Subdural hematomas in infants with benign enlargement of the subarachnoid spaces are not pathognomonic for child abuse

BACKGROUND AND PURPOSE

Patients who have benign enlargement of the subarachnoid spaces (BESS) have long been suspected of having an increased propensity for subdural hematomas either spontaneously or as a result of accidental injury. Subdural hematomas in infants are often equated with nonaccidental trauma (NAT). A better understanding of the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental trauma may help distinguish this group of patients from those who suffer subdural hematomas as a result of NAT. The purpose of this study is to describe the clinical and imaging characteristics of subdural hematomas that occur either spontaneously or as a result of accidental injury in infants with BESS.

METHODS

We conducted a retrospective review of all patients with BESS complicated by subdural hematomas evaluated at a single institution from 1998 to 2004. Data concerning the patient's clinical presentation, physical findings, imaging, and management are described.

RESULTS

During the study period, 7 patients with BESS complicated by subdural hematoma were identified. Their mean age at identification of the subdural hematoma was 7.4 months of age. In 5 cases, there was no recognized trauma before identification of the subdural hematoma. In 3 cases, baseline CT or MR imaging was available, showing prominent subarachnoid spaces without any evidence of subdural hemorrhage.

CONCLUSION

Although suspicious for NAT, subdural hematomas can occur in children either spontaneously or as a result of accidental trauma. Caution must be exercised when investigating for NAT based on the sole presence of subdural hematomas, especially in children who are otherwise well and who have BESS.

Reversible encephalopathy associated with tacrolimus in pediatric renal transplants

Neurological complications post transplant have been described with the use of calcineurin inhibitors. Although tacrolimus may be a better immunosuppressant than cyclosporine, its neurological side effects may be worse. Two children, living-related kidney transplant recipients, were treated with antibody induction, mycophenolate mofetil, prednisone, and tacrolimus. Soon after transplant, they each developed an encephalopathy, which when visualized by magnetic resonance imaging showed that it affected both white and grey matter of the brain. Although the encephalopathy was associated with the use of tacrolimus, there was a complete neurological recovery without cessation of the drug.

Brainstem Gliomas. A 10-year institutional review

Case records of 37 patients with a diagnosis of brainstem glioma treated at the Montreal Children's Hospital from June 1989 to June 1999 were reviewed. 15 patients had diffuse pontine gliomas and 22 patients had focal forms of brainstem gliomas. The two groups were compared with respect to age, clinical evolution, radiological appearance, type of surgery practised, histological diagnosis, adjuvant treatments and survival. A non-pontine brainstem location, a cystic or exophytic component, bright enhancement with gadolinium injection, a histological diagnosis of pilocytic astrocytoma or ganglioglioma were favourable prognostic factors. Progression-free survival and overall survival were significantly worse in the group of patients with diffuse pontine gliomas. The relative impact of radical surgery and/or radiotherapy is analysed. Surgery coupled to adjuncts such as navigation, ultrasound and monitoring plays an important role for focal brainstem lesions. Focal/conformal radiotherapy has an adjuvant role but better treatments are needed for the diffuse pontine brainstem lesions.

Neuromotor spectrum of periventricular leukomalacia in children born at term

The spectrum of neuromotor abnormalities of term children with periventricular leukomalacia (PVL) has never been specifically defined. We report 12 term children with PVL to delineate its long-term clinical correlates. A retrospective review of a standardized computer database and files of a single pediatric neurologist during a 7-year period was performed. The imaging studies were reviewed independently by two neuroradiologists. The mean age of the patients at the initial neurologic assessment was 24. 4 months (range 5-60); nine were males. The reason for the assessment was developmental delay in 10 (83.3%), seizure in one, and attention-deficit-hyperactivity disorder in one. Three children (25%) had normal motor examinations, three (25%) were hypotonic, three (25%) had spastic diplegia, two (16.7%) had spastic quadriplegia, and one (8.3%) had fine-motor abnormalities. Nine children (75%) had developmental delay (severe global delay in six), and two children (16.7%) had epilepsy; electroencephalograms were abnormal in six (50%). PVL was mild in five (41.7%), moderate in two (16.6%), and severe in five (41.7%) children. Four of eight children with global developmental delay had enlargement of cerebral sulci in addition to white matter changes. PVL in term children presents with a spectrum of neurologic abnormalities, particularly developmental delay and heterogeneous motor findings not limited to classic spastic diplegia. The clinician should consider the diagnosis of PVL in the context of term children with developmental delay and motor abnormalities, even in the absence of perinatal difficulties.

