UCSF pediatric radiology specialists address fetal MRI safety concerns and explain when to consider advanced imaging. Here’s current evidence to inform prognosis and interventional decisions for certain conditions, such as congenital diaphragmatic hernia (including a side-by-side comparison with ultrasound) and genitourinary anomalies. Offers referral information for the Fetal Treatment Center, which has almost 20 years of experience in fetal MRI.
Refer to Fetal Treatment Center All right, let's go ahead and start. So thank you again for joining us. This is our fifth futile treatment center. A webinar. My name is Aaron Matsuda. I'm the director for the fetal treatment center, both San Francisco and Oakland. And thank you for joining us. I'm just here to reassure everybody and let you all know we are here to partner with you and help take care of your patients. And at the end, we'll have our referral information available for you to answer, um, and reach out to us with any questions. Today. We are very excited to introduce our presentation on MRI and I'll have it go to the next slide, please. Mhm. And I'm very excited to share with you our speakers today, Dr Mark Suki. It's a radiologist specializing in abdominal imaging and ultrasound. He has a clinical interest in obstetrics and gynecology imaging as well as ultrasound guided procedures. Dr. Studies research interests include fetal development, maternal health during pregnancy and placenta create a spectrum disorder. He is also interested in novel methods of learning and ways to enhance radiology training, including through the use of pathology driven interactive case databases. Dr. Sylvie earned his degree at the David Geffen School of Medicine at U. C. L. A, where he was inducted into the Alpha Omega Alpha Honor Medical Society. He completed a residency in Diagnostic Radiology at the Mayo Clinic in Arizona, serving as to president, followed by a fellowship of abdominal imaging and ultrasound at UCSF. Dr. Jesse Corker is an associate professor of pediatric radiology and serves as the medical director of radiology for UCSF Mission Bay, an interim chief of pediatric radiology at UCSF Benioff Children's Hospital. His expertise and interests involved technique optimization and pediatric body M R E applications, including M R, Your Ah, Graffiti, M R Angiography and MRI. In addition on the call today we have Dr Shell Boschetti, who is an obstetrician and gynecologist who specializes in high risk pregnancy and prenatal genetics. She has special interest in prenatal diagnosis, fetal abnormalities and managing pregnancies complicated by medical genetics and disorders. She's also the associate director for the Fetal Treatment Center, associate medical director for the Fetal Treatment Center. All of us will be on the line to help answer any questions towards the end, so please feel free to submit them in the Q and A section. I'll turn it over to Dr Sue G. Thank you. Good morning, everyone. So my name is Mark. It's a pleasure to be here today with Dr Korea and Dr Chetty, and I'm going to be talking a little bit about our fetal MRI program here. Added value in the area of fetal intervention. And we're going to discuss some of the basics of the M R exam and then also focus a little bit on a couple of areas, particularly C D. H. Mm. These are my disclosures, none relevant for this talk. So the learning objectives for today we're going to try to understand how futile M R adds value to diagnosis and management of fetal anomalies. Want to learn how futile and mar is obtained, and we'll review cases demonstrating the utility of em are with some correlative ultrasound imaging. So we're gonna open up just by talking briefly about the safety of fetal M. R. Um, we'll talk about the protocol and details of the exam indications based on some of the society guidelines and, um, some of the more common indications that we use it for here, along with some cases and then advanced three D imaging. After my talk, Dr Corday is going to give some additional information and show some really interesting slides on advanced techniques and three D imaging. And then we'll end with a Q and A. So safety of MRI and fetal MRI. This is from Akagi, um, the guidelines for diagnostic imaging during pregnancy and lactation. And this basically just says that ULTRASONOGRAPHY and MRI are not associated with risk and are the imaging techniques of choice for the pregnant patient, but they should be used prudently, and only when use is expected to answer relevant clinical question. So a lot of these guidelines that I'm gonna show are pretty similar. But overall, uh, but all of them sort of speak to the same message, which is that people MRI is a safe imaging modality. This is from the American College of Radiology and the Society of Pediatric Radiology. Um, basically, there's summary statement is that the present data have not conclusively documented any deleterious effects of the MRI had 1.5 t and three t on the developing fetus. And for those of you that aren't too familiar with the Tesla strength, these are just different magnets, strengths. And