Mid-trimester fetal subdural hemorrhage: prenatal diagnosis

Worm Sign: A possible first-trimester sonographic marker for intracranial haemorrhage resulting in significant cortical disruption

Fetal intracranial haemorrhage (ICH) is a pathophysiological process involving haemorrhagic and hypoxic-ischaemic insults resulting in antenatal brain damage. Insults to the central nervous system are usually not detected until the second or third trimester. In this case presentation, we present a possible prenatal ultrasound marker, 'worm sign', representing cortical disruption secondary to suspected ICH at 13 weeks' gestation. According to current literature review, this is one of the first cases of ICH, diagnosed in the first-trimester and highlights the importance of early neurovascular and structural evaluation of the fetal brain at the time of first-trimester ultrasound screening.

Prenatal Diagnosis, Management, and Outcome of Fetal Subdural Haematoma: A Case Report and Systematic Review

BACKGROUND

Fetal subdural haematoma (SDH) is associated with poor prognosis.

OBJECTIVE

The conflicting evidence from the literature presents a challenge in prenatal counselling. We present a case study and systematic review of the literature for the management and outcome of fetal SDH.

METHODS

Systematic search of electronic database.

RESULTS

A total 45 cases were extracted from 39 papers. Prenatal ultrasonographic features were intracranial echogenicity (42%), lateral ventriculomegaly (38%), presence of an intracranial mass (31%), macrocephaly (24%), midline deviation of cerebral falx (20%), and intracranial fluid collection (11%). Further secondary features were noted including reversed diastolic flow in the middle cerebral artery (11%), echogenic bowel (4%), hydrops fetalis (2%), and elevated middle cerebral artery peak systolic velocity (2%) (all highly likely to be associated with fetal anaemia). The rates of termination of pregnancy, stillbirth, and neonatal death were 18% (8/45), 16% (7/45), and 11% (5/45), respectively. Overall, therefore, the fetal and perinatal mortality was 32% (12/37). Amongst the 24 survivors with available neurological outcome, 42% (10/24) and 58% (14/24) had abnormal and normal neurological outcome, respectively. Underlying aetiology of fetal SDH was not identified in 47% (21/45). Fetal SDH with an identifiable underlying aetiology was the only factor associated with a higher chance of normal neurological outcome when compared to fetal SDH without a detectable cause (78.5 vs. 21.4%, p = 0.035).

CONCLUSIONS

Stillbirth and neonatal death occurred in a significant proportion of fetal SDH. 58% of survivors had normal neurological outcome, and better prognosis was seen in SDH with identifiable underlying aetiology.

A rare immature teratoma of the tela chorioidea of the third ventricle: late-onset, intrapartum ultrasound diagnosis and postnatal outcome

We describe a previously unreported case of immature teratoma originating from the tela chorioidea of the third ventricle diagnosed during labor at term of pregnancy. Postnatal MR imaging and pediatric neurosurgery with postnatal outcome at 6 months of age are reported.

Prenatal diagnosis of intracranial immature teratoma in the third trimester using 2D and 3D sonography

Intracranial tumors are uncommon and represent 0.5-1.5 % of all pediatric tumors. Teratoma is the most frequent intracranial tumor found at birth. Large teratomas are extremely rare and have a guarded prognosis since they grow fast and cause brain tissue destruction. A 31-week primigravida was referred to our hospital for investigation of an intracranial mass seen in the fetus. Two-dimensional ultrasound showed a large heterogeneous solid mass with calcifications inside, measuring 5.3 × 4.8 cm. It was in the right cerebral hemisphere at the level of the middle and posterior fossa, thereby shifting the midline and causing severe ventriculomegaly that measured 3.5 cm at the level of the lateral ventricle. Three-dimensional ultrasound (3DUS) in multiplanar mode allowed us to assess the anatomical relationships between the mass and the midline structures. The neurosurgical team, who had suspected that the case was inoperable, was thus able to gain a better understanding of the case. Transfontanellar ultrasound was performed on the day after the birth and confirmed the previous findings. Moreover, a biopsy confirmed the histology of the mass: it was an immature teratoma. The infant died on the 24th day of life after a large expansion of head circumference. Intracranial teratomas are extremely severe because of their quick growth and mass effect, often leading to neonatal death within days. 3DUS is a new prenatal diagnostic method that makes it possible to assess the anatomical relationships between the mass and the intracranial structures, thus enabling better preoperative planning.

Early second-trimester diagnosis of intracranial teratoma

Congenital brain tumors are rare and, whether diagnosed prenatally or postnatally, the most frequent type is teratoma. Prenatal diagnosis relies on sonography and magnetic resonance imaging, and is usually achieved during the second or third trimester. We report a case of an intracranial tumor diagnosed in the early second trimester. The diagnosis had been suspected at first-trimester routine sonography, which showed a compressive intracranial mass with mild vascularization. Because of the poor prognosis, termination of pregnancy was discussed with the parents and was carried out at 14 weeks of gestation. Postmortem examination provided a diagnosis of right frontal immature teratoma.

