Fetal neurosonogram jucog feb 2013

Professor Hassan Nasrat FRCS, FRCOG
The Fetal Medicine Clinic
The First Clinic
JUCOG January 2013
Fetal
Nuerosonogram

Sunday, July 28, 13

2
Microcephaly
Anencephaly
Chiari
Malforma,on


 Head normal or smallHead normal or small
DiaDia



halus , T 21halus , T 21
Ventriculomegaly
HydranceHydrance
Hydranecphaly
Encephalocele
Occipital EncephaloceleOccipital Encephalocele
Imaging FindingsImaging Findings
 Herniated brain tissueHerniated brain tissue
 „„cyst within the cystcyst within the cyst““
 Ventriculomegaly 70Ventriculomegaly 70--
80%80%
 Microcephaly 25%Microcephaly 25%
 PolyhydramniosPolyhydramnios
 OligohydramniosOligohydramnios
CAVE:CAVE:
 Associated with multipleAssociated with multiple
syndroms ( Meckelsyndroms ( Meckel-- Gruber )Gruber )
Pilu
Holoprosencephaly
Hemimegalencephaly Arachnoid
cyst
ACC
SOP
Schizencephaly
SchizencephalySchizencephaly
PF-‐Fluid-‐Cyst
Yong seok et a
Vascular

Malforma,ons
Circle of Willis MallformationCircle of Willis Mallformation
Sunday, July 28, 13

Congenital
CNS
Anomalies
o Incidence
in
longtem
studies
about
1
%
o
Only
minimal
identified
at
birth

o
Screening
Increases
The
Number
Of

Referred
Cases
For
Evaluation
Of
Suspected

CNS
Anomalies.

o The
CNS
sonographic
appearance
changes

throughout
pregnancy

Sunday, July 28, 13

4
✤Embryonic
development
of
the
CNS

in
relation
to
sonographic
findings
✤Standard
Sonographic
Examination

of
the
CNS

✤Fetal
Neurosonography
and
the

Role
of
3
D

(systemic
approach
to

examination
of
the
Posterior
Fossa)
Learning
Objec,ves
Sunday, July 28, 13

Embryology of the
CNS
Sunday, July 28, 13

At
5th
Week
The
Cells

Destined
To
Form
The

Notochord
Infiltrate
Into

The
Embryonic
Disc.

I t
I n d u c e s
T h e

Overlying
Embryonic

Tissue
To
Thicken
And

Ultimately
Fold
Over

And
Fuse
As
The

Neural
Tube.

The
Fusion
Starts
In

The
Midtrunk
Of
The

E m b r y o
A n d

Subsequently
Extends

To
The
Cranial
And

Caudal
Ends

Neural
Crest
Neural
TubeNeural
Groove
Neural
Plate Ectoderm
Sunday, July 28, 13

7
Prosencephalon Mesencephalon
Rhombencephalon
Sunday, July 28, 13

Three orthogonal images and thick slice of three-dimensional reconstructed image (lower right) of normal brain at
the end of 8 weeks of gestation. The development of premature ventricular system is seen.
8
Sunday, July 28, 13

Three orthogonal images and thick slice of three-dimensional reconstructed image (lower right) of normal brain at
the end of 8 weeks of gestation. The development of premature ventricular system is seen.
8
Prosencephalon Mesencephalon
Sunday, July 28, 13

Normal brain development on the mid-sagittal section between 8 and 12 weeks of gestation). Note the remarkable changing of premature brain
appearance.
9
Sunday, July 28, 13

10
Changing
Ultrasound
appearance
of
the

The
Posterior
Fossa
throughout
gesta,on

C D
AJR:166, February 1996 SONOGRAPHIC ANATOMY OF DEVELOPING CEREBELLUM 433
C D
Fig. 13.-Drawings depicting some relevant features of fetal cerebellar development.C D
C DSunday, July 28, 13

11
The vermis develops superiorly to inferiorly.
Hypoplasia or developmental arrest results in
varying size deﬁcits of the inferior portion, leaving
a relatively square defect that communicates with
the fourth ventricle and separates the lower
cerebellar hemispheres.
Sunday, July 28, 13

12
C D
Fig. 13.-Drawings depicting some relevant features of fetal cerebellar development.
A, Axial drawing of developing cerebellum at 5 weeks’ gestational age shows that developing cerebellar hemispheres have not yet grown
toward midline and thatfourth ventricle is covered only byfourth ventricular roof,which is onlytwo cell layers thickatthis stage of development.
B, Sagittal drawing of developing cerebellum at 10 weeks’ gestational age shows small cerebellum located rostrally over fourth ventricle,
with caudal fourth ventricle being covered only by thin fourth ventricular roof.
C, Sagittal drawing at 16 weeks’ gestational age shows further caudal growth of cerebellum and vermis over fourth ventrIcle, with thick-
ening of caudal fourth ventricular roof.
0, Sagfttal drawing at 17 weeks’ gestational age shows cerebellum and vermis covering entire fourth ventricle.
We have shown that the sonognaphic appearance of nor-
mal cemebellar development can resemble pathology early in
the second trimester. Our findings indicate that the mature
relationships of the posterior fossa structures are not estab-
lished until at least 18 weeks’ gestational age; therefore, the
prenatal sonographic diagnosis of Dandy-Walker complex
4. Achinon R, Tadmor 0. Screening for fetal anomalies during the first tnimes-
ten of pregnancy: tnansvaginal versus transabdominal sonography. Ultra-
sound Obstet Gynecol 1991 1:186-191
5. Nicolaides KH, Azan G, Byrne D, Mansur C, Marks K. Fetal nuchal translu-
cency: ultrasound screening for chromosomal defects in first trimester of
pregnancy. BMJ 1992:304:867-869
6. Bronshtein M, Blumenfeld I, Kohn J, Blumenfeld Z. Detection ofcleft lip by early
teno
thic
and
Sunday, July 28, 13

