The etiology of lenticulostriate vasculopathy and the role of congenital infections

Basal Ganglia Stroke after Mild Traumatic Brain Injury in Mineralizing Lenticulostriate Vasculopathy

Although the association between basal ganglia (BG) stroke and mild traumatic brain injury (TBI) is well recognized, its association with lenticulostriate vasculopathy has only recently been described. We present the case of a 6-month-old female infant without personal or familiar relevant records who presented with left-sided hemiparesis and without altered consciousness after a mild TBI. An emergency computed tomography (CT) scan of the brain revealed bilateral linear calcifications along the course of the lenticulostriate arteries. Brain magnetic resonance imaging (MRI) revealed an ischemic lesion in the right BG and damage to the posterior limb of the right internal capsule. A few months after the ischemic event, the patient was asymptomatic. Given the clinical, radiological, and evolutionary characteristics of this group of patients, the term mineralizing angiopathy is proposed to define a specific clinical-imaging syndrome in infants who suffer a BG stroke after a mild TBI and present with the calcification of the lenticulostriate arteries.

Placental pathology associated with lenticulostriate vasculopathy (LSV) in preterm infants

OBJECTIVE

Our aim was to examine the frequency and type of placental abnormalities in neonates with LSV.

STUDY DESIGN

We prospectively reviewed cranial ultrasounds (cUS) from neonates born at ≤32 weeks of gestation at Parkland Hospital between 2012 and 2014. Our cohort included neonates with LSV and gestational age and sex matched controls with normal cUS. We retrieved placental pathology reports retrospectively and compared placental abnormalities in both groups.

RESULTS

We reviewed 1351 cUS from a total of 407 neonates. Placental pathology evaluations were complete for 64/65 (98%) neonates with LSV and 68/70 (97%) matched controls. There were no significant differences for any type of placental abnormities between LSV and control groups. However, infants with highest stage LSV were more likely to have large for gestational age (LGA) placentas (p = 0.01).

CONCLUSION

The association between LSV and LGA placenta may indicate a shared vascular response to an adverse prenatal environment.

Cranial US in Infants Exposed to Zika Virus: The NATZIG Cohort

Background Studies addressing neuroimaging findings as primary outcomes of congenital Zika virus infection are variable regarding inclusion criteria and confirmatory laboratory testing. Purpose To investigate cranial US signs of prenatal Zika virus exposure and to describe frequencies of cranial US findings in infants exposed to Zika virus compared to those in control infants. Materials and Methods In this single-center prospective cohort study, participants were enrolled during the December 2015-July 2016 outbreak of Zika virus infection in southeast Brazil (Natural History of Zika Virus Infection in Gestation cohort). Eligibility criteria were available cranial US and laboratory findings of maternal Zika virus infection during pregnancy confirmed with RNA polymerase chain reaction testing (ie, Zika virus-exposed infants). The control group was derived from the Zika in Infants and Pregnancy cohort and consisted of infants born to asymptomatic pregnant women who tested negative for Zika virus infection during pregnancy. Two radiologists who were blinded to the maternal Zika virus infection status independently reviewed cranial US scans from both groups and categorized them as normal findings, Zika virus-like pattern, or mild findings. Associations between cranial US findings and prenatal Zika virus exposure were assessed with univariable analysis. Results Two hundred twenty Zika virus-exposed infants (mean age, 53.3 days ± 71.1 [standard deviation]; 113 boys) and born to 219 mothers infected with Zika virus were included in this study and compared with 170 control infants (mean age, 45.6 days ± 45.8; 102 boys). Eleven of the 220 Zika virus-exposed infants (5%), but no control infants, had a Zika virus-like pattern at cranial US. No difference in frequency of mild findings was observed between the groups (50 of 220 infants [23%] vs 44 of 170 infants [26%], respectively; P = .35). The mild finding of lenticulostriate vasculopathy, however, was nine times more frequent in Zika virus-exposed infants (12 of 220 infants, 6%) than in control infants (one of 170 infants, 1%) (P = .01). Conclusion Lenticulostriate vasculopathy was more common after prenatal exposure to Zika virus, even in infants with normal head size, despite otherwise overall similar frequency of mild cranial US findings in Zika virus-exposed infants and in control infants. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Benson in this issue.

