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Fetal brain usg 1

The document discusses various congenital anomalies of the central nervous system (CNS) detectable through fetal brain ultrasound, including conditions like schizencephaly, encephalocele, and microcephaly. It emphasizes the importance of standard sonographic examination techniques, embryological development, and how sonographic appearances change throughout gestation. Additionally, it highlights the correlation between prenatal diagnoses and outcomes, indicating that isolated cases of certain anomalies often have better prognoses, while others may indicate more severe complications.

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Fetal Brain USG Presented by Dr. Vrishit Saraswat
Schizencephaly Encephalocele Microcephaly Anencephaly Chiari Malforma3on Head normal or small Ventriculomegaly Hydranecphaly - Holoprosencephaly Hemimegalencephaly Arachnoid cyst ACC SOP PF-‐Fluid-‐Cyst Vascular Malforma3ons
Congenital CNS Anomalies o Incidence in longtem studies about 1 % o Only minimal identified at birth o Screening Increases The Number Of Referred Cases For Evaluation Of Suspected CNS Anomalies. o The CNS sonographic appearance changes throughout pregnancy
• Embryonic development of the CNS •in relation to sonographic findings • Standard Sonographic Examination •of the CNS •Learning Objectives
Embryology of the CNS
And Fuse As The The Fusion Starts In It Induces The Overlying Embryonic Tissue To Thicken And Ultimately Fold Over Neural Tube. The Midtrunk Of The E m b r y o A n d Subsequently Extends To The Cranial And Caudal Ends Neural Crest Neural Tube Ectoderm At 5th Week The Cells Destined To Form The Notochord Infiltrate Into The Embryonic Disc. Neural Groove Neural Plate
Prosencephalon Mesencephalon Rhombencephalon 7
the end of 8 weeks of gestation. The development of premature ventricular system is seen. Three orthogonal images and thick slice of three-dimensional reconstructed image (lower right) of normal brain at 8
Prosencephalon Mesencephalon Three orthogonal images and thick slice of three-dimensional reconstructed image (lower right) of normal brain at 8
Normal brain development on the mid-sagittal section between 8 and 12 weeks of gestation). Note the remarkable changing of premature brain appearance. 9
10 Changing Ultrasound appearance of the The Posterior Fossa throughout gesta3on
11 The vermis develops superiorly to inferiorly. Hypoplasia or developmental arrest results in varying size deficits of the inferior portion, leaving a relatively square defect that communicates with the fourth ventricle and separates the lower cerebellar hemispheres.
1
sagittalaxial Effect of Gestational age (Posterior Fossa) sonograms of posterior fossa in 16-week-old fetus fourth ventricular roof is visualized in both planes (arrow) 13
Fourthnamely the (4) and acavum septi e u h Ve tric the ventri- ventri- its its closest the structures, follow after the l The normal for but are normal; (b) a however, this same section picture at 20 horns but are normal; (b) gure 1 Transvaginal scan of a 14-week fetus. (a) Oblique-1 (sagittal) section: the fetus is facing left. The choroid plexus fills the antrum the the lateral ventricles. The anterior horns appear prominent, this gestational age;a Frontal-2 (coronal) sonographic through the the anterior horn ore lateral ventricles.ventriculomegaly horns hydrocephalus this gestational age; however, this same sonographic picture 20 20 weeks o re is consistent with ventriculomegaly or hydrocephalus the is lateral consistent withThe horns normal for atat or he The Higher (see almost axial Three serial, o Three open axialand (horizontal) views with the the gure2 be ventriclefossa. (a) (a)a This isis(at this gesta mis appears to to of (b) somewhat higher, sides the wide the the and left of wide (at (at this appear age, to each other op (c) entity. C, appear nd Closer of a Each and the timetable. They reach well-known the 16th this ‘norm gure 2Lower-most Section (horizontal) views through the posterior fossa. (a) This is the lower-most section Still insert). The rmis2appears serial, almost (arrow) communicates throughfourth posterior through widethe the lower-most sectionnormal) median erture (foramenbe Magendie); and communicates withrightfourth ventricle through cerebellar hemispheres gestational closer normal) median erture (foramen of Magendie); (b) somewhat higher, the right and left sides of the cerebellar hemispherescerebellum closer to each othe ow); (c) higher still, no ‘vermiandefect’’ is seen and Of The Cerebellar Communicates With The fourth ventri- its closest anatomic structures, Ventricle cavum septi duncular cistern (cisterna postmenstrual week,fourth ‘normal’ pellucidi anatomic pericallosal artery, namelythe the well-known . Later, after narrows 16th postmenstrual week, developmentTo’ developmental pericallosal artery, follow developmen- en space narrows giving rise tal stage that allows for sonographic imaging until post- Magendie) rise to the median aperture 14 by those normal
15 Effect of Gesta=onal age (Lateral Ventricles)
16 Hypoplasia Or Dysplasia Should Not Be Diagnosed Prior To 18 Weeks, Before Vermian Development Is Complete. An Abnormally Steep Scanning Angle May Mimic A Prominent Cleft Between The Lower Portions Of The Cerebellar Hemispheres. The fetal cerebellum Pitfalls in diagnosis
17 Conclusion •TheCNS displays remarkable embryological and developmental changes throughout gestation. •Standard Approach of examination and evaluation of the CNS Should Be Followed
