Angiomi cavernosi multipli cerebrali ed epatici

Gli angiomi cavernosi cerebrali (ACC) sono una delle malformazioni vascolari del SNC meno frequenti. É nota peraltro la possibilità di ricorrenza familiare con modalità di trasmissione autosomica dominante. Presentiamo una famiglia italiana, seguita lungamente nel tempo, in cui 10 soggetti in 4 generazioni presentano ACC.

Il reperto cerebrale era associato ad angioma cavernoso epatico (ACE) in 2 soggetti e ad angioma cavernoso retinico (ACR) in uno.

La TC, eseguita in 9 soggetti, ha dimostrato una maggior capacità rispetto alla RM di rilevare le calcificazioni spesso presenti in queste malformazioni; la RM ha evidenziato d'altra parte un numero maggiore di cavernomi, soprattutto in sede sottotentoriale. 7 pazienti sono stati sottoposti ad esame angiografico con tecnica digitale sottrattiva. In nessun caso è stata dimostrata malformazione angiomatosa di tipo artero-venoso ed in 1 solo caso è stata rilevata una lieve persistenza di contrasto nelle fasi capillare-venose.

Riteniamo meritevole di segnalazione questa famiglia per:

l'associazione di ACC con ACE segnalata in 1 solo caso in letteratura (Filling - Katz) e la contemporanea associazione, pur in un solo paziente, di ACR; la costante molteplicità delle lesioni cerebrali, quasi sempre presenti sia in sede sopra che sottotentoriale; il contrasto tra la povertà dei sintomi e l'imponenza del quadro radiologico e la sua variabilità espressiva nelle diverse generazioni; l'elevato numero di soggetti affetti rispetto ad altre famiglie riportate in letteratura.

I rilievi clinico-radiologici nella presente casistica ed i dati riportati dalla letteratura suggeriscono la necessità di uno studio neuroradiologico complementare TC ed RM nei soggetti affetti da ACC e nei familiari.

Va peraltro tenuta presente la possibilità attuale di selezionare i pazienti da sottoporre ad angiografia tradizionale sulla base dei reperti ottenibili con angio-RM. Va sottolineata infine l'opportunità di una attenta e ponderata valutazione della terapia chirurgica proposta da molti autori, data la relativa benignità del decorso clinico riscontrata nei soggetti della nostra serie casistica.

Occipital Plagiocephaly

After the “Back to Sleep” campaign, promoted in 1992 by the American Academy of Paediatrics to prevent the Sudden Infant Death Syndrome (SIDS), it was recommended to place babies in a supine sleeping position. The incidence of SIDS has fallen dramatically since 1992, whereas there has been a major increase in the incidence of occipital plagiocephaly (OP). We report the data relative to the OP cases observed in the Paediatric Department of Padua Hospital between 1998 and 2003. 122 (63%) of the 194 cases of craniosynostosis observed presented OP. The 64 children that took part to the study were contacted and underwent neurological examination with an evaluation of skull shape and previous radiograms. We proposed to parents a questionnaire to define the risk factors and estimate the skull deformity over time. 58 of the 64 children presented positional plagiocephaly (PP), six had synostotic plagiocephaly (SP). Since 1998 there has been a progressive increase in cases of PP. There is a male prevalence (65%), but no side prevalence. Firstborns accounted for 33 (51%), whereas 11 were preterm infants (17%). 82% had a gestational age between the 38th and 40th week. The mean value of the Apgar Index was 8 at the first minute and 9 at the 5th minute. At birth the clinical presentation was: occipital flattening already present at birth in 23 children, preferential head orientation in 18, congenital torticollis in 12, ear asymmetry in 12, frontal bossing in ten. We noticed a mild developmental delay in 8 children (13%). The maximum degree of cranial asymmetry was observed in two peaks in cases of PP: at the third and fourth months (34 cases) and then at the sixth and seventh months (13 cases). The SP presented a progressive exacerbation of the deformity until surgery (done at the sixth to seventh months). PP improved by hygienic postural norms in six months; only three patients required surgery for aesthetic reasons. We observed a strict correlation between side of flattening and sleep head position ( χ2 test, p-value=2,256e-09) and a higher degree of occipital flattening at birth in patients with associated congenital torticollis (Mann-Whitney test, p-value=0.002744). In conclusion, OP is a common condition but essentially benign; it does not cause medical consequences but aesthetic problems. It is necessary to recognize the mild deformity in the newborns so as to intervene early with hygienic postural norms that can correct the asymmetry. The diagnosis is largely clinical and only in case of doubt are radiological examinations required (ultrasonography for sutures, 3D CT scans).

