Lower urinary tract function in ambulatory children with spina bifida

OBJECTIVE

To investigate lower urinary tract function in ambulatory children with myelomeningocele.

PATIENTS AND METHODS

The urological course of 45 children with myelomeningocele who walked either independently (19 children) or with ankle-foot orthotics (26 children) was reviewed. Follow-up ranged from 9 months to 13.5 years (mean 4.75 years).

RESULTS

A normal pattern of voiding was observed both clinically and during urodynamic evaluation in only three of the 45 children, with the remainder displaying neurogenic lower urinary tract dysfunction. The independent walkers and those with orthotics did not differ in the spectrum of lower urinary tract dysfunction or other variables. Those patients with persistent incontinence underwent an initial urodynamic evaluation when older (mean 3.7 years versus 6.4 weeks in those who were continent).

CONCLUSION

Ambulatory children with myelomeningocele suffer the full spectrum of lower urinary tract dysfunction. Given the potential danger of untreated lower urinary tract dysfunction, ambulatory children with myelomeningocele should receive the same diagnostic and therapeutic attention as their peers with more overt neurological deficits.

Skull base and calvarial deformities: association with intracranial changes in craniofacial syndromes

PURPOSE

To analyze the skull and brain malformations in patients with craniofacial syndromes.

METHODS

A retrospective analysis of imaging studies of 21 children with craniofacial anomalies (8 with Apert syndrome, 6 with Pfeiffer syndrome, 4 with Crouzon syndrome, 1 with Robert syndrome, 1 with Coffin-Lowry-syndrome, and 1 with Saethre-Chotzen syndrome) was carried out using CT (21 patients), MR imaging (9 patients), and MR venography (2 patients). A series of qualitative and quantitative assessments of the skull base and intracranial structures was performed.

RESULTS

Skull base abnormalities were present in all patients. Intracranial abnormalities included ventriculomegaly, frank hydrocephalus, callosal anomalies, hypoplasia/absence of the septum pellucidum, hypoplasia/dysplasia of the hippocampus, dysplasias or distortions of the cerebral cortex, and parenchymal hemorrhage. The anomalies of the corpus callosum, septum pellucidum, and hippocampus appeared primary, whereas the others may have been the result of brain distortion by the calvarial anomaly. MR imaging was more useful than CT for evaluating brain abnormalities. In the two patients in whom it was performed, MR venography showed anomalies of the venous system, indicating that venous anomalies, possibly related to the skull base hypoplasia, may contribute to the intracranial abnormalities.

CONCLUSION

A wide range of neuroimaging abnormalities are present in the craniofacial syndromes. Some of these are clearly primary, whereas others appear to be related to the small skull base and sutural synostoses. MR venography may prove useful in defining the cause of some of the associated anomalies.

Evolution of high-intensity basal ganglia lesions on T1-weighted MR in neurofibromatosis type 1

PURPOSE

To characterize the temporal evolution of the foci of T1 shortening in basal ganglia lesions in patients with neurofibromatosis type 1 (NF-1).

METHODS

A retrospective review of MR images of 37 patients with NF-1 revealed 8 patients in whom regions of T1 shortening were noted in the basal ganglia. We reviewed sequential images obtained in these selected patients with special attention to chronological changes in the foci of T1 shortening and their relationship to changes on T2-weighted images.

RESULTS

Regions of short T1 in the globus pallidus were observed in 8 patients. In 2 of 3 patients in whom foci of T1 shortening were not identified on the initial imaging study, T1 shortening developed and T2 prolongation diminished after an initial increase. In the third patient, T1 and T2 prolongation appeared simultaneously. Sequential scans in the other 5 patients, in whom areas of increased signal intensity in the globus pallidus were present on both T1-weighted and T2-weighted images on the initial MR examination, showed a diminution in the size of the region of T2 prolongation in 2 patients, an increase in the size of the region of T2 prolongation in 1 patient, a mixed pattern of change in the size of the region of T2 prolongation in 1 patient, and no change in the region of T2 prolongation in 1 patient. During the periods of these T2 changes, the areas of T1 shortening showed no significant interval change.

CONCLUSION

The foci of prolonged T2 relaxation in the basal ganglia appear to evolve in a manner similar to the foci of T2 prolongation in the white matter of the posterior fossa. However, the corresponding foci of short T1 in the basal ganglia may evolve with a different time course. In some patients, the foci of short T1 develop at a later time than the T2 prolongation and progress; these foci of short T1 do not appear to regress over periods as long as 90 months. Possible causes of the T1 shortening are remyelination and calcification.

Preterm delivery from 34 to 37 weeks of gestation: is respiratory distress syndrome a problem?

