Abstract
SummaryBackgroundIn utero MRI (iuMRI) detects fetal brain abnormalities more accurately than ultrasonography and provides additional clinical information in around half of pregnancies. We aimed to study whether postnatal neuroimaging after age 6 months changes the diagnostic accuracy of iuMRI and its ability to predict developmental outcome.MethodsFamilies enrolled in the MERIDIAN study whose child survived to age 3 years were invited to have a case note review and assessment of developmental outcome with the Bayley Scales of Infant and Toddler Development, the Ages and Stages Questionnaire, or both. A paediatric neuroradiologist, masked to the iuMRI results, reviewed the postnatal neuroimaging if the clinical report differed from iuMRI findings. Diagnostic accuracy was recalculated. A paediatric neurologist and neonatologist categorised participants' development as normal, at risk, or abnormal, and the ability of iuMRI and ultrasonography to predict developmental outcome were assessed.Findings210 participants had case note review, of whom 81 (39%) had additional investigations after age 6 months. The diagnostic accuracy of iuMRI remained higher than ultrasonography (proportion of correct cases was 529 [92%] of 574 vs 387 [67%] of 574; absolute difference 25%, 95% CI 21 to 29; p<0·0001). Developmental outcome data were analysed in 156 participants, and 111 (71%) were categorised as normal or at risk. Of these 111 participants, prognosis was normal or favourable for 56 (51%) using ultrasonography and for 76 (69%) using iuMRI (difference in specificity 18%, 95% CI 7 to 29; p=0·0008). No statistically significant difference was seen in infants with abnormal outcome (difference in sensitivity 4%, 95% CI −10 to 19; p=0·73).InterpretationiuMRI remains the optimal tool to identify fetal brain abnormalities. It is less accurate when used to predict developmental outcome, although better than ultrasonography for identifying children with normal outcome. Further work is needed to determine how the prognostic abilities of iuMRI can be improved.FundingNational Institute for Health Research Health Technology Assessment programme.
Highlights
The MERIDIAN 3-year follow-up study was designed to address these knowledge gaps across three projects, : project one was designed to recalculate the diagnostic accuracy of ultrasonography and in utero MRI (iuMRI) using diagnoses collected after 6 months of age; project two, to compare the ability of ultrasono graphy and iuMRI to predict developmental outcome around age 3 years; and project three, to study the devel opmental significance of isolated mild ventriculomegaly (IMVM), because of the large numbers of cases and perceived difficulties in antenatal progn ostication in this cohort
Added value of this study This study provides follow-up data on children diagnosed with a brain abnormality in utero, highlighting its diagnostic accuracy: it is rare for iuMRI to miss brain abnormalities that are visible on postnatal imaging after age 6 months
Our results suggest that iuMRI is better at identifying children with normal outcome compared with ultrasonography, possibly by moving fetuses with an intermediate prognosis on ultrasonography to a more accurate favourable or normal prognosis
Summary
The outcome reference diagnoses (ORD) used in the MERIDIAN study were either post-mortem results or neuroimaging done in the first 6 months of life, which was predominately cranial ultrasound. It is possible the neuroimaging ORD were incorrect or incomplete, and there is little published data to show how accurately ultrasonography and iuMRI provide prognostic infor mation on developmental outcomes.
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