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Righini A, Tortora M, Izzo G, Doneda C, Arrigoni F, Palumbo G, Parazzini C. Cutting-edge applications of fetal MR neuro-imaging in clinical routine: a pictorial essay. Neuroradiology 2023; 65:1813-1823. [PMID: 37910190 DOI: 10.1007/s00234-023-03242-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 10/18/2023] [Indexed: 11/03/2023]
Abstract
Over time, fetal MR neuro-imaging has undergone continuous improvement; presently, it plays a pivotal role in the diagnosis of an expanding array of complex neurological conditions. Within this pictorial essay, our focus will be exclusively directed towards those cutting-edge clinical applications, which currently yield valuable diagnostic insights on a single case basis. Specifically, the pictorial examples will center on some abnormal entities and their features at an earlier fetal stage.
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Affiliation(s)
- Andrea Righini
- Pediatric Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | - Mario Tortora
- Department of Advanced Biomedical Sciences, University of Naples Federico II, Naples, Italy.
| | - Giana Izzo
- Pediatric Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | - Chiara Doneda
- Pediatric Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | - Filippo Arrigoni
- Pediatric Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | | | - Cecilia Parazzini
- Pediatric Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
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Nguyen LH, Sharma M, Bordey A. 4E-BP1 expression in embryonic postmitotic neurons mitigates mTORC1-induced cortical malformations and behavioral seizure severity but does not prevent epilepsy in mice. Front Neurosci 2023; 17:1257056. [PMID: 37680968 PMCID: PMC10480503 DOI: 10.3389/fnins.2023.1257056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2023] [Accepted: 07/31/2023] [Indexed: 09/09/2023] Open
Abstract
Hyperactivation of the mechanistic target of rapamycin complex 1 (mTORC1) pathway during neurodevelopment leads to focal cortical malformations associated with intractable seizures. Recent evidence suggests that dysregulated cap-dependent translation downstream of mTORC1 contributes to cytoarchitectural abnormalities and seizure activity. Here, we examined whether reducing cap-dependent translation by expressing a constitutively active form of the translational repressor, 4E-BP1, downstream of mTORC1 would prevent the development of cortical malformations and seizures. 4E-BP1CA was expressed embryonically either in radial glia (neural progenitor cells) that generate cortical layer 2/3 pyramidal neurons or in migrating neurons destined to layer 2/3 using a conditional expression system. In both conditions, 4E-BP1CA expression reduced mTORC1-induced neuronal hypertrophy and alleviated cortical mislamination, but a subset of ectopic neurons persisted in the deep layers and the white matter. Despite the above improvements, 4E-BP1CA expression in radial glia had no effects on seizure frequency and further exacerbated behavioral seizure severity associated with mTORC1 hyperactivation. In contrast, conditional 4E-BP1CA expression in migratory neurons mitigated the severity of behavioral seizures but the seizure frequency remained unchanged. These findings advise against targeting 4E-BPs by 4E-BP1CA expression during embryonic development for seizure prevention and suggest the presence of a development-dependent role for 4E-BPs in mTORC1-induced epilepsy.
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Affiliation(s)
- Lena H. Nguyen
- Department of Neuroscience, School of Behavioral and Brain Sciences, University of Texas at Dallas, Richardson, TX, United States
- Departments of Neurosurgery and Cellular & Molecular Physiology, Wu Tsai Institute, Yale University School of Medicine, New Haven, CT, United States
| | - Manas Sharma
- Departments of Neurosurgery and Cellular & Molecular Physiology, Wu Tsai Institute, Yale University School of Medicine, New Haven, CT, United States
| | - Angelique Bordey
- Departments of Neurosurgery and Cellular & Molecular Physiology, Wu Tsai Institute, Yale University School of Medicine, New Haven, CT, United States
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George E, MacPherson C, Pruthi S, Bilaniuk L, Fletcher J, Houtrow A, Gupta N, Glenn OA. Long-Term Imaging Follow-up from the Management of Myelomeningocele Study. AJNR Am J Neuroradiol 2023:ajnr.A7926. [PMID: 37385677 PMCID: PMC10337608 DOI: 10.3174/ajnr.a7926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/23/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND PURPOSE Short-term results demonstrate that prenatal repair of a myelomeningocele is associated with a reduction in hydrocephalus and an increased likelihood of the reversal of Chiari II malformations compared with postnatal repair. The purpose of this study was to identify the long-term imaging findings at school age among subjects who underwent pre- versus postnatal repair of a myelomeningocele. MATERIALS AND METHODS A subset of subjects enrolled in the Management of Myelomeningocele Study who underwent either prenatal (n = 66) or postnatal (n = 63) repair of a lumbosacral myelomeningocele and had follow-up brain MR imaging at school age were included. The prevalence of posterior fossa features of Chiari II malformation and supratentorial abnormalities and the change in these findings from fetal to school-age MR imaging were compared between the 2 groups. RESULTS Prenatal repair of a myelomeningocele was associated with higher rates of normal location of fourth ventricle and lower rates of hindbrain herniation, cerebellar herniation, tectal beaking, brainstem distortion, and kinking at school age compared with postnatal repair (all P < .01). Supratentorial abnormalities, including corpus callosal abnormalities, gyral abnormalities, heterotopia, and hemorrhage, were not significantly different between the 2 groups (all P > .05). The rates of resolution of brainstem kinking, tectal beaking, cerebellar and hindbrain herniation, and normalization of fourth ventricle size from fetal to school age MR imaging were higher among the prenatal compared with postnatal surgery group (all, P < .02). CONCLUSIONS Prenatal repair of a myelomeningocele is associated with persistent improvement in posterior fossa imaging findings of Chiari II malformation at school age compared with postnatal repair.
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Affiliation(s)
- E George
- From the Departments of Radiology and Biomedical Imaging (E.G., O.A.G.)
| | - C MacPherson
- Biostatistics Center (C.M.), Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - S Pruthi
- Department of Radiology (S.P.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - L Bilaniuk
- Department of Radiology (L.B.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J Fletcher
- Department of Psychology (J.F.), University of Houston, Houston, Texas
| | - A Houtrow
- Department of Physical Medicine and Rehabilitation (A.H.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - N Gupta
- Neurological Surgery (N.G.)
- Pediatrics (N.G.), University of California, San Francisco, San Francisco, California
| | - O A Glenn
- From the Departments of Radiology and Biomedical Imaging (E.G., O.A.G.)
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Krajden Haratz K, Birnbaum R, Kidron D, Har-Toov J, Salemnick Y, Brusilov M, Malinger G. Malformation of cortical development with abnormal cortex: early ultrasound diagnosis between 14 and 24 weeks of gestation. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 61:559-565. [PMID: 36484522 DOI: 10.1002/uog.26139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2022] [Revised: 11/09/2022] [Accepted: 11/14/2022] [Indexed: 05/04/2023]
Abstract
OBJECTIVE To describe neurosonographic findings diagnostic or highly suggestive of the presence of malformations of cortical development involving the cortex that may be identified before 24 weeks of gestation. METHODS This was a retrospective single-center study of fetuses referred for neurosonography, during 2012-2019, with an abnormal cortical or sulcation pattern diagnosed early in the mid trimester. Stored files were analyzed for demographic data, abnormal brain findings, non-central nervous system abnormalities, final diagnosis and postnatal outcome. RESULTS The study cohort included 20 fetuses, with a mean gestational age at diagnosis of 18.7 (range, 14.4-23.6) weeks, in 11 of which the diagnosis was made before 20 weeks of gestation. Reasons for referral were: midline anomaly (n = 7), ventriculomegaly (n = 4), infratentorial findings (n = 3), suspected malformation of cortical development (n = 3), 'abnormal brain' (n = 2) and skeletal dysplasia (n = 1). On neurosonography, both the sulcation pattern and the cortical layer were abnormal in four cases, only the sulcation pattern was considered abnormal in seven and only the cortical layer was abnormal in nine. Nineteen fetuses presented with associated central nervous system anomalies and six also had non-central nervous system malformations. One case was recurrent. Eighteen parents opted for termination of pregnancy, including one selective termination in a twin pregnancy, and two fetuses were liveborn. CONCLUSIONS Familiarity with fetal brain anatomy and its early sonographic landmarks allowed early diagnosis of malformations involving cortical development. These patients are likely to represent the most severe cases and all had associated malformations. The presence of an abnormal cortical layer and/or abnormal overdeveloped sulci appear to be early signs of malformation of cortical development. © 2022 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- K Krajden Haratz
- Fetal Neurology Clinic, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - R Birnbaum
- Fetal Neurology Clinic, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - D Kidron
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
- Department of Pathology, Meir Hospital, Kfar Saba, Israel
| | - J Har-Toov
- Fetal Neurology Clinic, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Y Salemnick
- Fetal Neurology Clinic, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - M Brusilov
- Fetal Neurology Clinic, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - G Malinger
- Fetal Neurology Clinic, Lis Maternity Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
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Papaioannou G, Garel C. The fetal brain: migration and gyration anomalies - pre- and postnatal correlations. Pediatr Radiol 2023; 53:589-601. [PMID: 35913508 DOI: 10.1007/s00247-022-05458-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Revised: 06/16/2022] [Accepted: 07/13/2022] [Indexed: 10/16/2022]
Abstract
The cerebral cortex represents a laminar structure of precisely spatially organized neurons in horizontal layers and vertical columns. Neurogenesis, neuronal migration and neuronal wiring are tightly regulated and coordinated procedures that result in the accurate formation of the human cerebral cortex. Abnormal fetal corticogenesis results in several types of migration and gyration anomalies, known as malformations of cortical development, which have long been a topic of investigation. According to the stage of cortical development that is affected, with diverse genetic and non-genetic etiologies, these malformations can cause abnormal head size, abnormal brain surface and abnormal cortical layering with various degrees of neurodevelopmental delay and epilepsy. The pathogenesis of these malformations is multifactorial and includes genetic mutations or environmental insults, acquired either in utero at varying stages of brain development or during the perinatal period after corticogenesis. In this article, we focus on cortical malformations detected on fetal MRI. We present the main antenatal findings that should raise suspicion for malformations of cortical development, together with findings that might be missed on prenatal imaging and describe the correlations between fetal and postnatal MRI.
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Affiliation(s)
- Georgia Papaioannou
- Department of Pediatric Radiology, Mitera Maternity and Children's Hospital, 6 Erythrou Stavrou str, 15123, Maroussi, Athens, Greece.
| | - Catherine Garel
- Service de Radiologie, Hôpital d'Enfants Armand-Trousseau APHP, Sorbonne Université, Paris, France
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Fileva N, Severino M, Tortora D, Ramaglia A, Paladini D, Rossi A. Second trimester fetal MRI of the brain: Through the ground glass. JOURNAL OF CLINICAL ULTRASOUND : JCU 2023; 51:283-299. [PMID: 36785503 DOI: 10.1002/jcu.23423] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2022] [Accepted: 12/28/2022] [Indexed: 06/18/2023]
Abstract
Fetal MRI is an important tool for the prenatal diagnosis of brain malformations and is often requested after second-trimester ultrasonography reveals a possible abnormality. Despite the immature state of the fetal brain at this early stage, early suggestive signs of the presence of brain malformations can be recognized. To differentiate between the normal dynamics of the growing brain and the developing pathological conditions can be challenging and requires extensive knowledge of normal central nervous system developmental stages and their neuroradiological counterparts at those different stages. This article reviews the second-trimester appearances of some commonly encountered brain malformations, focusing on helpful tricks and subtle signs to aid in the diagnosis of such conditions as rhombencephalosynapsis, various causes of vermian rotation, molar tooth spectrum anomalies, diencephalic-mesencephalic junction dysplasia, ganglionic eminence anomalies, and the most common malformations of cortical development.
