Hydrocephalus in Children: Diagnostic Imaging and Radiological Characteristics
Jeff Edwards Gillian Lieberman, MD January 2002 Hydrocephalus in Children: Diagnostic Imaging and Radiological Characteristics Jeff Edwards, Harvard Medical School, Year III Gillian Lieberman, MD Jeff Edwards Gillian Lieberman, MD Agenda Introduction to the Patient Macrocephaly Basics of Hydrocephalus Diagnostic Imaging of Hydrocelphalus – Ultrasound, CT, MR Shunts 2 Jeff Edwards Gillian Lieberman, MD The Patient 6 yo boy with macrocephaly, which manifested in the first year of life as excessive head growth, accompanied by reduced activity and poor feeding. Other significant medical hx includes cognitive delay, osteogenesis imperfecta type 2, restrictive lung disease. Birth hx: born at 34 ½ wk premature by c-section with subsequent 25 day NICU course significant for apneic and bradycardic spells No family hx of large heads Used with permission of patient’s mother 3 Jeff Edwards Gillian Lieberman, MD Macrocephaly in Infant or Child Defined as a head circumference more than 2 SD above the mean for age and sex Excessive rate of head growth over time suggests increased intracranial pressure – Most often caused by hydrocephalus, extra-axial fluid collections, or neoplasms Macrocephaly with normal head growth rate suggests familial macrocephaly or true megalencephaly 4 Jeff Edwards Gillian Lieberman, MD DDx of Macrocephaly Causes Examples Pseudomacrocephaly, pseudohydrocephalus, catch-up growth Growing premature infant, recovery from malnutrition, congenital heart disease Increased intracranial pressure with dilated ventricles with other mass Benign familial macrocephaly (idiopathic external hydrocephalus) Progressive hydrocephalus, subdural effusion, hydrancephaly Arachnoid cyst, porencephalic cyst, brain tumor Benign enlargement of subarachnoid spaces, congenital communicating hydrocephalus, benign subdural collections of infancy 5 Jeff Edwards Gillian Lieberman, MD DDx of Macrocephaly (cont’d) Megalencephaly with neurocutaneous disorder with gigantism with dwarfism metabolic lysosomal other leukodystrophy Thickened skull Benign familial (see above) Neurofibromatosis, tuberous sclerosis Soto syndrome Achondroplasia Mucopolysaccharidoses, Krabbe’s disease, Ganglioside storage disease Metachromatic leukodystrophy Canavan spongy degeneration Fibrous dysplasia (bone), hemolytic anemia (marrow), sicklemia, thalasemia Modified from Hay, WW, et al. Current Pediatric Diagnosis & Treatment. 15th ed. New York: Lange Medical Books/McGraw Hill, 2001, p. 669. 6 Jeff Edwards Gillian Lieberman, MD Workup of Macrocephaly History – including family medical hx Physical exam – Neurological exam – Plotting measurement of head circumference for age and sex – Palpation of anterior fontanelle (if not closed) and of head for asymmetries or ridges – Listen for bruits in neck and head – In infants, transillumination of skull in a darkened room may reveal subdural effusions, hydrocephalus, hydranencephaly, or cystic defect Imaging studies Depending on hx, possible labs include toxoplasmosis serum antibody levels, lumbar puncture, subdural tap 7 Jeff Edwards Gillian Lieberman, MD Narrowed DDx for our Patient Hydrocephalus Space-occupying lesion (e.g., tumor or cyst) Extra-axial fluid collection (e.g., subdural effusion) Growing premature infant 8 Jeff Edwards Gillian Lieberman, MD Pathophysiology of Hydrocephalus Imbalance of CSF formation and absorption, resulting in an excess of CSF with subsequent increase in intracranial pressure CSF basics – Normal CSF production 02.-035 mL/min with a majority produced by the choroid plexus – Total volume of CSF in an adult ~ 120 mL 9 Jeff Edwards Gillian Lieberman, MD CSF Circulation & Ventricular System From Nolte, J. The Human Brain: An Introduction to Its Functional Anatomy. 4th ed. St. Louis: Mosby, 1999. 