Multiple cystic and focal encephalomalacia in infancy and childhood with brain stem damage

Sonographic Evaluation of Twin Embolization Syndrome

Twin embolization syndrome (TES) is a rare complication of twin-twin transfusion after intrauterine demise of one of a pair of twins sharing the same placenta. In such cases, infarcts in the surviving co-twin can cause structural and functional changes, presumably due to embolization of debris, thrombus, thromboplastic material, and toxins from the dying twin's circulation into the circulation of the other twin. Sonographic, clinical, and pathologic findings in 3 new cases are reported, and 38 previously reported cases of TES are reviewed. Of the 41 cases, 34 (83%) had evidence of a destructive structural brain defect. In the 34 cases with brain defects, 23 (68%) had intracranial cystic changes. Microcephaly had developed in the surviving twin by the time of delivery in 7 (41%) of the 17 cases with brain defects and evidence of twin fetal demise before 22 weeks. Intestinal atresia was noted in 4 of 41 cases (10%), and renal dysplasia or renal cortical necrosis was observed in 11 cases (27%). In cases of intrauterine demise of a monochorionic twin, careful follow-up evaluation of the surviving twin should be performed.

Prenatal stroke

The main focus of this chapter is the comprehensive description of the neuropathology, the imaging correlates and underlying mechanisms of prenatal stroke. We describe established prenatal stroke in subgroups similar to postnatal stroke: arterial (forebrain or hindbrain) infarction, venous thrombosis, primary lobar haemorrhage. This longitudinal classification should facilitate the study of risk factors and mechanisms. Forebrain lesions of arterial type present as porencephaly, (hemi)hydranencephaly, multicystic encephalopathy or schizencephaly. Venous prenatal forebrain stroke presents as simple porencephaly (in some of genetic nature) and sinus thrombosis. A list of rare porencephaly-like conditions is added for differentiation from arterial and venous porencephaly. Hindbrain infarctions (so far the only reported variants seem to be of arterial nature) present as brainstem disconnection, focal brainstem destruction, uni- or bilateral cerebellar destruction and focal spinal cord ischaemia. Prenatal intracranial haemorrhage and congenital brain infection should be considered in the differential diagnosis of prenatal stroke.

Neuropathology associated with stillbirth

Neuropathologic findings in stillbirths oftentimes provide insight into the specific mechanisms leading to death. Examination of the brains of stillborn infants may also identify pathophysiologic processes that result in prenatal brain injury in liveborn as well as stillborn infants and that lead to neurologic disorders in liveborn infants, such as cerebral palsy or the sudden infant death syndrome (SIDS). A variety of abnormalities are found in the brains of stillborns, the most common including cerebral white matter necrosis (periventricular leukomalacia) or gliosis, germinal matrix or intraventricular hemorrhage, cerebral infarcts, pontosubicular necrosis, and spinal cord or brainstem necrosis. The 2 major hypotheses that have been proposed for the pathophysiology of cerebral white matter injury in the perinatal period are hypoxia/ischemia and infection/cytokines as the basis for injury. The fetal brain may be selectively vulnerable to various insults at specific stages of development.

Clinical, neurophysiologic, and neuropathological features of an infant with brain damage of total asphyxia type (Myers)

An infant who demonstrated clinical features compatible with total asphyxia is reported. Immediately after birth, the patient manifested severe hypotonia and total absence of cranial nerve functions. Magnetic resonance imaging revealed abnormal intensity of the thalamus and putamen, and atrophy of the brainstem. Late components of brainstem auditory evoked potential were absent, but electroencephalography was normal. Postmortem autopsy revealed destructive lesions of the brainstem tegmentum, thalamus, basal ganglia, and spinal cord, but preserved cerebral cortex; findings consistent with those of total asphyxia as reported by Myers, and attributable to prenatal insult.

Discordant infantile encephalopathy with symmetrical thalamic calcifications in identical twins

Connatal thalamic calcifications in apparently uneventful pregnancies have been described in various case reports and in a single report in two sibs. On the other hand, this lesion is known to occur after a hypoxic-ischemic accident in the immature brain. In the present report infantile encephalopathy with symmetrical thalamic calcifications is observed in one sib of a monozygous twin pair. This observation adds to the evidence that the condition is acquired, most probably on the basis of hypoxia-ischemia, and provides strong evidence against autosomal-recessive inheritance.

Antenatal cerebral necrosis in monochorionic twins

Antenatal cerebral white matter necrosis occurs relatively frequently in monochorionic twins, particularly when one twin has died in utero or in the twin-twin transfusion syndrome. A case of antenatal cerebral necrosis in both of liveborn monochorionic twins is presented. It is proposed that placental artery-to-artery or vein-to-vein anastomoses may predispose twin fetuses to hemodynamic instability. Fluctuations in blood pressure or blood volume may then result in cerebral necrosis, without requiring the death of one twin or transfer of a blood-borne factor from one twin to the other.

Microgyric and necrotic cortical lesions in twin fetuses: original cerebral damage consecutive to twinning?

Extensive cortical necrosis associated with malformative microgyric-like lesions and with necrotic lesions of the white matter was observed in two male 25 week fetuses. These cases differed from previously reported cases of brain damage in monozygotic twins: both fetuses were affected and the lesions occurred early in pregnancy, before the end of neuronal migration, thus resulting in a cortical malformation associated with destructive lesions.