Unusual neuroimaging in a young boy with cerebral X-linked adrenoleukodystrophy

We describe the case of a 7-year-old boy with cerebral X-linked adrenoleukodystrophy presenting with neurobehavioral symptoms. Attention deficit with hyperactive behavior was followed by progressive memory retrieval deficits and difficulty in writing. A detailed review of the clinical history, clinical examination and contrast-enhanced brain nuclear magnetic resonance imaging disclosed indeed an atypical cerebral form of X-linked adrenoleukodystrophy with diffuse anterior and posterior white matter involvement with a typical rim of contrast enhancement. A severe clinical deterioration occurred despite dietary treatment and hormonal replacement therapy. These rare but severe forms of atypical cerebral X-linked adrenoleukodystrophy can more often mimic attention deficit/hyperactivity disorder and should, therefore, be considered in young males with progressive neurobehavioral symptoms, particularly when possibly related to frontal white matter involvement. An accurate clinical history and examination should determine whenever a contrast-enhanced head MRI should be indicated.

Tethered cord in patients with anorectal malformation: preliminary results

BACKGROUND

A tethered cord (TC) has been reported in as much as 50% of the patients affected by anorectal malformation (ARM). No guidelines for timing and modality of diagnosis and treatment have been established. We present the preliminary results of a multidisciplinary protocol carried out at our center.

METHODS

Seventy-four ARM patients underwent spinal magnetic resonance imaging (MRI). All TC patients underwent videourodynamic (UD), somatosensory-evoked potentials (SEPs), and neurological examination at baseline and, if normal, at 5 and 10 years of age. Conversely, when UD or SEP abnormalities were detected the follow-up was individually tailored at shorter time.

RESULTS

25/74 patients had a neuroradiological TC (33.7%). Based on the results of UD, SEP, and neurological status, four patients were untethered, eight are possible candidates, nine are stable, and four were excluded because of incomplete data.

DISCUSSION

Tethered cord is frequent in ARM patients. Because neurological deficits secondary to TC can contribute to neurological disability, we recommend routine MRI examination and a multidisciplinary program of follow-up in cases of TC. Preliminary results suggest the combined use of SEPs and UD could represent a useful adjunct to clinical examination in patients in whom a "wait and see" approach is preferred to the prophylactic surgery.

Clinical and diagnostic aspects of multiple sclerosis and acute monophasic encephalomyelitis in pediatric patients: a single centre prospective study

OBJECTIVE

The purpose of the study was to compare and contrast the initial presenting demographic, clinical, neuroimaging, and laboratory features in a cohort of children affected from multiple sclerosis (MS) or acute disseminated encephalomyelitis (ADEM).

METHODS

A 12-year prospective study was conducted in 68 pediatric patients (age<or=17 years) who presented with a first episode of central nervous system inflammation suggestive of a demyelinating multifocal pathology. All patients had undergone magnetic resonance imaging (MRI) and cerebrospinal fluid (CSF) examination. The mean follow-up period, as at ending on December 31, 2007, was 6.8+/-2.7 years (range 3.2-12.6 years).

RESULTS

At clinical onset, children who developed MS during the follow-up (48 patients; 34 females, 14 males; mean age at onset: 14.4+/-2.5) significantly differed from children affected by ADEM (20 patients; 8 females, 12 males; mean age at onset: 8.1+/-3.8) for the following parameters: prevalence of females affected (female/male ratio: 2.8 versus 0.6, P=0.03); mean age at onset (P<0.001); monosymptomatic onset (73% vs 30%, P=0.002); encephalopathy-like onset (0% vs 50%, P<0.001); presence of oligoclonal IgG bands (IgGOB) in CSF (83% vs 10%, P<0.001); and periventricular (79% vs 20%, P<0.001), brain stem (12.5% vs 60%, P=0.000), and basal ganglia (10% vs 50%, P<0.001) lesions at MRI.

