Borderlands in Obstetrical Ultrasound - HD

Introduction to Borderlands in Obstetrical Ultrasound

Hello, I'm Bob Harris.
I'm co-director of ultrasound at Dartmouth Hitchcock Medical Center in New Hampshire.
And I'm going to do a lecture today on borderlands and obstetrical ultrasound.
I'm gonna talk today about some of the cases in ultrasound that sort of drive me crazy and probably a lot of you folks too.
Not the so-called board cases that we show in board review sessions for our residents where there's gross abnormalities, such as this case of pori stenosis and severe hydrocephalus, but cases that are borderlands between the normal and abnormal in Webster's dictionary gives two terms.
The second term is a continuum, not a black or white finding, which I think is more appropriate.
And I've made the accessory definition of the gray zone between normal and abnormal findings in fetal ultrasound being the definition of borderland.
So the things I'm gonna talk to you about are echogenic bowel, echogenic intracardiac focus, NAL fold, and nuchal translucency, mild ventricular magaly.
And finish up with a little bit on Danny Walker spectrum.

Echogenic Bowel

So here's an example case of a 26-year-old woman who comes in at 17 weeks for a fetal morphology scan, low risk woman, and she has bright echogenic bowel.
Now the first thing we wanna know when we look at the bowel genicity, is it as bright as the bone and is harmonics on?
And the answer to both of those is yes, I think so.
We need to turn off the echogenic, turn off the harmonics, because when all this data came out about 10 or 12 years ago, machines did not have these capabilities and did not have harmonics.
We need to remove the harmonics, remove compound imaging, any sort of a new features that can improve the image quality and then reassess the bowel.
And you can see here's a harmonic image, much crisper image, bright bowel, and here's without harmonics, much less pleasing image aesthetically, but the bowel is still seen to be as bright as the bone.

Hyper coic bowel does occur pretty frequently.
In most cases where it's isolated, it's a normal variant, but there are significant pathologies associated with this, including aneuploidy, especially Trisomy 21 syndrome.
Cystic fibrosis is a common entity listed in the differential diagnosis.
Congenital torch infections, especially cytomegalovirus early onset growth restriction, can also be seen as causing hyper coic bowel and ingestion.
Fetal ingestion of intra amniotic blood has also been reported to be a cause the prevalences anywhere from a 0.5 to 1%, because we do a fair number of referral patients who our prevalence is probably three to 4%.
If you see it, it increases with transducer frequency.
So a higher resolution seven megahertz probe will make it more bright than a five megahertz probe.
And to be defined as abnormally hyper coic, it has to be equal to or greater than the bone echogenicity.
There are certainly increases with Trisomy 21, increased risk for fetal demise, increased risk for IUGR.
And it is fairly important to be able to distinguish this entity from the meconium peritonitis where the calcification, when encounters are coarse and chunky, oftentimes seen with pseudocyst with thick shaggy walls.
And the first, one of the first articles that described this almost 20 years ago in the Lancet, described relatively high positive predictive value for tri semi 21 or cystic fibrosis of 46%.
So I think that's a relatively skewed population.
I think we don't see it as often nowadays in our routine low, low risk population.

So here's an example with harmonics on, you can see the iliac crest here is being as bright as the hyper co foci in the bowel.
And without harmonics fundamental imaging, you can see here's the bowel, and it's still as bright as the ribs and the vertebral bodies here.
So that would qualify as a grade three epigenic bowel.
Sometimes it's a little tough to tell whether it's as bright as the bone.
So here's an example.
Harmonics is off on this case, still a little hard to tell whether it's as bright as bone.
So I have my technologist decrease the overall gain and see which one goes away first.
And they disappear at roughly the same level of gain.
So again, a case of grade three hyper cog bowel In a review of high risk cases in the literature meta-analysis, they found cystic fibrosis present in 26% of cases.
And the correlary of that is that in cystic fibrosis cases, all comers it's positive in about 11% of cases and employed in about 12% of cases IUGR and 15% fetal demise, and 9% and prematurity in 15%.
Of course, prematurity can be due to other factors as well as hyper coic bowel.
But this article concluded that in isolated findings, as an isolating find, isolated finding in low risk patients, hyper coic bowel was probably insignificant.
More recent study in 2012 looked at 63 cases.
They had 16% of their cases had chromosomal anomaly.
16% had CMV infection, only 2% had cystic fibrosis in this population, 5% had IUGR and 67% had normal outcomes.
I think that's the take home message.
The vast majority of these isolated findings will have normal outcomes.
So we use this to counsel our patients.
When we find this, about 13% had other major ultrasound anomalies that would pretend or be associated with other findings.

