[Cervical spinal cord compression in chondrodysplasia punctata: report of two cases]

AIM

To present two patients with chondrodysplasia punctata and cervical spine compression who had a chronic myelopathy.

CASE REPORTS

The patients are a boy who was seen in our service at 13 years of age because of a progressive spastic quadriparesis since infancy and muscle spasm, and a girl, actually 15-year-old, who was studied by us since 2 years of age because of the same problem and moderate mental retardation. Magnetic resonance study disclosed narrowing of the spinal canal at the level of C1-C2 and C5-C6. Surgical decompression was performed in both cases. The case 2 also received physiotherapy, myorrelaxing medication and botulinum toxin treatments. The case 2 has short stature and intellectual level below normality.

CONCLUSION

Chondrodysplasia punctata, that exhibits well defined clinical and radiological manifestations, is a disease that can present spinal cord compression during the first years of life. However, other pathological causes of still unknown origin may contribute to the progressive evolution and lack of recuperation of the problems derived of the spasticity as well as the mental retardation and the short stature.

[A study and follow-up of ten cases of benign enlargement of the subarachnoid spaces]

AIM

To present 10 cases with 'benign enlargement of the subarachnoid spaces' and its clinical and image evolution.

PATIENTS AND METHODS

We study 10 patients, 7 boys and 3 girls, because of macrocephaly. It was made a clinic and image follow-up from the first year of age to their cure. In the series, there are two monozygotic twins.

RESULTS

The patients had normal head circumference centile at birth, and it was 90 or higher at the age of 5 to 12 months, to keep stabilized, without decreasing, during the time of the study despite disappearing enlargement of the subarachnoid spaces. CT and especially magnetic resonance studies, showed the largest subarachnoid spaces and lateral ventricles between 5 and 12 months of age, and then, a slowly decrease to disappear in a period that was variable among the patients. A moderate enlargement was still found after 5 years of age in some cases. The clinic and image follow-up showed a parallel evolution since birth to 5 years in the pair of homozygous twins. Both showed possible reflux of the cerebrospinal fluid from the subarachnoid spaces to the cerebral ventricles, appearing cyst of the septum pellucidum, possibly due to the increase of the intraventricular pressure. The cyst did not disappear and kept the same size despite disappearing the enlargement of the subdural spaces and the normalization of the ventricular size. Psychomotor evolution has been normal, although most of patients show discrete hypotonus and motor coordination problems, attention deficit and/or hyperactivity.

CONCLUSION

Benign enlargement of the subarachnoid spaces has a spontaneous solution, but it can carried out in some cases more slowly than it is though. The disease seems hereditary and the most probable etiology is the difficulty in absorption of the cerebrospinal fluid during the first year of life or still longer. The picture, however, always has a spontaneous solution.

[Opercular syndrome after bilateral cerebral surgery: presentation of a case report]

AIM

To present a case of bilateral opercular syndrome after surgery on both cerebral hemispheres.

CASE REPORT

A girl was studied at 3 years of age because of a benign intracranial tumor in the middle region of the brain. At the age of 5 years, the tumor was partially removed through the right hemisphere. Three years latter, the patient was operated through the left hemisphere because of growth in the tumor to the left side of the brain. After the second operation, the patient showed the complete symptomatology of the bilateral opercular syndrome, which did not change during this year.

CONCLUSION

This is a case which the presence of a bilateral opercular syndrome seems to be caused by the surgical lesions of both opercular zones.

[Tourette's syndrome]

OBJECTIVE

To present a general view about update knowledge of Tourette's syndrome.

METHOD

There is reviewed the literature on the subject without presenting a personal series, and there are presented those reported in the literature.

CONCLUSIONS

Although there are a lot of studies that try to know the origin and nature of Tourette's syndrome, as well as the response of tics to the action of old and new drugs, it seems that we still have a long way to walk before finding solutions for the several diagnostic and therapeutic problems of this picture.

[Attention deficit hyperactivity syndrome and the capacity to practice sports]

OBJECTIVE

To know the sportive activities of children and adolescents, males, with attention deficit-hyperactivity disorder (ADHD).

