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Hartigan S, Walsh B. Perioperative management of patients with spina bifida. BJA Educ 2024; 24:203-209. [PMID: 38764443 PMCID: PMC11096439 DOI: 10.1016/j.bjae.2024.02.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/16/2024] [Indexed: 05/21/2024] Open
Affiliation(s)
- S. Hartigan
- Children's Health Ireland at Temple Street, Dublin, Ireland
| | - B. Walsh
- Children's Health Ireland at Temple Street, Dublin, Ireland
- School of Medicine, University College, Dublin, Ireland
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Mufti N, Aertsen M, Thomson D, De Vloo P, Demaerel P, Deprest J, Melbourne A, David AL. Longitudinal MRI in the context of in utero surgery for open spina bifida: A descriptive study. Acta Obstet Gynecol Scand 2024; 103:322-333. [PMID: 37984808 PMCID: PMC10823411 DOI: 10.1111/aogs.14711] [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: 06/16/2023] [Revised: 09/17/2023] [Accepted: 10/17/2023] [Indexed: 11/22/2023]
Abstract
INTRODUCTION Fetal surgery for open spina bifida (OSB) requires comprehensive preoperative assessment using imaging for appropriate patient selection and to evaluate postoperative efficacy and complications. We explored patient access and conduct of fetal magnetic resonance imaging (MRI) for prenatal assessment of OSB patients eligible for fetal surgery. We compared imaging acquisition and reporting to the International Society of Ultrasound in Obstetrics and Gynecology MRI performance guidelines. MATERIAL AND METHODS We surveyed access to fetal MRI for OSB in referring fetal medicine units (FMUs) in the UK and Ireland, and two NHS England specialist commissioned fetal surgery centers (FSCs) at University College London Hospital, and University Hospitals KU Leuven Belgium. To study MRI acquisition protocols, we retrospectively analyzed fetal MRI images before and after fetal surgery for OSB. RESULTS MRI for fetal OSB was accessible with appropriate specialists available to supervise, perform, and report scans. The average time to arrange a fetal MRI appointment from request was 4 ± 3 days (range, 0-10), the average scan time available was 37 ± 16 min (range, 20-80 min), with 15 ± 11 min (range, 0-30 min) extra time to repeat sequences as required. Specific MRI acquisition protocols, and MRI reporting templates were available in only 32% and 18% of units, respectively. Satisfactory T2-weighted (T2W) brain imaging acquired in three orthogonal planes was achieved preoperatively in all centers, and 6 weeks postoperatively in 96% of FSCs and 78% of referring FMUs. However, for T2W spine image acquisition referring FMUs were less able to provide three orthogonal planes presurgery (98% FSC vs. 50% FMU, p < 0.001), and 6 weeks post-surgery (100% FSC vs. 48% FMU, p < 0.001). Other standard imaging recommendations such as T1-weighted (T1W), gradient echo (GE) or echoplanar fetal brain and spine imaging in one or two orthogonal planes were more likely available in FSCs compared to FMUs pre- and post-surgery (p < 0.001). CONCLUSIONS There was timely access to supervised MRI for OSB fetal surgery assessment. However, the provision of images of the fetal brain and spine in sufficient orthogonal planes, which are required for determining eligibility and to determine the reversal of hindbrain herniation after fetal surgery, were less frequently acquired. Our evidence suggests the need for specific guidance in relation to fetal MRI for OSB. We propose an example guidance for MRI acquisition and reporting.
