1
|
Moeremans M, Avni FE, d'Haene N, Lam NM, Metens T, D'Hondt A. Combined prenatal US and post-mortem fetal MRI: can they replace conventional autopsy for fetal body abnormalities? Eur Radiol 2024; 34:632-642. [PMID: 37526669 DOI: 10.1007/s00330-023-09847-y] [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: 01/15/2023] [Revised: 05/06/2023] [Accepted: 05/16/2023] [Indexed: 08/02/2023]
Abstract
OBJECTIVES The acceptance of conventional autopsy (CA), the gold standard method for investigating fetal death, often remains problematic. Post-mortem magnetic resonance imaging (PMMRI) is increasingly advocated, particularly for neurologic malformations. However, PMMRI performances to diagnose non-neurologic malformations remain unclear. We aim to clarify whether a full body CA remains needed after prenatal ultrasound (US) and PMMRI in assessing non-neurologic fetal malformations. METHODS In this retrospective IRB-approved study, during a 6-year period, all fetuses who underwent PMMRI, prenatal US, and full body CA were included. Body abnormalities were identified in US, PMMRI, and CA reports. US and PMMRI images were all reviewed. All abnormalities were graded as major (2 points) or minor (1 point). Each technique (US, PMMRI, CA) was given a score by adding all grading points. In each fetus, results were compared for both separate and combined US and PMMRI to CA. Sensitivity and specificity were calculated for detecting major abnormalities. RESULTS Fifty fetuses were included. The score of CA, US, and PMMRI was respectively 53, 37, and 46. Compared with US-PMMRI, CA added information in 2 cases (4%) with major abnormalities and 7 cases (14%) with minor abnormalities. PMMRI and US were concordant in 36/50 (72%) fetuses. Separate US/PMMRI sensitivities and specificities for detecting major body malformations respectively were 80%/80% and 100%/94%. Combined US-PMMRI had a sensitivity of 90% and a specificity of 94%. Two cardiac malformations (2/6) were only described by CA. CONCLUSIONS After prenatal US and PMMRI, few additional fetal body malformations are discovered with CA. Nevertheless, fetal heart autopsy remains mandatory. CLINICAL RELEVANCE STATEMENT A cardiac conventional autopsy complemented by prenatal ultrasound and post-mortem MRI allows to detect all major fetal body abnormalities. With this efficient and much less invasive approach, a higher acceptance rate of fetal autopsy can be expected. KEY POINTS • Excepting cardiac malformations, most major fetal body malformations can reliably be identified by prenatal US combined with post-mortem MRI. • In the post-mortem diagnosis of fetal body malformations, a conventional autopsy limited to the fetal heart might replace a full body autopsy after a well-conducted prenatal US and post-mortem MRI.
Collapse
Affiliation(s)
- Marine Moeremans
- Department of Radiology, Hôpital Delta (CHIREC), 1160, Brussels, Belgium.
| | - Fred E Avni
- Department of Radiology, Hôpital Delta (CHIREC), 1160, Brussels, Belgium
| | - Nicky d'Haene
- Department of Pathology, Hospital Erasme, Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Ngoc My Lam
- Department of Pathology, Hospital Erasme, Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Thierry Metens
- Department of Radiology, Hôpital Erasme, Université Libre de Bruxelles (ULB), 1070, Brussels, Belgium
| | - Aurélie D'Hondt
- Department of Radiology, Hôpital Delta (CHIREC), 1160, Brussels, Belgium
| |
Collapse
|
2
|
Gupta N, Langeh N, Sharma A, Mridha A, Jana M, Barwad A, Mani K, Dadhwal V, Kumar A, Deka D, Kabra M. Minimally invasive autopsy in the evaluation of fetal malformations and stillbirths: A feasibility study. Birth Defects Res 2024; 116:e2280. [PMID: 38087877 DOI: 10.1002/bdr2.2280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 09/30/2023] [Accepted: 11/26/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Minimally invasive autopsy (MIA) using post-mortem magnetic resonance imaging with ancillary investigations is reported as accurate as conventional autopsy. This study assesses MIA's feasibility and accuracy compared to conventional autopsy. METHOD MIA and/or conventional autopsy were performed on malformed fetuses (14-20 weeks gestation) and stillbirths (>20 weeks gestation), with/without malformation. Concordance in diagnostic accuracy (95% confidence interval [CI]) and agreement (Kappa coefficient [k]) were assessed in malformed cases where both MIA and autopsy were conducted. RESULTS We enrolled 200 cases, including 100 malformed fetuses (<20 weeks) and 100 stillbirths (with/without malformations). Concordance of 97.3% was observed between MIA and autopsy in 156 malformed cases. The overall diagnostic accuracy of MIA was 96.04%. CONCLUSION While conventional autopsy remains the gold standard, MIA is feasible in tertiary care settings. It can be considered a potential alternative for post-mortem assessment, particularly in settings with limited facility of conventional autopsy and parental refusal.
Collapse
Affiliation(s)
- Neerja Gupta
- Department of Pediatrics, Division of Genetics, AIIMS, New Delhi, India
| | - Nitika Langeh
- Department of Pediatrics, Division of Genetics, AIIMS, New Delhi, India
| | - Aparna Sharma
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Asit Mridha
- Department of Pathology, AIIMS, New Delhi, India
| | - Manisha Jana
- Department of Radiodiagnosis, AIIMS, New Delhi, India
| | | | | | - Vatsla Dadhwal
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Atin Kumar
- Department of Radiodiagnosis, AIIMS, New Delhi, India
| | - Dipika Deka
- Department of Obstetrics and Gynaecology, AIIMS, New Delhi, India
| | - Madhulika Kabra
- Department of Pediatrics, Division of Genetics, AIIMS, New Delhi, India
| |
Collapse
|
3
|
De Keersmaecker B, Dendas W, Aertsen M, De Catte L. Postmortem MR in termination of pregnancy for central nervous system (CNS) anomalies. J Matern Fetal Neonatal Med 2023; 36:2197098. [PMID: 37031966 DOI: 10.1080/14767058.2023.2197098] [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: 04/11/2023]
Abstract
OBJECTIVES To evaluate the concordance of conventional autopsy (CA) and postmortem magnetic resonance (MR) after termination of pregnancy (TOP) in fetuses with prenatally detected central nervous system (CNS) anomalies. Second, to determine the most informative postmortem investigation in parental counseling. METHODS All TOPs between 2006 and 2016 with prenatally detected CNS involvement and having a postmortem MR and CA as postmortem examinations were retrospectively analyzed and concordance levels were established. RESULTS Of 764 TOPs, 255 cases had a CNS anomaly detected prenatally (33.4%). Fetal genetic anomalies (n = 40) and cases without both postmortem MR and CA were excluded, leaving 68 cases for analysis.Disagreement between postmortem MR and CA was observed in 22 cases (32.4%). In eight cases (11.8%), more information was obtained by CA compared with MR. However, only two cases with major additional findings were found when compared with prenatal diagnosis. In 14 cases (20.6%), MR was superior to CA either because of additional cerebral anomalies undetected by CA (n = 5) and/or because of severe autolysis hindering pathology of the CNS (n = 9). CONCLUSIONS Our data point out that an adequate postmortem evaluation, valuable in parental counseling, can be provided by a postmortem MR in 97% of the cases.Key PointsAn adequate postmortem evaluation, valuable in parental counseling, can be provided by a postmortem (PM) magnetic resonance (MR) in the majority of cases.PM MR is an excellent postmortem imaging tool for the brain.In cases with brain autolysis, PM MR is often the only informative PM investigation tool.PM MR is an essential adjunct to CA in the PM evaluation of pregnancies terminated for a central nervous system (CNS) anomaly.
Collapse
Affiliation(s)
- Bart De Keersmaecker
- Department of Obstetrics and Gynecology, University Hospital Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, AZ Groeninge, Kortrijk, Belgium
| | - Wendy Dendas
- Department of Obstetrics and Gynecology, University Hospital Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, Sint-Trudo Hospital, Sint-Truiden, Belgium
| | - Michael Aertsen
- Department of Radiology, University Hospital Leuven, Leuven, Belgium
| | - Luc De Catte
- Department of Obstetrics and Gynecology, University Hospital Leuven, Leuven, Belgium
| |
Collapse
|
4
|
Simcock IC, Lamouroux A, Sebire NJ, Shelmerdine SC, Arthurs OJ. Less-invasive autopsy for early pregnancy loss. Prenat Diagn 2023; 43:937-949. [PMID: 37127547 DOI: 10.1002/pd.6361] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/03/2023]
Abstract
Autopsy investigations provide valuable information regarding fetal death that can assist in the parental bereavement process, and influence future pregnancies, but conventional autopsy is often declined by parents because of its invasive approach. This has led to the development of less-invasive autopsy investigations based on imaging technology to provide a more accessible and acceptable choice for parents when investigating their loss. Whilst the development and use of more conventional clinical imaging techniques (radiographs, CT, MRI, US) are well described in the literature for fetuses over 20 weeks of gestational age, these investigations have limited diagnostic accuracy in imaging smaller fetuses. Techniques such as ultra-high-field MRI (>3T) and micro-focus computed tomography have been shown to have higher diagnostic accuracy whilst still being acceptable to parents. By further developing and increasing the availability of these more innovative imaging techniques, parents will be provided with a greater choice of acceptable options to investigate their loss, which may in turn increase their uptake. We provide a narrative review focussing on the development of high-resolution, non-invasive imaging techniques to evaluate early gestational pregnancy loss.
