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Magnetic resonance imaging of the fetal brain in monochorionic diamniotic twin gestation: correlation of cerebral injury with ultrasound staging and survival outcomes

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Abstract

Background

The current staging system of twin–twin transfusion syndrome (TTTS) is based on the ultrasound criteria and does not consider the cerebral injury.

Objective

To assess the incidence of cerebral damage on fetal MRI and correlate abnormal cerebral diffusion-weighted imaging (DWI) findings with survival outcome and the ultrasound staging of TTTS.

Materials and methods

We conducted a retrospective review of MRI/DWI of fetal brains and the electronic medical records in monochorionic diamniotic twin gestations. Axial DWI of each fetal brain was performed on 1.5-tesla (T) clinical magnet with b values of 0 s/mm2 and 700 s/mm2. We correlated MRI/DWI abnormalities with the Quintero staging system and survival outcomes of the fetuses.

Results

Thirty-four pregnancies (68 fetuses) with 42 fetal cerebral abnormalities were identified by MRI/DWI alone. Of these 42 fetal cerebral abnormalities, 33 fetal brain lesions were visible only on DWI (n=25 donor, n=8 recipients; n=30 unilateral, n=3 bilateral; n=26 diffuse, n=7 focal). Quintero staging in these 34 pregnancies was as follows: 9 Stage I, 7 Stage II, 13 Stage III, 4 Stage IV, 1 Stage V. There was no significant correlation between the presence of cerebral infarction or hemorrhage using MRI/DWI and ultrasound staging (P=0.138). The overall survival rate was 63.2% (43/68). There was a significant correlation between the presence of cerebral infarction or hemorrhage on MRI/DWI and delivery status (P=0.009).

Conclusion

Abnormal cerebral imaging findings on MRI/DWI from hypoxic–ischemic injury or hemorrhage can be seen at the beginning of the second trimester and do not correlate with the current ultrasound staging system; however, they do correlate with decreased survival. Fetal cerebral abnormalities could be incorporated into the TTTS staging system as an independent risk factor.

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References

  1. Robinson A, Teoh M, Edwards A et al (2017) Fetal brain injury in complicated monochorionic pregnancies: diagnostic yield of prenatal MRI following surveillance ultrasound and influence on prognostic counselling. Prenat Diagn 37:611–627

    Article  CAS  Google Scholar 

  2. Lewi L, Jani J, Blickstein I et al (2008) The outcome of monochorionic diamniotic twin gestations in the era of invasive fetal therapy: a prospective cohort study. Am J Obstet Gynecol 199:514.e1–514.e8

    Article  Google Scholar 

  3. Acosta-Rojas R, Becker J, Munoz-Abellana B et al (2007) Twin chorionicity and the risk of adverse perinatal outcome. Int J Gynaecol Obstet 96:98–102

    Article  CAS  Google Scholar 

  4. Glenn OA, Barkovich J (2006) Magnetic resonance imaging of the fetal brain and spine: an increasingly important tool in prenatal diagnosis: Part 2. AJNR Am J Neuroradiol 27:1807–1814

  5. Feldstein VA (2002) Understanding twin-twin transfusion syndrome: role of Doppler ultrasound. Ultrasound Q 18:247–254

    Article  Google Scholar 

  6. Quarello E, Molho M, Ville Y (2007) Incidence, mechanisms, and patterns of fetal cerebral lesions in twin-to-twin transfusion syndrome. J Matern Fetal Neonatal Med 20:589–597

    Article  Google Scholar 

  7. Urig MA, Clewell WH, Elliott JP (1990) Twin-twin transfusion syndrome. Am J Obstet Gynecol 163:1522–1526

    Article  CAS  Google Scholar 

  8. Ong SS, Zamora J, Khan KS, Kilby MD (2006) Prognosis for the co-twin following single-twin death: a systematic review. BJOG 13:992–998

    Article  Google Scholar 

  9. Weisz B, Hoffmann C, Ben-Baruch S et al (2014) Early detection by diffusion-weighted sequence magnetic resonance imaging of severe brain lesions after fetoscopic laser coagulation for twin-twin transfusion syndrome. Ultrasound Obstet Gynecol 44:44–49

    Article  CAS  Google Scholar 

  10. Salomon LJ, Ortqvist L, Aegerter P et al (2010) Long-term developmental follow-up of infants who participated in a randomized clinical trial of amniocentesis vs. laser photocoagulation for the treatment of twin-to-twin transfusion syndrome. Am J Obstet Gynecol 203:444.e1–444.e7

