48 Pooh & Pooh, Special Issue on 3D sonography in perinatal medicine

J. Perinat. Med. The assessment of fetal brain morphology and circulation by

30 (2002) 48±56
transvaginal 3D sonography and power Doppler

Ritsuko K. Pooh1 and Kyong Hon Pooh2

1Department of Perinatology, Taijukai-Kaisei General Hospital, Sakaide, Japan,

2Department of Neurosurgery, National Kagawa Children's Hospital, Zentsuji,
Japan

1 Objective ogy, sono-angiography, and volumetric analysis. In

High-frequency transvaginal sonography has con-
tributed to prenatal diagnosis of early fetal brain
[25]. Transvaginal approach to the fetal brain in
middle and late pregnancy, introduced in the be-
ginning of 1990s [10], opened a new field in med-
icine: ªneurosonographyº [24]. It was the first
practical application of three-dimensional central
nervous system assessment by two-dimensional
(2D) ultrasound. Transvaginal observation of the
fetal brain offers sagittal and coronal views of the
brain from fetal parietal direction [11, 15, 19, 24]
through the fontanelles and/or the sagittal suture
as ultrasound windows. Fetal intracranial struc-
ture can be demonstrated in serial oblique sec-
tions [24] via the same ultrasound window. This
method has contributed to prenatal diagnoses of
congenital brain abnormalities, especially when
compared with the conventional transabdominal
method. Furthermore, color/power Doppler tech-
nology [13, 14, 18] combined with transvaginal
ultrasound has made it possible to visualize fetal
vessels. In 1996, we demonstrated the brain circu-
lation from early to late gestation by the use of
transvaginal 2D power Doppler angiography [14]
and in 1999 also reported that transvaginal 2D
color Doppler demonstrated the intracranial ve-
nous circulation, one of the indices for increased
intracranial pressure [18].
Three-dimensional (3D) ultrasound, recently in-
troduced into the obstetrical field [3, 5, 6, 7, 9, 23]
has produced not only fetal superficial imaging,
but also multiplanar analysis of inside morphol-
fetal neuroscan, combining both transvaginal so-
nography and 3D ultrasound [12, 16, 17, 20, 21, 22,
26] may provide a great diagnostic tool for evalua-
tion of the three-dimensional structure of the fetal
brain. In 2000, we examined 326 normal cephalic
fetuses by transvaginal 3D sonography and de-
scribed its usefulness in fetal brain assessment
[21]. Our results showed that transvaginal 3D
multiplanar imaging could demonstrate the brain
structures in more cutting sections than conven-
tional 2D transvaginal sonography. The objective
of this article is to describe the use of transvaginal
3D ultrasound in prenatal neuroimaging and to
investigate its clinical usefulness.
2 Methods
Between January 1999 and September 2001, we
examined 25 fetuses with central nervous system
(CNS) diseases. From the 25 fetuses, 18 fetuses
with hydrocephalus, ventriculomegaly and/or
space occupying lesion were nominated for this
study. All fetuses were examined by transvaginal
3D sonography, VOLUSON 530D (Medison CO.,
Seoul, Korea) and fetal central nervous system
(CNS) abnormalities were evaluated. All 3D vo-
lume data sets were saved on magneto-optical
disks. Multiplanar image analysis (figure 1) and
volumetric assessment were performed off-line
using PC 3D-View, version 3.2 to 4.0 (Kretztech-
nik AG, Zipf, Austria). Volume image of target
organs of the intracranial cavity, lateral ventricle
and space-occupying lesion were rotated with 15

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Pooh & Pooh, Special Issue on 3D sonography in perinatal medicine 49

Figure 1. Tomographic brain images of the sagittal, coronal and axial sections (20 weeks' normal fetus). After 2 to 6
seconds' fan-scan of the fetal brain, three orthogonal views can be obtained and parallel slicing of each view is
possible.

Figure 2. 3D volumetry of normal fetal brain. Volume image of target organs of the intracranial cavity can be rotated
with 15 to 30 degrees manually traced (above). When image rotation and manual tracing are finished, extracted
images of target organs and estimated volume were automatically demonstrated (below).

