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Bruzek AK, Koller GM, Karuparti S, Varagur K, Dunbar A, Flanders TM, Mingo M, Sudanagunta K, Bligard KH, Odibo A, Vrecenak J, Mian A, Strahle JM. MRI analysis of neurodevelopmental anatomy in myelomeningocele: prenatal vs postnatal repair. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2024; 64:362-373. [PMID: 38237046 DOI: 10.1002/uog.27586] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 10/28/2023] [Accepted: 12/06/2023] [Indexed: 08/02/2024]
Abstract
OBJECTIVE Compared with postnatal repair, prenatal myelomeningocele (MMC) repair is associated with improved motor function and decreased need for cerebrospinal fluid (CSF) diversion. It is unknown how prenatal surgery alters neuroanatomical structures identifiable on magnetic resonance imaging (MRI). The purpose of this study was to use MRI to compare neurodevelopmental anatomy in patients undergoing fetal MMC repair compared with those undergoing postnatal repair. METHODS This was a retrospective review of neonates who underwent prenatal or postnatal MMC repair at our institution between 2016 and 2021. Imaging data, including prenatal ultrasound and pre- and postnatal MRI examinations, if available, were retrieved. We analyzed anatomical findings characteristically seen on MRI of the neuroaxis in patients with MMC and compared imaging findings between patients with prenatal vs postnatal MMC repair. RESULTS The study population included 61 patients who underwent surgical repair for MMC during the 6-year study period, of whom 25 underwent prenatal repair and 36 postnatal repair. CSF diversion was required in 24% of the prenatally repaired cohort vs 67% of the postnatally repaired cohort (P = 0.001). On postnatal MRI, a syrinx was present in 13% of the prenatally repaired cohort vs 42% in the postnatally repaired cohort (P = 0.02). Postnatal corpus callosal (CC) morphology was abnormal in 54% of the prenatally repaired cohort vs 53% of the postnatally repaired cohort (P = 0.92), while falx morphology was normal in 92% of the prenatally repaired cohort vs 34% of the postnatally repaired cohort (P < 0.001). On postnatal MRI, patients in the prenatally repaired cohort had a shorter tentorium-to-foramen-magnum distance compared with those in the postnatally repaired cohort (mean, 18.43 mm vs 22.42 mm; P = 0.01), a larger foramen magnum diameter (mean, 22.87 mm vs 18.94 mm; P < 0.001) and a smaller degree of hindbrain herniation (mean, 1.53 mm vs 8.72 mm; P < 0.001). The cerebral aqueduct was patent in 79% of the prenatally repaired cohort vs 100% of the postnatally repaired cohort on postnatal MRI (P = 0.008). Between the two cohorts, at postnatal MRI there was no significant difference in the presence of gray-matter heterotopia, presence of the septum pellucidum or size of the massa intermedia. CONCLUSIONS We report variations in developmental neuroanatomy in patients with MMC, including rates of CC dysgenesis, gray-matter heterotopia and additional cranial and spinal MRI findings. Compared to postnatal surgery, prenatal surgery is associated with changes to infratentorial anatomy, with minimal effect on supratentorial brain development. This information will be useful in counseling parents affected by fetal MMC and in understanding how prenatal repair of MMC affects brain development. © 2024 International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- A K Bruzek
- Department of Neurosurgery, Washington University, St Louis, MO, USA
| | - G M Koller
- Department of Neurosurgery, Washington University, St Louis, MO, USA
| | - S Karuparti
- School of Medicine, University of Missouri, Columbia, MO, USA
| | - K Varagur
- Department of Neurosurgery, Washington University, St Louis, MO, USA
| | - A Dunbar
- Department of Neurosurgery, Washington University, St Louis, MO, USA
| | - T M Flanders
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - M Mingo
- Department of Radiology, Washington University, St Louis, MO, USA
| | - K Sudanagunta
- Department of Radiology, Washington University, St Louis, MO, USA
| | - K H Bligard
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Washington University, St Louis, MO, USA
| | - A Odibo
- Department of Obstetrics and Gynecology, Division of Maternal-Fetal Medicine and Ultrasound, Washington University, St Louis, MO, USA
| | - J Vrecenak
- Department of Surgery, Washington University, St Louis, MO, USA
| | - A Mian
- Department of Radiology, Washington University, St Louis, MO, USA
| | - J M Strahle
- Department of Neurosurgery, Washington University, St Louis, MO, USA
