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Rabih Chaoui, Kai-Sven Heling
3D Ultrasound in Prenatal Diagnosis
Rabih Chaoui, Kai-Sven Heling
3D Ultrasound in
Prenatal Diagnosis
A Practical Approach
Prof. Dr. med. Rabih Chaoui
PD Dr. med. Kai-Sven Heling
Prenatal Diagnosis Clinic
Friedrichstraße 147
10117 Berlin, Germany
This is a translation of the original book in German:

3D-Sonografie in der pränatalen Diagnostik
Translated by Rabih Chaoui.
ISBN: 978-3-11-049651-2
e-ISBN (PDF): 978-3-11-049735-9
e-ISBN (EPUB): 978-3-11-049400-6
Library of Congress Cataloging-in-Publication Data

A CIP catalog record for this book has been applied for at the Library of Congress.
Bibliographic information published by the Deutsche Nationalbibliothek

The Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed
bibliographic data are available in the Internet at http://dnb.dnb.de.
The publisher, together with the authors and editors, has taken great pains to ensure that all
information presented in this work (programs, applications, amounts, dosages, etc.) reflects the
standard of knowledge at the time of publication. Despite careful manuscript preparation and proof
correction, errors can nevertheless occur. Authors, editors and publisher disclaim all responsibility
and for any errors or omissions or liability for the results obtained from use of the information, or
parts thereof, contained in this work.
The citation of registered names, trade names, trademarks, etc. in this work does not imply, even in
the absence of a specific statement, that such names are exempt from laws and regulations protec-
ting trademarks etc. and therefore free for general use.
© 2016 Walter de Gruyter GmbH, Berlin/Boston.

Typesetting: LVD GmbH, Berlin
Printing and Binding: Hubert & Co. GmbH & Co. KG, Göttingen
Cover image: © Rabih Chaoui, Kai-Sven Heling
♾ Printed on acid-free paper
Printed in Germany
www.degruyter.com
For Kathleen, Amin and Ella Chaoui.
For Rajae, Anais, Reem and Anna Heling.
Preface
The first three-dimensional (3D) ultrasound demonstration of a fetal face was per-
formed in 1989, a momentous event that was considered as the birth of 3D ultrasound.
More than 7 years later, the first major scientific event on 3D ultrasound occurred in
1997 when Professor Merz organized the first world congress on this topic.
The introduction of rapid computer processing around the year 2000 enabled the
widespread use of 3D ultrasound equipment. Indeed, more than half of the obstetrical
clinics and offices are currently using ultrasound equipment with 3D capabilities.
Despite this rapid expansion in 3D ultrasound equipment and a large body of scien-
tific literature on the use of 3D ultrasound in obstetrical imaging, very few textbooks
are available on this topic. This book is intended to fill this void, to serve as a guide on
this subject with a primary focus on the technical aspects of the 3D technology.
We have dedicated a significant part of our daily clinical practice on 3D ultra-
sound over the past decade and have organized and participated in numerous educa-
tional activities on 3D ultrasound. We have also been very active in research and dis-
covery on this topic and have contributed significantly to the current state-of-the art
of 3D ultrasound. This book is the culmination of our life work on this topic.
A successful 3D ultrasound examination has two important parts: the acquisition
of the 3D volume and the post-processing manipulation of the volume data set. In this
book the acquisition and manipulation of 3D volumes is explained in a step-by-step
practical approach.
The book is divided into three main sections: the first section provides details on
how to acquire the optimum volume, the second section describes various volume
rendering modes and the third section explains the organ-specific application of 3D
techniques. With more than 500 figures, the book provides an exemplary approach to
3D ultrasound in prenatal diagnosis.
We owe several people a debt of gratitude for their significant contribution to our
3D ultrasound journey. First and foremost, Dr. Bernard Benoit, a giant in the field of
ultrasound imaging, who has been and continues to be a great source of inspiration
to us. Many of the 3D ultrasound tools could not have been developed without his
tremendous technical and artistic experience. We also would like to thank the engi-
neering and management teams at Kretztechnik (General Electric-Healthcare) in Zipf,
Austria for their close cooperation, and their tireless support over the years. We thank
our patients who contributed to all the images in this book and who continues to
motivate us to push the limit of this technology forward.
This book will not have been realized without the professional team at DeGruyter
publishing, especially Mrs. Simone Witzel, Dr. Bettina Noto and Mrs. Anne Hirschel-
mann for their committed and unwavering support in this effort.
We have delayed production of this book on several occasions. The time has now
come to present you this book on the most recent available 3D ultrasound in obstetrics.
Berlin, December 2015 R. Chaoui, K. S. Heling
VIII Preface
Technical ultrasound words
All 3D examinations and experience in this book is based on Voluson ultrasound

equipment produced by the company General Electric, GE Healthcare. The images in
this book were generated with Voluson e8 and e10 machines and most tools presented
in this book as VCI®, TUI®, Magicut®, Glass-body mode®, HD-Live®, Sono-AVC®, VOCAL®
and others are protected names. To facilitate reading we decided to omit the ® sign in
all the book.
Some abbreviations are listet below:
Abbreviations
3D Three-dimensional Ultrasound
4D Four Dimensional Ultrasound
GA Gestational Age
HD High-Definition
Sono-AVC® Sono Automatic Volume Calculation
TUI® Tomographic Ultrasound Imaging
VCI® Volume Contrast Imaging
VOCAL® Virtual Organ Computer-aided AnaLysis (VOCAL)
Contents
Preface VII
Part I: Basics of 3D Ultrasound
1 Basics of 3D and 4D Volume Acquisition 3

1.1 Introduction 3
1.2 Preparing the volume acquisition 3
1.3 Types of volume acquisition 10
1.4 Conclusions 13
2 Orientation and Navigation within a Volume 15

2.1 Introduction 15
2.2 Storing and exporting volume data sets 15
2.3 Orientation in the three orthogonal planes 16
2.4 Navigation within the orthogonal planes 17
2.5 Artifacts in the multiplanar mode 23
2.6 Conclusions 25
Part II: Methods of 3D Rendering
3 3D Rendering of a Volume 29

3.1 Introduction 29
3.2 The render box and the orientation within a 3D volume 29
3.3 Artifacts in 3D rendering 30
3.4 Different rendering modes and the mixing of modes 34
3.5 Special effects in 3D: dynamic depth 3D rendering
and light source 39
3.6 Threshold, transparency, brightness and color scales 41
3.7 Magicut, the electronic scalpel 43
3.8 Multiple light sources and „HD-live studio“ 46
3.9 Conclusions 48
4 Volume Contrast Imaging (VCI) 49

4.1 Introduction 49
4.2 Principle of VCI 49
4.3 Static VCI 53
4.4 4D with VCI-Omniview 56
4.5 4D with VCI-A 58
4.6 Conclusions 61
X Contents
5 Multiplanar Display I – Orthogonal Mode and Omniview Planes 62

5.1 Principle 62
5.2 Multiplanar reconstruction and different ways
of displaying cross-sectional images 62
5.3 Practical approach in orthogonal mode 63
5.4 Practical approach in getting an „anyplane“ using
Omniview tool 64
5.5 Typical applications of Omniview planes 67
5.6 Conclusions 74
6 Multiplanar Display II: Tomographic Mode 75

6.1 Principle 75
6.2 Practical approach 75
6.3 Typical applications in tomographic mode 81
6.4 Conclusions 88
7 Surface Mode Rendering and HD-Live 93

7.1 Principle 93
7.3 Typical applications of surface mode 98
7.4 Conclusions 105
8 Maximum Mode Rendering 106

8.1 Principle 106
8.3 Typical applications of maximum mode 112
8.4 Conclusions 116
9 The Minimum Mode 117

9.1 Principle 117
9.3 Typical applications of minimum mode 119
9.4 Conclusions 124
10 The Inversion Mode 125

10.1 Introduction 125
10.3 Typical applications of inversion mode 127
10.4 Conclusions 132
11 The Silhouette Tool 133

11.1 Principle 133
Contents XI
11.2 Practical application 133

11.3 Typical applications of silhouette tool 137
12 The Glass-Body Mode and HD-Live Flow 143

12.1 Principle 143
12.3 Glass-body mode with HD-live flow function 148
12.4 Typical applications in the glass-body mode 148
12.5 HD-live flow using the color silhouette tool 153
13 The B-Flow Mode 156

13.1 Principle 156
13.3 Typical applications of the B-flow mode 158
14 Biplane Display using the Electronic Matrix Transducer 162

14.1 Principle 162
14.3 Typical applications of biplane mode 164
15 Calculation of 3D Volumes 178

15.1 Principle 178
15.3 Clinical application of volume calculation 184
Part III: Clinical Applications of Prenatal Diagnosis
16 3D Fetal Neurosonography 187

16.2 Fetal neurosonography with 3D ultrasound 187
16.3 3D visualization of specific brain structures 192
16.4 Reconstruction of fetal brain structures in 3D rendering 196
16.5 The intracranial vascular system in color Doppler 196
16.6 Fetal neurosonography before 14 weeks of gestation 200
XII Contents
17 3D of the Fetal Skeleton 206

17.1 Limitations in the assessment of the fetal skeleton
using 2D ultrasound 206
17.2 3D of fetal spine and ribs 206
17.3 3D of the fetal limbs 213
17.4 3D of the facial and cranial bones 216
18 3D of the Fetal Face 219

18.1 The sonographic examination of the face in 2D and 3D ultrasound 219
18.2 The face in multiplanar display 220
18.3 The normal face in 3D/4D surface mode 223
18.4 The abnormal face in 3D/4D 229
18.5 The facial bones in 3D/4D 234
19 3D Intrathoracic and Intraabdominal Organs 236

19.2 Intrathoracic organs 236
19.3 Intraabdominal organs 242
20 STIC and 3D/4D Fetal Echocardiography 255

20.1 The sonographic assessment of the heart in two-dimensional
ultrasound 255
20.2 Acquiring cardiac volumes 255
20.3 Fetal echocardiography in 3D/4D multiplanar reconstruction 257
20.4 Fetal heart in 3D/4D volume rendering 258
21 3D in Early Pregnancy 269

21.1 Background 269
21.2 3D volume rendering in early gestation 269
21.3 Multiplanar display in early gestation 278
Further literature references and sources 283
Index 287
Part I: Basics of 3D Ultrasound
1 Basics of 3D and 4D Volume Acquisition
1.1 Introduction
The current technology of 3D ultrasound is based on advanced mechanical or elec-

tronic transducers with the ability to acquire a volume or sequence of volumes. The
pictorial information acquired in a 3D volume can then be displayed on the screen in
different ways: either as one or multiple multiplanar 2D images (See Chapters 4, 5 and
6) or as a spatial volume, which projects external or internal anatomic features of a
volume (see Chapter 3). It is generally acknowledged that acquisition, display, and
manipulation of 3D volumes are techniques that entail a steep learning curve. The
“quality of a volume” to provide valuable information or a perfect 3D picture depends
not only on the skill of the examiner in the post-processing manipulation, but also on
the adjustment of the 2D image prior to volume acquisition. In this chapter, we discuss
some aspects of image optimization as well as some basics of volume acquisition.
1.2 Preparing the volume acquisition
Five important steps should be considered during the preparation of a 3D volume

acquisition. These steps are:
1. Optimization of the 2D image before volume acquisition
2. Choice of the best reference or starting plane with anticipation of the result expected
3. The box of acquisition or volume box
4. Acquisition angle
5. Volume quality and resolution
1.2.1 Optimization of the 2D image before volume acquisition
Before a 3D-, 4D- or STIC-volume is acquired, the 2D image optimization is mandatory

for obtaining optimal results. The term “reference plane” or “acquisition plane” is
then used to designate the starting 2D plane for a 3D acquisition. A 3D volume is a
collection of adjacent 2D images and the resolution in the complete volume improves
with the resolution of each single plane. Apart from the choice of line density and
image frame rate, optimization of the image also includes correct positioning of the
“region of interest” in the volume box and optimal positioning of the focus zone. In
this case, the choice of both the angle size of the box and the angle depth (acquisition
angle) are important. If the volume is acquired with color Doppler, the examiner
should also consider optimizing color resolution, color persistence and frame rate.
Figures 1.1 to 1.3 are examples of optimization of images prior to volume acquisition.
4 1 Basics of 3D and 4D Volume Acquisition
Fig. 1.1: Left: During the preparation of a 3D acquisition of a head and brain, part of the
head will be absent in this case. In the figure to the right, the image is more centered and
thus optimal for a 3D acquisition.
Fig. 1.2: Left. The image is not optimized and appears too “bright” with low contrast for a 3D
acquisition in surface mode. Right: After image optimization, amniotic fluid appears black
and transparent with the surface contours well defined.
1.2.2 Choice of the best starting plane at volume acquisition
In 3D ultrasound, the best image quality within a volume is found in the reference
plane and in the planes parallel to the reference plane, whereas the reconstructed
orthogonal or planes oblique to the reference plane have a reduced image quality.
Even if it is not always the case, it is still better if the operator knows what the volume
is going to be used for before the acquisition.
Fig. 1.3: Left: The preset of this image is not well adjusted neither for a static nor for a STIC
acquisition. The color Doppler is too large and the velocity scale is too low. The right figure
presents an optimized image prior to acquisition.
1.2.3 The acquisition box or volume box
The volume acquisition box or volume box determines two parameters of a 3D volume
in the 2D image, namely the height and width, corresponding to the X- and Y-axis
respectively (Fig. 1.5). It is recommended that the operator adjusts the box size to
include all anatomic components of a target volume. During an acquisition in 4D, the
box borders are selected close to the anatomic region of interest, and can be corrected
directly during the 4D display, however, for a static 3D recording, we recommend
choosing a large box in order to avoid excluding some structures adjacent to the ana-
tomic regions from the volume.
Fig. 1.4: The volume box has three

dimensions. Image height and width
are selected in 2D mode while the
depth of the volume box is selected
by choosing the acquisition angle
f.ex. 50°, 70° etc. (compare with next
figure).
Fig. 1.5: A volume box size consists of height, width and depth. The acquisition angle is the total
volume angle, which is during the acquisition half the angle in front and half the angle behind the
reference plane. The reference plane is the image the examiner sees on the screen while activating a
3D acquisition.
1.2.4 Acquisition angle
The angle of acquisition refers to the depth of a volume, corresponding to the Z-axis,
and is the sweep angle of the elements within the probe during acquisition (Fig. 1.5).
The angle of acquisition is adjusted by the operator with the choice of the size of the
volume box prior to the 3D volume acquisition. There is no gold standard for the best
angle of acquisition but the choice depends mainly on the anatomy of the target organ
and the type of acquisition. The angle of acquisition is then the total angle of the
volume, but during the acquisition half of the angle is present behind and the other
half in front of the reference or acquisition plane (Fig. 1.5). Depending on the organ
examined, the size and shape of the box will differ. Figures 1.6 and 1.7 present different
types of acquisition boxes. For instance, the volume box of a fetal spine sets the box
wide but the acquisition angle narrow (Fig. 1.6), while for the heart, width and depth
are almost equal (Fig. 1.7).
1.2.5 Acquisition quality
The 3D volume quality is selected by the user with the choice of the volume acquisition
duration. The examiner should keep in mind that, within a volume box with the same
Fig. 1.6: The shape of a volume box is generally defined by the organ examined. In the case of spine
and ribs the box is large with a rather narrow depth. The size of the volume box is displayed on the
screen with B for width 66° and V for Volume depth 40°.
Fig. 1.7: The choice of the volume box shape is often determined by the examined region: Left up:
typical volume box of a spine in a longitudinal view. Right up is an example of a box for a fetal face in
3D. The box in the left bottom image has a narrow volume depth in a STIC acquisition and the large
box in the right bottom image is for the acquisition of a large body part as the head, or abdomen and
thorax or a complete fetus in early gestation.
Fig. 1.8: With the same volume angle the choice of “high quality” acquisition (as maximum, high2,
high1) leads to the acquisition of many images, with the result of a high resolution image, while the
acquisition of few images leads to a low or middle quality volume.
Fig. 1.9: 3D volume of a fetus in low quality (upper images) and maximum quality (lower images)
acquisition with corresponding different resolutions in the acquired images.
acquisition angle, a slower sweep will allow the acquisition of more images and pro-
vides better resolution, while a quick sweep acquires fewer images, resulting in an
image of reduced resolution (Fig. 1.8). Moreover, if in a volume box more images are
available for 3D calculation, this results in better quality images of the reconstructed
B and C planes in the multiplanar display. In Figs. 1.9 and 1.10, compare the top and
bottom images. It should also be kept in mind that the best quality is not always
achieved by choosing the maximum resolution, and the examiner should find his or
her own preferred presets. Figure 1.11 reveals a fetus after a 3D acquisition in low res-
olution (left), in middle resolution (middle) and in highest resolution (right). In our
opinion, the middle image has the best quality with a smooth face, while the right
image has many details close to artifacts. In 3D static and 4D acquisition, the quality
of acquisition is referred to as low, medium, high and maximum, whereas in STIC
acquisition, the quality of acquisition is reflected in the duration of acquisition: 7.5, 10,
12.5, or 15 seconds. Figure 1.12 reveals the same fetus after a 3D static (left image) and
after a 4D acquisition (right image), both with high resolution.
Fig. 1.10: STIC volumes with an acquisition of short duration and corresponding low quality (upper
images) and acquisition with a long duration with a better resolution (lower images). The resolution
in both cases is different due to the different acquisition time.
Fig. 1.11: Fetal face after a 3D static acquisition in different qualities in “low”, “mid2” and
“maximum”. The middle image appears to be the best and demonstrates that the best result is not
always achieved by choosing the highest resolution.
Fig. 1.12: Acquisition of a fetal face with static 3D (left) and in 4D (right). Details recognition and
resolution are generally better with static 3D.
1.3 Types of volume acquisition
Four types of acquisition of a volume are used, namely

1. Static 3D
2. Real-time 4D with a mechanical 3D transducer (4D)
3. Spatial and temporal image correlation (STIC)
4. Real-time 4D with an electronic matrix transducer (4D)
1.3.1 3D Static acquisition
Principle: 3D Static refers to a single 3D volume acquired which contains an infinite

number of adjacent 2D still ultrasound planes with no regard to temporal or spatial
motion. Currently, this is the most common mode of volume acquisition in obstetrics
and gynecology.
Potential: This type of acquisition is easy to learn and can be rapidly performed,
allowing the examiner to acquire several volumes and to store them for later evalua-
tion. The static 3D acquisition is usually acquired with 2D preset but can also be com-
bined with color Doppler, power Doppler or B flow for vascular evaluation of volume
content. The post-acquisition rendering makes numerous displays possible, which are
discussed in greater detail in the following chapters.
Limitations: The main limitation of static 3D acquisition is its inability to assess

events related to movement, especially at the level of the heart in grayscale and in
combination with color or power Doppler. Valvular movements, myocardial contrac-
tility and flow events cannot be reliably assessed with static 3D. Another limitation is
the common occurrence of movement artifacts when movements occur during the
acquisition, as observed on fetal face, limbs, spine or others (see chapter 2,3).
1.3.2 Real-time 4D with a mechanical 3D transducer (4D)
Principle: Most 4D volume acquisitions are achieved today using a mechanical trans-
ducer with an integrated rotation motor. The principle is similar to the static 3D tech-
nology with the difference that the motor rotates continuously, thereby acquiring a
series of volumes to be displayed almost as one movement. The combination of a
series of 3D volumes within a time interval is then called 4D. Different terminologies
are used to describe this method, including real-time 3D, real-time 4D or 4D; in this
book we will only use the term 4D.
Potential: The major advantage of 4D acquisition is its ability to display instanta-

neously on the ultrasound screen real-time 4D volumes as they are acquired. This is
impressive especially when visualizing the face, hands and feet of a moving fetus.
Opening eyes, yawning or other movements make the fetus feel much more real and
human to the parents. This technique is ideal for beginners and many examiners since
the 3D image appears directly on the screen and can be adapted accordingly.
Limitations: The main limitation in this type of acquisition is the challenge of finding
a balance between a good quality 4D image on one hand and the speed of the rotation
within the motor on the other, to allow an almost live impression. On a routine good
resolution image of a fetal face in live 4D, 4 images per second are displayed; this is
nowhere near the 15 images per second or more needed to produce a “live” impression
of images. Therefore the image flow often appears not smooth, unless the fetal move-
ments are slow. Slow movements of fetal arms, legs, or facial grimace, yawning or eye
opening can be followed well using this technique.
1.3.3 Spatio-Temporal Image Correlation (STIC) acquisition
Principle: STIC acquisition is similar to a slow 3D acquisition of a duration between

7.5 and 15 seconds, and is used mainly for the acquisition of images of a beating heart
or vessels with pulsation. The software makes calculation of heart rate based on the
tissue excursion concurrent with cardiac motion possible. The acquired volume is
processed internally, where the systolic peaks are used to calculate the fetal heart rate
and the volume images are then rearranged according to their temporal events within
the heart cycle, thus creating a cine-like loop of a single cardiac cycle.
Potential: The advantages of STIC volume acquisition include the ability to assess
myocardial wall motion and valve excursion. The 4D information is available within
seconds from the volume acquisition. Once the reference plane is optimized, the STIC
acquisition can be easily achieved. STIC acquisition can be obtained from 2D gray-
scale imaging combined with other imaging modalities, such as color, power, or
high-definition Doppler and B-flow. If the 2D and color Doppler scanning conditions
are good, the STIC can then be used for offline reconstruction of planes and off-line
assessment. This potential of a virtual examination of the heart is one of the big poten-
tials of this technique. Its clinical use is discussed in Chapter 15.
Limitations: Disadvantages of STIC acquisition include a fairly delayed acquisition

time, which can be hampered by fetal movements or maternal breathing movements,
thus introducing artifact into the volume. Another limitation is the fact that a single
heart cycle is displayed as a cine loop, which makes this technique inaccurate in the
assessment of arrhythmias, in particular ectopic beats.
1.3.4 Real-time 4D with an electronic matrix transducer (4D)
Principle: The usual type of 3D mechanical transducer consists of one row of crystals
used to generate the 2D image and a mechanical motor that sweeps the ultrasound beam
so as to generate multiple 2D planes which are then stacked together to produce the 3D
volume. Recent electronic matrix transducers are designed with a rectangular area of
crystals (around 8000) arranged in rows. For a 2D examination few rows are activated
while for a real-time 4D examination almost all can be activated, if needed. The sweep
in 3D or 4D is achieved electronically by activating the neighboring crystal rows which
provides images two to four times faster than with mechanical 3D transducers.
Potential: In addition to the advantage of a 4D in almost real-time as explained above,

the advantage of the matrix probe is the speed of image acquisition, which is ideal for
following fetal movements and in fetal cardiology. It can also be expected that the
forthcoming years will see further improvements with the advent of faster processors.
Limitations: The main limitations today are the challenges associated with cramming
such major technology into a small transducer, in particular trying to reduce its weight
and the heat it produces. Another limitation is the speed of calculation of information
before displaying the images in a real time flow.
1.4 Conclusions
These days, the acquisition of 3D volumes can be achieved either with a mechanical
3D transducer or, more recently, with an electronic matrix transducer (Fig. 1.13). Before
commencing the acquisition, the examiner should decide on the target and how it
should be displayed with 3D. After 2D image optimization, a selection box is chosen
and height, width and depth of the volume box adapted according to the require-
ments. The volume box is centered, the volume quality is selected and the acquisition
type started as 3D static, STIC or 4D (Fig. 1.13). The volume data can be displayed on
the screen either as planes (known as multiplanar reconstruction or display) or as a
three-dimensional volume image in one of the numerous volume rendering modes
(Fig. 1.14). The next chapters will discuss the different ways of displaying and manip-
ulating 3D volume data in depth.
Mechanical Electronic
transducer matrix transducer
Biplane
Static 3D volume STIC volume 4D volumes
Fig. 1.13: Scheme presenting the possibilities of volumes acquisition. Using either a mechanical or
an electronic transducer the acquisition can be performed with the choice of static 3D, STIC volume
or 4D volumes. Moreover, the electronic matrix transducer enables the acquisition of biplane-im-
ages, which, however, cannot be further manipulated, as is the case in 3D volume data sets.
Static 3D volume STIC 4D volumes
Multiplanar reconstruction Volume rendering
Sectional planes: Volume images:

– Single plane – Surface mode
– Orthogonal mode – Transparency mode
– Tomography mode – Volume calculation
– Omniview planes
Fig. 1.14: Overview showing the different possibilities of volume rendering and display on the screen
after the acquisition of a volume either as static 3D, as STIC volume or as 4D volumes. A volume data
set can be displayed either as “planes” what is called multiplanar reconstruction or as a spatial
volume called “volume rendering”. The different rendering modes listed are discussed in the next
chapters.
2 Orientation and Navigation within a Volume
2.1 Introduction
In the previous chapter we discussed how a 3D volume acquisition is prepared and

a 3D volume data set acquired. In this chapter we explain how to display the result
of volume acquisition on the screen and how 2D and 3D images are extracted after
volume manipulation. Many examiners store the volume during the examination, to
edit it at the end of the examination or later. In order to achieve an ideal image from
a volume the examiner must know how to use the different tools in the 3D software
and how to navigate through the volume. In other words, 3D volume manipulation
represents a pure application of digital software that must be comprehensively
learned. Such expertise can be gained only with a lot of hands-on use of this soft-
ware, in combination with reading monographs and attending special courses in 3D
ultrasound. The aim of this chapter is to provide the user with some helpful tips and
hidden features that will help to gain an orientation in the volume and achieve a
good image. The 3D rendering of a volume with a spatial 3D result is discussed in the
next chapter.
2.2 Storing and exporting volume data sets
Occasionally the acquired volume is directly manipulated by the sonographer during

the examination. This carries a risk of losing the volume if an incorrect button is
pressed. For this reason, we recommend directly storing a good volume on the ultra-
sound machine hard drive prior to volume manipulation. When the data set is being
saved, care should be taken to choose the correct file format. This is generally achieved
by adjusting the configuration of the “storing buttons” when the ultrasound equip-
ment is delivered to an ultrasound center. A volume can be (wrongly) saved as an
image (Bitmap, TIFF, JPEG) or correctly as a volume (3D) dataset. Acquired STIC or 4D
volumes should be saved as a “volume cineloop” and not as 3D. Saving a volume in
the wrong format makes subsequent manipulation impossible. In order to determine
whether a volume or image is saved accurately on the machine, it is best to acquire
different images and volumes and to open and manipulate them at the end of the
examination. A simple trick is to check the size of the selected image: a figure has
around 1MB, while volumes are more than 5MB. STIC and 4D Volumes have an addi-
tional time-line symbol that serve to illustrate a series of volumes.
When working with a volume, the function “export” makes exporting as an image
(for example, the figures in this book) possible, for example as video clips (e.g., for use
with patients or in scientific talks) or as a digital data set. In order to export one
volume or a collection of volumes from one patient on an external drive, it is recom-
16 2 Orientation and Navigation within a Volume
mended that the data be exported as “uncompressed volume data” and in format
“.4dv”. Saving in this format makes it easier for the data to be selected for reimporting
into an ultrasound system of the same series or to be used on a remote computer with
the PC-Software 4D-view®.
2.3 Orientation in the three orthogonal planes
After a volume acquisition, in most cases the 3D-display on the screen is presented in
a multiplanar mode, mostly in the three orthogonal planes (Fig. 2.1). These planes are
labeled A, B and C, respectively. Plane A is shown in the upper left of the image and
refers to the reference plane during volume acquisition (see Chapter 1). Planes B and
C are digitally reconstructed planes orthogonal to plane A. Plane B is the 90° rotation,
and C corresponds to the horizontal plane. The acquisition angle corresponds to the
Fig. 2.1: In the orthogonal mode the volume data set is displayed as three planes perpendicular to
each other. In the upper left the reference plane A is displayed, in the upper right the 90° vertical
rotation plane and in the bottom left the 90° horizontal rotation plane C. In the B-plane the acquisi-
tion angle is recognized and when present movements artifacts can be identified in this plane
(see Figs. 2.13, 2.14).
aperture of plane B, while the width of the box is recognized in image A. The values
are displayed on the side of the image. The image in plane A is usually of best quality,
because it was directly visualized, while the images in planes B and C are of lower
resolution since they were calculated from the digital information. The display of a 3D
volume dataset can, however, be saved differently by the user such that a 3D rendering
or a tomographic image or others appears directly on the screen after volume acquisi-
tion.
2.4 Navigation within the orthogonal planes
Navigation within a volume enables the generation of new planes and can thus simu-
late an ultrasound examination (Figs. 2.2–2.6). The planes seen on the screen are inter-
related and any change within one plane affects the others. As starting plane the
so-called active plane is selected and can be recognized by the calipers on the border
of the image (Fig. 2.2 upper right). When the navigation is performed in the active
plane, the images change in the two other orthogonal planes. The examiner can switch
to another plane to continue navigation, which then becomes the active plane. In
general, navigation within a 3D volume can be achieved in three ways:
Fig. 2.2: This and next images illustrate how the intersection dot can be used for the navigation
within the volume. This dot always points to the same position displayed in the planes A, B and C. In
A it is displayed in yellow, in B in orange and in C in cyan. In this example all three planes intersect
in the liver, where the dot is seen. In the plane B the stomach is recognized. The examiner now
moves the point in plane B (arrow) placing it on the stomach and the images in plane A and B yield
the result as shown in Fig. 2.3.
Fig. 2.3: (see previous Fig. 2.2). After the intersection dot has been moved in plane B to be placed in
the stomach the images in A and C have changed to display new images, where the stomach is seen
as well. The dot always is pointed at the same place in all three planes. Now the examiner wants to
visualize the descending aorta. In plane B the point is moved to the descending aorta (arrow) and
two new planes A and C emerge.
Fig. 2.4: (see also Figs. 2.2 and 2.3). In this figure, the intersection point now lies in the plane B in
the aorta, which is also seen in planes A and C. Using this approach, the examiner can continue to
navigate within the volume. Often, the resulting image should be adjusted by slightly rotating the
volume, which is shown in the next figures.
Fig. 2.5: The 3D volume of a fetal face in orthogonal display mode. In the plane A, one has the
impression to recognize a good profile, but planes B and C demonstrate that the plane is oblique.
To adjust the volume, the intersection dot is moved in plane B to be placed on the nose (1, short
arrow) and the image rotated around this point (2, curved arrow), resulting in both eyes being
positioned horizontally (see result in Fig. 2.6), and in plane A the profile is now exactly seen in the
midline. This step of manipulation is called rotation.
1. By moving the intersection dot in one plane (called navigation),

