Imaging Guide to Inner Ear Malformations: An Illustrative Review

Inner ear malformation (IEM) with associated sensoryneural hearing loss (SNHL) is a major cause of childhood disability. Computed tomography (CT) and magnetic resonance imaging (MRI) imaging play important and often complementary roles in diagnosing underlying structural abnormalities and surgical planning allows for direct visualization of the cochlear nerve and is the preferred imaging modality prior to cochlear implantation. CT is helpful to assess osseous anatomy and when evaluating children with mixed hearing loss or syndromic associations. When reviewing these cases, it is important for the radiologist to be familiar with the key imaging features. In this article, we will present the imaging findings associated with different inner ear malformations associated with congenital sensorineural hearing loss.

Establishing language laterality: does resting-state functional MRI help?

OBJECTIVE

Task-based functional MRI (tb-fMRI) is now considered the standard, noninvasive technique in establishing language laterality in children for surgical planning. The evaluation can be limited due to several factors such as age, language barriers, and developmental and cognitive delays. Resting-state functional MRI (rs-fMRI) offers a potential path to establish language dominance without active task participation. The authors sought to compare the ability of rs-fMRI for language lateralization in the pediatric population with conventional tb-fMRI used as the gold standard.

METHODS

The authors performed a retrospective evaluation of all pediatric patients at a dedicated quaternary pediatric hospital who underwent tb-fMRI and rs-fMRI from 2019 to 2021 as part of the surgical workup for patients with seizures and brain tumors. Task-based fMRI language laterality was based on a patient's adequate performance on one or more of the following: sentence completion, verb generation, antonym generation, or passive listening tasks. Resting-state fMRI data were postprocessed using statistical parametric mapping, FMRIB Software Library, and FreeSurfer as described in the literature. The laterality index (LI) was calculated from the independent component (IC) with the highest Jaccard Index (JI) for the language mask. Additionally, the authors visually inspected the activation maps for two ICs with the highest JIs. The rs-fMRI LI of IC1 and the authors' image-based subjective interpretation of language lateralization were compared with tb-fMRI, which was considered the gold standard for this study.

RESULTS

A retrospective search yielded 33 patients with language fMRI data. Eight patients were excluded (5 with suboptimal tb-fMRI and 3 with suboptimal rs-fMRI data). Twenty-five patients (age range 7-19 years, male/female ratio 15:10) were included in the study. The language laterality concordance between tb-fMRI and rs-fMRI ranged from 68% to 80% for assessment based on LI of independent component analysis with highest JI and for subjective evaluation by visual inspection of activation maps, respectively.

CONCLUSIONS

The concordance rates between tb-fMRI and rs-fMRI of 68% to 80% show the limitation of rs-fMRI in determining language dominance. Resting-state fMRI should not be used as the sole method for language lateralization in clinical practice.

Machine-learning algorithm in acute stroke: real-world experience

AIM

To assess the clinical performance of a commercially available machine learning (ML) algorithm in acute stroke.

MATERIALS AND METHODS

CT and CT angiography (CTA) studies of 104 consecutive patients (43 females, age range 19-93, median age 62) performed for suspected acute stroke at a single tertiary institution with real-time ML software analysis (RAPID™ ASPECTS and CTA) were included. Studies were retrospectively reviewed independently by two neuroradiologists in a blinded manner.

RESULTS

The cohort included 24 acute infarcts and 16 large vessel occlusions (LVO). RAPID™ ASPECTS interpretation demonstrated high sensitivity (87.5%) and NPV (87.5%) but very poor specificity (30.9%) and PPV (30.9%) for detection of acute ischaemic parenchymal changes. There was a high percentage of false positives (51.1%). In cases of proven LVO, RAPID™ ASPECTS showed good correlation with neuroradiologists' blinded independent interpretation, Pearson correlation coefficient = 0.96 (both readers), 0.63 (RAPID™ vs reader 1), 0.69 (RAPID™ vs reader 2). RAPID™ CTA interpretation demonstrated high sensitivity (92.3%), specificity (85.3%), and negative predictive (NPV) (98.5%) with moderate positive predictive value (PPV) (52.2%) for detection of LVO (N=13). False positives accounted for 12.5% of cases, of which 27.3% were attributed to arterial stenosis.

CONCLUSION

RAPID™ CTA was robust and reliable in detection of LVO. Although demonstrating high sensitivity and NPV, RAPID™ ASPECTS interpretation was associated with a high number of false positives, which decreased clinicians' confidence in the algorithm. However, in cases of proven LVO, RAPID™ ASPECTS performed well and had good correlation with neuroradiologists' blinded interpretation.

A cross-sectional natural history study of aspartylglucosaminuria

Aspartylglucosaminuria (AGU) is a rare lysosomal storage disorder that causes stagnation of development in adolescence and neurodegeneration in early adulthood. Precision therapies, including gene transfer therapy, are in development with a goal of taking advantage of the slow clinical course. Understanding of disease natural history and identification of disease-relevant biomarkers are important steps in clinical trial readiness. We describe the clinical features of a diverse population of patients with AGU, including potential imaging and electrophysiological biomarkers. This is a single-center, cross-sectional study of the clinical, neuropsychological, electrophysiological, and imaging characteristics of AGU. A comprehensive assessment of eight participants (5 Non-Finnish) revealed a mean non-verbal IQ (NVIQ) of 70.25 ± 10.33 which decreased with age (rs = -0.85, p = 0.008). All participants demonstrated deficits in communication and gross/fine motor dysfunction. Auditory and visual evoked potentials demonstrated abnormalities in one or both modalities in 7 of 8 subjects, suggesting sensory pathway dysfunction. Brain imaging demonstrated T2 FLAIR hypointensity in the pulvinar nuclei and cerebral atrophy, as previously shown in the Finnish AGU population. Magnetic resonance spectroscopy (MRS) showed a 5.1 ppm peak corresponding to the toxic substrate (GlcNAc-Asn), which accumulates in AGU. Our results showed there was no significant difference between Finnish and Non-Finnish patients, and performance on standardized cognitive and motor testing was similar to prior studies. Age-related changes on functional assessments and disease-relevant abnormalities on surrogate biomarkers, such as MRS, could be used as outcome measures in a clinical trial.

