HDlive Silhouette in the evaluation of fetal

spine in myelomeningocele.
By Miguel Martínez-Rodríguez, M.D; Rosa Villalobos-Gómez, M.D; Rogelio Cruz-Martínez,
M.D, PhD, Medicina Fetal México, Santiago de Querétaro, Querétaro, México.

“Open spina bifida is the most common congenital

anomaly of the central nervous system (CNS). The
About the authors:
best way to diagnose fetal spina bifida is direct
examination of the spine. This is usually achieved
with two-dimensional (2-D) ultrasound by inspection
of the spinal vertebrae; however, this procedure
might be quite difficult in some fetuses, time
consuming and demands an experienced operator.
To overcome these challenges, three-dimensional
(3-D) ultrasound is able to provide a 3-D HDlive Dr. Rogelio Cruz Dr. Miguel Ángel Dra. Rosa Villalobos
Silhouette image of the fetal spine for defining the Martínez, M.D, Ph.D. Martínez Rodríguez, Gómez, MD.
level of the anatomical defect and extension of the Fetal Medicine and MD. Fetal Medicine and
Surgery Specialist Fetal Medicine and Cardiology Specialist
lesion in fetuses with myelomeningocele.”
Neurosonography
Specialist

About the institution:

“We are a group of specialists
experts in advanced prenatal
diagnosis and minimally
invasive fetal surgery.
We provide advanced and comprehensive care for the
health and safety of both the mother and baby in fetal
life, through the lastest technology and highly qualified
staff. As pioneers in Mexico, we are a national reference
center for the diagnosis and resolution of fetal diseases."

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Introduction
Open spina bifida is the most common congenital
anomaly of the central nervous system (CNS),
associated with long-term neurological handicap. It is
characterized by protrusion of meninges, spinal cord and
nerves through a defect in the overlying vertebral arches
and skin.
Prenatal diagnosis is usually suspected in the presence
of cranial ultrasound changes including scalloping of the
frontal bones or lemon sign, ventriculomegaly, and
posterior fossa obliteration or banana sign.
Nevertheless, the best way to diagnose fetal spina bifida
is direct examination of the spine1.
Defining the upper anatomical level of the lesion in
myelomeningocele is one of the main predictors of
postnatal neurological morbidity2. This is usually
achieved with two-dimensional (2-D) ultrasound by
Clinical Case Study
Patient History
Female patient, gestational age: 24 weeks.
Methods and Imaging Findings
Acquisition
The exam is done using a 3-D ultrasound equipment
(Voluson E10, GE Healthcare, Zipf, Austria). Initially, a
transabdominal and vaginal scan in 2-D of the fetal spine
is performed with both a matrix convex volumetric
RM6C probe and a convex volumetric RIC6-12-D probe
respectively; this is achieved by placing the fetal back
proximal to the transducer aligned to a mid-sagittal
plane. A correct alignment of the probe demonstrates an
image containing the vertebral bodies, spinous
processes and skin. In fetuses with myelomeningocele, a
defect is shown as loss in the skin continuity over an
osseous defect that may be accompanied by protrusion
of a cyst, which sometimes contains neural tissue
(Figure 1).
Volume acquisition
Once identified the spinal defect, the 3-D button is
activated and the region of interest (ROI) is adjusted to
inspection of the spinal vertebrae and searching for
dorsal defects accompanied with widening of the
transverse processes forming a characteristic V shape;
this requires longitudinal, transverse and coronal views
of the fetal spine3. Correct characterization of the size
and content of the defect permit an accurate prognosis
of the postnatal anatomical functional level and optimal
surgical planning.
In this paper we have the objective to describe how the
new technological advances in three-dimensional (3-D)
ultrasound can be used for clarifying fetal evaluations,
as we delineate the acquisition technique of a 3-D
HDlive Silhouette image of the fetal spine for defining
the level of the anatomical defect and extension of the
lesion in fetuses with myelomeningocele.
capture the defect and preferentially the whole
vertebral column longitudinally, with a profundity
enough to include the vertebral bodies. The sweep
angle is adjusted to 35-40º for each side, high quality is
settled and with the HDlive Silhouette preset a
surface rendering is obtained (Figure 2). Then, the ROI is
adjusted to only fit the defect (Figure 3), this way we
can visualize the dorsal cyst located at the anatomical
defect. The gains and profundity are reduced in order to
identify correctly the vertebral column and its
anatomical references, being the most caudal
articulated rib T12, the superior aspect of the iliac crest
L5 and the lowest and most ossified vertebra
representing S4. In a caudal progression, we count the
number of unaffected vertebral arches, initiating in T12
and we can clearly identify where the parallelism
between the lateral processes is lost. Figure 4
illustrates an example of an open spina bifida, in which
the defect initiates in the 2nd lumbar vertebra (Figure 4).
Figure 1. Ultrasound 2-D picture in a sagittal view of the spine, in a fetus with myelomeningocele
A dorsal defect in the back, compromising skin and dorsal arches is visualized as well
as a cyst emerging from the defect, which contain nerve roots (*). In this case, the last
ossified vertebral body corresponds to S4, and determination of the vertebral level
defect is initiated by counting the vertebral bodies in a cranial progression.