sagittalaxial
sonograms of posterior fossa in 16-week-old fetus
13
of posterior fossa in 13- to 14-week-old fetus. called acquisition in stea
A, Vermis is identified between cerebellar hemispheres rostrally (arrow). age of posteriorfossa in
B, Next caudal image identifies fourth ventricular roof joining cerebellar hemispheres fetus. Vermis is identified
(arrow) and separating fourth ventricle and cisterna magna. but not caudally at this s
Fig. 7.-Axial and
tenor fossa in 16-week-
A and B, Caudally,
thick enough to be v
and sagittal (B) planes
B, Next caudal image identifies fourth ventricular roof joining cerebellar hemispheres fetus. Vermis
(arrow) and separating fourth ventricle and cisterna magna. but not caudally
Fig. 7.-A
tenor fossa
A and
thick enoug
and sagittal
fourth ventricular roof is visualized in both planes (arrow)
Eﬀect
of
Gesta=onal
age
(Posterior
Fossa)
Sunday, July 28, 13

Lower-most Section
The Vermis Appears To
Be Open (arrow) And
Communicates With The
Fourth Ventricle
Through A Wide
Somewhat Higher Higher Still
No ‘vermian Defect’
Is Seen And The
Fourth Ventricle (4)
Appears As A
Discrete Entity.
14
duncular cistern (cisterna magna) and the fourth ventri-
. Later, after the 16th postmenstrual week, this ‘normal’
en space narrows as the growth and development of
e vermis progress, giving rise to the median aperture
ramen of Magendie) (Figure 2). Again, this normal
its closest anatomic structures, namely the cavum sep
pellucidi and the pericallosal artery, follow a well-know
developmental timetable. They do not reach a developmen
tal stage that allows for sonographic imaging until pos
menstrual weeks 18–19. To search for their presence befor
ure 1 Transvaginal scan of a 14-week fetus. (a) Oblique-1 (sagittal) section: the fetus is facing left. The choroid plexus fills the antrum
the lateral ventricle. The anterior horns appear prominent, but are normal; (b) a Frontal-2 (coronal) section through the anterior horn
the lateral ventricles. The anterior horns are normal for this gestational age; however, this same sonographic picture at 20 weeks o
re is consistent with ventriculomegaly or hydrocephalus
gure 2 Three serial, almost axial (horizontal) views through the posterior fossa. (a) This is the lower-most section (see insert). Th
rmis appears to be open (arrow) and communicates with the fourth ventricle through a wide (at this gestational age, normal) media
erture (foramen of Magendie); (b) somewhat higher, the right and left sides of the cerebellar hemispheres appear closer to each othe
row); (c) higher still, no ‘vermian defect’ is seen and the fourth ventricle (4) appears as a discrete entity. C, cerebellum
duncular cistern (cisterna magna) and the fourth ventri-
Later, after the 16th postmenstrual week, this ‘normal’
en space narrows as the growth and development of
vermis progress, giving rise to the median aperture
ramen of Magendie) (Figure 2). Again, this normal
nographic finding may be interpreted by those unfamiliar
its closest anatomic structures, namely the cavum septi
pellucidi and the pericallosal artery, follow a well-known
developmental timetable. They do not reach a developmen-
tal stage that allows for sonographic imaging until post-
menstrual weeks 18–19. To search for their presence before
they reach this critical stage in their development would
ure 1 Transvaginal scan of a 14-week fetus. (a) Oblique-1 (sagittal) section: the fetus is facing left. The choroid plexus fills the antrum
he lateral ventricle. The anterior horns appear prominent, but are normal; (b) a Frontal-2 (coronal) section through the anterior horns
he lateral ventricles. The anterior horns are normal for this gestational age; however, this same sonographic picture at 20 weeks or
re is consistent with ventriculomegaly or hydrocephalus
ure 2 Three serial, almost axial (horizontal) views through the posterior fossa. (a) This is the lower-most section (see insert). The
mis appears to be open (arrow) and communicates with the fourth ventricle through a wide (at this gestational age, normal) median
rture (foramen of Magendie); (b) somewhat higher, the right and left sides of the cerebellar hemispheres appear closer to each other
row); (c) higher still, no ‘vermian defect’ is seen and the fourth ventricle (4) appears as a discrete entity. C, cerebellum
eduncular cistern (cisterna magna) and the fourth ventri-
e. Later, after the 16th postmenstrual week, this ‘normal’
pen space narrows as the growth and development of
e vermis progress, giving rise to the median aperture
oramen of Magendie) (Figure 2). Again, this normal
onographic finding may be interpreted by those unfamiliar
its closest anatomic structures, namely the cavum septi
pellucidi and the pericallosal artery, follow a well-known
developmental timetable. They do not reach a developmen-
tal stage that allows for sonographic imaging until post-
menstrual weeks 18–19. To search for their presence before
they reach this critical stage in their development would
gure 1 Transvaginal scan of a 14-week fetus. (a) Oblique-1 (sagittal) section: the fetus is facing left. The choroid plexus fills the antrum
the lateral ventricle. The anterior horns appear prominent, but are normal; (b) a Frontal-2 (coronal) section through the anterior horns
the lateral ventricles. The anterior horns are normal for this gestational age; however, this same sonographic picture at 20 weeks or
ore is consistent with ventriculomegaly or hydrocephalus
gure 2 Three serial, almost axial (horizontal) views through the posterior fossa. (a) This is the lower-most section (see insert). The
ermis appears to be open (arrow) and communicates with the fourth ventricle through a wide (at this gestational age, normal) median
perture (foramen of Magendie); (b) somewhat higher, the right and left sides of the cerebellar hemispheres appear closer to each other
rrow); (c) higher still, no ‘vermian defect’ is seen and the fourth ventricle (4) appears as a discrete entity. C, cerebellum
The Right And Left Sides
Of The Cerebellar
Hemispheres Appear
Closer To Each Other
(arrow);
Eﬀect
Of
Scanning
Level
(Posterior
Fossa)
Sunday, July 28, 13

