UOG Journal Club: June 2012 Prenatal diagnosis and outcome of fetal posterior fossa fluid collectionsGandolfi Colleoni G, ...
Background Posterior Fossa Fluid Collections Wide spectrum of different entities and associated outcomes Similar anatomic ...
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections                                          Gandolf...
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections                                          Gandolf...
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections                                               Ga...
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections                                          Gandolf...
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections                                          Gandolf...
Sonography in fetuses with posterior fossa fluid collections (PFFC), associations with    other anomalies, intrauterine re...
Discordancies between fetal sonographic and MRI diagnoses and postnatal      diagnoses in eight fetuses with posterior fos...
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections                                            Gando...
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections                                              Gan...
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections                                            Gando...
Brainstem–vermis and brainstem–tentorium angles allow accurate       categorization of fetal upward rotation of cerebellar...
Brainstem–vermis and brainstem–tentorium angles allow accurate    categorization of fetal upward rotation of cerebellar ve...
Brainstem–vermis and brainstem–tentorium angles allow accurate       categorization of fetal upward rotation of cerebellar...
Brainstem–vermis and brainstem–tentorium angles allow accurate        categorization of fetal upward rotation of cerebella...
ResultsUltrasound findings    n            BV angle (◦)                    BT angle (◦)                            Mean   ...
Brainstem–vermis and brainstem–tentorium angles allow accurate          categorization of fetal upward rotation of cerebel...
Brainstem–vermis and brainstem–tentorium angles allow accurate    categorization of fetal upward rotation of cerebellar ve...
Brainstem–vermis and brainstem–tentorium angles allow accurate       categorization of fetal upward rotation of cerebellar...
Brainstem–vermis and brainstem–tentorium angles allow accurate         categorization of fetal upward rotation of cerebell...
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UOG Journal Club: Prenatal diagnosis and outcome of fetal posterior fossa fluid collections

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This Journal Club presentation provides a summary and discussion of the following free access articles published in UOG:

Prenatal diagnosis and outcome of fetal posterior fossa fluid collections
G. Gandolfi Colleoni, E. Contro, A. Carletti, T. Ghi, G. Campobasso, G. Rembouskos, G. Volpe, G. Pilu, P. Volpe.
Volume 39, Issue 6, Date: June 2012, pages 625–631

Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis
P. Volpe, E. Contro, F. De Musso, T. Ghi, A. Farina, A. Tempesta, G. Volpe, N. Rizzo, G. Pilu
Volume 39, Issue 6, Date: June 2012, 632–635

They can be accessed here:
http://onlinelibrary.wiley.com/journal/10.1002/(ISSN)1469-0705/homepage/journal_club_2012.htm

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UOG Journal Club: Prenatal diagnosis and outcome of fetal posterior fossa fluid collections

