Ultrasound

Ultrasound
Examination
Examination
of
of
the Fetal Brain
the Fetal Brain
Riga, December 2009
Riga, December 2009
What
What
I have to see in a routine
I have to see in a routine
examination ?
examination ?
Recognise normal as a normal
Recognise normal as a normal
Recognise abnormal as abnormal
Recognise abnormal as abnormal
Try to get right diagnosis
Try to get right diagnosis
B1
Slide 2
B1
BIE; 07.12.2009.
What you see is what you get
REMEMBER
REMEMBER
Measure BPD and HC at the level of
Measure BPD and HC at the level of
thalami and Cavum septi pellucidi (CSP).
thalami and Cavum septi pellucidi (CSP).
HC
HC
-
-
less affected by skull shape!!
less affected by skull shape!!
Cavum septi pelucidi
Anterior horn
Choroid plexus
Normal lateral ventricles < 10 mm
Thalamus
cerebellum
CM
Normal cisterna magna < 10 mm
cerebellum
Cisterna magna
CAVE: Oblique imaging simulates posterior fossa abnormalities!
REMEMBER
REMEMBER
Be aware diagnosing Dandy Walker
Be aware diagnosing Dandy Walker
malformation before vermis is fully formed
malformation before vermis is fully formed
( 18 weeks) !!
( 18 weeks) !!
CCA
CCA
Basic Examniation Checklist
Basic Examniation Checklist
Head + Neck Head + Neck
Midline & Falx Midline & Falx
Cavum septi pellucidi Cavum septi pellucidi
Lateral cerebral ventricls Lateral cerebral ventricls
Choroid Plexus Choroid Plexus
Cerebellum Cerebellum
Cisterna magna Cisterna magna
Examination of the spine
Examination of the spine
Sagital
Sagital
Transversal
Transversal
Frontal View
Frontal View

Skin echo above the spine
Skin echo above the spine

Vertebral morphologie
Vertebral morphologie

Spinal axis
Spinal axis

Movements of the spine
Movements of the spine

Fetal Brain
Fetal Brain
Patological Findings of
Patological Findings of
the fetal Brain
the fetal Brain
T.Reihs
T.Reihs
HC ~ 24 weeks!!, ventriculomegaly
25-years 1G 0P , 33 weeks
Microcephaly
Microcephaly
HC > 2
HC > 2
-
-
3 SD below the mean HC for GA
3 SD below the mean HC for GA
Clinical Issues
Clinical Issues

33%
33%
-
-
62% moderate / severe mental retardation
62% moderate / severe mental retardation
Imaging Findings
Imaging Findings

