Central nervous system tuberculoma mimicking a brain tumor: A case report

The central nervous system (CNS) is a rare but serious site of tuberculosis spread that manifests in three forms: meningitis, spinal arachnoiditis, and CNS tuberculoma. CNS tuberculoma, or intracranial tuberculous granuloma, is a caseating or non-caseating granulomatous reaction within the brain parenchyma that may mimic a brain tumor. We present the case of a 10-year-old male patient with a travel history to Western Africa who presented to our institution after his fourth tonic-clonic seizure over 2 months. MRI of the brain revealed a solitary cortical/subcortical enhancing intracranial mass with intralesional hemorrhage and mineralization, pathologically proven to represent a CNS tuberculoma. While rare, this etiology should be considered with the appropriate travel history and for which prompt treatment may improve outcomes in the pediatric population.

Rapid anatomical imaging of the neonatal brain using T2 -prepared 3D balanced steady-state free precession

PURPOSE

To develop a new approach to 3D gradient echo-based anatomical imaging of the neonatal brain with a substantially shorter scan time than standard 3D fast spin echo (FSE) methods, while maintaining a high SNR.

METHODS

T2 -prepration was employed immediately prior to image acquisition of 3D balanced steady-state free precession (bSSFP) with a single trajectory of center-out k-space view ordering, which requires no magnetization recovery time between imaging segments during the scan. This approach was compared with 3D FSE, 2D single-shot FSE, and product 3D bSSFP imaging in numerical simulations, plus phantom and in vivo experiments.

RESULTS

T2 -prepared 3D bSSFP generated image contrast of gray matter, white matter, and CSF very similar to that of reference T2 -weighted imaging methods, without major image artifacts. Scan time of T2 -prepared 3D bSSFP was remarkably shorter compared to 3D FSE, whereas SNR was comparable to that of 3D FSE and higher than that of 2D single-shot FSE. Specific absorption rate of T2 -prepared 3D bSSFP remained within the safety limit. Determining an optimal imaging flip angle of T2 -prepared 3D bSSFP was critical to minimizing blurring of images.

CONCLUSION

T2 -prepared 3D bSSFP offers an alternative method for anatomical imaging of the neonatal brain with dramatically reduced scan time compared to standard 3D FSE and higher SNR than 2D single-shot FSE.

Peripheral neurological complications during COVID-19: A single center experience

Background and aims

We highlight the peripheral neurologic complications of coronavirus disease 2019 (COVID-19) associated with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), an ongoing global health emergency.

Methods

We evaluated twenty-five patients admitted to the COVID-19 Recovery Unit (CRU) at New York-Presbyterian Weill Cornell University Medical Center after intensive care hospitalization with confirmed severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), whom neurology was consulted for weakness and/or paresthesias. All patients were clinically evaluated by a neuromuscular neurologist who performed electrodiagnostic (EDX) studies when indicated. Magnetic resonance imaging (MRI) of the affected regions, along with nerve and muscle biopsies were obtained in select patients to better elucidate the underlying diagnosis.

Results

We found fourteen out of twenty-five patients with prolonged hospitalization for COVID-19 infection to have peripheral neurological complications, identified as plexopathies, peripheral neuropathies and entrapment neuropathies. The other eleven patients were not found to have peripheral neurologic causes for their symptoms. Patients with peripheral neurological complications often exhibited more than one type of concurrently. Specifically, there were four cases of plexopathies, nine cases of entrapment neuropathies, and six cases of peripheral neuropathies, which included cranial neuropathy, sciatic neuropathy, and multiple mononeuropathies.

Conclusions

We explore the possibility that the idiopathic peripheral neurologic complications could be manifestations of the COVID-19 disease spectrum, possibly resulting from micro-thrombotic induced nerve ischemia.

Efficacy of Carboplatin and Isotretinoin in Children With High-risk Medulloblastoma: A Randomized Clinical Trial From the Children's Oncology Group

Importance

Brain tumors are the leading cause of disease-related death in children. Medulloblastoma is the most common malignant embryonal brain tumor, and strategies to increase survival are needed.

Objective

To evaluate therapy intensification with carboplatin as a radiosensitizer and isotretinoin as a proapoptotic agent in children with high-risk medulloblastoma in a randomized clinical trial and, with a correlative biology study, facilitate planned subgroup analysis according to World Health Organization consensus molecular subgroups of medulloblastoma.

Design, Setting, and Participants

A randomized clinical phase 3 trial was conducted from March 2007 to September 2018. Analysis was completed in September 2020. Patients aged 3 to 21 years with newly diagnosed high-risk medulloblastoma from Children's Oncology Group institutions within the US, Canada, Australia, and New Zealand were included. High-risk features included metastasis, residual disease, or diffuse anaplasia.

Interventions

Patients were randomized to receive 36-Gy craniospinal radiation therapy and weekly vincristine with or without daily carboplatin followed by 6 cycles of maintenance chemotherapy with cisplatin, cyclophosphamide, and vincristine with or without 12 cycles of isotretinoin during and following maintenance.

Main Outcomes and Measures

The primary clinical trial end point was event-free survival, using the log-rank test to compare arms. The primary biology study end point was molecular subgroup classification by DNA methylation array.

Results

Of 294 patients with medulloblastoma, 261 were evaluable after central radiologic and pathologic review; median age, 8.6 years (range, 3.3-21.2); 183 (70%) male; 189 (72%) with metastatic disease; 58 (22%) with diffuse anaplasia; and 14 (5%) with greater than 1.5-cm2 residual disease. For all participants, the 5-year event-free survival was 62.9% (95% CI, 55.6%-70.2%) and overall survival was 73.4% (95% CI, 66.7%-80.1%). Isotretinoin randomization was closed early owing to futility. Five-year event-free survival was 66.4% (95% CI, 56.4%-76.4%) with carboplatin vs 59.2% (95% CI, 48.8%-69.6%) without carboplatin (P = .11), with the effect exclusively observed in group 3 subgroup patients: 73.2% (95% CI, 56.9%-89.5%) with carboplatin vs 53.7% (95% CI, 35.3%-72.1%) without (P = .047). Five-year overall survival differed by molecular subgroup (P = .006): WNT pathway activated, 100% (95% CI, 100%-100%); SHH pathway activated, 53.6% (95% CI, 33.0%-74.2%); group 3, 73.7% (95% CI, 61.9%-85.5%); and group 4, 76.9% (95% CI, 67.3%-86.5%).

Conclusions and Relevance

In this randomized clinical trial, therapy intensification with carboplatin improved event-free survival by 19% at 5 years for children with high-risk group 3 medulloblastoma. These findings further support the value of an integrated clinical and molecular risk stratification for medulloblastoma.

Trial Registration

ClinicalTrials.gov Identifier: NCT00392327.

MBCL-16. EFFICACY OF CARBOPLATIN GIVEN CONCOMITANTLY WITH RADIATION AND ISOTRETINOIN AS A PRO-APOPTOTIC AGENT IN MAINTENANCE THERAPY IN HIGH-RISK MEDULLOBLASTOMA: A REPORT FROM THE CHILDREN’S ONCOLOGY GROUP

BACKGROUND

Metastasis, residual disease, and diffuse anaplasia are high-risk features in medulloblastoma.