as I'll show later, we scan typically at the three Tesla three Tesla magnets here at UCSF. And this is from the A C R 2020 practice parameter. So what about magnet strength and noise? I just mentioned that we have three T scanners here. Um, U C s f um, this was a study that was done to look at the safety of maternal and fetal MRI at three. T specifically, um, to evaluate the effects of them are on fetal growth and on neonatal hearing in units at low risk for congenital hearing impairment. So for those of you who have been around an MRI scanner of had an MRI before, you know that there's a lot of there can be a lot of noise associated with the magnet, depending on the, um, depending on the gradient coils. The sound that you hear sometimes, um, those are usually the gradient coils vibrating. So this study looked to see if there were any effects of those noises on the fetus. And it was a retrospective case control study of 81 million eights that had three TMR exams, fetal exams, and compared to 100 and 62 controls. They found no adverse events with respect to neonatal hearing or fetal growth. How about in the first trimester? No. Often a lot of these exams are done in the second trimester, but we also do them in the first trimester. Sometimes. This is an article from Jammeh in 2016 looking at the association between MMR during pregnancy and fetal and childhood outcomes. Um, it was designed to evaluate the long term safety after exposure to M R. In the first trimester, they had a fairly large population studies, so they looked at over almost a million and a half deliveries. But they had 17 over 1701st trimester MRI exams, and they found that exposure to EMR during the first trimester was not associated with increased risk of harm to the fetus or an early childhood. And they followed these kids up to four years of age. Now they did also look at gadolinium use, which they found was associated with some adverse outcomes, some connective tissue diseases. But we do not use gadolinium for these examinations here. So, um, the other advantage here UCSF is that we have a long standing, um, program that's existed for some time. This article is almost approaching 20 years. Now, this is from Dr Coakley, Dr. Glen. Dr Goldstein at all. And, um, basically, you know, this was looking at the prospective peace in a radiology journal on PLM are back in 2000 and four. This is a congenital diaphragmatic hernia case. And so we've had I've had a personally, a really great opportunity to work with some amazing mentors here, and this program has been around for some time. So just basic details of the exam. It's typically performed after 18 weeks gestation just to optimize visualization of the fetal anatomy, usually before 18 weeks. Um, it can be a little bit more challenging, um, exam times about an hour or less, but it can be variable depending on fetal motion. Um, one thing about M R is that when we take localizer sequences for an adult patient who still, um, it's usually a one time event, But with the fetus, the fetus is constantly moving, so it's a moving target, so to speak. And so each image and each sequence sort of serves as a localizer for the next one the mothers in the supine position. Sometimes they're scanning the lateral, the cubist position. If they have marked the hydro numbness or if they're scandal later and gestational age and then these are just a couple of our scanners. We most commonly scan on the G three t. But we also have a Philips three T scanner as well at Mission Bay, as well as some additional scanners over at Oakland. So I'm just going to talk about the protocol. Um, briefly, this is our These are the t two weighted images that we start with, and these are basically just getting a lay of the land there, an opportunity to look at a number of things. But we we take these multi plan on T two weighted images of Corona, a sagittal and axial image. And as you can see, it just gives you a nice idea of the fetus as in terms of the fetal scientist. So the presentation in this case, the fetus is symbolic. You can you can see the placenta. I'll go back to the saddle image here. So here we have the fetus in style presentation. You can see the the umbilical cord. Some of the extremities. But then you can also see the maternal bladder, the the cervix and often the placenta. In this case, you can't see the placenta as well. So these basically just give us a sense of overall, um, big picture. And it also gives us an opportunity Evaluate maternal agony, maternal abdomen and pelvis because we can see the maternal liver and bow and the annex as well, and then assess the placenta. Um, cervix. So here are a few the additional sequences that we typically run. This is a T one weighted sequence, a spoiled gradient sequence. And the purpose of this is usually to assess from meconium signal within bow, which you can see down here. This is a really nice sequence that allows us to see, uh, Meconium, for example, within the colon. And we can trace that all the way down to its expected position towards the rectum. We also have Sidney saddle images, these s sfp images, free