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Affiliation(s)
- Nevena Fileva
- Department of Radiology, Medical University of Sofia, Sofia, Bulgaria
| | | | - Domenico Tortora
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Antonia Ramaglia
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Dario Paladini
- Fetal Medicine and Surgery Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
| | - Andrea Rossi
- Neuroradiology Unit, IRCCS Istituto Giannina Gaslini, Genoa, Italy
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy
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Fetal Ultrasound and Magnetic Resonance Imaging Abnormalities in Congenital Cytomegalovirus Infection Associated with and without Fetal Growth Restriction. Diagnostics (Basel) 2023; 13:diagnostics13020306. [PMID: 36673117 PMCID: PMC9857471 DOI: 10.3390/diagnostics13020306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/09/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
Congenital cytomegalovirus infection (cCMV) can cause fetal growth restriction (FGR) and severe sequelae in affected infants. Clinicians generally suspect cCMV based on multiple ultrasound (US) findings associated with cCMV. However, no studies have assessed the diagnostic accuracy of fetal US for cCMV-associated abnormalities in FGR. Eight FGR and 10 non-FGR fetuses prenatally diagnosed with cCMV were examined by undergoing periodic detailed US examinations, as well as postnatal physical and imaging examinations. The diagnostic accuracy of prenatal US for cCMV-associated abnormalities was compared between FGR and non-FGR fetuses with cCMV. The diagnostic sensitivity rates of fetal US for cCMV-related abnormalities in FGR vs. non-FGR fetuses were as follows: ventriculomegaly, 66.7% vs. 88.9%; intracranial calcification, 20.0% vs. 20.0%; cysts and pseudocysts in the brain, 0% vs. 0%; ascites, 100.0% vs. 100.0%; hepatomegaly, 40.0% vs. 100.0%; splenomegaly, 0% vs. 0%. The diagnostic sensitivity of fetal US for hepatomegaly and ventriculomegaly in FGR fetuses with cCMV was lower than that in non-FGR fetuses with cCMV. The prevalence of severe long-term sequelae (e.g., bilateral hearing impairment, epilepsy, cerebral palsy, and severe developmental delay) in the CMV-infected fetuses with FGR was higher, albeit non-significantly. Clinicians should keep in mind the possibility of overlooking the symptoms of cCMV in assessing fetuses with FGR.
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Aertsen M, Dymarkowski S, Vander Mijnsbrugge W, Cockmartin L, Demaerel P, De Catte L. Anatomical and diffusion-weighted imaging of brain abnormalities in third-trimester fetuses with cytomegalovirus infection. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 60:68-75. [PMID: 35018680 DOI: 10.1002/uog.24856] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Revised: 12/16/2021] [Accepted: 12/21/2021] [Indexed: 06/14/2023]
Abstract
OBJECTIVES In this study of cytomegalovirus (CMV)-infected fetuses with first-trimester seroconversion, we aimed to evaluate the detection of brain abnormalities using magnetic resonance imaging (MRI) and neurosonography (NSG) in the third trimester, and compare the grading systems of the two modalities. We also evaluated the feasibility of routine use of diffusion-weighted imaging (DWI) fetal MRI and compared the regional apparent diffusion coefficient (ADC) values between CMV-infected fetuses and presumed normal, non-infected fetuses in the third trimester. METHODS This was a retrospective review of MRI and NSG scans in fetuses with confirmed first-trimester CMV infection performed between September 2015 and August 2019. Brain abnormalities were recorded and graded using fetal MRI and NSG grading systems to compare the two modalities. To investigate feasibility of DWI, a four-point rating scale (poor, suboptimal, good, excellent) was applied to assess the quality of the images. Quantitative assessment was performed by placing a freehand drawn region of interest in the white matter of the frontal, parietal, temporal and occipital lobes and the basal ganglia, pons and cerebellum to calculate ADC values. Regional ADC measurements were obtained similarly in a control group of fetuses with negative maternal CMV serology in the first trimester, normal brain findings on fetal MRI and normal genetic testing. RESULTS Fifty-three MRI examinations of 46 fetuses with confirmed first-trimester CMV infection were included. NSG detected 24 of 27 temporal cysts seen on MRI scans, with a sensitivity of 78% and an accuracy of 83%. NSG did not detect abnormal gyration visible on two (4%) MRI scans. Periventricular calcifications were detected on two MRI scans compared with 10 NSG scans. While lenticulostriate vasculopathy was detected on 11 (21%) NSG scans, no fetus demonstrated this finding on MRI. MRI grading correlated significantly with NSG grading of brain abnormalities (P < 0.0001). Eight (15%) of the DWI scans in the CMV cohort were excluded from further analysis because of insufficient quality. The ADC values of CMV-infected fetuses were significantly increased in the frontal (both sides, P < 0.0001), temporal (both sides, P < 0.0001), parietal (left side, P = 0.0378 and right side, P = 0.0014) and occipital (left side, P = 0.0002 and right side, P < 0.0001) lobes and decreased in the pons (P = 0.0085) when compared with non-infected fetuses. The ADC values in the basal ganglia and the cerebellum were not significantly different in CMV-infected fetuses compared with normal controls (all P > 0.05). Temporal and frontal ADC values were higher in CMV-infected fetuses with more severe brain abnormalities compared to fetuses with mild abnormalities. CONCLUSIONS Ultrasound and MRI are complementary during the third trimester in the assessment of brain abnormalities in CMV-infected fetuses, with a significant correlation between the grading systems of the two modalities. On DWI in the third trimester, the ADC values in several brain regions are abnormal in CMV-infected fetuses compared with normal controls. Furthermore, they seem to correlate in the temporal area and, to a lesser extent, frontal area with the severity of brain abnormalities associated with CMV infection. Larger prospective studies are needed for further investigation of the microscopic nature of diffusion abnormalities and correlation of different imaging findings with postnatal outcome. © 2022 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- M Aertsen
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - S Dymarkowski
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | | | - L Cockmartin
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - P Demaerel
- Department of Imaging and Pathology, KU Leuven, Leuven, Belgium
- Department of Radiology, University Hospitals Leuven, Leuven, Belgium
| | - L De Catte
- Division Woman and Child, Fetal Medicine Unit, Clinical Department of Obstetrics and Gynecology, University Hospital Gasthuisberg, Leuven, Belgium
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Accuracy and clinical utility of standard postmortem radiological imaging after early second trimester termination of pregnancy. Eur J Obstet Gynecol Reprod Biol 2022; 273:75-80. [PMID: 35504117 DOI: 10.1016/j.ejogrb.2022.04.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 04/09/2022] [Accepted: 04/24/2022] [Indexed: 11/21/2022]
Abstract
OBJECTIVE This study aims to assess accuracy and clinical utility of postmortem radiological exams [Magnetic Resonance Imaging (MRI), Computed Tomography (CT) and Radiography (XR)] after termination of pregnancy at <23 weeks' gestation for congenital fetal malformations in comparison to autopsy. STUDY DESIGN This a prospective single-center study on fetuses underwent termination of pregnancy for fetal defects. Overall concordance between any radiological exam and autopsy was evaluated. For postmortem MRI only, the following subgroups were analyzed: 1) total agreement; 2) agreement for main findings; 3) agreement for main findings but major relevant additional findings at autopsy; 4) total disagreement. RESULTS 174 cases were collected. The overall concordance with autopsy for main findings was 71% (115/163) for postmortem MRI and 99% (173/174) for prenatal ultrasound (US). Postmortem MRI detection rate was high for central nervous system (CNS) defects (98%), gastrointestinal, genitourinary and respiratory defects (100%), while it was poor for cardiovascular and musculoskeletal defects (25% and 42%, respectively). For musculoskeletal abnormalities, the performance of postmortem XR and postmortem CT exams improved the detection rate from 42% for postmortem MRI alone to 92%. CONCLUSIONS Postmortem MRI has a good overall concordance for fetal defects after termination of pregnancy performed at <23 weeks. Along with autopsy, postmortem MRI may be offered for all cases of CNS defects in order to prevent inconclusive exams due to autolysis of the brain tissue, while postmortem CT and postmortem XR are indicated for musculoskeletal defects. In the presence of multiple abnormalities or cardiac defects the couple should be counseled on the poor performance of radiological investigations.
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Nagaraj UD, Venkatesan C, Bierbrauer KS, Kline-Fath BM. Value of pre- and postnatal magnetic resonance imaging in the evaluation of congenital central nervous system anomalies. Pediatr Radiol 2022; 52:802-816. [PMID: 34232351 DOI: 10.1007/s00247-021-05137-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/30/2021] [Accepted: 06/10/2021] [Indexed: 12/12/2022]
Abstract
Fetal MRI and neonatal MRI of the central nervous system (CNS) are complementary tools that can help to accurately counsel and direct the management of children with anomalies of the central nervous system. Postnatal MRI can add to fetal MRI by allowing for monitoring of changes in the severity of disease, better delineation of a suspected prenatal anomaly, evaluation for secondary pathologies related to the primary diagnosis, and surgical management direction. In this review we discuss the roles of fetal and neonatal MRI in the diagnosis and treatment of congenital anomalies of the CNS through a series of case examples and how both are important in patient management.
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Affiliation(s)
- Usha D Nagaraj
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA. .,University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Charu Venkatesan
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Karin S Bierbrauer
- University of Cincinnati College of Medicine, Cincinnati, OH, USA.,Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Beth M Kline-Fath
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Alluhaybi AA, Altuhaini K, Ahmad M. Fetal Ventriculomegaly: A Review of Literature. Cureus 2022; 14:e22352. [PMID: 35223331 PMCID: PMC8860673 DOI: 10.7759/cureus.22352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2022] [Indexed: 11/05/2022] Open
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Simmons R, Martinez AB, Barkovich J, Numis AL, Cilio MR, Glenn OA, Gano D, Rogers EE, Glass HC. Disorders of Neuronal Migration/Organization Convey the Highest Risk of Neonatal Onset Epilepsy Compared With Other Congenital Brain Malformations. Pediatr Neurol 2022; 127:20-27. [PMID: 34933271 DOI: 10.1016/j.pediatrneurol.2021.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 11/02/2021] [Accepted: 11/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND Although seizures in neonates are common and often due to acute brain injury, 10-15% are unprovoked from congenital brain malformations. A better understanding of the risk of neonatal-onset epilepsy by the type of brain malformation is essential for counseling and monitoring. METHODS In this retrospective cohort study, we evaluated 132 neonates with congenital brain malformations and their risk of neonatal-onset epilepsy. Malformations were classified into one of five categories based on imaging patterns on prenatal or postnatal imaging. Infants were monitored with continuous video EEG (cEEG) for encephalopathy and paroxysmal events in addition to abnormal neuroimaging. RESULTS Seventy-four of 132 (56%) neonates underwent EEG monitoring, and 18 of 132 (14%) were diagnosed with neonatal-onset epilepsy. The highest prevalence of epilepsy was in neonates with disorders of neuronal migration/organization (9/34, 26%; 95% confidence interval [CI] = 13-44%), followed by disorders of early prosencephalic development (6/38, 16%; 95% CI = 6-31%), complex total brain malformations (2/16, 13%; 95% CI = 2-38%), and disorders of midbrain/hindbrain malformations (1/30, 3%; 95% CI = 0-17%). Of neonates with epilepsy, 5 of 18 (28%) had only electrographic seizures, 13 of 18 (72%) required treatment with two or more antiseizure medicines (ASMs), and 7 of 18 (39%) died within the neonatal period. CONCLUSION Our results demonstrate that disorders of neuronal migration/organization represent the highest-risk group for early-onset epilepsy. Seizures are frequently electrographic only, require treatment with multiple ASMs, and portend a high mortality rate. These results support American Clinical Neurophysiology Society recommendations for EEG monitoring during the neonatal period for infants with congenital brain malformations.
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Affiliation(s)
- Roxanne Simmons
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California
| | | | - James Barkovich
- Department of Radiology and Biomedical Engineering, University of California, San Francisco, San Francisco, California
| | - Adam L Numis
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California
| | - Maria Roberta Cilio
- Department of Pediatrics, Saint-Luc University Hospital, Catholic University of Louvain, Brussels, Belgium
| | - Orit A Glenn
- Department of Radiology and Biomedical Engineering, University of California, San Francisco, San Francisco, California
| | - Dawn Gano
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California; Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | - Elizabeth E Rogers
- Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California
| | - Hannah C Glass
- Department of Neurology and Weill Institute for Neuroscience, University of California, San Francisco, San Francisco, California; Department of Pediatrics, Benioff Children's Hospital, University of California, San Francisco, San Francisco, California; Department of Epidemiology and Biostatistics, University of California, San Francisco, San Francisco, California.
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The Role of Fetal Brain Magnetic Resonance Imaging in Current Fetal Medicine. J Belg Soc Radiol 2022; 106:130. [PMID: 36569393 PMCID: PMC9756908 DOI: 10.5334/jbsr.3000] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
In open spina bifida we studied the use of MRI for the assessment of the posterior fossa and prevalence of supratentorial anomalies before and after in utero repair. New postprocessing techniques were applied to evaluate fetal brain development in this population compared to controls. In fetuses with congenital diaphragmatic hernia, we evaluated the brain development in comparison to controls. Diffusion weighted imaging was applied to study difference between fetuses with proven first trimester cytomegalovirus infection and controls. Finally, we investigated the value of third trimester fetal brain MRI after treatment for complicated monochorionic diamniotic pregnancies.