  1. 1. UOG Journal Club: June 2012 Prenatal diagnosis and outcome of fetal posterior fossa fluid collectionsGandolfi Colleoni G, Contro E, Carletti A, Ghi T, Campobasso G, Rembouskos G, Volpe G, Pilu G, Volpe P Volume 39, Issue 6, Date: June 2012, pages 625–631 Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe P, Contro E, De Musso F, Ghi T, Farina A, Tempesta A, Volpe G, Rizzo N, Pilu G Volume 39, Issue 6, Date: June 2012, pages 632–635 Journal Club slides prepared by Dr Aly Youssef (UOG Editor for Trainees)
  2. 2. Background Posterior Fossa Fluid Collections Wide spectrum of different entities and associated outcomes Similar anatomic as well as sonographic appearance Diagnostic errors common Advances in prenatal imaging allows more detailed evaluation
  3. 3. Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections Gandolfi Colleoni et al., UOG 2012 Objective: to evaluate the diagnostic accuracy of fetal neurosonography and magnetic resonance imaging (MRI) in cases of posterior fossa fluid collections and to assess the outcome of affected infants
  4. 4. Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections Gandolfi Colleoni et al., UOG 2012 Methods• Prospective observational study• All fetuses with abnormal posterior fossa fluid collections• Detailed multiplanar neurosonographic evaluation• Whenever possible, serial sonograms and prenatal MRI were performed and fetal karyotype was obtained Outcomes• Prenatal diagnosis was compared with autopsy or postnatal MRI• Follow-up through medical records or parental interviews
  5. 5. Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections Gandolfi Colleoni et al., UOG 2012 Normal posterior fossa at midgestation Sagittal view TentoriumCavum Septi Pellucidi Cerebellar vermis Cisterna Magna NB The Torcular Herophili is difficult to image on ultrasound due to acoustic shadowing from the skull Axial view bones. In the current study its position was inferred by observing the angulation of the tentorium
  6. 6. Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections Gandolfi Colleoni et al., UOG 2012 Categorization of posterior fossa fluid collections (1) Blake’s pouch cyst Megacisterna magna Dandy–Walker malformationFindings Upward rotation of an Cisterna magna >10mm Upward rotation of the vermis intact vermis with normal with intact and normally (normal or hypoplastic) with torcular positioned cerebellum elevated torcularSagittal Axial
  7. 7. Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections Gandolfi Colleoni et al., UOG 2012 Categorization of posterior fossa fluid collections (2) Vermian hypoplasia Cerebellar hypoplasia Posterior fossa arachnoid cystFindings Hypoplastic vermis with Large cisterna magna with Cyst with mass effect normal torcular small cerebellum resulting in distortion of the cerebellumSagittal coronal Axial
  8. 8. Sonography in fetuses with posterior fossa fluid collections (PFFC), associations with other anomalies, intrauterine regression, outcome and accuracy of prenatal diagnosis Cases Associated No TOP Regression Sonographic Abnormal neurological (n) Anomalies follow (n) in utero diagnosis development postnatally up (n) (n) confirmed Isolated PFFC with (n) PFFC (n) associated anomalies (n)Blake’s pouch 32 8 3 2 11/27 17/18 1/20 1/5 cystMegacisterna 27 9 4 2 6/21 16/17 2/16 1/4 magna Dandy– 26 16 7 11 0/8 16/19 3/5 2/2 Walkermalformation Vermian 17 11 9 2 0/6 6/8 1/3 2/2 hypoplasia Cerebellar 2 2 0 2 0/0 2/2 0 0 hypoplasia Arachnoid 1 0 0 0 0/1 1/1 1/1 0 cystTotal (n, (%)) 105 46 23 19/105 17/63 58/65 8/45 6/13 (18) (27) (89) (16)
  9. 9. Discordancies between fetal sonographic and MRI diagnoses and postnatal diagnoses in eight fetuses with posterior fossa fluid collections Fetal sonography Fetal MRI Postnatal diagnosis Blake’s pouch cyst Blake’s pouch cyst Arachnoid cyst Blake’s pouch cyst Megacisterna magna Megacisterna magna Megacisterna magna Megacisterna magna Arachnoid cyst Dandy–Walker malformation andDandy–Walker malformation Dandy–Walker malformation cortical malformationDandy–Walker malformation Dandy–Walker malformation Joubert syndromeDandy–Walker malformation Dandy–Walker malformation Hemorrhage Vermian hypoplasia and cortical Vermian hypoplasia Vermian hypoplasia malformation Vermian hypoplasia Vermian hypoplasia Normal brain
  10. 10. Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections Gandolfi Colleoni et al., UOG 2012 Discussion• Fetal neurosonography allows accurate prenatal diagnosis• The diagnosis with sonography was correct in almost 90% of cases.• High diagnostic accuracy may be due to the multiplanar approach• MRI of limited value with the use of meticulous neurosonography (1/51 cases in the present study)