Intracranial calcifications in childhood: Part 1

This article is the first of a two-part series on intracranial calcification in childhood. Intracranial calcification can be either physiological or pathological. Physiological intracranial calcification is not an expected neuroimaging finding in the neonatal or infantile period but occurs, as children grow older, in the pineal gland, habenula, choroid plexus and occasionally the dura mater. Pathological intracranial calcification can be broadly divided into infectious, congenital, endocrine/metabolic, vascular and neoplastic. The main goals in Part 1 are to discuss the chief differences between physiological and pathological intracranial calcification, to discuss the histological characteristics of intracranial calcification and how intracranial calcification can be detected across neuroimaging modalities, to emphasize the importance of age at presentation and intracranial calcification location, and to propose a comprehensive neuroimaging approach toward the differential diagnosis of the causes of intracranial calcification. Finally, in Part 1 the authors discuss the most common causes of infectious intracranial calcification, especially in the neonatal period, and congenital causes of intracranial calcification. Various neuroimaging modalities have distinct utilities and sensitivities in the depiction of intracranial calcification. Age at presentation, intracranial calcification location, and associated neuroimaging findings are useful information to help narrow the differential diagnosis of intracranial calcification. Intracranial calcification can occur in isolation or in association with other neuroimaging features. Intracranial calcification in congenital infections has been associated with clastic changes, hydrocephalus, chorioretinitis, white matter abnormalities, skull changes and malformations of cortical development. Infections are common causes of intracranial calcification, especially neonatal TORCH (toxoplasmosis, other [syphilis, varicella-zoster, parvovirus B19], rubella, cytomegalovirus and herpes) infections.

Neurodevelopmental Abnormalities in Children With In Utero Zika Virus Exposure Without Congenital Zika Syndrome

IMPORTANCE

The number of children who were born to mothers with Zika virus (ZIKV) infection during pregnancy but who did not have apparent disability at birth is large, warranting the study of the risk for neurodevelopmental impairment in this population without congenital Zika syndrome (CZS).

OBJECTIVE

To investigate whether infants without CZS but who were exposed to ZIKV in utero have normal neurodevelopmental outcomes until 18 months of age.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study prospectively enrolled a group of pregnant women with ZIKV in Atlántico Department, Colombia, and in Washington, DC. With this cohort, we performed a longitudinal study of infant neurodevelopment. Infants born between August 1, 2016, and November 30, 2017, were included if they were live born, had normal fetal brain findings on magnetic resonance imaging and ultrasonography, were normocephalic at birth, and had normal examination results without clinical evidence of CZS. Seventy-seven infants born in Colombia, but 0 infants born in the United States, met the inclusion criteria.

EXPOSURES

Prenatal ZIKV exposure.

MAIN OUTCOMES AND MEASURES

Infant development was assessed by the Warner Initial Developmental Evaluation of Adaptive and Functional Skills (WIDEA) and the Alberta Infant Motor Scale (AIMS) at 1 or 2 time points between 4 and 18 months of age. The WIDEA and AIMS scores were converted to z scores compared with normative samples. Longitudinal mixed-effects regression models based on bootstrap resampling methods estimated scores over time, accounting for gestational age at maternal ZIKV infection and infant age at assessment. Results were presented as slope coefficients with 2-tailed P values based on z statistics that tested whether the coefficient differed from 0 (no change).

RESULTS

Of the 77 Colombian infants included in this cohort study, 70 (91%) had no CZS and underwent neurodevelopmental assessments. Forty infants (57%) were evaluated between 4 and 8 months of age at a median (interquartile range [IQR]) age of 5.9 (5.3-6.5) months, and 60 (86%) underwent assessment between 9 and 18 months of age at a median (IQR) age of 13.0 (11.2-16.4) months. The WIDEA total score (coefficients: age = -0.227 vs age2 = 0.006; P < .003) and self-care domain score (coefficients: age = -0.238 vs age2 = 0.01; P < .008) showed curvilinear associations with age. Other domain scores showed linear declines with increasing age based on coefficients for communication (-0.036; P = .001), social cognition (-0.10; P < .001), and mobility (-0.14; P < .001). The AIMS scores were similar to the normative sample over time (95% CI, -0.107 to 0.037; P = .34). Nineteen of 57 infants (33%) who underwent postnatal cranial ultrasonography had a nonspecific, mild finding. No difference was found in the decline of WIDEA z scores between infants with and those without cranial ultrasonography findings except for a complex interactive relationship involving the social cognition domain (P < .049). The AIMS z scores were lower in infants with nonspecific cranial ultrasonography findings (-0.49; P = .07).

