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Chapter 2 Normal Two- and Three-Dimensional Neurosonography of the Prenatal Brain
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Chapter 3
BIOMETRY OF THE FETAL BRAIN
Natan Haratz-Rubinstein ● Ana Monteagudo ● Ilan E. Timor-Tritsch
INTRODUCTION
Prenatal diagnosis should be instituted accurately and
early enough to achieve an excellent level of care of the
obstetric patient. Ultrasonography, with its increasingly
better resolution and image quality, is making it easier for
health care providers to make appropriate management
decisions. Assessing whether a structure is normal or
abnormal may not always be feasible, but if doubt exists
regarding its normalcy, it must be carefully and diligently
pursued. In addition, several measurements, such as the
biparietal diameter (BPD) and the head circumference
(HC), can be used to determine the gestational age of a
fetus, especially during the first half of pregnancy. Correct
estimation of gestational age is of paramount importance
because adequate management of both low- and high-risk
obstetric populations relies heavily on knowing the precise
gestational age.
The tables in this chapter have been compiled from
the literature for the sole purpose of serving as an easy
reference against which measurements can be compared.
An attempt has been made to include as many tables of
different parameters as possible. These tables, assembled
in a single chapter, will allow the sonographer or sonologist to more easily make the differentiation between
normal and abnormal measurements, without having to
search different textbooks and articles for a particular
measurement.
This chapter is divided into four main sections. The
first, crown-rump length (CRL), although not a brain or head
measurement, is included to provide a means of predicting
embryonic or fetal age. This parameter is of obvious importance and eliminates the need to turn to another source.
The second section, dealing with head measurements,
can be used not only to date the pregnancy but also to aid
in the diagnosis of microcephaly and alterations in fetal
head shape. This section also includes measurements of
orbital diameters, which can be of help in the diagnosis
of eye pathology.
The third section provides a variety of tables concerning the different portions of the fetal ventricular
system, mainly for the purpose of making early diagnosis
of ventriculomegaly possible. Congenital hydrocephaly is
one of the most frequently described anomalies, with an
incidence of 0.3 to 1.5 per 1000 births. The importance
of in utero detection of this anomaly cannot be overemphasized. This section also includes tables that we have
generated using the transvaginal-transfontanelle approach
to the fetal brain using 5 to 7.5 MHz transvaginal probes.
These tables enhance and complement the widely accepted
transabdominally generated tables, thereby advancing the
field of fetal neurosonography and giving new meaning to
the term early diagnosis .
The fourth and final section includes measurements
of other intracranial structures, such as the thalami, basal
nuclei, cerebellum, and cerebellomedullary cistern. These
can assist the sonographer or sonologist in the diagnosis
of pathologies such as Dandy-Walker and Arnold-Chiari
malformations.
This chapter attempts to provide the reader with a
unique reference guide to fetal brain measurements.
CROWN-RUMP LENGTH
Definition
The CRL represents the longest measurable length of the
embryo or fetus, excluding the inferior limbs or the yolk
1 , 2
sac.
How to Measure It ( Figure 3–1 )
In a longitudinal scan, the CRL is measured from a point
immediately over the middle of the midbrain (crown) to
the embryonic or fetal rump. O’Rahilly and Müller
gested that from 28 to 44 postovulatory days (6.0 to 8.5
postmenstrual weeks, * or Carnegie stages 13 to 18), the
maximum longitudinal length of the embryo is not truly
represented by the CRL, but by what they called the greatest length. This is explained by the fact that during these
stages, the normal flexion of the embryonic head locates
the middle of the midbrain below the highest point of the
head. As pregnancy advances, the head extends, making
* Fetal and embryonic age is described here in reference to postmenstrual
weeks. Postovulatory age is approximately 2 weeks less than postmenstrual age.
1
sug-
104
Chapter 3 Biometry of the Fetal Brain
CRL
CRL
Figure 3–1.
the middle of the midbrain match the highest point of the
head and thus becoming a true “crown” reference point
(see Chapters 1 and 2 ).
Comments
Although the CRL is obviously not a measurement of the
brain, it will be included in this chapter as a reference for
the assessment of estimated age, a parameter of utmost
importance when evaluating the embryo and the fetus,
and one against which most biometry tables are plotted. The validity of this parameter for determination of
age in the first trimester has been widely reported in the
literature.
2 – 4
The average of three measurements should
be used to diminish random errors in the technique.
The variability in predicting postmenstrual age with the
CRL changes over time, with a reported range of error
of ± 8% of the estimate.
