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Fetal Nuerosonogram Professor Hassan Nasrat FRCS, FRCOG
The Fetal Medicine Clinic
The First Clinic
JUCOG January 2013
Sunday, July 28, 13

Microcephaly
Holoprosencephaly
Head normal or small

Chiari Malforma3on
ACC

Dia


Anencephaly
Occipital Encephalocele
Schizencephaly
Schizencephaly
Circle of Willis Mallformation
Vascular Malforma3ons
SOP
Pilu
Imaging Findings
 Herniated brain tissue
 „cyst within the cyst“
 Ventriculomegaly 7080%
 Microcephaly 25%
 Polyhydramnios
 Oligohydramnios

Encephalocele
PF-­‐Fluid-­‐Cyst
CAVE:
 Associated with multiple
syndroms ( Meckel- Gruber )
Hydrance
halus , T 21
Ventriculomegaly
Hemimegalencephaly
Arachnoid cyst
Hydranecphaly
Yong seok et a
2
Sunday, July 28, 13
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 Sunday, July 28, 13
Learning Objec3ves
✤ Embryonic development of the CNS in relation to sonographic findings
✤ Standard Sonographic Examination of the CNS ✤ Fetal Neurosonography and the Role of 3 D (systemic approach to examination of the Posterior Fossa)
4
Sunday, July 28, 13
Embryology of the
CNS
Sunday, July 28, 13
At 5th Week The Cells Destined To Form The Notochord Infiltrate Into The Embryonic Disc. I t I n d u c e s T h e Overlying Embryonic Tissue To Thicken And Ultimately Fold Over And Fuse As The The Fusion Starts In 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 Groove
Neural Plate
Sunday, July 28, 13
Ectoderm
Neural Tube
Prosencephalon
Mesencephalon
Rhombencephalon
7
Sunday, July 28, 13
Three orthogonal images and thick slice of three-dimensional reconstructed image (lower right) of normal brain at
8
the end of 8 weeks of gestation. The development of premature ventricular system is seen.
Sunday, July 28, 13
Prosencephalon
Mesencephalon
Three orthogonal images and thick slice of three-dimensional reconstructed image (lower right) of normal brain at
8
the end of 8 weeks of gestation. The development of premature ventricular system is seen.
Sunday, July 28, 13
Normal brain development on the mid-sagittal section between 8 and 12 weeks of gestation). Note the remarkable changing of premature
9 brain
appearance.
Sunday, July 28, 13
AJR:166,
AJR:166,
Changing Ultrasound appearance of the The Posterior Fossa throughout gesta3on SONOGRAPHIC
February 1996
February 1996
AJR:166,
February 1996
ANATOMY
SONOGRAPHIC
ANATOMY
SONOGRAPHIC
OF DEVELOPING
433
CEREBELLUM
OF DEVELOPING
CEREBELLUM
ANATOMY
OF DEVELOPING
CEREBELLUM
433
433
10
C
Sunday,
CC July 28, 13Fig.
C
D
13.-Drawings
depicting
some
relevant
features
D
DD
of fetal cerebellar
development.
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.
11
Sunday, July 28, 13
C
D
Fig. 13.-Drawings
depicting
some relevant features
of fetal cerebellar
development.
A, Axial drawing
of developing
cerebellum
at 5 weeks’ gestational
age shows that developing cerebellar hemispheres have not yet grown
toward midline and thatfourth
ventricle is covered only byfourth ventricular roof,which
is onlytwo
cell layers thickatthis
stage of development.
B, Sagittal drawing of developing cerebellum at 10 weeks’ gestational age shows small cerebellum located rostrally over fourth ventricle,
with caudal fourth ventricle being covered only by thin fourth ventricular roof.
C, Sagittal
drawing at 16 weeks’ gestational age shows further caudal growth of cerebellum
ening
0,
of caudal
Sagfttal
fourth
drawing
ventricular
roof.
at 17 weeks’ gestational
age shows
cerebellum
We have shown that the sonognaphic
appearance
of normal cemebellar
development
can resemble
pathology
early in
the second
trimester.
Our findings
indicate
that the mature
relationships
of the posterior
fossa structures
are not established until at least 18 weeks’ gestational
age; therefore,
the
Sunday,
July
28, 13 diagnosis
prenatal
sonographic
of Dandy-Walker
complex
and vermis
covering
4. Achinon
entire
R, Tadmor
ten of pregnancy:
and vermis over fourth
fourth
0. Screening
tnansvaginal
ventrIcle,
teno
thic
and
with thick-
ventricle.
for fetal anomalies
versus transabdominal
1991 1:186-191
during
the first tnimesUltra-
sonography.
sound Obstet Gynecol
5. Nicolaides
KH, Azan G, Byrne D, Mansur C, Marks K. Fetal nuchal translucency: ultrasound screening for chromosomal
defects in first trimester of