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Kunpalin Y, Richter J, Mufti N, Bosteels J, Ourselin S, De Coppi P, Thompson D, David AL, Deprest J. Cranial findings detected by second-trimester ultrasound in fetuses with myelomeningocele: a systematic review. BJOG 2021; 128:366-374. [PMID: 32926566 PMCID: PMC8436766 DOI: 10.1111/1471-0528.16496] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/03/2020] [Indexed: 12/14/2022]
Abstract
Background Abnormal intracranial findings are often detected at mid‐trimester ultrasound (US) in fetuses with myelomeningocele (MMC). It is unclear whether these findings constitute a spectrum of the disease or are an independent finding, which should contraindicate fetal surgery. Objective To ascertain the spectrum and frequency of US‐detected cranial findings in fetuses with MMC. Search strategy MEDLINE, Embase, Web of Science and CENTRAL were searched from January 2000 to June 2020. Selection criteria Study reporting incidence of cranial US findings in consecutive cases of second‐trimester fetuses with MMC. Data collection and analysis Publication quality was assessed by Newcastle–Ottawa Scale (NOS) and modified NOS. Meta‐analysis could not be performed as a result of high clinical diversity and study heterogeneity. Main results Fourteen cranial US findings were reported in 15 studies. Findings in classic Chiari II malformation (CIIM) spectrum included posterior fossa funnelling (96%), small transcerebellar diameter (82–96%), ‘banana’ sign (50–100%), beaked tectum (65%) and ‘lemon’ sign (53–100%). Additional cranial findings were small biparietal diameter (BPD) and head circumference (HC) (<5th centile; 53 and 71%, respectively), ventriculomegaly (45–89%), abnormal pointed shape of the occipital horn (77–78%), thinning of the posterior cerebrum, perinodular heterotopia (11%), abnormal gyration (3%), corpus callosum disorders (60%) and midline interhemispheric cyst (42%). Conclusions We identified 14 cranial findings by second‐trimester US in fetuses with MMC. The relatively high incidence of these findings and their unclear prognostic significance might not contraindicate fetal surgery in the case of normal fetal genetic testing. Some cranial findings may independently affect postnatal outcome, however. Long‐term detailed follow‐up is required to investigate this. Tweetable abstract A high rate of cranial abnormalities found on second‐trimester ultrasound in fetuses with myelomeningocele. A high rate of cranial abnormalities found on second‐trimester ultrasound in fetuses with myelomeningocele.
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Affiliation(s)
- Y Kunpalin
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J Richter
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
| | - N Mufti
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK
| | - J Bosteels
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Cochrane Belgium, Belgian Centre for Evidence-Based Medicine (Cebam), Leuven, Belgium
| | - S Ourselin
- School of Biomedical Engineering & imaging Sciences, King's College London, London, UK
| | - P De Coppi
- Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of General Paediatric Surgery, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - D Thompson
- Department of Paediatric Neurosurgery, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - A L David
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - J Deprest
- Elizabeth Garrett Anderson Institute for Women's Health, University College London, London, UK.,Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium.,Department of Obstetrics and Gynaecology, University Hospitals Leuven, Leuven, Belgium
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Magnetic resonance imaging of the brainstem in children, part 1: imaging techniques, embryology, anatomy and review of congenital conditions. Pediatr Radiol 2021; 51:172-188. [PMID: 33496830 DOI: 10.1007/s00247-020-04953-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Revised: 09/10/2020] [Accepted: 12/20/2020] [Indexed: 10/22/2022]
Abstract
Part 1 of this series of two articles describes conventional and advanced MRI techniques that are useful for evaluating brainstem pathologies. In addition, it provides a review of the embryology, normal progression of myelination, and clinically and radiologically salient imaging anatomy of the normal brainstem. Finally, it discusses congenital diseases of the brainstem with a focus on distinctive imaging features that allow for differentiating pathologies. Part 2 of this series of two articles includes discussion of neoplasms; infections; and vascular, demyelinating, toxic and metabolic, and miscellaneous disease processes affecting the brainstem. The ultimate goal of this pair of articles is to empower the radiologist to add clinical value in the care of pediatric patients with brainstem pathologies.
