Connatal periventricular pseudocysts in the neonate

Evaluation of MRI Features and Neurodevelopmental Outcomes for Prenatally Diagnosed Periventricular Pseudocysts

Objectives: This study aimed to evaluate the morphologic features and neurodevelopmental outcomes of individuals prenatally diagnosed with a periventricular pseudocyst (PVPC). Methods: Pregnant women with a fetus prenatally diagnosed with PVPC by MRI were enrolled in this retrospective study. The fetuses with PVPCs were divided into group 1 (isolated PVPC) and group 2 (PVPC with additional findings). The surviving infants underwent brain MRI examinations and the Gesell Developmental Scale (GDS) test after birth. Independent sample t-tests were used to compare the differences in the developmental quotient (DQ) between group 1 and group 2. We also analyzed the correlations among the DQ, location (unilateral/bilateral), size (diameter), and number (single/multiple) of the PVPCs in group 1 using Lasso regression. Results: In total, 131 infants (group 1: 78 infants, group 2: 53 infants) underwent MRI examinations after birth, and 97 infants (group 1: 59 infants, group 2: 38 infants) underwent the GDS test. Upon follow-up, the sizes of the cysts had become smaller or disappeared after birth. The average DQ in group 2 was lower than that in group 1 (all with p < 0.001). In group 1, the location (unilateral/bilateral), size (diameter), and number (single/multiple) of the PVPC did not affect the DQ. Conclusions: The PVPCs became smaller or disappeared after birth. Isolated PVPCs usually have a normal presentation after birth regardless of the location, number, or size. For PVPCs with additional findings, the neurodevelopmental outcomes were inferior to those in isolated PVPCs.

Periventricular pseudocysts of noninfectious origin: Prenatal associated findings and prognostic factors

OBJECTIVE

The purpose of this study was to establish prognostic factors in fetuses diagnosed with periventricular pseudocysts (PVPCs) without known congenital infection, between 28 and 37 weeks of gestation.

METHODS

This retrospective study included cases of fetal PVPC from 2008 to 2018. PVPCs were classified according to location, number, extension, morphology, and size. Additional findings, MRI and genetic studies were recorded. Pregnancy outcome, postnatal, or postmortem results were obtained. Images from patients with normal (Group 1) and abnormal postnatal development (Group 2) were compared for analysis of factors predictive of outcome.

RESULTS

One-hundred and fifteen pseudocysts were observed in 59 patients. In 34 fetuses (57%), the PVPC was an isolated finding. Thirty-nine patients delivered live newborns, 27% opted for termination of pregnancy, and 4 patients were lost to follow-up. Eighty-four percent of the liveborns had normal development. When assessing for the influence of pseudocyst characteristics, a wide CSP, or large head circumference, neither of these affected the outcome. The presence of additional anomalies was the only positive predictor for abnormal development regradless of specific PVPC characteristics (P = .002).

CONCLUSIONS

In fetuses with PVPCs, the presence of additional anomalies was the only predictor for adverse postnatal outcome. No association between cystic characteristics and adverse outcome was observed.

The Lateral Ventricles: A Detailed Review of Anatomy, Development, and Anatomic Variations

The cerebral ventricles have been studied since the fourth century BC and were originally thought to harbor the soul and higher executive functions. During the infancy of neuroradiology, alterations to the ventricular shape and position on pneumoencephalography and ventriculography were signs of mass effect or volume loss. However, in the current era of high-resolution cross-sectional imaging, variation in ventricular anatomy is more easily detectable and its clinical significance is still being investigated. Interpreting radiologists must be aware of anatomic variations of the ventricular system to prevent mistaking normal variants for pathology. We will review of the anatomy and development of the lateral ventricles and discuss several ventricular variations.

The developing brain by trimester

Transient anatomical entities play a role in the maturation of brain regions and early functional fetal networks. At the postmenstrual age of 7 weeks, major subdivisions of the brain are visible. At the end of the embryonic period, the cortical plate covers the neopallium. The choroid plexus develops in concert with it, and the dorsal thalamus covers about half the diencephalic third ventricle surface. In addition to the fourth ventricle neuroepithelium the rhombic lips are an active neuroepithelial production site. Early reciprocal connections between the thalamus and cortex are present. The corticospinal tract has reached the pyramidal decussation, and the arteries forming the mature circle of Willis are seen. Moreover, the superior sagittal sinus has formed, and at the rostral neuropore the massa commissuralis is growing. At the viable preterm age of around 24 weeks PMA, white matter tracts are in full development. Asymmetric progenitor division permits production of neurons, subventricular zone precursors, and glial cells. Myelin is present in the ventral spinal quadrant, cuneate fascicle, and spinal motor fibers. The neopallial mantle has been separated into transient layers (stratified transitional fields) between the neuroepithelium and the cortical plate. The subplate plays an important role in organizing the structuring of the cortical plate. Commissural tracts have shaped the corpus callosum, early primary gyri are present, and opercularization has started caudally, forming the lateral fissure. Thalamic and striatal nuclei have formed, although GABAergic neurons continue to migrate into the thalamus from the corpus gangliothalamicum. Near-term PMA cerebral sublobulation is active. Between 24 and 32 weeks, primary sulci develop. Myelin is present in the superior cerebellar peduncle, rubrospinal tract, and inferior olive. Germinal matrix disappears from the telencephalon, except for the GABAergic frontal cortical subventricular neuroepithelium.

