Choroid plexus cysts: a normal finding on ultrasound

Isolated choroid plexus cysts and health and developmental outcomes in childhood and adolescence - A systematic review

OBJECTIVES

Choroid plexus cysts (CPCs) are incidental findings on ultrasound examination of the fetal brain. It is not known if isolated CPCs are associated with any adverse health or neurodevelopmental outcomes during the life course. This systematic review aimed to collate and synthesize the evidence on whether or not isolated choroid plexus cysts are associated with an increased risk of adverse health or developmental outcomes during childhood and adolescence.

METHODS

A search strategy was developed specifically for this study and applied to four electronic databases Medline (Ovid), Embase (Ovid), Web of Science, and Google Scholar. Studies were assessed and selected for inclusion if there was a measurement of CPC (including single or multiple; unilateral or bilateral; isolated or presenting alongside other markers) during the antenatal or early neonatal period (<7 days) with follow-up of children and adolescents for health and developmental outcomes measured at any time from age 1 month onwards. Study quality was assessed using the Newcastle-Ottawa Quality Assessment Scale. Due to heterogeneity in the types of outcome measures included and the timing of measurement of outcomes across the studies, it was not possible to pool data across studies and a narrative description of findings was presented.

RESULTS

Eight studies (three cohorts and five case series) met the inclusion criteria. Different methods were used for outcome assessment, such as in-person assessment, parent questionnaires, medical records, and telephone interviews with parents. Six studies measured outcomes only once during the specified duration of follow-up; two studies carried out paediatric reviews of the children several times during follow-up. There were no differences in developmental outcomes or physical health between babies with CPCs reported in the three cohort studies, and no abnormalities were detected in the children that were followed up in four of the five case series studies. Most of the included studies were graded as low quality due to the small sample size, high risk of selection bias, unclear definitions of CPC or lack of a comparison group.

CONCLUSIONS

The studies conducted to date do not provide evidence of adverse physical health outcomes or neurodevelopmental delays in babies with CPCs. However, most of these studies were small and included a narrow range of outcomes. Further research is needed to explore the relative incidence of outcomes such as ASD, ADHD, epilepsy and educational attainment in children with CPCs.

The Course and Neonatal Outcome of Choroid Plexus Extension to the Anterior Horn at the Routine Anatomy Scan

OBJECTIVES

Our objective was to examine the pregnancy course and immediate neonatal outcome of fetuses with an isolated extension of choroid plexus (CP) to the anterior horn during the second trimester.

METHODS

We prospectively collected the cases referred to us between July 2012 and January 2021 with isolated finding of CP extension to the anterior horn. Relevant clinical and demographic information was recorded, and a full anatomy scan including a comprehensive neurosonogram was performed. In cases of confirmed isolated extension of CP to the anterior horns, women were offered further investigation including fetal MRI, and ultrasound follow up.

RESULTS

We collected 29 eligible cases for analysis. The mean gestational age (GA ± SD) for diagnosis and referral was 19.24 ± 2.3 weeks. No other intracranial anomalies were detected in any of the cases, and the finding resolved at 25 ± 2.6 weeks. The average extension length and width to the anterior horn were 0.7 ± 0.3 cm, and 0.5 ± 0.1 cm, respectively. Eleven fetuses (38%) had choroid plexus cyst (CPC) in addition to the extension. Ten patients (35%) completed a fetal brain MRI, with no identified abnormalities. Gross neurological exam and Apgar score at birth were normal.

CONCLUSION

Extension of CP to anterior horn with or without CPC at mid-trimester seems to have spontaneous resolution with likely a good prognosis and no further implications.

Migrating Lateral Ventricle Choroid Plexus Cyst into the Fourth Ventricle Causing Acute Hydrocephalus

Choroid plexus cysts consist of abnormal folds of the choroid plexus that typically resolve prior to birth. Rarely, these cysts persist and may cause outflow obstruction of cerebrospinal fluid. In this article, we presented a 5-month-old male child patient who presented with lethargy, vomiting, and a bulging anterior fontanelle. Magnetic resonance imaging showed one large choroid plexus cyst had migrated from the right lateral ventricle through the third ventricle and cerebral aqueduct into the fourth ventricle causing outflow obstruction. The cyst was attached to the lateral ventricle choroid plexus by a pedicle. The cyst was endoscopically retrieved from the fourth ventricle intact and then fenestrated and coagulated along with several other smaller cysts. Histologic examination confirmed the mass was a choroid plexus cyst. The patient did well after surgery and did not require any cerebrospinal fluid diversion. Nine months after surgery, the patient continued to thrive with no neurological deficits. This case is the first we have found in the literature of a lateral ventricular choroid plexus cyst migrating into the fourth ventricle and the youngest of any migrating choroid plexus cyst. Only three other cases of a migrating choroid plexus cyst have been documented and those only migrated into the third ventricle. New imaging advances are making these cysts easier to identify, but may still be missed on routine sequences. High clinical suspicion for these cysts is necessary for correct treatment of this possible cause of hydrocephalus.

