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Erradi M, Kojmane W. Atresia of the Aqueduct of Sylvius as a cause of congenital hydrocephalus. Radiol Case Rep 2024; 19:3019-3022. [PMID: 38741690 PMCID: PMC11089285 DOI: 10.1016/j.radcr.2024.04.023] [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: 02/12/2024] [Revised: 04/02/2024] [Accepted: 04/08/2024] [Indexed: 05/16/2024] Open
Abstract
Hydrocephalus is defined as an anomaly in the flow of cerebrospinal fluid, with multiple and varied etiologies, both acquired and congenital. The most dominant etiology in the congenital aspect is the stenosis or atresia of the Sylvian Aqueduct, whether isolated or associated with other malformations. We report a case of congenital hydrocephalus due to a stenosis of the Aqueduct of Sylvius in a 2 and a half-year-old child, which was unrecognized in the neonatal period, and the importance of imaging, especially MRI, in the rapid diagnosis of this pathology.
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Affiliation(s)
- Mariam Erradi
- Neonatal Intensive Care Unit and Neonatology department, Mother-Child Hospital- HASSAN II CHU of Fez, Fez, Morocco
- Faculty of Medicine and Pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Mother-Child Hospital, HASSAN II University Hospital of Fez, Km 2.200 Route Sidi Harazem, P.O. Box 1893, 30070 Fez, Morocco
| | - Widade Kojmane
- Neonatal Intensive Care Unit and Neonatology department, Mother-Child Hospital- HASSAN II CHU of Fez, Fez, Morocco
- Faculty of Medicine and Pharmacy of Fez, Sidi Mohamed Ben Abdellah University, Mother-Child Hospital, HASSAN II University Hospital of Fez, Km 2.200 Route Sidi Harazem, P.O. Box 1893, 30070 Fez, Morocco
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Zamłyński M, Olejek A, Koszutski T, Bohosiewicz J, Mandera M, Zamłyński J, Maruniak-Chudek I, Herman-Sucharska I, Pastuszka A. Open Fetal Surgery for Ventricular-Amniotic Valve Implantation in Aqueductal Stenosis-Dependent Severe Fetal Hydrocephalus: A Case Report with 7-Year Follow-Up. Fetal Diagn Ther 2024; 51:278-284. [PMID: 38368860 DOI: 10.1159/000536121] [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: 09/19/2023] [Accepted: 12/27/2023] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Fetal ventriculomegaly is one of the most commonly diagnosed central nervous system pathologies of the second trimester, occurring with a frequency of 0.3-0.5/1,000 births. Severe fetal ventriculomegaly (SVM) may necessitate intrauterine intervention. Most such interventions have been made percutaneously with ultrasound guidance insertion of a pigtail catheter, which sadly often became obstructed or migrated. CASE PRESENTATION Our case report presents the possibility of ventriculo-amniotic valve implantation (VAVI) by classic hysterotomy in isolated severe fetal hydrocephalus (IVSM) due to aqueductal stenosis. The patient was operated on similarly to open fetal surgery MOMS criteria at 24+4/7 GA, with an initial lateral ventricular dimension of 22.5 mm. A female newborn was delivered by elective cesarean section at 31+1/7 GA due to PPROM (Apgar 10' 8 points, birth weight 1,600 g), required CPAP, and removal of the drainage system due to infection and narrow lateral ventricles. Evans index (EI) gradual increase and clinical symptoms of high-pressure hydrocephalus after 10 days required a ventricle-peritoneal shunt (VPS) implantation. The newborn was discharged home after 28 days with stabile hydrocephalus (EI: 0.59-0.6), in good clinical condition. The 7-year follow-up was complicated by epilepsy, VPS shunt infections, delay in motor and intellectual functions (mild to moderate), and symptoms of atypical autism, the phenotype possibly related to a variant in ZEB2 gene. CONCLUSION Intrauterine VAVI is a one-step procedure that is effective in draining CFS. The limitations of the method remain complications due to preterm labor and infection of the drainage system.
