Received: 12 September 2019 Revised: 28 December 2019 Accepted: 29 December 2019

DOI: 10.1002/pd.5649

ORIGINAL ARTICLE

Prenatal ultrasound findings of holoprosencephaly spectrum:

Unusual associations

Sara H. El-Dessouky1 | Mona M. Aboulghar2 | Hassan M. Gaafar2 |

Rana M. Abdella2 | Marwa F. Sharaf2 | Mohamed I. Ateya2 | Ahmed Ezz Elarab2 |
Walaa H. Zidan2 | Rania M. Helal2 | Samah M. Aboelsaud2 | Maha M. Eid3 |
Ghada M.H. Abdel-Salam4

1
Prenatal Diagnosis & Fetal Medicine
Department, Human Genetics and Genome Abstract
Research Division, National Research Centre, Objective: The objective of this study is to evaluate the prenatal diagnosis, postnatal
Cairo, Egypt
2 characteristics, and the spectrum of associated findings in fetuses with holopro-
Fetal Medicine Unit, Cairo University, Cairo,
Egypt sencephaly (HPE).
3
Human Cytogenetics Department, Human Methods: Fetal neurosonograms, postnatal assessment, and chromosomal analysis
Genetics and Genome Research Division,
National Research Centre, Cairo, Egypt were performed in a cohort of 25 fetuses with HPE.
4
Clinical Genetics Department, Human Results: The prevalence of HPE in high-risk pregnancies was 4.4:10 000. The alobar
Genetics and Genome Research Division,
subtype was the most frequently encountered, with 17 cases (68%). Interestingly,
National Research Centre, Cairo, Egypt
among them, four cases (16%) presented with the rare agnathia-otocephaly complex.
Correspondence
Chromosomal abnormalities were detected in 11 cases (44%), the most frequent being
Sara H. El-Dessouky, Prenatal Diagnosis & Fetal
Medicine Department, Human Genetics and trisomy 13 in seven cases (five alobar, one semilobar, and one lobar HPE), followed by
Genome Research Division, National Research
trisomy 18 in two cases with semilobar HPE. One case of alobar HPE had 45, XX,
Centre, Tahrir Street, Dokki, Cairo, Egypt.
Email: saraeldessouky@yahoo.com t(18;22) (q10;q10), −18p karyotyping, and one case of semilobar HPE was associated
with triploidy. Facial malformations in HPE spectrum ranged from cyclopia, proboscis,
Ghada M.H. Abdel-Salam, Clinical Genetics
Department, Human Genetics and Genome and arrhinia that were associated with the alobar subtype to hypotelorism and median
Research Division, National Research Centre,
cleft that were frequent among the semilobar and lobar subtypes. Associated neural
Tahrir Street, Dokki, Cairo, Egypt.
Email: ghada.abdelsalam@yahoo.com tube defects were identified in 12% of cases.
Conclusion: Our study illustrates the clinical and genetic heterogeneity of HPE and
Funding information
The authors received no specific funding for describes different chromosomal abnormalities associated with HPE.
this work.

1 | I N T RO DU CT I O N interhemispheric fissure: lobar, semilobar, and alobar HPE.5,6

Holoprosencephaly (HPE, MIM; 236100) is a common brain
malformation affecting the developing forebrain and midface, and
it results from incomplete midline cleavage of the prosencepha-
1,2
lon. Its prevalence is 1 in 200 to 250 during embryogenesis.
However, it is less common in live births (0.4-1.2/10 000) because
of the high proportion of intrauterine lethality.4
According to DeMyer's classification, three types of HPE with
increasing severity are described based on the degree of separation
of the prosencephalon and the presence or absence of the
Milder subtypes of HPE include middle interhemispheric (MIH) vari-
ant or syntelencephaly, characterized by the presence of a degree
of MIH fusion,7 and the septo-preoptic type, in which non-
separation is restricted to the septal and/or preoptic regions.8,9
3
Since both the forebrain and midface arise from the prechordal
mesoderm, HPE is usually associated with a spectrum of characteristic
craniofacial anomalies in approximately 80% of individuals, constituting
the “HPE sequence.”10 The most severe facial phenotypes include pro-
nounced microcephaly, cyclopia (a single eye or partially divided eye in a
single orbit with or without proboscis above the eye), ethmocephaly

Prenatal Diagnosis. 2020;40:565–576. wileyonlinelibrary.com/journal/pd © 2020 John Wiley & Sons, Ltd. 565
566 EL-DESSOUKY ET AL.

(extreme ocular hypotelorism with proboscis located between the eyes),

and cebocephaly (ocular hypotelorism with a single nostril).11 Less severe
facial phenotypes include premaxillary agenesis (ocular hypotelorism with
median cleft lip and palate and a single maxillary central incisor).12
Agnathia-otocephaly complex (AGOTC) is an extremely rare mal-
formation, which can be associated with HPE, with a reported preva-
lence of less than 1 per 70 000 births.13 It occurs due to failure of the
first arch development and is characterized by HPE in association with
a spectrum of malformations ranging from isolated agnathia, or virtual
absence of the mandible, to otocephaly, which refers to a broader
malformation of mandibular hypoplasia, downward displacement of
the ears and/or synotia (approximation of the ears in the midline),
with or without aglossia (no tongue), and microstomia (small mouth).14
It is considered a lethal condition due to severe compromise of the
upper respiratory tract.2,15
Holoprosencephaly may occur in isolation (nonsyndromic);
however, 18% to 25% of HPE cases occur as part of a syndrome.2
The etiology of HPE is extremely heterogeneous including monogenic,
What's already known about this topic?
• The clinical and genetic heterogeneity of holopro-
sencephaly (HPE) is already known, as well as its associa-
tion with trisomies 13 and 18.
What does this study add?
• Our study provides a preliminary prevalence of HPE
among high-risk pregnancies in Egypt.
• We present the clinical and imaging findings of the rare
association of HPE with triploidy and unbalanced translo-
cation of 18 and 22.
• This study highlights the known association of agnathia-
otocephaly spectrum with other midline defects, such as
neural tube defect and omphalocele.

