Decreased neonatal morbidity in 'stomach-down' left congenital diaphragmatic hernia: implications of prenatal ultrasound diagnosis for counseling and postnatal management.

OBJECTIVE: To evaluate the influence of stomach position on postnatal outcome in cases of left congenital diaphragmatic hernia (CDH) without liver herniation, diagnosed and characterized on prenatal ultrasound (US), by comparing those with ('stomach-up' CDH) to those without ('stomach-down' CDH) intrathoracic stomach herniation. METHODS: Infants with left CDH who underwent prenatal US and postnatal repair at our institution between January 2008 and March 2017 were eligible for inclusion in this retrospective study. Detailed prenatal US examinations, fetal magnetic resonance imaging (MRI) studies, operative reports and medical records of infants enrolled in the pulmonary hypoplasia program at our institution were reviewed. Cases with liver herniation and those with an additional anomaly were excluded. Cases in which bowel loops were identified within the fetal chest on US while the stomach was intra-abdominal were categorized as having stomach-down CDH. Cases in which bowel loops and the stomach were visualized within the fetal chest on US were categorized as having stomach-up CDH. Prenatal imaging findings and postnatal outcomes were compared between the two groups. RESULTS: In total, 152 patients with left CDH were initially eligible for inclusion. Seventy-eight patients had surgically confirmed liver herniation and were excluded. Of the 74 included CDH cases without liver herniation, 28 (37.8%) had stomach-down CDH and 46 (62.2%) had stomach-up CDH. Of the 28 stomach-down CDH cases, 10 (35.7%) were referred for a suspected lung lesion. Sixty-eight (91.9%) cases had postnatal outcome data available for analysis. There was no significant difference in median observed-to-expected (o/e) lung-area-to-head-circumference ratio (LHR) between cases with stomach-down CDH and those with stomach-up CDH (41.5% vs 38.4%; P = 0.41). Furthermore, there was no difference in median MRI o/e total lung volume (TLV) between the two groups (49.5% vs 44.0%; P = 0.22). Compared with stomach-up CDH patients, stomach-down CDH patients demonstrated lower median duration of intubation (18 days vs 9.5 days; P < 0.01), median duration of extracorporeal membrane oxygenation (495 h vs 223.5 h; P < 0.05), rate of supplemental oxygen requirement at 30 days of age (20/42 (47.6%) vs 3/26 (11.5%); P < 0.01) and rate of pulmonary hypertension at initial postnatal echocardiography (28/42 (66.7%) vs 9/26 (34.6%); P = 0.01). No neonatal death occurred in stomach-down CDH patients and one neonatal death was seen in a patient with intrathoracic stomach herniation. CONCLUSIONS: In infants with left CDH without liver herniation, despite similar o/e-LHR and o/e-TLV, those with stomach-down CDH have decreased neonatal morbidity compared to those with stomach herniation. Progressive or variable physiological distension of the stomach over the course of gestation may explain these findings. Stomach-down left CDH is mistaken for a lung mass in a substantial proportion of cases. Accurate prenatal US characterization of CDH is crucial for appropriate prenatal counseling and patient management. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

Fetal Intraventricular Hemorrhage in Open Neural Tube Defects: Prenatal Imaging Evaluation and Perinatal Outcomes.