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14
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Hart AR, Vasudevan C, Griffiths PD, Foulds N, Piercy H, de Lacy P, Boxall S, Howe D, Vollmer B. Antenatal counselling for prospective parents whose fetus has a neurological anomaly: part 2, risks of adverse outcome in common anomalies. Dev Med Child Neurol 2022; 64:23-39. [PMID: 34482539 DOI: 10.1111/dmcn.15043] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Revised: 07/31/2021] [Accepted: 08/02/2021] [Indexed: 12/14/2022]
Abstract
After diagnosis of a fetal neurological anomaly, prospective parents want to know the best and worst-case scenarios and an estimation of the risk to their infant of having an atypical developmental outcome. The literature on developmental outcomes for fetal neurological anomalies is poor: studies are characterized by retrospective design, small sample size, often no standardized assessment of development, and differing definitions of anomalies. This review provides an aide-memoir on the risks of adverse neurodevelopmental outcome for ventriculomegaly, cortical anomalies, microcephaly, macrocephaly, agenesis of the corpus callosum, posterior fossa anomalies, and myelomeningocele, to assist healthcare professionals in counselling. The data in this review should be used alongside recommendations on counselling and service design described in part 1 to provide antenatal counselling.
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Affiliation(s)
- Anthony R Hart
- Department of Perinatal and Paediatric Neurology, Sheffield Children's NHS Foundation Trust, Ryegate Children's Centre, Sheffield, UK
| | - Chakra Vasudevan
- Department of Neonatology, Bradford Royal Infirmary, Bradford, UK
| | - Paul D Griffiths
- Academic Unit of Radiology, Royal Hallamshire Hospital, University of Sheffield, Sheffield, UK
| | - Nicola Foulds
- Department of Clinical Genetics, Princess Anne Hospital, University Southampton NHS Foundation Trust, Southampton, UK
| | - Hilary Piercy
- The Centre for Health and Social Care, Sheffield Hallam University, Sheffield, UK
| | - Patricia de Lacy
- Department of Paediatric Neuosurgery, Sheffield Children's NHS Foundation Trust, Sheffield, UK
| | - Sally Boxall
- Wessex Fetal Medicine Unit, Princess Anne Hospital, Southampton, UK
| | - David Howe
- Wessex Fetal Medicine Unit, Princess Anne Hospital, Southampton, UK
| | - Brigitte Vollmer
- Clinical and Experimental Sciences, Faculty of Medicine, Paediatric and Neonatal Neurology, Southampton Children's Hospital, University Hospital Southampton NHS Foundation Trust, University of Southampton, Southampton, UK
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15
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Romaniello R, Arrigoni F, De Salvo P, Bonaglia MC, Panzeri E, Bassi MT, Parazzini C, Righini A, Borgatti R. Long-term follow-up in a cohort of children with isolated corpus callosum agenesis at fetal MRI. Ann Clin Transl Neurol 2021; 8:2280-2288. [PMID: 34850608 PMCID: PMC8670314 DOI: 10.1002/acn3.51484] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 11/11/2021] [Accepted: 11/12/2021] [Indexed: 12/02/2022] Open
Abstract
Objective This long‐term retrospective follow‐up study aimed to address the knowledge gap between prenatal diagnosis of complete isolated Agenesis of Corpus Callosum (cACC) at fetal MRI and postnatal neurodevelopmental outcome to improve prenatal counseling for parents. Methods Data on fetuses with isolated cACC from a single‐center MRI database built up in two decades were considered. Detailed postnatal clinical, neuropsychological evaluations were performed and descriptions of available neuroradiological and genetic data were provided. Results Following a detailed neuropsychological evaluation and a long‐term follow‐up, the subsequent results emerged: 38 school‐aged children (older than 6 years) of 50 (aged 2.5‐15 years) showed normal intellectual functions (50%), intellectual disability (21%), and borderline intelligence quotient (29%). Deficits in motor functions (58%), executive functions (37%), language (61%), memory abilities (58%), and academic performances (53%) were found. Twenty‐one percent of participants showed behavioral difficulties. Almost half of the participants underwent rehabilitation. Additional findings (21%) were detected at postnatal brain MRI, and a significant association between additional findings at postnatal imaging and abnormal neurodevelopmental outcome was observed. Interpretations This study supports the view that children with prenatal diagnosis of isolated cACC may present with several degrees of neurologic and neuropsychological impairment which become more evident only in their second decade of life. Postnatal MRI and detailed genetic analysis may add crucial information to prenatal data and substantially influence final judgment on the outcome and orient clinical management and counseling.
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Affiliation(s)
- Romina Romaniello
- Neuropsychiatry and Neurorehabilitation Unit, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Filippo Arrigoni
- Neuroimaging Lab, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Patrizia De Salvo
- Neuropsychiatry and Neurorehabilitation Unit, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Maria Clara Bonaglia
- Cytogenetics Laboratory, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Elena Panzeri
- Laboratory of Molecular Biology, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Maria Teresa Bassi
- Laboratory of Molecular Biology, Scientific Institute, IRCCS Eugenio Medea, Bosisio Parini, Lecco, Italy
| | - Cecilia Parazzini
- Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | - Andrea Righini
- Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | - Renato Borgatti
- Child Neurology and Psychiatry Unit, IRCCS Mondino Foundation, Pavia, Italy.,Department of Brain and Behavioral Sciences, University of Pavia, Pavia, Italy
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16
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Eyüboğlu İ, Dinç G. Fetal US and MRI in detection of craniospinal anomalies with postnatal correlation: single-center experience. Turk J Med Sci 2021; 51:1211-1219. [PMID: 33517612 PMCID: PMC8283491 DOI: 10.3906/sag-2011-122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 01/31/2021] [Indexed: 12/04/2022] Open
Abstract
Background/aim To reveal the contribution of magnetic resonance imaging (MRI) to ultrasound (US) in prenatal diagnosis of fetal craniospinal anomalies by retrospectively comparing the prenatal and postnatal findings. Materials and methods After institutional review board approval, between January 2010 and May 2020, 301 pregnant women, which had a gestational age between 19–37 weeks (mean 26.5 ± 6.1 weeks), diagnosed with cranial and spinal anomalies on fetal US and later on imaged with MRI were evaluated, and in 179 of those cases prenatal imaging findings were compared with postnatal findings. Results A total of 191 fetal craniospinal anomalies were detected in 179 pregnant women. MRI and US diagnosis were completely correct in 145 (75.9%) and 112 (58.6%), respectively. Diagnostic performance of MRI was significantly higher than that of the US (p < 0.05). Both prenatal MRI and US findings were concordant with postnatal diagnosis in 53% of the cases. In 28.7% cases, prenatal MRI contributed to US by either changing the wrong US diagnosis (8.9%), demonstration of additional findings (14%), or confirming the suspicious US diagnosis (5.8%). Conclusion Due to its high resolution and multiplanar imaging capability, fetal MRI contributes significantly to US in the correct prenatal diagnosis of craniospinal anomalies. This contribution especially is significant in neural tube defects, cortical malformations, and ischemic-hemorrhagic lesions.
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Affiliation(s)
- İlker Eyüboğlu
- Department of Radiology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
| | - Gülseren Dinç
- Department of Obstetrics and Gynecology, Faculty of Medicine, Karadeniz Technical University, Trabzon, Turkey
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17
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Abstract
The importance of fetal magnetic resonance imaging (MRI) in the prenatal diagnosis of central nervous system (CNS) anomalies is rapidly increasing. Fetal MRI represents a third level examination usually performed, as early as 18-20 weeks of gestational age, when a second level (expert) neuro-ultrasonography (US) evaluation raises the suspicion of a CNS anomaly or when a genetic disorder is known. Compared to the US, MRI has the advantage to allow a better visualization and characterization of brain structures so to detect anomalies not visible in the US, thus resulting in relevant implications for parent counselling and pregnancy management. Moreover, the improvement of MRI technologies permits to obtain ultrafast sequences, which minimize the drawback of movement artifacts, and to perform advanced studies. This review aims at providing a practical guide for trainees and fellows who are approaching fetal MRI. In the first part, we provide information about indications, safety and protocols based on the state-of-the-art sequences, with a mention on the innovations related to the use of a 3T scanner. The second part is focused on the normal development of the human fetal brain related to its MR appearance, whose knowledge is essential to detect possible abnormalities. The last section briefly describes the most frequent abnormalities in the fetal brain and spine as depicted by MRI.
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Affiliation(s)
- Giulia Moltoni
- Neuroradiology Unit, NESMOS (Neurosciences, Mental Health and Sensory Organs) Department, S. Andrea Hospital, University Sapienza, Rome, Italy
| | - Giacomo Talenti
- Neuroradiology Unit, Department of Diagnostics and Pathology, Verona University Hospital, Verona, Italy
| | - Andrea Righini
- Neuroradiology Unit, Pediatric Radiology Department, Vittore Buzzi Children's Hospital, Milan, Italy
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18
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Linh LT, Duc NM, Nhung NTH, My TTT, Luu DT, Lenh BV. Detecting Fetal Central Nervous System Anomalies Using Magnetic Resonance Imaging and Ultrasound. Med Arch 2021; 75:45-49. [PMID: 34012199 PMCID: PMC8116073 DOI: 10.5455/medarh.2021.75.45-49] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background: Most fetal abnormalities can be detected on ultrasound, the evaluation of fetal CNS abnormalities can be limited by various factors, including obesity, polyhydramnios, multiple pregnancies, and increased cranial ossification during the third trimester. Objective: This study aimed to evaluate the ability to detect fetal central nervous system (CNS) anomalies using in utero magnetic resonance imaging (iuMRI) and ultrasound (US) techniques. Methods: This prospective study was approved by the institutional review board (Ref: 2968/QĐ-ĐHYHN dated 11 July 2019), and the requirement to obtain the informed consent of patients was waived. This study included 66 fetuses with diagnosed or suspected CNS abnormalities based on the results of a prenatal screening US performed at the antenatal diagnosis center of the Central Obstetrics and Gynecology Hospital. All pregnant women with a suspected diagnosis of abnormal fetal CNS on US underwent 1.5-Tesla iuMRI within 14 days of the US at Hanoi Medical University Hospital between June 2019 and June 2020. Cohen’s kappa coefficient (κ) was used to determine the agreement between US and iuMRI findings. Results: A total of 66 pregnant women were examined, including 66 fetuses, for which 79 abnormalities were detected by US and 98 abnormalities were detected by iuMRI. The average gestational age was 29 weeks and 6 days. The comparison of iuMRI and US findings revealed similar diagnoses for 71 abnormalities (67%) and different diagnoses for 35 abnormalities (33%). The level of agreement between US and iuMRI was almost perfect for ventriculomegaly and cystic lesions, with κ values 0.87 and 0.84, respectively. The level of agreement between US and iuMRI was the weakest for hemorrhage, with a κ value 0 (no agreement), and cortical abnormalities, with a κ value of 0.46 (weak agreement). Conclusion: The level of agreement between US and iuMRI diagnoses was almost perfect for the detection of ventriculomegaly and was weakest for the detection of hemorrhage and cortical abnormalities, which were abnormalities detected by iuMRI but not by ultrasound.
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Affiliation(s)
- Le Tuan Linh
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Nguyen Minh Duc
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam.,Department of Radiology, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam.,Department of Radiology, Children's Hospital 2, Ho Chi Minh City, Vietnam
| | | | - Thieu-Thi Tra My
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Doan Tien Luu
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
| | - Bui Van Lenh
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
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19
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Choi JJ, Yang E, Soul JS, Jaimes C. Fetal magnetic resonance imaging: supratentorial brain malformations. Pediatr Radiol 2020; 50:1934-1947. [PMID: 33252760 DOI: 10.1007/s00247-020-04696-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 03/16/2020] [Accepted: 04/23/2020] [Indexed: 11/29/2022]
Abstract
Fetal MRI is the modality of choice to study supratentorial brain malformations. To accurately interpret the MRI, the radiologist needs to understand the normal sequence of events that occurs during prenatal brain development; this includes familiarity with the processes of hemispheric cleavage, formation of interhemispheric commissures, neuro-glial proliferation and migration, and cortical folding. Disruption of these processes results in malformations observed on fetal MRI including holoprosencephaly, callosal agenesis, heterotopic gray matter, lissencephaly and other malformations of cortical development (focal cortical dysplasia, polymicrogyria). The radiologist should also be familiar with findings that have high association with specific conditions affecting the central nervous system or other organ systems. This review summarizes and illustrates common patterns of supratentorial brain malformations and emphasizes aspects that are important to patient care.
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Affiliation(s)
- Jungwhan John Choi
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA.,Harvard Medical School, Boston, MA, USA
| | - Janet S Soul
- Harvard Medical School, Boston, MA, USA.,Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Camilo Jaimes
- Department of Radiology, Boston Children's Hospital, 300 Longwood Ave., Boston, MA, 02115, USA. .,Harvard Medical School, Boston, MA, USA. .,Fetal-Neonatal Neuroimaging and Developmental Science Center, Division of Newborn Medicine, Boston Children's Hospital, Boston, MA, USA.