F I G U R E 1 Prenatal and postmortem images of cases with holoprosencephaly (HPE) and features of agnathia-otocephaly spectrum
(progression from left to right). Case #14: A, Three-dimensional surface rendering of the face showing mild hypotelorism, down-slanting palpebral
fissures, low set ears, two patent nares, microstomia, and agnathia. B, Postmortem image confirms the presence of the above findings in addition
to aglossia and synotia. Case #15: C and D, Two- and three-dimensional ultrasound images at the midsagittal view of the fetal face profile
showing complete absence of the mandible. E and F, Postmortem images confirming the presence of agnathia in addition to microcephaly, severe
hypotelorism, down-slating palpebral fissures, midface hypoplasia, synotia, and otocephaly with ears fused in the midline. Case #16: G,
Postmortem image showing microcephaly, synophthalmia, midline frontal proboscis, chin-like structure with a blind-ending cavity in addition to
agnathia, and otocephaly. Case #17: H, Two-dimensional axial ultrasound image of the fetal skull showing an occipital encephalocele with brain
tissue herniating though a defect in the occipital bone in addition to microcephaly. I, Postmortem imaging confirming the microcephaly and
posterior cephalocele with microcephaly. J, Postmortem image of the face showing cyclopia; midline proboscis; the ears are horizontally placed
below the eyes and are completely fused (synotia and otocephaly); there are agnathia and astomia
EL-DESSOUKY ET AL. 567

chromosomal, and environmental factors.1,16 Pathogenic variants in a 2 | MATERIAL AND METHODS

growing list of genes including SHH, SIX3, ZIC2, and TGIF1 or less fre-
quently GLI2, PTCH1, DISP1, FOXH1, NODAL, TDGF1, CDON, GAS1,
DLL1, STIL, STAG2, and SMC1A have been reported.17 The genes
PRRX1, OTX2, and CRKL have been associated with AGOTC.18,19 The
prognosis and risk of recurrence differ according to the underlying eti-
ology. The risk of recurrence in euploid fetuses with HPE has been
reported to be 20%.16
Current prenatal diagnostic protocols of HPE involve combined fetal
imaging analyses (2D and 3D ultrasonography) with cytogenetic and
molecular genetic testing of suspected cases.1 Ultrasound is the best
screening method for identifying fetal central nervous system (CNS) mal-
formations, given its safety, widespread availability, low cost, good sensi-
tivity, and real-time evaluation of the fetus. High-frequency transducers,
transvaginal sonography, dedicated 3D transducers, and targeted neu-
rosonogram in addition to fetal magnetic resonance imaging (MRI) have
increased the ability to demonstrate structures or pathological conditions.5
In this study, we provide detailed sonographic appearance and
the prenatal and postnatal clinical data of HPE in a cohort of
25 fetuses. The phenotypes of those with and without chromosomal
abnormalities were also compared.
A cohort of 25 fetuses was diagnosed with HPE based on ultrasound
findings during the period from January 2017 to June 2019. The cases
were collected from a cohort of 56 700 pregnant females referred for
detailed fetal anatomy scan in the Cairo Fetal Medicine Unit (Cairo Uni-
versity). This research was reviewed and approved by the Medical
Research Ethics Committee of the National Research Centre according
to the “World Medical Association Declaration of Helsinki,” and written
informed consent was obtained.
All patients were examined by fetal medicine specialists with a
minimum of 5 years' experience using Voluson E8 or Voluson E6
(GE Medical Systems, Zipf, Austria) ultrasound machines with 4- to
8-MHz curvilinear abdominal probes and 5- to 9-MHz curvilinear
vaginal probe. Gestational age was calculated from the reported last
menstrual period or adjusted to fetal biometry where appropriate. The
ultrasound examination included a detailed fetal neurosonogram
accompanied by assessment of the fetal face and extended scan for
other associated structural malformations.
Prenatal ultrasound diagnosis was based on the association of
brain anomalies (wide monoventricular cavity, thalamic fusion, and

F I G U R E 2 Case #1: Fetus with alobar holoprosencephaly (HPE), cyclopia, proboscis, and trisomy 13. A, Axial oblique ultrasound (US) image of
alobar HPE; cerebral hemispheres fused with a single midline ventricle in the middle; in the occipital region, a large dorsal cyst is present, pushing
anteriorly the dorsal part of the prosencephalon. B, Coronal image showing the cerebral hemispheres, which are completely fused with a single
horseshoe-shaped midline ventricle in the middle, fused thalami, absence of midline structures, and minimal overlying brain tissue (thin brain
mantle). C, A fetal echocardiogram showing ventricular septal defect. D, Coronal US image of multicystic dysplastic kidney (MCDK) showing
several subcortical small cysts. E and F, Three-dimensional surface rendering of fetal face view showing proboscis, cyclopia, and arrhinia.
Postmortem image of the of fetal face confirming the presence of cyclopia, proboscis, and a single globe with no covering eyelid. G, Postmortem
showing an area of cutis aplasia congenita on the scalp. H, Postmortem image showing postaxial polydactyly of the feet. I, Trisomy 13 shown by
FISH on uncultured amniocyte with three copies of the red signal (LSI 13/Spectrum Red) representing three chromosome 13s
568 EL-DESSOUKY ET AL.