CONCLUSIONS AND RELEVANCE

This study found that infants with in utero ZIKV exposure without CZS appeared at risk for abnormal neurodevelopmental outcomes in the first 18 months of life. Long-term neurodevelopmental surveillance of all newborns with ZIKV exposure is recommended.

Subtle findings on fetal brain imaging in CMV infected pregnancies: What is the clinical significance? A retrospective analysis with outcome correlation

OBJECTIVE

To describe the prognosis of subtle findings on fetal brain imaging in pregnant women with primary CMV infection during pregnancy.

METHODS

This was a retrospective study. The data included: timing of infection, amniocentesis results, imaging findings, obstetric outcome, and developmental assessment.

RESULTS

For the 27 included patients, the time of infection was: periconception, first, second, third trimesters or unknown in 14.8%, 29.7%, 40.7%, 7.4%, and 7.4%, respectively. Seventy-four percent had only MRI findings; white matter hyperintense T2 signal (HT2) (51.8%), mild ventriculomegaly (18.5%), HT2 and temporal cyst (7.4%), dilated occipital horn (7.4%), Periventricular pseudo cyst (PVPC) with dilated occipital horn (3.7%), isolated PVPC (7.4%), choroid plexus cyst (3.7%). In 26% of fetuses, additional ultrasound findings were observed: Lenticulostriatal vasculopathy (LSV) (11.1%), LSV with PVPC (3.84%), isolated PVPC (3.84%), mild ventriculomegaly (3.84%), and bilateral temporal cysts (3.84%). In 66.6%, the MRI had false-positive findings (due to noninfected neonates). All children are developing normally, and one has a hearing deficit. Postnatal ultrasound (US) was normal in 21/27, with LSV in five, and a resolving subependymal cyst in one patient.

CONCLUSION

Subtle imaging findings are more common on MRI than US and the prognosis is most likely favorable. Performing amniocentesis will significantly reduce the false-positive rate.

Current status of infarction in the basal ganglia-internal capsule due to mild head injury in children using PRISMA guidelines

Post-traumatic basal ganglia-internal capsule (BGIC) infarction in pediatric patients is a relatively rare consequence of mild head injury (MHI). To the best of the authors' knowledge, at present, no comprehensive review has been published. To review research on BGIC infarction after MHI, a literature search was performed using the PubMed database and relevant search terms. According to recent data, MHI may cause BGIC infarction due to mechanical vasospasm of the perforating vessels in pediatric patients. The anatomical characteristics of the growing brain in infancy, mineralization of the lenticulostriate arteries and viral infection may all play a part in BGIC infarction after MHI, which often occurs within 24 months. Symptoms are not as severe and tend to disappear in the early period. Computed tomography or magnetic resonance imaging often shows BGIC infarction. There are also children with scattered calcification of the basal ganglia. Neural rehabilitation is a commonly accepted treatment. The prognosis of patients with BGIC infarction after MHI consistently improves.

Evaluation of clinically asymptomatic high risk infants with congenital cytomegalovirus infection

OBJECTIVE

To determine the frequency of abnormal findings on evaluation of neonates with congenital CMV infection who have a normal physical examination STUDY DESIGN: Retrospective, 2-center study (1996-2017) that reviewed results of complete blood cell count and platelets, serum alanine aminotransferase (ALT) and bilirubin concentrations, eye examination, cranial ultrasonography or other neuroimaging, and brainstem evoked responses performed on neonates with congenital CMV infection and a normal physical examination RESULTS: Of 34 infants with congenital CMV infection and a normal physical examination, 56% (19/34) had ≥1 abnormality: 39%, elevated ALT concentration; 45%, abnormal neuroimaging (five, lenticulostriate vasculopathy; six, intraventricular hemorrhage; four, calcifications); 12%, anemia; 16%, thrombocytopenia; and 3%, chorioretinitis. Seven (21%) infants had sensorineural hearing loss, and 18 infants received antiviral therapy.

CONCLUSION

Some infants with congenital CMV infection and a normal physical examination had abnormalities on laboratory or neuroimaging evaluation, which in some cases prompted antiviral treatment.