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50 Pooh & Pooh, Special Issue on 3D sonography in perinatal medicine

to 30 degrees on the three orthogonal views and
manually traced. When image rotation and man-
ual tracing were finished, extracted images of tar-
get organs and estimated volume were automati-
cally demonstrated (figure 2). Volume imaging
and volume calculation of the intracranial cavity,
enlarged ventricles, cystic lesion, cerebellum or
infratentrial space were performed in each case.
Longitudinal assessment of volume changes of
each target structure was done, and usefulness
of transvaginal 3D ultrasound was evaluated.
Secondly, by using 3D power Doppler of VOLU-
SON 530D (Medison Co., Seoul, Korea) or color
power angio of HDI 5000 (Advanced Technolo-
gies Laboratories, Bothell, USA), 56 normal ce-
phalic singleton fetuses between 18 and 32 weeks'
gestation with obtaining transfontanelle view of
the brain structure were examined to demonstrate
the intracranial vascular structure. Transvaginal B
mode sonography for orientation of the brain
structure was followed by automatic or manual
power Doppler volume acquisition and 3D recon-
struction of the brain circulation was performed.

Table I. 3D sonographic assessment in 18 cases with various CNS abnormalities

case sonographic diagnosis of CNS follow-up TV-3- longitudinal volumetric assess- use-
period DUS 3D assess- ment ful-
(weeks) ment ness
of 3D
US
1 Moderate ventriculomegaly with partial 20 to 21 2 possible ventricles yes
ACC times
2 Rhombencephalosynapsis, ventriculo- 24 to 40 5 possible ventricles yes
megaly
3 Huge arachnoid cyst, hemispheric 31 to 34 4 possible cyst, enlarged ven- yes
asymmetry tricle
4 Large cisterna magna 30 to 38 4 possible infratentrial space yes
5 Cerebral hypoplasia and hypoplastic CC 37 1 impossible ventricles yes
6 Cerebellar hypoplasia, mild ventriculo- 25 to 37 2 possible ventricles, cerebel- yes
megaly lum
7 Unilateral hydrocephalus 28 to 37 6 possible enlarged ventricle yes
8 Hydrocephalus, Chiari type II, Mye- 30 to 34 3 possible ventricles yes
loschisis
9 Asymmetrical hydrocephalus, Myelo- 18 1 impossible enlarged ventricle yes
meningocele
10 Supratentrial arachnoid cyst 29 to 38 8 possible cystic lesion yes
11 Asymmetrical hydrocephalus with ACC 33 to 37 5 possible ventricles yes
12 periventricular leukomalacia, ventricu- 27 to 37 6 possible ventricles yes
lomegaly
13 Defect of the SP, Meningocele, ventri- 37 to 38 2 possible ventricles yes
culomegaly
14 Intraventricular hemmorrhage, ventri- 12 to 38 12 possible ventricles yes
culomegaly
15 Defect of the SP, ventriculomegaly 29 to 38 6 possible ventricles yes
16 Hydrocephalus, Chiari type II, Myelo- 33 to 35 3 possible ventricles yes
meningocele
17 ACC, interhemispheric cyst, unilateral 30 to 31 2 impossible cyst, enlarged ven- yes
ventriculomegaly tricle
18 Dandy Walker variant, ventriculome- 12 to 37 12 possible ventricles yes
galy
TV; transvaginal, 3D; three-dimensional, US; ultrasound, ACC; agenesis of the corpus callosum, CC; corpus
callosum, SP; septum pellucidum

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Pooh & Pooh, Special Issue on 3D sonography in perinatal medicine 51

Figure 3. Tomographic images of the coronal, axial and sagittal sections of hydrocephalus. (31 weeks).

Figure 4. Three orthogonal views of 31 weeks' brain with arachnoid cyst. Supratentrial cystic lesion is seen on the
sagittal (upper left), coronal (upper right) and axial (lower left) sections.

