Schizencephaly: association with young maternal age, alcohol use, and lack of prenatal care

Schizencephaly Associated With Bipolar Affective Disorder

Schizencephaly is a rare congenital anomaly characterized by the formation of abnormal clefts in the brain. Despite the association of psychotic symptoms with various brain abnormalities or insults, their occurrence in individuals with schizencephaly is relatively infrequent. The association of bipolar disorder, with or without psychosis, with schizencephaly is rarer. A systematic search on PubMed using "Schizencephaly AND Bipolar Disorder" yielded only four case studies specifically addressing the connection between these two conditions. Here, we present a case of a 22-year-old male patient with a history of childhood seizures who developed first episode psychosis along with manic symptoms and was found to have closed-lip schizencephaly.

Epilepsy-associated open-lip schizencephaly with arachnoid cyst: a rare case report

Background

Schizencephaly is a rare congenital cerebral malformation characterized by clefts in the cerebral cortex. The traction effect and splitting of leptomeninges caused by schizencephaly potentially formed an arachnoid cyst.

Case presentation

We present a case of an 18-year-old male with history of several episodes of complex partial seizure over the last 2 months, with an electroencephalogram signified an epileptic form in the right temporal lobe. Brain magnetic-resonance imaging revealed an arachnoid cyst in the right temporal fossa and a grey matter-lined right temporal cleft consistent with open-lip schizencephaly. To the best of authors’ knowledge, only two previous similar cases have been reported in 1997. Our patient underwent cystoperitoneal shunt and was given double anti-epileptic agents, which successfully resolved and prevented the seizure episode during further follow-up.

Conclusion

New onset of seizure-associated schizencephaly in adult are very rare. In this case, space-occupying lesions effects from the enlarged arachnoid cysts caused seizure, which resolved after the cystoperitoneal shunt and double anti-epileptic agents.

Sudden Unexpected Death in Epilepsy: A Report of Three Commonly Encountered Anatomic Findings in the Forensic Setting With Recommendations for Best Practices

ABSTRACT

Sudden unexplained death in epilepsy (SUDEP) is the most common cause of death in children and young adults with epilepsy with epileptic patients harboring a 27 times increased risk of death from SUDEP. Structural brain lesions are encountered in up to 50% of autopsy cases. In this case series, we report 3 previously undiagnosed structural causes of SUDEP discovered at autopsy at our institution including schizencephaly, ganglioglioma, and focal cortical dysplasia. Our major recommendation is in cases with suspected SUDEP, formal neuropathological examination and tissue sampling should be employed to identify and characterize specific potential anatomic etiologies.

Bilateral open lip schizencephaly

Schizencephaly is a central nervous system (CNS) developmental disorder characterized by abnormal cleft extending from the lateral ventricles to the cerebral cortex. Clinically, it occurs as trans-mantle, closed lip and open lip types which may be unilateral or bilateral. The exact cause of schizencephaly is not known but genetic disorders, exposure to teratogens, viral infections and maternal age are implicated. We present a case of bilateral open lip schizencephaly with some degrees of neurological disorders caused by increased intra-cranial pressure (ICP) due to ventriculomegaly. We applied ventriculo-peritoneal shunt (V-P shunt) to the patient with considerable improvement after post-operative follow-up.

Traumatic epidural hematoma in a patient with severe schizencephaly

Schizencephaly is a rare congenital brain structural abnormality that is not clearly understood and has no specific treatment yet. Therefore, cases related to it should be added to the literature. This report aims to introduce a rare case of severe schizencephaly co-occurring with post-traumatic intracranial epidural hematoma.

Fetal Ultrasound and Magnetic Resonance Imaging Findings in Suspected Septo-Optic Dysplasia: A Diagnostic Dilemma

OBJECTIVES

To investigate prenatal imaging findings supporting a diagnosis of suspected septo-optic dysplasia (SOD) by fetal ultrasound (US), magnetic resonance imaging (MRI), or both.

METHODS

A retrospective review identified 11 patients with SOD: 9 had a clinical diagnosis of SOD postnatally, and 2 were terminated on the basis of suspicious prenatal imaging. Prenatal and neonatal imaging of the cavum septi pellucidi (CSP), frontal horns (FHs), and lateral ventricles was evaluated.