18 Standard Sonographic Examination of the FEtal CNS Sunday, July 28, 13
Sonography of the CNS Basic Examination “Neurosongram”” Sunday, July 28, 13
Planes of Basic Examination Sagital PlanesAxial Planes
Axial Planes Sunday, July 28, 13
Axial Planes a: Transventricular Sunday, July 28, 13
Axial Planes a: Transventricular b: Transthalamic Sunday, July 28, 13
Axial Planes a: Transventricular C: Transcerebeller b: Transthalamic Sunday, July 28, 13
The Transventricular plane Sunday, July 28, 13
The Transventricular plane Frontal hones Sunday, July 28, 13
The Transventricular plane Frontal hones Atrium Sunday, July 28, 13
The Transventricular plane Frontal hones Choroid Plexus Atrium Sunday, July 28, 13
The Transventricular plane Cavum Sep3 Pellucidi Frontal hones Choroid Plexus Atrium Sunday, July 28, 13
The Transthalamic Plane Sunday, July 28, 13
Thalami The Transthalamic Plane Sunday, July 28, 13
Thalami Hyppocamas Gyrus The Transthalamic Plane Sunday, July 28, 13
T T The Transcerebeller plane Sunday, July 28, 13
Cavum Sep3 Pellucidi T T The Transcerebeller plane Sunday, July 28, 13
Cavum Sep3 Pellucidi Frontal hones T T The Transcerebeller plane Sunday, July 28, 13
Cerebellum Cavum Sep3 Pellucidi Frontal hones T T The Transcerebeller plane Sunday, July 28, 13
Cerebellar vermi Cerebellum Cavum Sep3 Pellucidi Frontal hones T T The Transcerebeller plane Sunday, July 28, 13
Cistrerna Magna 2-‐10 mm Cavum Sep3 Pellucidi The Transcerebeller plane Cerebellar vermi Cerebellum Frontal hones T T Sunday, July 28, 13
Sagibal Planes Sunday, July 28, 13
Sagibal Planes A: The Midsagittal Plan Sunday, July 28, 13
Sagibal Planes b: Parasgittal plan A: The Midsagittal Plan Sunday, July 28, 13
Mid SagiGal Plane Corpus Callosum Cavum Sep3 Pellucidi Cerebellum 4th V 27
27 Mid SagiGal Plane Sunday, July 28, 13
28 The Corpus Callosum
Corpus Callosum midbrain Third Ventricle Pituitary Splenium Thalamus hypothalamus Fourth ventricl The Corpus Callosum Lateral Ventricles 28
29 Para-‐SagiGal Plane
30 Basic Examniation Checklist Head + Neck Midline & Falx Cavum septi pellucidi Lateral cerebral ventricls Choroid Plexus Cerebellum Cisterna magna
Main Abnormali3es can be Suspected on Basic Planes 31
Schizencephaly Encephalocele Microcephaly Anencephaly Chiari Malforma3on Head normal or small Dia Ventriculomegaly Hydranecphaly s : Holoprosencephaly Hemimegalencephaly Arachnoid cyst ACC SOP PF-‐Fluid-‐Cyst Yong seok et a Vascular Malforma3ons
33 •Ventriculomegaly (hydrocephalus) •Absent Cavum Septum Pellucidum •Agenesis of the Corpus Callosum •Fluid Collection in the posterior
(< 10 mm is normal). Independent of gesta7onal age Mild 10 – 15 mm Low Risk Severe > 15 mm High Risk mean = 6-‐8 mm Ventriculomegaly (hydrocephalus)
Lee Lateral Ventricle Aqueduct of Sylvius 4th Ventricle Right Lateral Ventricle Foramen of Monro 3rd Ventricle Cisterna Magna Pathogenesis: Ventriculomegaly 35
•Square Shaped, Interrupts and Fills The Space Between The Frontal Horns •The CSP: Becomes Visible At 16 Weeks, Obliterate Near Term Absent CSP
•Square Shaped, Interrupts and Fills The Space Between The Frontal Horns •The CSP: Becomes Visible At 16 Weeks, Obliterate Near Term Cavum Sep3 Pellucidi Absent CSP
A rare finding usually discovered Postnatally in children evaluated for developmental delay. Associated with various brain malformations: agenesis of the corpus callosum Holoprosencephaly. Setpo-‐optic dysplasia. Secondary to disruptive process: Hydrocephalus, Chiari II malformation, hydranecephaly. Absent CSP Sunday, July 28, 13
38 Agenesis of the Corpus Callosum
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245 Normal corpus callosum 3v 3v Par3al agenesis 3v 74 Agenesis of the corpus callosum Absent corpus callosum
Only The Rostrum (1), Genu (2) And Body (3) Are Visible; The Splenium Is Missing. The Corpus Callosum Is Short Posteriorly And Does Not Seem To Overlay The Quadrigeminal Plate 21-‐week Fetus With Par=al Agenesis Of The Corpus Callosum
Outcome of fetal ACC Varies between completely asymptoma3c appearance and severe neurologic problems 50 – 100 % of isolated cases will have normal neurological development at 3-‐11 years but Poor prognosis with associated anomalies  Progressive decline in intellect over the years  Most need special educa3on Long-‐term follow-‐up of children with prenatally diagnosed agenesis of corpus callosum (ACC) J. H. Stupin et al, USOG, 32, 2008
41 Fluid Collec3on in the Posterior Fossa
41 Fluid Collec3on in the Posterior Fossa •MegacisternaMagna
41 Fluid Collec3on in the Posterior Fossa •Blak’sPouchCyst •MegacisternaMagna
Fluid Collec3on in the Posterior Fossa •MegacisternaMagna •D-WMalformation&DW-Variant •Blak’sPouchCyst 41
Fluid Collec3on in the Posterior Fossa •MegacisternaMagna •Blak’sPouchCyst •D-WMalformation&DW-Variant •ArachnoidCyst 41
Anomalies Of The Meninges •MegacisternaMagna •Blak’sPouchCyst Anomalies Cerebellum •D-WMalformation&DW-Variant •ArachnoidCyst 42
Mega–Cisterna Magna 43 An Enlargement Of The Cisterna Magna Beyond 10 MmWithIntactVermis
Choriod Plexus Pathogenesis: Mega Cisterna Magna Lateral Ventricle Third Ventricle Cerebral Aqueduct Fourth Ventricle 44
Pathogenesis: Mega Cisterna Magna Lateral Ventricle Third Ventricle Cerebral Aqueduct Choriod Plexus TheForaminaOf LuschkaAndMagendie FenestrateDelayed Fourth Ventricle 44
45 Prognosis: •IsolatedCases: (97%-100%)AreNormal. •IfNotIsolated:Only11%HaveNormalOutcome. Nonisolated Cases Have VM, Congenital Infection KaryotypeAbnormalities. A Large Cisterna Magna Require Careful Search F OtherAbnormalities.
