Can Dynamic Magnetic Resonance Images Improve Prenatal Diagnosis of Robin Sequence.

BACKGROUND: Robin sequence (RS) is a triad of micrognathia, glossoptosis, and airway obstruction. Prenatal diagnosis of RS improves delivery planning and postnatal care, but the process for prenatal diagnosis has not been refined. The purpose of this study was to determine if dynamic cine magnetic resonance imaging (MRI) can improve the reliability of prenatal diagnosis for RS compared to current static imaging techniques. MATERIALS AND METHODS: This is a retrospective cross-sectional study including fetuses with prenatal MRIs obtained in a single center from January 2014 to November 2019. Fetuses were included if they: 1) had a prenatal MRI with cine dynamic sequences of adequate quality, 2) were live born, and 3) had postnatal craniofacial evaluation to confirm RS. Patients without postnatal confirmation of their prenatal findings were excluded. The primary predictor variable was imaging type (cine or static MRI). Outcome variables were tongue and airway measurements: 1) tongue height, 2) length and width, 3) tongue shape index, 4) observation of tongue touching the posterior pharyngeal wall, and 5) measurement of oropharyngeal space. All measurements were made independently on the cine images and on static MRI sequences for the same cohort of subjects by a pediatric radiologist. Data were analyzed using paired samples t tests and Fisher exact tests, and significance was set as P < .05. RESULTS: A total of 11 patients with RS were included in the study. The smallest airway space consistently demonstrated complete collapse on the cine series compared to partial collapse on static images (0 mm vs 1.7 ± 1.4 mm, P = .002). No other imaging variable was statistically significantly different between techniques. CONCLUSIONS: Cine imaging sequences on prenatal MRI were superior to static images in discerning complete collapse of the smallest airway space, an important marker of RS. This suggests a possible benefit to adding dynamic MRI evaluation for prenatal diagnosis of this condition.

A role for abdominal ultrasound in discriminating suspected necrotizing enterocolitis in congenital heart disease patients.

PURPOSE: We evaluated the diagnostic utility of abdominal ultrasound (AUS), an adjunct to abdominal X-ray (AXR), for necrotizing enterocolitis (NEC) in congenital heart disease (CHD) patients. METHODS: 86 patients with suspected NEC from 2009 to 2018 were classified as with CHD (n = 18) if they required cardiac intervention versus without CHD (n = 68). Clinical and radiological data were collected, including AXR and AUS concordance. Wilcoxon rank-sum test and Fisher's exact test were performed. RESULTS: CHD patients had higher birth weights (p < 0.001) and gestational ages (p < 0.001) than non-CHD patients. CHD patients presented more frequently with hypotension (p = 0.041) and less frequently with bilious emesis (p < 0.001). Overall, CHD patients were less likely to have AUS findings of pneumatosis (33.3 vs. 72.1%; p = 0.005) and decreased mural flow (0 vs. 20.6%; p = 0.035) compared to non-CHD patients. On concordance analysis, CHD patients had 3.9-fold more discordant studies with pneumatosis on AXR but not on AUS (33.3 vs. 8.8%; p = 0.016) compared to non-CHD patients. Urgent surgery was required in 5.6% of CHD patients versus 16.2% of non-CHD patients. CONCLUSION: CHD patients with suspected NEC represent a distinct clinical population. AUS has particular utility in assessing findings of bowel viability in the CHD NEC population, reflecting reduced rates of surgical NEC.

Abdominal ultrasound findings contribute to a multivariable predictive risk score for surgical necrotizing enterocolitis: A pilot study.