  11. 11. Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections Gandolfi Colleoni et al., UOG 2012 Strength of the study• This is the largest prospective series published so far of posterior fossa fluid collections recognized in utero• Results provide useful information for assessment and counseling in these cases. Weakness• About one quarter of our patients were lost to follow-up• Postnatal assessment of survivors was performed by different pediatricians who did not use a standard protocol.
  12. 12. Prenatal diagnosis and outcome of fetal posterior fossa fluid Collections Gandolfi Colleoni et al., UOG 2012 ConclusionsUltrasound and fetal MRI perform similarly in the characterization of fetalposterior fossa abnormalities, and a correct diagnosis can be made inabout 90% of casesMegacisterna magna and Blake’s pouch cysts are the most commonantenatal diagnoses. They are risk factors for associated anomalies. Whenisolated, they have a good chance of intrauterine resolution and a normaldevelopmental outcome in over 90% of casesDandy–Walker malformation and vermian hypoplasia have a guardedprognosis, with a very high likelihood of associated anomalies and/orneurologic impairment
  13. 13. Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe et al., UOG 2012Background • Fetal posterior fossa fluid collections associated with upward rotation of the cerebellar vermis range from benign asymptomatic conditions to severe abnormalities associated with neurological impairment • The most frequent of these anomalies, Blake’s pouch cyst, vermian hypoplasia and Dandy–walker malformation, have a similar sonographic appearance but a very different prognosis • A specific diagnosis with either ultrasound or magnetic resonance imaging is possible, but is frequently difficult and relies mostly upon subjective criteria
  14. 14. Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe et al., UOG 2012 Median view of the fetal brain 1. Brainstem–vermis (BV) angle (between a line drawn tangentially to the dorsal aspect of the brain stem and a second line drawn tangentially to the ventral contour of the 2 cerebellar vermis) 2. brainstem–tentorium (BT) angle (between the first line and a third line tangential to the lower edge of the tentorium) 1
  15. 15. Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe et al., UOG 2012 Objective: to evaluate the diagnostic contribution of an objective approach based on the brainstem–vermis (BV)angle and the brainstem–tentorium (BT) angle to the diagnosis of posterior fossa fluid collections
  16. 16. Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe et al., UOG 2012 Methods• Retrospective study• BV and BT angles were measured in fetuses with posterior fossa fluid collections with upward rotation of the cerebellar vermis• Prospectively collected normal fetuses at mid-gestation (controls)• Measurements were obtained from median views of the fetal brain• Both 2D images and 3D volumes were used for measurements
  17. 17. ResultsUltrasound findings n BV angle (◦) BT angle (◦) Mean SD Range Mean SD Range Controls 80 9.1 3.5 4–17 29.3 5.8 21–44Blake’s pouch cyst 12 23.0 2.8 19–26 42.2 7.1 32–52Vermian hypoplasia 7 34.9 5.4 24–40 52.1 7.0 45–66 Dandy–Walker 12 63.5 17.6 45–112 67.2 15.1 51–112 malformation 1= BV angle 2= BT angle Blake’s pouch cyst Vermian hypoplasia Dandy–Walker malformation
  18. 18. Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe et al., UOG 2012 BV angle BT angle• Controls always had a BV angle <18º and a BT angle<45º• The BV and BT angle significantly increased in each of the three subgroups of anomalies• The angle increasing with increasing severity of the condition.• There was more overlapping of the BT angle among groups
  19. 19. Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe et al., UOG 2012 Limitations of the study • Retrospective study • Reproducibility and repeatability of measurements unknown • The number of abnormal cases was relatively small (esepecially vermian hypoplasia)
  20. 20. Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe et al., UOG 2012 ConclusionBrainstem–vermis and brainstem–tentorium angles areobjective findings which may be useful in differentiating fetalposterior fossa fluid collections that are sonographicallysimilar but carry a very different prognosis
  21. 21. Brainstem–vermis and brainstem–tentorium angles allow accurate categorization of fetal upward rotation of cerebellar vermis Volpe et al., UOG 2012 Discussion points• What are the different types of posterior fossa fluid collections?• Is it possible to accurately classify these fetal posterior fossa fluidcollections by 2D/3D prenatal ultrasound?• What is the role for fetal MRI in patients with fetal posterior fossa fluidcollections?• Does this paper provide concrete evidence to base accurate prognosesfor the different fetal posterior fossa fluid collections?• In the light of the present data, how should women with fetal posteriorfossa fluid collections be counselled?

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