Prenatal Evaluation, Imaging Features, and Neurodevelopmental Outcome of Prenatally Diagnosed Periventricular Pseudocysts

BACKGROUND AND PURPOSE

Periventricular pseudocysts are cystic cavities that lack the ependymal cell lining found in true cysts. The aim of this study was to characterize periventricular pseudocysts and related findings and their neurodevelopmental outcome.

MATERIALS AND METHODS

This was a retrospective study of periventricular pseudocysts detected prenatally on fetal MR imaging in 26 fetuses. The fetuses were divided into group A (n = 8), which included cases with isolated periventricular pseudocysts, and group B (n = 18), which included cases of periventricular pseudocysts with additional findings. Cases were further subdivided into connatal cysts and subependymal pseudocysts. Data collected included prenatal history, MR imaging features, sonographic follow-up, and neurodevelopmental outcome.

RESULTS

All cases in group A (n = 8) had a normal outcome. In group B (n = 18), 6 pregnancies were terminated and 2 had an abnormal outcome. Both cases with an abnormal outcome involved patients with subependymal pseudocysts. No significant association was found between the morphologic features on MR imaging and the neurodevelopmental outcome.

CONCLUSIONS

Neurodevelopmental outcome in cases of isolated periventricular pseudocysts detected prenatally appears to be normal. A detailed evaluation should be performed to rule out additional brain findings, chromosomal aberration, and fetal malformation. This evaluation should include the following: maternal TORCH status, detailed fetal sonographic anatomic evaluation, fetal echocardiogram, fetal brain MR imaging, amniocentesis and karyotyping/comparative genomic hybridization, and genetic counseling. Additional findings on MR imaging, including mild-to-moderate dilated ventricles, asymmetric ventricles, or T2 hyperintense signal in the white matter without other findings or major fetal abnormality, appear to be benign. Connatal cysts appear to be benign.

Prenatal features of isolated subependymal pseudocysts associated with adverse pregnancy outcome

OBJECTIVES

To identify at prenatal ultrasound (US) the features of apparently isolated subependymal pseudocysts (SEPC) that may indicate underlying pathology and should lead to further investigations.

METHODS

This was a retrospective study of cases with SEPC detected on prenatal US and/or magnetic resonance imaging (MRI). Those with apparently isolated SEPC at US were classified into two groups as follows: Group 1 (n = 29): normal prenatal US and MRI (except for SEPC) and normal outcome; Group 2 (n = 12): normal prenatal cerebral US (except for SEPC) and abnormal prenatal cerebral MRI with or without abnormal outcome. A third group (n = 9) included cases with abnormal prenatal US and MRI. The latter cases with obvious cerebral abnormalities at US were excluded from the statistical analysis as they do not represent a diagnostic dilemma for clinicians. Groups 1 and 2 were analyzed, comparing them with respect to their SEPC characteristics (size, number, location in relation to the caudothalamic notch and the ventricular horns and morphology) and extracerebral abnormalities.

RESULTS

The mean ± SD SEPC great axis was longer in Group 2 (11.67 ± 5.82 mm) than it was in Group 1 (8.00 ± 5.64 mm) (P = 0.021), suggesting an optimal cut-off for size of SEPC of ≥ 9 mm (sensitivity = 75%, specificity = 62%) to maximize sensitivity for predicting pathological outcome. SEPC adjacent to the temporal horns and SEPC located posterior to the caudothalamic notch were observed more frequently in Group 2, indicating their association with poor outcome (P = 0.003 and P = 0.003, respectively). Atypical morphology and extracerebral abnormalities were observed more frequently in Group 2 (P = 0.013 and P = 0.044, respectively). There was no statistically significant difference between groups for either number or location of cysts along the inferior wall or adjacent to the lateral wall of the frontal horns (P = 0.591 and P = 0.156, respectively).