lack of median structures) with or without facial dysmorphism
(hypotelorism, orbital anomalies, and median facial clefts). Parents were
informed with the findings including the prognosis. Genetic counseling
and testing (amniocentesis for karyotyping or FISH) were offered to all
cases. Additionally, a three-generation pedigree was constructed for
each family to detect any consanguinity or similarly affected family
members. Postnatal examination and was done to all cases but postna-
tal MRI was arranged for those who continued pregnancy.
In 13 cases (52%), the parents opted to terminate the pregnancy, and
there was one (4%) intrauterine fetal death (IUFD) in a mother with
uncontrolled type 1 diabetes; in those cases, the parents refused
autopsy. Only 11 (44%) fetuses were born alive between 36 and
38 weeks; however, they died shortly after birth.
3.2 | Classification of HPE

Among the 25 cases of HPE, 17 were diagnosed at ultrasound with

3 | RESULTS
3.1 | Pregnancy characteristics and outcome
A total of 25 HPE fetuses were included in this study (nine males and
16 females). The prevalence of HPE in our cohort of high-risk preg-
nancies was 4.4:10 000, and the M:F sex ratio was 0.36 showing
female predominance. The mean gestational age at time of diagnosis
by ultrasound was 20 weeks ± 5 days (range 14-26 weeks). The mean
maternal age was 26.2 (range 18-36) years; mean paternal age was
34 (range 24-45) years. History of maternal diabetes was confirmed
in nine patients (36%); no history of exposure to teratogens or infec-
tions was reported. Consanguinity was present in eight cases (32%).
alobar HPE (68%), seven (28%) with semilobar, and one (4%) with
lobar HPE. Four cases (16%) presented with the rare AGOTC in asso-
ciation with alobar HPE (Figure 1).
In all our 17 cases of alobar HPE, the cerebral hemispheres were
completely fused into a holosphere, the interhemispheric fissure was
completely absent, and no midline structures were present, including
the entire falx cerebri, interhemispheric fissure, third ventricle, cavum
septum pellucidum, or corpus callosum. The interhemispheric fissure
and falx cerebri were present posteriorly in seven cases with
semilobar HPE, resulting in an evident posterior midline echo and
incompletely fused thalami. The frontal horns of the lateral ventricles
were fused forming a single “midline ventricle,” but the posterior
horns and trigones were separated. In the case with lobar HPE, there

F I G U R E 3 Case #25: Fetus with lobar holoprosencephaly (HPE) and trisomy 13. A, Axial plane of fetal head with lobar HPE showing
hypoplastic anterior interhemispheric fissure, fused rudimentary frontal horns, absent cavum septum pellucidum, and anteriormost part of the
interhemispheric fissure. B, Coronal ultrasound (US) shows an absent CSP, thin dysplastic corpus callosum, and fused fornices. C, Chromosomal
examination using G-banding technique showing trisomy 13. D and E, Three-dimensional surface rendering of face showing hypotelorism,
hypoplastic nose with flat nasal bridge, and a midline cleft associated with absence of the philtrum (premaxillary agenesis). Postmortem imaging of
the face matching the US findings. F and G, Three-dimensional surface rendering mode of lower extremities showing hyperextended knees and
bilateral arthrogryposis with deformed lower limbs; postmortem imaging matching the US findings
EL-DESSOUKY ET AL. 569

was near complete cleavage of the hemispheres, the interhemispheric
fissure was present along the entire midline, and the ventricles were
fused only in the most ventral aspects of the frontal neocortex, with
typical rudimentary frontal horns. The thalami were completely sepa-
rated, the third ventricle was present, the falx cerebri was present
anteriorly, the corpus callosum was normal, but the septum
pellucidum was absent.
3.3 | Chromosomal examination
Chromosomal analysis was performed in 24 (96%) fetuses. One with
IUFD was not available for sampling. Eleven cases (44%) had abnormal
karyotyping results. Trisomy 13 was the most common aberration and
was detected in seven cases (70%), of which five showed alobar
(Figure 2), one semilobar, and lobar HPE (Figure 3). Trisomy 18 was
detected in two cases (20%) with semilobar HPE (Figure 4). One case
with alobar HPE had a de novo 45, XX, t(18;22) (q10;q10), −18p
karyotyping with distal 18p deletion (Figure 5). Finally, one case (4%)
with semilobar HPE showed triploidy 69, XXY (Figure 6).
3.4 | Craniofacial and associated extracranial
anomalies
Four fetuses (16%) had agnathia-otocephaly and alobar HPE. Cyclopia
or synophthalmia was present in seven cases (28%), and all of them
had alobar HPE subtype. Hypotelorism was detected in 17 cases
(68%): 10 with alobar, six with semilobar, and one with lobar HPE.
Proboscis was evident in eight cases (32%) with alobar HPE; arhinia in
eight cases (32%) (seven with alobar and one with semilobar HPE);
cebocephaly with single nostril in two cases (8%) with semilobar HPE.
A depressed nasal bridge with flat nasal tip was present in seven cases
(28%) (two with alobar, four with semilobar, and one with lobar HPE).
Median cleft lip and palate was seen in 10 cases (40%); six of them
had alobar, and four semilobar HPE. Moreover, one fetus with
semilobar HPE (4%) and triploidy had relative macrocephaly, bilateral
anophthalmia, depressed nasal bridge with flat nasal tip, midline cleft
lip and palate, polydactyly, and large placenta (Figure 2).
Twenty fetuses (80%) had microcephaly with HC ≤ 3 SD below
the mean for gestational age (15 cases with alobar and five with
semilobar HPE); the head circumference was larger than the mean in

F I G U R E 4 Two cases with semilobar holoprosencephaly (HPE) and trisomy 18. A, Axial ultrasound (US) image showing lack of cleavage of the
anterior half of the hemispheres, with fused ventricles and absent falx and interhemispheric fissure anteriorly shows a continuous mantle of brain
anteriorly; but the two cerebral hemispheres are partially separated posteriorly, and posterior falx can be seen with normal posterior fossa
structures. B, Chromosomal examination using G-banding technique showing 47, XX, +18 karyotyping. Case #20: C and D, Three-dimensional
surface rendering mode showing omphalocele; postmortem photograph shows an omphalocele, which contains only bowel (no liver); the umbilical
cord inserts at the apex of the small defect. Case #21: E and F, Three-dimensional surface rendering of the fetal face showing moderate
hypotelorism and a single-nostril nose (cebocephaly); postmortem face profile of a neonate with cebocephaly confirming the moderate
hypotelorism and the single-nostril nose. G, Maximum rendering mode of the spine with spina bifida demonstrating lateral splaying of the lateral
vertebral processes with widening of the spinal canal (meningomyelocele at level of lumbar spine)
570 EL-DESSOUKY ET AL.

