MRCT and CT in the diagnosis of pediatric disease imaging: assessing imaging performance and clinical effects

OBJECTIVE

This study focused on analyzing the clinical value and effect of magnetic resonance imaging plus computed tomography (MRCT) and CT in the clinical diagnosis of cerebral palsy in children.

METHODS

From February 2021 to April 2023, 94 children diagnosed with cerebral palsy were selected from our hospital for study subjects. These patients were divided into CT and MRI groups, with CT examination given to the CT group and MRI examination given to the MRI group. The positive rate of the two examination methods in the diagnosis of cerebral palsy was compared, different imaging signs in two groups of children with cerebral palsy were compared, and the diagnostic test typing results between two groups were further analyzed.

RESULTS

The diagnostic positivity rate of the children in the MRI group was 91.49%, which was significantly higher than that of the children in the CT group (70.21%) (P < 0.05). In both groups, encephalomalacia, bilateral frontal subdural effusions, and gray-white matter atrophy of the brain were the main signs, and the difference in the proportion of these three imaging signs between the two groups was not significant (P > 0.05). Differences between the two groups examined for cerebral palsy subtypes were not significant (P > 0.05).

CONCLUSION

The positive rate of pediatric cerebral palsy examined by MRI is higher than that of CT diagnosis, but the clinic should organically combine the two to further improve the detection validity and accuracy.

Severe encephalopathy associated with SARS-CoV-2 Omicron BA.1 variant infection in a neonate

INTRODUCTION

The coronavirus disease 2019 (COVID-19), including the Omicron variant, is less severe in children than in adults. To date, there has been no detailed description of COVID-19-associated severe encephalopathy due to the Omicron variant during the neonatal and early infantile periods.

CASE PRESENTATION

During the outbreak of the Omicron variant, a 29-day-old male presented with a pale and ill appearance. The patient was intubated for mechanical ventilation owing to recurrent apnea, which subsequently turned out to be a breath-holding that may have been caused by seizure. In addition, nonconvulsive status epilepticus was observed. Total duration of repetitive seizure activities was approximately 30 min per hour when seizures were most severe. Brain magnetic resonance imaging (MRI) on day 14 revealed extensive hyperintensity in the T2 sequence, hypointensity in the fluid-attenuated inversion recovery (FLAIR) sequence in the deep and subcortical white matter, and diffusion restriction in the corpus callosum. The Omicron BA.1 variant of the severe acute respiratory syndrome coronavirus 2 was detected in his respiratory sample. Follow-up MRI on day 45 revealed multiple cystic cavitations.

CONCLUSION

Although COVID-19 is not severe in most children, life-threatening conditions such as COVID-19-associated severe encephalopathy can occur during the neonatal and early infantile periods.

Differences in Cerebrospinal Fluid Dynamics in Posttraumatic Hydrocephalus Versus Atrophy, Including Effect of Decompression and Cranioplasty

INTRODUCTION

Challenges in diagnosing post-traumatic hydrocephalus (PTH) have created a need for an accurate diagnostic tool. We aim to report CSF dynamics in PTH and atrophy, along with differences before and after cranioplasty.

METHODS

We retrospectively analyzed traumatic brain injury patients with ventriculomegaly who had infusion studies. We divided patients depending on CSF dynamics into two groups: 'likely PTH' (A) and 'likely atrophy' (B). A group of idiopathic normal pressure hydrocephalus shunt-responsive patients was used for comparison (C).

RESULTS

Group A consisted of 36 patients who were non-decompressed or had a cranioplasty in situ for over 1 month. Group B included 16 patients with low Rout, AMP, and dAMP, 9 of whom were decompressed. Rout and dAMP were significantly higher in Group A than B, but significantly lower than Group C (45 iNPH patients). RAP change during infusion in group A indicated depleted compensatory reserve compared to ample reserve in group B. Repeat studies in five decompressed patients post-cranioplasty showed all parameters increased.

CONCLUSIONS

Infusion tests are not useful in decompressed patients, whilst cranioplasty allowed differentiation between possible PTH and atrophy. Rout and AMP were significantly lower in PTH compared to iNPH and did not always reflect the degree of hydrocephalus reported on imaging.

