Pre- and post-stroke MRI and neuropsychological studies in sickle cell disease: a case study

The case of a patient with sickle cell disease is presented in which neuropsychological and magnetic resonance imaging studies were completed prior to and after a right hemispheric stroke. The contribution of a new MR perfusion technique in understanding the neurological complications in this patient is discussed. This case illustrates the complex pathophysiology of neuropsychological deficits in SCD and underscores the need to develop models that better reflect this complexity.

Bone marrow transplantation in a young child with sickle cell anemia

Bone marrow transplantation (BMT) is the only curative therapy available for hemoglobinopathies. BMT was performed on a young child with sickle cell anemia (SCA) after approximately 9 months of transfusion therapy following her initial stroke. The patient received a matched sibling donor (sickle trait) BMT. The conditioning regimen consisted of busulfan 4 mg/kg/day x 4, cyclophosphamide 50 mg/kg/day x 4. Graft vs. host disease prophylaxis was daily cyclosporine for 6 months. There were no significant complications during BMT. Engraftment occurred on day +17 and the patient was transfusion independent since day +45. Pre-BMT cerebral arteriography showed multiple stenotic cerebral vessels and a moya-moya pattern. Perfusion MRI demonstrated reduced capillary perfusion. Approximately 170 days after BMT the patient experienced episodes of transient left-sided weakness and speech problems. Neuroimaging revealed progression of large vessel pathology by angiography despite significant improvement in cortical perfusion (MR perfusion scan). Molecular analysis by PCR and DNA fingerprinting confirmed absence of mixed mosaicism. Rheologic evaluation showed normal corrected bulk viscosity. It is possible that progression of large vessel pathology and return of clinical symptoms in the face of normal rheologic parameters may be due to worsening of the already damaged cerebral vessels by the BMT conditioning regimen. Further evaluations of patients with SCA undergoing BMT after a stroke are needed to answer this question.

Dermoids of the eustachian tube: CT and MR findings with histologic correlation

Two patients with congenital dermoids of the eustachian tube presented with recurrent otitis media and chronic otorrhea resistant to antimicrobial therapy. CT demonstrated fat density, homogeneous lesions, filling and expanding the eustachian tube. On MR, signal from the lesions was consistent with fat, and the relationship with the internal carotid artery was better delineated than by CT. Microscopically, the masses consisted of a conglomeration of ectodermal and mesodermal elements.

MR findings in kernicterus

We describe the MR appearance of kernicterus (bilirubin encephalopathy). T2-weighted images show high signal bilaterally in the globus pallidus, a known area of cerebral deposition of bilirubin.

Review of the embryologic development of the pituitary gland and report of a case of hypophyseal duplication detected by MRI

We describe the clinical manifestations, associated abnormalities, MRI appearances and pathologic significance of a case of hypophyseal duplication. A 16-year-old girl presented with delayed sexual development and history of midline craniofacial anomalies. MRI revealed paired infundibula extending inferiorly to two small pituitary glands, a midline hypothalamic mass, and a midline cleft in the basisphenoid. Twelve cases of pituitary duplication have previously been described. The suggested pathogenesis is duplication of the prechordal plate and anterior end of the notochord during early embryologic development.

Familial erythrophagocytic lymphohistiocytosis: neuroradiologic evaluation with pathologic correlation

PURPOSE

To report neuroradiologic findings in eight patients with familial erythrophagocytic lymphohistiocytosis (FEL), a rare, fatal autosomal recessive disease of infancy.

MATERIALS AND METHODS

All patients underwent neuroradiologic magnetic resonance (MR) imaging and computed tomography before and after treatment. MR imaging-guided proton MR spectroscopy was performed in four.

RESULTS

Seizures, focal neurologic deficits, and gait abnormalities were the most common neurologic manifestations. Brain involvement on MR images was progressive and consisted of parenchymal atrophy, diffuse abnormal signal intensity in the white matter on T2-weighted images, focal hyperintense lesions in both the white and gray matter, delayed myelination, and parenchymal calcifications. MR spectroscopy showed lower ratios of N-acetyl aspartate to total creatine and higher ratios of choline-containing compounds to total creatine, suggestive of decreased neuronal density and gliosis.