procession images, and these allow us to assess for swallowing function. So, um, these are also known as bright blood sequences because you can see inside the heart here. The signal is somewhat right. Um So it's really great for assessing dynamic motion and assessing for swallowing for for example, in the case of a trick, you a soft shell fish to and then we also have these heavily T two weighted sequences like these M R C T sequences that can give us, um, you know, an adult. These are typically used to assess the biliary tree, but in the fetus that can be used for assessing urinary tract dilation and really any fluid filled structure. And Dr Corda is going to go into detail a little bit later about some of the additional sequences that we run here. So this is just an example of that s sfp sequence. This was a fetus who has what we suspect might be a general pouch. Colon has this dilated loop of bowel with this heterogeneous lee academic intra Luminal contents. And here's a corresponding, um, Sydney image, which basically you can nicely see the same loop of bowel which, if you sort of carefully scroll through this this is the bladder interior early. This is this loop of bell and there was a suspected connection or vestibule chronic fiscal in this case. But you can really nicely See the admixture and sort of the dynamic process as the fetuses. Um, urinating, for example. Um, so these these images give us really great dynamic information. Yeah, um, just briefly, um, are obviously we use it a lot for maternal evaluation and especially during pregnancy, to avoid any any radiation from C. T, for example. So in the setting of acute abdominal pain to evaluate the next to for G i g U issues or musculoskeletal disorders, um, also to assess the placenta and any uterine abnormalities, especially placenta previa, spectrum disorder, some more acute causes like a sub chorionic bleed or degenerating fibroids. And then this also gives us an opportunity to characterize any thing in the annex to, You know, it's not uncommon that we have an ultrasound, and incidentally, Mom has a fat containing mass in the annex. A probably a dermal, I'd say. But sometimes it's nice to be able to characterize those, especially if they're indeterminant ultrasound and Mark can give us that additional information. Um, here we also have a program, really a wonderful team called the multidisciplinary approach to the Placenta Service, or Maps, which takes care of patients with placenta created spectrum disorder. And I'm sure many of you already familiar with this, But basically, this is a condition in which there is abnormal presentation. Um, so the placenta is basically implanted, Um, sort of beyond the decision to and this, you know, after a one C section, there's an increased risk of 3% a 3% increase after one C section, but after each subsequent C section, the the numbers just continue to go up in terms of risk for this condition over 50% by the time you get to the to the fourth C section. And here's just a fetus. Susan M. R. That was showing this, uh, in a patient who had PTSD, who has this hematoma and had this large sort of almost circumferential placenta. And then this is our a couple of members of our team, one of our radiologists and surgeons, um, looking at the pathology of the the placenta and the uterus after hysterectomy. So we have really great multidisciplinary teams here which give us correlation between, uh, imaging, surgery and pathology, which really helps us to sort of align all those disciplines. So what are the indications for feudal MRI. Well, there are a couple of limitations of ultrasound that we are all pretty familiar with maternal body habits and in the setting of all ago and anti DRAM news and mark and certainly add a lot of value in some of these cases when it's really difficult to see anything. Sana graphically, um, so what are the advantages of them are specifically, well, superior. Soft tissue contrast resolution is one of them. Um, here you can see, uh, just a case of the This is just a corona image through the lungs. And you can see, um, really nicely how the how uniform the long signal is here. But this allows you to assess things like not only volumetrics are not only size and volume, but also signal characteristics within within an organ. And then here's an axial image through the fetal abdomen. This is the liver. This is the kidney. You can see. You can differentiate colon from small bowel, and this is the gallbladder CSF surrounding the spine. So it's a really nice differentiation in terms of soft tissue contrast resolution. The dynamic city imaging, which I mentioned earlier looking at for things like a tricky a soft shell fistula or any other kind of fistula in the abdomen like a chronic fistula, for example, and then surgical planning for fetal therapy. Um, so these are the practice guidelines from the swag, and these are basically they just describe The indications for fetal M are based on their guidelines. And a lot of you are familiar, I think, with the narrow indications, which we're not going to discuss too much here. But there there are a lot