Neuroimaging Perspectives of Perinatal Arterial Ischemic Stroke

Perinatal stroke ranks second only to that of adult stroke in the overall stroke incidence. It is a major contributor to long-term neurological morbidity, which includes cognitive dysfunction, cerebral palsy and seizures. Risk factors for stroke in the perinatal period differ from those in children and tend to be multifactorial. Differences in territorial predilection, response to injury, and stroke evolution exist when compared with childhood and adult stroke, and also among differing gestation age groups in the perinatal period (i.e., extreme preterm versus preterm versus term). The role of imaging is to diagnose stroke, exclude stroke mimics, establish the nature of stroke (arterial versus venous), and aid in prognostication. Magnetic resonance imaging is the mainstay of neuroimaging in perinatal stroke. Advanced imaging techniques such as diffusion tensor imaging and perfusion-weighted imaging are emerging as useful supplements to conventional imaging sequences. Here we describe the neuroimaging of perinatal arterial ischemic stroke with emphasis on imaging techniques, imaging phenotypes, stroke evolution, role of advanced imaging, and differences between stroke in preterm and term neonates. We also briefly describe the emerging role of fetal magnetic resonance imaging in the diagnosis of in utero stroke.

Multicystic encephalomalacia: An autopsy report of 4 cases

Multicystic encephalomalacia is varying sized cystic lesions in the brain encountered in developing fetuses or infants. These cysts start at the periventricular area and may extend onto the cortex. The cause of the formation of these cystic lesions is secondary to an ischemic or hypoxic insult, which leads to liquefactive necrosis and subsequent formation of gliotic cyst walls having an admixture of microglia. We discuss four autopsy cases that had multicystic encephalomalacia to highlight the scenarios in which these lesions are encountered.

Case Report of Immuno-Oncotherapy (IO) Provoked Encephalitis Mimicking Brain Metastasis in a Patient with History of Traumatic Brain Injury

BACKGROUND

Immuno-oncotherapy (IO) has revolutionized systemic cancer care but remains experimental in brain tumors. IO treatment risks multiorgan autoimmune inflammatory responses that limit its use. The central nervous system (CNS) is an immune-specialized compartment with restricted cellular access, thus fewer cases are reported for immune-mediated encephalitis. Interestingly, patients with history of blood-brain barrier compromise are potentially at higher risk for immune cell trafficking to the CNS.

CASE DESCRIPTION

We report the first case, to our knowledge, of a 70-year-old man with clear cell renal cell carcinoma with pulmonary metastases treated with lung irradiation, nephrectomy, and chemotherapy prior to switching to single-agent nivolumab IO. The patient presented with new-onset generalized tonic-clonic seizure and left visual field-cut. Review of patient history revealed remote traumatic brain injury (TBI). Brain imaging noted a solid-enhancing right occipital mass that was presumed metastasis versus lymphoma. Cerebrospinal fluid cytology was negative for malignancy but concerning for lymphoproliferative process not determined to be malignant. The patient started steroids and anti-epileptic therapy. After negative systemic cancer re-staging, IO was discontinued and steroids were initiated with demonstrated patient clinical improvement.

CONCLUSIONS

We concluded the diagnosis of immune-mediated encephalitis secondary to IO with collection of reactive T-cells within the area of encephalomalacia. The area of encephalomalacia from prior TBI served to compartmentalize the reactive lymphocytes, giving the appearance of a mass. Taken together, new onset seizure in patients on IO might signal encephalitis and CNS metastatic mimicry should be considered in patients with a prior history of TBI and encephalomalacia.

The Clinical and Molecular Characteristics of Molybdenum Cofactor Deficiency Due to MOCS2 Mutations

BACKGROUND

We explored the clinical and molecular characteristics of molybdenum cofactor deficiency due to MOCS2 muations.

METHODS

We summarize the genetic and clinical findings of previously reported patients with a MOCS2 mutation. We also present a new patient with novel neuroradiological findings associated with molybdenum cofactor deficiency due to a novel homozygous variant in the 5' untranslated region of the MOCS2 gene.

RESULTS

The study population comprised 35 patients with a MOCS2 gene mutation. All reported children had delayed motor milestones. The major initial symptom was seizures in neonatal period. Facial dysmorphism was present in 61% of the patients. Only one patient had ectopia lentis. Agenesis of the corpus callosum and an associated interhemispheric cyst in our case are novel neuroradiological findings.

CONCLUSIONS

The occurrence of neonatal seizures and feeding difficulties can be the first clinical signs of molybdenum cofactor deficiency. Although there is no effective therapy for this condition, early diagnosis and genetic analysis of these lethal disorders facilitate adequate genetic counseling.