CONCLUSION

Brain MR imaging and MR spectroscopy allow assessment of the severity of FEL and may aid in monitoring the response to treatment.

Congenital malformations causing skull base changes

Recent advances in imaging have enabled both the clinician and radiologist to better understand the therapeutic implications of congenital anomalies involving the skull base. Critical to this understanding is a full knowledge of normal embryologic development, anatomic detail, and clinical manifestations in the wide variety of congenital malformations involving the skull base. This review focuses on individual malformations in terms of their pathophysiology and their imaging findings of critical importance.

Cerebrovascular occlusive disease in childhood

It is clear that for many disorders involving the CNS in children, cerebrovascular occlusion with stroke or strokelike episodes may be an important part of their pathophysiology. In contrast to adults, no single entity is responsible for the majority of strokes in children. The incidence of childhood cerebrovascular occlusive disease is likely much higher than is recorded in the literature if one takes into account conditions in which vascular occlusion plays a significant but secondary role. In some disorders, the occlusive process is often produced by the therapy used to treat the underlying primary disorder (e.g., radiation injury) and often accounts for the greatest morbidity and mortality to the patient. Imaging plays an important role in the detection and follow-up of cerebrovascular occlusive disease in children. A better understanding by the radiologist of the full range of conditions that may be complicated by stroke is important if we are to play a role in early diagnosis and to help guide specific therapy aimed at preventing a recurrence of the event. Imaging has become complex; however, a combination of anatomic and functional imaging is essential in the appropriate workup and management of all children with cerebrovascular occlusive disease.

Meningioangiomatosis of the brain stem. Case report

The case is reported of meningioangiomatosis of the brain stem in a 3 1/2-year-old girl who suffered from vomiting, left facial weakness, difficulty in swallowing, and ataxia. This is believed to be the first reported case of meningioangiomatosis in the brain stem. Computerized tomography showed an intensely enhancing hyperdense mass in the left restiform body. Magnetic resonance imaging revealed that the lesion was isointense to gray matter on the T1-weighted image and hypointense on the T2-weighted image, with a surrounding zone of high T2 signal and intense enhancement. Angiography was normal. Surgical exploration demonstrated an intramedullary firm mass that was partially resected. Histologically, the mass consisted of a low-grade lesion of meningeal origin with spindle cells in a whorling pattern that were occasionally focused around small vessels. On 2-year follow-up imaging, the lesion remains unchanged in size. Certain particularities of this lesion are discussed in the context of the literature.

Comparison of T2-weighted spin-echo and fast spin-echo techniques in the evaluation of myelination

To evaluate T2-weighed fast spin-echo (FSE) and conventional spin-echo (CSE) magnetic resonance (MR) techniques in the assessment of brain myelination, 100 consecutive pediatric patients were imaged prospectively with both CSE and FSE sequences. All patients underwent a routine MR examination that included T2-weighted CSE imaging (imaging time, 10 minutes 21 seconds) and T2-weighted FSE imaging (imaging time, 2 minutes 5 seconds). The two techniques were compared for estimating the degree of myelination (using normal anatomic landmarks) by blind review. With T2-weighted CSE images as the "gold standard" for estimation of normal myelination, FSE images were evaluated to determine if they showed the degree of myelination similarly to CSE images. There was a strong correlation (P < .01) between CSE and FSE images in the estimation of myelination over a wide range of patient ages.

Childhood adrenoleukodystrophy: assessment with proton MR spectroscopy

PURPOSE

Image-guided, single-voxel, localized proton magnetic resonance (MR) spectroscopy was performed to assess white matter in childhood adrenoleukodystrophy (ALD).

MATERIALS AND METHODS

Eleven X-linked ALD subjects, seven with neurologic symptoms or white matter lesions at MR imaging and four asymptomatic patients, were compared with nine aged-matched, healthy volunteers.