CONCLUSION

When apparently isolated SEPC are observed at prenatal US, further investigations should be performed under the following circumstances: (1) SEPC great axis ≥ 9 mm; (2) SEPC adjacent to the occipital and temporal horns; (3) SEPC located posterior to the caudothalamic notch; (4) SEPC with atypical morphology.

Neurodevelopment outcome of newborns with cerebral subependymal pseudocysts at 18 and 46 months: a prospective study

OBJECTIVES

Subependymal pseudocysts (SEPC) are cerebral periventricular cysts located on the floor of the lateral ventricle and result from regression of the germinal matrix. They are increasingly diagnosed on neonatal cranial ultrasound. While associated pathologies are reported, information about long-term prognosis is missing, and we aimed to investigate long-term follow-up of these patients.

STUDY DESIGN

Newborns diagnosed with SEPC were enrolled for follow-up. Neurodevelopment outcome was assessed at 6, 18 and 46 months of age.

RESULTS

74 newborns were recruited: we found a high rate of antenatal events (63%), premature infants (66% <37 weeks, 31% <32 weeks) and twins (30%). MRI was performed in 31 patients, and cystic periventricular leukomalacia (c-PVL) was primarily falsely diagnosed in 9 of them. Underlying disease was diagnosed in 17 patients, 8 with congenital cytomegalovirus (CMV) infection, 5 with genetic and 4 with metabolic disease. Neurological examination (NE) at birth was normal for patients with SEPCs and no underlying disease, except one. Mean Developmental Quotient and IQ of these patients was 98.2 (±9.6SD; range 77-121), 94.6 (±14.2SD; 71-120) and 99.6 (±12.3SD; 76-120) at 6, 18 and 46 months of age, respectively, with no differences between the subtypes of SEPC. A subset analysis showed no outcome differences between preterm infants with or without SEPC, or between preterm of <32 GA and ≥32 GA.

CONCLUSIONS

Neurodevelopment of newborns with SEPC was normal when no underlying disease was present. This study suggests that if NE is normal at birth and congenital CMV infection can be excluded, then no further investigations are needed. Moreover, it is crucial to differentiate SEPC from c-PVL which carries a poor prognosis.

Newborn frontal horn cysts: cause for concern?

OBJECTIVE

To document the incidence, natural history and compare neurodevelopmental outcome of newborns with and without frontal horn cysts (FHC).

STUDY DESIGN

This was a case-control study. Newborns with and without FHC were identified and matched for demographics and worst cranial ultrasound scan (CUS) findings. Neurodevelopmental outcome was assessed at 18 to 24 months.

RESULT

A total of 30 FHC cases were identified from medical imaging database. Twenty-five cases occurred in preterm 32 weeks gestation with an incidence of 1% (25 of 2340). The diagnosis was made on the initial CUS in 28 cases. The cyst size and number varied from 1 to 18 mm and 1 to 6 respectively with no change noted on repeat CUS during hospital stay. Neurodevelopmental outcomes were not statistically significantly different between the groups.

CONCLUSION

FHC are not uncommon in the newborn period. They appear to be benign with no impact on neurodevelopmental outcome. This information is vital for counseling parents of infants with FHC.

Routine TORCH screening is not warranted in neonates with subependymal cysts

BACKGROUND

Congenital infections are associated with a wide variety of clinical symptoms, including subependymal cysts (SEC).

OBJECTIVE

To determine the co-occurrence of SEC and congenital infections, as diagnosed by TORCH serologic tests and/or cytomegalovirus (CMV) urine culture.

METHODS

We performed a retrospective study of all neonates admitted to our neonatal intensive care unit from 1998 to 2009 in whom SEC were detected on cranial ultrasound and TORCH serologic tests and/or CMV urine cultures were performed.

RESULTS

Fifty-nine neonates fulfilled the inclusion criteria. TORCH serologic tests were performed in 69% (41/59) of cases. Urine CMV culture was performed in 68% (40/59) of cases. None of the neonates tested positive for IgM Toxoplasma gondii, Rubella and Herpes simplex virus. Positive CMV IgM titers and/or a positive urine CMV culture were detected in 2% (1/59) of neonates.

CONCLUSION

The co-occurrence of TORCH congenital infections in infants with SEC is rare. Routine TORCH screening in neonates with SEC does not seem warranted.

