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1188 PART IV Obstetric and Fetal Sonographyee2ABmdCDEA*PFIG. 34.16 Holoprosencephaly. (A) Alobar holoprosencephaly(coronal view) at 13 menstrual weeks showsfused nubbin of thalamus (black arrow) capped by a singlehemisphere (white arrow) and underlying monoventricle.There is no falx or interhemispheric issure. Also note thetwo-vessel umbilical cord in this fetus with trisomy 13.(B) Hypotelorism. Axial view across face shows the eyes(e) in very close approximation. This is an example of thefacial abnormalities that are common with severe alobarholoprosencephaly. (C) Cup type of alobar holoprosencephaly.Midsagittal view shows the anterior “cup” of brainmantle (m) and a large dorsal cyst (d). (D) Semilobarholoprosencephaly at 20 weeks. There is a single monoventriclebut also rudimentary development of falx andinterhemispheric issure (arrow). (E) Syntelencephaly, ormiddle hemispheric variant of holoprosencephaly. There isa communication between the ventricles centrally (*), butthe anterior (A arrowhead) and posterior (P arrowhead)interhemispheric issures have formed. See also Video 34.7.
CHAPTER 34 The Fetal Brain 1189lobar holoprosencephaly forms cerebral hemispheres, it maybe diicult if not impossible to diagnose prenatally. Features thatsuggest lobar HPE include absence of septi pellucidi, fusion andsquaring of the frontal horns, and an abnormal appearance oftwo large nerve trunks, the fornices, which are rudimentaryand appear fused into a single tract above the third ventricle.With color Doppler sonography, the anterior cerebral artery mayhave an azygous (wandering) course, “crawling” under the skull.Fusion of the fornices in HPE may help diferentiate HPE fromsepto-optic dysplasia (SOD). 157Many authors emphasize detection of associated facialabnormalities in diagnosing HPE (see Fig. 34.16B). Facial changesare seen more frequently with more severe HPE and have beencategorized into four main groups, with severity approximatingdegree of brain abnormality. 151-155Facial Changes Associated WithHoloprosencephaly 155Cyclopia with single eye, with or without proboscisEthmocephaly (hypotelorism and proboscis between theeyes)Cebocephaly (hypotelorism, nose with single nostril)Median cleft lip and palate and hypotelorismSingle central incisorhe diferential diagnosis includes severe hydrocephalus,septo-optic dysplasia (SOD), absence of septi pellucidi,schizencephaly, hydranencephaly, and porencephaly. 153,158 Milderforms can be diicult to diagnose even ater delivery and mayneed specialized experienced neuroradiologic consultation. 153For counseling purposes, it is important to determine the degreeof cerebral malformation and whether it is isolated or part of asyndrome or associated with additional abnormalities. MRI andchromosome and genetic analysis can be helpful. 151,154Prognosis is variable and depends on severity of HPE, associatedabnormalities, and medical and neurologic complications.Severely afected fetuses do poorly or die in utero. Mildly afectedchildren may exhibit few symptoms and may live a normal life.About 75% need shunting. 151 In general, the severity of clinicalproblems and neurologic dysfunction correlates with the degreeof hemispheric and hypothalamic failure of separation and caninclude endocrinopathy (especially diabetes insipidus), temperaturedysregulation, motor and movement abnormalities, anddevelopmental delay. 154,159 Pregnancy termination is generallyconsidered ater prenatal diagnosis. Survivors are managedsymptomatically.he fourth variant of HPE, the middle interhemisphericform of HPE, also called syntelencephaly, has a separation ofthe anterior and posterior parts of the hemispheres, but fusionis present in the central region of the brain between parietalhemispheres, and the face is typically normal. In general, casesinvolve mild VM, absence of parts of the septi pellucidi, abnormalityof the midpart of the corpus callosum, and dorsal cysts. hecondition can resemble mild VM with septal fenestration. Coronalscanning may show fusion of the central parts of the hemisphere.MRI helps conirm this appearance and typically shows sylvianissures connecting abnormally across the midline 153,154,158,160 (seeFig. 34.16E).he middle interhemispheric form tends to have betteroutcomes with functional disabilities similar to those with lobarHPE, but endocrine functions are normal because the hypothalamustends to be spared.Posterior Fossa and CerebellumCerebellar development starts at about 6 to 7 weeks’ gestation,and the inal gross form is achieved by about 18 to 20 weeks. Itdevelops as thickenings of lateral rhombic lips, which enlargeposteriorly and are joined in the midline by the vermis, whichdevelops from the rostral aspect. hese thickenings grow intothe thin membranous dorsal aspect of the neural tube, the areamembranacea, which is the rhombencephalic “cyst” that isprominent in early pregnancy and later becomes the fourthventricle and fenestrates, forming the foramina of Magendie andLuschka. 27,29 here is a rapid acceleration of growth starting about24 weeks, ater which the rule that “cerebellar diameter = weeksgestation” no longer holds. Cerebellar components continue todevelop to about 7 months ater birth, and inal neuronal organizationcontinues to about 20 months ater delivery. As the posteriorfossa develops, the brainstem initially becomes lexed or kinked(mesencephalic, pontine, and cervical lexures) but againstraightens out by about 14 to 16 weeks as the spinal cord expandswith developing spinal nerve tracts. 