BACKGROUND: Abdominal ultrasound (AUS) is a promising adjunct to abdominal x-ray (AXR) for evaluating necrotizing enterocolitis (NEC). We developed a multivariable risk score incorporating AUS to predict surgical NEC. METHODS: 83 patients were evaluated by AXR and AUS for suspected NEC. A subset had surgical NEC. Multivariate logistic regression determined predictors of surgical NEC, which were incorporated into a risk score. RESULTS: 14/83 patients (16.9%) had surgical NEC. 10/83 (12.0%) patients required acute intervention, while 4/83 (4.8%) patients only required delayed surgery. Four predictors of surgical NEC were identified: abdominal wall erythema (OR: 8.2, p = 0.048), portal venous gas on AXR (OR: 29.8, p = 0.014), and echogenic free fluid (OR: 17.2, p = 0.027) and bowel wall thickening (OR: 12.5, p = 0.030) on AUS. A multivariable risk score incorporating these predictors had excellent area-under-the-curve of 0.937 (95% CI: 0.879-0.994). CONCLUSIONS: AUS, as an adjunct to physical exam and AXR, has utility for predicting surgical NEC.

Genetic diagnoses and associated anomalies in fetuses prenatally diagnosed with esophageal atresia.

Esophageal atresia (EA) is a congenital anomaly occurring in 2.3 per 10,000 live births. Due to advances in prenatal imaging, EA is more readily diagnosed, but data on the associated genetic diagnoses, other anomalies, and postnatal outcome for fetuses diagnosed prenatally with EA are scarce. We collected data from two academic medical centers (n = 61). Our data included fetuses with suspected EA on prenatal imaging that was confirmed postnatally and had at least one genetic test. In our cohort of 61 cases, 29 (49%) were born prematurely and 19% of those born alive died in the first 9 years of life. The most commonly associated birth defects were cardiac anomalies (67%) and spine anomalies (50%). A diagnosis was made in 61% of the cases; the most common diagnoses were vertebral defects, anal atresia, cardiac anomalies, tracheoesophageal fistula with esophageal atresia, radial or renal dysplasia, and limb anomalies association (43%, although 12% met only 2 of the criteria), trisomy 21 (5%), and CHARGE syndrome (5%). Our findings suggest that most fetuses with prenatally diagnosed EA have one or more additional major anomaly that warrants a more comprehensive clinical genetics evaluation. Fetuses diagnosed prenatally appear to represent a cohort with a worse outcome.

Can Robin Sequence Be Predicted From Prenatal Ultrasonography?

PURPOSE: Prenatal diagnosis of Robin sequence (RS) could promote safe delivery and improve perinatal care. The purpose of this study was to evaluate the correlation between prenatal ultrasonography (US) and magnetic resonance imaging (MRI) studies for assessing micrognathia to determine if US alone can be used to reliably screen for RS. MATERIALS AND METHODS: This was a retrospective case-control study of fetuses evaluated in the Advanced Fetal Care Center at Boston Children's Hospital from 2002 to 2017. To be included, 1) prenatal MRI and US must have been performed during the same visit, 2) the infant must have been live-born, and 3) the diagnosis must have been confirmed postnatally. Patients with images of inadequate quality for analysis were excluded. Patients were divided into 4 groups based on postnatal diagnosis: 1) RS (micrognathia, glossoptosis, and airway obstruction) (RS group), 2) micrognathia without RS (micrognathia group), 3) cleft lip and palate (CLP) without micrognathia (CLP group), and 4) gestational age-matched controls with normal craniofacial morphology (control group). The inferior facial angle (IFA) was measured using both imaging modalities and compared. Receiver operating characteristic curves were applied to identify a threshold for the diagnosis of RS from US. The sensitivity, specificity, positive predictive value, negative predictive value, and odds ratio were calculated. RESULTS: A total of 94 patients were included (mean gestational age at imaging, 24.9 ± 5.2 weeks), with 25 in the RS group (26.6%), 29 in the micrognathia group (30.9%), 23 in the CLP group (24.5%), and 17 in the control group (18.1%). The IFA was significantly smaller in the RS group than in all other groups on both US and MRI (P < .001). A moderate correlation was found between IFA measurements on US and MRI (intraclass correlation coefficient, 0.729). An IFA threshold on US of 45.5° maximized sensitivity (84%) and specificity (81%) for the diagnosis of RS. CONCLUSIONS: We suggest incorporating the IFA into routine prenatal US and referring patients for confirmatory MRI when the US IFA is lower than 45.5°.