pregnancy.
BMJ 1992:304:867-869
6. Bronshtein
M, Blumenfeld
I, Kohn J, Blumenfeld Z. Detection ofcleft lip by early
12
of posteriorB, Next
fossa caudal
in 13- image
to 14-week-old
called acquisition
in stea
identifies fetus.
fourth ventricular roof joining cerebellar hemispheres
fetus. Vermis
A, Vermis
is
identified
between
cerebellar
hemispheres
rostrally
(arrow).
age
of
posteriorfossa
in
(arrow) and separating
fourth ventricle
and cisterna
magna.
but not caudally
B, Next caudal image identifies fourth ventricular roof joining cerebellar hemispheres
fetus. Vermis is identified
(arrow) and separating
fourth ventricle
and cisterna
magna.
but not caudally at this s
Effect of Gesta=onal age (Posterior Fossa)
Fig. 7.-Axial
Fig. 7.-A
and
tenor fossa
tenor fossa in 16-weekA and
A and B, Caudally,
thickto enoug
thick enough
be v
and sagittal and
(B) sagittal
planes
axial
sagittal
sonograms of posterior fossa in 16-week-old fetus
fourth ventricular roof is visualized in both planes (arrow)
13
Sunday, July 28, 13
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
ure
Transvaginal
scananterior
ofaa14-week
14-week
fetus.(a)
(a)
Oblique-1(sagittal)
(sagittal)
section:
the
fetusisisfacing
facing
left.The
Thechoroid
choroid
plexus
fills
the
antrum
ure
Transvaginal
of
Oblique-1
section:
the
left.
plexus
the
antrum
the11lateral
ventricle. scan
The
hornsfetus.
appear
prominent,
but
are normal;
(b)
a fetus
Frontal-2
(coronal)
section
through
thefills
anterior
horns
the
lateral
ventricle.
The
anterior
horns
appear
prominent,
but
are
normal;
(b)
a
Frontal-2
(coronal)
section
through
the
anterior
horn
he
lateral
ventricle.
The
anterior
horns
appear
prominent,
but
are
normal;
(b)
a
Frontal-2
(coronal)
section
through
the
anterior
horns
the lateral ventricles. The anterior horns are normal for this gestational age; however, this same sonographic picture at 20 weeks
or
the
lateral
ventricles.
The
anterior
horns
are
normal
for
this
gestational
age;
however,
this
same
sonographic
picture
at
20
weeks
o
he
lateral
ventricles.
The
anterior
horns
are
normal
for
this
gestational
age;
however,
this
same
sonographic
picture
at
20
weeks
or
ore is consistent with ventriculomegaly or hydrocephalus
re
is
consistent
with
ventriculomegaly
or
hydrocephalus
re is consistent with ventriculomegaly or hydrocephalus
Effect Of Scanning Level (Posterior Fossa)
Higher
Still
Section
gure 2Lower-most
Three serial, almost
axial (horizontal) views
through the posterior
section
(see insert). The
Somewhat
Higherfossa. (a) This is the lower-most
ure 22appears
Three
serial,
almost
axial
(horizontal)
views
through
fossa.
(a)
isisthe
section
The
ermis
be open
(arrow)
communicates
the the
fourth
ventricle
through
aThis
wide
(at
this
gestational
age,(see
normal)
median
gure
Threeto
serial,
almost
axialand
(horizontal)
viewswith
through
theposterior
posterior
fossa.
(a)This
thelower-most
lower-most
section
(seeinsert).
insert).
Th
mis
appears
to
be
open
(arrow)
and
communicates
with
the
fourth
ventricle
through
a
wide
(at
this
gestational
age,
normal)
median
perture
(foramen
of
Magendie);
(b)
somewhat
higher,
the
right
and
left
sides
of
the
cerebellar
hemispheres
appear
closer
to
each
other
rmis appears to be open (arrow) and communicates with the fourth ventricle through a wide (at this gestational age, normal) media
rture The
(foramen
of
Magendie);
(b)
higher,
right
left
ofofthe
hemispheres
totoeach
rrow);
(c) higher
still,
noAppears
‘vermian
defect’
and the
ventricle
(4) appears
as a discrete
entity.‘vermian
C,appear
cerebellum
Vermis
To is seen
erture
(foramen
of
Magendie);
(b)somewhat
somewhat
higher,
thefourth
rightand
and
leftsides
sides
thecerebellar
cerebellar
hemispheres
appearcloser
closer
eachother
othe
No
Defect’
The
Right
And
Left
Sides
row);
(c)
higher
still,
no
‘vermian
defect’
is
seen
and
the
fourth
ventricle
(4)
appears
as
a
discrete
entity.
C,
cerebellum
row);Be
(c) higher
still, (arrow)
no ‘vermian And
defect’ is seen and the fourth ventricle (4) appears as a discrete entity. C, cerebellum
Open
Is Seen And The
Of
The
Cerebellar
Communicates
With
Theand theHemispheres
its closest
anatomic structures,
the cavum
eduncular
cistern (cisterna
magna)
fourth ventriFourthnamely
Ventricle
(4) septi
Appear
anatomic
structures,
namely
the
septi