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Bertsch M, Floyd M, Kehoe T, Pfeifer W, Drack AV. The clinical evaluation of infantile nystagmus: What to do first and why. Ophthalmic Genet 2017; 38:22-33. [PMID: 28177849 DOI: 10.1080/13816810.2016.1266667] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
INTRODUCTION Infantile nystagmus has many causes, some life threatening. We determined the most common diagnoses in order to develop a testing algorithm. METHODS Retrospective chart review. Exclusion criteria were no nystagmus, acquired after 6 months, or lack of examination. DATA COLLECTED pediatric eye examination findings, ancillary testing, order of testing, referral, and final diagnoses. Final diagnosis was defined as meeting published clinical criteria and/or confirmed by diagnostic testing. Patients with a diagnosis not meeting the definition were "unknown." Patients with incomplete testing were "incomplete." Patients with multiple plausible etiologies were "multifactorial." Patients with negative complete workup were "motor." RESULTS A total of 284 charts were identified; 202 met inclusion criteria. The three most common causes were Albinism (19%), Leber Congenital Amaurosis (LCA; 14%), and Non-LCA retinal dystrophy (13%). Anatomic retinal disorders comprised 10%, motor another 10%. The most common first test was MRI (74/202) with a diagnostic yield of 16%. For 28 MRI-first patients, nystagmus alone was the indication; for 46 MRI-first patients other neurologic signs were present. 0/28 nystagmus-only patients had a diagnostic MRI while 14/46 (30%) with neurologic signs did. The yield of ERG as first test was 56%, OCT 55%, and molecular genetic testing 47%. Overall, 90% of patients had an etiology identified. CONCLUSION The most common causes of infantile nystagmus were retinal disorders (56%), however the most common first test was brain MRI. For patients without other neurologic stigmata complete pediatric eye examination, ERG, OCT, and molecular genetic testing had a higher yield than MRI scan. If MRI is not diagnostic, a complete ophthalmologic workup should be pursued.
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Affiliation(s)
- Morgan Bertsch
- a Department of Ophthalmology and Visual Sciences, Wynn Institute for Vision Research , Roy J. and Lucille A. Carver College of Medicine, University of Iowa , Iowa City , Iowa , USA
| | - Michael Floyd
- a Department of Ophthalmology and Visual Sciences, Wynn Institute for Vision Research , Roy J. and Lucille A. Carver College of Medicine, University of Iowa , Iowa City , Iowa , USA.,b HealthPartners , Minneapolis , Minnesota , USA
| | - Taylor Kehoe
- a Department of Ophthalmology and Visual Sciences, Wynn Institute for Vision Research , Roy J. and Lucille A. Carver College of Medicine, University of Iowa , Iowa City , Iowa , USA.,c Physician Assistant Program , University of Iowa , Iowa City , Iowa , USA
| | - Wanda Pfeifer
- a Department of Ophthalmology and Visual Sciences, Wynn Institute for Vision Research , Roy J. and Lucille A. Carver College of Medicine, University of Iowa , Iowa City , Iowa , USA
| | - Arlene V Drack
- a Department of Ophthalmology and Visual Sciences, Wynn Institute for Vision Research , Roy J. and Lucille A. Carver College of Medicine, University of Iowa , Iowa City , Iowa , USA
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Williams VJ, Juranek J, Stuebing K, Cirino PT, Dennis M, Fletcher JM. Examination of frontal and parietal tectocortical attention pathways in spina bifida meningomyelocele using probabilistic diffusion tractography. Brain Connect 2013; 3:512-22. [PMID: 23937233 DOI: 10.1089/brain.2013.0171] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abnormalities of the midbrain tectum are common but variable malformations in spina bifida meningomyelocele (SBM) and have been linked to neuropsychological deficits in attention orienting. The degree to which variations in tectum structure influence white matter (WM) connectivity to cortical regions is unknown. To assess the relationship of tectal structure and connectivity to frontal and parietal cortical regions, probabilistic diffusion tractography was performed on 106 individuals (80 SBM, 26 typically developing [TD]) to isolate anterior versus posterior tectocortical WM pathways. Results showed that those with SBM exhibited significantly reduced tectal volume, along with decreased fractional anisotropy (FA) in posterior but not anterior tectocortical WM pathways when compared with TD individuals. The group with SBM also showed greater within-subject discrepancies between frontal and parietal WM integrity compared with the TD group. Of those with SBM, qualitative classification of tectal beaking based on radiological review was associated with increased axial diffusivity across both anterior and posterior tectocortical pathways, relative to individuals with SBM and a normal appearing tectum. These results support previous volumetric findings of greater impairment to posterior versus anterior brain regions in SBM, and quantifiably relate tectal volume, tectocortical WM integrity, and tectal malformations in this population.