P12.03 A Delphi survey to inform core ‘red flag’ symptoms for an electronic patient reported outcome system in glioblastoma follow up

BACKGROUND

Glioblastoma is a common and aggressive primary malignant brain tumour in adults associated with a poor prognosis and considerable symptom burden. Clinical review and serial neuroimaging remain the primary monitoring tools to assess for disease status. However, the evidence base for the existing surveillance imaging schedule is yet to be established. New models of follow up care are needed to demonstrate better patient outcomes in this patient cohort. There are indications that patient-reported outcome measures (PROMs) can contribute to improved survival and maintaining an optimal quality of life in other oncology populations.

MATERIALS AND METHODS

There are no standardised PROMs for the priority symptoms in glioblastoma patients, which can be used for evaluation in clinical care as a surrogate marker for disease progression. A broad set of symptoms were therefore initially identified in a targeted literature search and were further refined via Delphi methodology, with the aim to obtain consensus amongst a small expert panel involved in the care of glioblastoma patients. A three round Delphi email survey was conducted. Consensus was defined as 70% agreement.

RESULTS

Symptom and function constructs were assessed for relevance, relationship to disease and treatment, sensitivity to change, psychometric properties and patient acceptability. Consensus was reached on the red flag symptoms and symptom clusters to monitor, as well as the minimum severity thresholds needed to trigger an alert on an electronic symptom reporting system, which has been developed to allow patient self-reporting of symptoms during treatment.

CONCLUSION

The red flag symptoms to monitor, along with the symptom severity thresholds, informed an app-based symptom reporting system, which is currently being piloted in a feasibility study exploring triggered imaging using ePROMs. This has the potential to inform future clinical practice through development of patient reported biomarkers.

O15: DISRUPTION OF THE BLOOD-SPINAL CORD BARRIER PREDICTS PERMANENT PARAPLEGIA AFTER THORACOABDOMINAL AORTIC ANEURYSM REPAIR

Introduction

Paraplegia post-thoracoabdominal aortic aneurysm (TAAA) repair remains both a devastating and poorly understood complication. We related temporal changes in cellular and protein composition of cerebrospinal fluid (CSF) to neurological outcomes after TAAA repair to gain mechanistic insights driving paraplegia.

Method

Patients undergoing TAAA repair (open or endovascular) with a CSF drain were prospectively recruited between 2016-2018. CSF was collected pre-operatively and 24-hourly until removal. Daily neurological examinations were performed by blinded neurologists to the study. CSF cell content was characterised by flow cytometry and proteome analysed by tandem-mass-tag proteomics. An in-vivo rat model was modified using 15 minutes of aortic occlusion to produce consistent paraplegia. Rats were analysed neuro-behaviourally and histologically.

Result

CSF was analysed from 52 patients (age: 70.27+/-11.4; 66% male; open (n=9), endovascular (n=43)). 12 developed paraplegia of whom 5 remained permanently-paraplegic. Demographics were comparable between paraplegics, those who recovered and without post-op neurology. Permanent paraplegia was associated with a significant infiltration of CSF CD45+ leucocytes (P<0.0001). Levels of ADVS-1 was >3-fold higher in permanent-paraplegics CSF versus those who recovered (P=0.0008). ADVS-1 >15ng/ml predicted permanent paraplegia with 100% specificity. Pre-treatment with ADVS-1 inhibition significantly improved walking (<0.001) and increased astrocytic staining in the lateral corticospinal, reticulospinal and rubrospinal tracts versus controls (P=0.03, 0.04, 0.04 respectively).

Conclusion

Permanent paraplegia is associated with shedding of ADVS-1 from parenchymal cord into CSF and blood/spinal-cord barrier disruption leading to cord oedema/leucocyte infiltration. Pre-treatment with ADVS-1 inhibition led to neurobehavioural and histological improvements offering translational hope for this devastating complication.

Take-home message

ADVS-1 is a novel biomarker of paraplegia where accurate biomarkers have proven challenging but more importantly it has proven a therapeutic target with genuine translational potential.

A Cheek Mass in a 5-Year-Old Child

OBJECTIVES

To describe the management of a 5-year old female with a painless, mobile cheek mass.

METHODS

A retrospective chart review of presentation, imaging, pathology and management.

RESULTS

Magnetic resonance imaging showed a heterogenous mass with solid and lipomatous components. The mass was a lipoblastoma on histopathology and was excised completely with no evidence of recurrence.

CONCLUSIONS

The diagnosis and management of a cheek mass in a child is challenging. Imaging is important but not diagnostic. Surgical excision is the primary management of a lipoblastoma.