10 Jeff Edwards Gillian Lieberman, MD Epidemiology Incidence of congenital hydrocephalus is 23 per 1,000 live births Incidence of acquired hydrocephalus is not known About 100,000 shunts are implanted each year in the developed countries Incidence is equal in males and females 11 Jeff Edwards Gillian Lieberman, MD Symptoms of Hydrocephalus in Infants Poor feeding Irritability Reduced activity Vomiting 12 Jeff Edwards Gillian Lieberman, MD Signs in Infants Macrocephaly with excessive rate of head growth Dysjunction of sutures Dilated scalp veins Tense/bulging fontanelle Setting-sun sign: Eyes are deviated downward, the upper lids are retracted, and superior sclerae may be visible. Lower limb spasticity and hypertonia Papilledema often not present in infants 13 Jeff Edwards Gillian Lieberman, MD Symptoms in Children Altered behavior Slowing of mental capacity or decreased level of consciousness Headaches (initially in AM) Neck pain (2º to tonsilalar herniation) Vomiting (worse in AM) Blurred vision (2º to papilledema) Double vision (2º to Abducens nerve palsy) Stunted growth and sexual maturation from third ventricle dilatation obesity, precocious or delayed onset of puberty Difficulty in walking 2º to spasticity 14 Jeff Edwards Gillian Lieberman, MD Signs in Children Papilledema optic atrophy and vision loss (if increased intracranial pressure (ICP) goes untreated) Failure of upward gaze (2º to pressure on tectal plate through the suprapineal recess) Macewen sign: A "cracked pot" sound is noted on percussion of the head. Unsteady gait (2º to spasticity in lower extremities) Macrocephaly (sutures are closed, but chronic ICP will lead to progressive abnormal head growth) Uni- or bilateral sixth nerve palsy 15 Jeff Edwards Gillian Lieberman, MD Classifications of Hydrocephalus Congenital v. Acquired Communicating v. Noncommunicating 16 Jeff Edwards Gillian Lieberman, MD Congenital Hydrocephalus Most common category in children Usually present during infancy – Hydrocephalus presenting after age 6 months is less likely to be congenital, and neoplasm must be excluded 17 Jeff Edwards Gillian Lieberman, MD Congenital Causes Aqueduct (of Sylvius) stenosis – due to malformation (10% of all cases in newborns) Arnold-Chiari I &II, Vein of Galen, Klippel-Feil – Postinfectious: toxoplasmosis, cytomegalic inclusion disease, rubella, syphilis Obstruction of foramina of Luschka and Magendie – Dandy-Walker malformation (2-4% of newborns) Agenesis of foramen of Monro Bickers-Adams syndrome Achondroplasia 18 Jeff Edwards Gillian Lieberman, MD Acquired Causes Mass lesions – account for 20% of all cases in children – usually tumors (eg, medulloblastoma, astrocytoma), but cysts, abscesses, or hematoma also cause Intraventricular hemorrhage – 2º to prematurity, head injury, or rupture of a vascular malformation. Infections – Meningitis, especially bacterial, Mumps, cysticercosis Increased venous sinus pressure – 2º to achondroplasia, craniostenoses, or venous thrombosis. Iatrogenic – Hypervitaminosis A. Idiopathic 19 Jeff Edwards Gillian Lieberman, MD Communicating Hydrocephalus Overproduction of CSF (rare) – Choroid plexus papillomas (more common of the two) – Diffuse villous hyperplasia of choroid plexus Extraventricular (not between ventricles and subarachnoid space) obstruction by tumor, hemorrhage, infection, vascular abnormality, or structural abnormality – Possible sites: cerebellar subarachnoid space, basal cisterns, tentorial hiatus (Chiari malformation, achondroplasia) cerebral subarachnoid space 20 Jeff Edwards Gillian Lieberman, MD Noncommunicating Hydrocephalus An intraventricular obstruction by tumor, hemorrhage, infection, vascular abnormality, or structural abnormality Most common cause is aqueductal stenosis, often in association with Chiari II Common sites of obstruction – Lateral ventricle – Foramina of Monro – Third ventricle – Aqueduct – Fourth Ventricle 21 Jeff Edwards Gillian Lieberman, MD Fetal Diagnosis of Ventriculomegaly Primarily by obstetric ultrasound Defined as an atrium of a lateral ventricle larger than 11 mm – However, ultrasound cannot confirm whether ventriculomegaly is result of hyrdocephalus or loss of periventricular brain tissue in which the vacant space is passively filled with CSF May be detected as early as latter part of 1st trimester. Around 20-24 weeks, abnormal dilation of ventricles is more clearly detectable. 