Collapse
Affiliation(s)
- Ian C Simcock
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Audrey Lamouroux
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- Obstetrical Gynaecology Department, Nîmes University Hospital, Nîmes, France
- Clinical Genetics Department, Montpellier University Hospital, Montpellier, France
- ICAR Research Team, LIRMM, CNRS and Charles Coulomb Laboratory, UMR 5221 CNRS-UM, BNIF User Facility Imaging, University of Montpellier, Nîmes and Montpellier, Montpellier, France
| | - Neil J Sebire
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children, London, UK
| | - Susan C Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Owen J Arthurs
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| |
Collapse
|
5
|
O'Keefe H, Shenfine R, Brown M, Beyer F, Rankin J. Are non-invasive or minimally invasive autopsy techniques for detecting cause of death in prenates, neonates and infants accurate? A systematic review of diagnostic test accuracy. BMJ Open 2023; 13:e064774. [PMID: 36609326 PMCID: PMC9827258 DOI: 10.1136/bmjopen-2022-064774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 12/04/2022] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To assess the diagnostic accuracy of non-invasive or minimally invasive autopsy techniques in deaths under 1 year of age. DESIGN This is a systematic review of diagnostic test accuracy. The protocol is registered on PROSPERO. PARTICIPANTS Deaths from conception to one adjusted year of age. SEARCH METHODS MEDLINE (Ovid), EMBASE (Ovid), CINAHL (EBSCO), the Cochrane Library, Scopus and grey literature sources were searched from inception to November 2021. DIAGNOSTIC TESTS Non-invasive or minimally invasive diagnostic tests as an alternative to traditional autopsy. DATA COLLECTION AND ANALYSIS Studies were included if participants were under one adjusted year of age, with index tests conducted prior to the reference standard.Data were extracted from eligible studies using piloted forms. Risk of bias was assessed using Quality Assessment of Diagnostic Accuracy Studies-2. A narrative synthesis was conducted following the Synthesis without Meta-Analysis guidelines. Vote counting was used to assess the direction of effect. MAIN OUTCOME MEASURES Direction of effect was expressed as percentage of patients per study. FINDINGS We included 54 direct evidence studies (68 articles/trials), encompassing 3268 cases and eight index tests. The direction of effect was positive for postmortem ultrasound and antenatal echography, although with varying levels of success. Conversely, the direction of effect was against virtual autopsy. For the remaining tests, the direction of effect was inconclusive.A further 134 indirect evidence studies (135 articles/trials) were included, encompassing 6242 perinatal cases. The addition of these results had minimal impact on the direct findings yet did reveal other techniques, which may be favourable alternatives to autopsy.Seven trial registrations were included but yielded no results. CONCLUSIONS Current evidence is insufficient to make firm conclusions about the generalised use of non-invasive or minimally invasive autopsy techniques in relation to all perinatal population groups.PROSPERO registration numberCRD42021223254.
Collapse
Affiliation(s)
- Hannah O'Keefe
- NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Rebekka Shenfine
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Melissa Brown
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Fiona Beyer
- NIHR Innovation Observatory, Newcastle University, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Judith Rankin
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| |
Collapse
|
6
|
Tijssen MPM, Robben SGF, Klein WM, Hofman PAM. Postmortem Diffusion-Weighted Magnetic Resonance Imaging of the Brain in Perinatal Death: An Animal Control Study to Detect the Influence of Postmortem Interval. Top Magn Reson Imaging 2022; 31:43-50. [PMID: 36305817 DOI: 10.1097/rmr.0000000000000299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Accepted: 08/26/2022] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Diffusion-weighted imaging may be useful as part of a postmortem magnetic resonance imaging protocol. However, apart from the effect of temperature on apparent diffusion coefficient (ADC), normal postmortem ADC changes can influence the interpretation. Therefore, this study was conducted to evaluate the correlation between normal ADC changes and postmortem intervals (PMIs) and develop a reference standard for postmortem changes after temperature correction. MATERIALS AND METHODS Six premature lambs were scanned at different PMIs. ADC values were measured at different parenchymal locations. Correlation and linear regression between ADC values and PMI were analyzed for all locations, both uncorrected and corrected for temperature. RESULTS All locations showed a significant negative correlation between the PMI and ADC value, with (R2 = 0.581-0.837, P < 0.001) and without (R2 = 0.183-0.555, P < 0.001-0.018) temperature correction. CONCLUSIONS The postmortem interval is negatively correlated with ADC values in the brain. A correlation coefficient for the PMI can be calculated after temperature correction to predict ADC changes. However, further research is required to evaluate its clinical application in humans.
Collapse
Affiliation(s)
- Maud P M Tijssen
- Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands; and
| | - Simon G F Robben
- Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands; and
| | - Willemijn M Klein
- Department of Radiology, Radboud University Medical Center, Nijmegen, the Netherlands
| | - Paul A M Hofman
- Department of Radiology, Maastricht University Medical Center, Maastricht, the Netherlands; and
| |
Collapse
|
7
|
Shelmerdine SC, Arthurs OJ. Post-mortem perinatal imaging: what is the evidence? Br J Radiol 2022:20211078. [PMID: 35451852 DOI: 10.1259/bjr.20211078] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Post-mortem imaging for the investigation of perinatal deaths is an acceptable tool amongst parents and religious groups, enabling a less invasive autopsy examination. Nevertheless, availability is scarce nationwide, and there is some debate amongst radiologists regarding the best practice and optimal protocols for performing such studies. Much of the published literature to date focusses on single centre experiences or interesting case reports. Diagnostic accuracy studies are available for a variety of individual imaging modalities (e.g. post-mortem CT, MRI, ultrasound and micro-CT), however, assimilating this information is important when attempting to start a local service.In this article, we present a comprehensive review summarising the latest research, recently published international guidelines, and describe which imaging modalities are best suited for specific indications. When the antenatal clinical findings are not supported by the post-mortem imaging, we also suggest how and when an invasive autopsy may be considered. In general, a collaborative working relationship within a multidisciplinary team (consisting of radiologists, radiographers, the local pathology department, mortuary staff, foetal medicine specialists, obstetricians and bereavement midwives) is vital for a successful service.
Collapse
Affiliation(s)
- Susan C Shelmerdine
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, 30 Guilford Street, Bloomsbury, London, UK.,Department of Radiology, St. George's Hospital, Blackshaw Road, London, UK
| | - Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, 30 Guilford Street, Bloomsbury, London, UK
| |
Collapse
|
8
|
Tijssen MPM, Hofman PAM, Robben SGF. Postmortem Fetal Temperature Estimation with Magnetic Resonance Imaging: Apparent Diffusion Coefficient Measurements in the Vitreous Body and Cerebrospinal Fluid. Top Magn Reson Imaging 2022; 31:25-30. [PMID: 36269228 DOI: 10.1097/rmr.0000000000000295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
OBJECTIVES Magnetic resonance imaging (MRI) is increasingly used in postmortem fetal imaging. Several factors influence the quality of MRI in this setting, such as small size, autolytic and maceration changes, and temperature. Knowing the fetal temperature at the time of scanning can improve the MRI interpretation. Temperature can be calculated using diffusion-weighted imaging with measurements of the apparent diffusion coefficient (ADC) in the cerebrospinal fluid (CSF). However, this is complicated by small ventricle size and hemorrhage and, therefore, may be unreliable in postmortem imaging. The current study evaluated the feasibility and reliability of using the ADC for temperature measurements of the vitreous body compared to that of CSF. MATERIALS AND METHODS Two lambs were scanned postmortem at five different time points over 28 hours. Furthermore, 10 stillborn fetuses were scanned once, at 4 to 62 hours after birth. The temperature was measured with a digital thermometer and calculated using the ADCs of the vitreous body (lambs and fetuses) and CSF (fetuses). RESULTS There was an excellent correlation between measured and calculated temperatures in vitreous bodies of lambs (r = 0.997, P < 0.001) and fetuses (r = 0.970, P < 0.001). The correlation between measured and calculated temperatures in the CSF was poor (r = 0.522, P = 0.122). CONCLUSION The calculation of the temperature based on the ADC of the vitreous body is feasible and reliable for postmortem fetal imaging.
Collapse
Affiliation(s)
- Maud P M Tijssen
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | | |
Collapse
|
9
|
Simcock IC, Shelmerdine SC, Langan D, Anna G, Sebire NJ, Arthurs OJ. Micro-CT yields high image quality in human fetal post-mortem imaging despite maceration. BMC Med Imaging 2021; 21:128. [PMID: 34429085 PMCID: PMC8383392 DOI: 10.1186/s12880-021-00658-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2021] [Accepted: 08/01/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Current clinical post-mortem imaging techniques do not provide sufficiently high-resolution imaging for smaller fetuses after pregnancy loss. Post-mortem micro-CT is a non-invasive technique that can deliver high diagnostic accuracy for these smaller fetuses. The purpose of the study is to identify the main predictors of image quality for human fetal post-mortem micro-CT imaging. METHODS Human fetuses were imaged using micro-CT following potassium tri-iodide tissue preparation, and axial head and chest views were assessed for image quality on a Likert scale by two blinded radiologists. Simple and multivariable linear regression models were performed with demographic details, iodination, tissue maceration score and imaging parameters as predictor variables. RESULTS 258 fetuses were assessed, with median weight 41.7 g (2.6-350 g) and mean gestational age 16 weeks (11-24 weeks). A high image quality score (> 6.5) was achieved in 95% of micro-CT studies, higher for the head (median = 9) than chest (median = 8.5) imaging. The strongest negative predictors of image quality were increasing maceration and body weight (p < 0.001), with number of projections being the best positive imaging predictor. CONCLUSIONS High micro-CT image quality score is achievable following early pregnancy loss despite fetal maceration, particularly in smaller fetuses where conventional autopsy may be particularly challenging. These findings will help establish clinical micro-CT imaging services, addressing the need for less invasive fetal autopsy methods.