Catalyst Interface Engineering for Improved 2D Film Lift-Off and Transfer

The mechanisms by which chemical vapor deposited (CVD) graphene and hexagonal boron nitride (h-BN) films can be released from a growth catalyst, such as widely used copper (Cu) foil, are systematically explored as a basis for an improved lift-off transfer. We show how intercalation processes allow the local Cu oxidation at the interface followed by selective oxide dissolution, which gently releases the 2D material (2DM) film. Interfacial composition change and selective dissolution can thereby be achieved in a single step or split into two individual process steps. We demonstrate that this method is not only highly versatile but also yields graphene and h-BN films of high quality regarding surface contamination, layer coherence, defects, and electronic properties, without requiring additional post-transfer annealing. We highlight how such transfers rely on targeted corrosion at the catalyst interface and discuss this in context of the wider CVD growth and 2DM transfer literature, thereby fostering an improved general understanding of widely used transfer processes, which is essential to numerous other applications.

Think of the children: growing up with parents who have learning difficulties

This paper summarizes the findings of a research study that set out to explore how people who were brought up in a family headed by a parent or parents with learning difficulties managed the transition to adulthood. The authors focus on four key issues arising from their research: resilience in children, the notion of parental competence, the importance of family and the effects of social exclusion. Implications for policy and practice are also addressed.

Community-driven development for computational biology at Sprints, Hackathons and Codefests

Background

Computational biology comprises a wide range of technologies and approaches. Multiple technologies can be combined to create more powerful workflows if the individuals contributing the data or providing tools for its interpretation can find mutual understanding and consensus. Much conversation and joint investigation are required in order to identify and implement the best approaches.

Traditionally, scientific conferences feature talks presenting novel technologies or insights, followed up by informal discussions during coffee breaks. In multi-institution collaborations, in order to reach agreement on implementation details or to transfer deeper insights in a technology and practical skills, a representative of one group typically visits the other. However, this does not scale well when the number of technologies or research groups is large.

Conferences have responded to this issue by introducing Birds-of-a-Feather (BoF) sessions, which offer an opportunity for individuals with common interests to intensify their interaction. However, parallel BoF sessions often make it hard for participants to join multiple BoFs and find common ground between the different technologies, and BoFs are generally too short to allow time for participants to program together.

Results

This report summarises our experience with computational biology Codefests, Hackathons and Sprints, which are interactive developer meetings. They are structured to reduce the limitations of traditional scientific meetings described above by strengthening the interaction among peers and letting the participants determine the schedule and topics. These meetings are commonly run as loosely scheduled "unconferences" (self-organized identification of participants and topics for meetings) over at least two days, with early introductory talks to welcome and organize contributors, followed by intensive collaborative coding sessions. We summarise some prominent achievements of those meetings and describe differences in how these are organised, how their audience is addressed, and their outreach to their respective communities.

Conclusions

Hackathons, Codefests and Sprints share a stimulating atmosphere that encourages participants to jointly brainstorm and tackle problems of shared interest in a self-driven proactive environment, as well as providing an opportunity for new participants to get involved in collaborative projects.

Molecular mechanisms of toxicity of silver nanoparticles in zebrafish embryos

Silver nanoparticles cause toxicity in exposed organisms and are an environmental health concern. The mechanisms of silver nanoparticle toxicity, however, remain unclear. We examined the effects of exposure to silver in nano-, bulk-, and ionic forms on zebrafish embryos (Danio rerio) using a Next Generation Sequencing approach in an Illumina platform (High-Throughput SuperSAGE). Significant alterations in gene expression were found for all treatments and many of the gene pathways affected, most notably those associated with oxidative phosphorylation and protein synthesis, overlapped strongly between the three treatments indicating similar mechanisms of toxicity for the three forms of silver studied. Changes in oxidative phosphorylation indicated a down-regulation of this pathway at 24 h of exposure, but with a recovery at 48 h. This finding was consistent with a dose-dependent decrease in oxygen consumption at 24 h, but not at 48 h, following exposure to silver ions. Overall, our data provide support for the hypothesis that the toxicity caused by silver nanoparticles is principally associated with bioavailable silver ions in exposed zebrafish embryos. These findings are important in the evaluation of the risk that silver particles may pose to exposed vertebrate organisms.

Design and fabrication of hollow-core photonic crystal fibers for high-power ultrashort pulse transportation and pulse compression

We report on the recent design and fabrication of kagome-type hollow-core photonic crystal fibers for the purpose of high-power ultrashort pulse transportation. The fabricated seven-cell three-ring hypocycloid-shaped large core fiber exhibits an up-to-date lowest attenuation (among all kagome fibers) of 40 dB/km over a broadband transmission centered at 1500 nm. We show that the large core size, low attenuation, broadband transmission, single-mode guidance, and low dispersion make it an ideal host for high-power laser beam transportation. By filling the fiber with helium gas, a 74 μJ, 850 fs, and 40 kHz repetition rate ultrashort pulse at 1550 nm has been faithfully delivered at the fiber output with little propagation pulse distortion. Compression of a 105 μJ laser pulse from 850 fs down to 300 fs has been achieved by operating the fiber in ambient air.

Assessment of cochlear implant candidacy in patients with cochlear nerve deficiency using the P1 CAEP biomarker

OBJECTIVE

The goal of this report was to ascertain the efficacy of the P1 cortical auditory evoked potential (CAEP) biomarker as an objective tool to assist in the evaluation of cochlear implant (CI) candidacy in children with a radiological diagnosis of cochlear nerve deficiency (CND).

METHODS

Retrospective case study review of audiological and radiological findings was performed in four pediatric patients identified with CND and severe-to-profound sensorineural hearing loss. Cortical auditory evoked potential testing was conducted, and the presence and latency of the P1 component were analyzed.