22 Jeff Edwards Gillian Lieberman, MD Postnatal Diagnosis Diagnosis of hydrocephalus is made when the ventricles are enlarged in the absence of cerebral atrophy or dysgenesis Radiological Modalities – – – – Plain film Ultrasound CT MR 23 Jeff Edwards Gillian Lieberman, MD Structural characteristics of hydrocephalus Dilation of temporal and frontal horns of the lateral ventricles (often first sign) Enlargement of anterior or posterior recesses of third ventricle Narrowing of mamillopontine distance Narrowing of ventricular angle Effacement of cortical sulci = will return to point again 24 Jeff Edwards Gillian Lieberman, MD Hydrocephalus v. Cerebral Atrophy Enlargement of temporal horns commensurately with the bodies of the lateral ventricles is probably most sensitive and reliable sign in the differentiation of hydrocephalus from atrophy – In atrophy, there is less dilatation of the temporal horns than the lateral ventricles bodies – If sylvian fissures are enlarged, dilated temporal horns are not reliable sign Large or rapidly enlarging head suggests hydrocephalus Small or diminishing head circumference suggests atrophy 25 Jeff Edwards Gillian Lieberman, MD Hydrocephalus v. Cerebral Atrophy Ventricular Angle (left) tends to be smaller in hydrocephalus (shown above) than in atrophy. Frontal horn radius (right) tends to be larger in hydrocephalus than in atrophy. Courtesy of Dr. Nedda Hobbs and Children’s Hospital Boston Film Library 26 Jeff Edwards Gillian Lieberman, MD Plain Films and Hydrocephalus Prior to newer modalities, diagnosis was made by skull films showing: – split sutures – disproportionate craniofacial ratio – bulging of the anterior fontanel – erosion of the dorsum sellae – “hammered silver” appearance of calvarium 27 Jeff Edwards Gillian Lieberman, MD Ultrasound and Hydrocephalus If anterior fontanlle is open, intracranial structures including ventricles, parenchyma, and vessels are readily visualized in the coronal and sagittal planes. Used to evaluate for ventricular size, parenchymal and intraventricular hemorrhage, extracerebral fluid collections, cystic lesions, and solid parenchymal masses. From Kirks, DR. Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children. 3rd ed. Philadelphia: Lippincott-Raven Publishers: 1998, p. 66. 28 Jeff Edwards Gillian Lieberman, MD Normal Ultrasound Anterior to posterior coronal images of the patient at age 10 days (study done to look for intraparaenchymal or intraventricular hemorrhage) Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 29 Jeff Edwards Gillian Lieberman, MD Normal Ultrasound Frontal lobe Superior aspect of orbits Anterior coronal image of patient at 10 days Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 30 Jeff Edwards Gillian Lieberman, MD Normal Ultrasound Interhemispheric fissure Corpus callosum Frontal horn of lateral ventricle Sylvian fissure More posterior coronal image of patient at 10 days Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 31 Jeff Edwards Gillian Lieberman, MD Normal Ultrasound Body of lateral ventricle Corpus callosum Sylvian fissure Area of thalamus and third ventricle More posterior coronal image of patient at 10 days Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 32 Jeff Edwards Gillian Lieberman, MD Normal Ultrasound Sagittal Right Parasagittal Patient at 10 days Courtesy of Dr. Nedda Hobbs and Children’s Hospital Boston Film Library 33 Jeff Edwards Gillian Lieberman, MD