[Water-electrolyte abnormalities during pregnancy: maternal and fetal complications (about a case)]

Water-electrolyte abnormalities while pregnancy or for infant are very serious. We present a case of a woman at 26 weeks who had gestation pernicious vomiting that led to major extracellular dehydration, water intoxication and acute renal insufficiency. The etiology was a volvulus on common mesentery. Hyperemesis disappeared thanks to surgical treatment. The mother and her fetus would later present serious complications due to the water-electrolyte imbalance correction. The fetus suffered from cerebral hemorrhage and subdural hematoma subordinate to brain edema resorption. The mother presented centropontine myelinolysis. The treatment of electrolyte abnormalities during pregnancy could lead to serious complications for the mother and fatal for the foetus.

Quantitative MRI measurements of human fetal brain development in utero

Magnetic resonance imaging (MRI) allows for high resolution imaging of the central nervous system. We have tested the feasibility of using MRI in conjunction with quantitative image analysis to perform volumetric measurements of the brain in the developing human fetus in utero. The database comprises MR images of a total of 56 fetuses (gestational age 25-41 weeks) referred because of suspected abnormalities due to ultrasound findings, family history or maternal illness and scanned on a 1.5 T MR system using a single-shot fast spin echo (SSFSE) T2 sequence, slice thickness 3 mm, no gap. Four out of the 56 scans could not be used in the analysis due to poor image quality. Automatic segmentation (using NIH Image routines) was found to be unreliable in these fetal brains, so cerebral, cerebellar and ventricular regions were traced manually. Ventricular volumes did not vary with gestational age in normal fetuses (N=27, R=0.05, p=0.8) while cerebral parenchyma and cerebellum volumes increased significantly during the same period (R=0.67, p=0.0002 and R=0.51, p=0.0066 respectively). Two calculated parameters: percent ventricular asymmetry and volume ratio of ventricles to hemispheric parenchyma were found to be very sensitive to ventricular pathology; such that the mean value of the latter in normal fetuses was 4.4%+/-0.56 (mean+/-SEM, N=27) compared to 34.3%+/-17.6 (N=6, p<0.0001) in fetuses with ventriculomegaly. These results support the use of image analysis and MRI to produce normal growth curves as well as quantitative severity assessments of brain pathologies in the developing human fetus.

Fetal Magnetic Resonance Imaging of an Intracranial Venous Thrombosis

OBJECTIVE

To describe the magnetic resonance imaging findings of an antenatal intracranial venous thrombosis.

METHODS

Prenatal ultrasound (US) at 22 weeks' gestational age (GA) in a 27-year-old patient (G2 P1) revealed a nonspecific avascular echogenic mass above the cerebellum evaluated with MRI at 23 weeks' GA.

RESULTS

With MRI an enlarged occipital pericerebral space with a layered ovoid mass at the torcular herophili was demonstrated and MRI characteristics suggested a subacute cloth. In follow-up, an important enlargement of the mass was noticed on US examinations. After multidisciplinary consult and parental consent, a prostaglandin induction was performed at 25 weeks' GA. The baby died immediately after birth. Pathology confirmed the diagnosis of a venous thrombosis at the torcular herophili with extension into the superior sagittal sinus.

CONCLUSION

In our case, MRI findings were helpful in diagnosing an intracranial fetal venous thrombosis.

Second-trimester diagnosis of intracranial vascular anomalies in a fetus with subdural hemorrhage

OBJECTIVES

Risk factors for intracranial hemorrhage occurring in prenatal life are imperfectly known. A case of prenatal diagnosis of subdural hemorrhage associated with multiple intracranial vascular aneurysms is described.

METHODS

Sonography and magnetic resonance imaging of the fetal head were obtained at 21 weeks' gestation and compared with pathologic findings.

RESULTS

Sonography showed a large transonic mass displacing the normal intracranial structures. Magnetic resonance imaging demonstrated the hemorrhagic origin of the mass and showed multiple vascular anomalies. Postmortem examination confirmed the compression of the cerebral hemisphere by a blood collection, probably because of bleeding from one of the multiple vascular aneurysms into the subdural space.

CONCLUSION

Magnetic resonance imaging with the use of single-shot ultrafast sequences may be useful not only in the differential diagnosis of fetal intracranial hemorrhage but also in identifying vascular risk factors.

Alloimmune thrombocytopenia in the fetus: current management theories

Fetal alloimmune thrombocytopenia (AIT) affects only a small number of fetuses but the consequences may be devastating. Outcomes range from mild thrombocytopenia without signs or symptoms to intracranial hemorrhage (ICH) and fetal or neonatal death. Antenatal screening is available but not used routinely in the United States. The most frequent method of AIT identification is its diagnosis in the neonatal period (index neonate). AIT may be diagnosed antenatally if an ICH is noted on routine obstetric ultrasound. There are accurate predictors of AIT, as well as antenatal therapies, to prevent the occurrence of severe disease and ICH.