Occurrence of subdural hematomas in Dutch glutaric aciduria type 1 patients

Outcomes and prognostic factors of infantile acquired hydrocephalus: a single-center experience

AIM

To assess the etiologies and adverse outcomes of infantile acquired hydrocephalus and predict prognosis.

METHODS

A total of 129 infants diagnosed with acquired hydrocephalus were recruited from 2008 to 2021. Adverse outcomes included death and significant neurodevelopmental impairment which was defined as Bayley Scales of Infant and Toddler Development III score < 70, cerebral palsy, visual or hearing impairment, and epilepsy. Chi-squared was used to evaluate the prognostic factors of adverse outcomes. A receiver operating characteristic curve was calculated to determine the cutoff value.

RESULTS

Of 113 patients with outcome data, 55 patients (48.7%) had adverse outcomes. Late surgical intervention time (13 days) and severe ventricular dilation were associated with adverse outcomes. The combination of surgical intervention time and cranial ultrasonography (cUS) indices was a better predictive marker compared with any of them (surgical intervention time, P = 0.05; cUS indices, P = 0.002). Post-hemorrhage (54/113, 48%), post-meningitis (28/113, 25%), and hydrocephalus arising from both hemorrhage and meningitis (17/113, 15%) accounted for a large proportion of the etiologies in our study. Hydrocephalus occurs secondary to post-hemorrhage and had a favorable outcome compared with other etiologies in both preterm and term groups. A significant difference in adverse outcomes between the inherited error of metabolism as a cause and other etiologies (P = 0.02).

CONCLUSION

Late surgical treatment times and severe ventricular dilation can predict adverse outcomes in infants with acquired hydrocephalus. It is crucial to identify the causes of acquired hydrocephalus to predict the adverse outcomes. Research into measures of improving adverse outcomes following infantile acquired hydrocephalus is urgently necessary.

Standardizing genetic and metabolic consults for non-accidental trauma at a large pediatric academic center

BACKGROUND

Evaluations of suspected non-accidental trauma (NAT) often include consultation with genetic and metabolic teams to assess patients for rare genetic conditions that can mimic or exacerbate child abuse. Diagnoses that may be questioned during court proceedings include osteogenesis imperfecta (OI) and glutaric aciduria type 1 (GA1). Currently there are no official society guidelines for the genetic or metabolic workup of suspected NAT.

OBJECTIVE

To standardize consult recommendations for suspected NAT through collaboration between the Genetics and Genomics Division and the Child Protection Team (CPT).

PARTICIPANTS AND SETTINGS

Children evaluated for suspected NAT at a single pediatric referral center.

METHODS

A year of inpatient consult requests for suspected NAT to the genetics division were reviewed. The most common indications for consult were fractures and subdural hematoma. Consult recommendations for similar indications varied between providers. A standard operating procedure (SOP) with specific recommendations for suspected NAT consults for fractures, intracranial hemorrhage, and other indications was created based on expert reviews and other relevant literature. A questionnaire assessing division practice patterns for these consults was distributed both pre (n = 17) and post-introduction of the SOP (n = 11).

RESULTS

Adherence to the SOP and impact on suspected NAT consult recommendations were assessed at 18 months after SOP introduction. Consult recommendations were in line with the SOP for 7/11 consults pre-intervention and 6/7 consults post-intervention. Providers were more likely to report feeling extremely or very confident they were using evidence-based medicine for NAT consults post-intervention.