Our purpose was to evaluate the necessity of using tocolytic agents for preterm labor and the benefit of conservative management for preterm premature rupture of membranes from 34 to 37 weeks' gestation. All patients who had accurate obstetric dates and were delivered between 34 and 37 weeks' gestation with no other medical or obstetric problems were retrospectively evaluated for inclusion in the study. The rates of respiratory distress syndrome and other neonatal outcomes were evaluated. A total of 416 patients met criteria for admission into the study. During the thirty-fourth week of pregnancy the incidence of respiratory distress syndrome was 14.9% (p<0.05). Other neonatal complications were also more frequent in deliveries occurring during the thirty-fourth week of pregnancy than in those occurring in the thirty-fifth or thirty-sixth week. Fetal lung maturity studies should be considered and delivery possibly delayed through the thirty-fourth week of gestation to decrease neonatal morbidity in our population.

Radiologic classification of brain stem tumors: correlation of magnetic resonance imaging appearance with clinical outcome

Although tumors of the brain stem have traditionally been classified as a single entity, these tumors are increasingly being recognized as a heterogeneous group, with some subgroups having better prognoses for long-term survival. Although several systems for classification of brain stem tumors have been proposed, none have been based on data derived from contrast-enhanced magnetic resonance (MR) imaging. In this review, we present a classification scheme based on our review of the literature and of the MR scans of 64 patients with brain stem tumors. In addition, we assess the contribution of gadolinium to the classification of brain stem tumors and correlate the various tumor subtypes, based on MR appearance, with prognosis. Our results suggest that the most important factor in determining prognosis based on MR characteristics is whether the tumor is diffuse or focal. Focal tumors have an excellent prognosis regardless of the site of tumor origin. Diffuse tumors of the mesencephalon and pons have a significantly poorer prognosis than focal tumors (p = 0.0013), with diffuse pontine tumors having the worst prognosis. Differentiation of diffuse and focal medullary tumors was difficult, possibly explaining the lack of significant difference in the survival of patients with diffuse versus focal medullary tumors. The presence or absence of enhancement after the administration of paramagnetic contrast has no significant relation with outcome, overall or within specific tumor subgroups.

Quantitative determination of antibodies to type III group B streptococcal polysaccharide

The susceptibility of neonates to invasive infection with type III group B streptococci (GBS) in a radioactive antigen-binding assay (RABA) has been correlated with low maternal serum levels of capsular polysaccharide-specific antibodies. An ELISA was developed using capsular polysaccharide covalently coupled to human serum albumin. In sera from 35 healthy women, the range of IgG antibodies to GBS III polysaccharide was 0.05-33.0 micrograms/mL, and specific IgA antibodies were 0.08-1.1 micrograms/mL; however, no GBS III capsular polysaccharide-specific antibodies of the IgM isotype were detected by the ELISA. The levels of naturally acquired and vaccine-induced antibodies obtained with this ELISA correlated well with the results of the RABA (Spearman's rank correlation coefficient, .92). The ELISA has two major advantages over the RABA: It measures specific isotypes and subclasses of antibodies, and it can detect type III polysaccharide-specific antibodies at lower concentrations.

Gamma knife radiosurgery in children

52 pediatric patients were treated with radiosurgery at the University of California, San Francisco. Arteriovenous malformations were treated in 27 patients. Complete obliteration was noted in 4 of 12 patients imaged more than 2 years after radiosurgery. Arteriovenous malformation rebleed was noted in 1 patient. Symptomatic T2 changes were noted in 2 patients. Among 29 neoplasms treated in 25 patients, local control was noted in 5 of 7 low-grade gliomas, 5 of 14 high-grade gliomas, 4 of 5 craniopharyngiomas and 3 of 3 sarcomas. Three patients treated for neoplasms developed necrosis after radiosurgery.

Stereotactic insertion of an ommaya reservoir: technical note

BACKGROUND

Stereotactic insertion of catheters into deep-seated tumors or developmental cysts is easily accomplished, but connecting the catheter to an Ommaya reservoir while maintaining catheter position can be difficult. We describe a technique for easy placement of a catheter-Ommaya reservoir construct with one pass.

METHODS

Standard stereotactic imaging is performed. The distance from the outer table of the skull to the target point is measured. A catheter-Ommaya reservoir construct is assembled to this length and directed to the target position with a standard Cosman-Robert-Wells (CRW) stereotactic frame.

RESULTS

Use of this technique placed catheters into tumor or developmental cysts accurately and with no surgical complications in 12 patients.