161 here are many geneticand molecular mechanisms involved in cerebellar development,and these have additional roles in CNS and somatic development.Consequently, abnormal cerebellar development is oten accompaniedby developmental and functional changes in the cerebralcortex and other parts of the body. Speciic malformations maysuggest genetic syndromes, but any malformation can also resultfrom disruptive processes including infection or teratogenic,metabolic, or traumatic insults. 162,163 Functionally, the cerebellumnot only controls voluntary movements but is also involved innonmotor and cognitive functions. Many children with cerebellarmalformations come to medical attention because of developmentaland behavioral issues. 162,164-166he cerebellum is routinely examined with standard axialviews, focusing on transverse diameter, the intactness and sizeof the vermis, and the depth of the cisterna magna, which shouldmeasure less than 10 mm. 5 When an abnormality is suspected,midsagittal views are important to evaluate the integrity, size,rotation, and issures of the vermis as well as the appearance ofthe fourth ventricle and brainstem. Transvaginal scanning, 3-Dultrasound, and MRI including sagittal views are especially useful(Fig. 34.17). Care should be taken before 18 weeks to not mistakethe incompletely formed vermis for a defect. 30,86,167-171With careful technique, as discussed earlier, a small physiologicBlake pouch is visible in over 80% of fetuses, as a small cyst inthe midline just below the valleculae at the lower border of thecerebellum that does not afect the cerebellum in the midline(see Fig. 34.7A). When this structure enlarges, it can rotate thevermis or it may expand behind the cerebellum as a mega–cisternamagna. 29Additional anatomic features of the vermis are visible onmidsagittal views (see Fig. 34.17). he fourth ventricle is a small
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viiiContributorsOlga R. Brook, MDAs
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xContributorsChristy K. Holland, Ph
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xiiContributorsRupa Radhakrishnan,
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xxiiContentsVOLUME IIPART IV Obstet
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xxivVideo ContentsVideo 12.8 Angiog
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xxviVideo ContentsVideo 26.20 High-
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xxviiiVideo Contents42 Fetal Measur
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2 PART I Physicsphysics. he amplitu
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4 PART I Physics× ms×FIG. 1.4 Ult
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6 PART I Physicsθ 1 = 20°Tissue A
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8 PART I Physicssignature. Broad-ba
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10 PART I PhysicsFIG. 1.13 B-Mode I
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12 PART I PhysicsIn these transduce
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14 PART I PhysicsFIG. 1.17 Tissue H
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16 PART I PhysicsKey Points of Ultr
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18 PART I PhysicsA - Normal liverv
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20 PART I PhysicsFIG. 1.27 Reverber
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22 PART I Physics-0 dBUncorrected-0
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24 PART I Physicsθ = 0°cos θ = 1
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26 PART I PhysicsABFIG. 1.38 Color
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28 PART I PhysicsChanges in Doppler
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30 PART I PhysicsABFIG. 1.44 Wall F
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32 PART I PhysicsABCDFIG. 1.46 Alia
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CHAPTER2Biologic Effects and Safety
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36 PART I PhysicsPressurePulse repe
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38 PART I PhysicsUltrasound imaging
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40 PART I Physicsacoustic power and
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42 PART I PhysicsFIG. 2.6 Acoustic
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44 PART I PhysicsThe AIUM Statement
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46 PART I Physics1. Current ultraso
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48 PART I PhysicsEPIDEMIOLOGYWith a
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50 PART I Physicscontrols whether t
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52 PART I Physics70. Hwang JH, Tu J
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54 PART I PhysicsA B 5 μmFIG. 3.1
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56 PART I Physicsstudies with Levov
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58 PART I Physicsabdominal organs.