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Affiliation(s)
- Nada Mufti
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- School of Biomedical Engineering and Imaging Sciences (BMEIS)King's College LondonLondonUK
| | - Michael Aertsen
- Department of RadiologyUniversity Hospitals Katholieke Universiteit (KU)LeuvenBelgium
| | - Dominic Thomson
- Pediatric Neurosurgery DepartmentGreat Ormond Street Hospital for ChildrenLondonUK
| | - Phillippe De Vloo
- Department of NeurosurgeryUniversity Hospitals Katholieke Universiteit (KU)LeuvenBelgium
| | - Philippe Demaerel
- Department of RadiologyUniversity Hospitals Katholieke Universiteit (KU)LeuvenBelgium
| | - Jan Deprest
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- Department of Obstetrics and GynecologyUniversity Hospitals Katholieke Universiteit (KU)LeuvenBelgium
| | - Andrew Melbourne
- School of Biomedical Engineering and Imaging Sciences (BMEIS)King's College LondonLondonUK
- Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
| | - Anna L. David
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- Department of Obstetrics and GynecologyUniversity Hospitals Katholieke Universiteit (KU)LeuvenBelgium
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Chao AS, Jhang LS, Hsieh PCC. Prenatal Diagnosis and Outcomes of Cervical Meningocele and Myelomeningocele. J Med Ultrasound 2024; 32:21-24. [PMID: 38665341 PMCID: PMC11040477 DOI: 10.4103/jmu.jmu_51_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Accepted: 05/03/2023] [Indexed: 04/28/2024] Open
Abstract
Prenatal diagnosis of myelomeningocele remains challenging for obstetricians, ultrasonographers, and radiologists, although the increased maternal serum alpha-fetoprotein level aids in the confirmative diagnosis. Fetal cervical myelomeningocele and meningocele are very rare and unique types of myelomeningocele. Prenatal diagnosis of cervical myelomeningocele and meningocele should include the differential diagnosis and association of many intracranial and spino-skeletal pathogenetic variants and genetic diseases, including subependymal nodular heterotopia and Klippel-Feil syndrome. In this report, a comprehensive review of fetal cervical myelomeningocele with its prenatal diagnosis and long-term outcomes is presented.
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Affiliation(s)
- An-Shine Chao
- Department of Obstetrics and Gynecology, New Taipei Municipal Tucheng Hospital, New Taipei, Taiwan
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and University, Taoyuan, Taiwan
| | - Lan-Sin Jhang
- Department of Obstetrics and Gynecology, New Taipei Municipal Tucheng Hospital, New Taipei, Taiwan
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and University, Taoyuan, Taiwan
| | - Peter Ching-Chang Hsieh
- Department of Obstetrics and Gynecology, New Taipei Municipal Tucheng Hospital, New Taipei, Taiwan
- Department of Obstetrics and Gynecology, Chang Gung Memorial Hospital and University, Taoyuan, Taiwan
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Mufti N, Chappell J, Aertsen M, Ebner M, Fidon L, Deprest J, David AL, Melbourne A. Assessment of longitudinal brain development using super-resolution magnetic resonance imaging following fetal surgery for open spina bifida. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:707-720. [PMID: 37161647 PMCID: PMC10947002 DOI: 10.1002/uog.26244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 04/18/2023] [Accepted: 05/01/2023] [Indexed: 05/11/2023]
Abstract
OBJECTIVES Prenatal surgery is offered for selected fetuses with open spina bifida (OSB) to improve long-term outcome. We studied the effect of fetal OSB surgery on brain development using advanced magnetic resonance imaging (MRI) techniques to quantify the volume, surface area and shape of cerebral structures and to analyze surface curvature by means of parameters that correspond to gyrification. METHODS We compared MRI data from 29 fetuses with OSB before fetal surgery (mean gestational age (GA), 23 + 3 weeks) and at 1 and 6 weeks after surgery, with that of 36 GA-matched control fetuses (GA range, 21 + 2 to 36 + 2 weeks). Automated super-resolution reconstruction provided three-dimensional isotropic volumetric brain images. Unmyelinated white matter, cerebellum and ventricles were segmented automatically and refined manually, after which volume, surface area and shape parameter (volume/surface area) were quantified. Mathematical markers (shape index (SI) and curvedness) were used to measure gyrification. Parameters were assessed according to lesion type (myelomeningocele vs myeloschisis (MS)), postoperative persistence of hindbrain herniation (HH) and the presence of supratentorial anomalies, namely partial agenesis of the corpus callosum (pACC) and heterotopia (HT). RESULTS Growth in ventricular volume per week and change in shape parameter per week were higher