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Contribution of Transvaginal High-Resolution Ultrasound in Fetal Neurology

Article  in  Donald School Journal of Ultrasound in Obstetrics and Gynecology · April 2011

DOI: 10.5005/jp-journals-10009-1183

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10.5005/jp-journals-10009-1183
Contribution of Transvaginal High-Resolution Ultrasound in Fetal Neurology
REVIEW ARTICLE

Contribution of Transvaginal
High-Resolution Ultrasound in
Fetal Neurology
Ritsuko K Pooh
CRIFM Clinical Research Institute of Fetal Medicine, Pooh Maternity Clinic, Osaka, Japan

Correspondence: Ritsuko K Pooh, CRIFM Clinical Research Institute of Fetal Medicine, Pooh Maternity Clinic, 7-3-7, Uehommachi
Tennoji, Osaka 543-0001, Japan, Phone: +81-667758111, Fax: +81-667758122, e-mail: [email protected]

ABSTRACT

Transvaginal high-resolution ultrasound and three-dimensional (3D) ultrasound have been establishing sonoembryology as well as
neurosonography in the first trimester. Fetal brain is rapidly developing and changing its appearance week by week during pregnancy.
The most important organ, but it is quite hard to observe detailed structure of this organ by conventional transabdominal sonography. It
is possible to observe the whole brain structure by magnetic resonance imaging in the post half of pregnancy, but it is difficult in the first
half gestation, and transvaginal high-resolution 3D ultrasound is the most powerful modality. As for brain vascularization, main arteries
and veins have been demonstrated and evaluated in various CNS conditions. Transvaginal high-resolution 3D ultrasound can demonstrate
cerebral fine vascular anatomy, such as medullary vessels and it is greatly expected to estimate neurological prognosis relating with
vascular development during fetal period.
Keywords: Transvaginal sonography, Fetus, Neurology, High-resolution, 3D ultrasound.

INTRODUCTION brain during the second and third trimester was introduced in
the beginning of 1990s. It was the first practical application of
Imaging technologies have been remarkably improved and
three-dimensional central nervous system assessment by two-
contributed to prenatal evaluation of fetal central nervous system
dimensional (2D) ultrasound.4 Transvaginal observation of the
(CNS) development and assessment of CNS abnormalities in
fetal brain offers sagittal and coronal views of the brain from
utero.
fetal parietal direction5-8 through the fontanelles and/or the
Conventional transabdominal ultrasonography, by which it
sagittal suture as ultrasound windows. Serial oblique sections3
is possible to observe fetuses through maternal abdominal wall,
via the same ultrasound window reveal the intracranial
uterine wall and sometimes placenta, has been most widely
morphology in detail. This method has contributed to the
utilized for antenatal imaging diagnosis. By transabdominal
prenatal assessment of congenital CNS anomalies and acquired
approach, whole central nervous system of fetuses can be well
brain damage in utero.
demonstrated, for instance, the brain in the axial section and
the spine in the sagittal section. However, transabdominal
approach to the fetal central nervous system has several TRANSVAGINAL HIGH-RESOLUTION 3D
NEUROIMAGING
obstacles, such as maternal abdominal wall, placenta and fetal
cranial bones and it is difficult to obtain clear and detailed Three-dimensional (3D) ultrasound is one of the most attractive
images of fetal CNS structure. modality in the field of fetal ultrasound imaging. Automatic
Introduction of high-frequency transvaginal transducer has scan by dedicated 3D transducer produces motor driven
contributed to establishing “sonoembryology”1 and recent automatic sweeping and is called fan scan. With this method, a
general use of transvaginal sonography in early pregnancy shift and/or angle-change of the transducer is not required during
enabled early diagnoses of major fetal anomalies.2 In the middle scanning and scan duration needs only several seconds. After
and late pregnancy, fetal CNS is generally evaluated through acquisition of the target organ, multiplanar imaging analysis
maternal abdominal wall. The brain, however, is three- and tomographic imaging analysis are possible. Combination
dimensional structure, and should be assessed in basic three of both transvaginal high-resolution sonography and 3D
planes of sagittal, coronal and axial sections. Sonographic ultrasound9-16 may be a great diagnostic tool for evaluation of
assessment of the fetal brain in the sagittal and coronal sections, three-dimensional structure of fetal CNS. Recent advanced 3D
requires an approach from fetal parietal direction. Transvaginal ultrasound equipments have several useful functions as bellows:
sonography of the fetal brain opened a new field in medicine, • Surface anatomy imaging of spinal development, cranial
“neurosonography”.3 Transvaginal approach to the normal fetal surface and brain surface