2
Possible factors contributing to
this range are (1) normal biologic variation in fetal size,
(2) variation in the times of ovulation and fertilization,
and (3) errors attributed to the measurement technique.
Nevertheless, the CRL remains the gold standard measurement for dating pregnancy in the first trimester, with
the exception of in vitro fertilization cases ( Tables 3–1
and 3–2 ).
Blaas and colleagues
5
described the use of threedimensional (3D) transvaginal sonography to outline in
detail the outer contours of embryos at 7 to 10 weeks of
gestation. Using this technique, they were able to describe
the contours of the brain cavities, as well as calculate
volumes that corresponded well with the descriptions
from classic human embryology.
HEAD MEASUREMENTS
Biparietal Diameter
Definition
The BPD represents the widest transverse dimension of
the fetal head.
How to Measure It ( Figure 3–2 )
The fetal head should be imaged in a horizontal (axial)
plane. The transducer should be tilted to match the angle
of inclination of the head in the vertical axis of the fetus
so that a horizontal section can be obtained. This is recognized by the appearance of the midline echo and the
widest fetal head diameter at right angles with it. The
transducer should then be rotated (following the position
of the fetal spine) until the head appears as an ovoid and a
small anechoic area is detected in the midline, one-third of
the distance from the sinciput.
colleagues,
7
this plane represents a section along the sub-
6
According to Hadlock and
occipital-bregmatic axis, angled ~40°, to the canthomeatal
line. Intracranial landmarks that should be recognized in
an anterior-to-posterior fashion are (see Figure 3–2 for
abbreviations) the falx cerebri (F); the cavum septi pellucidi (CSP), which corresponds to the midline anechoic
area described by Campbell and Thoms;
6
the cerebral
peduncles (P); and again, the falx cerebri in the midline.
Laterally, one should be able to recognize, depending on
the age of the fetus, the anterior horns (AH) of the lateral
ventricles, the hypoechoic thalami (T), and the choroid
plexus (CP) in the atrium (A) of each lateral ventricle.
Halfway between the thalami and the calvarium, a linear
3
echo corresponding to the insula (I) can be seen, with the
pulsating middle cerebral artery within. Once the correct
plane has been identified, the calipers should be placed at
the outer surface of the skull table nearest the transducer
and at the inner margin of the opposite skull table, with
gain settings adjusted so that the width of the skull table
nearer the transducer is 3 to 5 mm.
Comments
The BPD was one of the first sonographic parameters used
to estimate fetal age.
predictor of menstrual age in the first half of pregnancy,
being the most accurate between 12 and 18 (± 1.2) weeks.
As pregnancy progresses, the BPD loses its power to correctly predict gestational age, with a margin of error of
± 3.2 weeks at 36 to 42 weeks ( Tables 3–3 and 3–4 ).
The observed variation in the third trimester has
been related to (1) technical errors in imaging, (2) genetic
variations in head size in fetuses of equal age, and (3) differences in the times of ovulation and fertilization during
the menstrual period.
Sonographic measurement of the BPD may be misleading if the fetal head shape is abnormal. It has been postulated that extrinsic factors such as breech presentation
8
It has been shown to be a reliable
9
Chapter 3 Biometry of the Fetal Brain
Table 3 –1. NOMOGRAM OF THE SONOGRAPHICALLY DETERMINED CROWN-RUMP LENGTH AS A
FUNCTION OF GESTATIONAL AGE
105
Postmenstrual
Gestational
Age (weeks + days)
CRL (mm) Postmenstrual
Gestational
Mean SD Mean SD
Age (weeks + days)
CRL (mm)
6 + 2 6.7 2.9 10 + 2 35.5 6.9
6 + 3 7.4 3.1 10 + 3 36.9 7.0
6 + 4 8.0 3.2 10 + 4 38.4 7.2
6 + 5 8.7 3.4 10 + 5 39.9 7.3
6 + 6 9.5 3.5 10 + 6 41.4 7.4
7 + 0 10.2 3.7 11 + 0 43.0 7.6
7 + 1 11.0 3.8 11 + 1 44.6 7.7
7 + 2 11.8 3.9 11 + 2 46.2 7.9
7 + 3 12.6 4.1 11 + 3 47.8 8.0
7 + 4 13.5 4.2 11 + 4 49.5 8.1
7 + 5 14.4 4.4 11 + 5 51.2 8.3
7 + 6 15.3 4.5 11 + 6 52.9 8.4
8 + 0 16.3 4.6 12 + 0 54.7 8.6
8 + 1 17.3 4.8 12 + 1 56.5 8.7
8 + 2 18.3 4.9 12 + 2 58.3 8.8
8 + 3 19.3 5.1 12 + 3 60.1 9.0
8 + 4 20.4 5.2 12 + 4 62.0 9.1
8 + 5 21.5 5.3 12 + 5 63.9 9.3
8 + 6 22.6 5.5 12 + 6 65.9 9.4
9 + 0 23.8 5.6 13 + 0 67.8 9.5
9 + 1 25.0 5.8 13 + 1 69.8 9.7
9 + 2 26.2 5.9 13 + 2 71.8 9.8
9 + 3 27.4 6.0 13 + 3 73.9 10.0
9 + 4 28.7 6.2 13 + 4 76.0 10.1
9 + 5 30.0 6.3 13 + 5 78.1 10.2
9 + 6 31.3 6.5 13 + 6 80.2 10.4
10 + 0 32.7 6.6 14 + 0 82.4 10.5
10 + 1 34.0 6.7
CRL, crown-rump length; SD, standard deviation.