CONCLUSIONS

Our findings depict a pattern of demographic, clinical, neuroimaging, and laboratory findings that can help to distinguish, at clinical onset, children suffering from ADEM from those who will develop MS. Childhood-onset MS seems not to differ from adult-onset MS from both clinical and paraclinical features.

[Visual motor and visual defects in spina bifida]

Among the numerous problems that Spina Bifida (SB) patients are faced with, impairments to the visual apparatus are often considered late and are not covered extensively in the literature. At the Pediatric Department of the University of Padua, an assessment of the visual function of 59 SB patients between 5 months and 26 years of age (29 male and 30 female) has been carried out by means of an ophthalmologic protocol As far as the alteration of the exstrinsic ocular mobility is concerned, 44% (26/59) of our patients revealed a manifest squint and only 3% (two patients) suffered from a latent squint. The most frequent type is a convergent squint (80%). The assessment of visual acuity made through Optotype was good in 82% of the cases (unlike what is commonly reported in the literature) and mild in 18%. None of the patients manifested hypovision. Refraction defects were present in 59% (34/59) of the patients. Regular ophthalmologic evaluations from birth or from diagnosis allow ophthalmologic treatments that are tailored to children suffering from SB and also enable them to reach and maintain a good visual standard and to observe the subtle symptoms of endocranial hypertension sooner. An early discovery and correct treatment of visual problems improves cognitive and motive performance as well as the autonomy of SB patients.

[Visual motor and visual defects in spina bifida]

Among the numerous problems that spina bifida (SB) patients are faced with, impairments to the visual apparatus are often considered late and are not covered extensively in the literature. At the Pediatric Department of the University of Padua, an assessment of the visual function of 59 SB patients between 5 months and 26 years of age (29 male and 30 female) has been carried out by means of an ophthalmologic protocol. As far as the alteration of the exstrinsic ocular mobility is concerned, 44% (26/59) of our patients revealed a manifest squint and only 3% (two patients) suffered from a latent squint. The most frequent type is a convergent squint (80%). The assessment of visual acuity made through Optotype was good in 82% of the cases (unlike what is commonly reported in the literature) and mild in 18%. None of the patients manifested hypovision. Refraction defects were present in 59% (34/59) of the patients. Regular ophthalmologic evaluations from birth or from diagnosis allow ophthalmologic treatments that are tailored to children suffering from SB and also enable them to reach and maintain a good visual standard and to observe the subtle symptoms of endocranial hypertension sooner. An early discovery and correct treatment of visual problems improves cognitive and motive performance as well as the autonomy of SB patients.

Clear-cell meningioma in a 22-month-old male: a case report and literature review

We report a case of spinal clear-cell meningioma occurring in a 22-month-old male who presented a right limp and then refused to walk. Spinal magnetic resonance imaging demonstrated a large, intradural tumor from T(11) to L(4), which was totally excised. The patient's postoperative recovery was uneventful and 5 months after surgery he began walking again. The latest follow-up magnetic resonance imaging of the brain and spine, obtained 42 months after diagnosis, was negative for tumor recurrence. Though clear-cell meningioma is a rare form of meningioma, it should be considered in the differential diagnosis of any space-occupying lesion of the spine arising in very young children. Complete surgical removal is necessary because it is potentially aggressive and may recur. After surgery, an accurate follow-up is warranted.