at 6 weeks after surgery in fetuses with OSB compared with controls (median, 2500.94 (interquartile range (IQR), 1689.70-3580.80) mm3 /week vs 708.21 (IQR, 474.50-925.00) mm3 /week; P < 0.001 and 0.075 (IQR, 0.047-0.112) mm/week vs 0.022 (IQR, 0.009-0.042) mm/week; P = 0.046, respectively). Ventricular volume growth increased 6 weeks after surgery in cases with pACC (P < 0.001) and those with persistent HH (P = 0.002). During that time period, the change in unmyelinated white-matter shape parameter per week was decreased in OSB fetuses compared with controls (0.056 (IQR, 0.044-0.092) mm/week vs 0.159 (IQR, 0.100-0.247) mm/week; P = 0.002), particularly in cases with persistent HH (P = 0.011), MS (P = 0.015), HT (P = 0.022), HT with corpus callosum anomaly (P = 0.017) and persistent HH with corpus callosum anomaly (P = 0.007). At 6 weeks postoperatively, despite OSB fetuses having a lower rate of change in curvedness compared with controls (0.061 (IQR, 0.040-0.093) mm-1 /week vs 0.094 (IQR, 0.070-0.146) mm-1 /week; P < 0.001), reversing the trend seen at 1 week after surgery (0.144 (IQR, 0.099-0.236) mm-1 /week vs 0.072 (IQR, 0.059-0.081) mm-1 /week; P < 0.001), gyrification, as determined using SI, appeared to be increased in OSB fetuses overall compared with controls. This observation was more prominent in fetuses with pACC and those with severe ventriculomegaly (P-value range, < 0.001 to 0.006). CONCLUSIONS Following fetal OSB repair, volume, shape and curvedness of ventricles and unmyelinated white matter differed significantly compared with those of normal fetuses. Morphological brain changes after fetal surgery were not limited to effects on the circulation of cerebrospinal fluid. These observations may have implications for postnatal neurocognitive outcome. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- N. Mufti
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- School of Biomedical Engineering and Imaging Sciences (BMEIS)King's College LondonLondonUK
| | - J. Chappell
- School of Biomedical Engineering and Imaging Sciences (BMEIS)King's College LondonLondonUK
| | - M. Aertsen
- Department of RadiologyUniversity Hospitals Katholieke Universiteit (KU) LeuvenLeuvenBelgium
| | - M. Ebner
- School of Biomedical Engineering and Imaging Sciences (BMEIS)King's College LondonLondonUK
| | - L. Fidon
- School of Biomedical Engineering and Imaging Sciences (BMEIS)King's College LondonLondonUK
| | - J. Deprest
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- Department of Obstetrics and GynaecologyUniversity Hospitals Katholieke Universiteit (KU) LeuvenLeuvenBelgium
| | - A. L. David
- Elizabeth Garrett Anderson Institute for Women's HealthUniversity College LondonLondonUK
- Department of Obstetrics and GynaecologyUniversity Hospitals Katholieke Universiteit (KU) LeuvenLeuvenBelgium
- National Institute for Health and Care Research University College London Hospitals Biomedical Research CentreLondonUK
| | - A. Melbourne
- School of Biomedical Engineering and Imaging Sciences (BMEIS)King's College LondonLondonUK
- Medical Physics and Biomedical EngineeringUniversity College LondonLondonUK
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Akbas H, Guven ESG, Guven S, Kizilirmak R, Albayrak M, Aydogan Z, Kul S. Evaluation of the height of the corpus callosum body region in fetal meningomyelocele malformation. J Gynecol Obstet Hum Reprod 2023; 52:102619. [PMID: 37295771 DOI: 10.1016/j.jogoh.2023.102619] [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: 12/12/2022] [Revised: 05/26/2023] [Accepted: 06/06/2023] [Indexed: 06/12/2023]
Abstract
PURPOSE To investigate height of the corpus callosum (CC) in order to describe the corpus callosum anomalies in fetuses with meningomyelocele (MMC) and compare these findings with the corpus callosum of healthy fetuses. METHODS In this study, fetal MRI examinations were performed on 44 fetal MMC malformation cases. As the control group, 34 fetal MRI examinations, which were anatomically normal, were evaluated retrospectively. In the study group, lateral ventricle diameter, the level and diameter of the MMC defect, and CC height were measured. In the control group, CC height and lateral ventricular diameter were measured. RESULTS The mean CC body height was 1.36 mm in the study group, and 2.48 mm in the control group. The height of the CC body region of the study population was inclined to be thinner compared with the control population (p<0.001). CONCLUSIONS The fact that the height of the CC body region was found to be thinner in fetal MRI in cases of MMC compared with normal fetuses suggests that various callosal anomalies are uncertain, investigation of additional callosal anomalies may be beneficial in the decision for the continuation of pregnancy, and termination or intrauterine surgery in cases with MMC. Further large case group studies are needed.