RESULTS

Compared with those from normal white matter, MR spectra from white matter lesions (n = 6) showed 65% reduction in the ratio of N-acetyl aspartate (NAA) to total creatine (tCr) (P < .01); 55% increase in the ratio of choline-containing compounds (Cho) to tCr (P < .02); substantial levels of tCr; 94% increase in the ratio of glutamate, glutamine, or inositol to tCr (P < .02); and lactate accumulation in four patients. Patients without brain lesions (n = 4) exhibited a 51% increase in Cho-to-tCr ratio (P < .01) and 11% nonsignificant increase in NAA-to-tCr ratio.

CONCLUSION

Proton MR spectroscopy may prove a valuable technique for noninvasive diagnostic and prognostic assessment of ALD.

Cystic malformations of the posterior fossa: differential diagnosis clarified through embryologic analysis

Cystic or cyst-like malformations of the posterior fossa represent a spectrum of disorders, including the Dandy-Walker malformation, vermian-cerebellar hypoplasia, mega cisterna magna, and arachnoid cyst. Differentiation of these lesions may be difficult with routine cross-sectional imaging; however, an accurate diagnosis is essential for proper treatment planning and genetic counseling. Dandy-Walker malformation is easily diagnosed on the basis of the classic triad: complete or partial agenesis of the vermis, cystic dilatation of the fourth ventricle, and enlarged posterior fossa. Vermian-cerebellar hypoplasia is a general classification that describes congenital malformations with a normal-sized posterior fossa, varying degrees of vermian and cerebellar hypoplasia, and a prominent retrocerebellar cerebrospinal fluid space that communicates freely with a normal or dilated fourth ventricle. Mega cisterna magna can be asymmetric and can manifest apparent mass effect, simulating the appearance of an arachnoid cyst; therefore, ventriculography or cisternography may be needed to demonstrate communication of the cystic mass with the subarachnoid space. A careful review of the embryologic development is essential in understanding these malformations and in making a more accurate radiologic diagnosis.

Localized proton MR spectroscopy of the brain in children

Small-voxel (3.0-8.0 cm3), magnetic resonance (MR) imaging-guided proton MR spectroscopy was performed in 54 patients (aged 6 days to 19 years) with intracranial masses (n = 16), neurodegenerative disorders (n = 34), and other neurologic diseases (n = 4) and in 23 age-matched control subjects without brain disease. A combined short TE (18 msec) stimulated-echo acquisition mode (STEAM) and long TE (135 and/or 270 msec) spin-echo point-resolved spatially localized spectroscopy (PRESS) protocol, using designed radio-frequency pulses, was performed at 1.5 T. STEAM spectra revealed short T2 and/or strongly coupled metabolites; prominent resonances were obtained from N-acetyl aspartate (NAA), choline-containing compounds (Cho), and total creatine (tCr). Lactate was well resolved with the long TE PRESS sequence. Intracranial tumors were readily differentiated from cerebrospinal fluid (CSF) collections. All tumors showed low NAA, high Cho, and reduced tCr levels. Neurodegenerative disorders showed low or absent NAA levels and enhanced mobile lipid, glutamate and glutamine, and inositol levels, consistent with neuronal loss, gliosis, demyelination, and amino acid neurotoxicity. Preliminary experience indicates that proton MR spectroscopy can contribute in the evaluation of central nervous system abnormalities of infants and children.

Cerebral perfusion in children: detection with dynamic contrast-enhanced T2*-weighted MR images

Cerebral perfusion dynamics were assessed with dynamic contrast material-enhanced T2*-weighted magnetic resonance (MR) imaging in 33 subjects aged 3-20 years. Group A (n = 20) had sickle cell anemia without clinical evidence of cerebrovascular disease. Group B (n = 13) consisted of 12 patients with cerebrovascular disease and homozygous sickle cell anemia and one patient without that anemia. All subjects underwent conventional MR imaging and a dynamic study in which a spoiled gradient-echo pulse sequence was used to generate images (acquisition time, 2.5 seconds) during injection of a compact bolus of gadopentetate dimeglumine (0.1 mmol/kg). For qualitative analysis, the dynamic images were displayed in cine mode. Group A demonstrated symmetric sequential region patterns of loss of signal intensity within 10 seconds of injection. Group B exhibited signal loss asymmetries that corresponded to cerebrovascular lesions on conventional MR images. Quantitative analysis enabled estimation of hemodynamic parameters, including relative cerebral blood volume, relative cerebral blood flow, and mean transit time. This method of assessment of cerebral perfusion dynamics complements conventional MR imaging.