PATIENTS AND METHODS

There were studied 100 patients, all males, with ages ranging 6 to 16 years (average: 9.28 years), 50 of the hospital and 50 of the private consultation. The subgroup of ADHD was identified in all patients. The patients were asked on the sports most usually made, although the response had to be confirmed by the parents.

RESULTS

Twenty-five cases showed attention deficit, 16 hyperactivity, and 59 combined form. If only one sport is to have had in consideration, football was the most practiced sport, with 20 cases. If a second sportive activity was also considered, cycling was the most practiced sport, with 29 cases, while only 23 patients played football (more than a 50% as goalkeeper) if we wanted the two first options. A less number of cases made basketball, swimming, judo or taekwondo, vasque ball and several others. Thirty three patients did not make any sport and most of them showed an unsporting attitude. Less than a half of the cases showed motivation to practice sport and less than a third was disciplined obeying the orders of the coach and/or the leader.

CONCLUSION

The patients with ADHD mostly show little motivation for the sport activities, being cycling and football (preferable as goalkeeper) the two most frequently practiced. The patients usually show little motivation and discipline.

[Joubert's syndrome. Presentation of two adult siblings with favorable evolution]

We present the case of two siblings with Joubert's syndrome. They had breathing problems of unknown origin during the neonatal period. Their evolution has been followed-up from the first years of age until the present. They are now 26 and 22 years old, respectively. Both patients have a "borderline" mental level, are apparently normal, but have had progressive evolution and psychic and motor improvement. They can read, write and use the four operations in mathematics and can work with the computer. Both siblings are working in the familial agriculture, can play football at an elemental level with other young people of their village, and ride a bicycle and motorcycle. Both patients show normal gait and have difficulty running. Their language is normal, although somewhat slow. They perform their personal self-care that includes independent bathing, independent dressing, independent toileting and independent shaving. Their contact with other people is good. They are shy with women. They manage money. They have good social integration. One patient has bilateral strabismus and the other has unilateral ptosis.

Síndrome de Williams-Beuren: presentación de 82 casos

OBJECTIVE

We performed a retrospective review of a series of 82 cases of Williams-Beuren syndrome (WBS) and associated diseases.

MATERIAL AND METHODS

A series of 82 patients (47 males and 35 females) who consulted at the hospital because of mental retardation and/or congenital cardiopathy were included. The patients were studied mainly from a neurological and cardiological point of view, and secondarily because of endocrinological and nephrological problems. Since description of the chromosomal abnormalities provoking the syndrome, we perform karyotyping in all patients with suspected WBS.

RESULTS

Alterations mainly consisted of distinctive facial appearance (100 %), mental retardation with friendly behavior (90 %), congenital cardiopathy (85.4 %), mostly consisting of supravalvular aortic stenosis (72 %), with (12 %) or without (60 %) pulmonary stenosis, and behavior typical of attention deficit-hyperactivity disorder, which usually manifested at the age of 4 to 5 years in both boys and girls. Approximately 90 % started to walk and speak later than average. Birthweight was below 3000 g in 65 % of the patients in whom this datum was included in the medical record. Eleven of the 13 patients (84.5 %) studied showed the typical deletion of WBS.

CONCLUSION

Study of patients with WBS should be multidisciplinary. Most patients require help during schooling and subsequent vocational guidance.

Cerebellar hypoplasia with heterotopic purkinje cells in the molecular layer and preservation of the granule layers associated with severe encephalopathy. A new entity?

We present the case of an infant girl, born to first cousins, with a clinical phenotype consisting of microcephaly, hypotonia, strabismus and severe psychomotor retardation. Magnetic resonance imaging (MRI) showed global cerebellar atrophy involving the vermis and both hemispheres. The patient's serum transferrin levels were consistently unremarkable. Cerebellar biopsy, performed at 13 months of age, revealed heterotopic Purkinje cells in the molecular layer, but preservation of the external and internal granular layers. To our knowledge, this histological pattern of cerebellar cortical disorganization has not been described previously. The consanguinity of the parents suggests an autosomal recessive inheritance.

[Congenital bilateral opercular syndrome. Presentation of three cases]

OBJECTIVE

To present three children with bilateral opercular syndrome and the associated pathology.