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Affiliation(s)
- Humeyra Akbas
- Department of Perinatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey.
| | | | - Suleyman Guven
- Department of Gynecology and Obstetrics, Karadeniz Technical University School of Medicine, Trabzon, Turkey
| | - Rukiye Kizilirmak
- Department of Perinatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Mehmet Albayrak
- Department of Perinatology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Zeynep Aydogan
- Department of Radiology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
| | - Sibel Kul
- Department of Radiology, Karadeniz Technical University Faculty of Medicine, Trabzon, Turkey
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Kunpalin Y, Sichitiu J, Krishan P, Blaser S, Shannon P, Van Mieghem T, Shinar S. Midline suprapineal pseudocyst in brain of fetuses with open spina bifida. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2023; 62:383-390. [PMID: 37058393 DOI: 10.1002/uog.26221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 03/25/2023] [Accepted: 03/30/2023] [Indexed: 06/19/2023]
Abstract
OBJECTIVES Recently, it was noted that fetuses with open spina bifida (OSB) may have a midline cystic structure evident on ultrasound. Our aims were to determine the prevalence of this cystic structure, shed light on its pathophysiology and investigate the association between its presence and other characteristic brain findings in fetuses with OSB. METHODS This was a single-center retrospective study of all fetuses with OSB and available cineloop images in the axial plane referred to the Ontario Fetal Centre, Toronto, Canada, between June 2017 and May 2022. Ultrasound and magnetic resonance imaging (MRI) data obtained between 18 + 0 and 25 + 6 weeks were reviewed in search of a midline cystic structure. Pregnancy and lesion characteristics were collected. Transcerebellar diameter (TCD), clivus-supraocciput angle (CSA) and additional brain abnormalities (abnormal cavum septi pellucidi (CSP), abnormal corpus callosum (CC) and periventricular nodular heterotopia (PNH)) were assessed. In cases of in-utero repair, imaging findings were reviewed postoperatively. In cases of termination, neuropathological findings were reviewed, if available. RESULTS Of 76 fetuses with OSB, 56 (73.7%) had a suprapineal cystic structure on ultrasound. The percentage of agreement between ultrasound and MRI detection was 91.5% (Cohen's kappa coefficient, 0.78 (95% CI, 0.57-0.98)). Brain autopsy in terminated cases revealed a dilatation of the posterior third ventricle, with redundant tela choroidea and arachnoid forming the membranous roof of the third ventricle, anterior and superior to the pineal gland. A cyst wall could not be identified, indicating that the structure was a pseudocyst. The presence of the pseudocyst was associated with a smaller CSA (pseudocyst absent, 62.11 ± 9.60° vs pseudocyst present, 52.71 ± 8.22°; P = 0.04). When the pseudocyst was present, its area was correlated inversely with TCD (r, -0.28 (95% CI, -0.51 to -0.02); P = 0.04). Fetal surgery did not have any impact on the growth rate of the pseudocyst (fetal surgery, 5.07 ± 3.29 mm2 /week vs expectant management, 4.35 ± 3.17 mm2 /week; P = 0.58). The presence of the pseudocyst was not associated with abnormal CSP, CC or presence of PNH. None of the cases with available postnatal follow-up required surgical procedure related to the pseudocyst. CONCLUSIONS Approximately 75% of all OSB cases have a suprapineal pseudocyst. Its presence is associated with the degree of hindbrain herniation but not with abnormalities of the CSP and CC or presence of PNH. Thus, it should not be regarded as additional brain pathology and should not preclude fetuses from undergoing fetal surgery for OSB. © 2023 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- Y Kunpalin
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - J Sichitiu
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - P Krishan
- Department of Diagnostic Imaging, Hospital for Sick Children and University of Toronto, Toronto, Canada
- Ontario Fetal Centre, Toronto, Canada
| | - S Blaser
- Department of Diagnostic Imaging, Hospital for Sick Children and University of Toronto, Toronto, Canada
- Ontario Fetal Centre, Toronto, Canada
| | - P Shannon
- Division of Pathology and Laboratory Medicine, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - T Van Mieghem
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
- Ontario Fetal Centre, Toronto, Canada
| | - S Shinar
- Fetal Medicine Unit, Department of Obstetrics and Gynaecology, Mount Sinai Hospital and University of Toronto, Toronto, Canada
- Ontario Fetal Centre, Toronto, Canada