of advantages to fetal m r for for CNS evaluation, most notably looking at the posterior fossa corpus callosum anomalies, enlarged ventricles, neural tube defects and then an assessment of twin twin transfusion syndrome following laser laser therapy. This was one of our cases recently was an open just a mile a minute ago. Seal repair in utero. This was the first one I've seen, and just a really impressive operation to be able to see that from imaging to get the M r and then to follow it through, um, and federal intervention. So what about the body indications, though? Well, there are a number of body indications. Most, um, I think there's there are many institutions that routinely acquire fetal Lamar's in conjunction with their ultrasound exams. One of the indications for that is congenital diaphragmatic hernia at several of these institutions. Um, but it's also useful for for problem solving a number of other complex anomalies within the fetus. For example, urinary tract anomalies when there's markedly dilated your orders and you can't really tell where things are going. And Mark can be a really useful tool for that. For assessing the anatomy, Chester abdominal cysts and masses again for that soft tissue characterization to get some enhanced characterization of the Mass and then vascular malformation. Some Fangio as things of that nature. So let's move on to C. D. H. I'm just going to cover the literature briefly on this just to give you a sense of where fetal M R is today on C. D H and why, um, it might be an added what it can do in terms of adding value to both diagnosis and prognosis for C. D. H. So we know that the imaging factors that influence prognosis for CDH are associated feel anomalies, Um, typically, whether or not the liver is up or down, but the percent liver herniation and then feed along volumetrics or feet along volumes. Rather so, uh, typically, you know, we look at the liver as sort of a dichotomous variable. If there's either absence of liver herniation, absence of their generation is the most reliable. Predict your postnatal survival, so we typically look at the presence of the liver being either up or down. Um, this is a sort of a meta analysis of 338 studies that was done in 2010 and looked at 407 fetuses with liver up and 303 fetuses with liver down group. And they found that the survival was 45% in the liver up group. Here's saddle M R of a fetus. You can see there quite a substantial amount of liver herniated into the chest, surrounded by this fluid and then the liver down group. This is a Corona image of the fetus, and you can see the nice contour of the right and left a paddock lobes, which are below the diaphragm. Here's the heart displaced into the right chest, and here's the stomach bubble up in the chest, and this group had a significantly better survival, 74 to 45%. But we know that liver herniation is not strictly a dichotomous variable up or down, there can be various variable degrees of how much liver is actually herniated in the chest. So with that, there are a number of studies. Fetal, um, are studies that look at volumes of the liver in the chest, either as a function of the thoracic volume or as a volume of the total liver. This is a study from the Texas group that was looking at the percent of liver as a ratio of the thoracic volume. So here is a Corona image. You can see this stomach is up. And then there are these sequential axial images to the fetus, which basically allow for measuring the total thoracic volume minus the spine, measuring the lungs and then measuring the amount of liver that's up. This was a retrospective study of 15 ft 15 fetuses with isolated CDH. They found that the liver was up in their cohort. Most of the fetuses had a liver up or herniated liver, and they found that when the liver occupied greater than 20% of the chest the neonatal deaths were significantly increased in their group, and it's a fairly small group, but 86% compared to 13%. So when, um with this ratio greater than 20% they had quite quite a differential. Well, what about the percent liver herniation relative to deliver volume itself? This has also been studied pretty extensively now, Um, liver herniation in this case is considered a continuous variable. So not just up or down, and not just a percentage of the thorax, but how much as a function of its total volume is up into the chest. So this was also from Texas Children's groups, a retrospective study of 53 fetuses with left side and see DHS. And they looked at the percentage of liver herniation, which was defined as the ratio of the herniated liver volume. So this part of the liver that's terminated into the chest as a function of the total liver volume. So the way you do this is you have continuing slices on m R I, and basically you can trace these out individually and take the sum multiplied by the slice of thickness, and, uh, and you can get volumes from that so again, as a dichotomous variable, they looked at this as either liver up and liver down to see what sort of accuracy they could do, Um, have for predicting outcomes. And they found that with just liver up