Sloping forhead
Sloping forhead

Ventriculomegaly
Ventriculomegaly

Associated brain anomalies 67%
Associated brain anomalies 67%

Consider fetal MR!!! DD. : Craniosynostosis
Consider fetal MR!!! DD. : Craniosynostosis
14 +4 weeks
Exencephaly, Anencephaly
Exencephaly, Anencephaly
Cranial defect covered by Cranial defect covered by
angiomatous stroma angiomatous stroma
CRL CRL- -less than expected less than expected
Polyhidramnios common Polyhidramnios common
AF echogenic due to AF echogenic due to
disolved neural tissue disolved neural tissue
Chiari Malformation
Chiari Malformation
Chiari Malformation
Chiari Malformation
Clinical Issues Clinical Issues
AFP, AFP,
High morbidity &mortality High morbidity &mortality
4%aneuploidy rate 4%aneuploidy rate
CS at delivery term CS at delivery term
80% need ventriculoperitoneal 80% need ventriculoperitoneal
shunt shunt
Can reverse with in utero surgery Can reverse with in utero surgery
Preventive threatment with folic Preventive threatment with folic
acid acid
Imaging Findings Imaging Findings
Posterior fossa Posterior fossa banana banana
sign sign
Calvarial lemon sign Calvarial lemon sign
Ventruculomegaly Ventruculomegaly
CM obliteration CM obliteration
Head normal or small Head normal or small
Diagnostic Checklist Diagnostic Checklist
Amniocentesis Amniocentesis
Cranial findings easier to Cranial findings easier to
see than ONTD see than ONTD
Compressed CM may be Compressed CM may be
only finding!! only finding!!
Spina bifida
Spina bifida
Clinical issues:AFP Clinical issues:AFP
Imaging Findings Imaging Findings
Spleyed dorsal osification centers Spleyed dorsal osification centers
MMC sack MMC sack
73% lumbar, 80% with overlaying 73% lumbar, 80% with overlaying
sac sac
Transverse view best for seeing Transverse view best for seeing
bony defect bony defect
99% Chiari II Malformaition 99% Chiari II Malformaition
24% clubfoot 24% clubfoot
40%additional anomalies 40%additional anomalies
Diagnostic Checklist Diagnostic Checklist
Amniocentesis Amniocentesis
Cisterna magna entlarged? Cisterna magna entlarged?
Cranial markers? Cranial markers?
Level of defect? Level of defect?
Mild ventriculomegaly
Mild ventriculomegaly
Imaging Findings
Imaging Findings
Lateral ventricle 10 Lateral ventricle 10- -12 mm 12 mm
Internal wall to wall measurement Internal wall to wall measurement
30% resolve in utero 30% resolve in utero
Rearly unilateral Rearly unilateral
Diagnostic Checklist
Diagnostic Checklist
Idiopathic MV is a diagnosis of Idiopathic MV is a diagnosis of
exclusion exclusion
Amniocentesis Amniocentesis
Maternal infection screening Maternal infection screening
Fetal MR Fetal MR
Hydrocephalus , T 21
Hydrocephalus , T 21
Hydrancephaly
Hydrancephaly
Hydranencephaly
Hydranencephaly
Compleet destruction of the Compleet destruction of the
cerebral hemispheres cerebral hemispheres
Falx present Falx present
Normal posterior fossa Normal posterior fossa
Fluid filled supratentorial Fluid filled supratentorial
space space
85%mortality by the first year 85%mortality by the first year
Misdaignosed as Misdaignosed as
hydrocephalus hydrocephalus
Fetal MR to evaluate Fetal MR to evaluate
presence of cortical mantle presence of cortical mantle
CAVE: Circle of villis intact CAVE: Circle of villis intact
in hydrocephalus!! in hydrocephalus!!
Dr. Pons
Occipital Encephalocele
Occipital Encephalocele
Imaging Findings Imaging Findings
Herniated brain tissue Herniated brain tissue
cyst within the cyst cyst within the cyst
Ventriculomegaly 70 Ventriculomegaly 70- -
80% 80%
Microcephaly 25% Microcephaly 25%
Polyhydramnios Polyhydramnios
Oligohydramnios Oligohydramnios
CAVE: CAVE:
Associated with multiple Associated with multiple
syndroms ( Meckel syndroms ( Meckel- - Gruber ) Gruber )
Holoprosencephaly
Holoprosencephaly
Pilu
Imaging Findings
Imaging Findings
Absent Absent butterfly butterfly sign sign
Single ventricle Single ventricle
Absent midline structures Absent midline structures
CSP CSP
Falx Falx
3rd ventricle 3rd ventricle
CCA CCA
Dorsal sac Dorsal sac
Fused thalami Fused thalami
Facial malformations Facial malformations
( face predict brain) ( face predict brain)
19 weeks
23 weeks
Hemimegalencephaly
Choroid Plexus Cyst
Choroid Plexus Cyst
1% at 20 weeks scan
1% at 20 weeks scan
Cyst > 2 mm
Cyst > 2 mm
Dissapear with 3rd trimester
Dissapear with 3rd trimester
12% with other anomalies
12% with other anomalies
50% T18 ( ass. Anomalies, SGA)
50% T18 ( ass. Anomalies, SGA)
Amniocentesis when CPC+ high risk
Amniocentesis when CPC+ high risk
1:400 Aneuploidy in low risk
1:400 Aneuploidy in low risk
CPC + minor sono marker CPC + minor sono marker
~ ~
20% risk 20% risk
CPC + major sono marker CPC + major sono marker
~ ~
50% risk 50% risk
Arachnoid cyst
Arachnoid cyst
Imaging Findings
Imaging Findings
Extraaxial anehogenic, avascular cyst Extraaxial anehogenic, avascular cyst
Hydrocephalus Hydrocephalus
Makrocephaly Makrocephaly
Mostly Mostly occur in area of the cerebral fissure & occur in area of the cerebral fissure &
midline midline
30% occure in 30% occure in posterior fossa posterior fossa
AC+ACC ~ likely to be AC+ACC ~ likely to be glioependymal cyst glioependymal cyst