F I G U R E 5 Case #6: Fetus with alobar holoprosencephaly (HPE), cyclopia, proboscis, and monosomy 18p due to unbalanced translocation
between chromosomes 18 and 22. A, Axial ultrasound imaging showing the cerebral hemispheres, which are completely fused with a single
horseshoe-shaped midline ventricle in the middle, fused thalami, absence of midline structures, and minimal overlying brain tissue (thin brain
mantle). B, Chromosomal examination using G-banding technique showing 45, XX, t(18;22) (q10;q10), −18p. C, Three-dimensional surface
rendering of fetal face view showing proboscis, cyclopia, and arrhinia. D, Postmortem confirmation of fetus showing cyclopia, proboscis, and a
single globe with no covering eyelid

the case of semilobar HPE with triploidy. Additionally, a dorsal cyst
was observed in three cases with alobar and one with semilobar HPE.
Associated neural tube defects were present in three cases
(12%), (one with large posterior cephalocele and agnathia-alobar
HPE complex, one with small frontal cephalocele and alobar, and one
with lumbar meningomyelocele with associated Chiari II malforma-
tion and semilobar HPE). Major structural anomalies were detected
prenatally in 13 cases (52%). These included cardiac anomalies in
nine cases (36%), genitourinary anomalies in seven (28%), skeletal
anomalies in the form of postaxial polydactyly of both hands and
feet in five (20%), bilateral talipus in two (8%); and associated
arthrogryposis multiplex congenita in one (4%). Omphalocele was
detected in two cases (8%); and aplasia cutis congenita in one case
associated with trisomy 13 (4%) (Figure 5). Eleven cases (44%) had
intrauterine growth retardation (IUGR). Further details, the cerebral
and facial findings of the fetuses are described in Tables 1–4 and
Figures 1 to 6.
4 | DISCUSSION
In the present study, we describe the prenatal ultrasound findings of a
cohort of 25 fetuses with HPE spectrum, in which chromosomal
abnormalities were detected in 11 fetuses (44%) including trisomy
13, trisomy 18, unbalanced translocation between chromosomes
18 and 22 resulting in monosomy 18p, and triploidy. Our results are in
line with published evidence showing 32% to 41% chromosomal
abnormalities among patients with HPE.1,2,20-22
The prevalence of HPE in our study was 4.4/10 000, which is
higher than what is reported in the literature.23-26 Interestingly, a
similar higher prevalence was described by Naguib et al27 in Kuwait
and by Lai et al28 in a cohort of patients from Southern Taiwan. The
most likely explanation is that our hospital is the main referral center
for prenatal diagnosis in Egypt.
In the present study, trisomy 13 is the most common cause of
HPE, detected in seven cases (28%); five of them had alobar, one
had semilobar, and one lobar HPE, which is in accordance with previ-
ous studies.1,2,21,29 The mechanism of HPE in trisomy 13 is not under-
stood, but it has been postulated that ZIC2, a gene commonly
associated with HPE, is located at 13q32.3.30 Promising models for
unraveling the pathogenicity of trisomy 13 are stem cell and gene
expression research.2,31
Trisomy 18 is the second most common aneuploidy associated
with HPE in our study. Two cases with semilobar HPE (8%) had
trisomy 18. However, HPE is an uncommon CNS manifestation in
trisomy 18, which is more frequently associated with corpus callosum
EL-DESSOUKY ET AL. 571

F I G U R E 6 Case #18: Fetus with semilobar holoprosencephaly (HPE) and triploidy. A, Axial oblique ultrasound (US) image showing lack of
cleavage of the anterior half of the hemispheres, with fused ventricles and absent falx and interhemispheric fissure anteriorly; but the two
cerebral hemispheres are partially separated posteriorly, and posterior falx can be seen with normal posterior fossa structures. B, Chromosomal
examination using G-banding technique showing 69, XXY. C and D, Three-dimensional surface rendering mode of the fetal face demonstrating
bilateral anophthalmia, relative macrocephaly, and midline facial cleft. E, Postmortem image of the infant showing bilateral anophthalmia, midline
cleft associated with absence of the philtrum and nose (premaxillary agenesis), low set ears, and postaxial polydactyly of both hands and feet