Collapse
Affiliation(s)
- Ian Craig Simcock
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK.
- Great Ormond Street Hospital for Children, UCL Great Ormond Street Institute of Child Health, London, UK.
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK.
| | - Susan Cheng Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Hospital for Children, UCL Great Ormond Street Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Dean Langan
- Great Ormond Street Hospital for Children, UCL Great Ormond Street Institute of Child Health, London, UK
| | - Guy Anna
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Hospital for Children, UCL Great Ormond Street Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Neil James Sebire
- Great Ormond Street Hospital for Children, UCL Great Ormond Street Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children, London, UK
| | - Owen John Arthurs
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK
- Great Ormond Street Hospital for Children, UCL Great Ormond Street Institute of Child Health, London, UK
- NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| |
Collapse
|
10
|
Shelmerdine SC, Hutchinson JC, Lewis C, Simcock IC, Sekar T, Sebire NJ, Arthurs OJ. A pragmatic evidence-based approach to post-mortem perinatal imaging. Insights Imaging 2021; 12:101. [PMID: 34264420 PMCID: PMC8282801 DOI: 10.1186/s13244-021-01042-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2021] [Accepted: 06/24/2021] [Indexed: 12/16/2022] Open
Abstract
Post-mortem imaging has a high acceptance rate amongst parents and healthcare professionals as a non-invasive method for investigating perinatal deaths. Previously viewed as a 'niche' subspecialty, it is becoming increasingly requested, with general radiologists now more frequently asked to oversee and advise on appropriate imaging protocols. Much of the current literature to date has focussed on diagnostic accuracy and clinical experiences of individual centres and their imaging techniques (e.g. post-mortem CT, MRI, ultrasound and micro-CT), and pragmatic, evidence-based guidance for how to approach such referrals in real-world practice is lacking. In this review, we summarise the latest research and provide an approach and flowchart to aid decision-making for perinatal post-mortem imaging. We highlight key aspects of the maternal and antenatal history that radiologists should consider when protocolling studies (e.g. antenatal imaging findings and history), and emphasise important factors that could impact the diagnostic quality of post-mortem imaging examinations (e.g. post-mortem weight and time interval). Considerations regarding when ancillary post-mortem image-guided biopsy tests are beneficial are also addressed, and we provide key references for imaging protocols for a variety of cross-sectional imaging modalities.
Collapse
Affiliation(s)
- Susan C Shelmerdine
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK. .,UCL Great Ormond Street Institute of Child Health, London, UK. .,Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK.
| | - J Ciaran Hutchinson
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
| | - Celine Lewis
- Population, Policy and Practice Department, UCL GOS Institute of Child Health, London, UK.,North Thames Genomic Laboratory Hub, Great Ormond Street Hospital, London, UK
| | - Ian C Simcock
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
| | - Thivya Sekar
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
| | - Neil J Sebire
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
| | - Owen J Arthurs
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.,UCL Great Ormond Street Institute of Child Health, London, UK.,Great Ormond Street Hospital NIHR Biomedical Research Centre, London, UK
| |
Collapse
|
11
|
Simcock IC, Shelmerdine SC, Hutchinson JC, Sebire NJ, Arthurs OJ. Human fetal whole-body postmortem microfocus computed tomographic imaging. Nat Protoc 2021; 16:2594-2614. [PMID: 33854254 DOI: 10.1038/s41596-021-00512-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 01/05/2021] [Indexed: 02/02/2023]
Abstract
Perinatal autopsy is the standard method for investigating fetal death; however, it requires dissection of the fetus. Human fetal microfocus computed tomography (micro-CT) provides a generally more acceptable and less invasive imaging alternative for bereaved parents to determine the cause of early pregnancy loss compared with conventional autopsy techniques. In this protocol, we describe the four main stages required to image fetuses using micro-CT. Preparation of the fetus includes staining with the contrast agent potassium triiodide and takes 3-19 d, depending on the size of the fetus and the time taken to obtain consent for the procedure. Setup for imaging requires appropriate positioning of the fetus and takes 1 h. The actual imaging takes, on average, 2 h 40 min and involves initial test scans followed by high-definition diagnostic scans. Postimaging, 3 d are required to postprocess the fetus, including removal of the stain, and also to undertake artifact recognition and data transfer. This procedure produces high-resolution isotropic datasets, allowing for radio-pathological interpretations to be made and long-term digital archiving for re-review and data sharing, where required. The protocol can be undertaken following appropriate training, which includes both the use of micro-CT techniques and handling of postmortem tissue.
Collapse
Affiliation(s)
- Ian C Simcock
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK.,UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - Susan C Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK.,UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - J Ciaran Hutchinson
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK.,Department of Histopathology, Great Ormond Street Hospital for Children, London, UK
| | - Neil J Sebire
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK.,Department of Histopathology, Great Ormond Street Hospital for Children, London, UK
| | - Owen J Arthurs
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, UK. .,UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, UK. .,NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK.
| |
Collapse
|
12
|
Abstract
PURPOSE OF REVIEW Uptake of perinatal autopsy has declined in the West over the past 30 years, largely because of reduced parental acceptance of a traditional invasive autopsy. Several studies have recently investigated the decline to identify the key factors and how they may be mitigated. RECENT FINDINGS Three main themes were identified that have been found to improve uptake of perinatal autopsy: improved communication, in particular ensuring the consent process was conducted as a conversation with time spent talking through the procedure and allowing time for questions; health professional training to ensure staff discussing autopsy with parents have adequate understanding of the procedure and are able to convey confidence and empathy; and availability of less invasive autopsy, including noninvasive as well as minimally invasive options. These should be offered alongside standard autopsy, which some parents may still prefer. SUMMARY This review highlights that the discussions that take place, and the options that are available to parents, can profoundly impact whether or not they consent to autopsy investigation. Further research should focus on the impact of offering less invasive options as well as evaluating the training and support materials that have recently been developed.
Collapse
Affiliation(s)
- Celine Lewis
- Population, Policy and Practice, UCL Great Ormond Street Institute of Child Health
- North Thames Genomic Laboratory Hub, Great Ormond Street NHS Foundation Trust
| | - Ian C Simcock
- Department of Clinical Radiology, Great Ormond Street Hospital for Children
- UCL Great Ormond Street Institute of Child Health
- National Institute for Health Research Biomedical Research Centre, Great Ormond Street Hospital, London, United Kingdom
| | - Owen J Arthurs
- Department of Clinical Radiology, Great Ormond Street Hospital for Children
- UCL Great Ormond Street Institute of Child Health
- National Institute for Health Research Biomedical Research Centre, Great Ormond Street Hospital, London, United Kingdom
| |
Collapse
|
13
|
Tumanova UN, Shchegolev AI, Kovalev AV. [Technical and methodological support for postmortem radiation examinations in the pathological departments and the forensic bureau]. Sud Med Ekspert 2021; 64:51-57. [PMID: 33739071 DOI: 10.17116/sudmed20216402151] [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: 11/17/2022]
Abstract
The purpose of the work is to analyze the technical and methodological features of postmortem radiation studies based on literature data and the results of our own experience. To designate such studies, the term thanatoradiology has been proposed. The basis for the effective conduct of a thanatodiological examination is adequate technical support, which equally consists of the capabilities of the equipment for obtaining radiographs, CT and MR tomograms (type and generation of the device, technical features of a particular model), as well as the capabilities of the radiologist's workstation with the help of which the computer processing of the obtained images is carried out, three-dimensional reconstructions are performed, the calculation of planar and volumetric parameters and additional information is obtained. The use of an X-ray unit allows one to assess only pronounced pathology and the presence of foreign objects. The effectiveness of a computed tomography device depends on the choice of the slice thickness and the step of the examination table. Research on a magnetic resonance imager is effective at certain magnetic induction strength, the form of a magnetic coil and the used mode of recording a pulse sequence. The objectivity and efficiency of digital processing of tomograms consists of the type of a radiologist's workstation and installed programs for post-processing tomograms, including for modeling three-dimensional images and color mapping. The choice of a specific method of postmortem radiation research should be determined mainly by the research objectives. Research should be carried out taking into account age, body weight, individual characteristics and the state of body tissues. Today, it is advisable to use radiation methods as part of a comprehensive pathological and anatomical or forensic medical research to improve the quality and shorten the autopsy duration. The development of a unified protocol for postmortem CT and MRI studies that meets the pathological, anatomical and forensic requirements remains an urgent task.
