Persistent reversed end diastolic flow in the fetal middle cerebral artery: an ominous finding

Abstract

Fetal persistent middle cerebral artery reversed end diastolic flow is a rare and ominous finding. Previous cases have been associated with intracranial hemorrhage, growth restriction, anaemia, and hepatic anomaly. Intrauterine demise or early neonatal death is a common outcome. We report the case of persistent middle cerebral artery reversed end diastolic flow in a well-grown fetus at 32 weeks' gestation resulting from acute, severe anaemia due to a large feto-maternal hemorrhage. An emergency cesarean section was performed and the neonate required advanced resuscitation and immediate blood transfusion. Postnatal magnetic resonance imaging confirmed a hemorrhagic parietal infarct and bilateral ischaemic changes in the basal ganglia. This provides further evidence that persistent middle cerebral artery reversed end diastolic flow in any fetus is an ominous finding warranting urgent diagnostic evaluation and/or delivery.

Persistent reversed end‐diastolic flow of the middle cerebral artery: A rare and concerning finding

“…The increased intracranial pressure results in reversed enddiastolic flow of the MCA. 5,9 The cause of fetal intracranial hemorrhage in our case was associated with maternal warfarin therapy. Fetal hemorrhage can occur even in low dosages (≤5 mg daily) as reported in other studies.…”

“…So far, only a few reports are similar to our case. 2,6,8,12,15 This reversed flow has been reported as a rare finding related to pathological fetal conditions, such as fetal growth restriction, 3,4,7,10,11,13 fetomaternal hemorrhage, 1,5,9 and congenital hydrocephalus. 14 Some cases had a transient period of reversed flow, which was possibly from temporary extracranial compression such as increased transducer compression or anhydramnios/oligohydramnios.…”

“…1,2,4,[6][7][8]10,12,14,15 However, some studies reported that fetuses survived and subsequently required neurological follow-up; however, no study reported long-term neurological outcomes. 3,5,9,11,[13][14][15] A wide range of intervals between the diagnosis of reversed end-diastolic flow of the MCA and adverse event or delivery were reported. [4][5][6][7][8][9]11,12,[14][15][16][17] In healthy fetuses, there is a high resistance of cerebral blood flow with a continuous forward flow of the MCA.…”

“…3,5,9,11,[13][14][15] A wide range of intervals between the diagnosis of reversed end-diastolic flow of the MCA and adverse event or delivery were reported. [4][5][6][7][8][9]11,12,[14][15][16][17] In healthy fetuses, there is a high resistance of cerebral blood flow with a continuous forward flow of the MCA. However, specific fetal conditions relating to an increased intracranial pressure can cause persistent reversed end-diastolic flow of the MCA.…”

Prenatal Diagnosis of Autosomal Recessive Renal Tubular Dysgenesis with Anhydramnios Caused by a Mutation in the AGT Gene

“…An unexpected finding was that the fetus presented with MCA-REDF before birth. MCA-REDF is an extremely rare prenatal sonographic finding and only a few cases that were associated with fetal growth restriction, anemia, intraventricular hemorrhage, and a rare hepatic anomaly were reported in the literature; all documented cases suffered from poor neonatal outcomes [23]. We measured MCA Doppler at 33 +2 wGA for this case because of small fetal size for GA and anhydramnios.…”