CONCLUSIONS

This technique is simple, safe, reliable, and requires no special equipment. It avoids the risk of dislodging the catheter when it is being connected to the Ommaya reservoir, reducing the chances of cyst leakage and collapse.

Group B streptococci elicit leukotriene B4 and interleukin-8 from human monocytes: neonates exhibit a diminished response

Neonatal monocytes have diminished function compared with adult cells. The ability to recruit neutrophils through elaboration of chemoattractants has not been evaluated in humans. The pattern of chemoattractant release induced by group B streptococci (GBS) also is unknown. Adult and cord blood monocytes were stimulated with GBS. Supernatants were used as the attractant in blind well chambers; migration to neonatal supernatants was diminished. Interleukin-8 (IL-8) and leukotriene B4 (LTB4) were released in greater quantities by adult monocytes in response to either GBS or lipopolysaccharide. Opsonization of GBS was not required for IL-8 release. Adult monocytes released more LTB4 when stimulated with unopsonized GBS than with opsonized GBS; the neonate's LTB4 production did not increase. IL-8 and LTB4 accounted for the majority of chemoattractant activity released in response to GBS. Decreased production of LTB4 and IL-8 may contribute to the neonate's poor host response to GBS.

Radiation therapy for primary intracranial germ-cell tumors

PURPOSE

To evaluate the diagnosis, therapy, and survival of patients with intracranial germ-cell tumors. To define the role of prophylactic craniospinal irradiation and chemotherapy necessary to impact on survival.

METHODS AND MATERIALS

Forty-eight patients with surgically confirmed or suspected primary intracranial germ-cell tumors treated at UCSF between 1968-1990 were reviewed. Thirty-four patients had a pathologic diagnosis, including 24 germinomas, 3 malignant teratomas, 2 choriocarcinomas, 1 embryonal carcinoma, 1 endodermal sinus tumor, and 3 mixed tumors. Information obtained included histology, location, cerebrospinal fluid (CSF) cytology, alpha-fetoprotein (AFP), and beta-human chorionic gonadotropin (B-HCG), metastatic evaluation, radiation details, survival, and sites of failure. Minimum follow-up time was 2 years and ranged to a maximum of 24 years, with a median of 8 years.

RESULTS

Median age at diagnosis was 16 years with 36 males and 12 females. Ten of 32 patients had elevated B-HCG at diagnosis; 6 of 29 had elevations of AFP. Cerebrospinal fluid cytology was negative in 35 of 36 patients evaluated; myelography or spinal MRI was positive in only 1 of 31 patients studied. Five-year actuarial disease-free survival after irradiation was 91% for germinomas, 63% for unbiopsied tumors, and 60% for nongerminoma germ-cell tumors with doses of 50-54 Gy to the local tumor site with or without whole-brain or whole-ventricular irradiation. Routine prophylactic cranio-spinal axis irradiation was not given with a spinal only failure rate of 2%. Eleven of 48 patients have expired, with an actuarial 5-year survival rate of 100% for germinomas, 79% for nonbiopsied tumors, and 80% for nongerminoma germ-cell tumors.

CONCLUSION

With complete diagnostic craniospinal evaluation, spinal irradiation is not necessary. Cure rates for germinomas are excellent with irradiation alone. Multidrug chemotherapy is necessary with irradiation for nongerminoma germ-cell tumors. Histology is the most important prognostic factor; therefore, all patients should have surgical conformation of their diagnosis so that appropriate treatment can be given.

Compression of the common peroneal nerve by a cyst of the lateral meniscus. A case report

Ganglion cysts that compress the common peroneal nerve frequently arise from the proximal tibiofibular joint. In a 60-year-old man, the nerve was compressed by a cyst that arose from the lateral meniscus and extended around the posterolateral aspect of the fibular neck. The origin and extent of the lesion, which could not be determined by clinical examination, was seen through magnetic resonance imaging. Cysts arising from the lateral meniscus should be considered in the differential diagnosis of compression of the common peroneal nerve.

Predictive value of antepartum ultrasound examination for anomalies in twin gestations

The purpose of this study was to evaluate the accuracy of antenatal ultrasonography in the detection of fetal anomalies among twin gestations cared for in a specialized antepartum twin clinic. A retrospective study was performed of 245 consecutive twin gestations followed in our twin clinic. The sensitivity, specificity and diagnostic indices of ultrasound to detect prenatal anomalies in the 490 infants delivered from July 1988 to October 1994 were determined. Fourteen infants had isolated congenital anomalies, and ten had multiple anomalies. The overall prevalence of congenital anomalies was 4.9%. Antepartum ultrasound examination had a sensitivity of 88% and a specificity of 100% for the detection of an anomalous infant, with a positive predictive value of 100% and a negative predictive value of 99%. The sensitivity of ultrasound for each individual anomaly within the cohort was 82%, with 100% specificity, 100% positive predictive value, and 98% negative predictive value. Our conclusions are that serial antepartum ultrasound examination of twins for congenital anomalies in our institution is very specific, with high positive and negative predictive values. The sensitivity, while also excellent, has limitations, which should be discussed with the patient.