Okay, here's a case that came through our laboratory about a year and a half ago was a 33 week fetus being followed up for a growth disturbance.
And we saw the bowel was very, very bright here.
Here's the bowel and the stomach and much brighter than the ribs or vertebral body.
And when I saw this, I was got very agitated and said, well, we should get a KUB on the mother, or at least on the baby after the baby's born.
Well, they didn't do that.
And here's a picture of the with the harmonics turned off again, it's still bright, much brighter than the ribs or the vertebral bodies.
And they didn't get any subsequent imaging on the patient when he was born.
Baby was healthy, apparently normal, and nothing in the medical record about him having any abdominal catastrophe.
So we don't have any further imaging.
What I assume happened was that there was some very inspissated, thick meconium in the colon that appeared to be appeared or mimicked meconium peritonitis or hyper, very hyper coic bowel.
Another example of harmonics versus fundamentals, and we're instituting this in our laboratory where the technologist does the dual imaging mode where she, he or she takes the first image with harmonics, which is what we usually use by default.
And then when you see hyper coic bowel turn the harmonics off, and in many cases it disappears.
So to summarize, once chromosomal defects, cystic fibrosis, any kind of structural abnormalities or growth problems have been excluded, payers can be generally counseled that the prognosis is excellent regardless of whether there's the presence or absence of blood stain amniotic fluid.
In Sarah's case, the index case that we mentioned, all cystic fibrosis studies were negative.
All infection titers were negative for torch.
Her trisomy 21 integrated screening risk was quite low, less than one in 10,000.
But after the hyper coic bowel, her risk is raised now to one in 1500, still not very low.
She declined amniocentesis.
The bowel reverted to normal genicity on a subsequent study ordered in the third trimester, which we generally don't do, but the clinician wanted it and her outcome was a normal term birth healthy baby.
This is the information sheet we used in ultrasound.
It lists the likelihood ratio of various findings over here in the left column.
The middle column is risk.
And over in the third column is definition.
You can see that the hyper co bowel is about a likelihood ratio of about seven.
Other things, short, long bones, humerus and femur Echogenic intracardiac focus is a much lower risk factor.
Absent nasal bone is a very high risk factor, as is nuchal thickening.

Echogenic Intracardiac Focus

This is a case of an isolated intracardiac echogenic focus for our second topic of discussion.
One can see here that echogenic focus in the left ventricle on this four chamber cardiac view, when you take harmonics off, it remains as bright as the adjacent rib or vertebral body here.
So this is a grade three echogenic focus.
If we do a side by side comparison, this is fundamental imaging.
This is conventional image.
This is, sorry, this is harmonic imaging.
You can see that both cases it is as bright as bone.
So a little interactive portion of this talk we have, what is the significance of intracardiac genic focus?
We have the various choices here, and you can have more than one correct answer.
So we'll go over some of these in the next few slides.
It does occur much more, even much more commonly than the hyper coic bowel around three to four to 5% of normal fetuses.
Again, depends on a lot of variable findings, such as fetal position.
If the heart is or apex is anterior, you'll see it much more commonly than if it's posterior.
If the patient is a thin patient, you'll see it much more commonly than an obese patient.
And sonographer experience and quality of the imaging equipment is also a very important factor.
It's felt to be reflection from the papillary muscles and corde tendon.
A and the few pathologic studies that have been done have shown calcifications or fibrosis in the papillary muscles.
In high risk patients, it has a relatively high likelihood ratio of four, but in the general population or low risk patients, much lower likelihood ratio of 1.5.
And some studies actually have shown no relationship between isolated echocardio, echogenic focus in the heart and trisomy 21.
But most studies do show a strong association with Trisomy 13 if it's present in the right ventricle as opposed to the left ventricle, or in both ventricles, there's a higher aneuploidy risk.
And if it's isolated and low risk women, the bottom line is it has no significance.
And we don't even counsel our patients if this is the only finding that we're seeing on the screening ultrasound provided.
They are low risk there.
It does seem to be much more common in Asian women.
So if you have a patient, a large percentage of Asian women in your population, you'll see it even more.
So what is the significance of IEF?
It is B and d.
It is dependent on the fetal heart positioning, maternal body habits and ethnicity.
And it is considered a minor marker for aneuploid and high risk women.