Normal Ultrasound Corpus callosum Third ventricle Thalamus Fourth ventricle Pons Sagittal Patient at 10 days Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 34 Jeff Edwards Gillian Lieberman, MD Normal Ultrasound Body of lateral ventricle Right Parasagittal Patient at 10 days Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 35 Jeff Edwards Gillian Lieberman, MD Abnormal Ultrasound Anterior to posterior coronal images of patient at age 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital Boston Film Library 36 Jeff Edwards Gillian Lieberman, MD Abnormal Ultrasound Dilated frontal horns of lateral ventricles Superior aspect of orbit Anterior coronal image of patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 37 Jeff Edwards Gillian Lieberman, MD Abnormal Ultrasound Dilated frontal horns of lateral ventricles Dilated temporal horn of lateral ventricle Dilated temporal horn of lateral ventricle More posterior coronal image of patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 38 Jeff Edwards Gillian Lieberman, MD Abnormal Ultrasound Dilated bodies of lateral ventricles Dilated temporal horns of lateral ventricles Dilated third ventricle More posterior coronal image of patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 39 Jeff Edwards Gillian Lieberman, MD Abnormal Ultrasound Sagittal Right Parasagittal Left Parasagittal Patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 40 Jeff Edwards Gillian Lieberman, MD Abnormal Ultrasound Dilated body of lateral ventricle Dilated third ventricle Sagittal Patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 41 Jeff Edwards Gillian Lieberman, MD Abnormal Ultrasound Dilated frontal horn of lateral ventricle Dilated temporal horn of lateral ventricle Dilated body of lateral ventricle Right Parasagittal Patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 42 Jeff Edwards Gillian Lieberman, MD Comparison of Ultrasound Sections Coronal images of patient at 10 days Coronal images of patient at 14 months 43 Jeff Edwards Gillian Lieberman, MD Comparison of Ultrasound Sections Patient at 10 days Sagittal Right Parasagittal Patient at 14 months 44 Jeff Edwards Gillian Lieberman, MD CT/MRI Findings in Acute Hydrocephalus Temporal horns are preferentially dilated anteroposterially – Size > 2 mm – Normally, temporal horns are slit-like and barely visible Ballooning of frontal horns of lateral ventricles and third ventricle (ie, "Mickey mouse" ventricles) Periventricular interstitial edema Sylvian and interhemispheric fissures are not visible 45 Jeff Edwards Gillian Lieberman, MD CT/MRI Findings in Acute Hydrocephalus (cont’d) Fourth ventricle is usually normal in size Ratio between largest width of the frontal horns and the internal diameter from inner-table to inner-table at this level should be greater than 0.5 Ratio of largest width of frontal horns to maximal biparietal diameter > 30% Upward bowing of corpus callosum on sagittal MRI 46 Jeff Edwards Gillian Lieberman, MD CT/MRI Findings in Chronic Hydrocephalus Temporal horns may be less prominent than in acute hydrocephalus Third ventricle may herniate into sella turcica, which may be eroded Corpus callosum may be atrophied (best appreciated on sagittal MRI) With long-standing untreated hydrocephalus, white matter will undergo irreversible demyelination 47 Jeff Edwards Gillian Lieberman, MD Periventricular Interstitial Edema Transependymal CSF resorption from ventricular lumen to the parenchyma On CT, appears as hypodensity in periventricular region with indistinct ventricular margins On MR, appears as rim of prolonged T1 or T2 relaxation times surrounding lateral venticles – proton density image or a fluid attenuated inversion recovery (FLAIR) image is much more sensitive Seen particularly at the superlateral angles of the frontal horns Not seen in neonates or young infants (immature brain has normally high water content) 