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60 PART I PhysicsHarmonic B-Mode Im
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62 PART I PhysicsFIG. 3.9 Contrast-
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64 PART I Physicsdramatic manifesta
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66 PART I Physics5 µmFIG. 3.15 Fra
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68 PART I Physicsplatelet lysis), n
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70 PART I PhysicsEnhancement1 2 3 4
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72 PART I Physics46. Hamilton MF, B
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PART TWO: Abdominal and Pelvic Sono
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76 PART II Abdominal and Pelvic Son
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100 PART II Abdominal and Pelvic So
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ABFIG. 5.20 Microabscesses in Two P
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ABFIG. 6.32 Distal Cholangiocarcino
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CHAPTER7The PancreasThomas Winter a
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CHAPTER8The Gastrointestinal TractS
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ABFIG. 8.16 Lymphadenopathy in Two
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A B CD E FG H IFIG. 8.23 Inlammator
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FIG. 8.56 Gastrointestinal Stromal
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CHAPTER9The Kidney and Urinary Trac
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Remnant ofpronephrosMesonephrosBMes
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CHAPTER11The Adrenal GlandsChristin
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CHAPTER12The RetroperitoneumRaymond
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CHAPTER13Dynamic Ultrasound of Hern
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CHAPTER14The PeritoneumAnthony E. H
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CHAPTER15The UterusDouglas Brown an
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CHAPTER16The AdnexaRochelle Filker
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692 PART III Small Parts, Carotid A
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CHAPTER20The Parathyroid GlandsBonn
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*** *FIG. 21.8 Terminal Ductolobula
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CHAPTER22The ScrotumDaniel Sommers
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CHAPTER23Overview of Musculoskeleta
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CHAPTER25Musculoskeletal Interventi
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ABCDFIG. 25.15 Biceps Tendon Sheath
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CHAPTER27Peripheral VesselsMark E.
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ABFIG. 27.29 Chronic Deep Venous Th
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1000 PART III Small Parts, Carotid
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e2APPENDIXUltrasound Artifacts: A V
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FIG. A.18 Comet-Tail Artifact. On c
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e12APPENDIXUltrasound Artifacts: A
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I-2 IndexAcetabulumdescription of,
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I-4 IndexAnemiafetal, hydrops from,
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I-6 IndexAttenuationcoeicient, 36of
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I-8 IndexBlood low. See also Cerebr
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I-10 IndexBreast(s) (Continued)thic
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I-12 IndexCat-scratch disease, pedi
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I-14 IndexChorion laeve, 1465-1466C
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I-16 IndexContrast agents (Continue
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I-18 IndexCyst(s) (Continued) Cyst(
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I-20 IndexDoppler ultrasound (Conti
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I-22 IndexEndocardial cushion(s), 1
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I-24 IndexFibroma(s) (Continued)par
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I-26 IndexGerminal epithelium, 565G
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I-28 IndexHematoma(s) (Continued)pe
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I-30 IndexHoloprosencephaly (HPE) (
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I-32 IndexImplants, breast (Continu
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I-34 IndexJaundice (Continued)bile
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I-36 IndexLipomyelocele, closed spi
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I-38 IndexMammary ductsnormal sonog
