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Grand Rounds

Can Prenatal Brain Imaging of Fetuses Undergoing Prenatal NTD Repair Predict Who will Require Postnatal Hydrocephalus Treatment?

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BACKGROUND AND PURPOSE:

  • Zarutskie et al. (Ultrasound in Obstetrics & Gynecology, 2019) examined if prenatal brain imagining in fetuses that underwent prenatal NTD repair could predict the need for postnatal hydrocephalus treatment

METHODS:

  • Retrospective study
    • Fetuses who underwent prenatal in-utero myelomeningocele repair
  • Timing of data collection
    • Presurgery ultrasound
    • Presurgery MRI
    • 6-week postsurgery MRI
    • Predelivery ultrasound
  • Independent variables collected
    • Gestational age
    • Head circumference
    • Mean ventricular width
    • Ventricular volume (MRI only)
    • Hindbrain herniation (HBH) score (MRI only)
    • Level of lesion (LOL) defined as the upper bony spinal defect (presurgery ultrasound only)
  • Additional variables were calculated based on measurements
    • Change in degrees of HBH
    • Ventricular width growth (mm/week)
    • Ventricular volume growth (mL/week)
  • Pediatric neurosurgeon determined need for hydrocephalus treatment based on standard of care
    • ventriculoperitoneal shunt or endoscopic third ventriculostomy with choroid plexus cauterization
  • Predictive value assessed using
    • ROC curves
    • Logistic regression analyses

RESULTS:

  • 50 fetuses included
    • 32 open hysterectomy | 18 fetoscopic repair
    • 2 neonates in fetoscopic group died and were therefore not included in final analysis
  • Mean gestational age
    • Presurgery ultrasound: 21.8 weeks
    • Presurgery MRI: 22.0 weeks
    • Postsurgery MRI: 30.4 weeks
    • Predelivery ultrasound 31.0 weeks
  • 16 subjects required hydrocephalus treatment
  • Strongest individual predictor for HT: Degree of HBH on postsurgery MRI
    • HBH score on postsurgery MRI: AUC 0.86 (P <0.01)
    • MRI ventricular volume growth: AUC 0.79 (P = 0.01)
    • Change in HBH: AUC 0.82 (P = 0.01)
    • Postsurgery MRI ventricular volume: AUC 0.73 (P = 0.03)
    • Mean ventricular width on predelivery ultrasound (0.73; P = 0.01)
  • Other variables had lower AUCs < 0.7
  • Combining studies improved accuracy with the best prediction when using
    • Ventricular volume growth ≥2.02 mL/week and/or HBH of 3 on postsurgery MRI
    • Odds ratio (OR) 42 (95% CI, 4–431; accuracy 84%)
  • Another strong predictor (following logistic regression)
    • Persistence of severe HBH 6 weeks after surgery (MRI)
    • OR 39 (95% CI, 4–369; accuracy 84%)
  • Similar results using MOMS trial criteria for hydrocephalus treatment

CONCLUSION:

  • The most accurate predictor of the need for postnatal HT
    • Significant growth (> 2.02 mL/week) in ventricular volume
    • 6-week postsurgery MRI with HBH score of 3 and lack of reversal of HBH
    • Mean ventricular width ≥ 15 mm on presurgery ultrasound
  • Many baseline measurements (e.g., degree of HBH) prior to surgery were poor predictors
  • The authors also conclude that aside from predictive value and counseling aid, the results of this study support the hypothesis that HBH is a significant driver of hydrocephalus in these patients

Learn more – Primary Sources:

Prenatal brain imaging for predicting need for postnatal hydrocephalus treatment in fetuses that had neural tube defect repair in utero

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Related ObG Topics:

NICHD Study Update: Does Prenatal Surgery of Myelomeningocele Improve Motor Development Beyond 2 Years Follow-Up?
Prenatal vs Postnatal Spina Bifida Repair and the Impact on Neurodevelopmental Impairment
Neural Tube Defects: Definitions, Key Clinical Findings and Management

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