Benign paroxysmal vertigo of childhood

Benign paroxysmal vertigo of childhood (BPV) is a paroxysmal, non-epileptic, recurrent event characterized by subjective or objective vertigo that occurs in neurologically intact children. We recorded the history and the clinical aspects of 19 cases presenting with neurological problems to the outpatient clinic at the Pediatrics Department of Padova University between 1987 and 1998 and re-examined in 1999. Details were collected on the characteristics of their vertigo: age at onset, mode of onset, trigger factors, duration, frequency and recurrence of episodes, duration of symptoms in time and age at disappearance. An attempt was also made to establish any family history of migraine and kinetosis and the most important data were compared, when possible, with those reported in the literature. Differential diagnosis and pathogenetic hypothesis were also reported. It is worth emphasizing that it is important for pediatricians to be aware of these benign events to ensure a correct diagnostic approach, avoiding the child and family any pointless anxiety or costly and sometimes invasive diagnostic procedures.

CCM1 gene mutations in families segregating cerebral cavernous malformations

Cerebral cavernous malformations (CCM) are vascular anomalies, sometimes inherited as an autosomal dominant trait, which can cause strokes and seizures. Recently, mutations of the CCM1 gene (chromosome 7q) have been found in a subset of families. The authors found 10 new mutations by screening 29 families and five seemingly sporadic cases of CCM. The mutations predicted truncation of the Krit1 mRNA encoded by CCM1, supporting the contention that CCM result from loss of Krit1 protein function and the possibility that this protein acts as a tumor suppressor.

Benign paroxysmal torticollis of infancy

Benign paroxysmal torticollis is an episodic functional disorder of unknown etiology that occurs in the early months of life in healthy individuals. The child's head tilts to one side for a few hours or days, usually without any associated symptoms. The disorder, which disappears within the first few years of life, is often misinterpreted and the patient pointlessly undergoes numerous tests. We present our series of 22 patients observed at the pediatric neurology outpatients clinic in Padova with a view to refreshing the pediatrician's memory on this frequent, benign pathology.

Anticipation in familial cavernous angioma: ascertainment bias or genetic cause

OBJECTIVES

Anticipation has been linked to unstable trinucleotide repeats in many neurological disorders. We examined the hypothesis of genetic anticipation in familial cavernous angioma (FCA) of the central nervous system.

MATERIAL AND METHODS

The mean ASO of affected individuals was compared between successive generations in 55 families. Intergenerational pair-wise comparisons were employed to avoid several ascertainment biases. Regarding severity of disease both type of manifestation and number of cavernous angiomas were compared between generations.

RESULTS

The mean ASO decreased significantly both from the first to the second generation (31.6 vs 17.8 years; P = 0.000) and from the second to the third generation (17.8 vs 6.7 years; P = 0.002). The pair-wise comparisons also showed significantly earlier ASO. No clear evidence for anticipation with regard to severity of disease was found.

CONCLUSIONS

Molecular genetic studies will determine whether trinucleotide repeats are the underlying mechanism for our observation of anticipation in FCA.

Amplification of the Xq28 FRAXE repeats: extreme phenotype variability?

We report on a new case of FRAXE mutation identified through the screening of a population of FRAXA-negative mentally retarded individuals. The index case, a 4-year-old boy with distinct minor anomalies and mental retardation with severe verbal impairment, his older brother, referred to as normal, and the mother have undergone careful clinical and molecular evaluation. The molecular defect, characterized by standard Southern blot analysis, is represented by a hypermethylated "full mutation" in the 2 boys and by a unique, altered, presumably unmethylated, band in the mother, which is interpreted as a "premutation." The cytogenetic analysis failed to detect a folate-sensitive Xq27-28 fragile site in either "fully mutated" individual. The phenotype and intellectual performance of the 15-year-old brother of the propositus appeared completely normal. Our propositus shares some traits with previously described FRAXE-mutated subjects, suggesting an association with the Xq28 molecular defect; nevertheless, we find it difficult to reconcile the molecular identity and phenotypic difference in these mutated members of the same family. This could be a case of extreme phenotypic variability or a result of a more complicated molecular mechanism.

