A. Giancotti

Role of fetal MRI in the diagnosis of cerebral ventriculomegaly assessed by ultrasonography

PurposeTo evaluate the additional diagnostic value of fetal MRI to evaluate cerebral ventriculomegaly assessed by ultrasonography (US) for the possibility to change the diagnosis, the counseling and the management of pregnancy.Materials and MethodsFrom february 2006 to october 2008, we studied 55 pregnant women by fetal MRI (mean age 28 years), 4 with twin pregnancy, for a total of 59 fetuses with mean gestational age of 27 weeks. The number of fetuses affected by ventriculomegaly assessed by US was 55. All fetuses had a US diagnosis of ventriculomegaly: 29 fetuses with isolated ventriculomegaly and 26 fetuses with ventriculomegaly associated with CNS (central nervous system) abnormalities (18) and with no CNS abnormalities (8).ResultsThe findings showed that the two techniques are substantially in agreement in defining the degree of VM, with the exception of some cases in which the disagreement could be attributed to the possible progression of the dilatation between the US and MRI examinations, which sway between two days and two weeks. We proved a low correlation between US and MRI in the evaluation of ventriculomegaly associated either with CNS or non-CNS anomalies: in fact while fetal MRI detected 26/55 (47,3%) VM associated with CNS anomalies, US demonstrated only 18/55(32,7%). Referring to VM associated with non-CNS anomalies, MRI diagnosed 10/55 cases (18,2%) compared to 8/55 fetuses (14,5%) showed by US.ConclusionsOur experience demonstrated that fetal MRI has an important role as adjunctive tool to sonography in the evaluation of cerebral ventriculomegaly for the additional informations given to parents and for the possibility to change the diagnosis, the counseling and the management of pregnancy.RiassuntoObiettivoLo scopo del nostro studio è valutare il ruolo della risonanza magnetica nell’inquadramento diagnostico delle ventricolomegalie per le conseguenze che un cambiamento della diagnosi può avere sul counselling materno, sul management della gravidanza e sulla pianificazione di eventuali interventi pre e postnatali, nell’ottica di una gestione multidisciplinare.Materiali e metodiNel periodo compreso fra febbraio 2006 ed ottobre 2008, abbiamo sottoposto a risonanza magnetica 55 donne in stato di gravidanza (età media 28 aa), 4 delle quali con gravidanze gemellari, per un totale di 59 feti di età gestazionale con età gestazionale media di 27 settimane. Il numero di feti interessati da ventricolomegalia secondo l’indicazione ecografica era di 55. Tutti i feti avevano diagnosi ecografica di ventricolomegalia: 29 feti con ventricolomegalia isolata e 26 feti con ventricolomegalia associata; in particolare in quest’ultimo gruppo 18 feti riportavano associazioni con anomalie del SNC ed 8 feti con anomalie di altri distretti.RisultatiÈ emerso così che le due metodiche sono sostanzialmente in accordo nel definire l’entità della ventricolomegalia, fatta eccezione per alcuni casi nei quali la discordanza potrebbe attribuirsi alla possibile progressione della dilatazione nell’arco di tempo intercorso fra ecografia e risonanza magnetica, variabile fra 2 giorni e 2 settimane. Minor grado di accordo è invece emerso dal confronto rispetto alla associazione delle ventricolomegalie con ulteriori anomalie sia del SNC fetale che di altri organi e apparati. Infatti la RM ha evidenziato 26/55 (47,3%) VM associate ad anomalie del SNC, versus 18/55 (32,7%) diagnosi di associazione con ulteriori anomalie encefaliche poste con l’ecografia; quanto alle associazioni con anomalie di altri distretti la RM ne ha posto diagnosi in 10/55 casi (18,2%) e l’ecografia in 8/55 feti (14,5%).ConclusioniIn base ai nostri risultati concludiamo che qualora si riscontri una ventricolomegalia vadano sempre informati i genitori circa il rischio di ulteriori anomalie associate e di conseguenti possibili ripercussioni sullo sviluppo psicomotorio del nascituro rispetto alla popolazione normale, consigliandone l’approfondimento diagnostico con i mezzi diagnostici disponibili.

Magnetic resonance imaging versus ultrasonography in fetal pathology.

