Isolated choroid plexus cyst in low-risk women less than 35 years old

Isolated choroid plexus cysts and health and developmental outcomes in childhood and adolescence - A systematic review

OBJECTIVES

Choroid plexus cysts (CPCs) are incidental findings on ultrasound examination of the fetal brain. It is not known if isolated CPCs are associated with any adverse health or neurodevelopmental outcomes during the life course. This systematic review aimed to collate and synthesize the evidence on whether or not isolated choroid plexus cysts are associated with an increased risk of adverse health or developmental outcomes during childhood and adolescence.

METHODS

A search strategy was developed specifically for this study and applied to four electronic databases Medline (Ovid), Embase (Ovid), Web of Science, and Google Scholar. Studies were assessed and selected for inclusion if there was a measurement of CPC (including single or multiple; unilateral or bilateral; isolated or presenting alongside other markers) during the antenatal or early neonatal period (<7 days) with follow-up of children and adolescents for health and developmental outcomes measured at any time from age 1 month onwards. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Due to heterogeneity in the types of outcome measures included and the timing of measurement of outcomes across the studies, it was not possible to pool data across studies and a narrative description of findings was presented.

RESULTS

Eight studies (three cohorts and five case series) met the inclusion criteria. Different methods were used for outcome assessment, such as in-person assessment, parent questionnaires, medical records, and telephone interviews with parents. Six studies measured outcomes only once during the specified duration of follow-up; two studies carried out paediatric reviews of the children several times during follow-up. There were no differences in developmental outcomes or physical health between babies with CPCs reported in the three cohort studies, and no abnormalities were detected in the children that were followed up in four of the five case series studies. Most of the included studies were graded as low quality due to the small sample size, high risk of selection bias, unclear definitions of CPC or lack of a comparison group.

CONCLUSIONS

The studies conducted to date do not provide evidence of adverse physical health outcomes or neurodevelopmental delays in babies with CPCs. However, most of these studies were small and included a narrow range of outcomes. Further research is needed to explore the relative incidence of outcomes such as ASD, ADHD, epilepsy and educational attainment in children with CPCs.

The Course and Neonatal Outcome of Choroid Plexus Extension to the Anterior Horn at the Routine Anatomy Scan

OBJECTIVES

Our objective was to examine the pregnancy course and immediate neonatal outcome of fetuses with an isolated extension of choroid plexus (CP) to the anterior horn during the second trimester.

METHODS

We prospectively collected the cases referred to us between July 2012 and January 2021 with isolated finding of CP extension to the anterior horn. Relevant clinical and demographic information was recorded, and a full anatomy scan including a comprehensive neurosonogram was performed. In cases of confirmed isolated extension of CP to the anterior horns, women were offered further investigation including fetal MRI, and ultrasound follow up.

RESULTS

We collected 29 eligible cases for analysis. The mean gestational age (GA ± SD) for diagnosis and referral was 19.24 ± 2.3 weeks. No other intracranial anomalies were detected in any of the cases, and the finding resolved at 25 ± 2.6 weeks. The average extension length and width to the anterior horn were 0.7 ± 0.3 cm, and 0.5 ± 0.1 cm, respectively. Eleven fetuses (38%) had choroid plexus cyst (CPC) in addition to the extension. Ten patients (35%) completed a fetal brain MRI, with no identified abnormalities. Gross neurological exam and Apgar score at birth were normal.

CONCLUSION

Extension of CP to anterior horn with or without CPC at mid-trimester seems to have spontaneous resolution with likely a good prognosis and no further implications.