Recurrent artery of Heubner infarction in infancy

Classically, acquired occlusion of the recurrent artery of Heubner (RAH) results in hemiparesis with faciobrachial predominance. Infarction in the territory of the RAH represents a specific stroke syndrome not yet described in infancy with a range of motor and functional manifestations. An infant is described with apparent congenital infarction of the recurrent artery of Heubner. The child had prominent involvement of the contralateral upper extremity with athetosis. Neuroimaging changes were evident in the vascular territory classically attributed to the RAH. The clinician should suspect congenital RAH infarction in those infants with congenital upper-extremity athetosis.

Septo-optic dysplasia plus: a spectrum of malformations of cortical development

The authors describe three children with septo-optic dysplasia (SOD)-plus: SOD and an associated malformation of cortical development. All three children had developmental delay, and two of the children had significant associated motor deficits. The associated cortical malformations with SOD include a spectrum of disorders of neuronal organization, not limited, as previously described, to schizencephaly. SOD-plus should be suspected in children with SOD and developmental delay.

Knobloch syndrome involving midline scalp defect of the frontal region

We report on a 4-year-old boy with Knobloch syndrome. He has vitreoretinal degeneration, high myopia, cataract, telecanthus, hypertelorism, and a high-arched palate. He also has a defect of the anterior midline scalp with involvement of the frontal bone as documented by a computed tomography (CT) scan. The brain was normal on CT scan and magnetic resonance imaging. We present a review of the 23 published cases with this syndrome. Our patient illustrates the importance of investigating for underlying ocular and central nervous system pathology whenever midline scalp defects are present.

Cree leukoencephalopathy: neuroimaging findings

PURPOSE

To describe the computed tomographic (CT) and magnetic resonance (MR) imaging findings in Cree leukoencephalopathy.

MATERIALS AND METHODS

The authors retrospectively reviewed the medical records and neuroimaging studies in 12 infants with Cree leukoencephalopathy (CT in 12 infants, MR in six). The diagnosis was established clinically in six patients and at autopsy in the other six.

RESULTS

At CT, extensive, diffuse, and symmetric hypoattenuation was seen in the cerebral and cerebellar white matter in all 12 patients. Hypoattenuation was also seen in the corpus callosum in 11 (92%), internal capsule in 10 (83%), globus pallidus in nine (75%), brainstem in nine (75%), and thalamus in four (33%). The caudate nucleus and putamen were spared. On T2-weighted MR images in six patients, the cerebral and cerebellar white matter, including the subcortical arcuate fibers, was hyperintense as were the internal capsule, corpus callosum, corticospinal tracts, and globus pallidus. The thalamus was affected in four (67%) patients, pons in five (83%), and medulla in four (33%). The caudate nucleus and putamen were not affected.

CONCLUSION

Cree leukoencephalopathy causes striking symmetric and diffuse involvement of the cerebral and cerebellar white matter and brainstem with sparing of the caudate nucleus and putamen.

Cerebral bleeding, infarcts, and presumed extrapontine myelinolysis in hypernatraemic dehydration

The neuroimaging findings in an infant with hypernatremic dehydration are presented. Brain parenchymal haemorrhage and extensive multiple infarcts were present in the acute stage. Follow-up CT showed bilateral, symmetrical changes presumed to indicate extrapontine myelinolysis in the thalamus and globus pallidus. MRI confirmed sparing of the pons. Only three previous cases of neuroimaging abnormalities due to hypernatraemia have been described in the radiological literature.

Tuberous sclerosis complex and neonatal seizures

Tuberous sclerosis complex is a multisystemic neurocutaneous disorder, manifesting variably during infancy and childhood that remains poorly described in neonates. When described in this population, tuberous sclerosis complex is most commonly associated with cardiac rhabdomyomas and brain tumors, but is rarely mentioned as an etiology for neonatal seizures. We report two children with tuberous sclerosis presenting for neonatal seizures. Neuroimaging findings of neonatal tuberous sclerosis complex are discussed. Given the absence of many of the traditional stigmata of tuberous sclerosis complex in the neonate, seizures should be considered an important presenting feature of this disorder in this particular age group.

Magnetic resonance imaging in children with voiding dysfunction: is it indicated?

PURPOSE

We evaluated the role of magnetic resonance imaging (MRI) of the lumbosacral spinal cord in children with complicated voiding dysfunction and normal neuro-orthopedic examination.

MATERIALS AND METHODS

We reviewed the records of 32 consecutive children with complicated enuresis who were referred for neurosurgical evaluation, including those with a history of refractory voiding dysfunction or incontinence associated with persistent vesicoureteral reflux, encopresis, or associated leg or back pain. Nine patients were excluded from study because of urethral or anorectal anomalies, or failure to meet the inclusion criteria. Eligible for study inclusion were 23 children with a mean age of 8.9 years. Complete neurological and orthopedic examinations were normal in all patients except 1 with mild scoliosis and 1 with congenital facial palsy.