or liver down, the accuracy for predicting mortality was 49% and the need for ECMO about 53%. Whereas when they took the percentage of deliver herniation and used to cut off of 21st 21% um, they found that their accuracy increased pretty substantially with predicting mortality 87% of the time and the need for ECMO 79% of the time. So now we have the liver herniation. We know a little bit about the lung volumes. Well, the next This is from Dr Rwanda's group. They took a number of these variables that we're familiar with, and they sort of combined a lot of them to see which one would yield the highest diagnostic or prognostic accuracy. Um, and they found that mortality and need for ECMO was best predicted by a combination of, uh, MRI observed to expected total lung volumes, which we'll discuss in a second and then the percent liver herniation, which we just saw. So then they found an 83% accuracy for predicting mortality, compared to about 70% for LHR by ultrasound. So these are their area under the curve values, and they found about 83% for this combination, which was the highest one. And you can see a number of variables which might be familiar with some of these other ones are our other MRI, volumetrics and ways of calculating. I'll show you one of them, but this seems to be the most, uh, most predictive at this point. Based on the literature, the combination of looking at the total lung volumes in the fetal are in the fetus by M. R. Um, comparing that to its expected volume based on gestational age and then combining that with the percent liver herniation. So this is, uh, in this chart. You might also know that there's this PPV This is the percent predicted pulmonary volume, and this is another way of calculating the It's another metric that you can use by MRI, and we've certainly done that here for some time as well. What you're seeing Three separate images Corona images of the fetus. Um, we measure and trace out the lung. Um, that we can see not only the contour of the side that's contra lateral to the C d. H, but also the its lateral side If there's any, um, Lung Perrin comma there and then the entire chest volume and the media spinal volume. And this is also a nice technique. But you can imagine that just looking at this right now there is variability that can be introduced while you're doing this. It can be challenging sometimes because the fetus is moving, remember? So there's motion artifact on some of these images. Um, and then just tracing it in general yields some degree of inaccuracy. But you know, again, we're comparing that to, um to not only this method, but other methods of measuring the lungs by m. R. And by ultrasound, and we really want to standardize this as much as possible. So using this PPV, it was found that their threshold that is most commonly cited as 15% less than 15% is associated with significantly higher risk of prolonged casino support and or death. So how do we do this today? Well, this is from Mary Anna Myers Group in Colorado, and this is just some images that they use as an example of how to measure the lung volumes. This is in a program called Terra Recon, which we also have here at UCSF. We have a couple of different ways of doing this, but basically they measure the lungs here, and then they can calculate the total lung volume. And again, you can do this by M. R. The nice thing, as opposed to the LHR, is that you can measure the lung on the contra on the side That's contra lateral to see th but again, if there's any, um, functional or potentially functional prank Emma on the side, that's its lateral to the herniation. You can also add that into your your volume calculations. So Dr Myers Group has put together this table that basically shows normative total fetal lung volumes by gestational age. And you can see here basically, you just look at the gestational age and then, um, you can find a mean standard deviations. And then there's this inter quartile range as well. And you know, we know that pulmonary hyperplasia and hypertension are really one of the most significant sources of neonatal morbidity. So it's really helpful to see where the fetus lies in terms of how much expected lung volume, they'll have lung capacity. This particular table and this particular study is, has additional utility for lung volumes between, um, for fetuses between 19 and 22 weeks. For those of you that are familiar with the ripens formula that particular study used, um, had a smaller number of had a smaller number of fetuses early in the second trimester. So many of those values were combined. Many of those the gestational ages were combined. So particularly for this range, this table has particularly, um, has is particularly valuable. And we do stand, you know, fetuses between 22 22 weeks, not uncommonly so. I think it's particularly helpful. Um, this is a group. This is from the national group, just looking at ultrasound. And so just to tie all this together, why is all of this important? Why do we Why do we care? Well, right now. So this was from the NAFTA. This had 19 participants from 9 ft oh centers or basically centers that