15
Eﬀect
of
Gesta=onal
age
(Lateral
Ventricles)
Sunday, July 28, 13

16
Hypoplasia Or Dysplasia Should Not Be
Diagnosed Prior To 18 Weeks, Before Vermian
Development Is Complete.
An Abnormally Steep Scanning Angle May
Mimic A Prominent Cleft Between The
Lower Portions Of The Cerebellar
Hemispheres.
The fetal cerebellum
Pitfalls in diagnosis
Sunday, July 28, 13

17
Conclusion
•TheCNS
displays
remarkable

embryological
and
developmental

changes
throughout
gestation.
•Standard
Approach
of
examination
and

evaluation
of
the
CNS
Should
Be

Followed
Sunday, July 28, 13

18
Standard Sonographic
Examination of the
FEtal CNS
Sunday, July 28, 13

Sonography
of
the
CNS
Basic
Examination “Neurosongram”
Sunday, July 28, 13

Planes
of
Basic
ExaminaEon
Axial
Planes SagiZal
Planes
Sunday, July 28, 13

Axial
Planes
Sunday, July 28, 13

Axial
Planes
a:
Transventricular
Sunday, July 28, 13

Axial
Planes
a:
Transventricular
b:
Transthalamic

Sunday, July 28, 13

Axial
Planes
a:
Transventricular
C:
Transcerebeller

b:
Transthalamic

Sunday, July 28, 13

The
Transventricular
plane
Sunday, July 28, 13

The
Transventricular
plane
Frontal
hones
Sunday, July 28, 13

The
Transventricular
plane
Frontal
hones
Atrium
Sunday, July 28, 13

The
Transventricular
plane
Frontal
hones
Choroid

Plexus
Atrium
Sunday, July 28, 13

The
Transventricular
plane
Cavum
SepE
Pellucidi
Frontal
hones
Choroid

Plexus
Atrium
Sunday, July 28, 13

The
Transthalamic

Plane
Sunday, July 28, 13

Thalami
The
Transthalamic

Plane
Sunday, July 28, 13

Thalami
Hyppocamas

Gyrus
The
Transthalamic

Plane
Sunday, July 28, 13

T
T
The
Transcerebeller

plane
Sunday, July 28, 13

Cavum
SepE
Pellucidi
T
T
The
Transcerebeller

plane
Sunday, July 28, 13

Cavum
SepE
Pellucidi
Frontal
hones
T
T
The
Transcerebeller

plane
Sunday, July 28, 13

Cerebellum
Cavum
SepE
Pellucidi
Frontal
hones
T
T
The
Transcerebeller

plane
Sunday, July 28, 13

Cerebellar
vermis
Cerebellum
Cavum
SepE
Pellucidi
Frontal
hones
T
T
The
Transcerebeller

plane
Sunday, July 28, 13

Cerebellar
vermis
Cistrerna
Magna
2-‐10
mm
Cerebellum
Cavum
SepE
Pellucidi
Frontal
hones
T
T
The
Transcerebeller

plane
Sunday, July 28, 13

SagiZal
Planes

Sunday, July 28, 13

SagiZal
Planes

A:
The
Midsagittal

Plan
Sunday, July 28, 13

SagiZal
Planes

b:
Parasgittal
plane
A:
The
Midsagittal

Plan
Sunday, July 28, 13

27
Mid
SagiGal
Plane

Corpus
Callosum Cavum
Sep,
Pellucidi
Cerebellum
4th
V
Sunday, July 28, 13

27
Mid
SagiGal
Plane

Sunday, July 28, 13

28
The
Corpus
Callosum
Sunday, July 28, 13

28
Corpus
Callosum
Lateral
Ventricles
Third
Ventricle
midbrain
Pituitary
Splenium
Thalamus
hypothalamus
Fourth
ventricle
The
Corpus
Callosum
Sunday, July 28, 13

29
Para-‐SagiGal
Plane

Sunday, July 28, 13

30
Basic Examniation ChecklistBasic Examniation Checklist
Head + NeckHead + Neck
Midline & FalxMidline & Falx
Cavum septi pellucidiCavum septi pellucidi
Lateral cerebral ventriclsLateral cerebral ventricls
Choroid PlexusChoroid Plexus
CerebellumCerebellum
Cisterna magnaCisterna magna
Sunday, July 28, 13

Main
AbnormaliEes
can
be

Suspected
on
Basic
Planes
31
Sunday, July 28, 13

32
Microcephaly
Anencephaly
Chiari
Malforma,on


DiaDia



Ventriculomegaly
HydranceHydrance
Hydranecphaly
Encephalocele
80%80%
CAVE:CAVE:
Pilu
Holoprosencephaly
cyst
ACC
SOP
Schizencephaly
PF-‐Fluid-‐Cyst
Yong seok et a
Vascular

Malforma,ons
Sunday, July 28, 13

32
Microcephaly
Anencephaly
Chiari
Malforma,on


DiaDia



Ventriculomegaly
HydranceHydrance
Hydranecphaly
Encephalocele
80%80%
CAVE:CAVE:
Pilu
Holoprosencephaly
cyst
ACC
SOP
Schizencephaly
PF-‐Fluid-‐Cyst
Yong seok et a
Vascular

Malforma,ons
Ventriculomegaly
Sunday, July 28, 13

32
Microcephaly
Anencephaly
Chiari
Malforma,on


DiaDia



Ventriculomegaly
HydranceHydrance
Hydranecphaly
Encephalocele
80%80%
CAVE:CAVE:
Pilu
Holoprosencephaly
cyst
ACC
SOP
Schizencephaly
PF-‐Fluid-‐Cyst
Yong seok et a
Vascular

Malforma,ons
ACC
Ventriculomegaly
Sunday, July 28, 13

32
Microcephaly
Anencephaly
Chiari
Malforma,on


DiaDia



Ventriculomegaly
HydranceHydrance
Hydranecphaly
Encephalocele
80%80%
CAVE:CAVE:
Pilu
Holoprosencephaly
cyst
ACC
SOP
Schizencephaly
PF-‐Fluid-‐Cyst
Yong seok et a
Vascular

Malforma,ons
ACC
PF-‐Fluid-‐Cyst
Ventriculomegaly
Sunday, July 28, 13

33
•Ventriculomegaly
(hydrocephalus)
•Absent
Cavum
Septum
Pellucidum
•Agenesis
of
the
Corpus
Callosum
•Fluid
Collection
in
the
posterior
fossa
Sunday, July 28, 13

(<
10
mm
is
normal).