RESULTS

Three out of four children demonstrated robust P1 CAEP responses, indicating activation of the central auditory pathways by auditory stimulation, despite the diagnosis of CND. These children were considered good candidates for cochlear implantation.

DISCUSSION

Although cochlear implantation in children is a fairly routine procedure, cases exist for which implant candidacy is questionable. Among these cases are children with CND. In these children, cochlear implantation may be contraindicated due to the likelihood that the implant electrodes may not stimulate the VIII nerve adequately. Magnetic resonance imaging (MRI) is considered the gold standard in the assessment of CND, but this measure is not always sufficient to determine CI candidacy in cases of CND. The addition of the P1 CAEP measurement to the usual electrophysiological, audiometric, and radiological test battery may prove to be useful in determining CI options for children with CND.

An unusual case of pneumocephalus

The authors present an unusual cause of pneumocephalus in a previously fit and well female octogenarian who presented with acute onset altered level of consciousness and generalised weakness. Radiological imaging demonstrated widespread cerebritis with pneumocephalus and gas within the superior sagittal sinus. Blood culture grew Clostridium septicum, a virulent but rare organism that can infect normal tissues. The close association between C septicum and both haematological and bowel malignancies must be considered if this organism is cultured.

High average power, high energy 1.55 μm ultra-short pulse laser beam delivery using large mode area hollow core photonic band-gap fiber

We demonstrate high average power, high energy 1.55 μm ultra-short pulse (<1 ps) laser delivery using helium-filled and argon-filled large mode area hollow core photonic band-gap fibers and compare relevant performance parameters. The ultra-short pulse laser beam-with pulse energy higher than 7 μJ and pulse train average power larger than 0.7 W-is output from a 2 m long hollow core fiber with diffraction limited beam quality. We introduce a pulse tuning mechanism of argon-filled hollow core photonic band-gap fiber. We assess the damage threshold of the hollow core photonic band-gap fiber and propose methods to further increase pulse energy and average power handling.

Radiographic diagnosis of trans-stapedial cerebrospinal fluid fistula

OBJECTIVE

To report the high-resolution computed tomography and magnetic resonance imaging (MRI) findings of a bulging oval window in children with recurrent meningitis and congenital cerebrospinal fluid fistula.

STUDY DESIGN

Case series.

SETTING

Academic medical center children's hospital.

SUBJECTS AND METHODS

A series of eight ears in four children with profound, bilateral sensorineural hearing loss and perilymphatic hydrops were evaluated. Two patients presented with recurrent meningitis. All children were assessed with high-resolution computed tomography, and two children also underwent MRI.

RESULTS

Seven of eight ears had a common cavity malformation. The vestibular compartment showed severe dysplasia (n = 5), moderate dysplasia (n = 1), or a single semicircular canal (n = 2). The lamina cribrosa was clearly absent in four of eight ears. Its presence was difficult to assess in ears with small internal auditory canals. A bulging oval window, present in six of eight ears, was defined as a fluid density on high-resolution computed tomography or a hyperintense mass demonstrated by T2-weighted MRI protruding from the vestibule into the middle ear cavity. When present, this herniation of a fluid-filled sac could be seen on both MRI and computed tomography. This imaging finding was surgically confirmed in two patients.

CONCLUSION

The bulging oval window, which represents a fluid-filled sac, can be identified by both high-resolution computed tomography and MRI. Communication between the middle ear and the subarachnoid space through the inner ear is an important etiology for recurrent meningitis in children with sensorineural hearing loss.

Labyrinthitis ossificans: How accurate is MRI in predicting cochlear obstruction?

Objective: To determine the accuracy of preoperative MRI in predicting cochlear obstruction in pediatric patients with a history of bacterial meningitis.

Methods: A case series with chart review was performed at a tertiary care multidisciplinary cochlear implant program. Forty-five children with hearing loss that resulted from bacterial meningitis were implanted from 1991 to 2006. Twenty-five children had preoperative MRI with high-resolution axial T2-weighted images to assess for cochlear patency.

Results: Seventeen of 25 patients (68%) had surgical evidence of cochlear obstruction. Six patients (37.5%) required circummodiolar drill-outs, and one patient (6.25%) underwent placement of a double array cochlear implant. The nine remaining patients (56%) with cochlear obstruction required removal of fibrous tissue or drilling of the inferior basal turn, but did not require manipulation of the ascending basal turn to achieve full electrode insertion. The sensitivity, specificity, and positive and negative predictive value of MRI predicting intraoperative cochlear obstruction with 95 percent confidence intervals was 94.1 percent (71–99), 87.5 percent (47–99), 94.1 percent (71–99) and 87.5 percent (47–99), respectively.

Conclusion: Preoperative high-resolution T2 MRI may be useful in predicting cochlear obstruction in patients with a prior history of bacterial meningitis.

Advantages of Magnetic Resonance Imaging over Computed Tomography in Preoperative Evaluation of Pediatric Cochlear Implant Candidates

OBJECTIVES

To compare magnetic resonance imaging (MRI) to high-resolution computed tomography (HRCT) in the preoperative evaluation of pediatric cochlear implant candidates.

METHODS

The charts of pediatric cochlear implant candidates evaluated between July 1, 2000 and November 30, 2003 with an MRI scan of the inner ear were included in the study. Fifty-six patients were included. Associated HRCT scans were examined. Abnormalities of the cochlea, cochlear nerve, endolymphatic sac, endolymphatic duct, vestibule, and modiolus were noted. A pediatric neuroradiologist gave an opinion as to whether patients with anomalies seen with MRI but without associated HRCT would have been identified by HRCT.