agenesis, hydrocephalus, Dandy-Walker malformation, and cerebellar
hypoplasia.32-34
Additionally, neural tube defects, such as myelomeningocele,
have also been described as part of the clinical developmental malfor-
mation spectrum of trisomy 18 and were detected in one of our cases
in association with semilobar HPE.33 Interestingly, in the present
study, one case (4%) with alobar HPE had de novo unbalanced trans-
location between chromosomes 18 and 22 resulting in monosomy for
18p. The peculiar aspect of this case is the association with a dele-
tion at 18p encompassing TGIF1 gene and the HPE phenotype.
TGIF1 gene is located on a critical region of 18p11.31; and this
gene's alterations account for only 2% of the patients with HPE
35,36
with 1% for mutations and 1% for large deletions. Given sev-
eral previous reports showing monosomy 18p in association with
HPE and adding more evidences of its pathogenicity,37,38 more
research is needed to delineate the infrequent association between
both trisomy 18 and monosomy 18p with HPE and to delineate the
mechanism by which different alterations in TGIF1 gene dosage can
result in the same HPE phenotype.
Interestingly, one of the fetuses with semilobar HPE had triploidy
(4%). This represents a very rare occurrence of triploidy: At 16 weeks
of gestation, ultrasound scan showed relative macrocephaly, bilateral
anophthalmia, premaxillary agenesis with median facial cleft, and a
noncystic large placenta. Triploidy association with semilobar HPE is
extremely rare, with only two reported cases.39 Associated placental
abnormalities, midline facial clefts, and alobar HPE were the most
common anomalies. Our case had bilateral anopthalmia that had not
been reported before in cases with HPE and triploidy.
Our study includes four cases with AGOTC in association with
alobar HPE and a normal karyotype. Adjuvant 3D ultrasound was
of considerable utility; the most striking ultrasound feature was
the detection of an abnormal facial profile in the form of an absent
mandible, melotia/synotia in all the four cases. The agnathia spec-
trum with HPE facial findings has been described by Kauvar et al 14
and by Petracchi et al.16 Our findings ranged from isolated
agnathia with mild ocular hypotelorism and microstomia to severe
hypotelorism and protuberance of the nose-mouth complex resem-
bling proboscis with agnathia. The severest form of HPE facies with
cyclopia or synophthalmia and proboscis was found in two cases in
addition to otocephaly. Moreover, one of these cases showed
agnathia-otocephaly, combined with large posterior cephalocele. The
mechanisms by which HPE and agnathia occur in humans are still not
fully understood and present a challenging area for research, given
the likely complex etiology.2,14
The spectrum of facial malformations was diverse. The most
severe facial malformations of cyclopia, synopthalmia, and proboscis
TABLE 1 Clinical, ultrasound, and cytogenetic characteristics of the cases with alobar HPE
572

History of
GA at Fetal Maternal HPE
Patient No. Diagnosis, wk Sex Consanguinity Diabetes Subtype Face Associated Findings Karyotyping Outcome Postnatal MRI
1 18 M − − Alobar Cyclopia, proboscis IUGR, microcephaly, congenital 47, XY, +13 TOP NP
heart disease, cystic renal
dysplasia, polydactyly, aplasia
cutis congenita
2 16 F − − Alobar Hypotelorism, arhinia, midline IUGR, microcephaly, congenital 47, XX, +13 TOP NP
cleft lip and palate heart disease, enlarged
echogenic kidneys
3 19 F − − Alobar Hypotelorism, proboscis, midline IUGR, microcephaly, cystic renal 47, XX, +13 TOP NP
cleft lip and palate dysplasia, polydactyly
4 22 M − − Alobar Hypotelorism, depressed nasal IUGR, microcephaly, congenital 47, XY, +13 Birth at 36 wk Alobar HPE
bridge with flat nasal tip, heart disease, omphalocele,
midline cleft lip and palate cystic renal dysplasia
5 20 F + + Alobar Cyclopia, proboscis IUGR, microcephaly, congenital 47, XX, +13 TOP NP
heart disease, polydactyly
6 23 F − + Alobar Synophthalmia, proboscis, IUGR, microcephaly 45, XX, t(18;22) Birth at 36 wk Alobar
microstomia (q10;q10),
−18p
7 21 F + − Alobar Cyclopia, proboscis Microcephaly 46, XX Birth at 37 wk Alobar HPE
8 19 M − − Alobar Synophthalmia, proboscis Microcephaly, bilateral talipus 46, XY TOP NP
9 20 F + − Alobar Hypotelorism, arhinia, midline Microcephaly 46, XX Birth at 38 wk Alobar
cleft lip and palate
10 22 M − + Alobar Hypotelorism, arhinia Microcephaly, frontal 46, XY Birth 36 wk Alobar HPE
cephalocele
11 24 F − + Alobar Hypotelorism, proboscis − 46, XX TOP NP
12 14 M + − Alobar Hypotelorism, arhinia, midline − 46, XY TOP NP
cleft lip and palate
13 21 F − + Alobar Hypotelorism, arhinia, midline Microcephaly 46, XX Birth at 38 wk NP
cleft lip and palate
14 22 M + − Alobar Agnathia-otocephaly, synotia, Microcephaly, congenital heart 46, XY Birth at 36 wk NP
astomia, hypotelorism, arhinia disease, hypospadias
15 21 F − − Alobar Agnathia-otocephaly, synotia, Microcephaly 46, XX Birth at 36 wk Alobar HPE
microstomia, hypotelorism,
depressed nasal bridge with
flat nasal tip
16 23 F − − Alobar Agnathia, melotia, microstomia, Microcephaly, genitourinary 46, XX TOP NP
synophthalmia, arhinia anomalies
17 22 F − − Alobar Agnathia, astomia, synotia, Microcephaly, large posterior 46, XX TOP NP
cyclopia, proboscis cephalocele

Abbreviations: F, female; GA, gestational age; HPE, holoprosencephaly; IUGR, intrauterine growth retardation; M, male; MRI, magnetic resonance imaging; NP, not performed; TOP, termination of pregnancy.
EL-DESSOUKY ET AL.
TABLE 2 Clinical, ultrasound, and cytogenetic characteristics of the cases with semilobar and lobar HPE
EL-DESSOUKY ET AL.