Blake’s Pouch
46 Blake’s Pouch Cyst
Lateral Ventricle Third Ventricle Cerebral Aqueduct Choriod Plexus foramina of Luschka and Magendie leads to dilatation of the fourth ventricle and and elevation of the vermis awayfromthebrainstem. Fourth Ventricle Pathogenesis: Blake’s Pouch Cyst Nonfenestration of the There is no communication between the cyst and the subarachnoid space 47
Lateral Ventricle Third Ventricle Cerebral Aqueduct Choriod Plexus foramina of Luschka and Magendie leads to dilatation of the fourth ventricle and and elevation of the vermis awayfromthebrainstem. Fourth Ventricle Pathogenesis: Blake’s Pouch Cyst Nonfenestration of the There is no communication between the cyst and the subarachnoid space 47
✦Complete Or Partially Agenesis Of The Cerebellar Dandy-Walker Malformation 48 ASpectrumOfAnomaliesOfThePosteriorFossa. •Dandy-WalkerMalformation: ✦IncreaseOfThePosteriorFossa, Vermis, ✦ATentoriumElevation •VariantOfDandy-Walker: ✦Hypoplasia Of The Cerebellar Vermis In Different Degrees With Or Without Increase Of The Posterior Fossa.
ctions Dandy-Walker Malformation Elevated tentorium and high position of the torcula Small, rotated, raised, or absent vermis Cystic dilation of the fourth ventricle communicating with a posterior fossa fluid space 49
50 ThePrognosis: BetterInIsolatedDWS. KaryotypeAbnormalitiesInAbout15%. NeonatalMortality: 12%To55%. NeonatalMorbidity: •IntelligenceIsNormalInAbout40% •BorderlineIn20% •SubnormalIn40%.
Figure Torcular Is Found InANormalandy–Walker Malformation position the torcular igure 2 on of the tentorium cerebelli. Inthe direction by theultrasound the direction tentorium cerebelli. In (a)The Torcular Is Displaced Higher orcular found normal position, about the same level as he site of insertion of the neck muscles on the posterior skull; thisite of insertion of the neck muscles on the posterior skull; thisSkull a Blake a pouch cyst. In (b) the torcular is displaced higBlake’s 51 The AsThe found Insertion normala OfThe Neck Muscles isSunday, July 28, 13 ’s pouch cyst. In (b) the torcular is displaced higher th
• • • • Are Benign, Noncommunicating Fluid Collections Within Arachnoid Membranes. Location: Intracranially And In The SpinalCanal. Order Of Frequency Are The Sylvian Fissure Or Temporal Fossa, Posterior Fossa, Over The Cerebral Convexity, AndMidlineSupratentorial, Most Appear Stable And Require No Surgical Treatment. Occasionally They Arachnoid Cysts Interfere With CSF Circulation And RequireDecompression.
The Differential Diagnosis Depends On The Location. In The Posterior Fossa: DandyWalker Malformation, Inferior Vermian Hypoplasia, Mega–cisterna Magna, And Blake’s Pouch Cysts. Supratentorial Cysts: Cavum Veli Interpositi, Aneurysm Of Vein Of Galen, Hemorrhage, And Cystic Tumors. 53
54 Prenatal diagnosis and outcome of fetal posterior fossa fluid collections G. GANDOLFI COLLEONI et al, Ultrasound Obstet Gynecol 2012; 39: 625–631
Vermian Hypoplasia N=17 55 Blake’s Pouch Cyst N = 32 Arachnoid Cyst N=1 Megacisterna Magna N = 27 Cerebellar Hypoplasia N=2 Dandy – Walker Malformation N=26 105 Fetuses Sonographic diagnoses were accurate in 88%
✦Isolated Cases Of Blake’s Pouch Cyst And Megacisterna Magna Have An Excellent Prognosis, With A High Probability Of Intrauterine Resolution And Normal Intellectual Development In Almost All Cases. ✦Dandy – Walker Malformation And Vermian Hypoplasia, Even When They Appear Isolated Antenatally, Are Associated With An Abnormal OutcomeInHalfOfCases. 56
57 •Black’s Pouch Cyst, DW Malformatio Mega-‐Cisterna Magna Can give Si Sonographic features. •However the prognosis is greatly vari •Careful Neurosonographic assessment us D or Fetal MRI is often Needed Conclusion Sunday, July 28, 13
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245 Brain stem Cerebellar vermis Angled Insona3on of Posterior Fossa Visualize brain Stem 4v 65
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245 4v hemisphere hemisphere hemisphere vermis hemisphere tentorium 4v tentorium vermis vermian fissures
Normal Posterior Fossa At Midgesta=on SagiGal viewAxial view Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
SagiGal viewAxial view Normal Posterior Fossa At Midgesta=on Cavum Sep3 Pellucidi Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
SagiGal viewAxial view Normal Posterior Fossa At Midgesta=on Cavum Sep3 Pellucidi Cerebellar vermis Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
SagiGal viewAxial view Normal Posterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
SagiGal viewAxial view Normal Posterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Tentorium Cisterna Magna Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20 Sunday, July 28, 13
SagiGal viewAxial view Normal Posterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Tentorium Cisterna Magna Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