duncular
cistern
magna)
the
ventripellucidi
and
the pericallosal
artery,
follow
acavum
well-known
e. Later,
16thVe
postmenstrual
this ‘normal’
its closest
closest
anatomic
structures,
namely
the
cavum
sep
duncular
cistern
(cisterna
thefourth
fourth
ventri- its
F o uafter
r t hthe(cisterna
nmagna)
t r i c land
eandweek,
Appears
As
A
Closer
To
Each
Other
pellucidi
and
the
pericallosal
artery,
follow
a
well-known
Later,
after
the
16th
postmenstrual
week,
this
‘normal’
developmental
timetable.
They artery,
do not reach
pen
space
narrows
as postmenstrual
the growth and
development
of
pellucidi and the
pericallosal
followa adevelopmenwell-know
. Later,
after
the 16th
week,
this ‘normal’
Through
A
Wide
Discrete
Entity.
en
space
the
ofof developmental
(arrow);
tal
stage that timetable.
allows
forThey
sonographic
imaging
until poste vermis
progress,
giving
rise to and
the
median
aperture
developmental
timetable.
Theydodonot
notreach
reacha adevelopmendevelopmen
en
space narrows
narrows as
as
the growth
growth
and development
development
vermis
progress,
giving
rise
median
Magendie)
(Figure
2).the
Again,
thisaperture
normal
eoramen
vermis of
progress,
giving
rise to
to
the
median
aperture
ramen
Magendie)
2).
this
normal
onographic
may (Figure
be
interpreted
by those
unfamiliar
ramen of
of finding
Magendie)
(Figure
2). Again,
Again,
this
normal
Sunday,
July
28,
13
nographic finding may be interpreted by those unfamiliar
tal
allows
for
sonographic
imaging
until
post14 before
menstrual
weeks
18–19.
search for their
presence
talstage
stagethat
that
allows
forTo
sonographic
imaging
until
pos
menstrual
for
they
reachweeks
this 18–19.
critical
stage
in their
development
would
menstrual
weeks
18–19.To
Tosearch
search
fortheir
theirpresence
presencebefore
befor
they reach this critical stage in their development would
Effect of Gesta=onal age (Lateral Ventricles)
15
Sunday, July 28, 13
The fetal cerebellum
Pitfalls in diagnosis
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.
16
Sunday, July 28, 13
Conclusion
•TheCNS displays remarkable embryological and developmental changes throughout gestation.
•Standard Approach of examination and evaluation of the CNS Should Be Followed
17
Sunday, July 28, 13
Standard Sonographic
Examination of the
FEtal CNS
18
Sunday, July 28, 13
Sunday, July 28, 13
Sonography of the CNS
Basic Examination “Neurosongram”
Sunday, July 28, 13
Planes of Basic Examina3on
Axial Planes
Sunday, July 28, 13
Sagibal 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
b: Transthalamic C: Transcerebeller 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
Atrium
Sunday, July 28, 13
Choroid Plexus
The Transventricular plane
Cavum Sep3 Pellucidi
Frontal hones
Atrium
Sunday, July 28, 13
Choroid Plexus
The Transthalamic Plane
Sunday, July 28, 13
The Transthalamic Plane
Thalami
Sunday, July 28, 13
The Transthalamic Plane
Thalami
Hyppocamas Gyrus
Sunday, July 28, 13
The Transcerebeller plane
T
T
Sunday, July 28, 13
The Transcerebeller plane
T
T
Cavum Sep3 Pellucidi
Sunday, July 28, 13
The Transcerebeller plane
Frontal hones
T
T
Cavum Sep3 Pellucidi
Sunday, July 28, 13
The Transcerebeller plane
Cerebellum
Frontal hones
T
T
Cavum Sep3 Pellucidi
Sunday, July 28, 13
The Transcerebeller plane
Cerebellar vermis
Cerebellum
Frontal hones
T
T
Cavum Sep3 Pellucidi
Sunday, July 28, 13
The Transcerebeller plane
Cerebellar vermis
Cerebellum
Frontal hones
T
T
Cavum Sep3 Pellucidi
Sunday, July 28, 13
Cistrerna Magna
2-­‐10 mm
Sagibal Planes Sunday, July 28, 13
Sagibal Planes A: The Midsagittal Plan
Sunday, July 28, 13
Sagibal Planes b: Parasgittal plane
A: The Midsagittal Plan
Sunday, July 28, 13
Mid SagiGal Plane Corpus Callosum
Cavum Sep3 Pellucidi
Cerebellum
4th V
27
Sunday, July 28, 13
Mid SagiGal Plane 27
Sunday, July 28, 13
The Corpus Callosum
28
Sunday, July 28, 13
The Corpus Callosum
Lateral Ventricles
Splenium
Corpus Callosum
Thalamus
hypothalamus
Third Ventricle
Pituitary
Fourth ventricle
midbrain
28
Sunday, July 28, 13
Para-­‐SagiGal Plane 29
Sunday, July 28, 13
Basic Examniation Checklist
Head + Neck
Midline & Falx
Cavum septi pellucidi
Lateral cerebral ventricls
Choroid Plexus
Cerebellum
Cisterna magna
30
Sunday, July 28, 13
Main Abnormali3es can be Suspected on Basic Planes
31
Sunday, July 28, 13