Independent

of
gesta7onal
age

Mild
10
–
15
mm
Low
Risk

Severe
>
15
mm

High
Risk

mean
=
6-‐8

mm
Ventriculomegaly
(hydrocephalus)
Sunday, July 28, 13

Le]
Lateral
Ventricle
Right
Lateral
Ventricle
3rd

Ventricle
4th

Ventricle
35
Aqueduct
of
Sylvius
Foramen
of
Monro

Cisterna
Magna
Pathogenesis:
Ventriculomegaly
Sunday, July 28, 13

•Square
Shaped,
Interrupts
and
Fills
The
Space
Between
The
Frontal
Horns
•The
CSP:
Becomes
Visible
At
16

Weeks,
Obliterate
Near
Term
Absent
CSP
Sunday, July 28, 13

•Square
Shaped,
Interrupts
and
Fills
The
Space
Between
The
Frontal
Horns
•The
CSP:
Becomes
Visible
At
16

Weeks,
Obliterate
Near
Term
Cavum
SepE
Pellucidi
Absent
CSP
Sunday, July 28, 13

A
rare
finding
usually
discovered
Postnatally
in

children
evaluated
for
developmental
delay.
Associated
with
various
brain
malformations:
agenesis
of
the
corpus
callosum
Holoprosencephaly.
Setpo-‐optic
dysplasia.
Secondary
to
disruptive
process:
Hydrocephalus,

Chiari
II
malformation,
hydranecephaly.

Absent
CSP
Sunday, July 28, 13

38
Agenesis
of
the
Corpus
Callosum

Sunday, July 28, 13

Only
The
Rostrum
(1),
Genu
(2)
And
Body
(3)
Are
Visible;
The
Splenium
Is

Missing.
The
Corpus
Callosum
Is
Short
Posteriorly
And
Does
Not
Seem
To
Overlay

The
Quadrigeminal
Plate
21-‐week
Fetus
With
Par=al
Agenesis
Of
The
Corpus
Callosum
Sunday, July 28, 13

Outcome
of
fetal
ACC
 Varies
between
completely
asymptomaEc

appearance
and
severe
neurologic
problems
 50
–
100
%
of
isolated
cases
will
have
normal

neurological
development
at
3-‐11
years
but
Poor

prognosis
with
associated
anomalies

Progressive
decline
in
intellect
over
the
years

Most
need
special
educaEon

Long-‐term
follow-‐up
of
children
with
prenatally
diagnosed
agenesis
of
corpus
callosum
(ACC)

J.
H.
Stupin
et
al,
USOG,
32,
2008
Sunday, July 28, 13

41
Fluid
Collec,on
in
the
Posterior
Fossa
Sunday, July 28, 13

41
Fluid
Collec,on
in
the
Posterior
Fossa
•Megacisterna Magna
Sunday, July 28, 13

41
Fluid
Collec,on
in
the
Posterior
Fossa
•Blak’s Pouch Cyst
Sunday, July 28, 13

41
Fluid
Collec,on
in
the
Posterior
Fossa
•Megacisterna Magna •D-W Malformation &DW- Variant
Sunday, July 28, 13

41
Fluid
Collec,on
in
the
Posterior
Fossa
•Arachnoid Cyst
•D-W Malformation &DW- Variant
Sunday, July 28, 13

42
•Arachnoid Cyst
•D-W Malformation &DW- Variant
Anomalies Of The
Meninges
Anomalies
Cerebellum
Sunday, July 28, 13

Mega–Cisterna Magna
43
An Enlargement Of The Cisterna Magna Beyond 10
Mm With Intact Vermis
Sunday, July 28, 13

44
Lateral
Ventricle
Pathogenesis: Mega Cisterna Magna
Cerebral
Aqueduct
Choriod
Plexus
Third

Ventricle
Fourth
Ventricle
Sunday, July 28, 13

44
Lateral
Ventricle
Pathogenesis: Mega Cisterna Magna
Cerebral
Aqueduct
Choriod
Plexus
Third

Ventricle
TheForaminaOf
LuschkaAndMagendie
FenestrateDelayed
Fourth
Ventricle
Sunday, July 28, 13

45
Prognosis:
•Isolated Cases: (97%-100%)Are Normal.
•If Not Isolated:Only 11% Have Normal Outcome.
Nonisolated Cases Have VM, Congenital Infection, Or
Karyotype Abnormalities.
A Large Cisterna Magna Require Careful Search For
Other Abnormalities.
Sunday, July 28, 13

46
Blake’s Pouch Cyst
Sunday, July 28, 13

47
Lateral
Ventricle
Cerebral
Aqueduct
Choriod
Plexus
Third

Ventricle
Nonfenestration of the
foramina of Luschka and
Magendie leads to dilatation
of the fourth ventricle and
and elevation of the vermis
away from the brain stem.
Fourth
Ventricle
Pathogenesis: Blake’s Pouch Cyst
There is no communication between the
cyst and the subarachnoid space
Sunday, July 28, 13

Dandy-Walker Malformation
48
ASpectrum OfAnomalies Of The Posterior Fossa.
• Dandy-Walker Malformation:
✦Increase Of The Posterior Fossa,
✦Complete Or Partially Agenesis Of The CerebellarVermis,
✦ATentorium Elevation
• Variant Of Dandy-Walker:
✦Hypoplasia Of The Cerebellar Vermis In Different
Degrees With Or Without Increase Of The Posterior
Fossa.
Sunday, July 28, 13