The Distended Fetal Hypopharynx: A Sensitive and Novel Sign for the Prenatal Diagnosis of Esophageal Atresia.

BACKGROUND/PURPOSE: Although advances have been made in the prenatal diagnosis of esophageal atresia (EA), most neonates are not identified until after birth. The distended hypopharynx (DHP) has been suggested as a novel prenatal sign for EA. We assess its diagnostic accuracy and predictive value on ultrasound (US) and magnetic resonance imaging (MRI), both alone and in combination with the esophageal pouch (EP) and secondary signs of EA (polyhydramnios and a small or absent fetal stomach). METHODS: We retrospectively reviewed fetal US and MRI reports and medical records of 88 pregnant women evaluated for possible EA from 2000 to 2016. Seventy-five had postnatal follow-up that confirmed or disproved the diagnosis of EA and were included in our analysis. RESULTS: Seventy-five women had 107 study visits (range 1-4). DHP and/or EP were seen on US and/or MRI in 36% of patients, and 78% of those patients had EA. DHP was 24% more sensitive for EA than EP, while EP was 30% more specific. After 28weeks of gestation, DHP had a predictive accuracy for EA of 0.929 (P=0.001). CONCLUSIONS: DHP is a sensitive additional prenatal sign of EA. More accurate diagnosis of EA allows for improved counseling regarding delivery, postnatal evaluation, and surgical correction. TYPE OF STUDY: Diagnostic. LEVEL OF EVIDENCE: Level II.

Imaging features and prognostic factors in fetal and postnatal torcular dural sinus malformations, part II: synthesis of the literature and patient management.

BACKGROUND: Torcular dural sinus malformations (tDSMs) are described as slow flow dural arteriovenous fistulae with frequently poor outcomes in the neuroangiographic literature, but other etiologies have been proposed in the obstetric literature, where outcomes have been more favorable. OBJECTIVE: To review tDSMs reported in the literature of multiple specialties for features that support a common etiology, and to identify key prognostic factors, with an emphasis on tDSM trajectory highlighted in part I. METHODS: Analysis of imaging features and clinical outcome for 77 prenatal and 22 postnatal tDSMs reported in 37 papers from the literature. RESULTS: In addition to large venous lakes, 36% of prenatal and 96% of postnatal tDSMs had evidence of arterialization, where specifically assessed. For fetal cases, where there was an observable natural history, 97% underwent a spontaneous decrease-13% after an initial increase and only 1 case with subsequent enlargement after a decrease. Prenatal cases had 83% survival (62% with a favorable outcome) whereas postnatal cases had 59% survival (29% favorable). In addition to a postnatal diagnosis, unfavorable features included ventriculomegaly, parenchymal injury, arterialization, and need for intervention. Favorable features included decreasing tDSM size, presence of clot, and increasing clot percentage. CONCLUSIONS: Neonatal and fetal tDSMs have overlapping imaging appearances, suggesting a common etiology, where neonatal tDSMs represent those rare fetal tDSMs that do not undergo spontaneous regression and have a propensity for worse outcomes. Decrease in tDSM size is a critical observation when managing a tDSM because it is generally irreversible and associated with a favorable outcome.

Imaging features and prognostic factors in fetal and postnatal torcular dural sinus malformations, part I: review of experience at Boston Children's Hospital.