Holoprosencephaly
Microcephaly
Head normal or small

Chiari Malforma3on
ACC

Dia


Anencephaly
Occipital Encephalocele
Schizencephaly
Schizencephaly
Circle of Willis Mallformation
Vascular Malforma3ons
SOP
Pilu
Imaging Findings
 Herniated brain tissue
 „cyst within the cyst“
 Ventriculomegaly 7080%
 Microcephaly 25%
 Polyhydramnios
 Oligohydramnios

Encephalocele
PF-­‐Fluid-­‐Cyst
CAVE:
 Associated with multiple
syndroms ( Meckel- Gruber )
Hydrance
halus , T 21
Ventriculomegaly
Hemimegalencephaly
Arachnoid cyst
Hydranecphaly
Yong seok et a
32
Sunday, July 28, 13

Holoprosencephaly
Microcephaly
Head normal or small

Chiari Malforma3on
ACC

Dia


Anencephaly
Occipital Encephalocele
Schizencephaly
Schizencephaly
Circle of Willis Mallformation
Vascular Malforma3ons
SOP
Pilu
Imaging Findings
 Herniated brain tissue
 „cyst within the cyst“
 Ventriculomegaly 7080%
 Microcephaly 25%
 Polyhydramnios
 Oligohydramnios

Encephalocele
PF-­‐Fluid-­‐Cyst
CAVE:
 Associated with multiple
syndroms ( Meckel- Gruber )
Hydrance
halus , T 21
Ventriculomegaly
Hemimegalencephaly
Arachnoid cyst
Hydranecphaly
Yong seok et a
32
Sunday, July 28, 13

Holoprosencephaly
Microcephaly
Head normal or small

Chiari Malforma3on
ACC

Dia


Anencephaly
Occipital Encephalocele
Schizencephaly
Schizencephaly
Circle of Willis Mallformation
Vascular Malforma3ons
SOP
Pilu
Imaging Findings
 Herniated brain tissue
 „cyst within the cyst“
 Ventriculomegaly 7080%
 Microcephaly 25%
 Polyhydramnios
 Oligohydramnios

Encephalocele
PF-­‐Fluid-­‐Cyst
CAVE:
 Associated with multiple
syndroms ( Meckel- Gruber )
Hydrance
halus , T 21
Ventriculomegaly
Hemimegalencephaly
Arachnoid cyst
Hydranecphaly
Yong seok et a
32
Sunday, July 28, 13

Holoprosencephaly
Microcephaly
Head normal or small

Chiari Malforma3on
ACC

Dia


Anencephaly
Occipital Encephalocele
Schizencephaly
Schizencephaly
Circle of Willis Mallformation
Vascular Malforma3ons
SOP
Pilu
Imaging Findings
 Herniated brain tissue
 „cyst within the cyst“
 Ventriculomegaly 7080%
 Microcephaly 25%
 Polyhydramnios
 Oligohydramnios