2. By rotating the axes (called rotation), or
3. By scrolling through the volume and getting parallel images (called translation).
Planes are called A, B or C (Fig. 2.1), while axes are labeled X, Y and Z and dis-
played in different colors (Figs. 2.7, 2.8).
Navigation with the intersection dot: In the orthogonal mode display, the three
planes A,B and C are perpendicular to one other and the intersection of all three
planes is the intersection dot (Fig. 2.3). This dot can be actively clicked by the exam-
iner and moved from its position, which results in a change in the two other planes
(Figs. 2.3, 2.4). Since the dot always indicates all three planes to the same structure, it
can be placed and changed in any plane depending on the region of interest. Such
navigation can always be achieved in any of the A, B or C planes. Figures 2.2 to 2.4
illustrate a step-by-step navigation using the intersection dot.
Rotation: Selecting one of the X-, Y- or Z-axes makes rotation of the image along this
axis possible (Figs. 2.5, 2.6). The axes can be rotated either by using one of the three
knobs on the machine or by selecting one of the lines. Instead of trying to work out
Fig. 2.6: The 3D volume in Fig. 2.5 was adjusted so that both eyes in plane B are positioned horizon-
tally. In next step, plane C was adjusted to align the face axis and get in plane A the profile exactly in
the midline.
Fig. 2.7: This image is part of a volume in orthogonal display mode and this plane A illustrates the
three axes X, Y and Z resp. as horizontal line, vertical line and as a dot. In Fig. 2.8 these lines were
drawn for a better understanding of the rotation steps.
Fig. 2.8.: Orthogonal display mode with the lines X, Y and Z, which were drawn for a better under-
standing. The arrows show the rotation directions, which result when the buttons X , Y or Z are
rotated in both directions.
Fig. 2.9: In a volume, here displayed as tomography mode, the examiner can also scroll through dif-
ferent parallel planes. The resulting images are then shown, image-by-image. Scrolling can be used
in any plane in the volume to display parallel planes starting from the plane of interest.
Fig. 2.10: When scrolling through a volume, the images displayed are parallel planes to the starting
plane and scrolling corresponds to translation movements, which is a sliding along a horizontal
axis. In addition to navigating with the dot and rotating along axes, translation is the third way of
navigating within a volume.
Fig. 2.11: During navigation through a volume with axis rotation and translation the orientation was
lost as shown in this case. The use of the INIT-button makes it possible to return to the initial image
of the volume at the stage of volume acquisition, as shown in Fig. 2.12.
Fig. 2.12: The figure presents the image of Fig. 2.11 after activating the INIT-Button. The lateral view
of the face can now be viewed as the original image.
which knob leads to which rotation, most beginners will use trial and error, turning
one knob and seeing what happens on the screen.
Translation: After selecting an active plane on the screen, the activation of the knob
“translation” will lead to scrolling through parallel planes to the active plane (Figs. 2.9,
2.10). This scrolling resembles a sliding movement with the transducer during a live
examination.
“INIT”, the initial position and starting point: Occasionally, after turning different
knobs and moving the intersection dot, the examiner may lose the orientation
(Fig. 2.11). The easiest way to recover is to press the button “INIT” (for initial position),
which will then return the volume display to its initial position (Figs. 2.11, 2.12) when
it was acquired and stored.
2.5 Artifacts in the multiplanar mode
Artifacts occur more commonly in 3D than in 2D sonography. They occur during the
3D volume acquisition and are either due to maternal movements such as breathing,
laughing, etc., or more commonly due to fetal movements. Artifacts arising during
Fig. 2.13: Images in plane A is directly recorded during volume acquisition while images in planes B
or C are digitally reconstructed images from adjacent images of plane A and can thus reflect move-
ment artifacts. Artifacts during volume acquisition are therefore best recognized in planes B and C.
Fig. 2.14: Artifacts due to fetal movements during acquisition are rarely seen in plane A, but almost
always in planes B and C (see explanation in Fig. 2.13)
volume acquisition are best recognized in the B-Plane in the orthogonal mode
(Figs. 2.13, 2.14). While significant movements are easily recognized, small movement
artifacts lead to only slight distortion of the image, which may escape detection.
Decent artifacts during volume acquisition of regions like brain, heart, abdominal
organs or skeleton remain often hidden. The examiner should therefore always bear
in mind that a 3D examination is a reconstructed examination of acquired planes,
which can become important when measurements are performed. In the next chapter
we will discuss the impact of artifacts upon 3D rendering of a volume data set.
2.6 Conclusions
The post processing working on a volume is a prerequisite for understanding 3D

volume ultrasound. The two important steps are the orientation and the navigation
within a volume. The best orientation is achieved in the three orthogonal planes,
called A-, B- or C-planes, where the intersection dot is directed to the same point in the
three planes. The navigation within a volume is best achieved in multiplanar than in
volume display. The intersection dot can be used to navigate within the single planes,
while the volume axes X, Y and Z are used to rotate the images of the volume and the
planes, as in tomography, in order to scroll (translation) from image to image. These
basic steps allow generating planes out of the volume, even if these are not ideally
visualized during live scan and opens thus a new field in imaging. The navigation
additionally makes it possible to simulate an examination out of volumes.
Part II: Methods of 3D Rendering
3 3D Rendering of a Volume
3.1 Introduction
For many users, the spatial reconstruction of a volume with the display of a 3D image
on the screen, especially an image of the face, has been synonymous with 3D ultra-
sound. In design and 3D terminology this spatial reconstruction is usually called “ren-
dering”. The 3D rendering of an ultrasound volume data set is performed according to
some principles and standards that will be explained in this chapter. Understanding
some basics of rendering and manipulation can be very helpful in the achievement of
good quality images in the different rendering modes. These modes are described sep-
arately in chapters 7–13.
3.2 The render box and the orientation within a 3D volume
In the multiplanar mode, 3D volume rendering can be selected by activating the “Ren-
dering” button. A rectangle will then appear in the 3 planes (A, B and C) and an addi-
tional fourth 3D calculated image is displayed in the right lower corner (Fig. 3.1). This
volume-rendering box, hereinafter referred to as the “render box” in this book, can be
modified in its height, width and depth. The render box allows the user to select the
information to be included in the 3D calculation (see Figs. 3.2 to 3.6). The result can be
recognized immediately in the 3D rendered image. All sides of the box are white with
the exception of one side that is displayed in green in two planes (Figs. 3.2 to 3.6). This
is the “projection line” or “green line” (similar to a camera) from which the 3D image
perspective is seen. To facilitate orientation, the box has two orientation points, a
rectangle and a rhombus, that are also displayed in the 3D box (Fig. 3.6). With more
experience, orientation in the 3D image becomes easier and the green box with the
marks can be removed from the 3D image (Figs. 3.3–3.5). The perspective from which
the image is seen in 3D can also be modified (Figs. 3.3–3.5). In order to visualize the
face, the line is often placed directly in the amniotic fluid in front of the face (Fig. 3.2).
Figures 3.3–3.5 illustrate examples of how changing the line of projection influences
the result. Under certain anatomic conditions (e.g., imaging of the heart), it may be
necessary to change the line into a curve (Fig. 3.4). This can be achieved by modifying
the position of a point to obtain a curved line.
Once placed within the volume at its final position including the required infor-
mation, the render box can be “fixed” for further manipulation. Using this selection,
the orientation lines disappear (Fig. 3.7). In other words, from the entire volume
acquired, only the information placed within the render box is then available for
further 3D volume manipulation; the adjacent information is no longer displayed in
the 3D image. Following this step, the electronic Magicut scalpel can be used to
30 3 3D Rendering of a Volume
Fig. 3.1: By activating the button “Rendering”, the examiner can switch from the orthogonal display
mode to the volume-rendering mode. In planes A, B and C a render box appears and in the lower
right panel the calculated 3D image is displayed. Size of the box can be changed by changing
the position of one of the six borders of the box, defining thus the ultrasound information to be
displayed in the volume (see next figure). The “green” projection line shows the perspective of view
into the volume.
remove parts of the image, the image can be rotated or the information in the box
displayed in different modes. These actions are known as “manipulation of the
volume”.
3.3 Artifacts in 3D rendering
Artifacts in 3D are often the result of fetal movements during volume acquisition and
rarely due to maternal movements. These artifacts can easily be identified during 3D
rendering directly on the displayed image (Fig. 3.8). While large movements cause
obvious artifacts that make the image of no value for further interpretation, some
minor fetal motions lead to slight image distortions that may escape detection. Small
Fig. 3.2: In the 3D rendering mode of a fetal face the “green” projection line is placed on the top in
front of the face (arrows).
Fig. 3.3: In this example the volume was rotated and a vertical line (arrows) was selected, to visual-
ize the face. We do not recommend such an approach, since the orientation in planes A, B and C gets
easily lost. Generally it is better to keep the position of the planes only slightly unchanged as shown
in the previous figure.
Fig. 3.4: In this STIC volume the projection line (arrows) is placed inside the thorax directly within
the heart just under the aortic root (plane B). This enables the demonstration of the four-chamber-
view in surface mode (also refer to Chapter 20).
Fig. 3.5: Upper panel: The projection line is placed in the amniotic fluid in front of the face (arrows).
In the lower images, the projection line is placed behind the face and the so-called reverse-face view
is displayed.
Fig. 3.6: The 3D image (lower right panel) only displays the information included in the render box.
Here the upper part of the head is out of the box and therefore not seen in 3D. For a better orienta-
tion in the render box two marks are displayed on the box and in the corresponding images, namely
a square and a rhombus.
Fig. 3.7: In this case, the render box was “fixed” or “frozen”, which means that the 3D image infor-
mation can be rotated, magnified and manipulated without a change in the information included
in it. The green box can still be seen in the 3D figure but with increasing experience, the box can be
removed from the image, as is seen in most figures in this book.
Fig. 3.8: During acquisition,

these fetuses moved and the
3D images show the corre-
sponding movement artifacts.
In the lower right image, the
artifact generated a typical
Pinocchio nose in this fetus.
artifacts on the face are often recognized immediately, while in other regions, small
artifacts may escape detection. In 4D the examiner switches immediately to the image
without artifacts, while in 3D the user has to repeat the volume acquisition. Figure 3.8
presents some 3D motion artifacts.
3.4 Different rendering modes and the mixing of modes
The render box offers the possibility to display images from the acquired volume by
using different modes. The rendered 3D image appears then as a 2D projection on the
2D monitor with the impression of a 3D effect (like all 3D images in this book). The
render box often includes information from different fetal structures, which have dif-
ferent ultrasound properties: fluid is anechoic, bony structures hyperechoic and
tissue hypoechoic. When the render box and the projection line have been selected,
the ultrasound system assesses all signals in the depth of the box seen from the pro-
jection line and the selected mode displays the required information. Generally there
are two algorithms for 3D rendering with different types of visualization: either surface
rendering or transparent rendering.
3.4.1 Surface modes rendering
In surface mode rendering (Figs. 3.9 top, 3.10) the ultrasound signals that are analyzed
are mainly those directly behind the projection line. In general, the projection line is
placed in the amniotic fluid in such a way that the fetal skin becomes visible. In
Chapter 7, the different applications of the surface mode are discussed. Different
display algorithms are provided in surface mode rendering and are discussed in this
section. Their selection depends on the object to be visualized and also for “aesthetic”
aspects. The following calculations and display modes are available:
Surface smooth, surface texture: In these modes, only the surface next to the pro-
jection line is displayed (Fig. 3.9 top, 3.10). In surface texture, the exact grayscale
information present in the images is displayed and for surface smooth, the grayscale
information is slightly blurred with a filter and displayed smoothly.
Fig. 3.9: Once a 3D rendering image is displayed on the screen the examiner can choose different
modes of rendering. Here we see images for the same fetus, presented in surface smooth, surface
texture, maximum and light mode.
Light mode: Dark and light are displayed predominantly here so that structures near
the projection line are displayed as light and those deeper are displayed as dark
(Fig. 3.9, bottom right). The light mode is almost never used, only occasionally with
inversion mode.
Gradient light mode: In this mode the surface is displayed as if illuminated by a light
source with a depth-effect (Fig. 3.10, top left). Structures, which are perpendicular to
insonation, are shown brighter than the other insonated regions. With gradient light,
the best results are achieved when there is adequate fluid around the structure.
HD-live mode: High-definition (HD)-live mode was introduced a few years ago to
improve the surface image and deliver a realistic skin-like image (Fig. 3.10d, 3.11). A
new transparency function was recently added to HD-live mode that highlights the
contours and is called “silhouette” function. Silhouette enables gradual transparency
display within the whole volume. Chapter 11 discusses the use of the silhouette func-
tion.
Fig. 3.10: Generally speaking, a mixture of two display modes is applied in a 3D image. The figure
shows a fetal face in “gradient light” (a) and “surface texture” (b) and a better result in c) in a mixture
of 70/30 %. The figure in d) is a result of a combination of High-definition (HD-) live surface and
smooth of 50/50. There is no perfect combination, since each user has his personal preference.
Fig. 3.11: These figures show the step-by-step manipulation of a fetal face volume using HD-Live.
The panel at left reveals that surface mode rendering with gradient light has been selected after 3D
acquisition. The middle figure presents the result after the switch to HD-live mode with 50/50 ratio
of “texture” and “smooth”. The final image (right) is the result after increasing HD-live to 100 %,
increasing shadowing and transparency and changing the position of light source.
3.4.2 Transparency mode rendering
While surface mode displays only the first layer, in the transparency mode different
details can be highlighted within the render box. Depending on the object of interest,
all signals included in the render box are analyzed and demonstrated accordingly.
Maximum mode is a transparency mode in which all hyperechoic information in the

render box is calculated and projected (Fig. 3.12, top left) (also refer to Chapter 8). This
render mode is used to visualize bones and is ideal in the examination of the fetal
skeletal system (see Chapter 17).
Minimum mode is a transparency mode in which all anechoic information in the

entire volume is calculated and projected (Fig. 3.12, top left) (also refer to Chapter 9).
This approach is ideal to visualize fluid-filled organs as well as the heart and large
vessels.
Inversion mode inverts (as the name implies) the echogenicity of volume compo-
nents and is thus the inversion of the information displayed with the minimum mode.
Signals from neighboring structures are suppressed (Fig. 3.12, bottom left) (see
Chapter 10).
Fig. 3.12: Demonstration of different organs and regions by using different transparent modes as

maximum mode, minimum mode, inversion mode and X-Ray contrast mode. Please refer to the text
and corresponding chapters regarding different modes.
X-Ray mode is a transparent contrast mode used for the visualization of hypoechoic
tissue and is calculated as a mixture of minimum and maximum transparency modes.
The ideal regions of interest for the use of this mode are the lungs, abdominal organs,
brain (Fig. 3.12), and other regions. The X-Ray mode is most often combined with a thin
slice such as that used in volume contrast imaging (VCI) (see Chapter 4).
Silhouette mode is as previously mentioned used to visualize the contours of internal

structures. This mode is combined with HD-live mode and gradual transparency can
be selected (see Chapter 11).
With increasing experience the examiner comes to realize that all of these modes
provide the best results when used in combination. A button can be used to adjust the
distribution between the two modes used. For the face of the fetus, for example, a
70 % gradient light and 30 % surface texture can be selected. Minimum and X-Ray
modes is another good combination. When using HD-live, the image becomes
smoother when HD-live smooth is increased (Fig. 3.11).
3.5 Special effects in 3D: dynamic depth 3D rendering and light source 39
In the different chapters, other combinations are discussed, such as color Doppler
with the glass-body mode, B-Flow with static 3D and STIC or the new HD-live with the
silhouette tool.
3.5 Special effects in 3D: dynamic depth 3D rendering

and light source
The 3D visualization on the screen, whether on the ultrasound system or on the com-
puter, is in the end a projection of a 3D image onto a 2D surface and does not need (as
used in consumer electronics today) stereoscopic glasses. For this reason, in recent
years additional image enhancements have been introduced for 3D imaging that aim
to highlight the spatial impression. Two functions in particular are of importance:
3D dynamic depth rendering: This software displays structures that are deep in the
volume visualized with colors blue, gray or black, and with the color switch between
sepia and blue a depth rendering can be appreciated. Often this is amniotic fluid that
appears nicely blue. The level of depth effect can, however, be adjusted. These colors
can then be shaded based on the depth of the regions examined: nearby areas are
shown lighter and deeper areas darker. Figure 3.13 presents an example without (a)
and with depth rendering in gray (b) and blue (c). In early pregnancy, the entire fetus
with the amniotic cavity can be easily visualized and highlighted very well with this
deep rendering (Fig. 3.14).
Fig. 3.13: The effect of depth can be improved by using the tool “dynamic depth rendering“, which
adds a color blue or black to the structures that are deep in the volume, making the amniotic fluid
blue in this case. The image to the left is the raw image and the images in the middle and to the
right and are the result after adding black and blue respectively. The level of color can be adjusted
according to the depth information in the image (see Fig. 3.14).
Fig. 3.14: The 3D effect by coloring the surrounding liquid (see previous figure), can be ideally
applied to early gestation where a fetus or an embryo are well surrounded by amniotic fluid.
Fig. 3.15: With the recent software the 3D effect can be improved by using a light source. Similar
to a torch the lighting can be placed in different positions with a shadow recognized behind the
structures. Ideally for a fetal face we prefer to place the light source in the upper part of the image
(see also Fig. 3.16).
3.6 Threshold, transparency, brightness and color scales 41
Fig. 3.16: The light source can be used for special effects in early gestation. It can be positioned in
the upper part of the image, from the side or even as shown in the lower right panel from behind.
The light source is seen on the screen to the lower right of the image.
Light source function: A few years ago, a new option was added to the modes already
discussed that enables the illumination of the 3D image with a light source. The 3D
image usually appears as if light is projected directly from the front onto the image.
The new software allows the user to move a light source around a sphere so as to illu-
minate the image from different perspectives, even from behind (Fig. 3.15, 3.16). This
effect is particularly impressive when used with HD-live with its skin-like tone (see
Figs. 3.11, 3.15) and this lighting effect provides good results, particularly in early ges-
tation (Fig. 3.16). The new multiple light source function is discussed at the end of the
chapter (see Fig. 3.8).
3.6 Threshold, transparency, brightness and color scales
The quality of a rendered 3D image depends mainly on the 2D image prior to volume
acquisition, as explained in Chapter 1. During 3D volume manipulation some tools can
be applied to improve the quality of the 3D image.
Threshold: The function “Threshold” or “Gray Threshold” defines the level of gray
scale used in the display of the 3D image calculation (Fig. 3.17). This knob can be used
mainly to eliminate weak artifacts and speckles to highlight structures with true
Fig. 3.17: Increasing the level of “threshold” and its impact on the 3D image. The magenta color
shadow appears only as long as the knob is used. There is no „ideal“ threshold level but the level
is selected according to the result seen on the screen.
Fig. 3.18: In 3D rendering modes different colors can be chosen from gray to different sepia colors as
well as the new skin-like HD-live. Most patients associate however the sepia color with the 3D color,
and is still the most popular 3D color.
signals. A very low threshold (< 20) may be needed to visualize fine structures such as
the amniotic membrane or the umbilical cord. A middle threshold (25–40) is used to
display a wide range of gray scale information such as in the fetal skin, while a high
threshold (>50) can be applied to highlight bones in maximum mode or other struc-
tures in the inversion mode. Sometimes, the umbilical cord can be faded out with an
increase in threshold.
Transparency and Gain: The level of transparency can be increased and the image
appears transparent in its depth. More gray scale information can also be obtained by
increasing the gain, but this results in more artifacts and less detail.
Brightness and contrast: This can be subsequently modified only to a modest degree
in most 3D systems and are used to enhance the image.
Color tints: Different color tints can be selected to color the 3D image, such as the
classical sepia, but also gray, blue, ice or different skin tones. This coloring is often
used to increase the 3D effect (Fig. 3.18). Most users have only a small number of colors
that they use regularly.
3.7 Magicut, the electronic scalpel
It is rare that the user manages to acquire a very good 3D image in a single attempt
without the need for further corrections. In most cases of static 3D volumes, the image
Fig. 3.19: The electronic scalpel is also known by the name “Magicut”. After a volume data set is
frozen, the volume can be rotated in all directions and undesired information can be removed.
On the left this structure (placenta or uterine wall) is obstructing the face and has to be removed
(arrows). After a vertical rotation (right) the interfering information can be clearly identified and
removed with Magicut (see next figure).
Fig. 3.20: Left: With Magicut the structure in front of the face is removed after rotating the volume.
The face then appears clearer on the right side, but there still are structures besides and behind the
head, which can be removed.
Fig. 3.21: Left: Adjacent to the head the disturbing structures (see Fig. 3.20) can also be removed
with Magicut. The image on the right is already very good but can still be improved as shown in
next figure.
is improved after some retouching and the use of some of the manipulation tools
described above. This is often needed to better visualize some regions, or simply for
aesthetic reasons. The electronic scalpel, also called Magicut, can be used after the
image is fixed. Different tools can be used here such as the deletion of the surrounding
structures. By rotating the volume, the structure to be deleted can be shown floating
freely and can simply be deleted without affecting the surrounding structures.
Figures 3.19 to 3.22 provide an example of the use of the Magicut tool to obtain the
optimal image.
One special function of Magicut is the depth or selective deletion, which allows
the user to selectively delete slice-by-slice a specific area without deleting the struc-
tures behind it. Of special interest is the use of Magicut in 3D volumes acquired with
color Doppler and displayed in glass-body mode. It is possible in such cases to sepa-
Fig. 3.22: The figure on the left is rotated and visualized from the top resulting in the figure in the
middle. The aim is now to remove the information in front and behind the face. The result is then
seen in the right panel with a face appearing like an artistic “bas-relief”. Figure 3.18 was manipu-
lated in a similar manner.
Fig. 3.23: Instead of using manually Magicut to remove structures in front of the face, the recent soft-
ware also makes it possible to automatically detect this information and to remove it. This feature
called “Sono-Render-Live” adjusts as demonstrated in the lower panel, the green line in a curved
shape (arrows) to fit to the region of interest. The sensitivity of this tool can also be adjusted.
rately erase either the structures on the grayscale image or those of color Doppler or
both. Please refer to Chapter 12 for more details.
A newly introduced function called “Sono-Render Live” (Fig. 3.23) makes auto-
matic modification of the shape of the green line during volume rendering possible.
Instead of the complicated deletion of some structures with Magicut, the software
identifies, as illustrated in Fig. 3.23, the free fluid between the face and the anterior
wall or placenta, and places the projection line (even curved) in this area so that the
face appears instantly. This tool is mainly important during a live 4D examination in
which the use of Magicut would be too time-consuming.
3.8 Multiple light sources and “HD-live studio”
The introduction of a new light source a few years ago (see Fig. 3.5) provided the new
possibility to improve the 3D effect in many rendering images, especially in combina-
tion with HD-live. In the most recent software release, an amelioration of this artistic
approach to 3D is facilitated by the possibility of using up to three light sources at the
same time, as in photography studios, and is therefore called “HD-live studio”
(Figs. 3.24–3.27). The examiner needs to have some understanding in using these
(a) (b)
(c) (d)
Fig. 3.24: The fetus at 12 weeks is displayed in 3D HD-live smooth with one light source. The exam-
ples in (b), (c) and (d) illustrate the same volume but applying the new HD-live studio with three light
sources and special light effects. The circles indicate the light sources used.
3.8 Multiple light sources and “HD-live studio” 47
Fig. 3.25: HD-live displayed with multiple light sources applied on an embryo at 8 weeks (left)
and the same fetus two weeks later at 10 weeks (right) of gestation.
Fig. 3.26: HD-live display with multiple light sources applied to a fetus at 11 weeks (left)
and the same fetus after removing the different neighboring structures with Magicut.
Fig. 3.27: The fetal face in 3D can be displayed very softly and artistically with the use of multiple
light spots as revealed in these examples.
sources, as the position of each light source, its distance to the object and its type, can
be changed separately. Preliminary examples of the use of these techniques are illus-
trated in Figs. 3.24 to 3.27.
3.9 Conclusions
The 3D rendering of a volume is far more complex than navigation in the different
planes and requires intensive familiarization with the 3D software and its different
manipulation tools. The use of the render box, the green line and the orientation are
the basics to be learned before further steps of volume manipulation are applied. The
ultrasound information included in the render box can be displayed in 3D, either in a
surface or in a transparent mode display (Fig. 3.28). The Magicut tool is used to clean
the image and highlight the structures of interest, while the light source can be used
to increase the spatial impression. The different render modes and other tools are
discussed in the next chapters of this section.
Volume rendering
Surface modes Transparency modes Volume calculation
– Surface smooth – Maximum mode – VOCAL

– Surface texture – Minimum mode – Sono AVC
– Gradient light – Inversion mode
– Light – X-ray mode
– HD-live surface – HD-live silhouette
– HD-live smooth – Glass body mode
Fig. 3.28: Overview of the different volume rendering modes either in surface mode or in the
different transparency modes with the different displays as illustrated in Figs. 3.9–3.12.
4 Volume Contrast Imaging (VCI)
4.1 Introduction
During certain 4D or static 3D examinations, it may be of great additional value to

obtain a thin 3D slice of the studied view instead of a single plane. The advantage of
this approach is an increase in the resolution and contrast and a decrease in the arti-
facts. This is the principle of Volume Contrast Imaging (VCI). VCI can be applied in
real-time mode (as in 4D) used as VCI-A and VCI-C or VCI-Omniview, by getting a slice
of the A-plane or the C-Plane or an Omniview plane respectively. In recent software the
term VCI-C was replaced by the term VCI-Omniview. In static 3D, the static VCI is
applied.
4.2 Principle of VCI
A single reconstructed 2D image out of a 3D volume includes true information as well

as artifacts called “noise” or “speckles”. With the activation of the VCI tool and the
choice of a thin slice, the artifacts are reduced and the quality of the image resolution
and the contrast are increased (Fig. 4.1 right).
The principle is simple and is illustrated in Figs. 4.2. and 4.3. In Fig. 4.2, high
amplitude peaks represent the true ultrasound information, while low amplitude
peaks represent speckles and artifacts. Comparing two successive planes of an image,
true information is found in the same spots with the same intensity on the images,
while artifacts differ in intensity and position. Superimposing successive images, the
required information from anatomic structures is enhanced whereas randomly gener-
Fig. 4.1: The left image of the embryo was reconstructed from a volume and reveals a low resolution
with speckle. In the right image VCI was activated with the result of less artifacts and an increased
resolution.
50 4 Volume Contrast Imaging (VCI)
Strong signals from

anatomical structures
Volume Contrast Imaging VCI
Weak signals from artifacts

(speckle, noise)
Fig. 4.2: Principles of Volume Contrast Imaging (VCI). The figure in VCI is reconstructed from several
adjacent images (here two are shown). Signals from true tissue information are high and present at
the same place in adjacent images, while signals from noise and speckles are weak and present at
different places. The sum of two adjacent images (VCI) increases the intensity from true signals and
information from noise and speckle is too low and almost eliminated.
Fig. 4.3: Series of schemes illustrating the VCI effect. In this fetal face from a 13 weeks fetus the true
information present in adjacent images is from nasal bone, maxilla, chin, and brain tissue. However,
artifacts are found in the different parts of the images, as illustrated with stars and circles. Adding
three images leads to an increase in the true information and an almost disappearance of the arti-
facts around (compare with clinical example in the following figures).
4.2 Principle of VCI 51
Fig. 4.4: Two images from a static 3D volume of a brain in tomography mode left panel as native
image. The right panel shows the image after activating VCI (here 1 mm) (arrow), which appears
clearer and with a better contrast.
Fig. 4.5: Omniview display of the midsagittal view of an embryo. In the upper panel, native recon-
struction of the plane of interest has a reduced resolution (upper right image), while in the lower
panel VCI tool was activated and provides better contrast and resolution of the reconstructed image
(lower right image).
Fig. 4.6: 3D volume with a coronal visualization of lung, heart, diaphragm and liver. The upper
images present a native image with tomography mode. The lower images show the result after
activating VCI and increasing contrast and details recognition.
ated noise and speckles in different slices are reduced or sometimes eliminated
(Figs. 4.2 and 4.3).
In Fig. 4.3 the principle is illustrated with a schematic diagram of a face where the
final image from a VCI slice of the face shows more resolution and contrast than each
of the single successive images.
An example is provided in Fig. 4.4. In this tomography mode two planes of the
intracranial structures are visualized. The images on the left are the original volume
images whereas the images on the right are the images after activating the VCI with
increasing the contrast. In this case the X-Ray contrast mode was activated.
Another example in early gestation can be observed in Fig. 4.5 and that of lung
and liver imaging is demonstrated in Fig. 4.6.
4.3 Static VCI 53
4.3 Static VCI
VCI can be applied to any multiplanar, tomographic or selected plane display (as in
Omniview) to enhance the image quality and contrast (see Chapters 2, 5 and 6 for
examples). The image appears as a plane but in reality it is a thin slice. The slice thick-
ness can be selected from 1 to 20 mm depending on the information to be displayed.
The rendering mode of the slice can be selected as in regular 3D rendering, as
surface, maximum, minimum or X-Ray modes.
X-Ray mode: This mode is ideally used for enhancement of tissue information and is
used in the imaging of brain, lungs, kidneys, nuchal translucency and others. In most
cases a thin slice 1–5 mm is selected (see examples in Figs. 4.4–4.8).
Maximum mode: is ideally used to demonstrate spine, extremities, long bones or skull
bones (Fig. 4.9). A good slice is selected between 5–20 mm thickness. Figure 4.10 shows
an intrauterine device with pregnancy demonstrated with VCI with maximum mode.
Minimum mode is good for use in anechoic structures and can be used in combina-
tion with X-Ray mode.
Inversion mode until recently was not available with VCI but is now available with
the electronic probe in 4D (Fig. 4.11)
Fig. 4.7: Left: fetus with a thickened nuchal translucency (arrow) as seen by a transabdominal
examination. The same case is shown on the right following a transvaginal examination with a 3D
volume acquisition and reconstruction of the sagittal view. Using VCI increases the image quality.
The severity of nuchal thickening (arrows) can be better appreciated and a precise measurement can
be performed.
Fig. 4.8: In this fetus lying in vertex presentation, the corpus callosum cannot be visualized. After an
axial 3D volume acquisition of the head and placing the reconstructed plane along the falx cerebri
and cavum septi pellucidi (CSP) in the left image, the corpus callosum (CC) can be reconstructed
(right). The image quality is improved by adding VCI with 2 mm thickness.
Fig. 4.9: Lateral acquisition of a 3D static volume of the fetal head with a VCI of 20 mm and maximum
mode display revealing the skull bones with the corresponding sutures.
4.3 Static VCI 55
Fig. 4.10: Pregnancy with an intrauterine device (IUD). On the left, the IUD can be seen horizontally
and its shape cannot be assessed in 2D ultrasound. On the right, the reconstruction of the IUD with
3D volume acquisition and the use of Omniview and VCI illustrate the shape of the IUD in a projected
mode.
Fig. 4.11: Acquisition at the level of the abdomen demonstrating the kidneys with the tomogra-
phy mode. The combination of a VCI-slice of 2 mm with minimum mode display highlights the
hypoechoic renal pelvis and reveals the presence of a mild pyelectasis.
Fig. 4.12: In this case, Omniview with

a VCI slice of 18 mm and surface mode
was used. For surface mode display
often it is better to use conventional
3D or 4D acquisition modes instead of
Omniview with VCI.
Fig. 4.13: A demonstration of the hard palate with a curved Omniview line and VCI. The display was
selected as a mixture of maximum and surface modes.
Surface mode is rarely used, since a thin slice is rarely needed to demonstrate a
surface. Instead a standard 3D or 4D is usually more useful since the 3D effect of
surface mode is enhanced when the volume is larger. Occasionally, surface mode is
combined with X-Ray and maximum modes (Fig. 4.13).
4.4 4D with VCI-Omniview
During a 4D examination, the examiner can also directly draw a straight or a curved
line along the region of interest to obtain a corresponding section or view. The result
4.4 4D with VCI-Omniview 57
Fig. 4.14: 4D with Omniview and VCI with direct demonstration of the vermis (short arrow) and
the corpus callosum (long arrow). The line is drawn during the 4D examination and the VCI slice
(here 2 mm) is activated.
Fig. 4.15: Lateral view of the fetal skull in 4D. A curved Omniview line was drawn lateral to the skull
and a slice of 12 mm thickness was selected. The maximum mode display then makes direct visual-
ization of skull bones with the coronary suture possible.
Fig. 4.16: Direct demonstration of spine and ribs with 4D ultrasound and curved line Omniview
and VCI of 14 mm thickness using a mechanical transducer.
can be improved by combining with VCI with an appropriate thickness. The 3D result
is directly displayed side-by-side of the 2D image. The authors have good experience
with this technique and use it in screening examinations. In a fetus with cephalic
presentation, the online reconstruction of the corpus callosum and vermis (Fig. 4.14)
can be directly achieved by selecting a straight line with a thin layer of 1–3 mm and the
X-Ray mode. Another possibility is the combination of VCI with maximum mode for
the demonstration of skull bones with sutures (Fig. 4.15) or spine with ribs (Fig. 4.16).
Figures 4.14 and 4.15 illustrate examples of the use of VCI with maximum mode.
4.5 4D with VCI-A
VCI of the A plane is a technique of scanning with a slice instead of only with 2D plane.
This technique can be utilized using a mechanical probe (Figs. 4.17, 4.18) but with low
frame rate and poor resolution. Resolution was improved with the advent of the elec-
tronic matrix transducer (see Chapter 1), which enables the examiner to make a rapid
image calculation (Figs. 4.19, 4.20). Slice thickness and rendering display can be
adjusted as needed. VCI-A can be used to examine the fetal lung, heart, kidneys, face,
brain and other organs. Figures 4.17–4.20 present images acquired with VCI-A. In our
experience, combining this technique with X-Ray mode can be used to improve con-
Fig. 4.17: Direct transabdominal visualization of the corpus callosum using VCI-A. The left image
presents the direct insonation in 2D and the right image is the live 4D display using a 5 mm slice in
VCI-A with increased contrast.
Fig. 4.18: Direct demonstration of a four-chamber plane in 2D (left) and after activation of VCI-A
(right). The right image shows a better contrast when using an 8 mm VCI-A slice. This image was
obtained with a mechanical 3D transducer and a low frame rate of 14 Hz. Better resolution can be
achieved with an electronic transducer, as illustrated in next images.
Fig. 4.19: Left: a fetus with occipital encephalocele in 2D with low contrast. The right image reveals
an improved image after activating the VCI-A with a 5mm slice. This was obtained with an electronic
transducer and an image frame rate of 23 Hz.
Fig. 4.20: Two cardiac anomalies demonstrated with VCI-A. The heart appears with a higher contrast
when using a slice of 3 mm (left) and 2 mm (right). The left image shows a hypoplastic left heart
syndrome with a small left ventricle (LV). The right image shows a normal looking four-chamber-view,
but behind the heart, the descending aorta (Ao) can be seen and to its right the dilated azygos vein
(AZ) in a fetus with an interruption of the inferior vena cava with azygos continuity. These images
were acquired with an electronic transducer and image frame rate of 47 Hz and 35 Hz resp.; right
ventricle (RV).
trast discrimination between adjacent regions as heart-thymus, cardiac myocardi-

um-lumen, corpus callosum-cortex or kidneys-bowel. The skeletal system can be well
highlighted during the live examination when combined with maximum mode. VCI-A
used on a matrix probe can also be combined with inversion mode, and this is further
discussed below in Chapter 10.
4.6 Conclusions
VCI is an interesting additional tool to use in 3D and 4D examinations, which makes

rapid use of a 3D slice possible instead of going through the many steps of volume
acquisition and rendering. Combined with Omniview, its potential use is increased,
especially when curved lines are applied.
5 Multiplanar display I – Orthogonal Mode
and Omniview Planes
5.1 Principle
An ultrasound examination is still based on the demonstration of standard 2D cross-sec-
tional images of the organ or region examined. Hence, most examiners attempt visualiz-
ing such “standard” planes during their examination and some examiners may still feel
unfamiliar with the successive images displayed in the tomographic or orthogonal mode.
The fetal profile, the four-chamber-view of the heart, the mid-sagittal view of the
corpus callosum or the longitudinal view of the spine are all standard planes to be
visualized during a routine examination. Some planes, however, cannot be, effort-
lessly, achieved during fetal ultrasound examinations.
The aim of this chapter is to demonstrate methods to obtain those typical
cross-sectional planes out of a volume data set and their clinical application.
The potential use of such a feature is still not fully explored, but in the future it
may constitute an integral part of the regular examination, at least once automation
and image pattern recognition is widely applied in ultrasound imaging. Another main
advantage of storing a volume data set is the ability to perform a virtual offline exam-
ination from the stored volumes. This feature, the so-called “virtual second opinion”,
can be carried out remotely with benefits that have been proven in several single and
multicenter studies
5.2 Multiplanar reconstruction and the different ways

of displaying cross-sectional images
The demonstration of single images from a digital volume data set can occur in differ-
ent ways. In the field of imaging, the general term used for such technique is multipla-
nar reconstruction, “MPR”. In 3D ultrasound the nomenclature used differ slightly
from one manufacturing company to another. In the system used by the authors the
term “multiplanar” is often used as a synonym for “orthogonal mode”. In this book we
will use “multiplanar reconstruction” or “multiplanar display” as a broader term and
discuss the different modalities separately:
Currently the following three modalities of multiplanar reconstruction in volume
ultrasound are available:
– Single or multiple images in multiplanar orthogonal mode
– Single or multiple images in tomographic mode
– Single image slices acquired by selective cutting within the volume using tools
like “Omniview”. With the latter it is possible not only to cut within the volume
using a straight line but also to adjust a curved line or to draw any multipoint line
and get an “anyplane”.
5.3 Practical approach in orthogonal mode 63
In any of the modalities used in order to improve the quality of reconstructed images
and reduce the speckles, the authors recommend applying the “Volume Contrast
Imaging” (VCI) function as discussed in Chapter 4, or to use the 3D-SRI speckle reduc-
tion filter, where available.
5.3 Practical approach in orthogonal mode
Before acquiring a volume the preset can be selected to display the result either in
orthogonal or in tomographic mode. Once the images are displayed the examiner
seeks first the most familiar image to start the manipulation on. In some situations it
is helpful to scroll through the volume or to navigate in the different planes by using
the intersection dot as explained in Chapter 2. Once the image, which is close to the
ideal plane, is reached the examiner then uses rotation (spinning) in the different
planes to align the structure of interest along one of the typical fetal axes (falx, spine,
aorta, etc.), which would facilitate orientation.
Figures 5.1–5.3 provide a step-by-step of how an ideal midsagittal view with the
nuchal translucency and the nasal bone is generated out of a transvaginal volume of
Fig. 5.1: Step-by-step reconstruction of a plane out of a volume data set. During a transvaginal
examination, it is often difficult to manipulate the transducer to obtain the ideal view of the struc-
ture of interest. In this case the examiner tried to obtain a view of the profile and decided to do it by
reconstruction. The acquisition of the fetal face is performed from the side, as close as possible to
the final plane of interest (see next images).
64 5 Multiplanar display I – Orthogonal Mode and Omniview Planes
Fig. 5.2: Taking the volume of Fig. 5.1 the VCI tool is activated to enhance contrast and the intersec-
tion dot is placed on a well identifiable structure as the falx cerebri (arrow). In the bottom the falx is
oblique in plane C. Therefore, the lower image is turned until the falx aligns with the X-axis and the
plane in B is aligned as well. The result is seen in Fig. 5.3.
the fetal face: Due to the limitations of transducer manipulation, the profile could not
be initially visualized and a volume was thus acquired. After activating the VCI the falx
cerebri was in a first step sought (B plane in Fig. 5.2) and was aligned along the Y-axis.
In the C plane, the falx is still oblique and will be aligned along the X-axis in the next
step (Fig. 5.3). In this plane, the profile is clearly visible and the visualization of the
single plane (Fig. 5.4.) now makes the measurement of the nasal bone and nuchal
translucency possible. Figures 5.5 and 5.6 reveal how the maxilla was visualized by
manipulating a volume in a first and second trimester fetus.
5.4 Practical approach in obtaining an “anyplane”