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20
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The prevalence of brain lesions after in utero surgery for twin-to-twin transfusion syndrome on third-trimester MRI: a retrospective cohort study. Eur Radiol 2020; 31:4097-4103. [PMID: 33210202 DOI: 10.1007/s00330-020-07452-x] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 08/22/2020] [Accepted: 11/02/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVE Due to the increased risk of antenatal brain lesions, we offer a third-trimester magnetic resonance imaging (MRI) scan to all patients who underwent an in utero intervention for twin-twin transfusion syndrome (TTTS). However, the usefulness of such a policy has not been demonstrated yet. Therefore, we determined the prevalence of antenatal brain lesions detected on third-trimester MRI and the proportion of lesions detected exclusively on MRI. MATERIALS AND METHODS We conducted a retrospective cohort study of monochorionic diamniotic twin pregnancies complicated by TTTS that underwent laser coagulation of the vascular anastomoses or fetal reduction by umbilical cord occlusion between 2010 and 2017. We reviewed the third-trimester MRI findings and compared those with the prenatal ultrasonography. RESULTS Of the 141 patients treated with laser coagulation and 17 managed by cord occlusion, 112/141 (79%) and 15/17 (88%) patients reached 28 weeks. Of those, 69/112 (62%) and 11/15 (73%) underwent an MRI between 28 and 32 weeks. After laser coagulation, MRI detected an antenatal brain lesion in 6 of 69 pregnancies (9%) or in 6 of 125 fetuses (5%). In 4 cases (67%), the lesion was detected only on MRI. In the 11 patients treated with cord occlusion, no brain lesions were diagnosed. CONCLUSION The prevalence of brain lesions detected by third-trimester MRI is higher compared to prenatal ultrasonography alone, making MRI a useful adjunct to detect antenatal brain lesions in twin pregnancies after in utero treatment for TTTS. KEY POINTS • In utero interventions for twin-to-twin transfusion syndrome (TTTS) do not prevent the occurrence of antenatal brain lesions. • Fetal magnetic resonance imaging (MRI) has high accuracy in detecting anomalies of cortical development and can be a useful adjunct to ultrasonography in diagnosing certain brain abnormalities. • After laser coagulation of the anastomoses for TTTS, third-trimester MRI diagnosed a brain lesion that was not detected earlier on ultrasound scan in 6% of pregnancies.
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21
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Douglas Wilson R, Van Mieghem T, Langlois S, Church P. Guideline No. 410: Prevention, Screening, Diagnosis, and Pregnancy Management for Fetal Neural Tube Defects. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:124-139.e8. [PMID: 33212246 DOI: 10.1016/j.jogc.2020.11.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
OBJECTIVE This revised guideline is intended to provide an update on the genetic aspects, prevention, screening, diagnosis, and management of fetal neural tube defects. TARGET POPULATION Women who are pregnant or may become pregnant. Neural tube defect screening should be offered to all pregnant women. OPTIONS For prevention: a folate-rich diet, and folic acid and vitamin B12 supplementation, with dosage depending on risk level. For screening: second-trimester anatomical sonography; first-trimester sonographic screening; maternal serum alpha fetoprotein; prenatal magnetic resonance imaging. For genetic testing: diagnostic amniocentesis with chromosomal microarray and amniotic fluid alpha fetoprotein and acetylcholinesterase; fetal exome sequencing. For pregnancy management: prenatal surgical repair; postnatal surgical repair; pregnancy termination with autopsy. For subsequent pregnancies: prevention and screening options and counselling. OUTCOMES The research on and implementation of fetal surgery for prenatally diagnosed myelomeningocele has added a significant treatment option to the previous options (postnatal repair or pregnancy termination), but this new option carries an increased risk of maternal morbidity. Significant improvements in health and quality of life, both for the mother and the infant, have been shown to result from the prevention, screening, diagnosis, and treatment of fetal neural tube defects. BENEFITS, HARMS, AND COSTS The benefits for patient autonomy and decision-making are provided in the guideline. Harms include an unexpected fetal diagnosis and the subsequent management decisions. Harm can also result if the patient declines routine sonographic scans or if counselling and access to care for neural tube defects are delayed. Cost analysis (personal, family, health care) is not within the scope of this clinical practice guideline. EVIDENCE A directed and focused literature review was conducted using the search terms spina bifida, neural tube defect, myelomeningocele, prenatal diagnosis, fetal surgery, neural tube defect prevention, neural tube defect screening, neural tube defect diagnosis, and neural tube defect management in order to update and revise this guideline. A peer review process was used for content validation and clarity, with appropriate ethical considerations. VALIDATION METHODS The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and weak recommendations). INTENDED AUDIENCE Maternity care professionals who provide any part of pre-conception, antenatal, delivery, and neonatal care. This guideline is also appropriate for patient education. RECOMMENDATIONS (GRADE RATINGS IN PARENTHESES).
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22
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Douglas Wilson R, Van Mieghem T, Langlois S, Church P. Directive clinique n o 410 : Anomalies du tube neural : Prévention, dépistage, diagnostic et prise en charge de la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2020; 43:140-157.e8. [PMID: 33212245 DOI: 10.1016/j.jogc.2020.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIF La présente directive clinique révisée vise à fournir une mise à jour sur les aspects génétiques, la prévention, le dépistage, le diagnostic et la prise en charge des anomalies du tube neural. POPULATION CIBLE Les femmes enceintes ou qui pourraient le devenir. Il convient d'offrir le dépistage des anomalies du tube neural à toutes les femmes enceintes. OPTIONS Pour la prévention : un régime alimentaire riche en acide folique et des suppléments d'acide folique et de vitamine B12 selon une posologie d'après le niveau de risque. Pour le dépistage : l'échographie obstétricale du deuxième trimestre, le dépistage échographique du premier trimestre, le dosage de l'alphafœtoprotéine sérique maternelle et l'imagerie par résonance magnétique prénatale. Pour les tests génétiques : l'amniocentèse diagnostique avec analyse chromosomique sur micropuce et le dosage de l'alphafœtoprotéine et de l'acétylcholinestérase dans le liquide amniotique et le séquençage de l'exome fœtal. Pour la prise en charge de la grossesse : la réparation chirurgicale prénatale, la réparation chirurgicale postnatale et l'interruption de grossesse avec autopsie. Pour les grossesses subséquentes : les options de prévention et de dépistage et les conseils. RéSULTATS: La recherche et la mise en œuvre du traitement chirurgical fœtal en cas de diagnostic prénatal de myéloméningocèle ont ajouté une option thérapeutique fœtale importante aux options précédentes (réparation postnatale ou interruption de grossesse), mais cette nouvelle option comporte un risque accru de morbidité maternelle. La prévention, le dépistage, le diagnostic et le traitement des anomalies du tube neural se révèlent entraîner des améliorations importantes à la mère et au nourrisson en matière de santé et de qualité de vie. BéNéFICES, RISQUES ET COûTS: Le type et l'ampleur des bénéfices, risques et coûts attendus pour les patientes grâce à la mise en œuvre de la présente directive clinique par un établissement de soins de santé intègrent un canal maternel préconception et prénatal adéquat comprenant l'accès des patientes aux soins, les conseils, les analyses et examens, l'imagerie, le diagnostic et l'interprétation. Les bénéfices relatifs à l'autonomie de la patiente et au processus décisionnel sont énoncés dans la présente directive clinique. Les risques comprennent un diagnostic fœtal inattendu et les décisions de prise en charge subséquentes. Le fait que la patiente refuse les échographies habituelles et le retard du conseil ou d'accès aux soins en cas d'anomalie du tube neural comportent également des risques. L'analyse des coûts (personnels, familiaux, santé publique) ne fait pas partie de la portée de la présente directive clinique. DONNéES PROBANTES: Afin de mettre à jour et réviser la présente directive, une revue de la littérature ciblée et dirigée a été effectuée à l'aide des termes de recherche suivants : spina bifida, neural tube defect, myelomeningocele, prenatal diagnosis, fetal surgery, neural tube defect prevention, neural tube defect screening, neural tube defect diagnosis et neural tube defect management. Un processus d'examen par les pairs a été utilisé pour la validation et la clarté du contenu, avec des considérations appropriées d'ordre éthique. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant l'approche d'évaluation, de développement et d'évaluation (GRADE). Consulter l'annexe A en ligne (le tableau A1 pour les définitions et le tableau A2 pour les interprétations des recommandations fortes et faibles). PROFESSIONNELS CONCERNéS: Professionnels des soins de maternité qui offrent des soins préconception, prénataux, obstétricaux ou néonataux. La présente directive clinique convient également aux fins d'éducation des patientes. RECOMMANDATIONS (CLASSEMENT GRADE ENTRE PARENTHèSES).
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23
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Jezberova M, Kosutzka Z, Waczulikova I, Kolnikova M, Cunderlik A, Lehotska V. Agreement between prenatal ultrasound and 3.0T magnetic resonance imaging in the assessment of anomalies of the central nervous system: A single-center experience in Slovakia. Int J Gynaecol Obstet 2020; 152:365-373. [PMID: 32975312 DOI: 10.1002/ijgo.13388] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Revised: 07/18/2020] [Accepted: 09/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To assess the concordance of in-utero magnetic resonance imaging (MRI) findings at 3.0T in fetuses with suspect abnormalities of the central nervous system (CNS) on ultrasonography. METHODS A retrospective study was done on 222 pregnant women indicated for fetal MRI, with the examination performed within 2 weeks from indication. The inclusion criteria for patients were age 18 years or older with the fetus at 18 weeks of gestation or more. Fetal CNS pathologies were divided into six categories: ventriculomegaly; supratentorial midline abnormalities (ACC); supratentorial space-occupying lesions; abnormalities of the posterior fossa; destructive cerebral lesions; and cortical formation abnormalities (CFA). Chance-adjusted agreement was assessed using unweighted Cohen's kappa (κ). RESULTS The best agreement between ultrasound and MRI was observed in ventriculomegaly (κ=0.817; 95% confidence interval [CI] 0.76-0.88). There was only a moderate agreement in ACC (κ=0.483; 95% CI 0.35-0.61). CFA pathologies had a poor agreement between the modalities (κ=0.140; 95% CI -0.03 to 0.31). CONCLUSION Ultrasonography has good overall agreement with MRI in diagnosing fetal CNS anomalies. CFA had the most disagreement between ultrasound and MRI. The prognostic implication of these findings can be used for parental neuro-counseling but should be investigated further.
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Affiliation(s)
- Michaela Jezberova
- Department of Magnetic Resonance Imaging, Dr. Magnet Ltd., Bratislava, Slovakia
| | - Zuzana Kosutzka
- 2nd Department of Neurology, Faculty of Medicine, Comenius University, Bratislava, Slovakia
| | - Iveta Waczulikova
- Department of Nuclear Physics and Biophysics, Faculty of Mathematics, Physics and Informatics, Comenius University, Bratislava, Slovakia
| | - Miriam Kolnikova
- Department of Pediatric Neurology, Comenius University Faculty of Medicine and National Institute of Children's Diseases, Bratislava, Slovakia
| | - Anton Cunderlik
- Department of Obstetrics and Gynecology, Slovak Medical University Bratislava, Comenius University, Bratislava, Slovakia
| | - Viera Lehotska
- 2nd Radiology Department, Faculty of Medicine of Comenius University in Bratislava and St. Elizabeth's Cancer Institute Bratislava, Bratislava, Slovakia
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Recio Rodríguez M, Andreu-Vázquez C, Thuissard-Vasallo IJ, Cano Alonso R, Bermejo López C, Tamarit Degenhardt I, Martínez Ten P. Real-Life Diagnostic Accuracy of MRI in Prenatal Diagnosis. Radiol Res Pract 2020; 2020:4085349. [PMID: 33062332 PMCID: PMC7542514 DOI: 10.1155/2020/4085349] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 11/17/2022] Open
Abstract
There is some controversy about the value of fetal MRI in prenatal diagnosis, and most of the studies examine its accuracy in central nervous system (CNS) pathology. The objective of this retrospective study was to assess the diagnostic accuracy and usefulness of fetal MRI in the prenatal diagnosis of central nervous system (CNS) pathology and non-CNS pathology. Patients referred to the Radiology Department between 2007 and 2018 for a fetal MRI after detection of an anomaly in the fetal ultrasound, a high-risk pregnancy, or an inconclusive fetal ultrasound (n = 623) were included in the study. Postnatal diagnosis was used to assess the diagnostic accuracy of MRI. Fetal MRI was considered to provide additional information over fetal ultrasound when findings of the fetal MRI were not detected in the fetal ultrasound or when established a pathological condition that was not detected in the fetal ultrasound. Fetal MRI provided useful information for the perinatal management and prognosis over fetal ultrasound when findings of the fetal MRI changed the postnatal prognosis, leaded to the decision to legally terminate the pregnancy, changed prenatal or postnatal follow-up, or helped in the planning of prenatal or postnatal treatment. Fetal MRI offered an accurate diagnosis in 97% of cases (compared to 90.4% of fetal ultrasound; p < 0.001). Concordance between fetal ultrasound and fetal MRI was 92.1%. Fetal MRI provided additional information over fetal ultrasound in 23.1% of cases. In 11.6% of cases, the information was useful for the perinatal management and prognosis. In 45 cases (7.2%), fetal MRI was the only accurate diagnosis. In conclusion, fetal MRI has a superior diagnostic accuracy, especially in CNS pathology, and provides additional useful information in CNS, thoracic, and abdominal pathology.