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Ritsuko K Pooh

• Bony structural imaging of the calvaria and vertebrae imaging of the calvaria and vertebrae are useful in cases of
• Multiplanar imaging of the intracranial structure craniosynostosis and spina bifida. Figure 3 shows the
• Tomographic ultrasound imaging of fetal brain in any cutting craniovertebral imaging in an acranial case. Surface anatomy
section imaging can demonstrate the brain surface shown in Figures 4
• Thick slice imaging of the intracranial structure (volume and 5. Migration occurs during 3 to 5 gestational month but the
contrast imaging, VCI) gyration and sulcation can be visualized in the late pregnancy.
• Simultaneous volume contrast imaging of the same section Figure 4 shows obviously different appearance of the brain
or vertical section of fetal brain structure surface at 19 and 30 weeks of gestation. Figure 5 shows the
• Volume calculation of target organs, such as intracranial brain surface with less gyration at 33 weeks of gestation seen
cavity, ventricle, choroid plexus and intracranial lesions in a case of pachygyria. Thus, brain development can be
• Inversion mode demonstrating hypoechoic parts, such as objectively understandable by surface reconstructed imaging.
ventricles and cystic lesions. In Multiplanar imaging of the brain structure and
It is well known that 3D ultrasound demonstrates the surface tomographic ultrasound imaging (TUI, Fig. 2 left and Fig. 6)
anatomy. In cases of CNS abnormalities, facial abnormalities are quite helpful to understand intracranial detailed brain
and extremities anomalies are often complicated. Therefore, structure. It is possible to compare the anatomy in exactly same
surface reconstructed images are helpful. In the first trimester, cutting sections. Figure 1 (lower picture) shows changing
surface reconstructed imaging show the changing appearance appearance of early premature brain development in the mid-
from early neural tube to spinal cord between 6 and 9 weeks of sagittal cutting section between 8 and 10 weeks of gestation.
gestation, shown in Figure 1 (upper picture). In early pregnancy, Figure 7 shows the changing appearance of sylvian fissure
small cephalocele can be demonstrated (Fig. 2). Bony structural during the second and early third trimesters. Figure 8 shows

Fig. 3: Craniovertebral imaging in an acranial case. Left upper image

is 2D ultrasound imaging and left lower image is multiplanar imaging.
Right picture shows 3D bony structure of craniovertebral part. Acrania
and opening of cervical vertebrae are demonstrated
Fig. 1: Transvaginal 3D images of early fetal CNS development.
Changing appearance from early neural tube to spinal cord between 6
and 9 weeks of gestation (upper picture). Changing appearance of
early premature brain development in the mid-sagittal cutting section
between 8 and 10 weeks of gestation (lower picture)

Fig. 2: Cephalocele at 12 weeks of gestation. Left figure; tomographic Fig. 4: Normal brain 3D surface anatomy in 19 and 30 weeks of
ultrasound imaging (TUI). Right figure; 3D reconstructed image gestation. Notice obviously different appearance of the smooth brain
surface at 19 weeks and matured brain surface with gyration at
30 weeks

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Contribution of Transvaginal High-Resolution Ultrasound in Fetal Neurology

superior point of TUI to MRI is that it is easily possible to

change slice width, to rotate the images, to magnify images,
and to rotate images to any directions. This function is extremely
useful for detailed CNS assessment and also for consultation to
neurosurgeons and neurologists. Figure 9 shows abnormal
migration disorder in the second trimester. The intracranial brain
structure is quite abnormal and it is difficult to obtain the
orientation but TUI is quite helpful to show the intracranial
structure very clearly. Thick slice imaging of the intracranial
structure and simultaneous volume contrast imaging (VCI) of
the same plane or vertical plane of conventional 2D image are
often convenient to observe the gyral formation inside lateral
ventricles.14 The premature brain image obtained by use of VCI
clearly demonstrates anatomical CNS structure.
Fig. 5: Abnormal brain 3D surface anatomy in pachygyria. The brain Volume extracted image and volume calculation of the fetal
surface with less gyration at 33 weeks of gestation is well-demonstrated
in a case of pachygyria brain in early pregnancy was reported from 1990s.17-21 On three
orthogonal images, the target organ can be traced automatically
or manually with rotation of volume imaging data. After tracing,
volume extracted image is demonstrated and volume calculation
data is shown. 3D fetal brain volume measurements have a good
intraobserver and interobserver reliability22,23 and could be used
to determine estimated gestational age. Volume analysis by 3D
ultrasound provides exceedingly informative imaging data.
Volume analysis of the structure of interest provides an
intelligible evaluation of the brain structure in total, and
longitudinal and objective assessment of enlarged ventricles
and intracranial occupying lesions (Fig. 10). Any intracranial
organ can be chosen as a target for volumetry, no matter how
distorted its shape and appearance may be. In new method of
inversion mode, the cystic portions within the volume are
displayed entirely as an echogenic area, while the grayscale
portions of the image are rendered as transparent24 and recently
Fig. 6: Tomographic ultrasound imaging of normal brain in coronal it has been applied in fetal diagnosis.25,26
cutting section at 20 weeks
Inversion mode is inverted imaging technology which shows
volume of only hypoechoic parts. Figure 11 shows TUI and
early intracranial hemorrhage case and dedicated transvaginal inversion-mode images of enlarged ventricles seen at 19 weeks
high-frequent sonography detected the subtle change of of gestation.
ventricular wall between 16 and 17 weeks of gestation. TUI Thus, owing to transvaginal high-resolusion 3D neuro-
demonstrates multi-parallel cutting sections and is quite similar imaging, details of CNS normal development and maldevelop-
imaging technology to magnetic resonance imaging. The ment have been elucidated.