BACKGROUND AND PURPOSE: Fetal imaging is crucial in the evaluation of open neural tube defects. The identification of intraventricular hemorrhage prenatally has unclear clinical implications. We aimed to explore fetal imaging findings in open neural tube defects and evaluate associations between intraventricular hemorrhage with prenatal and postnatal hindbrain herniation, postnatal intraventricular hemorrhage, and ventricular shunt placement. MATERIALS AND METHODS: After institutional review board approval, open neural tube defect cases evaluated by prenatal sonography between January 1, 2013 and April 24, 2018 were enrolled (n = 504). The presence of intraventricular hemorrhage and gray matter heterotopia by both prenatal sonography and MR imaging studies was used for classification. Cases of intraventricular hemorrhage had intraventricular hemorrhage without gray matter heterotopia (n = 33) and controls had neither intraventricular hemorrhage nor gray matter heterotopia (n = 229). A total of 135 subjects with findings of gray matter heterotopia were excluded. Outcomes were compared with regression analyses. RESULTS: Prenatal and postnatal hindbrain herniation and postnatal intraventricular hemorrhage were more frequent in cases of prenatal intraventricular hemorrhage compared with controls (97% versus 79%, 50% versus 25%, and 63% versus 12%, respectively). Increased third ventricular diameter, specifically >1 mm, predicted hindbrain herniation (OR = 3.7 [95% CI, 1.5-11]) independent of lateral ventricular size and prenatal intraventricular hemorrhage. Fetal closure (n = 86) was independently protective against postnatal hindbrain herniation (OR = 0.04 [95% CI, 0.01-0.15]) and postnatal intraventricular hemorrhage (OR = 0.2 [95% CI, 0.02-0.98]). Prenatal intraventricular hemorrhage was not associated with ventricular shunt placement. CONCLUSIONS: Intraventricular hemorrhage is relatively common in the prenatal evaluation of open neural tube defects. Hindbrain herniation is more common in cases of intraventricular hemorrhage, but in association with increased third ventricular size. Fetal closure reverses hindbrain herniation and decreases the rate of intraventricular hemorrhage postnatally, regardless of the presence of prenatal intraventricular hemorrhage.

Myelomeningocele sac associated with worse lower-extremity neurological sequelae: evidence for prenatal neural stretch injury?

OBJECTIVE: To determine whether the presence of a myelomeningocele (MMC) sac and sac size correlate with compromised lower-extremity function in fetuses with open spinal dysraphism. METHODS: A radiology database search was performed to identify cases of MMC and myeloschisis (MS) diagnosed prenatally in a single center from 2013 to 2017. All cases were evaluated between 18 and 25 weeks. Ultrasound reports were reviewed for talipes and impaired lower-extremity motion. In MMC cases, sac volume was calculated from ultrasound measurements. Magnetic resonance imaging reports were reviewed for hindbrain herniation. The association of presence of a MMC sac and sac size with talipes and impaired lower-extremity motion was assessed. Post-hoc analysis of data from the multicenter Management of Myelomeningocele Study (MOMS) randomized controlled trial was performed to confirm the study findings. RESULTS: In total, 283 MMC and 121 MS cases were identified. MMC was associated with a lower incidence of hindbrain herniation than was MS (80.9% vs 100%; P < 0.001). Compared with MS cases, MMC cases with hindbrain herniation had a higher rate of talipes (28.4% vs 16.5%, P = 0.02) and of talipes or lower-extremity impairment (34.9% vs 19.0%, P = 0.002). Although there was a higher rate of impaired lower-extremity motion alone in MMC cases with hindbrain herniation than in MS cases, the difference was not statistically significant (6.6% vs 2.5%; P = 0.13). Among MMC cases with hindbrain herniation, mean sac volume was higher in those associated with talipes compared with those without talipes (4.7 ± 4.2 vs 3.0 ± 2.6 mL; P = 0.002). Review of the MOMS data demonstrated similar findings; cases with a sac on baseline imaging had a higher incidence of talipes than did those without a sac (28.2% vs 7.5%; P = 0.007). CONCLUSIONS: In fetuses with open spinal dysraphism, the presence of a MMC sac was associated with fetal talipes, and this effect was correlated with sac size. The presence of a larger sac in fetuses with open spinal dysraphism may result in additional injury through mechanical stretching of the nerves, suggesting another acquired mechanism of injury to the exposed spinal tissue. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

Sonographic appearance of focal thyroiditis.

OBJECTIVE: The purpose of this study is to report the sonographic appearance of focal thyroid nodules that prove to be lymphocytic thyroiditis on fine-needle aspiration. CONCLUSION: In a patient population undergoing sonography for palpable nodular disease without known thyroiditis, focal nodules of thyroiditis had a wide variety of appearances. They most commonly appeared as solid hyperechoic nodules with ill-defined margins. However, the echogenicity was variable, and calcification and cystic-appearing regions were also noted. The vascularity of these nodules as assessed with color Doppler and power Doppler sonography also varied widely. Biopsy of these lesions is still necessary because there are no sonographic features that can reliably diagnose these lesions as thyroiditis and differentiate them from other lesions.