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Affiliation(s)
- Mateusz Zamłyński
- Department of Gynecology, Obstetrics and Oncological Gynecology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Anita Olejek
- Department of Gynecology, Obstetrics and Oncological Gynecology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Tomasz Koszutski
- Department of Pediatric Surgery and Urology, Faculty of Medical Sciences in Katowice, Katowice, Poland
| | - Janusz Bohosiewicz
- Department of Pediatric Surgery and Urology, Faculty of Medical Sciences in Katowice, Katowice, Poland
| | - Marek Mandera
- Department of Pediatric Neurosurgery, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Jacek Zamłyński
- Department of Gynecology, Obstetrics and Oncological Gynecology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Iwona Maruniak-Chudek
- Department of Neonatology and Neonatal Intensive Care, Faculty of Medical Sciences in Katowice, Medical University of Silesia, Katowice, Poland
| | - Izabela Herman-Sucharska
- Department of Radiology, Faculty of Health Sciences, Jagiellonian University Medical College, Kraków, Poland
| | - Agnieszka Pastuszka
- Department of Descriptive and Topographic Anatomy, School of Medicine with Division of Dentistry Zabrze, Medical University of Silesia in Katowice, Katowice, Poland
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Emery SP, Lopa S, Peterson E, Jelin AC, Treadwell MC, Gebb J, Galan HL, Bergh E, Criebaum A, McLennan A, Lillegard J, Blumenfeld YJ. Prenatal Diagnosis of Fetal Aqueductal Stenosis: A Multicenter Prospective Observational Study through the North American Fetal Therapy Network. Fetal Diagn Ther 2024; 51:216-224. [PMID: 38320542 DOI: 10.1159/000536037] [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: 04/14/2023] [Accepted: 12/07/2023] [Indexed: 02/08/2024]
Abstract
INTRODUCTION A critical component of an evidence-based reassessment of in-utero intervention for fetal aqueductal stenosis (fetal AS) is determining if the prenatal diagnosis can be accurately made at a gestational age amenable to in-utero intervention. METHODS A multicenter, prospective, observational study was conducted through the North American Fetal Therapy Network (NAFTNet). Pregnancies complicated by severe central nervous system (CNS) ventriculomegaly (lateral ventricle diameter >15 mm) not secondary to a primary diagnosis (myelomeningocele, encephalocele, etc.) were recruited at diagnosis. Imaging and laboratory findings were recorded in an online REDCap database. After evaluation, investigators were asked to render their degree of confidence in the diagnosis of fetal AS. The prenatal diagnosis was compared to the postnatal diagnosis obtained through neonatal neuroimaging. Performance characteristics of ultrasound and magnetic resonance imaging (MRI) were calculated, as was the mean gestational age at diagnosis. RESULTS Between April 2015 and October 2022, eleven NAFTNet centers contributed 64 subjects with severe fetal CNS ventriculomegaly. Of these, 56 had both prenatal and postnatal diagnoses recorded. Ultrasound revealed 32 fetal AS true positives, 4 false positives, 7 false negatives, and 13 true negatives, rendering a sensitivity of 0.82, a specificity of 0.76, a positive predictive value of 0.89, and a negative predictive value of 0.65. The mean gestational age at diagnosis by ultrasound was 25.5 weeks (std +/- 4.7 weeks). The proportion of agreement (true positive + true negative/n) was highest at 24 weeks gestation. For fetal MRI (n = 35), the sensitivity for fetal AS was 0.95, specificity was 0.69, positive predictive value was 0.84, and negative predictive value was 0.90. MRI was performed at 25 weeks on average. CONCLUSION The prenatal diagnosis of fetal AS can be made with accuracy at a gestational age potentially amenable to in-utero intervention. Only 7% of subjects were incorrectly diagnosed prenatally with fetal AS by ultrasound and 11% by MRI. Diagnostic accuracy of fetal AS will likely improve with increased experience.