Subdural hematoma in glutaric aciduria type 1: High excreters are prone to incidental SDH despite newborn screening

Subdural hematoma (SDH) was initially reported in 20% to 30% of patients with glutaric aciduria type 1 (GA1). A recent retrospective study found SDH in 4% of patients, but not in patients identified by newborn screening (NBS). 168 MRIs of 69 patients with GA1 (age at MRI 9 days - 73.8 years, median 3.2 years) were systematically reviewed for presence of SDH, additional MR and clinical findings in order to investigate the frequency of SDH and potential risk factors. SDH was observed in eight high-excreting patients imaged between 5.8 and 24.4 months, namely space-occupying SDH in two patients after minor accidental trauma and SDH as an incidental finding in six patients without trauma. In patients without trauma imaged at 3 to 30 months (n = 36, 25 NBS, 27/9 high/low excreters), incidence of SDH was 16.7% (16% in NBS). SDH was more common after acute (33.3%) than insidious onset of dystonia (14.3%) or in asymptomatic patients (5.9%). It was only seen in patients with wide frontoparietal CSF spaces and frontotemporal hypoplasia. High excreters were over-represented among patients with SDH (6/27 vs 0/9 low excreters), acute onset (10/12), and wide frontoparietal CSF spaces (16/19). Incidental SDH occurs despite NBS and early treatment in approximately one in six patients with GA1 imaged during late infancy and early childhood. Greater risk of high excreters is morphologically associated with more frequent enlargement of external CSF spaces including frontotemporal hypoplasia, and may be furthered aggravated by more pronounced alterations of cerebral blood volume and venous pressure.

Abusive head trauma: neuroimaging mimics and diagnostic complexities

Traumatic brain injury is responsible for approximately half of all childhood deaths from infancy to puberty, the majority of which are attributable to abusive head trauma (AHT). Due to the broad way patients present and the lack of a clear mechanism of injury in some cases, neuroimaging plays an integral role in the diagnostic pathway of these children. However, this nonspecific nature also presages the existence of numerous conditions that mimic both the clinical and neuroimaging findings seen in AHT. This propensity for misdiagnosis is compounded by the lack of pathognomonic patterns and clear diagnostic criteria. The repercussions of this are severe and have a profound stigmatic effect. The authors present an exhaustive review of the literature complemented by illustrative cases from their institutions with the aim of providing a framework with which to approach the neuroimaging and diagnosis of AHT.

Genetic consultations in cases of unexplained fractures and haemorrhage: an evidence-based approach

PURPOSE OF REVIEW

When infants and young children present with suspected physical abuse, it is critical to follow standard guidelines and rule out alternative causes of fracture and haemorrhage. A multidisciplinary team involved in the initial evaluation typically includes paediatrics, radiology, child protective services and/or law enforcement, and in complex cases, haematology, neurology, and genetics. A comprehensive genetics consultation includes review of the history of present illness, birth and past medical history, review of growth curves, family history, physical examination, radiological findings, and when indicated, biochemical and/ or genetic testing.

RECENT FINDINGS

A number of reports have mischaracterized several genetic disorders as child abuse mimics. There is a difference between a differential diagnosis, which includes every condition that can cause a fracture and/or subdural haemorrhage, and a mimic, so called because it can be difficult to differentiate from child abuse. In this review, we discuss the differential diagnosis for infantile fractures and subdural bleeds, highlight cardinal signs and symptoms of genetic disorders, and demonstrate that these genetic disorders can be readily differentiated and diagnosed using a stepwise approach. Genetic disorders rarely, if ever, are truly mimics of child physical abuse.

SUMMARY

In cases of suspected child physical abuse, multidisciplinary evaluations by paediatric specialists, keen clinical judgment, complete physical examinations, and judicious testing provides an evidence-based, time tested approach to excluding genetic disorders and diagnosing suspected child physical abuse.

Pediatric Glutaric Aciduria Type 1: 14 Cases, Diagnosis and Management

Introduction

Glutaric aciduria type I is an autosomal recessive disorder of lysine metabolism due to the defect of the enzyme glutaryl-CoA dehydrogenase. The regression of milestones following an intercurrent infection with disabling dystonia is the common presentation. We report the clinical features, diagnosis, and management of 14 south Indian children with glutaric aciduria type I.