using Omniview tool
A good alternative is using the new Omniview tool. After few adjustments of the image
to identify parts of the structure of interest, the examiner can draw directly within the
volume a straight or a curved line and get simultaneously the reconstructed image.
Since the reconstructed “Omniview-image” appears simultaneously, an adjustment of
5.4 Practical approach in obtaining an “anyplane” using Omniview tool 65
Fig. 5.3: Continuing Fig. 5.2. Now the falx lies in the X-axis and the intersection dot is on the falx
cerebri and in the plane A the profile is well recognized. Fig. 5.4 reveals the final result.
Fig. 5.4: Result of a fetal profile reconstructed from the volume data set of an oblique view of the
fetal face (see Figs. 5.1–5.3). Now nasal bone and nuchal translucency are well seen and the nuchal
translucency is measured.
Fig. 5.5: Orientation in a transvaginally acquired 3D volume of a fetal face at 13 weeks’ to demon-

strate the maxilla. The intersection dot lies on the maxilla and is observable in all planes. The con-
trast of the image was increased by choosing a VCI slice of 1 mm in combination with X-Ray contrast
and maximum mode.
Fig. 5.6: Demonstration of the maxilla in second trimester in the orthogonal mode demonstrated
without VCI. The intersection dot and the planes are adjusted in a way to observe a sagittal view of
the maxilla in the plane A (upper left) with a perpendicular plane in the upper right panel. Plane C
confirms that the volume has a good orientation.
Fig. 5.7: Use of Omniview on a 3D volume of thorax and abdomen. The user can draw up to three
lines and in this case two lines generate axial planes across the heart (upper right panel) and at the
level of the urinary bladder (lower right panel). The third horizontal line is a frontal view of thorax,
lungs, diaphragm, stomach and bladder (Lower left panel). While planes 1 and 2 resulted from
straight lines, the line 3 was selected as curved line.
the placed line can be directly achieved. In the actual software up to three lines can
be drawn at the same time and are recognizable by different colors (Figs. 5.7, 5.8). After
a line is placed it can be moved in parallel or tilted. An Omniview line can be drawn
as a straight, curved or a free drawn line (Fig. 5.7). The resulting image can be used
either as projected line or, in a few cases, with a curved line, which can also be dis-
played as a stretched line. In order to improve image quality, it is recommended to
reduce speckles by using either the 3D-SRI filter or to combine it with VCI-mode. Inter-
estingly the use of Omniview-tool is not only limited to a static 3D volume but can be
used in a 4D or a STIC volume as well.
5.5 Typical applications of Omniview planes
Thorax and abdomen: Figure 5.7 reveals that Omniview can ideally be used in visu-
alizing thoracic and abdominal organs, where typical cross-sectional planes are doc-
umented. Figure 5.8 demonstrates a simple way to highlight the kidneys in a volume.
Fetal brain: Figures 5.9 to 5.11 provide examples of fetal neurosonography where
Omniview allowed a rapid reconstruction of the corpus callosum, vermis and a coronal
view of cavum septi pellucidi and other structures.
Fig. 5.8: Use of Omniview in the visualization of kidneys. The 3D volume was acquired in a fetal dor-
soanterior position and kidneys are found left and right to the spine. Two Omniview lines are drawn
parasagittal (1, yellow line, 2, magenta line) and one frontal (3, cyan line) highlighting the kidneys
from different perspectives.
Fig. 5.9: Omniview with VCI for the demonstration of the corpus callosum. The falx cerebri and cavum
septi pellucidi are used as landmarks.
Fig. 5.10: Omniview with VCI for the demonstration of vermis and brain stem.
Fig. 5.11: After a lateral static 3D acquisition of a fetal head, three Omniview lines are drawn to
demonstrate the corpus callosum (CC) in a sagittal plane, a coronal plane for the cavum septi pellu-
cidi (CSP) and another posterior coronal plane to visualize the cerebellum (CER).
Fetal skeleton: The fetal spine and skull bones can also be demonstrated quite well
by combining Omniview with VCI and maximum mode, as shown in Figs. 5.12 and 5.13.
Depending on the examined organ and fetal position, a decision can be made as to
whether a straight or curved line should be selected (Figs. 5.12, 5.13). The maxilla with
the hard and soft palate can often be visualized with the orthogonal mode (Figs. 5.5,
5.6) but in some occasions it is more reliable to use Omniview for a targeted visualiza-
tion either with a curved or a drawn line (Figs. 5.14, 5.15).
Fetal heart: Omniview can be used on the fetal heart either with STIC in gray scale or
in color Doppler. Standard views as the four-chamber-view and the three-vessel-tra-
chea view can be well and rapidly demonstrated using this tool (Fig. 5.16). A direct
view over the atrioventricular valves can demonstrate the en-face view and the valvu-
lar apparatus.
Early pregnancy: Early scan performed before 14 weeks’ gestation has a limited pos-
sibility of transducer manipulation. In such situations Omniview helps in getting
reconstructed planes of some typical regions of interest. Figure 5.17 provides an
example of the intracranial translucency. Interesting but not yet of any clinical value
is the free hand drawing of an Omniview line, as illustrated in the example of a
stretched embryo in Fig. 5.18.
Fig. 5.12: On a static 3D volume a curved Omniview line with a VCI slice of 12 mm and maximum
mode display demonstrates spine and ribs in this case.
Fig. 5.13: Skull bones can be clearly observed and identified after a lateral acquisition of a fetal head
and the use of Omniview, here as a curved line, with 19mm wide thickness and maximum mode.
Fig. 5.14: After a 3D volume acquisition of a face from below, the maxilla with hard palate can be
demonstrated by using a curved Omniview line, a VCI of 4 mm and in this case with maximum mode
(compare with Fig. 5.15).
Fig. 5.15: In this example a free-hand Omniview line was drawn along hard and soft palate and a VCI
slice of 4 mm was selected. The palate and the uvula region are visualized.
Fig. 5.16: Omniview can also be used on the fetal heart, in this case in combination with color
Doppler. In the orientation plane in the upper left panel, three lines were drawn and the result is
seen in the three panels, as a four-chamber-view (yellow), a three-vessel-trachea view (magenta)
and a frontal view of the cardiac valves (cyan).
Fig. 5.17: On a 3D volume of a fetal brain in early gestation the Omniview line enables the visualiza-
tion of the intracranial translucency (arrow).
Fig. 5.18: An interesting application of Omniview is the free-hand drawn line. On the example of an
embryo at 9 weeks’ gestation, the line can demonstrate a stretched and projected fetus with brain
and body.
5.6 Conclusions
Initially, navigation within a volume in the different planes needs a learning curve.
Scrolling and spinning within the volume enables understanding as to how to obtain
the plane of interest easily and to highlight the needed details. In our teaching expe-
rience, we observed that once the examiner gets used to the orientation within a
volume, he will then easily start using it during routine scans. Particularly, the use of
Omniview can be rapidly integrated into a live examination either on a 3D volume or
during 4D examination. In this book, many examples are provided on the use of dif-
ferent multiplanar or Omniview tools.
6 Multiplanar Display II: Tomographic Mode
6.1 Principle
Three-dimensional ultrasound is often associated with a spatial visualization of the

fetus rather than with serial parallel planes as shown in tomographic mode. In the last
years, however, increasing experience in 3D ultrasound has shown that one of the
main advantages of a digital volume data set, is the post-processing, which makes it
possible to obtain any 2D plane (see Chapter 5) or series of planes out of the volume
block, especially when the fetus is not easily accessible for a live scan. Storing such a
volume block further makes displaying parallel slices of an area similar to those with
CT and MR imaging possible. This functions to demonstrate the adjacent structures or
to show the extent of a lesion when present. Although an ultrasound examination is
still a dynamic online examination generating live planes and instantaneously assess-
ing them, we believe that in the future, tomographic ultrasound imaging will become
increasingly important, not only for documenting reports but also in the growing field
of ultrasound image automation. This chapter highlights different aspects of the tomo-
graphic mode display.
6.2 Practical approach
In Chapter 2, orthogonal mode was presented with the display of three planes and the
intersection point used for navigation within the volume.
One of the other important navigation tools is the “translation” within the volume
called scrolling (see Chapter 2). The user, interested in parallel scrolling, can alterna-
tively apply the tomographic mode. Tomographic ultrasound imaging (TUI) is a multi-
planar mode display of the volume as parallel planes similar to tomographic images
obtained from CT and MR workstations. After choosing the region of interest the exam-
iner controls the number of planes (slices) to display on the screen as well as the inter-
slice distance. The region of interest is set, then the tomographic mode is activated and
parallel slices are seen on the screen in addition to the reference image typically found
in the upper left corner. The adjustable interslice distance is displayed in the upper
corner orientation image. In tomographic mode, all the manipulation tools of the
orthogonal mode can be used, such as navigation with the intersection dot, rotation of
planes and scrolling within the volume. The user can apply these manipulation tools
only in the reference plane, which leads to immediate change in the other planes dis-
played. In order to improve image quality it is recommended to reduce speckles by
adding either the 3D-SRI filter or to activate the VCI-mode (see Chapter 4).
Figures 6.1–6.10 demonstrate the different possibilities of tomographic mode.
Figure 6.1 reveals the original volume displayed in orthogonal mode. With plane A
76 6 Multiplanar Display II: Tomographic Mode
Fig. 6.1: A 3D volume containing the fetal thorax and abdomen, here displayed in orthogonal mode,
is used as a basic volume to demonstrate tomography mode in next Figs. 6.2–6.10.
Fig. 6.2: In tomography mode display, the upper left image is the orientation plane. The number of
planes can be selected arbitrarily. A green asterisk marks the reference plane and two planes are in
front and two behind the reference plane in this case. The interslice distance can be changed accord-
ingly (see red square) and in this case 5.5 mm distance was selected.
Fig. 6.3: The same display as in Fig. 6.2, but plane B was activated. The orientation plane is in the
upper left panel, with the demonstration of parasagittal planes from left to right.
Fig. 6.4: The same display as in Fig. 6.1 and 6.2, but in this case, plane C is activated with the
demonstration of coronal planes from anterior to posterior.
Fig. 6.5: The same display as in Fig. 6.2, but here the number of displayed slices was changed from
3×2 to 3×3. The interslice distance is now 2.5 mm.
Fig. 6.6: The same display as in Fig. 6.5 but the number of images was changed to 4×4 images.
Fig. 6.7: The same display as in Fig. 6.5 but in this figure the interslice distance was augmented
to 7.5 mm. The figure in the middle remains unchanged, however the other 6 images change.
Fig. 6.8: In this example with 2×2 images the distance between the slices was increased to 9.5 mm.
Fig. 6.9: In this example with 2×1 images, the four-chamber view can be observed. The solid line shows
the plane of interest on the orientation plane and this approach can be used to scroll through the volume.
Fig. 6.10: Using the same presets as the previous figure, the section in the upper abdomen was
selected and now shows the stomach.
selected as reference plane and tomography activated, parallel images to this plane
are displayed (Fig. 6.2.). If the examiner chooses the B or C plane as a reference plane,
the result is then parallel planes of lateral or coronal views as illustrated in Figs. 6.3 or
6.4. Figure 6.5 shows a tomographic mode image with the typical labeling, the refer-
ence plane with an asterisk and the adjacent planes with the – or + sign and a number
which is the multiplication of the interslice distance. If the interslice distance is

changed as shown in Fig. 6.6, the reference plane remains but the other images
change. The number of slices displayed on the screen can be changed from 2 × 1, 2 × 2,
3 × 2, 3 × 3, 4 × 4 etc. as outlined in Figs. 6.5–6.10. Figures 6.9 and 6.10 show the scroll-
ing within a volume using tomographic mode and the planes can be slightly adjusted
by rotating selectively the X-, Y- or Z-axis.
6.3 Typical applications in tomographic mode
Tomography of the fetal head, face and brain: Tomographic mode can be ideally
used in the assessment of head, face, and brain. For fetal neurosonography either
transabdominal (Fig. 6.11, 6.12) or transvaginal (Figs. 6.13, 6.14) volume acquisition
can be applied. Tomography provides an overview wherein all intracerebral land-
marks can be visualized at one glance (also refer to Chapter 16). The example in
Fig. 6.11 illustrates an overview of the normal brain anatomy and Fig. 6.12 reveals a
fetus with ventriculomegaly. In the adjacent planes, one can recognize the normal
cerebellum and in another plane the dilated third ventricle. Therefore, in this over-
view, diagnoses such as Chiari II malformation, Dandy-Walker syndrome or holopros-
encephaly can be ruled out and the likely diagnosis is aqueduct stenosis. The cavum
septi pellucidi is clearly observed and identified in a coronal view in tomographic
mode, and Figs. 6.13 and 6.14 illustrate normal and abnormal findings.
Fig. 6.11: 3D volume of a fetal brain demonstrated in tomography mode. Almost all of the information
required is visualized at one glance in these axial planes.
Fig. 6.12: Fetus at 19 weeks’ gestation with ventriculomegaly demonstrated in tomography mode.

Following structures can be identified: the bilaterally dilated lateral ventricles, the falx cerebri, the
normal appearance of the cerebellum and the dilated 3rd ventricle (3.Ventr.). Most likely, the under-
lying reason could be attributed to an aqueductal stenosis and the visualized details practically rule
out diagnoses such as Chiari II malformation, Dandy Walker syndrome and holoprosencephaly.
Fig. 6.13: Transvaginal neurosonography in tomography mode with coronal planes. Typical structures
such as the corpus callosum (CC), the cavum septi pellucidi (CSP) and insula are clearly observed
and identified.
Fig. 6.14: Transvaginal neurosonography in two fetuses with abnormal findings. Left: ventricu-
lomegaly with dilatation of the anterior horns with cavum septi pellucidi. Right: Agenesis of septum
pellucidum with fusion of the anterior lateral ventricles.
Tomography of thoracic and abdominal organs: Tomography is ideal for an over-

view of thorax and abdomen especially for the clear delineation of structures as lungs,
diaphragm, heart and abdominal organs (Figs. 6.15–6.17). This allows for accurate
assessment of the extent of a lesion, such as in hydrothorax (Fig. 6.16) or in hypere-
chogenic lung (Fig. 6.17). The tomography of the renal system (Figs. 6.18–6.20) is rarely
typically used but can have a valuable application when an abnormality is identified.
Information from the different abdominal organs can be best displayed in tomography
of axial cross-sections showing the typical features such as liver, stomach, bowel,
bladder, abdominal wall and kidneys (Fig. 6.6). Tomographic mode is an ideal way of
documenting a lesion, particularly in the presence of fetal anomalies. Figures 6.21–
6.23 provide some examples, such as the double bubble sign in duodenal atresia, an
ileus in one fetus and the extent of ascites in another fetus. Such image documenta-
tion can be of great value for follow up examinations.
Tomography of the fetal heart: A complete cardiac examination has to be achieved

in different planes therefore tomographic mode can be considered as an ideal tool to
provide the complete picture (Figs. 6.24–6.26). Fetal heart tomography can be used
either with a grayscale (Fig. 6.24) or with a color-Doppler (Fig. 6.25) STIC volume or
rarely in 4D mode. Typical adjacent planes such as a four-chamber-view, a five-cham-
Fig. 6.15: In this case, the fetal thorax heart, lungs, liver and diaphragm are well recognized in
tomography mode.
Fig. 6.16: Mild pleural effusion as demonstrated in 2×1 tomography mode.

Fig. 6.17: This figure illustrates a left sided hyperechogenic lung. Tomography mode displays the local-
ization and the extent of the lesion, as well the difference in the echogenicity of the contralateral lung.
Fig. 6.18: This 3D volume acquisition reveals the lumbar region with both kidneys (arrows), here in
tomography mode in transverse planes.
Fig. 6.19: This 3D volume acquisition depicts the lumbar region with both kidneys (arrows), here in
tomography mode in sagittal and parasagittal planes.
Fig. 6.20: Fetus with multicystic renal dysplasia displayed in tomography mode. An overview of the
lesion can be better demonstrated with tomography mode.
Fig. 6.21: Transverse 3D volume acquisition of the upper abdomen in tomography mode in a fetus
with double bubble sign (*) and suspected duodenal atresia.
Fig. 6.22: Tomography mode of the abdomen in a fetus with ileus and bowel perforation.
The stomach (*) can be seen in the lower planes.
Fig. 6.23: Fetus with ascites and skin edema in cardiac failure. The extent of ascites can be assessed
and documented with tomography mode in comparison to single images. These findings are better
compared when using tomography mode, especially in follow up examinations.
ber-view and a three-vessel-trachea view can be well and rapidly demonstrated with
this tool. More on fetal heart tomography is discussed in the chapter on the fetal heart.
Tomography in early gestation: In early gestation, optimal information is best pro-

vided by combining transvaginal 3D ultrasound with tomographic mode (Figs. 6.27,
6.28). Due to the limitations of transvaginal probe manipulation, typical planes are
more easily reconstructed from a volume than directly visualized in 2D. The acquisi-
tion of a 3D volume and its display in multiplanar mode, especially in tomographic
mode, provides a good overview, particularly for regions such as the brain and face
(Figs. 6.27, 6.28) also for the thorax, abdomen (Fig. 6.29) and others.
6.4 Conclusions
Tomographic mode display provides an optimal overview of the region of interest. The
all-in-one view of an organ, along with its neighboring structures, makes an accurate
examination possible and is helpful when documenting a finding. The possibility of
visualizing this region in a range of 2 to 16 successive planes at a time provides a flex-
ibility to display the individual information needed. With more experience, typical
Fig. 6.24: Tomography mode of a STIC volume of the heart. The structures can be visualized from the
upper abdomen to the great vessels.
Fig. 6.25: Tomography mode of a STIC volume acquisition in color Doppler in the cardiac phase
between diastole and systole. The four-chamber-view can be recognized in diastole (lower middle
panel) and the systole is seen in the three-vessel-view; aorta (AO), left ventricle (LV), pulmonary
artery (PA), right ventricle (RV).
Fig. 6.26: Tomography mode of a STIC volume acquisition in color Doppler in a fetus with a right-
sided aortic arch. The four-chamber-view is seen in the lower right panel. In the upper middle panel,
the trachea can be identified (arrow) between aorta (Ao) and pulmonary artery (PA); left ventricle
(LV), right ventricle (RV).
Fig. 6.27: First Trimester screening with the view of the profile in tomography mode. Nasal bone
(yellow arrow), maxilla, mandible, both eyes (white arrows) and the posterior fossa with the intracra-
nial translucency (*) are viewable together in one display.
Fig. 6.28: Tomography mode of an axial view to the fetal brain at 12 weeks’ gestation with the brain
hemispheres, the large choroid plexus and the posterior fossa.
Fig. 6.29: Tomography mode of the body of a fetus at 13 weeks’ gestation with the demonstration
of diaphragm (yellow arrow), lungs, liver, stomach (*), kidneys (arrows) and the left-sided heart
position.
examination standards can be identified for the different body parts where volume
depth and interslice distance can be saved in specific presets. Fetal heart and brain
are ideal regions to be examined with this tool, and Chapters 16 and 20 present some
abnormal findings demonstrated in these planes, and Chapter 19 presents some
abnormal findings of fetal thoracic, gastrointestinal and renal organs.
7 Surface Mode Rendering and HD-Live
7.1 Principle
Surface mode is, in general, the most popular and most commonly used 3D and 4D
display mode. It is used to render an image of the surface of a structure, which is best
visualized when positioned in the interface between fluid and that structure. Within
the render box, the surface mode displays the most superficial layer nearest to the
green rendering line (see Chapter 2). It is used to easily demonstrate the face, anterior
or posterior surface of the body, the limbs or the complete fetus in early gestation. In
addition, structures within the fetal body can be displayed with surface mode as
cardiac chambers, intracerebral ventricular system, lungs and others. Surface mode
can be used in different volume acquisitions as 3D static, 4D, or STIC or in combina-
tion with live or static Omniview.
In order to acquire an adequate 3D or 4D volume, the examiner essentially aims for an

initial 2D image with a high contrast between adjacent structures, as between the
anechoic amniotic fluid and the echoic fetal skin. The presets of the 2D image were
discussed in Chapter 1. Figures 7.1.–7.3 demonstrate the impact of a prior optimal gray
scale “gain level” on the resulting acquisition. A dark amniotic fluid in 2D is a prereq-
uisite for a good surface mode image as shown in Figs. 7.1 and 7.3. The positioning of
the region of interest should allow, where possible, the insonation to be perpendicular
on, and not parallel to, the surface to be rendered (as explained in Figs. 7.4 and 7.5). In
Fig. 7.4, the arm is clearly observed and identified in 2D, however the 3D results are not
satisfactory. Only a perpendicular insonation of the arm, as shown in Fig. 7.5, results
in an adequate 3D image.
Ideally the object of interest should lie horizontally and parallel to the camera
(rendering) line (Fig. 7.6). During 3D static volume acquisition we also recommend
choosing a wide box to include a larger area than the only selected region of interest
(Fig. 7.7). This approach avoids missing fetal parts in the 3D rendered image as shown
in Figure 7.7. Particularly in early gestation where the complete fetus can be visualized,
a small volume box may result in a fetus with parts of arms and legs missing on the
final 3D image. This, more commonly, applies to static 3D, whereas with 4D, the exam-
iner can adjust the resulting image in live mode accordingly.
After volume acquisition, the examiner begins “rendering” by changing the size
of the box of the region of interest to include the organs to be displayed. The render
box is then fixed and one of the different surface mode functions is activated. The
quality of the display differs according to the presets of the ultrasound system and the
94 7 Surface Mode Rendering and HD-Live
Fig. 7.1: 3D volume of surface mode of a face. The preset of grayscale image is not optimized and
demonstrates a low contrast. The grayish appearing amniotic fluid results in an inadequate 3D
surface image. Additional changes should be made, as can be seen in Figs. 7.2 and 7.3.
Fig. 7.2: The same volume is shown in Fig. 7.1 but with post-processing increasing the gain and
threshold suppresses the gray amniotic fluid and the 3D image of the face can be seen. The image is
acceptable, but still appears too bright (see also Fig. 7.3).
Fig. 7.3: This is the same fetus as in Fig. 7.1, but in this case, the 2D image has been optimized prior
to volume acquisition. The amniotic fluid now exhibits a good contrast during acquisition and the
facial result in 3D surface mode is better than the example in Fig. 7.1.
Fig. 7.4: For a good 3D image, not only the contrast but also the insonation angle is important during
volume acquisition. In the panel to the left, the hand is clearly visible in 2D but for a 3D volume
acquisition the fingers are parallel to the ultrasound waves and are not well displayed on the 3D
surface image as seen in the middle panel. The right image is the result after rotating the volume.
Fig. 7.5: In comparison to Fig. 7.4 the insonation of hand and fingers (left panel) is now perpendicu-
lar and ideal for a 3D acquisition. The result is better than in Fig. 7.4.
Fig. 7.6: 3D volume acquisition of a face in surface mode with a good insonation. The approach is
from the side, with both forehead and face almost horizontal.
examiner can switch between the different surface rendering modes and their combi-
nations. The following modes are currently the most commonly used (also refer to
Chapter 3): Surface smooth, Surface texture, Gradient light, and the combination of
High-definition (HD-) live surface und HD-smooth. There are no “best” presets, since
a mixture of different modes can be also a matter of “optical taste” or preference.
Figures 7.8–7.10 illustrate some examples of common combinations used by the
different individuals. Initially, the reader can try applying the 40/60 mixture of surface
smooth and gradient light in this mode.
Reducing the gray threshold and augmenting the transparency can improve the
image. Magicut can be used (see Chapter 3) to remove structures in front of the region
of interest, provided the removed part casts no shadows on the background image.
Fig. 7.7: 3D volume acquisition with a small volume box (upper panel). The face is seen, however, a
part of the hand is missing due to the small volume box. Choosing a larger box (lower panel) in static
3D acquisition also makes it possible to include structures in the area of the region of interest. The
hands can now be seen in the lower panel.
Fig. 7.8: 3D surface mode of fetal faces displayed with different rendering tools.
Fig. 7.9: When visualizing a fetal face, additional neighboring structures can also be visualized. In
these examples, an arm and ear, a foot, an umbilical cord (short arrow) and even a true knot of the
umbilical cord (long arrow) are seen adjacent to the face.
Recently, we often have used the light source and changed its position to create a
depth impression and spatial effect. In combination with dynamic rendering, the
image can be improved by choosing the blue color, which lends the amniotic fluid a
new dimension (see Chapter 3). The image quality is tremendously improved by the
use of the skin-like presets called HD-live, especially when the image smoothness is
increased. For more information on 3D facial rendering, please refer to Chapter 18,
which is dedicated to the fetal face.
7.3 Typical applications of surface mode
Head and face: The most common use of surface mode is for visualizing the fetal face,
and this is separately discussed in Chapter 18. The face can be examined in 3D or 4D,
at different gestational ages, from different perspectives and displayed with different
colors (Figs. 7.8–7.10). In 4D, it is possible to appreciate various fetal facial expressions
and movements, including swallowing, yawning, opening of the eyes and many
others. In addition to the frontal view, a lateral view enables the visualization of the
fetal profile and ear, which can by far be better assessed this way than by using con-
Fig. 7.10: In surface mode, the fetal hands can be clearly seen, and their normal anatomy assessed
ventional 2D. In the first half of gestation, the fontanels and sutures of the fetal skull
are still large and can be easily seen with the surface mode by reducing the gain or
increasing the transparency. The approaches regarding the “how-to” when it comes to
displaying the face is discussed in Chapters 3 and 18. The post-processing manipula-
tion of a fetal face volume has also been explained above in Chapter 3.
Fetal limbs: Arms, legs, hands and feet can be visualized well from different angles
and with different resolutions using surface mode. In most situations hands are in
proximity of the face and are displayed with it (Figs. 7.9–7.11). An increase in the quality
of acquisition provides then a better demonstration of fingers and toes. Further
improvement of the image is achieved by adjusting the softness of the image and the
position of the light source (Figs. 7.12, 7.13). Anomalies, such as the absence of extrem-
ities, polydactyly, clubfeet and so on, can therefore be visualized well using the 3D
surface mode (Figs. 7.11–7.13).
Demonstration of body surface: The fetal dorsal and ventral surface with the umbil-
ical cord insertion can be easily visualized in early gestation. These can also be
demonstrated in more advanced gestational ages, provided there is enough amniotic
Fig. 7.11: Anomalies of the hands (arrows) displayed with surface mode: Polydactyly left, mit-
ten-hand in Apert syndrome (middle) and absent hand (right).
Fig. 7.12: The feet are easily visualized in surface mode, often side-by-side or sometimes crossed
Fig. 7.13: 3D Surface mode of feet anomalies such as clubfoot (left), absent foot (middle) and foot
edema (right) in a fetus with Turner’s syndrome.
fluid volume to facilitate a surface mode view. Fetal anomalies as gastroschisis,

omphalocele (Fig. 7.14), spina bifida (Fig. 7.15), sacrococcygeal teratoma (Fig. 7.16) and
other anomalies viewed on the surface can be clearly observed in surface mode. In
gastroschisis, the bowel loops can be visualized in detail in early and late gestation,
as will be demonstrated in Chapter 19. Identifying and displaying the gender can be
ideally achieved using surface mode. Related anomalies, such as hypospadia or rare
instances of hypertrophy of the clitoris, can be well delineated from normal external
genitalia (Chapter 19).
Overview of the complete fetus and fetuses of multiple gestations: Instead of

magnifying to limit the 3D view to the face, limbs or other fetal parts, the examiner can
also attempt to display the complete fetus. Ideally, a complete view of the fetus is
Fig. 7.14: 3D surface mode in two fetuses with omphalocele (arrow), left at 12 and right at 18 weeks’
gestation.
Fig. 7.15: 3D surface mode of the back of a normal fetus (left), a fetus with myelomeningocele
(middle) and a fetus with myeloschisis (right).
possible between 8 and 18 weeks’ gestation (Figs. 7.17–7.16). At later stages of gestation,

the fetus is generally too large to be completely visualized in one image.
In multiple gestations, surface mode is ideal for obtaining a complete overview of the
fetuses (Fig. 7.18). The amniotic membrane in monochorionic twins is often too thin to
demonstrate, but on the other hand can be easily differentiated from a thick separat-
ing chorion/amnion layer in dichorionic twins. The position and number of fetuses
can be visualized well using the surface mode.
Placenta, umbilical cord and amniotic membranes: The overview provided with
surface mode used to display the fetus can also demonstrate the surrounding struc-
tures such as the placenta, the umbilical cord at its insertion and course, amniotic
bands and various uterine anomalies.
Fig. 7.16: 3D surface mode of the complete fetus at 22 weeks’ gestation (left). By comparison, the
right panel illustrates a fetus with a sacrococcygeal teratoma.
Fig. 7.17: 3D surface mode in two fetuses at 13 weeks’ gestation showing the complete body.
Fig. 7.18: 3D surface mode in twin pregnancies.
Visualization within the body, such as the heart, brain and other organs: Surface
mode can be applied to internal body organs, especially the heart (Chapter 20), the
brain (Chapter 16) thorax and abdomen (Chapter 19). When applied to the heart, the
cardiac cavities can be well seen in the four-chamber-view. Cardiac phases, diastole
and systole, can be well identified in a STIC acquisition as well (Fig. 7.19). Other planes
can be well recognized if needed, such as the five-chamber-view or the three-vessels-
view and en-face views of the atrioventricular or semilunar valves.
In examining other organs, surface mode is rarely used in normal fetal examina-
tions. However, in some anomalies, surface mode can be utilized, especially when an
increased fluid interface is present as found in ascites (Fig. 7.20), duodenal atresia
with double bubble sign (Fig. 7.21 left), hydrothorax (Fig. 7.21 right), hydrocephaly
(Fig. 7.22), megacystis, cystic kidneys, hydronephrosis and others.
Fig. 7.19: STIC volume acquisition of a heart with a view into the ventricles in surface mode, in this
case, during systole with closed atrioventricular valves (arrows) and in diastole with opened valves.
Fig. 7.20: Ascites in 3D surface mode with view into the ascites on liver and bowel. Note the position
of the “green projection line” placed into the ascites.
(a) (b)
Fig. 7.21: Surface mode in two fetuses with malformations. Axial view at the level of the abdomen in
a fetus (a) with duodenal atresia and double bubble sign (*). Axial view at the level of the thorax in a
fetus (b) with pleural effusion (*). The left lung (LL) and the heart (H) are shifted to the right; right lung
(RL), left (L).
Fig. 7.22: Two fetuses with hydrocephaly after a transvaginal 3D acquisition with the demonstration
of the dilated lateral ventricles in surface mode. The right figure demonstrates how the ventricles
communicate across the midline and the choroid plexus (*) hangs across the midline to the opposite
site (arrow) in severe ventriculomegaly.
7.4 Conclusions
It is recommended that examiners acquire the surface mode manipulation skills, since
this is the most widely used application in 3D fetal imaging. The documentations of
normal body surface findings are becoming increasingly important to complete a 2D
assessment of a fetus. In abnormal findings, surface mode can rapidly provide an
overview of the anomaly encountered, thus making it more understandable for
patients and peers.
8 Maximum Mode Rendering
8.1 Principle
The maximum mode is mainly used for the spatial visualization of hyperechogenic
structures as the fetal bones. In this transparency mode all hyperechogenic structures
found within the render box are highlighted and displayed as a projection. In the
upper panel of Figure 8.1, we see the face of a fetus rendered with surface mode and
after activation of maximum mode (lower panel) the skin is not seen anymore and
only hyperechogenic signals from the facial bones are displayed. Another example is
provided in Fig. 8.2. In general, cranial bones, ribs and other curvilinear bones cannot
be properly observed in a single 2D plane, and one of the advantages of maximum
mode is the ability to demonstrate a projection of the bones.
(a)
(b)
Fig. 8.1: 3D volume of a face in surface mode (a) and after switching to maximum mode (b) with a
choice of a narrow volume box. In the lower image, one can recognize the individual facial bones
with the metopic suture (arrow), orbits, nasal bones, maxilla and mandible.
Fig. 8.2: Demonstration of an arm in surface mode (left) and in maximum mode (right). For maximum
mode effect, the size of the box was reduced to only include the arm, with the result that structures
behind the arm are not seen.
During volume acquisition, care should be taken to record a volume large enough to
include the complete region of interest. A better result is achieved if the 2D image gain
is reduced and the contrast increased during volume acquisition to allow bones to
appear “bright” and the surrounding tissue as “dark”. In early gestation, it often
appears difficult to display the bones in 3D due to their reduced ossification and in
third trimester the skin of the fetus has an increased echogenicity and often overlaps
the information from the bony structures. Therefore, in our experience, maximum
mode is best performed between 15 and 25 weeks’ gestation enabling clear bones visu-
alization.
An acquisition box large enough to include the region of interest is selected
(Fig. 8.3) once the preset of the 2D image is adjusted. In general, it is better to use a flat
box depth when only including the superficial bones with very little information from
the neighboring tissue or skin (Fig. 8.4 and 8.5). The resolution of the 3D volume
(“low”, “mid1” to “maximum”) depends on the duration of volume acquisition as
shown in Fig. 8.6. Maximum mode is not only used in 3D static and 4D volume acqui-
sition (Fig. 8.6), but also with VCI-Omniview (Figs. 8.7, 8.8) and a slice thickness of 15
to 20 mm is recommended in all these cases. Generally speaking, a “maximum mode”
of 100 % is selected, but occasionally a mixture of maximum with surface mode
(80/20 %) with an increased threshold can provide a better image.
An interesting tool is also the examination with VCI-A (see chapter 4) in combina-
tion with maximum mode: The 4D examination, ideally performed using a matrix
probe, enables the visualization of the bones of interest using a slice of 15–20 mm
thickness (Figs. 8.9–8.11).
108 8 Maximum Mode Rendering
Fig. 8.3: Volume acquisition of a spine with ribs prior to display with maximum mode, but here first
seen in the orthogonal display. Note that the image is rather dark with increased contrast in order to
better highlight the bones.
Fig. 8.4: In this example, the size of the volume box is still large (double arrow). In such a case, all
signals within the box are calculated while only the information from the bony structures is needed.
A better result can be achieved with a narrow box, as illustrated in the next figure.
Fig. 8.5: Conversely to Fig. 8.4 the volume box is now narrow (double arrow) to mainly include the
bony structures. The 3D image now has a better contrast and reveals more details.
Fig. 8.6: 3D acquisition of a spine in two different resolutions and maximum mode rendering. The
acquisition was achieved in the upper panel using a “mid1” quality, whereas and “max” was used in
the lower panel. From the results it is possible to recognize the different 3D image resolutions.
Fig. 8.7: Use of Volume Contrast Imaging (VCI) and Omniview tool as VCI-Omniview during a 4D
examination. During the 2D examination of the spine, the Omniview line is placed along the spine
with a slice thickness of 17 mm and the maximum mode selected (see next figure).
Fig. 8.8: VCI-Omniview, as explained in previous figure, here provided in different resolutions at