48 Jeff Edwards Gillian Lieberman, MD Periventricular Interstitial Edema T2-weighted image of 5 ½ yo boy who presented with 3 weeks of bifrontal headache, morning vomiting, and blurred vision Courtesy of Dr. R. Michael Scott and Children’s Hospital, Boston Film Library 49 Jeff Edwards Gillian Lieberman, MD Computed Tomography and Hydrocephalus Pros: widely available, rapid, compatible with life support devices, often requires no patient sedation Should be performed with and without contrast 50 Jeff Edwards Gillian Lieberman, MD CT Patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 51 Jeff Edwards Gillian Lieberman, MD CT Patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 52 Jeff Edwards Gillian Lieberman, MD CT Expansion of extra-axial CSF spaces Widened sulci with overall effacement of sulci Enlarged frontal horns + third ventricle = “Mickey Mouse” ventricles Gray-white matter junction is intact Enlarged temporal horns Note: no evidence of periventricular interstitial edema Brachycephaly Patient at 14 months Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 53 Jeff Edwards Gillian Lieberman, MD Comparison of CTs at Similar Levels of Section Normal adult Patient Normal from Mori, K. MRI of the Central Nervous System: A Pathology Atlas. Tokyo: Springer-Verlag, 1991, p. 15. 54 Jeff Edwards Gillian Lieberman, MD CT Flattening of posterior occiput Patient at 23 months s/p Ventriculoperitoneal (VP) shunt placement Courtesy of Dr. Nedda Hobbs and Children’s Hospital, Boston Film Library 55 Jeff Edwards Gillian Lieberman, MD Patient 2: MRI and Hyrdocephalus 11 yo girl who presented with three days of headache and nausea/vomiting Courtesy of Dr. R. Michael Scott and Children’s Hospital, Boston Film Library 56 Jeff Edwards Gillian Lieberman, MD MRI Dilated right lateral ventricle Decompressed left lateral ventricle Shift of midline structures to left Slight periventricular edema 11 yo girl who presented with three days of headache and nausea/vomiting Courtesy of Dr. R. Michael Scott and Children’s Hospital Boston, Film Library 57 Jeff Edwards Gillian Lieberman, MD MRI Same 11 yo girl with non-enhancing hyperintense mass most consistent with colloid cyst Courtesy of Dr. R. Michael Scott and Children’s Hospital, Boston Film Library 58 Jeff Edwards Gillian Lieberman, MD Comparison of MRIs at Similar Levels of Section Normal 11 yo girl Our 11 yo girl Normal from Bisese, JH, Wang, AM. Pediatric Cranial MRI: An Atlas of Normal Development. New York: Springer-Verlag, 1994, p.94 59 Jeff Edwards Gillian Lieberman, MD MRI Right pneumocephalus and small subdural hematoma causing mass effect on right frontal lobe Postoperative edema in left thalamus Same 11 yo girl s/p colloid cyst removal one day prior Courtesy of Dr. R. Michael Scott and Children’s Hospital, Boston Film Library 60 Jeff Edwards Gillian Lieberman, MD Comparison of MRIs Ventricles are mildly dilated but improved from the prior study Before surgery After surgery 11 yo girl with colloid cyst Courtesy of Dr. R. Michael Scott and Children’s Hospital, Boston Film Library 61 Jeff Edwards Gillian Lieberman, MD Patient 3: MRI Stenotic aqueduct 5 ½ yo boy who presented with 3 weeks of bifrontal headache, morning vomiting, and blurred vision Courtesy of Dr. R. Michael Scott and Children’s Hospital, Boston Film Library 62 Jeff Edwards Gillian Lieberman, MD Comparisons of MRIs Stenotic aqueduct Normal adult 5 ½ yo boy with stenotic aqueduct Normal from Truwit, CL, Lempert, TE. High Resolution Atlas of Cranial Neuroanatomy. Baltimore: Williams & Wilkins. 1994, p2 63 Jeff Edwards Gillian Lieberman, MD Shunts Principle of shunting is to establish a communication between the CSF (ventricular or lumbar) and a drainage cavity (peritoneum, right atrium, pleura) In principle, a shunt is a plastic tube less than 1/8 of an inch thick that allows one-directional flow of CSF by responding to pressure differences between the ventricle and the cavity to which the shunt terminates. There is a valve system that regulates the flow as well as a reservoir, which can be felt through the skin. This reservoir allows for sampling of CSF by needle aspiration. 