HYDROCEPHALUS,

HYDRANCEPHALY,
HOLOPROSENCEPHALY
 HYDROCEPHALUS
• A progressive enlargement of ventricular system due to inadequate passage of cerebrospinal
fluid (CSF) from its production site within cerebral ventricles to its site of absorption into
the systemic circulation, resulting in abnormally accelerated head growth.
• Approximately 2,7 out of 1,000 births globally, in which the incidence of congenital
hydrocephalus was approximately 1,2 out of 1,000 births
• Classified based on its etiology as congenital/ developmental (intrinsic causes) and acquired
(extrinsic causes)
• Traditionally it was also classified based on its pathogenesis (obstructive or nonobstructive)
and genetics (syndromic or non syndromic)

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol
 PATHOGENESIS OF HYDROCEPHALUS

the consequence of imbalance in intracranial CSF inflow and outflow, classified into:
(1) CSF flow obstruction (non-communicating),
(2) impaired CSF absorption (communicating, due to subarachnoid villi inflammation or
venous sinus pressure elevation),
(3) CSF overproduction (communicating, due to functional choroid plexus papilloma).

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol
 PRENATAL DIAGNOSIS OF CONGENITAL
HYDROCEPHALUS

ultrasonography (US) :
(1) persistent enlargement of posterior horn lateral ventricle width (atrial width) measured 10-
15 mm (mild ventriculomegaly),
(2) > 15 mm (severe ventriculomegaly)

increase in postnatal head size and tense major fontanelle (due to increase in intracranial
pressure)

The key features that led to the diagnosis of severe hydrocephalus were the complete midline
falx and the thin mantle of cortical tissue

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol
 Extreme
hydrocephaly.
A very thin cerebral
mantle (CM) is seen.
The lateral ventricles
(LV) almost completely
occupy the cranial
cavity. Note the
prominent midline
structure (falx cerebri).
This rules out the
diagnosis of
holoprosencephaly and
hydranencephaly. The
Early hydrocephaly. An axial scan of the fetal head shows BPD is within the
early ventriculomegaly. The body of the lateral ventricle (LV) normal range for the
is dilated. The choroid plexus (CP) seems shrunken in relation
to the size of the lateral ventricles. The lateral ventricular gestational age.
width (LVW) is 2.15 cm. The hemispheric width (HW) is 4.43
cm. The LVW-HW ratio is increased (48%). CM = cerebral
mantle.

Fadel HE. Antenatal Diagnosis of Fetal Intracranial Anomalies. J Child Neurol. 1989;4(1_suppl):S107-S112. doi:10.1177/0883073889004001S16
Typical signs of fetal hydrocephalus: the left ventricular posterior horn (arrow A) and right lateral
ventricle (arrow B) are widened, and the choroid plexus is floating (a “dangling choroid”) (arrows C, D)

Zhou Y-H, Zheng M-H. Abnormality in a fetus on ultrasound. BMJ. Published online February 23, 2017:j688. doi:10.1136/bmj.j688
 HYDRANENCEPHALY (HE)
• Condition most commonly associated with cerebral cortex absence in bilateral hemispheres
or unilateral hemisphere (hemi-hydranenchephaly/HHE) in rare occasions
• One of the most rare severe forms of bilateral cerebral cortical anomaly which only affects
approximately 2.1 out of 100,000 births or pregnancies

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol
 ETIOPATHOGENESIS HYDRANENCEPHALY
(HE)
There are some hypothesized theory, which includes:
• Vascular accident/circulation developmental theory,
• Early organogenesis disruption theory and encephaloclastic destruction theory.

• Many reports suggested that vascular accident has been associated with:
• Intrauterine infections (toxoplasmosis, enterovirus, adenovirus, parvovirus, cytomegalovirus,
herpes simplex, epstein barr and respiratory syncytial virus),
• Toxic exposures (smoking, cocaine abuse, estrogen, sodium valproate)
• Other risk factors (young maternal age, mono-chorionic twin pregnancy, factor XIII deficiency
and prior intra-cerebral hemorrhage)

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly.
Indones J Obstet Gynecol
 DIFFERENTIAL DIAGNOSIS OF
HYDRANENCEPHALY

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol. Published online July 31, 2022:170-176. doi:10.32771/inajog.v10i3.1597
 PRENATAL DIAGNOSIS OF HYDRANENCEPHALY (HE)