acquisition (arrows) during 4D examination. The image on the left had a resolution of “low”, the
middle image “mid” and right image had a “high” resolution.
Fig. 8.9: Volume Contrast Imaging (VCI) of the A-plane, as VCI-A-acquisition (arrow). Instead of
obtaining 2D images, the examination is performed in 4D with the live acquisition of a slice (here,
8 mm thickness). In this case, maximum mode is activated. A hand and fingers are displayed in
different 2D planes (left), but in a VCI-A slice, both can be displayed together in one slice (right).
Fig. 8.10: VCI-A (see explanation

in Fig. 8.9) of the spine and
scapula in a slice thickness of
12 mm in maximum mode.
Fig. 8.11: VCI-A of the spine in a

normal fetus in the upper and
in a fetus with a hemivertebra
(arrow) in the lower image.
8.3 Typical applications of maximum mode
In the following, some clinical aspects are briefly presented and abnormal cases are
demonstrated in Chapter 17 and 18 on the fetal skeleton and fetal face.
Visualization of spine and ribs: A dorsal view with a narrow 3D/4D box over the
spine is ideal, with VCI-Omniview as a straight or curved line or with VCI-A (Figs. 8.4–8.8
and Figs. 8.10–8.13). Figure 8.12 displays ribs with 13, 16 and 21 weeks’ gestation and
Figure 8.13 shows a dorsal and lateral view of the spine. In this view, spine shape and
symmetry of vertebral bodies are well seen, a view which is ideal in the demonstration
of spina bifida, hemivertebra, kyphoscoliosis, ribs number and others (Fig. 8.14). Also
refer to Chapter 17.
Fontal view of the face: An acquisition of a volume of the face from the front enables
the visualization of the bony face (Fig. 8.15) with frontal bones with metopic suture,
orbits with nasal bones, maxilla and mandible. Absent nasal bones (Fig. 8.16), abnor-
mal metopic suture, facial clefts, abnormal orbit size are the main fields of interest
(see Chapter 18).
Cranial bones and sutures: Maximum mode is ideal for visualizing the curved shape
of cranial bones with sutures and fontanelles (Fig. 8.17). This approach is also excel-
lent for the demonstration of wide sutures, abnormal ossifications as the prematurely
closed sutures in craniosynostosis.
Fig. 8.12: Fetal spine and ribs in a fetus at 13 (left), at 16 (middle) and at 21 weeks’ gestation (right).
Note the increased ossification of spine and ribs with advancing gestation.
Fig. 8.13: Spine with a view from

dorsal (left) and from lateral (right)
in maximum mode.
Fig. 8.14: Rib numbers and vertebral bodies: In the left image, one can count typically 12 rib pairs, in
the fetus in the middle there are 11 rib pairs and the right fetus displays evidence of a hemivertebra
(arrow) with a kinking of the spine.
Fig. 8.15: During a 4D examination, placing the VCI-Omniview line with a maximum mode rendering
directly on the face is possible. In this example, the slice thickness is 12 mm. The fetal face exhibits
details, as was illustrated earlier in Fig. 8.1.
Fig. 8.16: Fetus with absent ossification of nasal bone in 2D (left) and in 3D maximum mode from
lateral (middle) and from anterior (right).
Fig. 8.17: The cranial bones (left) can be visualized well with a lateral insonation and in maximum
mode display. Following bones are recognized: Frontal (F), parietal (P), sphenoid (S), Temporal (T)
and occipital bones (O) as well as the mandible (M). Right: in a 3D acquisition from the top with
maximum mode the big fontanelle (*) is well seen.
Fig. 8.18: This fetal arm lies horizontally on the 2D image (left). This is the ideal position to be exam-
ined in 3D/4D (right), in this case with VCI-Omniview with a slice thickness of 12 mm and maximum
mode.
Visualization of long bones and limbs: The long bones of arm and leg together with
hands and feet can be observed clearly using maximum mode (Fig. 8.18). The 3D ren-
dering is ideal when long bones lie horizontally with an almost perpendicular inson-
ation (Fig. 8.18). The proportion of bones, skeletal anomalies, clubfeet and abnormal-
ities in hands and feet are important questions of interest.
8.4 Conclusions
Maximum mode is the ideal 3D tool for demonstrating the different parts of the fetal
skeleton. The easiest way to learn is to start with a static 3D of the fetal spine and long
bones. Best results are achieved in a perpendicular insonation of horizontal lying
bones. A thin slice either in 3D static or in VCI-Omniview enables the selection of the
region of interest. Chapter 17 discusses some 3D skeletal anomalies in greater detail.
9 The Minimum Mode
9.1 Principle
In general, fluid-filled structures are easily recognizable on ultrasound due to their

echolucency and sharp borders to adjacent neighboring structures. The advantage of
the transparency minimum mode is the ability of rendering information within the
volume box by highlighting hypo- or anechoic structures. Other tools used for the
demonstration of echolucent organs are inversion mode (see Chapter 10) and silhou-
ette mode (Chapter 11).
Before volume acquisition, care should be taken in preparing the 2D image by optimiz-
ing the contrast in a way that fluid is seen as “black” in color without artifacts and
speckles (Fig. 9.1). Ideally, the acquisition is achieved from a perspective with the
lowest shadowing from bones as possible, since shadows will act on the rendered
image in the same manner as fluid. For a volume to be rendered with a minimum
mode, the examiner should select a flat volume box to primarily include solely the
organs of interest, with only very little information from additional neighboring tissue
(Figs. 9.1–9.3). Within the box, the presence of amniotic fluid should be avoided, as it
casts a large black shadow (Fig. 9.1). In other words the anterior and posterior line of
the volume box should be placed in the tissue and not in the amniotic fluid (Fig. 9.2).
Fig. 9.1: The render box has been placed over the fetal abdomen and the minimum mode activated.
The box is deep and includes amniotic fluid, and therefore the image appears almost black in
minimum mode, while no structures are identifiable (see next Fig. 9.2).
118 9 The Minimum Mode
Fig. 9.2: The Fig. 9.1 render box is now less deep and less amniotic fluid is present in the volume
box. Thorax and abdomen contours can be better recognized (see further Fig. 9.3).
Fig. 9.3: The render box is now flat and minimum mode can reveal the hypoechoic organs such as
the heart (H), stomach (*), gallbladder (GB) and bladder (BL).
A good result is often achieved with a “minimum mode” combined with “X-Ray mode”
(80/20 % mix). However, the “threshold” should be increased and in some occasions
post-processing change of contrast and gain may improve the image result. A rotation
along the vertical Y-axis often provides a better 3D effect in the region of interest
(Figs. 9.4 and 9.5).
Fig. 9.4: Thorax and abdomen in minimum mode in anterio-posterior (left) and lateral projection
(right). In both views, typical structures are demonstrated, such as the stomach, gallbladder, heart
position and umbilical vein.
Fig. 9.5: Heart, lungs and diaphragm are projected in minimum mode in anterio-posterior and in
lateral projection
9.3 Typical applications of minimum mode
Typical structures that are displayed with minimum mode in the normal fetus are the
echolucent organs as bladder, stomach, gallbladder, umbilical vein and portal venous
system in the abdomen (Figs. 9.1–9.3), in thorax the heart with the great vessels
(Figs. 9.4, 9.5) and in the head the intracerebral ventricular system. Since some fetal
anomalies are often associated with increased fluid accumulation, these can be clearly
demonstrated, not only in minimum mode (Figs. 9.6–9.15), but also with inversion or
silhouette modes (see Chapter 10 and 11).
Fig. 9.6: In comparison to the fetus in

Fig. 9.4 (left), this fetus has a partial
situs inversus and the 3D minimum
mode display illustrates the stomach
(*) on the right side (R) and the heart on
the left (L).
Intraabdominal organs with vasculature: One of the typical approaches easily used
in combination with minimum mode is the frontal acquisition of abdomen and thorax
(Figs. 9.4, 9.5). The 3D view is then either from frontal or lateral with the projection of
situs with stomach, heart, diaphragm but also umbilical vein with gallbladder, infe-
rior vena cava and descending aorta. In this view, situs inversus or ambiguus can be
well recognized (Fig. 9.6). In a lateral view, it is easy to differentiate an abnormal
course of the umbilical vein in agenesis or atypical course of the ductus venosus from
a normal finding (Fig. 9.7). The absence of the stomach filling or better a dilated
stomach as observed in double bubble sign (Fig. 9.8) can be well-documented using
Fig. 9.7: Abnormal course of Ductus venosus (arrow) with color Doppler (left) and in projection in
minimum mode (right); umbilical vein (UV), aorta (AO), inferior vena cava (IVC).
Fig. 9.8: Stomach in duodenal atresia with double bubble sign, as illustrated in 2D (left), in 3D
minimum mode in coronal (middle) and lateral projection (right).
Fig. 9.9: Bilateral pyelectasis in axial view in 2D (left) and in Fig. 9.10: Severe hydro-
minimum mode in coronal projection (right). nephrosis with megaureter
and vesico-ureteral reflux dis-
played in minimum mode.
minimum mode. Other abnormal conditions in the abdomen with increased fluid are
the presence of megacystis, hydronephrosis with or without a dilated ureter (Figs. 9.9,
9.10), multicystic renal dysplasia (Fig. 9.11) and others. Ascites is better displayed
using surface mode, as illustrated in Chapter 19.
Thorax with heart and great vessels: A frontal acquisition of the thoracic cavity
using minimum mode reveals the heart shape with the crossing of the vessels, as well
as the both slightly echogenic lungs and the dark border of the diaphragm (Fig. 9.5). A
lateral view makes the demonstration of the crossing of the great vessels with the
Fig. 9.11: Multicystic renal dysplasia with many cysts of different size in 2D (left) and in minimum
mode (right).
Fig. 9.12: A fetus with unilateral pleural effusion in minimum mode. Left) the anterio-posterior
projection with the heart (H) shifted to the right (R), and stomach (*) on the left (L). The image on the
right shows the projection from a lateral view.
aortic arch possible (Figs. 9.4, 9.5). Abnormal findings such as lungs cysts, hydrotho-
rax (Fig. 9.12), and stomach position in diaphragmatic hernia (Fig. 9.13) and others can
be clearly observed and identified with this rendering mode. Heart defects, however,
are more difficult to demonstrate, unless the size or course of the great vessels is
affected (Fig. 9.14). For this purpose, we generally prefer to use inversion mode.
Fig. 9.13: Left: A fetus with a left-sided congenital diaphragmatic hernia with the stomach (*) left
(L) in thorax and the heart (H) shifted to the right (R) in 2D. Right: anterio-posterior projection in
minimum mode revealing the position of the stomach in the thoracic cavity at the same level as the
heart and to its left. Compare with a normal finding in Fig. 9.4 to the left.
Fig. 9.14: 3D lateral projection in

minimum mode of a fetal heart in
complete transposition of the great
arteries with the parallel course of
aorta (AO) and pulmonary artery
(PA) arising from the right (RV)
and left ventricle (LV) respec-
tively. Stomach (*) is seen in the
abdomen.
Intracerebral ventricular system: The fluid-filled ventricular system can also be

well demonstrated with minimum mode (Fig. 9.15). However, bone shadowing is a
main limitation of this application in the 2nd and 3rd trimester, and we therefore rec-
ommend the volume acquisition ideally be performed through the fontanelle.
Minimum mode can ideally be applied in abnormalities with increased fluid accumu-
lation as found in ventriculomegaly, hydrocephaly, holoprosencephaly, absent septum
pellucidum and others. An interesting application is the demonstration of the cerebral
Fig. 9.15: Projection with Omniview of the intracerebral ventricular system at 9 weeks’ gestation. In
minimum mode both lateral ventricles (*) can be well identified as well as the developing third (3v)
and fourth (4v) ventricles.
ventricles in early gestation (Fig 9.15), even before 10 weeks’ gestation. At this stage,
skull bones are only slightly ossified and the ventricles adequately filled with fluid. A
combination of minimum and X-Ray mode is good for obtaining an appropriate con-
trast image as shown in Figure 9.15. This approach has been replaced in recent years
by silhouette mode (see Chapter 11).
9.4 Conclusions
Minimum mode can be used as a projection highlighting the anechoic structures

across a volume, similar to an X-Ray examination in radiology. Transparent structures
and their neighboring organs can be clearly observed and identified and abnormally
increased fluid in the fetal body can be well displayed. Diagnoses as hydronephrosis,
hydrothorax, double bubble, cystic lesions and hydrocephaly can be visualized using
minimum mode. Interestingly, hyperechoic lesions as seen in hyperechogenic lungs
or kidneys can be well highlighted in comparison to neighboring tissues as well. The
two prerequisites for a good result are, on the one hand, avoiding bone shadowing
during acquisition and on the other, using a narrow display box mainly avoiding the
presence of amniotic fluid. In recent years, however, minimum mode has been less
used as a single render mode and other transparent modes have gained in preference.
10 The Inversion Mode
10.1 Introduction
In Chapter 9 we explained the principle and clinical use of minimum mode display.
Inversion mode rendering, on the other hand, starts from the minimum mode render-
ing and merely inverts the color of the information (similar to negative/positive film),
thus presenting the hypoechoic structures as echogenic solid structures. It blackens
most of the surrounding tissue information. The image is similar to a 3D digital cast of
the structures of interest and the spatial depth is better appreciated in comparison to
minimum mode. As opposed to minimum mode, Magicut (see Chapter 3) can be
applied on an inversion mode volume to remove artifacts around the region of interest.
Similar to minimum mode acquisition, the volume should ideally be acquired with as
less shadow as possible, since shadow will be displayed on inversion mode as echo-
genic information. Before volume acquisition, the image contrast should be increased
to have a clear black-gray discrimination and a better border recognition. The volume
depth for inversion mode should include the complete region to be demonstrated.
After a volume is acquired and the inversion mode selected, the image turns to
black with some information displayed in inversion mode (Fig. 10.1). The size of the
box has to be adapted to include the region of interest and then the „threshold“ level
has to be increased (level 70 or more) until the result of the inversion appears on the
screen (Fig. 10.2). In some systems the preset of inversion is the color „light“, but the
authors prefer to use “gradient light” or HD-live, which can be well combined with a
surface mode. Magicut can be used to remove additional neighboring artifacts (see
Chapter 3, Fig. 10.3) and the “gain” and “threshold” buttons can be used to improve
the image. Figures 10.1 to 10.3 illustrate an example of step-by-step image display.
Inversion mode can be applied to 3D and 4D volumes. Recently, with the advent
of the electronic matrix probe, inversion mode has also become available for use in
combination with the VCI-A live scanning mode (see Chapter 4) (Fig. 10.4). In this
mode, a slice thickness between 1 and 20 mm can be selected and displayed in inver-
sion mode. All anechoic spaces such as the heart, great vessels, stomach and others
can be displayed in a live scanning mode. A good example can be seen in Fig. 10.4; the
method is discussed briefly in Chapter 20.
126 10 The Inversion Mode
Step 1: Activate inversion mode and select gradient light
Fig. 10.1: Main steps for a 3D rendering with inversion mode as demonstrated on a STIC volume of
a heart. The render box is placed over the heart, the inversion mode activated and gradient light is
selected (continued in Fig. 10.2)
Step 2: Increase the gray threshold
Fig. 10.2: In a second step, the threshold level is increased, for example from 30 to 60 (arrow), and
gain level is adapted until the targeted anatomic details are visualized (continued in Fig. 10.3).
Step 3: Remove artifacts with Magicut
Fig. 10.3: In a third step, artifacts from ribs shadowing and other interfering structures are erased
with the Magicut electronic scalpel and the image is finalized by adjusting threshold and gain.
Fig. 10.4: 4D examination of thorax and abdomen in a longitudinal view with VCI-A in combination
with inversion mode with the electronic transducer. Choosing an 8 mm thickness layer the examiner
can see at the same time the aorta (Ao), the inferior vena cava (IVC), the umbilical vein (UV) and the
heart in a projection highlighted with the inversion mode rendering.
10.3 Typical applications of inversion mode
There are many similarities between the use of minimum and inversion mode and we
recommend referring to Chapter 9 for the organs or regions of interest.
Thorax und Abdomen: In inversion mode, the anechoic structures can be visualized
in the thorax and abdomen under normal and abnormal conditions. Typical struc-
tures are the stomach (Fig. 10.5), bladder, gallbladder (Fig. 10.6) and different vessels
in thorax and abdomen (Figs. 10.4, 10.7).
Intracerebral ventricular system: Fluid filled ventricular system can be demon-

strated with inversion mode especially in the early embryonic period (Fig. 10.8). One
of the main limitations of inversion mode is the lack of the demonstration of the sur-
rounding structures. However, inversion mode has been used clinically to study the
embryology of brain development, especially the ventricular system between 8 and 13
weeks of gestation (Fig. 10.8) and differentiated from conditions as holoprosenceph-
aly. Later in gestation inversion mode can be used in conditions with increased fluid
accumulation, as in ventriculomegaly, which is best demonstrated after transvaginal
volume acquisition (Figs. 10.9, 10.10).
Urogenital system: Abnormal findings of kidneys when associated with fluid accumu-
lation can be clearly demonstrated and identified with inversion mode. Typically con-
Fig. 10.5: Stomach of a normal fetus in minimum mode (Left) and in inversion mode (middle image).
By comparison, the image to the right reveals a stomach with the double bubble sign that typical of
duodenal atresia. The gallbladder (arrow) is also displayed.
Fig. 10.6: Axial view of the abdomen with gallbladder in minimum mode (left) and inversion mode
(right).
Fig. 10.7: Left: 3D volume acquisition of an axial cross-section of the fetal abdomen at the level of
stomach (*) and liver at 33 weeks’ gestation with the umbilical vein (UV) and hepatic vessels. Middle:
The display in inversion mode enables the demonstration of stomach (*), hepatic veins (HV) and
umbilical vein (UV) with the portal system. Right: In this case, the stomach and hepatic veins were
digitally removed and the umbilical vein can thus be recognized with its connection to the portal sinus
(PS).
Fig. 10.8: The intracerebral ventricular system of a 9 week-old embryo as displayed in minimum mode
(left) and in inversion mode (right); lateral ventricle (LV), rhombencephalon (Rb), third ventricle (3V).
Fig. 10.9: Ventriculomegaly in a fetus at 30 weeks’ gestation after transvaginal 3D volume acquisi-

tion and inversion mode rendering. The ventricular system is presented along with other neighbor-
ing information that is mainly the result of shadowing (upper left). After the removal of artifacts with
Magicut, only both lateral ventricles (LV) are displayed with the cavum septi pellucidi (CSP) between,
as seen from a lateral view (upper right) and from a cranial view (lower panel).
Fig. 10.10: Ventricular system of a fetus at 20 weeks with agenesis of the septum pellucidum after
a transvaginal 3D volume acquisition. Left: In 2D, both anterior horns (*) of lateral ventricles are
communicating due to the absence of the laminae of the septum pellucidum. Right: After inversion
mode rendering and manipulation with Magicut, the ventricles communicating along the midline are
clearly observable from a cranial view. Compare with the lower image in Fig. 10.9.
ditions examined are multicystic renal dysplasia (Fig. 10.11), hydronephrosis (Fig. 10.12,

10.13), megacystis and others. Some examples are presented in Figs. 10.10 to 10.13.
Heart and great vessels: One of the main fields of inversion mode is the heart and its
neighboring vessels, where the spatial orientation can be clearly demonstrated
(see Figs. 10.1–10.3). Inversion mode can be used in both static 3D and in STIC
(Figs. 10.14) or in combination with VCI-A in normal and abnormal cases (Figs. 10.3,
10.4, 10.14–10.16). A good contrast volume can be displayed from the front to show the
atria, ventricles and the crossing of the great vessels. Inversion mode can be displayed
in surface smooth, gradient light or HD-live mode.
Fig. 10.11: Multicystic renal dysplasia in 2D (left) and in inversion mode (right). The individual cysts are
clearly observable in 2D but are spatially better demonstrated in 3D inversion mode with HD-live color.
Fig. 10.12: Hydronephrosis in a fetus with vesico-ureteral reflux in 2D (left) and in inversion mode
(right). Dilated pelvis (*), the calyces and ureter (U) are well recognized.
Fig. 10.13: Hydronephrosis in a fetus with vesico-ureteral reflux displayed in minimum mode (left) and
in inversion mode (right) with the spatial visualization of the dilated ureter (U), pelvis (*) and calyces.
Fig. 10.14: STIC acquisition of two hearts as revealed by inversion mode rendering. Left: Normal heart
with the right (RV) and left (LV) ventricle and the normal crossing of aorta (AO) and pulmonary artery (PA).
In the fetus on the right, there is a transposition of the great arteries with parallel course of AO and PA.
Fig. 10.15: 4D acquisition in a cross section of the mediastinum at the level of great vessels with
VCI-A in inversion mode (electronic matrix transducer). In this projection, the crossing of the great
arteries is well recognized; aorta (AO), pulmonary artery (PA).
Fig. 10.16: 4D acquisition in an oblique cross-section of the mediastinum at the level of great vessels
with VCI-A in combination with inversion mode (electronic matrix transducer). With this projection
the parallel course of the great vessels in this fetus with transposition of the great arteries is well
recognized; aorta (Ao), left ventricle (LV), pulmonary artery (PA), right ventricle (RV).
10.4 Conclusions
Fluid in the fetal body with a good discrimination to its neighboring tissue and not in
the shadow of bones is the ideal region to be displayed with the inversion mode. The
image is similar to a digital cast and can be improved by changing the direction of
light. A prerequisite for a good image is an optimized contrast 2D image before acqui-
sition and a good balance when using the threshold and the gain buttons. Often, a
Magicut is needed to remove additional artifact information.
11 The Silhouette Tool
11.1 Principle
When rendering structures within a 3D render box, the examiner can generally choose
between surface and transparent modes or a mixture of both. New software intro-
duced in 2014 enables (see Chapter 7) the demonstration of contours of the structures
present in the volume (Fig. 11.1). This tool is called silhouette, and in the actual soft-
ware can only be used in combination with the HD-live rendering mode. The intensity
of silhouette contour can be increased gradually (currently from 0–100). For this
purpose, transparency and gain functions are used in the optimization of the image
results. This chapter shares the authors’ first experiences when using this application.
We believe that the potential of this new method has not been yet fully exploited.
11.2 Practical application
A prerequisite for using the silhouette tool is the activation of HD-live mode. The result
essentially depends on the size and the amount of the information within the render
box. The examiner can select the intensity of the silhouette level, depending on the
structures to be demonstrated. Silhouette images range from the mild smoothing of a
Fig. 11.1: Transvaginal 3D volume acquisition of a fetus at 12 weeks’ gestation displayed with HD-live
and silhouette effect. The placenta anterior to the fetus has only been partly removed with Magicut,
but the silhouette effect enables creating a partly transparent effect with the placenta.
The silhouette is level 50 of transparency.
134 11 The Silhouette Tool
Fig. 11.2: Profile of a fetus with HD-live and different silhouette levels. The image to the left displays
the profile without the silhouette effect (0) and then increasing the level of silhouette transparency
from 25, to 50 and 70. Note the increasing transparency and smoothing of the image in addition to
the wax-like and glossy effect.
Fig. 11.3: Embryo at 8 weeks’ gestation without silhouette effect (left), then with smooth silhouette
effect (level 40), where the contours are well seen (middle) and then an almost transparent embryo
when silhouette is high (level 80) (right). In the right embryo, the intracerebral ventricles have
started to become visible.
surface mode image providing contours that appear wax-like (Level 0–10) (Fig. 11.2) to
the sole display of contours with almost complete transparency of the surrounding
structures (Level 60–100) (Fig. 11.3). The silhouette tool is actually the most powerful
tool to effectively highlight the contours of anechoic structures within a render box. In
early pregnancy, the fetus or embryo can be visualized completely with the silhouette
tool (Fig. 11.1, 11.3, 11.4). Fluid accumulations in the body such as a thickened nuchal
translucency (Fig. 11.5) or cystic structures or other anomalies can be highlighted very
well using this function.
A silhouette image can be easily manipulated with the Magicut electronic scalpel.
This can be applied in two ways. In one approach, the image is first optimized in the
11.2 Practical application 135
Fig. 11.4: Fetus at 12 weeks’ gestation with silhouette effect and different light source positions.
Left image with light source from cranial and right image with light source from posterior.
Fig. 11.5: Fetus with thickened nuchal translucency at 11 weeks’ gestation. In the left image in
surface rendering mode, a thickened region of the neck is slightly evident (arrow). In the right image
and using silhouette, increased nuchal fluid can be visualized well (arrow).
HD-live function (e.g., a fetus in first trimester or a face in the second trimester), and
then unneeded information is removed using Magicut. In the next step the silhouette
tool is used to emphasize the contours making the structures anterior to the region of
interest more transparent (Figs. 11.3, 11.5). In another approach, the silhouette func-
tion is activated in a first step on the raw volume data set (e.g. in early pregnancy)
(Fig. 11.6) and the transparency level is increased until only contours are visible
(Fig. 11.6b). At this point, Magicut can be used to easily remove the unneeded struc-
tures that can be well differentiated from their neighboring tissue (Fig. 11.6c). In a next
step, silhouette is reduced to optimize the image (Fig. 11.6d). The example in Figure 11.6
illustrates this step-by-step approach.
(a)
(b)
(c)
(d)
11.3 Typical applications of the silhouette tool 137
One of the important steps that significantly improve the silhouette image is the
change of the light source position (Fig. 11.6d) (see Chapter 3). In the right lower corner
of the image, the light source position is displayed. The user can lighten the volume
from the side, from above or for thin volumes even from behind resulting in different
light effects.
11.3 Typical applications of the silhouette tool
In our first experiences, we did achieve good results when applying it to some condi-
tions, which are presented below. We therefore encourage to the user explore new
applications using the silhouette tool.
Early pregnancy: Ranging from the visualization of the 5 mm embryo up to the fetus
at 14 weeks’ gestation, the silhouette can be applied during the complete first trimes-
ter to provide surprisingly impressive images (Figs. 11.1, 11.3–11.8). A prerequisite,
however, is an excellent 3D volume quality, which usually is achieved with a transvag-
inal transducer. Ideally, the volume size is selected as large as possible, which in turn
allows for a better visualization of the embryo/fetus and its surrounding area. The
amniotic cavity can be easily visualized with this tool, thus contributing to a good
differentiation of a multiple pregnancy. The intracranial structures can also be visual-
ized well in this time interval.
Body contours: Body contours are softened with the silhouette tool. In the first,
second or third trimester, the silhouette provides a soft “veil” on the surface of the face
(Fig. 11.2, 11.9) For this purpose, the silhouette tool can be highly useful in abnormal
conditions where the skin contour is involved, such as in myelomeningocele
(Fig. 11.10), omphalocele, gastroschisis, cleft lip and palate (Fig. 11.11) or in thickened
nuchal translucency (Fig. 11.5). Bony structures such as the spine and ribs can also be
imaged as contours with the silhouette after increasing the threshold (see Fig. 11.12).
◂ Fig. 11.6: Step-by-step use of silhouette tool with Magicut in early gestation in a 12 week-old
fetus. (a) After a transvaginal acquisition of a large volume box HD-live is activated. In figure (b) the
silhouette level is increased to the maximum (level 100) until the fetal and surrounding contours
are seen. (c) The volume is rotated and by using Magicut, the structures to be removed are better to
identify and can be erased subsequently. (d) The volume is rotated as in the first step and silhouette
is reduced (to level 20) and the light source adjusted.
Fig. 11.7: A fetus at 13 weeks’ gestation with conventional surface mode (left) and after HD-live render
mode activation with a low silhouette level (Level 15). The fetus appears slightly transparent (ribs),
but neither the intracranial ventricles nor information within or behind the fetus are displayed.
Fig. 11.8: A fetus with triploidy with narrow chest and head-abdomen discrepancy. Body contours
and some intracerebral details are seen with silhouette effect.
Fig. 11.9: A fetal face in HD-live surface rendering on the left and in the right panel after adding mild
silhouette effect leading to a wax-like skin.
(a) (b)
Fig. 11.10: Two fetuses in early gestation with anomalies. (a) Fetus at 11 weeks’ gestation with an
intrahepatic cyst (arrow), which is visible with the transparency effect of silhouette; (b) Fetus with
myelomeningocele (arrow), which can be well distinguished from the neighboring structures, such
as the umbilical cord.
Fig. 11.11: Two fetuses at 22 weeks’ gestation with facial clefts displayed with HD-live and silhouette.
Fetus with cleft lip (left) and with cleft lip and palate (right). Adapting the position of the light source
the finding can be better highlighted.
Fetal heart: The silhouette can also be applied to a STIC heart volume. This enables a
good demonstration of the contours of the myocardium, valves and papillary muscles
(Fig. 11.13a). Anomalies of the cardiac chambers and great vessels can be highlighted.
Figure 11.13b displays a fetus with intracardiac rhabdomyoma, where the tumors are
well differentiated from the adjacent structures. Silhouette can also be combined with
HD-live color Doppler flow (see Glass-body mode in Chapter 12), where the grayscale
information is well smoothed in the image and recently also the color Doppler infor-
mation.
Intracerebral ventricular system and other hypoechoic structures in the body:

The silhouette is an ideal tool for displaying the hypoechoic structures and can be
used in the visualization of the intracerebral ventricular system (Fig. 11.14). Silhouette

is ideal for spatial visualization of the ventricular system of the embryo, at a time
where ossification of the cranial bones has not yet occurred. Figures 11.15 and 11.16
illustrate such conditions. Later in pregnancy, the interventricular system can be
clearly demonstrated and identified by scanning through the fontanels and condi-
tions as ventriculomegaly (Fig. 11.17), or holoprosencephaly can be visualized well.
Other anechoic spaces in the body such as the normal or abnormal stomach, the mul-
Fig. 11.12: Spine and ribs of a fetus at 13 and at 22 weeks’ gestation with HD-live, high threshold and
silhouette.
(a) (b)
Fig. 11.13: (a) Four-chamber view of a normal heart at 22 weeks’ gestation with the use of silhouette.
In comparison the right fetus (b) has heart tumors as rhabdomyoma (arrows).
ticystic (Fig. 11.10a) or severely dilated kidneys and other accumulations of fluid can
be regions of interest to be visualized with this tool. The regions of interest are similar
to those discussed in Chapters 9 and 10 covering the use of minimum and inversion
mode.
Fig. 11.14: Fetus with agenesis of septum pellucidum (left) with the lateral display of the corpus
callosum and on the right in a coronal view with the typical image of the fused anterior ventricles in
the midline with the absence of a separating septum pellucidum.
Fig. 11.15: Embryo at 8 weeks’ gestation with HD-live and silhouette effect. The transparency enables
to recognize the intracranial ventricles (see next figure).
Fet. 11.16: Embryo at 8 weeks’ gestation with high level of silhouette effect, with a view from lateral
(left) and then a view from ventral (right). Note the clear display of the ventricular walls.
Fig. 11.17: Two fetuses with ventriculomegaly at 14 (left) and at 17 weeks’ gestation (right). The view
is across the fontanelle and the silhouette effect is activated. Note that the dilated ventricles with
large plexus choroidei are recognized with the silhouette effect.
11.4 Conclusions
The recently introduced silhouette tool displays images with an almost artistic effect,
yet with increasing experience, the clinical benefit becomes readily apparent. The
application of silhouette in early gestation provides a rapid overview of the position
and shape of the embryo and fetus. Surface regions can certainly be displayed
smoothly with this tool, but its real power mainly lies in the visualization of anechoic
structures within the render box. As opposed to inversion mode, the surrounding
structures are visible when using silhouette. One of the promising applications is the
ability to provide a visualization of the embryo’s ventricular system in early preg-
nancy. As the tool becomes more commonly used, further applications of this new will
become apparent.
12 The Glass-Body Mode and HD-Live Flow
12.1 Principle
It is well known that color Doppler sonography in the fetus is not only used to examine
the heart, but also in the assessment of different organs in normal fetuses and in
fetuses with malformations. The examined vessels generally have a spatial course and
the 3D reconstruction can demonstrate the course and branching of the vessels. There
are different methods of 3D rendering of the vessels, such as inversion or minimum
mode, where only the lumen is visualized with 3D. Smaller vessels can be made visible
only by the demonstration of blood flow, by using color Doppler, power Doppler or
high-definition flow. In this chapter, the term color Doppler is used for all three
Doppler tools. 3D visualization as static 3D, 4D or STIC in combination with color
Doppler can be displayed with the tool named 3D glass-body mode. This mode can
visualize blood flow either separately in 3D or together with the surrounding struc-
tures as glass-body mode (Figs. 12.1, 12.2).
Fig. 12.1: Volume acquisition of the thoraco-abdominal vessels with STIC or static 3D in combination
with color Doppler. In 3D rendering mode, the user can choose between different displays, either
only grayscale (upper left), only color Doppler information (upper right) or a mixture of both as glass-
body mode (lower panel); hepatic vein (HV), umbilical vein (UV), inferior vena cava (IVC), aorta (AO).
144 12 The Glass-Body Mode and HD-Live Flow
Fig. 12.2: 3D glass-body mode with different levels of transparency: in the image optimization the
user can choose the level of mix between grayscale and color Doppler information separately. In the
left panel an example of a placenta and in the right panel an example of thoracoabdominal vessels.
In the upper images the mix grayscale to color is 100/0 %. The images in the middle are the result
of a 50/50 % mix. The best effect is achieved with a 10/90 % mix with the color Doppler information
selected as surface mode.
Prior to volume acquisition, the user should optimize the color presets to improve the
visualization of the blood flow in the heart or in the vessels of interest. For a volume
acquisition in static 3D, both frame rate and persistence should be kept at high level.
The more images displayed per second in 2D, the more images with color information
can be then acquired in a 3D volume. If the persistence is low and high pulsations are
present, then many images are stored in the volume without color information. The 3D
reconstruction of the vessel then reveals interruptions in its course. An exception is
STIC volumes, wherein pulsations are needed.
Prior to volume acquisition, it is recommended that a sweep be performed with
the transducer to check whether all vessels can be easily visualized and are potentially
present in the volume to be acquired. The volume is then acquired at a middle resolu-
tion, using either static 3D or STIC. An examination with live 4D in combination with
Fig. 12.3: 3D glass-body mode with a manipulation with Magicut. Different Magicut functions can be
selected either that both grayscale and color-Doppler information are erased (middle) or only gray
scale or only color Doppler.
color Doppler is also possible, but actually exhibits limitations due to the lower reso-
lution.
After the volume has been acquired, the user can select the render mode display
either in B-mode alone, in color Doppler alone, or in a combination of the two as glass-
body mode (Fig. 12.1). For a better result in glass-body mode, the degree of transpar-
ency should be adapted as shown in following the steps as outlined in Figure 12.2.
Magicut can also be used to selectively remove grayscale structures anterior to or
around the region of interest in order to highlight the color Doppler information
(Figs. 12.3 to 12.8). It is important to emphasize that Magicut offers additional func-
tions in glass-body mode, including the possibility of deleting either the grayscale or
color Doppler information separately, or both, together (Fig. 12.3). The best way to
proceed is to acquire an umbilical cord in the 3D glass-body mode and to try the dif-
ferent tools. In Figs. 12.3 to 12.10, examples of umbilical cords are illustrated in which
the Magicut was used to edit and selectively delete information. Artifacts due to small
signals from the vessels can also be selectively removed.
Fig. 12.4: Placenta with the umbilical cord insertion in 3D glass-body mode (left) and after Magicut
manipulation (right).
Fig. 12.5: 3D glass-body mode of the umbilical cord insertion on the placenta in an anterior placenta
(upper images), a posterior placenta (lower left) and as velamentous insertion in placenta bipartita
(lower right).
Fig. 12.6: Upper left: An umbilical cord coil as seen in grayscale. Upper right: the perfusion is
demonstrated with high-definition flow. Lower left: a static 3D volume is acquired and the lower
right image illustrates the result after volume manipulation with Magicut.
Fig. 12.7: 3D glass-body mode in three different umbilical cords with different courses.
Fig. 12.8: In color Doppler, a true or a false knot in the umbilical cord is suspected (left). In 3D glass-
body mode (right), the true knot is recognized due to the spatial display.
Fig. 12.9: Left: Color Doppler in the lower uterine segment indicates (arrows) free vessels along the
internal cervical os, as vasa praevia. In the right figure, in 3D glass-body mode one can recognize the
umbilical cord insertion as a velamentous insertion with the course of the vessels along the cervix.
Fig. 12.10: Fetus with a single umbilical artery and fivefold umbilical cord around the neck in HD-flow
(left) and in 3D glass-body mode and HD-live-flow display (right).
12.3 Glass-body mode with HD-live flow function
New software has been recently released that uses the light source, which was already
discussed in Chapter 2, now in combination with glass-body mode. This software,
called HD-live flow, enhances the spatial and depth effect of the vessel course. Figure
12.11 presents two fetuses with the conventional 3D glass-body mode and in compari-
son using HD-live flow. Many of the figures in this chapter were displayed with this
new tool.
12.4 Typical applications in the glass-body mode
Visualization of the umbilical and placental vessels: The visualization of the pla-
cental and umbilical vessels is generally easy to achieve (Figs. 12.1–12.10) due to
absence of fetal movements. They are the ideal vessels to be examined when learning
the technique. From a clinical point of view, the origin and course of the umbilical
cord can be assessed to visualize typical conditions, which include velamentous inser-
tion (Fig. 12.5), vasa previa (Fig. 12.9), umbilical cord knot (Fig. 12.8), nuchal cord
(Fig. 12.10) and others.
Visualization of the liver and abdominal vessels: Either in a longitudinal

