Eva I. Rubio

Prenatal MRI Findings of Fetuses with Congenital High Airway Obstruction Sequence

Objective To define the MRI findings of congenital high airway obstruction sequence (CHAOS) in a series of fetuses. Materials and Methods Prenatal fetal MR images were reviewed in seven fetuses with CHAOS at 21 to 27 weeks of gestation. The MRI findings were reviewed. The MRI parameters evaluated included the appearance of the lungs and diaphragm, presence or absence of hydrops, amount of amniotic fluid, airway appearance, predicted level of airway obstruction, and any additional findings or suspected genetic syndromes. Results All the fetuses viewed (7 of 7) demonstrated the following MRI findings: dilated airway below the level of obstruction, increased lung signal, markedly increased lung volumes with flattened or inverted hemidiaphragms, massive ascites, centrally positioned and compressed heart, as well as placentomegaly. Other frequent findings were anasarca (6 of 7) and polyhydramnios (3 of 7). MRI identified the level of obstruction as laryngeal in five cases and tracheal in two cases. In four of the patients, surgery or autopsy confirmed the MRI predicted level of obstruction. Associated abnormalities were found in 4 of 7 (genetic syndromes in 2). Postnatal radiography (n = 3) showed markedly hyperinflated lungs with inverted or flattened hemidiaphragms, strandy perihilar opacities, pneumothoraces and tracheotomy. Two fetuses were terminated and one fetus demised in utero. Four fetuses were delivered via ex utero intrapartum treatment procedure. Conclusion MRI shows a consistent pattern of abnormalities in fetuses with CHAOS, accurately identifies the level of airway obstruction, and helps differentiate from other lung abnormalities such as bilateral congenital pulmonary airway malformation by demonstrating an abnormally dilated airway distal to the obstruction.

Congenital lung lesions: prenatal MRI and postnatal findings

BackgroundCongenital lung lesions refer to a spectrum of malformations and developmental abnormalities of the foregut, pulmonary airways and vasculature. These lesions range from small, asymptomatic to large space-occupying masses that can increase risk of fetal death and respiratory compromise after birth. Prenatal sonography has been used for routine screening in pregnancy. The advent of prenatal magnetic resonance imaging leads to complementary use in the diagnosis of fetal anomalies, including in fetuses with congenital lung lesions.ObjectiveTo determine whether fetal MRI can differentiate congenital lung lesions by comparing prenatal diagnosis with postnatal imaging and pathology.Materials and methodsIn a 4-year period, 76 fetuses with suspected lung lesions were referred for fetal MRI. We retrospectively reviewed the MR exams and assigned a specific diagnosis based on predetermined criteria. We then compared the prenatal diagnosis to postnatal imaging and pathology.ResultsOf 76 cases, 7 were excluded because of an alternative diagnosis. Of the 69 remaining patients, 3 died and 13 were lost to follow-up. Among the 53 patients, there were 56 lung lesions. Four of these lesions were difficult to diagnose because of size and location. Based on imaging records we gave the remaining 52 lesions a specific prenatal diagnosis: 28 congenital pulmonary airway malformations (CPAM), 4 bronchopulmonary sequestrations (BPS), 9 cases of overinflation, 9 hybrid lesions and 2 bronchogenic cysts. The prenatal diagnosis was concordant with postnatal evaluation in 51 of the 52 lung lesions. One fetus given the diagnosis of CPAM prenatally was diagnosed with a hybrid lesion postnatally.ConclusionPrenatal MRI is highly accurate in defining congenital lung anomalies. When fetal MRI findings suggest a specific diagnosis, postnatal findings confirmed the prenatal MRI diagnosis in 98% of cases.

Late gestation fetal magnetic resonance imaging–derived total lung volume predicts postnatal survival and need for extracorporeal membrane oxygenation support in isolated congenital diaphragmatic hernia

PURPOSE Magnetic resonance imaging (MRI) has been used as an imaging modality to assess pulmonary hypoplasia in congenital diaphragmatic hernias (CDHs). The objective of this study was to determine if there is a correlation between late gestational fetal MRI-derived total lung volumes (TLVs) and CDH outcomes. METHODS From 2006 to 2009, 44 patients met criteria of an isolated CDH with a late gestational MRI evaluation. The prenatal TLV (in milliliters) was obtained between 32 and 34 weeks gestation. The measured study outcomes included survival, need for extracorporeal membrane oxygenation (ECMO), and length of stay. RESULTS There were 39 left and 5 right CDH patients. The average TLV was significantly lower for nonsurvivors (P = .01), and there was a significant association between lower TLV and the need for ECMO (P = .0001). When stratified by TLV, patients with a TLV of greater than 40 mL had a 90% survival vs 35% survival for a TLV of less than 20 mL. Furthermore, patients with a TLV greater than 40 mL had a lower rate of ECMO use (10%) than patients with a TLV of less than 20 mL (86%). Shorter length of stay was found to correlate with increasing TLV (P = .022). CONCLUSION Late gestation fetal MRI-derived TLV significantly correlates with postnatal survival and need for ECMO. Fetal MRI may be useful for the evaluation of patients who present late in gestation with a CDH.

