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Phillip
Ramm GradDip
The
Choroid Plexus Cyst
Controversy
|
1.
Introduction
1.1. The Atmosphere of Ultrasound
1.2.
The
Paradigm of Cyst Criteria
1.3.
Purpose
of This Study
2.
Development of the Choroid Plexus
2.1.
Choroid Plexus Growth
& Development
2.2.
Stage I
2.1.
Stage II
2.2.
Stage III
2.3.
Stage IV
2.4.
Conclusion
3.
What is a Choroid Plexus Cyst?
3.1.
Anatomical Definition
3.2.
Ultrasound Definitions
3.3.
Choroid Plexus “Pseudocyst”
3.4.
Conclusion
4.
Geelong
Hospital Choroid Plexus Cyst Survey
4.1.
Initial Reason for the Survey
4.2.
Methodology
4.3.
Results
4.4.
Conclusion
5.
Technical Factors in the
Rise of the CPC Controversy
5.1.
Improved Equipment
5.2.
Concentration on the Fetal Brain
5.3.
Sonographer Skill
& Training
6.1.
Association with Chromosomal Abnormalities
6.2.
Incidence of CPC
6.3.
Rate of Aneuploidy versus Risk of Aneuploidy
6.4.
Differences in the Referral Population and
Indications for Scanning
6.5.
Risk in Down Syndrome
6.6.
Conclusion
7.
The Paradigm is
Established: Attempts to find Useful Criteria
7.1.
Early Protocols used the Size, Bilaterality, Persistence Paradigm
7.2.
Routine Amniocentesis
7.3.
Anomaly Scan
7.4.
Australian Protocols
7.5.
Publishing Bias in Response to the Paradigm
7.6.
Conclusion
8.
Size
8.1.
Large Size in Early Reports
8.2.
Changing Size
8.3.
Reviews of Size
8.4.
Statistical Analysis
8.5.
Conclusion
9.
Bilaterality
9.1.
Imaging Problems
9.2.
Lower Hemisphere Preponderance
9.3.
Statistical Analysis
9.4.
Number of Cysts – Confusion of Terminology
9.5.
Conclusion
10.
Persistence / Late
Disappearance
10.1.
Early “Evidence” of Persistence
10.2.
The Need for Reassurance
10.3.
How Late is Late?
10.4.
Lack of Concurrence in the Literature
10.5.
Statistical Analysis
10.6.
Conclusion
11.1.
Trisomy 18 Reviews,
CPC and/or Other Abnormalities
11.2.
CPC, Abnormalities and T18
11.3.
Risk of “Isolated” CPC in Fetuses with T18
11.4.
Malformation Rate
11.5.
Statistical Analysis
11.6.
Conclusion
12.
Ultrasound Detectable
Abnormalities in Trisomy 18: Review and Discussion
12.1.
Abnormal Cephalic Index
12.2.
Strawberry Shaped Head
12.3.
Small / Abnormal Cerebellum
12.4.
Cisterna
Magna > 9mm – Dandy Walker Malformation / Syndrome
12.5.
Arnold-Chiari
Malformation / Spinal Defects
12.6.
Agenesis of Corpus Callosum
12.7.
Cystic Hygroma
12.8.
Nuchal Oedema / Translucency
12.9.
Hypotelorism
12.10.
Facial Cleft
12.11.
Micrognathia
12.12.
Small Ear
12.13.
Cardiac Defects / Septal
Defects
12.14.
Renal Anomaly
12.15.
Omphalocele / Exomphalos
12.16.
Diaphragmatic Hernia
12.17.
“Absent” Stomach (Presumed Oesophageal
Atresia, OA)
12.18.
Abnormal Extremities: Introduction
12.19.
Radial Aplasia /
Radial Ray Syndrome (Absent Thumb)
12.20.
Overlapping Fingers / Clenched Fist (Camptodactyly) / Polydactyly
12.21.
Talipes / Rockerbottom Feet / Short Hallux
12.22.
Hydramnios
12.23.
Intra-Uterine Growth Retardation
12.24.
Two Vessel Cord (Single Umbilical Artery, SUA)
12.25.
Allantoic / Cord Cysts
12.26.
Signs of Other Chromosomal Abnormalities
12.27.
Conclusion
13.
When is Karyotpying Indicated?
13.1.
The “At-Risk” Patient
13.2.
Biochemical and 1st Trimester Ultrasound Tests
13.3.
Risk of Karyotyping
13.4.
A Balance of Risks
13.5.
The “Routine Scan” Has Become the “Routine
Anomaly Scan”
13.6.
Trials of Routine Ultrasound
13.7.
How Well Are We Scanning?
13.8.
Hard Signs and Soft Signs
13.9.
The Isolated Sign
13.10.
Having Found a Chromosomal Sign …?
13.11.
What Does the Knowledge of Karyotype
Provide?
13.12.
Trisomy 18 and
Amniocentesis
13.13.
Conclusion
14. Management of the Fetus with CPC
14.1. A Comparison of the Ethical and Economic Implications of Suggested Protocols
14.2.
Three Suggested Protocols
14.3.
Outcomes
14.4.
Information Established in this Research
14.5.
200 Cases of T18
14.6.
Protocol 1 – Do Nothing
14.7.
Protocol 2 – Amnio for
all Fetuses with CPC (including Isolated CPC)
14.8.
Protocol 3 – Amnio for
Those with CPC and Other Abnormality(ies)
14.9.
Which Protocol is More Effective?
14.10.
Which Protocol Can be
Ethically Justified?
14.11.
Which Protocol is More Cost Effective
14.12.
Conclusion
15.1.
Routine Scan Pro-forma
15.2.
Chromosomal Marker Pro-forma
15.3.
Conclusion
16.
Summary:
16.1.
Conclusion
Appendices:
2. Glossary
4. Maternal Age Modified Risks
5. Prevalence of T18
6. Proforma:
2nd and 3rd Trimester Worksheet
7. Proforma:
Chromosomal Markers Worksheet
8. ASUM Guidelines: 18-20
Week Obstetrical Scan
Presentations
Based On This Research