(Figs. 12.11–12.13) or in an axial cross-section (Fig. 12.14) of the abdomen, the intrahe-
patic veins, inferior vena cava and descending aorta can be well demonstrated. From
a clinical point of view, this approach can be used in suspected agenesis or abnormal
course of the ductus venosus (Fig. 12.12) as well as in interrupted inferior vena cava
with azygos continuation (Fig. 12.13) and in other rare atypical courses of vessels. In
anomalies affecting the ductus venosus, the examiner should focus on the visualiza-
tion of the portal system, which can be visualized well using 3D color Doppler in a
cranial-caudal acquisition (Fig. 12.14).
Visualization of heart and great vessels: The largest experience with glass-body
mode is available from 3D fetal echocardiography (Fig. 12.15, 12.16) (see also
Chapter 20). The visualization of the cardiac chambers with a septal defect or a hypo-
Fig. 12.11: Longitudinal view of the abdominal vessels with the drainage of the ductus venosus (DV)
together with inferior vena cava (IVC) and hepatic vein (HV) at the subdiaphragmatic vestibulum level,
left in the conventional glass-body mode and on the right the same view in another fetus displayed
with HD-live flow and light source (in the bottom of the image); aorta (AO), umbilical vein (UV).
Fig. 12.12: 3D glass-body mode with HD-live flow display in a fetus (left) without ductus venosus with
the connection of the umbilical vein (UV) directly into the inferior vena cava (IVC). In the fetus on the
right, the connection of the ductus venosus is in an atypical ectatic vein with a course to the left side
of the IVC; aorta (AO), hepatic veins (HV). Compare with the normal finding in Fig. 12.11.
Fig. 12.13: 2D color Doppler (left), 3D glass-body mode (middle) and HD-live flow display (right) in a
fetus with interruption of the inferior vena cava and azygos vein continuation. Two vessels aorta (AO)
and azygos vein have a side-by-side course with different directions of blood flow.
Fig. 12.14: Abdomen axial cross-section view in color Doppler from a cranial view on the intrahepatic
vessels. In (a) demonstrated in the conventional 3D glass-body mode and in (b) with the new HD-live
flow display. In (a) the spatial course of many vessels is visualized but the image in (b) reveals a
better effect of depth with a good discrimination of the vessels of interest. Scrolling plane by plane
(b), (c) and (d) reveals the hepatic veins (HV) and the different parts of the portal system; Ductus (DV)
venosus, umbilical vein (UV), portal vein (PV), inferior vena cava (IVC), aorta (AO).
plastic ventricle is rarely the anomaly of interest in glass-body mode, but rather anom-
alies involving the great vessels (Fig. 12.15, 12.16). Difference in size, in blood flow
direction, spatial arrangement or course of the vessels are some of the information
that can be demonstrated by using the 3D glass-body mode. Typical anomalies provid-
ing a good 3D images include transposition of the great arteries (Fig. 12.16b), right or
double aortic arch, hypoplastic left heart syndrome, aortic coarctation and can be well
differentiated from a normal finding. The best view is generally achieved with a cranial
to caudal view from the perspective of the mediastinum or from the upper left side.
Visualization of the intracerebral vessels: Intracerebral arteries and veins can be

visualized using glass-body mode, ideally from a sagittal section where in addition to
the pericallosal artery the internal cerebral veins with the straight sinus and the supe-
rior sagittal sinus can be demonstrated (Fig. 12.17). Clinical conditions such as the
abnormal course of the anterior cerebral artery in complete or partial agenesis of the
corpus callosum, abnormal vasculature in vein of Galen aneurysmal malformation or
other disorders can be visualized well with this technique (see Chapter 16). The intra-
Fig. 12.15: STIC with color Doppler and glass-body mode rendering of a heart. In the background the
ventricles are identified while the crossing of the great vessels appears in the foreground. Compare
the difference with figure 12.16 with the HD-live flow display; aorta (AO), left ventricle (LV), pulmo-
nary artery (PA), right ventricle (RV).
(a) (b)
Fig. 12.16: STIC volume of a heart in glass-body mode and HD-live flow display in a normal fetus (a)
and (b) in a fetus with a d-transposition of the great arteries (curved arrows), aorta (AO), left ventri-
cle (LV), pulmonary artery (PA), right ventricle (RV).
cranial venous anatomy in 3D is a new field of research, either examining the relation-
ship between venous development and cortical maturation or focusing on the course
of the veins in different brain anomalies, but in these cases best images are demon-
strated by using the transvaginal approach. Figure 12.18 demonstrates the 3D render-
ing of the circulus of Willis in 3D glass-body mode.
Fig. 12.17: Intracranial arteries and veins in 3D glass-body mode (left) and HD-live flow display
(right). The view is a sagittal view on the anterior cerebral artery, the pericallosal artery, the internal
cerebral vein (ICV) and superior sagittal sinus (SSS).
Fig. 12.18: Circulus of Willis in 3D glass-body mode.
12.5 HD-live flow using the color silhouette tool
In the most recent software release 2016/2017, a new application of silhouette was
introduced and can be applied in the color Doppler 3D when displayed in HD-live flow.
This can be used for color Doppler, High-definition flow and power Doppler (Fig. 12.19–
12.23). With the actual HD-live flow a glossy surface of the flow is displayed and gives
(a) (b) (c)
Fig. 12.19: Umbilical cord insertion on the placenta displayed with the three different 3D glass-body
mode tools. In (a) the usual glass-body mode, in (b) in combination with HD-live flow and in (c)
displayed in the newest combination of silhouette tool with glass-body-mode. Note in (c) that the
vessels become almost transparent and the borders of the vessels are clearly seen as a silhouette.
(a) (b)
(c) (d)
Fig. 12.20: Two examples of an umbilical cord displayed in HD-live flow, left panels (a), (c) and after
the use of the new silhouette tool for color Doppler, right panels (b), (d). Note the transparency of
the vessels with this new mode
(a) (b)
Fig. 12.21: A sagittal view on heart and abdominal vessels (as in Fig. 12.11) in a fetus displayed with
3D-HD-Flow (a) and power Doppler glass-body mode (b) both with in combination with silhouette effect;
aorta (Ao), ductus venosus (DV), inferior vena cava (IVC), umbilical artery (UA), umbilical vein (UV).
a spatial effect of the visualized vessels (Fig. 12.20a,c). In the new software of color
Doppler silhouette, blood flow becomes more transparent and the border of the
vessels and blood flow are displayed (Fig. 12.20b,d). This color silhouette of flow
enables to see the shape of flow even behind the vessels, as illustrated in the few
examples in Figs. 12.19–19.23. The clinical use needs to be studied further.
(a) (b)
Fig. 12.22: STIC volumes of two normal hearts at 13 (a) and 22 (b) weeks’ gestation in glass-body
mode and HD-live flow display in combination with the new silhouette tool for color Doppler. Note
the transparency of the vessels in this new display.
(a) (b)
Fig. 12.23: (a) Color Doppler and HD Flow with silhouette display in a fetus with interrupted inferior
vena cava showing aorta (Ao) and azygos vein (Azyg.) side by side (compare with Fig. 12.13). (b) The
same display in a fetus with an aberrant right subclavian artery (ARSA). PA, pulmonary artery.
12.6 Conclusions
Glass-body mode is generally used to visualize blood flow in the heart and in the
vessels by combining color Doppler and 3D. The vessels can be viewed alone or
together with the neighboring structures displayed in grayscale. Not only the heart,
but also other regions with a well-developed vasculature as liver, brain, lung or pla-
centa are good areas for application of glass-body mode. The fetal cardiac examina-
tion with a view from the mediastinum provides a spatial demonstration of the heart
with the crossing of the great vessels. The combination with HD-live flow enables a
significantly better spatial visualization of the blood vessels and has currently become
an important adjunct to glass-body mode display.
13 The B-Flow Mode
13.1 Principle
B-flow technology is a special technique that enables visualization of blood flow

from the grayscale image without the use of Doppler signals. This technique makes
the direct visualization of blood cell reflectors in grayscale mode possible and the
information is displayed together with the 2D information but mainly flow events are
visualized, while any other specific information from neighboring structures is not
clearly visible. On the screen, the blood flow then appears in a contrast-rich color
against the surrounding information (Fig. 13.1). Both the grayscale as well as the
B-flow image have the same principle of visualization, so the image frame rate
remains unchanged. Blood flow as event can be visualized, but unlike Doppler no
information on flow direction, speed, or turbulences is available with the B-flow.
Since the information is angle-independent, it can be used for vessels with a hori-
zontal course (Fig. 13.1). B-flow is very sensitive and tiny vessels can be visualized
side-by-side to the large ones. Therefore the B-flow image compared with color
Doppler not only has a significantly higher frame rate, but also displays a better
spatial resolution. B-flow can be used in both static 3D (Fig. 13.2) as well as STIC
volume acquisition (Figs. 13.3, 13.4).
Fig. 13.1: Longitudinal view of thorax and abdomen in B-flow demonstrating the heart (H), aorta (AO)
and abdominal vessels with umbilical vein (UV) and ductus venosus (DV). Neighboring structures
cannot be visualized in B-flow mode.
13.1 Principle 157
Fig. 13.2: Static 3D rendering with B-flow of heart, aorta (AO) and abdominal vessels as inferior vena
cava (IVC), ductus venosus (DV) and umbilical vein (UV).
Fig. 13.3: STIC volume with B-Flow after a STIC acquisition in gray mode (left) and in gradient light
display (right).
Fig. 13.4: STIC Volume with B-flow displayed with

HD-live; aorta (AO), ductus venosus (DV), inferior
vena cava (IVC), umbilical vein (UV), umbilical
artery (UA).
158 13 The B-Flow Mode
Prior to volume acquisition, the examiner should adjust the preset of the grayscale
image and the B-flow. In our experience, the key features to be optimized are the
sensitivity and persistence of B-flow. A high sensitivity and moderate persistence is
suitable for visualizing pulsations on the heart. By contrast, a high persistence and
lower sensitivity is needed for small vessels and veins to prevent image overlapping.
Prior to volume acquisition, a sweep can be performed to check whether the region
of interest includes all vessels of interest. The volume is then acquired using either
static 3D or STIC mode. After volume acquisition, the examiner can check whether
all vessels of interest are included in the volume box and do not exhibit motion arti-
facts. Often images with B-flow are not informative enough and the user is encour-
aged to switch to the rendering mode and visualize the result in the 3D render mode.
In our experience, increasing the gain and choosing the 3D surface mode for the
display in gradient light provides a good image of the vessels of interest. Artifacts
due to signals from tiny vessels or movements can be selectively removed with the
Magicut electronic scalpel.
13.3 Typical applications of the B-Flow mode
Only few examiners have focused on the use of B-flow in combination with 3D or STIC.
These have mainly focused on the heart and the great vessels as well as tiny vessels
such as the pulmonary veins or the fetal vessels in early gestation.
Visualization of intrahepatic and abdominal vessels: The longitudinal acquisition

of a volume provides a good approach to demonstrate the aorta, inferior vena cava
umbilical vein with Ductus venosus and the intrahepatic vessels (Figs. 13.2–13.6). In
our opinion, this is the best plane to acquire experience with this technique.
Visualization of heart and great vessels: The heart and the great vessels are best
acquired using STIC. Lateral, ventral or cranial acquisition provides the good results,
for example, in demonstrating course and crossing of the great vessels. Figures 13.7
and 13.8 present examples of the application on the heart.
Other areas: Other areas with good perfusion are also suitable, including the pla-
centa, umbilical cord, intracranial vessels, as illustrated in Figs. 13.9 and 13.10.
13.3 Typical applications of the B-Flow mode 159
Fig. 13.5: Abnormal dilated umbilical vein (UV) in grayscale (left) and in static 3D-B-Flow rendering
(right).
Fig. 13.6: Static 3D rendering after

B-Flow demonstration of the aortic arch
(AO) and inferior vena cava (IVC).
Fig. 13.7: Right aortic arch (RAO) with left ductus arteriosus (DA) and U-Sign visualized with STIC
B-Flow and 3D rendering with gradient light (left) and HD-live (right); descending aorta (AOD),
pulmonary artery (PA).
160 13 The B-Flow Mode
Fig. 13.8: Double aortic arch in B-Flow and 3D rendering. One recognizes the right (RAO) and left
aortic arch (LAO), the ductus arteriosus (DA) and the pulmonary artery (PA) with the left branch (LPA).
All three vessels merge into the descending aorta (AO), pulmonary artery (PA). The asterisk indicates
the position of the trachea, which cannot be seen in B-Flow mode.
Fig. 13.9: STIC volume display with B-flow, revealing a true knot of the umbilical cord (left) and in
surface mode B-flow rendering display
13.3 Typical applications of the B-Flow mode 161
Fig. 13.10: Static 3D B-flow demonstration of the intracranial vessels in a fetus with an aneurysm
of the vein of Galen (arrows).
13.4 Conclusions
The initial optimism surrounding the application of B-flow in combination with 3D or

STIC has leveled off somewhat in recent years. The application is ideal for use in areas
with small vessels and blood flows, where the examiner must consider whether the
spatial demonstration of the vessels without the surroundings provides enough infor-
mation. The authors prefer to use the bidirectional color Doppler in 3D and STIC for
the examination of tiny and large vessels, as already explained in Chapter 12.
14 Biplane Display Using the Electronic Matrix
Transducer
14.1 Principle
One of the special features of an electronic matrix probe is the construction of the
transducer with multiple rows of crystals instead of a single one, found in conven-
tional mechanical transducers. With these multiple rows of crystals (64 rows in
some), the transducer footprint has more than 8,000 elements, hence the name
“matrix array transducers”. In conventional mechanical 3D probes, a single row of
crystals is used to generate the 2D image and once the 3D acquisition is selected, a
mechanical motor sweeps the ultrasound beam in order to generate multiple 2D
planes compiled to form the 3D volume. With the use of rapid processors in comput-
ers, matrix transducers are able to electronically steer the ultrasound beam through
a selected volume box and to acquire volumes 2 to 4 times faster than a 3D mechan-
ical transducer. This rapid acquisition of ultrasound planes makes an enhanced res-
olution within the 3D volume possible, as well as the simultaneous display of two
planes in real-time in a promising display, which is referred to as “biplane display”.
Additionally, the transducer can display a thin slice of the region of interest called
VCI-A in 4D (see Chapter 4) much more rapidly than is possible with a mechanical
probe. In this chapter, we present our preliminary experiences with biplane display,
providing typical examples.
The examination is first performed in 2D with the matrix probe and the image and
the region of interest adjusted and optimized (see Chapter 1). The aperture angle of
the image should be kept as narrow as possible, and the biplane display is then
activated. The image is instantly split into two images A and B as dual image
(Fig. 14.1). The left image is plane A and is the scanning plane, where a vertical line
appears. This line can be freely controlled, moved and placed along the region of
interest. The right image is plane B and is the orthogonal plane along the line placed
in plane A. (Fig. 14.1).
While the examination is performed as usual as can be seen in the images in plane
A on the left, the panel on the right side simultaneously reveals the orthogonal corre-
sponding images along the biplane-line placed in A. The biplane examination can be
performed in grayscale or in combination with color-Doppler. The use of zoom enables
the magnification of one region to better focus on it. From a practical point of view,
biplane can be used in two ways, as illustrated in Figs. 14.1 to 14.3: One approach is to
keep the position of the line unchanged and move the transducer so that the struc-
Fig. 14.1: Examination of the spine with biplane mode with the dual image. The examination plane is
on the left and the image on the right is a perpendicular cross-section plane along the line placed in
the left image, here at the level of a thoracic vertebral body. Ribs can be seen in the right image. See
also Figs. 14.2 and 14.3.
Fig. 14.2: Biplane examination of the spine. The previous figure was first visualized but in order to
visualize the lumbosacral region, the position of the biplane line was kept unchanged and the trans-
ducer moved toward the sacral region. Another possibility is provided in next figure.
164 14 Biplane Display Using the Electronic Matrix Transducer
Fig. 14.3: Biplane examination of the spine as in the two previous figures. Another possibility of visu-
alizing the lumbosacral region is to control and move the biplane line and place it along the sacral
region as showed in this example.
tures of interest are arranged successively along the biplane-line (Fig. 14.2) and the
orthogonal images are generated on the right panel. Another approach is to keep the
scanning image still and to move the biplane-line to produce successive correspond-
ing orthogonal images in the right panel (Fig. 14.3). In the latter approach, the ultra-
sound system must permanently re-assess the line position and calculate all images,
which is accompanied by a slight delay in scanning. The authors recommend that the
user simply tries to work with this interesting type of display; in this chapter, we share
some applications acquired through our preliminary experiences.
14.3 Typical applications of biplane mode
Once the examiner uses the biplane-display in many examinations, he realizes that
this new modality of scanning is not limited to screening examinations, but can also
be used in suspected fetal anomalies.
Examination of head and face: The head and face are routinely examined in several
planes in 2D and 3D multiplanar mode. The biplane mode therefore offers an ideal tool
for the demonstration of many anatomical structures. While the head, for example, is
examined in a transverse plane, in the biplane image the cavum septi pellucidi
(Fig. 14.4), the lateral ventricles, the Sylvian fissure or the posterior fossa can be visu-
Fig. 14.4: Examination of the brain using the biplane mode at the level of the cavum septi pellucidi
(*) in both orthogonal planes. The original plane on the left is the standard axial plane of the head.
In the image to the right, both anterior horns (short arrows) and the corpus callosum (long arrow)
are seen, which are not seen in the left plane.
Fig. 14.5: Agenesis of corpus callosum visualized in biplane mode. The head is examined in the stan-
dard axial plane as can be seen in figure 14.4, but in this case the cavum septi pellucidi is absent (?)
in both planes. In the biplane image on the right, the anterior horns are seen shifted laterally.
Fig. 14.6: Examination of the head in a coronal view and in biplane mode a midsagittal view of the
corpus callosum is visualized (arrows).
Fig. 14.7: A fetus with an occipital encephalocele in biplane mode. Brain tissue can be recognized in
the cele.
Fig. 14.8: Axial view of the head in a fetus with choroid plexus cysts. In the left image, only one cyst
can be seen, but the biplane image reveals both.
alized simultaneously. Anomalies such as agenesis of the corpus callosum can be sus-
pected with this mode as can be seen in Fig. 14.5. If the fetus is in breech presentation,
the brain can be examined through the fontanelle in a coronal view and the corpus
callosum can be visualized simultaneously in biplane mode (Fig. 14.6). Other brain
anomalies can be visualized in one plane and verified with the biplane mode in the
other (Fig. 14.7–14.8).
Additionally, biplane mode is particularly helpful in the assessment of the fetal
face (Fig. 14.9, 14.10), where the examination can be started either from the profile in
a sagittal insonation or from an axial or a coronal view (Fig. 14.9–14.14). The simplest
approach is probably to obtain a profile and simultaneously tilt the biplane-line from
the plane of the eyes (Fig. 14.9), down to the nose and then to the upper and lower jaw
(Fig. 14.10). Facial anomalies such as cleft lip, cleft palate and other malformations
can be clearly demonstrated and identified with the biplane mode and the abnormal
finding is better assessed when displayed in the two planes at the same time (Fig. 14.11–
14.14). A similar approach can also be performed already in the first trimester screen-
ing as illustrated in Fig. 14.13.
Examination of the heart: The biplane mode is an interesting new tool for the exam-
ination of the heart, chest and mediastinum. At the level of the heart, the four-cham-
Fig. 14.9: Biplane mode in the examination of the fetal face. The profile of the fetus is visualized and
the biplane is placed at the level of the eyes. On the left the eyes are not seen but in the orthogonal
biplane image both eyes and orbits are displayed (see also Fig. 14.10).
Fig. 14.10: Biplane mode of the face. The profile is seen as in the previous figure but the biplane line
is placed now at the level of the mouth with the visualization of the intact maxilla (compare with next
figure).
Fig. 14.11: Biplane mode of the face in a bilateral cleft lip and palate (arrows). The biplane examina-
tion is performed by visualizing the profile and placing the line along the maxilla.
Fig. 14.12: Biplane mode in a bilateral cleft lip and palate (arrows). The biplane mode is the result of
a coronal view of the face.
Fig. 14.13: Biplane mode in a bilateral cleft lip and palate (arrows) in a fetus at 13 weeks’ gestation.
In the left image the “maxillary gap” is seen, where the line is placed and the suspicion is confirmed
in the resulting biplane image.
Fig. 14.14: Biplane mode in a fetus with lymphangioma of the neck. The extent of the finding can be
better appreciated by adding the orthogonal plane in the assessment in 2D. Also compare with Fig. 18.21.
ber view can be examined while simultaneously, a sagittal section of the aortic arch,
ductal arch (Fig. 14.15) and venous system can also be visualized. Anomalies affecting
the great arteries or the venous system in the mediastinum can be demonstrated in
these planes simultaneously (Fig. 14.16). An interesting view is the visualization of the
interventricular septum in two planes, mainly the direct view of the septal surface
(Figs. 14.17–14.19). This novel view makes it possible to check the integrity of the inter-
ventricular septum in grayscale or in combination with color Doppler. Figures 14.15–
14.20 illustrate examples of fetal hearts under normal and abnormal conditions.
Examination of chest, abdomen, skeletal system and other areas: The biplane
display also has significant potential when it comes to the examination of different
fetal organs. The visualization of the spine has already been demonstrated in Fig. 14.1
and this approach can aid in the accurate assessment of the height of the lesion in
spina bifida (Fig. 14.21) or in hemivertebra. The lungs and abdominal organs can also
be examined quite well using biplane mode and this display facilitates obtaining a
better overview of normal and abnormal conditions. Figures 14.22 to 14.26 illustrate
examples of some anomalies demonstrated in biplane mode.
Fig 14.15: Biplane mode in a normal heart. The examination is performed in the five-chamber view
plane (left). The biplane view simultaneously displays the aortic arch.
Fig. 14.16: Biplane mode of a heart with a left persistent superior vena cava (arrows). The examina-
tion is performed in the four-chamber-view (left) and the biplane mode reveals the left superior caval
vein with its course from the neck toward the heart in an orthogonal plane (arrows).
Fig. 14.17: Biplane mode display of the interventricular septum of the heart with a muscular ventric-
ular septal defect (arrow) in grayscale. The defect is suspected in the left and confirmed in the right
image.
Fig. 14.18: Biplane mode display of the interventricular septum in color Doppler in a heart with a
muscular ventricular septal defect (arrow). The defect is suspected in the left and confirmed in the
right image.
Fig. 14.19: Biplane mode of the interventricular septum in a fetus with heart tumors, diagnosed as
rhabdomyomas. A large rhabdomyoma (*) is found in the region of the septum and left ventricle. In
biplane mode, it is possible to observe that the aortic valve is not obstructed (arrow) by the tumor.
Fig. 14.20: Biplane mode in color Doppler in a fetus with transposition of the great arteries. The
parallel course of the great vessels (arrows) is recognized in the orthogonal biplane.
Fig. 14.21: Myelomeningocele in biplane mode in a fetus at 21 weeks’ gestation. Moving and con-
trolling the biplane line facilitates a good assessment of the level of the lesion.
Fig. 14.22: Both kidneys can be ideally assessed in two orthogonal planes, as shown in this biplane
mode example.
Fig. 14.23: A fetus with multicystic renal dysplasia in biplane mode.

Fig. 14.24: Biplane mode in color Doppler in a fetus with an omphalocele with the demonstration of
aorta (AO) and umbilical vein (UV).
Fig. 14.25: Biplane visualization of a hyperechogenic lung in lung sequestration (*). In the right part
of the figure, which is orthogonal to the left panel, the normal upper lung lobe (arrow) is recogniz-
able and has a normal size and echogenicity.
Fig. 14.26: Biplane visualization of a fetus with ascites (*).The extent of the finding can be better
appreciated in this mode.
14.4 Conclusions
Given the fact that it is a newly developed modality, the examination with biplane
mode requires a learning curve in order to familiarize oneself with it and rapidly inte-
grate it into routine screening. Our preliminary experience has shown that the main
benefit of biplanar display mode is ability to obtain information quickly and simulta-
neously on two planes, which proves to be superior to that of a single 2D image.
15 Calculation of 3D Volumes
15.1 Principle
Fetal biometry is an intrinsic part of the prenatal ultrasound examination. During a

routine examination, measurements of diameters, circumferences or areas are con-
ducted and compared with reference ranges. During a fetal examination, volume cal-
culations are rarely performed and when needed, the examiner simply makes his or
her assessment based on an ideal form of the region of interest when calculating dis-
tances and areas. The acquisition of a 3D volume is a good prerequisite for a reliable
measurement of a volume. Generally speaking, few techniques are available for
volume calculation and depending on the region of interest, the calculation can be
accomplished quickly and easily, or in a complicated and time-consuming way. In this
chapter, we discuss the two main tools that are typically used for volume calculation.
3D volume measurements can be performed in different ways. The most well-known

and common technique is with VOCAL-software (see below). Additional tools have
been introduced in recent years that facilitate the automatic rapid measurement of
echolucent regions. There is general agreement that the need to conduct measure-
ments in prenatal diagnosis will increase in the future and that there will thus be a call
for more simplified volume measurement tools. As it is, the few techniques available
for conducting volume measurements are quite time-consuming in their implementa-
tion, and this certainly goes a long way to explaining why most volume calculations
are reported in research studies yet not used in clinical practice. In the following, we
discuss two techniques, namely, VOCAL and Sono-AVC software.
15.2.1 Virtual Organ Computer-aided Analysis (VOCAL)-Software
VOCAL software is still the most commonly used technique for a calculation of a
volume. Following a static 3D volume acquisition, the structure to be measured is
displayed in the orthogonal mode and magnified in order to be placed in the center of
the image. Once the VOCAL software is activated, a vertical line appears with two tri-
angles present on the two poles of this line. The user manually moves each triangle,
placing each on the poles of the area to be measured (Fig. 15.1). In the next step, the
outline drawing is selected either manually, semiautomatically, or automatically. The
automatic drawing of the contours is reliable when a single echolucent structure with
well-defined borders is selected such as the stomach, bladder, or a cyst, which
Fig. 15.1: Step-by-step 3D volume calculation using VOCAL: Once the region of interest is displayed
in orthogonal mode, the VOCAL function is then selected. A vertical line appears with two triangles.
These are placed manually at the two poles of the selected area, in this case the lung.
Fig. 15.2: The next step in VOCAL volume calculation (see Fig. 15.1): After the region of interest has
been magnified and the triangles placed on the poles, the type of outline drawing is selected, either
as manual or semiautomatic. Once the outline is drawn well, the measurement is then confirmed
and an automatic rotation of the volume to the next image occurs.
180 15 Calculation of 3D Volumes
Fig. 15.3: The next step in VOCAL volume calculation (see Figs. 15.1, 15.2): The user now proceeds in a
similar fashion to Fig. 15.2, moving from image to image and drawing the outline and confirming the
result until all steps have been completed. The number of rotations can be selected by the operator
prior to volume calculation.
Fig. 15.4: The next step in VOCAL volume calculation (see Figs. 15.1–15.3): At the conclusion of the
previous steps of drawing the lines and rotating the volume the result is displayed on the screen
highlighting the measured region of interest to the lower right, in this instance the lung, after calcu-
lation. At this stage, some corrections can be made by reviewing one or other of the planes to adjust
contour drawings.
Fig. 15.5: The 3D VOCAL result for the previously assessed lung. The result can be displayed in differ-
ent colors as a solid area (left) or as a mesh (right).
however is rarely the case. In most cases, however, for the evaluation of kidneys,
lungs, placenta and other structures, automatic recognition of contours is difficult
and selecting the manual or semiautomatic function is recommended. This then
allows the user to draw or modify the outline according to the ultrasound information
on the screen (Fig. 15.2). Once the user has finished drawing the outline, this step is
manually confirmed and the image automatically changes to the next image by a few
degrees rotation along the long axis. The same steps are confirmed and adjusted and
manually corrected in each plane (Figs. 15.3, 15.4) until a complete 180° rotation is
achieved. The more rotation steps that are selected, the more precise the volume cal-
culation will be. Figures 15.1 to 15.5 demonstrate the step-by-step approach for lung
volume measurement using VOCAL. The visualization of the calculated volume is dis-
played at the end on the screen either with a solid or a mesh envelope (Fig. 15.5).
15.2.2 Sono Automatic Volume Calculation (Sono AVC™)
This recently released software volume calculation tool is used in gynecological

ultrasound for the automated measurement of cysts and follicles. The software auto-
matically recognizes single or multiple echolucent areas as cysts and calculates the
corresponding volumes accordingly (Figs. 15.6–15.10). The user selects the area with
the organs of interest by placing them within the render box. The structures to be
measured can be added or removed selectively by means of a simple mouse click. It
should be kept in mind that the software automatically recognizes echolucent areas
and therefore shadows can lead to artifacts. On the other hand, this technique is the
quickest technique for volume calculation of cysts, especially when multiple cysts
need to be measured (Fig. 15.10). Therefore, the measurement of a filled stomach
Fig. 15.6: 3D volume calculation with Sono Automatic Volume Calculation (Sono-AVC). After selecting
the region of interest where the liquid is to be measured (here the stomach), the region can be selec-
tively clicked with the mouse while activating Sono-AVC (see Fig. 15.7).
Fig. 15.7: 3D volume calculation with Sono-AVC: Following the mouse click, the liquid is identified
and the volume displayed. The 3D shape of the stomach is displayed and the volume calculated.
Fig. 15.8: 3D volume calculation with Sono-AVC, here in a fetus with double bubble sign in duodenal
atresia.
Fig. 15.9: 3D volume calculation with Sono-AVC in a fetus with hydronephrosis in pelvic-ureteral

junction obstruction.
Fig. 15.10: 3D volume calculation with Sono-AVC in a fetus with multicystic renal dysplasia. The
volumes for different individual cysts can be separately calculated and displayed. Measurements are
illustrated for the different cysts in different colors, and the numbers refer to the region measured.
(Figs. 15.7, 15.8), or the fluid volume in the dilated renal pelvis (Fig. 15.9) or the cyst
volumes in multicystic kidneys (Fig. 15.10) can easily be calculated. Also refer to the
example in Chapter 19.
15.3 Clinical application of volume calculation
Volume calculations and corresponding reference ranges were reported for early ges-
tation including volume of placenta, gestational sac and embryo. The lung is another
common organ for measurement in normal fetuses and fetuses at high-risk for pulmo-
nary hypoplasia. Volume measurements were reported for different structures such as
the liver, brain, placenta, kidneys, lateral ventricles, cardiac cavities and others. One
of the main applications of volume measurements is the fetal weight estimation by
calculating the volume of an extremity or in combination with other volume measure-
ments. However, the routine use of volume calculation is still uncommon and is
mainly performed in research studies.
15.4 Conclusions
3D volume measurements are important in selected cases in prenatal ultrasound, but

performing such calculations is still quite time-consuming. VOCAL and Sono-AVC are
the most commonly used tools and require a degree of experience before being used
effectively and easily, which limits their use in routine ultrasounds.
Part III: Clinical Applications of Prenatal Diagnosis
16 3D Fetal Neurosonography
16.1 Introduction
The ultrasound examination of the fetal brain mainly focuses on the interval between
15 and 40 weeks of gestation. The first section of this chapter deals with this interval
and demonstrates the potential of 3D ultrasound under normal and abnormal condi-
tions. Nevertheless, recently, with the increased use of high-resolution transvaginal
sonography in combination with 3D techniques, effective sonoembryology of the
brain between 7 and 14 weeks of gestation has become possible. We discuss some
aspects of this development in the second part of the chapter.
16.2 Fetal neurosonography with 3D ultrasound
Ultrasound screening of the fetal brain is performed from 15 weeks of gestation

onwards, mainly by demonstrating axial planes that are typically used to measure the
biparietal and transcerebellar diameters. In fetuses at high-risk for CNS anomalies or
when an abnormality is suspected, during routine screening additional coronal and
sagittal sectional planes are recommended as part of a comprehensive fetal neuroso-
nogram. Additional planes are often difficult to obtain, especially in unfavorable fetal
positions, such as in a vertex presentation. Usually at this point, additional time-con-
suming transvaginal sonography has to be performed. With 3D neurosonography, the
examiner can acquire a volume and as explained in Chapters 2–5, subsequently recon-
struct any sectional plane needed. Alternatively, he can examine directly with 4D and
generate these planes online during the live examination. One of the main advantages
of 3D multiplanar mode is the possibility of virtually reconstructing the midline struc-
tures from a volume data set that has been acquired from an axial or oblique insona-
tion of the fetal head. Moreover, tomographic mode enables the visualization of the
region of interest together with the adjacent structures in one single image. The 3D
volume acquisition can be achieved from different insonation angles as an axial,
coronal or sagittal approach.
Axial 3D-acquisition: The easiest acquisition is achieved from an axial view of the
head, often when the fetus is in a vertex presentation. In tomographic display mode
(Fig. 16.1), the parallel cross-sectional planes provide a good overview of the brain
anatomy. As illustrated in Figure 16.1, the landmarks such as the cerebellum with cis-
terna magna, cortex tissue, posterior and anterior horns of the lateral ventricle and
falx cerebri with cavum septi pellucidi can be visualized in a single image. Figures 16.1
to 16.4 illustrate 3D volume images with multiplanar mode of normal and abnormal
fetal brains.
188 16 3D Fetal Neurosonography
Fig. 16.1: A 3D volume data set of an axial acquisition of a fetal brain displayed in tomographic
mode. The different planes displayed provide an overview of the main structures of a normal brain as
the falx cerebri (Falx), the lateral ventricles (Lat.V), the choroid plexus (Plexus), the thalami (Th), the
cavum septi pellucidi (Csp), the Sylvian fissure (arrow), the cortex and the cerebellum with cisterna
magna (circle).
Sagittal or coronal 3D-acquisitions: A better resolution of the midline structures is