GA at History of HPE
Patient No. Diagnosis, wk Fetal Sex Consanguinity Maternal Diabetes Subtype Face Associated Findings Karyotyping Outcome Postnatal MRI
18 16 M − − Semilobar Bilateral anophthalmia, IUGR, macrocephaly, Triploid 69, XXY TOP NP
depressed nasal bridge polydactyly, large
with flat nasal tip, placenta
midline cleft lip and
palate
19 18 M − + Semilobar Hypotelorism, proptosis, IUGR, microcephaly, 47, XY, +13 TOP NP
arrhinia, midline cleft congenital heart
lip and palate disease, polydactyly,
bilateral talipus
20 22 M − − Semilobar Hypotelorism, depressed IUGR, omphalocele 47, XY, +18 TOP NP
nasal bridge with flat
nasal tip, midline cleft
lip and palate
21 20 F − − Semilobar Hypotelorism, depressed IUGR, microcephaly, 47, XX, +18 Birth at 37 wk Semilobar HPE lumbar
nasal bridge with flat lumbar meningomyeleocele
nasal tip, midline cleft meningomyeleocele,
lip and palate congenital heart
disease, bilateral
enlarged echogenic
kidneys, bilateral
clenched hands
22 24 F + + Semilobar Hypotelorism, depressed Microcephaly 46, XX Birth at 36 wk Semilobar
nasal bridge with flat
nasal tip
23 20 F + + Semilobar Hypotelorism, Microcephaly, congenital 46, XX Birth at 36 wk NP
cebocephaly heart disease
24 21 F + + Semilobar Hypotelorism, Microcephaly NP IUFD NP
cebocephaly
25 26 F − − Lobar Hypotelorism, depressed IUGR, congenital heart 47, XX, +13 TOP NP
nasal bridge with flat disease, arthrogyposis
nasal tip with deformed lower
limbs

Abbreviations: F, female; GA, gestational age; HPE, holoprosencephaly; IUGR, intrauterine growth retardation; M, male; MRI, magnetic resonance imaging; NP, not performed; TOP, termination of pregnancy.
573
574 EL-DESSOUKY ET AL.

TABLE 3 Comparison between HPE fetuses who showed chromosomal abnormalities and those with normal karyotype

Alobar HPE(17) Semilobar and Lobar HPE(8)

Fetuses With Fetuses With Fetuses With

Abnormal Karyotype Normal Karyotype Abnormal Fetuses With Normal
(6;35.3%) (11;64.7%) Karyotypea (5;62.5%) Karyotype (2;25%)
Gestational age 19 wk 6 d 21 wk 1 d 20 wk 4 d 21 wk 6 d
Sex ratio (M:F) 2:4 4:7 3:2 2 females
Consanguinity 1 (12.5%) 4 (50%) 0 3 (37.5%)
Microcephaly 6 (30%) 9 (45%) 2 (10%) 2 (10%)
IUGR 6 (54.5%) 0 5 (45.5%) 0
Cyclopia or synophthalmia 3 (42.8%) 4 (57.1%) 0 0
Proboscis 4 (50%) 4 (50%) 0 0
Hypotelorsim 3 (17.6%) 7 (41.2%) 4 (23.5%) 2 (11.7%)
Arrhinia 1 (12.5%) 6 (75%) 1 (12.5%) 0
Cebocephaly 0 0 0 1 (50%)
Midline cleft lip and palate 3 (30%) 3 (30%) 4 (40%) 0
Depressed nasal bridge with flat nasal tip 1 (14.3%) 1 (14.3%) 4 (57.1%) 1 (14.3%)
Agnathia otocephaly spectrum 0 4 (100%) 0 0
Neural tube defects 0 2 (66.6%) 1 (33.3%) 0
Congenital heart disease 4 (44.4%) 1 (11.1%) 3 (33.3%) 1 (11.1%)
Genitourinary anomalies 4 (57.1%) 2 (28.6%) 1 (14.3%) 0
Skeletal anomalies 3 (37.5%) 1 (12.5%) 4 (50%) 0
Omphalocele 1 (50%) 0 1 (50%) 0
Aplasia cutis congenita 1 (100%) 0 0 0

Abbreviation: HPE, holoprosencephaly.

a
Karyotyping was not performed to one fetus of with semilobar HPE.

TABLE 4 Brain ultrasound findings encountered for each subtype of HPE

Alobar HPE Semilobar HPE Lobar HPE

Number of cases 17 7 1
Cortical hemispheres fusion Complete fusion No anterior separation but some No separation of the most
posterior separation ventral frontal cortex
Interhemispheric fissure Absent Present only posteriorly Hypoplastic anteriorly and
present posteriorly
Corpus callosum Absent Absent Thin and hypoplastic
Cavum septum pellucidum Absent Absent Absent
Lateral ventricles Single midline monoventricle Absent anterior horns of lateral Partially fused anterior horns
ventricles of lateral ventricles
Third ventricle Absent Absent Present
Dorsal cyst Present (three cases) Present (one case) Absent
Thalamus Often fused Partial fusion Usually fully separated

Abbreviation: HPE, holoprosencephaly.