BACKGROUND: Even for the most common dural sinus malformation (DSM), the torcular DSM (tDSM), generalizable statements about etiology and prognosis are difficult because neurosurgeons/neuroradiologists and obstetrical imagers have focused on different patient age groups, have reported different outcomes, and have offered differing pathophysiologic explanations. OBJECTIVE: To examine the imaging features and outcomes of a local cohort of tDSMs across fetal-neonatal life for commonalities. METHODS: Review of imaging and clinical outcome for a local cohort of 12 tDSM patients (9 fetal, 3 postnatal). RESULTS: All 12 tDSMs had similar imaging characteristics, including enlargement of the torcular and intraluminal thrombus early on, later evolving to peripheral scar tissue after treatment or spontaneous regression. Spontaneous decrease in size of the tDSM was observed in 6 prenatal and 1 postnatal case, and this decrease appeared to be irreversible once it occurred. One of 9 prenatal tDSMs was demonstrated to have arteriovenous fistulae in utero, while 2 of 3 postnatal diagnoses had arteriovenous fisutlae. All 6 prenatal tDSM diagnoses followed to term and all 3 postnatal diagnoses had a grossly normal neurologic outcome after a median of 12 months of age. CONCLUSIONS: Prenatal and postnatal tDSMs have overlapping imaging features suggesting a common etiology, and involution of a tDSM is a key imaging biomarker for a favorable outcome. While there is reason for concern with postnatally diagnosed tDSMs, good outcomes may still be achieved across the fetal-neonatal age spectrum of presentations. These findings are generalized in part II of this article.

Micrognathia and Oropharyngeal Space in Patients With Robin Sequence: Prenatal MRI Measurements.

PURPOSE: Micrognathia is the initiating feature of Robin sequence (RS) and leads to airway obstruction. Prenatal identification of micrognathia is currently qualitative and has not correlated with postnatal findings in previous studies. Oropharyngeal airway space has not been evaluated prenatally. The purposes of this study were to 1) quantitate mandibular characteristics and oropharyngeal size at prenatal magnetic resonance imaging (MRI) and 2) identify differences in fetuses with postnatal RS compared with those with micrognathia (without RS) and normal controls. MATERIALS AND METHODS: This is a retrospective case-control study of fetuses with prenatal MRIs performed from 2002 through 2017 who were live born and evaluated postnatally for craniofacial findings. Postnatal findings were used to divide patients into 3 groups: 1) RS (micrognathia, glossoptosis, and airway obstruction), 2) micrognathia without RS ("micrognathia"), and 3) a gestational-age matched control group with normal craniofacial morphology ("control"). Inferior facial angle (IFA), jaw index, and oropharyngeal space (OPS) were calculated and compared among groups. RESULTS: Of 116 patients in this study, 27 had RS (23%), 35 had micrognathia (30%), and 54 were control subjects (47%). IFA, jaw index, and OPS were statistically significantly smaller in the RS group compared with the comparison groups (P < .0001). CONCLUSIONS: Prenatal MRI measurements of micrognathia and OPS are considerably different in patients with RS compared with other groups, including those with micrognathia alone. These measurements might serve as reliable prenatal predictors of RS.

Pathogenesis of Cleft Palate in Robin Sequence: Observations From Prenatal Magnetic Resonance Imaging.

PURPOSE: The etiology of the palatal cleft in Robin sequence (RS) is unknown. The purpose of this study was to assess the position of the fetal tongue at prenatal magnetic resonance imaging (MRI) and to suggest a potential relation between tongue position and development of the cleft palate seen in most patients with RS. MATERIALS AND METHODS: This is a retrospective case-and-control study including fetuses with prenatal MRIs performed in the authors' center from 2002 to 2017. Inclusion criteria were 1) prenatal MRI of adequate quality, 2) liveborn infant, and 3) postnatal diagnosis of RS (Robin group) or cleft lip and palate (CLP group). Patients with postnatal RS without a palatal cleft were excluded. A control group with normal facial morphology was matched by gestational age. The outcome variable was tongue position at fetal MRI, described as within the cleft, along the floor of the mouth (normal), other, or indeterminate. RESULTS: One hundred twenty-two patients with mean gestational age at MRI of 25.8 ± 4.9 weeks were included (Robin, n = 21 [17%]; CLP, n = 47 [39%]; control, n = 54 [44%]). The tongue was visualized within the palatal cleft in 76.2% of the Robin group and 4.3% of the CLP group. The tongue was found along the floor of the mouth (normal) in the remainder of the Robin and CLP groups and in 100% of the control group. CONCLUSION: These findings suggest a relation between in utero tongue position and the development of cleft palate in RS.