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I-40 IndexMolar pregnancy. See Hyda
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I-42 IndexNonrhizomelic chondrodysp
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I-44 IndexPancreas (Continued)percu
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I-46 IndexPeritoneum (Continued)tum
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I-48 IndexPosterior fossa (Continue
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I-50 IndexPyloric musclehypertrophy
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I-52 IndexSample volume size, Doppl
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I-54 IndexSpectral broadening, in D
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I-56 IndexSuperoanteromedial ridge,
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I-58 Indexhrombosis (Continued)of s
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I-60 IndexTrisomy 18 (Edwards syndr
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I-62 IndexUrinary tract, pediatric
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I-64 IndexWalker-Warburg syndromeco
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DIAGNOSTICULTRASOUND
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DIAGNOSTICULTRASOUND5TH EDITIONCARO
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ABOUT THE EDITORSCarol M. Rumack, M
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ContributorsviiCONTRIBUTORSJacques
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ContributorsixPeter M. Doubilet, MD
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ContributorsxiAna P. Lourenco, MDAs
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ContributorsxiiiWendy hurston, MDAs
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In memory of my parents, Drs. Ruth
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PrefacexviiPREFACEhe ith edition of
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AcknowledgmentsxixACKNOWLEDGMENTSWe
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ContentsxxiCONTENTSVOLUME IPART I P
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Video ContentsxxiiiVIDEO CONTENTS4
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Video Contentsxxv19 The Thyroid Gla
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Video Contentsxxvii33 The Fetal Fac
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Video Contentsxxix52 The Pediatric
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DIAGNOSTICULTRASOUND
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PART FOUR: Obstetric and Fetal Sono
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CHAPTER 28 Overview of Obstetric Im
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ABCDFIG. 28.9 Second-Trimester Biom
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CHAPTER 29 Bioeffects and Safety of
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CHAPTER 30 The First Trimester 1049
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CHAPTER 31 Chromosomal Abnormalitie
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ABCDFIG. 31.12 Sonographic Findings
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CHAPTER32Multifetal PregnancyMary C
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CHAPTER 32 Multifetal Pregnancy 111
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ABFIG. 32.5 Sonographic Findings Se
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CHAPTER33The Fetal Face and NeckAna
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CHAPTER 33 The Fetal Face and Neck
Page 1309 and 1310: CHAPTER 33 The Fetal Face and Neck
Page 1317 and 1318: ABCDFIG. 33.13 Hypertelorism With E
Page 1319 and 1320: ABCDFIG. 33.16 Dacryocystocele. (A)
Page 1327 and 1328: ABCDEFFIG. 33.24 Unilateral Complet
Page 1339 and 1340: CHAPTER 34 The Fetal Brain 1167impo
Page 1341 and 1342: CHAPTER 34 The Fetal Brain 1169cmAB
Page 1343 and 1344: CingulatePOCalcarineAB21 wkCD25 wkI
Page 1345 and 1346: CHAPTER 34 The Fetal Brain 1173FIG.
Page 1347 and 1348: CHAPTER 34 The Fetal Brain 1175LTAR
Page 1349 and 1350: CHAPTER 34 The Fetal Brain 1177CC12
Page 1351 and 1352: CHAPTER 34 The Fetal Brain 1179SPEC
Page 1353 and 1354: CHAPTER 34 The Fetal Brain 1181ABCD
Page 1355 and 1356: CHAPTER 34 The Fetal Brain 1183asym
Page 1357 and 1358: CHAPTER 34 The Fetal Brain 1185FIG.
Page 1359: CHAPTER 34 The Fetal Brain 1187Cere
Page 1363 and 1364: CHAPTER 34 The Fetal Brain 1191ABCF
Page 1365 and 1366: CHAPTER 34 The Fetal Brain 1193ABCF
Page 1367 and 1368: CHAPTER 34 The Fetal Brain 1195spor
Page 1369 and 1370: ABCCCDEFFIG. 34.24 Type 2 Lissencep
Page 1371 and 1372: CHAPTER 34 The Fetal Brain 1199ABFI
Page 1373 and 1374: CHAPTER 34 The Fetal Brain 120120 w
Page 1375 and 1376: CHAPTER 34 The Fetal Brain 1203Ultr
Page 1377 and 1378: CHAPTER 34 The Fetal Brain 1205ABCD
Page 1379 and 1380: VSSABHHPHCDEFFIG. 34.35 Intracrania
Page 1381 and 1382: CHAPTER 34 The Fetal Brain 1209VABC
Page 1383 and 1384: CHAPTER 34 The Fetal Brain 1211Huma
Page 1385 and 1386: CHAPTER 34 The Fetal Brain 1213121.
