Prospective detection and differential diagnosis of cystic posterior fossa anomalies by assessing posterior brain at 11–14 weeks

Background The role of the first-trimester scan has expanded from aneuploidy screening to the diagnosis of fetal malformations. Abnormal appearance of the posterior brain at 11–14 weeks gestation is a marker of cerebral anomalies; in fact an increased amount of fluid, particularly when the choroid plexus of the fourth ventricle is not visible and only 2 brain spaces instead of 3 are seen, may indicate the presence of cystic or cyst-like posterior fossa anomalies, such as Blake's pouch cyst or Dandy-Walker malformation. Objective The purpose of this study was to assess the role of ultrasound scanning in the identification of cystic posterior fossa anomalies at 11–14 weeks gestation. Study Design A prospective cohort study of fetuses with cystic appearance of the posterior fossa at 11–14 weeks gestation was performed. In all cases and in a control group of 40 normal fetuses, the brainstem–tentorium angle was also measured. The presence or absence of cystic posterior anomalies was determined at birth or at postmortem evaluation. Results In the period 2014–2018, 32 fetuses with an increased brainstem-occipital bone distance and/or failure to visualize the choroid plexus of fourth ventricle (2 brain spaces) were seen. Of these, 18 fetuses were terminated in the first trimester because of associated anomalies and were excluded from the study because of unavailable autoptic findings. The remaining 14 fetuses eventually were found to have a Dandy-Walker malformation in 4 cases, a Blake's pouch cyst in 8 cases, and normal brain anatomy in 2 cases. Two brain spaces were seen in all cases with Dandy-Walker malformation and in 2 of 8 cases with Blake's pouch cyst. Both brainstem-occipital bone measurement and brainstem–tentorium angle were significantly different in fetuses with Dandy-Walker malformation, Blake's pouch cyst, and control subjects (P<.0001). The brainstem-occipital bone z-scores of fetuses with Dandy-Walker malformation and Blake's pouch cyst were always +3 or more and +1.7 or more, respectively. The brainstem–tentorium angle z-scores were always –5 or less and –0.1 or less, respectively. Conclusion Our study confirms that sonography of the posterior brain at 11–14 weeks gestation allows the identification of cystic posterior fossa anomalies. A large brainstem-occipital bone predicts Dandy-Walker malformation or Blake's pouch cyst. The presence of 2 brain spaces and a small brainstem–tentorium angle are correlated significantly with the presence of Dandy-Walker malformation. The role of the first-trimester scan has expanded from aneuploidy screening to the diagnosis of fetal malformations. Abnormal appearance of the posterior brain at 11–14 weeks gestation is a marker of cerebral anomalies; in fact an increased amount of fluid, particularly when the choroid plexus of the fourth ventricle is not visible and only 2 brain spaces instead of 3 are seen, may indicate the presence of cystic or cyst-like posterior fossa anomalies, such as Blake's pouch cyst or Dandy-Walker malformation. The purpose of this study was to assess the role of ultrasound scanning in the identification of cystic posterior fossa anomalies at 11–14 weeks gestation. A prospective cohort study of fetuses with cystic appearance of the posterior fossa at 11–14 weeks gestation was performed. In all cases and in a control group of 40 normal fetuses, the brainstem–tentorium angle was also measured. The presence or absence of cystic posterior anomalies was determined at birth or at postmortem evaluation. In the period 2014–2018, 32 fetuses with an increased brainstem-occipital bone distance and/or failure to visualize the choroid plexus of fourth ventricle (2 brain spaces) were seen. Of these, 18 fetuses were terminated in the first trimester because of associated anomalies and were excluded from the study because of unavailable autoptic findings. The remaining 14 fetuses eventually were found to have a Dandy-Walker malformation in 4 cases, a Blake's pouch cyst in 8 cases, and normal brain anatomy in 2 cases. Two brain spaces were seen in all cases with Dandy-Walker malformation and in 2 of 8 cases with Blake's pouch cyst. Both brainstem-occipital bone measurement and brainstem–tentorium angle were significantly different in fetuses with Dandy-Walker malformation, Blake's pouch cyst, and control subjects (P<.0001). The brainstem-occipital bone z-scores of fetuses with Dandy-Walker malformation and Blake's pouch cyst were always +3 or more and +1.7 or more, respectively. The brainstem–tentorium angle z-scores were always –5 or less and –0.1 or less, respectively. Our study confirms that sonography of the posterior brain at 11–14 weeks gestation allows the identification of cystic posterior fossa anomalies. A large brainstem-occipital bone predicts Dandy-Walker malformation or Blake's pouch cyst. The presence of 2 brain spaces and a small brainstem–tentorium angle are correlated significantly with the presence of Dandy-Walker malformation.