Collapse
Affiliation(s)
- U N Tumanova
- Acad. V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - A I Shchegolev
- Acad. V.I. Kulakov National Medical Research Center for Obstetrics, Gynecology and Perinatology, Moscow, Russia
| | - A V Kovalev
- Russian Medical Academy of Continuing Postgraduate Education, Moscow, Russia
| |
Collapse
|
14
|
Shelmerdine SC, Sebire NJ, Arthurs OJ. Diagnostic accuracy of postmortem ultrasound vs postmortem 1.5-T MRI for non-invasive perinatal autopsy. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2021; 57:449-458. [PMID: 32149428 PMCID: PMC8432154 DOI: 10.1002/uog.22012] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2019] [Revised: 12/12/2019] [Accepted: 02/14/2020] [Indexed: 06/10/2023]
Abstract
OBJECTIVES To determine the diagnostic accuracy of postmortem magnetic resonance imaging (PM-MRI) and postmortem ultrasound (PM-US) for perinatal autopsy in the same patient cohort, and to determine whether PM-US can provide the same anatomical information as PM-MRI. METHODS In this prospective, 5-year (July 2014-July 2019) single-center study, we performed 1.5-T PM-MRI and PM-US in an unselected cohort of perinatal deaths. The diagnostic accuracies of both modalities were calculated, using autopsy as the reference standard. As a secondary objective, the concordance rates between the two imaging modalities for the overall main diagnosis and for five anatomical regions (brain, spine, thorax, heart and abdomen) were calculated. RESULTS During the study period, 136 cases underwent both PM-US and PM-MRI, of which 88 (64.7%) also underwent autopsy. There was no significant difference in the rates of concordance with autopsy between the two modalities for overall diagnosis (PM-US, 86.4% (95% CI, 77.7-92.0%) vs PM-MRI, 88.6% (95% CI, 80.3-93.7%)) or in the sensitivities and specificities for individual anatomical regions. There were more non-diagnostic PM-US than PM-MRI examinations for the brain (22.8% vs 3.7%) and heart (14.7% vs 5.1%). If an 'imaging-only' autopsy had been performed, PM-US would have achieved the same diagnosis as 1.5-T PM-MRI in 86.8% (95% CI, 80.0-91.5%) of cases, with the highest rates of agreement being for spine (99.3% (95% CI, 95.9-99.9%)) and cardiac (97.3% (95% CI, 92.4-99.1%)) findings and the lowest being for brain diagnoses (85.2% (95% CI, 76.9-90.8%)). CONCLUSION Although there were fewer non-diagnostic cases using PM-MRI than for PM-US, the high concordance rate for overall diagnosis suggests that PM-US could be used for triaging cases when PM-MRI access is limited or unavailable. © 2020 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
Collapse
Affiliation(s)
- S. C. Shelmerdine
- Department of Clinical RadiologyGreat Ormond Street Hospital for ChildrenLondonUK
- UCL Great Ormond Street Institute of Child HealthGreat Ormond Street Hospital for ChildrenLondonUK
| | - N. J. Sebire
- UCL Great Ormond Street Institute of Child HealthGreat Ormond Street Hospital for ChildrenLondonUK
- Department of HistopathologyGreat Ormond Street Hospital for ChildrenLondonUK
- NIHR Great Ormond Street Hospital Biomedical Research CentreLondonUK
| | - O. J. Arthurs
- Department of Clinical RadiologyGreat Ormond Street Hospital for ChildrenLondonUK
- UCL Great Ormond Street Institute of Child HealthGreat Ormond Street Hospital for ChildrenLondonUK
- NIHR Great Ormond Street Hospital Biomedical Research CentreLondonUK
| |
Collapse
|
15
|
Shelmerdine SC, Simcock IC, Hutchinson JC, Guy A, Ashworth MT, Sebire NJ, Arthurs OJ. Postmortem microfocus computed tomography for noninvasive autopsies: experience in >250 human fetuses. Am J Obstet Gynecol 2021; 224:103.e1-103.e15. [PMID: 32682860 PMCID: PMC7805479 DOI: 10.1016/j.ajog.2020.07.019] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 07/02/2020] [Accepted: 07/14/2020] [Indexed: 12/16/2022]
Abstract
Background Noninvasive imaging autopsy alternatives for fetuses weighing <500 grams are limited. Microfocus computed tomography has been reported as a viable option in small case series with the potential to avoid an invasive autopsy. Implementation of postmortem microfocus computed tomography in a large cohort as part of routine clinical service has yet been unreported, and realistic “autopsy prevention rates” are unknown. Objective This study aimed to describe the range of abnormalities detectable on fetal microfocus computed tomography in a clinical setting and additional findings identified on the antenatal ultrasound and to estimate the invasive autopsy avoidance rate (ie, cases in which imaging was sufficient to deem autopsy unnecessary). Study Design A prospective observational case series of all fetuses referred for microfocus computed tomography imaging at a single institution was conducted for 3 years (2016–2019). Imaging was reported by 2 pediatric radiologists before autopsy, with “decision to proceed” based on the specialist perinatal pathologists’ judgment and parental consent. Agreement rates between microfocus computed tomography and antenatal ultrasound were evaluated, and where feasible, diagnostic accuracy for microfocus computed tomography was calculated using autopsy as a reference standard. Results A total of 268 fetuses were included (2–350 grams body weight; 11–24 weeks’ gestation), with cause for demise in 122 of 268 (45.5%). Of the 122 fetuses, 64 (52.5%) exhibited fetal anomalies. Although 221 of 268 (82.5%) fetuses had consent for invasive autopsy, only 29 of the 221 (13.1%) underwent this procedure, which implied an autopsy avoidance rate of 192 of 221 (86.9%). Complete agreement was present for all brain, thoracic, and abdominal pathologies, whereas sensitivity and specificity for cardiac anomalies were 66.7% and 91.7%, respectively. Microfocus computed tomography and antenatal ultrasound agreement was found in 219 of 266 cases (81.9%), with partial agreement in 21 of 266 (7.9%) and disagreement in 26 of 266 (10.5%), mostly because of additional cardiac, soft tissue, or genitourinary findings by microfocus computed tomography, which were not seen on the ultrasound. Conclusion Fetal microfocus computed tomography imaging is a viable and useful tool for imaging early gestational fetuses and can avoid the need for invasive autopsy. Confirmation of antenatal diagnoses is achieved in most cases, and additional anomalies may also be detected.
Collapse
Affiliation(s)
- Susan C Shelmerdine
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, United Kingdom; UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, United Kingdom; National Institute for Health Research Biomedical Research Centre, Great Ormond Street Hospital, London, United Kingdom.
| | - Ian C Simcock
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, United Kingdom; UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, United Kingdom; National Institute for Health Research Biomedical Research Centre, Great Ormond Street Hospital, London, United Kingdom
| | - John Ciaran Hutchinson
- Department of Paediatric Pathology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Anna Guy
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Michael T Ashworth
- Department of Paediatric Pathology, Great Ormond Street Hospital for Children, London, United Kingdom
| | - Neil J Sebire
- UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, United Kingdom; Department of Paediatric Pathology, Great Ormond Street Hospital for Children, London, United Kingdom; National Institute for Health Research Biomedical Research Centre, Great Ormond Street Hospital, London, United Kingdom
| | - Owen J Arthurs
- Department of Clinical Radiology, Great Ormond Street Hospital for Children, London, United Kingdom; UCL Great Ormond Street Institute of Child Health, Great Ormond Street Hospital for Children, London, United Kingdom; National Institute for Health Research Biomedical Research Centre, Great Ormond Street Hospital, London, United Kingdom
| |
Collapse
|
16
|
Reid C, Arthurs OJ, Calder AD, Sebire NJ, Shelmerdine SC. The significance of internal calcifications on perinatal post-mortem radiographs. Clin Radiol 2020; 75:561.e25-561.e34. [PMID: 32252991 PMCID: PMC7296345 DOI: 10.1016/j.crad.2020.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2019] [Accepted: 03/06/2020] [Indexed: 11/29/2022]
Abstract
AIM To determine whether the presence of internal calcifications on perinatal post-mortem skeletal surveys (PMSS) are associated with certain diagnoses of fetal loss. METHODS AND MATERIALS A 6-month retrospective, single-centre, cohort study was conducted on PMSS performed for perinatal death assessment. One reader re-reviewed all PMSS images for the presence and location of internal calcifications, and noted whether these were included within the original radiology report. Findings at autopsy were then reviewed independently by a second researcher and cause of fetal loss or main diagnosis recorded. Chi-squared tests were conducted to identify differences between those with and without internal calcifications at PMSS. RESULTS Two hundred and thirty perinatal deaths (mean gestational age 18 weeks; average 12–35 weeks) were included in the study, of which 42 (18.3%) demonstrated intra-abdominal calcifications, and 16/42 (38.1%) were mentioned in the radiology reports. Most calcifications were found to be within the lumen of the gastrointestinal tract, and in the left upper quadrant of the abdomen. There was no statistical difference between identifiable causes for fetal loss at autopsy in cases with and without calcification at PMSS (59.5% versus 58.5% respectively, p=0.904). Nevertheless, where calcification and a cause for fetal loss were found, the aetiology was more likely to be due a fetal rather than placental issue. CONCLUSION The presence of internal calcifications on PMSS was not associated with an increased likelihood of explainable fetal loss or particular diagnosis at autopsy. Fetal calcifications on post-mortem skeletal surveys are not significantly associated with causes of fetal loss. When present, internal calcifications were usually seen in lower gestational aged fetuses, intra-abdominal in location, with the majority being intraluminal. The majority of radiologists do not report internal fetal calcifications on radiographs, without significant consequences for final outcome at autopsy.