Evaluation of the Association between Fetal Cardiac Disorders with Choroid Plexus Cyst in Fetuses

Choroid plexus cysts (CPCs) are often transient and benign findings observed in pregnancy screenings. This study aimed to examine the association between the frequency of congenital heart diseases and the detection of CPCs. In this prospective case-control study, pregnant mothers with no predisposing risk factors for the development of fetal cardiac abnormalities were eligible for entry. Based on the presence or absence of CPCs on ultrasound, the enrolled fetuses were divided into two groups. All patients (n = 100) underwent two-dimensional and color Doppler echocardiography to identify potential cardiac anomalies. Overall, CPCs were detected in 53 enrolled fetuses, and the remainder were enrolled as controls (n = 47). Pathological findings, such as echogenic intracardiac focus (EIF), ductal spasm, atrial septal defect (ASD), pericardial effusion, cardiomyopathy, and congenital heart disease were found in neither group. In the CPC group, two mild and six trivial cases of tricuspid regurgitation (TR) were detected. In the controls, five cases of trivial TR were identified. In conclusion, the presence of CPCs was not associated with significant functional or structural fetal cardiac abnormalities, which may be due to altered developmental mechanisms.

A Bayesian risk analysis for Trisomy 21 in isolated choroid plexus cyst: combining a prenatal database with a meta-analysis

OBJECTIVE

The purpose of this study was to quantify the possible additional risk of a fetus with an isolated choroid plexus cyst (ICPC) for Trisomy 21 by combining a large controlled cohort study with data from existent studies.

METHODS

We searched our prenatal database between 2000 and 2014 for all singleton pregnancies between 18 + 0 and 26 + 6 gestational weeks with either an isolated choroid plexus cyst (study group) or no abnormality found in the detailed ultrasound scan (control group). We assessed all prenatal karyotyping results if invasive testing was performed and attempted to collect the postnatal outcome reports of all patients. The prevalence of Down syndrome was calculated. By using previous studies that met our inclusion criteria, a meta-analysis following the Bayesian Independent Model was created. From this meta-analysis, we computed the posterior predictive distribution of the probability (Trisomy 21 | ICPC) = P1 including posterior means, standard deviations, quantiles (2.5, 50, and 97.5%). By calculating the posterior of the difference (Δ) between the probability (Trisomy 21 | ICPC) and the probability (Trisomy 21 | Normal Ultrasound) = P2, we investigated the additional risk of an ICPC (ΔB = P1-P2).

RESULTS

Overall, we detected 1220 fetuses with an isolated plexus cyst at 19-27 weeks of gestational age (GA). In our study group, the prevalence of Trisomy 21 was 2/1220 (0.16, 95% CI: 0.1-0.6%). The median of the pooled probability of Trisomy 21 given isolated PC across the studies included in the meta-analysis was 0.2% (CI: 0.1-0.4%). In the given periods (GA and time), 66,606 (74.8%) out of 89,056 investigated fetuses met the inclusion criteria and had a normal ultrasound result without any abnormality. The Δ between our study group and the control group was 0.08% (CIΔA: 0-0.5%). Including the meta-analysis, the median of the posterior distribution of Δ between P1 and P2 was 0.08% (CIΔB: 0-0.4%) (ΔB = P1-P2).

CONCLUSION

The posterior distribution of Δ between P1 and P2 including the meta-analysis corresponds to showing no difference between the cases and controls (95% CIΔB: 0-0.4%). The additional risk of a fetus with an ICPC for Trisomy 21 is 97.5% likely to be lower than 0.4% (about 1/250). However, in our collective, the positive predictive value of ICPC for Down syndrome was 0.16% (about 1/625). In prenatal counseling, the additional risk should be added to the individual risk (based on maternal age, earlier screening test results, and sonographic markers) and the diagnostic options including fetal DNA and diagnostic procedures should be discussed according to the posterior individual risk.

Association of Fetal Choroid Plexus Cysts With Trisomy 18 in a Population Previously Screened by Nuchal Translucency Thickness Measurement

OBJECTIVE

The study's aim was to determine any association between choroid plexus cysts (CPCs) and trisomy 18 in a population of fetuses previously screened by nuchal translucency (NT) thickness measurement.

METHODS

During the study period (May 1999 to December 2004), 7,795 fetuses had an NT scan and second-trimester fetal anatomical scan at our institution. The prevalence of trisomy 18 was determined among four types of pregnancies: 1) those with isolated CPCs, 2) those with CPCs and enlarged NT, 3) those with CPCs and other ultrasound markers, and 4) those with CPCs, enlarged NT, and other ultrasound markers. The fetal outcome according to NT and presence of CPCs was calculated. Incidence rates of enlarged NT and CPCs in fetuses with trisomy 18 and fetuses with normal chromosomes were also evaluated.