Phase III multicenter clinical investigation to determine the safety and efficacy of gadoteridol in children suspected of having neurologic disease

A phase III open-label clinical trial was conducted at 11 institutions to determine the safety and efficacy of gadoteridol in children suspected of having neurologic disease. One hundred three children were included in the safety analysis; 92 were evaluated for efficacy (76 intracranial and 16 spinal examinations). Three adverse events were reported in two children. All adverse events were considered minor and resolved spontaneously without treatment or sequelae. In a comparison of enhanced T1-weighted magnetic resonance images with unenhanced T1- and T2-weighted images, enhancement of disease was noted in 70% of the intracranial and 38% of the spinal examinations. Additional diagnostic information was reported in 82% of the postcontrast intracranial examinations and 62% of the spinal examinations. Use of this additional information contributed to a potential modification of patient diagnosis in 48% of intracranial and 20% of spinal cases with additional information. These results indicate excellent safety and efficacy for use of gadoteridol in children with suspected intracranial or spinal disease.

Evaluation of the craniocervical junction in Down syndrome: correlation of measurements obtained with radiography and MR imaging

Measurement of the atlas-dens interval is the radiographic standard for identification of patients with Down syndrome at high risk for neurologic injury from spinal cord compression. In 17 pediatric patients with Down syndrome, measurements of the atlas-dens interval, distance between the clivus and posterior odontoid process, and width of the neural canal obtained with plain radiographs were compared to predict the width of the subarachnoid space on magnetic resonance (MR) images. In all patients, cervical radiography and craniocervical MR imaging were prospectively performed during lateral flexion and extension. The width of the subarachnoid space was measured with MR imaging. When the 95% confidence interval for correlation coefficients of regression was used, subarachnoid space width on MR images correlated with neural canal width on radiographs better than with either atlas-dens interval or clivus-posterior odontoid process distance (P = .05). Measurement of neural canal width is a better predictor of potential spinal cord compression than the atlas-dens interval or clivus-posterior odontoid process distance and should be emphasized in screening examinations performed with plain radiography.

Clinical proton MR spectroscopy of neurodegenerative disease in childhood

PURPOSE

To determine the contribution of MR spectroscopy in the assessment of childhood neurodegenerative disease.

METHODS

Fifty-one subjects (7 weeks to 17 years of age), 22 with either hereditary (n = 16) or acquired (n = 6) neurodegenerative disorders and 29 age-matched control subjects, were studied with combined proton MR spectroscopy and MR imaging. Single-voxel (2.0-8.0 cc) MR spectra were acquired at 1.5 T, with either short-echo-stimulated echoes and/or long-echo spin echoes.

RESULTS

MR spectra exhibited signals from n-acetyl-, creatine-, and choline-containing compounds, neurotransmitters (glutamate), intracellular mediators (inositols), and glycolytic products (lactate). Abnormal MR spectra in neurodegenerative disorders reflected: demyelination, neuronal loss, and gliosis (increased mobile lipid presence and reduction of n-acetylaspartate to choline); metabolic acidosis (lactate accumulation); and neurotransmitter neurotoxicity (increased glutamate, glutamine, and inositols).

CONCLUSION

Proton MR spectroscopy may complement MR imaging in diagnostic assessment and therapeutic monitoring of neurodegenerative disorders.

Efficacy of gadoteridol for contrast-enhanced magnetic resonance imaging in children

RATIONALE AND OBJECTIVES

This study assesses the efficacy of gadoteridol for contrast-enhanced magnetic resonance imaging (MRI) in children.