METHODS

This was a randomized phase 3 study. Patients age 3–21 years with high-risk medulloblastoma received (+/-) daily carboplatin with 36Gy craniospinal radiation and weekly Vincristine followed by six cycles of maintenance chemotherapy with Cisplatin, Cyclophosphamide and Vincristine (+/) 12 cycles of isotretinoin during and following maintenance. The primary endpoint was event-free survival, with exact log-rank test to compare arms. Retrospective molecular analysis included DNA methylation and exome sequencing.

RESULTS

Of 294 medulloblastoma patients enrolled, 261 were eligible by central review of radiology and pathology, median age 8.6 years (range 3.3–21.2), 70% male, 189 (72%) with metastatic disease, 58 (22%) with diffuse anaplasia, 14 (5%) with >1.5cm2 residual disease. The 5-year EFS and OS for all subjects was 63%+4 and 73%+3, respectively. Isotretinoin randomization was closed due to futility. 5-year EFS was 66 + 5 with carboplatin versus 59 + 5 without (p=0.11), with effect exclusively observed in Group 3 subtype: 73%+8 with carboplatin versus 54%+9 without (p<0.05). Overall survival differed by molecular subgroup (p=0.006): WNT 100%, SHH 54%+11, Group 3 74%+6, Group 4 77%+5 at 5 years. MYC amplification or isochromosome 17 were unfavorable in Group 3 (p=0.029). Chromosome 11 loss or chromosome 17 gain were favorable in group 4 (p<0.001). No survival difference was observed with TP53 mutation in SHH subtype in this high-risk cohort.

CONCLUSIONS

Therapy intensification with carboplatin improved survival for high-risk group 3 medulloblastoma. These findings further support an integrated clinical and molecular risk stratification for medulloblastoma.

Phase II Study of Nonmetastatic Desmoplastic Medulloblastoma in Children Younger Than 4 Years of Age: A Report of the Children's Oncology Group (ACNS1221)

PURPOSE

Nodular desmoplastic medulloblastoma (ND) and medulloblastoma with extensive nodularity (MBEN) have been associated with a more favorable outcome in younger children. However, treatment-related neurotoxicity remains a significant concern in this vulnerable group of patients.

PATIENTS AND METHODS

ACNS1221 was a prospective single-arm trial of conventional chemotherapy for nonmetastatic ND and MBEN based on a modified HIT SKK 2000 regimen excluding intraventricular methotrexate, aiming to achieve similar outcome (2-year progression-free survival [PFS] ≥ 90%) with reduced treatment-related neurotoxicity. Secondary objectives included feasibility of timely central pathology review and evaluation of tumor molecular profile.

RESULTS

Twenty-five eligible patients (15 males and 10 females; median age, 18.7 months) were enrolled. Eighteen patients had ND and 7 had MBEN histology. Three patients had residual disease at baseline. The study closed early because of a higher than expected relapse rate. Twelve patients experienced relapse-local (n= 6), distant (n = 3), and combined (n = 3)-at a median of 9.8 months from diagnosis (range, 8.9-13.7 months), and 2 patients died of disease. Two-year PFS and overall survival rates were 52% (95% CI, 32.4% to 71.6%) and 92% (95% CI, 80.8% to 100.0%) respectively. Patients older than 12 months of age (P = .036) and ND histology (P = .005) were associated with worse PFS. No patients with MBEN histology experienced relapse. All tumor samples clustered within the sonic hedgehog (SHH) group. Methylation analysis delineated 2 subgroups, SHH-I and SHH-II, which were associated with 2-year PFS rates of 30.0% (95% CI, 1.6% to 58.4%) and 66.7% (95% CI, 44.0% to 89.4%), respectively (P = .099).

CONCLUSION

The proposed modified regimen of conventional systemic chemotherapy without serial intraventricular methotrexate injection failed to achieve the targeted 2-year PFS of 90%. With this cohort, we prospectively confirmed the existence of two SHH subgroups and observed a trend toward worse outcome for SHH-I patients.

Comparative Prey Spectra Analyses on the Endangered Aquatic Carnivorous Waterwheel Plant (Aldrovanda vesiculosa, Droseraceae) at Several Naturalized Microsites in the Czech Republic and Germany

The critically endangered carnivorous waterwheel plant (Aldrovanda vesiculosa, Droseraceae) possesses underwater snap traps for capturing small aquatic animals, but knowledge on the exact prey species is limited. Such information would be essential for continuing ecological research, drawing conclusions regarding trapping efficiency and trap evolution, and eventually, for conservation. Therefore, we performed comparative trap size measurements and snapshot prey analyses at seven Czech and one German naturalized microsites on plants originating from at least two different populations. One Czech site was sampled twice during 2017. We recorded seven main prey taxonomic groups, that is, Cladocera, Copepoda, Ostracoda, Ephemeroptera, Nematocera, Hydrachnidia, and Pulmonata. In total, we recorded 43 different prey taxa in 445 prey-filled traps, containing in sum 461 prey items. With one exception, prey spectra did not correlate with site conditions (e.g. water depth) or trap size. Our data indicate that A. vesiculosa shows no prey specificity but catches opportunistically, independent of prey species, prey mobility mode (swimming or substrate-bound), and speed of movement. Even in cases where the prey size exceeded trap size, successful capture was accomplished by clamping the animal between the traps' lobes. As we found a wide prey range that was attracted, it appears unlikely that the capture is enhanced by specialized chemical- or mimicry-based attraction mechanisms. However, for animals seeking shelter, a place to rest, or a substrate to graze on, A. vesiculosa may indirectly attract prey organisms in the vicinity, whereas other prey capture events (like that of comparably large notonectids) may also be purely coincidental.

Extensive Molecular and Clinical Heterogeneity in Patients With Histologically Diagnosed CNS-PNET Treated as a Single Entity: A Report From the Children's Oncology Group Randomized ACNS0332 Trial

PURPOSE

Children with histologically diagnosed high-risk medulloblastoma, supratentorial primitive neuroectodermal tumor of the CNS (CNS-PNET), and pineoblastoma (PBL) have had poor survival despite intensive treatment. We included these patients in this Children's Oncology Group trial. Molecular profiling later revealed tumor heterogeneity that was not detectable at protocol inception. Enrollment of patients with CNS-PNET/PBL was subsequently discontinued, and outcomes for this part of the study are reported here.

PATIENTS AND METHODS

In this phase III, four-arm prospective trial, consenting children age 3-22 years with newly diagnosed CNS-PNET were randomly assigned (1:1) to receive carboplatin during radiation and/or adjuvant isotretinoin after standard intensive therapy. Primary outcome measure was event-free survival (EFS) in the intent-to-treat population. Molecular tumor classification was retrospectively completed using DNA methylation profiling.