with arrhinia have an overall prevalence in patients with HPE ranging
from 7.4% to 27%, and they are invariably associated with the alobar
subtype, as described in many published series.40,41 Similar findings
were detected in our cohort. Less severe findings as hypotelorism,
depressed nasal bridge with flat nasal tip, and median cleft lip/palate
were found in both alobar and semilobar HPE cases; similar results
were noticed previously.10 On the other hand, our series included a
case of lobar HPE with almost normal facial appearance apart from
mild hypotelorism.
Although alobar and semilobar types of HPE can be diagnosed in
the first trimester,8,42 the mean age of diagnosis in our study was
20 weeks + 5 days. The explanation for this relatively late diagnosis is
EL-DESSOUKY ET AL.
that most of our cases missed the first trimester scan. Only two of our
cases were diagnosed as early as 14 and 15 weeks' gestation due to the
absence of the “butterfly sign” normally formed by the two choroid plex-
uses within the lateral ventricles, as reported in other studies.8,42
Neural tube defects were detected in three cases (12%) of our
HPE cohort, including a case with lumbar meningomyelocele, which
had trisomy 18. On the other hand, the cases with frontal and poste-
rior cephaloceles had normal karyotyping. Similar findings were
reported in other studies and presumably accounted for the rarity
with which these malformations occur together.1
Twenty fetuses (80%) had microcephaly with HC ≤ 3 SD below
the mean for gestational age. In comparison, increased size of the
head due to a relative macrocephaly was observed in the case with
semilobar HPE and triploidy. A dorsal cyst was observed in three
cases with alobar and one case with semilobar HPE. In the current
study, the presence of a dorsal cyst strongly correlates with thalamic
fusion and hence alobar HPE.8,43
Systemic examination of our cases revealed varying patterns of
extracranial abnormalities in 18 cases (72%) most commonly cardiac,
renal anomalies, followed by polydactyly and omphalocele with a pre-
ponderance in fetuses with chromosomal abnormalities.22 Finally,
maternal diabetes was present in nine of our cases (36%). Maternal
diabetes was recognized as a risk factor in other studies.44,45
A limitation of our study is that although a chromosomal etiol-
ogy was established in 44% of cases, we were not able to arrange
for either a CGH or exome sequencing studies for the euploid
fetuses, which could have detected additional genetic causes of the
abnormal findings. Compliance of parents as regards the fetal MRI
and postmortem fetal autopsy was poor, which is another limitation
of the study.
In conclusion, this study highlights the clinical and genetic hetero-
geneity of HPE showing extremely rare cases with triploidy and
monosomy 18p as a result of an unbalanced translocation of 18 and
22 (q10;q10). Further, we describe four cases with the agnathia-
otocephaly spectrum.
ACKNOWLEDGEMEN TS
The authors thank the families for their participation and cooperation.
CONF LICT OF IN TE RE ST
The authors declare no conflict of interest.
DATA AVAI LAB ILITY S TATEMENT
The data supporting the findings of this study are available with the
corresponding authors upon request.
ORCID
Sara H. El-Dessouky https://orcid.org/0000-0001-7572-9128
RE FE R ENC E S
1. Van den Veyver IB. Prenatally diagnosed developmental abnormalities
of the central nervous system and genetic syndromes: a practical
review. Prenat Diagn. 2019;39(9):666-678.
575
2. KruszkaPand Muenke M. Syndromes associated with holoprosencephaly.
Am J Med Genet C Semin Med Genet. 2018;178(2):229-237.
3. Bulakbasi N, Cancuri O, Kocao glu M. The middle interhemispheric
variant of holoprosencephaly: magnetic resonance and diffusion ten-
sor imaging findings. Br J Radiol. 2016;89(1063):20160115.
4. Bous SM, Solomon BD, Graul-Neumann L, Neitzel H, Hardisty EE,
Muenke M. Holoprosencephaly-polydactyly/pseudotrisomy 13: a pre-
sentation of two new cases and a review of the literature. Clin
Dysmorphol. 2012;21(4):183-190.
5. Ionescu CA, Vladareanu S, Tudorache S, et al. The wide spectrum of
ultrasound diagnosis of holoprosencephaly. MedUltrason. 2019;21(2):
163-169.
6. De Myer WE, Zeman W, Palmer CG. The face predicts the brain: diag-
nostic significance of median facial anomalies for holoprosencephaly
(arhinencephaly). Pediatrics. 1964;3:256-263.
7. Winter TC, Kennedy AM, Woodward PJ. Holoprosencephaly: a sur-
vey of the entity, with embryology and fetal imaging. Radiographics.
2015;35:275-290.
8. Ionescu CA, Calin D, Navolan D, et al. Alobar holoprosencephaly asso-
ciated with a rare chromosomal abnormality: case report and litera-
ture review. Medicine (Baltimore). 2018;97:e11521.
9. Rajalakshmi PP, Gadodia A, Priyatharshini P. Middle interhemispheric
variant of holoprosencephaly: a rare midline malformation. J Pediatr
Neurosci. 2015;10(3):244-246.
10. Leombroni M, Khalil A, Liberati M, D'Antonio F. Fetal midline anoma-
lies: diagnosis and counselling part 2: septal anomalies. Eur J Paediatr
Neurol. 2018;22(6):963-971.
11. Dewan P, Rohatgi S, Roy S, Batra P. Ethmocephaly: a rare cephalic
disorder. J Pediatr Neurosci. 2016;11(1):92-93.
12. Hamza A, Higgins MJ. Holoprosencephaly. Autops Case Rep. 2017;7
(4):22-25.
13. Hisaba WJ, Milani HJ, Araujo Júnior E, et al. Agnathia-otocephaly:
prenatal diagnosis by two- and three-dimensional ultrasound and
magnetic resonance imaging. Case Report Med Ultrason. 2014;16(4):
377-379.
14. Kauvar EF, Solomon BD, Curry CJ, et al. Holoprosencephaly and
agnathia spectrum: presentation of two new patients and review of the