An extremely severe case of Aicardi-Goutières syndrome 7 with a novel variant in IFIH1

We describe herein an extremely severe case of Aicardi-Goutières syndrome 7 (AGS7). The female patient was the daughter of nonconsanguineous parents and developed cardiomegaly, pericardial effusion, splenomegaly, and intracranial calcification during the fetal period. Because her cardiotocogram showed a non-reassuring fetal status, she was delivered at 29 weeks and 4 days of gestation by an emergency cesarean section. After birth, she suffered from respiratory distress, pulmonary hypertension, refractory fever, recurrent thrombocytopenia, and abdominal distention caused by hepatomegaly and ascites. She showed a lenticulostriate vasculopathy, which was compatible with the fetal intracranial calcification. Despite various intensive care procedures, she died of gradually progressive pulmonary hypertension at 3 months of age. After her death, whole exome sequencing on the patient and the parents was performed and revealed a novel, de novo, heterozygous mutation in the IFIH1 gene (IFIH1:NM_022168:exon12:c.2439A > T:p.Glu813Asp). On the basis of the mutation and the clinical features, the diagnosis was AGS7. Although AGS7 has been regarded as a relatively mild subtype of Aicardi-Goutières syndrome, this case indicates that the c.2439A > T variant of AGS7 can be fatal in early infancy.

Hyperechogenicity of lenticulostriate vessels: A poor prognosis or a normal variant? A seven year retrospective study

BACKGROUND

Lenticulostriate vasculopathy (LSV) is a hyperechogenicity of the lenticulostriate branches of the basal ganglia and/or thalamus' middle cerebral arteries and is frequently seen in neonatology. Our study primarily describes the perinatal data and long-term follow-up of newborns with lenticulostriate vessel hyperechoic degeneration. Secondly, it describes the cerebral imaging data as a function of perinatal factors and neurodevelopmental follow-up of these newborns.

METHODS

This retrospective study assesses the outcome of newborns with LSV hyperechogenicity on cerebral ultrasound (two grades). These children were born between January 2008 and September 2015 and were treated in a large level III neonatal intensive care unit. Thirty-four term-equivalent age children underwent MRIs using a standardized protocol of T2, T1 3D, diffusion and spectro-MRI sequences. The MRIs retrospectively measured the white matter and basal ganglia apparent diffusion coefficients (ADC).

RESULTS

Fifty-eight neonates, ranging from 25 to 42 weeks gestational age (GA), were diagnosed with LSV. There was a significantly increased high-grade LSV when accompanied by fetal heart rate abnormalities (p = 0.03) and the neonate's need for respiratory support at birth (P = 0.002). The mean ADC score was substantially superior in the high-grade versus the low-grade LSVs (p = 0.023). There were no noteworthy outcome differences between a high and low grade LSV. The mean ADC for basal ganglions was appreciably higher in children with a severe prognoses (death or developmental disorder) as compared to children with no abnormalities (p < 0.01).

CONCLUSION

From the results of our study, it appears that a low-grade LSV could be considered as a normal variant. There are no unifying diagnostic criteria for LSV on cerebral ultrasound. With a cerebral MRI, the use of ADC values of basal ganglia may well underscore the importance of such data in predicting long-term outcomes.

Lenticulostriate vasculopathy in preterm infants: a new classification, clinical associations and neurodevelopmental outcome

OBJECTIVE

To examine the inter-rater reliability for the diagnosis of LSV on cranial ultrasound (cUS), determine the risk factors associated with LSV and its progression, and examine neurodevelopmental outcome.

STUDY DESIGN

Prospective case-control study of neonates ≤32wks of gestation assessed for LSV by serial cUS (n = 1351) between 2012 and 2014 and their neurodevelopment at 18-36mon-corrected age compared to controls.

RESULTS

Agreement for LSV on cUS improved from Κappa 0.4-0.7 after establishing definitive criteria and guidelines. BPD was the only variable associated with the occurrence and the progression of LSV. Cytomegalovirus (CMV) infection occurred in one neonate (1.5%). Neurodevelopmental outcome of neonates with LSV did not differ from controls.

CONCLUSIONS

Establishment of well-defined stages of LSV improves the reliability of the diagnosis and allows identification of neonates with progression of LSV. Although LSV was associated with BPD, it was not associated with congenital CMV infection.