RESULTS

Eighty-five participants with institutionally diagnosed CNS-PNETs/PBLs were enrolled. Of 60 patients with sufficient tissue, 31 were nonpineal in location, of which 22 (71%) represented tumors that were not intended for trial inclusion, including 18 high-grade gliomas (HGGs), two atypical teratoid rhabdoid tumors, and two ependymomas. Outcomes across tumor types were strikingly different. Patients with supratentorial embryonal tumors/PBLs exhibited 5-year EFS and overall survival of 62.8% (95% CI, 43.4% to 82.2%) and 78.5% (95% CI, 62.2% to 94.8%), respectively, whereas patients with molecularly classified HGG had EFS and overall survival of 5.6% (95% CI, 0% to 13.0%) and 12.0% (95% CI, 0% to 24.7%), respectively. Neither carboplatin, nor isotretinoin significantly altered outcomes for all patients. Survival for patients with HGG was similar to that of historic studies that avoid craniospinal irradiation and intensive chemotherapy.

CONCLUSION

For patients with CNS-PNET/PBL, prognosis is considerably better than previously assumed when molecularly confirmed HGGs are removed. Identification of molecular HGGs may spare affected children from unhelpful intensive treatment. This trial highlights the challenges of a histology-based diagnosis for pediatric brain tumors and indicates that molecular profiling should become a standard component of initial diagnosis.

Management of Tiny Meningiomas: To Resect or Not Resect

Meningiomas are most often benign primary intracranial tumors that are frequently found incidentally on imaging. Larger sized meningiomas may present with symptoms such as seizures and headaches. Smaller meningiomas are commonly asymptomatic and usually observed with serial imaging. We present two female patients, both of whom were found to have very small left frontal meningiomas that marginated Broca’s area. The first patient in this case series experienced episodes resembling seizures which consisted of weakness, vision loss, and slurred speech, as well as subtle language dysfunction in her day-to-day conversations. The second patient presented with headaches and an enlarging meningioma. Both meningiomas were surgically resected and the patients’ symptoms resolved. Small meningiomas should not be overlooked as they may very well be the source of neurologic symptoms.

ACNS1221: A phase II study for the treatment of non metastatic desmoplastic medulloblastoma in children less than 4 years of age—A report from the Children Oncology Group

10505

Background: Nodular desmoplastic medulloblastoma and medulloblastoma with extensive nodularity (ND/MBEN) have been associated with a more favorable outcome in younger children. However, treatment-related neurotoxicity remains a significant concern in this vulnerable group of patients. Methods: We prospectively conducted a single-arm multicenter trial of conventional chemotherapy for non-metastatic ND/MBEN, based on a modified HIT SKK2000 regimen excluding the use of intraventricular methotrexate (MTX) injection, with the aim to achieve a similar outcome with reduced treatment related neurotoxicity. The design required 37 patients and targeted a 2-year PFS of ≥ 90%. Secondary objectives included evaluation of feasibility of timely central pathology review, prospective evaluation of the cohort’s molecular profile and neurocognitive outcomes. Results: Between 12/2013 and 07/2016, 26 patients were enrolled, including 16 males and 10 females, diagnosed at a median age of 19.7 months (7.1-42.9 months). Four patients had residual disease at baseline. There were 19 ND and 7 MBEN medulloblastoma, confirmed by central pathology review. All cases were reviewed within 10 days by at least 2 of the 3 neuropathologists. The study was closed early following interim analysis due to a higher than expected relapse rate. At last follow-up, 7 patients had relapsed (3 local, 2 distant and 2 combined) at a median time of 9.7 months from diagnosis (range, 9.5-13.7 months). One patient subsequently died of disease. The current median follow-up for the 25 survivors is 1 year (range, 0.2-1.9 years) and the 1 year PFS rate is 66.2% (SE 12.2%). Based on the currently available information, older age (p = 0.07) and ND histology (p = 0.009) appear to be associated with worse PFS. To date none of the patients with MBEN histology have relapsed. Conclusions: The proposed modified regimen of chemotherapy without intraventricular MTX failed to achieve the desirable 2 y PFS of 90%, leading to premature closure of the study. Ongoing molecular characterization of the cohort may help uncover patients who may still benefit from this regimen. Clinical trial information: NCT02017964.

MRI assessment of the effects of acetazolamide and external lumbar drainage in idiopathic normal pressure hydrocephalus

Background

The objective was to identify changes in quantitative MRI measures in patients with idiopathic normal pressure hydrocephalus (iNPH) occurring in common after oral acetazolamide (ACZ) and external lumbar drainage (ELD) interventions.

Methods

A total of 25 iNPH patients from two clinical sites underwent serial MRIs and clinical assessments. Eight received ACZ (125-375 mg/day) over 3 months and 12 underwent ELD for up to 72 hours. Five clinically-stable iNPH patients who were scanned serially without interventions served as controls for the MRI component of the study. Subjects were divided into responders and non-responders to the intervention based on gait and cognition assessments made by clinicians blinded to MRI results. The MRI modalities analyzed included T1-weighted images, diffusion tensor Imaging (DTI) and arterial spin labelling (ASL) perfusion studies. Automated threshold techniques were used to define regions of T1 hypo-intensities.

Results

Decreased volume of T1-hypointensities and decreased mean diffusivity (MD) within remaining hypointensities was observed after ACZ and ELD but not in controls. Patients responding positively to these interventions had more extensive decreases in T1-hypointensites than non-responders: ACZ-responders (4,651 ± 2,909 mm³), ELD responders (2,338 ± 1,140 mm³), ELD non-responders (44 ± 1,188 mm³). Changes in DTI MD within T1-hypointensities were greater in ACZ-responders (7.9% ± 2%) and ELD-responders (8.2% ± 3.1%) compared to ELD non-responders (2.1% ± 3%). All the acetazolamide-responders showed increases in whole-brain-average cerebral blood flow (wbCBF) estimated by ASL (18.8% ± 8.7%). The only observed decrease in wbCBF (9.6%) occurred in an acetazolamide-non-responder. A possible association between cerebral atrophy and response was observed, with subjects having the least cortical atrophy (as indicated by a positive z-score on cortical thickness measurements) showing greater clinical improvement after ACZ and ELD.

Conclusions

T1-hypointensity volume and DTI MD measures decreased in the brains of iNPH patients following oral ACZ and ELD. The magnitude of the decrease was greater in treatment responders than non-responders. Despite having different mechanisms of action, both ELD and ACZ may decrease interstitial brain water and increase cerebral blood flow in patients with iNPH. Quantitative MRI measurements appear useful for objectively monitoring response to acetazolamide, ELD and potentially other therapeutic interventions in patients with iNPH.

Treatment of chronic pain: diffusion tensor imaging identification of the ventroposterolateral nucleus confirmed with successful deep brain stimulation

BACKGROUND/AIMS

A variety of pain syndromes have been treated successfully with deep brain stimulation (DBS) by targeting the thalamic ventroposterolateral (VPL) nucleus. The purpose of this study was to preoperatively identify the thalamic VPL nucleus by diffusion tensor imaging (DTI) fiber tractography (FT) and confirm it intraoperatively.