METHODS

Patients were examined by MRI before and after receiving 0.10 mmol/kg gadoteridol. Blinded and unblinded readers analyzed brain and spine MRI studies from a multicenter clinical trial involving 101 patients at 11 sites. Ninety-two cases (76 brain, 16 spine) were evaluated by unblinded investigators, and 91 cases (76 brain, 15 spine) were evaluated by three neuroradiologists unaffiliated with any investigational site and blinded to clinical information.

RESULTS

Unblinded readers noted enhancement of brain pathology in 70% of cases versus 50% to 67% among blinded readers. Unblinded readers determined that additional diagnostic information was available after contrast in 82% of brain studies (average, 64% for blinded readers) and would have changed patient diagnoses in 48% of these studies (average, 46% for blinded readers). In spine cases, enhancement of pathology was noted in 38% (unblinded) and 33% to 40% (blinded). Additional diagnostic information was available after contrast in 63% of spine studies (unblinded), or an average of 58% (blinded), and patient diagnoses would have changed in 20% (unblinded), or an average of 59% (blinded).

CONCLUSIONS

Gadoteridol is suitable for enhanced MRI detection, localization, and characterization of central nervous system pathology in children.

Imaging of the brain in children

As proclaimed by the National Institutes of Health, the 1990s have been designated the "decade of the brain." Within this decade, we can expect to see an emergence of functional imaging in addition to the traditional role of anatomic neuroimaging to separate normal from pathologic anatomy. Technical advances continue to redefine the upper limits of resolution for both anatomic and functional imaging and provide us with a greater understanding of how disease processes affect normal brain growth and development. For example, whereas improvements in anatomic resolution will provide greater insight into understanding congenital malformations of the brain, through functional imaging, we will better understand the effect of disease on normal brain growth and development.

Color Doppler US imaging during pediatric neurosurgical and neuroradiologic procedures

Experience with color Doppler imaging (CDI) during 16 pediatric intraoperative and one percutaneous neuro-radiologic procedures was reviewed to assess whether CDI increased the success rate or decreased the procedure time, thus contributing substantially to procedure performance. Intraoperative CDI was used to rapidly identify abnormal vessels or displacement of normal vessels and correlated with preoperative studies. In six cases (four vascular malformations, one mycotic aneurysm, and one hamartoma), surgical resection was altered on the basis of flow information obtained. In one case of percutaneous embolization of a Galenic malformation, CDI provided information contributing to the cessation of the procedure. In six cases (debulking of three gliomas, resection of one vascular malformation, and two biopsies of nonneoplastic conditions), information was added but did not alter the surgical approach. In the remaining four cases (three cerebrospinal fluid drainage procedures, one posterior fossa decompression), no additional information was obtained. Consultation among the ultrasound staff, neuroradiologists, and neurosurgeons before the operative procedure maximized the usefulness of CDI, thus aiding in the success of surgery.

Balloon dilatation of esophageal strictures in children

Traditionally, the treatment of esophageal strictures in children has been done with mercury bougies in a prograde fashion or with Tucker dilators passed along a guide wire in a retrograde manner. An alternative approach has used a balloon dilatation catheter passed over a guide wire previously placed under fluoroscopic guidance. Over the past 5 years, this technique has been used in 43 procedures for both discrete and diffuse strictures. The interventions were performed in a total of 15 patients ranging in age from 8 months to 21 years. In all cases, there was improvement of the preceding symptoms following dilatation. This report details the experience with this technique at Children's Hospital Medical Center, Cincinnati, Ohio, emphasizing the indications, contraindications, and potential complications associated with balloon dilatation of esophageal strictures in children.