Neurodevelopment in very low birth weight premature infants with postnatal subependymal cysts

The aim of this study was to investigate the neurodevelopmental outcome in very low birth weight infants with postnatal subependymal cysts. During a 3-year period, postnatal subependymal cysts were diagnosed by serial cranial ultrasound in 21 very low birth weight infants born prior to 33 weeks' gestation. These infants and 116 healthy very low birth weight controls were evaluated with the Bayley Scales of Infant Development at 2 years of age. Preterm infants with postnatal subependymal cysts had a significantly lower Psychomotor Development Index (P = .034) and were more likely than the normal group to have motor developmental delay (Psychomotor Development Index <70) (P = .013). The findings indicate that postnatal subependymal cyst is a significant risk factor for impaired motor development in very low birth weight infants (odds ratio 5.73, 95% confidence interval 1.57-20.97).

Differential Diagnosis of Intracranial Cystic Lesions at Head US: Correlation with CT and MR Imaging

The differential diagnosis of intracranial cystic lesions at head ultrasonography (US) includes a broad spectrum of conditions: (a) normal variants, (b) developmental cystic lesions, (c) cysts due to perinatal injury, (d) vascular cystlike structures, (e) hemorrhagic cysts, and (f) infectious cysts. These lesions vary in prevalence from common (cavum of the septum pellucidum, subependymal cyst, choroid plexus cyst) to rare (vein of Galen malformation). US can provide important information about the anatomic location, size, and shape of the lesions as well as their mass effect on adjacent structures. Differential diagnosis may be difficult because there is substantial overlap of US features between many of these conditions. However, if careful attention is paid to the location and characteristics of the cyst, a more specific diagnosis may be suggested. Understanding the spectrum of appearances of the various intracranial cystic lesions at head US improves the diagnostic yield, enables one to understand their pathogenesis, and facilitates patient care.

Adult unilateral periventricular pseudocysts with ipsilateral headache

OBJECTIVES

Unilateral periventricular pseudocysts (PVPC), manifesting as ipsilateral headache have been only rarely reported in adults.

CASE REPORT

In a 48-year-old woman, right-sided, pulsating headache occurred in 1999. Headache exclusively extended over the right head and periorbitally; it was frequently associated with a feeling of cold, lasted maximally for 1 day, and occasionally went along with nausea and right-sided lacrimation. Since January 2003, headache occurred daily with varying intensity. For headache, she was regularly taking doxepin (25 mg). Ordinary analgesics and tryptanes were only of minimal effect. Since 2001, left-sided hemi-hypesthesia occurred. CT and MRI scans of the brain disclosed right-sided cysts in the white matter with a maximal diameter of 1cm, partially grouped and partially disseminated and bilateral calcifications of the basal ganglia. Since hypoxemia/ischemia, subependymal hemorrhage, CNS infection, developmental defect of the mantle layer, chromosomal disorder, Zellweger syndrome, carbon monoxide intoxication, trauma, or mitochondriopathy were not causative, the etiology of PVPC remained questionable.

CONCLUSIONS

Rarely, unilateral PVPC become symptomatic in adulthood, manifesting as ipsilateral headache, contralateral hemi-hypesthesia, depression, collapses, and slight cognitive decline. Clinical progression of the disease is not necessarily related to the progression of the imaging findings. PVPC should be included in the differential diagnosis of unilateral headache.

Clinical features of infants with subependymal germinolysis and choroid plexus cysts

BACKGROUND

Periventricular cysts are not rare findings in neonates. However, they are sometimes associated with serious clinical complications, such as congenital viral infections and anomalies.

METHODS

We performed a retrospective follow-up study on newborns who had periventricular cysts on routine cranial ultrasound examination.

RESULTS

We followed 13 infants (three preterm) with periventricular cysts. Ten had single or multiple germinolysis cysts and the remaining three had choroid plexus cysts. All infants had various kinds of underlying complications, including congenital viral infection (two with cytomegalovirus and one with rubella),Sotos syndrome (n = 4), intrauterine growth retardation (n = 5), large-for-dates(n = 4), congenital heart disease (n = 1),myelomeningocele (n = 1) and other minor anomalies. All cases of germinolysis except for one developed a neurodevelopmental abnormality and/or delay. In contrast,all three cases with choroid plexus cysts appeared to develop well,despite the underlying complications.

CONCLUSIONS

Germinolysis cysts seem to be associated with systemic diseases and should be treated as a high-risk sign for impaired neurological development.