SagiGal viewAxial view Normal Posterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Tentorium Cisterna Magna Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
SagiGal viewAxial view Normal Posterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Tentorium Cisterna Magna Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
Categoriza3on of posterior fossa fluid collec3ons (1)
Blake’s pouch cyst Megacisterna magna D-‐W Findings Upward rotation of an intact vermis with normal torcular Cisterna magna >10mm with intact and normally positioned cerebellum Upward rotation of the v (normal or hypoplastic) w elevated torcular Categoriza3on of posterior fossa fluid collec3ons (1) SagiGal Axial
79 Axial View •Transverse Diameter Of The Cerebellum. •The Intactness And Size Of The Vermis. •The Depth Of The Cisterna Magna (10 Mm)
Measurement of brainstem–vermis (BV) and 80Figure 1 The Vermis: Shape, Size, Fissures brainstem–tento Cavum Sep3 Pellucidi The Tentorium: Level case after acquisition of an ultrasound volume starting from an axi
(BV) angle Brainstem-tentorium (BT)angle Brainstem-vermis Cavum Sep3 Pellucidi
Blake’s Pouch Cyst Cerebellar Vermis Hypoplasi Dandy–Walker Malformation. TheAngles Has The Widest Measurement In DA Malformation 82 and (BT) (BT) (a) A (a) A view the of the fetal brain is after of of volume starting from an an axial and the anatomic are are 1 Measurement of brainstem–vermis (BV) brainstem–tentoriumangles. angles.median median ofviewfetal brain is obtain e acquisitionan ultrasound volume starting from axial view)view) the and main anatomic landmarks landmarks ide angentially tangentially dorsal dorsal aspect aspect brain brain stema second second is drawn tangentially tangentially ventra vermis; the interposed angle (1) is the BV angle; the BT angle (2) is measured between the first line and a third line tangential to the tent to to the aspect of of the stem and and a line line is drawn to the to the ventral of the of the drawn Measurement of brainstem–vermis (BV) angle (1) and brainstem–tentorium (BT) angle (2) in fetuses with: (a) Blake’s pouch cys Figure 2
84 Fetal posterior fossa fluid collections associated With upward rotation of the cerebellar verm is ranged 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 Conclusion
85 In Summary
Examination Of The Posterior FossaAnd The Cerebellum Midsagittal ViewsAxial View 86
Prac3cal Approach to the DD of Posterior Fossa Cyst and Cys3c like Lesions
Prac3cal Approach to the DD of Posterior Fossa Cyst and Cys3c like Lesions 1. Is the Vermis Present?Is the Vermis intact?
Prac3cal Approach to the DD of Posterior Fossa Cyst and Cys3c like Lesions 1. Is the Vermis Present?Is the Vermis intact? 2. Is the Toruclar in a normal posi3on (tentorial Cerebelli)?
Prac3cal Approach to the DD of Posterior Fossa Cyst and Cys3c like Lesions 1. Is the Vermis Present?Is the Vermis intact? 2. Is the Toruclar in a normal posi3on (tentorial Cerebelli)? 3. What is the shape of the cerebellar clee?
Prac3cal Approach to the DD of Posterior Fossa Cyst and Cys3c like Lesions 1. Is the Vermis Present?Is the Vermis intact? 2. Is the Toruclar in a normal posi3on (tentorial Cerebelli)? 3. What is the shape of the cerebellar clee? 4. Brainstem–vermis (BV)Angle And Brainstem– tentorium (BT)Angle
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245 Normal Megacisterna magna Vermian hypoplasia Blake’s pouch cyst tentorium Dandy-‐Walker malforma3on 89
Standard and Fetal Neurosonography 90 Take Home Message
91
91 ✦examina3on of the Fetal CNS should be follow a Standard Protocol
91 ✦examina3on of the Fetal CNS should be follow a Standard Protocol ✦Examina3on should include at least three axial planes.
91 ✦examina3on of the Fetal CNS should be follow a Standard Protocol ✦Examina3on should include at least three axial planes. ✦In Each plane the defined landmarks should should be reported as normal or suspicious
91 ✦examina3on of the Fetal CNS should be follow a Standard Protocol ✦Examina3on should include at least three axial planes. ✦In Each plane the defined landmarks should should be reported as normal or suspicious ✦In the presence of possible abnormali3es pa3ent should be referred for detailed neuorsonogram which include mutli-‐planner 3 D Sanning.
91 ✦examina3on of the Fetal CNS should be follow a Standard Protocol ✦Examina3on should include at least three axial planes. ✦In Each plane the defined landmarks should should be reported as normal or suspicious ✦In the presence of possible abnormali3es pa3ent should be referred for detailed neuorsonogram which include mutli-‐planner 3 D Sanning. ✦3 D scanning with mul3planner analysis offers comparable analysis to fetal MRI
92 Thanks

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Fetal brain usg 1

  • 1.
    Fetal Brain USG Presentedby Dr. Vrishit Saraswat
  • 2.