Clinical Issues
Clinical Issues
Prognosis good if isolated Prognosis good if isolated
Amniocentesis Amniocentesis
Consider fetal MR Consider fetal MR
Allways check Doppler Allways check Doppler
Agenesis of the Corpus
Agenesis of the Corpus
Callosum
Callosum
Agenesis of the Corpus Callosum
Agenesis of the Corpus Callosum
Imaging Findings
Imaging Findings
Teardrop Teardrop- - shaped ventricels shaped ventricels
Absent CSP Absent CSP
Elevation of the 3rd ventricle Elevation of the 3rd ventricle
CNS CNS- -anomalies 50% anomalies 50%
Clinical issue
Clinical issue
Chromosomal anomalies in 10 Chromosomal anomalies in 10- -20% 20%
Caryotyp, fetal MR Caryotyp, fetal MR
CAVE: Can be missed <18 CAVE: Can be missed <18- -20 weeks 20 weeks
Septo
Septo
-
-
Optic
Optic
-
-
Dysplasia (SOP)
Dysplasia (SOP)
Imaging finding
Imaging finding
Absent SCP Absent SCP
Anterior horns connected Anterior horns connected
across the midline across the midline
Squared Squared- -off off appearence appearence
of fronatl horns of fronatl horns
Clinical Issues
Clinical Issues
Brain anomalies 75 Brain anomalies 75- -90% 90%
Pituitary insuff. 45% Pituitary insuff. 45%
Isolated optic nerve Isolated optic nerve
hypoplasia hypoplasia
Ass. Brain anomalies Ass. Brain anomalies
Schizencephaly
Schizencephaly
Schizencephaly
Schizencephaly
Imaging Findings
Imaging Findings
Defect of brain parenchyma Defect of brain parenchyma extending from inner extending from inner
table of skull to underlying ventricle table of skull to underlying ventricle
Gray matter lines cleft Gray matter lines cleft
Open Open lipp type lipp type
Closed Closed lipp type ( often missed) lipp type ( often missed)
Clinical Issues
Clinical Issues
Seizures Seizures
Developmental delay, mental retardation, motor Developmental delay, mental retardation, motor
impairment impairment
Fetal MRI Fetal MRI
Shizencephaly
Shizencephaly
-
-
DD
DD
Hydrancephaly Hydrancephaly
Near complete absence of the Near complete absence of the
cerebrum. Intact meninges and cranial cerebrum. Intact meninges and cranial
vault. vault.
Holoprosencephaly Holoprosencephaly
Monoventricular cavity with a single Monoventricular cavity with a single
midline thalamic mass. Midline facial midline thalamic mass. Midline facial
anomalies anomalies
Arachnoid Cyst Arachnoid Cyst
Cyst Cyst - - less likely to be symmetric. less likely to be symmetric.
Typically do not communicate with Typically do not communicate with
lateral ventricle lateral ventricle
Porencephaly Porencephaly
May appear similar to schizencephaly May appear similar to schizencephaly
if bilateral and near the sylvian fissures if bilateral and near the sylvian fissures
(CT and MR may demonstrate lack of (CT and MR may demonstrate lack of
gray matter lined cleft). gray matter lined cleft).
Dandy Walker Continuum:classic
Dandy Walker Continuum:classic
A) Dandy Walker malformation DWM A) Dandy Walker malformation DWM
B) Dandy Walker Variant DWC B) Dandy Walker Variant DWC
C) Persistent Blake pouch cyst BPC C) Persistent Blake pouch cyst BPC
D) Mega cysterna magna MCM D) Mega cysterna magna MCM
Large
Large
PF big cerebrospinal cyst
PF big cerebrospinal cyst
4V
4V
-
-
appears open
appears open
Hydrocephalus may be present
Hydrocephalus may be present
Diagnosis bevor 18 weeks
Diagnosis bevor 18 weeks
additional anomalies 70
additional anomalies 70
-
-
90%
90%
Chromosomal anomalies 50%
Chromosomal anomalies 50%
Mortality 40%
Mortality 40%
Dandy Walker Continuum:classic
Dandy Walker Continuum:classic
Yong seok et al.
Dandy Walker Contiunuum :variant
Dandy Walker Contiunuum :variant
Imaging Findings
Imaging Findings
Communication between IV Communication between IV
ventricle and CM ventricle and CM
Keyhole Keyhole appearance of the appearance of the
4th ventricle 4th ventricle
Abnormal karyotype ~ 30%
Abnormal karyotype ~ 30%
Variable prognosis
Variable prognosis
Cisterna magna > 10 mm
Mega Cisterna Magna MCM
Blake pouch cyst BPC
Blake pouch cyst BPC
Circle of Willis Mallformation
Circle of Willis Mallformation
Vein of galen malformation
- Elongated midline
cystic structure
- Cardiomegaly
- Hydrops
-Turbulent flow
Ateriovenous fistula
Sada et all 2009
Brain teratoma
Brain teratoma
Choroid plexus papiloma
Choroid plexus papiloma
M.Murata et al. 2008
REMEMBER
REMEMBER
Color Doppler should ALLWAYS be
Color Doppler should ALLWAYS be
performed on any cystic brain lesion!!
performed on any cystic brain lesion!!
First trimester Examination
First trimester Examination
Chaoui et al.
Chaoui et al.
Spina bifida
Spina bifida
-
-
absence of the 4th
absence of the 4th
ventricle
ventricle
Chaoui et al.
Crouzon Syndrom
Crouzon Syndrom
Graphic material
Graphic material
Own data
Own data
Prof. M. Hansman
Prof. M. Hansman
Medscape
Medscape
Fetus Net
Fetus Net
ISUOG Atlas of obstetric ultrasound
ISUOG Atlas of obstetric ultrasound

Online Education and Training
Online Education and Training
http://www.isuog.org
http://www.isuog.org
Marry Christmas and Happy New
Year
Martinsplatz 2a
Kaiserpassage
53113 Bonn
www.praenatal-bonn.com
Dr. (HR) Tatjana Reihs
F fr Gynkologie und Geburtshilfe
Schwerpunkt Prnatalmedizin
Ultraschalldiagnostik DEGUM II