Encephalocele
PF-­‐Fluid-­‐Cyst
CAVE:
 Associated with multiple
syndroms ( Meckel- Gruber )
Hydrance
halus , T 21
Ventriculomegaly
Hemimegalencephaly
Arachnoid cyst
Hydranecphaly
Yong seok et a
32
Sunday, July 28, 13
•Ventriculomegaly (hydrocephalus)
•Absent Cavum Septum Pellucidum
•Agenesis of the Corpus Callosum
•Fluid Collection in the posterior fossa
33
Sunday, July 28, 13
Ventriculomegaly (hydrocephalus)
Mild 10 – 15 mm
Low Risk mean = 6-­‐8 mm
Severe > 15 mm High Risk (< 10 mm is normal). Independent of gesta7onal age Sunday, July 28, 13
Pathogenesis: Ventriculomegaly
Lee Lateral Ventricle
Right Lateral Ventricle
Foramen of Monro Aqueduct of Sylvius
4th Ventricle
3rd Ventricle
Cisterna Magna
35
Sunday, July 28, 13
Absent CSP
•Square Shaped, Interrupts and Fills The Space Between The Frontal Horns
•The CSP: Becomes Visible At 16 Weeks, Obliterate Near Term
Sunday, July 28, 13
Absent CSP
Cavum Sep3 Pellucidi
•Square Shaped, Interrupts and Fills The Space Between The Frontal Horns
•The CSP: Becomes Visible At 16 Weeks, Obliterate Near Term
Sunday, July 28, 13
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. Sunday, July 28, 13
Agenesis of the Corpus Callosum 38
Sunday, July 28, 13
21-­‐week Fetus With Par=al Agenesis Of The 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
Sunday, July 28, 13
Outcome of fetal ACC
 Va r i e s b e t we e n co m p l e te l y a sy m p to m a 3 c 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
Sunday, July 28, 13
Fluid Collec3on in the Posterior Fossa
41
Sunday, July 28, 13
Fluid Collec3on in the Posterior Fossa
•Megacisterna Magna
41
Sunday, July 28, 13
Fluid Collec3on in the Posterior Fossa
•Megacisterna Magna
•Blak’s Pouch Cyst
41
Sunday, July 28, 13
Fluid Collec3on in the Posterior Fossa
•Megacisterna Magna
•D-W Malformation &DW- Variant
•Blak’s Pouch Cyst
41
Sunday, July 28, 13
Fluid Collec3on in the Posterior Fossa
•Megacisterna Magna
•Blak’s Pouch Cyst
•D-W Malformation &DW- Variant
•Arachnoid Cyst
41
Sunday, July 28, 13
Anomalies Of The
Meninges
•Megacisterna Magna
•Blak’s Pouch Cyst
Anomalies
Cerebellum
•D-W Malformation &DW- Variant
•Arachnoid Cyst
42
Sunday, July 28, 13
Mega–Cisterna Magna
An Enlargement Of The Cisterna Magna Beyond 10
Mm With Intact Vermis
43
Sunday, July 28, 13
Pathogenesis: Mega Cisterna Magna
Lateral Ventricle
Third Ventricle
Cerebral Aqueduct
Choriod Plexus
Fourth Ventricle
44
Sunday, July 28, 13
Pathogenesis: Mega Cisterna Magna
The Foramina Of
Lateral Ventricle
Luschka And Magendie
Fenestrate Delayed
Third Ventricle
Cerebral Aqueduct
Choriod Plexus
Fourth Ventricle
44
Sunday, July 28, 13
Prognosis:
• Isolated Cases: (97%-100%) Are Normal.
• If Not Isolated: Only 11% Have Normal Outcome.
Nonisolated Cases Have VM, Congenital Infection, Or
Karyotype Abnormalities.
A Large Cisterna Magna Require Careful Search For
Other Abnormalities.
45
Sunday, July 28, 13
Blake’s Pouch Cyst
46
Sunday, July 28, 13
Pathogenesis: Blake’s Pouch Cyst
Nonfenestration of the
foramina of Luschka and
Lateral Ventricle
Magendie leads to dilatation
of the fourth ventricle and
and elevation of the vermis
away from the brain stem.
Third Ventricle
Cerebral Aqueduct
Choriod Plexus
Fourth Ventricle
There is no communication between the
cyst and the subarachnoid space
47
Sunday, July 28, 13
Pathogenesis: Blake’s Pouch Cyst
Nonfenestration of the
foramina of Luschka and
Lateral Ventricle
Magendie leads to dilatation
of the fourth ventricle and
and elevation of the vermis
away from the brain stem.
Third Ventricle
Cerebral Aqueduct
Choriod Plexus
Fourth Ventricle
There is no communication between the
cyst and the subarachnoid space
47
Sunday, July 28, 13
Dandy-Walker Malformation
A Spectrum Of Anomalies Of The Posterior Fossa.
• Dandy-Walker Malformation:
✦Increase Of The Posterior Fossa,
Complete
Or
Partially
Agenesis
Of
The
Cerebellar
✦
Vermis,
✦A Tentorium Elevation
• Variant Of Dandy-Walker:
✦Hypoplasia Of The Cerebellar
Vermis In Different
Degrees With Or Without Increase Of The Posterior
Fossa.
48
Sunday, July 28, 13
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
Sunday, July 28, 13
The Prognosis :
Better In Isolated DWS.
Karyotype Abnormalities In About 15%.
Neonatal Mortality:
12% To 55%.
Neonatal Morbidity:
•Intelligence Is Normal In About 40%
•Borderline In 20%
•Subnormal In 40%.
50
Sunday, July 28, 13
Blake’s
Pouch Cyst
igure
2 2The
position
ofof
thethe
torcular
Herophili
(arrows)
is inferred
Dandy–Walker
Malformation
Figure
The
position
torcular
Herophili
(arrows)
is inferre
The Torcular Is Found In A Normal
The
Torcular Is
DisplacedIn
Higher
non
ultrasound
byby
the
direction
thethe
tentorium
cerebelli.
(a)(a)
theth
Position,
At About
The
Same
Levelofof
ultrasound
the
direction
tentorium
cerebelli.
In
Than Usual, Indicating That This
As
The
Site
Of
Insertion
Of
The
orcular
is is
found
inin
a normal
position,
at at
about
thethe
same
level
as as
torcular
found
a
normal
position,
about
same
level
Is
A
Neck Muscles On The Posterior
he
site
ofof
insertion
ofof
thethe
neck
muscles
onon
thethe
posterior
skull;
this
theSkull
site
insertion
neck
muscles
posterior
skull;
51 thi
pouch cyst. In (b) the torcular is displaced higher than
isaSunday,
aBlake’s
Blake’s
July 28, 13 pouch cyst. In (b) the torcular is displaced higher than
Arachnoid Cysts
•
Are Benign, Noncommunicating Fluid
Collections
Within
Arachnoid
Membranes.
•
Location: Intracranially And In The
Spinal Canal.
•
Order Of Frequency Are The Sylvian
Fissure Or Temporal Fossa, Posterior
Fossa, Over The Cerebral Convexity,
