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3D reconstruction of diaphragmatic defects in CDH: a fetal MRI study

Florian Prayer, Martin Metzelder, Wilfried Krois, Peter C Brugger, Gerlinde M Gruber, Michael Weber, Anke Scharrer, Alexander Rokitansky, Georg Langs, Daniela Prayer, Ewald Unger, Gregor Kasprian
Ultrasound in Obstetrics & Gynecology 2019 April 15

OBJECTIVES: To assess the clinical feasibility and validity of fetal MRI-based 3D reconstructions to localize, classify, and quantify diaphragmatic defects in congenital diaphragmatic hernia (CDH).

METHODS: Manual segmentation of the diaphragm based on 65 in vivo and four postmortem fetal MRI scans of 46 CDH cases (gestational age 16 - 38 gestational weeks (GW)) was performed using SSFP, T2-weighted, and T1-weighted sequences and ITK-Snap. The resultant 3D models of the fetal diaphragm and its defect(s) were validated by postmortem MRI segmentation in four cases and/or comparison to a reference classification based on autopsy and surgery reports. Areas of the intact diaphragm and the defect were measured and defect-to-diaphragmatic ratios (DDR) were calculated. The need for prosthetic patch repair and diaphragm growth dynamics, in cases with repeated in vivo fetal MRI scans, were analyzed based on DDR.

RESULTS: Fetal MRI-based manual segmentation of the diaphragm in CDH was feasible in 65/65 (100%) fetal MRI scans. Based on 3D diaphragmatic models, one bilateral and 45 unilateral defects were further classified as posterolateral (23 of 47, 48.9%), lateral (7 of 47, 14.9%), anterolateral (0 of 47, 0%), and hemidiaphragmatic (17 of 47, 36.2%). Localization of the defect was correctly identified in 37/37 (100%) cases where this information was available. In 5/19 (26.3%) cases with follow-up fetal MRI scans, the initial CDH classification was altered by the results of the second scan. All of the 33 fetuses who underwent postnatal diaphragmatic repair surgery, with a DDR of 54 or higher, received a diaphragmatic patch. Individual DDR at initial and follow-up in vivo fetal MRI scans correlated significantly (p<0.001).

CONCLUSION: Three-dimensional, MRI-based reconstruction of the fetal diaphragm in CDH is valid to visualize, localize, classify, and quantify the defect. Planning of postnatal surgery may be optimized by MR-based prediction of patch necessity and the ability to personalize patch designs based on 3D-printable templates. This article is protected by copyright. All rights reserved.


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