64 Jeff Edwards Gillian Lieberman, MD Shunts CSF is simply absorbed in the drainage cavity Ventriculoperitoneal (VP) shunt is the most common – lateral ventricle is the usual proximal location – advantage is that the need to lengthen the catheter with growth may be obviated by using a long peritoneal catheter Like all foreign bodies, shunts can malfunction or become infected Only about 25% of patients with hydrocephalus are treated successfully without shunt placement Diagram of VP and VA shunts From http://www.cinn.org/conditio ns/hydrocephalus.html 65 Jeff Edwards Gillian Lieberman, MD Common Shunt Complications Ventricular end Atrial end – Blockage – Thrombosis – Disconnection – Infection – Migration – Hemorrhage – Infection – Isolated or “trapped” fourth ventricle – Secondary craniosynostosis – Calvarial thickening – Slit ventricle syndrome Peritoneal end – Infection (peritonitis, adhesions) – CSF “pseudotumor”, encystment 66 Jeff Edwards Gillian Lieberman, MD Patient 4 Shunt Series Plain films used to aid in confirming proper location of shunt 3 ½ yo boy s/p VP shunt placement Courtesy of Dr. Ron Becker and Children’s Hospital, Boston Film Library 67 Jeff Edwards Gillian Lieberman, MD CSF Shunt Scintigraphy In different patient evaluated for possible shunt malfunction, there is normal progression of tracer down the shunt catheter, with free spillage into the peritoneal cavity by 15 min. There is no reflux into the ventricles. Normal transit time ~ 10-20 min. Transit time > 30 min is abnormal. From Vreeland, TH, Wallis, J. Diagnosis: Normal CSF shunt scintigraphy. http://gamma.wustl.edu/cs001te117.html 68 Jeff Edwards Gillian Lieberman, MD References Barkovich, AJ. Pediatric Neuroimaging. 3rd ed. Philadelphia: Lippincott Williams & Wilkins, 2000. Barr, LL. Neonatal Cranial Ultrasound. Rad Clin N Am 1999; 37: 1127-46. Bisese, JH, Wang, AM. Pediatric Cranial MRI: An Atlas of Normal Development. New York: Springer-Verlag, 1994. Chicago Institute of Neurosurgery and Neuroresearch. Hydrocephalus. http://www.cinn.org/conditions/hydrocephalus.html Goetz. Textbook of Clinical Neurology. 1st ed. W. B. Saunders Company, 1999. Hay, WW, et al. Current Pediatric Diagnosis & Treatment. 15th ed. New York: Lange Medical Books/McGraw Hill, 2001. Heilman, KM, Watson, RT, Greer, M. Handbood for Differential Diagnosis of Neurologic Signs and Symptoms. New York: Appleton-Century-Crofts, 1977. Hord, ED. Hydrocephalus. http://www.emedicine.com/neuro/topic161.html 69 Jeff Edwards Gillian Lieberman, MD References (cont’d) The Hydrocephalus Association. http://www.hydroassoc.org/information/index.html Kirks, DR. Practical Pediatric Imaging: Diagnostic Radiology of Infants and Children. 3rd ed. Philadelphia: Lippincott-Raven Publishers: 1998. Mori, K. MRI of the Central Nervous System: A Pathology Atlas. Tokyo: Springer-Verlag, 1991. Nolte, J. The Human Brain: An Introduction to Its Functional Anatomy. 4th ed. St. Louis: Mosby, 1999. Rumack, CM, Johnson, ML. Perinatal and Infant Brain Imaging: Role of Ultrasound and Computed Tomography. Chicago: Year Book Medical Publishers, 1984. Truwit, CL, Lempert, TE. High Resolution Atlas of Cranial Neuroanatomy. Baltimore: Williams & Wilkins. 1994. Vreeland, TH, Wallis, J. Diagnosis: Normal CSF shunt scintigraphy. http://gamma.wustl.edu/cs001te117.html 70 Jeff Edwards Gillian Lieberman, MD Acknowledgements Gillian Lieberman, MD Pamela Lepkowski Lolita Lewis Nedda Hobbs, MD R. Michael Scott, MD Ron Becker, MD Daniel Saurborn, MD Alexandru Bageac, MD Michael Stella, MD Larry Barbaras Cara Lyn D’amour The Patient and his Mom 71
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