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Downloaded for Personal Use Only Consensus Paper 175 3D imaging of the fetal face – Recommendations from the International 3D Focus Group Authors E. Merz (Germany), J. Abramovicz (USA), K. Baba (Japan), H.-G. K. Blaas (Norway), J. Deng (UK/China), L. Gindes (Israel), W. Lee (USA), L. Platt (USA), D. Pretorius (USA), R. Schild (Germany), P. Sladkevicius (Sweden), I. Timor-Tritsch (USA) Key words Introduction mary 3-orthogonal-plane image (●" Fig. 1) [9], " ● 3 D ultrasound ! the object is displayed so that the image at the ●" fetus Three-dimensional and four-dimensional ultra- top left always corresponds to that visualized in ●" face sound (3 D/4 D US) technology can be easily ap- the monitor during 2 D US scanning. This permits plied to routine prenatal diagnosis and can provide to draw a valid conclusion on the position of the images of the fetal face that cannot be achieved embryo/fetus at the time of volume scanning. with two-dimensional ultrasound (2 D US) [1 – 7]. Following display of all 3 perpendicular planes The most recent 3 D/4 D US technology facilitates the object can be rotated in all 3 dimensions. the 3 D/4 D US examinations even for the less train- However, this can lead to a loss in spatial orienta- ed sonographer and gives the examiner the oppor- tion. To avoid such a confusion the ISUOG 3 D Fo- tunity to identify the normal and abnormal fetal cus Group [9] has recommended to rotate the vol- face in the most appropriate imaging mode [8]. ume in such a way that the embryo/fetus may at The purpose of publishing these recommenda- all times be visualized in an upright sagittal posi- tions was to demonstrate the different possibili- tion in the image at the top right (secondary 3-or- ties of assessing the normal and abnormal fetal thogonal-plane image) (●" Fig. 2). This ensures face with 3 D/4 D ultrasound and to give the op- that the object of interest is visualized automatic- erator an overview of the benefit resulting from ally in an anatomically correct position in the cor- the application of that technology. onal and transverse plane, regardless of the possi- ble vertex or breech presentation. With the three-orthogonal-plane display all con- Display modes ventional scan planes can be viewed, as well as ! planes that are unattainable with traditional 2 D In contrast to conventional 2 D US, which pro- US. The simultaneous display of all three perpen- vides only one imaging mode to demonstrate the dicular sectional planes provides an ideal basis for fetus, 3 D/4 D US technology offers the ability to a detailed survey of the fetus and allows the de- Bibliography review the fetal face in different display modes monstration of a specific 2 D plane to be precisely DOI http://dx.doi.org/ [7, 8]: 1. three-orthogonal-plane (= triplanar1 or controlled. To optimize the position of the face, This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. 10.1055/s-0031-1299378 1 Published online: 2012 multiplanar ) display, 2. parallel-plane (= tomo- the cursor dot should be placed between the or- 1 1 Ultraschall in Med 2012; 33: graphic or multislice ) display, 3. 3 D surface dis- bits in the coronal plane and the face rotated in 175–182 © Georg Thieme play and 4. 3 D transparent display (maximum, x- all planes until it is symmetrical (●" Fig. 2). Verlag KG Stuttgart · New York · ray and minimum mode). In addition some ultra- ISSN 0172-4614 sound systems allow also an ‘any plane slicing’ 2. Parallel-plane (= tomographic) display Correspondence and a mixing of two different modes (eg. mode 1 With the parallel-plane display [7, 8] the region of Eberhard Merz, M. D. 70 % and mode 2 30 %). Furthermore 4 D US allows interest can be displayed on the monitor in sever- Professor and Director, volume visualization of 3 D images of the fetus in al parallel slices similarly to CT or MRI (●" Fig. 3 – Department of Obstetrics & real-time. 5). This display enables a detailed tomographic Gynecology, Hospital Nordwest survey of the fetal face in sagittal, coronal and – Steinbacher Hohl 2 26 1. Three-orthogonal-plane display transverse slices at different distances. The sagit- 60488 Frankfurt/Main In this display [7, 8] all three mutually perpendi- Germany cular planes are displayed simultaneously on the Tel.: ++ 49/69/76 01 35 79 1 These terms are widely used simultaneously. However, monitor immediately after volume acquisition in Fax: ++ 49/69/76 01 36 13 from the logical point of view, they are not as precise as [email protected] 3 D or in 4 D (real time) US scanning. In this pri- the main term. Merz E et al. 3D imaging of… Ultraschall in Med 2012; 33: 175–182 176 Consensus Paper tal planes are helpful to demonstrate the profile and the orbits, most of the overlaying structures in any of the slice images, or in the coronal planes to assess the orbits and the palate and the the 3 D image itself. However, when overlaying structures (eg. transverse planes to evaluate the orbits, palate, maxilla and limb bones) create acoustic shadows, the electronic scalpel can- mandible. not overcome those artifacts. The best surface images can be achieved when the fetal face is looking towards the probe, when 3. 