Max C Lee and David M Frim Initial Evaluation

The neonatal period presents unique challenges to the neurosurgeon, especially in terms of patient size, developmental stage and impact upon long-term outcome. In newborns, the neurological examination is often limited (see Chapter 1) and significant intracranial abnormalities can exist without causing neurological deficits. The immediate management of a newborn focuses on resuscitation: airway, breathing and circulation. Infants delivered at term may only require limited suctioning before normal respiration starts. Premature infants, conversely, may need aggressive resuscitation, including intubation and ventilation.

In most cases, neurosurgical problems in the neonatal period are caused either by trauma or developmental anomalies. The physical examination should focus on these two areas. First, the cranial vault and extremities should be examined carefully for bruising, swelling, or deformity. Scalp swelling and cranial injuries can often be very difficult to distinguish from molding occurring as a result of a normal vaginal delivery. If any doubt exists, an imaging study should be considered. The dorsal midline axis from nose to coccyx should be carefully examined for any cutaneous sign indicating an abnormality in neural tube closure (see Chapter 8 for more details).

The head circumference must be measured and plotted on appropriate charts after correcting for gestational age. Hydrocephalus can result from many precipitating conditions and can be completely asymptomatic aside from a large cranial vault. Normal head circumference growth is 0.5 to 0.75 cm/week for the first 3 weeks and 1 cm/week thereafter. It should be noted that approximately 80% of final head growth is completed by 3 years of age. The anterior and posterior fontanelles provide unique access to the intracranial compartment and an indirect reflection of intracranial pressure (ICP). The anterior fontanelle is diamond shaped and usually closes by 18 months of age. The posterior fontanelle is triangular in shape and closes by 2 to 3 months. In infants with raised ICP the fontanelle bulges and does not become depressed when the infant is held upright.

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