Prenatal diagnosis and management of congenital lobar emphysema.

BACKGROUND: Congenital lobar emphysema (CLE) is a rare anomaly of lung development that usually presents in the neonatal period with respiratory distress and pulmonary lobar hyperinflation. The routine use of prenatal ultrasonography has resulted in the early identification and serial evaluation of congenital lung lesions. CLE can be distinguished from other congenital lung lesions on ultrasonography by the differences in echogenicity and reflectivity. METHODS: Two cases of CLE diagnosed at midgestation by ultrasonography and ultrafast fetal magnetic resonance imaging (MRI), along with serial sonographic documentation of their prenatal course were reviewed. RESULTS: The CLE lesions decreased in size over the course of the pregnancy, similar to that seen with other congenital lung lesions such as cystic adenomatoid malformation and bronchopulmonary sequestration. However, these neonates with CLE showed marked air-trapping and respiratory distress requiring lobectomy in the early neonatal period. CONCLUSIONS: These cases provide insight into the prenatal course of CLE and underscore the need for continued postnatal evaluation of fetuses even those in whom the lesions appear to have resolved in utero. These patients should have ready access to postnatal surgical intervention.

Sonography during early pregnancy: dependence of threshold and discriminatory values on transvaginal transducer frequency.

OBJECTIVE: Our goal was to determine if normal and abnormal pregnancies could be distinguished at smaller sac sizes with a higher frequency transvaginal transducer than with a 5-MHz transducer. SUBJECTS AND MATERIALS: Thirty-nine patients with potentially abnormal pregnancies identified with a 5-MHz transvaginal transducer were immediately reimaged with a 9-5-MHz transducer. We compared our ability to visualize the yolk sac, embryo, and cardiac activity relative to mean sac diameter on imaging at both frequencies in women with normal and abnormal pregnancies. RESULTS: Of the 39 pregnancies, 22 (56%) were normal or probably normal. Using the 5-MHz transducer, a yolk sac was first seen in a 6.4-mm gestational sac but was not definitively seen in 12 gestational sacs measuring 5-13 mm. Using the 9-5-MHz transducer, yolk sacs were identified in all gestational sacs measuring 4.6-13 mm, and live embryos were seen in five of eight sacs measuring 8.1-13 mm. The largest normal gestational sac without a live embryo measured 11 mm. When we compared these pregnancies with 17 (44%) abnormal pregnancies, we found that all pregnancies that had no yolk sac by the time the gestational sac measured 5.0 mm or no live embryo by 13 mm had abnormal findings on higher frequency imaging. CONCLUSION: The ability to visualize the yolk sac and embryo in early pregnancy is critically dependent on transvaginal transducer frequency. Threshold values and discriminatory sizes used to distinguish normal and abnormal pregnancies are smaller on higher frequency than on lower frequency imaging and, therefore, should be redetermined for specific transducer frequencies.

Diagnosis and staging of ovarian cancer: comparative values of Doppler and conventional US, CT, and MR imaging correlated with surgery and histopathologic analysis--report of the Radiology Diagnostic Oncology Group.

PURPOSE: To determine the optimal imaging modality for diagnosis and staging of ovarian cancer. MATERIALS AND METHODS: Two hundred eighty women suspected to have ovarian cancer were enrolled in a prospective study before surgery. Doppler ultrasonography (US), computed tomography (CT), and magnetic resonance (MR) imaging were used to evaluate the mass; conventional US, CT, and MR imaging were used to stage spread. RESULTS: All three modalities had high accuracy (0.91) for the overall diagnosis of malignancy. In the ovaries, the accuracy of MR imaging (0.91) was higher than that of CT and significantly higher than that of Doppler US (0.78). In the extraovarian pelvis and in the abdomen, conventional US, CT, and MR imaging had similar accuracies (0.87-0.95). In differentiation of disease confined to the pelvis from abdominal spread, the specificity of conventional US (96%) was higher than that of CT and significantly higher than that of MR imaging (88%), whereas the sensitivities of MR imaging (98%) and CT (92%) were significantly higher than that of conventional US (75%). CONCLUSION: MR imaging is superior to Doppler US and CT in diagnosis of malignant ovarian masses. There is little variation among conventional US, CT, and MR imaging as regards staging.