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52 Pooh & Pooh, Special Issue on 3D sonography in perinatal medicine
3 Results
Our 18 cases were associated with various CNS
abnormalities, which are shown in table I. 16 of the
18 cases were referral and two cases (cases 14 and
18) were examined in our institute from early
pregnancy. Transvaginal neuroscan was per-
formed in all cases. Follow-up scanning proce-
dures started between 12 and 37 weeks' gestation
with variable follow-up periods. Transvaginal 3D
neuroscan was attempted every one or two weeks,
and the number of scans varied between 1 and 12.
In two cases (cases 5 and 9) only one scan was
carried out because of immediate termination of
pregnancy, thus making longitudinal assessment
impossible. Case 6 was followed-up for 13 weeks
but transvaginal scan was successful only twice
due to fetal inappropriate position. By multiplane
image analyses, the brain pathology could be de-
monstrated in the coronal, axial and sagittal sec-
tions (figures 3 and 4). Longitudinal changing ap-
pearance in the same cutting section of the
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enlarged ventricle (figure 5) or cystic lesion was
demonstrated all cases, and volumetric assessment
(figure 6) was also successful in all cases. 3D multi-
plane image analysis and volumetric data were
shown using computer presentation to neurosur-
geons, neonatologists and parents in prenatal con-
sultation and counselling. In all cases, brain
pathology was compared with the normal struc-
ture of the same gestational age on the same
cutting section. In cases where longitudinal assess-
ment was possible, the changing appearance of the
brain pathology in the same cutting section and
changing volume data were evaluated.
In the second study of visualization of the brain
circulation, the Doppler acquisition time was be-
tween 5.6 and 26 seconds. In 29 cases (51.8 %), the
Willis' ring, anterior cerebral arteries, bilateral
middle cerebral arteries and their branches were
symmetrically demonstrated (figure 7). Causes of
failure of vascular demonstration were fetal head
movements during volume acquisition.
Figure 5. Demonstration of
longitudinal (29 to 36 weeks'
gestation) changing appearance
of the enlarged ventricle in the
same cutting section (case with
unilateral ventriculomegaly).
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Pooh & Pooh, Special Issue on 3D sonography in perinatal medicine 53

Figure 6. Volume images and estimated volume of abnormal brain structure. a) Enlarged ventriclar volume in a
bilateral hydrocephalic case. b) Interhemispheric cyst volume in a case with agenesis of the corpus callosum.
c) Enlarged ventricular volume in a case with unilateral ventriculomegaly. d) Arachnoid cyst volume.

Figure 7. Normal cerebral vascular image by 3D sono-angiography (30 weeks). Middle and anterior cerebral
arteries and their branches are seen.

4 Discussion requires shifting and changing the angle of the

4.1 Intracranial multiplane imaging analysis
The advantage of transvaginal 2D imaging of the
fetal brain is that a series of sagittal oblique sec-
tions and coronal oblique sections are produced
from the same ultrasound window. However, this
transducer within the narrow space of the vagina,
considerable scanning duration for image data
storage and skillful use of the transducer [20,
21]. Fan-scanning of transvaginal 3D automatic
volume acquisition, which requires only 1.84 to
6. 07 seconds for brain scanning without a shift and