Dealing With Brain MRI Findings in Pediatric Patients With Endocrinological Conditions: Less Is More?

Neuroimaging is a key tool in the diagnostic process of various clinical conditions, especially in pediatric endocrinology. Thanks to continuous and remarkable technological developments, magnetic resonance imaging can precisely characterize numerous structural brain anomalies, including the pituitary gland and hypothalamus. Sometimes the use of radiological exams might become excessive and even disproportionate to the patients' medical needs, especially regarding the incidental findings, the so-called "incidentalomas". This unclarity is due to the absence of well-defined pediatric guidelines for managing and following these radiological findings. We review and summarize some indications on how to, and even if to, monitor these anomalies over time to avoid unnecessary, expensive, and time-consuming investigations and to encourage a more appropriate follow-up of brain MRI anomalies in the pediatric population with endocrinological conditions.

Choroid plexus cysts-antenatal course and postnatal outcome in a tertiary hospital in North India

PURPOSE

To assess the gestational course and postnatal outcome of antenatally diagnosed choroid plexus cysts.

METHODS

From January 2015 to October 2017, mothers carrying foetuses with choroid plexus cysts (CPCs) were followed up prospectively till delivery, and subsequent postnatal assessment of all the babies was done. Progress of the lesions was monitored during pregnancy with ultrasound (USG) scans and postnatally analysed with clinical assessment and USG examination of the cranium.

RESULTS

A total of 67 mothers of antenatally diagnosed CPCs were referred to the Paediatric Surgery Unit for opinion. Mean gestational age at the time of diagnosis was 19 ± 2.1 weeks (17-28 weeks) while mean age of the mothers at the time of referral was 26 ± 3.3 years (19-35 years). Sixty four mothers have undergone repeat antenatal scans after the diagnosis, and the CPCs disappeared completely in 60 (93.8%) of them. The CPCs persisted but reduced in size in 2 (4.1%), and the other 2 have been lost to follow-up. Thirty eight patients (56.7%) have unilateral CPCs. Mean size of cysts is 6.08 ± 3.0 mm (2.4‑14.8 mm). One foetus, in which the CPC disappeared antenatally, developed it again on the postnatal scans, but is doing well on follow-up. Thirteen babies (19.4%) have other associated congenital malformations as well.

CONCLUSIONS

CPCs may involve one or both ventricles and disappear in approximately 95% of the cases, mostly within 2 months from the diagnosis. The size of the cyst has no relation to its rate of disappearance. Postnatal persistence of CPCs is uncommon and the neurological sequel is unlikely; hence, prospective parents should be reassured accordingly.

Cerebral ultrasound findings in infants exposed to crack cocaine during gestation

BACKGROUND

Prenatal exposure to cocaine has been associated with a wide spectrum of structural abnormalities in infant brains. The growing use of crack, a smokable and extremely addictive form of cocaine, could exacerbate the situation.

OBJECTIVE

The purpose of this study was to determine the frequency, type and severity of cerebral lesions detected by transfontanellar US in newborns exposed to crack during gestation.

MATERIALS AND METHODS

This was a retrospective study, involving a review of the medical records of children who were born to crack-using women and who were subjected to transfontanellar US imaging during their first days of life.

RESULTS

Transfontanellar US revealed abnormalities in 45/129 newborns examined (34.9%). The changes detected were subependymal cysts in 24 infants (18.6%), lenticulostriate vasculopathy in 18 infants (14%), subependymal hemorrhage in 9 infants (7%), and choroid plexus cysts in 9 infants (7%).

CONCLUSION

All of the abnormalities found by US examination were discrete and likely without clinical significance for the babies. However, prospective studies with a long period of tracking are needed to determine whether there are later consequences on the neurodevelopment of children with prenatal exposure to crack.

Anterior choroid plexus cysts: distinction from germinolysis by high-resolution sonography

BACKGROUND

The aim of the present paper was to develop criteria identifying anterior choroid plexus cysts (ACPC) and distinguish these from germinolytic pseudocysts.

METHODS

Cerebral sonography was performed in 2200 neonates with mean gestational age 40 completed weeks (range 23-42 weeks) and mean birthweight of 3450 g (range 340-4610 g). In the last 300 neonates cystic formations in the caudothalamic groove were studied prospectively using a high-resolution ultrasound system with linear scanhead, and the previous results were re-evaluated.

