Is fetal cerebral MRI worthwhile in antenatally diagnosed isolated cleft lip with or without palate?

Alveolar Cleft Size on Prenatal Two-Dimensional Ultrasonography Predicts Cleft of the Secondary Palate in Unilateral Cleft Lip

SUMMARY

Prenatal diagnosis of cleft palate (CP) is challenging. The current study's objective was to investigate whether prenatal alveolar cleft width is associated with the likelihood of a cleft of the secondary palate in unilateral cleft lip (CL). The authors reviewed two-dimensional ultrasound (US) images in fetuses with unilateral CL from January of 2012 to February of 2016. Images of the fetal face were obtained with a linear and/or curved probe in the axial and coronal planes. Measurements of the alveolar ridge gap were taken by the senior radiologist. Postnatal phenotype findings were compared with prenatal findings. Thirty patients with unilateral CL met inclusion criteria; average gestational age was 26.67 ± 5.11 weeks (range, 20.71 to 36.57 weeks). Ten fetuses were found to have an intact alveolar ridge by prenatal US; postnatal examination confirmed intact secondary palate in all. Small alveolar defects (<4 mm) were noted in three fetuses; postnatal examination documented CP in a single patient. CP was confirmed in 15 of the remaining 17 fetuses who had alveolar cleft width greater than 4 mm. An alveolar defect of greater than or equal to 4 mm on prenatal US was associated with greater likelihood of a cleft of the secondary palate [c 2 (2, n = 30) = 20.23; P < 0.001]. In the setting of unilateral CL, prenatal US documentation of alveolar defects greater than or equal to 4 mm are highly predictive of the presence of a cleft of the secondary palate. Conversely, an intact alveolar ridge is associated with an intact secondary palate.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Diagnostic, II.

Contribution of computed tomography and magnetic resonance imaging in the analysis of fetal craniofacial malformations

A wide range of craniofacial malformations can be diagnosed in utero using ultrasonography. However, even with highly experienced sonographers and diagnostic physicians and optimal conditions of examination, some anatomical structures cannot be properly analyzed by this technique. The aim of this pictorial essay is to show the additional value of fetal magnetic resonance imaging and computed tomography in this setting and to illustrate the role of these modalities in facial clefts; craniosynostosis; ear, eye and nose abnormalities; otomandibular dysplasias; and facial cephaloceles.

[Ultrasound scan of a fetus with facial cleft must be done from the lip to the uvula: What's new?]

Facial cleft are the most frequent craniofacial anomalies with an incidence of one for 1000 births, all births combined, and require specialized multidisciplinary care. Since 2005, the systematic realization of two ultrasound views (nose-lip and profile) is recommended for the exploration of the fetal face in the 2nd trimester of pregnancy. Application of these recommendations should allow screening of the majority of cleft lip and palate. However, cleft palates, without labiomaxillary involvement, are currently largely underdiagnosed at prenatal ultrasound, although they can be associated with a syndromic diagnosis in up to 30% of cases. The aim of this work is to describe, from embryology to surgical consultation, the complete ultrasound examination of a fetus with a classic facial cleft.

Accurate diagnosis of fetal cleft lip/palate by typical signs of magnetic resonance imaging

OBJECTIVE

This study aims to evaluate the accuracy of magnetic resonance imaging (MRI) in diagnosing orofacial clefts and proposes specific signs for determining the type of cleft.

METHODS

Pregnant women in whom fetal facial malformations are suspected by ultrasonography (US) underwent 1.5 T MRI. The accuracy of the prenatal US and MRI diagnosis was compared with the postnatal findings.

RESULTS

A total of 71 fetuses were included in the final analysis, which comprised of 35 cases of isolated cleft lip, six cases of cleft lip and alveolus, 21 cases of cleft lip and palate, four cases of isolated cleft palate, and five normal fetuses. MRI was more sensitive than US (MRI 100%, US 77.5%; Fisher's exact test: MRI vs US P=0.000). The accuracy of MRI for all types was 100%. Specific signs (Inverted T, L/anti-L, U, and "Notch" signs) were proposed, indicating the normal hard, unilateral cleft, bilateral cleft, and cleft soft palates, respectively, which can facilitate the identification of different types of cleft palates.

CONCLUSION

MRI can accurately diagnose the type of cleft based on typical signs, which can serve as a definite diagnostic modality and an effective supplement of US.

The prenatal diagnosis and classification of cleft palate: the role and value of magnetic resonance imaging

OBJECTIVE

The aim of this study was to evaluate the value of MRI in the prenatal diagnosis and classification of cleft palate (CP).