RESULTS

For the entire population, ten trisomy 18 cases were diagnosed prenatally (prevalence, 0.13%). Among fetuses with enlarged NT, the likelihood ratio of trisomy 18 was significantly increased in fetuses with CPCs compared with fetuses without such cysts (333.6 versus 15.2, P = .002). However, among fetuses with normal NT, no significant difference was demonstrated for likelihood ratio of trisomy 18 between fetuses with and without CPCs.

CONCLUSION

In pregnancies complicated by isolated CPCs, fetal karyotyping is not indicated when no additional anomaly is detected on ultrasonographic examination and first-trimester NT results are normal.

The practice patterns of second trimester fetal ultrasonography: A questionnaire survey and an analysis of checklists

Objective

To analyze practice patterns and checklists of second trimester ultrasonography, and to investigate management plans when soft markers are detected among Korean Society of Ultrasound in Obstetrics and Gynecology (KSUOG) members.

Methods

An internet-based self-administered questionnaire survey was designed. KSUOG members were invited to the survey. Checklists of the second trimester ultrasonography were also requested. In the questionnaire survey, general practice patterns of the second trimester ultrasonography and management schemes of soft markers were asked. In the checklists analysis, the number of items were counted and also compared with those recommended by other medical societies.

Results

A total of 101 members responded. Eighty-seven percent routinely recommended second trimester fetal anatomic surveillance. Most (91.1%) performed it between 20+0 and 23+6 weeks of gestation. Written informed consents were given by 15.8% of respondents. Nearly 60% recommended genetic counseling when multiple soft markers and/or advanced maternal age were found. Similar tendencies were found in the managements of individual soft markers. However, practice patterns were very diverse and sometimes conflicting. Forty-eight checklists were analyzed in context with the number and content of the items. The median item number was 46.5 (range, 17 to 109). Of 49 items of checklists recommended by International Society of Ultrasound in Obstetrics and Gynecology and/or American Congress of Obstetricians and Gynecologists, 14 items (28.6%) were found in less than 50% of the checklists analyzed in this study.

Conclusion

Although general practice patterns were similar among KSUOG members, some of which were conflicting, and there is a need for standardization of the practice patterns and checklists of second trimester ultrasonography, which also have very wide range of spectrum.

Development and functions of the choroid plexus-cerebrospinal fluid system

The choroid plexus (ChP) is the principal source of cerebrospinal fluid (CSF), which has accepted roles as a fluid cushion and a sink for nervous system waste in vertebrates. Various animal models have provided insights into how the ChP-CSF system develops and matures. In addition, recent studies have uncovered new, active roles for this dynamic system in the regulation of neural stem cells, critical periods and the overall health of the nervous system. Together, these findings have brought about a paradigm shift in our understanding of brain development and health, and have stimulated new initiatives for the treatment of neurological disease.

Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging (MRI) in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and MRI in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost effectiveness, and to identify research opportunities. This article is the executive summary of the workshop.

Fetal imaging: Executive summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and magnetic resonance imaging in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost-effectiveness and to identify research opportunities. This article is the executive summary of the workshop.

Fetal imaging: executive summary of a joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for Maternal-Fetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop

Given that practice variation exists in the frequency and performance of ultrasound and magnetic resonance imaging (MRI) in pregnancy, the Eunice Kennedy Shriver National Institute of Child Health and Human Development hosted a workshop to address indications for ultrasound and MRI in pregnancy, to discuss when and how often these studies should be performed, to consider recommendations for optimizing yield and cost effectiveness, and to identify research opportunities. This article is the executive summary of the workshop.