RESULTS

In 22 neonates choroid plexus cysts outside the typical location in the choroid plexus glomus could be attributed to the anterior part of the choroid plexus in the lateral ventricles (prospectively analyzed in 16 of 300 neonates: 5% prevalence on high-resolution sonography). ACPC were located medial and behind germinolytic pseudocysts and best realized during sweep of the scanhead through the caudothalamic groove. In contrast to germinolytic pseudocysts, they had a spherical form, no septation and a thick, partial double wall. Larger cysts seemed to bounce.

CONCLUSIONS

ACPC are not rare and are identified by their location, form, and movement.

Screening for aneuploidy: the genetic sonogram

Over the past 10 years, the use of ultrasound in aneuploidy risk estimation has improved the way obstetrics is practiced. It allows patients to obtain more personalized risk assessment and has allowed many women a reasonable alternative to invasive testing. The addition of soft markers to the sonographic screening for aneuploidy has been extremely beneficial, especially when considered in combination with other ultrasound findings. The best estimate of risk seems to be achieved through the combined use of ultrasound, maternal serum screening, and maternal age. The literature supports the use of soft markers only when applied to the high-risk population, where the prevalence of aneuploidy is increased. If this information is applied to the low-risk populations, especially in isolation, the lower prevalence of aneuploidy makes the positive predictive value too low to be of any value in counseling patients. As with many screening tests it occasionally misses the diagnosis, and every patient needs to understand this potential shortcoming. It is a personal decision regarding their willingness to accept the risk of a missed diagnosis versus the risk of fetal loss from an invasive procedure. Although it is far from perfect, in the right hands and with appropriate counseling ultrasound is an excellent tool. This is such an important decision for women and their families, and it is worth the time it takes to explain the benefits and limitations of this test.

Clinical features of infants with subependymal germinolysis and choroid plexus cysts

BACKGROUND

Periventricular cysts are not rare findings in neonates. However, they are sometimes associated with serious clinical complications, such as congenital viral infections and anomalies.

METHODS

We performed a retrospective follow-up study on newborns who had periventricular cysts on routine cranial ultrasound examination.

RESULTS

We followed 13 infants (three preterm) with periventricular cysts. Ten had single or multiple germinolysis cysts and the remaining three had choroid plexus cysts. All infants had various kinds of underlying complications, including congenital viral infection (two with cytomegalovirus and one with rubella),Sotos syndrome (n = 4), intrauterine growth retardation (n = 5), large-for-dates(n = 4), congenital heart disease (n = 1),myelomeningocele (n = 1) and other minor anomalies. All cases of germinolysis except for one developed a neurodevelopmental abnormality and/or delay. In contrast,all three cases with choroid plexus cysts appeared to develop well,despite the underlying complications.

CONCLUSIONS

Germinolysis cysts seem to be associated with systemic diseases and should be treated as a high-risk sign for impaired neurological development.

Second trimester choroid plexus cysts and trisomy 18

OBJECTIVES

In this study, the aims were to reveal the incidence of isolated choroid plexus cyst in our population, and to discuss the accuracy of distinguishing either an isolated or non-isolated choroid plexus cyst.

METHODS

The study population was consisted of 10594 pregnant women. The patients with choroid plexus cysts were classified into two groups: isolated and non-isolated. Detailed ultrasonographic examination and genetic counseling were performed and triple screening test was ordered. The incidence, sensitivity, specificity, false-positive rate and likelihood ratio of cases with isolated choroid plexus cyst for trisomy 18 were determined.

RESULTS

Choroid plexus cysts were identified in 109 patients (109/10594; 1.02%). In 102 patients isolated choroid plexus cysts, and in seven patients additional fetal anomalies supporting trisomy 18 were detected. Trisomy 18 was detected in four patients, and one of them had isolated choroid plexus cyst. The likelihood ratio in cases of isolated choroid plexus cysts for trisomy 18 was 9.51 (95% confidence interval, 0.2-41).

CONCLUSIONS

According to the study the individual risk for trisomy 18 in isolated choroid plexus cyst should be calculated by using the likelihood ratio. These data allows the physician to express the individual risk of trisomy 18 and permits more accurate genetic counseling.

Intracranial neonatal neurosonography: an update

This article reviews salient features of a normal neonatal cranial ultrasound examination with suggestions concerning techniques that take advantage of new developments in ultrasound technology. It also illustrates pathologic findings in such areas as congenital abnormalities, intracranial hemorrhage, and infection. Recent publications on the subject of neurodevelopmental outcome are explored, pointing out how varying descriptions of intraventricular hemorrhages affect their results.

