy FT with rapidly increased HC

34. S/p ETV and suprasellar cyst fenestration ( T2WI and PC)

35. Conclusion: FETAL CINE Valuable tool in prenatal assessment of preservation or impairment of some fetal functions Specially in fetuses with head and neck lesions PLANNING FOR DELIVERY AND SURGERY AFTER BIRTH

36. Conclusion: postnatal CINE Valuable tool in assessment intracranial CSF flow dynamics and evaluation of effectiveness of endoscopic neurosurgical procedures performed to change route of flow of CSF. Future GI tract assessment?

37. THANK YOU.THE END