literature. Am J Med Genet C Semin Med Genet. 2010;154C(1):158-169.
15. Chaoui R, Heling KS, Thiel G, Karl K. Agnathia-otocephaly with
holoprosencephaly on prenatal three-dimensional ultrasound. Ultra-
sound Obstet Gynecol. 2011;37(6):745-748.
16. Petracchi F, Crespo L, Michia C, Igarzabal L, Gadow E. Holopro-
sencephaly at prenatal diagnosis: analysis of 28 cases regarding etiopatho-
genic diagnoses. Prenat Diagn. 2011;31(9):887-891.
17. Kruszka P, Berger SI, Casa V, et al. Cohesin complex-associated
holoprosencephaly. Brain. 2019;142:2631-2643.
18. Rodriguez N, Casasbuenas A, Andreeva E, Odegova N, Wong AE,
Sepulveda W. First-trimester diagnosis of agnathia-otocephaly com-
plex: a series of 4 cases and review of the literature. J Ultrasound
Med. 2019;38(3):805-809.
19. Patat O, van Ravenswaaij-Arts CM, Tantau J, et al. Otocephaly-
dysgnathia complex: description of four cases and confirmation of the
role of OTX2. Mol Syndromol. 2013;4(6):302-305.
20. Dubourg C, Kim A, Watrin E, et al. Recent advances in understanding
inheritance of holoprosencephaly. Am J Med Genet C Semin Med
Genet. 2018;178(2):258-269.
21. Solomon BD, Rosenbaum KN, Meck JM, Muenke M. Holopro-
sencephaly due to numeric chromosome abnormalities. Am J Med
Genet C Semin Med Genet. 2010c;154C:146-148.
22. Blaas HG, Eriksson AG, Salvesen KA, et al. Brains and faces in
holoprosencephaly: pre and postnatal description of 30 cases. Ultra-
sound Obstet Gynecol. 2002;19:24-38.
23. Orioli IM, Castilla EE. Clinical epidemiologic study of holopro-
sencephaly in South America. Am J Med Genet A. 2007;143A:3088-
3099.
576
24. Bullen PJ, Rankin JM, Robson SC. Investigation of the epidemiology
and prenatal diagnosis of holoprosencephaly in the north of England.
Am J Obstet Gynecol. 2001;184:1256-1262.
25. Leoncini E, Baranello G, Orioli IM. Frequency of holoprosencephaly in
the International Clearinghouse Birth Defects Surveillance Systems:
searching for population variations. Birth Defects Res A Clin Mol Tera-
tol. 2008;82:585-591.
26. Ong S, Tonks A, Woodward ER, Wyldes MP, Kilby MD. An epidemio-
logical study of holoprosencephaly from a regional congenital anom-
aly register: 1995-2004. Prenat Diagn. 2007;27:340-347.
27. Naguib KK, Al-Awadi SA, Moussa MA, et al. Syndromal and
nonsyndromal cleft lip with or without cleft palate in Kuwait. Ann
Saudi Med. 1989;9(4):388-392.
28. Lai TH, Chang CH, Yu CH, Kuo PL, Chang FM. Prenatal diagnosis of
alobar holoprosencephaly by two-dimensional and three-dimensional
ultrasound. Prenat Diagn. 2000;20:400-403.
29. Kagan KO, Staboulidou I, Syngelaki A, Cruz J, Nicolaides KH. The
11-13-week scan: diagnosis and outcome of holoprosencephaly,
exomphalos and megacystis. Ultrasound Obstet Gynecol. 2010;36(1):
10-14.
30. Roessler E, Lacbawan F, Dubourg C, et al. The full spectrum of
holoprosencephaly-associated mutations within the ZIC2 gene in
humans predicts loss-of-function as the predominant disease mecha-
nism. Hum Mutat. 2009;30(4): E541–554.
31. Zhang R, Hao L, Wang L, et al. Gene expression analysis of induced
pluripotent stem cells from aneuploid chromosomal syndromes. BMC
Genomics. 2013;14(5):S8.
32. Rosa RFM, Correia EPE, Bastos CS, et al. Trisomy 18 and
holoprosencephaly. Am J Med Genet A. 2017;173(7):1985-1987.
33. Rosa RF, Rosa RC, Zen PR. Trisomy 18: review of the clinical, etio-
logic, prognostic, and ethical aspects. Rev Paul Pediatr. 2013;1:
111-120.
34. Cereda A, Carey JC. The trisomy 18 syndrome. Orphanet J Rare Dis.
2012;7:81.
35. Mercier S, Dubourg C, Garcelon N, et al. New findings for phenotype-
genotype correlations in a large European series of holoprosencephaly
cases. J Med Genet. 2011;48(11):752-760.
36. Dubourg C, Bendavid C, Pasquier L, Henry C, Odent S, David V.
Holoprosencephaly. Orphanet J Rare Dis. 2007;2:8.
EL-DESSOUKY ET AL.
37. Yi Z, Yingjun X, Yongzhen C, Liangying Z, Meijiao S, Baojiang C. Pre-
natal diagnosis of pure partial monosomy 18p associated with
holoprosencephaly and congenital heart defects. Gene. 2014;533(2):
565-569.
38. Chen CP, Huang JP, Chen YY, et al. Chromosome 18p deletion syn-
drome presenting holoprosencephaly and premaxillary agenesis: pre-
natal diagnosis and a CGH characterization using uncultured
amniocytes. Gene. 2013;527(2):636-641.
39. Chuang TY, Chang SY, Chen CP, et al. Digynic triploidy in a fetus pre-
senting with semilobar holoprosencephaly. Taiwan J Obstet Gynecol.
2018 Dec;57(6):881-884.
40. Sharma G, Heier L, Kalish RB, Troiano R, Chasen ST. Use of fetal mag-
netic resonance imaging in patients electing termination of pregnancy
by dilation and evacuation. Am J Obstet Gynecol. 2003;189:990-993.
41. Naikwadi A, Rege R, Hameed S. Antenatal sonographic diagnosis of
semilobar holoprosencephaly with associated cleft lip and palate. BJR
Case Rep 2018;5(1):20180013.
42. Sepulveda W, Dezerega V, Be C. First-trimester sonographic diagno-
sis of holoprosencephaly: value of the “butterfly” sign. J Ultrasound
Med. 2004;23:761-765.
43. Chaudhari HD, Thakkar G, Darji P, Khokhani P. Prenatal ultrasound
diagnosis of holoprosencephaly and associated anomalies. BMJ Case
Rep. 2012;2012.
44. Solomon BD, Retterer K, Juusola J. Holoprosencephaly: a clinical
genomics perspective. Am J Med Genet C Semin Med Genet. 2018;178
(2):194-197.
45. Essa AA, Feleke LA, Ahmed DM. Semilobar holoprosencephaly with
cebocephaly associated with maternal early onset preeclampsia: a
case report. J Med Case Reports. 2018;12(1):207.
How to cite this article: El-Dessouky SH, Aboulghar MM,
Gaafar HM, et al. Prenatal ultrasound findings of
holoprosencephaly spectrum: Unusual associations. Prenatal
Diagnosis. 2020;40:565–576. https://doi.org/10.1002/
pd.5649