Collapse
Affiliation(s)
- C Reid
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - O J Arthurs
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; UCL Great Ormond Street Institute of Child Health, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - A D Calder
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK
| | - N J Sebire
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; UCL Great Ormond Street Institute of Child Health, London, UK; NIHR Great Ormond Street Hospital Biomedical Research Centre, London, UK
| | - S C Shelmerdine
- Great Ormond Street Hospital for Children NHS Foundation Trust, London WC1N 3JH, UK; UCL Great Ormond Street Institute of Child Health, London, UK.
| |
Collapse
|
17
|
Shelmerdine SC, Langan D, Mandalia U, Sebire NJ, Arthurs OJ. Maceration determines diagnostic yield of fetal and neonatal whole body post-mortem ultrasound. Prenat Diagn 2020; 40:232-243. [PMID: 31743482 PMCID: PMC7028035 DOI: 10.1002/pd.5615] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 11/07/2019] [Accepted: 11/08/2019] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To determine factors in nondiagnostic fetal and neonatal post-mortem ultrasound (PMUS) examinations. METHODS All fetal and neonatal PMUS examinations were included over a 5-year study period (2014-2019). Nondiagnostic image quality by body parts (brain, spine, thorax, cardiac, and abdomen) was recorded and correlated with patient variables. Descriptive statistics and logistic regression analyses were performed to identify significant factors for nondiagnostic studies. RESULTS Two hundred sixty-five PMUS examinations were included, with median gestational age of 22 weeks (12-42 wk), post-mortem weight of 363 g (16-4033 g), and post-mortem interval of 8 days (0-39 d). Diagnostic imaging quality was achieved for 178/265 (67.2%) studies. It was high for abdominal (263/265, 99.2%), thoracic (264/265, 99.6%), and spine (265/265, 100%) but lower for brain (210/265, 79.2%) and cardiac imaging (213/265, 80.4%). Maceration was the best overall predictor for nondiagnostic imaging quality (P < .0001). Post-mortem fetal weight was positively associated with cardiac (P = .0133) and negatively associated with brain imaging quality (P = .0002). Post-mortem interval was not a significant predictor. CONCLUSIONS Fetal maceration was the best predictor for nondiagnostic PMUS, particularly for brain and heart. Fetuses with marked maceration and suspected cardiac or brain anomalies should be prioritised for post-mortem MRI.
Collapse
Affiliation(s)
- Susan Cheng Shelmerdine
- Department of Clinical RadiologyGreat Ormond Street Hospital for ChildrenLondonUK
- UCL Great Ormond Street Institute of Child HealthGreat Ormond Street Hospital for ChildrenLondonUK
| | - Dean Langan
- UCL Great Ormond Street Institute of Child HealthGreat Ormond Street Hospital for ChildrenLondonUK
| | - Uday Mandalia
- Department of Clinical RadiologyGreat Ormond Street Hospital for ChildrenLondonUK
| | - Neil James Sebire
- UCL Great Ormond Street Institute of Child HealthGreat Ormond Street Hospital for ChildrenLondonUK
- Department of HistopathologyGreat Ormond Street Hospital for ChildrenLondonUK
| | - Owen John Arthurs
- Department of Clinical RadiologyGreat Ormond Street Hospital for ChildrenLondonUK
- UCL Great Ormond Street Institute of Child HealthGreat Ormond Street Hospital for ChildrenLondonUK
| |
Collapse
|
18
|
Shelmerdine SC, Hutchinson JC, Arthurs OJ, Sebire NJ. Latest developments in post-mortem foetal imaging. Prenat Diagn 2019; 40:28-37. [PMID: 31525275 DOI: 10.1002/pd.5562] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Revised: 08/29/2019] [Accepted: 09/07/2019] [Indexed: 12/11/2022]
Abstract
A sustained decline in parental consent rates for perinatal autopsies has driven the development of less-invasive methods for death investigation. A wide variety of imaging modalities have been developed for this purpose and include post-mortem whole body magnetic resonance imaging (MRI), ultrasound, computed tomography (CT) and micro-focus CT techniques. These are also vital for "minimally invasive" methods, which include potential for tissue sampling, such as image guidance for targeted biopsies and laparoscopic-assisted techniques. In this article, we address the range of imaging techniques currently in clinical practice and those under development. Significant advances in high-field MRI and micro-focus CT imaging show particular promise for smaller and earlier gestation foetuses. We also review how MRI biomarkers such as diffusion-weighted imaging and organ volumetric analysis may aid diagnosis and image interpretation in the absence of autopsy data. Three-dimensional printing and augmented reality may help make imaging findings more accessible to parents, colleagues and trainees.
Collapse
Affiliation(s)
- Susan C Shelmerdine
- Department of Radiology Great Ormond Street Hospital for Children NHS Foundation Trust London, London, UK.,UCL Great Ormond Street Institute of Child Health London, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre London, London, UK
| | - John C Hutchinson
- Department of Radiology Great Ormond Street Hospital for Children NHS Foundation Trust London, London, UK.,UCL Great Ormond Street Institute of Child Health London, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre London, London, UK
| | - Owen J Arthurs
- Department of Radiology Great Ormond Street Hospital for Children NHS Foundation Trust London, London, UK.,UCL Great Ormond Street Institute of Child Health London, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre London, London, UK
| | - Neil J Sebire
- Department of Radiology Great Ormond Street Hospital for Children NHS Foundation Trust London, London, UK.,UCL Great Ormond Street Institute of Child Health London, London, UK.,NIHR Great Ormond Street Hospital Biomedical Research Centre London, London, UK
| |
Collapse
|
19
|
Shelmerdine SC, Singh M, Norman W, Jones R, Sebire NJ, Arthurs OJ. Automated data extraction and report analysis in computer-aided radiology audit: practice implications from post-mortem paediatric imaging. Clin Radiol 2019; 74:733.e11-733.e18. [PMID: 31160039 DOI: 10.1016/j.crad.2019.04.021] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Accepted: 04/24/2019] [Indexed: 10/26/2022]
Abstract
AIM To determine local departmental adherence to the paediatric post-mortem magnetic resonance imaging (MRI) protocols, using a customised automated computational approach. MATERIALS AND METHODS A retrospective review of 460 whole-body post-mortem MRI examinations performed at Great Ormond Street Hospital for Children over a 5.5-year period was assessed for adherence to a full or abbreviated imaging sequence protocol. A simple computer program was developed to batch process DICOM (digital imaging and communications in medicine) files, extracting imaging sequence details, followed by natural language processing (NLP) of authorised reports to automate information extraction of diagnostic image quality. RESULTS The program was able to extract study parameters from the entire dataset (approximately 80 GB of data) in a few hours, and retrieve information on diagnostic image quality using NLP with an overall diagnostic accuracy for data extraction of 96.7% (445/460, 95% confidence interval [CI]: 94.7-98%). The full imaging protocol was adhered to in 305/460 (66.3%) cases, and an abbreviated protocol in 140/460 (30.4%) cases. Overall, 423/460 (91.9%) of studies were of diagnostic quality. These included 298/305 (97.7%) of the full protocol, 111/140 (79.3%) of the abbreviated protocol. In only five cases were the examinations non-diagnostic for all body systems, all of whom weighed <100 g (24.7-72 g) and imaged using the abbreviated protocol. CONCLUSION The present study demonstrated a successful application of an automated approach for data collection for audit and quality assessment purposes using paediatric post-mortem imaging as a specific example. Re-audit of these data following change implementation will be straightforward now that the automated workflow is clearly established.
Collapse
Affiliation(s)
- S C Shelmerdine
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; UCL Great Ormond Street Institute of Child Health, London, UK.
| | - M Singh
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - W Norman
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - R Jones
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - N J Sebire
- UCL Great Ormond Street Institute of Child Health, London, UK; Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - O J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK; UCL Great Ormond Street Institute of Child Health, London, UK
| |
Collapse
|
20
|
Staicu A, Albu C, Popa-Stanila R, Chiriac L, Boitor-Borza D, Bondor C, Kovacs T, Caracostea G, Rotar IC, Turcu RVF, Simon S, Muresan D, Stamatian F. Potential clinical benefits and limitations of fetal virtopsy using high-field MRI at 7 Tesla versus stereomicroscopic autopsy to assess first trimester fetuses. Prenat Diagn 2019; 39:505-518. [PMID: 30980413 DOI: 10.1002/pd.5457] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 03/21/2019] [Accepted: 03/23/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE The aim of this study was to establish the diagnostic accuracy of high-field magnetic resonance imaging (MRI) at 7 Tesla (T) compared with that of stereomicroscopic autopsy for assessing first trimester fetuses. METHODS Nine consecutive cases of first trimester fetuses resulting from spontaneous and therapeutic pregnancy termination were considered. The cases were divided into two groups according to gestational age: the Embryo Group with cases of nine to 10 gestational weeks (GWs) and the Fetus Group with cases of 13 GWs. The first group was scanned using three-dimensional fast imaging with steady state precession (3D FISP), and the second group was scanned using a two-dimensional (2D) turbo spin-echo high-resolution T2-weighted imaging (T2 WI) protocol. A radiologist and two embryologists interpreted the images. All cases were evaluated by invasive autopsy, with pathologist blinded to the imaging results. In total, the database included 270 items for evaluation (9 cases × 30 structures/case). RESULTS The global agreement between fetal high-field virtopsy and microscopic or stereomicroscopic autopsy was evaluated using 225 evaluation items visible by both methods. Overall, using microscopic examination and stereomicroscopic autopsy as the gold standard, fetal high-field virtopsy had a sensitivity of 94.6% [95% CI, 87.2-98.3] and a specificity of 97.6% [95% CI, 95-98.8]. The positive predictive value (PPV) was 93% [95% CI, 85.7-96.6], and the negative predictive value (NPV) was 98.2% [95% CI, 95.7-99.4]. Cohen kappa coefficient of agreement was k = 0.92 [95% CI, 0.82-0.97], and the McNemar test showed p = 1.00. CONCLUSIONS Virtual autopsy using high-field MRI at 7 T can be considered a safe alternative approach to stereomicroscopic autopsy for the assessment of fetal structural anomalies at the end of the first trimester of pregnancy.