Results

Males predominated the study (57.1%). The mean age of onset of the symptoms was 8.57 ± 3.57 months. The mean age at the time of diagnosis was 35.21 ± 48.31 months. The history of consanguinity was noted in 57.1%. Development was normal prior to the onset of acute crises in nearly three fourths. Acute crises triggered by infection followed by the regression of milestones was the major presenting feature in 10 children (71.4%). Macrocephaly was another prominent feature in an equal number. Bat's wing appearance (fronto temporal atrophy) was present in all children. Nearly 80% had moderate to severe disability in the form of dystonic movement disorder and spastic quadriparesis.

Conclusion

Glutaric aciduria type Ihas to be identified and managed early to have a better outcome.

Beware of Osteogenesis Imperfecta: Subdural Hematoma in a 10-Year-Old Child With Minor Head Trauma

Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by disruption of normal collagen formation resulting in varying degrees of ligamentous laxity and skeletal vulnerability; the low bleeding potential is easily overlooked. Subdural hematoma (SDH) is a common neurosurgical condition, classically related to the rupture of bridging cortico-dural veins after trauma. In the pediatric population, the age distribution shows a massive preponderance for children in their early first decade. We report a very unusual case of SDH in a 10-year-old boy with OI type I, with history of minor trauma. SDH remains exceedingly rare in OI, and its pathophysiology is unclear. To the best of our knowledge, this is the first report of a unilateral subacute SDH associated with OI in a child of such advanced age. These cases may also carry legal ramifications, including misdiagnosis of child abuse in ambiguous situations that are not thoroughly investigated.

The neuroimaging mimics of abusive head trauma

Abusive head trauma (AHT) is a significant cause of morbidity and mortality in the paediatric population, typically in children under the age of two years. Neuroimaging plays a key role in the diagnostic work up of these patients as information regarding the mechanism of injury is often lacking and the findings on examination can be nonspecific. A number of conditions, both traumatic and atraumatic can mimic AHT based on neuroimaging features alone. The repercussions associated with a diagnosis or misdiagnosis of AHT can be severe and radiologists therefore need to be aware of and familiar with the imaging differentials of AHT. In this paper we review the imaging findings of the radiological mimics of AHT and focus on features that can help differentiate these entities from AHT.

Organic acidurias in adults: late complications and management

Organic acidurias (synonym, organic acid disorders, OADs) are a heterogenous group of inherited metabolic diseases delineated with the implementation of gas chromatography/mass spectrometry in metabolic laboratories starting in the 1960s and 1970s. Biochemically, OADs are characterized by accumulation of mono-, di- and/or tricarboxylic acids ("organic acids") and corresponding coenzyme A, carnitine and/or glycine esters, some of which are considered toxic at high concentrations. Clinically, disease onset is variable, however, affected individuals may already present during the newborn period with life-threatening acute metabolic crises and acute multi-organ failure. Tandem mass spectrometry-based newborn screening programmes, in particular for isovaleric aciduria and glutaric aciduria type 1, have significantly reduced diagnostic delay. Dietary treatment with low protein intake or reduced intake of the precursor amino acid(s), carnitine supplementation, cofactor treatment (in responsive patients) and nonadsorbable antibiotics is commonly used for maintenance treatment. Emergency treatment options with high carbohydrate/glucose intake, pharmacological and extracorporeal detoxification of accumulating toxic metabolites for intensified therapy during threatening episodes exist. Diagnostic and therapeutic measures have improved survival and overall outcome in individuals with OADs. However, it has become increasingly evident that the manifestation of late disease complications cannot be reliably predicted and prevented. Conventional metabolic treatment often fails to prevent irreversible organ dysfunction with increasing age, even if patients are considered to be "metabolically stable". This has challenged our understanding of OADs and has elicited the discussion on optimized therapy, including (early) organ transplantation, and long-term care.

