a rare case of exencephaly abstract id- iria -1221
TRANSCRIPT
20 years old G2 A1 lady Presented at 18 weeks POG for anamoly scan Antenatal period uneventful till date
USG
Obstetric USG Deficient cranial
vault above the levels of orbit
Brain tissue seen protruding out of the defect
Polyhydramnios
Provisional diagnosis - Exencepahaly
MRI Patient taken up for MRI
same day
To confirm presence of exencephaly
T2 HASTE sequences were performed
Fidings Supraorbital cranial vault
was absent Disorganised brain tissue
seen protruding out of the defect
Bilaterally prominent orbits : Frog Eye sign
DISCUSSION ACRANIA- EXENCEPHALY- ANENCEPAHALY SEQUENCE
Acrania is the absence of the calvarium; the skull base may be intact Exencephaly is acrania with protrusion of a substantial
portion of the CNS into the amniotic cavity Anencephaly is acrania with absence of most or all of the
brain tissue
Anencephaly is classified anatomically as merocrania when the defect does not involve the foramen
magnum holoacrania when the defect extends through the foramen
magnum; Holoacrania with rachischisis if spinal defects are
associatedType of Neural tube defect
DISCUSSION
Incidence is around 1:1000. There is a recognised female predilection with a F:M of ~4:1.
As with many other malformations, a number of associated abnormalities are recognised: other neural tube defects: spina bifida (especially
cervical) congenital heart defects cleft lip/palate diaphragmatic hernia(s) spinal dysraphism skeletal anomalies: e.g. clubfeet gastrointestinal abnormalities: e.g. omphalocele urinary tract abnormalities: hydronephrosis most
common
EXENCEPHALY Exencephaly is characterised by calvarial absence
and loss of fetal brain tissue to variable degrees and is considered a precursor to anencephaly in the acrania-exencephaly-anencephaly sequence.
Absence of the cranial vault exposes the brain to contact with the amniotic fluid. Initially, an excessive growth of the encephalic structures occurs with a normal development of eyes and cranial nerves
Susequently, destructive processes of the exposed brain occur
The eventual result is anencephaly Markers : maternal serum alpha feto protein
(MSAFP) levels are highly elevated
RADIOGRAPHIC FEATURES
Imaging features have some overlap with that of anencephaly except that there is some brain tissue presence:
cranial vault is absent or poorly formed, cephalad to orbits
nasal bone may be absent in most cases brain tissue is herniating or dangling in
amniotic fluid brain tissue may be attached to the amniotic
membrane
US is an extremely accurate technique for the diagnosis of acrania, with almost 100% sensitivity.
Transvaginal US can be useful when the fetal head is low in the pelvis and not easily visible
The calcification of the bone structures of the skull can be discerned at the 10th week of gestation; therefore, it is suggested not to attempt a diagnosis before this week
The characteristic US feature is represented by absent visualization of the cranial vault above the orbits, which appear prominent; the thalami and ventricles are not detectable
In anencephaly it is difficult to recognize the cerebral tissue, while in exencephaly it is usually possible to detect a normal amount of cerebral tissue
AMNIOTIC BAND SEQUENCE WITH EXENCEPHALY
Amniotic bands are thin fibrous bands causing regional constrictions, amputations and disruption of cranial bone formation .The brain tissue is covered by only a vascular layer of epithelium, and can be slowly degraded by the amniotic fluid and degenerate into anencephaly.
MRI: Usually HASTE T2 or SSFSE sequence is
used , which is very fast and thus prevents motion artifacts
PROGNOSIS
Exencephaly is a precursor to anencephaly, and essentially a lethal condition
Advise and counselling for abortion is to be given to the parents.
REFRENCES
1. Wilkins-haug L, Freedman W. Progression of exencephaly to anencephaly in the human fetus--an ultrasound perspective. Prenat. Diagn. 1991;11 (4): 227-33
2. Bianchi DW, Crombleholme TM, D'Alton ME. Fetology, diagnosis & management of the fetal patient. McGraw-Hill Professional. (2000)
3. Timor-tritsch IE, Greenebaum E, Monteagudo A et-al. Exencephaly-anencephaly sequence: proof by ultrasound imaging and amniotic fluid cytology. J Matern Fetal Med. 5 (4): 182-5.
4. Papp Z, Csécsei K, Tóth Z et-al. Exencephaly in human fetuses. Clin. Genet. 1986;30 (5): 440-4.
5. Merz E, Bahlmann F. Ultrasound in obstetrics and gynecology. Thieme Medical Publishers. (2005)