CASE REPORTS

We describe three patients, two of them are foster children, who have language problems, of chewing, of swallowing as well as continuous dribbling. Moreover, two case showed seizures that started at early age and were resisting to the antiepileptic medication. Motor deficit was disclosed in other two cases. The three patients were studied of the clinic, EEG and image point of view. The opercular bilateral syndrome diagnostic was made by the three dimensional magnetic resonance (3DMR) findings in the three cases. The images revealed open and large sylvian fissures and thickened insular cortex as well as polymicrogyria.

CONCLUSION

The opercular syndrome shows peculiar clinical symptoms, but the diagnosis is made by the 3DMR alterations.

[Unilateral cerebellar hypoplasia: an alteration of vascular origin?]

AIMS

To present nine cases of unilateral cerebellar hypoplasia and to show the clinical alterations and the possible etiology.

CASE REPORTS

A retrospective analysis of the clinical, radiological and perinatal features of a series of nine infantile cases with unilateral cerebellar hypoplasia was made. The unilateral cerebellar hypoplasia was demonstrated in all patients after computarized tomography or magnetic resonance (MR) studies. Angiographic study was performed in six patients, in most of them by MR arteriography, with demonstration of vascular anomalies in the cerebellar and/or vertebral arteries in most of the patients. However, other types of malformations of the posterior fossa were also observed: retrocerebellar cyst associated with obstruction of the aqueduct (two cases), cutaneous hemangioma or vascular malformation (two cases), and psychomotor retardation (five cases), being this last disturbance the most frequent clinical alteration.

CONCLUSIONS

The unilateral cerebellar hypoplasia is a relatively rare malformation and it is more frequently associated with psychomotor retardation than with cerebellar symptomatology. Hypoplasia or aplasia of the cerebellar arteries, of probable early intrauterine origin, would be the cause of this malformation.

[Proteus syndrome: report of two cases]

Proteus syndrome is a complex disorder, consisting of mesodermal and skeletal malformations as well as hamartomatous overgrowth. It is characterized by highly variable presentation and mosaic-pattern lesions. The two cases described herein illustrate the wide polymorphism of this syndrome. The second case also had a pubic fracture, which we have not previously seen reported in the medical literature on Proteus syndrome.

[Cutaneous hemangiomas, vascular malformations and associated disorders. A new neurocutaneous syndrome]

OBJECTIVE

Cutaneous hemangiomas and vascular malformations constitute a systemic disease that is the most frequent of the neurocutaneous syndromes reported to date. It appears more frequently in women than in men. The aim of this study was to describe the characteristics of this new neurocutaneous syndrome.

MATERIAL AND METHODS

We studied a large number of patients who presented cutaneous hemangiomas and/or vascular malformations located anywhere on the body. The patients underwent periodic clinical follow-up and imaging studies due to their aesthetic, functional and/or neurological problems.

RESULTS

Clinical evaluation revealed a wide range in the size and severity of cutaneous vascular lesions and in their relationship with various internal anomalies, which were almost always located in the areas underlying the cutaneous vascular lesions. Those situated in the head, face, neck and chest were first discovered and are the best known. The most frequent findings were cerebellar malformations, persistence of the trigeminal artery, absence of the carotid or vertebral arteries and congenital heart disease. Many of the patients with this syndrome had mental retardation or borderline mental retardation.

CONCLUSIONS

This disorder appears more frequently in females than in males. It is the most recently described neurocutaneous syndrome and is also the most prevalent. This syndrome is associated with numerous disorders that can be located in the areas underlying the cutaneous vascular lesions anywhere on the body. Cutaneous hemangiomas and subjacent hemangiomatous tumors, like other associated vascular abnormalities, can show a parallel, spontaneous increase or decrease in size without treatment. Complete occlusion of the vessels can occur while vascular malformations show no progression or involution. This new neurocutaneous syndrome is also known as Pascual-Castroviejo type II syndrome and PHACE.