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Sahuquillo J, Moncho D, Ferré A, López-Bermeo D, Sahuquillo-Muxi A, Poca MA. A Critical Update of the Classification of Chiari and Chiari-like Malformations. J Clin Med 2023; 12:4626. [PMID: 37510741 PMCID: PMC10380265 DOI: 10.3390/jcm12144626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 06/27/2023] [Accepted: 07/05/2023] [Indexed: 07/30/2023] Open
Abstract
Chiari malformations are a group of craniovertebral junction anomalies characterized by the herniation of cerebellar tonsils below the foramen magnum, often accompanied by brainstem descent. The existing classification systems for Chiari malformations have expanded from the original four categories to nine, leading to debates about the need for a more descriptive and etiopathogenic terminology. This review aims to examine the various classification approaches employed and proposes a simplified scheme to differentiate between different types of tonsillar herniations. Furthermore, it explores the most appropriate terminology for acquired herniation of cerebellar tonsils and other secondary Chiari-like malformations. Recent advances in magnetic resonance imaging (MRI) have revealed a higher prevalence and incidence of Chiari malformation Type 1 (CM1) and identified similar cerebellar herniations in individuals unrelated to the classic phenotypes described by Chiari. As we reassess the existing classifications, it becomes crucial to establish a terminology that accurately reflects the diverse presentations and underlying causes of these conditions. This paper contributes to the ongoing discussion by offering insights into the evolving understanding of Chiari malformations and proposing a simplified classification and terminology system to enhance diagnosis and management.
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Affiliation(s)
- Juan Sahuquillo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
| | - Dulce Moncho
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Clinical Neurophysiology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Alex Ferré
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Sleep Unit, Pneumology Department, Vall d'Hebron Hospital Universitari, Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Diego López-Bermeo
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Aasma Sahuquillo-Muxi
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
| | - Maria A Poca
- Department of Neurosurgery, Vall d'Hebron University Hospital, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Neurotraumatology and Neurosurgery Research Unit, Vall d'Hebron Institut de Recerca (VHIR), Vall d'Hebron Barcelona Hospital Campus, Passeig Vall d'Hebron 119-129, 08035 Barcelona, Spain
- Department of Surgery, Universitat Autònoma de Barcelona, Bellaterra, 08193 Barcelona, Spain
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George E, MacPherson C, Pruthi S, Bilaniuk L, Fletcher J, Houtrow A, Gupta N, Glenn OA. Long-Term Imaging Follow-up from the Management of Myelomeningocele Study. AJNR Am J Neuroradiol 2023; 44:861-866. [PMID: 37385677 PMCID: PMC10337608 DOI: 10.3174/ajnr.a7926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 05/23/2023] [Indexed: 07/01/2023]
Abstract
BACKGROUND AND PURPOSE Short-term results demonstrate that prenatal repair of a myelomeningocele is associated with a reduction in hydrocephalus and an increased likelihood of the reversal of Chiari II malformations compared with postnatal repair. The purpose of this study was to identify the long-term imaging findings at school age among subjects who underwent pre- versus postnatal repair of a myelomeningocele. MATERIALS AND METHODS A subset of subjects enrolled in the Management of Myelomeningocele Study who underwent either prenatal (n = 66) or postnatal (n = 63) repair of a lumbosacral myelomeningocele and had follow-up brain MR imaging at school age were included. The prevalence of posterior fossa features of Chiari II malformation and supratentorial abnormalities and the change in these findings from fetal to school-age MR imaging were compared between the 2 groups. RESULTS Prenatal repair of a myelomeningocele was associated with higher rates of normal location of fourth ventricle and lower rates of hindbrain herniation, cerebellar herniation, tectal beaking, brainstem distortion, and kinking at school age compared with postnatal repair (all P < .01). Supratentorial abnormalities, including corpus callosal abnormalities, gyral abnormalities, heterotopia, and hemorrhage, were not significantly different between the 2 groups (all P > .05). The rates of resolution of brainstem kinking, tectal beaking, cerebellar and hindbrain herniation, and normalization of fourth ventricle size from fetal to school age MR imaging were higher among the prenatal compared with postnatal surgery group (all, P < .02). CONCLUSIONS Prenatal repair of a myelomeningocele is associated with persistent improvement in posterior fossa imaging findings of Chiari II malformation at school age compared with postnatal repair.