Collapse
Affiliation(s)
- Adelina Staicu
- 1st Department of Obstetrics and Gynaecology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Camelia Albu
- Department of Pathology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Centre of Advanced Research Studies, Emergency County Hospital, IMOGEN, Cluj-Napoca, Romania
| | - Roxana Popa-Stanila
- Centre of Advanced Research Studies, Emergency County Hospital, IMOGEN, Cluj-Napoca, Romania.,Department of Radiology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Liviu Chiriac
- Department of Medical Biophysics, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,National Magnetic Resonance Centre, Babeș Bolyai University, Cluj-Napoca, Romania
| | - Dan Boitor-Borza
- Department of Human Anatomy and Embryology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Cosmina Bondor
- Department of Medical Informatics and Biostatistics, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Tunde Kovacs
- 1st Department of Obstetrics and Gynaecology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.,Centre of Advanced Research Studies, Emergency County Hospital, IMOGEN, Cluj-Napoca, Romania
| | - Gabriela Caracostea
- 1st Department of Obstetrics and Gynaecology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Ioana Cristina Rotar
- 1st Department of Obstetrics and Gynaecology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - R V Flaviu Turcu
- National Magnetic Resonance Centre, Babeș Bolyai University, Cluj-Napoca, Romania.,Faculty of Physic, Babeș Bolyai University, Cluj-Napoca, Romania
| | - Simion Simon
- National Magnetic Resonance Centre, Babeș Bolyai University, Cluj-Napoca, Romania.,Faculty of Physic, Babeș Bolyai University, Cluj-Napoca, Romania
| | - Daniel Muresan
- 1st Department of Obstetrics and Gynaecology, "Iuliu Haţieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
| | - Florin Stamatian
- Centre of Advanced Research Studies, Emergency County Hospital, IMOGEN, Cluj-Napoca, Romania
| |
Collapse
|
21
|
Shelmerdine SC, Arthurs OJ, Gilpin I, Norman W, Jones R, Taylor AM, Sebire NJ, Chitty LS. Is traditional perinatal autopsy needed after detailed fetal ultrasound and post-mortem MRI? Prenat Diagn 2019; 39:818-829. [PMID: 30892705 DOI: 10.1002/pd.5448] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2019] [Revised: 02/27/2019] [Accepted: 03/14/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To determine the additional yield from autopsy following prenatal ultrasound and post-mortem magnetic resonance imaging (PMMR) for structural abnormalities. METHOD PMMR was performed on consecutive fetuses over a 6-year period. Prenatal ultrasound and PMMR findings were categorised as concordant, partially concordant or discordant findings. The yield of new and clinically significant information from autopsy was assessed. Diagnostic accuracies for both modalities were calculated, using autopsy as reference standard. RESULTS Our study consisted of 81 fetuses. PMMR and prenatal ultrasound findings were concordant in 44/81 (54.3%), partially concordant in 26/81 (32.1%) and discordant in 11/81 (13.6%) cases. In 19/81 cases (23%), autopsy provided additional information, which appeared clinically significant in 12 cases. In 10 of those 12 cases, there was discordance between PMMR and ultrasound. In only 2 of 44 cases where ultrasound and PMMR were concordant, did autopsy provide clinically significant information. Diagnostic accuracy rates for ultrasound were sensitivity of 76.8% (66.6%, 84.6%), specificity of 92.5% (88.9%, 95.0%). For PMMR the sensitivity was 79.0% (68.9%, 86.5%), specificity 97.9% (95.5%, 99.0%). PMMR had a significantly higher concordance rate with autopsy than ultrasound (89.0 vs 93.8%; P < .001). CONCLUSION Where PMMR and ultrasound are concordant, there is little additional yield from autopsy.
Collapse
Affiliation(s)
- Susan C Shelmerdine
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Owen J Arthurs
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Isobel Gilpin
- Perinatal Neurology and Neonatology, Imperial College London, London, UK
| | - Wendy Norman
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, London, UK
| | - Rod Jones
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, London, UK
| | - Andrew M Taylor
- Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, London, UK
| | - Neil J Sebire
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,UCL Great Ormond Street Institute of Child Health, London, UK
| | - Lyn S Chitty
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,Genetics and Genomic Medicine, UCL Great Ormond Street Institute of Child Health, London, UK
| |
Collapse
|
22
|
Shelmerdine SC, Chung KL, Hutchinson JC, Elliott C, Sebire NJ, Arthurs OJ. Feasibility of Postmortem Imaging Assessment of Brain: Liver Volume Ratios with Pathological Validation. Fetal Diagn Ther 2019; 46:360-367. [PMID: 30970374 PMCID: PMC6979430 DOI: 10.1159/000497158] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Accepted: 01/21/2019] [Indexed: 01/17/2023]
Abstract
Introduction Organ volumes at postmortem magnetic resonance imaging (PMMR) should reflect autopsy organ weights, and thus brain: liver volume ratios on imaging could be a surrogate for weight volume ratios at autopsy to indicate fetal growth restriction (FGR). This study aims to determine whether imaging-based organ volume ratios can replace autopsy organ weight ratios. Materials and Methods An unselected cohort of perinatal deaths underwent PMMR prior to autopsy. Semiautomated brain and liver volumes were compared to autopsy organ weights and ratios. Ratios were compared using Bland-Altman plots, and intra- and interobserver variability was assessed. Results A total 49 fetuses (25 male, 51%) at 17–42 weeks gestation were assessed. There was a reasonable correlation between autopsy-derived brain: liver weight ratios (AB: LwR) and imaging-derived brain: liver volume ratios (IB: LvR; r = 0.8). The mean difference between AB: LwR and IB: LvR was +0.7 (95% limits of agreement range −1.5 to +2.9). In a small subset where FGR was present, the optimal IB: LvR ≥5.5 gave 83.3% sensitivity and 86.0% specificity for diagnosis. There was acceptable agreement within readers (mean difference in IB: LvRs 0.77 ± 2.21) and between readers −0.36 ± 0.68. Conclusion IB: LvR provides a surrogate evaluation of AB: LwRs, and may be used as a marker of FGR where autopsy is declined.
Collapse
Affiliation(s)
- Susan C Shelmerdine
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom,
| | - Kimberly L Chung
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - John C Hutchinson
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.,Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Claire Elliott
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | - Neil J Sebire
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.,Developmental Biology and Cancer Programme, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| | - Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom.,Imaging and Biophysics, UCL Great Ormond Street Institute of Child Health, London, United Kingdom
| |
Collapse
|
23
|
Hellkvist A, Wikström J, Mulic-Lutvica A, Ericson K, Eriksson-Falkerby C, Lindgren P, Penno E, Axelsson O. Postmortem magnetic resonance imaging vs autopsy of second trimester fetuses terminated due to anomalies. Acta Obstet Gynecol Scand 2019; 98:865-876. [PMID: 30694559 PMCID: PMC6618902 DOI: 10.1111/aogs.13548] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2018] [Accepted: 01/11/2019] [Indexed: 01/02/2023]
Abstract
Introduction Our aim was to investigate the accuracy of postmortem fetal magnetic resonance imaging (MRI) compared with fetal autopsy in second trimester pregnancies terminated due to fetal anomalies. A secondary aim was to compare the MRI evaluations of two senior radiologists. Material and methods This was a prospective study including 34 fetuses from pregnancies terminated in the second trimester due to fetal anomalies. All women accepted a postmortem MRI and an autopsy of the fetus. Two senior radiologists performed independent evaluations of the MRI images. A senior pathologist performed the fetal autopsies. The degree of concordance between the MRI evaluations and the autopsy reports was estimated as well as the consensus between the radiologists. Results Thirty‐four fetuses were evaluated. Sixteen cases were associated with the central nervous system (CNS), five were musculoskeletal, one cardiovascular, one was associated with the urinary tract, and 11 cases had miscellaneous anomalies such as chromosomal aberrations, infections and syndromes. In the 16 cases related to the CNS, both radiologists reported all or some, including the most clinically significant anomalies in 15 (94%; CI 70%‐100%) cases. In the 18 non‐CNS cases, both radiologists reported all or some, including the most clinically significant anomalies in six (33%; CI 5%‐85%) cases. In 21 cases (62%; CI 44%‐78%), both radiologists held opinions that were consistent with the autopsy reports. The degree of agreement between the radiologists was high, with a Cohen's Kappa of 0.87. Conclusions Postmortem fetal MRI can replace autopsy for second trimester fetuses with CNS anomalies. For non‐CNS anomalies, the concordance is lower but postmortem MRI can still be of value when autopsy is not an option.
Collapse
Affiliation(s)
- Anna Hellkvist
- Center for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden
| | - Johan Wikström
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ajlana Mulic-Lutvica
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - Katharina Ericson
- Department of Immunology, Genetics and Pathology, Uppsala University, Uppsala, Sweden
| | | | - Peter Lindgren
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden.,Center for Fetal Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Eva Penno
- Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Ove Axelsson
- Center for Clinical Research Sörmland, Uppsala University, Eskilstuna, Sweden.,Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| |
Collapse
|
24
|
Shelmerdine SC, Simcock IC, Hutchinson JC, Aughwane R, Melbourne A, Nikitichev DI, Ong JL, Borghi A, Cole G, Kingham E, Calder AD, Capelli C, Akhtar A, Cook AC, Schievano S, David A, Ourselin S, Sebire NJ, Arthurs OJ. 3D printing from microfocus computed tomography (micro-CT) in human specimens: education and future implications. Br J Radiol 2018; 91:20180306. [PMID: 29698059 DOI: 10.1259/bjr.20180306] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Microfocus CT (micro-CT) is an imaging method that provides three-dimensional digital data sets with comparable resolution to light microscopy. Although it has traditionally been used for non-destructive testing in engineering, aerospace industries and in preclinical animal studies, new applications are rapidly becoming available in the clinical setting including post-mortem fetal imaging and pathological specimen analysis. Printing three-dimensional models from imaging data sets for educational purposes is well established in the medical literature, but typically using low resolution (0.7 mm voxel size) data acquired from CT or MR examinations. With higher resolution imaging (voxel sizes below 1 micron, <0.001 mm) at micro-CT, smaller structures can be better characterised, and data sets post-processed to create accurate anatomical models for review and handling. In this review, we provide examples of how three-dimensional printing of micro-CT imaged specimens can provide insight into craniofacial surgical applications, developmental cardiac anatomy, placental imaging, archaeological remains and high-resolution bone imaging. We conclude with other potential future usages of this emerging technique.