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Affiliation(s)
- Stephen P Emery
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA
| | - Samia Lopa
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of Pittsburgh School of Medicine, UPMC Magee-Womens Hospital, Pittsburgh, Pennsylvania, USA
| | - Erika Peterson
- Department of Obstetrics and Gynecology, Medical College of Wisconsin, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Angie C Jelin
- Department of Gynecology and Obstetrics, Johns Hopkins University, The Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Marjorie C Treadwell
- Department of Obstetrics and Gynecology, Wayne State University School of Medicine, University of Michigan Hospital, Ann Arbor, Michigan, USA
| | - Juliana Gebb
- Division of Pediatric General, Fetal and Thoracic Surgery, University of Pennsylvania, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Henry L Galan
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Children's Hospital Colorado, Denver, Colorado, USA
| | - Eric Bergh
- Department of Obstetrics and Gynecology, University of Texas at Houston, Children's Memorial Hermann Hospital, Houston, Texas, USA
| | - Amanda Criebaum
- Department of Obstetrics and Gynecology, St. Louis Fetal Care Institute, St. Louis, Missouri, USA
| | - Amelia McLennan
- Department of Obstetrics and Gynecology, University of California Davis, UC Davis Medical Center, Sacramento, California, USA
| | - Joseph Lillegard
- Department of Surgery, Children's Minnesota, Minneapolis, Minnesota, USA
| | - Yair J Blumenfeld
- Department of Obstetrics and Gynecology, Stanford University, Stanford Medicine Children's Health Stanford, Palo Alto, California, USA
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Emery SP, Greene S, Elsisy M, Chung K, Ye SH, Kim S, Wagner WR, Hazen N, Chun Y. In vitro and in vivo assessment of a novel ultra-flexible ventriculoamniotic shunt for treating fetal hydrocephalus. J Biomater Appl 2023; 37:1423-1435. [PMID: 36063383 DOI: 10.1177/08853282221125309] [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: 11/15/2022]
Abstract
Fetal aqueductal stenosis (AS) is one of the most common causes of congenital hydrocephalus, which increases intracranial pressure due to partial or complete obstruction of cerebrospinal fluid (CSF) flow within the ventricular system. Approximately 2-4 infants per 10,000 births develop AS, which leads to progressive hydrocephalus, which enlarges the head often necessitating delivery by cesarean section. Most babies born with AS are severely neurologically impaired and experience a lifetime of disability. Therefore, a new device technology for venticuloamniotic shunting is urgently needed and has been studied to ameliorate or prevent fetal hydrocephalus development, which can provide a significant impact on patients and their family's quality of life and on the decrease of the healthcare dollars spent for the treatment. This study has successfully validated the design of shunt devices and demonstrated the mechanical performance and valve functions. A functional prototype shunt has been fabricated and subsequently used in multiple in vitro tests to demonstrate the performance of this newly developed ventriculoamniotic shunt. The shunt contains a main silicone-nitinol composite tube, a superelastic 90° angled dual dumbbell anchor, and an ePTFE valve encased by a stainless-steel cage. The anchor will change its diameter from 1.15 mm (collapsed state) to 2.75 mm (deployed state) showing up to 1.4-fold diameter change in human body temperature. Flow rates in shunts were quantified to demonstrate the valve function in low flow rates mimicking the fetal hydrocephalus condition showing "no backflow" for the valved shunt while there is up to 15 mL/h flow through the shunt with pressure difference of 20 Pa. In vivo ovine study results show the initial successful device delivery and flow drainage with sheep model.
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Affiliation(s)
- Stephen P Emery
- Department of Obstetrics, Gynecology & Reproductive Sciences, Divisions of Maternal-Fetal Medicine, 6620Magee Womens Hospital of UPMC, Pittsburgh, PA, USA
| | - Stephanie Greene
- Department of Neurological Surgery, Division of Neurosurgery, 6619Children's Hospital of Pittsburgh of UPMC, Pittsburgh, PA, USA
| | - Moataz Elsisy
- Mechanical Design and Production Department, 63526Cairo University, Giza, Egypt
| | - Kaitlin Chung
- Department of Biengineering, 6614University of Pittsburgh, Pittsburgh, PA, USA
| | - Sang-Ho Ye
- Department of Surgery, 6595UPMC, Pittsburgh, PA, USA
| | - Seungil Kim
- Department of Surgery, 6595UPMC, Pittsburgh, PA, USA
| | | | - Nika Hazen
- Center for Preclinical Studies, 536993University of Pittsburgh McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
| | - Youngjae Chun
- Department of Biengineering, 6614University of Pittsburgh, Pittsburgh, PA, USA.,Department of Industrial Engineering, 6614University of Pittsburgh, Pittsburgh, PA, USA.,McGowan Institute for Regenerative Medicine, Pittsburgh, PA, USA
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Start AO, Ryan GA, Cathcart B, Hughes H, Higgins S, Corcoran S, Walsh J, Carroll S, Mahony R, Crimmins D, Caird J, Colleran G, McParland P, McAuliffe FM. Severe fetal ventriculomegaly: Fetal morbidity and mortality, caesarean delivery rates and obstetrical challenges in a large prospective cohort. Prenat Diagn 2021; 42:109-117. [PMID: 34870870 DOI: 10.1002/pd.6072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 09/12/2021] [Accepted: 10/07/2021] [Indexed: 11/11/2022]