    Article  Google Scholar 

  11. Quintero RA, Morales WJ, Allen MH et al (1999) Staging of twin–twin transfusion syndrome. J Perinatol 19:550–555

    Article  CAS  Google Scholar 

  12. Merhar SL, Kline-Fath BM, Meinzen-Derr J et al (2013) Fetal and postnatal brain MRI in premature infants with twin-twin transfusion syndrome. J Perinatol 33:112–118

    Article  CAS  Google Scholar 

  13. Gomes Neto O, Marins M, Botelho RD et al (2014) Feasibility and reproducibility of diffusion-weighted magnetic resonance imaging of the fetal brain in twin-twin transfusion syndrome. Prenat Diagn 34:1182–1188

    Article  Google Scholar 

  14. Society for Maternal-Fetal Medicine, Simpson LL (2013) Twin-twin transfusion syndrome. Am J Obstet Gynecol 208:3–18

    Article  Google Scholar 

  15. Griffiths PD, Sharrack S, Chan KL et al (2015) Fetal brain injury in survivors of twin pregnancies complicated by demise of one twin as assessed by in utero MR imaging. Prenat Diagn 35:583–591

    Article  CAS  Google Scholar 

  16. Tarui T, Khwaja OS, Estroff JA et al (2012) Altered fetal cerebral and cerebellar development in twin-twin transfusion syndrome. AJNR Am J Neuroradiol 33:1121–1126

    Article  CAS  Google Scholar 

  17. Garel C, Delezoide AL, Elmaleh-Berges M et al (2004) Contribution of fetal MR imaging in the evaluation of cerebral ischemic lesions. AJNR Am J Neuroradiol 25:1563–1568

    PubMed  Google Scholar 

  18. Mari G, Roberts A, Detti L et al (2001) Perinatal morbidity and mortality rates in severe twin-twin transfusion syndrome: results of the international Amnioreduction registry. Am J Obstet Gynecol 185:708–715

    Article  CAS  Google Scholar 

  19. Berghella V, Kaufmann M (2001) Natural history of twin-twin transfusion syndrome. J Reprod Med 46:480–484

    CAS  PubMed  Google Scholar 

  20. Gul A, Aslan H, Polat I et al (2003) Natural history of 11 cases of twin-twin transfusion syndrome without intervention. Twin Res 6:263–266

    PubMed  Google Scholar 

  21. Nikkels PG, Hack KE, van Gemert MJ (2008) Pathology of twin placentas with special attention to monochorionic twin placentas. J Clin Pathol 61:1247–1253

    Article  CAS  Google Scholar 

  22. Lewi L, Gucciardo L, Van Mieghem T et al (2010) Monochorionic diamniotic twin pregnancies: natural history and risk stratification. Fetal Diagn Ther 27:121–133

    Article  Google Scholar 

  23. Rossi AC, Vanderbilt D, Chmait RH (2011) Neurodevelopmental outcomes after laser therapy for twin-twin transfusion syndrome: a systematic review and meta-analysis. Obstet Gynecol 118:1145–1150

    Article  Google Scholar 

  24. Roberts D, Neilson JP, Kilby MD, Gates S (2014) Interventions for the treatment of twin-twin transfusion syndrome. Cochrane Database Syst Rev 30:CD002073

    Google Scholar 

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Authors and Affiliations

  1. Department of Radiology, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA

    Murat Kocaoglu, Beth M. Kline-Fath, Maria A. Calvo-Garcia & Usha D. Nagaraj

  2. Division of Biostatistics and Epidemiology, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH, USA

    Bin Zhang

  3. Department of Pediatrics, College of Medicine, University of Cincinnati, Cincinnati, OH, USA

    Bin Zhang

Authors
  1. Murat Kocaoglu
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  2. Beth M. Kline-Fath
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  3. Maria A. Calvo-Garcia
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  4. Bin Zhang
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  5. Usha D. Nagaraj
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Correspondence to Murat Kocaoglu.

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Kocaoglu, M., Kline-Fath, B.M., Calvo-Garcia, M.A. et al. Magnetic resonance imaging of the fetal brain in monochorionic diamniotic twin gestation: correlation of cerebral injury with ultrasound staging and survival outcomes. Pediatr Radiol 50, 1131–1138 (2020). https://doi.org/10.1007/s00247-020-04661-w

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  • DOI: https://doi.org/10.1007/s00247-020-04661-w

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