MRI findings in multifetal pregnancies complicated by twin reversed arterial perfusion sequence (TRAP)

BackgroundTwin reversed arterial perfusion sequence (TRAP) is a rare complication in multifetal monochorionic pregnancies in which a normal “pump” twin provides circulation to an abnormal acardiac co-twin, resulting in high-output cardiac dysfunction in the pump twin.ObjectiveTo define fetal MRI findings of TRAP sequence.Materials and methodsFetal MR images were retrospectively reviewed in 35 pregnancies complicated by TRAP sequence. Abnormalities of the pump twin, acardiac twin, umbilical cord, placenta and amniotic fluid were reviewed.ResultsAcardiac twins were classified as: acephalus (51%), anceps (40%), amorphus (9%), acormus (0%). Common findings in acardiac twins include subcutaneous edema (77%), absent cardiac structures (86%), absent or abnormal thoracic cavity (100%), abnormal abdominal organs (100%), superior limbs absent (46%) or abnormal (51%), and inferior limbs present but abnormal (83%). There were pump twin findings of cardiac dysfunction in 43% and intracranial ischemic changes in 3%. Umbilical cord anomalies were present in 97%.ConclusionAcardiac twins present with a predictable pattern of malformation with poorly developed superior structures, more normally formed inferior structures and absent or rudimentary heart. Although usually absent, abnormal heart structures can be seen and do not exclude TRAP sequence. Pump twins are commonly normal with exception of findings of cardiac dysfunction and possible brain ischemia.

Ovary and Testicle and Everything in Between: Lesions and Imaging in the Newborn

Assessment of the neonatal reproductive tract requires an understanding of embryology, awareness of common clinical presentations, and familiarity with normal newborn variation. This review of the neonatal reproductive tract emphasizes the use of sonography in the evaluation of developmental, acquired, and neoplastic conditions in male and female newborns. Anchored in embryologic origins, the discussion also includes descriptions of findings that may be encountered in prenatal imaging. Comments on clinical correlation are included to guide appropriate triaging of these complex cases. Imaging pearls and pitfalls are incorporated into this review, including the recognized effects of maternal hormones in female infants.

Time-Out: It's Radiology's Turn—Incidence of Wrong-Patient or Wrong-Study Errors

OBJECTIVE The purpose of this study was to describe the utility of a two-person verification system (Rad Check) in successfully decreasing wrong-patient or wrong-study errors. MATERIALS AND METHODS In this retrospective study performed at a tertiary-care pediatric hospital, monthly radiology incident reports from January 2009 through December 2014 were reviewed for documentation of wrong-patient or wrong-study events. The date, imaging modality, nature of the event, and number of imaging studies for this time period by year were recorded and analyzed. These data were tracked before and after implementation of the two-person verification system in July 2012. RESULTS Over 72 months, 45 reported wrong-patient or wrong-study events were confirmed. The data were analyzed before and after implementation of a two-person verification system implemented in July 2012, midway through the study period. Over the first 42 months, 36 wrong-patient or wrong-study occurrences were identified, corresponding to an average of one error every 35 days, with the number of days between events ranging from 3 to 150. After implementation of the verification process, nine events were documented over 30 months, corresponding to an average of one error every 101 days, with the maximum number of days between events exceeding 410. CONCLUSION Wrong-patient or wrong-study events can be significantly reduced by utilizing a brief two-person verification approach. More robust documentation of these events is warranted so that individual institutions can assess the incidence of these events within their own department and develop tailored plans to prevent these errors.

Achondroplasia in the Premature Infant: An Elusive Diagnosis in the Neonatal Intensive Care Unit

Achondroplasia is a difficult prenatal diagnosis to make before the late second and third trimester. We describe two cases where an infant was born prematurely with no overt signs of achondroplasia. Despite multiple chest and abdominal radiographs during the neonatal course, the diagnosis was not made until term equivalent age was reached. We retrospectively reviewed these two cases to highlight the elusive findings of achondroplasia in the premature infant.

Performance Quality Improvement Projects: Suggestions for Radiologists Who Image Children

p f w b p d t p a i i All patients deserve the highest quality radiology services, but several characteristics make the goals of quality improvement (QI) critical in pediatrics. Unique vulnerabilities of children include a heightened sensitivity to doses of radiation and medication, age-related physiology, and characteristic pathologies. Although many QI projects relevant to adult imaging can be extended to pediatric imaging, beware of a broad brush. In some cases, extrapolating even simple measures to your pediatric patients, such as documenting the glomerular filtration rates of patients receiving intravenous contrast, is different in children than in adults [1,2]. As always, QI projects should be consequential to patients, address gaps in performance, be data driven, and be evidence based [3,4]. Here, we offer a “quick-start guide” for QI projects relevant to radiology practices dealing with pediatric patients.

Team counseling in prenatal evaluation: the partnership of the radiologist and genetic counselor.

Fetal medicine programs within children’s hospitals have been developed to ensure access to pediatric specialists across multiple disciplines. The cases that present to these programs are usually complex and require involvement of a multidisciplinary care team. Although some providers on the team limit their focus to their pediatric specialty when counseling patients, the radiologist and genetic counselor have a distinct perspective allowing them to take the larger picture into account in the evaluation of the fetus. As first responders, they come together to review images and identify which consultants are most appropriate to counsel the families, and they can help guide patient discussions. In this paper we demonstrate how the combined expertise of the genetic counselor and pediatric radiologist can facilitate more accurate diagnoses and guide the appropriate management of complex fetal anomalies.