do endoscopic curricular inclusion. So intervention for CDH. Um and the participants were observed measuring lung area by ultrasound, using one of these three methods the anterior posterior method, the longest method and the trace method. And you can see in their study that there's quite a bit of variability from the participants. And remember, a lot of these are expert centers as well. So the AP AP um, these are from photo centers are blue, and then the non Fido centers are from red. But even among the photo centers, the anterior posterior the longest in the trace methods the trace method has was thought to be the most, um, reproducible and I was also reported as the most commonly done. But there is some variability. Um, and each of these can potentially yield some differences in how you calculate the LHR and therefore potentially influence how we're counseling these patients as well. So here are a couple of websites, Um, but they also cited in this article total trial that EU is one of them parasitology, which I use almost every day, and you can see these three different methods of the It's basically you're at the four chamber view of the heart. The AP method, you're taking directly, um, sort of anterior posterior and then perpendicular to that with the aorta, the longest method you're taking this longest diameter and then the perpendicular line to that. And then the trace method is basically using, at least for the radiologist were using packs, typically just to trace around the lung to get this. And this was thought to be the most reproducible measure. So, you know, a couple of things between ultrasound and MRI for C. D. H. There are some, uh, some differences that we can assess and the one that I really want to focus on is the idea of a hernia sac. Um, by m r. There is this this entity called CDH with hernia sac, and it is described in literature. We had a case of this recently, um, which I think it would be very interesting and diagnostically challenging to differentiate sometimes from an event duration, for example. But these are some images from the literature. This is also from the Texas group, which basically looked at predictive value of m our findings for identification of our earliest AC, and they identified three things which which can help to identify a sac, which the importance of that is that the surgeons, knowing that there's a stack, could potentially have some added value for the surgeons and planning for the for the repair. But what they found is that when there was fluid either asides or pleural fluid surrounding the sack or when there was this smooth convex, um, sort of convex contained appearance that they had basically higher sensitivity, they had a predictive value for identifying a sack. So I think there's, you know, it's very difficult sometimes to identify are really differentiate this entity from an event duration. But there are some signs that at least suggest the possibility of this the presence of a sack, which could potentially be valuable for preoperative planning. This was from that case, actually, um, just recently the you know, I think on initial ultrasound and how the appearance of an event operation and, um and, uh anyway, this baby eventually went to surgery and had a ch one fact, which, to be honest, was relatively new entity for me. I But speaking to the surgeons, it was really interesting just to hear about the different perspectives in terms of how a primary repair differs from the patch repairs. And why I really trying to differentiate this antenna, antenna, Italy or even you in Italy can be important for, um, for surgical planning. So I'm just going to briefly move on to a couple of other useful areas for fetal MRI, and I'm gonna switch over to Dr Corday here. Um, one of my one of my other areas of particular interest are urinary tract anomalies, and I find them are to be really helpful for these cases. Um, this is a just a fetus and sagittal plane. You can see there's this very dilated bladder, and this is really not uncommon. I'll show you a couple more cases. Um, but do you abnormalities? You know, they're very common. They account for about 30 50% of structural abnormalities at birth. They can range from mild pelvic kisses to Reno. A Genesis and M R can be particularly useful, as we mentioned earlier in the setting of either Allah go hide Romney's or anhydrous genius. And then you know these We have several sequences that Dr Corday will look at this as well to help us identify some of the dilated structures And finally, it's helpful for planning through for interventions such as Vesco. Amniotic, shunting is it? Do you think so? You're just a few sequences, and I'm just going to kind of skip through this quickly because Dr Corday has additional slides. But basically we have these free procession images, which we discussed earlier. These are are sort of standard T two weighted images, and you can see dilation of the collecting system. And then you have all these sort of these additional dilated structures dilated, ureter and bladder. We also have these two unweighted sequences, which I mentioned