Abstract
INTRODUCTION Severe fetal ventriculomegaly (VM) is defined as an enlargement of the atria of the lateral cerebral ventricles (Vp) of greater than 15 mm. While it is well established that it confers significant risk of morbidity and mortality to the neonate, there is limited information pertaining to the caesarean delivery rates and the obstetric management of these complex cases. The aim of this study was twofold: firstly, to determine survival rates in fetuses with severe VM, and secondly to determine the caesarean delivery rates in continuing pregnancies. We explore the obstetric challenges associated with these difficult cases. METHODS This was a prospective observational study of patients with antenatal severe VM, attending the Department of Fetal Medicine, National Maternity Hospital, Dublin, Ireland, from 1st January 2011 to 31st July 2020. Data were obtained from the hospital database and those with severe VM (Vp > 15 mm) were identified. The rates of chromosomal abnormalities, the survival rates and the caesarean delivery (CD) rates for the overall group were then determined. The data were then further sub-divided into two groups: 1. Vp < 20 mm and 2. Vp > 20 mm, and the results compared. Statistical analysis was performed using the Chi-Square test. RESULTS A total of N = 95 pregnancies with severe VM were included for analysis, of which additional structural abnormalities on ultrasound were apparent in 67/95 (70.5%) and 28/95 (29.5%) had isolated severe VM. Chromosomal abnormalities were diagnosed in 15/95 (15.8%) of cases, with (2/28) 7.1% in the isolated SVM group versus (13/67) 19.4% in the non-isolated SVM group. The overall survival rate (excluding TOP) was 53/74 (71.6%), with 20/23 (86.9%) in the isolated SVM group. The overall CD rate was 47/72 (65.3%), which was significantly higher than the CD for the hospital during the same time period of 25.4% (P < 0.01). The data were subdivided into Vp < 20 and Vp > 20 and those with a Vp > 20 had higher rates of additional intracranial findings on ultrasound (Vp < 20 13/41 (31.7%) versus Vp > 20 32/54 (59.3%) (P < 0.05)) and macrocrania (Vp < 20 14/41 (34.1%) versus Vp > 20 35/54 (64.8%) (P < 0.05)). No significant difference was observed in the overall survival or CD rates between the two groups. CONCLUSION In conclusion this study reports significant fetal morbidity and mortality with severe VM with high CD rates observed in this cohort. Significant challenges exist in relation to the obstetric management and counseling of parents regarding an often uncertain neonatal prognosis. In continuing pregnancies with significant macrocrania delivery plans should be individualized to improve neonatal outcomes where possible and minimize harm to the mother.
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Affiliation(s)
- Alex O Start
- UCD Perinatal Research Centre, University College Dublin, The National Maternity Hospital, Dublin, Ireland.,Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Gillian A Ryan
- UCD Perinatal Research Centre, University College Dublin, The National Maternity Hospital, Dublin, Ireland.,Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Barbara Cathcart
- Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Heather Hughes
- Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Shane Higgins
- UCD Perinatal Research Centre, University College Dublin, The National Maternity Hospital, Dublin, Ireland.,Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Siobhan Corcoran
- UCD Perinatal Research Centre, University College Dublin, The National Maternity Hospital, Dublin, Ireland.,Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Jennifer Walsh
- UCD Perinatal Research Centre, University College Dublin, The National Maternity Hospital, Dublin, Ireland.,Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Stephen Carroll
- Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Rhona Mahony
- Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Darach Crimmins
- Neurosurgery Department, Children's University Hospital, Dublin, Ireland.,UCD School of Medicine, University College Dublin, Dublin, Ireland
| | - John Caird
- Neurosurgery Department, Children's University Hospital, Dublin, Ireland
| | - Gabrielle Colleran
- UCD School of Medicine, University College Dublin, Dublin, Ireland.,Radiology Department, The National Maternity Hospital, Dublin, Ireland
| | - Peter McParland
- UCD Perinatal Research Centre, University College Dublin, The National Maternity Hospital, Dublin, Ireland.,Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
| | - Fionnuala M McAuliffe
- UCD Perinatal Research Centre, University College Dublin, The National Maternity Hospital, Dublin, Ireland.,Fetal Medicine Department, The National Maternity Hospital, Dublin, Ireland