RESULTS

Urodynamic studies revealed instability in 14 cases, hypertonia in 7, hyporeflexia in 2 and detrusor-sphincter dyssynergia in 4. Skeletal abnormalities, mostly spina bifida occulta, were detected in 16 of the 23 children (70%). Spinal MRI was normal in 21 patients (91.3%), including 1 with a tethered cord and lipoma associated with a complex skeletal abnormality, and 1 with a nonprogressive, nonsurgical T7 to T9 syrinx. Only the case of lipoma required neurosurgical intervention.

CONCLUSIONS

The value of MRI is limited in children with voiding dysfunction and a normal neuro-orthopedic assessment. This study should be reserved for patients with associated neuroorthopedic findings or complex skeletal deformity on plain x-ray.

Magnetic resonance imaging in children with voiding dysfunction: is it indicated?

PURPOSE

We evaluated the role of magnetic resonance imaging (MRI) of the lumbosacral spinal cord in children with complicated voiding dysfunction and normal neuro-orthopedic examination.

MATERIALS AND METHODS

We reviewed the records of 32 consecutive children with complicated enuresis who were referred for neurosurgical evaluation, including those with a history of refractory voiding dysfunction or incontinence associated with persistent vesicoureteral reflux, encopresis, or associated leg or back pain. Nine patients were excluded from study because of urethral or anorectal anomalies, or failure to meet the inclusion criteria. Eligible for study inclusion were 23 children with a mean age of 8.9 years. Complete neurological and orthopedic examinations were normal in all patients except 1 with mild scoliosis and 1 with congenital facial palsy.

RESULTS

Urodynamic studies revealed instability in 14 cases, hypertonia in 7, hyporeflexia in 2 and detrusor-sphincter dyssynergia in 4. Skeletal abnormalities, mostly spina bifida occulta, were detected in 16 of the 23 children (70%). Spinal MRI was normal in 21 patients (91.3%), including 1 with a tethered cord and lipoma associated with a complex skeletal abnormality, and 1 with a nonprogressive, nonsurgical T7 to T9 syrinx. Only the case of lipoma required neurosurgical intervention.

CONCLUSIONS

The value of MRI is limited in children with voiding dysfunction and a normal neuro-orthopedic assessment. This study should be reserved for patients with associated neuroorthopedic findings or complex skeletal deformity on plain x-ray.

Infantile epileptic encephalopathy (Ohtahara syndrome) and migrational disorder

A case of early infantile epileptic encephalopathy (EIEE) with suppression-bursts (Ohtahara syndrome) associated with a diffuse cerebral migrational and maturation disorder evident on microscopic examination is reported. Although virtually all reported cases of EIEE are secondary to a congenital or acquired structural malformation of cortical development, EIEE is sometimes identified only by detailed neuropathologic examination, as confirmed by this case report. In addition to the malformation of cortical development, the patient demonstrated an absence of gamma-aminobutyric acid in the cerebrospinal fluid. All children with EIEE should be thoroughly examined by magnetic resonance imaging, cerebrospinal fluid amino acid level determination, and detailed postmortem neuropathologic examination.

Sleep-disordered breathing in children with myelomeningocele

BACKGROUND

Although patients with myelomeningocele and the Chiari II malformation are known to have sleep apnea and respiratory control deficits, the prevalence, types, severities, and associations of sleep-disordered breathing (SDB) have not been adequately defined.

METHODS

A cross-sectional study of our myelomeningocele clinic population was undertaken to correlate polysomnographic results with historical data and findings from magnetic resonance imaging of the Chiari malformation, pulmonary function results, and nocturnal pulse oximetry.

RESULTS

A questionnaire survey of symptoms was available for 107 of 109 children (98% of the clinic population), and 83 patients agreed to undergo overnight polysomnography. Breathing during sleep was classified as normal in 31 cases (37%), mildly abnormal in 35 cases (42%), and moderately/severely abnormal in 17 cases (20%). Among the 17 patients with moderately/severely abnormal SDB, 12 patients had predominantly central apneas and 5 had predominantly obstructive apnea. Patients with a thoracic or thoracolumbar myelomeningocele, those who had previously had a posterior fossa decompression operation, those with more severe brain-stem malformations, and those with pulmonary function abnormalities were more likely to have moderately/severely abnormal SDB, relative risks (95% confidence intervals) 9.2 (2.9 to 29.3), 3.5 (1.3 to 8.9), 3.0 (0.9 to 10.5), and 11.6 (1.6 to 81.3), respectively. Failure of obstructive SDB to resolve after adenotonsillectomy in four patients suggested abnormal control of pharyngeal airway patency during sleep. Nocturnal pulse oximetry accurately predicted moderately/severely abnormal SDB with a sensitivity of 100% and a specificity of 67%.