And Midline Supratentorial,
•
Most Appear Stable And Require No
Surgical Treatment. Occasionally They
Interfere With CSF Circulation And
Require Decompression.
Sunday, July 28, 13
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
Sunday, July 28, 13
Prenatal diagnosis and outcome of fetal posterior
fossa fluid collections
G. GANDOLFI COLLEONI et al,
Ultrasound Obstet Gynecol 2012; 39: 625–631
54
Sunday, July 28, 13
105
Fetuses
Blake’s Pouch Cyst
N = 32
Arachnoid Cyst
N=1
Megacisterna Magna
N = 27
Cerebellar Hypoplasia
N=2
Sonographic
diagnoses
were accurate
in 88%
Sunday, July 28, 13
Dandy – Walker Malformation
N=26
Vermian Hypoplasia
N=17
55
✦ 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
Outcome In Half Of Cases.
56
Sunday, July 28, 13
Conclusion
•Black’s Pouch Cyst, DW Malformation, and Mega-­‐Cisterna Magna Can give Similar Sonographic features. •However the prognosis is greatly varialbe.
•Careful Neurosonographic assessment using 3 D or Fetal MRI is often Needed
57
Sunday, July 28, 13
Technical Guideline
How do we do it? Practical advice on imaging-based
techniques and investigations
Three dimensional ultrasound
examination of the fetal central
nervous system
Gianluigi Pilu, Tullio Ghi, Angela Carletti,
Maria Segata, Antonella Perolo, Nicola Rizzo
From the Department of Obstetrics and Gynecology
University of Bologna, Italy
Address for correspondence: [email protected]
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
Sunday, July 28, 13
3D ultrasound is a data set that contains a large number o f 2 D p l a n e s ( B -­‐ m o d e images). e.g. If the page of a book is one 2D plane, then the book itself is the en3re data set. The 3 D probe acquire the data by moving a B mode transducer within a housing like a hand held Japanese fan .
Sunday, July 28, 13
Pyramid Of Volume Informa=on
✴ “Walking” through the volume is similar to leafing through the pages of a book i.e. walking through the various 2D planes that make up the entire volume. ✴ The Volume can be dissected in any plane, to get “Multiplanar Imaging” Sunday, July 28, 13
the acquired volume unlike the defined rectangle shape of a book looks like a pyramid or triangle of volume informa3on with a broad base 3D volumes of the fetal brain obtained from
an axial approach: the ‘start’ scan
Cavum septi pellucidi
midline
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–24561
Sunday, July 28, 13
midline
A
C
Sunday, July 28, 13
B
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
midline
A
C
Sunday, July 28, 13
B
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
midline
A
B
A and B rotated on Z
plane until midline is
aligned with C plane
C
Sunday, July 28, 13
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
A
B
Corpus callosum + cavum septi pellucidi
Cerebellar vermis
C
Sunday, July 28, 13
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
Acoustic shadow
midline
Corpus callosum
Cavum sep* pellucidi
midline
Corpus callosum + cavum sep* pellucidi
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
Sunday, July 28, 13
64
Angled Insona3on of Posterior Fossa to Visualize brain Stem
4v
Brain stem
Cerebellar vermis
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
Sunday, July 28, 13
65
hemisphere
hemisphere
tentorium
4v
vermis
hemisphere
hemisphere
tentorium
vermis
vermian fissures
4v
Sunday, July 28, 13
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
body
atrium
Occipital horn
Temporal horn
Sylvian fissure
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
Sunday, July 28, 13
67
68
Sunday, July 28, 13
69
Sunday, July 28, 13
70
Sunday, July 28, 13
71
Sunday, July 28, 13
72
Sunday, July 28, 13
73
Sunday, July 28, 13
Agenesis of the corpus callosum
Normal corpus callosum
3v
Absent corpus callosum
3v
Par3al agenesis
3v
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
Sunday, July 28, 13
74
Normal Posterior Fossa At Midgesta=on
Axial view
SagiGal view
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Sunday, July 28, 13
Normal Posterior Fossa At Midgesta=on
Cavum Sep3 Pellucidi
Axial view
SagiGal view
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Sunday, July 28, 13
Normal Posterior Fossa At Midgesta=on
Cavum Sep3 Pellucidi
Cerebellar vermis
Axial view
SagiGal view
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Sunday, July 28, 13
Normal Posterior Fossa At Midgesta=on
Cisterna Magna
Cavum Sep3 Pellucidi
Cerebellar vermis
Axial view
SagiGal view
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Sunday, July 28, 13
Normal Posterior Fossa At Midgesta=on
Cisterna Magna
Cavum Sep3 Pellucidi
Cerebellar vermis
Tentorium
Axial view
Cisterna Magna
SagiGal view
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Sunday, July 28, 13
Normal Posterior Fossa At Midgesta=on
Cisterna Magna
Cavum Sep3 Pellucidi
Cerebellar vermis
Tentorium
Axial view
Cisterna Magna
SagiGal view
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Sunday, July 28, 13
Normal Posterior Fossa At Midgesta=on
Cisterna Magna
Cavum Sep3 Pellucidi
Cerebellar vermis
Tentorium
Axial view
Cisterna Magna
SagiGal view
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Sunday, July 28, 13
Normal Posterior Fossa At Midgesta=on
Cisterna Magna
Cavum Sep3 Pellucidi
Cerebellar vermis
Tentorium
Axial view
Cisterna Magna
SagiGal view
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Sunday, July 28, 13
Applica=on of 3 D Imaging in Prenatal diagnosis of Fetal Posterior Fossa Fluid Collec=on
76
Sunday, July 28, 13
Prenatal diagnosis and outcome of fetal posterior fossa fluid Collec=ons