Page 1387 and 1388: CHAPTER 34 The Fetal Brain 1215221.
Page 1389 and 1390: CHAPTER 35 The Fetal Spine 1217ABCF
Page 1391 and 1392: CHAPTER 35 The Fetal Spine 1219L1S3
Page 1393 and 1394: CHAPTER 35 The Fetal Spine 1221FTFT
Page 1395 and 1396: CHAPTER 35 The Fetal Spine 1223FIG.
Page 1397 and 1398: CHAPTER 35 The Fetal Spine 1225TABL
Page 1399 and 1400: CHAPTER 35 The Fetal Spine 1227Feta
Page 1401 and 1402: CHAPTER 35 The Fetal Spine 1229MMAB
Page 1403 and 1404: ABCDEFFIG. 35.15 Skin-Covered Myelo
Page 1405 and 1406: CHAPTER 35 The Fetal Spine 1233diic
Page 1407 and 1408: CHAPTER 35 The Fetal Spine 1235CCSC
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CHAPTER 35 The Fetal Spine 1239BSCT
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CHAPTER 35 The Fetal Spine 124162.
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CHAPTER36The Fetal ChestDorothy Bul
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CHAPTER 36 The Fetal Chest 1245seco
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CHAPTER 36 The Fetal Chest 1247TABL
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CHAPTER 36 The Fetal Chest 1249Left
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CHAPTER 36 The Fetal Chest 12511ABC
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CHAPTER 36 The Fetal Chest 1253ABCF
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CHAPTER 36 The Fetal Chest 1255cent
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CHAPTER 36 The Fetal Chest 1257Left
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CHAPTER 36 The Fetal Chest 1259ABCD
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CHAPTER 36 The Fetal Chest 1261RTLT
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CHAPTER 36 The Fetal Chest 1263ARig
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CHAPTER 36 The Fetal Chest 12659. B
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CHAPTER 36 The Fetal Chest 1267107.
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CHAPTER 36 The Fetal Chest 1269204.
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CHAPTER 37 The Fetal Heart 1271TABL
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CHAPTER 37 The Fetal Heart 1273TABL
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CHAPTER 37 The Fetal Heart 1275Plac
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CHAPTER 37 The Fetal Heart 1277ADop
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CHAPTER 37 The Fetal Heart 1279LVRV
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CHAPTER 37 The Fetal Heart 1281RARV
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CHAPTER 37 The Fetal Heart 1283RARV
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CHAPTER 37 The Fetal Heart 1285Norm
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CHAPTER 37 The Fetal Heart 1287RVLV
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CHAPTER 37 The Fetal Heart 1289RVTA
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CHAPTER 37 The Fetal Heart 1291LVRA
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CHAPTER 37 The Fetal Heart 1293Aspl
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CHAPTER 37 The Fetal Heart 1295PLVL
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CHAPTER 37 The Fetal Heart 1297HR-L
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CHAPTER 37 The Fetal Heart 129951.
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CHAPTER 38 The Fetal Gastrointestin
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UrogenitalsinusMesonephrosMesonephr
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CHAPTER 39 The Fetal Urogenital Tra
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CHAPTER 40 The Fetal Musculoskeleta
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CHAPTER 41 Fetal Hydrops 1413ABFIG.