49
ctions
Cystic dilation of the
f o u r t h v e n t r i c l e
communicating with a
posterior fossa fluid
space
Small, rotated, raised,
or absent vermis
Elevated tentorium and
high position of the
torcula
Dandy-Walker Malformation
Sunday, July 28, 13

50
ThePrognosis :
BetterInIsolatedDWS.
KaryotypeAbnormalities InAbout 15%.
Neonatal Mortality:
12% To 55%.
Neonatal Morbidity:
•Intelligence Is NormalInAbout40%
•Borderline In 20%
•Subnormal In 40%.
Sunday, July 28, 13

51
Dandy–Walker Malformation
The Torcular Is Displaced Higher
Than Usual, Indicating That This
Is A
Figure 2 The position of the torcular Herophili (arrows) is inferre
on ultrasound by the direction of the tentorium cerebelli. In (a) th
torcular is found in a normal position, at about the same level as
the site of insertion of the neck muscles on the posterior skull; thi
is a Blake’s pouch cyst. In (b) the torcular is displaced higher than
igure 2 The position of the torcular Herophili (arrows) is inferred
n ultrasound by the direction of the tentorium cerebelli. In (a) the
orcular is found in a normal position, at about the same level as
he site of insertion of the neck muscles on the posterior skull; this
a Blake’s pouch cyst. In (b) the torcular is displaced higher than
The Torcular Is Found In A Normal
Position, At About The Same Level
As The Site Of Insertion Of The
Neck Muscles On The Posterior
Skull
Sunday, July 28, 13

• Are Benign, Noncommunicating Fluid
Collections Within Arachnoid
Membranes.
• Location: Intracranially And In The
Spinal Canal.
• Order Of Frequency Are The Sylvian
Fissure Or Temporal Fossa, Posterior
Fossa, Over The Cerebral Convexity,
And Midline Supratentorial,
• Most Appear Stable And Require No
Surgical Treatment. Occasionally They
Interfere With CSF Circulation And
RequireDecompression.
Arachnoid Cysts
Sunday, July 28, 13

The Differential Diagnosis
53
Depends On The Location.
In The Posterior Fossa:
DandyWalker Malformation, Inferior Vermian
Hypoplasia, Mega–cisterna Magna, And Blake’s Pouch
Cysts.
Supratentorial Cysts:
Cavum Veli Interpositi, Aneurysm Of Vein Of Galen,
Hemorrhage, And Cystic Tumors.
Sunday, July 28, 13

54
Prenatal diagnosis and outcome of fetal posterior
fossa ﬂuid collections
G. GANDOLFI COLLEONI et al,
Ultrasound Obstet Gynecol 2012; 39: 625–631
Sunday, July 28, 13

N = 32
Megacisterna Magna
N = 27
Dandy – Walker Malformation
N=26
Vermian Hypoplasia
N=17
Cerebellar Hypoplasia
N=2
55
105
Fetuses
Arachnoid Cyst
N=1
Sonographic
d i a g n o s e s
were accurate
in 88%
Sunday, July 28, 13

56
✦Isolated Cases Of Blake’s Pouch Cyst And
Megacisterna Magna Have An Excellent Prognosis,
With A High Probability Of Intrauterine Resolution
And Normal Intellectual Development In Almost All
Cases.
✦Dandy – Walker Malformation And Vermian
Hypoplasia, Even When They Appear Isolated
Antenatally, Are Associated With An Abnormal
Outcome In Half Of Cases.
Sunday, July 28, 13

57
•Black’s
Pouch
Cyst,
DW
Malformation,
and

Mega-‐Cisterna
Magna
Can
give
Similar

Sonographic
features.

•However
the
prognosis
is
greatly
varialbe.
•Careful
Neurosonographic
assessment
using
3

D
or
Fetal
MRI
is
often
Needed
Conclusion
Sunday, July 28, 13

Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
Technical Guideline
How do we do it? Practical advice on imaging-based
techniques and investigations
Three dimensional ultrasound
examination of the fetal central
nervous system
Gianluigi Pilu, Tullio Ghi, Angela Carletti,
Maria Segata, Antonella Perolo, Nicola Rizzo
From the Department of Obstetrics and Gynecology
University of Bologna, Italy
Address for correspondence: gianluigi.pilu@unibo.it
Sunday, July 28, 13

3D
ultrasound
is
a
data
set

that
contains
a
large
number

of
2D
planes
(B-‐mode

images).

e.g.
If
the
page
of
a
book
is

one
2D
plane,
then
the
book

itself
is
the
enEre
data
set.

The
3
D
probe
acquire
the
data
by

moving
a
B
mode
transducer
within
a

housing
like
a
hand
held
Japanese
fan
.
Sunday, July 28, 13

Pyramid
Of
Volume
Informa=on
✴ “Walking”
through
the

volume
is
similar
to

leafing
through
the

pages
of
a
book
i.e.

walking
through
the

various
2D
planes
that

make
up
the
entire

volume.

✴ The
Volume
can
be

dissected
in
any
plane,

to
get
“Multiplanar

Imaging”

the
acquired
volume
unlike
the

deﬁned
rectangle
shape
of
a
book

looks
like
a
pyramid
or
triangle
of

volume
informaEon
with
a
broad

base

Sunday, July 28, 13

61
3D volumes of the fetal brain obtained from
an axial approach: the ‘start’ scan
3D volumes of the fetal brain obtained from
an axial approach: the ‘start’ scan
Cavum septi pellucidi midline
Sunday, July 28, 13

midline
A B
C
Sunday, July 28, 13

midline
A B
C
A and B rotated on Z
plane until midline is
aligned with C plane
Sunday, July 28, 13

A B
C
Corpus callosum + cavum septi pellucidi
Cerebellar vermis
Acoustic shadow
Sunday, July 28, 13

Originally
published
in
midline
midline
Corpus
callosum
Cavum
sep*
pellucidi
Corpus
callosum
+
cavum
sep*
pellucidi
64
Sunday, July 28, 13