Bilateral congenital ocular cysts

This report presents an unusual case of bilateral congenital ocular cysts. These are in the spectrum of congenital cystic eye and microphthalmos with cysts. Diagnostic evaluation, including orbital B-scan ultrasonography, computed tomography and magnetic resonance imaging is described. Pathologic evaluation of the orbital cysts was consistent with congenital cystic eye. An associated microphthalmic eye was not detected with serial sectioning of both specimens. Examination of the orbit at exploration as well as pre- and post-operative MRI scans failed to demonstrate the presence of a microphthalmic eye in either orbit. Failure to detect a microphthalmic eye clinically, by diagnostic imaging studies, or serial microscopic sections of the cysts supports the diagnosis of congenital cystic eye. This child has associated mild facial clefting (median cleft lip and cleft palate) and basal cephalocele. Histopathologically documented cases of ocular abnormalities associated with basal encephalocele have not been reported. To the authors' knowledge, MRI findings of congenital ocular cysts have been reported once previously in a case of microphthalmos with cyst, however, histopathologic correlation has not been reported previously.

Cerebral infarctions due to CNS infection with Enterobacter sakazakii

Recent reports have implicated Enterobacter sakazakii, a gram-negative enteric bacillus, in neonatal sepsis and meningitis. Cases of severe central nervous system involvement, including ventriculitis, brain abscess, infarction, and cyst formation, have been described. We present serial head CT findings in a case of neonatal E. sakazakii meningitis complicated by a ring enhancing cerebral infarction which mimicked abscess formation. In meningitis secondary to this agent, a recognized pattern of cerebral hypodensity with or without cystic degeneration late in the course of the infection is likely to represent cerebral infarction rather than an abscess especially if there is a lack of culture evidence of a bacterial infection.

Congenital scalp defects: Adams-Oliver syndrome. A case report and review of the literature

Localized agenesis of the scalp is a well-recognized phenomenon, with over 300 cases reported in the literature. These defects have previously been called congenital ulcer of the newborn, Streeters spots or aplasia cutis congenita (ACC). First described 160 years ago, ACC is recognized as a heterogenous group of disorders all having focal absence of scalp. Type III ACC, Adams-Oliver syndrome, consists of a scalp defect associated with a distal limb anomaly. Typically, the lesions appear as small ulcerations which may heal spontaneously. Larger lesions associated with underlying bony defects occur, and may cause death secondary to infection or hemorrhage from the sagittal sinus. We report a case of Adams-Oliver syndrome that required surgical excision and closure because of involvement of the sagittal sinus documented by multiple imaging modalities.

Reversal sign on CT: effect of anoxic/ischemic cerebral injury in children

A retrospective study was performed to determine the clinical and pathologic features, etiology, and outcome of children with the reversal sign. The reversal sign, a striking CT finding, probably represents a diffuse, anoxic/ischemic cerebral injury. CT features of the reversal sign are diffusely decreased density of cerebral cortical gray and white matter with a decreased or lost gray/white matter interface, or reversal of the gray/white matter densities and relatively increased density of the thalami, brainstem, and cerebellum. Twenty children with the reversal sign were retrospectively analyzed. We divided the patients into three groups: (1) acute reversal, (2) intermediate group, and (3) chronic reversal. There were nine cases of trauma (seven of child abuse); nine hypoxia/anoxia incidents (birth asphyxia, drowning, status epilepticus); one bacterial meningitis; and one degenerative encephalitis. All acute- and intermediate-group patients had respiratory problems requiring ventilator support and intensive care. In five of seven patients who died, autopsy findings were consistent with anoxic/ischemic encephalopathy. Surviving patients have profound neurologic deficits with severe developmental delay. The CT reversal sign carries a poor prognosis and indicates irreversible brain damage.

Management of cerebral cavernous angiomas in children presenting with seizures

Until recently intracranial cavernous angiomas were thought to be rare vascular malformations that usually presented in adulthood as an intracerebral hemorrhage, an expanding mass lesion, or with the new onset of seizures. Prior to the advent of computed tomography (CT), and more recently magnetic resonance imaging (MRI), their diagnosis in childhood was extremely rare. However, the CT and MRI features of cavernous angioma are quite distinctive and allow early diagnosis and treatment. Advances in surgical techniques permit successful removal of these potentially devastating lesions and amelioration of the associated seizure disorder. Seven children with cerebral cavernous angiomas have been treated at the Children's Hospital Medical Center since 1980. Six children presented with seizures and one with an intracerebral hemorrhage. All had characteristic findings on CT and/or MRI and underwent surgical excision of symptomatic lesions. Intraoperative sonography, electrocorticography, and cortical mapping were used when indicated and were found to be helpful in the surgical management of these patients. Our experience suggests that symptomatic cerebral cavernous angiomas in children are not as rare as previously thought and that surgical treatment using modern neurosurgical techniques is both safe and appropriate and can be helpful in the management of associated seizures.