CONCLUSIONS

The pathogenesis of SDB in patients with myelomeningocele involves the functional level of the spinal lesions, congenital and acquired brainstem abnormalities, pulmonary function abnormalities, disorders of upper airway maintenance, and sleep state. Polysomnography and nocturnal pulse oximetry should be performed in high-risk patients to detect and classify SDB.

Duplicated odontoid process: plain radiographic and CT appearance of a rare congenital anomaly of the cervical spine

We describe a duplication of the odontoid process in a 6-year-old patient that included a partially fused midline ossicle on the anterior arch of C-1, fusion of the anterior lip of the foramen magnum and the arch of C-1, and an incomplete bony posterior arch of C-1.

Use of the prone position in the MRI evaluation of spinal cord retethering

In order to determine the impact of magnetic resonance imaging (MRI) in the management of spinal cord retethering, we retrospectively reviewed case and imaging records of 51 patients who underwent MRI examination in supine and prone positions. Group 1 included 8 control patients without cord tethering. They exhibited a normal level of the conus medullaris with normal surrounding subarachnoid space, and consistent anterior migration of the conus within the dural sac on MRI in prone position. Group 2 included 17 patients with tethered cord secondary to occult spinal dysraphism (spinal cord lipoma in 6 patients, thick filum terminale in 4, diastematomyelia in 4, myelomeningocele manqué in 2, and dermoid tumour in 1). Supine and prone MRI performed at a median period of time of 6 months after untethering showed resolution of posterior tethering in 5 out of the 7 patients who exhibited pre-operatively dorsal attachment of the spinal cord to the dura. Anterior migration of the conus or of the cord/filum complex in prone position was observed in only 24% of the cases. Group 3 included 26 patients with secondary tethered cord following prior myelomeningocele closure. Their MRI performed at a median interval of time of 11 months following untethering demonstrated resolution of the posterior cord tethering in only 8 out of the 24 patients who exhibited this feature pre-operatively. Anterior migration within the expanded dural sac was never noted in this group. We conclude that spine MRI is of limited value and that prone-positioned MRI is of no additional use in the evaluation of spinal cord retethering.

Traumatic aneurysm from shaken baby syndrome: case report

OBJECTIVE AND IMPORTANCE

We present a 6-week-old infant who developed a traumatic aneurysm from clearly documented shaken baby syndrome. Despite the theoretical similarity in the mechanism of such injuries, this is the first aneurysm reported that resulted from such a cause. The infant is also the youngest reported patient to have suffered from a traumatic aneurysm.

CLINICAL PRESENTATION

Police records documented shaking of the child as well as direct impact on the child's head. Three weeks later, the patient developed an intracerebral hemorrhage, which was revealed by angiography to have resulted from a pericallosal artery aneurysm.

TECHNIQUE

The aneurysm was totally resected through a porencephalic cyst, which had developed secondary to ischemic injury to the brain.

CONCLUSION

The temporal course, as well as the location of this traumatic aneurysm, is similar to that in older patients.

Encephaloduroarterio-synangiosis in a child with sickle cell anemia and moyamoya disease

We report a black girl with sickle cell anemia. On prophylactic exchange transfusion protocol, she experienced cerebrovascular accidents at 3 and 3.5 years of age, both associated with transient right hemiparesis. At 7.5 years of age, she presented with a partial motor seizure and a left hemiparesis. A cerebral angiogram demonstrated stenosis at the origins of both middle and anterior cerebral arteries bilaterally with extensive basal collateralization. She underwent uncomplicated bilateral encephaloduroarteriosynangiosis (EDAS) procedures using both superficial temporal arteries. At age 9 years, the patient presented with a severe headache and tunnel vision secondary to a stenosis of both posterior cerebral arteries. She underwent bilateral EDAS procedures using both occipital arteries. No complication was encountered. Postoperative cerebral angiogram demonstrated impressive neovascularity at the sites of all four EDAS procedures. Different treatment options of moyamoya disease are discussed.