Gandolfi Colleoni et al., UOG 2012
Brainstem–vermis and brainstem–tentorium angles allow accurate
categorization of fetal upward rotation of cerebellar vermis
P. VOLPE*, et al
Ultrasound Obstet Gynecol 2012; 39: 632–635
77
Sunday, July 28, 13
Categoriza3on of posterior fossa fluid collec3ons (1)
Sunday, July 28, 13
Categoriza3on of posterior fossa fluid collec3ons (1)
Findings
Blake’s pouch cyst
Megacisterna magna
Upward rotation of an intact vermis with normal torcular
Cisterna magna >10mm with intact and normally positioned cerebellum
SagiGal
Axial
Sunday, July 28, 13
D-­‐W Upward rotation of the vermis (normal or hypoplastic) with
elevated torcular
Axial View
• Transverse
Diameter Of
The Cerebellum.
• The Intactness And Size
Of The Vermis.
• The Depth Of The
Cisterna Magna (10 Mm)
Sunday, July 28, 13
79
Cavum Sep3 Pellucidi
The Tentorium: Level The Vermis: Shape, Size, Fissures
Figure 1 Measurement of brainstem–vermis (BV) and brainstem–tento
80
thisJulycase
Sunday,
28, 13 after acquisition of an ultrasound volume starting from an axi
Cavum Sep3 Pellucidi
Brainstem-tentorium
(BT) angle
Brainstem-vermis
Figure 1 Measurement of brainstem–vermis
(BV) and brainstem–tento
(BV) angle
81
this case after acquisition of an ultrasound volume starting from an axi
Sunday, July 28, 13
1 Measurement
of brainstem–vermis
and brainstem–tentorium
(BT) angles.
(a) A median
of the
fetalis brain
is obta
Measurement
of brainstem–vermis
(BV)(BV)
and
brainstem–tentorium
(BT) angles.
(a) A(a)
median
viewview
ofview
the
brain
(in
Figure 1 Measurement
of brainstem–vermis
(BV)
and brainstem–tentorium
(BT) angles.
A median
of fetal
the fetal
brainobtained
is obtained
eter
after
acquisition
of
an
ultrasound
volume
starting
from
an
axial
view)
and
the
main
anatomic
landmarks
are
identified.
(b)
acquisition
of an ultrasound
volume volume
startingstarting
from an
axial
and the
anatomic
landmarks
are are
identified.
(b)(b)
A line
this case
after acquisition
of an ultrasound
from
anview)
axial view)
andmain
the main
anatomic
landmarks
identified.
A lini
angentially
to the
aspect
ofbrain
the
brain
stem
is
drawn
tangentially
to
ventral
contour
ofcerebellar
the cerebe
gentially
to the
dorsal
aspect
ofaspect
the
stem
and
aand
second
line isline
drawn
tangentially
to the
contour
of the
cerebellar
drawn
tangentially
todorsal
the
dorsal
of the
brain
stem
anda asecond
second
line
is drawn
tangentially
toventral
thethe
ventral
contour
of the
the
interposed
angle
is(1)
theisangle;
BV
angle;
theangle
BTBT
angle
between
the
first
line
and
aline
third
line
tangential
totentoriu
the te
interposed
angle
(1) angle
is(1)
the
BV
the
BT
(2)
is (2)
measured
between
the first
line
and
aand
third
tangential
to the
tentorium
vermis;
the interposed
the BV
angle;
the
angle
(2)isismeasured
measured
between
the
first
line
a third
line
tangential
to the
Measurement Of Brainstem–vermis (BV) Angle (1) And
Brainstem–tentorium (BT) In Three Conditions
Blake’s Pouch
Cyst
Cerebellar Vermis
Hypoplasi
Dandy–Walker
Malformation.
The Angles Has The Widest Measurement In DA
Malformation
82
Figure
2 Measurement
Sunday,
July 28, 13 of brainstem–vermis (BV) angle (1) and brainstem–tentorium (BT) angle (2) in fetuses with: (a) Blake’s pouch cys
Blake’s pouch
cyst
Dandy–Walker
malformation
Vermian hypoplasia
Dandy–Walker malformation
1212
7
12
23.0
63.5
34.9
63.5
Brainstem–vermis Angle
2.8
17.6
5.4
17.6
60
40
20
0
0
7.0
15.1
32–52
15.1
51–1
45–66
51–112
Brainstem– Tentorium Angle
Normal
Normal
Blake’s pouch Vermian Dandy–Walker
cyst
hypoplasia malformation
Blake’s pouch Vermian Dandy–Walker
hypoplasia
malformation
Figure 3 Box-and-whiskercyst
plot of distribution
of brainstem–vermis
angle in controls and in fetuses with upward rotation of the
vermis. Medians
by a of
linebrainstem–vermis
inside each box,
Figure 3cerebellar
Box-and-whisker
plot are
of indicated
distribution
th and 75th percentiles by box limits and 5th and 95th percentiles
25
angle in controls and in fetuses with upward rotation of the
by lower and upper bars, respectively.
Brainstem–tentorium angle (°)
Brainstem–tentorium angle (°)
Brainstem–vermis angle (°)
Brainstem–vermis angle (°)
20
67.2 7.1
80
80
40
42.2
52.1
67.2
80
80
60
19–26
45–112
24–40
45–112
60 60
40
40
20
20 Normal
Blake’s pouch
cyst
Normal
Vermian Dandy–Walker
hypoplasia malformation
Blake’s pouch
Vermian
Dandy–Walk
cyst
hypoplasia malformatio
Figure 4 Box-and-whisker plot of distribution
of brainstem–
tentorium angle in controls and in fetuses with upward rotation of
the cerebellar vermis. Medians are indicated by a line inside each
Figure 4 Box-and-whisker plot of distribution of brainstem–
box, 25th and 75th percentiles by box limits and 5th and 95th
tentorium
angle
inupper
controls
in fetuses with upward rotation o
percentiles
by lower
and
bars,and
respectively.
Box-and-whisker plot of distribution of
Box-and-whisker
of
cerebellar
vermis. Medians are plot
indicatedof
by a distribution
line inside each box,
th
th
th
th
25 and 75 percentiles by box limits and 5 and 95 percentiles
tentorium
angle
in controls
andinside
in each
cerebellar vermis.
Medians
are indicated
by a line
brainstem–vermis
angle in controls and in thebrainstem–
by lowerhad
andaupper
bars, <
respectively.
th
th
th
BV angle
18◦ and a BT angle < 45◦ . The BV
25 and
75 upward
percentilesrotation
by box limits
andcerebellar
5 and 95th
box,
fetuses
with
of
the
fetuses
upward increased
rotationinofeach
theofcerebellar
Table
2 Statistical
brainstem–vermis
(BV) and
angle with
was significantly