Congenital chest lesions: diagnosis and characterization with prenatal MR imaging.

PURPOSE: To evaluate prenatal magnetic resonance (MR) imaging for diagnosis of fetal chest masses and to determine if MR imaging provides information in addition to that of ultrasonography (US). MATERIALS AND METHODS: Eighteen pregnant women were referred for MR imaging of possible fetal chest tumors seen at US (16 congenital cystic adenomatoid malformation [CCAM], two bronchopulmonary sequestration [BPS]). The presence, position, size, and characteristics of masses were determined and correlated with postnatal results. RESULTS: The MR imaging diagnoses were three cases of congenital diaphragmatic hernia, nine of CCAM, two of BPS, and one each of foregut cyst, lung atresia, tracheal atresia, and bronchial stenosis. MR imaging results were in agreement with US results in nine fetuses and in disagreement in nine. MR imaging diagnoses were confirmed at surgery or autopsy in 17 fetuses. MR imaging results led to an error in diagnosis in one fetus with BPS. CONCLUSION: Fetal chest masses had characteristic MR imaging appearances. MR imaging was accurate for distinguishing congenital diaphragmatic hernia from CCAM and was useful for less common diagnoses and determination of the origin of very large chest tumors. Prenatal diagnosis was changed in some patients owing to MR results and affected treatment and counseling of parents. MR imaging is a valuable adjunct to US for prenatal diagnosis of fetal chest masses.

Prenatal MRI evaluation of congenital diaphragmatic hernia.

The objective of this paper is to evaluate the efficacy of various magnetic resonance imaging (MRI) sequences and the general usefulness of prenatal MRI in determining the position of the fetal liver and visualizing lung tissue in fetuses who have congenital diaphragmatic hernia (CDH). This was a retrospective review of prenatal MRI of fetuses with a confirmed diagnosis by surgery or autopsy of CDH. MRI was performed in a 1.5-Tesla magnet using fast gradient echo, half-Fourier single-shot turbo spin-echo (HASTE) and echo planar images. The presence of a chest mass, position of the stomach and liver and visualization of the lungs by MRI was noted in all fetuses. This was compared to ultrasound studies performed the same day and correlated with postnatal or autopsy studies. The fetuses were 18-36 weeks gestational age (mean 24.5 weeks). MRI diagnosed left CDH (33), right CDH (4), and bilateral CDH (1) and agreed with the postnatal diagnosis in all patients. Ultrasound (US) diagnosed left CDH (33), right CDH (2), and congenital cystic adenomatoid malformation (3). MRI changed the diagnosis in four patients. The fetal liver was easily demonstrated with MRI in all fetuses and was herniated into the chest in 25 of the 38. US diagnosed liver up in 21. Correlation with postnatal studies found MRI correctly diagnosed liver position in 37 out of 38 cases. US correctly diagnosed liver position in 32 out of 38. Both lungs could be visualized in all fetuses with MRI. MRI accurately and easily diagnoses CDH and can differentiate it from other chest masses. MRI was superior to US in demonstrating the position of the fetal liver above or below the diaphragm. MRI reliably visualized fetal lung tissue. These findings are important for counseling parents, selecting fetal surgical candidates, and estimating prognosis.

Comparison of resistive index versus pulsatility index in assessing the benign etiology of adnexal masses.

Retrospective analysis of pelvic sonograms with colorguided spectral Doppler evaluation of 189 adnexal masses yielded four malignancies, 20 benign neoplasms, 32 cysts, and 14 endometriomas. Fifty-eight masses were presumed benign on additional imaging. Pulsatility index (PI) < 1.0 was seen in 70% neoplasms, 63% benign cysts and 50% endometriomas. Thirteen percent of benign cysts and no neoplasms had resistive index (RI) < 0.4. Fifty percent malignancies had PI < 1.0. None had RI < 0.4. Both thresholds lack sufficient sensitivity and specificity for distinguishing benign and malignant lesions.