provided by a 3D acquisition through the anterior fontanelle, transabdominally when
the fetus is in breech presentation (Figs. 16.5, 16.6) or transvaginally in vertex presen-
tation (Fig. 16.7). A volume acquired through the fontanelle can be used to display a
series of coronal or parasagittal sectional planes. The best resolution is provided by
transvaginal volume acquisition (Figs. 16.7–16.9). Figures 16.5 to 16.9 illustrate exam-
ples of transabdominal & transvaginal 3D volumes acquired through the fontanelle in
normal and abnormal fetuses.
The intracranial structures are best assessed with a multiplanar reconstruction
display such as the orthogonal, tomographic or Omniview mode. Quite often, the
additional combination with volume contrast imaging (VCI) (see Chapter 4) improves
the resolution of the reconstructed image, as illustrated in Figures 16.6–16.10.
Fig. 16.2: A fetus with holoprosencephaly displayed in tomographic mode.
Fig. 16.3: A fetus with agenesis of the corpus callosum demonstrated in tomographic mode. The cavum
septi pellucidi is absent (?) and in the midline there is a dilated interhemispheric fissure (arrow). The
shape of the lateral ventricles (Lat.V) demonstrates the typical colpocephaly; falx cerebri (Falx).
Fig. 16.4: Schizencephaly (circle) in tomography mode. In the planes, cranial and caudal to the
lesion the cortex appears intact.
Fig. 16.5: Coronal sectional planes in tomographic mode after a transabdominal volume acquisition
through the fontanelle. Following structures can be recognized: The interhemispheric fissure (IHF),
the corpus callosum (CC), the cavum septi pellucidi (Csp), the thalami (Th), the insula (Ins) and the
anterior horns with the lateral ventricles (Lat.Vent.).
Fig. 16.6: Sagittal sectional planes after a transabdominal 3D acquisition through the fontanelle with
a tomographic mode rendering The midline structures as the corpus callosum (CC) and the vermis
with the posterior fossa are well seen.
Fig. 16.7: Sagittal and parasagittal sectional planes after a transvaginal 3D acquisition through the
fontanelle with a rendering in tomographic mode. The focus is on the midline structures, which are
well recognized as the corpus callosum (CC), vermis and lateral ventricles (Lat.Vent.). With the choice
of a larger interslice distance the insula (Ins) could have been displayed as well.
Fig. 16.8: Coronal sections after a transabdominal 3D volume acquisition through the fontanelle in
a fetus with agenesis of the corpus callosum. In this view no corpus callosum can be seen but the
typical “steer horn” shape (circle). The frontal anterior horns (*) are in this anomaly compressed and
lateralized.
16.3 3D visualization of specific brain structures
In fetal neurosonography, some structures need to be visualized and have to be recon-

structed with 3D multiplanar rendering. The steps for the corpus callosum and vermis
are explained below:
The corpus callosum: For the experienced examiner, the visualization of the corpus
callosum is considered as a part of a comprehensive ultrasound examination. This
structure is either demonstrated directly or with a rapid reconstruction of a sagittal
plane after of a 3D volume acquisition from an axial plane. An important landmark is
the cavum septi pellucidi as orientation point, both during volume acquisition and 3D
rendering (Figs. 16.10, 16.11). Figures 16.10 and 16.11 explain the 3D reconstruction of
the corpus callosum step-by-step.
In addition to this visualization using 3D static mode, the corpus callosum can
also be directly reconstructed in 4D during a live examination, for example by using
Fig. 16.9: Coronal sections after a transvaginal 3D volume acquisition through the fontanelle in a
fetus with agenesis of the corpus callosum (circle) similar to the case in Fig. 16.8, but this fetus
additionally has a schizencephaly (arrows), which thanks to the display in tomographic mode can be
recognized in the adjacent planes.
Fig. 16.10: Despite the vertex position in this fetus the corpus callosum, which cannot be seen, can
be reconstructed from an axial volume acquisition. The orientation is best achieved by locating the
cavum septi pellucidi (CSP) and placing the intersection dot in the Csp. The axes of the head (dashed
arrows) are still oblique but should be aligned with the horizontal line (see next figure).
Fig. 16.11: After the intersection dot was placed on the cavum septi pellucidi, the planes A and B are
rotated in a way that the axis of the falx cerebri is aligned along the horizontal axis (dashed line).
Now the corpus callosum (CC) appears in the C-plane.
VCI-Omniview. In the presence of a complete agenesis of the corpus callosum, the

axial view of the brain reveals the typical teardrop shape of the lateral ventricles,
called colpocephaly, as well as the absence of the cavum septi pellucidi (Fig. 16.3). In
the coronal view, the absence of the cavum septi pellucidi is confirmed and the ante-
rior horns are displaced laterally providing a typical image described as the “steer
horn” shape (Figs. 16.8–16.9).
The cerebellar vermis: Cerebellar anatomy is generally assessed in the axial view.
This includes the demonstration of the normal shape of both hemispheres with the
vermis present in between, and the cisterna cerebello medullaris additionally has a
normal size, while the inferior part of the vermis is visualized and separates the 4th
ventricle from the cisterna. Ideally, not only the cerebellum and cisterna magna should
be included in a 3D volume but, when possible, the brain stem should also be as well
(Fig. 16.12). After volume acquisition, the images are rotated in such a way that the
middle axis and vermis are aligned. In the C-plane, the vermis shape and size are then
recognized especially in its relationship to the cisterna magna and brain stem
(Fig. 16.12). Similarly to the corpus callosum, the cerebellar vermis can also be directly
visualized during a 4D examination using VCI-Omniview, as previously explained
(Fig. 4.14).
Fig. 16.12: A vertex presentation of the cerebellar vermis (arrow) can be reconstructed after a 3D
volume acquisition. In this reconstruction, the corpus callosum (CC) can also be seen in this midline
section. The asterisk is placed in the cisterna magna.
Fig. 16.13: Orthogonal sectional planes after a transvaginal volume acquisition through the fonta-
nelle in a normal fetus. The intersection dot is placed in the upper plane on the chiasma opticum
(long arrows) and the image in the upper right plane was rotated in a way to have the base of the
skull horizontal and visualize the chiasma opticum (short arrows) in plane C (lower plane). Note the
X-shape of the chiasma (lower plane).
On encountering suspicious findings while examining the axial planes, the

demonstration of a midsagittal view of the vermis with its neighboring structures is of
great importance when attempting to diagnose anomalies. In this view, the shape, size
and position of the vermis can be objectively assessed. Conditions such as a mega
cisterna magna can also be well differentiated from a Blake’s pouch cyst, a partial or
complete agenesis of the vermis or a true Dandy-Walker malformation.
Other brain structures in 3D multiplanar render mode: Some structures in the

brain can be demonstrated directly in a 2D scan, but many others are difficult to visu-
alize depending on the fetal position. In such conditions, it is worth learning the use
of the 3D volume acquisition with the reconstruction of the plane of interest. The free
movement of the transducer is limited and the structures can be more easily visualized
in 3D, especially during a transvaginal examination. Parasagittal views can demon-
strate the horns of the lateral ventricles, whereas coronal views provide insight into
the basal ganglia, the symmetry of the cortex and other structures of the brain. At the
base of the skull, even the optic chiasm can occasionally be visualized using 3D, as
illustrated in Fig. 16.13.
16.4 Reconstruction of fetal brain structures in 3D rendering
The use of 3D is mainly used for the multiplanar visualization of specific fetal brain
structures, but in some situations there is still a space for 3D volume rendering of
some regions using the different modes presented in this book. Our experience has
shown that some rendering modes like surface, minimum, inversion or glass-body
mode as well as Silhouette and Sono-AVC tools are able to be implemented well in fetal
neurosonography. Figures 16.14–16.18 demonstrate some examples of different modes
and Chapter 21 provides additional images in early brain development in 3D.
16.5 The intracranial vascular system in color Doppler
Major intracerebral arteries and veins can be visualized well either from an axial or a
sagittal approach. The left and right internal carotid arteries and the basilar artery
enter the skull at its base to soon form the Circulus of Willis, which can be easily visu-
alized using color Doppler and 3D glass-body mode (Fig. 12.18). One of the main arter-
ies, visualized in a midsagittal view, is the anterior cerebral artery that continues
along the corpus callosum to form the pericallosal and callosomargnial artery. In
fetuses with partial or complete agenesis of the corpus callosum, these arteries
demonstrate an abnormal course, as can be seen in Fig. 16.19. Recently, the intracra-
nial venous system has been intensively explored. Interest not only focused on the
Fig. 16.14: Surface mode and cranial view into the brain at the level of the transventricular plane,
in a normal fetus (a) and in fetuses with abnormal findings. Fetus in (b) with open spina bifida and
abnormal head shape (“lemon shaped”)(arrows), in (c) in ventriculomegaly (arrow) and in (d) in
choroid plexus cysts (arrows).
Fig. 16.15: Surface mode with HD-live silhouette with cranial view into the brain, in a normal fetus
(a) and in fetuses with anomalies, in (b) with holoprosencephaly and monoventricle (curved arrow),
in (c) in ventriculomegaly (double arrow) and in (d) in Dandy-Walker syndrome with a dilated poste-
rior fossa with an absence of the cerebellum (arrow).
Fig. 16.16: Upper panel: Fetus with bilateral ventriculomegaly with the cavum septi pellucidi in
between displayed in minimum mode (upper left) and in inversion mode (upper right). Lower panel:
fetus with holoprosencephaly and monoventricle in minimum mode (lower left) and the inversion
mode of the ventricular shape (lower right).
Fig. 16.17: Fetus with occipital encephalocele in tomographic mode with brain tissue in the cele (*)
(see also Fig. 16.18 left).
Fig. 16.18: Surface mode rendering in two fetuses with an occipital encephalocele (left) and suboc-
cipital meningocele (right). In the fetus on the left, brain tissue is recognized in the cele (*) (same
fetus as in Fig. 16.17).
Fig. 16.19: Glass-body mode of the anterior cerebral artery with an atypical course in two fetuses
with a complete (left) and a partial (right) agenesis of the corpus callosum.
sinuses as the superior and inferior sagittal sinus, straight and transversal sinus, but
also on other veins such as the vein of Galen, the internal cerebral vein, and cortical
veins (Fig. 12.17). The typical anomalies affecting the veins include the vein of Galen
aneurysmal malformation (Fig. 16.20), the pial arteriovenous malformations or
abnormal courses of veins, such as falcine sinus.
Fig. 16.20: Two fetuses with an aneurysm of the Galen vein in color Doppler in glass-body mode
and HD-live flow.
16.6 Fetal neurosonography before 14 weeks of gestation
Interest in normal fetal anatomy and anomalies in the first 14 weeks’ gestation has
increased following the introduction and routine use of nuchal translucency screen-
ing. For many years, the evaluation of the brain at this gestational age was reduced to
the demonstration of the skull, excluding anencephaly and the visualization of the
falx cerebri, excluding alobar holoprosencephaly. With the advent of the intracranial
translucency and its potential for early detection of an open spina bifida, there was an
increased interest in understanding brain development and anatomy in the first tri-
mester. In many conditions, a 3D volume with tomographic mode display (Fig. 16.21)
provides a good overview of the intracranial anatomy, providing the ability to differ-
entiate between normal and abnormal findings (Fig. 16.22). Figure 16.23, in Omniview
mode, reveals the intracerebral changes in the brain of a 12 week-old fetus with open
spina bifida. Another example is provided in Figure 21.23.
Few scientists have further examined the embryonic development of the human
brain before 10 weeks’ gestation with 3D ultrasound (Figs. 16.24, 16.25). These days,
the study of the embryonic brain can be performed in vivo with 3D ultrasound. In so
doing, different multiplanar mode displays are applied to demonstrate the regions of
interest, plane by plane. Interestingly, few volume-rendering modes are also able to
demonstrate the developing ventricular system. Different 3D render modes are
shown in Figs. 16.26–16.29. In the future, with the aid of these techniques, it is
expected that more knowledge will become available during this early stage of brain
development and that high-risk patients will then be able to be examined earlier in
gestation.
Fig. 16.21: Transvaginal 3D volume acquisition of head and brain displayed in tomographic mode. In
this overview many structures can be seen in one glance as the choroid plexus of the lateral ventricle
(Plexus), the falx cerebri (Falx), the aqueduct of Sylvius between both cerebral peduncles (*) and the
fourth ventricle as intracranial translucency in an axial view (arrow).
Fig. 16.22: Fetus at 12 weeks’ gestation with holoprosencephaly clearly demonstrated and identified
in tomographic mode. No midline is recognized in comparison to Figure 16.21.
Fig. 16.23: Fetus with open spina bifida and intracranial changes, displayed in Omniview planes.
Upper right: axial view of the posterior fossa at the level of the cerebral peduncles with the aqueduct
of Sylvius (*), shifted toward the occipital bone. Lower left, compressed posterior fossa without a
transparency (arrow). Lower right) thickened brain stem (double arrow).
Fig. 16.24: 3D volume of head and brain at 9 weeks in the orthogonal mode. Both hemispheres are
separated; the choroid plexuses and the rhombencephalon can be also good identified.
Fig. 16.25: 3D volume of a head at 9 weeks’ gestation. Using Omniview, a midline has been placed
and a midsagittal view of the embryonic brain is demonstrated.
Fig. 16.26: Left: Head of a fetus at 12 weeks’ gestation in 3D in surface mode and HD-live display. In
the right figure, the head has been opened with Magicut and both hemispheres are recognized with
both choroid plexuses (*) separated by the falx cerebri (Falx).
Fig. 16.27: Head of two fetuses at 12 weeks’ of gestation with a view from cranial displayed in surface
mode and HD-live with silhouette effect. Left: Normal anatomy with falx cerebri (Falx) and both
halves of the brain with the large plexus choroidei (*). By comparison, in the right image the fetus
exhibits the typical features of holoprosencephaly with monoventricle (double arrow) with lack of
separation of the thalami.
Fig. 16.28: The lateral ventricles can be visualized before 11 weeks’ gestation with inversion mode
(left) and Sono-AVC (right) as digital cast.
Fig. 16.29: Head of a normal fetus at 12 weeks’ gestation from a front and lateral view displayed with
a silhouette tool and revealing both lateral ventricles.
16.7 Conclusions
Fetal neurosonography is an important component of a comprehensive ultrasound to

rule out fetal brain malformations, especially in the second half of gestation. The com-
bination of 3D with 2D ultrasound facilitates the assessment of the fetal brain provid-
ing the possibility of reconstructing planes that are inaccessible with routine scan-
ning. The reconstruction, as well as the offline analysis and detailed visualization of
structures using the multiplanar mode, represents the important benefits of 3D exam-
inations. The tomographic demonstration of sectional planes also offers a reliable tool
for comparison with other diagnostic modalities as the MR-examination of fetal brain.
The study of early embryonic brain development under normal and abnormal condi-
tions using 3D ultrasound provides significant future potential.
17 3D of the Fetal Skeleton
17.1 Limitations in the assessment of the fetal skeleton

using 2D ultrasound
The examination of the fetal bones using 2D ultrasound is often limited to the bones
that are easily accessible. During a routine screening long bones are measured, the
spine is visualized in different planes and the hands and feet are demonstrated.
Cranial bones are not evaluated in 2D ultrasound unless indirectly by visualizing
the profile or during the measurement of the biparietal diameter. A better approach
to visualize the cranial bones and other parts of the fetal skeleton is the examina-
tion with 3D or 4D ultrasound in combination with maximum mode rendering, as
explained in Chapter 8. This mode enables the demonstration of the skeletal system
under normal and abnormal conditions. The combination of the use of multiplanar
modes as the orthogonal, tomography or Omniview modes with VCI (see Chapters
3, 4 and 5) can help in the extraction of typical bones displayed in maximum mode.
The ideal technique, however, remains the 3D volume acquisition with a maximum
mode rendering, as outlined earlier in Chapter 8. The recent introduction of a high
resolution VCI-A with maximum mode during a live 4D examination with the elec-
tronic matrix transducer (as detailed in Chapter 4) is promising. This chapter dis-
cusses the examination of the skeletal system under normal and abnormal condi-
tions.
17.2 3D of fetal spine and ribs
The fetal spine can be imaged using various 3D methods, as illustrated in Figs. 17.1–17.6
and explained earlier in Chapter 8. These tools facilitate a good visualization of the
spine with the vertebral bodies and arches at the different stages of ossification. In
Fig. 8.12, the varying degrees of ossification between the 1st and 2nd trimester can be
well recognized. Navigation through the volume enables also the visualization of the
vertebral bodies with the corresponding intervertebral disks (Figs. 17.3–17.5). Vertebral
bodies can be also visualized separately using Magicut or multiplanar mode, as shown
in Fig. 17.5. In a coronal projection, the spine is seen with the ribs, which makes it
possible to assess the symmetry and number of ribs (Fig. 17.1).
Typical anomalies that are amenable to be assessed using 3D include the different
forms of open and closed spina bifida, such as myelocele (Figs. 17.7, 17.8), myelomenin-
gocele (Fig. 17.9), meningocele, lipomeningocele and others. Figures 17.1 to 17.9 demon-
strate typical images of fetuses with normal and abnormal spines.
Other vertebral abnormalities as hemivertebra or more severe findings, such as
kyphoscoliosis, are often already identified using 2D, but the complete picture in its
Fig. 17.1: 3D volume data set of a spine (fetus at 22 weeks) displayed in multiplanar orthogonal
rendering mode (left) and in maximum mode (right).
Fig. 17.2: After a static 3D volume acquisition, the user can apply the Omniview mode to demonstrate
the planes of interest. Three lines have been placed on the reference plane (upper left): the yellow
line reveals a sagittal plane (upper right), while the two oblique planes (magenta and cyan) are
placed at the level of the lateral spinal arches and vertebral bodies.
208 17 3D of the Fetal Skeleton
Fig. 17.3: Omniview can also be used during the live 4D examination to demonstrate spine and ribs.
This is achieved by combining with Volume Contrast Imaging (VCI) (here 14mm thickness) in combi-
nation with maximum mode.
Fig. 17.4: In a 3D volume with maximum mode rendering the image can be rotated or the perspective
can be changed. Left: View from dorsal on spine and ribs. Middle: Lateral view on the spine with the
intact skin covering the spine and right: view in a deeper layer from dorsal with a direct view on the
vertebral bodies.
Fig. 17.5: The user can also selectively cut out anatomic structures out of a volume. In this example,
one vertebra was cut out (left) and magnified (right). In a cross-section, one can recognize the three
ossification centers as the vertebral body and the laminae of the vertebral arches (*).
Fig. 17.6: Biplane display of the spine. In the left image, the spine is visualized in a sagittal plane
and an axial cross-section of the spine (right) is displayed along the biplane line.
Fig. 17.7: Omniview planes in a fetus with myeloschisis (myelocele) (arrow) revealing an axial
cross-section at the level of the defect (upper right), at a level few vertebrae higher than the defect
(lower right) and in a coronal direct view on the defect (lower left).
Fig. 17.8: Omniview in a fetus with myeloschisis (myelocele) with a 17 mm slice and surface mode
with a direct view of the defect (arrow).
Fig. 17.9: Lateral view of the back of a fetus with lumbosacral myelomeningocele (arrow) in surface
mode (left) and in maximum mode (right).
Fig. 17.10: Three fetuses with hemivertebra (arrow) in maximum mode with several deviations of
the spine. The extent of deviation is better appreciated and demonstrated with 3D maximum mode
rendering.
Fig. 17.11: Fetus with a closed spina bifida and severe spine and ribs anomalies in a case of spondy-
locostal dysostosis. The finding can be better appreciated by switching from surface mode (left) to
maximum mode (right).
Fig. 17.12: Spine in maximum mode in a normal fetus (left) and in a fetus with a rare skeletal disease
(right). Note the thin ribs and the abnormal arrangements of the low thoracic ribs
Fig. 17.13: Lateral view of the spine in maximum mode in a normal fetus (left). In the two other
fetuses in the middle and right images, one can recognize the interruption of the lumbosacral spine
in a case of segmental spinal dysgenesis. In the fetus to the right, there is a severe caudal regres-
sion syndrome in the presence of maternal diabetes mellitus.
full extent is better demonstrated using 3D with the maximum mode rendering, as can
be seen in Figures 17.10 and 17.11.
Anomalies that affect the ribs, either as an isolated finding or part of syndromic
conditions, are uncommon. Figures 17.11–17.13 reveal fetuses with anomalies affecting
ribs and spine.
17.3 3D of the fetal limbs
The limbs can be visualized in 3D not only using the surface mode but also in their
bony parts by switching to maximum mode rendering (Figs. 17.14 to 17.18). Ideally, the
acquisition plane should be a perpendicular view of the arm or leg (see Figs. 7.4, 7.5
and 8.18) in order to obtain a good perspective of the examined limb. Ideally, the arm
or leg should lie horizontally during volume acquisition and the hand or foot should
be included in the volume, which makes a good volume often a challenge. However,
once this approach is successful, the visualization of the limb reliably confirms the
(a) (b) (c) (d)
Fig. 17.14: Maximum mode with the demonstration of the forearm with radius (R), ulna (U) and hand;
(a) normal fetus, (b) Fetus with a “mitten-hand” with syndactyly in Apert syndrome, (c) Fetus with
absent hand, (d) fetus with radius aplasia, short ulna (arrow) and typical hand position.
Fig. 17.15: A fetus with absent forearm in surface mode (left) and in maximum mode (right).
Fig. 17.16: The arms of three fetuses with skeletal dysplasias displayed in maximum mode rendering.
The fetus on the left had a short-rib polydactyly syndrome as Ellis-van-Creveld syndrome, the fetus
in the middle had an osteogenesis imperfecta and in the fetus on the right had a thanatophoric
dysplasia.
Fig. 17.17: Clubfoot in a fetus displayed in surface mode (left), in VCI-A with maximum mode (middle)
and in static 3D with maximum mode (right).
Fig. 17.18: Bilateral clubfeet in surface mode (left) and in maximum mode (right).
normal anatomy and in abnormal conditions the extent of the lesion can be well doc-
umented to its full extent (Figs. 17.14 to 17.18). Typical findings affecting the upper and
lower limbs can be complex and their spectrum wide (see Figs. 17.14–17.18), as is the
case in partial or complete absence of an extremity, in radius aplasia, in various skel-
etal dysplasias with shortened, bowed or fractured bones or in the frequent finding of
a clubfoot. Isolated anomalies of the hands including polydactyly, oligodactyly, cleft
hand or syndactyly can be well documented by selective rendering of the hand.
17.4 3D of the facial and cranial bones
A 3D visualization of the bones of the head includes both the facial bones (Fig. 17.19) as
well as the other cranial bones with their corresponding sutures and fontanelles
(Figs. 17.20, 17.21). The information provided by 2D ultrasound in this field is limited and
3D has an incomparable advantage in the rendering of bones. The patterns of the
metopic suture have already been intensively examined under normal and abnormal
conditions (Fig. 17.19) in a few studies. Some of the typical abnormal findings are the
fused metopic suture in fetuses with alobar holoprosencephaly or the wide metopic
suture typically found in Apert syndrome in association with craniosynostosis of the
coronary suture (Fig. 17.19, Fig. 18.19). The hypoplastic or non-ossified nasal bone can
be well detected in the frontal and lateral view (see Fig. 8.15). In the presence of ence-
phaloceles or other “tumors” on the head or face, 3D sonography can help in the assess-
ment as to whether a bony defect is present and can help demonstrate its size. The
presence of additional bones, so-called Wormian bones, can occasionally be found in
the metopic suture or in the fontanelles, but their clinical impact is still not understood.
17.4 3D of the facial and cranial bones 217
Fig. 17.19: 3D maximum mode with a view from anterior on the bony face with the frontal bones and
metopic suture. The fetus on the left is a normal fetus; the fetus in the middle has a wide metopic
suture in Apert syndrome due to coronal suture synostosis, and the fetus on the right has a holo-
prosencephaly with synostosis of the metopic suture with cleft lip and palate (*) and trisomy 13.
Fig. 17.20: Maximum mode of a lateral view of the cranial bones in a normal fetus (left) and in a fetus
with Apert syndrome and coronal suture synostosis (right). The coronal suture in the fetus on the left
can be recognized (arrow) but appears fused in the right fetus (?).
Fig. 17.21: A fetus with an unknown skeletal disease of the family of cleidocranial dysplasia. Note the
abnormal ossification of the parietal bone (circle). Compare with a normal ossification in Fig. 17.20
left.
17.5 Conclusions
Maximum mode is a good prerequisite for accurately examining the fetal skeleton
using 3D volume display. Most bones of the body are better examined in a 3D volume
than in 2D ultrasound. The normal anatomy can be well differentiated from abnormal
conditions affecting the areas of interest such as the spine and ribs, the upper and
lower limbs and the bony face and skull. A good prerequisite is a good insonation
angle and a high-contrast image. Anomalies of limbs and spine either isolated or as
part of skeletal dysplasias can be clearly demonstrated and identified using maximum
mode. The assessment of the bony face and skull can be of significant help when
assessing syndromic conditions, but there is a learning curve required when obtaining
reliable images.
18 3D of the Fetal Face
18.1 The sonographic examination of the face

in 2D and 3D ultrasound
The 2D ultrasound examination of the fetal face typically focuses on a midsagittal

view in order to visualize the profile and a frontal view to demonstrate both orbits and
the mouth-nose triangle. A systematic examination generally comprises panning the
face longitudinally from left to right across the profile, including an axial sweep in
transverse sections from the orbits across nose and lips, and to the upper and lower
jaw. The ears are rarely assessed during a 2D examination. The profile is also one of
the most important views a pregnant woman expects to see, as it is one of the few
ultrasound images that a layperson can are easily identify. However, a fetal face today
is best displayed by 3D surface rendering as illustrated in Chapter 7 and in this chapter.
One of the main advantages of the 3D surface rendering mode is the ability of demon-
strating the entire face in a single realistic view so that that the fetus is personified,
intensifying the bonding between mother and child. It is also noteworthy to observe
how the facial features change with advancing gestation (Fig. 18.1). Early in the third
Fig. 18.1: Fetal faces displayed in 3D surface mode. Shape and proportions of the face change
significantly between 12 weeks’ (left panel), around 22 weeks’ (middle panel) and around 30 weeks’
gestation (panel right).
220 18 3D of the Fetal Face
trimester, the images of the face strikingly start to resemble the features of the neonate
(see later). 3D ultrasound of the face is, however, not synonymous with surface mode
and includes other rendering modes, depending on the clinical question, as will be
discussed in this chapter.
18.2 The face in multiplanar display
For the examination of the face in multiplanar display, the acquisition is performed
best in an axial section with the face revealed in an anterior position and both orbits
visible in the initial image, or in a midsagittal view starting from the profile plane. By
navigating through the volume either in multiplanar orthogonal (Fig. 18.2) or in
tomography mode (Fig. 18.3), the face can then be visualized with all details needed,
such as the forehead, the eyes, the nose, the mouth and jaw (Figs. 18.2, 18.3, 18.4). In
some situations, the examiner can use the Omniview mode to selectively display a few
structures such as the hard and soft palate in normal fetuses (Fig. 18.5) and for apply-
ing this approach in fetuses with a cleft lip and palate (Fig. 18.6). Figure 18.7 presents
the face of a fetus with microphthalmia in tomography mode.
Fig. 18.2: Face in multiplanar display in orthogonal mode. The intersection point (navigation point)
has been placed on the nose and the images rotated and adapted correspondingly.
18.2 The face in multiplanar display 221
Fig. 18.3: Face in multiplanar display in tomography mode. The reference plane at the upper left
reveals the profile, while the tomographic images present axial parallel slices of the face from the
eyes (lower right) to the mandible (upper right).
Fig. 18.4: Demonstration of the hard palate (thick arrow) in orthogonal mode in a normal fetus (left)
and in a fetus with bilateral cleft-lip and palate (two arrows).
Fig. 18.5: Selective planes in multiplanar mode, displayed as Omniview planes. Three cross-section
planes displayed in yellow, magenta and cyan have been placed in the reference plane in the upper
left image to illustrate the typical features. The orbits are visualized in the upper right plane, in
the lower left plane the nose-mouth triangle view and in the lower right plane an axial view of the
maxilla (compare with Fig. 18.6.).
Fig. 18.6: The fetus with a mediolateral cleft lip and palate (arrow), displayed in Omniview mode. The
selective placement of the three lines (yellow, magenta and cyan) in the reference plane is enhanced
with the additional use of VCI and makes the selective demonstration of the regions of interest
possible. The two orbits appear normal and the defect is displayed in a coronal view (lower left) and
in an axial view (lower right).
Fig. 18.7: The face in multiplanar display in tomographic mode in a fetus with unilateral microph-
thalmia (arrow). The different planes reveal the difference between the normal (short arrow) and
abnormal eye (long arrow) (lower right panel).
18.3 The normal face in 3D/4D surface mode
3D and 4D visualization of the fetal face is often the first and most desired application
to learn in 3D volume sonography. Before starting, care should be taken to ensure that
enough amniotic fluid is present in front of the face and no objects (such as hands or
umbilical cord) hide the face during volume acquisition. For a good image acquisition,
the examiner should proceed like a photographer by approaching the face from a
slightly antero-lateral position. In our experience, the most important areas to focus
on are the nose and mouth, which should be the central points during volume acqui-
sition. The volume box should be large enough to include adjacent structures to the
face. It is important to emphasize a difference in viewing the profile in 2D and 3D
ultrasound: Figures 18.8 and 18.9 present two fetal profiles in which the 2D images are
acceptable. However, the 3D image of the face in Fig. 18.8 is not as good as the in
Fig. 18.9. In acquiring a good 3D image of the face, we recommend keeping the chin,
mouth, nose and forehead at a same horizontal level; otherwise, if the mouth area is
lower, the mouth-chin region will not be identifiable in 3D, as Figs. 18.8 and 18.9
demonstrate. The 3D effect is even more realistic if, in addition to the face, hands or
other structures can be observed together (Fig. 18.10).
After a volume is acquired, a few steps undertaken in volume manipulation can
significantly improve the final result (also refer to Chapter 3). The 3D volume is first
Fig. 18.8: 3D static acquisition of a fetal profile with mouth and chin low in the image, meaning
that the distance from the surface to the chin is long, whereas the distance to the forehead is short
(left). The result in 3D demonstrates that the mouth-chin area cannot be optimally observed (see the
difference compared to Fig. 18.9).
Fig. 18.9: 3D static acquisition of a fetal profile with the face almost horizontal to the mouth, chin
and forehead, and almost at the same level in 2D (left). The distance from the transducer to the chin
and to the forehead is similar, resulting in a good 3D picture of the face, especially the mouth and
chin area, as compared to the previous figure.
Fig. 18.10: Most facial images are manipulated with the Magicut tool to improve the image. Here are
two examples. In the upper images, the structures in front of the hand and behind the head were
erased. In the lower images, the primary result (left) is acceptable but the nuchal cord might bother
the mother and can easily be removed with Magicut (right).
fixed and “unneeded” structures are removed with Magicut (Fig. 18.10). In some cases
modifying the level of gain and threshold can help in reducing obstructing or disturb-
ing artifacts. An almost natural effect is achieved by selecting HD-live smooth, which
lends the surface a soft skin tone. Moreover, the rendered image can be processed with
a softening filter by increasing both the shadow level and the transparency. The posi-
tion of the light source can be adjusted to lighten the face from the top rather than the
front (see Fig. 3.15). Figures 18.11 and 18.12 present a collection of images that were
acquired and manipulated in the manner explained earlier. The intensive use of
Magicut and other functions is only possible to a limited extent in a 4D examination
due to the fact that the images are permanently changing while the fetus is moving. In
a live 4D exam, the examiner is mainly concentrating on other details of the face, such
as the opening of mouth or eyes, the facial expressions or the hand movements in
front of the face. Figures 18.13 and 18.14 illustrate examples of changes in fetal facial
expressions as observed in a sequence of subsequent images from 4D volumes. The 4D
examination is of particular interest in the third trimester, when features and grimaces
become more explicit (Fig. 18.13). In the third trimester, the fetal physiognomy appears
very realistic and close to neonatal features. Figure 18.15 illustrates five 3D fetal pro-
files after 28 weeks’ gestation that emphasize the differences in fetal faces. Figure 18.16
demonstrates the similarities between two fetal faces and their respective neonatal
Fig. 18.11: Collection of 3D face images in surface mode around 20–25 weeks’ gestation. Different
facial expressions are evident, and at this gestational age, the orbit region frequently appears to
exhibit mild exophthalmia, which is normal. The eyes are always closed.
Fig. 18.12: A typical behavior in fetuses is holding the hand in front of the head and face, which can
be visualized well in both 3D and 4D.
Fig. 18.13: A small series of images from a cine loop of 4D volumes illustrating two fetal facial expres-
sions. The upper panel shows the fetus smiling, while the lower panel shows the fetus grimacing.
Fig. 18.14: During a 4D examination, it is often possible to observe facial expressions such as

yawning, swallowing, showing the tongue, smiling, sucking the thumb, thinking and opening
the eyes.
Fig. 18.15: In the 3rd trimester after ca. 28 weeks’ gestation, fetuses start to acquire their own per-
sonal facial features. The shape of nose and mouth, the facial proportions and the thickness of the
cheeks lends the face its typical features, which resemble the postnatal appearance. Here we can
observe the profile of five fetuses with different features. The parents often compare the images
with a previous child or themselves.
Fig. 18.16: Comparison of a profile of two 3rd trimester fetuses in 3D with the postnatal profile.
Forehead, nose and mouth are often identical pre- and postnatally.
appearance. The assessment of the lateral part of the face with cheek and ear can also
be a part of the 3D assessment of the face, and are discussed in the next section.
18.4 The abnormal face in 3D/4D
From the very outset of the use of 3D sonography, there has always been significant
interest in the demonstration of facial dysmorphism. In addition to specific facial fea-
tures in 2D, 3D surface mode rendering is still the main 3D display used for this assess-
ment. This mode makes a good demonstration of the proportions of the face and its
different regions possible, such as the forehead, the eyes, nose, mouth, chin and ears.
Using this approach, abnormal conditions such as microcephaly, macrocephaly
(Fig. 18.17), facial anomalies (Figs. 18.18, 18.19), different types of cleft lip and palate
(Fig. 18.20), skin tags (Fig. 18.21), trisomy 21 (Fig. 18.22) and other dysmorphic features
such as Pierre-Robin syndrome or the flat profile in Binder syndrome (Fig. 18.23) can
Fig. 18.17: Fetuses with abnor-