METHODS

We collected 94 fetal cases that were suspected of cleft palate with or without cleft lip by prenatal ultrasound (US) and then carried out further MRI to examine the entire body of each fetus within 1 week. The diagnoses resulting from MRI and US examination were compared separately with the final diagnoses obtained from postnatal physical examination or fetal autopsy. The diagnostic accuracy between MRI and US was then determined.

RESULTS

During the follow-up period, the results for 6 fetuses (6.38%) were lost. Of the remaining 88 cases, the final diagnoses identified 23 cases of cleft lip (CL), 45 cases of unilateral cleft lip with cleft palate (UCLP), 4 cases of median cleft lip with cleft palate (MCLP), 12 cases of bilateral cleft lip with cleft palate (BCLP), 3 cases of unilateral cleft lip and cleft alveolus (CLA), and 1 case of isolated cleft palate (CPO). The total accuracy rate of US was 59.09%, while that of MRI was 92.05%. More importantly, 81 cases were accurately identified by MRI; the accuracy rate for CL, UCLP, MCLP, BCLP, CLA, and CPO was 86.96%, 95.56%, 100%, 91.67%, 66.67%, and 100%, respectively.

CONCLUSION

Our results suggest that MRI could be a useful adjunct to US examination in the prenatal diagnosis of fetuses with cleft palate, and further demonstrates the classification and degree of involvement of the cleft palate.

KEY POINTS

• MRI is a useful adjunct to prenatal ultrasound. • MRI has a higher accuracy rate for CP. • The accurate classification of CP diagnosed by MRI can guide clinical management.

MR Imaging of the Fetal Face: Comprehensive Review

The human face is a complex anatomic structure with an equally complex embryologic development. Derangement of the developmental process can result in various structural anomalies, which range from a mainly cosmetic deformity, such as cleft lip, to potentially life-threatening conditions such as arhinia. These anomalies (a) can occur as isolated anomalies; (b) can be associated with intracranial, spinal, or dental anomalies; or (c) can be a part of various syndromes, thus serving as diagnostic clues in such cases. Proper evaluation of fetal facial deformities can help in prognostication, family counseling, and prenatal or early postnatal intervention. Ultrasonography (US) is the first line of investigation in these cases. However, when US does not allow complete evaluation of these anomalies owing to its inherent limitations, magnetic resonance (MR) imaging allows comprehensive evaluation of the anomaly itself and also evaluation of various associations and the treatment approach. The embryology of the fetal facial structures is considered with regard to the MR imaging technique and the MR imaging anatomy. The MR imaging features of various structural anomalies are described and classified into six groups, namely, orofacial clefts, orbital anomalies, nasal anomalies, facial masses, external ear anomalies, and abnormal face shape or profile. Also, the key associations and relevant treatment implications are reviewed. The article provides a "one-stop shop" review of these unique disorders-from basic understanding of the embryology to applying the knowledge in clinical practice, helping the interprofessional team and the patients alike. ^©RSNA, 2018.

Additional post-natal diagnoses following antenatal diagnosis of isolated cleft lip +/− palate

INTRODUCTION

Cleft lip with or without palate (CLP) can be diagnosed antenatally through ultrasound, and may be categorised as apparently isolated versus associated with other malformations. Limited data exist on the long-term outcomes following antenatal diagnosis of apparently isolated CLP.

AIM

This study examined the long-term post-natal outcomes of CLP when found in isolation antenatally, in order to determine the rates of unexpected additional anomalies, developmental delay or genetic syndromes.

PATIENTS AND METHODS

A retrospective chart review of antenatal and post-natal medical charts was completed for a ten-year period between January 2000 and December 2009. At least 2 years of available post-natal clinical information was required for inclusion in the study.

RESULTS

A total of 97 cases of antenatally isolated CLP were ascertained. Fifteen pregnancies were terminated. Follow-up data were available for 81 liveborns, though 4 were lost to follow-up prior to 2 years of age. Twelve of the 77 children meeting study criteria were identified to have other major malformations and/or developmental disability either later in the pregnancy or post-natally. Findings included familial clefting syndromes, trisomy 21, autism spectrum disorders, brain malformations, fetal alcohol syndrome and Kabuki syndrome, among other findings. Another 11 children had additional anomalies of minor impact. Examples of findings include a perimembranous ventricular septal defect, mild unilateral optic nerve hypoplasia, mild pulmonary artery stenosis with a small atrial septal defect, and transient delays in fine and gross motor skills. No children with clefting of the lip only had major additional diagnoses.