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Affiliation(s)
- E George
- From the Departments of Radiology and Biomedical Imaging (E.G., O.A.G.)
| | - C MacPherson
- Biostatistics Center (C.M.), Milken Institute School of Public Health, The George Washington University, Washington, DC
| | - S Pruthi
- Department of Radiology (S.P.), Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - L Bilaniuk
- Department of Radiology (L.B.), Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - J Fletcher
- Department of Psychology (J.F.), University of Houston, Houston, Texas
| | - A Houtrow
- Department of Physical Medicine and Rehabilitation (A.H.), University of Pittsburgh, Pittsburgh, Pennsylvania
| | - N Gupta
- Neurological Surgery (N.G.)
- Pediatrics (N.G.), University of California, San Francisco, San Francisco, California
| | - O A Glenn
- From the Departments of Radiology and Biomedical Imaging (E.G., O.A.G.)
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Advances in Fetal Surgical Repair of Open Spina Bifida. Obstet Gynecol 2023; 141:505-521. [PMID: 36735401 DOI: 10.1097/aog.0000000000005074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2022] [Accepted: 10/03/2022] [Indexed: 02/04/2023]
Abstract
Spina bifida remains a common congenital anomaly of the central nervous system despite national fortification of foods with folic acid, with a prevalence of 2-4 per 10,000 live births. Prenatal screening for the early detection of this condition provides patients with the opportunity to consider various management options during pregnancy. Prenatal repair of open spina bifida, traditionally performed by the open maternal-fetal surgical approach through hysterotomy, has been shown to improve outcomes for the child, including decreased need for cerebrospinal fluid diversion surgery and improved lower neuromotor function. However, the open maternal-fetal surgical approach is associated with relatively increased risk for the patient and the overall pregnancy, as well as future pregnancies. Recent advances in minimally invasive prenatal repair of open spina bifida through fetoscopy have shown similar benefits for the child but relatively improved outcomes for the pregnant patient and future childbearing.
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Avesani G, Perazzolo A, Elia L, Anghelone AG, Gaudino S, Russo L, Genco E, Di Paola V, Massimi L, De Santis M, Tamburrini G, Manfredi R. Fetal MRI prior to intrauterine surgery of open neural tube defects: What does the radiologist need to know. LA RADIOLOGIA MEDICA 2023; 128:113-124. [PMID: 36525177 DOI: 10.1007/s11547-022-01579-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Accepted: 12/07/2022] [Indexed: 12/23/2022]
Abstract
The management of myelomeningocele study trial showed significant prognostic improvement in fetal repair before 26 weeks of gestation. Hence, surgery in utero represents the best treatment option for open-neural tube defects (NTDs). Fetal surgery of open-NTDs has specific inclusion and exclusion criteria, which can be adequately studied with fetal MRI. The main concern: the spine (spinal defects other than Myelomeningocele and Myeloschisis, the level of the lesion higher than T1 or lower than S1 and the degree of kyphosis ≥ 30°), the skull/brain (no cerebellum herniation and Chiari II malformation and the presence of any intracranial abnormality unrelated to open NTDs), the uterus (cervix length less than 2 cm, multiple gestations and placental and uterine abnormalities) and any other fetal abnormality not attributed to spinal defect. In this review, we describe the fundamental role of fetal MRI in supporting therapeutic decisions in pre-surgery intrauterine planning through the accurate and comprehensive description of findings, providing a proposal of a structured report. In addition, we describe how post-surgical MRI is important in investigating the effectiveness of surgery and detecting repairing complications.