METHODS AND RESULTS

FT was performed to identify the thalamic VPL nucleus in 6 healthy volunteers and a patient with intractable chronic pain. The patient had preoperative DTI followed by DBS with the electrode placed by conventional stereotactic methods. Postoperative CT images of the DBS electrode tip were fused with the preoperative DTI and the electrode was noted to be in the position of the VPL nucleus predicted preoperatively by FT. The electrode was then used as a seed region of interest (ROI) to confirm FT back to the somatosensory cortex. Clinical confirmation was also achieved with the patient's pain relief. In all volunteers, VPL nuclei were identified in similar locations in both thalami, although slight inter- and intrasubject differences were observed.

CONCLUSION

DTI has the potential to identify the thalamic nuclei in individuals, which would be more accurate than anatomical localization and likely identical to intraoperative physiological testing. Postoperative DBS electrode placement and the affected cortical areas can be confirmed with coregistration of CT and FT using the electrode as a seed ROI.

Novel hydrogel application in minimally invasive surgical approaches to spontaneous intracranial hypotension

The authors report 2 cases of orthostatic headaches associated with spontaneous intracranial hypotension (SIH) secondary to CSF leaks that were successfully treated with an alternative dural repair technique in which a tubular retractor system and a hydrogel dural sealant were used. The 2 patients, a 63-year-old man and a 45-year-old woman, presented with orthostatic headache associated with SIH secondary to suspected lumbar and lower cervical CSF leaks, respectively, as indicated by bony defects or epidural fluid collection. Epidural blood patch repair failed in both cases, but both were successfully treated with the minimally invasive application of a hydrogel dural sealant as a novel adjunct to traditional dural repair techniques. Both patients tolerated the procedure well. Moreover, SIH symptoms and MRI signs were completely resolved at 1-month follow-up in both patients.

The minimally invasive dural repair procedure with hydrogel dural sealant described here offers a viable alternative in patients in whom epidural blood patches have failed, with obscure recalcitrant CSF leaks at the cervical as well as lumbar spinal level. The authors demonstrate that the adjuvant use of sealant is a safe and efficient repair method regardless of dural defect location.

Therapeutic hypothermia in neonates and selective hippocampal injury on diffusion-weighted magnetic resonance imaging

BACKGROUND

Hippocampal injury is most often observed in conjunction with basal ganglia injury after hypoxia-ischemia in term newborns. Objective was to determine perinatal characteristics leading to selective hippocampal injury vs basal ganglia injury on diffusion-weighted imaging in term encephalopathic infants following intrapartum hypoxia-ischemia treated with selective head cooling and to correlate specific injury to subsequent neurodevelopmental outcome.

METHODS

Retrospective chart review of obstetric and/or perinatal risk factors and patient characteristics in term infants treated with selective head cooling. All infants met standard enrollment criteria for cooling. MRI was obtained at a median of 7 days of life. Abnormal outcome was defined as spastic quadriplegia, cognitive delay, both, or death.

RESULTS

Fifty-seven infants were included for analysis. Diffusion-weighted imaging findings included normal (n = 31), basal ganglia injury (n = 16), and selective hippocampal injury (n = 10). No differences in gestational age, birth weight, sex, or labor complications between groups. More infants in the basal ganglia vs hippocampal group required delivery room cardiopulmonary resuscitation (P = 0.05), exhibited persistent severe acidosis, severe amplitude electroencephalography suppression, and encephalopathy at birth (P < 0.05). Abnormal neurodevelopmental outcome or death was observed in 88% vs 10% of infants in the basal ganglia vs the hippocampal group, respectively (P = 0.0001).

CONCLUSIONS

Infants with hippocampal injury on diffusion-weighted imaging recovered from an intrapartum asphyxial insult more rapidly as reflected by an earlier correction of acid-base status, were less likely to need cardiopulmonary resuscitation, and were less severely encephalopathic. These findings highlight the exquisite vulnerability of the hippocampus to acute hypoxia unaffected by selective head cooling, whereas the normal appearance of the basal ganglia in these infants suggests a neuroprotective effect of cooling.

Open-label, short-term, repetitive transcranial magnetic stimulation in patients with Alzheimer's disease with functional imaging correlates and literature review

BACKGROUND

Accumulating evidence suggests repetitive transcranial magnetic stimulation (rTMS) may be beneficial in ameliorating cognitive deficits in Alzheimer's disease (AD).

METHODS

AD patients received four high-frequency rTMS sessions over the bilateral dorsolateral prefrontal cortex (DLPFC) over two weeks. Structured cognitive assessments were administered at baseline, at 2 weeks after completion of rTMS, and at 4 weeks post treatment. At these same times, tolerant patients underwent functional magnetic resonance imaging (fMRI) while performing structured motor and cognitive tasks. We also reviewed literature regarding the effects of rTMS on cognitive function in AD.

RESULTS

A total of 12 patients were enrolled, eight of whom tolerated the fMRI. Improvement was seen in Boston Diagnostic Aphasia Examination tests of verbal and non-verbal agility 4 weeks post-treatment. The fMRI analysis showed trends for increased activation during cognitive performance tasks immediately after and at 4 weeks post-treatment. Our literature review revealed several double-blind, sham-controlled studies, all showing sustained improvement in cognition of AD patients with rTMS.

CONCLUSIONS

There was improvement in aspects of language after four rTMS treatments, sustained a month after treatment cessation. Our results are consistent with other studies and standardization of treatment protocols using functional imaging may be of benefit.

Low-dose acetazolamide reverses periventricular white matter hyperintensities in iNPH

OBJECTIVE

To assess the effects of low-dose acetazolamide treatment on volumetric MRI markers and clinical outcome in idiopathic normal-pressure hydrocephalus (iNPH).

METHODS

We analyzed MRI and gait measures from 8 patients with iNPH with serial MRIs from an institutional review board-approved imaging protocol who had been treated off-label with low-dose acetazolamide (125-375 mg/day). MRI studies included fluid-attenuated inversion recovery and 3D T1-weighted high-resolution imaging. Automated analyses were employed to quantify each patient's ventricular, global white matter hyperintensities (WMH), and periventricular WMH (PVH) volumes prior to and throughout treatment. Clinical outcome was based on gait changes assessed quantitatively using the Boon scale.

RESULTS

Five of 8 patients responded positively to treatment, with median gait improvement of 4 points on the Boon scale. A significant decrease in PVH volume (-6.1 ± 1.9 mL, p = 0.002) was seen in these patients following treatment. One patient's gait was unchanged and 2 patients demonstrated worsened gait and were referred for shunt surgery. No reduction in PVH volume was detected in the latter 2 patients. Nonperiventricular WMH and lateral ventricle volumes remained largely unchanged in all patients.

CONCLUSIONS

These preliminary findings provide new evidence that low-dose acetazolamide can reduce PVH and may improve gait in iNPH. PVH volume, reflecting transependymal CSF, is shown to be a potential MRI indicator of pharmacologic intervention effectiveness. Further studies of pharmacologic treatment of iNPH are needed and may be enhanced by incorporating quantitative MRI outcomes.

CLASSIFICATION OF EVIDENCE

This study provides Class IV evidence that low-dose acetazolamide reverses PVH volume and, in some cases, improves gait in iNPH.

