Fetal MRI. Page 1 of 69

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1 Fetal MRI Poster No.: C-0878 Congress: ECR 2015 Type: Educational Exhibit Authors: Y. Kocaba# Köksel, M. A. Oztek, C. Y. Sanhal, S. Toru, #. Mendilcio#lu, M. #im#ek, K. Karaali; Antalya/TR Keywords: Obstetrics, Diagnostic procedure, MR, Obstetrics (Pregnancy / birth / postnatal period) DOI: /ecr2015/C-0878 Any information contained in this pdf file is automatically generated from digital material submitted to EPOS by third parties in the form of scientific presentations. References to any names, marks, products, or services of third parties or hypertext links to thirdparty sites or information are provided solely as a convenience to you and do not in any way constitute or imply ECR's endorsement, sponsorship or recommendation of the third party, information, product or service. ECR is not responsible for the content of these pages and does not make any representations regarding the content or accuracy of material in this file. As per copyright regulations, any unauthorised use of the material or parts thereof as well as commercial reproduction or multiple distribution by any traditional or electronically based reproduction/publication method ist strictly prohibited. You agree to defend, indemnify, and hold ECR harmless from and against any and all claims, damages, costs, and expenses, including attorneys' fees, arising from or related to your use of these pages. Please note: Links to movies, ppt slideshows and any other multimedia files are not available in the pdf version of presentations. Page 1 of 69

2 Learning objectives # In this study, we aimed to present MRI findings of some fetal pathologies. Background # Ultrasound imaging of the fetus has remained the mainstay of prenatal screening and diagnosis, and it will continue to be the first-line modality owing to its lower cost, wide availability, and convenience. However it has some limitations such as small imaging area, low soft tissue contrast,low quality imaging in oligohydroamniosis and limitations secondary to calvarial calcifications after 33 weeks of pregnancy. # MRI, on the other hand, provides excellent soft tissue contrast, a large field of view, and relative operator independence. Fetal MRI may be needed if the US examination is inadequate due to technical reasons, when anomaly is detected in prenatal screening and further investigation is required, and in cases where there is an increased risk of fetal abnormalities. The majority of previous reports were concerned with fetal central nervous system (CNS) and chest disorders. MR imaging can also demonstrate non-cns fetal anatomy and pathologic conditions clearly. In this study, we aimed to present some MRI findings of fetal pathologies. Fetal magnetic resonance images of our department were reviewed. Fetal MRI of patients with confirmed pathological or clinical diagnosis were included in the study. Findings and procedure details Case 1: Corpus Callosum Agenesis and Colpocephaly (Figures 1-4) Page 2 of 69

3 Fig. 1: Case 1. Colpocephaly and corpus callosum agenesis. References: - Antalya/TR Page 3 of 69

4 Fig. 2: Case 1. Colpocephaly and corpus callosum agenesis. References: - Antalya/TR Page 4 of 69

5 Fig. 3: Case 1. Colpocephaly and corpus callosum agenesis. Red arrows show colpocephaly. References: - Antalya/TR Page 5 of 69

6 Fig. 4: Case 1. Colpocephaly and corpus callosum agenesis. Red arrow shows corpus callosum agenesis. References: - Antalya/TR Case 2: Intracranial Hemorrhage (Figures 5,6) # A premature baby born in 28th gestational week has prenatal intracranial hemorrhage visible as hyperintensity in the left lateral ventricle and caudothalamic sulcus. The baby died one month after birth. Page 6 of 69

7 Fig. 5: Case 2. Prenatal intracranial hemorrhage. Arrow shows hyperintense, hemorrhage in the caudotalamic sulcus. References: - Antalya/TR Page 7 of 69

8 Fig. 6: Case 2. Prenatal intracranial hemorrhage. Arrow shows hyperintense, hemorrhage in the left lateral ventricle. References: - Antalya/TR Case 3: Dolichocephaly (Figure 7) # Dolichocephaly (also called scaphocephaly) is growth of the head in the anteroposterior direction due to premature closure of the sagittal suture. Page 8 of 69