Macrocephaly and chromosome disorders: a case report

We report the case of a young patient with macrocephaly. After excluding the most frequent causes of macrocephaly (hereditary disorders, degenerative, osseous and metabolic diseases, neurocutaneous syndromes and cerebral malformations), the likelihood of a chromosome disorder was investigated, revealing an unbalanced de novo translocation: 46,X,der(X),t(X;7) (q13 or q13.2; q11.23 or q21.11), i.e., a partial trisomy of the long arm of chromosome 7, associated with a partial monosomy of the long arm of chromosome X. Though this chromosome disorder is relatively rare, it should be considered in the differential diagnosis of patients under one year of age presenting with macrocephaly, scoliosis and non-progressive psychomotor retardation.

Electroclinical diagnosis of Angelman syndrome: a study of 7 cases

The authors describe 7 new cases of Angelman syndrome (AS: 3 males and 4 females) diagnosed on the basis of clinical features (dysmorphic facial features, severe mental retardation with absent speech, peculiar jerky movements, ataxic gait and paroxysms of inappropriate laughter) and neurophysiological findings. Failure to detect deletion of the long arm of chromosome 15 or the absence of epileptic seizure were not considered sufficient to exclude a diagnosis of AS. Feeding problems, developmental delay and early signs of ataxia, especially tremor on handling objects and unstable posture when seated, proved effective as clinical markers for early diagnosis of AS. The EEG patterns characteristic of AS were found within the first 2 years of life (under 18 months in the majority of cases). The authors conclude that AS should be included in differential diagnosis in a child aged under 12 months having cryptogenic psychomotor retardation with prevalent language compromise. Repeat EEG recordings are needed to check for the typical trace, and cytogenetic investigations are mandatory.

Acute hemiparesis associated with ciprofloxacin

Images

Familial cerebral, hepatic, and retinal cavernous angiomas: a new syndrome

New, non-invasive neuroradiological techniques [computed tomography (CT) and magnetic resonance (MR)] have led to reassessment of the incidence of cavernous angioma of the brain (CCA), which is sometimes multiple and associated with cavernomas in other organs. CCA is known to be familial, with dominant autosomal transmission. This paper concerns a family with multiple CCA, sometimes in association with liver angiomas, in ten members belonging to four different generations. These malformations can vary in clinical expression: no neurological symptoms have been detected in subjects from the first or second generations, but they were found in adult age in subjects from the third generation; two fourth-generation patients came under our observation at 2.5 years of age. Symptoms include partial epileptic fits, which sometimes become generalized later and which are generally controlled adequately by therapy. Patients also present paresthesia and occasional motor deficiencies corresponding to CCA bleeding episodes; these symptoms have always abated with medical treatment alone. None of the patients are mentally retarded or restricted in their daily lives. Neuroradiological investigations (CT, MR, angiography) reveal typical multiple brain lesions in all patients. Given the first-generation patient's clinical history of symptomatic hepatomegaly and the postmortem finding of multiple liver and brain cavernomas, liver ultrasonography was performed on all members of the family. Liver angioma was detected in two subjects from the second and third generations. Retinal angioma was detected in one patient with quadrantanopsia.(ABSTRACT TRUNCATED AT 250 WORDS)

Childhood stroke associated with familial protein S deficiency

Cerebral infarction is a rare pathology among children and its etiology can be identified in almost two-thirds of cases. The remaining one-third are considered idiopathic. Recently, inherited disorders of blood coagulation predisposing to thrombosis have been taken into account as a possible cause of childhood stroke. We describe here a case of a 6-year-old child presenting with ischemic stroke and protein S (PS) defect. The family study suggested inheritance of the defect. The immunological characterization of PS in the affected family members was consistent with a defect mainly in the free form of PS. In the case here reported no associated predisposing condition to stroke could be identified but familial PS defect was found. No therapy was administered. Nevertheless symptoms disappeared spontaneously and there were no recurrences at the 1 year follow-up. Diagnostic imaging techniques demonstrated that a reduction in the cerebral ischemic area had occurred 2 months after the stroke.

Congenital muscular dystrophy, brain and eye abnormalities: one or more clinical entities?