Sonography of transjugular intrahepatic portosystemic shunts: detection of elevated portosystemic gradients and loss of shunt function.

PURPOSE: To evaluate the role of ultrasound (US) in the detection of elevated portosystemic gradients and loss of shunt function in patients with a transjugular intrahepatic portosystemic shunt (TIPS). MATERIALS AND METHODS: The authors' prospectively compared 151 Doppler hepatic sonograms with follow-up portal venograms in 64 patients with TIPS. Sonographic data from within the portal system, hepatic arteries, and three areas within the TIPS were collected. Statistical analysis of these parameters was used to establish the US criteria for shunt dysfunction. RESULTS: Midshunt velocity thresholds of less than 50 and less than 60 cm/sec yielded sensitivities and specificities of 46% and 93%, and 57% and 89%, respectively, for the detection of portosystemic gradients exceeding 15 mm Hg. Use of a threshold midshunt velocity of less than 60 cm/sec or main portal vein velocity of less than 40 cm/sec raised the shunt dysfunction detection sensitivity to 86%, with a specificity of 54%. CONCLUSION: Doppler US is an effective noninvasive screening tool for detecting elevated portosystemic gradients and evaluating the functional status of a TIPS. Midshunt velocities of less than 60 cm/sec or main portal vein velocities less than 40 cm/sec are a useful threshold for detecting shunt dysfunction.

First-trimester US parameters of failed pregnancy.

PURPOSE: To test the reliability of established ultrasound (US) parameters in predicting the outcome of first-trimester pregnancy. MATERIALS AND METHODS: The authors retrospectively reviewed 2,655 first-trimester US scans in 2,285 patients. Parameters tested against outcome were (a) a yolk sac and mean gestational sac diameter of 8 mm on transvaginal US scans, (b) an embryo and mean sac diameter of 16 mm on transvaginal US scans, and (c) a difference between the mean sac diameter and crown-rump length of less than 5 mm (oligohydramnios) at 5.5-9.0 weeks gestation. RESULTS: Thirty (22%) of 135 patients without yolk sacs and with an 8-mm mean sac diameter developed live embryos: 24 had normal follow-up or delivery; six were lost to follow-up. Five (8%) of 59 patients with no depiction of embryos and with a 16-mm mean sac diameter developed live embryos: Two delivered, one spontaneously aborted, one had death of one twin embryo before being lost to follow-up, and one was lost to follow-up. Seventeen (0.74%) of 2,285 patients had early oligohydramnios: Six (35%) had normal follow-up scans or delivery, two (12%) spontaneously aborted, and nine (53%) were lost to follow-up. CONCLUSION: Established parameters predictive of early pregnancy failure potentially result in misdiagnosis of nonviability or poor prognosis when applied to a large, unselected patient population. Close follow-up is necessary in cases with borderline abnormal findings.

Intrauterine low density in women over 50. Assessment of significance and recommendations for follow-up.

Patients over 50 years old with intrauterine low density on enhanced computed tomography were analyzed. Uterine volume and volume of intrauterine low density were calculated. Intrauterine low density was expressed as a percent of uterine volume. At 1-year follow-up, 23 (63.9%) had uterine malignancy and 13 (36.2%) had benign findings. All patients whose intrauterine low density exceeded 35% of the total uterine volume had a malignancy (p < 0.001). If intrauterine low density exceeds 35% of uterine volume, evaluation of uterine malignancy should be performed regardless of symptoms.

Prenatal diagnosis of a chest wall hamartoma and sternal cleft.

We present the prenatal evaluation and diagnosis of a disorganized chest wall hamartoma with underlying sternal cleft in a family with a prior offspring with the VATER association. The possibility that these conditions are linked to mesodermal defects with a common pathogenic etiology is suggested.

Strategy for repeat biopsy of patients with prostatic intraepithelial neoplasia detected by prostate needle biopsy.