Angiocentric glioma mimicking encephalomalacia

Angiocentric glioma is a rare low-grade neoplasm of the central nervous system which typically presents with medication-refractory seizures in children and young adults. On magnetic resonance imaging, angiocentric glioma is classically T1 hypointense and T2/FLAIR hyperintense. We present the case of a 40-year-old male who had been followed by our institution for 17 years for management of epilepsy. Initial and repeat brain imaging showed an apparent region of cystic encephalomalacia in the right frontal lobe. In an attempt to control his seizures, the lesion was resected. Grossly, the cut surface of the specimen was characterized by multiple small cystic spaces. Microscopically, the lesion was composed of an infiltrative population of glial cells variably arranged in perivascular “pseudorosettes,” nodules, and subpial “palisades.” The final diagnosis was angiocentric glioma. This is the second reported case of an angiocentric glioma mistaken for encephalomalacia.

Novel Imaging Finding and Novel Mutation in an Infant with Molybdenum Cofactor Deficiency, a Mimicker of Hypoxic-Ischaemic Encephalopathy

Molybdenum cofactor deficiency is a rare metabolic disorder manifesting with early onset seizures, developmental delay, microcephaly, and spasticity. In this report, we describe a three-month-old infant with neonatal onset, poorly controlled seizures, developmental delay, microcephaly, spastic quadriparesis and visual insufficiency. Magnetic resonance imaging of brain had shown cystic encephalomalacia involving bilateral parieto-occipital lobe and elevated lactate in magnetic resonance spectroscopy. Restricted diffusion noted along the corticospinal tract in our case is a novel imaging finding in patients with molybdenum cofactor deficiency. Low serum uric acid and elevated urine sulfite excretion were observed. A novel homozygous mutation was detected in exon 4 of molybdenum cofactor synthesis 2 (MOCS2) gene. Early infantile or neonatal onset seizures, developmental delay, microcephaly and cystic encephalomalacia in neuroimaging mimicking hypoxic-ischaemic encephalopathy should raise the suspect for molybdenum cofactor deficiency. Screening of all neonates for urinary sulfite metabolites would help in early diagnosis and management. Early diagnosis and treatment with cyclic pyranopterin monophosphate could arrest the progression of molybdenum cofactor deficiency type A. More research is needed to explore further treatment options in this otherwise lethal disorder.

T-Cells Underlie Some but Not All of the Cerebellar Pathology in a Neonatal Rat Model of Congenital Lymphocytic Choriomeningitis Virus Infection

Lymphocytic choriomeningitis virus (LCMV) infection during pregnancy injures the human fetal brain. Neonatal rats inoculated with LCMV are an excellent model of congenital LCMV infection because they develop cerebellar injuries similar to those in humans. To evaluate the role of T-lymphocytes in LCMV-induced cerebellar pathology, congenitally athymic rats, deficient in T-lymphocytes were compared with euthymic rats. Peak viral titers and cellular targets of infection were similar, but viral clearance from astrocytes was impaired in the athymic rats. Cytokines and chemokines rose to higher levels and for a greater duration in the euthymic rats than in their athymic counterparts. The euthymic rats developed an intense lymphocytic infiltration, accompanied by destructive lesions of the cerebellum and a neuronal migration defect because of T-cell-mediated alteration of Bergmann glia. These pathologic changes were absent in the athymic rats but were restored by adoptive transfer of lymphocytes. Athymic rats were not free of pathologic effects, however, as the virus induced cerebellar hypoplasia. Thus, T-lymphocytes play key roles in LCMV clearance, cytokine/chemokine responses, and pathogenesis of destructive lesions and neuronal migration disturbances but not all pathology is T-lymphocyte-dependent. Cerebellar hypoplasia from LCMV occurs even in the absence of T-lymphocytes and is likely due to the viral infection itself.

Surgical Resection for Epilepsy Following Cerebral Gunshot Wounds

OBJECTIVE

The surgical management of epilepsy after penetrating gunshot wounds (GSWs) to the head has not been described in the modern era. Given the extensive damage to the cranium and cortex from such injuries, the safety and efficacy of surgical intervention are unclear. We report surgical strategy and outcomes after resection for medically refractory epilepsy following GSWs in 4 patients.

METHODS

A prospectively compiled database of 325 patients with epilepsy was used to identify patients undergoing surgery for medically refractory epilepsy after a GSW to the brain. Seizure frequency, scalp and intracranial electroencephalography evaluation, type of resection, and seizure outcomes were compiled.

