Current state of perinatal postmortem magnetic resonance imaging: European Society of Paediatric Radiology questionnaire-based survey and recommendations

Longitudinal MRI in the context of in utero surgery for open spina bifida: A descriptive study

INTRODUCTION

Fetal surgery for open spina bifida (OSB) requires comprehensive preoperative assessment using imaging for appropriate patient selection and to evaluate postoperative efficacy and complications. We explored patient access and conduct of fetal magnetic resonance imaging (MRI) for prenatal assessment of OSB patients eligible for fetal surgery. We compared imaging acquisition and reporting to the International Society of Ultrasound in Obstetrics and Gynecology MRI performance guidelines.

MATERIAL AND METHODS

We surveyed access to fetal MRI for OSB in referring fetal medicine units (FMUs) in the UK and Ireland, and two NHS England specialist commissioned fetal surgery centers (FSCs) at University College London Hospital, and University Hospitals KU Leuven Belgium. To study MRI acquisition protocols, we retrospectively analyzed fetal MRI images before and after fetal surgery for OSB.

RESULTS

MRI for fetal OSB was accessible with appropriate specialists available to supervise, perform, and report scans. The average time to arrange a fetal MRI appointment from request was 4 ± 3 days (range, 0-10), the average scan time available was 37 ± 16 min (range, 20-80 min), with 15 ± 11 min (range, 0-30 min) extra time to repeat sequences as required. Specific MRI acquisition protocols, and MRI reporting templates were available in only 32% and 18% of units, respectively. Satisfactory T2-weighted (T2W) brain imaging acquired in three orthogonal planes was achieved preoperatively in all centers, and 6 weeks postoperatively in 96% of FSCs and 78% of referring FMUs. However, for T2W spine image acquisition referring FMUs were less able to provide three orthogonal planes presurgery (98% FSC vs. 50% FMU, p < 0.001), and 6 weeks post-surgery (100% FSC vs. 48% FMU, p < 0.001). Other standard imaging recommendations such as T1-weighted (T1W), gradient echo (GE) or echoplanar fetal brain and spine imaging in one or two orthogonal planes were more likely available in FSCs compared to FMUs pre- and post-surgery (p < 0.001).

CONCLUSIONS

There was timely access to supervised MRI for OSB fetal surgery assessment. However, the provision of images of the fetal brain and spine in sufficient orthogonal planes, which are required for determining eligibility and to determine the reversal of hindbrain herniation after fetal surgery, were less frequently acquired. Our evidence suggests the need for specific guidance in relation to fetal MRI for OSB. We propose an example guidance for MRI acquisition and reporting.

Current utilization of pediatric postmortem imaging in North America: a questionnaire-based survey

BACKGROUND

Postmortem imaging is used more widely as the number of conventional autopsies has decreased over the last several decades. It is widely accepted in Europe, Asia and Oceania, but there has been a delay in acceptance in North America. Education, scanning protocols, resourcing and clinical incentives are needed to support this emerging field.

OBJECTIVE

To determine the use of postmortem imaging and define perceived barriers to its implementation with the goal of expanding postmortem imaging in the United States and Canada.

MATERIALS AND METHODS

We sent an online survey to active members of the Society for Pediatric Radiology (SPR) addressing the use of postmortem imaging, indications, readers, practical aspects, anticipated barriers and potential solutions to more widespread use.

RESULTS

More than 50% of the 50 institutions that returned surveys used postmortem computed tomography; 24% used postmortem magnetic resonance imaging. Most postmortem imaging cases were read by radiologists. Fewer than 50% had formal correlation with autopsy results or an established relationship with the local medical examiner. Seven institutions reported reimbursement for postmortem imaging. Major barriers to postmortem imaging included lack of funding and lack of interest among clinicians. Funding and education were seen as important issues requiring attention.