Originally
published
in
Ultrasound
Obstet
Gynecol
2007;
30:
233–245
4v
Brain
stem Cerebellar
vermis
Angled
Insona,on
of
Posterior
Fossa
to

Visualize
brain
Stem
65
Sunday, July 28, 13

4v
hemisphere
hemisphere
hemisphere
hemisphere
vermis
tentorium
tentorium
4v
vermis
vermian fissures
Sunday, July 28, 13

Originally
published
in
Ultrasound
Obstet
Gynecol
2007;
30:
233–245
body atrium
Occipital

horn
Temporal
horn
Sylvian
ﬁssure
67
Sunday, July 28, 13

Originally
published
in
Ultrasound
Obstet
Gynecol
2007;
30:
233–245
3v
Normal
corpus
callosum
Absent
corpus
callosum
3v
3v
Par,al
agenesis
74
Agenesis
of
the

corpus
callosum
Sunday, July 28, 13

Normal
Posterior
Fossa
At
Midgesta=on
SagiGal
viewAxial view
Prenatal
diagnosis
and
outcome
of
fetal
posterior
fossa
ﬂuid
Collec=ons
Gandolﬁ
Colleoni
et
al.,
UOG
2012
Sunday, July 28, 13

Normal
Posterior
Fossa
At
Midgesta=on
SagiGal
viewAxial view
Cavum
Sep,

Pellucidi
Prenatal
diagnosis
and
outcome
of
fetal
posterior
fossa
ﬂuid
Collec=ons
Gandolﬁ
Colleoni
et
al.,
UOG
2012
Sunday, July 28, 13

Normal
Posterior
Fossa
At
Midgesta=on
SagiGal
viewAxial view
Cavum
Sep,

Pellucidi
Cerebellar
vermis
Prenatal
diagnosis
and
outcome
of
fetal
posterior
fossa
ﬂuid
Collec=ons
Gandolﬁ
Colleoni
et
al.,
UOG
2012
Sunday, July 28, 13

Normal
Posterior
Fossa
At
Midgesta=on
SagiGal
viewAxial view
Cavum
Sep,

Pellucidi
Cisterna
Magna
Cerebellar
vermis
Prenatal
diagnosis
and
outcome
of
fetal
posterior
fossa
ﬂuid
Collec=ons
Gandolﬁ
Colleoni
et
al.,
UOG
2012
Sunday, July 28, 13

Normal
Posterior
Fossa
At
Midgesta=on
SagiGal
viewAxial view
Cavum
Sep,

Pellucidi
Cisterna
Magna
Tentorium
Cerebellar
vermis
Prenatal
diagnosis
and
outcome
of
fetal
posterior
fossa
ﬂuid
Collec=ons
Gandolﬁ
Colleoni
et
al.,
UOG
2012
Cisterna
Magna
Sunday, July 28, 13

76
Applica=on
of
3
D
Imaging
in

Prenatal
diagnosis
of
Fetal

Posterior
Fossa
Fluid
Collec=on
Sunday, July 28, 13

77
Prenatal
diagnosis
and
outcome
of
fetal
posterior
fossa
ﬂuid

Collec=ons
Gandolﬁ
Colleoni
et
al.,
UOG
2012
Brainstem–vermis and brainstem–tentorium angles allow accurate
categorizationoffetalupwardrotationofcerebellarvermis
P. VOLPE*, et al
Sunday, July 28, 13

Categoriza,on
of
posterior
fossa
ﬂuid
collec,ons
(1)
Sunday, July 28, 13

Blake’s
pouch
cyst Megacisterna
magna D-‐W

Findings
Upward
rotation
of
an
intact
vermis

with
normal
torcular
Cisterna
magna
>10mm
with
intact

and
normally
positioned
cerebellum
Upward
rotation
of
the
vermis

(normal
or
hypoplastic)
with
elevated
torcular
SagiGal

Axial
Categoriza,on
of
posterior
fossa
ﬂuid
collec,ons
(1)
Sunday, July 28, 13

79
•Transverse Diameter Of
The Cerebellum.
•The Intactness And Size
Of The Vermis.
•The Depth Of The
Cisterna Magna (10 Mm)
Axial
View
Sunday, July 28, 13

80Figure 1 Measurement of brainstem–vermis (BV) and brainstem–tento
this case after acquisition of an ultrasound volume starting from an axi
Cavum
Sep,

Pellucidi
The
Vermis:
Shape,
Size,
Fissures
The
Tentorium:
Level

Sunday, July 28, 13

81Figure 1 Measurement of brainstem–vermis (BV) and brainstem–tento
this case after acquisition of an ultrasound volume starting from an axi
Brainstem-vermis
(BV) angle
Brainstem-tentorium
(BT)angle
Cavum
Sep,

Pellucidi
Sunday, July 28, 13

Blake’s Pouch
Cyst
Measurement Of Brainstem–vermis (BV) Angle (1) And
Brainstem–tentorium (BT) In Three Conditions
Cerebellar Vermis
Hypoplasi
Dandy–Walker
Malformation.
The Angles Has The Widest Measurement In DA
Malformation
82
Figure 1 Measurement of brainstem–vermis (BV) and brainstem–tentorium (BT) angles. (a) A median view of the fetal brain is obtained
this case after acquisition of an ultrasound volume starting from an axial view) and the main anatomic landmarks are identified. (b) A lin
drawn tangentially to the dorsal aspect of the brain stem and a second line is drawn tangentially to the ventral contour of the cerebellar
vermis; the interposed angle (1) is the BV angle; the BT angle (2) is measured between the first line and a third line tangential to the tentoriu
Figure 2 Measurement of brainstem–vermis (BV) angle (1) and brainstem–tentorium (BT) angle (2) in fetuses with: (a) Blake’s pouch cys
Measurement of brainstem–vermis (BV) and brainstem–tentorium (BT) angles. (a) A median view of the fetal brain is obtained (in
ter acquisition of an ultrasound volume starting from an axial view) and the main anatomic landmarks are identified. (b) A line i
gentially to the dorsal aspect of the brain stem and a second line is drawn tangentially to the ventral contour of the cerebellar
interposed angle (1) is the BV angle; the BT angle (2) is measured between the first line and a third line tangential to the tentorium
1 Measurement of brainstem–vermis (BV) and brainstem–tentorium (BT) angles. (a) A median view of the fetal brain is obta
e after acquisition of an ultrasound volume starting from an axial view) and the main anatomic landmarks are identified. (b)
angentially to the dorsal aspect of the brain stem and a second line is drawn tangentially to the ventral contour of the cerebe
the interposed angle (1) is the BV angle; the BT angle (2) is measured between the first line and a third line tangential to the te
Sunday, July 28, 13