Follow-up of sonographically detected soft markers for fetal aneuploidy

Sonographic soft markers of fetal Down syndrome were first reported in the 1980s. With improvements in aneuploidy screening, detection rates of 90% and higher are possible, and such screening is offered to women of all ages. The utility of sonographic detection and reporting of soft markers, particularly to women at low risk of fetal aneuploidy, is controversial. Some soft markers have no additional significance beyond an association with aneuploidy, while some potentially indicate other pathology, and therefore require sonographic follow-up or other evaluation. The definitions of soft markers vary among reported series, and any practice using such markers to adjust the risk of aneuploidy should carefully determine the most appropriate definitions as well as likelihood ratios and how to apply these in practice.

The trisomy 18 syndrome

The trisomy 18 syndrome, also known as Edwards syndrome, is a common chromosomal disorder due to the presence of an extra chromosome 18, either full, mosaic trisomy, or partial trisomy 18q. The condition is the second most common autosomal trisomy syndrome after trisomy 21. The live born prevalence is estimated as 1/6,000-1/8,000, but the overall prevalence is higher (1/2500-1/2600) due to the high frequency of fetal loss and pregnancy termination after prenatal diagnosis. The prevalence of trisomy 18 rises with the increasing maternal age. The recurrence risk for a family with a child with full trisomy 18 is about 1%. Currently most cases of trisomy 18 are prenatally diagnosed, based on screening by maternal age, maternal serum marker screening, or detection of sonographic abnormalities (e.g., increased nuchal translucency thickness, growth retardation, choroid plexus cyst, overlapping of fingers, and congenital heart defects ). The recognizable syndrome pattern consists of major and minor anomalies, prenatal and postnatal growth deficiency, an increased risk of neonatal and infant mortality, and marked psychomotor and cognitive disability. Typical minor anomalies include characteristic craniofacial features, clenched fist with overriding fingers, small fingernails, underdeveloped thumbs, and short sternum. The presence of major malformations is common, and the most frequent are heart and kidney anomalies. Feeding problems occur consistently and may require enteral nutrition. Despite the well known infant mortality, approximately 50% of babies with trisomy 18 live longer than 1 week and about 5-10% of children beyond the first year. The major causes of death include central apnea, cardiac failure due to cardiac malformations, respiratory insufficiency due to hypoventilation, aspiration, or upper airway obstruction and, likely, the combination of these and other factors (including decisions regarding aggressive care). Upper airway obstruction is likely more common than previously realized and should be investigated when full care is opted by the family and medical team. The complexity and the severity of the clinical presentation at birth and the high neonatal and infant mortality make the perinatal and neonatal management of babies with trisomy 18 particularly challenging, controversial, and unique among multiple congenital anomaly syndromes. Health supervision should be diligent, especially in the first 12 months of life, and can require multiple pediatric and specialist evaluations.

Isolated prenatal choroid plexus cysts do not affect child development

OBJECTIVE

To examine the effect of isolated prenatal choroid plexus cysts (CPCs) on child cognitive, behavioral, motor, and autonomic development at 18 months of age.

METHODS

A prospective design was implemented to identify CPC cases and controls in mid-pregnancy. Cases (n = 25) and controls (n = 45) participated in a follow-up visit when children were 18 months of age. Child mental and motor development was assessed using standard developmental assessments, socioemotional and behavioral functioning during testing was rated by examiners, and accelerometers provided measures of motor activity and energy expenditure. Cardiac patterns were collected using a three-lead electrocardiogram (ECG) and quantified as indicators of autonomic control of the heart, including vagal tone.

RESULTS

No significant differences were found in any outcome measure between children with prenatal CPC detection and those without.

CONCLUSION

Findings should provide reassurance to practitioners and parents that isolated CPCs in fetuses with normal karyotypes do not affect child development after birth.

Second trimester prenatal ultrasound for the detection of pregnancies at increased risk of Trisomy 18 based on serum screening

OBJECTIVE

To describe ultrasound findings in fetuses with Trisomy 18.

METHODS

Prospective population-based cohort study of second trimester ultrasound among Californian women who were at increased risk of chromosome abnormality based on serum screening between November 1999 and April 2001. Structural anomalies plus the following soft markers were assessed: nuchal fold thickening, choroid plexus cyst (CPC), echogenic intracardiac focus, echogenic bowel, renal pyelectasis, clenched hands; clinodactyly; short femur, short humerus and a single umbilical artery (SUA).