Four children with congenital muscular dystrophy (CMD), eye and brain abnormalities are described. Their clinical and neuroradiological features are compatible with a diagnosis of Walker-Warburg syndrome (WWS), according to the criteria proposed by Dobyns et al. (i.e., presence of type II lissencephaly, typical cerebellar and retinal malformations, CMD), who also conclude that WWS is indistinguishable from the muscle-eye-brain disease (MEBD) described by Santavuori. On the basis of our own experience and two recently published series, we emphasize certain features that are different in patients with WWS and patients with MEBD, which make their inclusion in the same syndrome dubious.

Antiphospholipid syndrome in a child with trisomy 21: the relationship between anticardiolipin G antibodies and the von Willebrand factor

A young child with trisomy 21 developed severe multiple arterial thromboses in a three-phase clinical course which proved fatal. The episodes were characterized by high levels of both IgG anticardiolipin antibodies and the von Willebrand factor. The data suggest that there is a relationship between these two elements and the clinical events which followed.

[Gastroesophageal reflux and infantile cerebral palsy: our experience and review of the literature]

22 infant and children, all tetraplegic from cerebral palsy were admitted to our hospital for suspected gastroesophageal reflux. This working diagnosis was confirmed in 17 of them (77%) by an upper GI series and/or 24 hour oesophageal pH monitoring. All 17 were treated with medical therapy. In only 12.5% of them gastroesophageal symptoms improved. Seven children underwent surgery with complete resolution of vomiting in 57% of cases. These data confirm the high frequency of gastroesophageal reflux in children with cerebral palsy and its poor response to medical therapy. Most of these patients require surgical treatment, which unfortunately does not always resolve this vexing problem.

Congenital muscular dystrophy: brain alterations in an unselected series of Western patients

The typical form of congenital muscular dystrophy (CMD) described in Western countries is generally considered different from its Japanese variant because of the absence of CNS involvement. Evaluations from both a clinical and a neuroradiological point of view were made of the CNS functions of 12 unselected Western children affected by CMD. In five patients, clinical observation and intelligence tests showed a mild to severe mental retardation. One of these patients suffered also from a severe form of epilepsy. In the same five patients, various degrees of white matter hypodensity, ventricular enlargement and cerebral atrophy were also detected. Similar neuroradiological abnormalities were also found in five of the seven children who did not have clinical symptoms or signs of CNS involvement. In one of these cases, necropsy neuropathological examination showed the gyral anomalies characteristic of the Japanese type of CMD. This study clearly indicates the high frequency of subclinical CNS alterations in typical Western CMD, suggesting that it should be considered a type of myoencephalopathy like its Japanese counterpart.

[Juvenile osteomyelitis and osteopetrosis. A case report]

A case of mandibular osteomyelitis in a child affected by osteopetrosis is presented. Systemic antibiotic therapy was ineffective and surgery was required to obtain a partial control of infection.

Hypomelanosis of Ito and hemimegalencephaly

Hypomelanosis of Ito is a congenital neurocutaneous syndrome with a particular pattern of swirling hypopigmentation. Multiple extracutaneous abnormalities involving the central nervous system, the eyes, and musculoskeletal structures occur in over two-thirds of the cases. This report describes two patients with typical unilateral cutaneous lesions associated with extracutaneous features, including hypertrophy of the cerebral hemisphere contralateral to the cutaneous hypopigmentation. Magnetic resonance imaging and EEG findings support the diagnosis of hemimegalencephaly, as has recently been reported in other isolated cases of this rare phakomatosis.

[Finding of focal heterotopy with magnetic resonance. Description of a case associated with late onset epilepsy]

A case of late onset focal epilepsy in a mentally and neurologically normal girl in which the MRI showed a focal heterotopia is presented. The efficacy of this new procedure in detecting migratory disorders is discussed and the scanty literature reviewed. This case suggests that in the future more cases of epilepsy previously classified as "cryptogenetic" will be demonstrated as secondary to developmental abnormalities.

[Rett syndrome: clinical aspects and EEG for an early diagnostic assessment]

Clinical and EEG findings have been analysed in six patients with Rett syndrome with a mean follow-up of 3 years and 9 months. After reviewing the diagnostic criteria for inclusion, which are essentially clinical, we emphasize two aspects which have been shortly considered in the literature: a) epileptic seizures, b) peculiar differential characteristics between primary autism and the Rett syndrome behaviour. Moreover, we underline the importance of serial EEG poligraphic records for early diagnosis.