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Patel A, Abou-Al-Shaar H, Chiang MC, Algattas HN, McDowell MM, Stone JG, Mitchell EB, Emery SP, Greene S. Neuroophthalmological manifestations of congenital aqueductal stenosis. J Neurosurg Pediatr 2021; 28:320-325. [PMID: 34171841 DOI: 10.3171/2021.2.peds20824] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Accepted: 02/11/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Congenital aqueductal stenosis (CAS) is a common etiology of hydrocephalus that occurs in a subset of infants and may be linked to an increased incidence of ophthalmological abnormalities and delayed developmental milestones. Although hydrocephalus is common and widely studied, sparse literature exists on patients with isolated (no identifiable genetic link) CAS along with analysis of ophthalmological manifestations. In this study, the authors sought to describe the ophthalmological abnormalities and delayed developmental milestones of patients with isolated CAS. METHODS Data of patients with CAS were prospectively entered and monitored in a surgical database maintained by the Department of Neurological Surgery at Children's Hospital of Pittsburgh from January 2005 to October 2016. Patients with a family history of congenital hydrocephalus, positive testing for genetic forms of aqueductal stenosis, other congenital abnormalities suggesting an underlying genetic syndrome, and stenosis/obstruction due to secondary causes were excluded from this study. Prenatal and perinatal history, CSF diversion history, and a variety of outcomes, including ophthalmological deficits and developmental milestones, were collected and analyzed. RESULTS A total of 41 patients with isolated CAS were identified, with a mean follow-up duration of 6 years. Among that cohort, 26 patients (63.4%) developed neuroophthalmological complications, which were further stratified. Fourteen patients (34.1%) developed strabismus and 11 (26.8%) developed astigmatism, and 1 patient (2.4%) with papilledema was recorded. Among patients with ophthalmological abnormalities, 76.9% had delayed developmental milestones (p = 0.045). CONCLUSIONS Patients with CAS were found to have increased risk of ophthalmological abnormalities requiring correction, along with an increased risk of delayed developmental milestones. Importantly, there was a significant correlation between the development of ophthalmological abnormalities and delayed developmental milestones that was independent of CSF diversion history. Larger patient cohort studies are required to explore whether earlier development of hydrocephalus, as is the case in CAS, causes elevated rates of neurological and ophthalmological complications, and if earlier CSF diversion correlates with improved outcomes.
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Affiliation(s)
- Aneek Patel
- 1Department of Neurosurgery, New York University School of Medicine, New York, New York
| | | | | | | | | | | | | | - Stephen P Emery
- 4Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Fetal therapy for congenital hydrocephalus-where we came from and where we are going. Childs Nerv Syst 2020; 36:1697-1712. [PMID: 32601902 DOI: 10.1007/s00381-020-04738-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Accepted: 06/10/2020] [Indexed: 10/24/2022]
Abstract
Despite unfavorable outcomes during the early experience with in utero intervention for congenital hydrocephalus, improvements in prenatal diagnosis, patient selection, and fetal surgery techniques have led to a renewed interest in fetal intervention for congenital hydrocephalus. Research studies and clinical evidence shows that postnatal cerebrospinal fluid diversion to release intraventricular pressure and cerebral mantle compression usually arrives late to avoid irreversible brain damage. Make sense to decompress those lateral ventricles as soon as possible during the intrauterine life when hydrocephalus is antenatally detected. We present a historical review of research in animal models as well as clinical experience in the last decades, traveling until the last years when some research fetal therapy groups have made significant progress in recapitulating the prenatal intervention for fetuses with congenital obstructive hydrocephalus.
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Emery SP, Narayanan S, Greene S. Fetal aqueductal stenosis: Prenatal diagnosis and intervention. Prenat Diagn 2019; 40:58-65. [PMID: 31306500 DOI: 10.1002/pd.5527] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2019] [Revised: 06/04/2019] [Accepted: 07/08/2019] [Indexed: 12/19/2022]
Abstract
Fetal severe central nervous system ventriculomegaly is associated with poor neurologic outcomes, usually driven by a primary malformation, deformation, or disruption of brain parenchyma. In utero shunting of excess cerebrospinal fluid (CSF) in hopes of improving neurologic outcomes was attempted in the 1980s but was abandoned due to perceived lack of effect, likely due to technological limitations of the time that precluded proper patient selection. Little progress on the antenatal management of severe ventriculomegaly has been made in the intervening decades. A multidisciplinary, evidence-based reassessment of ventriculoamniotic shunting for isolated fetal aqueductal stenosis (FAS), a unique form of severe ventriculomegaly (supratentorial intracranial hypertension), is currently underway. An accurate diagnosis of FAS must precede in utero intervention. Magnetic resonance imaging (MRI) will be an excellent adjunct to high-resolution prenatal ultrasound and next-generation genetic testing to correctly diagnose FAS in a timely fashion while excluding other intracranial and extracranial anomalies. This manuscript will briefly discuss the history, current management, and future directions of the prenatal diagnosis and potential intervention for FAS.