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ABCDFIG. 41.2 Ascites. (A) Fluid ou
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CHAPTER 41 Fetal Hydrops 1417A B CD
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CHAPTER 41 Fetal Hydrops 1423later
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CHAPTER 41 Fetal Hydrops 1427CHABCH
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CHAPTER 41 Fetal Hydrops 1429Monoch
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CHAPTER 41 Fetal Hydrops 1431feedin
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CHAPTER 41 Fetal Hydrops 1433TABLE
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CHAPTER 41 Fetal Hydrops 1435sampli
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CHAPTER 41 Fetal Hydrops 1437Predel
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CHAPTER 41 Fetal Hydrops 143973. Ma
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CHAPTER 41 Fetal Hydrops 1441169. I
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CHAPTER42Fetal Measurements: Normal
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CHAPTER 42 Fetal Measurements 1445F
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CHAPTER 42 Fetal Measurements 1447T
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CHAPTER 42 Fetal Measurements 1451p
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CHAPTER 42 Fetal Measurements 1453d
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CHAPTER 42 Fetal Measurements 1455A
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CHAPTER 42 Fetal Measurements 1459A
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CHAPTER 42 Fetal Measurements 14618
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CHAPTER 42 Fetal Measurements 14631
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CHAPTER43Sonographic Evaluation oft
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CHAPTER 43 Sonographic Evaluation o
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CHAPTER44Cervical Ultrasound and Pr
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CHAPTER 44 Cervical Ultrasound and
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PART FIVE: Pediatric SonographyCHAP
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CHAPTER 45 Neonatal and Infant Brai
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CHAPTER46Duplex Sonography of the N
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CHAPTER 46 Duplex Sonography of the
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CHAPTER47Doppler Sonography of the
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CHAPTER 47 Doppler Sonography of th
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CHAPTER 48 The Pediatric Head and N
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CHAPTER 49 The Pediatric Spinal Can
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RA B CDEFGFIG. 49.27 Neuroblastoma
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CHAPTER50The Pediatric ChestChetan
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CHAPTER 50 The Pediatric Chest 1703
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CHAPTER 51 The Pediatric Liver and
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ABCFIG. 51.39 Hepatosplenomegaly. W
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CHAPTER52The Pediatric Urinary Trac
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CHAPTER 52 The Pediatric Urinary Tr
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TABLE 52.4 Mean Total Renal Volumes
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CHAPTER53The Pediatric Gastrointest
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CHAPTER 53 The Pediatric Gastrointe
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CHAPTER 54 Pediatric Pelvic Sonogra
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CHAPTER 55 The Pediatric Hip and Ot
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ABCDFIG. 55.13 Normal and Dislocate
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CHAPTER 56 Pediatric Interventional
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ABCFIG. 56.15 Access for Drainage o
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APPENDIXUltrasound Artifacts: A Vir
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APPENDIX Ultrasound Artifacts: A Vi
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IndexAAA anastomoses. See Arterial/
Page 2181 and 2182:
Index I-3Adnexa (Continued)transvag
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Index I-5Arrays, transducer, 11-12A
Page 2185 and 2186:
Index I-7Bioefects (Continued) Biop
Page 2187 and 2188:
Index I-9Brain, neonatal/infant (Co
Page 2189 and 2190:
Index I-11Carcinoma(s) (Continued)
Page 2191 and 2192:
Index I-13Cervix (Continued)for sym
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Index I-15Color Doppler ultrasound
Page 2195 and 2196:
Index I-17Cystic artery, 194promine
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Index I-19Diabetes mellituschronic
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Index I-21Echinococcal disease (Con
Page 2201 and 2202:
Index I-23Exudate ascites, 506-507E
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Index I-25Gallbladder (Continued)ad
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Index I-27Gyriabnormalities of, in
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Index I-29Hernia(s). See also Diaph
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Index I-31Hyperechoic tissue, in br
Page 2211 and 2212:
Index I-33Internal jugular vein (IJ
Page 2213 and 2214:
Index I-35Kidneys, pediatric (Conti
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Index I-37Liver transplantation (Co
Page 2217 and 2218:
Index I-39Mesentery, small bowel, 5
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Index I-41Nasal bone, fetal (Contin
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Index I-43Orbits, fetal (Continued)
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Index I-45Patau syndrome. See Triso
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Index I-47Pleural efusionsfetal, 12
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Index I-49Prostate (Continued)thera
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Index I-51Renal transplantation (Co
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Index I-53Shunt(s) (Continued) Skel
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Index I-55Splenic vein (Continued)t
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Index I-57Testis(es) (Continued)cys
Page 2237 and 2238:
Index I-59Transcranial Doppler (TCD
Page 2239 and 2240:
Index I-61Umbilical cord, 1481-1487
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Index I-63Vein of Galen (Continued)
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