Dandy–Walker malformation 12 63.5 17.6 45–112 67.2 15.1 51–1
80
60
40
20
0
Brainstem–vermisangle(°)
Normal Blake’s pouch
cyst
Vermian
hypoplasia
Dandy–Walker
malformation
Figure 3 Box-and-whisker plot of distribution of brainstem–vermis
angle in controls and in fetuses with upward rotation of the
cerebellar vermis. Medians are indicated by a line inside each box,
25th and 75th percentiles by box limits and 5th and 95th percentiles
by lower and upper bars, respectively.
had a BV angle < 18◦
and a BT angle < 45◦
. The BV
angle was significantly increased in each of the three
subgroups of anomalies (Figure 3, Table 2), the angle
increasing with increasing severity of the condition. The
BT angle demonstrated a similar pattern, but there was
more overlapping among groups (Figure 4, Table 2).
80
60
40
20
Brainstem–tentoriumangle(°)
cyst
Vermian
hypoplasia
Dandy–Walk
malformatio
Figure 4 Box-and-whisker plot of distribution of brainstem–
tentorium angle in controls and in fetuses with upward rotation o
the cerebellar vermis. Medians are indicated by a line inside each
box, 25th and 75th percentiles by box limits and 5th and 95th
percentiles by lower and upper bars, respectively.
Table 2 Statistical comparison of brainstem–vermis (BV) and
brainstem–tentorium (BT) angles in controls and in fetuses with
upward rotation of the cerebellar vermis
P (Mann–Whitney U-test)
Comparison* BV angle BT angle
Blake’s pouch cyst 12 23.0 2.8 19–26 42.2 7.1 32–52
Vermian hypoplasia 7 34.9 5.4 24–40 52.1 7.0 45–66
Dandy–Walker malformation 12 63.5 17.6 45–112 67.2 15.1 51–112
80
60
40
20
0
Brainstem–vermisangle(°)
cyst
Vermian
hypoplasia
Dandy–Walker
malformation
Figure 3 Box-and-whisker plot of distribution of brainstem–vermis
angle in controls and in fetuses with upward rotation of the
cerebellar vermis. Medians are indicated by a line inside each box,
25th and 75th percentiles by box limits and 5th and 95th percentiles
by lower and upper bars, respectively.
had a BV angle < 18◦
and a BT angle < 45◦
. The BV
angle was significantly increased in each of the three
subgroups of anomalies (Figure 3, Table 2), the angle
increasing with increasing severity of the condition. The
BT angle demonstrated a similar pattern, but there was
more overlapping among groups (Figure 4, Table 2).
DISCUSSION
Our results suggest that measurement of the BV angle
discriminates accurately posterior fossa fluid collections
80
60
40
20
Brainstem–tentoriumangle(°)
cyst
Vermian
hypoplasia
Dandy–Walker
malformation
Figure 4 Box-and-whisker plot of distribution of brainstem–
tentorium angle in controls and in fetuses with upward rotation of
the cerebellar vermis. Medians are indicated by a line inside each
box, 25th and 75th percentiles by box limits and 5th and 95th
percentiles by lower and upper bars, respectively.
Table 2 Statistical comparison of brainstem–vermis (BV) and
brainstem–tentorium (BT) angles in controls and in fetuses with
upward rotation of the cerebellar vermis
P (Mann–Whitney U-test)
Comparison* BV angle BT angle
Controls vs Blake’s pouch cyst
fetuses
< 0.00000005 < 0.000005
Controls vs Dandy–Walker
fetuses
< 0.00000005 < 0.00000005
Box-and-whisker plot of distribution of
brainstem–vermis angle in controls and in
fetuses with upward rotation of the cerebellar
vermis. Medians are indicated by a line inside
each box, 25th and 75th percentiles by box
limits and 5th and 95th percentiles by lower
and upper bars, respectively.
Box-and-whisker plot of distribution of
brainstem– tentorium angle in controls and in
fetuses with upward rotation of the cerebellar
vermis. Medians are indicated by a line inside
each box,25th and 75th percentiles byboxlimits
and 5th and 95th percentiles by lower and upper
bars,respectively.
Brainstem–vermis Angle Brainstem–TentoriumAngle
Sunday, July 28, 13

84
Fetal posterior fossa fluid collections associated
with upward rotation of the cerebellar vermis range
from benign asymptomatic conditions to severe
abnormalities associated with neurological
impairment.
The most frequent of these anomalies, Blake’s
pouch cyst, vermian hypoplasia and Dandy–
Walker malformation, have a similar sonographic
appearancebutaverydifferentprognosis
Conclusion
Sunday, July 28, 13

85
In
Summary
Sunday, July 28, 13

Examination Of The Posterior Fossa And
The Cerebellum
Midsagittal ViewsAxial View
86
Sunday, July 28, 13

PracEcal
Approach
to
the
DD
of
Posterior
Fossa

Cyst
and
CysEc
like
Lesions
Sunday, July 28, 13

PracEcal
Approach
to
the
DD
of
Posterior
Fossa

Cyst
and
CysEc
like
Lesions
1. Is
the
Vermis
Present?Is
the
Vermis
intact?
Sunday, July 28, 13