Reproduced, with permission, from Robinson HP, 1975.
3
106
Chapter 3 Biometry of the Fetal Brain
Table 3–2. PREDICTED MENSTRUAL AGE FROM CROWN-RUMP LENGTH MEASUREMENTS
CRL (cm) MA (weeks) CRL (cm) MA (weeks) CRL (cm) MA (weeks)
0.2 5.7 4.2 11.1 8.2 14.2
0.3 5.9 4.3 11.2 8.3 14.2
0.4 6.1 4.4 11.2 8.4 14.3
0.5 6.2 4.5 11.3 8.5 14.4
0.6 6.4 4.6 11.4 8.6 14.5
0.7 6.6 4.7 11.5 8.7 14.6
0.8 6.7 4.8 11.6 8.8 14.7
0.9 6.9 4.9 11.7 8.9 14.8
1.0 7.2 5.0 11.7 9.0 14.9
1.1 7.2 5.1 11.8 9.1 15.0
1.2 7.4 5.2 11.9 9.2 15.1
1.3 7.5 5.3 12.0 9.3 15.2
1.4 7.7 5.4 12.0 9.4 15.3
1.5 7.9 5.5 12.1 9.5 15.3
1.6 8.0 5.6 12.2 9.6 15.4
1.7 8.1 5.7 12.3 9.7 15.5
1.8 8.3 5.8 12.3 9.8 15.6
1.9 8.4 5.9 12.4 9.9 15.7
2.0 8.6 6.0 12.5 10.0 15.9
2.1 8.7 6.1 12.6 10.1 16.0
2.2 8.9 6.2 12.6 10.2 16.1
2.3 9.0 6.3 12.7 10.3 16.2
2.4 9.1 6.4 12.8 10.4 16.3
2.5 9.2 6.5 12.8 10.5 16.4
2.6 9.4 6.6 12.9 10.6 16.5
2.7 9.5 6.7 13.0 10.7 16.6
2.8 9.6 6.8 13.1 10.8 16.7
2.9 9.7 6.9 13.1 10.9 16.8
3.0 9.9 7.0 13.2 11.0 16.9
3.1 10.0 7.1 13.3 11.1 17.0
3.2 10.1 7.2 13.4 11.2 17.1
3.3 10.2 7.3 13.4 11.3 17.2
3.4 10.3 7.4 13.5 11.4 17.3
(continued)
Chapter 3 Biometry of the Fetal Brain
107
Table 3–2. PREDICTED MENSTRUAL AGE FROM CROWN-RUMP LENGTH MEASUREMENTS (CONTINUED)
CRL (cm) MA (weeks) CRL (cm) MA (weeks) CRL (cm) MA (weeks)
3.5 10.4 7.5 13.6 11.5 17.4
3.6 10.5 7.6 13.7 11.6 17.5
3.7 10.6 7.7 13.8 11.7 17.6
3.8 10.7 7.8 13.8 11.8 17.7
3.9 10.8 7.9 13.9 11.9 17.8
4.0 10.9 8.0 14.0 12.0 17.9
4.1 11.0 8.1 14.1 12.1 18.0
CRL, Crown-rump length; MA, menstrual age.
Modified, with permission, from Hadlock FP, Shah YP, Kanon DJ, Lindsey JV. Fetal crown-rump length: Reevaluation of relation to menstrual age
(5–18 weeks) with high-resolution real time US. Radiology. 1992;182:501–505.
and oligohydramnios can alter fetal head shape.