9 Fig. 7: Case 3. Dolicocephaly. References: - Antalya/TR Case 4: Lissencephaly (Figures 8-10) # Lissencephaly is characterised by congenital cortical malformations presenting as minimal to no sulcation of the brain. This case had a prenatal diagnosis of lissencephaly, and after 4 years of follow-up, was stil unable to walk or speak. Page 9 of 69

10 Fig. 8: Case 4. Coronal image shows lissencephaly. References: - Antalya/TR Page 10 of 69

11 Fig. 9: Case 4. Transverse image shows lissencephaly. References: - Antalya/TR Page 11 of 69

12 Fig. 10: Case 4. Sagittal image shows lissencephaly. References: - Antalya/TR Page 12 of 69

13 Case 5: Iniencephaly (Figure 11) Iniencephaly is a rare neural tube defect characterised by occipital bone defect, total or partial absence of cerviocthoracic vertebrae and fetal head fixed in retroflexion. Fig. 11: Case 5. Iniencephaly. References: - Antalya/TR Page 13 of 69

14 Case 6: Sintelencephaly (Figures 12,13) Sintencephaly (also known as middle interhemispheric variants) is characterised by an abnormal midline connection of the cerebral hemispheres between the posterior frontal and parietal regions. Our case has fusion in posterior part of the frontal lobes and an absent interventricular septum. Fig. 12: Case 6. Sintelencepahly. Red arrow in the transverse image shows fusion in posterior part of frontal lobes. References: - Antalya/TR Page 14 of 69

15 Fig. 13: Case 6. Sintelencephaly. Red arrow in the transeverse image demonstrates absence of interventricular septum References: - Antalya/TR Case 7: Dandy-Walker Variant (Figures 14,15) # The MRI of this case cerebellar hemispheres and vermis were not clearly observed and the case was suggested to be Dandy-Walker variant. The pregnancy terminated on 22nd gestational week. Page 15 of 69

16 Fig. 14: Case 7. Dandy-Walker variant. References: - Antalya/TR Page 16 of 69

17 Fig. 15: Case 7. Dandy-Walker variant. Page 17 of 69

18 References: - Antalya/TR Case 8: Congenital Diaphragmatic Hernia (Figure 16) # Congenital diaphragmatic hernia (CDH) is a congenital malformation of the diaphragm, usually occurs posterolaterally on the left (in which case it is called Bochdalek hernia). Presence of liver herniation and the size of the hernia are associated with the degree of pulmonary hypoplasia, thus these factors are important for fetal prognosis. # Our case was a term baby girl with a prenatal diagnosis of CDH who died 3 days after birth. # MR imaging revealed stomach and intestinal loops in the left hemithorax with the heart pushed to the right. Page 18 of 69

19 Fig. 16: Case 8. Congenital Diaphragmatic Hernia (CDH). MR image shows stomach and intestinal loops in the left hemithorax (arrows), with the heart pushed right. References: - Antalya/TR Case 9: Congenital Pulmonary Airway Malformation (CPAM) (Figures 17-20) # CPAM was until recently called described as Congenital Cystic Adenomatoid Malformation (CCAM). It is a multi-cystic mass of segmental lung tissue with abnormal Page 19 of 69

20 bronchial proliferation, accounting for approximately 25% of congenital lung lesions. Its estimated incidence is approximately 1: live births with a male predominance # Our case is a 20 year-old, in her 24th week of pregnancy. During prenatal screening a thoracic cystic mass was detected. # Fetal MRI showed a ~2.5x2 cm, cystic mass (hyperintense on T2-weighted sequences) located at medial part of left lower lobe. # Cystic mass was excised totally by video thoracoscopic surgery. Histopathology was reported as 'Congenital Cystic Adenomatoid Malformation Type II' Page 20 of 69

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22 Fig. 17: Case 9. Congenital Pulmonary Airway Malformation (CPAM). Fetal MRI shows a cystic mass (hyperintense on T2-weighted sequences) located at medial part of left lower lobe (arrow). References: - Antalya/TR Page 22 of 69