Teratoma of the neonatal head and neck: A 41-year experience.

OBJECTIVE: To review our institution's experience with the presentation, evaluation, and management of teratoma of the head and neck in the neonatal population. DESIGN: Retrospective case series (November 1970 through September 2011). SETTING: Tertiary care children's hospital. PATIENTS: 14 patients (12 boys and 2 girls). INTERVENTION: Detailed review of presentation, diagnostic approaches, surgical management, and outcomes. MAIN OUTCOME MEASURES: Anatomic sites, use of pre and post-natal imaging, use of EXIT (ex utero intrapartum treatment) procedure, presenting symptoms, surgical approaches, additional therapeutic modalities, and outcomes are reviewed. RESULTS: Seven patients were diagnosed prenatally, while the remaining 7 patients were diagnosed at birth or shortly thereafter. The tumor emanated from the neck in 9 patients, the nasopharynx/oropharynx in 3 patients, the external nose in 1 patient and the face in 1 patient. Nine patients had associated upper airway obstruction. Four underwent an EXIT procedure, with 3 requiring intubation and 1 requiring tracheostomy. All patients underwent surgical resection. One patient demonstrated recurrence at follow-up. CONCLUSIONS: Teratoma of the head and neck, though rare, is an important part of the differential diagnosis of neck masses in children, particularly in the perinatal period. The ability to make this diagnosis prenatally with high-resolution fetal ultrasound and MRI (magnetic resonance imaging) permits planning for airway and tumor management prior to delivery. An EXIT procedure should be considered when airway compromise by tumor compression is suspected. Early surgical excision is the treatment of choice and recurrence is rare when a complete resection is achieved.

Percent predicted lung volume changes on fetal magnetic resonance imaging throughout gestation in congenital diaphragmatic hernia.

PURPOSE: Percent predicted lung volume (PPLV)<15% on fetal MRI predicts high-risk CDH. Potential changes in PPLV throughout gestation and impact on risk stratification are unknown. We reviewed CDH patients with serial fetal MRIs to follow PPLV and determine correlation with postnatal outcomes. METHODS: CDH patients with serial fetal MRIs from 2005 to 2015 were included. We recorded prenatal MRI gestational age (GA) and PPLV, postnatal ECMO use, and survival. Data were analyzed by logistic regression and Fisher's exact test. RESULTS: 57 patients had 127 fetal MRI studies. PPLV decreased from mean 25.4% to 19.6% between GA 22.1 and 32.6weeks. A steeper decline in PPLV, regardless of final PPLV, was independently predictive of higher ECMO use (p=0.046) and death (p=0.045). All patients with first PPLV<15% remained high-risk with poor outcomes. Of those with first PPLV>15%, 31% dropped below 15%, having similar ECMO use as the high-risk cohort, but trending toward greater survival (p=0.09). Those with first and final PPLV>15% had significantly less ECMO use (p=0.015) and greater survival (p<0.001) than the high-risk cohort. CONCLUSIONS: On average, PPLV decreases throughout gestation in fetuses with CDH. Serial MRI is recommended for those with initial PPLV>15%, as clinical outcomes tend to mirror the lowest PPLV. TYPE OF STUDY: Treatment study LEVEL OF EVIDENCE: III.

Prenatal Features Predictive of Robin Sequence Identified by Fetal Magnetic Resonance Imaging.