10 , 11
In
an attempt to identify variations in the shape of the fetal
skull that might adversely affect the potential of the BPD
in estimating age, Hadlock and associates
12
developed
the so-called cephalic index (CI). When this parameter is abnormal, other measurements, such as the HC,
abdominal circumference, or femur length, should be used
to predict fetal age.
CEPHALIC INDEX
Definition
The CI is the relationship between the short and long axes
of the fetal skull, measured at the level of the BPD.
X
A
I
T
AH
CSP
F
AH
T
A
I
HC
CP
P
P
CP
++
OFD
F
How to Measure It
The widest transverse and longitudinal (occipitofrontal
diameter [OFD]) dimensions of the fetal skull at the level of
the BPD are measured from outer margin to outer margin.
The CI can then be calculated using the following simple
equation:
CI = short axis (transverse)/long axis (OFD) × 100
Comments
The clinical application of the CI lies in its property to
discriminate between the normal fetal head shape and the
head that is abnormal enough to alter fetal age estimation
based on the BPD. Thus, in situations that may modify
X
BPD
Figure 3–2.
108
Chapter 3 Biometry of the Fetal Brain
Table 3–3. PREDICTED FETAL BIPARIETAL DIAMETER AT SPECIFIC MENSTRUAL AGES
Menstrual
Age
(weeks)
Biparietal
Diameter
(cm)
12.0 1.7 26.0 6.5
12.5 1.9 26.5 6.7
13.0 2.1 27.0 6.8
13.5 2.3 27.5 6.9
14.0 2.5 28.0 7.1
14.5 2.7 28.5 7.2
15.0 2.9 29.0 7.3
15.5 3.1 30.0 7.6
16.0 3.2 30.5 7.7
16.5 3.4 31.0 7.8
17.0 3.6 31.5 7.9
17.5 3.8 32.0 8.1
18.0 3.9 32.5 8.2
18.5 4.1 33.0 8.3
19.0 4.3 33.5 8.4
19.5 4.5 34.0 8.5
20.0 4.6 34.5 8.6
20.5 4.8 35.0 8.7
21.0 5.0 35.5 8.8
21.5 5.1 36.0 8.9
22.0 5.3 36.5 8.9
22.5 5.5 37.0 9.0
23.0 5.6 37.5 9.1
23.5 5.8 38.0 9.2
24.0 5.9 38.5 9.2
24.5 6.1 39.0 9.3
25.0 6.2 39.5 9.4
25.5 6.4 40.0 9.4
Reproduced, with permission, from Hadlock and colleagues, 1984.
Menstrual
Age
(weeks)
Biparietal
Diameter
(cm)
29.5 7.5
9
Chapter 3 Biometry of the Fetal Brain
Table 3–4. ASSESSMENT OF GESTATIONAL AGE FROM THE BIPARIETAL DIAMETER
Gestational Age (weeks + days)
109
Biparietal Diameter (mm)
10 7 + 0 10 + 1 13 + 1
11 7 + 2 10 + 2 13 + 3
12 7 + 3 10 + 4 13 + 4
13 7 + 5 10 + 5 13 + 5
14 7 + 6 10 + 6 14 + 0
15 8 + 1 11 + 1 14 + 1
16 8 + 2 11 + 2 14 + 3
17 8 + 4 11 + 4 14 + 4
18 8 + 5 11 + 5 14 + 6
19 9 + 0 12 + 0 15 + 0
20 9 + 1 12 + 2 15 + 2
21 9 + 3 12 + 3 15 + 3
22 9 + 4 12 + 5 15 + 5
23 9 + 6 12 + 6 16 + 0
24 10 + 1 13 + 1 16 + 1
25 10 + 2 13 + 3 16 + 3
26 10 + 4 13 + 4 16 + 5
27 10 + 6 13 + 6 17 + 0
28 11 + 0 14 + 1 17 + 1
29 11 + 2 14 + 3 17 + 3
30 11 + 4 14 + 4 17 + 5
31 11 + 6 14 + 6 18 + 0
32 12 + 1 15 + 1 18 + 1
33 12 + 3 15 + 3 18 + 3
34 12 + 4 15 + 5 18 + 5
35 12 + 6 16 + 0 19 + 0
36 13 + 1 16 + 2 19 + 2
37 13 + 3 16 + 4 19 + 4
38 13 + 5 16 + 6 19 + 6
39 14 + 0 17 + 1 20 + 1
40 14 + 2 17 + 3 20 + 3
41 14 + 4 17 + 5 20 + 5
5th Percentile 50th Percentile 95th Percentile
(continued)