    Schizencephaly Encephalocele Microcephaly Anencephaly Chiari Malforma3on Head normalor small Ventriculomegaly Hydranecphaly - Holoprosencephaly Hemimegalencephaly Arachnoid cyst ACC SOP PF-‐Fluid-‐Cyst Vascular Malforma3ons
  • 3.
    Congenital CNS Anomalies oIncidence in longtem studies about 1 % o Only minimal identified at birth o Screening Increases The Number Of Referred Cases For Evaluation Of Suspected CNS Anomalies. o The CNS sonographic appearance changes throughout pregnancy
  • 4.
    • Embryonic developmentof the CNS •in relation to sonographic findings • Standard Sonographic Examination •of the CNS •Learning Objectives
  • 5.
  • 6.
    And Fuse AsThe The Fusion Starts In It Induces The Overlying Embryonic Tissue To Thicken And Ultimately Fold Over Neural Tube. The Midtrunk Of The E m b r y o A n d Subsequently Extends To The Cranial And Caudal Ends Neural Crest Neural Tube Ectoderm At 5th Week The Cells Destined To Form The Notochord Infiltrate Into The Embryonic Disc. Neural Groove Neural Plate
  • 7.
  • 8.
    the end of8 weeks of gestation. The development of premature ventricular system is seen. Three orthogonal images and thick slice of three-dimensional reconstructed image (lower right) of normal brain at 8
  • 9.
    Prosencephalon Mesencephalon Three orthogonalimages and thick slice of three-dimensional reconstructed image (lower right) of normal brain at 8
  • 10.
    Normal brain developmenton the mid-sagittal section between 8 and 12 weeks of gestation). Note the remarkable changing of premature brain appearance. 9
  • 11.
    10 Changing Ultrasound appearanceof the The Posterior Fossa throughout gesta3on
  • 12.
    11 The vermis developssuperiorly to inferiorly. Hypoplasia or developmental arrest results in varying size deficits of the inferior portion, leaving a relatively square defect that communicates with the fourth ventricle and separates the lower cerebellar hemispheres.
  • 13.
  • 14.
    sagittalaxial Effect of Gestationalage (Posterior Fossa) sonograms of posterior fossa in 16-week-old fetus fourth ventricular roof is visualized in both planes (arrow) 13
  • 15.
    Fourthnamely the (4) andacavum septi e u h Ve tric the ventri- ventri- its its closest the structures, follow after the l The normal for but are normal; (b) a however, this same section picture at 20 horns but are normal; (b) gure 1 Transvaginal scan of a 14-week fetus. (a) Oblique-1 (sagittal) section: the fetus is facing left. The choroid plexus fills the antrum the the lateral ventricles. The anterior horns appear prominent, this gestational age;a Frontal-2 (coronal) sonographic through the the anterior horn ore lateral ventricles.ventriculomegaly horns hydrocephalus this gestational age; however, this same sonographic picture 20 20 weeks o re is consistent with ventriculomegaly or hydrocephalus the is lateral consistent withThe horns normal for atat or he The Higher (see almost axial Three serial, o Three open axialand (horizontal) views with the the gure2 be ventriclefossa. (a) (a)a This isis(at this gesta mis appears to to of (b) somewhat higher, sides the wide the the and left of wide (at (at this appear age, to each other op (c) entity. C, appear nd Closer of a Each and the timetable. They reach well-known the 16th this ‘norm gure 2Lower-most Section (horizontal) views through the posterior fossa. (a) This is the lower-most section Still insert). The rmis2appears serial, almost (arrow) communicates throughfourth posterior through widethe the lower-most sectionnormal) median erture (foramenbe Magendie); and communicates withrightfourth ventricle through cerebellar hemispheres gestational closer normal) median erture (foramen of Magendie); (b) somewhat higher, the right and left sides of the cerebellar hemispherescerebellum closer to each othe ow); (c) higher still, no ‘vermiandefect’’ is seen and Of The Cerebellar Communicates With The fourth ventri- its closest anatomic structures, Ventricle cavum septi duncular cistern (cisterna postmenstrual week,fourth ‘normal’ pellucidi anatomic pericallosal artery, namelythe the well-known . Later, after narrows 16th postmenstrual week, developmentTo’ developmental pericallosal artery, follow developmen- en space narrows giving rise tal stage that allows for sonographic imaging until post- Magendie) rise to the median aperture 14 by those normal
  • 17.
    15 Effect of Gesta=onalage (Lateral Ventricles)
  • 18.
    16 Hypoplasia Or DysplasiaShould Not Be Diagnosed Prior To 18 Weeks, Before Vermian Development Is Complete. An Abnormally Steep Scanning Angle May Mimic A Prominent Cleft Between The Lower Portions Of The Cerebellar Hemispheres. The fetal cerebellum Pitfalls in diagnosis
  • 19.
    17 Conclusion •TheCNS displays remarkable embryologicaland developmental changes throughout gestation. •Standard Approach of examination and evaluation of the CNS Should Be Followed
  • 20.
    18 Standard Sonographic Examination ofthe FEtal CNS Sunday, July 28, 13
  • 21.
    Sonography of theCNS Basic Examination “Neurosongram”” Sunday, July 28, 13
  • 22.
    Planes of BasicExamination Sagital PlanesAxial Planes
  • 23.
  • 24.
  • 25.
    Axial Planes a: Transventricular b:Transthalamic Sunday, July 28, 13
  • 26.
    Axial Planes a: Transventricular C:Transcerebeller b: Transthalamic Sunday, July 28, 13
  • 27.
  • 28.
    The Transventricular plane Frontalhones Sunday, July 28, 13
  • 29.