BACKGROUND: Prenatal magnetic resonance imaging is increasingly used to detect congenital anomalies. The purpose of this study was to determine whether prenatal magnetic resonance imaging accurately characterizes features predictive of postnatal Robin sequence so that possible airway compromise and feeding difficulty at birth can be anticipated. METHODS: The authors retrospectively identified pregnant women who underwent fetal magnetic resonance imaging between 2002 and 2014 and were found to be carrying a fetus with micrognathia. Micrognathia was subjectively categorized as minor, moderate, or severe. Pregnancy outcome was determined as follows: intrauterine fetal demise, elective termination, early neonatal death, or viable infant. Postnatal findings of micrognathia, Robin sequence, and associated anomalies were compared to prenatal findings. RESULTS: Micrognathia was identified in 123 fetuses. Fifty-two pregnancies (42.3 percent) produced a viable infant. The remainder resulted in termination in the fetal period or death shortly after birth resulting from unrelated causes. For infants who lived, prenatal micrognathia was categorized as minor (55.1 percent), moderate (30.6 percent), or severe (14.3 percent). Forty-two percent of neonates with minor prenatal micrognathia had postnatal micrognathia; however, only 11.1 percent had Robin sequence. All neonates with moderate fetal micrognathia had postnatal micrognathia, and the majority had Robin sequence (86.7 percent). All newborns with severe micrognathia had Robin sequence and all prenatally diagnosed with glossoptosis had Robin sequence. CONCLUSIONS: Prenatal findings of moderate or severe micrognathia or glossoptosis are predictive of postnatal Robin sequence, thus expediting appropriate perinatal management of airway and feeding problems. CLINICAL QUESTION/LEVEL OF EVIDENCE: Diagnostic, IV.

Prenatal Imaging of Craniosynostosis Syndromes.

This article reviews the prenatal diagnosis of those syndromes in which craniosynostosis is a key feature. Although not an exhaustive list, the authors highlight conditions that may be encountered with some regularity, especially in a higher volume fetal imaging center. Rare conditions are also discussed. Normal sutural anatomy and development are first reviewed, followed by a discussion of specific syndromes, the salient imaging findings, and pathologic as well as postnatal correlations when possible.

Thickness of orbicularis oris muscle in unilateral cleft lip: before and after labial adhesion.

BACKGROUND: Our protocol for closure of unilateral complete or severe incomplete cleft lip begins with active dentofacial orthopedics (Latham device) followed by nasolabial adhesion and alveolar gingivoperioplasty. We have observed that preliminary adhesion provides more orbicularis oris muscle for the second-stage labial repair. METHODS: A quantitative prospective assessment of all patients undergoing nasolabial adhesion by the senior author between November of 2009 and July of 2010 was undertaken to assess whether there is an increase in lateral orbicularis oris muscle mass by the time of formal repair. Standard anthropometric points were placed before nasolabial adhesion and again at the second-stage closure. Ultrasonographic measurements of orbicularis muscle thickness were made on both lateral labial elements along a line drawn between sbal and cphi. The mean interval increase in thickness of lateral orbicularis oris was determined. RESULTS: Sixteen patients underwent nasolabial adhesion during the study period. Four patients with asymmetric bilateral cleft lip patients and 2 patients who did not have a second ultrasonographic study were excluded. The remaining 10 patients in the study had a nasolabial adhesion at a mean age of 3.9 months (range, 3.1-4.3 months). Mean orbicularis oris thickness before adhesion was 0.7 mm on the cleft side and 1.2 mm on the noncleft side. The increase in orbicularis thickness after the mean interoperative interval of 2.9 months (range, 2.6-3.5 months) was calculated. On the cleft side, there was 0.8 mm (138%) mean increase in orbicularis oris muscle thickness compared with 0.4 mm (32%) mean increase on the noncleft side. CONCLUSIONS: Labial adhesion in preparation for repair of unilateral complete or severe incomplete cleft lip results in a measurable increased thickness of lateral orbicularis oris. This additional muscular bulk is useful in construction of the philtral ridge.