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Affiliation(s)
- Stephen P Emery
- School of Medicine, Departments of Obstetrics, Gynecology and Reproductive Sciences, University of Pittsburgh, Pittsburgh, PA
| | - Srikala Narayanan
- School of Medicine, Department of Radiology, University of Pittsburgh, Pittsburgh, PA
| | - Stephanie Greene
- School of Medicine, Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA
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Litwinska M, Litwinska E, Czaj M, Polis B, Polis L, Szaflik K. Ventriculo-amniotic shunting for severe fetal ventriculomegaly. Acta Obstet Gynecol Scand 2019; 98:1172-1177. [PMID: 30977122 DOI: 10.1111/aogs.13622] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 12/30/2018] [Accepted: 04/04/2019] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Severe fetal cerebral ventriculomegaly, observed in about 1 in 1000 newborns, is associated with a high risk of perinatal death and neurodevelopmental delay in survivors. The objective of this study was to evaluate the efficiency of ventriculo-amniotic shunting for drainage of severe fetal cerebral ventriculomegaly and the neurodevelopment of survivors at the age of 2 years. MATERIAL AND METHODS This was a retrospective study of 44 fetuses with severe bilateral ventriculomegaly treated with ventriculo-amniotic shunting in a tertiary fetal therapy center between 2010 and 2015. RESULTS Shunt insertion was successfully carried out at a median gestational age of 25 weeks (range 20-33 weeks). There were three fetal deaths within 24 hours of the procedure and 41 live births at a median gestational age of 37 weeks (range 28-39 weeks). Neurodevelopment at 2 years of age was evaluated using the Bayley scale in the 38 survivors. In the 27 cases with isolated ventriculomegaly 19 (70.4%; 95% confidence interval [95% CI] 51.5%-84.2%) had normal or mild neurodevelopmental delay and 8 (29.6%; 95% CI 15.6%-48.5%) were moderately or severely delayed. In the 11 with non-isolated ventriculomegaly 2 (18.2%; 95% CI 5.1%-4.8%) had normal or mild neurodevelopmental delay and 9 (81.8%; 95% CI 52.3%-94.9%) babies were moderately or severely delayed. CONCLUSIONS Ventriculo-amniotic shunting is an option for the management of severe ventriculomegaly and results in normalization of the ventricular diameter. However, a high proportion of survivors have neurodevelopmental delay and the possible beneficial effect of ventriculo-amniotic shunting needs to be assessed by randomized studies.
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Affiliation(s)
- Magdalena Litwinska
- Department of Gynecology, Fertility and Fetal Therapy, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Ewelina Litwinska
- Department of Perinatology and Gynecology, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Marta Czaj
- Department of Gynecology, Fertility and Fetal Therapy, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Bartosz Polis
- Department of Neurosurgery, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Lech Polis
- Department of Neurosurgery, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
| | - Krzysztof Szaflik
- Department of Gynecology, Fertility and Fetal Therapy, Polish Mother's Memorial Hospital Research Institute, Lodz, Poland
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10
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Emery SP, Greene S, Murdoch G, Wiley CA. Histologic Appearance of Iatrogenic Obstructive Hydrocephalus in the Fetal Lamb Model. Fetal Diagn Ther 2019; 47:7-14. [PMID: 30974442 DOI: 10.1159/000497360] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2018] [Accepted: 01/29/2019] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Documentation of histologic findings associated with congenital hydrocephalus in the fetal lamb model is a critical step in evaluating the efficacy of ventriculoamniotic shunting in the human fetus. METHODS Four fetal sheep had hydrocephalus induced at approximately 95 days' gestation. Two co-twins remained as controls. The ewes were euthanized at term. The lamb brains were fixed in formalin, paraffin-embedded, stained, and analyzed for markers of neuropathology. Astrocytosis, microgliosis, and axonal loss were assessed with immunocytochemistry for glial fibrillary acidic protein, ionized calcium-binding adapter, and neurofilament/amyloid precursor protein, respectively. Cortical gray matter extracellular matrix was assessed with staining for the lectin Wisteria Floribunda agglutinin. RESULTS Hydrocephalic lamb brains demonstrated deep white matter damage with loss of projecting axonal tracts in regions physically distorted by hydrocephalus, similar to that seen in hydrocephalic humans. There was no evidence of abnormal neocortical neuronal migration; however, there was evidence for delayed maturation of the neocortical gray matter, possibly from increased intracerebral pressure and subsequent ischemia. Control lamb brains demonstrated none of the above findings. CONCLUSION This histological approach can be used to further define the mechanism of brain damage associated with hydrocephalus and interpret the efficacy of ventriculoamniotic shunting on fetal lamb brain neuroanatomy.