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Affiliation(s)
- Manuel Recio Rodríguez
- Departamento de Diagnóstico por Imagen, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | - Cristina Andreu-Vázquez
- Departamento de Medicina, Facultad de Ciencias Biomédicas, Universidad Europea de Madrid, Madrid, Spain
| | | | - Raquel Cano Alonso
- Departamento de Diagnóstico por Imagen, Hospital Universitario Quironsalud Madrid, Madrid, Spain
| | | | - Ines Tamarit Degenhardt
- Departamento de Obstetricia y Ginecología, Hospital Universitario Quironsalud Madrid, Madrid, Spain
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Fetal brain age estimation and anomaly detection using attention-based deep ensembles with uncertainty. Neuroimage 2020; 223:117316. [PMID: 32890745 DOI: 10.1016/j.neuroimage.2020.117316] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 07/25/2020] [Accepted: 08/24/2020] [Indexed: 12/30/2022] Open
Abstract
MRI-based brain age prediction has been widely used to characterize normal brain development, and deviations from the typical developmental trajectory are indications of brain abnormalities. Age prediction of the fetal brain remains unexplored, although it can be of broad interest to prenatal examination given the limited diagnostic tools available for assessment of the fetal brain. In this work, we built an attention-based deep residual network based on routine clinical T2-weighted MR images of 659 fetal brains, which achieved an overall mean absolute error of 0.767 weeks and R2 of 0.920 in fetal brain age prediction. The predictive uncertainty and estimation confidence were simultaneously quantified from the network as markers for detecting fetal brain anomalies using an ensemble method. The novel markers overcame the limitations in conventional brain age estimation and demonstrated promising diagnostic power in differentiating several types of fetal abnormalities, including small head circumference, malformations and ventriculomegaly with the area under the curve of 0.90, 0.90 and 0.67, respectively. In addition, attention maps were derived from the network, which revealed regional features that contributed to fetal age estimation at each gestational stage. The proposed attention-based deep ensembles demonstrated superior performance in fetal brain age estimation and fetal anomaly detection, which has the potential to be translated to prenatal diagnosis in clinical practice.
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26
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Imaging diagnosis of ventriculomegaly: fetal, neonatal, and pediatric. Childs Nerv Syst 2020; 36:1669-1679. [PMID: 31624860 DOI: 10.1007/s00381-019-04365-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/02/2019] [Indexed: 10/25/2022]
Abstract
Ventriculomegaly is the term used to describe abnormal enlargement of ventricles in the brain. Neuroimaging, whether it is by ultrasound, computed tomography, or magnetic resonance imaging, is the key to its identification and can help to diagnose its cause and guide management in many cases. The implementation of the imaging modalities and potential differential considerations varies from the fetus, infant, and pediatric patient. Here we discuss how the imaging modalities can be used in these patient populations and review some of the differential considerations.
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Righini A, Genovese M, Parazzini C, Severino M, Scola E, Pinelli L, Conte G, Derrico I, Di Maurizio M, Talenti G, Mandefield L, Jarvis D, Palumbo G, Guerrini R, Rossi A, Triulzi F, Griffiths PD. Cortical formation abnormalities on foetal MR imaging: a proposed classification system trialled on 356 cases from Italian and UK centres. Eur Radiol 2020; 30:5250-5260. [PMID: 32405748 DOI: 10.1007/s00330-020-06899-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/03/2020] [Accepted: 04/15/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To formulate a classification system for foetal cortical formation abnormalities (CFAs) based on in utero magnetic resonance (iuMR) appearances and trial it in 356 cases. METHODS This retrospective study included all cases of foetal CFA diagnosed between 2000 and 2017 from seven centres in Italy and UK. All of the studies were reviewed by a panel of paediatric neuroradiologists experienced in iuMR with the aid of an algorithm designed to categorise the abnormalities. RESULTS Consensus expert review confirmed 356 foetuses with CFA and the first level of classification distinguished bilateral CFA (229/356-64%) from unilateral CFA (127/356-36%) cases with sub-classification of the bilateral cases into asymmetric (65/356-18%) and symmetric (164/356-46%) involvement. There was a statistically significant excess of foetuses with small head size, e.g. 17% of the cohort had a bi-parietal diameter < 3rd centile. There was a small but statistically significant excess of males in the cohort. Further categorisation was made on fine anatomical structure. CONCLUSIONS It is often not possible to classify foetal CFA using the principles and nomenclature used in paediatric neuroradiology. We have created a classification system for foetal CFA based on the analysis of 356 cases and believe that this will assist future research designed to correlate ante-natal and post-natal imaging features and understand the clinical sequelae of CFA described in utero. KEY POINTS • We describe a morphological classification system of foetal brain cortical formation abnormalities that can be used in clinical practice. • This classification system can be used in future research studies to evaluate the long-term imaging and clinical outcomes of foetal brain cortical formation abnormalities in 17- to 38-week gestational age range. • The practical value of the work is in providing a framework and language to look for imaging clues that may differentiate between different CFA in further studies.
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Affiliation(s)
- Andrea Righini
- Pediatric Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | - Maurilio Genovese
- Pediatric Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | - Cecilia Parazzini
- Pediatric Radiology and Neuroradiology Department, Children's Hospital V. Buzzi, Milan, Italy
| | - Mariasavina Severino
- Neuroradiology Department, IRCCS-Gaslini Children's Research Hospital, Genoa, Italy
| | - Elisa Scola
- Neuroradiology Department, IRCCS-Fondazione Policlinco di Milano, Milan, Italy
| | - Lorenzo Pinelli
- Neuroradiology Department, Spedali Civili, Piazzale Spedali Civili, 1, 25123, Brescia, Italy
| | - Giorgio Conte
- Neuroradiology Department, IRCCS-Fondazione Policlinco di Milano, Milan, Italy
| | - Ignazio Derrico
- Neuroradiology Department, University Hospital, Padua, Italy
| | | | - Giacomo Talenti
- Neuroradiology Department, University Hospital, Padua, Italy
| | - Laura Mandefield
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Deborah Jarvis
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
| | - Giovanni Palumbo
- Neuroradiology Department, Spedali Civili, Piazzale Spedali Civili, 1, 25123, Brescia, Italy.
| | - Renzo Guerrini
- Neuroscience Department, Children's Hospital Meyer, Florence, Italy
| | - Andrea Rossi
- Neuroradiology Department, IRCCS-Gaslini Children's Research Hospital, Genoa, Italy
| | - Fabio Triulzi
- Neuroradiology Department, IRCCS-Fondazione Policlinco di Milano, Milan, Italy
| | - Paul D Griffiths
- Academic Unit of Radiology, University of Sheffield, Sheffield, UK
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Fantasia I, Bussani R, Gregori M, Zennaro F, D'Ottavio G, Monasta L, Cortivo C, Quadrifoglio M, Maso G, Ricci G, Ottaviani C, Militello R, Stampalija T. Intrauterine versus post-mortem magnetic resonance in second trimester termination of pregnancy for central nervous system abnormalities. Eur J Obstet Gynecol Reprod Biol 2020; 250:31-35. [PMID: 32387889 DOI: 10.1016/j.ejogrb.2020.04.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Revised: 04/10/2020] [Accepted: 04/14/2020] [Indexed: 02/09/2023]
Abstract
OBJECTIVE To evaluate if limiting factors of intrauterine magnetic resonance imaging (iuMRI) performed in the early second trimester of pregnancy (19-23 weeks) affect its accuracy in comparison to post-mortem MRI (pmMRI) in fetuses that underwent termination of pregnancy (TOP) for central nervous system (CNS) defects. STUDY DESIGN This is a secondary analysis of a 10 years prospective observational study. Cases of TOP < 23 weeks for CNS malformation that had undergone neurosonography (NSG), iuMRI, pmMRI and autopsy were included. The agreement between iuMRI and pmMRI was calculated. The autopsy represented the gold-standard. RESULTS Overall, 143 TOPs for fetal congenital anomaly underwent the post-mortem diagnostic protocol. Of these, 31 cases underwent iuMRI and pmMRI for CNS abnormality. Three cases were excluded due to brain autolysis at autopsy. Corpus callosum defects were the most represented (16/28; 57 %). In only one case of posterior fossa defect, pmMRI identified the presence of vermian hypoplasia not diagnosed at iuMRI. In 2 cases (7%), iuMRI added clinically relevant additional findings to NSG, that were posteriorly confirmed by pmMRI. CONCLUSIONS The study shows that, at 19-23 weeks and for CNS defects, limiting factors that might influence the performance of iuMRI have little influence on iuMRI accuracy. This finding is particularly important for professionals who work in countries with legal bound for TOP in the early second trimester.
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Affiliation(s)
- Ilaria Fantasia
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy.
| | - Rossana Bussani
- Institute of Pathological Anatomy, Trieste University Hospital, Trieste, Italy
| | - Massimo Gregori
- Department of Pediatric Radiology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Floriana Zennaro
- Department of Pediatric Radiology, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Giuseppina D'Ottavio
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Lorenzo Monasta
- Clinical Epidemiology and Public Health Research Unit, Institute for Maternal and Child Health - IRCCS "Burlo Garofolo", Trieste, Italy
| | - Caterina Cortivo
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Mariachiara Quadrifoglio
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Gianpaolo Maso
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy
| | - Giuseppe Ricci
- Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Chiara Ottaviani
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
| | - Roberto Militello
- UOP Ostetricia e Ginecologia, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Tamara Stampalija
- Department of Obstetrics and Gynecology, Institute for Maternal and Child Health IRCCS "Burlo Garofolo", Trieste, Italy; Department of Medicine, Surgery and Health Sciences, University of Trieste, Trieste, Italy
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Abstract
OBJECTIVES To review the current imaging techniques available for the evaluation of the fetal brain. FINDINGS Ultrasound remains the initial screening modality with routine scanning typically performed at 18-20 weeks gestation. When a central nervous system (CNS) abnormality is noted by ultrasound, MRI is increasingly being used to further clarify findings. Fetal MRI has the unique ability to provide high detailed anatomical information of the entire human fetus with high contrast resolution. This technique has grown due to the development of rapid single shot image acquisition sequences, improvement of motion correction strategies and optimizing shimming techniques. CONCLUSIONS The assessment of fetal CNS anomalies continues to improve. Advanced MRI techniques have allowed for further delineation of CNS anomalies and have become a cornerstone in the assessment of fetal brain well-being. Those interpreting fetal studies need to be familiar with the strengths and limitations of each exam and be sensitive to the impact discussing findings can have regarding perinatal care and delivery planning. Collaboration with neurologists, neurosurgeons, geneticists, counselors, and maternal fetal specialists are key in providing the best care to the families we treat.
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Affiliation(s)
- Agustin M Cardenas
- Department of Radiology, Children's of Alabama University of Alabama at Birmingham
| | - Matthew T Whitehead
- Department of Radiology, Children's of Alabama University of Alabama at Birmingham
| | - Dorothy I Bulas
- Department of Radiology, Children's of Alabama University of Alabama at Birmingham; George Washington School of Medicine, Washington, DC.
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Diogo MC, Glatter S, Binder J, Kiss H, Prayer D. The MRI spectrum of congenital cytomegalovirus infection. Prenat Diagn 2020; 40:110-124. [PMID: 31802515 PMCID: PMC7027449 DOI: 10.1002/pd.5591] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2019] [Revised: 09/16/2019] [Accepted: 10/07/2019] [Indexed: 01/01/2023]
Abstract
Human cytomegalovirus (CMV) is an ubiquitous pathogen, with a high worldwide seroprevalence. When acquired in the prenatal period, congenital CMV (cCMV) is a major cause of neurodevelopmental sequelae and hearing loss. cCMV remains an underdiagnosed condition, with no systematic screening implemented in pregnancy or in the postnatal period. Therefore, imaging takes a prominent role in prenatal diagnosis of cCMV. With the prospect of new viable therapies, accurate and timely diagnosis becomes paramount, as well as identification of fetuses at risk for neurodevelopmental sequelae. Fetal magnetic resonance imaging (MRI) provides a complementary method to ultrasound (US) in fetal brain and body imaging. Anterior temporal lobe lesions are the most specific finding, and MRI is superior to US in their detection. Other findings such as ventriculomegaly, cortical malformations and calcifications, as well as hepatosplenomegaly, liver signal changes and abnormal effusions are unspecific. However, when seen in combination these should raise the suspicion of fetal infection, highlighting the need for a full fetal assessment. Still, some fetuses deemed normal on prenatal imaging are symptomatic at birth or develop delayed cCMV-associated symptoms, leaving room for improvement of diagnostic tools. Advanced MR sequences may help in this field and in determining prognosis, but further studies are needed.