Impact of skull base development on endonasal endoscopic surgical corridors

OBJECT

Scarce morphometric data exist on the developing skull base as a corridor for endonasal endoscopic approaches (EEAs). Furthermore, the impact of skull base lesions on its development has not been assessed. The authors describe a novel set of anatomical parameters characterizing the developmental process as well as the utility of these parameters in preoperative planning and a feasibility assessment of EEAs for neurosurgical treatment of skull base lesions in children.

METHODS

Based on specific MRI sequences in 107 pediatric patients (2-16 years of age) without skull base lesions (referred to here as the normal population), 3 sets of anatomical parameters were analyzed according to age group and sex: drilling distance, restriction sites, and working distance parameters. A separate set of patients undergoing EEAs was analyzed in similar fashion to address the impact of skull base lesions on the developmental process.

RESULTS

The volume of the sphenoid sinus significantly increases with age, reaching 6866.4 mm(3) in the 14-16 years age group, and directly correlates with the pneumatization type (r = 0.533, p = 0.0001). The pneumatization process progresses slowly in a temporal-posterior direction, as demonstrated by the growth trend of the sellar width (r = 0.428, p = 0.0001). Nasal restriction sites do not change significantly with age, with little impact on EEAs. The intercarotid distance is significantly different only in the extreme age groups (3.9 mm, p = 0.038), and has an important impact on the transsphenoidal angle and the intracranial dissection limits (r = 0.443, p < 0.0001). The 14.9° transsphenoidal angle at 2-4 years has a 37.6% significant increase in the 11-13 years age group (p = 0.001) and is highly dependent on pneumatization type. Age-dependent differences between working parameters are mostly noted for the extreme age groups, such as the 8.6-mm increase in nare-vomer distance (p = 0.025). The nare-sellar distance is the only parameter with significant differences based on sex. Skull base lesions induce a high degree of variance in skull base measurements, delaying development and decreasing parameter values. Skull base parameters are interdependent. Nare-sellar distance can be used to assess global skull base development because it highly correlates with the intercarotid distance in both the normal population and in patients harboring skull base lesions.

CONCLUSIONS

Skull base development is a slow, gradual, age-dependent, sex-independent process significantly altering endonasal endoscopic corridors. Preoperative MRI measurements of the pediatric skull base are thus a useful adjunct in choosing the appropriate corridor and in assessing working angles and limits during dissection or reparative surgery. Skull base lesions can significantly impact normal skull base development and age-dependent growth patterns.

Differential diagnosis of normal pressure hydrocephalus by MRI mean diffusivity histogram analysis

BACKGROUND AND PURPOSE

Accurate diagnosis of normal pressure hydrocephalus is challenging because the clinical symptoms and radiographic appearance of NPH often overlap those of other conditions, including age-related neurodegenerative disorders such as Alzheimer and Parkinson diseases. We hypothesized that radiologic differences between NPH and AD/PD can be characterized by a robust and objective MR imaging DTI technique that does not require intersubject image registration or operator-defined regions of interest, thus avoiding many pitfalls common in DTI methods.

MATERIALS AND METHODS

We collected 3T DTI data from 15 patients with probable NPH and 25 controls with AD, PD, or dementia with Lewy bodies. We developed a parametric model for the shape of intracranial mean diffusivity histograms that separates brain and ventricular components from a third component composed mostly of partial volume voxels. To accurately fit the shape of the third component, we constructed a parametric function named the generalized Voss-Dyke function. We then examined the use of the fitting parameters for the differential diagnosis of NPH from AD, PD, and DLB.

RESULTS

Using parameters for the MD histogram shape, we distinguished clinically probable NPH from the 3 other disorders with 86% sensitivity and 96% specificity. The technique yielded 86% sensitivity and 88% specificity when differentiating NPH from AD only.

CONCLUSIONS

An adequate parametric model for the shape of intracranial MD histograms can distinguish NPH from AD, PD, or DLB with high sensitivity and specificity.

Clinical demand for chest/abdomen/pelvis anatomy following thoracic or lumbar spine CT

The purpose of this study is to determine how often CT is repeated to obtain chest/abdomen/pelvis data outside the reconstructed field of view (FOV) on a prior spine CT. Radiology records of 1,239 consecutive thoracic and lumbar spine CT exams of 1,025 patients from January 1, 2006 to December 31, 2008 were retrospectively reviewed to identify patients who subsequently had CT studies of the chest, abdomen, and/or pelvis. The CT data were also evaluated for contrast enhancement, slice thickness, radiation dose, and reason for subsequent CT exam. Over 3 years, 290 of the 1,239 (24%) spine CT exams were followed by CT of the same anatomic region to evaluate extraspinal anatomy. The use or nonuse of contrast in these follow-up studies was the same as the preceding spine study in 91 cases, which were repeated on the same day (n = 37), within 7 days (n = 19), within 8-30 days (n = 15), or after 30 days (n = 20). Fourteen of 25 (56%) T spine CTs and 34 of 52 (65%) L spine CTs without contrast were followed by a chest CT or abdomen/pelvis CT without contrast within 7 days, respectively. Among 31 pediatric exams, 6 of 31 (19%) spine CTs were followed by a CT of the same anatomic region, all within 7 days. Reconstructing full FOV images of spine CT scans in addition to the standard coned down spine FOV may reduce redundant CT imaging and radiation dose.

Gene therapy for late infantile neuronal ceroid lipofuscinosis: neurosurgical considerations

OBJECT

The authors conducted a phase I study of late infantile neuronal ceroid lipofuscinosis using an adenoassociated virus serotype 2 (AAV2) vector containing the deficient CLN2 gene (AAV2(CU)hCLN2). The operative technique, radiographic changes, and surgical complications are presented.

METHODS

Ten patients with late infantile neuronal ceroid lipofuscinosis disease each underwent infusion of AAV2(CU)hCLN2 (3 x 10(12) particle units) into 12 distinct cerebral locations (2 depths/bur hole, 75 minutes/infusion, and 2 microl/minute). Innovative surgical techniques were developed to overcome several obstacles for which little or no established techniques were available. Successful infusion relied on preoperative stereotactic planning to optimize a parenchymal target and diffuse administration. Six entry sites, each having 2 depths of injections, were used to reduce operative time and enhance distribution. A low-profile rigid fixation system with 6 integrated holding arms was utilized to perform simultaneous infusions within a practical time frame. Dural sealant with generous irrigation was used to avoid CSF egress with possible subdural hemorrhage or altered stereotactic registration.

RESULTS

Radiographically demonstrated changes were seen in 39 (65%) of 60 injection sites, confirming localization and infusion. There were no radiographically or clinically defined complications.

CONCLUSIONS

The neurosurgical considerations and results of this study are presented to offer guidance and a basis for the design of future gene therapy or other clinical trials in children that utilize direct therapeutic delivery.

Neurological deterioration in late infantile neuronal ceroid lipofuscinosis

BACKGROUND

Late infantile neuronal ceroid lipofuscinosis (LINCL) is associated with progressive degeneration of the brain and retina starting in early childhood.

METHODS

Thirty-two individual neurologic, ophthalmologic, and CNS imaging (MRI and MRS) assessments of 18 children with LINCL were analyzed. Disease severity was followed by two rating scales, one previously established but modified to solely assess the brain and exclude the retinal disease (modified Hamburg LINCL scale), and a newly developed scale, with expanded evaluation of the CNS impairment (Weill Cornell LINCL scale).