Nuchal Fold and Nuchal Translucency

Nuchal Fold

Moving on to our third subject.
This is the fetal nuchal translucency or NAL fold.
This is a sentinel patient, a 21 week fetus for morphology, routine morphology who was actually referred in from an outside institution because she had a small, relatively thick NAL fold of six millimeters.
Historically the thickened nucle fold was first mentioned in around 1985 when the second trimester screening started relatively vigorously.
And then we had the introduction of the genetic sonogram in the mid 1990s per promulgated by Dr. Eff among other physicians.
And then in the early two thousands, we had the initiation of the first trimester NCLE translucency screening.
And here's an example of a slightly thickened NAL fold of six millimeters.
So another interactive slide here, what is too thick for NAL fold and how late we measure NAL fold.
There'll be four choices here.
We'll come back to this in a few minutes here.
But an interesting study done in the American Journal of OB GYN in 2008 looked at nuchal fold various thresholds and seeing what the various sensitivity and specificity and performance characteristics were.
And with ncle fold more than six millimeters, sensitivity was quite low, but the likelihood ratio was quite high around 12.
Whereas if the nuchal fold was threshold was chosen at five millimeters, you picked up a few more cases, 15%, you had slightly lower specificity of 97% compared to six millimeters, but the likelihood ratio is five.
So those are kind of important things to remember.
We'll talk about that in just a second too.
And one thing I wanna review is the base theorem where you have a pre-test probability of something occurring, you do a diagnostic test, in this case ultrasound, and you come up with a post-test probability or percentage.
And this is a really relative simple way to get base theorem.
What we can, one can do is calculate the odds of an event occurring in one theoretical possibility I have is of the Red Sox winning the World Series, which is probably coming up in the next couple weeks.
We'll say it's 70%, some fanatic people think may occur, but the odds or probability of an event occurring in this case would be 0.7 over 0.3 or one minus the probability of an event or two and one third.
And then if you convert that back from probability into odds, probability equals odds over one plus odds or two and one third over three and one third or 0.7.
So that's how the two are closely interrelated.
So you take the pretest odds times the likelihood ratio of a diagnostic test and likelihood ratio, just the sensitivity over one minus the specificity, that multiplication will give you the post-test odds and convert it back to probability and you get the chances of something happening.
So in our patient, the 24-year-old has a low baseline pretest odds or prevalence of risk of aneuploidy of approximately one in 1400, then has the thick NCAL fold, which has a likelihood ratio of 11, as we showed with the ultrasound screening form as an isolated finding.
So we multiply the pretest risk of one in 1400 times likelihood ratio of 11 equals the post-test risk of one in 127, which is much higher risk than the age-based risk of a 35-year-old woman of one in 250, which is our cutoff for offering women amniocentesis.
So she had a higher risk than one in 250, but she declined genetic counseling and her outcome was quite healthy and normal, a normal spontaneous vaginal delivery term infant.
So what is too thick after 21 weeks really is not really any good data.
So we can't determine that.
So what is the answer to our question here?
It's really the first two, either six millimeters or five millimeters, but the latest you can really measure the NCLE fold is 20.6 weeks after that.
There's no good data at Dartmouth Hitchcock for various reasons, we have chosen five millimeters.