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Affiliation(s)
- Giacomo Avesani
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | | | - Lorenzo Elia
- Università Cattolica del Sacro Cuore, Rome, Italy
| | | | - Simona Gaudino
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
| | - Luca Russo
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.
| | - Enza Genco
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Valerio Di Paola
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy
| | - Luca Massimi
- Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico "A. Gemelli" IRCCS, Rome, Italy
| | - Marco De Santis
- Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Scienze della Salute della Donna, del Bambino e di Sanità Pubblica, Fondazione Policlinico "A. Gemelli" IRCCS, Rome, Italy
| | - Gianpiero Tamburrini
- Università Cattolica del Sacro Cuore, Rome, Italy.,Dipartimento di Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico "A. Gemelli" IRCCS, Rome, Italy
| | - Riccardo Manfredi
- Dipartimento di Diagnostica per Immagini, Radioterapia Oncologica ed Ematologia, Fondazione Policlinico "A. Gemelli" IRCCS, Largo Agostino Gemelli 8, 00168, Rome, Italy.,Università Cattolica del Sacro Cuore, Rome, Italy
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11
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Ece B, Aydın S, Kantarci M. Antenatal imaging: A pictorial review. World J Clin Cases 2022; 10:12854-12874. [PMID: 36569012 PMCID: PMC9782949 DOI: 10.12998/wjcc.v10.i35.12854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2022] [Revised: 10/17/2022] [Accepted: 11/28/2022] [Indexed: 12/14/2022] Open
Abstract
Today, in parallel with the use of imaging modalities increases in all fields, the use of imaging methods in pregnant women is increasing. Imaging has become an integral component of routine pregnancy follow-up. Imaging provides parents with an early opportunity to learn about the current situation, including prenatal detection of anomalies or diseases, etiology, prognosis, and the availability of prenatal or postnatal treatments. Various imaging modalities, especially ultrasonography, are frequently used for imaging both maternal and fetal imaging. The goal of this review was to address imaging modalities in terms of usefulness and safety, as well as to provide demonstrative examples for disorders. And this review provides current information on selecting a safe imaging modality to evaluate the pregnant and the fetus, the safety of contrast medium use, and summarizes major pathological situations with demonstrative sonographic images to assist radiologists and obstetricians in everyday practice.
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Affiliation(s)
- Bunyamin Ece
- Department of Radiology, Kastamonu University, Kastamonu 37150, Turkey
| | - Sonay Aydın
- Department of Radiology, Erzincan University, Erzincan 24142, Turkey
| | - Mecit Kantarci
- Department of Radiology, Erzincan University, Erzincan 24142, Turkey
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12
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Trigo L, Eixarch E, Bottura I, Dalaqua M, Barbosa AA, De Catte L, Demaerel P, Dymarkowski S, Deprest J, Lapa DA, Aertsen M, Gratacos E. Prevalence of supratentorial anomalies assessed by magnetic resonance imaging in fetuses with open spina bifida. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2022; 59:804-812. [PMID: 34396624 DOI: 10.1002/uog.23761] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/29/2021] [Accepted: 08/02/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVES To determine the prevalence of brain anomalies at the time of preoperative magnetic resonance imaging (MRI) assessment in fetuses eligible for prenatal open spina bifida (OSB) repair, and to explore the relationship between brain abnormalities and features of the spinal defect. METHODS This was a retrospective cross-sectional study, conducted in three fetal medicine centers, of fetuses eligible for OSB fetal surgery repair between January 2009 and December 2019. MRI images obtained as part of the presurgical assessment were re-evaluated by two independent observers, blinded to perinatal results, to assess: (1) the type and area of the defect and its anatomical level; (2) the presence of any structural central nervous system (CNS) anomaly and abnormal ventricular wall; and (3) fetal head and brain biometry. Binary regression analyses were performed and data were adjusted for type of defect, upper level of the lesion (ULL), gestational age (GA) at MRI and fetal medicine center. Multiple logistic regression analysis was performed in order to identify lesion characteristics and brain anomalies associated with a higher risk of presence of abnormal corpus callosum (CC) and/or heterotopia. RESULTS Of 115 fetuses included, 91 had myelomeningocele and 24 had myeloschisis. Anatomical level of the lesion was thoracic in seven fetuses, L1-L2 in 13, L3-L5 in 68 and sacral in 27. Median GA at MRI was 24.7 (interquartile range, 23.0-25.7) weeks. Overall, 52.7% of cases had at least one additional brain anomaly. Specifically, abnormal CC was observed in 50.4% of cases and abnormality of the ventricular wall in 19.1%, of which 4.3% had nodular heterotopia. Factors associated independently with higher risk of abnormal CC and/or heterotopia were non-sacral ULL (odds ratio (OR), 0.51 (95% CI, 0.26-0.97); P = 0.043), larger ventricular width (per mm) (OR, 1.23 (95% CI, 1.07-1.43); P = 0.005) and presence of abnormal cavum septi pellucidi (OR, 3.76 (95% CI, 1.13-12.48); P = 0.031). CONCLUSIONS Half of the fetuses assessed for OSB repair had an abnormal CC and/or an abnormal ventricular wall prior to prenatal repair. The likelihood of brain abnormalities was increased in cases with a non-sacral lesion and wider lateral ventricles. These findings highlight the importance of a detailed preoperative CNS evaluation of fetuses with OSB. © 2021 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of International Society of Ultrasound in Obstetrics and Gynecology.