[Extracranial and intracranial vascular abnormalities and nevus of Ota in the same family]

We present a 17 year old patient suffering from hemangioma on the left side of his face and neck. The evolution of his disease has been followed-up since he was 8 1/2 months old. His mother has nevus of Ota in the sclera and adjacent zones in both sides. At the age of 8 1/2 months, the patient had an ischemic stroke in the territory of the left middle cerebral artery during the surgical correction of the aortic arch coarctation. The conventional arteriogram performed at 10 months of life showed several malformations of the intracranial and extracranial arteries. At the age of 16 years the cutaneous hemangioma was atrophic and a new angiographic study by magnetic resonance arteriography (MRA) showed all the vascular anomalies with higher objectivity than the conventional arteriography, especially the absence of some arteries and the abnormal position of some others. Moreover it could detect the decrease of the caliber of the intracranial arteries and the disappearance of hemangiomatous malformations even though the patient had not received any treatment for the cutaneous hemangioma. We think that this syndrome, which still has no definite name, has a parallel spontaneous biological process with progressing vascular size during the first months or years of life and, later, the vessels regress slowly but progressively, leading to a small caliber or even the occlusion of the vessels of the cutaneous hemangioma and of the abnormal extracranial and intracranial arteries. At the same time, there is a slow but progressive presence of transdural collateral vascularization of the brain. We do not find any relationship between the hemangiomatous syndrome of the patient and the nevus of Ota of his mother.

[Symbiosis between paediatric neurology and neuropsychology: personal experience and the current panorama]

OBJECTIVE

To show the possibilities of child neurologist and neuropsychologist to share the work on many patients with neurological and behavioral pathologies.

METHOD

Child neurologists and neuropsychologists have an important work to share in the future. Every expert must know what type of disease corresponds to the knowledge acquired during the studies in the University School as well as to the functions permitted by the authorities, always thinking to get the best results to the patients, the families and the surrounding people.

[Effects of corticosteroids in the management of Duchenne muscular dystrophy: our experience]

Objective To evaluate the clinical course in patients with Duchenne muscular dystrophy admitted to our department who received corticosteroid treatment and to compare their course with that in patients who did not receive corticosteroid treatment.Patients and methodsWe performed a retrospective study of 20 pediatric patients with a diagnosis of Duchenne muscular dystrophy who were offered corticosteroid treatment: 10 patients received deflazacort and 10 refused the treatment. The MRC muscular strength scale and Vignos' functional scale were used to evaluate clinical course, which was compared in both groups.ResultsUntreated patients showed progressive worsening. Corticosteroid-treated patients showed disease stabilization both in muscular strength and functional performance. In addition, muscular balance improved in 70 % of these patients, but only 2 % showed functional improvement. The positive effect of steroid treatment had a mean duration of 12 months. Loss of independent gait occurred at similar ages in both groups (10.3 vs. 10.5 years). The results of Achilles' tendon surgery were poor.ConclusionsCorticosteroids produced clinical stabilization and improved muscular strength. Functional improvement was not significant, including loss of gait, probably because this loss also depends on an increase in joint contracture. Good coordination among multiprofessional teams is essential to achieve optimal results.

[Hemangiomas, and cutaneous and intracranial vascular deformations (Pascual-Castroviejo syndrome tipe II ). A case report]

OBJECTIVE

To present a case with several cutaneous hemangiomas associated with intracranial hemangiomas and possibly with an intrahepatic hemangioma.

CASE REPORT

A boy, 17 months old, showing several cutaneous hemangiomas and epileptic seizures resisting to antiepileptic medication, who also presented psychomotor retardation. The study by angiographic magnetic resonance (AMR ) revealed the presence of three small intracranial angiomas and possibly a hepatic hemangioma. The seizures were controlled with antiepileptic medication.

CONCLUSION

This case shows the association of the cutaneous hemangiomas and the subjacent vascular alterations also hemangiomas in this patient which are included in the most frequent neurocutaneous disease, which is known as Pascual Castroviejo syndrome.

Congenital vascular malformations in childhood

Congenital vascular malformations are an important group of vascular anomalies that occur very early in the pregnancy. Most of these malformations occur between the third and the seventh weeks of the embryonic development. Malformations can affect the arteries, veins, capillaries, and venous sinuses, involving an isolated vessel or a part of the vascular system. There are malformations that affect the vessel size or course, and others that show pathology of the wall anatomy of the vessel. Magnetic resonance angiography (MRA) is improving the study conditions of this pathology. Treatment of most of the vascular malformations--some of them giving clinical symptoms during adulthood--still constitutes a challenge.