RESULTS

Of the 112 temporal bones imaged with MRI, the following abnormalities were encountered: 32% (36/112) had abnormalities of the cochlear turns, 30% (34/112) had abnormal signal in the modiolus, 23% (26/112) had abnormal vestibulae, 16% (18/112) had abnormal endolymphatic ducts, 15% (17/112) had abnormal endolymphatic sacs, 12% (13/112) had abnormalities of the cochlear nerves, 29% (17/56) had abnormalities of the brain. HRCT cannot directly evaluate the cochlear nerve. Available HRCT findings were combined with radiologic opinion and compared with MRI findings. The percentages of abnormalities identifiable by HRCT when compared with those seen with MRI are cochlea 42% (15/36), modiolus 35% (12/34), vestibulae 88% (23/26), endolymphatic duct 100% (18/18), and endolymphatic sac 6% (1/17).

CONCLUSION

MRI is more sensitive and specific in diagnosing soft tissue abnormalities in the inner ear than HRCT in cochlear implant candidates (Fig. 4). Moreover, the abnormalities detected with MRI are more likely to influence the implantation process (e.g., asymmetric nerve aplasia, cochlear obstruction). (Figure is included in full-text article).

Automated variance reduction for MCNP using deterministic methods

In order to reduce the user's time and the computer time needed to solve deep penetration problems, an automated variance reduction capability has been developed for the MCNP Monte Carlo transport code. This new variance reduction capability developed for MCNP5 employs the PARTISN multigroup discrete ordinates code to generate mesh-based weight windows. The technique of using deterministic methods to generate importance maps has been widely used to increase the efficiency of deep penetration Monte Carlo calculations. The application of this method in MCNP uses the existing mesh-based weight window feature to translate the MCNP geometry into geometry suitable for PARTISN. The adjoint flux, which is calculated with PARTISN, is used to generate mesh-based weight windows for MCNP. Additionally, the MCNP source energy spectrum can be biased based on the adjoint energy spectrum at the source location. This method can also use angle-dependent weight windows.

MR venography in the pediatric patient

BACKGROUND AND PURPOSE

Little is known about age-related changes in posterior fossa venous anatomy on 2D time-of-flight MR venography (MRV) or about artifacts that limit its accuracy in diagnosing venous occlusive disease. We evaluated pediatric appearances of posterior fossa venous drainage.

METHODS

One hundred and eight children with normal MR imaging or minimal congenital anomalies underwent 2D MRV. Transverse sinus dominance and absence and the presence of an occipital sinus were correlated with age. Venous structure conspicuity was compared on source and maximum intensity projection images.

RESULTS

Right, left, and codominance of the transverse sinus, respectively, was as follows: at < 25 months, 37%, 21%, and 42%; 25 months to 5 years, 35%, 30%, 35%; and > or =6 years, 50%, 16%, 34%. Transverse sinus dominance was not related to age between the three groups (P=.58, chi-square contingency), but some relationship was observed when patients <6 years were compared to those > or =6 years (P=.032). Chi-square trends showed a mildly positive correlation between age and an absent transverse sinus (P=.026) and a decreasing trend in the presence of an occipital sinus with age (P=.038). Saturation effects due to in-plane/slow flow were worse in patients <25 months; effects in the transverse sinuses or internal jugular veins were miminized with coronal or axial imaging, respectively.

CONCLUSION

2D TOF MRV shows age-related changes in venous anatomy. Caution should be used before posterior fossa venous occlusive disease is diagnosed on the basis of signal intensity loss, especially in neonates and young infants.

Thermodynamic law for adaptation of plants to environmental temperatures

A thermodynamic law of adaptation of plants to temperature is developed. Plant growth rate is proportional to the product of the metabolic rate and the metabolic efficiency for production of anabolic products. Over much of the growth temperature range, metabolic rate is proportional to mean temperature and efficiency is proportional to the reciprocal of temperature variability. The mean temperature and short-term (hours to weeks) variability of temperature during the growth season at a particular location thus determine the optimum energy and growth strategy for plants. Because they can grow and reproduce most vigorously, plants with a growth rate vs. temperature curve that matches the time-at-temperature vs. temperature curve during the growth season are favored by natural selection. The law of temperature adaptation explains many recent and long-standing observations of plant growth and survival, including latitudinal gradients of plant diversity and species range.

Acute methotrexate neurotoxicity: findings on diffusion-weighted imaging and correlation with clinical outcome

BACKGROUND AND PURPOSE

Acute lymphocytic leukemia (ALL) is a common malignancy of childhood treated with methotrexate (MTX), which is associated with acute neurotoxicity. We evaluated diffusion-weighted (DW) and conventional MR images in children with ALL and acute MTX-induced neurotoxicity, with clinical correlation.

METHODS

Five patients aged 12-15 years underwent fluid-attenuated inversion recovery (FLAIR), T2-weighted fast spin-echo and gradient-echo, T1-weighted gadolinium-enhanced spin-echo, and DW imaging within 24 hours of symptom onset. Records were reviewed for the temporal relationship to MTX administration, strokelike symptoms, and neurologic outcome.

RESULTS

Six strokelike events were temporally related to intrathecal MTX given 6-11 days before symptom onset. FLAIR images showed abnormal hyperintensity in the callosal splenium in one patient but were otherwise normal. Diffusion abnormalities were frontoparietal in three events and frontal in one; nonfluent aphasia was seen in all. Bilateral frontoparietal diffusion abnormalities were associated with bilateral upper-extremity weakness, right-sided hemiparesis, or left-sided hemiparesis (one patient each); one patient had mild facial droop. Unilateral precentral subcortical diffusion abnormality was associated with contralateral motor deficit and ipsilateral upper-extremity sensory loss. Strokelike symptoms resolved rapidly and were not associated with other signs of encephalopathy. Subsequent intrathecal MTX administration was not associated with recurrence in four patients.