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Affiliation(s)
- L Trigo
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
| | - E Eixarch
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
| | - I Bottura
- Fetal and Neonatal Therapy Group, Hospital Sabará, São Paulo, Brazil
| | - M Dalaqua
- Department of Radiology, Hospital Israelita Albert Einsten, São Paulo, Brazil
- School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, Brazil
| | - A A Barbosa
- Fetal and Neonatal Therapy Group, Hospital Sabará, São Paulo, Brazil
- School of Medicine, Faculdade Israelita de Ciências da Saúde Albert Einstein (FICSAE), São Paulo, Brazil
| | - L De Catte
- Department of Radiology, UZ KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, UZ KU Leuven, Leuven, Belgium
| | - P Demaerel
- Department of Radiology, UZ KU Leuven, Leuven, Belgium
| | - S Dymarkowski
- Department of Radiology, UZ KU Leuven, Leuven, Belgium
| | - J Deprest
- My FetUZ Fetal Research Center, Department of Development and Regeneration, Biomedical Sciences, KU Leuven, Leuven, Belgium
- Department of Obstetrics and Gynecology, UZ KU Leuven, Leuven, Belgium
- Institute of Women's Health, University College London, London, UK
| | - D A Lapa
- Fetal Therapy Program, Hospital Israelita Albert Einsten, São Paulo, Brazil
- Department of Hospital Infantil Sabará, São Paulo, Brazil
| | - M Aertsen
- Department of Radiology, UZ KU Leuven, Leuven, Belgium
| | - E Gratacos
- BCNatal-Fetal Medicine Research Center, Hospital Clínic and Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centre for Biomedical Research on Rare Diseases (CIBER-ER), Barcelona, Spain
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13
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[Prenatal ultrasound prognostic of myelomeningocele at the era of fetal surgery]. ACTA ACUST UNITED AC 2021; 49:617-629. [PMID: 34020095 DOI: 10.1016/j.gofs.2021.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Indexed: 11/21/2022]
Abstract
Myelomeningocele (MMC) is a severe congenital condition responsible for motor and sensory impairments of the lower limbs, incontinence and cognitive impairment. Its screening, sometimes as early as the first trimester, is one of the major goals of modern prenatal care, supported by the emergence of prenatal surgery that results in a significant improvement in motor function, ambulation and ventriculoperitoneal shunt rate in patients undergoing in-utero surgery. From screening to pre- and post-operative prognostic evaluation, prenatal ultrasound is now an essential tool in the antenatal management of this condition. Using the multi planar and three-dimensional modes, it can be used to assess the vertebral level of MMC, which remains the key antenatal prognostic marker for motor function and ambulation, incontinence and the need for a ventriculo-peritoneal shunt. A careful and systematic ultrasound examination also makes it possible to assess the severity and progression of ventriculomegaly, to search for associated cerebral, spinal cord or vertebral anomalies, or to rule out exclusion criteria for in-utero surgery such as severe kyphosis or serious cortical anomalies. New tools from post-natal evaluation, such as the "metameric" ultrasound assessment of lower limb mobility, appear to be promising either for the initial examination or after in-utero surgery. Ultrasonography, associated with fetal MRI, cytogenetic and next generation sequencing, now allows a highly customized prognostic evaluation of these fetuses affected by MMC and provides the parents with the best possible information on the expected benefits and limitations of fetal surgery.
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