earlier, which help us to identify meconium, which can be really useful for cases that are associated with urinary tract pathologies such as mega systems, micro colon cases. So here's just a couple of cases just to show you how profound sometimes you know the Mega Sisters can be. Here's the fetus at 21 weeks in symbolic presentation. So this mother's bladder, um and you know, this whole thing is basically the dilated urinary bladder, just for perspective purposes. This is the gallbladder of the mother, and, you know, even with this degree of dilation, which can make a scanning quite difficult. We can still see some of the additional anatomy. Here's a companion case at 19 weeks again, massively dilated urinary bladder and the fetus can start to see the kidney. Here, this fetuses also in symbolic presentation. And you can see sort of this dis plastic appearance of the of the kidney in this case. So we stage this and just you know, there's a staging system for this that runs from mild says to, um, mild to basically fetal renal failure 124 And the importance is that as these stages progress, um, some of these fetuses may be candidates for best co amniotic shunting, and the importance of Stage four disease is that it's associated with pulmonary hyperplasia and ultimately, the need for neonatal dialysis. So here's just a case of, uh, placement of a best co amniotic shunt into the dilated bladder. Um, here you can see the shunt traversing that space, and, you know, we do counsel these patients. These chunks can come out, but they can be quite effective. From what I've seen, uh, following initial placement here is just that shunt again, placed into the bladder and then into the amniotic space. Um, as far as research goes, you know, there are some groups that are looking at some novel sequences like G wi diffusion weighted imaging with these 80 C maps, Um, these are sequences that we also typically do run for the body. But they have additional potential for differentiating normal prank Emma from renal disease. And there are groups that basically have been mapping out values. These ABC values, um, to to look at trends over time and gestation. So there's a lot of additional information in M R that we currently don't take full advantage of, but that I think, you know, we run these sequences typically, and I think there's a lot more information that we continue to, uh to gain. I'm just going to close with this last case. This was a tetralogy of low case with absent pulmonary valve syndrome. Um, and basically, you can see this fetus that had really markedly dilated, um, pulmonary arteries with this particular entity called apps and pulmonary valve syndrome. Um, these fetuses have abnormal curia type in about 70%. Um, it's associated with a rudimentary, this plastic pulmonary valve and these severe dilation of the pulmonary arteries. And the importance of that is that the pulmonary arteries can cause bronchial compression or respiratory compromise. And so what was cool about this case, and quite interesting, I think again, coming back to the soft tissue resolution, um, and differentiation of MRI you can see in this case is a sagittal image of the fetal lungs. And you can see that this is much brighter in the expected distribution of the right middle lobe compared to the lower lobe and just for reference, this is a normal fetus and that they're trimester. You can see homogeneous, normal, increased signal throughout the lungs. But here we have kind of this differentiation. So what happened? Post natally. Well, this baby went on to have a chest radiograph at birth, and you can see that there's consolidation in the right middle lobe. Um, the neonatal had a CT, which really nicely shows again the same distribution of of collapse or add electricity within this exact same distribution. So something that you know I think really adds value is just looking at the signal characteristics of MRI. In addition to them morphological information that gives us so with that, I'm going to actually switch over to Dr Corda if you have any questions, this is my email address. Thank you so much for your attention. Um, and we'll have a brief Q and A after this as well. All right, thanks so much. Again, from Mark for that excellent review of this Really outstanding. An interesting topic. Um, so again, I'm Dr Jesse Corti, a, um, a pediatric radiologist at the UCSF Benioff Children's Hospital and, uh, among a few of the different hats that I wear. One of them is also the co director for the Center for Advanced three D imaging. And so, with specific interest in mar protocol, optimization and use of three D techniques. So, um, wanted to spend just a few minutes to piggyback off Mark's great talk to talk a little bit about some of the applications we've been looking at with three d imaging. Let's see, uh, Mark, will I advanced? Like, perfect. So yes. Um, so just a quick disclosure. I am founder and consultant of Syria Medical, which is a software startup. And so when would we use specialist techniques? So when there are some of the instances when I find this particularly helpful. Well, one of