RT Journal
A1 Sutton LN, Adzick N, Bilaniuk LT, Johnson MP, Crombleholme TM, Flake AW
T1 IMprovement in hindbrain herniation demonstrated by serial fetal magnetic resonance imaging following fetal surgery for myelomeningocele
JF JAMA
JO JAMA
YR 1999
FD November 17
VO 282
IS 19
SP 1826
OP 1831
DO 10.1001/jama.282.19.1826
UL http://dx.doi.org/10.1001/jama.282.19.1826
AB Context 
                  Hindbrain herniation occurs in a large percentage of children with myelomeningocele
and is the leading cause of death in this population. The effect of early
fetal closure of myelomeningocele on hindbrain herniation is unknown.Objective 
                  To determine whether early fetal closure of myelomeningocele affects
hindbrain herniation.Design 
                  Case series of patients undergoing fetal myelomeningocele closure with
serial measurements of hindbrain herniation and a mean follow-up of 182 days.Setting 
                  Tertiary care medical center.Participants 
                  Ten patients undergoing fetal myelomeningocele closure at 22 to 25 weeks'
gestation between March 1998 and February 1999.Main Outcome Measures 
                  Need for shunt placement; degree of hindbrain herniation (grades 0-3)
found on magnetic resonance imaging (MRI) performed prior to surgery and 3
and 6 weeks after fetal surgery, as well as shortly after birth; gestational
age at delivery.Results 
                  All initial fetal MRI scans performed at 19 to 24 weeks' gestation showed
significant (grade 3) cerebellar herniation and absence of spinal fluid spaces
around the cerebellum. Six fetuses were delivered electively at 36 weeks'
gestation after lung maturity was established. The other 4 were delivered
prematurely, at 25, 30, 30, and 31 weeks of gestation, and the 25-week gestation
neonate died. All 9 surviving neonates showed improvement in the hindbrain
hernia at the 3-week postoperative fetal scan (grade 2, n = 4; grade 1, n
= 5). On the postnatal scan, all patients showed grade 1 hindbrain herniation.
Only 1 patient required placement of a ventriculoperitoneal shunt.Conclusion 
                  In this series of patients, fetal myelomeningocele closure resulted
in improvement in hindbrain herniation as demonstrated by serial MRI scans.