    The Transventricular plane Frontalhones Atrium Sunday, July 28, 13
  • 30.
    The Transventricular plane Frontalhones Choroid Plexus Atrium Sunday, July 28, 13
  • 31.
    The Transventricular plane CavumSep3 Pellucidi Frontal hones Choroid Plexus Atrium Sunday, July 28, 13
  • 32.
  • 33.
  • 34.
  • 35.
  • 36.
    Cavum Sep3 Pellucidi T T TheTranscerebeller plane Sunday, July 28, 13
  • 37.
    Cavum Sep3 Pellucidi Frontalhones T T The Transcerebeller plane Sunday, July 28, 13
  • 38.
    Cerebellum Cavum Sep3 Pellucidi Frontalhones T T The Transcerebeller plane Sunday, July 28, 13
  • 39.
    Cerebellar vermi Cerebellum Cavum Sep3Pellucidi Frontal hones T T The Transcerebeller plane Sunday, July 28, 13
  • 40.
    Cistrerna Magna 2-‐10 mm CavumSep3 Pellucidi The Transcerebeller plane Cerebellar vermi Cerebellum Frontal hones T T Sunday, July 28, 13
  • 41.
  • 42.
    Sagibal Planes A: TheMidsagittal Plan Sunday, July 28, 13
  • 43.
    Sagibal Planes b: Parasgittalplan A: The Midsagittal Plan Sunday, July 28, 13
  • 44.
    Mid SagiGal Plane CorpusCallosum Cavum Sep3 Pellucidi Cerebellum 4th V 27
  • 45.
  • 46.
  • 47.
  • 48.
  • 49.
    30 Basic Examniation Checklist Head+ Neck Midline & Falx Cavum septi pellucidi Lateral cerebral ventricls Choroid Plexus Cerebellum Cisterna magna
  • 50.
    Main Abnormali3es canbe Suspected on Basic Planes 31
  • 51.
    Schizencephaly Encephalocele Microcephaly Anencephaly Chiari Malforma3on Head normalor small Dia Ventriculomegaly Hydranecphaly s : Holoprosencephaly Hemimegalencephaly Arachnoid cyst ACC SOP PF-‐Fluid-‐Cyst Yong seok et a Vascular Malforma3ons
  • 52.
    33 •Ventriculomegaly (hydrocephalus) •Absent CavumSeptum Pellucidum •Agenesis of the Corpus Callosum •Fluid Collection in the posterior
  • 53.
    (< 10 mmis normal). Independent of gesta7onal age Mild 10 – 15 mm Low Risk Severe > 15 mm High Risk mean = 6-‐8 mm Ventriculomegaly (hydrocephalus)
  • 54.
    Lee Lateral Ventricle Aqueductof Sylvius 4th Ventricle Right Lateral Ventricle Foramen of Monro 3rd Ventricle Cisterna Magna Pathogenesis: Ventriculomegaly 35
  • 55.
    •Square Shaped, Interruptsand Fills The Space Between The Frontal Horns •The CSP: Becomes Visible At 16 Weeks, Obliterate Near Term Absent CSP
  • 56.
    •Square Shaped, Interruptsand Fills The Space Between The Frontal Horns •The CSP: Becomes Visible At 16 Weeks, Obliterate Near Term Cavum Sep3 Pellucidi Absent CSP
  • 57.
    A rare findingusually discovered Postnatally in children evaluated for developmental delay. Associated with various brain malformations: agenesis of the corpus callosum Holoprosencephaly. Setpo-‐optic dysplasia. Secondary to disruptive process: Hydrocephalus, Chiari II malformation, hydranecephaly. Absent CSP Sunday, July 28, 13
  • 58.
    38 Agenesis of theCorpus Callosum
  • 59.
    Originally published inUltrasound Obstet Gynecol 2007; 30: 233–245 Normal corpus callosum 3v 3v Par3al agenesis 3v 74 Agenesis of the corpus callosum Absent corpus callosum
  • 60.
    Only The Rostrum(1), Genu (2) And Body (3) Are Visible; The Splenium Is Missing. The Corpus Callosum Is Short Posteriorly And Does Not Seem To Overlay The Quadrigeminal Plate 21-‐week Fetus With Par=al Agenesis Of The Corpus Callosum
  • 61.
    Outcome of fetalACC Varies between completely asymptoma3c appearance and severe neurologic problems 50 – 100 % of isolated cases will have normal neurological development at 3-‐11 years but Poor prognosis with associated anomalies  Progressive decline in intellect over the years  Most need special educa3on Long-‐term follow-‐up of children with prenatally diagnosed agenesis of corpus callosum (ACC) J. H. Stupin et al, USOG, 32, 2008
  • 62.
    41 Fluid Collec3on inthe Posterior Fossa
  • 63.
    41 Fluid Collec3on inthe Posterior Fossa •MegacisternaMagna
  • 64.
    41 Fluid Collec3on inthe Posterior Fossa •Blak’sPouchCyst •MegacisternaMagna
  • 65.
    Fluid Collec3on inthe Posterior Fossa •MegacisternaMagna •D-WMalformation&DW-Variant •Blak’sPouchCyst 41
  • 66.
    Fluid Collec3on inthe Posterior Fossa •MegacisternaMagna •Blak’sPouchCyst •D-WMalformation&DW-Variant •ArachnoidCyst 41
  • 67.
  • 68.
    Mega–Cisterna Magna 43 An EnlargementOf The Cisterna Magna Beyond 10 MmWithIntactVermis
  • 69.
    Choriod Plexus Pathogenesis: MegaCisterna Magna Lateral Ventricle Third Ventricle Cerebral Aqueduct Fourth Ventricle 44
  • 70.