CONCLUSION

Diffusion abnormalities in acute MTX neurotoxicity indicated cerebral dysfunction but not necessarily overt structural injury to the cerebrum. Subsequent demyelination or gliosis could not be predicted on the basis of diffusion abnormalities. A single strokelike episode with diffusion abnormalities should not necessarily prompt modification of potentially curative chemotherapeutic regimens.

Skip metastasis in osteosarcoma

Skip metastasis is rare in high-grade osteosarcoma and indicates a very poor prognosis. The authors describe two patients who had high-grade osteosarcoma and skip metastasis. MRI detected the skip lesion in both patients, and both lesions were confirmed by histology. The patients were treated with adjuvant chemotherapy and radical surgical resection. Both are alive and free of disease 3 and 6 years from diagnosis.

Late onset seizures, hemiparesis and blindness in hemolytic uremic syndrome

Neurologic complications of hemolytic uremic syndrome, including seizures, usually occur early during the acute phase of the illness. We report a3-year-old girl with classic diarrhea-associated hemolytic uremic syndrome who developed late onset seizures, hemiparesis and transient blindness on the 17th hospital day, at which time her recovery was characterized by improvement in her blood pressure, serum electrolytes, renal function, hematocrit and platelet count. A CT and MR revealed brainstem and posterior parietal and occipital infarct/edema. The association of these radiologic findings within the posterior distribution along with visual loss and seizures are unique to posterior reversible encephalopathy syndrome. Within 7 days, she regained motor function and vision and had no further seizure activity. At 6 months follow-up, physical examination revealed normal motor function and vision and a repeat MR showed near resolution of the previous findings with minimal occipital lobe gliosis. This case report describes the uncommon finding of late onset seizures occurring during the recovery phase of hemolytic uremic syndrome with MR findings consistent with posterior reversible encephalopathy syndrome.

Nonperioperative strokes in children with central nervous system tumors

BACKGROUND

Nonperioperative strokes are rare yet potentially devastating events for children with central nervous system (CNS) tumors. The incidence of and risk factors for nonperioperative strokes in children with CNS tumors is unknown.

METHODS

The authors performed a retrospective review of children from their institution with CNS tumors. The incidence of stroke in the nonperioperative period and the influence of patient demographic factors, coexisting genetic diseases, tumor type, and treatment modality on the subsequent occurrence of a stroke were determined.

RESULTS

Eight hundred seven consecutive patients from the authors' institution with CNS tumors were observed for a combined 3224 nonperioperative years. Thirteen patients (1.6%) had a nonperioperative stroke, for an incidence of 4.03 strokes/1000 years of nonperioperative patient follow-up. Eight patients were males, and the median age at diagnosis of a CNS tumor was 4.8 years (range, 0.3-18.6 years). The median duration from diagnosis of a CNS tumor until the occurrence of stroke was 2.3 years (range, 0.3-15.8 years). Among numerous potential risk factors individually examined by chi-square analysis, only treatment with radiation therapy was associated with the subsequent development of a stroke (chi-square, P = 0.007). By logistic regression analysis, treatment with radiation therapy and a diagnosis of an optic pathway glioma were the only statistically significant variables associated with a stroke.

CONCLUSIONS

Strokes are much more common among children with CNS tumors. Children treated with radiation therapy and those with optic pathway gliomas have a higher association with the occurrence of a subsequent nonperioperative stroke. Because children with optic pathway gliomas may be at particularly high risk of stroke after radiation therapy, the desired beneficial therapeutic effects of irradiation must always be weighed against its potentially adverse effects, including stroke.

Is first trimester exposure to the combination of antiretroviral therapy and folate antagonists a risk factor for congenital abnormalities?

OBJECTIVES

To assess use of antiretroviral therapy (ART) by HIV positive pregnant women in London since 1994 and the risk of congenital abnormalities associated with multidrug exposure during the first trimester of pregnancy.

METHODS

Retrospective multicentre study of medical, obstetric, and paediatric notes of all mother-infant pairs, where the mother was known to be HIV infected before delivery, using a standardised proforma.

RESULTS

In this study of 195 mother-infant pairs, use of ART during any stage of pregnancy increased from 33.3% in 1994 to 92.5% in 1999 (p=0.01, trend). First trimester exposure increased from 0% in 1994 to 27.5% in 1999 (p=0.00045, trend). Congenital malformations were observed in nine infants (4.6%). Compared with infants not exposed to ART or folate antagonists during the first trimester (n=148), exposure to both ART and folate antagonists during the first trimester (n=13) was associated with an increased risk of congenital abnormalities (4% v 23.1%; OR 7.10, 95% CI 1.5, 34.2). No malformations were observed in the 34 children exposed to either ART or folate antagonists alone during the first trimester.

CONCLUSION

An increasing number of HIV infected women conceived while on ART. Although there is no evidence of teratogenicity caused by ART if given alone during the first trimester, exposure to the combination of ART and folate antagonists was associated with a significantly higher risk of congenital abnormalities in this cohort.

Congenital foregut duplication cysts of the anterior tongue

OBJECTIVE

To review our experience with foregut duplication cysts of the anterior tongue, an unusual and rarely encountered mass in this location.