23 Fig. 18: Case 9. Congenital Pulmonary Airway Malformation (CPAM). Fetal MRI shows a cystic mass (hyperintense on T2-weighted sequences) located at medial part of left lower lobe (arrow). References: - Antalya/TR Fig. 19: Case 9. Congenital Pulmonary Airway Malformation (CPAM). Postnatal thoracic MRI shows a cystic mass located at medial part of left lower lobe (arrow). References: - Antalya/TR Page 23 of 69

24 Fig. 20: Case 9. Congenital Pulmonary Airway Malformation (CPAM). Postnatal thoracic MRI shows a cystic mass located at medial part of left lower lobe (arrow). References: - Antalya/TR Case 10: Lymphangioma (Figures 21,22) # Cystic lesion was detected at prenatal screening and the patient was directed to our radiology department at 24th week of pregnancy. # In Fetal MRI, a cystic lesion extending from the anterior part of face (starting from the orbital level) passing through the both side of the neck, to the anterior chest wall was demonstrated. Pathology has been reported as 'lymphangioma'. Page 24 of 69

25 Fig. 21: Case 10. Lymphangioma. Cystic lesion (arrow) extends from the anterior part of face, starting from the orbital level, passing through the both side of the neck, to the anterior chest wall. References: - Antalya/TR Page 25 of 69

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27 Fig. 22: Case 10. Lymphangioma. Cystic lesion (arrow) extends from the anterior part of face, starting from the orbital level, passing through the both side of the neck, to the anterior chest wall. References: - Antalya/TR Case 11: Lymphangioma (Figure 23) # An intra-abdominal cystic lesions wass detected at prenatal screening. # Fetal MRI showed an ~7cm in diameter cystic lesion under the liver that pushes right kidney medially. Its histopathology has been reported as 'Cystic Lymphangioma' Page 27 of 69

28 Fig. 23: Case 11. Lymphangioma. MRI shows a cystic lesion (arrow) under the liver that pushes right kidney medially. References: - Antalya/TR Page 28 of 69

29 Case 12: Hemangioma? or Lymphangioma? (Figures 24,25) # Fetal MRI showed a subcutaneous cystic lesion ~7x5,5x2 cm in size, that extends from the right thoracoabdominal junction to sacral region. # Patient is being follow-up since 2 years. Lesion size is currently ~5 cm. No intervention has been planned. Page 29 of 69

30 Fig. 24: Case 12. Hemangioma? Lymphangioma? Arrow shows a cystic lesion (~7x5,5x2 cm) that extends from the right thoracoabdominal junction to sacral region. References: - Antalya/TR Fig. 25: Case 12. Hemangioma? Lymphangioma? Arrow shows a cystic lesion (~7x5,5x2 cm) that extends from the right thoracoabdominal junction to sacral region. References: - Antalya/TR Case 13: Sacrococcygeal Teratoma (Figure 26) Page 30 of 69

31 # Sacrococcygeal teratoma is the most common neoplasm in fetus. Its incidence is estimated at ~1: # In Fetal MRI of our patient, a heterogeneous mass that has fatty intensity fields, protruding from the sacrum is seen # After termination of the pregnancy, pathology has been reported as 'sacrococcygeal teratoma' Fig. 26: Case 13. Sacrococcygeal teratoma. MRI shows a heterogeneous mass (arrows) that has fatty intensity fields, protruded from the sacrum. References: - Antalya/TR Case 14: Posterior Urethral Valve (Figures 27,28) Page 31 of 69

32 # In our case, grade III-IV pelvicalyceal dilatation is observed in both kidneys. The bladder is distended and extends up to the bladder subdiaphragmatic level Fig. 27: Case 14. Posterior urethral valve. MRI shows bilateral grade III-IV pelvycalyceal dilation (arrows). References: - Antalya/TR Page 32 of 69