3 D surface display there is enough amniotic fluid in front of the face and when there This display mode [7, 8] provides three-dimensional surface ima- are no overlaying structures causing shadows. ges of the fetal face (●" Fig. 6, 7). There are different rendering (calculation) algorithms to depict the fetal face: surface mode, 4. Transparent display soft surface mode, light mode, and soft light mode (●" Fig. 8). In terms of the different transparent modes (maximum mode, X- Two of these modes can be mixed in different percentages. ray mode), the maximum mode (= maximum intensity display) The prerequisites for high-quality 3 D US images of the fetal sur- [7, 8, 11 – 13] can be used to visualize hyperechogenic structures. face are the presence of a sufficient amniotic fluid pocket in front This mode provides a complete survey of the fetal skull and facial of the structure being imaged and the absence of overlying or ad- bones (●" Fig. 9). To get high quality pictures this mode can be jacent structures [2]. However, in some cases the face is hidden mixed with surface mode. by overlying or adjacent structures. In order to obtain a high qual- ity surface image those structures have to be removed with the electronic scalpel [10]. This tool allows the examiner to remove Fig. 1 Three-orthogonal-plane display of a fetus in breech presentation at Fig. 2 Secondary 3-orthogonal-plane image after rotation the fetus of 25 weeks of gestation. Primary 3-orthogonal-plane image after acquisition. Fig. 1 into an upright position and horizontal rotation of 90°. Plane a =co- Plane a = sagittal plane. Plane b = transverse plane (bird’s eye view). Plane ronal plane at orbit level. Plane b = median plane. Plane c = transverse plane c = coronal plane (= frontal view). Plane a demonstrates the 2 D US image at orbit level. This demonstration shows the fetal face always in an anato- during acquisistion. le = left, ri = right. mically correct position: le = left, ri = right. Fig. 3 Parallel-plane (= tomographic) display showing several slices of the fetal face at distances of 5.0 mm (sagittal views). 23 weeks of gestation. This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. Merz E et al. 3D imaging of… Ultraschall in Med 2012; 33: 175–182 Consensus Paper 177 Fig. 4 Parallel-plane (= tomographic) display showing several slices of the fetal face at distances of 5.0 mm (coronal views). 23 weeks of gestation. Fig. 5 Parallel-plane (= tomographic) display showing several slices of the fetal face at distances of 5.0 mm (transverse views). 23 weeks of gesta- tion. 4 D ultrasound (= real time 3 D US) [7, 8] 4 D US technology allows real time visualization of the fetus in any of the modes described above. In particular, with fast acquisi- tion of up to 35 volumes per second, both the surface and move- ments of the fetus can be demonstrated constantly on the screen. This enables the physician to study fetal facial movements such as yawning, sucking, swallowing, mimicking [9] and offers the par- ents the opportunity to observe fetal movements. From the diag- This document was downloaded for personal use only. Unauthorized distribution is strictly prohibited. nostic point of view 4 D US is always helpful in the moving fetus, and 3 D US in the fetus at rest. 3 D US imaging of the fetal face in the first trimester (11 – 14 weeks of gestation) ! Fig. 6 Three-orthogonal-plane display and 3 D US surface rendered image Normal anatomy of a fetus at 23 weeks of gestation after rotation the face into an upright In the first trimester 3 D US can be applied for the profile and for position and horizontal rotation of 90°. Upper left: Coronal image of face. demonstration of normal ossification (●" Table 1). While the profile Upper right: Sagittal view. The volume box is positioned close to the sur- with nose, lips and chin can be shown with the three-orthogonal- face of the face. The green arrow and the green line demonstrate the plane display and a 3 D US surface rendered image as well camera position. Lower left: Axial view of the orbits. Lower right: A surface- " rendered image of the fetal face (frontal view).
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