"Pseudo-BECRS": intracranial focal lesions suggestive of a primary partial epilepsy syndrome

Benign epilepsy of childhood with rolandic spikes (BECRS) is an electroclinical entity that is the most common primary partial epilepsy syndrome of childhood. Typically presenting between the ages of 3 and 13 years, it is characterized by a well-recognized seizure pattern arising in a normal child with EEG findings restricted to rolandic/centrotemporal regions. Seizure control is usually easily achieved and prognosis is believed to be uniformly good. Some authors have suggested that individuals fitting the electroclinical parameters of this entity need not undergo neuroimaging due to the benign evolution of this disorder. Five patients presenting over a 13-year period with peribuccal seizures, normal neurologic examinations, and EEG data initially suggestive of BECRS found to have focal lesions on neuroimaging are summarized. Independent bilateral centrotemporal epileptiform abnormalities were seen in 3 patients. Imaging studies (CT, MRI, or both) documented a mass lesion in all in variable locations. Histologic examination documented a low-grade astrocytoma in 3 patients and a cavernous angioma in another. The fifth patient refused treatment or biopsy. Careful retrospective review of the clinical features of these patients reveals variable atypical features in each. Therefore, despite an electroclinical phenotype initially suggestive of the BECRS presentation, the presence of atypical clinical features raises the possibility of an underlying structural lesion and thus a negative neuroimaging study may in some patients be essential to the definitive accurate diagnosis of BECRS.

Glutaric acidemia type II: neuroimaging and spectroscopy evidence for developmental encephalomyopathy

Glutaric acidemia type II is associated with neonatal hypoketotic hypoglycemia, metabolic acidosis, profound hypotonia, progressive cardiomyopathy, and early death. Deficiency of either electron transfer flavoprotein or electron transport flavoprotein:ubiquinone oxidoreductase leads to intramitochondrial accumulation of metabolites of compounds oxidized by enzymes that transfer electrons to flavoprotein. No detailed results of antemortem neuroimaging or magnetic resonance spectroscopy have been described previously. We investigated a patient with typical neonatal onset glutaric acidemia type II without obvious dysmorphogenesis or renal malformations. Cranial tomographic scan revealed hypoplastic temporal lobes and marked widening of the sylvian fissures ("bat-wing" appearance). Cranial magnetic resonance imaging documented underdeveloped frontal and temporal lobes with delayed myelination and hypoplasia of the corpus callosum. 31P-Magnetic resonance spectroscopy of muscle was grossly abnormal with a very low energy state consistent with mitochondrial dysfunction. 1H-Magnetic resonance spectroscopy of brain revealed elevated intracerebral lactate concentration and abnormally high choline/creatine ratio suggestive of dysmyelination. These findings constitute the first in vivo evidence of a developmental encephalomyopathy in glutaric acidemia type II.

Lesionectomy of MRI detected lesions in children with epilepsy

The results of complete excision of cerebral lesions detected by MRI in 18 children presenting with epilepsy were analyzed. There were 14 boys and 4 girls with a mean age of 9.2 years. The average age of onset of seizures was 6.8 years. The mean time from onset of seizures to surgery was 2.3 years. Often, CT scans suggested that the lesions were indolent. MRI was better in differentiating neoplastic from developmental lesions. Angiography was non-contributory in this series. Interictal EEGs showed epileptiform activity correlating with imaging studies in 54% of children. The lesion was completely surgically excised in all patients. This was confirmed by intra-operative ultrasound and postoperative imaging. Electrocorticography was performed prior to and after the resection, but residual spiking did not lead to further resection. The average postoperative follow-up was 5.7 years. Five patients had low grade astrocytomas, 4 had gangliogliomas, 1 a mixed astrocytoma-oligodendroglioma, 3 had cortical dysplasia, 2 infantile desmoplastic gangliogliomas, 2 hamartomata, and 1 cavernous angioma. Sixteen patients have been seizure-free since surgery. Only 2 have partial seizures. Thus, all patients benefited from the resection, with respect to seizure control. In those with temporal lobe lesions, improvement in IQ was seen postoperatively. Early consideration of surgery in patients with epilepsy and lesions demonstrated by MRI is suggested.

Encephaloduroarteriosynangiosis (EDAS) for the treatment of childhood moyamoya disease

Moyamoya disease is defined by the angiographic demonstration of stenosis or occlusion of the vessels of the anterior circulation at the base of the brain and the concomitant development of collateral blood supply. Untreated, the disease is often clinically progressive, resulting in significant neurologic sequelae. Encephaloduroarteriosynangiosis (EDAS), which involves the transposition of a segment of a scalp artery onto the surface of the brain, is a surgical treatment aimed at improving collateral blood flow. Six children underwent 8 EDAS procedures and were followed from 6 months to 9 years after surgery. No patient experienced further deterioration in neurologic status. Postoperative angiography demonstrated cerebral revascularization from the donor scalp artery on 3 of the 6 EDASs that were studied. The 2 patients who did not revascularize after EDAS demonstrated angiographic regression of their disease. The data suggest that EDAS is a safe procedure for the treatment of childhood moyamoya disease. Given the potential severity of the sequelae, early operative intervention is recommended in all children with this disease.