DESIGN

A retrospective review of patients with anterior tongue foregut duplication cysts identified between 1990 and 2000.

SETTING

Academic, tertiary care children's medical center.

PATIENTS

Six pediatric patients (5 boys and 1 girl) ranging in age from birth to 8 months at diagnosis.

INTERVENTION

Three patients underwent preoperative magnetic resonance imaging (MRI). All 6 patients underwent excisional biopsy.

MAIN OUTCOME MEASURES

Clinical description of foregut duplication cysts, ability to make the diagnosis preoperatively, and recurrence rates.

RESULTS

No patient presented with respiratory compromise, despite the large size of the anterior tongue masses (range, 1.5-2.4 cm). An MRI study was performed in 3 patients, all given a presumptive diagnosis of dermoid cyst based on the radiographic findings. No patient was diagnosed correctly prior to surgical excision. All patients underwent surgical excision, and the average time from birth to surgical excision was 11 months (range, 3 days to 3.7 years). Surgical pathologic findings were reported as a foregut duplication cyst (enterocystoma) in all patients, with 3 specimens containing foci of gastric mucosa. No recurrence has occurred at 1-month follow-up.

CONCLUSIONS

Foregut duplication cysts rarely present in the anterior tongue and are easily misdiagnosed preoperatively. An MRI study is helpful in preoperative planning, although all lesions were radiologically indistinguishable from dermoid cysts. These masses may be an underappreciated entity in the differential diagnosis of congenital anterior tongue masses.

The use of gated cine phase contrast and MR venography in achondroplasia

OBJECTS

Foramen magnum and jugular foramen stenosis, well-known problems in achondroplasia, may result in brain stem compression and venous outflow obstruction, respectively. We studied a series of children with achondroplasia using gated cine phase contrast (PC) CSF flow studies to evaluate CSF dynamics across the foramen magnum and MR venography (MRV) to depict obstructed venous drainage.

METHODS

Ten patients (9 months to 11 years, mean 2.85 years) were referred for possible brain stem compression. MRI included routine sequences, cine PC with velocity encoding (VENC) = 5 cm/s, and MRV. Six patients, including the asymptomatic patient, had brain stem compression without tonsillar herniation; two had tonsillar herniation; and two had neither brain stem compression nor tonsillar herniation. Abnormal tonsillar movement was seen only with tonsillar herniation. MRV showed steno-occlusive disease of the internal jugular vein (IJV) in nine patients, sigmoid sinus in four, and absent or hypoplastic transverse sinus in seven. Veno-occlusive disease was not progressive. No patient had massive hydrocephalus, although larger ventricles were associated with more profuse venous collateral formation and more severe degrees of IJV stenosis. Three patients have undergone CSF diversion.

CONCLUSIONS

MR imaging may be useful in defining the pathophysiology of brain stem compression and hydrocephalus in achondroplasia.

MR venography in children with complex craniosynostosis

PURPOSE

Chronic venous hypertension due to jugular foramen stenosis has been proposed as an etiology for the hydrocephalus and tonsillar herniation seen in some patients with complex craniosynostosis. We report the use of MR venography (MRV) to evaluate venous outflow obstruction in this clinical setting.

MATERIALS AND METHODS

We studied 17 patients, (ages 4 months to 34 years; mean 7.3 years) with complex craniosynostosis; 8 patients with Crouzon's syndrome, 2 with Apert's, 1 with Pfeiffer's and 6 patients without an eponymous classification. MR imaging included routine imaging sequences and axial 2D TOF MRV. Patterns of venous drainage and the presence of hydrocephalus and tonsillar herniation were noted.

RESULTS

Jugular vein obstruction was seen in 12/17 patients; in 5/8 patients with Crouzon's, 1/2 with Apert's, the single patient with Pfeiffer's and 5/6 patients with nonsyndromic craniosynostosis. The predominant collateral drainage was via the posterior condylar veins. Nine of 12 (75%) of the patients with abnormal MRV had hydrocephalus; 3/8 patients with Crouzon's, 1/2 patients with Apert's, and 5/6 nonsyndromic patients. Two patients had hydrocephalus with normal MRV. Ten patients had tonsillar herniation, which was associated with shunted hydrocephalus in 7/10 patients, and hydrocephalus seen prior to shunt placement in 3/9. Nine of 10 patients with tonsillar herniation had an abnormal MRV, while 1 patient had a normal MRV. Venous pressures measured in 1 patient showed an 8-mm-Hg differential across the skull base.

CONCLUSIONS

The posterior condylar veins appear pivotal in maintaining venous drainage when the jugular bulbs are occluded. Although the association between venous outflow obstruction, hydrocephalus and tonsillar herniation is intriguing, evidence of venous outflow obstruction by MRV may not be indicative of significant intracranial venous hypertension.

Velogenic Newcastle disease in imported caged birds

Velogenic Newcastle disease was diagnosed in pet birds intended for importation into Canada. Virological and histopathological examination confirmed the presence of the disease. The group of birds was denied entry into Canada. Similar birds illegally imported are a potential source of velogenic Newcastle disease virus and are a threat to domestic poultry.

Idiopathic ischemic cerebral infarction in childhood: depiction of arterial abnormalities by MR angiography and catheter angiography

BACKGROUND AND PURPOSE

We report our experience with MR imaging, MR angiography, and catheter angiography in children with acute idiopathic cerebral infarction and suggest that catheter angiography may still play an important role in this setting.