Neurogenic vesico-urethral dysfunction in children with cerebral palsy

20 children with severe cerebral palsy and history of urinary incontinence and recurrent urinary infection underwent radio--and neuro-urologic evaluation. Vesico-ureteral reflux was found in 7 patients. In 9, who had presented episodes of urine sub-retention, a urodynamic study demonstrated detrusor muscle hyperreflexia in all, deficit of vesicourethral sensation in 5 and detrusor-sphincter dyssynergia in 2. These functional findings are compatible with an upper motor neuron lesion, and may be the cause of episodes of altered bladder emptying, and consequently, urinary infection.

Impairment of polymorphonuclear leucocyte function during therapy with synthetic ACTH in children affected by epileptic encephalopathies

Therapy with synthetic ACTH (zinc tetracosactide) in children affected by epileptic encephalopathy is often associated with a large number of infectious complications. We studied the phagocytic activity of polymorphonuclear leucocytes (PMN) in 9 children with West or Lennox-Gastaut syndrome, measuring PMN superoxide anion production during the phagocytosis of particles of Zymosan and after phorbol myristate acetate (PMA) stimulation. The test was performed before, during and after therapy with zinc tetracosactide (0.02 mg/kg/day for 15 days). At the same time plasma immunoglobulins, C3, C4, C3 activator and cortisol were determined. During treatment PMN phagocytic function was significantly reduced but returned to normal levels after suspension of therapy. The other hematological parameters considered remained within the normal range. During the follow-up of the patients we observed 15 infectious episodes (3 mucocutaneous candidiasis, 2 enterocolitis, 4 urinary tract infections, 1 otitis media, 3 bronchiolitis, 2 pneumonia). One of the patients died of a bilateral pneumonia. Three children were treated with ACTH on alternating days. In these patients PMN phagocytic activity was less impaired and 2 infectious episodes rapidly resolved. Alternate day ACTH therapy seems to be preferable.

Risk factors in long-term sequelae of central nervous system prophylaxis in successfully treated children with acute lymphocytic leukemia

Seventy-two successfully treated patients with acute lymphocytic leukemia, all in first complete remission and all off therapy, who had received CNS prophylaxis (radiotherapy, 2,400 rad, plus intrathecal methotrexate), were studied by computed tomography (CT) of the brain, EEGs, and neurologic evaluations 3 to 9 years after the end of prophylaxis. Thirty-five patients showed CT brain scan abnormalities: intracranial calcifications (twelve); widening of the subarachnoid spaces (eight); isolated dilatation of ventricular spaces (three) and with frontal periventricular hypodensity (two); dilatation of ventricular and subarachnoid spaces (nine); and a hypodense area (one). Only 17 patients showed aspecific EEG abnormalities which were never linked to CT scan findings. None of our patients presented major motor deficits at the neurologic examination. A stepwise logistic regression technique showed that age less than 5 years at the time of prophylaxis was the most important risk factor (p = 0.008) of CT brain scan abnormalities followed by neurets (p = 0.037) and sex (p = 0.10). Furthermore, the multivariate analysis pointed out that the interactions between these variables were not significant and the effects were only of the first order.

[Torticollis and neck tumors: presentation of a case]

Stiff neck in children is a quite frequent sign of various pathological processes, not always benign in nature. Here is referred the case of a extradural cervical tumor in which stiff neck, associated with nucal rigidity, was for a long time the only symptom of the underlying process. The association of cervical tumor with stiff neck as the only longlasting initial symptom has only sporadically been reported. The authors analyse the various causes of stiff neck from the clinical and anatomo-pathological viewpoints, including age of patient at onset.