Congenital nasolacrimal mucoceles: CT evaluation

A congenital nasolacrimal mucocele, a lacrimal sac mucocele with intranasal extension, is an uncommon mass arising in the medial canthal region of the orbit. The authors describe four infants who presented with medial canthal masses and nasal airway obstruction. All underwent computed tomographic (CT) evaluation, which revealed the triad of cystic dilatation of the lacrimal sac, dilatation of the nasolacrimal duct, and an intranasal cystic mass. Appropriate therapy was determined following identification of the intranasal cystic component. Relevant discussions of the embryology, clinical presentation, and the characteristic CT findings of infants with congenital nasolacrimal mucoceles are included.

Choroideremia and hypopituitarism: an association

Choroideremia is a rare X-linked, progressive, degenerative disease of the retina and choroid. We describe 2 patients, one a female, with choroideremia documented to have hypopituitarism and neurological abnormalities. We hypothesize that this previously undescribed association results from a degenerative process involving tissues of neural origin, or from contiguous submicroscopic gene deletions in the X chromosome region that define choroideremia and possibly hypopituitarism.

Mediastinal hemorrhage during extracorporeal membrane oxygenation

A case of mediastinal hemorrhage along with hemorrhage into a pneumatocele while on extracorporeal membrane oxygenation (ECMO) is presented. Computerized tomography of the chest was utilized to support the diagnosis. Barotrauma to the lungs best explains the inciting event that allowed the hemorrhage to occur once the patient was heparinized for ECMO. This complication serves to point out the importance of commencing early ECMO support before widespread pulmonary and mediastinal barotrauma develops.

Percutaneous drainage of chest abscesses in children

Seven patients ranging in age from 3 to 18 years underwent percutaneous drainage of eight intrathoracic abscesses. Five of the abscesses were mediastinal or paramediastinal and resulted from esophageal perforation or esophageal anastomotic leakage. The abscesses resolved in each case, with a mean catheter drainage time of 28 days and no need for surgical intervention. Three of the abscesses were intrapulmonary, and each lay adjacent to a pleural surface. All three lung abscesses resolved within 19-24 days, without thoracotomy or wedge resection.

Aggressive fibromatosis of the tongue: MR demonstration

A case of aggressive fibromatosis of the tongue is described in a 9-year-old boy. Magnetic resonance was used in the initial evaluation and revealed a well defined mass in the anterior third of the tongue which was mildly hypointense on a T1-weighted image and minimally hyperintense on a T2-weighted image. Magnetic resonance was useful in indicating the benign nature of the tumor, in defining its extent, and for follow-up after local surgical resection.

Reversal sign on CT: effect of anoxic/ischemic cerebral injury in children

A retrospective study was performed to determine the clinical and pathologic features, etiology, and outcome of children with the reversal sign. The reversal sign, a striking CT finding, probably represents a diffuse, anoxic/ischemic cerebral injury. CT features of the reversal sign are diffusely decreased density of cerebral cortical gray and white matter with a decreased or lost gray/white matter interface, or reversal of the gray/white matter densities and relatively increased density of the thalami, brainstem, and cerebellum. Twenty children with the reversal sign were retrospectively analyzed. We divided the patients into three groups: (1) acute reversal, (2) intermediate group, and (3) chronic reversal. There were nine cases of trauma (seven of child abuse); nine hypoxia/anoxia incidents (birth asphyxia, drowning, status epilepticus); one bacterial meningitis; and one degenerative encephalitis. All acute- and intermediate-group patients had respiratory problems requiring ventilator support and intensive care. In five of seven patients who died, autopsy findings were consistent with anoxic/ischemic encephalopathy. Surviving patients have profound neurologic deficits with severe developmental delay. The CT reversal sign carries a poor prognosis and indicates irreversible brain damage.