PracEcal
Approach
to
the
DD
of
Posterior
Fossa

Cyst
and
CysEc
like
Lesions
1. Is
the
Vermis
Present?Is
the
Vermis
intact?
2. Is
the
Toruclar
in
a
normal
posiEon
(tentorial

Cerebelli)?
Sunday, July 28, 13

PracEcal
Approach
to
the
DD
of
Posterior
Fossa

Cyst
and
CysEc
like
Lesions
1. Is
the
Vermis
Present?Is
the
Vermis
intact?
2. Is
the
Toruclar
in
a
normal
posiEon
(tentorial

Cerebelli)?
3. What
is
the
shape
of
the
cerebellar
cled?
Sunday, July 28, 13

PracEcal
Approach
to
the
DD
of
Posterior
Fossa

Cyst
and
CysEc
like
Lesions
1. Is
the
Vermis
Present?Is
the
Vermis
intact?
2. Is
the
Toruclar
in
a
normal
posiEon
(tentorial

Cerebelli)?
3. What
is
the
shape
of
the
cerebellar
cled?
4. Brainstem–vermis (BV) Angle And Brainstem–
tentorium (BT) Angle
Sunday, July 28, 13

88
Published online 14 May 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.11071
Prenatal diagnosis and outcome of fetal posterior fossa fluid
collections
G. GANDOLFI COLLEONI*, E. CONTRO*, A. CARLETTI*, T. GHI*, G. CAMPOBASSO†,
G. REMBOUSKOS†, G. VOLPE‡, G. PILU* and P. VOLPE†
*Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy; †Fetal Medicine Unit, Di Venere and Sarcone Hospitals,
ASL Bari, Bari, Italy; ‡Department of Obstetrics and Gynecology, University of Bari, Bari, Italy
KEYWORDS: cerebellar anomalies; Dandy–Walker malformation; fetus; megacisterna magna; prenatal diagnosis; ultrasound
ABSTRACT
Objective To evaluate the accuracy of fetal imaging
in differentiating between diagnoses involving posterior
fossa fluid collections and to investigate the postnatal
outcome of affected infants.
Methods This was a retrospective study of fetuses with
posterior fossa fluid collections, carried out between 2001
and 2010 in two referral centers for prenatal diagnosis. All
fetuses underwent multiplanar neurosonography. Parents
were also offered fetal magnetic resonance imaging (MRI)
and karyotyping. Prenatal diagnosis was compared with
autopsy or postnatal MRI findings and detailed follow-up
was attempted by consultation of medical records and
interview with parents and pediatricians.
Results During the study period, 105 fetuses were exam-
fluid collections from mid gestation. Blake’s pouch cyst
and megacisterna magna are risk factors for associated
anomalies but when isolated have an excellent prognosis,
with a high probability of intrauterine resolution and
normal intellectual development in almost all cases.
Conversely, Dandy–Walker malformation and vermian
hypoplasia, even when they appear isolated antenatally,
are associated with an abnormal outcome in half of cases.
Copyright © 2012 ISUOG. Published by John Wiley &
Sons, Ltd.
INTRODUCTION
Fluid collections in the fetal posterior fossa encompass
a wide spectrum of different entities, ranging from
normal variants to severe anomalies1
. They may have
Figure 1 Categorization of posterior fossa fluid collections on ultrasound: (a,b) Blake’s pouch cyst; (c,d) megacisterna magna; (e,f) vermian
hypoplasia; (g,h) Dandy–Walker malformation; (i,j) cerebellar hypoplasia; (k,l) arachnoid cyst of the posterior fossa.
Blacke’s
Pouch
Cyst Cystegacisterna
Magna
Vermian
Hypoplasia D-‐W
Malforma,on
Cerebellar
Hypoplasia Arachinoid
Cyst-‐Pos
Fossa

Sunday, July 28, 13

Originally
published
in
Ultrasound
Obstet
Gynecol
2007;
30:
233–245
Normal Megacisterna
magna Blake’s
pouch
cyst
Vermian
hypoplasia Dandy-‐Walker
malforma,on
tentorium
89
Sunday, July 28, 13

Standard
and
Fetal

Neurosonography
90
Take
Home
Message
Sunday, July 28, 13

91
✦examina,on
of
the
Fetal
CNS
should
be
follow
a

Standard
Protocol
Sunday, July 28, 13

91
✦examina,on
of
the
Fetal
CNS
should
be
follow
a

Standard
Protocol
✦Examina,on
should
include
at
least
three
axial

planes.
Sunday, July 28, 13

91
✦examina,on
of
the
Fetal
CNS
should
be
follow
a

Standard
Protocol
✦Examina,on
should
include
at
least
three
axial

planes.
✦In
Each
plane
the
deﬁned
landmarks
should

should
be
reported
as
normal
or
suspicious
Sunday, July 28, 13

91
✦examina,on
of
the
Fetal
CNS
should
be
follow
a

Standard
Protocol
✦Examina,on
should
include
at
least
three
axial

planes.
✦In
Each
plane
the
deﬁned
landmarks
should

should
be
reported
as
normal
or
suspicious
✦In
the
presence
of
possible
abnormali,es
pa,ent

should
be
referred
for
detailed
neuorsonogram

which
include
mutli-‐planner
3
D
Sanning.
Sunday, July 28, 13

91
✦examina,on
of
the
Fetal
CNS
should
be
follow
a

Standard
Protocol
✦Examina,on
should
include
at
least
three
axial

planes.
✦In
Each
plane
the
deﬁned
landmarks
should

should
be
reported
as
normal
or
suspicious
✦In
the
presence
of
possible
abnormali,es
pa,ent

should
be
referred
for
detailed
neuorsonogram

which
include
mutli-‐planner
3
D
Sanning.
✦3
D
scanning
with
mul,planner
analysis
oﬀers

comparable
analysis
to
fetal
MRI
Sunday, July 28, 13

92
Thanks

Sunday, July 28, 13

Fetal neurosonogram jucog feb 2013

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