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Affiliation(s)
- Mariana C. Diogo
- Department of Image Guided TherapyUniversity Clinic for Neuroradiology and Musculoskeletal Radiology, Medical University of ViennaViennaAustria
| | - Sarah Glatter
- Department of Image Guided TherapyUniversity Clinic for Neuroradiology and Musculoskeletal Radiology, Medical University of ViennaViennaAustria
- Department of Pediatrics and Adolescent MedicineMedical University of ViennaViennaAustria
| | - Julia Binder
- Department of Obstetrics and GynecologyMedical University of ViennaViennaAustria
| | - Herbert Kiss
- Department of Obstetrics and GynecologyMedical University of ViennaViennaAustria
| | - Daniela Prayer
- Department of Image Guided TherapyUniversity Clinic for Neuroradiology and Musculoskeletal Radiology, Medical University of ViennaViennaAustria
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Morphology and function: from fetal brain image to childhood outcomes. THE LANCET CHILD & ADOLESCENT HEALTH 2019; 4:95-96. [PMID: 31786092 DOI: 10.1016/s2352-4642(19)30387-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2019] [Accepted: 11/14/2019] [Indexed: 11/22/2022]
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Di Mascio D, Sileo FG, Khalil A, Rizzo G, Persico N, Brunelli R, Giancotti A, Panici PB, Acharya G, D'Antonio F. Role of magnetic resonance imaging in fetuses with mild or moderate ventriculomegaly in the era of fetal neurosonography: systematic review and meta-analysis. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2019; 54:164-171. [PMID: 30549340 DOI: 10.1002/uog.20197] [Citation(s) in RCA: 57] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 10/14/2018] [Accepted: 12/07/2018] [Indexed: 02/05/2023]
Abstract
OBJECTIVES To report the rate of additional central nervous system (CNS) anomalies detected exclusively on prenatal magnetic resonance imaging (MRI) in fetuses diagnosed with isolated mild or moderate ventriculomegaly (VM) on ultrasound, according to the type of ultrasound protocol adopted (dedicated neurosonography vs standard assessment of the fetal brain), and to explore whether the diagnostic performance of fetal MRI in detecting such anomalies is affected by gestational age at examination and laterality and degree of ventricular dilatation. METHODS MEDLINE, EMBASE, CINAHL and Clinicaltrials.gov were searched for studies reporting on the prenatal MRI assessment of fetuses diagnosed with isolated mild or moderate VM (ventricular dilatation of 10-15 mm) on ultrasound. Additional anomalies detected only on MRI were classified as callosal, septal, posterior fossa, white matter, intraventricular hemorrhage, cortical, periventricular heterotopia, periventricular cysts or complex malformations. The rate of additional anomalies was compared between fetuses diagnosed on dedicated neurosonography, defined as a detailed assessment of the fetal brain, according to the International Society of Ultrasound in Obstetrics and Gynecology guidelines, and those diagnosed on standard fetal brain assessment. The rate of additional CNS anomalies missed on prenatal MRI and detected only at birth was calculated and compared between fetuses that had early (at or before 24 weeks' gestation) and those that had late (after 24 weeks) MRI. Subanalysis was performed according to the laterality (uni- vs bilateral) and degree (mild vs moderate, defined as ventricular dilatation of 10-12 and 13-15 mm, respectively) of ventricular dilatation. Whether MRI assessment led to a significant change in prenatal management was explored. Random-effects meta-analysis of proportions was used. RESULTS Sixteen studies (1159 fetuses) were included in the systematic review. Overall, MRI detected an anomaly not identified on ultrasound in 10.0% (95% CI, 6.2-14.5%) of fetuses. However, when stratifying the analysis according to the type of ultrasound assessment, the rate of associated anomalies detected only on MRI was 5.0% (95% CI, 3.0-7.0%) when dedicated neurosonography was performed compared with 16.8% (95% CI, 8.3-27.6%) in cases that underwent a standard assessment of the fetal brain in the axial plane. The overall rate of an additional anomaly detected only at birth and missed on prenatal MRI was 0.9% (95% CI, 0.04-1.5%) (I2 , 0%). There was no difference in the rate of an associated anomaly detected only after birth when fetal MRI was carried out before, compared with after, 24 weeks of gestation (P = 0.265). The risk of detecting an associated CNS abnormality on MRI was higher in fetuses with moderate than in those with mild VM (odds ratio, 8.1 (95% CI, 2.3-29.0); P = 0.001), while there was no difference in those presenting with bilateral, compared with unilateral, dilatation (P = 0.333). Finally, a significant change in perinatal management, mainly termination of pregnancy owing to parental request, following MRI detection of an associated anomaly, was observed in 2.9% (95% CI, 0.01-9.8%) of fetuses undergoing dedicated neurosonography compared with 5.1% (95% CI, 3.2-7.5%) of those having standard assessment. CONCLUSIONS In fetuses undergoing dedicated neurosonography, the rate of a CNS anomaly detected exclusively on MRI is lower than that reported previously. Early MRI has an excellent diagnostic performance in identifying additional CNS anomalies, although the findings from this review suggest that MRI performed in the third trimester may be associated with a better detection rate for some types of anomaly, such as cortical, white matter and intracranial hemorrhagic anomalies. Copyright © 2018 ISUOG. Published by John Wiley & Sons Ltd.
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Affiliation(s)
- D Di Mascio
- Department of Gynecological-Obstetric and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - F G Sileo
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
| | - A Khalil
- Fetal Medicine Unit, St George's University Hospitals NHS Foundation Trust, University of London, London, UK
- Vascular Biology Research Centre, Molecular and Clinical Sciences Research Institute, St George's University of London, London, UK
| | - G Rizzo
- Division of Maternal and Fetal Medicine, Ospedale Cristo Re, University of Rome Tor Vergata, Rome, Italy
- Department of Obstetrics and Gynecology, The First I.M. Sechenov Moscow State Medical University, Moscow, Russia
| | - N Persico
- Department of Obstetrics and Gynecology 'L. Mangiagalli', Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Science and Community Health, University of Milan, Milan, Italy
| | - R Brunelli
- Department of Gynecological-Obstetric and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - A Giancotti
- Department of Gynecological-Obstetric and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - P B Panici
- Department of Gynecological-Obstetric and Urological Sciences, Sapienza University of Rome, Rome, Italy
| | - G Acharya
- Department of Clinical Science, Intervention and Technology, Karolinska Institute, Stockholm, Sweden
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
| | - F D'Antonio
- Women's Health and Perinatology Research Group, Department of Clinical Medicine, Faculty of Health Sciences, UiT - The Arctic University of Norway, Tromsø, Norway
- Department of Obstetrics and Gynecology, University Hospital of Northern Norway, Tromsø, Norway
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The rate of brain abnormalities on in utero MRI studies in fetuses with normal ultrasound examinations of the brain and calculation of indicators of diagnostic performance. Clin Radiol 2019; 74:527-533. [PMID: 30987757 DOI: 10.1016/j.crad.2019.03.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Accepted: 03/01/2019] [Indexed: 12/30/2022]
Abstract
AIM To estimate the rate of unexpected brain abnormalities detected by in utero magnetic resonance imaging (iuMRI) in fetuses without abnormalities at ultrasonography (USS). MATERIALS AND METHODS A prospective cohort study of pregnant women whose fetus had no structural brain (or body) abnormalities recognised on antenatal ultrasonography. Women were recruited from 12 centres across the UK and underwent iuMRI at 18 gestational weeks or more in the [blinded for review]. The imaging studies were reviewed by an experienced neuroradiologist. The positive and negative predictive values of both USS and iuMRI have been calculated by combining the results of this study with the results from the main [blinded for review] study. RESULTS One hundred and ninety-eight pregnant women were recruited and underwent iuMRI of 205 fetuses. Brain abnormalities were shown on iuMRI in two fetuses that were not recognised on USS (one case of a focal cortical abnormality and one case of mild ventriculomegaly). The negative predictive value for USS was 99.5% and 100% for iuMRI. CONCLUSIONS To the authors' knowledge, this is the first study comparing USS and iuMRI in low-risk pregnancies. USS has a comparatively high rule-out for fetal brain abnormalities and should remain the screening tool of choice.
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Prayer D, Paladini D, Deprest J. Current Controversies in Prenatal Diagnosis 1: Should MRI be performed on all fetuses with mild ventriculomegaly? Prenat Diagn 2019; 39:331-338. [PMID: 30614017 DOI: 10.1002/pd.5416] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Revised: 12/27/2018] [Accepted: 12/29/2018] [Indexed: 12/18/2022]
Abstract
A ventricular diameter of 10 mm correlates with more than two standard deviations of the normal and hence is qualified as ventriculomegaly. The relevance of this is dependent on whether there are associated infectious, genetic, or structural problems. The chance for neurodevelopmental delay in isolated ventriculomegaly less than 15 mm is 7.9% (4.7-11.1), and less if it is unilateral. It can be further divided in mild (10-12) or moderate (13-15), though this is not widely accepted. As part of the workup, structural assessment today may include ultrasound or magnetic resonance imaging, or both. Discussants agreed that the diagnostic performance of both methods is as good as the expertise with which the images are acquired and interpreted. Discussants agreed that when the initial neurosonogram is normal, the likelihood of finding significant findings on MRI is low. Nevertheless, some anomalies may only be picked up or better worked out by fetal MRI. In utero follow-up is advocated, as progression may indicate a poorer outcome, and some conditions are only obvious late in pregnancy. Most benefit for future patients is expected from appropriate training in prenatal neuroimaging.
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Affiliation(s)
- Daniela Prayer
- Department of Biomedical Imaging and Image-guided Therapy, Division of Neuroradiology and Musculoskeletal Radiology, Medical University of Vienna, Vienna, Austria
| | - Dario Paladini
- Fetal Medicine and Surgery Unit, Istituto G. Gaslini, Genoa, Italy
| | - Jan Deprest
- Clinical Department of Obstetrics and Gynaecology, University Hospitals Leuven, and Academic Development and Regeneration, Cluster Woman and Child, KU Leuven, Leuven, Belgium.,Institute for Women's Health, University College London, London, UK
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35
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van der Knoop BJ, Vermeulen RJ, Verbeke JIML, Pistorius LR, de Vries JIP. Fetal MRI, lower acceptance by women in research vs. clinical setting. J Perinat Med 2018; 46:983-990. [PMID: 29031020 DOI: 10.1515/jpm-2016-0360] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2016] [Accepted: 08/31/2017] [Indexed: 12/28/2022]
Abstract
AIM To determine acceptance of pregnant women to undergo fetal magnetic resonance imaging (MRI) examination in research and clinical setting. METHODS A prospective study included a research group [part of a study comparing brain ultrasound (US) to MRI in fetuses at risk for acquired brain damage] and a clinical group [fetuses with suspected (brain) anomalies after structural US examination] from 2011 to 2014. All women were advised to use sedatives. MRI declinations, use of sedation, MRI duration and imaging quality were compared between both groups. RESULTS Study participation was accepted in 57/104 (55%) research cases. Fetal MRI was performed in 34/104 (33%) research and 43/44 (98%) clinical cases. Reasons to decline study participation were MRI related in 41%, and participation was too burdensome in 46%. Acceptance was highest for indication infection and lowest in alloimmune thrombocytopenia and monochorionic twin pregnancy. Sedatives were used in 14/34 research and 43/43 clinical cases. Scan duration and quality were comparable (21 and 20 min in research and clinical cases, respectively, moderate/good quality in both groups). CONCLUSIONS Pregnant women consider MRI more burdensome than professionals realize. Two-third of women at risk for fetal brain damage decline MRI examination. Future studies should evaluate which information about fetal MRI is supportive.