CONCLUSION

While most responding institutions provide pediatric postmortem imaging, the modalities, protocols, reporting procedures and clinical correlation vary widely. A lack of funding and few opportunities for education are limiting factors. Attention to these issues along with active support from the SPR are seen as potential solutions to recognize the value and promote widespread acceptance of postmortem imaging.

Current and future funding streams for paediatric postmortem imaging: European Society of Paediatric Radiology survey results

BACKGROUND

Perinatal and childhood postmortem imaging has been accepted as a noninvasive alternative or adjunct to autopsy. However, the variation in funding models from institution to institution is a major factor prohibiting uniform provision of this service.

OBJECTIVE

To describe current funding models employed in European and non-European institutions offering paediatric postmortem imaging services and to discuss the perceived barriers to future postmortem imaging service provision.

MATERIALS AND METHODS

A web-based 16-question survey was distributed to members of the European Society of Paediatric Radiology (ESPR) and ESPR postmortem imaging task force over a 6-month period (March-August 2021). Survey questions related to the radiologic and autopsy services being offered and how each was funded within the respondent's institute.

RESULTS

Eighteen individual responses were received (13/18, 72.2% from Europe). Only one-third of the institutions (6/18, 33.3%) have fully funded postmortem imaging services, with the remainder receiving partial (6/18, 33.3%) or no funding (5/18, 27.8%). Funding (full or partial) was more commonly available for forensic work (13/18, 72%), particularly where this was nationally provided. Where funding was not provided, the imaging and reporting costs were absorbed by the institute.

CONCLUSION

Increased access is required for the expansion of postmortem imaging into routine clinical use. This can only be achieved with formal funding on a national level, potentially through health care commissioning and acknowledgement by health care policy makers and pathology services of the value the service provides following the death of a fetus or child. Funding should include the costs involved in training, equipment, reporting and image acquisition.

Post-mortem perinatal imaging: what is the evidence?

Post-mortem imaging for the investigation of perinatal deaths is an acceptable tool amongst parents and religious groups, enabling a less invasive autopsy examination. Nevertheless, availability is scarce nationwide, and there is some debate amongst radiologists regarding the best practice and optimal protocols for performing such studies. Much of the published literature to date focusses on single centre experiences or interesting case reports. Diagnostic accuracy studies are available for a variety of individual imaging modalities (e.g. post-mortem CT, MRI, ultrasound and micro-CT), however, assimilating this information is important when attempting to start a local service.In this article, we present a comprehensive review summarising the latest research, recently published international guidelines, and describe which imaging modalities are best suited for specific indications. When the antenatal clinical findings are not supported by the post-mortem imaging, we also suggest how and when an invasive autopsy may be considered. In general, a collaborative working relationship within a multidisciplinary team (consisting of radiologists, radiographers, the local pathology department, mortuary staff, foetal medicine specialists, obstetricians and bereavement midwives) is vital for a successful service.

A pragmatic evidence-based approach to post-mortem perinatal imaging

Post-mortem imaging has a high acceptance rate amongst parents and healthcare professionals as a non-invasive method for investigating perinatal deaths. Previously viewed as a 'niche' subspecialty, it is becoming increasingly requested, with general radiologists now more frequently asked to oversee and advise on appropriate imaging protocols. Much of the current literature to date has focussed on diagnostic accuracy and clinical experiences of individual centres and their imaging techniques (e.g. post-mortem CT, MRI, ultrasound and micro-CT), and pragmatic, evidence-based guidance for how to approach such referrals in real-world practice is lacking. In this review, we summarise the latest research and provide an approach and flowchart to aid decision-making for perinatal post-mortem imaging. We highlight key aspects of the maternal and antenatal history that radiologists should consider when protocolling studies (e.g. antenatal imaging findings and history), and emphasise important factors that could impact the diagnostic quality of post-mortem imaging examinations (e.g. post-mortem weight and time interval). Considerations regarding when ancillary post-mortem image-guided biopsy tests are beneficial are also addressed, and we provide key references for imaging protocols for a variety of cross-sectional imaging modalities.