Nuchal Translucency

Okay, moving on to the closely related NAL translucency.
We've just backed up the screening process to the first trimester.
And this is a very popular phenomenon.
Generally the thick nal translucency is considered to be more than 2.5 to three millimeters.
The way we measure this is obviously known to most of you sonographers or ologists.
It's a very precise meticulous measurement.
Sonographers or doctors have to become credentialed to do this, meaning test cases to a central agency.
You measure the inner to inner border of the skin to the soft tissues over the cervical spine, and it is strongly associated with an aneuploidy, also with cardiac defects, lymphatic disorders, fetal infections and anemia.
And some people think it's a form fruit of cystic hydroma.
It's also important to remember that some cases of thick nal translucency may be normal variants in a few cases.
Here's an example of a very thick NAL translucency five millimeters here, and it actually extends down over the trunk in pelvis.
This is a cystic hydroma that's actually a much thicker than the average nal translucency.
Here's a very markedly thickened nal translucency that is actually a cystic hydro grown with ated cystic collections here, and very thick two to three centimeters.
Nuc translucency appears to arise from altered composition of the extracellular matrix that is encoded on chromosomes 21, 18 and 13.
So if you have a trisomy, an extra chromosome of one of these chromosomes, you'll therefore get extra cellular protein matrix thickening.
Other causes are cardiac failure or cardiac abnormalities, venous congestion, abnormal delayed development of lymphatic system, oral lymphatic drainage abnormalities, and finally fetal anemia and infection.
A recent study on the ultrasound findings in Trisomy 21, besides nuc translucency or absent nasal bone at about 43%, a major heart anomaly or defect in 41%, an aberrant right subclavian artery in 25%, an extra cardiac abnormality in 24%, and mild ectasis divine is greater than five millimeters and 17% and a thick nuchal fold greater than or equal to five millimeters and 16%.

Mild Ventricular Megaly

So moving onto our fourth topic of mild ventricular magaly.
This is a mildly dilated ventricle measuring 13 millimeters.
The conventional thinking has been all along that normal ventricles should not be greater than 10 millimeters throughout gestation.
I think people like this number, it's easy to remember, it's a relative round number.
But I think there's some data that's been around for actually quite a while that shows some ventricles may be up to 11, 12, even 13 millimeters in normal situations.
A place to measure the ventricular atrium is at the level of the G gloma near the atrium.
But always be aware that some sonographers or doctors may measure the lateral sulcus of the white matter as it dives down to go more caught at in the brain.
And here's an example.
This is not the ventricle up here.
This is the lateral sulcus of the white matter.
Here's another picture.
L is the lateral sulcus of the white matter.
Here's the F for the fox, and another shot here.
And here's where you wanna measure the ventricles back in the atria where the core plexus fills it.
Some not good measurements that you'll recognize probably from being a astute sonographer or a sinologist.
One can see that the ventricle here is actually measuring 14 millimeters, but it's a oly sagittal view.
So you're actually seeing the ventricle from a sagittal plane more so than an axial plane.
Here is a place where the sonographers got a more axial view, but they placed the calipers in the frontal horn, not the place to measure the ventricles.
Another view showing again, funnel horn placement here again, not good.
And this is a more of a coronal shot here.
We're getting some of the cerebellum and not the position to measure the ventricle.
So you wanna have an axial shot just above the thalami at the level of the atria.
This is a good picture for measuring the ventricles, but the CaTECH has placed the calipers on the white matter here, so getting both the white matter and the ventricles getting a ventricle that's purportedly 13 millimeters, but the ventricle is actually quite normal.