Cranial ultrasound abnormalities identified at birth: their relationship to perinatal risk and neurobehavioral outcome

OBJECTIVES

Minor cranial ultrasound abnormalities, such as mild ventricular enlargement, choroid plexus cysts, and subependymal cysts, have been identified in 3% to 5% of the newborn population. Although clinicians generally consider these abnormalities to be insignificant for the outcome of the newborn, few convincing data have been published to support this optimism. The objectives of this study were to identify potential risk factors associated with the identification of cranial ultrasound abnormalities at birth and to determine if the abnormalities were related to neurobehavioral sequelae in the newborn.

METHODS

Three hundred eight women were enrolled in this prospective, longitudinal maternal-infant health and development study either at the time they entered the public health care system for prenatal care or at delivery if they had no prenatal care. Each woman participated in an in-depth psychosocial interview at the end of each trimester of pregnancy. Retrospective chart review by experienced medical personnel was used to compile data for the Hobel perinatal risk score for each study participant after delivery. Offspring underwent cranial ultrasound evaluation, the Amiel-Tison Neurologic Assessment, and the Brazelton Neonatal Behavioral Assessment Scale within 96 hours of birth by experienced examiners blinded to any maternal-infant history.

RESULTS

Of the 308 women originally enrolled in the study, 301 delivered living infants. Of these, 266 infants (88%) underwent a cranial ultrasound evaluation and are the subject of this article. For the purposes of the current study, infants were divided into those with normal (n = 239) and those with abnormal (n = 27) ultrasound results. Abnormal ultrasound results included the following lesions: subependymal cyst (n = 13); mild ventricular enlargement (n = 6); choroid plexus cysts (n = 3); a combination of cysts and increased ventricular size (n = 2); a 7-mm midline cyst in the superior posterior portion of the third ventricle (n = 1); subependymal hemorrhage and ventricular enlargement (n = 1); and increased ventricular size, subependymal hemorrhage and cysts, and two small, right thalamic calcifications (n = 1). There were no significant differences between those with an abnormal ultrasound and those with a normal ultrasound for birth weight, length, gestational age, rate of prematurity, frequency of nulliparity, or frequency of small for gestational age infants. However, infants with an abnormal ultrasound had a significantly smaller mean head circumference than those with a normal ultrasound (34.5 +/- 1.9 cm vs 33.7 +/- 1.9 cm). The infants with an abnormal ultrasound had a higher median prenatal (50 vs 45), neonatal (14 vs 8), and total (94 vs 77) Hobel risk score but not a higher labor-delivery score. There were no significant differences when these groups were compared on additional risk factors not included in the Hobel scoring system such as race and socioeconomic status. In addition, mothers who used a greater number of drugs during the first trimester of pregnancy were more likely to have an infant with an abnormal ultrasound at birth such that the probability of having an abnormal ultrasound rose to 22% by the time the pregnant women were using four drugs. Neurologic examinations revealed no differences between the infants with normal and abnormal ultrasounds. There were also no group differences for five of the seven Brazelton cluster scores, the excitable or depressed clusters, or eight of the nine qualifier scores. However, infants with abnormal ultrasounds performed significantly better on the habituation (7.3 +/- 0.8 vs 6.6 +/- 1.5) and autonomic regulation (6.5 +/- 0.8 vs 6.0 +/- 1.0) clusters but more poorly on the cost of attention qualifier score (4.9 +/- 1.2 vs 5.5 +/- 1.2) on the Brazelton Neonatal Behavioral Assessment Scale.

CONCLUSION

Infants with an abnormal cranial ultrasound at birth had higher perinatal risk scores. (ABSTRACT TRUNCATED)

Screening for chromosomal abnormality

Screening for fetal abnormalities has become one of the most high profile health care issues of modern times. This issue is predicated on major advances in health care technology that permit wider detection of fetal anomalies, including the development of more advanced biochemical markers and improvements in ultrasound imaging. The effectiveness of these screening methods and their rational application is a point of great controversy, and is the cause of considerable unease in clinical obstetrical practice. This article reviews the general concepts of fetal screening for fetal chromosome abnormalities and then focuses on certain aspects of ultrasound screening that are particularly controversial. The scientific basis for each ultrasound finding (e.g., nuchal translucency) is reviewed, as well as the frequently divergent clinical experience with the finding. Finally, a plea is made for the development of a more scientific database for fetal ultrasound screening, and the setting of fetal screening guidelines for practicing physicians based on diagnostic accuracy and cost-effectiveness.

Choroid plexus cysts and aneuploidy

The association of choroid plexus cysts with fetal aneuploidy, particularly trisomy 18, was first noted in 1986. Through the years there have been numerous reports on this subject, but no consensus has been reached with regard to chromosomal risk. In this review, we attempt to summarise published reports on second trimester choroid plexus cysts, with an emphasis on the strengths and weaknesses of each report. Based on these reports, additional malformations are a significant risk factor for aneuploidy and an indication for determination of fetal karyotype. The management of isolated choroid plexus cysts remains controversial.