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Affiliation(s)
- Stephen P Emery
- Department of Obstetrics, Gynecology and Reproductive Sciences, Magee-Womens Hospital of the University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA,
| | - Stephanie Greene
- Department of Neurological Surgery, Children's Hospital of the University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Geoffrey Murdoch
- Division of Neuropathology, Department of Pathology, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Clayton A Wiley
- Division of Neuropathology, Department of Pathology, University of Pittsburgh Medical Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
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Kline-Fath BM, Arroyo MS, Calvo-Garcia MA, Horn PS, Thomas C. Congenital aqueduct stenosis: Progressive brain findings in utero to birth in the presence of severe hydrocephalus. Prenat Diagn 2018; 38:706-712. [PMID: 29927492 DOI: 10.1002/pd.5317] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 06/10/2018] [Accepted: 06/13/2018] [Indexed: 11/11/2022]
Abstract
PURPOSE To evaluate the effects of progressive hydrocephalus on the developing brain in a cohort of fetuses diagnosed with congenital aqueduct stenosis by comparing prenatal magnetic resonance imaging and postnatal imaging. METHODS This IRB approved single center retrospective review of prenatally diagnosed children with congenital aqueduct stenosis interrogated changes in the brain between prenatal and postnatal imaging and analyzed statistics using SAS software package version 9.3. RESULTS Thirty fetuses imaged at a mean gestational age of 26 weeks had aqueduct obstruction confirmed by postnatal imaging. Progressive hydrocephalus required shunting in all but one patient (97%). Those patients with increasing hydrocephalus showed increase in ventricular rupture (60%), loss of septal leaflets (47%), and reduction in white matter and corpus callosum volume (43%). Cerebellar ectopia developed in 27% with 6% meeting the criteria for Chiari I malformation. CONCLUSION Hydrocephalus in the fetus results in enlarging ventricular rupture, loss of the septum pellucidum leaflets, volume reduction of brain parenchyma including corpus callosum, and risk for Chiari I anomaly. Given advances in fetal surgery and imaging in the last 3 decades, there may be cause to revisit the idea of in utero cerebral spinal fluid diversion as a means to potentially ameliorate progressive loss of the developing brain.
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Affiliation(s)
- Beth M Kline-Fath
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Monica S Arroyo
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Maria A Calvo-Garcia
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Paul S Horn
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Cameron Thomas
- Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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12
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Heaphy-Henault KJ, Guimaraes CV, Mehollin-Ray AR, Cassady CI, Zhang W, Desai NK, Paldino MJ. Congenital Aqueductal Stenosis: Findings at Fetal MRI That Accurately Predict a Postnatal Diagnosis. AJNR Am J Neuroradiol 2018. [PMID: 29519789 DOI: 10.3174/ajnr.a5590] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Congenital aqueductal stenosis is a common cause of prenatal ventriculomegaly. An accurate diagnosis provides prognostic information and may guide obstetric management. The purpose of this study was to identify specific anatomic findings on prenatal MR imaging that can be used as predictors of congenital aqueductal stenosis. MATERIALS AND METHODS Prenatal and postnatal MRIs of fetuses referred to our institution for ventriculomegaly between June 2008 and August 2015 were reviewed. Imaging findings in postnatally confirmed congenital aqueductal stenosis (disease group) were compared with those of ventriculomegaly cases from other causes (control group). Univariate analysis was performed using the Fisher exact test and the Wilcoxon rank test, and multivariate analysis, via the random forest method. RESULTS Forty-three cases of ventriculomegaly had a confirmed postnatal diagnosis of congenital aqueductal stenosis. Thirty-two ventriculomegaly cases negative for congenital aqueductal stenosis were included in the control group. Dominant findings associated with an accurate prenatal diagnosis of congenital aqueductal stenosis on multivariate analysis included the following: enlarged inferior third ventricular recesses, enlargement of the lateral ventricles and third ventricle, and an abnormal corpus callosum. Findings that significantly increase the probability of congenital aqueductal stenosis (high positive predictive value) included the following: enlarged third ventricular recesses, aqueduct funneling, hemorrhage in the cerebral aqueduct, ventricular diverticulum, rhombencephalosynapsis, and dystroglycanopathy-related cerebellar dysplasia. CONCLUSIONS Our study identified specific characteristics on fetal MR imaging that can be used as predictors of the diagnosis of congenital aqueductal stenosis. Most of these findings are secondary to the obstructive nature of the resulting hydrocephalus. Common associated malformations such as rhombencephalosynapsis and dystroglycanopathies should also increase the suspicion of congenital aqueductal stenosis when present with ventriculomegaly.