Fig. 7: Changing appearance of sylvian fissure during the second and early third trimesters

Donald School Journal of Ultrasound in Obstetrics and Gynecology, April-June 2011;5(2):93-99 95

Ritsuko K Pooh

Fig. 8: Early intracranial hemorrhage/porencephaly case (upper figures) Fig. 10: 3D volume extraction and volumetric analysis of lateral ventricle
dedicated transvaginal high-frequent sonography detected the subtle and intracranial cavity. Each volume of right (RV) and left ventricles
change of ventricular wall between 16 and 17 weeks of gestation (LV) and intracranial cavity volume can be calculated by 3D volumetry.
(arrows). (Left lower) ventricular wall is irregular and hyperechogenic Total ventricular volume/intracranial cavity (ICC) volume shows
(red arrows), indicating intraventricular hemorrhage. (Right lower) MR ventricles occupying rate and it is useful for longitudinal assessment of
image of the same fetus at 20 weeks. Asterisks indicate the missing ventriculomegaly cases
brain (porencephaly) because of early brain hemorrhage

Fig. 9: Abnormal migration disorder in the second trimester. (Upper

figures) TUI in the sagittal (left) and coronal (right). The intracranial
brain structure is quite abnormal and it is difficult to obtain the orientation
but TUI is quite helpful to show the intracranial structure very clearly.
Lower left picture shows the brain surface at autopsy in the same case.
Abnormal gyration which cannot exist at 21 weeks is seen. Lower right
figure is normal smooth brain surface at the same gestation for
comparison

TRANSVAGINAL HIGH-RESOLUTION 3D
NEUROANGIOGRAPHY
The author first reported brain circulation demonstrated by
transvaginal 2D power Doppler in 1996. 27 Thereafter,
transvaginal 3D power Doppler assessment of fetal brain Fig. 11: TUI and inversion mode of enlarged ventricle at 19 weeks of
vascularity was successful.20,28 Recently, owing to the advanced gestation. Ventricular appearance is objectively demonstratable by
inversion mode
technology of directional power Doppler, furthermore
sophisticated 3D angiostructural images have been able to be
demonstrated with vascular direction.29 In the first trimester, it the fetal brain circulation at 14 weeks by 3D bidirectional power
is possible to demonstrate the fetal cranial circulation clearly Doppler. Furthermore, recent high-frequent transvaginal
as early as 7 weeks of gestation (Fig. 12). Brain circulation can neuroscan has been able to demonstrate the medullary vessels
be well-documented during the first trimester. Figure 13 shows from the cortex towards subependymal area. Medullary veins

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Contribution of Transvaginal High-Resolution Ultrasound in Fetal Neurology

Fig. 12: Early cranial circulation at 7 weeks of gestation. Left upper

shows B-mode image of sagittal section and right figure shows fetal
circulation by bidirectional power Doppler technology

are demonstrated between pia mater and longitudinal vein of

Schlesinger in the anterior coronal cutting section and between
brain surface and periventricular subependymal area in the
parasagittal section29 (Fig. 14). Medullary vessels are detectable
Fig. 14: Medullary vessels in normal 29-week fetus by 3D bidirectional
from early second trimester and they rapidly develop during power Doppler. (Upper) Coronal cutting section of 2D (left) and 3D
second trimester as shown in Figure 15. Medullary vessels are reconstructed images (right). (Lower) parasagittal cutting section of 2D
developing according to advancing gestational age in normal (left) and 3D reconstructed images (right). Medullary veins are
demonstrated between pia mater and longitudinal vein of Schlesinger
cases and maldevelopment of those vessels may relate with the in the anterior coronal cutting section and between brain surface and
postnatal neurological prognosis.29 Figure 16 shows two cases; periventricular subependymal area in the parasagittal section
one case had morphologically normal brain structure but
abnormally maldeveloped medullary vessels and the other case
had morphologically abnormal brain structure (ventriculo-
megarly) but normally developed medullary vessels. The former
case had unfavorable neurological prognosis and the latter case
have had favorable neurological prognosis. Of course, we have
to be prudent to jump to conclusion because each case has
different basic diseases or syndromes, therefore we have to
analyze case by case.

FUTURE ASPECT
As described in this article, transvaginal high-resolution Fig. 15: Development of medullary vessels in the second trimester.
ultrasound technology has greatly contributed to fetal Medullary vessels (yellow circles) at 19 and 24 weeks of gestation.
These images were taken from the same fetus. Thus, medullary vessels
neuroscience. Neurological prognosis should be longitudinally are detectable from early second trimester and they are rapidly
and carefully evaluated according to precise diagnoses. developing during second trimester

Fig. 13: Brain circulation at 14 weeks by 3D bidirectional power Doppler. (Left) Volume contrast imaging in coronal cutting section. (Middle) 3D
bidirectional power Doppler reconstructed image with B-mode. (Right) Brain angiography by 3D bidirectional power Doppler. These three images
are obtained by a single acquisition

Donald School Journal of Ultrasound in Obstetrics and Gynecology, April-June 2011;5(2):93-99 97

Ritsuko K Pooh

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