mal head shape and size. The
fetus on the left has a micro-
cephaly and the fetus on the
right has a macrocephaly in
Apert syndrome (also refer to
Fig. 18.19). Note the dispropor-
tion between the forehead and
the middle face.
Fig. 18.18: A fetus with severe facial anomalies involving eyes, nose and mouth in association with
holoprosencephaly; the fetus on the left exhibits a proboscis, the fetus in the middle cyclopia and
otocephaly and the fetus on the right fetus exhibits arrhinia, median cleft and hypotelorism.
(a) (b)
(c) (d) (e)
Fig. 18.19: A fetus with Apert syndrome at 23 weeks’ gestation with coronal suture synostosis and
wide metopic sutures. The typical characteristics of this abnormality are recognizable in these
images: (a) profile in 2D with turricephaly, (b) frontal bossing, (c) macrocephaly with hypertelorism
and exophthalmia, (d) increasing transparency demonstrating wide metopic suture. In (e), the fetus
has its hand in front of its face, and the typical “mitten-hand” is identifiable.
(a) (b) (c)
(d) (e) (f)
Fig. 18.20: Fetuses with different facial clefts (arrows): Unilateral cleft lip (a) and (d), mediolateral
cleft lip and palate in (b) and (e) and medial cleft lip and palate in (c) and (f).
Fig 18.21: Left: Fetus with a neck lymphangioma, clearly observable with the surface mode.
Right: Fetus with tags on the left cheek.
Fig. 18.22: Frontal view of the face in 3D surface mode in two fetuses with trisomy 21. A few fetuses
are notable due to their opened mouth (images left). One of the interesting features is the propor-
tion of nose and mouth with a small nose and microstomia. Nose and mouth have the same width as
compared to normal fetuses, where mouth is larger than the nose width.
Fig. 18.23: Fetuses with facial dysmorphism in 2D and 3D. Upper images: Fetus with a Pierre-Robin
syndrome. The finding is very recognizable in 2D (upper left). A line from the chin to the upper
lip has a course far from the forehead and can be used in the 3D image of the face as well. Lower
images: Fetus with middle face hypoplasia suspecting Binder syndrome or Binder face. The underly-
ing etiology can be different but most commonly it is a chondrodyplasia punctata. In this case, there
was a chromosomal anomaly.
be clearly demonstrated and identified. In this chapter, the reader can compare normal
faces in 3D in Figures 18.8 to 18.16 with abnormal faces in Figures. 18.17 to 18.24.
The demonstration of the cheek and the ear, which are not clearly observable in
2D ultrasound, has become also part of the 3D evaluation of the face, under both
normal and abnormal conditions (Figs. 18.21, 18.24, 18.25). Figure 18.25 illustrates
examples of normal and abnormal findings of the ears.
Fig. 18.24: Fetus with a tumor of the eye and orbit in orthogonal mode (left) and in 3D surface mode
(right).
(a) (b) (c) (d)
(e) (f) (g) (h)
Fig. 18.25: The ears also can provide variants that can be visualized well in 3D. Normal ears in the
upper images in (a) to (d). In the lower panel of images, abnormal ears are illustrated in (e) small ear
in trisomy 21, in (f) a dysplastic ear and in (g) and (h) a microtia in syndromic conditions.
18.5 The facial bones in 3D/4D
The facial bones can be best demonstrated in maximum mode (see Chapter 7). The
volume acquisition can be performed either in static 3D, in 4D or in VCI-Omniview
mode. Prerequisites for optimal bone visualization in 3D are the reduction of the gain
and the increase of contrast in 2D before volume acquisition. The volume is acquired
either from a sagittal view or a lateral insonation of the face depending on the region
to be displayed. To better highlight the bones in maximum mode, VCI-Omniview slice
thickness should be selected around 15–20 mm.
In a frontal view of the face in maximum mode, both frontal bones are identifiable
with the metopic suture, the two orbits, nasal bone, maxilla and the mandible
(Fig. 18.26a). Figures 8.15, 17.19 and 18.26 reveal normal and different abnormal findings
in this view. It is also possible to visualize the profile by rotating this view. A lateral
insonation and acquisition can visualize the cranial bones with maxilla and mandible
(Figs. 4.9, 4.15, 8.17,17.20,17.21). The reverse face view, a view of the face from behind
(Fig. 18.27) was introduced as a novel view for the assessment of facial clefts (Fig. 18.28).
(a) (b) (c)
(d) (e) (f)
Fig. 18.26: Bony face displayed in maximum mode; (a) a normal fetus with the typical landmarks
as the metopic suture (1), nasal bone (2), orbitae (3), maxilla (4), and mandible (5). By comparison,
fetuses from (b) to (f) exhibit abnormalities of the bony face as b) fetus with craniosynostosis (here
in Apert syndrome) with wide metopic suture, (c) with synostosis of the metopic suture, (d) fetus
with absent nasal bone, (e) fetus with mediolateral cleft lip and palate and (f) fetus with left-sided
microphthalmia with different size of orbits.
18.5 The facial bones in 3D/4D 235
Fig. 18.27: Reverse face view in a normal fetus. This approach demonstrates the face from the inside.
The projection line is placed in the face with a view from inside to outside.
Fig. 18.28: Reverse face view in a fetus with mediolateral cleft lip and palate.
18.6 Conclusions
Despite the wide range of different displays on offer in volume ultrasound, 3D and 4D
visualization of the fetal face is still the most commonly performed examination and is
still the first 3D image that an examiner learns to perform. Facial anomalies can be dis-
played quite well in multiplanar mode, but 3D surface rendering provides a spatial view
of the face that is often very similar to the postnatal image. A prerequisite for a good 3D
image is using a good preset in grayscale 2D prior to acquisition, a large box that includes
adjacent structures such as limbs and a good laterally conducted facial insonation rather
than from the front. A step-by-step manipulation of the 3D image with Magicut, with
different surface modes and smooth skin then enables the demonstration of a very real-
istic image. Facial features and grimaces become more apparent in the third trimester and
are best visualized with 4D ultrasound. Facial anomalies, such as facial clefts or anoma-
lies of the eyes, nose, lips and ears or some syndromic conditions, can be visualized in 3D
quite well, but in general this is an augmentation of the information demonstrated in 2D.
19 3D Intrathoracic and Intraabdominal Organs
19.1 Introduction
In the previous chapters, the applications of 3D and 4D in fetal echocardiography,

neurosonography and in the examination of the fetal face and fetal skeleton have
been discussed. The examination of the intraabdominal and intrathoracic organs
under normal and abnormal conditions can also be achieved using different 3D
modes as have been presented in the Chapters 1–15. It is generally agreed that a
finding demonstrated in the tomography mode provides better documentation than
a single image or a collection of single images. In abnormal findings, a 3D volume
rendering often provides a better picture on the extent of the finding than is possible
in 2D. In this chapter, we discuss the potential applications of using different 3D
tools for the intrathoracic and intraabdominal organs, summarized in tables and
illustrated with examples.
19.2 Intrathoracic organs
The typical anomalies affecting the intrathoracic organs (without the heart) include
a congenital diaphragmatic hernia mainly focusing on the shifting of the intratho-
racic organs (Figs. 19.1–19.3) and the demonstration of the different lung sizes with
the hypoplastic lung on the ipsilateral site. Lung anomalies as the congenital cystic
adenomatoid malformation (CCAM) (Fig. 19.4), the bronchopulmonary sequestration
(Figs. 19.5–19.9) and other cystic lesions also can be visualized using 3D. In hydrotho-
rax, the extent of the lesion can be better assessed and documented with 3D ultra-
sound (Fig. 19.10) and the volume can be calculated with VOCAL or Sono-AVC.
Tomography mode is the best 3D tool for documenting a lesion with its adjacent
organs, but the new biplane mode visualized with the electronic probe (see Chapter
14) provides a reliable overview on the extent of the lung lesion with its neighboring
organs during a live examination (see Fig. 14.25). Table 19.1 summarizes common
diagnoses affecting the intrathoracic organs with suggestions for possible 3D tools
that can be applied. Figures 19.1 to 19.10 illustrate examples of 3D visualization of
intrathoracic lesions.
Fig. 19.1: Left: In this fetus with a left-sided diaphragmatic hernia, the stomach (*) is left (L) in
the thorax and the heart (H) shifted to the right (R) in 2D. Right: In a coronal 3D projection, here
displayed in minimum mode, one can recognize stomach and heart side-by-side. Compare with a
normal finding in Fig. 9.4.
Fig. 19.2: A left-sided diaphragmatic hernia demonstrated in 3D tomography mode with the stomach
(*) adjacent to the heart (H). This can also be identified in the reference plane in the upper left image.
238 19 3D Intrathoracic and Intraabdominal Organs
Fig. 19.3: Axial view of the thorax in surface mode in two fetuses with a left-sided diaphragmatic
hernia. In the thorax, the heart is shifted to the right (R) and the right lung (RL) is able to be identi-
fied, but the stomach position (*) can be alternately be found either posterior or anterior to the left
side of the heart.
Fig. 19.4: An isolated cyst in the right thoracic cavity (arrow) demonstrated in tomography mode. This
is likely a bronchogenic cyst and surrounded with hyperechogenic lung tissue, but no additional cysts.
Fig. 19.5: Tomography mode for a fetus with a congenital cystic adenomatoid malformation of the
lung (CCAM). Arrows are pointing to the multiple middle-size cysts in one right lung lobe.
Fig. 19.6: Tomographic mode in a left hyperechogenic lung with suspected lung sequestration.
Fig. 19.7: Quantification of the volume of the hyperechogenic lung segment in the previous case
using the VOCAL tool (see Chapter 15).
Fig. 19.8: The lung lesion in the fetus is displayed with the orthogonal mode and reveals the extent
of the finding.
Fig. 19.9: The presence of a feeding

artery (arrow) from the descending
aorta (AO) is a typical finding in lung
sequestration. This finding is ideally
demonstrated with 3D glass-body mode
and HD-live flow; Heart (H).
Fig. 19.10: Left-sided hydrothorax (*) with the heart shifted to the right and compression of the left lung
(arrow). Left: Cranial view in minimum mode; in the images to the middle and right, a view from the left
side into the thorax with surface mode displayed in gradient light (middle) and in HD-live (right).
Table 19.1: Typical intrathoracic anomalies with the potential use of different 3D render modes.
Anomalies 3D Techniques
Congenital diaphragmatic hernia Tomography mode

Minimum mode
Surface mode
VOCAL for lung volume calculation
CCAM: Congenital Cystic Adenomatoid Malfor- Tomography mode

mation of the lung Minimum mode
Sono-AVC (cysts volume calculation)
Table 19.1: (Continued)
Bronchopulmonary Sequestration Tomography mode

Minimum mode
Glass-body mode for visualization of feeding vessel
Hydrothorax Tomography mode

Minimum mode
Surface mode
Sono-AVC (Fluid volume calculation)
19.3 Intraabdominal organs
19.3.1 The gastrointestinal tract
Anomalies of the gastrointestinal tract (GIT) include abnormal position of the stomach
(e.g., situs inversus), obstruction of the GIT (e.g., duodenal atresia, ileus) (Fig. 19.11,
19.12) and abdominal wall defects (Fig. 19.13–19.16). Intrahepatic anomalies mainly
Fig. 19.11: Tomographic mode with an antero-posterior view on thorax, diaphragm (arrow) and
abdomen with a dilated stomach and duodenum (*) in double bubble sign in a fetus with trisomy 21
at 27 weeks’ gestation. The double bubble sign can be better displayed with the volume rendering,
as illustrated in next figure; heart (H).
Fig. 19.12: Double bubble sign in duodenal atresia in minimum mode (upper left) and in inversion
mode with HD-live display (upper right). In the lower left panel, the stomach and duodenum are
displayed with Sono-AVC after volume calculation while in lower right image; the visualization with
the new silhouette tool is presented. The gallbladder (arrow) is also well-visualized in some of these
images.
Fig. 19.13: Omphalocele in a fetus at 12 and 16 weeks’ gestation in surface mode.

Fig. 19.14: Omphalocele in a fetus at 24 and 32 weeks’ gestation in surface mode.
Fig. 19.15: Gastroschisis in a fetus at 21 and 26 weeks’ gestation in surface mode rendering.

The later the gestational age the more dilated are the bowels (see next figure).
affect the intrahepatic vessels as the agenesis of the Ductus venosus or the interrup-
tion of the intrahepatic inferior vena cava with azygos continuation (see Chapter 12).
The presence of ascites, either isolated or as part of generalized fetal hydrops, can be
well documented with 3D either with tomography mode (Fig. 6.23) or even in surface
mode. Surface mode in ascites resembles the image of “virtual laparoscopy” as pre-
sented in Figures 19.17 and 19.18. Table 19.2 summarizes common diagnoses affecting
the GIT with suggestions for possible 3D tools that can be used. Figures 19.11 to 19.18
illustrate examples of 3D visualization of anomalies of the GIT.
Fig. 19.16: Gastroschisis in a fetus at 28 and then at 32 weeks’ gestation displayed in surface mode
and HD-live rendering. Bowels are often dilated in late gestation. In the third trimester (right), the
difference between small intestine (short arrow) and colon (long arrow) can be well recognized,
especially when highlighted with the silhouette tool; Knee (K).
Fig. 19.17: A fetus with ascites in 2D image (left) and in surface mode (right) with deep dynamic
rendering reminding a “virtual laparoscopy”. One can recognize the liver (L), bowel (short arrow)
and the bursa omentalis (*) quite well. The bowel and bursa cannot be easily differentiated (see
next figure). The long arrow points to the umbilical vein, which postnatally has its course on the liver
surface as ligamentum falciforme.
Fig. 19.18: The same fetus with ascites as in previous figure displayed in “virtual laparscopy” here in
HD-Live mode with low (left) and high (right) silhouette level. The bursa omentalis (*) appears more
transparent than the bowel (arrow); liver (L).
Table 19.2: Typical anomalies of the gastrointestinal system with the potential use of different 3D
render modes.
Situs inversus Tomography mode

Minimum mode
Duodenal atresia Tomography mode

Minimum mode und Inversion mode
Sono-AVC (Stomach-Duodenum Volume)
Omphalocele / Gastroschisis Tomography mode

Surface mode
Glass-body mode
Ileus Tomography mode

Minimum mode
Intrahepatic vessels Glass-body mode

Minimum mode
Ascites Tomography mode

Minimum mode
Surface mode
19.3.2 The urogenital System
Anomalies of the urogenital system include the obstruction of the upper and lower
urinary tract (Figs. 19.19–19.22), cystic dysplastic kidneys (Figs. 19.23–19.28), anoma-
lies of the renal anlage as pelvic kidney, horseshoe kidney and renal agenesis. Ovarian
cysts are additionally included in this group (Figs. 19.29–19.30) as well as the assess-
ment of the external genitalia. The latter can be well evaluated in 3D ultrasound,
Fig. 19.19: Bilateral pyelectasia with multiplanar mode using Omniview planes. The three lines were
placed to visualize the right and the left kidney in an anterio-posterior view, as well as in coronal
view (lower left panel).
Fig. 19.20: Fetus with a bilateral pyelectasia with the demonstration of the dilated renal pelvis with
minimum mode.
Fig. 19.21: Tomographic mode of an axial view of the abdomen in a fetus with a vesico-ureteral reflux
with hydronephrosis (arrow) and kinking of the ureter (U). The finding can be better appreciated in a
volume rendering display; Bladder (BL).
Fig. 19.22: A fetus with a vesico-ureteral reflux with hydronephrosis revealed in 2D image (left), in
inversion mode (middle and right images). The bladder (BL) and the dilated kinked ureter (U) can be
well recognized with the hydronephrosis (arrow) in this coronal view.
Fig. 19.23: A fetus with bilateral polycystic kidneys (arrows) in an autosomal recessive polycystic
kidney disease displayed in tomographic mode. Tomography rendering provides a good overview
of the extent of the finding.
Fig. 19.24: Volume Contrast Imaging of the A-plane (VCI-A) with contrast enhancement of the kidneys
(arrow) in the left fetus with a normal kidney and in the right fetus with an enlarged polycystic
kidney.
Fig. 19.25: A fetus with a multicystic kidney in multiplanar mode.
Fig. 19.26: A fetus from the previous figure with a multicystic kidney visualized in 3D rendering
modes as minimum and inversion mode. In the right panel the individual cysts were displayed and
calculated separately with Sono-AVC (see Chapter 15, continued in next figure).
Fig. 19.27: A fetus from the previous images with a multicystic kidney. The rendering is in inversion
mode and the display is in HD-live, but in the left panel, the light source has been placed behind the
kidney while in the right panel, the silhouette function has been activated.
Fig. 19.28: Multicystic renal dysplasia displayed in surface, in minimum, inversion and Sono-AVC mode.
Fig. 19.29: A fetus at 30 weeks’ gestation with an isolated cyst (arrows) localized in the low left
abdomen, beneath the stomach (*). The likely diagnosis in the female fetus is an ovarian cyst, dis-
played here in tomographic mode. The cyst is typical echolucent without echodensity signals inside
it. In the image to the right, the volume of the cyst was calculated with Sono-AVC. Compare with the
follow-up in the next figure.
Fig. 19.30: A fetus shown in the previous figure with an ovarian cyst (arrows); here four weeks later
with cyst hemorrhage.
Fig. 19.31: 3D surface mode in a male (a) and female fetus (b) and in two fetuses
with abnormal genitalia in (c) and (d).
which often enables a good differentiation between normal and abnormal findings
(Fig. 19.31). Table 19.3 summarizes common anomalies of the urogenital system with
suggestions for possible 3D tools that can be applied. Figures 19.19–19.31 illustrate
examples of 3D visualization of lesions of the urogenital system.
Table 19.3: Typical anomalies of the urogenital system with the potential use of different 3D render
modes.
Pyelectasis, hydronephrosis, pelviureteric junction Tomography mode

obstruction, vesico-ureteral reflux, duplex kidney Minimum mode
with ureterocele Inversion mode
Sono-AVC
Megacystis Tomography mode

Minimum- und Inversion mode
Surface mode
Table 19.3: (Continued).
Multicystic und polycystic renal dysplasia Tomography mode

Minimum mode
Inversion mode
Sono-AVC
Horseshoe kidney, pelvic kidney, Tomography mode

Omniview mode
Volume Contrast Imaging
Genital anomalies Surface mode

Tomography mode
Renal agenesis Tomography mode

Glass-body mode
Volume Contrast Imaging
19.4 Conclusions
The examination of the intrathoracic and intraabominal organs including the gastro-
intestinal and renal system can be achieved with both the multiplanar and volume
display. From a clinical point of view, the most important tool in abnormalities in
these regions is tomography mode, with the demonstration of the examined lesion in
its extent and with its surrounding anatomy. Moreover, in some specific conditions in
fluid-filled organs such as hydrothorax, ascites, duodenal atresia, hydronephrosis or
cystic kidneys, or, anomalies in body contours such as in omphalocele, gastroschisis
or abnormal genitalia others, volume displays can then provide a more complete
spatial view of the lesion.
20 STIC and 3D/4D Fetal Echocardiography
20.1 The sonographic assessment of the heart

in two-dimensional ultrasound
A fetal echocardiographic examination includes the demonstration and documenta-

tion of a series of planes, which include the axial section of the upper abdomen, the
four chamber view, the five chamber view, the short axis view, the three-vessel-trachea
view and if needed, longitudinal planes of the aortic arch, the ductal arch and the
veins. Improved diagnostic accuracy can be achieved by combining grayscale evalua-
tion with the color Doppler to demonstrate diastolic and systolic hemodynamics in the
cardiac chambers and vessels. While atria, ventricles and atrioventricular valves are
simultaneously visualized in the single four-chamber-view plane, the great vessels
can only be assessed by tilting the transducer to demonstrate their origin and their
spatial course and relationship to each other. The documentation of a cardiac exam-
ination for a later evaluation or for a second opinion still occurs in many places by
storing single images or video clips, the main limitation of which, however, is that
they only include what has been seen and recorded by the examiner. 3D/4D fetal echo-
cardiography offers important benefits for all the points outlined above, which are
explained below in this chapter.
20.2 Acquiring cardiac volumes
Acquiring a cardiac volume, as was already described in Chapter 1, can be performed

using static 3D, STIC or 4D with a mechanical or electronic transducer. Acquisition
type depends on the question to be answered and the methodology was already
explained in Chapter 1.
Static 3D acquisition This technique of 3D-acquisition is rapid and has a high-reso-

lution. However, wall and valve movements are the main limitation for fetal heart
examinations, as they produce movement artifacts. Despite this limitation, a volume
with good resolution often provides acceptable information on the anatomy of the
chambers and the great vessels, provided the information needed does not depend on
wall movements, as is the case in valve atresia or hypokinesia. These can be reliably
assessed by viewing the static 3D size of cardiac structures and their relationships to
each other. Static 3D cannot be reliably combined with color Doppler, since direction
of blood flow is dependent on the phase of the cardiac cycle. The authors prefer the
use of power Doppler in static 3D acquisition, given its uniform color display, espe-
cially to demonstrate the course of the vessels.
256 20 STIC and 3D/4D Fetal Echocardiography
STIC volume acquisition The best cardiac volumes are acquired with STIC technique
and these can be ideally used for off-line evaluation of fetal cardiac structures and
movements. STIC volume acquisition can occur in combination with a grayscale
(Fig. 20.1), color Doppler (Fig. 20.2), power Doppler, and B-Flow modes. Prior to
volume acquisition it is recommended that the examiner optimize the color to clearly
Fig. 20.1: STIC volume of a heart displayed in the three orthogonal planes A, B and C,
Fig. 20.2: STIC volume in color Doppler displayed in the three orthogonal planes A, B and C.
20.3 Fetal echocardiography in 3D/4D multiplanar reconstruction 257
visualize flow events in heart and vessels (see Chapter 1). The starting plane for the
acquisition mainly depends on both the question of interest and the result expected.
Volumes acquired for the demonstration of cardiac cavities can be best acquired start-
ing from the four- or five-chamber-plane, whereas volumes for the assessment of the
positions of the great vessels and their course are accquired from an axial plane of the
upper mediastinum. A longitudinal or oblique acquisition is recommended if the
aortic or ductal arch or the abdominal vessels are to be visualized.
4D acquisition with an electronic matrix transducer: With this probe, the 4D

examination can be performed in almost “real-time” with the display of 20–30 volumes
per seconds. The 4D examination can be performed in different rendering modes as
the orthogonal or tomographic modes or in 3D volume rendering displays. The combi-
nation with color Doppler is possible, but the frame rate is often too low. An interest-
ing combination is the combination of 4D with VCI-A (see chapter 4), which displays
an image with high-contrast as the result of a thin slice scanning instead of a large 4D
volume or a single 2D plane. 4D with a matrix probe can be used in arrhythmia. The
combination of 4D with different 3D render modes such as color Doppler or inversion
mode should make this technique interesting for new applications in the future.
20.3 Fetal echocardiography in 3D/4D multiplanar reconstruction
The ultrasound examination of a fetal heart consists on the visualization of different

cross-sectional planes that are close to each other and demonstrating the typical
structures of interest. These planes can be generated from an acquired volume and
displayed in either orthogonal (Figs. 20.1, 20.2) or tomography mode (Figs. 20.3–20.5)
or by using few selective Omniview planes (Figs. 20.6, 20.7). The combination with
color Doppler enables the assessment of systolic and diastolic events in the cardiac
chambers and great vessels. Any cross-sectional plane can be reconstructed from a
good digital static 3D or STIC volume. Also, in STIC volume, a single hypothetical
cardiac cycle is stored as an infinite loop. A STIC volume can be visualized in slow
motion and stopped at any phase of the cardiac cycle, enabling a detailed analysis of
different phases of the cardiac cycle (Fig. 20.8). The intracardiac hemodynamic
changes can be particularly well analyzed in STIC volumes acquired in combination
with color Doppler. Since the complete heart is included in a digital volume any sec-
tional plane (“plane of interest”) can be reconstructed off-line. This allows the previ-
ously described typical planes to be extracted from the volume and the needed cardiac
examination can be virtually performed. Extracted images can be demonstrated in
one of the multiplanar render mode displays as single, orthogonal, tomographic or
Omniview planes. The quality of the reconstructed images in grayscale can be slightly
increased by adding VCI or SRI tools (see Chapter 4). In several clinical studies, it was
demonstrated that such volumes allow a reliable off-line diagnosis and therefore can
Fig. 20.3: STIC volume in tomographic mode presenting different planes, such as the abdomen with
stomach (*), heart in the four-chamber view and aorta (Ao) with pulmonary artery (PA) in the upper
mediastinum; left ventricle (LV), right ventricle (RV).
be sent to obtain a second opinion or be used in teaching fetal echocardiography. This

approach is ideal, especially for teaching purposes, because a cardiac examination
can be simulated on a STIC volume and the examiner can learn how to place the
typical sectional planes to obtain the information revealing the diagnosis by working
on volume samples of cardiac anomalies. In the Figs. 20.1 to 20.11, some examples of
normal and abnormal hearts are presented in different multiplanar mode displays.
The examination of the heart with biplane mode offers important additional informa-
tion and was already discussed in Chapter 14.
20.4 Fetal heart in 3D/4D volume rendering
Similar to the imaging of a fetal face in surface mode, heart volumes can also be recon-
structed in different 3D rendering modes. The rendering can focus on the demonstra-
tion of the surface of the walls and lumen in the ventricles or the great vessels or
highlight the visualization of blood flow in the heart and the corresponding vessels.
Following rendering modes are generally used:
In surface mode, the examiner can emphasize the demonstration of the interface
between the cardiac cavities and walls. For methodological aspects, please refer to
Fig. 20.4: STIC volume in tomographic mode with the most important planes as four-chamber-view,
Five-chamber-view and three-vessel-trachea view.
Fig. 20.5: STIC volume in tomographic mode in color Doppler in diastole with the filling of the right
(RV) and left (LV) ventricle and systole with the visualization of aorta (Ao) in five-chamber-view and
aorta and pulmonary artery (PA) in the three-vessel-trachea-view.
Fig. 20.6: STIC volume in Omniview display: In the reference plane (upper panel left) where the heart
is seen in a sagittal view the Omniview lines are placed at typical levels demonstrating the four-
chamber-view (Plane 1, upper panel right), the five-chamber-view (Plane 2, lower panel right) and
the three-vessel-trachea view (Plane 3, lower panel left).
Fig. 20.7: STIC volume in Omniview mode in color Doppler. A curved line was drawn and placed
directly in front of the atrioventricular (AV) valves and great vessels. The effect in image b) reveals
the flow across both AV valves in the right (RV) and left (LV) ventricle. The great vessels lie typically
in a position that aorta (Ao) is embedded between both AV-valves and the pulmonary artery (PA)
slightly to its right.
(a) (b)
Fig. 20.8: STIC volume with the visualization of the four-chamber-view. With a STIC volume each
phase of the cardiac cycle can be selected and here reveals the systole (a) and diastole with open
valves (b).
Fig. 20.9: STIC volume in tomographic mode, illustrating a fetus with dextrocardia with heart on the
right (arrow) and stomach (*) left-sided and the cardiac axis pointing the right (R); left (L).
Fig. 20.10: STIC volume in tomographic mode in color Doppler shows in this fetus in comparison to a
normal finding (Fig. 20.5) a transposition of the great arteries with a parallel course (arrows) of aorta
(Ao) and pulmonary artery (PA); right ventricle (RV), left ventricle (LV).
Fig. 20.11: STIC volume in tomographic mode in color Doppler in systole in a fetus with pulmonary
stenosis. aorta (Ao) arising from the five-chamber view appears normal, but a turbulent flow (circle)
can be identified across the pulmonary artery (PA).
Chapter 7. Figures 20.12–20.14 illustrate normal and abnormal findings in the four-
chamber view.
An interesting reconstruction is possible using minimum mode that resembles a
projection of an X-ray image (Fig. 20.15). This particular method was extensively
explained in Chapter 9. The use of this rendering mode has become less common in
recent years, mainly due to the advent of other more sensitive 3D rendering modes.
A much more plastic image is displayed when using inversion mode rendering.
The heart can be displayed like a 3D digital casting with the visualization of the cham-
bers and great vessels, as was already explained in Chapter 10 and illustrated in
Figs. 10.1–10.3. This mode allows viewing the spatial course of the great vessels, as
indicated in Fig. 20.16.
Glass-body mode alone (Fig. 20.17) or in combination with the HD-live flow func-
tion (Fig. 20.18) (also refer to Chapter 12) enables the examiner to make the best spatial
visualizations of blood flow in the ventricles and the great vessels. Anomalies in the
ventricular plane (Fig. 20.19) as well as the spatial course of the great vessels
(Figs. 20.20–20.22) can be demonstrated using this approach. This mode can be well
used in cases with abnormal courses of the great vessels, such as a right or double
aortic arch or in transposition of the great vessels, but also in hypoplastic vessels or
vessels with an atypical course.
An interesting application is provided by the combination of B-flow (Chapter 13)
with static 3D or STIC. The sensitive signals of blood flow that are demonstrated with
Fig. 20.12: STIC volume with the four-chamber-view demonstrated in surface mode rendering. The
projection line (“green line”) is placed over the chambers and under the origin of the aorta.
(a) (b) (c)
Fig. 20.13: STIC volume of the four-chamber view in surface mode rendering: In the normal heart (a)
both right (RV) and left (LV) ventricle and right (RA) and left (LA) atria are well seen. The fetus (b) has
an atrioventricular septal defect (AVSD) (*) and the fetus c) an Ebstein’s anomaly where the tricuspid
valve has a lower insertion in the RV (arrow)
(a) (b) (c)
Fig. 20.14: STIC volume of the four-chamber view in surface mode rendering in a normal heart (a)
showing both right (RV) and left (LV) ventricle and right (RA) and left (LA) atria. In comparison the
fetus in (b) has a hypoplastic left heart syndrome (HLHS) with a small LV and the fetus (c) a hypoplas-
tic RV in tricuspid atresia with ventricular septal defect (TA+VSD).
(a) (b)
Fig. 20.15: STIC volume and minimum mode rendering as demonstrated in a fetus (a) with trans-
position of the great arteries (TGA), with the aorta (Ao) arising from the right (RV) and the pulmonary
artery (PA) from the left ventricle (LV). Fetus (b) has a double outlet right ventricle (DORV) and both
Ao and PA are seen to arise from the RV.
(a) (b)
Fig. 20.16: STIC in a fetus with transposition of the great arteries (TGA), with the aorta (Ao) arising
from the right ventricle (RV) and the pulmonary artery (PA) displayed in surface mode (a) and in
inversion mode (b).
(a) (b)
Fig. 20.17: Color-Doppler STIC volume in glass-body mode rendering. The left and right panels reveal
that, depending on the position of the projection line (arrows), a different result can be obtained.
In the left panel (a), the green line is placed under the origin of the aorta (upper left) and only the
four-chamber-view in diastole is visualized here. In the right panel (b), the projection line has been
placed over the great vessels (upper right) and in the rendered image one recognizes both the four-
chamber-view in the background and the great vessels in the front.
Fig. 20.18: A similar display of a normal heart as seen in Fig. 20.17, but here with the use of the
HD-live flow tool with a light source. The light-dark effect with shadowing has the ability to increase
the perception of a 3D effect. Compare with images of abnormal hearts in Figs. 20.20–20.22.
(a) (b) (c)
Fig. 20.19: A fetus with an atrioventricular septal defect in systole (a) with closed valves, in diastole
with open valves (b) with the defect (*) clearly visible. In (c) with color Doppler and HD-live mode,
blood flow is illustrated streaming from both atria into the ventricles across the large central defect
(*); right and left atrium (RA, LA), right and left ventricle (RV, LV).
Fig. 20.20: STIC with color Doppler and glass-body mode rendering with HD-live flow with a view
from left lateral on the great vessels. In a normal finding (left), the crossing of the aorta (AO) and
pulmonary artery (PA) is clearly visible in the lateral view merging into the descending aorta (AOD).
The fetus in the center has a pulmonary atresia with a reverse flow in the tortuous Ductus arteriosus
(DA). On the right, we see a fetus with hypoplastic left heart syndrome; the reverse flow is clearly
visible in the tiny aortic isthmus.
Fig. 20.21: STIC with color Doppler and glass-body mode rendering with HD-live flow with a view
from the mediastinum on the great vessels in a fetus with a right aortic arch. In the image on the
left, the trachea (arrow) can be observed between both the aortic arch (Ao) on the right and the pul-
monary artery (PA) on the left on a plane in color Doppler. In the 3D display on the right image, the
spatial demonstration of the course of the great vessels better illustrates the course of the vessels
merging into the descending aorta.
Fig. 20.22: STIC with color Doppler and glass-body mode rendering (left) and in combination with
HD-live flow (right) in two fetuses with a transposition of the great arteries (curved arrows). See the
explanation in Fig. 20.16.
B-flow are not only ideal for visualizing large, but also small vessels, such as the pul-
monary arteries and veins. In our experience, however, we have found that 3D/4D in
combination with B-flow is more complicated to use as compared with other modes
and we prefer to use the previously described HD-live flow with 3D or STIC for the
spatial visualization of tiny vessels.
The calculation of volumes using VOCAL or Sono-AVC offers interesting applica-
tions for the calculation of ejection fraction and other volumes, but it is still mainly
used in research units rather than in actual clinical practice.
20.5 Conclusions
The 3D/4D examination of the heart has revolutionized fetal echocardiography. The
significant advantage lies both in the spatial visualization of a heart with the great
arteries as well as in the offline manipulation of heart volumes in order to virtually
reconstruct any needed sectional plane. To extend the use of 3D and STIC on the fetal
heart, efforts should be made in facilitating the acquisition and the compression of
volumes and in the improvement on the automatic detection of landmarks within a
cardiac volume in order to effectively use a software like the Sono-VCAD on routine
scan.
21 3D in Early Pregnancy
21.1 Background
The widespread introduction of first trimester nuchal translucency screening between