    Pathogenesis: Mega CisternaMagna Lateral Ventricle Third Ventricle Cerebral Aqueduct Choriod Plexus TheForaminaOf LuschkaAndMagendie FenestrateDelayed Fourth Ventricle 44
  • 71.
    45 Prognosis: •IsolatedCases: (97%-100%)AreNormal. •IfNotIsolated:Only11%HaveNormalOutcome. Nonisolated CasesHave VM, Congenital Infection KaryotypeAbnormalities. A Large Cisterna Magna Require Careful Search F OtherAbnormalities.
  • 72.
  • 73.
  • 74.
    Lateral Ventricle Third Ventricle Cerebral Aqueduct ChoriodPlexus foramina of Luschka and Magendie leads to dilatation of the fourth ventricle and and elevation of the vermis awayfromthebrainstem. Fourth Ventricle Pathogenesis: Blake’s Pouch Cyst Nonfenestration of the There is no communication between the cyst and the subarachnoid space 47
  • 75.
    Lateral Ventricle Third Ventricle Cerebral Aqueduct ChoriodPlexus foramina of Luschka and Magendie leads to dilatation of the fourth ventricle and and elevation of the vermis awayfromthebrainstem. Fourth Ventricle Pathogenesis: Blake’s Pouch Cyst Nonfenestration of the There is no communication between the cyst and the subarachnoid space 47
  • 76.
    ✦Complete Or PartiallyAgenesis Of The Cerebellar Dandy-Walker Malformation 48 ASpectrumOfAnomaliesOfThePosteriorFossa. •Dandy-WalkerMalformation: ✦IncreaseOfThePosteriorFossa, Vermis, ✦ATentoriumElevation •VariantOfDandy-Walker: ✦Hypoplasia Of The Cerebellar Vermis In Different Degrees With Or Without Increase Of The Posterior Fossa.
  • 77.
    ctions Dandy-Walker Malformation Elevated tentoriumand high position of the torcula Small, rotated, raised, or absent vermis Cystic dilation of the fourth ventricle communicating with a posterior fossa fluid space 49
  • 78.
  • 79.
    Figure Torcular IsFound InANormalandy–Walker Malformation position the torcular igure 2 on of the tentorium cerebelli. Inthe direction by theultrasound the direction tentorium cerebelli. In (a)The Torcular Is Displaced Higher orcular found normal position, about the same level as he site of insertion of the neck muscles on the posterior skull; thisite of insertion of the neck muscles on the posterior skull; thisSkull a Blake a pouch cyst. In (b) the torcular is displaced higBlake’s 51 The AsThe found Insertion normala OfThe Neck Muscles isSunday, July 28, 13 ’s pouch cyst. In (b) the torcular is displaced higher th
  • 80.
    • • • • Are Benign, NoncommunicatingFluid Collections Within Arachnoid Membranes. Location: Intracranially And In The SpinalCanal. Order Of Frequency Are The Sylvian Fissure Or Temporal Fossa, Posterior Fossa, Over The Cerebral Convexity, AndMidlineSupratentorial, Most Appear Stable And Require No Surgical Treatment. Occasionally They Arachnoid Cysts Interfere With CSF Circulation And RequireDecompression.
  • 81.
    The Differential Diagnosis DependsOn The Location. In The Posterior Fossa: DandyWalker Malformation, Inferior Vermian Hypoplasia, Mega–cisterna Magna, And Blake’s Pouch Cysts. Supratentorial Cysts: Cavum Veli Interpositi, Aneurysm Of Vein Of Galen, Hemorrhage, And Cystic Tumors. 53
  • 82.
    54 Prenatal diagnosis andoutcome of fetal posterior fossa fluid collections G. GANDOLFI COLLEONI et al, Ultrasound Obstet Gynecol 2012; 39: 625–631
  • 83.
    Vermian Hypoplasia N=17 55 Blake’s PouchCyst N = 32 Arachnoid Cyst N=1 Megacisterna Magna N = 27 Cerebellar Hypoplasia N=2 Dandy – Walker Malformation N=26 105 Fetuses Sonographic diagnoses were accurate in 88%
  • 84.
    ✦Isolated Cases OfBlake’s Pouch Cyst And Megacisterna Magna Have An Excellent Prognosis, With A High Probability Of Intrauterine Resolution And Normal Intellectual Development In Almost All Cases. ✦Dandy – Walker Malformation And Vermian Hypoplasia, Even When They Appear Isolated Antenatally, Are Associated With An Abnormal OutcomeInHalfOfCases. 56
  • 85.
    57 •Black’s Pouch Cyst,DW Malformatio Mega-‐Cisterna Magna Can give Si Sonographic features. •However the prognosis is greatly vari •Careful Neurosonographic assessment us D or Fetal MRI is often Needed Conclusion Sunday, July 28, 13
  • 86.
    Originally published inUltrasound Obstet Gynecol 2007; 30: 233–245 Brain stem Cerebellar vermis Angled Insona3on of Posterior Fossa Visualize brain Stem 4v 65
  • 87.
    Originally published inUltrasound Obstet Gynecol 2007; 30: 233–245 4v hemisphere hemisphere hemisphere vermis hemisphere tentorium 4v tentorium vermis vermian fissures
  • 88.
    Normal Posterior FossaAt Midgesta=on SagiGal viewAxial view Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
  • 89.
    SagiGal viewAxial view NormalPosterior Fossa At Midgesta=on Cavum Sep3 Pellucidi Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
  • 90.
    SagiGal viewAxial view NormalPosterior Fossa At Midgesta=on Cavum Sep3 Pellucidi Cerebellar vermis Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
  • 91.