[Ischemic cerebrovascular accidents in childhood. Problems of neuroradiological diagnosis]

The authors present 19 cases of stroke with subsequent hemiplegia in children from 5 months to 15 years of age. These cases are not strictly correlated with haematologic alterations. The aetiopathogenesis remains uncertain in the most of patients, in which predisposing causes are absent and angiographic pictures do not demonstrate anatomical lesions or occlusions of cerebral vessels. In our series, cerebral angiography was performed in 16 children and showed vascular alterations only in 6 cases. CT scan some time after the acute hemiplegia, demonstrated low-density areas in 12 cases over 17 examined, with the characteristic evolution of ischemic lesions.

Acute-onset transient hydrocephalus after suspension of ACTH therapy for infantile spasms: a case report

A baby with infantile spasms (West's syndrome) who developed acute-onset transient hydrocephalus 10 days after suspending ACTH treatment is described. Hydrocephalus is an unusual complication of ACTH therapy, the more common complication being benign intracranial hypertension. The probable common pathogenic mechanism of altered CSF reabsorption which may lead to the two different clinical states, depending on age of patient, is discussed.

[Benign intracranial hypertension in infants]

B.I.H. or Pseudotumor is rare in children particularly under the first year of age. In addition, the syndrome at this age presents some peculiarities as compared with the adult form. This report describes the authors' experience with patients aged 4 to 12 months. Bulging fontanelle was the presenting symptom in all. Papilledema, strabismus, were present only in 1 case and vomiting in 4. Treatment was limited to lumbar puncture which was initially performed to rule out an acute CSN inflammatory process. In 8 patients the syndrome was precipitated by medications (sulfenazone - nalidixic acid); 3 had a prior history of 3 days of fever and roseola infantum, in 2 cases precipitanting factors were not found. Since the prompt remission of the intracranial hypertension (24 to 96 hours) neuroradiological investigations were not performed.

[Epidemiology of cerebral palsy in children]

Cerebral palsy is not a simple clinical or even aetiological entity, nevertheless is a chronic disability characterized by aberrant control of movement or posture appearing early in life. As for as incidence and prevalence studies are concerned, comparison of studies of age--specific prevalence rates is made difficult by differences in definition, methods and parameters used for medical evaluation. The epidemiology of CP is very important in the defining the entity of the problem, the need for facilities and services. The need for a current and perhaps continuing national statistical survey of the incidence and prevalence of CP is stressed.

[A rare complication of ventriculo-peritoneal shunt: intracranial migration of the derivative system]

Two cases of intracranial migration of ventriculo-peritoneal shunt are described. The Authors discussed the possible pathogenesis and the surgical techniques required to prevent this rare complication.

CT and ACTH treatment in infantile spasms

Computed tomography of 8 cases with West's syndrome before, during and after ACTH treatment are reported. The scans, performed at the third week of therapy, showed consistent widening of the sulci, cisterns and ventricles in all the patients. Of these, 2 patients underwent ICP monitoring which showed higher than normal values. A return to the normal ICP values in association with the disappearance of the CT findings was observed in both cases. It is concluded that widening of the sulci, cisterns and ventricles are not findings of atrophy, but a condition of initial communicating hydrocephalus, which is in accordance with the hypotheses of Riikonen and Lyen.

[Value and limits of C.T. scan in neurologics diseases in infancy and childhood (author's transl)]

The results obtained in 151 children who underwent C.T. scan at the Pediatric Department of the University of Padova are reported. The high incidence of negative or aspecific results in the cases of static encephalopathy, in primary generalized epilepsy and in acute diffuse cerebral infectious process is emphasized. C.T. confirmed its high diagnostic value in tuberous sclerosis and cerebral abscess. While non providing the precise diagnosis it may be helpful in some demyelinating diseases. In secondary generalized epilepsy and in partial epilepsy C.T. scan may suggest the prognosis and a possible surgical approach. On the basis of these results and of other published reports a greater selectivity in the use of C.T. is strongly recommended.

9p trisomy: a new case due to maternal t(9;18) translocation

A case of a patient carrying a 9p trisomy due to a maternal t(9;18) (p 13;p11) translocation is reported. In addition to the principal findings which characterize the 9p trisomy syndrome, this case presents some dysmorphic features due to the partial deletion of chromosome 18.