Anatomical and Physiological Differences between Children and Adults Relevant to Traumatic Brain Injury and the Implications for Clinical Assessment and Care

General and central nervous system anatomy and physiology in children is different to that of adults and this is relevant to traumatic brain injury (TBI) and spinal cord injury. The controversies and uncertainties in adult neurotrauma are magnified by these differences, the lack of normative data for children, the scarcity of pediatric studies, and inappropriate generalization from adult studies. Cerebral metabolism develops rapidly in the early years, driven by cortical development, synaptogenesis, and rapid myelination, followed by equally dramatic changes in baseline and stimulated cerebral blood flow. Therefore, adult values for cerebral hemodynamics do not apply to children, and children cannot be easily approached as a homogenous group, especially given the marked changes between birth and age 8. Their cranial and spinal anatomy undergoes many changes, from the presence and disappearance of the fontanels, the presence and closure of cranial sutures, the thickness and pliability of the cranium, anatomy of the vertebra, and the maturity of the cervical ligaments and muscles. Moreover, their systemic anatomy changes over time. The head is relatively large in young children, the airway is easily compromised, the chest is poorly protected, the abdominal organs are large. Physiology changes—blood volume is small by comparison, hypothermia develops easily, intracranial pressure (ICP) is lower, and blood pressure normograms are considerably different at different ages, with potentially important implications for cerebral perfusion pressure (CPP) thresholds. Mechanisms and pathologies also differ—diffuse injuries are common in accidental injury, and growing fractures, non-accidental injury and spinal cord injury without radiographic abnormality are unique to the pediatric population. Despite these clear differences and the vulnerability of children, the amount of pediatric-specific data in TBI is surprisingly weak. There are no robust guidelines for even basics aspects of care in children, such as ICP and CPP management. This is particularly alarming given that TBI is a leading cause of death in children. To address this, there is an urgent need for pediatric-specific clinical research. If this goal is to be achieved, any clinician or researcher interested in pediatric neurotrauma must be familiar with its unique pathophysiological characteristics.

Dentate Update: Imaging Features of Entities That Affect the Dentate Nucleus

The dentate nucleus is a cerebellar structure involved in voluntary motor function and cognition. There are relatively few entities that affect the dentate, and the clinical features of these conditions are often complex and nonspecific. Because these entities are rarely encountered, the formulation of a differential diagnosis can be difficult. Many of the conditions are reversible or treatable with early intervention. Therefore, it is important to recognize classic clinical presentations and their associated characteristic imaging findings. We provide a summary of entities that affect the dentate nucleus and a diagnostic workflow for approaching dentate nucleus imaging abnormalities.

Proposed recommendations for diagnosing and managing individuals with glutaric aciduria type I: second revision

Glutaric aciduria type I (GA-I; synonym, glutaric acidemia type I) is a rare inherited metabolic disease caused by deficiency of glutaryl-CoA dehydrogenase located in the catabolic pathways of L-lysine, L-hydroxylysine, and L-tryptophan. The enzymatic defect results in elevated concentrations of glutaric acid, 3-hydroxyglutaric acid, glutaconic acid, and glutaryl carnitine in body tissues, which can be reliably detected by gas chromatography/mass spectrometry (organic acids) and tandem mass spectrometry (acylcarnitines). Most untreated individuals with GA-I experience acute encephalopathic crises during the first 6 years of life that are triggered by infectious diseases, febrile reaction to vaccinations, and surgery. These crises result in striatal injury and consequent dystonic movement disorder; thus, significant mortality and morbidity results. In some patients, neurologic disease may also develop without clinically apparent crises at any age. Neonatal screening for GA-I us being used in a growing number of countries worldwide and is cost effective. Metabolic treatment, consisting of low lysine diet, carnitine supplementation, and intensified emergency treatment during catabolism, is effective treatment and improves neurologic outcome in those individuals diagnosed early; treatment after symptom onset, however, is less effective. Dietary treatment is relaxed after age 6 years and should be supervised by specialized metabolic centers. The major aim of this second revision of proposed recommendations is to re-evaluate the previous recommendations (Kölker et al. J Inherit Metab Dis 30:5-22, 2007b; J Inherit Metab Dis 34:677-694, 2011) and add new research findings, relevant clinical aspects, and the perspective of affected individuals.