Selective brainstem injury in an asphyxiated newborn

We report the clinical, radiological, and neuropathological features of selective brainstem injury in an asphyxiated term infant. Disproportionate injury to thalamus, basal ganglia, and brainstem with relative sparing of cortex and subcortical white matter is observed occasionally after acute total asphyxia. Although this entity has been well documented neuropathologically, the specific computed tomographic findings have not been reported previously to our knowledge, and the clinical correlation is recognized rarely.

Spinal cord transection, cerebral ischaemic and brain-stem injury in a baby following a Kielland's forceps rotation

A full-term infant suffered a high cervical cord transection after a Kielland 's forceps rotation and extraction. Quadriplegia developed immediately and initial cerebral swelling was followed by atrophy with ventricular dilatation on CT examination. Death occurred at 60 days. At post-mortem complete necrosis of the cervical cord at C2-C3 with old haemorrhage in the meninges was found, with damage to the inferior corpora quadrigemina , the thalamus, striatum, cerebellar and cerebral cortex. The mechanism is discussed briefly.

Multicystic encephalopathy--a polyetiologic condition in early infancy: morphologic, pathogenetic and clinical aspects

Eleven observations of severe multicystic encephalopathy ( MCE ) in young infants and in a two-year-old child provide the basis for a summing-up and discussion of the various aspects of this characteristic polyetiologic phenomenon occurring in early infancy. In all cases the triggering causes or underlying disorders were different, although in five cases the common pathogenetic mechanism was a disturbance of circulation and/or respiration (acute respiratory distress syndrome). In two cases the basic disorders were a suppurative and a granulomatous meningoencephalitis. Carbon monoxide poisoning had occurred in one and diffuse meningocerebral angiomatosis in another two cases. In the eleventh case, one of a complicated twin birth, the exact cause of the MCE remained obscure. These cases together with those recorded in the literature demonstrate that the surprisingly constant pattern of damage in MCE , which results from different etiologic conditions, should be due to a specific mode of reaction of the infantile brain to a common pathogenetic mechanism. Anoxia with hypercapnia and the formation of brain edema are discussed as the basic events in the pathogenesis of MCE .

Infantile multicystic encephalomalacia after maternal bee sting anaphylaxis during pregnancy

We report a case of infantile multicystic encephalomalacia after maternal bee sting anaphylaxis in the 30th week of pregnancy. The clinical features and findings at necropsy are described, and it is suggested that these are the result of severe fetal hypoxia secondary to maternal hypotension.

Mechanisms of brain damage in twins

The brains of 18 twins dying in the perinatal period showed a variety of lesions. Eleven had subependymal cell plate hemorrhage which had ruptured into the lateral ventricles in five. Five had periventricular damage. Three had anoxic neuronal damage. One acardiac monster had bilateral cerebral infarction. One pair had unequal sized brains, probably due to unequal intrauterine nutrition. Twins have a high perinatal mortality and morbidity; as well, intrauterine events may alter brain growth and development in each twin unequally, so they are an imperfect model to study the effect of genes and environment on intelligence.

Multicystic encephalomalacia due to fetal viral encephalitis

Two children, aged 2 weeks and 2 months, with multicystic encephalomalacia aer described. Although computerized tomography (CT) scan was used for the diagnosis, the value of the simple method of transillumination is stressed. The mother of one child had mumps with meningitis at 26 weeks' gestation. The other child had an echovirus 11 isolated from the cerebrospinal fluid and herpesvirus hominis (HVH) from the skin at 8 weeks. We speculate that the changes in the brains of these babies may be due to the respective viruses causing a fetal encephalitis.

Radiological Diagnosis of Periventricular and Subcortical Leukomalacia

Nine newborn infants with histories of perinatal asphyxia are presented. The pneumoencephalographic findings which led to the diagnosis are typical and constant. They include marked subcortical atrophy with rounded, dilated, and undisplaced lateral ventricles. Cystography with 3 cc of air demonstrated multiple subcortical and pareventricular cavities, without communication with the ventricular system, but with the typical honeycomb appearance of paraventricular and subcortical leukomalacia described in postmortem findings. The CT findings are typical, and provide the location of the cavities as well as their density.

Multicystic encephalomalacia of infancy: clinico-pathological report of 7 cases

Clinical follow up and complete neuropathological examination was made on seven cases of multicystic encephalomalacia of infancy. Etiological factors were carefully studied in all the cases. They consisted of prenatal injuries presenting as a cord prolapse, in 3 cases; prolonged labour with marked cyanosis; abdominal trauma during gestation, and various maternal infections at different stages of pregnancy. Pathological interest is centred on the variable involvement of different areas of the brain, generally sparing the cerebellum and brain stem, and being minimal or absent in the occipito-temporal areas. This distribution may be explained by a different effect of the "causal agency" on these different areas, or by a different capacity of these regions to react against injury. Among the etiological factors reviewed in the literature, the anoxic theory appears the most probable, as there was a close parallelism between lesions and vascular areas, mainly the carotid and vertebro-basilar systems.