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Affiliation(s)
- Bloeme J van der Knoop
- Department of Obstetrics and Gynaecology, VU University Medical Center, P.O. Box 7057, 1007 MB Amsterdam, The Netherlands, Tel.: +31 (0) 20 4443239 or +31 (0) 20 4444444, pager 6112, Fax: +31 (0) 20 4443333.,Neuroscience Campus, VU University, Amsterdam, The Netherlands
| | - Roland J Vermeulen
- Department of Child Neurology, VU University Medical Center, P.O. Box 7057,1007 MB Amsterdam, TheNetherlands
| | - Jonathan I M L Verbeke
- Department of Pediatric Radiology, VU University Medical Center, P.O. Box 7057,1007 MB Amsterdam, TheNetherlands
| | - Lourens R Pistorius
- Department of Obstetrics and Gynaecology, University Medical Center Utrecht, Utrecht, TheNetherlands
| | - Johanna I P de Vries
- Department of Obstetrics and Gynaecology, VU University Medical Center, P.O. Box 7057,1007 MB Amsterdam, TheNetherlands.,Research Institute MOVE, VU University, Amsterdam, TheNetherlands
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Fishel-Bartal M, Watad H, Hoffmann C, Achiron R, Barzilay E, Katorza E. Fetal brain MRI in polyhydramnios: is it justified? J Matern Fetal Neonatal Med 2018; 32:3986-3992. [PMID: 29865922 DOI: 10.1080/14767058.2018.1480605] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Introduction: Despite meticulous investigation of polyhydramnios cases, in many of these cases, congenital anomalies are detected only after birth. The aim of our study was to explore the contribution of fetal brain MRI to the detection of CNS anomalies in cases of polyhydramnios. Materials and methods: This was retrospective cohort study on fetuses referred for the investigation of polyhydramnios at a single tertiary center. All fetuses underwent a detailed sonographic anatomical scan and a fetal brain MRI. Isolated and nonisolated polyhydramnios were differentiated according to associated anomalies. MRI findings were compared between the groups. Results: A total of 46 fetuses were included in the study. Brain anomalies were detected in ultrasound in 12 (26%) cases while MRI detected brain anomalies in 23 (50%) cases. MRI detected more anomalies in fetuses with nonisolated compared to isolated polyhydramnios (62.9% and 31.6%, respectively, p = .019). Conclusions: Fetal brain MRI may contribute to the evaluation of fetuses with polyhydramnios. The clinical value and cost-effectiveness of MRI use in the routine work-up of polyhydramnios should be assessed in future studies.
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Affiliation(s)
- Michal Fishel-Bartal
- Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Hadel Watad
- Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Chen Hoffmann
- Diagnostic Radiology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Reuven Achiron
- Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Eran Barzilay
- Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
| | - Eldad Katorza
- Antenatal Diagnostic Unit, Department of Obstetrics and Gynecology, Chaim Sheba Medical Center, Tel Hashomer, Sackler School of Medicine, Tel Aviv University , Tel Aviv , Israel
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Aboutanos SZ, McAndrew K, Unkle J, Wornom IL. Pontine Tegmental Cap Dysplasia and Challenges in Facial Reconstructive Surgery. Cleft Palate Craniofac J 2018; 55:127-131. [PMID: 34162062 DOI: 10.1177/1055665617721924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Pontine tegmental cap dysplasia (PTCD) is a rare condition that affects the brain stem and multiple cranial nerves, which can result in bilateral facial palsies, hearing loss, bilateral trigeminal nerve dysfunction, oculomotor apraxia, feeding difficulties, seizures, hypotonia, and undeveloped speech. We document a case in which a patient with PTCD presents with a challenging lip deformity and requires multidisciplinary treatment to improve reconstructive surgical success and treatment outcomes. An extensive literature review was conducted. This report serves to increase awareness of PTCD and the need for multidisciplinary teams to participate in reconstruction of facial defects in a complex medical setting.
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Affiliation(s)
| | - Karen McAndrew
- The Cleft and Craniofacial Team at St. Mary's, Richmond, VA, USA
| | - John Unkle
- The Cleft and Craniofacial Team at St. Mary's, Richmond, VA, USA
| | - Isaac L Wornom
- The Cleft and Craniofacial Team at St. Mary's, Richmond, VA, USA
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Trevathan E. Editorial brain malformation surveillance in the Zika era. ACTA ACUST UNITED AC 2017; 106:869-874. [PMID: 27891785 PMCID: PMC5132043 DOI: 10.1002/bdra.23582] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 09/26/2016] [Accepted: 09/27/2016] [Indexed: 12/19/2022]
Abstract
The current surveillance systems for congenital microcephaly are necessary to monitor the impact of Zika virus (ZIKV) on the developing human brain, as well as the ZIKV prevention efforts. However, these congenital microcephaly surveillance systems are insufficient. Abnormalities of neuronal differentiation, development and migration may occur among infants with normal head circumference who have intrauterine exposure to ZIKV. Therefore, surveillance for congenital microcephaly does not ascertain many of the infants seriously impacted by congenital ZIKV infection. Furthermore, many infants with normal head circumference and with malformations of the brain cortex do not have clinical manifestations of their congenital malformations until several months to many years after birth, when they present with clinical manifestations such as seizures/epilepsy, developmental delays with or without developmental regression, and/or motor impairment. In response to the ZIKV threat, public health surveillance systems must be enhanced to ascertain a wide variety of congenital brain malformations, as well as their clinical manifestations that lead to diagnostic brain imaging. Birth Defects Research (Part A) 106:869–874, 2016. © 2016 The Authors Birth Defects Research Part A: Clinical and Molecular Teratology Published by Wiley Periodicals, Inc.
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Affiliation(s)
- Edwin Trevathan
- The Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt Institute for Global Health, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.,The Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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40
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Manganaro L, Bernardo S, Antonelli A, Vinci V, Saldari M, Catalano C. Fetal MRI of the central nervous system: State-of-the-art. Eur J Radiol 2017; 93:273-283. [PMID: 28668426 DOI: 10.1016/j.ejrad.2017.06.004] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2016] [Revised: 05/31/2017] [Accepted: 06/05/2017] [Indexed: 12/17/2022]
Abstract
Prenatal ultrasonographic (US) examination is considered as the first tool in the assessment of fetal abnormalities. However, several large-scale studies point out that some malformations, in particular central nervous system (CNS) anomalies, are not well characterized through US. Therefore, the actual malformation severity is not always related to prenatal ultrasound (US) findings. Over the past 20 years, ultrafast Magnetic Resonance Imaging (MRI) has progressively increased as a prenatal 3rd level diagnostic technique with a good sensitivity, particularly for the study of fetal CNS malformations. In fact, CNS anomalies are the most common clinical indications for fetal MRI, representing about 80% of the total examinations. This review covers the recent literature on fetal brain MRI, with emphasis on techniques, safety and indications.
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Affiliation(s)
- Lucia Manganaro
- Department of Radiology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Silvia Bernardo
- Department of Radiology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Amanda Antonelli
- Department of Radiology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Valeria Vinci
- Department of Radiology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Matteo Saldari
- Department of Radiology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
| | - Carlo Catalano
- Department of Radiology, Sapienza University of Rome, Viale Regina Elena 324, 00161, Rome, Italy.
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Rethmann C, Scheer I, Meuli M, Mazzone L, Moehrlen U, Kellenberger CJ. Evolution of posterior fossa and brain morphology after in utero repair of open neural tube defects assessed by MRI. Eur Radiol 2017; 27:4571-4580. [DOI: 10.1007/s00330-017-4807-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2016] [Revised: 02/23/2017] [Accepted: 03/13/2017] [Indexed: 11/29/2022]
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Wilson RD. Anomalies fœtales affectant le tube neural : Dépistage / diagnostic prénatal et prise en charge de la grossesse. JOURNAL OF OBSTETRICS AND GYNAECOLOGY CANADA 2017; 38:S496-S511. [PMID: 28063560 DOI: 10.1016/j.jogc.2016.09.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Telencephalic Flexure and Malformations of the Lateral Cerebral (Sylvian) Fissure. Pediatr Neurol 2016; 63:23-38. [PMID: 27590993 DOI: 10.1016/j.pediatrneurol.2016.05.005] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2015] [Accepted: 05/04/2016] [Indexed: 11/20/2022]
Abstract
After sagittal division of the prosencephalon at 4.5 weeks of gestation, the early fetal cerebral hemisphere bends or rotates posteroventrally from seven weeks of gestation. The posterior pole of the telencephalon thus becomes not the occipital but the temporal lobe as the telencephalic flexure forms the operculum and finally the lateral cerebral or Sylvian fissure. The ventral part is infolded to become the insula. The frontal and temporal lips of the Sylvian fissure, as well as the insula, all derive from the ventral margin of the primitive telencephalon, hence may be influenced by genetic mutations with a ventrodorsal gradient of expression. The telencephalic flexure also contributes to a shift of the hippocampus from a dorsal to a ventral position, the early rostral pole of the hippocampus becoming caudal and dorsal becoming ventral. The occipital horn is the most recent recess of the lateral ventricle, hence most vulnerable to anatomic variations that affect the calcarine fissure. Many major malformations include lack of telencephalic flexure (holoprosencephaly, extreme micrencephaly) or dysplastic Sylvian fissure (lissencephalies, hemimegalencephaly, schizencephaly). Although fissures and sulci are genetically programmed, mechanical forces of growth and volume expansion are proposed to be mainly extrinsic (including ventricles) for fissures and intrinsic for sulci. In fetal hydrocephalus, the telencephalic flexure is less affected because ventricular dilatation occurs later in gestation. Flexures can be detected prenatally by ultrasound and fetal magnetic resonance imaging and should be described neuropathologically in cerebral malformations.
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Sefidbakht S, Dehghani S, Safari M, Vafaei H, Kasraeian M. Fetal Central Nervous System Anomalies Detected by Magnetic Resonance Imaging: A Two-Year Experience. IRANIAN JOURNAL OF PEDIATRICS 2016; 26:e4589. [PMID: 27729957 PMCID: PMC5046157 DOI: 10.5812/ijp.4589] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2015] [Revised: 02/18/2016] [Accepted: 03/12/2016] [Indexed: 12/28/2022]
Abstract
BACKGROUND Magnetic resonance imaging (MRI) is gradually becoming more common for thorough visualization of the fetus than ultrasound (US), especially for neurological anomalies, which are the most common indications for fetal MRI and are a matter of concern for both families and society. OBJECTIVES We investigated fetal MRIs carried out in our center for frequency of central nervous system anomalies. This is the first such report in southern Iran. MATERIALS AND METHODS One hundred and seven (107) pregnant women with suspicious fetal anomalies in prenatal ultrasound entered a cross-sectional retrospective study from 2011 to 2013. A 1.5 T Siemens Avanto scanner was employed for sequences, including T2 HASTE and Trufisp images in axial, coronal, and sagittal planes to mother's body, T2 HASTE and Trufisp relative to the specific fetal body part being evaluated, and T1 flash images in at least one plane based on clinical indication. We investigated any abnormality in the central nervous system and performed descriptive analysis to achieve index of frequency. RESULTS Mean gestational age ± standard deviation (SD) for fetuses was 25.54 ± 5.22 weeks, and mean maternal age ± SD was 28.38 ± 5.80 years Eighty out of 107 (74.7%) patients who were referred with initial impression of borderline ventriculomegaly. A total of 18 out of 107 (16.82%) patients were found to have fetuses with CNS anomalies and the remainder were neurologically normal. Detected anomalies were as follow: 3 (16.6%) fetuses each had the Dandy-Walker variant and Arnold-Chiari II (with myelomeningocele). Complete agenesis of corpus callosum, partial agenesis of corpus callosum, and aqueductal stenosis were each seen in 2 (11.1%) fetuses. Arnold-Chiari II without myelomeningocele, anterior spina bifida associated with neurenteric cyst, arachnoid cyst, lissencephaly, and isolated enlarged cisterna magna each presented in one (5.5%) fetus. One fetus had concomitant schizencephaly and complete agenesis of the corpus callosum. CONCLUSIONS MRI is superior to ultrasound and physical exam of live births in detection of CNS anomalies. In this investigation within a single referral center in southern Iran, anomalies included Dandy-Walker variant and Arnold-Chiari II as the most common findings. Other findings with lower incidence were complete and partial agenesis of corpus callosum, aqueductal stenosis, anterior spina bifida, schizencephaly, arachnoid cyst, lissencephaly, and isolated enlarged cisterna magna.