PURPOSE: We evaluated the strategy for repeat biopsy of patients with prostatic intraepithelial neoplasia without concurrent carcinoma detected on prostate needle biopsy. MATERIALS AND METHODS: Of 1,275 consecutive patients undergoing prostate needle biopsy 61 were identified with prostatic intraepithelial neoplasia but without concurrent prostate carcinoma. Of the 61 patients 53 had undergone repeat biopsy. The medical records, transrectal ultrasound, and operative and pathological reports of these patients were reviewed. RESULTS: Repeat biopsy was done in 53 patients with prostatic intraepithelial neoplasia, yielding carcinoma in 15, prostatic intraepithelial neoplasia without carcinoma in 8 and benign tissue in 30. The yield of carcinoma from repeat biopsy of a prostatic intraepithelial neoplasia site was 8.3% (7 of 84 sites). A total of 18 sites of carcinoma was detected by repeat biopsy of a previous random biopsy site (8), a prostatic intraepithelial neoplasia site only (5), a transrectal ultrasound nodule (3), a palpable nodule and prostatic intraepithelial neoplasia site (1), and a transrectal ultrasound nodule and prostatic intraepithelial neoplasia site (1). Carcinoma was as frequently detected by repeat biopsy of a prostatic intraepithelial neoplasia site (6 patients) as by random repeat biopsy (6 patients). CONCLUSIONS: Repeat prostate needle biopsy of patients with prostatic intraepithelial neoplasia should include random repeat biopsy and repeat biopsy of transrectal ultrasound abnormalities as well as previous sites of prostatic intraepithelial neoplasia.

Follow-up of benign hypoechoic peripheral zone lesions of the prostate gland: US characteristics and cancer prevalence.

PURPOSE: To evaluate the role of biopsy-proved benign peripheral zone hypoechoic lesions of the prostate gland, ultrasonographic (US) characteristics at follow-up, prostate-specific antigen (PSA) levels, and digital rectal examination (DRE) in prediction of cancer risk. MATERIALS AND METHODS: Retrospective analysis was performed for 105 consecutive patients with 148 benign hypoechoic lesions discovered at transrectal US (TRUS) and diagnosed with US-guided needle biopsy. At least one repeat TRUS study was performed in each patient. RESULTS: Among the benign lesions, 72% changed at follow-up TRUS, either disappearing or becoming smaller, less hypoechoic, and more vague. Cancer developed in 13% of patients. In 93% of patients in whom cancer developed, the appearance changed in the peripheral zone at follow-up TRUS. In this patient population, the positive predictive value for development of cancer was 16% with a changing TRUS appearance, 19% with an abnormal DRE result, and 27% with an elevated level of PSA; only the latter was statistically significant. CONCLUSION: The PSA value, alone or in combination with a changing TRUS appearance, is the best indicator for development of cancer.

Emergency department screening for ectopic pregnancy: a prospective US study.

PURPOSE: To determine the effectiveness of pelvic sonography as a screening test for ectopic pregnancy. MATERIALS AND METHODS: Pelvic sonograms were prospectively analyzed in 1,427 consecutive patients with a serum level of the beta subunit of human chorionic gonadotropin of over 1,500 IU/L. RESULTS: Sonograms were diagnostic in 1,158 patients and indeterminate in 269. When indeterminate studies were considered falsely negative, the diagnostic accuracy was 81%. Twenty-four percent of patients with indeterminate studies were subsequently proved to have ectopic pregnancy. In ectopic pregnancy (n = 103), the most common finding was a complex adnexal mass (specificity = 92% [P < .001]). The sensitivity and specificity of screening sonography for ectopic pregnancy were 99% and 84%, respectively. CONCLUSION: Pelvic sonography is an effective screening test for ectopic pregnancy. Having a one in four chance of harboring an ectopic pregnancy, patients with indeterminate studies require close follow-up. The presence of a complex adnexal mass is a strong predictor of ectopic pregnancy.

Pancreatic sparing of focal fatty infiltration.

PURPOSE: To describe typical findings of focal fatty sparing of the pancreas. MATERIALS AND METHODS: Computed tomography, ultrasonography, and/or magnetic resonance imaging were performed in seven patients. RESULTS: In these patients, the area of sparing of fatty change was within the head or uncinate process of the pancreas. CONCLUSION: Differentiating pancreatic fatty sparing from true neoplasm by means of cross-sectional imaging obviates the need for invasive diagnostic studies.