Ganglioglioma presenting as a vascular lesion in a 10-year-old boy. Case report

The authors present the case of a 10-year-old boy admitted for evaluation of a generalized seizure and a history of headaches. Computerized tomography (CT) and gadolinium-enhanced magnetic resonance (MR) imaging demonstrated a large nonhomogeneous contrast-enhancing mass of the left frontal lobe, with a large cystic component. Cerebral angiography revealed the lesion to be highly vascular and fed entirely by the internal carotid artery system. The patient underwent craniotomy and the lesion was completely removed. Neuropathological study revealed that the tumor was a ganglioglioma. On review of the literature, it was found that gangliogliomas often present in the second and third decade, are known to have cystic components, and are contrast-enhancing on CT and MR imaging; however, they are classically known to be avascular on angiography. This case of a markedly vascular ganglioglioma emphasizes that these tumors should be included in the differential diagnosis of vascular supratentorial lesions.

Intraventricular central neurocytoma

A case of central neurocytoma treated surgically is described. The authors review the literature. Emphasis is placed on radiological and pathological features not previously described. In particular, the intra-operative ultrasound appearance is described. The role of adjunctive radiotherapy is also discussed.

Otitis media and CNS complications

Intracranial complications from otitis media can be quite devastating to the patient if an early diagnosis is not made. Patients may develop meningitis, venous sinus thrombosis or cranial nerve palsies, as well as intracranial abscess. The presenting features in such cases may be subtle and include headache, nausea, vomiting, personality changes and signs of increased intracranial pressure as well as focal neurological deficits. A case of intracranial brain abscess is presented in a patient with a history of chronic otitis media with cholesteatoma. Delay in the diagnosis of intracranial complications of otitis media can lead to improper treatment with increased morbidity and mortality. The etiology and treatment of complications affecting the CNS is discussed.

Dysplastic gangliocytoma (Lhermitte-Duclos disease): CT and MR imaging

Dysplastic gangliocytoma (Lhermitte-Duclos disease) is a rare entity. Usually presenting as a posterior fossa mass, dysplastic gangliocytoma is not a true neoplasm but a hard-to-characterize lesion that may represent an abnormality of cell migration or a phacomatosis. Previous reports of CT findings are rare in the radiologic literature, and high-field (1.5 Tesla) MR images have never been described in the pediatric age group. We present a case of dysplastic gangliocytoma in a one-year-old boy with CT and MR findings.

Intraspinal epidermoid tumour: late complication of lumbar puncture

Images

Neonatal dural sinus thrombosis

Dural sinus thrombosis in the newborn period has been infrequently documented and its clinical presentation remains obscure. Seventeen patients, all of whom were born at term with dural sinus thrombosis diagnosed in the neonatal period, were retrospectively identified and reviewed. Diagnosis was determined by unenhanced computed tomography which demonstrated a dense sagittal sinus with concomitant small ventricles. Two patients had ancillary studies (i.e., cerebral angiography and nuclear flow scan) which confirmed the diagnosis. Only 4 patients had evidence of perinatal asphyxia. Three patients were identified as having associated conditions known to predispose them to dural sinus thrombosis. None of the patients tested had an identifiable hypercoagulable state. Neonatal seizures were the initial presentation in 15 patients. Seizure onset predominantly occurred during the first week of life. Subsequent examinations were available in all 17 patients and ranged up to 6 years. Only 3 patients had seizures beyond the neonatal period. In 11 of 12 infants with no history of perinatal asphyxia, neurodevelopmental outcomes were normal. Two of 4 infants with perinatal asphyxia had neurologic sequelae. Dural sinus thrombosis represents an important and under-recognized cause of neonatal seizures in term infants. In the absence of perinatal asphyxia, normal neuro-developmental outcome is likely and the risk of seizure recurrence is low.