33 Fig. 28: Case 14. Posterior urethral valve. Bladder is distended (arrow) and extends up to the subdiaphragmatic level. References: - Antalya/TR Cases 15-16: 2. Exitus Fetus (Figures 29-31) # In the first case (Figure 29), one of the fetuses is macerated (dead). In the second case (Figures 30,31), fetus at the top is dead, and has sever subcutaneous and intracranial edema. Page 33 of 69

34 Fig. 29: Case 15. Exitus fetus. MRI shows that one of the fetuses is macerated (dead). References: - Antalya/TR Page 34 of 69

35 Fig. 30: Case 16. Exitus fetus. Fetus at the top (dead) has severe subcutaneous and intracranial edema. References: - Antalya/TR Page 35 of 69

36 Fig. 31: Case 16. Exitus fetus. Fetus at the top (dead) has severe subcutaneous and intracranial edema. References: - Antalya/TR Images for this section: Page 36 of 69

37 Fig. 1: Case 1. Colpocephaly and corpus callosum agenesis. Page 37 of 69

38 Fig. 2: Case 1. Colpocephaly and corpus callosum agenesis. Page 38 of 69

39 Fig. 3: Case 1. Colpocephaly and corpus callosum agenesis. Red arrows show colpocephaly. Page 39 of 69

40 Fig. 4: Case 1. Colpocephaly and corpus callosum agenesis. Red arrow shows corpus callosum agenesis. Page 40 of 69

41 Fig. 5: Case 2. Prenatal intracranial hemorrhage. Arrow shows hyperintense, hemorrhage in the caudotalamic sulcus. Page 41 of 69

42 Fig. 6: Case 2. Prenatal intracranial hemorrhage. Arrow shows hyperintense, hemorrhage in the left lateral ventricle. Page 42 of 69

43 Fig. 7: Case 3. Dolicocephaly. Page 43 of 69

44 Fig. 8: Case 4. Coronal image shows lissencephaly. Page 44 of 69

45 Fig. 9: Case 4. Transverse image shows lissencephaly. Page 45 of 69

46 Fig. 10: Case 4. Sagittal image shows lissencephaly. Page 46 of 69

47 Fig. 11: Case 5. Iniencephaly. Page 47 of 69

48 Fig. 12: Case 6. Sintelencepahly. Red arrow in the transverse image shows fusion in posterior part of frontal lobes. Page 48 of 69

49 Fig. 13: Case 6. Sintelencephaly. Red arrow in the transeverse image demonstrates absence of interventricular septum Page 49 of 69

50 Fig. 14: Case 7. Dandy-Walker variant. Page 50 of 69

51 Fig. 15: Case 7. Dandy-Walker variant. Page 51 of 69

52 Fig. 16: Case 8. Congenital Diaphragmatic Hernia (CDH). MR image shows stomach and intestinal loops in the left hemithorax (arrows), with the heart pushed right. Page 52 of 69

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54 Fig. 17: Case 9. Congenital Pulmonary Airway Malformation (CPAM). Fetal MRI shows a cystic mass (hyperintense on T2-weighted sequences) located at medial part of left lower lobe (arrow). Page 54 of 69

55 Fig. 18: Case 9. Congenital Pulmonary Airway Malformation (CPAM). Fetal MRI shows a cystic mass (hyperintense on T2-weighted sequences) located at medial part of left lower lobe (arrow). Fig. 19: Case 9. Congenital Pulmonary Airway Malformation (CPAM). Postnatal thoracic MRI shows a cystic mass located at medial part of left lower lobe (arrow). Page 55 of 69

56 Fig. 20: Case 9. Congenital Pulmonary Airway Malformation (CPAM). Postnatal thoracic MRI shows a cystic mass located at medial part of left lower lobe (arrow). Page 56 of 69

57 Fig. 21: Case 10. Lymphangioma. Cystic lesion (arrow) extends from the anterior part of face, starting from the orbital level, passing through the both side of the neck, to the anterior chest wall. Page 57 of 69