them, Just as market alluded to where? Some of these areas where we have very complex anatomy, particularly general, you're G. You abnormalities. You malformations, indirectly malformations things that are very challenging to be able to conceptualize three dimensionally by just looking at two dimensional imaging. And so really, this is one instance where I find it very helpful. Another potential instance is the use of this imaging in multiple or conjoined twins being able to again tease out areas of connections, areas where there may be some potentials for abnormalities or really very complex anatomy. I find this very helpful. And then finally, overall, just troubleshooting just generically when looking at a cyst or a mass being able to understand the relationships of various structures to one another. I think this is very helpful. Um, so in particular, if we advance aside, what we can see is this application where we can essentially obtain a volumetric slab of imaging for three dimensional information in a pediatric patient. Or excuse me, a fetal patient where we can see this information acquired in one plane, but then reformatted into any number of other planes much as we would a, C t or any other type of information. And so again, when the patient is obliquely positioned. So in this case of conjoined twins were able to see the airway on one side and then the airway on another side. So again, being able to tease out this anatomy here and seeing it in two separate planes allows us information that we might otherwise have to obtain in multiple different acquisitions were able to get this in one single acquisition. So this is our steady state three procession. This is an example of our three D heavily t two weighted three D imaging as we can see the M R C P sequence that we have obtained and modified here, which is able to really to emphasis the fluid containing structures. And then we can take this and then turn this into a three D reformatted image here. So, um, what we're actually seeing is the fetal urinary tracts here in three dimensions here with the urinary bladder as well as the right and left collecting system. And we can even take this a step further and take this information this volumetric information even turn this into three dimensional interactive model. As we have here. If we do a click through, we can see that we've segmented out this three dimensional information here. And we can even show this in a virtual or augmented reality format or even three d print this. And so you can imagine how this might be useful for pre surgical planning for interventions and ultimately, even things like interventional guidance. So again, some of the things that we're working on here one of the other things then, um, as far as future direction. So where do we see this going? Well, one, I think, definitely is in the acquisition. So really being able to obtain this information rather than going from tens of minutes to tens of seconds to be able to really use things like machine learning techniques to improve our image acquisition time and then to obtain higher resolution imaging. So volumetric sequences such that we can not only get dynamic imaging but also capture high resolution, thin slice imaging that we can then use for using things like functional imaging so obtaining, just as Mark says things like diffusion weighted imaging or diffusion track. Ta graffiti, d t. I imaging so that we can also get functional information to be able to tell using things like spectroscopy. Even I think there's some really exciting avenues for development in this field that can give us not only high resolution and atomic imaging, but also show us functional information as well. So those are just a few things that I wanted to highlight of some of the things that we're working on and just tell you a little bit about What are the directions that we see for this modality to go? Thank you very much. Awesome. Thank you, Jesse. Mm. So, um mhm. Aaron, uh, this is just are just briefly. This is some of our group just a few of, uh, the members of our team who perform ultrasound here as well as do some of the body imaging for M R. I. This is, uh we're very fortunate here. Then. We're very fortunate here. Excuse me. And that we have a really outstanding ultrasound groups. So are correlative imaging. Can be, um I I find that MRI is a really great adjunct, but it's great having such a strong ultrasound presence here. Thank you. To the both of you. for a wonderful presentation. Uh, if you know somebody who really wanted to be here and miss this, don't worry. We'll be sending out an email in a couple of weeks with the link to this. If you missed any of our previous activity, Webinars, you can see a link down there to go back and see some of our other our other webinars, one of which did highlight and focus on C B H. In addition, I have a list of our physician liaisons who have all worked very hard to help make this happen. Next slide, please. And to refer a patient to use this ethical treatment center below is the information for both RSF and our Oakland campus as well as our you're out.