Somatosensory evoked response abnormalities in high-risk newborns

In a previous study from our laboratory, the prognostic significance of the auditory brainstem evoked response was assessed in high-risk neonates. An abnormal auditory brainstem evoked response predicted neurologic deficits at age 1 year; however, a normal result did not predict a normal outcome. In order to evaluate the prognostic utility of examining other sensory pathways, somatosensory evoked responses were elicited following median nerve stimulation. Testing was performed at 37-44 weeks conceptional age (defined as gestational age plus chronologic age) and at 2 and 6 months conceptional ages. Those patients studied included 34 high-risk neonates and 18 healthy, term infants as controls. Ten of the 34 patients had abnormal somatosensory evoked responses. Abnormalities included increased absolute (N19, P22) and interwave (N13-N19, N19-P22) latencies and flat potentials, alone or in combination. Three children with flat potentials demonstrated a persistence of this abnormality on subsequent examination and they later presented clinically with spastic quadriparesis. Four infants with increased latencies manifested normal responses on subsequent examination. Recently, these 4 patients exhibited tone abnormalities and mild developmental deficits; developmental outcome, however, will be assessed in a blind study at 1 year of age as part of this ongoing prospective study. Preliminary results suggest that somatosensory evoked responses may be valuable as an electrophysiologic predictor of outcome.

Maturation of cerebellar neuroblastoma into ganglioneuroma with melanosis. A histologic, immunocytochemical, and ultrastructural study

A ganglioneuroma with areas of melanosis was resected from the cerebellum of a 6.5-year-old girl. At 2.5 years of age, she was diagnosed to have cerebellar neuroblastoma, which was incompletely resected and then radiated. Histologic, ultrastructural, and immunocytochemical studies undertaken on tissue from both stages of the tumor demonstrated a neuroblastic origin and differentiation into a predominantly neuronal tumor with limited astroglial participation. In addition, widespread deposition of basal lamina material, perineuronal distribution of S-100 protein-bearing cells and melanosis were found. The various features and unusual biology of the tumor are discussed in the light of a review of the literature.

Subacute necrotizing encephalomyelopathy (Leigh disease): CT study

Leigh disease, or subacute necrotizing encephalomyelopathy (SNE), is a familial, degenerative disorder characterized by lesions of the gray and white matter in the brain and spinal cord. Low attenuation in the putamina on computed tomography (CT) scans is considered to be characteristic of the disease. The authors used CT to study five patients, in three of whom the disease was confirmed histologically. In one of the patients with documented SNE, there was extensive gray matter lucency with normal basal ganglia. CT scans obtained in a second patient showed diffuse, diseased white matter with focal cortical extension and bilateral caudate involvement. In the other three cases, CT scans revealed the usual changes that occur in the basal ganglia. The appearance of SNE on CT scans thus reflects the variable and widespread distribution of the disease. The absence of radiologically detectable abnormalities in the basal ganglia should not deter one from the diagnosis of Leigh disease given in the appropriate clinical context.

Sonography of the neonatal craniocervical junction

To determine the value of ultrasound scanning of the craniocervical junction in neonates via a posterior approach, we examined 50 infants with normal posterior fossae, 10 with congenital abnormalities, and eight with intracranial hemorrhage. Good evaluation of the cisterna magna, medulla, tonsils, vermis, cervical cord, and central canal was possible in most cases. In nine patients with spinal dysraphism, all displayed a Chiari II malformation; of these, a kink at the medullary cord junction was seen in six, and a cerebellar peg was noted in four. In one case, the Chiari malformation was confirmed by myelography, and all nine patients had some of the intracranial features of Chiari II malformation seen via the standard anterior fontanelle approach. The 10th patient in this group had a quadrigeminal plate cyst and gross hydrocephalus. In another four infants, diffuse subarachnoid blood in the cisterna magna was seen after recent intraventricular hemorrhage. A further two of four patients with posthemorrhagic hydrocephalus had localized clots. Direct scanning at the craniocervical junction was easily performed and allowed good evaluation of this area in normal infants and in patients with Chiari II malformation. This technique also allowed visualization of subarachnoid blood and clots obstructing the outlet of the fourth ventricle.

Computed tomography of intracranial gangliogliomas

Thirteen patients with pathologically proven gangliogliomas were studied radiographically. The computed tomographic (CT) features of these 13 lesions and the other 35 cases in the literature were analyzed. Although the CT appearance of gangliogliomas was varied, certain characteristics were noted. The most common location was in the cerebral hemispheres, most often the temporal lobe. At least part of the tumor was low density in 71% of the unenhanced CT examinations. There were focal calcifications in 35% and enhancement with contrast material in 50%.

Aphasia and handedness in relation to hemispheric side, age at injury and severity of cerebral lesion during childhood

The effects of the variables of hemispheric side of lesion, age at injury and severity of cerebral damage on language performance and hand dominance were investigated in groups of hemiparetic children. Severity of cerebral damage was defined by the degree of structural abnormality shown on computed tomography (CT) scans. Tests of auditory verbal comprehension and object naming were used as indicators of productive and receptive language skills. The responses to a series of questions on a handedness inventory provided a rated measure of hand dominance. The results indicated that language deficits characterize the performance of all patient groups with left cerebral injuries. Impairments are more profound, however, in the case of left hemisphere injuries acquired after the age of 5 years. In addition, prenatal and early postnatal left cerebral lesions consistently result in strong sinistrality. It is concluded that the crucial variable underlying the demonstration of language deficits and left hand dominance is not severity of lesion but age at injury and hemispheric side of lesion.