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59 Fig. 22: Case 10. Lymphangioma. Cystic lesion (arrow) extends from the anterior part of face, starting from the orbital level, passing through the both side of the neck, to the anterior chest wall. Page 59 of 69

60 Fig. 23: Case 11. Lymphangioma. MRI shows a cystic lesion (arrow) under the liver that pushes right kidney medially. Fig. 24: Case 12. Hemangioma? Lymphangioma? Arrow shows a cystic lesion (~7x5,5x2 cm) that extends from the right thoracoabdominal junction to sacral region. Page 60 of 69

61 Fig. 25: Case 12. Hemangioma? Lymphangioma? Arrow shows a cystic lesion (~7x5,5x2 cm) that extends from the right thoracoabdominal junction to sacral region. Page 61 of 69

62 Fig. 26: Case 13. Sacrococcygeal teratoma. MRI shows a heterogeneous mass (arrows) that has fatty intensity fields, protruded from the sacrum. Page 62 of 69

63 Fig. 27: Case 14. Posterior urethral valve. MRI shows bilateral grade III-IV pelvycalyceal dilation (arrows). Page 63 of 69

64 Fig. 28: Case 14. Posterior urethral valve. Bladder is distended (arrow) and extends up to the subdiaphragmatic level. Page 64 of 69

65 Fig. 29: Case 15. Exitus fetus. MRI shows that one of the fetuses is macerated (dead). Page 65 of 69

66 Fig. 30: Case 16. Exitus fetus. Fetus at the top (dead) has severe subcutaneous and intracranial edema. Page 66 of 69

67 Fig. 31: Case 16. Exitus fetus. Fetus at the top (dead) has severe subcutaneous and intracranial edema. Page 67 of 69

68 Conclusion Due to its superior soft tissue contrast, large field of vision and being operator independent, fetal MRI is an important imaging modality that may affect perinatal management. It is especially used for pathologies involving the central nervous system, but is capable of demonstrating pathologies in other systems as well. Personal information References Coakley FV, Glenn OA, Qayyum A, Barkovich AJ, Goldstein R, Filly RA. Fetal MRI: a developing technique for the developing patient. AJR Am J Roentgenol Jan;182(1): Shinmoto H1, Kuribayashi S. MRI of fetal abdominal abnormalities. Abdom Imaging Nov-Dec;28(6): Reddy UM, Abuhamad AZ, Levine D, Saade GR; Fetal Imaging Workshop Invited Participants. Fetal imaging: Executive summary of a Joint Eunice Kennedy Shriver National Institute of Child Health and Human Development, Society for MaternalFetal Medicine, American Institute of Ultrasound in Medicine, American College of Obstetricians and Gynecologists, American College of Radiology, Society for Pediatric Radiology, and Society of Radiologists in Ultrasound Fetal Imaging Workshop.Am J Obstet j.ajog Gynecol May;210(5): doi: / Prayer D, Brugger PC, Prayer L. Fetal MRI: techniques and protocols. Pediatr Radiol Sep;34(9): Epub 2004 Jul 28. Shinmoto H, Kashima K, Yuasa Y, Tanimoto A, Morikawa Y, Ishimoto H, Yoshimura Y, Hiramatsu K. MR imaging of non-cns fetal abnormalities: a pictorial essay. Radiographics Sep-Oct;20(5): Page 68 of 69

69 Plunk MR, Chapman T. The fundamentals of fetal MR imaging: Part 1. Curr Probl Diagn Radiol Nov-Dec;43(6): doi: /j.cpradiol Epub 2014 Jul 22. Plunk MR, Chapman T. The fundamentals of fetal magnetic resonance imaging: Part 2. Curr Probl Diagn Radiol Nov-Dec;43(6): doi: / j.cpradiol Epub 2014 Jun 25. Cho JY, Lee YH. Fetal tumors: prenatal ultrasonographic findings and clinical characteristics. Ultrasonography Oct;33(4): doi: /usg Epub 2014 Jun 20. Page 69 of 69