Central nervous system involvement in neonatal lupus erythematosus

Computerized tomography (CT) of the brain was performed in 10 of 11 consecutive infants with neonatal lupus erythematosus (NLE) (five boys and six girls). Ten of the 11 infants had brain neurosonography. Nine of 10 infants had abnormal CT scans. There was diffuse, markedly reduced attenuation of the cerebral white matter in four infants studied in the first week of life, and also in an infant 5 weeks of age. Patchy reduced subcortical white matter attenuation was observed in another 5-week-old infant. Basal ganglia calcifications were present in two infants at 2 months of age, one of whom also had mild ventriculomegaly. A patient with macrocephaly studied at 4 months of age had enlarged ventricles and subarachnoid spaces consistent with benign macrocephaly of infancy. Cerebral ultrasound examination was abnormal in all five infants studied in the first week of life and in one infant at 2 months of age. Findings included subependymal cysts (4), echogenic white matter (3), and echogenic lenticulostriate vessels (3). Apart from one case of macrocephaly, there was no clinical evidence of neurologic disease and the subsequent development of these infants has been normal. Subclinical central nervous system (CNS) disease in NLE is likely to be a transient phenomenon that resolves as maternal antibodies are cleared from the infant's circulation. It is important to be aware of these neuroimaging abnormalities to avoid misdiagnosis of congenital viral infection in a newborn with multisystem NLE. The potential for neurologic sequelae is uncertain.

Subependymal pseudocysts in the fetal brain: prenatal diagnosis of two cases and review of the literature

Subependymal pseudocysts are cerebral cysts found in 5% of all neonates. When they are isolated and typical, they result from persistence of the germinal matrix, have a good prognosis and regress spontaneously within a few months. However, associated anomalies are frequent and in such cases the prognosis is poor. They can be of infectious, vascular, metabolic or chromosomal origin. Subependymal pseudocysts have rarely been described in the antenatal period. We report the prenatal diagnosis of two cases of isolated pseudocysts at 32 and 23 weeks. Both ultrasonography and magnetic resonance imaging assisted in the diagnosis and there was normal postnatal outcome in both cases.

Prenatal cocaine exposure and cranial sonographic findings in preterm infants

PURPOSE

Prenatal cocaine exposure has been linked with subependymal hemorrhage and the formation of cysts that are detectable on cranial sonography in neonates born at term. We sought to determine if prenatal cocaine exposure increases the incidence of subependymal cysts in preterm infants.

METHODS

We retrospectively reviewed the medical records and cranial sonograms obtained during a 1-year period on 122 premature (< 36 weeks of gestation) infants. Infants were categorized into 1 of 2 groups: those exposed to cocaine and those not exposed to cocaine. Infants were assigned to the cocaine-exposed group if there was a maternal history of cocaine abuse during pregnancy or if maternal or neonatal urine toxicology results were positive at the time of delivery.

RESULTS

Five of the 122 infants were excluded from the study because of insufficient medical and drug histories. The incidence of subependymal cysts in the 117 remaining infants was 14% (16 of 117). The incidence of subependymal cysts in infants exposed to cocaine prenatally was 44% (8 of 18) compared with 8% (8 of 99) in the unexposed group (p < 0.01).

CONCLUSIONS

We found an increased incidence of subependymal cyst formation in preterm infants who were exposed to cocaine prenatally. This result is consistent with results of similar studies in term infants.

Subependymal caudothalamic groove hyperechogenicity and neonatal chronic lung disease

Chronic lung disease is associated with several poorly defined risk factors for impaired cerebral development. Late neonatal onset of subependymal hyperechogenic areas in the caudothalamic groove has been reported in association with dexamethasone treatment and postnatal cytomegalovirus infection. We reviewed charts of 18 patients who developed subependymal hyperechogenicity beyond the first week of life, as well as charts of 79 patients belonging to a prospective surfactant study group. Thirteen of the 18 patients with subependymal hyperdensities had been treated with surfactant and were all found in the subgroup with chronic lung disease. In the surfactant-treated patients who did not develop chronic lung disease, we could not find any patient with subependymal hyperdensities. From the remaining five patients with ultrasound lesions, but who were not treated with surfactant, three had developed chronic lung disease. There was no evident association with dexamethasone treatment or cytomegalovirus infection. Our results support the idea of an association between chronic lung disease and the described echographic lesions in the caudothalamic groove, but the nature of the link between them is still unclear.

Transient bifrontal solitary periventricular cysts in term neonates

We describe three children born at term investigated for neonatal seizures or transient apnoea. Cranial ultrasound and MRI unexpectedly revealed symmetrical periventricular cysts adjacent to the anterior horns. We found no evidence of prenatal viral infection, intraventricular or subependymal haemorrhage or hypoxic-ischaemic lesions. The lesions were not seen on MRI at 3 months of age, but there was no compensatory dilatation of the anterior horns nor secondary loss of white matter. The appearance and location of these transient cysts were different from those of the cystic changes which typically follow germinal matrix haemorrhage or periventricular leukomalacia. Their pathogenesis and clinical significance remain to be determined.