Congenital pineoblastoma in the newborn: ultrasound evaluation

Transfontanelle, real-time ultrasound (US) examinations were performed in two newborn infants with congenital pineoblastoma. The tumors were hyperechoic relative to the surrounding cerebral tissue. Both were midline lesions that abutted on the posterior portion of the third ventricle, causing obstructive hydrocephalus. The US findings were correlated with CT, pathologic examination, and clinical follow-up study.

Computed tomography brain scans in long term survivors of childhood acute lymphoblastic leukemia

There have been varying frequencies cited for the occurrence of abnormal brain CT scans in leukemic patients and conflicting evidence about the significance of these abnormalities and their relationship to sanctuary therapy. Our study of CT brain scans in 26 long survivors of acute lymphoblastic leukemia showed an overall prevalence of 35% abnormal scans. There was no statistically significant difference between the number of abnormal scans in patients given radiotherapy as part of their CNS prophylaxis and those receiving only intrathecal methotrexate. Because the children in each treatment group were evenly matched with respect to other treatment variables possibly relevant to the causation of abnormal brain scans, a strong case is made for more rigorous design of such studies, preferably in a prospective fashion, looking simultaneously at other parameters of brain structure and function.

Neonatal intracranial hemorrhage. A clinical and serial computerized tomographic study

Forty-six neonates with intracranial hemorrhage were classified into three groups on the basis of the major computerized tomography (CT) scan findings: Group I consisted of 24 cases of subarachnoid hemorrhage, Group II 20 cases of intracerebral and/or intraventricular hemorrhage, and Group III two cases of subdural hemorrhage. The initial scans in Group I showed blood in the interhemispheric fissure and the supratentorial recess. Sixty percent had an associated hypodensity in the frontal and/or parietal areas, thought to be an indication of ischemia. Changes in the configuration of the ventricular system were infrequent. Initial scans in Group II showed hematomas as follows: one in the brain stem, five in the basal ganglia, 10 in the temporal lobes, and 11 in the ventricles. In 70% of these cases, changes in the configuration of the ventricular system were seen, including compression of a lateral ventricle by mass effect, ventricular dilatation with blood, and obstructive hydrocephalus. Subarachnoid blood was an associated finding in 55% of cases, and focal and diffuse cerebral edema in 40%. Scans in both Group III patients initially showed a mass effect from a subdural clot. In all, 30 patients had one or more follow-up CT scans, and 13 of these were scanned at regular intervals. None of the Group I patients developed hydrocephalus, but 85% of Group II patients with intraventricular blood extending from an intracerebral hemorrhage had this complication. A seizure disorder occurred in 31% of Group I patients and 20% of Group II patients, where it was seen exclusively in those with an intralobar hematoma. A major motor disturbance occurred in 16% of patients; their Ct scans showed evidence of brain destruction involving enlargement of a lateral ventricle, porencephaly, or focal atrophy. Computerized tomography is a useful adjunct to the diagnosis, management, and follow-up study of neonatal intracranial hemorrhage, and correlates well with the clinical findings.

Reduced serum 1,25-(OH)2 vitamin D3 levels in prednisone-treated adolescents with systemic lupus erythematosus

The serum levels of 1,25-(OH)2 vitamin D3 were assayed in samples from 12 adolescent patients with SLE. Subnormal levels were observed in 7 of these 12 patients. Low levels of the metabolically active polar metabolite of vitamin D3 may contribute to the development of osteopenia observed in this disease. The cumulative effects of the osteoporotic and anti vitamin D effects of long term steroid therapy in children with SLE may require the cautious administration of supplemental vitamin D.

Aneurysmal bone cyst of the orbit with unusual angiographic features

A 14 month old boy with sudden onset of proptosis of the left eye due to an aneurysmal bone cyst of the orbit is reported. Sequential plain films of the orbital region demonstrated changes ranging from subtle loss of bone definition of the orbital margin to the characteristic appearance of an aneurysmal bone cyst twelve months later. Arteriography at the time of the initial evaluation demonstrated prolonged retention of the contrast medium which we believe represents changes secondary to the number of giant cells present in the tumor rather than the relative vascularity of the lesion. While aneurysmal bone cyst of the orbit is extremely rare, it should be included in the differential diagnosis of proptosis in the pediatric age group.