PurposeThis paper describes our experience with magnetic resonance imaging (MRI) in the assessment of fetal anatomical structures and major fetal pathologies.Materials and methodsThe retrospective study included 128 pregnant women between the 22nd and 38th week of gestation. We used the following imaging protocol: T2-weighted single-shot fast spin-echo sequences for all foetuses and, in selected cases, gradient echo with steady-state free precession (SSFP), T1-weighted spoiled gradient echo [fast low-angle shot (FLASH)] with and without fat saturation, and T2 thick-slab sequences with multiplanar technique. In 32 cases, we performed diffusion-weighted sequences with apparent diffusion coefficient (ACD) maps on the brain, the kidneys and the lungs.ResultsWe achieved diagnostic-quality images in 125 of 128 patients; MR image quality was unsatisfactory in three cases only. In 16 cases with previous negative ultrasound (US) findings, MRI confirmed the US diagnosis. MRI confirmed the positive US diagnosis in 67 of 109 cases (61.5%); in 11 cases it changed the US diagnosis, and in 31/109 the examination was negative. In addition, MRI identified other anomalies not recognised during US examination.ConclusionsWith its ultrafast sequences, fetal MRI provides good detail of normal fetal anatomy and allows characterisation of suspected anomalies.RiassuntoObiettivoPresentare la nostra esperienza con la risonanza magnetica nella valutazione delle strutture anatomiche e delle patologie principali nel feto.Materiali e metodiLo studio retrospettivo include 128 donne in gravidanza tra la 22a e la 38a settimana di gestazione. Abbiamo utilizzato il seguente protocollo: per tutti i feti sequenze T2 pesate Single Shot Fast Spin Echo e in casi selezionati sequenze Gradient Echo con tecnica steady state free precession (SSFP), sequenze spoiled gradient echo T1 pesate (Fast Low Angle Shot, FLASH) con e senza saturazione del segnale del grasso e sequenze T2 thick slab acquisite con tecnica multiplanare. In 32 casi, abbiamo effettuato sequenze pesate per diffusione con il coefficiente di diffusione apparente (ADC) su cervello, reni e polmoni.RisultatiIn 125 pazienti su 128, l’esame ha mostrato una buona qualità; solo in 3 casi le immagini RM non sono risultate soddisfacenti. Nei 16 casi già negativi all’ecografia, l’RM ha confermato il risultato ecografico. L’RM ha confermato come positive 67 diagnosi ecografiche su 109 casi (61,5%); in 11 casi, invece, l’RM ha modificato la diagnosi ecografica ed in 31 pazienti l’esame è risultato negativo. Inoltre l’RM ha consentito di riconoscere ulteriori anomalie che non sono state diagnosticate durante l’esame ecografico.ConclusioniL’RM fetale, grazie alle sequenze ultra-fast, consente di visualizzare buoni dettagli dell’anatomia fetale e di caratterizzare sospette anomalie.

Diffusion-weighted MR imaging and apparent diffusion coefficient of the normal fetal lung: preliminary experience.

To assess if a correlation is present between apparent diffusion coefficient (ADC) values and normal lung maturation during gestation to define potential reference values as indicators of the lung development.

Mean platelet volume: Association with adverse neonatal outcome

The aim of the study was to investigate on a possible association between maternal mean platelet volume (MPV) and oxygen-metabolic changes in pregnancies affected by altered maternal-fetal Doppler velocimetry. We considered the altered maternal-fetal Doppler velocimetry group (n = 57) pregnant women admitted to our Institution for a pregnancy complication associated to the event Pre-eclampsia (PE) and intrauterine growth retardation (IUGR), with altered Doppler velocimetry in the umbilical artery ( UA) (high pulsatility index, absence or reverse end diastolic flow (ARED), blood flow cephalisation) and/or bilateral increased resistance in uterine arteries. Out of these cases, 25 pregnancies were complicated by PE and 32 pregnancies were complicated by IUGR. We included 145 normotensive third trimester pregnant women as a normal maternal-fetal Doppler velocimetry control group. From all women, 20 ml of whole venous blood was obtained from the antecubital vein soon after Doppler velocimetry evaluation. MPV was significantly higher in women with abnormal Doppler velocimetry compared to those with normal Doppler velocimetry (8.0 fl [7.0–8.7] vs. 9.1 fl [8.0–10.6], <0.001. Values are median [interquartiles]). We performed a ROC curve in order to find an MPV cut-off able to predict an uneventful event in Doppler velocimetry compromised fetuses (neonatal O2 support > 48 hrs or intubation and/or pH < 7.2 at umbilical blood gas analysis (UBGA)). An MPV ≥ 10 fl was significantly related to the former diagnostic endpoints compared to that of non-compromised fetuses (sensitivity: 45%, specificity: 89.7%, 95 CI: 18.8–66, p < 0.01). Our study suggests that pregnancies affected by Doppler velocimetry alterations, an MPV value ≥ 10 fl may be associated with severe oxygen support and/or low UA ph at birth.