Clinical indicators of childhood retropharyngeal abscess

Retropharyngeal abscess is a rare but distinctive cause of airway obstruction in childhood. Early recognition permits emergent airway management and surgical drainage. Even when the presentation is insidious and does not include respiratory compromise, early clinical diagnosis of retropharyngeal cellulitis and appropriate medical treatment may halt progression to an abscess. Delay in the diagnosis and management of a retropharyngeal abscess may lead to potentially lethal complications involving vital structures. A case of an infant whose diagnosis of retropharyngeal abscess was delayed because of absence of respiratory compromise is reported. Relapse of retropharyngeal abscess despite surgical drainage and appropriate antibiotic treatment was a complication of infection in this patient. Clinical indicators providing an early diagnosis of retropharyngeal infection, and aspects of evaluation, management, and outcome, are discussed.

The treatment of brain stem and thalamic gliomas with 78 Gy of hyperfractionated radiation therapy

PURPOSE

To see whether increasing the dose of hyperfractionated radiation therapy from 72 to 78 Gy would increase survival time in patients with gliomas, particularly those with brain stem or thalamic tumors.

METHODS

Seventy-eight patients with a clinical and radiographic diagnosis of a brain stem or thalamic glioma were enrolled in a trial to receive 78 Gy (1.0 Gy twice a day). Six patients with disease in other sites were also treated. The initial response to therapy was determined by comparing pretreatment magnetic resonance images and neurological examinations with those obtained within 2 weeks of completing therapy; subsequent responses were determined from bimonthly follow-up images. Time-to-tumor progression was measured from the date radiation therapy began until the date of documented radiographic or clinical progression. Survival time was measured from the date radiation therapy began until the date of death. Cox proportional hazards analysis was used to estimate the effects of specific variables on survival.

RESULTS

Of 81 evaluable patients, 68 received > or = 76 Gy, 10 received between 70 and 75 Gy, and 3 received between 60 and 68 Gy. The overall response or stabilization rate was 70.4%. Tumor size decreased in 30.8% of patients; 39.5% had stable disease, and 29.6% had immediate progression. The median survival time was 12.7 months (16.1 months for adults and 10.8 months for children). The median time to tumor progression was 9.0 months (11.4 months for adults and 8.4 months for children). A duration of symptoms < or = 2 months and a diffuse lesion were each associated with shorter survival and progression times.

CONCLUSIONS

For patients with brain stem or thalamic gliomas, increasing the dose of radiation therapy from 72 to 78 Gy did not significantly improve survival. Different treatment strategies are clearly needed.

Radiation-induced telangiectasia in the brain simulates cryptic vascular malformations at MR imaging

PURPOSE

To analyze the magnetic resonance (MR) imaging, clinical, and pathologic features of radiation-induced telangiectasia of the brain.

MATERIALS AND METHODS

The clinical and radiation therapy records were reviewed of 20 patients who developed focal hypointense lesions on T2-weighted MR images obtained after radiation therapy of the central nervous system. Pathologic material was reviewed in six patients.

RESULTS

Eleven patients had solitary lesions, and nine had multiple foci on MR images. Fourteen of the 20 patients were less than 20 years old. The appearance ranged from small hypointense foci to larger regions of acute hemorrhage. Hematomas occurred at the site of a previously identified focus of T2 shortening in five patients. Pathologic findings included ectatic thin-walled vessels surrounded by hemosiderin and gliosis, with minimal evidence of necrosis.

CONCLUSION

Radiation-induced telangiectasia in the brain results in varying amounts of hemorrhage and, occasionally, parenchymal hematomas, and may appear similar to cryptic vascular malformations on T2-weighted MR images.

Pattern of recurrence of medulloblastoma after low-dose craniospinal radiotherapy

PURPOSE

We retrospectively evaluated relapse of medulloblastoma after low- or high-dose craniospinal radiotherapy, and after conventional or hyperfractionated posterior fossa irradiation.

METHODS AND MATERIALS

Ninety-two pediatric patients were treated postoperatively since 1970 at the University of California, San Francisco. Until 1989, we employed conventional fractionation with low (< or = 30 Gy) or high-dose craniospinal fields and low-dose (< or = 56 Gy) posterior fossa boosts. Recently, hyperfractionation delivered low- or high-dose to the craniospinal axis and high-dose to the posterior fossa. Most patients treated after 1979 received chemotherapy.