Figure 2. Ultrasound 3-D picture with HDlive Silhouette in a sagittal view of the spine, in the
same fetus of Figure 1. The ROI was adjusted to fit all the defect and most of the spinal
column, the profundity and gains have not been adjusted. A divergence between the
posterior arches of the spine is noted to initiate in L2.
Figure 3. Ultrasound 3-D picture with HDlive Silhouette in a sagittal view of the spine, with
the ROI adjusted to fit only the defect, and the principal anatomical landmarks of the
spinal defect are visualized. The arrow points the tethered spinal cord, (+) signalizes
the placode, the nerve roots (*) and (**) indicate the dorsal muscles.

Figure 4. Ultrasound 3-D picture with HDlive Silhouette in a sagittal view of the spine, with
adjustment of profundity and gains, which permits visualization of the first costovertebral
articulation (T12) and the divergence of the posterior arches initiating in L2 (*).
Conclusion
We describe an easy method for defining the upper
anatomical level and the extension of the lesion in case
of open spina bifida using last-generation 3-D ultrasound
rendering with HDlive Silhouette.
Clinical Key Points
• 3-D ultrasound allows the spatial visualization of some
structures not easily visualized in 2-D ultrasound.
• Volumetric examination reduces dependence on good
fetal posture for acquisition, helping in the case of a
less experienced users.

Technical Highlight References

HDlive is a rendering method that produces incredibly
realistic images of the fetus. By using virtual lighting,
HDlive generates a shading effect that creates greater
depth perception, helps reveal hidden details, and can
provide a deeper understanding of relational anatomy.
HDlive Silhouette, is the next level of this technology
that allows to dynamically apply transparency to certain
structures within the rendered volume, allowing an
evaluation from solid surface structures to the
development of the internal anatomy of the fetus. This
new method takes advantage of the excellent image
quality provided by the latest generation of
beamforming technology, speckle reduction algorithms
and composite resolution imaging technologies in
Voluson systems.
1. Malinger G, Paladini D, Haratz KK, Monteagudo A, Pilu
GL, Timor-Tritsch IE. ISUOG Practice Guidelines
(updated): sonographic examination of the fetal
central nervous system. Part 1: performance of
screening examination and indications for targeted
neurosonography. Ultrasound Obstet Gynecol 2020;
56: 476-484.
2. Rintoul NE, Sutton LN, Hubbard AM, Cohen B,
Melchionni J, Pasquariello PS, Adzick NS. A new look at
myelomeningoceles: functional level, vertebral level,
shunting, and the implications for fetal intervention.
Pediatrics 2002; 109: 409-413.
3. Coleman BG, Langer JE, Horii SC. The diagnostic
features of spina bifida: the role of ultrasound. Fetal
Diagn Ther 2015; 37: 179-196.

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