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Affiliation(s)
- K J Heaphy-Henault
- From the Department of Radiology (K.J.H.-H.), Hartford Hospital, Hartford, Connecticut
| | - C V Guimaraes
- Department of Radiology (C.V.G., A.R.M.-R., C.I.C., N.K.D., M.J.P.) .,Department of Radiology (C.V.G.), Stanford University School of Medicine, Lucile Packard Children's Hospital, Stanford, California
| | - A R Mehollin-Ray
- Department of Radiology (C.V.G., A.R.M.-R., C.I.C., N.K.D., M.J.P.)
| | - C I Cassady
- Department of Radiology (C.V.G., A.R.M.-R., C.I.C., N.K.D., M.J.P.)
| | - W Zhang
- Outcomes and Impact Service (W.Z.), Texas Children's Hospital, Houston, Texas
| | - N K Desai
- Department of Radiology (C.V.G., A.R.M.-R., C.I.C., N.K.D., M.J.P.)
| | - M J Paldino
- Department of Radiology (C.V.G., A.R.M.-R., C.I.C., N.K.D., M.J.P.)
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13
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Pisapia JM, Sinha S, Zarnow DM, Johnson MP, Heuer GG. Fetal ventriculomegaly: Diagnosis, treatment, and future directions. Childs Nerv Syst 2017; 33:1113-1123. [PMID: 28510072 DOI: 10.1007/s00381-017-3441-y] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 04/28/2017] [Indexed: 11/25/2022]
Abstract
Fetal ventriculomegaly (VM) refers to the enlargement of the cerebral ventricles in utero. It is associated with the postnatal diagnosis of hydrocephalus. VM is clinically diagnosed on ultrasound and is defined as an atrial diameter greater than 10 mm. Because of the anatomic detailed seen with advanced imaging, VM is often further characterized by fetal magnetic resonance imaging (MRI). Fetal VM is a heterogeneous condition with various etiologies and a wide range of neurodevelopmental outcomes. These outcomes are heavily dependent on the presence or absence of associated anomalies and the direct cause of the ventriculomegaly rather than on the absolute degree of VM. In this review article, we discuss diagnosis, work-up, counseling, and management strategies as they relate to fetal VM. We then describe imaging-based research efforts aimed at using prenatal data to predict postnatal outcome. Finally, we review the early experience with fetal therapy such as in utero shunting, as well as the advances in prenatal diagnosis and fetal surgery that may begin to address the limitations of previous therapeutic efforts.
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Affiliation(s)
- Jared M Pisapia
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, 3rd Floor Silverstein Pavilion, Philadelphia, PA, 19104, USA.
| | - Saurabh Sinha
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, 3rd Floor Silverstein Pavilion, Philadelphia, PA, 19104, USA
| | - Deborah M Zarnow
- Division of Neuroradiology, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Mark P Johnson
- The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Gregory G Heuer
- Department of Neurosurgery, University of Pennsylvania, 3400 Spruce Street, 3rd Floor Silverstein Pavilion, Philadelphia, PA, 19104, USA.,The Center for Fetal Diagnosis and Treatment, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
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14
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Aggarwal S. Counseling for Fetal Central Nervous System Defects. JOURNAL OF FETAL MEDICINE 2017. [DOI: 10.1007/s40556-017-0121-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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15
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Moaddab A, Nassr AA, Belfort MA, Shamshirsaz AA. Ethical issues in fetal therapy. Best Pract Res Clin Obstet Gynaecol 2017; 43:58-67. [PMID: 28268059 DOI: 10.1016/j.bpobgyn.2017.02.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2016] [Revised: 02/05/2017] [Accepted: 02/06/2017] [Indexed: 02/03/2023]
Abstract
The introduction of routine fetal ultrasound and the technical improvements in ultrasound equipment have greatly increased our ability to diagnose fetal anomalies. As a consequence, congenital anomalies are diagnosed today earlier and in a greater number of patients than ever before. The development of fetal intervention and fetal surgery techniques, improved anesthesia methodology, and sophisticated perinatal care at the limits of viability, have now made prenatal management of some birth defects or fetal malformations a reality. The increasing number of indications for fetal therapy and the apparent desire of parents to seek out these procedures have raised concern regarding the ethical issues related to the therapy. While fetal therapy may have a huge impact on the prenatal management of some congenital birth defects and/or fetal malformations, because of the invasive nature of these procedures, the lack of sufficient data regarding long-term outcomes, and the medical/ethical uncertainties associated with some of these interventions there is cause for concern. This chapter aims to highlight some of the most important ethical considerations pertaining to fetal therapy, and to provide a conceptual ethical framework for a decision-making process to help in the choice of management options.
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Affiliation(s)
- Amirhossein Moaddab
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States
| | - Ahmed A Nassr
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States; Department of Obstetrics and Gynecology, Women's Health Hospital, Assiut University, Assiut, Egypt
| | - Michael A Belfort
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States
| | - Alireza A Shamshirsaz
- Department of Obstetrics and Gynecology, Baylor College of Medicine and Texas Children's Fetal Center, Houston, Texas, United States.
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