Collapse
Affiliation(s)
- Susan C Shelmerdine
- 1 UCL Great Ormond Street Institute of Child Health , London , UK.,2 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Ian C Simcock
- 1 UCL Great Ormond Street Institute of Child Health , London , UK.,2 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - John Ciaran Hutchinson
- 1 UCL Great Ormond Street Institute of Child Health , London , UK.,3 Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Rosalind Aughwane
- 4 Department of Medical Physics and Biomedical Engineering, Translational Imaging Group, University College London , London , UK
| | - Andrew Melbourne
- 4 Department of Medical Physics and Biomedical Engineering, Translational Imaging Group, University College London , London , UK
| | - Daniil I Nikitichev
- 4 Department of Medical Physics and Biomedical Engineering, Translational Imaging Group, University College London , London , UK.,5 Department of Medical Physics and Biomedical Engineering, University College London , London , UK
| | - Ju-Ling Ong
- 6 Craniofacial Unit, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | | | | | - Emilia Kingham
- 8 UCL Culture, Bidborough House, 38-50 Bidborough Street, London UK
| | - Alistair D Calder
- 2 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Claudio Capelli
- 9 Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London UK.,10 Institute of Cardiovascular Science, University College London , London , UK
| | - Aadam Akhtar
- 10 Institute of Cardiovascular Science, University College London , London , UK
| | - Andrew C Cook
- 10 Institute of Cardiovascular Science, University College London , London , UK
| | - Silvia Schievano
- 1 UCL Great Ormond Street Institute of Child Health , London , UK.,9 Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London UK.,10 Institute of Cardiovascular Science, University College London , London , UK
| | - Anna David
- 11 Institute for Women's Health, University College London , London , UK
| | - Sebastian Ourselin
- 4 Department of Medical Physics and Biomedical Engineering, Translational Imaging Group, University College London , London , UK
| | - Neil J Sebire
- 1 UCL Great Ormond Street Institute of Child Health , London , UK.,3 Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| | - Owen J Arthurs
- 1 UCL Great Ormond Street Institute of Child Health , London , UK.,2 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust , London , UK
| |
Collapse
|
25
|
Postmortem fetal magnetic resonance imaging: where do we stand? Insights Imaging 2018; 9:591-598. [PMID: 29869137 PMCID: PMC6108974 DOI: 10.1007/s13244-018-0627-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2018] [Revised: 03/28/2018] [Accepted: 04/11/2018] [Indexed: 12/05/2022] Open
Abstract
Abstract Postmortem fetal magnetic resonance imaging (PMFMRI) is increasingly used thanks to its good overall concordance with histology paralleling the rising incidence of parental refusal of autopsy. The technique could become a routine clinical examination but it needs to be standardized and conducted by trained radiologists. Such radiologists should be aware of not only the (congenital and acquired) anomalies that can involve the fetus, but also of the “physiological” postmortem changes. In this article, we intend to focus on the contribution of PMFMRI based on the existing literature and on our own experience, as we presently perform the technique routinely in our clinical practice. Key Points • Concordance rates between PMFMRI and autopsy are high for detecting fetal pathologies. • PMFMRI is more acceptable for parents than traditional autopsy. • PMFMRI is becoming widely used as a part of the postmortem investigations. • A dedicated radiologist needs to learn to interpret correctly a PMFMRI. • PMFMRI can be easily realized in daily clinical practice.
Collapse
|
26
|
Postmortem microfocus computed tomography for early gestation fetuses: a validation study against conventional autopsy. Am J Obstet Gynecol 2018; 218:445.e1-445.e12. [PMID: 29410108 DOI: 10.1016/j.ajog.2018.01.040] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/11/2018] [Accepted: 01/23/2018] [Indexed: 11/22/2022]
Abstract
BACKGROUND Perinatal autopsy provides useful clinical information in up to 40% of cases. However, there is a substantial unmet clinical need with regards to postmortem investigation of early gestation fetal loss for parents for whom standard autopsy is either not available or not acceptable. Parents dislike the invasive nature of autopsy, but current clinical imaging techniques do not provide high-enough imaging resolution in small fetuses. We hypothesized that microfocus computed tomography, which is a rapid high-resolution imaging technique, could give accurate diagnostic imaging after early gestation fetal loss. OBJECTIVE The objective of the study was to evaluate the diagnostic accuracy of microfocus computed tomography for noninvasive human fetal autopsy for early gestation fetuses, with the use of conventional autopsy as the reference standard. STUDY DESIGN We compared iodinated whole body microfocus computed tomography in 20 prospectively recruited fetuses (11-21 weeks gestation from 2 centers) with conventional autopsy in a double-blinded manner for a main diagnosis and findings in specific body organs. Fetuses were prepared with 10% formalin/potassium tri-iodide. Images were acquired with a microfocus computed tomography scanner with size-appropriate parameters. Images were evaluated independently by 2 pediatric radiologists, who were blinded to formal perinatal autopsy results, across 40 individual indices to reach consensus. The primary outcome was agreement between microfocus computed tomography and conventional autopsy for overall diagnosis. RESULTS Postmortem whole body fetal microfocus computed tomography gave noninvasive autopsy in minutes, at a mean resolution of 27μm, with high diagnostic accuracy in fetuses at <22 weeks gestation. Autopsy demonstrated that 13 of 20 fetuses had structural abnormalities, 12 of which were also identified by microfocus computed tomography (92.3%). Overall, microfocus computed tomography agreed with overall autopsy findings in 35 of 38 diagnoses (15 true positive, 18 true negative; sensitivity 93.8% [95% confidence interval, 71.7-98.9%], specificity 100% [95% confidence interval, 82.4-100%]), with 100% agreement for body imaging diagnoses. Furthermore, after removal of nondiagnostic indices, there was agreement for 700 of 718 individual body organ indices that were assessed on microfocus computed tomography and autopsy (agreement, 97.5%; 95% confidence interval, 96.1-98.4%), with no overall differences between fetuses at ≤14 or >14 weeks gestation (agreement, 97.2% and 97.9%, respectively). Within first-trimester fetal loss cases (<14 weeks gestation), microfocus computed tomography analysis yielded significantly fewer nondiagnostic indices than autopsy examination (22/440 vs 48/348, respectively; P<.001). CONCLUSION Postmortem whole-body fetal microfocus computed tomography gives noninvasive, detailed anatomic examinations that are achieved in minutes at high resolution. Microfocus computed tomography may be preferable to magnetic resonance imaging in early gestation fetuses and may offer an acceptable method of examination after fetal loss for parents who decline invasive autopsy. This will facilitate autopsy and subsequent discussions between medical professionals who are involved in patient care and counselling for future pregnancies.
Collapse
|
27
|
Nijkamp J, Sebire N, Bouman K, Korteweg F, Erwich J, Gordijn S. Perinatal death investigations: What is current practice? Semin Fetal Neonatal Med 2017; 22:167-175. [PMID: 28325580 PMCID: PMC7118457 DOI: 10.1016/j.siny.2017.02.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Perinatal death (PD) is a devastating obstetric complication. Determination of cause of death helps in understanding why and how it occurs, and it is an indispensable aid to parents wanting to understand why their baby died and to determine the recurrence risk and management in subsequent pregnancy. Consequently, a perinatal death requires adequate diagnostic investigation. An important first step in the analysis of PD is to identify the case circumstances, including relevant details regarding maternal history, obstetric history and current pregnancy (complications are evaluated and recorded). In the next step, placental examination is suggested in all cases, together with molecular cytogenetic evaluation and fetal autopsy. Investigation for fetal-maternal hemorrhage by Kleihauer is also recommended as standard. In cases where parents do not consent to autopsy, alternative approaches such as minimally invasive postmortem examination, postmortem magnetic resonance imaging, and fetal photographs are good alternatives. After all investigations have been performed it is important to combine findings from the clinical review and investigations together, to identify the most probable cause of death and counsel the parents regarding their loss.
Collapse
Affiliation(s)
- J.W. Nijkamp
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands,Corresponding author. Department of Obstetrics and Gynecology, University Medical Centre Groningen, CB 21, P.O. box 30001, 9700 RB Groningen, The Netherlands.
| | - N.J. Sebire
- Department of Pediatric Pathology, Clinical Molecular Genetics, Great Ormond Street Hospital for Children and UCL Institute of Child Health, London, UK
| | - K. Bouman
- Department of Genetics, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - F.J. Korteweg
- Department of Obstetrics and Gynecology, Martini Hospital, Groningen, The Netherlands
| | - J.J.H.M. Erwich
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - S.J. Gordijn
- Department of Obstetrics and Gynecology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| |
Collapse
|
28
|
Hutchinson JC, Shelmerdine SC, Simcock IC, Sebire NJ, Arthurs OJ. Early clinical applications for imaging at microscopic detail: microfocus computed tomography (micro-CT). Br J Radiol 2017; 90:20170113. [PMID: 28368658 DOI: 10.1259/bjr.20170113] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Abstract
Microfocus CT (micro-CT) has traditionally been used in industry and preclinical studies, although it may find new applicability in the routine clinical setting. It can provide high-resolution three-dimensional digital imaging data sets to the same level of detail as microscopic examination without the need for tissue dissection. Micro-CT is already enabling non-invasive detailed internal assessment of various tissue specimens, particularly in breast imaging and early gestational fetal autopsy, not previously possible from more conventional modalities such as MRI or CT. In this review, we discuss the technical aspects behind micro-CT image acquisition, how early work with small animal studies have informed our knowledge of human disease and the imaging performed so far on human tissue specimens. We conclude with potential future clinical applications of this novel and emerging technique.