RESULTS

For the 18 children, the Weill Cornell scale yielded a closer correlation with both age and time since initial clinical manifestation of the disease than did the modified Hamburg scale. There were no significant differences as a function of age or time since initial manifestation of the disease in the rating scales among the most frequent CLN2 mutations (G3556C, 56% of all alleles or C3670T, 22% of all alleles). Measurements of cortical MRS N-acetyl-aspartate content, MRI ventricular, gray matter and white matter volume, and cortical apparent diffusion coefficient correlated to a variable degree with the age of the children and the time since initial clinical manifestation of the disease. All imaging measurements correlated better with the Weill Cornell CNS scale compared to the modified Hamburg LINCL scale.

CONCLUSION

The data suggest that the Weill Cornell late infantile neuronal ceroid lipofuscinosis (LINCL) scale, together with several of the MRI measurements, may be useful in the assessment of severity and progression of LINCL and for the evaluation of novel therapeutic strategies.

Phenotypic features associated with mutations in steroidogenic acute regulatory protein

CONTEXT

Mutations in the gene encoding steroidogenic acute regulatory protein (StAR) are the most common cause of lipoid congenital adrenal hyperplasia (lipoid CAH), a disorder characterized by adrenal insufficiency and deficient gonadal steroid synthesis, resulting in female external genitalia in both genetic sexes.

OBJECTIVE

We describe three new cases of lipoid CAH caused by novel mutations in the StAR gene.

PATIENTS

An XY subject of Yemeni descent presented with adrenal insufficiency and severe undervirilization. Magnetic resonance imaging (MRI) of the brain showed enlarged subarachnoid spaces consistent with frontal and temporal atrophy. Two XX siblings of Palestinian descent presented with neonatal adrenal insufficiency. One had a borderline intelligence quotient and features of attention deficit hyperactivity disorder. MRI showed areas of supratentorial white matter lesions. In her sister, MRI revealed a Chiari-I malformation.

RESULTS

The XY subject was found to have a missense mutation (R182C). Both XX siblings had a dinucleotide deletion at nucleotides 327-328 that induces a frame shift that truncates the StAR protein after 68 amino acids.

CONCLUSIONS

These cases broaden the spectrum of known StAR mutations and suggest that disorders of central nervous system development may arise because of StAR deficiency and/or the metabolic consequences of neonatal adrenal deficiency.

Clinical protocol. Administration of a replication-deficient adeno-associated virus gene transfer vector expressing the human CLN2 cDNA to the brain of children with late infantile neuronal ceroid lipofuscinosis

Late infantile neuronal ceroid lipofuscinosis (LINCL) is a fatal childhood neurodegenerative lysosomal storage disease with no known therapy. There are estimated to be 200 to 300 children in the United States at any one time with the disease. LINCL is a genetic disease resulting from a deficiency of tripeptidyl peptidase I (TPP-I), a proteolytic enzyme encoded by CLN2, the gene that is mutated in individuals with LINCL. The subjects are chronically ill, with a progressive CNS disorder that invariably results in death, typically by age 8 to 12 years. The strategy of this clinical study is based on the concept that persistent expression in the CNS of the normal CLN2 cDNA with production of sufficient amounts of TPP-I should prevent further loss of neurons, and hence limit disease progression. To assess this concept, an adeno-associated virus vector (AAV2CUh-CLN2) will be used to transfer to and express the human CLN2 cDNA in the brain of children with LINCL. The vector consists of the AAV2 capsid enclosing the 4278-base single-stranded genome consisting of the two inverted terminal repeats of AAV serotype 2 and an expression cassette composed of the human cytomegalovirus (CMV) enhancer, the chicken beta-actin promoter/splice donor and 5' end of the intron, the 3' end of the rabbit P-globin intron and splice acceptor, the human CLN2 cDNA with an optimized Kozak translation initiation signal, and the polyadenylation/transcription stop codon from rabbit 3-globin. The proposed study will include 10 individuals and will be divided into two parts. Group A, to be studied first, will include four individuals with the severe form of the disease. Group B of the trial will include six individuals with a moderate form of the disease. After direct intracranial administration of the vector, there will be neurological assessment based on the LINCL clinical rating scale and magnetic resonance imaging/magnetic resonance spectroscopy assessment of the brain in regions of vector administration. The data generated will help evaluate two hypotheses: (1) that it is safe to carry out direct intracranial administration of the AAV2cuhCLN2 vector to the CNS of individuals with LINCL, and (2) that administration of the AAV2cuhCLN2 vector will slow down or halt the progression of the disease in the central nervous system.

Endovascular management of dolichoectasia of the posterior cerebral artery report

Congenital or nonatherosclerotic dolichoectasia is a rare condition; its etiology, natural history, and indications and technique of treatment are not yet clarified. During a workup for recent headaches and left-sided paresthesia in a 48 year-old female patient, brain MR imaging and cerebral angiography showed a large dolichoectasia of the P2 segment of the right posterior cerebral artery (PCA). The patient passed endovascular testing for occlusion of P2 with both balloon test occlusion and selective amytal testing. Endovascular coil occlusion of the right PCA dolichoectasia was successfully performed with hydrogel coils.

Advances in the endoscopic management of suprasellar arachnoid cysts in children

OBJECT

Suprasellar arachnoid cysts present unique management problems. The authors retrospectively reviewed six cases, in which endoscopic ventriculocystocisternotomy was performed, to identify specific neuroimaging features that aid both the accurate diagnosis of this entity and the postoperative assessment of fenestration patency.

METHODS

Six consecutive children underwent treatment for suprasellar arachnoid cysts. Consistent radiographic features in all cases were identified. Through a single entry site, endoscopic fenestration was performed at both the apical and basal cyst membranes. Outcome was assessed using clinical examination, quantitative changes in cyst size, and triplanar magnetic resonance (MR) imaging with flow-sensitive (long TR) sequences. In every case, the suprasellar cysts displayed three diagnostic MR imaging features: 1) vertical displacement of the optic chiasm/tracts; 2) upward deflection of the rostral mesencephalon and mammillary bodies; and 3) effacement of the ventral pons. Two patients initially underwent placement of a ventriculoperitoneal shunt before the cysts were recognized, but MR images obtained after shunt placement revealed the cysts. In a mean follow-up period of 26.2 months, all patients improved clinically. Postoperative imaging revealed a mean cyst volume decrease of 52.7% and a return to more normal suprasellar and prepontine anatomy. Flow-sensitive MR imaging confirmed pulsation artifact at all 12 fenestration sites. There was no surgery-related death and no additional cerebrospinal fluid diversion procedure was required.

CONCLUSIONS

To aid in the accurate diagnosis of prepontine arachnoid cysts, the authors identified several pathognomonic features on sagittal MR images: vertical deflection of the optic chiasm and mammillary bodies, as well as pontine effacement. Dual endoscopic fenestration into the intraventricular compartment and basal cistern is safe, and it effectively provides symptomatic relief by decreasing the cyst size. Triplanar flow-sensitive MR imaging sequences can confirm fenestration patency without the need for cine-mode MR imaging.