Seven millimeters here when the calipers are correctly positioned, ventricular mely occurs, not uncommonly, it's estimated to be one per a thousand live births, but most people think this is an underestimate due to some stillborns or patients not having a ultrasound in the first or second trimester.
And the ventricles in males are felt to be slightly larger than females normally.
And most pe or some experts allow up to 11 to 12 millimeters.
So we'll talk about mild ventricular mely now that's defined as 10 to 15 millimeters.
And the bottom line is that the isolated finding of myop ventricular magaly may not have serious long-term consequences.
There is a slightly increased risk of CNS and non CNS anomalies if it's an isolated finding, especially in females, much more so than males, or if both lateral ventricles are dilated or if the ventricles are more than 12 millimeters.
A few studies talking about this, this is one from the white journal.
Ultrasound and obstetrics and gynecology had an abnormal outcome in a quarter of patients.
4% had perinatal death, 4% had ploidy, 9% had ultrasound, false negatives for malformations, and 11% had neurologic sequela, female fetuses, much more neuro sequela, 23% versus 5%.
When the ventricles measured more than or equal to 12 millimeters.
They found that when the ventricles were only dilated on one side, usually a benign process when it was bilateral, they were more often associated with aneuploidy.
And we offer amniocentesis when it's bilateral mild ventriculomegaly.
We also recommend torch screening as one study from Europe found 16% of hydrocephalus cases were related to torch infections.
Rarely is it a marker of more severe CNS lesions.
This is a larger study of 176 patients, and patients were broken down into mild, moderate, or severe ventricular magaly.
Most of the cases were in the isolated group, around 60%, about a quarter in the group B, and about 40% in group C.
And they found if it was an isolated finding, those patients who were alive at a at two years were 98% of group A, 80% of group B, and only 33% of group C.
And of those who were still living at two years, they found normal neurodevelopmental outcome in 93% of group A patients, 75% of group B, and 63% of group C, which is somewhat a surprising finding given the more severity of the hydrocephalus in those cases.
They did find an increased risk for developmental delay in about a third of the cases versus 5% of controls.
And they did also find a serious significant correlation between vent ventricular size and mental development index.
But again, they found that the Venice were only borderline dilated up to 12 millimeters.
Patients did well.
If they were above this level, they were monitored more closely and they tended to have a worse prognosis.
And the natural course during pregnancy was that 60% of the dilated ventricles remain stable, 30% resolved and 10% worsened.
They also found a developmental delay to be greater in more than 12 millimeter dilatation than in less than 12 millimeters, 23% to compared to 3%.
And they found that most fetuses with isolated mild ventricular meli resulted in healthy infants.
But you can see that there, there's somewhat conflicting data on this and I think most reasonable experts in this would recommend a fetal MRI if there is hydrocephalus detected in utero.
But you can see the counseling patients is difficult.
There's conflicting data that's pretty much all over the map.
A marked ventriculomegaly, I think is not such a dilemma.
Ventricle is more than 15 millimeters can be either isolated, usually due to aqueduct stenosis or communicating hydrocephalus.
Other neuro tube defects can cause it, including q malformation, midline defects or aneuploidy, chromosomal disorders and syndromes.
These tend to have a bad prognosis.
Here's a case of moderate to severe hydrocephalus at 18 weeks, 15 millimeters and 18 millimeters, and at 35 weeks has progressed to 49 millimeters with not much cortical cortex left.