US assessment of estrogen-responsive organ growth among healthy term infants: piloting methods for assessing estrogenic activity.

BACKGROUND: A mother's circulating estrogen increases over the third trimester, producing physiological effects on her newborn that wane postnatally. Estrogenization might be prolonged in newborns exposed to exogenous estrogens, such as isoflavones in soy formula. OBJECTIVE: We evaluated ultrasonography for monitoring growth of multiple estrogen-responsive organs in healthy infants and developed organ-growth trajectories. MATERIALS AND METHODS: We studied 38 boys (61 visits) from birth to age 6 months and 41 girls (96 visits) from birth to age 1 year using a partly cross-sectional, partly longitudinal design. We measured uterus and ovaries in girls, testes and prostate in boys, and kidneys, breasts, thymus, and thyroid in all children. We imaged all organs from the body surface in one session of < 1 h. RESULTS: Uterine volume decreased from birth (P < 0.0001), whereas ovarian volume increased sharply until age 2 months and then decreased (P < 0.001). Testicular volume increased with age (P < 0.0001), but prostatic volume showed minimal age trend. Breast bud diameter showed no age trend in girls but declined from birth in boys (P = 0.03). CONCLUSION: US examination of multiple estrogen-responsive organs in infants in a single session is feasible and yields volume estimates useful for assessing potential endocrine disruptor effects on organ growth.

Fetal brain volumetry through MRI volumetric reconstruction and segmentation.

PURPOSE: Fetal MRI volumetry is a useful technique but it is limited by a dependency upon motion-free scans, tedious manual segmentation, and spatial inaccuracy due to thick-slice scans. An image processing pipeline that addresses these limitations was developed and tested. MATERIALS AND METHODS: The principal sequences acquired in fetal MRI clinical practice are multiple orthogonal single-shot fast spin echo scans. State-of-the-art image processing techniques were used for inter-slice motion correction and super-resolution reconstruction of high-resolution volumetric images from these scans. The reconstructed volume images were processed with intensity non-uniformity correction and the fetal brain extracted by using supervised automated segmentation. RESULTS: Reconstruction, segmentation and volumetry of the fetal brains for a cohort of twenty-five clinically acquired fetal MRI scans was done. Performance metrics for volume reconstruction, segmentation and volumetry were determined by comparing to manual tracings in five randomly chosen cases. Finally, analysis of the fetal brain and parenchymal volumes was performed based on the gestational age of the fetuses. CONCLUSION: The image processing pipeline developed in this study enables volume rendering and accurate fetal brain volumetry by addressing the limitations of current volumetry techniques, which include dependency on motion-free scans, manual segmentation, and inaccurate thick-slice interpolation.

The presentation and management of fibromatosis colli.

We conducted a systematic chart review to identify all infants with fibromatosis colli who had been seen at Children's Hospital in Boston from January 1999 through December 2004. We found 7 such cases, which involved 4 boys and 3 girls, aged 1 to 3.5 weeks at presentation. We compiled information on each patient's birth history, presenting signs and symptoms, significant medical history, imaging findings, management, follow-up, and outcome. Six of the 7 patients presented with a neck mass, and the remaining patient presented with neck "fullness." Five patients developed torticollis at some point. All patients were treated conservatively with physiotherapy. Five patients experienced a complete resolution of signs and symptoms, and the other 2 experienced improvement. Based on our findings, we recommend that early management of fibromatosis colli include observation and physiotherapy to prevent or reverse torticollis and the craniofacial asymmetry that can result. Similarly attractive is the opportunity that physiotherapy provides for parents to involve themselves in the care of their newborn. It is important, therefore, to quickly identify fibromatosis colli as such in order to avoid unnecessary expenditures of resources and to promptly begin conservative treatment.