the three
percentiles
bycomparison
lower andofupper
bars, respectively.
brainstem–tentorium
(BT)
angles
in
controls
and
in
fetuses
with
subgroups of anomalies (Figure 3, Table 2), the angle
vermis.
Medians
arevermis
indicated by a line
inside
vermis.
Medians
inside
◦ are indicated by a line
◦
upward
rotation
of
the
cerebellar
had a increasing
BV anglewith
< 18
and aseverity
BT angle
45 . TheThe
BV
increasing
of the<condition.
each
box, 25thcomparison
and 75th percentiles
by box limits
2 Statistical
of brainstem–vermis
(BV) and
th percentiles
BT box,
angle
demonstrated
a75
similar
pattern,
angle
was
significantly
increased
in
each but
of there
the
three
each
25th and
by was
box Table
P (Mann–Whitney
U-test)
brainstem–tentorium
(BT)
angles
in
controls
and
in
fetuses
with
more overlapping
among
groups3,
(Figure
4, 2),
Table
2). angle
subgroups
of anomalies
(Figure
Table
the
th
th
and
5
and
95
percentiles
by
lower
and
upper
upward*rotation of the cerebellar
vermis
limits and 5th and 95th percentiles by lower Comparison
BV angle
BT angle
increasing with increasing severity of the condition. The
BT and
angle
a similar pattern, but there was
Dupper
I Sdemonstrated
C U S Sbars,
I O N respectively.
more overlapping among groups (Figure 4, Table 2).
Our results suggest that measurement of the BV angle
discriminates
Sunday,
July 28, 13 accurately posterior fossa fluid collections
bars, respectively.
Controls vs Blake’s pouch cyst
fetuses
Controls
vs Dandy–Walker
Comparison
*
fetuses
< 0.00000005
< 0.000005
P (Mann–Whitney
U-test)
< 0.00000005
0.00000005
BV <
angle
BT angle
Conclusion
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
84
Sunday, July 28, 13
In Summary
85
Sunday, July 28, 13
Examination Of The Posterior Fossa And
The Cerebellum
Axial View
Midsagittal Views
86
Sunday, July 28, 13
Prac3cal Approach to the DD of Posterior Fossa Cyst and Cys3c like Lesions
Sunday, July 28, 13
Prac3cal Approach to the DD of Posterior Fossa Cyst and Cys3c like Lesions
1. Is the Vermis Present?Is the Vermis intact?
Sunday, July 28, 13
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)?
Sunday, July 28, 13
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?
Sunday, July 28, 13
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
Sunday, July 28, 13
Blacke’s Pouch Cyst
Cystegacisterna Magna
Ultrasound Obstet Gynecol 2012; 39: 625–631
Published online 14 May 2012 in Wiley Online Library (wileyonlinelibrary.com). DOI: 10.1002/uog.11071
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* and P. VOLPE†
Vermian Hypoplasia
D-­‐W Malforma3on
*Department of Obstetrics and Gynecology, University of Bologna, Bologna, Italy; †Fetal Medicine Unit, Di Venere and Sarcone Hospitals,
ASL Bari, Bari, Italy; ‡Department of Obstetrics and Gynecology, University of Bari, Bari, Italy
K E Y W O R D S: cerebellar anomalies; Dandy–Walker malformation; fetus; megacisterna magna; prenatal diagnosis; ultrasound
ABSTRACT
Cerebellar ypoplasia
Objective To H
evaluate
the accuracy
of fetal imaging
in differentiating between diagnoses involving posterior
fossa fluid collections and to investigate the postnatal
outcome of affected infants.
Methods This was a retrospective study of fetuses with
posterior fossa fluid collections, carried out between 2001
and 2010 in two referral centers for prenatal diagnosis. All
fetuses underwent multiplanar neurosonography. Parents
were also offered fetal magnetic resonance imaging (MRI)
and karyotyping. Prenatal diagnosis was compared with
autopsy or postnatal MRI findings and detailed follow-up
was attempted by consultation of medical records and
interview with parents and pediatricians.
fluid collections from mid gestation. Blake’s pouch cyst
and megacisterna magna are risk factors for associated
anomalies but when isolated have an excellent prognosis,
with a high probability of intrauterine resolution and
normal intellectual development in almost all cases.
Conversely, Dandy–Walker malformation and vermian
hypoplasia, even when they appear isolated antenatally,
are associated with an abnormal outcome in half of cases.
Copyright  2012 ISUOG. Published by John Wiley &
Sons, Ltd.
Arachinoid Cyst-­‐Pos Fossa INTRODUCTION
88
Fluid collections in the fetal posterior fossa encompass
wideBlake’s
spectrum
of cyst;
different
ranging
from(e,f) vermian
Figure 1 Categorization of posterior fossa fluid collections on ultrasound:a (a,b)
pouch
(c,d) entities,
megacisterna
magna;
1
Sunday, July
28,
13 During themalformation;
normal
variants tocyst
severe
anomalies
hypoplasia;
(g,h)
Dandy–Walker
(i,j)fetuses
cerebellar
(k,l) arachnoid
of the
posterior. They
fossa.may have
Results
study period, 105
were hypoplasia;
exam-
Normal
Megacisterna magna
Blake’s pouch cyst
tentorium
Vermian hypoplasia
Dandy-­‐Walker malforma3on
Originally published in Ultrasound Obstet Gynecol 2007; 30: 233–245
Sunday, July 28, 13
89
Take Home Message
Standard and Fetal Neurosonography
90
Sunday, July 28, 13
91
Sunday, July 28, 13
✦ examina3on of the Fetal CNS should be follow a Standard Protocol
91
Sunday, July 28, 13
✦ examina3on of the Fetal CNS should be follow a Standard Protocol
✦ Examina3on should include at least three axial planes.
91
Sunday, July 28, 13
✦ 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
Sunday, July 28, 13
✦ 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
Sunday, July 28, 13
✦ 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
91
Sunday, July 28, 13
Thanks 92
Sunday, July 28, 13
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