Dandy Walker Spectrum

Alright, our last topic will be the large cisterna magna or the Dandy walker spectrum.
The cisterna magna is generally considered to be normal between two and 10 millimeters, although I consider up to 12 millimeters to be okay.
If it's more than this, it's considered too large.
If it's an isolated finding and the ventricles are normal and no other CNS lesions, most likely a very good outcome.
But the key to checking out the large cisterna magnet is make sure there's a verus present.
We'll go over this in just a few seconds.
And remember, the dandy walker spectrum is a continuum from the large cistern of magnet, which is more benign to the Danny Walker variant, to the more severe Danny Walker Malformation syndrome, where you have a dilated fourth ventricle absent inferior verus, and a large cistern of magna, oftentimes with hydrocephalus and other abnormalities using example of a large cistern of Magna 13 millimeters.
You see, the verus is present.
There's no continuation of the cisterna magna with the fourth ventricle, and the ventricles are totally normal six millimeters normal outcome.
Another patient did have verian hypoplasia.
You did see a communication with the inferior through the inferior verus from the cisterna magna to the fourth ventricle here.
You see it persisting in here.
And this patient actually did have a little bit of developmental delay.
Remember to regard the verus here's the superior verus the inferior verus in this midline shot.
Here's the fourth ventricle, cisterna Magna.
And the verus is the entity that that lives in the middle of the cerebellum.
This is the inferior verus.
There's also superior verus and lots of sub nuclei as well.
But the inferior verus is key to analyzing the large cistern of Magna.
Here's a large cistern, a Magna 14 millimeters.
14 millimeters, but again, there's no communication with the ci stern of Magna and the fourth ventricle normal outcome.
This is a case from the literature recently, the Journal of Ultrasound and Medicine this month had a case or two cases discovered in the first trimester around 11 and a half weeks of this dilated cystic structure in the back of the brain that turned out to be a Danny Walker variant.
One of the cases was terminated and the other one had an MRI that did show some abnormalities in the brain, so it can be seen in the first trimester.
This is a like second case from the G case series that shows the inferior, inferior verian hypoplasia.
Here's the fourth ventricle with communication in the cistern of Magna and the ponds here.
Another case of Danny Walker.
This had Verian Aplasia, you see communication and the cistern of Magna to the fourth ventricle here and communications Cisterna magnet to the fourth ventricle absent of verus inferior verus A patient who had a Frank Danny Walker malformation with a dilated cys Magna.
And you can see the complete obliteration inferior verus with communication with the fourth ventricle here and marked dilatation of the ventricles Lateral vents measure 22 millimeters here.
And here's another clip showing the huge cisterna magna communicating with the fourth ventricle.
Danny Walker malformation.
Another example of just a mega cisterna Magna that looked quite striking initially, but you can see the verus is intact.
There's no communication with the fourth ventricle, and this baby's done quite well.
The case of Danny Walker malformation see ventricular Magaly, and you can see the fourth ventricle communicating with the s cys mag, which in this case is not all that big.
Another example of cisterna of Danny Walker variant.
This is an inferior mian aplasia, but there's no ventricular dilatation here.
Just communication with the cisterna magna and the fourth ventricle.
It's just a couple MRIs to reinforce the idea that there is a mega cistern Oma, which has a good prognosis here, and the arachnoid cysts, which probably does not have a good prognosis until you take care of the arachnoid cyst, but it can be quite mass like and compress the pons and the midbrain and brainstem.
Always beware of the coronal view.
If you're scanning more coronally, you can get the fourth ventricle extending through the framing of Luka through the cistern mag.
Make it look like there is some inferior verian aplasia or hypoplasia.
But this is just a reflection of the altered coronal view rather than it being a truly axial view.
A couple other things in the differential for large CI sternum magna verian hypoplasia is Blake's pouch cyst, which can be a very wide spectrum from asymptomatic to full-blown hydrocephalus, if so, kind of a variable presentation and JU syndrome, which is a mostly autosomal recessive spontaneous mutation that has primarily verian absence or hypoplasia, and quite significant neurologic abnormalities, including hypotonia developmental delay, ataxia abnormal eye movements.
And this condition should be suspected when there's abnormal the shaped fourth ventricle connecting to a normal sized cisterna Magna.
Here's a Blake's pouch cyst with a communication between the fourth ventricle and the cisterna magna outcomes of posterior FOSS anomalies.
Study from the University of Cincinnati recently looked at 59 patients, nine Danny Walker malformation cases, sort of the full blown spectrum.
Three six with the verian hypo GSIs or hypoplasia, sort of the Danny Walker variant, and then 14 with mega cistern and magna only.
Those with isolated mega cistern and Magna turned out to be normal.
The verian hypoplasia were mostly normal and the presence of intracranial abnormalities were abnormal.
Brain stems were associated with poor outcomes.
A study from Italy last year of 105 patients with posterior fossa fluid collections found that they're fairly mixed etiology Blake's pouch cyst in 32 mega cisterna mag in 26 27.
Danny Walker malformation in 26, Verian Hypoplasia 17 cerebellar hypoplasia and two, and arachnoid cyst in one.
The ultrasound diagnosis was accurate in 88% of cases.
An MRI was only more accurate In one out of 51 cases, an podio was present in 26%.
And Blake's pouch cyst mag cisterna Magna had spontaneous resolution in one third of cases, so sometimes they'll go away during the pregnancy.
But the bottom line take home messages are over.
90% of isolated findings had normal developmental outcome at one to five years.
And isolated Danny Walker malformation ine hyperplasia had normal developmental outcome in 50% of cases.

Summary

So summary of the borderlands of ob ultrasound in these topics I've discussed are echogenic bowel.
Always remember to turn off harmonics, evaluate the bowel in that situation.
If it is echogenic with conventional imaging, there is a relative risk of seven euploidy.
Especially if the patient is high risk, either elderly or older than 35, or has abnormal serum screening markers.
In the case of the echogenic intracardiac focus, it's so common we tend to ignore it if it's the isolated finding.
Much more commonly seen in thin patients with a cardiac apex anteriorly, the NCLE fold.
Translucency thickening has a high positive predictive value for Trisomy 21, but other abnormalities, especially lymphatic disorders or cardiac abnormalities in mild ventricular magaly, I think we may wanna consider raising the threshold for ventricular magaly to 12 millimeters, especially in males.
If the ventricles are 12 to 15 millimeters mildly dilated, follow those patients up with one or two ultrasounds during the pregnancy.
Do a very detailed fetal survey, and probably get a fetal MRI in cases of events, ventricles being more than 12 millimeters.
Large cisterna magnar or D walker, spectrum d remember the large cisterna mag, the normal cisterna mag is between two and 12 millimeters.
There's no high dose ephalus.
It's generally a good prognosis, diagnosis, and that's all.
Thank you.