Toxic pediatric parkinsonism: report of a child with metabolic studies and response to treatment

We successfully treated a child with parkinsonism secondary to cytosine arabinoside with levodopa/carbidopa and attempted to elucidate the pathogenesis of the disorder by sequential analysis of cerebrospinal fluid biogenic amines, sequential magnetic resonance imaging, and fluorodopa positron emission tomography, which revealed both permanent and reversible biochemical and structural alterations. The parkinsonian disorder resolved in 9 months. Metabolic changes and structural abnormalities on imaging studies were chronologically correlated with the clinical course.

Use of fetal magnetic resonance imaging in patients electing termination of pregnancy by dilation and evacuation

OBJECTIVE

The purpose of this study was to determine whether magnetic resonance imaging of the fetal brain before dilation and evacuation enhances diagnosis when equivocal ultrasound findings and disrupted autopsy specimens exist.

STUDY DESIGN

Patients with equivocal fetal brain abnormalities on ultrasound examination who were considering termination of pregnancy were evaluated retrospectively. Abdominal and pelvic magnetic resonance imaging was performed for further evaluation, and orthogonal fetal brain images were obtained. A multidisciplinary team reviewed all cases and discussed the findings, possible causes, and recurrence risks with each patient.

RESULTS

Seven patients with fetal brain anomalies underwent magnetic resonance imaging before dilation and evacuation. Magnetic resonance imaging diagnoses included intracranial hemorrhages, semilobar holoprosencephaly, intracranial teratoma, multiple cerebral infarcts, and unilateral cerebellar hypoplasia. In all cases, magnetic resonance imaging provided valuable information and helped distinguish possible genetic syndromes from likely sporadic disorders of brain development.

CONCLUSION

Magnetic resonance imaging can provide insight into diagnosis, cause, and recurrence risks for patients who choose dilation and evacuation because of fetal brain abnormalities.

Results of preoperative embolization for metastatic spinal neoplasms

OBJECT

Arterial embolization reduces blood loss in patients undergoing surgery for hypervascular spinal tumors. The objectives of this study were twofold: 1) to evaluate the role of magnetic resonance (MR) imaging in predicting tumor vascularity and 2) to assess the effectiveness of preoperative embolization in devascularizing these tumors.

METHODS

Fifty-one patients with metastatic spinal neoplasms underwent angiography, preoperative embolization, and excision of the lesion between 1995 and 2000. The MR imaging studies were correlated with tumor vascularity on angiograms. Embolization was angiographically graded on a five-point scale ranging from no embolization (Grade A) to total embolization (Grade E). The embolization grade was correlated with intraoperative blood loss. The mean age was 57 years, the male/female ratio was 1.2:1, and back pain was present in all patients. Metastatic renal cell carcinoma (30 cases) and thoracic spine involvement (33 cases) were most frequent. The positive predictive value of MR imaging in determining tumor vascularity was 77%, whereas the negative predictive value was 21%. Total embolization (Grade E) was achieved in 34 patients. A shared vascular pedicle between a radiculomedullary artery (RMA) and a tumor diminished the likelihood of complete embolization (p = 0.02). Small asymptomatic cerebellar infarctions were demonstrated in two cases. The mean intraoperative blood loss was 2,586 ml. Following Grade D or E embolization, intraoperative bleeding was largely related to unembolized epidural veins.

CONCLUSIONS

Tumor histology and MR imaging findings are predictive of hypervascularity, however, hypervascular tumors may not be detected by standard MR imaging sequences. Superselective catheterization permits Grade D or E embolization in 80% of patients. Shared blood supply with an RMA is the most important factor precluding complete embolization.

Large intraosseous arteriovenous malformation of the maxilla - a case report with review of literature

Large intraosseous arteriovenous malformations (AVM) of the maxilla are rare lesions, which are probably hamartomas. We report a case of an 8-year-old child who presented with exsanguinating hemorrhage after an attempted dental biopsy. The management of dental intraosseous AVMs includes transarterial embolization and direct intralesional injection of liquid acrylic (NBCA). This approach avoids mutilating surgery and its sequelae in children. We present this case for its rarity and the intralesional use of acrylic glue in its management.

Posterior distribution of infarcts in strokes related to cardiac operations

BACKGROUND

Stroke complicates cardiac surgical procedures in a substantial number of patients. The mechanism of stroke is predominantly embolic, although hypoperfusion may play a role. The aim of this study was to determine whether radiologic appearances in this population were consistent with an embolic cause.

METHODS

We reviewed computed tomographic scans and medical records in 24 patients who suffered stroke after cardiac operation. Stroke was evident at 24 hours in 19 patients (79%). Infarcts were multiple in 16 and single in 3 patients (group 1). The remaining 5 patients suffered stroke beyond 24 hours and had single infarcts on computed tomographic scan (group 2).

RESULTS

In group 1, 15 patients (79%) had bilateral cerebellar infarcts, 4 (74%) had posterior cerebral artery infarcts, 10 (53%) had posterior watershed infarcts, and 11 patients (58%) had middle cerebral artery branch infarcts. The mean number of vascular territories involved was 5.1 (range, 1 to 10). Mobile atheromatous plaque was present in the ascending aorta or arch in 5 of 9 patients (56%) in group 1. In group 2, stroke occurred in close association with atrial or ventricular fibrillation in 3 of 5 patients (60%).

CONCLUSIONS

In patients with radiologic evidence of infarction, perioperative strokes after cardiac operation are typically multiple, and involve the posterior parts of the brain, consistent with atheroembolization. Delayed strokes may be attributable to cardiogenic embolism.

Cogenital bony nasal cavity deformities

Although the most common form of nasal obstruction in neonates is soft tissue edema, congenital bony nasal deformities are being recognized as an important cause of newborn airway obstruction. In addition to the well described choanal atresia, CT imaging of the newborn in respiratory distress reveals two other forms of bony nasal cavity deformities: nasal pyriform aperture stenosis and nasal cavity stenosis. All of the three types of bony nasal cavity deformities have characteristic anatomical features, are associated with distinctive congenital anomalies, and are postulated to have differing embryological causes. Five patients with congenital bony nasal cavity deformities are presented. These cases illustrate the clinical and radiological presentation of varied types of congenital nasal cavity obstruction as well as the criteria used to guide clinical management.

Magnetic resonance imaging in the congenital adrenal hyperplasia population: increased frequency of white-matter abnormalities and temporal lobe atrophy

Congenital adrenal hyperplasia results from an adrenal enzyme deficiency, that causes an underproduction of glucocorticoids and sometimes mineralocorticoids and a resultant overproduction of androgens, until treatment with replacement glucocorticoids is instituted. The goal of this study was to determine the frequency and etiology of white-matter changes and temporal lobe atrophy demonstrable on magnetic resonance imaging (MRI) in a group of children and young adults with congenital adrenal hyperplasia. About one third of the patients evidenced white-matter abnormalities or temporal lobe atrophy. All patients, except one with a known stroke, had normal neurologic examinations. Exposure to excess exogenous glucocorticoids in the process of being treated for congenital adrenal hyperplasia is the most theoretically appealing explanation for these MRI findings. However, the relationship of MRI findings to treatment status (over-versus under-suppressed) does not run in clear parallel.