Imaging of congenital central nervous system infections

Congenital central nervous system (CNS) infections are a cause of significant morbidity and mortality. The recent Zika virus outbreak raised awareness of congenital CNS infections. Imaging can be effective in diagnosing the presence and severity of infection. In this paper we review the clinical presentations and imaging characteristics of several common and less common congenital CNS infections.

Is lenticulostriated vasculopathy an unfavorable prognostic finding in infants with congenital cytomegalovirus infection?

BACKGROUND

Lenticulostriated vasculopathy (LSV) detected in head ultrasound (HUS) has been related to neurological and hearing sequelae in infants with congenital cytomegalovirus (cCMV) infection.

OBJECTIVE

To assess the role of LSV in predicting neurodevelopmental and hearing outcomes in infants with cCMV infection.

STUDY DESIGN

We enrolled consecutive infants who were affected by cCMV infection and underwent HUS within the first month of life. Data on clinical onset and course, laboratory findings, visual/hearing functions and neurodevelopmental outcome were collected. As controls, infants with suspected intrauterine exposure to Toxoplasma and with no confirmed congenital toxoplasmosis were considered.

RESULTS

Data from 161 infants with cCMV infection (105 symptomatic) and 133 controls were analyzed. HUS was normal in 66 (41%) cCMV patients. Among these, 28 (42.4%) were symptomatic and 38 (57.6%) asymptomatic infants. The percentage of patients with no HUS abnormalities was higher in asymptomatic (38/56, 67.9%) than in symptomatic infants (28/105, 26.7%) (p<0.05). LSV, as isolated or associated with other brain abnormalities, was diagnosed in 64/161 (39.7%) patients with cCMV compared to 24/133 (18%) controls (p<0.05). In cCMV group, LSV was found in 51 (48.6%) symptomatic infants and in 13 (72.2%) asymptomatic patients (p>0.05). Overall, in the whole population of 95 patients with cCMV and abnormal HUS results, LSV (alone or with other findings) did not represent a risk factor for unfavorable neurological and hearing outcome. Similar results were obtained when we limited the analysis to the group of symptomatic cCMV patients.

CONCLUSIONS

Although LSV is a common HUS finding in infants with cCMV infection, its presence is not predictive of an adverse outcome. Our data suggest that HUS as a single neuroimaging investigation is unreliable in selecting candidates to antiviral therapy, mainly in presence of LSV as isolated finding.

Loss of function of PCDH12 underlies recessive microcephaly mimicking intrauterine infection

OBJECTIVE

To identify the genetic basis of a recessive syndrome characterized by prenatal hyperechogenic brain foci, congenital microcephaly, hypothalamic midbrain dysplasia, epilepsy, and profound global developmental disability.

METHODS

Identification of the responsible gene by whole exome sequencing and homozygosity mapping.

RESULTS

Ten patients from 4 consanguineous Palestinian families manifested in utero with hyperechogenic brain foci, microcephaly, and intrauterine growth retardation. Postnatally, patients had progressive severe microcephaly, neonatal seizures, and virtually no developmental milestones. Brain imaging revealed dysplastic elongated masses in the midbrain-hypothalamus-optic tract area. Whole exome sequencing of one affected child revealed only PCDH12 c.2515C>T, p.R839X, to be homozygous in the proband and to cosegregate with the condition in her family. The allele frequency of PCDH12 p.R839X is <0.00001 worldwide. Genotyping PCDH12 p.R839X in 3 other families with affected children yielded perfect cosegregation with the phenotype (probability by chance is 2.0 × 10(-12)). Homozygosity mapping revealed that PCDH12 p.R839X lies in the largest homozygous region (11.7 MB) shared by all affected patients. The mutation reduces transcript expression by 84% (p < 2.4 × 10(-13)). PCDH12 is a vascular endothelial protocadherin that promotes cellular adhesion. Endothelial adhesion disruptions due to mutations in OCLN or JAM3 also cause congenital microcephaly, intracranial calcifications, and profound psychomotor disability.

CONCLUSIONS

Loss of function of PCDH12 leads to recessive congenital microcephaly with profound developmental disability. The phenotype resembles Aicardi-Goutières syndrome and in utero infections. In cases with similar manifestations but no evidence of infection, our results suggest consideration of an additional, albeit rare, cause of congenital microcephaly.