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Picciotti PM, Fiorita A, Calò L, Battista M, Paolucci V, Ausili E, Massimi L, Rendeli C. Vestibular evoked myogenic potentials in children affected by myelomeningocele. Childs Nerv Syst 2012; 28:1761-5. [PMID: 22562194 DOI: 10.1007/s00381-012-1779-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2012] [Accepted: 04/16/2012] [Indexed: 12/01/2022]
Abstract
PURPOSE The aim of the present study is to establish if the vestibular evoked myogenic potentials (VEMPs) could be used as a clinical test for the evaluation of vestibular function in children affected by myelomeningocele (MMC). MATERIALS AND METHODS Fifteen children, aged between 3 and 17 years, who had been affected by MMC were investigated. Data obtained from these children were compared with normal data from healthy children of the same age. Electromyographic activity of sternocleidomastoid muscle was recorded, while children were laid supine and asked to raise their head off the bed in order to activate their neck flexors bilaterally. The saccular receptors were acoustically stimulated with a logon of 500 Hz at an intensity of 130 dB peSPL presented monaurally through earphones. In each recording, we analyzed latencies and amplitudes of the p13-and n23 waves and the amplitude ratio between the two ears. RESULTS VEMPs were detected to be normal in 13 patients. In particular, the mean p13 and mean n23 latencies were 15.7 (±1.4) and 21.7 (±1.1) ms, respectively; the mean amplitude value was 84.7 (±36.6), while the mean amplitude ratio was 17.4 (±12). A comparison of latencies and amplitude ratios between the children and healthy control group did not reveal any significant difference. On the contrary, a comparison of amplitude values between the two groups showed significant differences. CONCLUSION In conclusion, vestibulocollic reflex is normal in patients affected by MMC, and VEMPs could represent a valid and noninvasive technique eligible to investigate the vestibular functions in these children.
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Affiliation(s)
- Pasqualina M Picciotti
- Department of Otorhinolaryngology, Catholic University of the Sacred Heart, Rome, Italy.
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Callen AL, Stengel JW, Filly RA. Supratentorial abnormalities in the Chiari II malformation, II: tectal morphologic changes. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2009; 28:29-35. [PMID: 19106353 DOI: 10.7863/jum.2009.28.1.29] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/27/2023]
Abstract
OBJECTIVE The sonographic diagnosis of fetal myelomeningocele has improved mainly because the diagnostic focus has shifted from observation of spinal manifestations to observation of cranial abnormalities. Intracranial diagnostic criteria rely on abnormalities in the posterior fossa. We describe abnormalities in tectal morphologic characteristics that, although well described on magnetic resonance imaging, have received little attention in the sonographic literature. This study analyzed the frequency of this observation and technical aspects that improve its visualization. METHODS From a database of obstetric sonograms, we identified all cases of sonographically detected myelomeningocele. The search covered the years 1999 to 2007. We retrospectively reviewed the fetal intracranial findings with special attention to elongation or "beaking" of the tectum. RESULTS A total of 89 fetuses were identified. The mean and median gestational ages were 22 weeks 4 days and 22 weeks 2 days, respectively. Of the 89 cases, 59 (66%) had an abnormal tectal shape. The abnormality was seen in 77% of cases judged to be suboptimally visualized and 62% of cases with good visualization. Tectal abnormalities were seen equally well in fetuses before and after 24 weeks. Finally, tectal abnormalities were seen more frequently as the severity of posterior fossa findings increased. CONCLUSIONS Tectal morphologic alteration is a common supratentorial feature of the Chiari II malformation on prenatal sonography both before and after 24 weeks' gestation. Its frequency increases with the severity of posterior fossa abnormalities. Therefore, it may be useful as a supratentorial indicator of both the presence and, potentially, the severity of the Chiari II malformation.
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Affiliation(s)
- Andrew L Callen
- Department of Radiology, University of California San Francisco, San Francisco, CA 94143-0628, USA
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Caines E, Dahl M, Holmström G. Longterm oculomotor and visual function in spina bifida cystica: a population-based study. ACTA ACUST UNITED AC 2007; 85:662-6. [PMID: 17403023 DOI: 10.1111/j.1600-0420.2007.00905.x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
PURPOSE To document and describe the development from birth of visual and oculomotor functions in a group of children with spina bifida cystica (myelomeningocele and myeloschisis [MMC]). The emphasis in this study is on findings at 12-14 year follow-up. METHODS Twenty children aged 12-14 years with myelomeningocele and Chiari-related malformations were examined by an orthoptist and a paediatric ophthalmologist. A further child who did not wish to participate actively in the study is also reported. Visual acuity for near and distance, refractometer readings in cycloplegia, the presence of ocular motility disorders and nystagmus were recorded. Accommodation, convergence, colour vision and stereo acuity were assessed and the fundus and media were examined. RESULTS Six children (29%) in the study group had subnormal vision, although no child was visually impaired. Eleven (52%) showed manifest strabismus and 17 (81%) had a significant refractive error. Near visual acuity was normal in nearly all the children, but accommodation was defective in 10. Nine children had nystagmus and two had optic atrophy. No visual field defects were found. CONCLUSIONS The high incidence of ocular disturbances in children with spina bifida highlights the importance of regular ophthalmological investigation and follow-up.
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Affiliation(s)
- Elizabeth Caines
- Department of Ophthalmology, University Hospital, Uppsala, Sweden.
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