    SagiGal viewAxial view NormalPosterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
  • 92.
    SagiGal viewAxial view NormalPosterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Tentorium Cisterna Magna Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20 Sunday, July 28, 13
  • 93.
    SagiGal viewAxial view NormalPosterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Tentorium Cisterna Magna Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
  • 94.
    SagiGal viewAxial view NormalPosterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Tentorium Cisterna Magna Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
  • 95.
    SagiGal viewAxial view NormalPosterior Fossa At Midgesta=on Cisterna Magna Cavum Sep3 Pellucidi Cerebellar vermis Tentorium Cisterna Magna Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons Gandolfi Colleoni et al., UOG 20
  • 96.
    Categoriza3on of posteriorfossa fluid collec3ons (1)
  • 97.
    Blake’s pouch cystMegacisterna magna D-‐W Findings Upward rotation of an intact vermis with normal torcular Cisterna magna >10mm with intact and normally positioned cerebellum Upward rotation of the v (normal or hypoplastic) w elevated torcular Categoriza3on of posterior fossa fluid collec3ons (1) SagiGal Axial
  • 98.
    79 Axial View •Transverse DiameterOf The Cerebellum. •The Intactness And Size Of The Vermis. •The Depth Of The Cisterna Magna (10 Mm)
  • 99.
    Measurement of brainstem–vermis(BV) and 80Figure 1 The Vermis: Shape, Size, Fissures brainstem–tento Cavum Sep3 Pellucidi The Tentorium: Level case after acquisition of an ultrasound volume starting from an axi
  • 100.
  • 101.
    Blake’s Pouch Cyst Cerebellar Vermis Hypoplasi Dandy–Walker Malformation. TheAnglesHas The Widest Measurement In DA Malformation 82 and (BT) (BT) (a) A (a) A view the of the fetal brain is after of of volume starting from an an axial and the anatomic are are 1 Measurement of brainstem–vermis (BV) brainstem–tentoriumangles. angles.median median ofviewfetal brain is obtain e acquisitionan ultrasound volume starting from axial view)view) the and main anatomic landmarks landmarks ide angentially tangentially dorsal dorsal aspect aspect brain brain stema second second is drawn tangentially tangentially ventra vermis; the interposed angle (1) is the BV angle; the BT angle (2) is measured between the first line and a third line tangential to the tent to to the aspect of of the stem and and a line line is drawn to the to the ventral of the of the drawn Measurement of brainstem–vermis (BV) angle (1) and brainstem–tentorium (BT) angle (2) in fetuses with: (a) Blake’s pouch cys Figure 2
  • 102.
    84 Fetal posterior fossafluid collections associated With upward rotation of the cerebellar verm is ranged 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 Conclusion
  • 103.
  • 104.
    Examination Of ThePosterior FossaAnd The Cerebellum Midsagittal ViewsAxial View 86
  • 105.
    Prac3cal Approach tothe DD of Posterior Fossa Cyst and Cys3c like Lesions
  • 106.
    Prac3cal Approach tothe DD of Posterior Fossa Cyst and Cys3c like Lesions 1. Is the Vermis Present?Is the Vermis intact?
  • 107.
    Prac3cal Approach tothe DD of Posterior Fossa Cyst and Cys3c like Lesions 1. Is the Vermis Present?Is the Vermis intact? 2. Is the Toruclar in a normal posi3on (tentorial Cerebelli)?
  • 108.
    Prac3cal Approach tothe DD of Posterior Fossa Cyst and Cys3c like Lesions 1. Is the Vermis Present?Is the Vermis intact? 2. Is the Toruclar in a normal posi3on (tentorial Cerebelli)? 3. What is the shape of the cerebellar clee?
  • 109.
    Prac3cal Approach tothe DD of Posterior Fossa Cyst and Cys3c like Lesions 1. Is the Vermis Present?Is the Vermis intact? 2. Is the Toruclar in a normal posi3on (tentorial Cerebelli)? 3. What is the shape of the cerebellar clee? 4. Brainstem–vermis (BV)Angle And Brainstem– tentorium (BT)Angle
  • 110.
    Originally published inUltrasound Obstet Gynecol 2007; 30: 233–245 Normal Megacisterna magna Vermian hypoplasia Blake’s pouch cyst tentorium Dandy-‐Walker malforma3on 89
  • 111.
  • 112.
  • 113.
    91 ✦examina3on of theFetal CNS should be follow a Standard Protocol
  • 114.
    91 ✦examina3on of theFetal CNS should be follow a Standard Protocol ✦Examina3on should include at least three axial planes.
  • 115.
    91 ✦examina3on of theFetal CNS should be follow a Standard Protocol ✦Examina3on should include at least three axial planes. ✦In Each plane the defined landmarks should should be reported as normal or suspicious
  • 116.
    91 ✦examina3on of theFetal CNS should be follow a Standard Protocol ✦Examina3on should include at least three axial planes. ✦In Each plane the defined landmarks should should be reported as normal or suspicious ✦In the presence of possible abnormali3es pa3ent should be referred for detailed neuorsonogram which include mutli-‐planner 3 D Sanning.
  • 117.
    91 ✦examina3on of theFetal CNS should be follow a Standard Protocol ✦Examina3on should include at least three axial planes. ✦In Each plane the defined landmarks should should be reported as normal or suspicious ✦In the presence of possible abnormali3es pa3ent should be referred for detailed neuorsonogram which include mutli-‐planner 3 D Sanning. ✦3 D scanning with mul3planner analysis offers comparable analysis to fetal MRI
  • 118.