METHODS

During the past 8 years, 18 children with idiopathic cerebral infarction underwent MR imaging and catheter angiography; 17 were also studied with MR angiography. MR imaging was done within 34 hours after onset of hemiplegia or seizures or both. Sixteen patients underwent catheter angiography within 36 hours of MR imaging; 12 studies were performed within 22 hours. Two patients underwent catheter angiography, in both cases within 72 hours. Infarcts were compared with arterial abnormalities seen at catheter angiography, and the results of MR angiography were compared with those seen at catheter angiography.

RESULTS

Comparing MR angiography with catheter angiography, we found the positive predictive value of MR angiography for arteriopathy was 100%, with a negative predictive value of 88%. MR angiography was equivalent to catheter angiography in the detection and depiction of proximal middle cerebral artery disease; however, depiction of disease in the internal carotid artery (ICA) and detection of peripheral embolic disease were better with catheter angiography than MR angiography.

CONCLUSION

Basal ganglia lesions associated with ICA disease by MR angiography should probably be studied with digital subtraction angiography, as MR angiography did not depict the length and severity of ICA disease as well as catheter angiography did. Hemispheric infarcts should be studied with catheter angiography, as emboli may occur in the absence of heart disease; the circle of Willis may be uninvolved with embolic disease, and MR angiography is not sensitive to emboli in small peripheral intracranial arteries.

Against the odds: growing up with parents who have learning difficulties

For this article we drew on material from a study in which we explored how people who were brought up in a family headed by a parent or parents with learning difficulties managed the transition to adulthood. Using evidence from in-depth interviews, we provided an assessment of how the now-adult children came through what would generally be seen as a risk-filled upbringing. Despite the problems they encountered in their childhood, many of which originated outside the home, most of the informants had maintained a valued relationship with their family and remained close to their mother.

Specific interactions between human integrin alpha v beta 3 and chimeric hepatitis B virus core particles bearing the receptor-binding epitope of foot-and-mouth disease virus

Purified integrin alpha v beta 3 was used in solid-phase binding studies with chimeric hepatitis B cores which carry the RGD-containing loop of VP1 protein of the foot-and-mouth disease virus (FMDV). High levels of specific binding between the integrin and the particles were detected by enzyme-linked immunosorbent assays. The binding was Mn2+ cation dependent and could be competed with fibronectin, vitronectin, and the peptide GRGDSPK. Particles in which the RGD motif had been mutated to RGE failed to bind, indicating that the chimeric cores bound specifically to the ligand binding site of integrin alpha v beta 3. Electron micrographs showed several individual alpha v beta 3 molecules bound to the surface of each chimeric particle. Collectively, these data constitute firm evidence that the RGD-containing loop of FMDV is critical for binding to alpha v beta 3 and provide support for identification of alpha v beta 3 as a potential cellular receptor for FMDV.

The use of depth interviewing with vulnerable subjects: lessons from a research study of parents with learning difficulties

This paper explores the practicalities of using the technique of depth interviewing with people who have learning difficulties. The authors set out to provide other researchers with guidance in the use of the life story approach and to demonstrate its utility with this vulnerable and devalued group of informants. They conclude that depth interviewing can provide new knowledge not accessible through other methods of data collection, and offers a way of giving people with learning difficulties a voice in the making of their own history.

Mutation of either of two cysteine residues or deletion of the amino or carboxy terminus of nonstructural protein NS1 of bluetongue virus abrogates virus-specified tubule formation in insect cells

Virus-specific tubules are characteristic of orbivirus infections and are likely to play an important role in virus morphogenesis. It has been shown that for bluetongue virus (BTV), the prototype orbivirus in the family Reoviridae, the virus-encoded NS1 protein forms tubules in insect cells when the BTV segment M6 gene is expressed by using a baculovirus vector. To understand the function of NS1 tubules and to identify the sequences involved in their polymerization, a series of mutant NS1 genes was generated and expressed in insect cell cultures by using baculovirus vectors. Three of the mutants were deletion mutants. One (AcNS1.dNT10) lacked 10 of the amino-terminal amino acids, and the other two mutants (AcNS1.dCT20 and AcNS1.dCT43) lacked 20 or 43 of the carboxy-terminal amino acids. In addition, site-directed mutants were constructed in which various single cysteines or pairs of cysteines were changed to serines. The ability of each mutant protein to form tubules was investigated. None of the deletion mutants formed tubules. The constructs in which the cysteines at amino acid positions 337 and/or 340 were replaced by serines (e.g., AcNS1.C337S,C340S) also did not form tubules. Instead, the NS1 protein of these and the deletion mutants made ribbon-like structures which formed large aggregates. Mutations involving six other cysteines (i.e., AcNS1.C37S,C43S,AcNS1.C462S,C465S, AcNS1.C104S, and AcNS1.C364S) produced tubules. The results show that both the amino and carboxy termini of the NS1 protein molecule and the cysteines at residues 337 and 340 are essential for tubule formation.

Preparation of platelet concentrates after overnight hold at 20 degrees C

The clinical demand for platelet concentrates has increased dramatically in the last decade, and poses logistical problems for regional transfusion centres. Pietersz et al. (Vox Sang 1989; 56: 145-150) have shown that it is possible to prepare clinically effective platelet concentrates with substantially reduced white cell contamination, whilst maintaining satisfactory levels of factor VIII:C after holding whole blood at 20 degrees C overnight. This approach offers a method of production that will allow platelet concentrates to be prepared from potentially all donations collected, without resorting to extensive out-of-hours working. Following laboratory evaluation of the procedure we were able to reproduce Pietersz's findings, although hypotonic shock response results were less favourable than observed in our routine platelet concentrates.