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Affiliation(s)
- Sepideh Sefidbakht
- Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Sakineh Dehghani
- Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
- Corresponding author: Sakineh Dehghani, Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran. Tel: +98-9171076240, Fax: +98-7136474329, E-mail:
| | - Maryam Safari
- Imaging Research Center, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Homeira Vafaei
- Department of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, IR Iran
| | - Maryam Kasraeian
- Department of Obstetrics and Gynecology, Shiraz University of Medical Sciences, Shiraz, IR Iran
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Bekiesinska-Figatowska M, Romaniuk-Doroszewska A, Duczkowska A, Duczkowski M, Iwanowska B, Szkudlińska-Pawlak S. Fetal MRI versus postnatal imaging in the MR-compatible incubator. Radiol Med 2016; 121:719-28. [PMID: 27255502 PMCID: PMC4989009 DOI: 10.1007/s11547-016-0649-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2016] [Accepted: 05/09/2016] [Indexed: 12/28/2022]
Abstract
Introduction One of the aims of fetal magnetic resonance imaging (MRI) is to avoid postnatal scanning. However, clinicians sometimes wish to have postnatal confirmation of prenatal findings. This study’s purpose was to check whether there was indeed the added value of neonatal MRI performed in the MR-compatible incubator (INC) after fetal examination. Materials and methods Material consists of 25 neonates (14 girls) who underwent prenatal and postnatal MRI in a 1.5 T scanner, the latter in INC. Mean time of prenatal MRI was 30th gestational week, of postnatal MRI—16th day of life. Results In 14 cases (56 %) postnatal findings were the same as prenatal ones. In 11 (44 %) postnatal MRI showed some different/new/more precise results, in two the differences were attributed to other factors than the advantage of postnatal MRI over prenatal one. Altogether then postnatal results were partly discordant with prenatal ones in 9/25 cases (36 %). Conclusions In most cases there was no added value of postnatal MRI as compared to prenatal one. This value lied in small details that could not have been noticed on prenatal MRI or required contrast medium administration to be noticed. On the other hand, MR examination performed with use of the dedicated neonatal coils in the MR-compatible incubator is a safe and reliable method of visualization of these small details with better spatial resolution thus helping to establish final diagnosis, treatment plan and prognosis.
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Affiliation(s)
| | - Anna Romaniuk-Doroszewska
- Department of Diagnostic Imaging, Institute of Mother and Child, ul. Kasprzaka 17a, 01-211, Warsaw, Poland
| | - Agnieszka Duczkowska
- Department of Diagnostic Imaging, Institute of Mother and Child, ul. Kasprzaka 17a, 01-211, Warsaw, Poland
| | - Marek Duczkowski
- Department of Diagnostic Imaging, Institute of Mother and Child, ul. Kasprzaka 17a, 01-211, Warsaw, Poland
| | - Beata Iwanowska
- Department of Diagnostic Imaging, Institute of Mother and Child, ul. Kasprzaka 17a, 01-211, Warsaw, Poland
| | - Sylwia Szkudlińska-Pawlak
- Department of Diagnostic Imaging, Institute of Mother and Child, ul. Kasprzaka 17a, 01-211, Warsaw, Poland
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Rehder R, Yang E, Cohen AR. Variation of the slope of the tentorium during childhood. Childs Nerv Syst 2016; 32:441-50. [PMID: 26362679 DOI: 10.1007/s00381-015-2899-8] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/01/2015] [Indexed: 01/17/2023]
Abstract
BACKGROUND AND PURPOSE Neural structures in the posterior fossa grow at different rates during development. While there are computationally intensive approaches to analyze growth of the cerebellum and brainstem, there is a paucity of information about summary measures of normal posterior fossa development suitable for real-time clinical use. The present study investigates changes in the trajectory of the tentorium as measured by the occipital and tentorial angles at different stages of development. METHODS A retrospective study was conducted drawing from a Boston Children's Hospital database of over 1500 magnetic resonance imaging (MRI) studies. The imaging study population included fetuses older than 20 gestational weeks and children between the ages of 0 and 10 years. Two parameters were measured for all subjects: (1) the tentorial angle (the angle between the tentorium and a line from the internal occipital protuberance to the tuberculum sellae) and (2) the occipital angle (the angle between the tentorium and a line from the internal occipital protuberance to the opisthion). Descriptive statistics were used to analyze the study cohort. RESULTS We reviewed 1510 brain MRI studies, and 367 studies met the inclusion criteria (125 fetal and 242 postnatal studies). During fetal development, the inclination of the tentorium showed an ascending course, while it plateaus after birth. CONCLUSIONS During the second and third trimesters, the tentorial and occipital angles steadily increase reflecting the dynamic growth of the posterior fossa structures. Postnatally, the tentorial angle decreases and the tentorium slopes downward and plateaus, possibly due to stabilization of posterior fossa development and ongoing growth of the cerebrum. Together, these findings suggest that the tentorial angle can serve as an imaging biomarker of posterior fossa development during the second half of fetal life.
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Affiliation(s)
- Roberta Rehder
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA
| | - Edward Yang
- Department of Radiology, Boston Children's Hospital, Harvard Medical School, Boston, MA, USA
| | - Alan R Cohen
- Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, 300 Longwood Avenue, Boston, MA, 02115, USA.
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Conte G, Parazzini C, Falanga G, Cesaretti C, Izzo G, Rustico M, Righini A. Diagnostic Value of Prenatal MR Imaging in the Detection of Brain Malformations in Fetuses before the 26th Week of Gestational Age. AJNR Am J Neuroradiol 2015; 37:946-51. [PMID: 26721771 DOI: 10.3174/ajnr.a4639] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2015] [Accepted: 11/05/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE In several countries, laws and regulations allow abortion for medical reasons within 24-25 weeks of gestational age. We investigated the diagnostic value of prenatal MR imaging for brain malformations within 25 weeks of gestational age. MATERIALS AND METHODS We retrospectively included fetuses within 25 weeks of gestational age who had undergone both prenatal and postnatal MR imaging of the brain between 2002 and 2014. Two senior pediatric neuroradiologists evaluated prenatal MR imaging examinations blinded to postnatal MR imaging findings. With postnatal MR imaging used as the reference standard, we calculated the sensitivity, specificity, positive predictive value, and negative predictive value of the prenatal MR imaging in detecting brain malformations. RESULTS One-hundred nine fetuses (median gestational age at prenatal MR imaging: 22 weeks; range, 21-25 weeks) were included in this study. According to the reference standard, 111 malformations were detected. Prenatal MR imaging failed to detect correctly 11 of the 111 malformations: 3 midline malformations, 5 disorders of cortical development, 2 posterior fossa anomalies, and 1 vascular malformation. Prenatal MR imaging misdiagnosed 3 findings as pathologic in the posterior fossa. CONCLUSIONS The diagnostic value of prenatal MR imaging between 21 and 25 weeks' gestational age is very high, with limitations of sensitivity regarding the detection of disorders of cortical development.
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Affiliation(s)
- G Conte
- From the Departments of Radiology and Neuroradiology (G.C., C.P., C.C., G.I., A.R.) Department of Health Sciences (G.C.), University of Milan, Milan, Italy
| | - C Parazzini
- From the Departments of Radiology and Neuroradiology (G.C., C.P., C.C., G.I., A.R.)
| | - G Falanga
- Department of Biopathology and Medical and Forensic Biotechnologies (G.F.), Section of Radiological Sciences, University of Palermo, Palermo, Italy
| | - C Cesaretti
- From the Departments of Radiology and Neuroradiology (G.C., C.P., C.C., G.I., A.R.)
| | - G Izzo
- From the Departments of Radiology and Neuroradiology (G.C., C.P., C.C., G.I., A.R.)
| | - M Rustico
- Gynecology and Obstetrics (M.R.), Children's Hospital Vittore Buzzi, Milan, Italy
| | - A Righini
- From the Departments of Radiology and Neuroradiology (G.C., C.P., C.C., G.I., A.R.)
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Nagaraj UD, Peiro JL, Bierbrauer KS, Kline-Fath BM. Evaluation of Subependymal Gray Matter Heterotopias on Fetal MRI. AJNR Am J Neuroradiol 2015; 37:720-5. [PMID: 26585262 DOI: 10.3174/ajnr.a4585] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Accepted: 09/08/2015] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND PURPOSE Subependymal grey matter heterotopias are seen in a high proportion of children with Chiari II malformation and are potentially clinically relevant. However, despite its growing use, there is little in the literature describing its detection on fetal MRI. Our aim was to evaluate the accuracy in diagnosing subependymal gray matter heterotopias in fetuses with spinal dysraphism on fetal MR imaging. MATERIALS AND METHODS This study is a retrospective analysis of 203 fetal MRIs performed at a single institution for spinal dysraphism during a 10-year period. Corresponding obstetric sonography, postnatal imaging, and clinical/operative reports were reviewed. RESULTS Of the fetal MRIs reviewed, 95 fetuses were included in our analysis; 23.2% (22/95) were suspected of having subependymal gray matter heterotopias on fetal MR imaging prospectively. However, only 50% (11/22) of these cases were confirmed on postnatal brain MR imaging. On postnatal brain MR imaging, 28.4% (27/95) demonstrated imaging findings consistent with subependymal gray matter heterotopia. Only 40.7% (11/27) of these cases were prospectively diagnosed on fetal MR imaging. CONCLUSIONS Fetal MR imaging is limited in its ability to identify subependymal gray matter heterotopias in fetuses with spinal dysraphism. It is believed that this limitation relates to a combination of factors, including artifacts from fetal motion, the very small size of fetal neuroanatomy, differences in imaging techniques, and, possibly, irregularity related to denudation of the ependyma/subependyma in the presence of spinal dysraphism and/or stretching of the germinal matrix in ventriculomegaly.
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Affiliation(s)
- U D Nagaraj
- From the Departments of Radiology and Medical Imaging (U.D.N., B.M.K.-F) University of Cincinnati College of Medicine (U.D.N., J.L.P., K.S.B., B.M.K.-F), Cincinnati, Ohio.
| | - J L Peiro
- Pediatric Surgery (J.L.P.) University of Cincinnati College of Medicine (U.D.N., J.L.P., K.S.B., B.M.K.-F), Cincinnati, Ohio
| | - K S Bierbrauer
- Pediatric Neurosurgery (K.S.B.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio University of Cincinnati College of Medicine (U.D.N., J.L.P., K.S.B., B.M.K.-F), Cincinnati, Ohio
| | - B M Kline-Fath
- From the Departments of Radiology and Medical Imaging (U.D.N., B.M.K.-F) University of Cincinnati College of Medicine (U.D.N., J.L.P., K.S.B., B.M.K.-F), Cincinnati, Ohio
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Tosello B, Brévaut-Malaty V, Chaumoître K, Gire C. A case of Norman-Roberts syndrome identified from postnatal diagnosis of microlissencephaly. Fetal Pediatr Pathol 2015; 34:197-201. [PMID: 25927602 DOI: 10.3109/15513815.2015.1031414] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Lissencephaly is a rare brain malformation. What differentiates microlissencephaly from classical lissencephaly and other variants is the presence of severe microcephaly. Very few postnatal cases of Norman-Roberts syndrome are described in the literature. We report a case of microlissencephaly with a polymalformative syndrome that prompted postnatal diagnosis of Norman-Roberts syndrome.
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Affiliation(s)
- Barthélémy Tosello
- Department of Neonatology, Assistance Publique-Hôpitaux de Marseille, North University Hospital , Marseille , France
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50
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Teixeira SR, Blondiaux E, Cassart M, Couture A, Moutard ML, Whalen S, Gelot A, Ducou le Pointe H, Garel C. Association of periventricular nodular heterotopia with posterior fossa cyst: a prenatal case series. Prenat Diagn 2015; 35:337-41. [DOI: 10.1002/pd.4543] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Revised: 10/20/2014] [Accepted: 12/01/2014] [Indexed: 12/22/2022]
Affiliation(s)
- Sara R. Teixeira
- Service de Radiologie; Hôpital d'Enfants Armand-Trousseau-Hôpitaux Universitaires de l'Est Parisien (APHP), Université Pierre et Marie Curie; Paris VI France
| | - Eléonore Blondiaux
- Service de Radiologie; Hôpital d'Enfants Armand-Trousseau-Hôpitaux Universitaires de l'Est Parisien (APHP), Université Pierre et Marie Curie; Paris VI France
| | - Marie Cassart
- Service d'Imagerie Médicale; Hôpital d'Ixelles-Etterbeek; Bruxelles Belgium
| | - Alain Couture
- Service de Radiopédiatrie; Hôpital Arnaud de Villeneuve; Montpellier France
| | - Marie-Laure Moutard
- Service de Neurologie Pédiatrique; Hôpital d'Enfants Armand-Trousseau; Paris France
| | - Sandra Whalen
- Service de Génétique Médicale, Hôpital de la Pitié-Salpétrière; Université Pierre et Marie Curie; Paris VI France
| | - Antoinette Gelot
- Unité de Neuropathologie, Service d'anatomo-pathologie, Hôpital d'Enfants Armand-Trousseau; APHP, Université Pierre et Marie Curie; Paris VI France
| | - Hubert Ducou le Pointe
- Service de Radiologie; Hôpital d'Enfants Armand-Trousseau-Hôpitaux Universitaires de l'Est Parisien (APHP), Université Pierre et Marie Curie; Paris VI France
| | - Catherine Garel
- Service de Radiologie; Hôpital d'Enfants Armand-Trousseau-Hôpitaux Universitaires de l'Est Parisien (APHP), Université Pierre et Marie Curie; Paris VI France
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