Efficacy of three different antithrombotic regimens on pregnancy outcome in pregnant women affected by recurrent pregnancy loss

Introduction: Recurrent pregnancy loss (RPL) is a common health problem affecting 1–5% of women at reproductive age. Aim of the study: Evaluation of three different antithrombotic treatments in women with antecedent of RPL, comparing the results in negative and positive to thrombophilic screening pregnant women. Materials and methods: We recruited 361 women with an antecedent of two or more pregnancy losses. From this group, 167 women became pregnant and considered for the study. The evaluated pregnant women were divided as negative/positive to thrombofilic screening: (a) 80 (48%) with negative thrombophilic screening, (b) 87 (52%) positive to thrombophilic screening. Pregnant women included in the study and considered negative or positive for thrombophilic screening, were randomized into three different therapy groups: (a) group 1: Acetil salicylic acid (ASA) 100 mg daily until third month of pregnancy, (b) group 2: low molecular-weight heparin (LMWH) – enoxaparine 40 mg daily until third month of pregnancy, (c) group 3: ASA 100 mg plus LMWH 40 mg daily until third month of pregnancy. Results: In 80 negative to thrombophilic screening pregnant women, the comparison of efficacy of the three treatments, shows that all three treatment regimens were significantly effective comparing live births against fetal losses. In 87 positive to thrombophilic screening pregnant women, the comparison of efficacy for the three regimens, shows that the therapy with LMWH or LMWH plus ASA are significantly protective against fetal losses with respect to ASA, which showed a high number of fetal losses (11 live births, 18 fetal losses). Comment: We suggest that thromboprophylaxis is indicated in women with RPL independently from positiveness to thrombophilic markers.

Fetal MRI with diffusion-weighted imaging (DWI) and apparent diffusion coefficient (ADC) assessment in the evaluation of renal development: preliminary experience in normal kidneys

PurposeThe study aimed to investigate the correlation between apparent diffusion coefficient (ADC) and gestational age by applying diffusion-weighted imaging (DWI) in the study of normal fetal kidneys.Materials and methodsWe performed magnetic resonance (MR) imaging on 88 fetuses (gestational age range 17–40 weeks) after ultrasound had ruled out urinary system malformations. A multiplanar study of the urinary system was obtained by using conventional T2-weighted sequences and echoplanar imaging (EPI). DW sequences with ADC maps were subsequently acquired, and kidney ADC values were correlated with gestational age by diving the fetuses into six groups according to age.ResultsWe found a correlation between ADC values and gestational age. The ADC values, ranging from 0.99 to 1.62×10−3 mm2/s [mean 1.22; 95% confidence interval (CI) 1.19–1.25, standard deviation (SD) 0.147], showed a tendency to decrease with increasing gestational age. The relationship between ADC values and gestational age was expressed by a linear regression equation: ADC (mm2/s)=1.69–0.0169 (GA) (R2=37.7%, R2 ADJ=37.0%, p<0.005, Pearson correlation=−0.614).ConclusionsDWI with ADC mapping provides functional information on fetal renal parenchyma development and may thus become a useful tool in the management of pregnancy and treatment of the newborn child.RiassuntoObiettivoApplicare le sequenze pesate in diffusione (DWI) nello studio dei reni fetali, per valutare l’esistenza di una correlazione fra coefficiente di diffusione apparente (ADC) ed età gestazionale nei feti sani.Materiali e metodiAbbiamo studiato con esame RM 88 feti (età gestazionale 17–40 settimane), già valutati con esame ecografico che escludeva malformazioni del tratto urinario. L’apparato urinario fetale è stato studiato con sequenze T2 pesate ultraveloci; successivamente sono state acquisite sui reni fetali sequenze DWI (con calcolo automatico delle mappe di ADC) ed i valori di ADC messi in relazione con l’età gestazionale, suddividendo i feti in sei gruppi in base all’età gestazionale. La normale funzionalità renale è stata confermata dopo la nascita attraverso dati clinico-laboratoristici ed ecografia renale.RisultatiAbbiamo riscontrato che i valori di ADC, compresi fra 0,99 e 1,62×10−3 mm2/s (media 1,22; 95% CI 1,19–1,25; deviazione standard 0,147) tendono a decrescere con l’aumentare delle settimane di gestazione. La migliore correlazione è stata espressa dall’equazione di regressione lineare: ADC (mm2/s)=1,69–0,0169 (GA) (R2=37,7%, R2 ADJ=37,0%, p<0,005, correlazione di Pearson=–0,614). Conclusioni. Le sequenze DWI ed le mappe di ADC, fornendo informazioni funzionali sullo sviluppo del parenchima renale fetale, risultano di grande utilità soprattutto nella gestione della gravidanza e nel management post-natale.