RESULTS

All 4 patients underwent direct electrocorticography recordings either with implanted electrodes or intraoperatively that were used to drive surgical decision making. All patients had intracranial shrapnel fragments and large areas of encephalomalacia on imaging. Intracranial electrodes were placed in 2 patients to localize seizure onsets. Two patients underwent frontal lobe resections, and the other 2 patients underwent multilobar resections. Latency between injury and epilepsy surgery was 12 years, and mean age at surgery was 28 years. In all cases, epilepsy surgery led to a significant improvement in seizure control (Engel class I, 2 patients; II, 1 patient; and III, 1 patient).

CONCLUSIONS

Epilepsy is common after penetrating head injury, and the incidence is likely to increase given the growing numbers of armed conflicts in urban centers worldwide. In selected cases, intracranial monitoring and surgical resections may be safely performed and can lead to favorable seizure outcomes.

Progressive cognitive decline in an adult patient with cleidocranial dysplasia

Cleidocranial dysplasia is a skeletal disorder characterized by a defective skull and defective clavicles caused by RUNX2, an activator of osteoblast differentiation. Consistent with the expression pattern of RUNX2, this disorder typically affects the skeletal system, but not the central nervous system. A 56-year-old man with the prototypic skeletal defects of cleidocranial dysplasia and a RUNX2 deletion presented with a progressive cognitive decline after the age of 40 years. After a failed cranioplasty during childhood, he had worn a protective helmet until young adulthood. His current neuroimaging studies revealed extensive cystic encephalomalacia beneath the defective skull, suggesting that his cognitive decline could likely be attributed to repetitive cerebral contusions. Late-onset progressive cognitive decline in the context of a defective skull accompanied by extensive cystic encephalomalacia illustrates the importance of natural calvarial protection against head injury. Since the majority of patients with cleidocranial dysplasia do not wear protective helmets beyond childhood, mainly for cosmetic reasons, a discussion of whether the social disadvantage outweighs the potential risk of brain parenchymal injury may be necessary.

Neurological impairment in a surviving twin following intrauterine fetal demise of the co-twin: a case study

It has been established that twin pregnancies are at an increased risk for complications, including the risk of morbidity or mortality for one or both of the infants. Cerebral palsy and other associated neurological deficits also occur at higher rates in twin pregnancies. This report examines two cases of intrauterine demise of one twin with subsequent survival of the co-twin. In both cases, the surviving infant suffered significant neurological sequelae. Impairments observed in these two cases include multicystic encephalomalacia and periventricular leukomalacia as well as the subsequent development of cerebral palsy. This case study explores the predisposing factors, incidence, pathophysiology, consequences, and future research implications of these findings.

Role of electroencephalogram and neuroimaging in first onset afebrile and complex febrile seizures in children from Kashmir

OBJECTIVES

(1) To determine the frequency of abnormal neuroimaging in children with new-onset afebrile and complex febrile seizures; (2) to draw a correlation between Electroencephalogram (EEG) and neuroimaging.

STUDY DESIGN

A hospital-based prospective study.

MATERIALS AND METHODS

A total of 276 children (6 months to 14 years of age), who presented with new-onset afebrile or complex febrile seizures, underwent EEG and neuroimaging [Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI)].

RESULTS

Generalized seizures constituted the major seizure group in our study - 116/276 (42%) - followed by partial seizures 86/276 (31.2%) and complex febrile seizure in 64/276 (23.2%). Generalized as well as partial seizures were more common in children aged 6-14 years, while complex febrile seizures were predominantly seen in children less than 6 years old. Most of the patients with generalized and partial seizures had EEG abnormalities, while EEG abnormalities were uncommon in patients with complex febrile seizures. A total of 27/276 (9.8%) patients with seizure disorder had abnormal CT scans and this abnormality was more common in patients with partial seizures. CT abnormality was seen more commonly in those patients who had an abnormal EEG. EEG and CT correlation showed that patients with abnormal EEG had higher rates of CT abnormality, ie, 16.1% (25/155). Abnormal MRI was seen in 32/157 (20.4%) of patients; accuracy of picking abnormality by MRI, when EEG was abnormal, was 24.8% (P<0.05).

CONCLUSION

Our findings indicate that clinical examination and EEG results are good indicators for neuroimaging, and these can be used as one of the criteria for ordering neuroimaging in new-onset seizures.