Computed arthrotomography as an adjunct to pediatric arthrography

Computed arthrotomography was compared with conventional arthrography in ten cases and with both pluridirectional arthrotomography and conventional arthrography in five cases. Six elbows, five hips, three ankles, and one wrist were examined. Indications included pain, locking, congenital hip dislocation, posttraumatic joint deformity, and postinfectious joint deformity. Compared with conventional arthrography, computed arthrotomography provided additional information in ten of 15 (67%) cases and provided the same information in four cases. Arthrography and computed arthrotomography were complementary in one case. Compared with pluridirectional arthrotomography, computed arthrotomography provided additional information in two of five (40%) cases. In the remaining three cases, computed arthrotomography and pluridirectional arthrotomography provided equal information. In no case did pluridirectional arthrotomography provide additional information. Computed arthrotomography was useful in demonstrating loose bodies, differentiating air bubbles from loose bodies, and determining the intra- or extraarticular location of ossific densities. Computed arthrotomography appears to be a useful adjunct to arthrography in detecting loose bodies and in evaluating anatomically complex cases.

Hamartoma of the tuber cinereum: a comparison of MR and CT findings in four cases

Hamartoma of the tuber cinereum is a well-recognized cause of central precocious puberty. We report three patients with an isodense, nonenhancing mass within the interpeduncular cistern identified by CT. In a fourth patient, the CT scan was normal. MR imaging was obtained in all cases and demonstrated a sessile or pedunculated mass of the posterior hypothalamus arising from the region of the tuber cinereum. The smallest mass was 2 mm in diameter and was found in the patient in whom the CT scan was normal. The signal intensity of the masses was generally homogeneous and isointense relative to gray matter on T1- and intermediate-weighted images, and hyper-intense on T2-weighted images. MR imaging accurately diagnoses hypothalamic hamartomas, identifies small hamartomas of the tuber cinereum more sensitively than CT does, and provides optimal imaging for serial evaluation while the patient is being treated medically.

Necrotizing enterocolitis: value of radiographic findings to predict outcome

To investigate whether radiographic findings could be used to predict pan-necrosis (necrosis of 75% or more of the jejunum, ileum, and colon), we reviewed the serial abdominal radiographs and clinical records of 147 infants with necrotizing enterocolitis. Pan-necrosis occurred in 29 infants (20%) and was always fatal. The presence and degree of pneumatosis intestinalis, pneumoperitoneum and portal venous gas were studied. Pan-necrosis occurred least frequently in infants with mild or moderate pneumatosis intestinalis (8% and 12%, respectively), and with moderate frequency in those with pneumoperitoneum (33%). Pan-necrosis was found most frequently in infants with severe pneumatosis intestinalis (56%), portal venous gas (61%), or the combination of severe pneumatosis intestinalis and portal venous gas (79%). The mortality rates in these three groups were 63%, 65%, and 86%, respectively. Thus, infants with the worst outcome (those who develop pan-necrosis) can be identified on plain films by detection of severe pneumatosis intestinalis and portal venous gas.

Percutaneous gastrostomy and percutaneous gastrojejunostomy in children: antegrade approach

Twenty-five percutaneous gastrostomies and nine percutaneous gastrojejunostomies were performed in 24 children aged 4 months to 22 years. Indications for percutaneous gastrostomy included severe injury to the central nervous system (nine patients), malignancy (seven patients), failure to thrive (four patients), degenerative central nervous system disease (one patient), and miscellaneous conditions (three patients). All procedures were performed under local anesthesia and sedation. An antegrade approach is described for percutaneous gastrostomy and percutaneous gastrojejunostomy placement. No major complication occurred, and only three skin infections have been encountered. The children were evaluated and followed up by a nutritional support team. Early experience with percutaneous gastrostomy and percutaneous gastrojejunostomy in the pediatric population suggests that the technique is safe and applicable to children of all ages and sizes. In particular, the antegrade approach appears to be an acceptable solution for enteric alimentation.