RESULTS

Median follow-up was 70 months. Five-year disease-free survival was 36% (22% for poor-risk vs. 59% for good-risk patients). Five-year overall survival was 52% (43% for poor vs. 68% for good-risk). Neither the dose to the posterior fossa nor the craniospinal axis was statistically related to recurrence. Failure in the posterior fossa occurred despite boosts greater than 56 Gy. Females, over the age of 6 years, had significantly better relapse-free survival than males of the same age. Six of the 54 patients who relapsed were long-term survivors.

CONCLUSIONS

Low-dose craniospinal radiotherapy, where the majority of patients received chemotherapy, was not associated with increased failure. High-dose posterior fossa hyperfractionation did not improve control. Long-term survival was noted in a number of patients after relapse. We recommend 60 Gy or greater with conventional fractions to the primary area, and continued study of low-dose craniospinal irradiation with adjuvant chemotherapy.

Demonstration of circulating group B streptococcal immune complexes in neonates with meningitis

Group B streptococci are the major cause of sepsis and fatal shock in neonates in the United States. Although a number of clinical features have been associated with enhanced severity of disease, the role of soluble immune complex formation in group B streptococcal infection has not been evaluated. We determined the frequency with which circulating immune complexes occurred in 16 infants with nonfatal type III, group B streptococcal meningitis, using an immunoglobulin-specific C1q enzyme immunoassay. Ten healthy, age-matched infants served as a control group. Elevated levels of immunoglobulin M (IgM)-containing immune complexes were present in the sera of four (25%) patients with group B streptococcal meningitis. Group B antigen was detected in precipitated IgM immune complexes from each of these four infants by competitive enzyme-linked immunosorbent assay. In addition, IgG-containing immune complexes were present in 56% of sick and 60% of control infants. Group B antigen was demonstrated in the serum of a sick neonate containing only IgG immune complexes but not in controls. Our findings indicate that a subset of infants with type III, group B streptococcal meningitis develop IgM immune complexes containing group B-specific antigen, and these may persist for up to 3 months in some patients.

Progression of multiple cryptic vascular malformations associated with anomalous venous drainage. Case report

The case of a young girl with a pericallosal venous malformation associated with multiple cryptic vascular malformations (CVM's) is described. The presenting cryptic malformation, which hemorrhaged, was completely excised, but the venous malformation was not. Routine follow-up magnetic resonance images obtained over the past 9 years have documented the development of multiple new cryptic malformations along the radicles of the venous malformation. Magnetic resonance imaging and cerebral angiography revealed venous outflow obstruction at the junction of the venous malformation with the straight sinus. The association of CVM's with anomalous venous drainage patterns and the role of venous hypertension in the pathogenesis of cryptic malformations are discussed. This case suggests that CVM's associated with a venous malformation may recur and new ones may develop if the venous malformation is not excised, particularly if venous hypertension is also present. The likelihood of a surgical cure in these patients may depend on complete excision of both anomalies, which is rarely feasible because of the potentially devastating results of resecting a venous malformation. Alternative treatments for patients with both types of lesions are discussed.

Complement and antibody in neutrophil-mediated killing of type V group B streptococcus

Serious infections caused by type V group B streptococci (GBS) are increasing. The requirements for antibody, complement, and neutrophil receptors in the killing of 12 clinical type V GBS isolates were investigated. When tested at concentrations of 33%, 5% and 1%, a human serum pool promoted neutrophil-mediated killing of the 12 isolates at a mean of 83% +/- 9%, 77% +/- 17%, and 14% +/- 28%, respectively. Addition of heated immune rabbit serum to the 5% or 1% pool increased killing significantly (97% +/- 2% or 80% +/- 15%, respectively, P < .01). With hypogammaglobulinemic serum, complement-mediated killing ranged from 74% +/- 2% for a strain designated resistant to 98% +/- 1% for a strain designated sensitive. Neutrophil-mediated killing was not altered by use of human sera deficient in C4 or C7 but was reduced significantly with C3-deficient serum (P < .05). Maximal inhibition of neutrophil-mediated killing was observed by monoclonal antibody blockade of complement receptor (CR) 3 alone or in combination with CR1 or Fc receptor III. Thus, C3 is required and specific antibody promotes neutrophil-mediated killing of type V GBS. Neutrophil CR3 and either CR1 or Fc receptor III optimize phagocytosis. A number of host responses function in concert to effect optimal neutrophil-mediated killing of clinical isolates of type V GBS.