Collapse
Affiliation(s)
- J Ciaran Hutchinson
- 1 Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,2 UCL Great Ormond Street Institute of Child Health, London, UK
| | - Susan C Shelmerdine
- 2 UCL Great Ormond Street Institute of Child Health, London, UK.,3 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Ian C Simcock
- 2 UCL Great Ormond Street Institute of Child Health, London, UK.,3 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Neil J Sebire
- 1 Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,2 UCL Great Ormond Street Institute of Child Health, London, UK
| | - Owen J Arthurs
- 2 UCL Great Ormond Street Institute of Child Health, London, UK.,3 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| |
Collapse
|
29
|
Arthurs OJ, Hutchinson JC, Sebire NJ. Current issues in postmortem imaging of perinatal and forensic childhood deaths. Forensic Sci Med Pathol 2017; 13:58-66. [PMID: 28083782 PMCID: PMC5306347 DOI: 10.1007/s12024-016-9821-x] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/05/2016] [Indexed: 11/27/2022]
Abstract
Perinatal autopsy practice is undergoing a state of change with the introduction of evidence-based cross-sectional imaging, driven primarily by parental choice. In particular, the introduction of post mortem magnetic resonance imaging (PMMR) has helped to advance less-invasive perinatal autopsy in the United Kingdom (UK) and Europe. However, there are limitations to PMMR and other imaging techniques which need to be overcome, particularly with regard to imaging very small fetuses. Imaging is also now increasingly used to investigate particular deaths in childhood, such as suspected non-accidental injury (NAI) and sudden unexpected death in infancy (SUDI). Here we focus on current topical developments the field, with particular emphasis on the application of imaging to perinatal autopsy, and pediatric forensic deaths. Different imaging modalities and their relative advantages and disadvantages are discussed, together with other benefits of more advanced cross-sectional imaging which currently lie in the research domain. Whilst variations in local imaging service provision and need may determine different practice patterns, and access to machines and professionals with appropriate expertise and experience to correctly interpret the findings may limit current practices, we propose that gold standard perinatal and pediatric autopsy services would include complete PMMR imaging prior to autopsy, with PMCT in suspicious childhood deaths. This approach would provide maximal diagnostic yield to the pathologist, forensic investigator and most importantly, the parents.
Collapse
Affiliation(s)
- Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, WC1N 3JH, UK.
- Institute of Child Health, UCL, London, UK.
| | - John C Hutchinson
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Neil J Sebire
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| |
Collapse
|
30
|
Arthurs OJ, van Rijn RR, Whitby EH, Johnson K, Miller E, Stenzel M, Watt A, Taranath A, Perry DH. ESPR postmortem imaging task force: where we begin. Pediatr Radiol 2016; 46:1363-9. [PMID: 27412272 DOI: 10.1007/s00247-016-3639-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2016] [Accepted: 05/04/2016] [Indexed: 11/24/2022]
Abstract
A new task force on postmortem imaging was established at the annual meeting of the European Society of Paediatric Radiology (ESPR) in Graz, Austria, in 2015. The postmortem task force is separate from the child abuse task force as it covers all aspects of fetal, neonatal and non-forensic postmortem imaging. The main focus of the task force is the guidance and standardization of non-radiographic postmortem imaging, particularly postmortem CT and postmortem MRI. This manuscript outlines the starting point of the task force, with a mission statement, outline of current experience, and short- and long-term goals.
Collapse
Affiliation(s)
- Owen J Arthurs
- Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, Great Ormond Street, London, WC1N 3JH, UK. .,Institute of Child Health, UCL, London, UK.
| | - Rick R van Rijn
- Department of Radiology, Emma Children's Hospital - Academic Medical Center Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Elspeth H Whitby
- Academic unit of Reproductive and Developmental Medicine, University of Sheffield, Sheffield, S10 1SF, UK
| | - Karl Johnson
- Radiology Department, Birmingham Children's Hospital, Steelhouse Lane, Birmingham, B4 6NH, UK
| | - Elka Miller
- Department of Medical Imaging, Children's Hospital of Eastern Ontario, University of Ottawa, 401 Smyth Road, Ottawa, ON, K1H 8L1, Canada
| | - Martin Stenzel
- Department of Radiology, University Hospital Freiburg, Hugstetter Str. 55, D-79106, Freiburg, Germany
| | - Andrew Watt
- Department of Diagnostic Imaging & Clinical Physics, The Royal Hospital for Children, 1345 Govan Road, Glasgow, G51 4TF, UK
| | - Ajay Taranath
- Department of Medical Imaging, Women's and Children's Hospital, 72 King William St., North Adelaide, South Australia, Australia
| | - David H Perry
- Radiology Department, National Women's Health and Starship Children's Hospital, Auckland City Hospital, Park Road, Grafton, Auckland, New Zealand
| |
Collapse
|
31
|
Norman W, Jawad N, Jones R, Taylor AM, Arthurs OJ. Perinatal and paediatric post-mortem magnetic resonance imaging (PMMR): sequences and technique. Br J Radiol 2016; 89:20151028. [PMID: 26916282 DOI: 10.1259/bjr.20151028] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
As post-mortem MRI (PMMR) becomes more widely used for investigation following perinatal and paediatric deaths, the best possible images should be acquired. In this article, we review the most widely used published PMMR sequences, together with outlining our acquisition protocol and sequence parameters for foetal, perinatal and paediatric PMMR. We give examples of both normal and abnormal appearances, so that the reader can understand the logic behind each acquisition step before interpretation, as a useful day-to-day reference guide to performing PMMR.
Collapse
Affiliation(s)
- Wendy Norman
- 1 Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,2 Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, London, UK
| | - Noorulhuda Jawad
- 3 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK
| | - Rod Jones
- 1 Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,2 Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, London, UK
| | - Andrew M Taylor
- 1 Cardiorespiratory Division, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,2 Centre for Cardiovascular Imaging, UCL Institute of Cardiovascular Science, London, UK
| | - Owen J Arthurs
- 3 Department of Radiology, Great Ormond Street Hospital for Children NHS Foundation Trust, London, UK.,4 Institute of Child Health, UCL, London, UK
| |
Collapse
|
32
|
Hutchinson JC, Arthurs OJ, Ashworth MT, Ramsey AT, Mifsud W, Lombardi CM, Sebire NJ. Clinical utility of postmortem microcomputed tomography of the fetal heart: diagnostic imaging vs macroscopic dissection. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2016; 47:58-64. [PMID: 26415141 DOI: 10.1002/uog.15764] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Revised: 09/11/2015] [Accepted: 09/18/2015] [Indexed: 06/05/2023]
Abstract
OBJECTIVES Congenital cardiac malformations are commonly identified at perinatal autopsy, which can be challenging in fetuses of early gestation and in macerated fetuses. Our objective was to examine fetal complex congenital heart disease by microcomputed tomography (micro-CT), using standard autopsy as the gold standard. METHODS In this ethically approved study, ex-vivo isolated fetal heart and fetal heart-lung blocks underwent iodine preparation prior to micro-CT, and were fixed in formalin after the micro-CT examination. Images were acquired using a microfocus-CT scanner with individual specimen image optimization. Twenty-one indices assessed normally at autopsy were evaluated for each dataset. Cardiac dissection was performed using a dissecting microscope within 24 h of the micro-CT examination. RESULTS We examined six fetal hearts, comprising five with complex congenital cardiac malformations at a gestational age of 17-23 weeks and an anatomically normal heart of 23 weeks' gestation for reference. All specimens demonstrated excellent internal contrast at micro-CT examination, and the correct overall diagnosis was made in all cases. There was agreement for 114/126 indices assessed on micro-CT and at autopsy dissection (overall concordance of 95.8% (95% CI, 90.5-98.2%)). Micro-CT was particularly useful in the assessment of ventricular morphology in macerated fetuses. CONCLUSIONS Micro-CT of small ex-vivo fetal specimens can provide highly accurate three-dimensional rendering of complex congenital fetal heart disease. This approach represents a significant advance in postmortem imaging and confirms the potential of this technology for non-invasive examination of small fetuses and organs.
Collapse
Affiliation(s)
- J C Hutchinson
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, UCL Institute of Child Health & Great Ormond Street Hospital for Children, London, UK
| | - O J Arthurs
- Institute of Child Health, UCL, London, UK
- Paediatric Radiology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - M T Ashworth
- Department of Histopathology, UCL Institute of Child Health & Great Ormond Street Hospital for Children, London, UK
| | | | - W Mifsud
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, UCL Institute of Child Health & Great Ormond Street Hospital for Children, London, UK
| | - C M Lombardi
- Department of Radiology, Studio Diagnostico Eco, Vimercate, Milan, Italy
| | - N J Sebire
- Institute of Child Health, UCL, London, UK
- Department of Histopathology, UCL Institute of Child Health & Great Ormond Street Hospital for Children, London, UK
| |
Collapse
|