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54 Pooh & Pooh, Special Issue on 3D sonography in perinatal medicine
angle-change of the transducer [21], has solved the
problems of transvaginal 2D scanning. Rotating
brain volume image produces multiplanar image
analysis of the fetal intracranial structure in any
cutting section. It is possible to demonstrate not
only the sagittal and coronal sections but also the
axial section of the brain, which cannot be demon-
strated from parietal direction by conventional
2D transvaginal sonography. Parallel slicing pro-
vides a tomographic visualization of internal mor-
phology similar to MR imaging. Transvaginal 3D
multiplanar imaging, which demonstrates the
brain structures in more cutting sections than con-
ventional 2D transvaginal sonography [21], en-
ables a longitudinal observation in exactly the
same section. Timor-Tritsch and his colleagues
[26] used the same 3D neuroscan and reported
easy demonstration of `the three horn view': the
entire lateral ventricle including the anterior, pos-
terior and inferior horns. In our study, we used the
three horn view in evaluating longitudinal change
of enlarged ventricles as shown in figure 5. Three
orthogonal views can be rotated simultaneously,
the `marker dot' [12] on each view indicates the
same point of the brain structure and helps neuro-
navigation in rotating brain image and parallel
tomographic slicing. Monteagudo and her collea-
gues [12] used the same methods of transvaginal
3D neuroscan and concluded that the ability to
`navigate' in the volume and the `marker dot'
enable exact location of normal structures and
evaluation fetal brain pathology. Saved raw vo-
lume data can be repeatedly reviewed and easy
consultation by internet is possible [12, 21]. Thus,
transvaginal 3D ultrasound and off-line multipla-
nar image analysis provides intelligible informa-
tion on the intracranial condition in utero.
4.2 Volumetric analysis of brain structure
Blaas and his colleagues first reported 3D volume
imaging of fetus brain cavities at seven to ten weeks
Abstract
Objective: The objective of this article is to describe the
use of transvaginal 3D ultrasound in prenatal neuroima-
ging and to investigate its clinical usefulness.
Methods: Firstly, 18 fetuses with hydrocephalus, ventri-
culomegaly and/or space occupying lesion were exam-
ined by transvaginal 3D sonography, and fetal CNS ab-
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of gestation in 1995 [1]. They extracted the detailed
structure of premature hemisphere, diencephalon,
mesencephalon, and rhombencephalon in vivo by
3D ultrasound. Thereafter, they reported volume
estimation of fetal brain cavities in early fetuses [2].
In our study, fetal brain abnormalities in middle
and late pregnancy were evaluated utilizing virtual
organ computer aided analysis (VOCALTM). Vo-
lume analysis of the structure of interest provides
an intelligible evaluation of the brain structure in
total, and also longitudinal and objective assess-
ment of enlarged ventricles and intracranial occu-
pying lesions. Any intracranial organ can be chosen
as a target for volumetry, no matter how distorted
its shape and appearance may be.
4.3 3D sono-angiography of brain vessels
3D Doppler technology has great potential for
detecting the brain vasculature and brain perfu-
sion during pregnancy, which plays an important
role for brain development [16, 17, 22]. Recently,
several reports have been published to detect Ga-
len's aneurysm by 3D power Doppler [4, 8]. The
fetal head position, long acquisition time of
3D power Doppler and fetal head movements still
represent problems for the demonstration of fetal
brain vessels by 3D Doppler system. Future ad-
vances in technology resulting in short acquisition
times and allowing detection of fine vascular anat-
omy will resolve some of the present difficulties.
5 Conclusion
Transvaginal 3D imaging technology provides us
not only with comprehensive intracranial images
in exactly the right sections, but also with objective
volume data. Prenatal information with objective
data analyses is useful in consultation for both
neurological specialists and parents, and leads to
proper management of cases with CNS diseases.
normalities were evaluated. Multiplanar image analysis
and volumetric assessment were performed off-line.
Longitudinal volume changes of target structure were
evaluated, and usefulness of transvaginal 3D ultrasound
was evaluated. Secondly, in 56 normal cephalic fetuses of
between 18 and 32 weeks, 3D Doppler volume acquisi-
J. Perinat. Med. 30 (2002)
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Pooh & Pooh, Special Issue on 3D sonography in perinatal medicine
tion and reconstruction of the intracranial vascular
structure were performed.
Results: Longitudinal changing appearance in the same
cutting section of the enlarged ventricle or cystic lesion
could be demonstrated in all cases and volumetric as-
sessment was also successful in all cases. Longitudinal
objective data were useful in the brain assessment, con-
sultation and counselling. 3D Doppler acquisition time
Keywords: Circulation, fetal brain, hydrocephalus, intracranial cyst, morphology, power Doppler, three-dimensional
ultrasound, transvaginal sonography, ventricle, volume.
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55
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ultrasonography of the fetal brain. Semin Perinat Three-dimensional ultrasound evaluation of the
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