Role of foetal MRI in the evaluation of ischaemic-haemorrhagic lesions of the foetal brain

Abstract Objective: The purpose of this study is to define the role of foetal magnetic resonance imaging (MRI) in evaluating cerebral ischaemic-haemorrhagic lesions and the extension of parenchymal injuries. Study design: From September 2006 to September 2010, 271 foetal MRI have been performed on cases referred to us for ultrasound suspect of brain abnormalities or cytomegalovirus infection and Toxoplasma serum conversion. Foetal MRI was performed with a 1.5-T magnet system without mother sedation. Results: Foetal MRI detected ischaemic-haemorrhagic lesions in 14 of 271 foetuses, consisting of 5% incidence. MRI confirmed the diagnosis in three of 14 cases with ultrasonography (US) suspect of ischaemic-haemorrhagic lesions associated with ventriculomegaly. In one of 14 cases with US findings of cerebellar haemorrhage, MRI confirmed the diagnosis and provided additional information regarding the parenchymal ischaemic injury. In eight of 14 cases with US suspect of ventriculomegaly (3), corpus callosum agenesis (2), hypoplasia of cerebellar vermis (1), holoprosencephaly (1) and spina bifida (1), MRI detected ischaemic and haemorrhagic lesions unidentified at US examination. In two of 14 foetuses with US suspect of intracerebral space-occupying lesion, MRI modified the diagnosis to extra-axial haematoma associated with dural sinus malformation. Results were compared with post-mortem findings or afterbirth imaging follow-up. Conclusions: Foetal MRI is an additional imaging modality in the diagnosis of cerebral ischemic-haemorrhagic lesions, and it is useful in providing further information on the extension of the parenchymal injury and associated abnormalities, thus improving delivery management.

Magnetic resonance imaging of fetal heart: anatomical and pathological findings.

Abstract Congenital heart disease is one of the most frequent prenatal malformation representing an incidence of 5/1000 live births; moreover, it represents the first cause of death in the first year of life. There is a wide range of severity in congenital heart malformations from lesions which require no treatment such as small ventricular septal defects, to lesions which can only be treated with palliative surgery such as hypoplastic left heart syndrome. A good prenatal examination acquires great importance in order to formulate an early diagnosis and improve pregnancy management. Nowadays, echocardiography still represents the gold standard examination for fetal heart disease. However, especially when preliminary ultrasound is inconclusive, fetal MRI is considered as a third-level imaging modality. Preliminary experiences have demonstrated the validity of this reporting a diagnostic accuracy of 79%. Our article aims to outline feasibility of fetal MRI in the anatomic evaluation, the common indication to fetal MRI, its role in the characterization of congenital heart defects, and at last its main limitations.

Dandy–Walker Malformation: is the ‘tail sign’ the key sign?

The study aims to demonstrate the value of the ‘tail sign’ in the assessment of Dandy–Walker malformation.

Fetal Abdominal Lymphangioma Enhanced by Ultrafast MRI

Abdominal lymphangioma represents an uncommon congenital anomaly. Herein, we describe an unusual case, which on routine antenatal ultrasonography masqueraded as isolated ascites. Subsequent fetal MRI at 27 weeks’ gestation implemented antenatal assessment of the lesion, prompting further investigations and straightforward postnatal treatment. Fetal MRI represents a valuable adjunct to antenatal ultrasonography for the evaluation of cystic abdominal masses.