The role of the cranial base in facial growth: experimental craniofacial synostosis in the rabbit

Craniofacial synostosis designates premature fusion in sutures of the cranial vault (calvarium). When craniofacial synostosis is associated with a syndrome (e.g., Apert, Crouzon), premature fusion of the cranial base has been postulated to occur as well. This study was designed to determine whether the primary growth disturbance in craniofacial synostosis is located at the cranial base (i.e., spheno-occipital synchondrosis) or the calvarial vault (i.e., coronal and sagittal sutures) or both. Sixty newborn New Zealand White rabbits were randomly assigned to six groups: (I) calvarial control, (II) cranial base control, (III) cranial base immobilization, (IV) coronal suture immobilization, (V) coronal and sagittal suture immobilization, and (VI) cranial base and coronal and sagittal suture immobilization. An anterior cervical microsurgical approach to the cranial base was used, while cranial vault sutures were exposed through a bicoronal scalp incision. All sutures were fused by periosteal abrasion and application of methyl cyanoacrylate. Cephalograms were taken at 30, 60, and 90 days postoperatively to assess craniofacial growth. Linear and angular measurements of facial, calvarial, and basicranial growth were subjected to multivariate analysis. Analysis indicated that (1) craniofacial length was shortened most significantly by cranial base fusion, (2) cranial base fusion and cranial vault fusion had an additive effect on craniofacial length restriction, (3) the anterior cranial base was significantly shortened by cranial base and cranial vault fusion (p < 0.05), (4) the posterior cranial base was shortened by cranial base fusion only (p < 0.05), and (5) cranial base fusion alone significantly flattened the cranial base angle (p < 0.05), whereas cranial vault fusion alone did not. These results suggest that cranial base fusion alone may account for many dysmorphic features seen in craniofacial synostosis. This model is consistent with the findings of other investigators and confirms both a primary directive and translational role of the cranial base in craniofacial growth.

Failure of steroid replacement to consistently normalize pituitary function in congenital adrenal hyperplasia: hormonal and MRI data

Exogenous glucocorticoid replacement in patients with congenital adrenal hyperplasia (CAH), who due to an adrenal 21-hydroxylase enzyme deficiency are unable to produce endogenous glucocorticoids, is aimed at normalizing hypothalamic-pituitary-adrenal function. Excess androgen production by the adrenals is thus decreased. Despite standard glucocorticoid replacement doses (12.5-40 mg, 10.5-27 mg/m2/day hydrocortisone equivalents) 4 of 7 patients ranging in age from 14 to 33 years had abnormalities of the pituitary on MRI. Three appeared to have microadenomas and 1 had an empty sella. Five (3 salt wasters, 2 simple virilizers) of these 7 patients had 60-min p.m. ovine corticotropin-releasing hormone (oCRH) stimulation studies. The mean (logarithm) area under the ACTH curve for 0-60 min after oCRH stimulation was significantly greater in patients than controls (p < 0.0001). Mean ACTH at each time point before and after oCRH stimulation was similarly greater in patients than controls (p < 0.05). Two of these patients had pituitary microadenomas, 1 had an empty sella; all 3 were salt wasters. Despite standard glucocorticoid replacement, adolescent and young adult patients with CAH tend to have high basal ACTH and ACTH hyperresponsiveness to oCRH, as well as structural abnormalities of the pituitary. The inevitable periods of under- and overexposure to glucocorticoids in CAH patients may over time cause abnormalities of the hypothalamic-pituitary-adrenal axis.

Acquired stuttering after a second stroke in a two-year-old

An almost two-year-old left-handed girl with a history of a left-hemisphere stroke at the age of one year developed a transient stutter with newly acquired white matter infarctions. Her course suggests that developmental stuttering may reflect anomalous dominance and/or atypical interhemispheric connectivity.

Bilateral middle cerebral artery occlusions in neurocysticercosis

BACKGROUND

Bilateral hemispheric strokes in a young adult are very rare. We describe a case of neurocysticercosis in a young male with bilateral middle cerebral artery occlusions.

CASE DESCRIPTION

Axial tomographic imaging revealed lesions compatible with cysticerci adjacent to each middle cerebral artery initial segment, and occlusion of both arteries at that level was demonstrated by angiography. Extensive medical workup disclosed no other risk factors for stroke.

CONCLUSIONS

Neurocysticercosis should be considered in the differential diagnosis of stroke in a young patient.

Detection of brain metastases: comparison of contrast-enhanced MR with unenhanced MR and enhanced CT

Contrast-enhanced MR studies were compared with noncontrast MR and contrast-enhanced CT scans in the evaluation of intraparenchymal brain metastases. Fifty consecutive inpatients were studied with short and long repetition time (TR) sequences before and after the administration of gadopentetate dimeglumine. In addition, a delayed short TR sequence was performed. The contrast CT, noncontrast MR, immediate postcontrast short TR sequence, postcontrast long TR sequence, and delayed postcontrast short TR sequence were each read blindly and independently by two neuroradiologists. These results were then compared with a final interpretation, reached by all the neuroradiologists in the study, using all the clinical information and imaging findings. Postcontrast short TR scans proved to be superior to other sequences. They were particularly useful in the detection of metastases in the posterior fossa and cortex. The delayed postcontrast short TR scan held no definite advantage over the immediate postcontrast short TR scan, although metastases were sometimes seen slightly better after the delay. While long TR sequences were not always sensitive or specific, they often did provide ancillary information and were particularly useful in cases of hemorrhagic metastases. Because of these findings, we recommend that the evaluation of intraparenchymal metastases consist of a single postcontrast long TR scan followed by a single postcontrast short TR scan. While these sequences should be very accurate in the detection of metastases, we also generally perform a single precontrast short TR scan as well, since the question of hemorrhage or bone lesion may be clinically relevant.

Confirmation by Magnetic Resonance Imaging of Bell's Cruciate Paralysis in a Young Child with Chiari Type I Malformation and Minor Head Trauma

We report the case of a young girl who suffered bilateral upper extremity paralysis after minor head trauma. Her clinical picture, as well as radiographic evidence of a fracture at C1, led to the diagnosis of Bell's cruciate paralysis, caused by a small lesion in the rostral part of the pyramidal decussation. Magnetic resonance images showed, in addition to a Chiari Type I malformation, an abnormality in the medulla. All previous cases of cruciate paralysis lack both pathological and radiographic supporting evidence.

Confirmation by magnetic resonance imaging of Bell's cruciate paralysis in a young child with Chiari type I malformation and minor head trauma

We report the case of a young girl who suffered bilateral upper extremity paralysis after minor head trauma. Her clinical picture, as well as radiographic evidence of a fracture at C1, led to the diagnosis of Bell's cruciate paralysis, caused by a small lesion in the rostral part of the pyramidal decussation. Magnetic resonance images showed, in addition to a Chiari Type I malformation, an abnormality in the medulla. All previous cases of cruciate paralysis lack both pathological and radiographic supporting evidence.