11 and 14 weeks’ gestation has led to an increased interest in ultrasound screening in
early gestation. The use of high-resolution transabdominal and transvaginal trans-
ducers has opened a new time window in the diagnosis of fetal malformations in early
gestation. From the first sonographic evidence of cardiac activity and until 14 weeks
of gestation, the brain, heart, face, extremities and other organs can be examined
during early development. During this period, the 3D visualization of the whole fetus
is possible using surface and other rendering modes, which offer additional imaging
possibilities, as discussed later in this chapter. The fetus can be visualized transab-
dominally (Fig. 21.1a) but a better resolution is achieved with transvaginal ultrasound
(Fig. 21.1b). With the exception of figures 21.1a and 21.2, all other images in this chapter
were acquired using 3D transvaginal ultrasound. As discussed in other chapters, dif-
ferent rendering modes can also be applied in early gestation (Fig. 21.2).
21.2 3D volume rendering in early gestation
The use of the surface mode is the most commonly used 3D rendering mode in early
gestation, as it makes the optimal visualization of the developing embryo and fetus
possible. Images acquired using 3D surface mode of the embryo are currently similar
to photographic images and drawings from embryology as demonstrated in Fig. 21.3.
(a) (b)
Fig. 21.1: 3D surface mode providing a picture of the complete fetus at 12 weeks’ gestation by trans-
abdominal (a) and transvaginal (b) examination. The image on the right has a higher resolution.
270 21 3D in Early Pregnancy
Fig. 21.2: A fetus after transabdominal examination with surface mode and different rendering
modes. The modes used from left to right are: gradient light, HD-live mode, HD-live mode with
silhouette, HD-live mode with silhouette with back light source.
(a) (b) (c) (d)
Fig. 21.3: Development of the embryo between 7 and 10 weeks’ gestation with increasing crown-
rump length from 16 mm (a), 21 mm (b), 29 mm (c) to 36 mm (d).
As early as 11 weeks’ gestation, the integrity of the fetus along with the proportions of
the head, trunk, extremities and other details can be reliably demonstrated. Figures 21.4
and 21.5 illustrate fetuses between 11 and 13 weeks’ gestation. Severe anomalies affect-
ing the body surface can be immediately recognized in 3D by clinicians and patients as
well, but caution is recommended when relying solely in 3D image before a compre-
hensive evaluation is obtained in 2D imaging. Figures 21.6 and 21.12 present examples
of normal fetuses and fetuses with thickened nuchal translucency, omphalocele, spina
bifida, facial anomalies, and arm and leg malformations. Care is advised in assessing
the gender in 3D ultrasound in early gestation, as male and female genitalia can appear
similar and thus lead to erroneous predictions. 3D ultrasound plays a critical role in
Abb. 21.4: Different fetuses between 11 and 13 weeks’ gestation examined transvaginally
with 3D surface mode and gradient light display.
Fig. 21.5: Different fetuses between 11 and 13 weeks’ gestation in 3D surface mode and HD-live mode
display
Fig. 21.6: Neck region (arrows) in surface mode in three different fetuses. Left: Normal appearing
neck. Middle: thickened nuchal translucency, Right: Nuchal hygroma. The fetus in the middle image
had a rare chromosomal aberration and the fetus on the right, Turner’s syndrome.
Fig. 21.7: Surface mode in two fetuses at 12 weeks on the left with a closed anterior abdominal wall
(arrow) and on the right with an omphalocele (arrow).
Fig. 21.8: Two fetuses with omphalocele (long arrow). The fetus on the left has a normal looking
hand, while the fetus on the right exhibits the typical finding of a radius aplasia, in both cases at
high-risk for the presence of a trisomy 18.
Fig. 21.9: Back region of two fetuses at

12 weeks in surface mode. The fetus on
the left has a normal looking back, while
the fetus on the right has an open spina
bifida with myelomeningocele.
(a) (b) (c)
(d) (e) (f)
Fig. 21.10: A fetal face in normal fetuses at 12–13 weeks’ gestation (a–c) and in abnormal head and
face (d-f). The aspect of the anterior face with eyes, nose, mouth and ears is well recognized in the
upper images (a–c). In the lower panel, the abnormal fetuses are well recognized with anencephaly
(d), with facial anomaly in holoprosencephaly with hypotelorism, cebocephaly and low position of
the ear (e) and in (f) in a fetus with facial dysmorphism with cleft lip and palate.
ruling out major fetal malformations in early gestation in pregnant women with a
history of prior severe fetal malformations. In anomalies with fluid accumulation in
the body, 3D surface mode can also be used in combination with increased transpar-
ency mode for a better demonstration of the severity of the lesion, as illustrated in
Figs. 11.5 and 21.13. In multiple pregnancies, fetuses can be visualized well along with
surrounding structures. Monochorionic and dichorionic twin pregnancies demon-
strate different thickness of the amniotic membranes and can be well differentiated,
(a) (b) (c) (d)
Fig. 21.11: Fetal hand in surface mode between 11 and 13 weeks. The images reveal: (a) normal hand,
(b) hand with lower arm in radius aplasia, (c) brachydactyly (short fingers) in a case of autosomal
dominant inheritance from the mother, (d) the absence of the hand in a fetus with trisomy 21.
Fig. 21.12: Legs in surface mode; left: Fetus with normal legs, middle: Fetus with abnormal leg in
context of caudal regression, right: Distal defect of the leg in a fetus with femur-fibula-ulna complex.
but the diagnosis is more reliable performed in 2D ultrasound with the lambda- and
T-signs. 3D examples of abnormal twin pregnancies, such as a TRAP sequence or con-
joined twins are presented in Fig. 21.16 and can be diagnosed in one glance.
Maximum mode is infrequently applied in early gestation due to the reduced level
of ossification in the fetal skeleton and the rare diagnosis of skeletal disorders.
Figure 21.17 provides an example of maximum mode with demonstration of the spine
in a normal and abnormal fetus.
One of the interesting applications for 3D sonography in the embryonic and early fetal
period appears to be the demonstration of brain structures under normal and abnor-
mal conditions (see Chapter 15). While minimum mode is rarely applied in these con-
ditions, the inversion mode can be used to visualize the intracerebral ventricular
system in early gestation (Fig. 21.18). Other tools used include Sono-AVC or the new
silhouette technique (Fig. 21.19) (also refer to Chapter 11), with a potential for more
clinical applications in the future.
Fig. 21.13: Fetuses with fluid accumulation in the body. Upper panel: Fetus with megacystis and
dilated abdomen and the right image demonstrates an opening of the abdomen with Magicut,
revealing a dilated bladder (arrow). In the lower panel to the left, one recognizes an intrahepatic cyst
in this fetus displayed in a transparency silhouette mode, while the right image presents the cyst
after being opened with Magicut (arrow).
Fig. 21.14: Dichorionic diamniotic twin pregnancy at 10 weeks with a thick separating membrane
(arrows) between both cavities displayed in surface mode and silhouette (compare with Fig. 21.15).
Fig. 21.15: Monochorionic diamniotic twin pregnancy at 11 weeks with a thin separating membrane
between both cavities displayed in surface mode with silhouette (compare with Fig. 21.14.).
Fig. 21.16: Discordant monochorionic twin pregnancies at 11 weeks. Left: The image presents an
acardiac twin (arrow) in a TRAP sequence, where TRAP stands for Twin-Reverse-Arterial-Perfusion.
Right: Typical 3D surface mode image of thoracopagus as one type of conjoined twins.
Fig. 21.17: Fetal spine in maximum mode left in a normal fetus at 13 weeks and in the right figure in a
fetus at 12 weeks with deviated spine in a body-stalk anomaly.
Fig. 21.18: Intracerebral ventricular system of a fetus at 9 weeks in orthogonal mode and static VCI
(left) and in inversion mode (right); lateral ventricle (LV), 3rd ventricle (3V), Rhombencephalon (Rb).
Fig. 21.19: Intracerebral ventricular system of a fetus at 8 weeks (left) and 9 weeks (right) displayed
with silhouette; lateral ventricle (LV), 3rd ventricle (3V), Rhombencephalon (Rb).
21.3 Multiplanar display in early gestation
If a high-resolution image is needed in early gestation, especially in 3D multiplanar

reconstruction, acquiring the volume using the transvaginal approach is recom-
mended. Given that embryos and fetuses infrequently are positioned and presented in
an optimum position in order to visualize all of the anatomic structures in 2D ultra-
sound, the acquisition of 3D volumes and the reconstruction of planes can be of sig-
nificant help (see Figs. 5.1–5.4). This can be achieved by a static 3D scan with the mul-
tiplanar, tomographic or Omniview reconstruction of one or more section images. This
principle was explained earlier in Chapters 5 and 6.
Using tomography mode, the examiner is able to present the complete anatomy of
the fetus in one display, thus documenting intracranial anatomy, face and eyes, nose
and mouth, chest with heart position, stomach, abdominal wall, kidneys and urinary
bladder as well as the limbs. Such a reconstruction cannot be always used for the mea-
surement of the nuchal translucency (as illustrated in Fig. 5.4). On the other hand, in the
presence of a thickened nuchal translucency or a cystic hygroma, multiplanar recon-
struction can provide reliably an image of a midsagittal view to document the severity
of the finding. The fetal spine, the limbs, the profile and the internal organs such as
lungs, diaphragm, kidneys and others can be well reconstructed in the sectional planes.
The brain is probably the best organ to examine, starting at 7 weeks gestation and using
multiplanar mode. One can then follow brain development in a step-by-step fashion
into the early second trimester. Figures 21.20–21.25 illustrate examples of the use of the
multiplanar orthogonal and tomographic mode in early gestation under normal and
abnormal conditions and Fig. 21–26 is an example on the use of STIC with color Doppler.
Fig. 21.20: Fetuses with anomalies (arrow) displayed in a reconstructed cross-sectional plane in

multiplanar mode and enhanced with VCI-mode. Upper left: A fetus with omphalocele; upper right,
a fetus with nuchal hygroma; lower left, a fetus with anencephaly; and lower right, a fetus with
megacystis.
Fig. 21.21: A fetus at 12 weeks’ gestation with hydrothorax (*) in 2D (left) and in tomographic mode
(right).
Fig. 21.22: Intracranial structures in multiplanar orthogonal mode with normal brain anatomy.
Intracranial translucency (*), slim brain stem (double arrow) and two separated thalami (T) are well
recognized.
Fig. 21.23: Intracranial structures in multiplanar orthogonal mode in a fetus with an open spina
bifida. The posterior fossa is abnormal with a typically thickened brain stem (double arrow) and
almost absent cerebrospinal fluid with no typical intracranial translucency (compare with Fig. 21.22).
Fig. 21.24: The tomographic mode of a fetus with holoprosencephaly reveals the absent falx cerebri with
the fused ventricles (*) and thalami (T). Compare this with Fig. 21.22 where the thalami are separated.
Fig. 21.25: Maxilla of a normal fetus at 13 weeks’ gestation (upper panel) and the “maxillary gap”
(lower panel) in a fetus with a cleft lip and palate demonstrated in multiplanar orthogonal mode in
combination with VCI.
Fig. 21.26: Transvaginal STIC acquisition with color Doppler of a heart with 13 weeks. To the left in
multiplanar mode and to the right in glass-body mode. The upper left panel presents the diastolic
and lower left panel the systolic phase. The right panel reveals the four-chamber view in glass-body
mode with the filling of both ventricles.
21.4 Conclusions
The 3D/4D examination has revolutionized the examination of the early embryo and
fetus. The combination of transvaginal ultrasound and 3D has the main advantage of
reconstructing any plane in order to obtain typical views. Limitations of the manipu-
lation of the transvaginal probe can be overcome by combining with multiplanar 3D
reconstruction and different volume rendering modes. Images acquired in high-reso-
lution can provide valuable information on the developing embryo and fetus. Brain
structures in particular can be studied in their embryologic development. The external
view of the fetus in normal and abnormal conditions can reliably be achieved with the
surface mode and is ideally for the visualization of the external structures as face,
limbs and anterior abdominal wall, back and others. The accurate examination of the
embryo and fetus has been tremendously improved since the introduction of 3D ultra-
sound.
Further literature references and sources
Performing a literature search in PubMed end of 2015 with the words “3D, ultrasound, fetal” reveals
around 1,000 hits. We found that in such a monography, it is impossible to present a comprehen-
sive literature list especially given the fact that this book has been conceived as a practical book.
We hereby provide a short list of some literature sources, including some books and journal articles,
which partly or completely discuss both technical as well as clinical aspects of 3D ultrasound.
Books
Abu-Rustum RS. A Practical Guide to 3D Ultrasound. London: CRC Press, Taylor & Francis Group, 2014
Abuhamad A, Chaoui R. A Practical Guide to Fetal Echocardiography: Normal and Abnormal Hearts.
3rd ed. Philadelphia: Lippincott-Williams Wilkins, 2015
Gembruch U, Hecher K, Steiner H. Ultraschalldiagnostik in Geburtshilfe und Gynäkologie, 2. Auflage,
Heidelberg, Springer-Verlag, 2016
Kurjak A, Azumendi G. The Fetus in Three Dimensions: Imaging, Embryology and Fetoscopy. London:
Taylor & Francis, 2007
Levaillant JM, Bault J-P, Benoit B. Pratique de l´ échographie volumique-Echographie obstetricale.
Paris: Sauramps Medical, 2008
Levaillant JM, Bault J-P, Benoit B, Couly G. La Face Foetale Normale et Pathologique : Aspects
Échographiques. Paris: Sauramps Medical, 2013
Paladini D, Volpe P. Ultrasound of Congenital Fetal Anomalies. London: CRC Press, Taylor & Francis
Group, 2014
Articles
Abuhamad A, Falkensammer P, Reichartseder F, Zhao Y. Automated retrieval of standard diagnostic
fetal cardiac ultrasound planes in the second trimester of pregnancy: a prospective evaluation
of software. Ultrasound Obstet Gynecol 2008; 31: 30–36
Abuhamad AZ. Standardization of 3-dimensional volumes in obstetric sonography: a required step
for training and automation. J Ultrasound Med 2005; 24: 397–401
Acar P, Dulac Y, Taktak A, Abadir S. Real-time three-dimensional fetal echocardiography using matrix
probe. Prenat Diagn 2005; 25: 370–375
Achiron R, Gindes L, Zalel Y, Lipitz S, Weisz B. Three- and four-dimensional ultrasound: new methods
for evaluating fetal thoracic anomalies. Ultrasound Obstet Gynecol 2008; 32: 36–43
Benacerraf BR, Shipp TD, Bromley B. How sonographic tomography will change the face of obstetric
sonography: a pilot study. J Ultrasound Med 2005; 24: 371–378
Benacerraf BR. Inversion mode display of 3D sonography: applications in obstetric and gynecologic
imaging. AJR Am J Roentgenol 2006; 187: 965–971
Benoit B, Chaoui R. Three-dimensional ultrasound with maximal mode rendering: a novel technique
for the diagnosis of bilateral or unilateral absence or hypoplasia of nasal bones in second-
trimester screening for Down syndrome. Ultrasound Obstet Gynecol 2005; 25: 19–24
Benoit B, Chaoui R, Heling KS. Static Volume Contrast Imaging (Static VCI): Principle and Clinical
applications. GE-White Papers 2009;: 1–11
Benoit B. The value of three-dimensional ultrasonography in the screening of the fetal skeleton.
Childs Nerv Syst 2003; 19: 403–409
284 Further literature references and sources
Campbell S, Lees C, Moscoso G, Hall P. Ultrasound antenatal diagnosis of cleft palate by a new
technique: the 3D “reverse face” view. Ultrasound Obstet Gynecol 2005; 25: 12–18
Chaoui R, Kalache KD, Hartung J. Application of three-dimensional power Doppler ultrasound in
prenatal diagnosis. Ultrasound Obstet Gynecol 2001; 17: 22–29
Chaoui R, Heling KS, Karl K. Ultrasound of the fetal veins part 2: Veins at the cardiac level. Ultraschall
Med 2014; 35: 302–18–quiz319–21
Chaoui R, Levaillant JM, Benoit B, Faro C, Wegrzyn P, Nicolaides KH. Three-dimensional sonographic
description of abnormal metopic suture in second- and third-trimester fetuses. Ultrasound
Obstet Gynecol 2005; 26: 761–764
Chaoui R, Heling KS, Kainer F, Karl K. (Fetal Neurosonography using 3-dimensional Multiplanar
Sonography)(German). Z Geburtsh Neonatol 2012; 216: 54–62
Chaoui R, Heling K, Karl K. Ultrasound of the Fetal Veins Part 1: The Intrahepatic Venous System.
Ultraschall Med 2014; 35: 208–228
Chaoui R, Benoit B. Volume Ultrasound, rendering modes and clinical application. GE-White Papers
2006;: 1–8
Chaoui R, Hoffmann J, Heling KS. Three-dimensional (3D) and 4D color Doppler fetal echocardi-
ography using spatio-temporal image correlation (STIC). Ultrasound Obstet Gynecol 2004; 23:
535–545
Chaoui R, Nicolaides KH. From nuchal translucency to intracranial translucency: towards the early
detection of spina bifida. Ultrasound Obstet Gynecol 2010; 35: 133–138
Chaoui R, Heling KS. Grundlagen der 3D- und 4D-Echokardiographie beim Fetus unter Nutzung der
Spatio-Temporal-Image-Correlation(STIC)-Software. Ultraschall Med 2006; 27: 1–7
Chaoui R, Heling KS. Three-dimensional ultrasound in prenatal diagnosis. CurrOpinObstet Gynecol
2006; 18: 192–202
Chaoui R, Rake A, Heling KS. Drei- und vierdimensionale fetale Echokardiographie. Gynäkologe
2006; 39: 15–24
Chaoui R, Heling KS. New developments in fetal heart scanning: Three- and four-dimensional fetal
echocardiography. Semin Fetal Neonatal Med 2005; 10: 567–577
DeVore GR, Falkensammer P, Sklansky MS, Platt LD. Spatio-temporal image correlation (STIC): new
technology for evaluation of the fetal heart. Ultrasound Obstet Gynecol 2003; 22: 380–387
DeVore GR, Polanco B, Sklansky MS, Platt LD. The “spin” technique: a new method for examination
of the fetal outflow tracts using three-dimensional ultrasound. Ultrasound Obstet Gynecol
2004; 24: 72–82
Deng J. Terminology of three-dimensional and four-dimensional ultrasound imaging of the fetal heart
and other moving body parts. Ultrasound Obstet Gynecol 2003; 22: 336–344
Espinoza J, Kusanovic JP, Goncalves LF, Nien JK, Hassan S, Lee W, Romero R. A novel algorithm for
comprehensive fetal echocardiography using 4-dimensional ultrasonography and tomographic
imaging. J Ultrasound Med 2006; 25: 947–956
Espinoza J, Goncalves LF, Lee W, Chaiworapongsa T, Treadwell MC, Stites S, Schoen ML, Mazor M,
Romero R. The use of the minimum projection mode in 4-dimensional examination of the fetal
heart with spatiotemporal image correlation. J Ultrasound Med 2004; 23: 1337–1348
Espinoza J, Lee W, Comstock C, Romero R, Yeo L, Rizzo G, Paladini D, Vinals F, Achiron R, Gindes L,
Abuhamad A, Sinkovskaya E, Russell E, Yagel S. Collaborative study on 4-dimensional echocar-
diography for the diagnosis of fetal heart defects: the COFEHD study. J Ultrasound Med 2010;
29: 1573–1580
Goncalves LF, Espinoza J, Romero R, Kusanovic JP, Swope B, Nien JK, Erez O, Soto E, Treadwell MC.
Four-dimensional ultrasonography of the fetal heart using a novel Tomographic Ultrasound
Imaging display. J PerinatMed 2006; 34: 39–55
Further literature references and sources 285
Goncalves LF, Romero R, Espinoza J, Lee W, Treadwell M, Chintala K, Brandl H, Chaiworapongsa T.

Four-dimensional ultrasonography of the fetal heart using color Doppler spatiotemporal image
correlation. J Ultrasound Med 2004; 23: 473–481
Heling KS, Chaoui R. The Use of the Minimum Mode in Prenatal Ultrasound Diagnostics –
Possibilities and Limitations. J Turkish-German Gynecol Assoc 2008; 9: 212–216
Karl K, Heling KS, Chaoui R. Ultrasound of the Fetal Veins Part 3: The Fetal Intracerebral Venous
System. Ultraschall Med 2016; 37: 6–26
Kim MS, Jeanty P, Turner C, Benoit B. Three-dimensional sonographic evaluations of embryonic brain
development. J Ultrasound Med 2008; 27: 119–124
Lee W, Chaiworapongsa T, Romero R, Williams R, McNie B, Johnson A, Treadwell M, Comstock CH. A
diagnostic approach for the evaluation of spina bifida by three-dimensional ultrasonography. J
Ultrasound Med 2002; 21: 619–626
Lee W, Goncalves LF, Espinoza J, Romero R. Inversion mode: a new volume analysis tool for
3-dimensional ultrasonography. J Ultrasound Med 2005; 24: 201–207
Leibovitz Z, Haratz KK, Malinger G, Shapiro I, Pressman C. Fetal posterior fossa dimensions: normal
and anomalous development assessed in mid-sagittal cranial plane by three-dimensional
multiplanar sonography. Ultrasound Obstet Gynecol 2014; 43: 147–153
Martinez-Ten P, Perez-Pedregosa J, Santacruz B, Adiego B, Barrón E, Sepulveda W. Three-dimensional
ultrasound diagnosis of cleft palate: “reverse face”, “flipped face” or “oblique face” which
method is best? Ultrasound Obstet Gynecol 2009; 33: 399–406
Merz E, Abramowicz J, Blaas HG, Deng J, Gindes L, Lee W, Platt LD, Pretorius D, Schild R, Sladkevicius
P, Timor-Tritsch I. 3D imaging of the fetal face - Recommendations from the International 3D
Focus Group. Ultraschall Med 2012; 33: 175–182
Merz E, Welter C. 2D and 3D Ultrasound in the evaluation of normal and abnormal fetal anatomy in
the second and third trimesters in a level III center. Ultraschall Med 2005; 26: 9–16
Michailidis GD, Papageorgiou P, Economides DL. Assessment of fetal anatomy in the first trimester
using two- and three-dimensional ultrasound. The British journal of radiology 2002; 75:
215–219
Moeglin D, Talmant C, Duyme M, Lopez AC. Fetal lung volumetry using two- and three-dimensional
ultrasound. Ultrasound Obstet Gynecol 2005; 25: 119–127
Paladini D, Vassallo M, Sglavo G, Lapadula C, Martinelli P. The role of spatio-temporal image
correlation (STIC) with tomographic ultrasound imaging (TUI) in the sequential analysis of fetal
congenital heart disease. Ultrasound Obstet Gynecol 2006; 27: 555–561
Paladini D, Volpe P, Sglavo G, Vassallo M, De Robertis V, Marasini M, Russo MG. Transposition of
the great arteries in the fetus: assessment of the spatial relationships of the arterial trunks by
four-dimensional echocardiography. Ultrasound Obstet Gynecol 2008; 31: 271–276
Paladini D, Giovanna Russo M, Vassallo M, Tartaglione A. The “in-plane” view of the inter-ventricular
septum. A new approach to the characterization of ventricular septal defects in the fetus.
Prenat Diagn 2003; 23: 1052–1055
Paladini D, Sglavo G, Masucci A, Pastore G, Nappi C. Role of four-dimensional ultrasound (spatio-
temporal image correlation and Sonography-based Automated Volume Count) in prenatal
assessment of atrial morphology in cardiosplenic syndromes. Ultrasound Obstet Gynecol 2011;
38: 337–343
Pashaj S, Merz E. Prenatal Demonstration of Normal Variants of the Pericallosal Artery by 3D
Ultrasound. Ultraschall Med 2014; 35: 129–133
Pilu G. Three dimensional ultrasound of cranio-facial anomalies. GE-White Papers 2006;: 1–12
Pilu G, Ghi T. Preliminary experience with Advanced Volume Contrast Imaging (VCI) and Omniview in
obstetric and gynecologic ultrasound. GE-White Papers 2012;: 1–6
286 Further literature references and sources
Pilu G, Segata M, Ghi T, Carletti A, Perolo A, Santini D, Bonasoni P, Tani G, Rizzo N. Diagnosis of
midline anomalies of the fetal brain with the three-dimensional median view. Ultrasound
Obstet Gynecol 2006; 27: 522–529
Pilu G, Ghi T, Carletti A, Segata M, Perolo A, Rizzo N. Three-dimensional ultrasound examination of
the fetal central nervous system. Ultrasound Obstet Gynecol 2007; 30: 233–245
Platt LD, Devore GR, Pretorius DH. Improving cleft palate/cleft lip antenatal diagnosis by
3-dimensional sonography: the “flipped face” view. Journal of Ultrasound in Medicine 2006; 25:
1423–1430
Pooh RK. Neurosonoembryology by three-dimensional ultrasound. Semin Fetal Neonatal Med 2012;
17: 261–268
Ruano R, Benachi A, Aubry MC, Dumez Y, Dommergues M. Volume contrast imaging: A new approach
to identify fetal thoracic structures. J Ultrasound Med 2004; 23: 403–408
Sarut Lopez A, Heling KS, Chaoui R. 3D-Ultraschall in der Pränataldiagnostik. Gynäkologische Praxis
2012;: 23–34
Tonni G, Grisolia G, Sepulveda W. Second trimester fetal neurosonography: reconstructing cerebral
midline anatomy and anomalies using a novel three-dimensional ultrasound technique. Prenat
Diagn 2014; 34: 75–83
Vinals F, Munoz M, Naveas R, Giuliano A. Transfrontal three-dimensional visualization of midline
cerebral structures. Ultrasound Obstet Gynecol 2007; 30: 162–168
Volpe P, Campobasso G, Stanziano A, De Robertis V, Di Paolo S, Caruso G, Volpe N, Gentile M. Novel
application of 4D sonography with B-flow imaging and spatio-temporal image correlation (STIC)
in the assessment of the anatomy of pulmonary arteries in fetuses with pulmonary atresia and
ventricular septal defect. Ultrasound Obstet Gynecol 2006; 28: 40–46
Xiong Y, Chen M, Chan LW, Ting YH, Fung TY, Leung TY, Lau TK. Scan the fetal heart by real-time
three-dimensional echocardiography with live xPlane imaging. Journal of Maternal-Fetal and
Neonatal Medicine 2012; 25: 324–328
Yeo L, Romero R, Jodicke C, Oggè G, Lee W, Kusanovic JP, Vaisbuch E, Hassan S. Four-chamber view
and “swing technique” (FAST) echo: a novel and simple algorithm to visualize standard fetal
echocardiographic planes. Ultrasound Obstet Gynecol 2011; 37: 423–431
Index
A – Chiasma opticum 195
A-plane 16, 17 – Corpus callosum 54, 57, 59, 60, 62, 67, 82,
Abdomen 141, 165, 166, 190, 191, 193,
– Biplane 175, 177 – Early pregnancy 124, 141, 200–204, 142,
– gallbladder 118, 119, 127, 128, 243 278, 280
– glass-body mode 149, 150, 154 – Glass-body mode 152, 153, 196
– inversion mode 127, 128, 243 – Inversion mode 38, 198, 204, 277, 129
– minimum mode 117–122 – Omniview 68, 69, 73, 200, 202, 203
– orthogonal mode 17, 18, 76 – Orthogonal mode 63–65, 193–195
– portal venous system 128, 149, 150 – Silhouette 141, 142, 197, 199, 203–205
– stomach 17, 80, 118, 120, 121, 128, 182, 237 – Surface mode 105, 197,
– tomographic mode 76–80, 85–88, 249, 250 – Tomographic mode 81–83, 187–195, 201, 281
– VCI 55, 65 CNS, anomalies
– volume, VOCAL 182, 183 – Agenesis septum pellucidum 83, 123, 130, 141
Abdomen, anomalies – Agenesis corpus callosum 151, 165, 167, 189,
– Ascites 83, 88, 104, 177, 244–246 192, 193, 194, 196, 199
– Cyst 275 – Anencephaly 200, 273, 279
– Double bubble 83, 87, 104, 120, 121, 128, – Choroid plexus cyst 167, 197
183, 242, 243, – Dandy-Walker Malformation 81, 196, 197
– Ductus venosus anomaly 120, 149 – Encephalocele 60, 166, 198, 199
– Gastroschisis 101, 244, 245, 246 – Holoprosencephaly 123, 127, 189, 197, 198,
– Hydronephrosis 121, 130, 131, 248, 253 201, 204, 230, 281
– Ileus 87, 242 – Spina bifida 102, 112, 139, 171, 174, 197, 202,
– Multicystic kidneys 83, 122, 130, 175, 184, 206, 211, 212, 273,
250, 251, 254 – Vein of Galen aneurysm 161, 200
– Omphalocele 101, 137, 176, 243, 246, 272 – Ventriculomegaly 81, 82, 105, 129, 142, 197
– Polycystic kidneys 249, 250, 254 C-Plane 16, 17
– Pyelectasia 121, 247 Cardiac, see STIC and heart anomalies
– Situs inversus 120, 242, 246 Color Doppler 143–155
Acquisition plane 3, 6
Acquisition3D 11, E
Acquisition, 4D 11 Echocardiography, see STIC and heart anomalies
Acquisition, STIC 11, 70, 90, 131, 151, 152, 155, Embryo 47, 49, 73, 129, 134, 141, 142, 203, 270,
157, 256–268 274, 278,
Angle, acquisition 3, 6
Arm, see hand, skeleton F
Artifact 11, 23, 24, 30, 34, 49 Face
– Ear 219, 233
B – Eyes 220, 223, 228, 230, 234
B-Flow 39, 156–161, 256 – maximum mode 106, 114, 115, 234, 235,
B-Plane 16, – Nose 228, 230,
Biplane 13, 162–177, 209 – surface mode 223–233
– tomographic mode 220–222
C Face, anomalies
CNS – Clef lip and palate 139, 169, 170, 217, 221,
– Cerebellum 69, 81, 82, 187, 188, 194, 197 222, 231, 234, 273, 281
288 Index
– Ear anomaly 219, 233 – Hyperechogenic lung 85, 176, 239

– Eye anomaly 220, 223, 228, 230, 234 – Lung sequestration 85, 176, 241
– in holoprosencephaly 230, – Volume, VOCAL 240
– Lymphangioma 170, 231
– Syndrome 215 ,217, 229, 230, 232, 234 M
Foot 100, 101, 213, 215 Magicut 43–45, 136
Malformation, see organ
G Matrix transducer 162–177
Gain 43, 93–95 Maxillary gap 170, 281
Glass-body mode 143–155, 196, 265–268 Maximum mode 106–116, 206–218
Microphthalmia 213
H Minimum mode 117–124
Hand Multiplanar reconstruction 62–92
HD-Live 36, 37, 133–136, 226, 275
HD-Live flow, see Glass-body mode N
Heart, see STIC Navigation 17–23
Heart, anomalies Navigation dot, see intersection dot 17–19
– Atrioventricular septal defect 264, 266, Neurosonography, see brain
– Azygos vein continuity 60, 149, 150, 155, 244
– Dextrocardia 261 O
– Double aortic arch 151, 160, 263 Omniview 54–58, 64–74
– Double outlet right ventricle 264 Orientation 29, 33
– Ebstein’s anomaly 264
– Hypoplastic left heart syndrome 60, 151, R
264, 267 Render box 30, 33, 34, 126
– Pulmonary atresia 267 Rotation 19, 23
– Pulmonary stenosis 262
– Rhabdomyoma 139, 140, 173 S
– Right aortic arch 90, 151, 159, 267 Scrolling 19, 22, 23, 75
– Transposition of the great arteries 123, 131, Skeleton, see maximum mode
132, 152174, 262, 264, 265, 268, Skeletal, anomalies
– Tricuspid atresia 264 – absent nasal bone 106, 112, 115, 216, 234
– Ventricular septal defect 172, 173, 264 – Apert syndrome 100, 214, 216, 217, 229, 230
– Clef lip and palate 112, 137, 139, 167, 169,
I 170, 216, 217, 220, 221, 231, 273, 281,
Init 22, 23 – Clubfoot 99, 101, 116, 215, 216
Intersection point 17–20 – Craniosynostosis 112, 216, 234
Intrauterine device (IUD) 55 – Feet anomalies 101, 116, 213, 215, 216, 274
Inversion mode 125–132 – Hand anomalies 214, 215, 216, 230, 274
– Hemivertebra 112, 114, 206, 211, 212
L – Skeletal dysplasia 213–216
Light source 40, 41, 46, 47, 135, 137, 225, 251, – Spina bifida 102, 112, 139, 171, 174, 197, 202,
Lung, normal 38, 52, 53, 67, 83, 84, 118, 119, 206, 211, 212, 273
Lung, anomalies Silhouette 133–142, 153, 154, 155, 243, 246,
– Congenital diaphragmatic hernia 123, 237, 270, 275, 276
238 Skull bones 54, 57, 70
– Cyst 238 Sono-AVC 178, 182–184, 204, 243, 246, 250,
– Cystic adenomatoid malformation 239 251, 252,
– Hydrothorax 84, 122, 241 Static 3D 11
Index 289
STIC 9, 12, 13, 89, 90, 104, 126, 131, 151, 152, VCI-Omniview 49, 56, 114,
155, 157, 255–268 VCI, static 49
Surface mode 35–37 VOCAL 178–184
Volume box 3–9
T Volume Contrast Imaging (see VCI)
Threshold 41–43, 94–96 Volume data sets 15
Tomography mode 62, 75–92 Volume measurement 178–184
Translation 19, 22, 23, 75 Volume rendering 29–48
Twins 102, 274, 276
– conjoint 276 X
– TRAP 276 X-Ray mode 38, 53, 56, 66, 124,
V
VCI 49–61
VCI-A 58–60, 127, 132

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This is a translation of the original book in German:

Library of Congress Cataloging-in-Publication Data

Bibliographic information published by the Deutsche Nationalbibliothek

© 2016 Walter de Gruyter GmbH, Berlin/Boston.

Technical ultrasound words

All 3D examinations and experience in this book is based on Voluson ultrasound

Some abbreviations are listet below:

Part I: Basics of 3D Ultrasound

1 Basics of 3D and 4D Volume Acquisition 3

2 Orientation and Navigation within a Volume 15

Part II: Methods of 3D Rendering

3 3D Rendering of a Volume 29

4 Volume Contrast Imaging (VCI) 49

5 Multiplanar Display I – Orthogonal Mode and Omniview Planes 62

6 Multiplanar Display II: Tomographic Mode 75

7 Surface Mode Rendering and HD-Live 93

8 Maximum Mode Rendering 106

9 The Minimum Mode 117

10 The Inversion Mode 125

11 The Silhouette Tool 133

11.2 Practical application 133

12 The Glass-Body Mode and HD-Live Flow 143

13 The B-Flow Mode 156

14 Biplane Display using the Electronic Matrix Transducer 162

15 Calculation of 3D Volumes 178

Part III: Clinical Applications of Prenatal Diagnosis

16 3D Fetal Neurosonography 187

17 3D of the Fetal Skeleton 206

18 3D of the Fetal Face 219

19 3D Intrathoracic and Intraabdominal Organs 236

20 STIC and 3D/4D Fetal Echocardiography 255

21 3D in Early Pregnancy 269

Further literature references and sources 283

The current technology of 3D ultrasound is based on advanced mechanical or elec-

1.2 Preparing the volume acquisition

Five important steps should be considered during the preparation of a 3D volume

1.2.1 Optimization of the 2D image before volume acquisition

Before a 3D-, 4D- or STIC-volume is acquired, the 2D image optimization is mandatory

1.2.2 Choice of the best starting plane at volume acquisition

1.2.3 The acquisition box or volume box

Fig. 1.4: The volume box has three

1.3 Types of volume acquisition

Four types of acquisition of a volume are used, namely

1.3.1 3D Static acquisition

Principle: 3D Static refers to a single 3D volume acquired which contains an infinite

Limitations: The main limitation of static 3D acquisition is its inability to assess

1.3.2 Real-time 4D with a mechanical 3D transducer (4D)

Potential: The major advantage of 4D acquisition is its ability to display instanta-

1.3.3 Spatio-Temporal Image Correlation (STIC) acquisition

Principle: STIC acquisition is similar to a slow 3D acquisition of a duration between

Limitations: Disadvantages of STIC acquisition include a fairly delayed acquisition

1.3.4 Real-time 4D with an electronic matrix transducer (4D)

Potential: In addition to the advantage of a 4D in almost real-time as explained above,

Static 3D volume STIC volume 4D volumes

Static 3D volume STIC 4D volumes

Multiplanar reconstruction Volume rendering

Sectional planes: Volume images:

In the previous chapter we discussed how a 3D volume acquisition is prepared and

2.2 Storing and exporting volume data sets

Occasionally the acquired volume is directly manipulated by the sonographer during

2.3 Orientation in the three orthogonal planes

2.4 Navigation within the orthogonal planes