Cobb syndrome: case report

We present a 7-year-old boy in whom cutaneous hemangioma and intramedullary and paraspinal arteriovenous malformations were associated. Magnetic resonance arteriography revealed the presence of the two arterovenous malformations, and the selective intercostal arteriography demonstrated that the intraspinal and paraspinal arteriovenous malformations were supplied by the same intercostal arteries. Rubbing the back was required to detect the cutaneous changes, which were only suspected by casual inspection.

[Comorbid disorders of the attention deficit with hyperactivity disorder]

OBJECTIVE

To show the comorbid pathology associated with the attention deficit/hyperactivity disorder (ADHD) during the pediatric and adult ages.

PATIENTS AND METHODS

We use the disorders included by the international literature as the most frequents. There are included as main disorders: problems of affectivity, learning disabilities, dyslexia, vehicle driving problems, anxiety, bipolar disorder, motor coordination problems, tics and Tourette syndrome, oppositional defiant disorder, impulsive aggressive, antisocial behavior, and predisposition to delinquency, and to be alcohol and drugs abusers.

CONCLUSION

The presence of comorbid disorders in the ADHD may show a higher severity of the disorder which makes that many of these subjects to be predisposed to be in contact with psychiatrics, policemen and justice during the entire life.

[Cutaneous haemangioma associated with a hepatic haemangioma and neurofibromatosis type 1 (NF1)]

OBJECTIVE

To present a girl with cutaneous cavernous hemangioma associated with hemangioma of the liver and neurofibromatosis type 1 (NF1).

PATIENTS AND METHODS

A 3 year old girl showed cutaneous cavernous hemangioma on the right hypochondral region and numerous caf au lait spots. She was studied with abdominal echography and abdominal and thoracic magnetic resonance (MR) as well as with cerebral MR angiography.

RESULTS

Both image studies, echography and MR, revealed a mass 2 x 2 cm of hemangiomatous type in the upper zone of the liver, near the external cutaneous cavernous hemangioma. Echographical follow up showed a progressive diminution of the hepatic hemangioma size. At 2 1/2 years of age a voluminous thoracic tumor extending between aorta and sternon very difficult of being removed was found.

CONCLUSION

Hemangioma of the liver appears to be related with cutaneous cavernous hemangioma as a finding of the syndrome of Pascual Castroviejo II. Furthermore, the patient has NF1 which has not been previously related with the cutaneous and/or the liver pathology.

[Disorders of the nervous system and alteration of the fundus oculi]

OBJECTIVE

To show the neurological disorders associated with ocular changes mainly affecting retina and which can be seen during the first year of age.

DEVELOPMENT

It is used the personal experience and the reported papers of the literature related with the subject to make a short review of the main neurological, biochemical, radiological and genetical alterations as well as the peculiarities of the lesions that we can see by the ocular fundus exploration, and we try to show through images the retinal alterations associated with the neurological diseases of very young children.

CONCLUSION

The retinal alterations that we can see by ocular fundus exploration can lead us to an early neurological diagnosis.

T-STAR gene: fine mapping in the candidate region for childhood absence epilepsy on 8q24 and mutational analysis in patients

Childhood absence epilepsy (CAE) is one of the most common epilepsies in children. At least four phenotypic subcategories of CAE have been proposed. Among them, a subtype persisting with tonic-clonic seizures has been mapped to 8q24 (ECA1 MIM 600131). By constructing a physical map for the 8q24 region, we recently narrowed the ECA1 locus to a 1.5-Mb region. In the present communication, we show that T-STAR gene is located within the ECA1 region. T-STAR is a novel member of STAR (for signal transduction and activation of RNA) family, and is predicted to encode a spermatogenesis related RNA-binding protein. T-STAR is located within the markers D8S2049 and D8S1753 and its complete coding region spans nine exons. In addition to its known expression in testis, moderate level of transcripts for T-STAR gene was detected in brain, heart and is highly abundant in skeletal muscle. Mutational analysis for the T-SATR gene in CAE families did not show any sequence variation in the coding region, and this suggests that the T-STAR gene is not involved in the pathogenesis of persisting CAE. However, genomic organization of T-STAR gene characterized in the present report might help in understanding the biological functions of T-STAR as well as its suspected involvement in other disorders mapped on this region.