RESULTS

Overall, 8763 women underwent ultrasound evaluation, including 56 whose fetuses had Trisomy 18. Ultrasound anomalies were seen in 89% of Trisomy 18 fetuses, as compared with 14% of normal fetuses. If the genetic sonogram was normal (no structural anomaly and no soft marker), the risk was reduced by approximately 90%. The ultrasound soft markers were typically seen in conjunction with structural anomalies in affected fetuses and in the absence of a structural anomaly, most isolated ultrasound soft markers were not associated with Trisomy 18. The only exception was an isolated CPC, seen as the only finding in 11% of fetuses with Trisomy 18.

CONCLUSIONS

If the genetic sonogram is used as a sequential test following serum biochemistry, a normal ultrasound study reduces the likelihood of Trisomy 18 substantially even if a woman has abnormal serum biochemistry. The presence of an isolated CPC raises the risk, but not high enough to prompt invasive testing.

[Role of "subtle" ultrasonographic signs during antenatal screening for trisomy 21 during the second trimester of pregnancy: meta-analysis and CPDPN protocol of the Grenoble University Hospital]

OBJECTIVE

A meta-analysis about subtle ultrasonographic signs in second trimester of pregnancy.

MATERIALS AND METHODS

196 articles dealing with the subject--from 1985 to July 2002--were studied. Data on the 11 reported signs were collected from 92 theoretically and/or statistically valid studies. Then, the studies were selected according to several criteria: isolated characteristic, defined thresholds, calculable sensitivity and specificity. After checking for homogeneity, a likelihood ratio was calculated for some of the signs.

RESULTS

This meta-analysis of the second trimester ultrasonographic signs of Down's syndrome enabled us to estimate the likelihood ratio (LHR) of six signs. At 22 weeks'gestation (WG) these signs are: pyelectasis equal to or greater than 5 mm; nuchal fold thickness equal to or greater than 6 mm; persistence of choroid plexus cysts; shortness of the femur and humerus below the tenth percentile; hyperechogenic bowe; and nasal bone length less than 2.5 mm.

CONCLUSION

These validated ultrasonographic signs are independent of nuchal translucency thickness at 12 WG and of maternal serum biochemistry. This allows to calculate a combinate risk for nuchal translucency, maternal serum biochemistry and second trimester ultrasonographic signs when they are validated.

Controversial ultrasound findings

This article has reviewed a few of the more controversial findings in the field of obstetric ultrasound. For each one evidence-based strategies for the management of affected pregnancies have been suggested, derived from what the authors believe is the best information available. In some cases, this information is very limited, which can make counseling these patients extremely difficult. Some physicians find using specific likelihood ratios helpful in these complex discussions. An example of the relative likelihood ratios for several markers of trisomy 21 is illustrated in Table 10. Although the management of each of the findings discussed in this article is different, a few generalizations can be made. To begin with, the detection of any abnormal finding on ultrasound should prompt an immediate detailed ultrasound evaluation of the fetus by someone experienced in the diagnosis of fetal anomalies. If there is more than one abnormal finding on ultrasound, if the patient is over the age of 35, or if the multiple marker screen is abnormal, an amniocentesis to rule out aneuploidy should be recommended. Of the six ultrasound findings reviewed here, the authors believe that only echogenic bowel as an isolated finding confers a high enough risk of aneuploidy to recommend an amniocentesis in a low-risk patient. The other findings in isolation in a low-risk patient seem to confer only a modest increased risk of aneuploidy, if any, and this risk is certainly less than the risk of unintended loss from amniocentesis. Wherever possible, modifiers of this risk, such as maternal age, history, and first and second multiple marker screening, should be used to define more clearly the true risk of aneuploidy. As obstetric ultrasound moves forward, particularly into the uncharted waters of clinical use of three- and four-dimensional ultrasound, one can expect a whole new crop of ultrasound findings with uncertain clinical significance. Clinicians are well advised to await well-designed studies to determine the clinical significance of these findings before altering clinical care.