Ultrasonography (US) :
(1) Abnormal features of HE for as early as 21st – 23rd weeks of gestation with impressions
of absent cerebral hemispheres without any intact cortical rim, which is replaced by
homogenous echogenic materials (cerebrospinal fluid, necrotic glial tissues and/ or
ependymal debris) filling the supratentorial space with preserved brain stem (midbrain),
thalamus, basal ganglia, choroid plexus and cerebellum in most cases
(2) Cerebral cortex is fully absent in most cases; but there may be partial preservation of
frontal, occipital, or both lobes

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol
 Hydranencephaly. This axial scan of the fetal
head shows the thalami and brain stem (solid
arrow) protruding into the fluid-filled cranial
cavity. There are no midline structures nor
evidence of cerebral hemispheres. This is to be
differentiated from extreme hydrocephaly. by
the absence of a midline structure and from
holoprosencephaly. by the absence of cortical
tissue especially in the frontal region. CS =
cervical spine; UW = uterine wall.

Fadel HE. Antenatal Diagnosis of Fetal Intracranial Anomalies. J Child Neurol. 1989;4(1_suppl):S107-S112. doi:10.1177/0883073889004001S16
 2D Transabdominal Ultrasound of fetal head (Axial View) at 37 weeks' gestation: (A)
transventricular plane showing absent of bilateral cerebral cortex with no intact cortical rim and falx
cerebri disruption, (B) transthalamic plane showing thalami and midbrain structures were still present,
(C) transcerebellar plane showing cerebellum and other posterior fossa structures were still present.

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol
 HOLOPROSENCEPHALY (HSE)
• Incomplete cleavage of prosencephalon; hence it does not clearly divide in diencephalon two
halves of telencephalon and lateral ventricles
• The most common forebrain developmental malformation, affecting 1 out of 250 prenatal
fetus and only 1 out of 6000 live births.
• Classified into three main types and one variant: alobar, semi-lobar, lobar, and
interhemispheric average fusion variant.

Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol
 • Failure to identify the “butterfly sign”
during a first-trimester ultrasound
examination is associated with a
reported detection rate of 100%.

• Individuals with all types of HPE

lack a normal CSP, which makes
failure to identify this structure a
useful diagnostic clue for the milder
forms of HPE.

Normal choroid plexus 12 weeks of gestation

Monteagudo A. Holoprosencephaly. Am J Obstet Gynecol. 2020;223(6):B13-B16.
doi:10.1016/j.ajog.2020.08.178
Coronal section showing Axial section showing Axial section showing
a single ventricular cavity fused thalami fused thalami and Three-dimensional
with absent midline proboscis reconstruction of the
structures
profile of alobar
holoprosencephaly

Monteagudo A. Holoprosencephaly. Am J Obstet Gynecol. 2020;223(6):B13-B16. doi:10.1016/j.ajog.2020.08.178

 • Alobar holoprosencephaly. A
single ventricular (V) cavity is
seen in this axial scan of the fetal
head. The residual cortical tissue
appears as a crescent-shaped
mantle (CM) mainly in the frontal
region

Fadel HE. Antenatal Diagnosis of Fetal Intracranial Anomalies. J Child Neurol. 1989;4(1_suppl):S107-S112. doi:10.1177/0883073889004001S16
 PRENATAL DIAGNOSIS OF HOLOPROSENCEPHALY

Ultrasonography (US) :
(1) Presence of midline malformation and brainstem anomalies
(2) A single primitive ventricle structure with fused thalamus in the midline and complete
absence of: interhemispheric fi ssure, corpus callosum, septum pellucidum, neuropophysis,
third ventricle, olfactory bulb, and tract.
(3) Inter-hemispheric fissure is still partially preserved posteriorly in semi-lobar hpe and in
anterior-posteriorly in lobar hpe.
 REFERENCES
• Hermawan GN, I. Nym. Gde. D. Mahardhika, Jennie D. Sutantio, Dyana S. Velies. Prenatal
Differential Diagnosis and Prospective Management of Hydranencephaly. Indones J Obstet
Gynecol. Published online July 31, 2022:170-176. doi:10.32771/inajog.v10i3.1597

• Monteagudo A. Holoprosencephaly. Am J Obstet Gynecol. 2020;223(6):B13-B16.

doi:10.1016/j.ajog.2020.08.178

• Zhou Y-H, Zheng M-H. Abnormality in a fetus on ultrasound. BMJ. Published online
February 23, 2017:j688. doi:10.1136/bmj.j688

• Fadel HE. Antenatal Diagnosis of Fetal Intracranial Anomalies. J Child Neurol.

1989;4(1_suppl):S107-S112. doi:10.1177/0883073889004001S16