RESULTS

The appearance of the CSP varied on US and MRI. Complete ("fused") FHs or partial absence of the CSP was reported in 6 of 11 patients by fetal US and 7 of 8 patients by fetal MRI. The diagnosis of SOD was prospectively suspected prenatally in 6 of 11 and in an additional 5 of 11 cases retrospectively. Fetal MRI incorrectly initially reported normal morphologic abnormalities for 2 cases with partial absence of the CSP, whereas US accurately identified the morphologic abnormalities in 1 of these cases before MRI. Imaging features were first suggested at anatomic US (4 patients) and follow-up prenatal US (2 patients). Neonatal imaging was concordant in all 9 live births: 5 completely absent CSP, 3 partially absent CSP, and 1 completely present CSP. Clinical manifestations included optic nerve hypoplasia (9 of 9), panhypopituitarism (5 of 9), and neurodevelopmental delays.

CONCLUSIONS

Primary imaging features of SOD are "continuous" FHs with complete or partial absence of the CSP. Septo-optic dysplasia can be suspected in utero and can appear isolated but has substantial associated central nervous system anomalies identified on fetal MRI or after birth. Partial absence of the CSP can be a prenatal sign of suspected SOD, although fetal MRI lacked the spatial resolution to identify it accurately in all cases.

Maternal anemia and pediatric neurological morbidity in the offspring - Results from a population based cohort study

OBJECTIVE

Maternal anemia (Hemoglobin, <11 mg/dl) has been shown to affect fetal growth and pregnancy outcome. We aimed to study a possible association between maternal anemia and the risk for neurological morbidity in the offspring, during a follow-up period of up to 18 years.

STUDY DESIGN

A population-based cohort analysis was performed at the Soroka University Medical Center (SUMC), a single regional tertiary center comparing total and specific subtypes of neurological morbidities associated with hospitalizations among children stratified by three maternal post-partum hemoglobin categories: ≥11 mg/dl (no anemia); 11.0 mg/dl > Hb ≥ 7 mg/dl (mild-to-moderate anemia) and <7 mg/dl (severe anemia). Data on pregnancy course and outcome, and later offspring hospitalizations, were compared between the three study groups. All singleton deliveries between the years 1991-2014 were included in the analysis, and congenital malformations were excluded. A Kaplan-Meier survival curve was used to compare cumulative hospitalization incidence based on maternal anemia status, and a Weibull survival multivariable hazard model was constructed to adjust for confounding variables.

RESULTS

The study population included 217,358 deliveries of which 50.6% were in mothers who were not anemic, 49.0% in mothers with moderate anemia and 0.4% in mothers with severe anemia. During the follow up period (0-18 years, median 10.22 years), 2.1% of offspring were hospitalized with a neurological diagnoses. Neurological hospitalization incidence decreased from 2.95/1000 person years, in the severe anemia group, to 2.32/1000 person years and 2.01/1000 person years, among the mild-to-moderate and no anemia groups, respectively (p = 0.007). The association between maternal anemia and offspring long-term pediatric neurological morbidity remained significant in a Weibull hazards model controlled for gestational age, delivery mode, SGA and insufficient prenatal care (adjusted HR 1.55; 1.05-2.31 and adjusted HR 1.13; 1.06-1.20; among the severe and mild-to-moderate anemia, vs. no anemia, respectively).

CONCLUSION

Children born to anemic mothers are at an increased risk for pediatric neurological-related hospitalizations.

Malformations of cortical development

Malformations of cortical development (MCDs) compose a diverse range of disorders that are common causes of neurodevelopmental delay and epilepsy. With improved imaging and genetic methodologies, the underlying molecular and pathobiological characteristics of several MCDs have been recently elucidated. In this review, we discuss genetic and molecular alterations that disrupt normal cortical development, with emphasis on recent discoveries, and provide detailed radiological features of the most common and important MCDs. Ann Neurol 2016;80:797-810.

Successful surgery for refractory seizures associated with bilateral schizencephaly: two case reports and literature review

Schizencephaly is a rare malformation of cortical development resulting from cell migration defects that occur unilaterally or bilaterally. The type of the schizencephalic cleft can be open lip or closed lip. Patients suffering from refractory seizures secondary to schizencephaly should be considered for surgical treatment. In this paper, we retrospectively analyzed two patients with confirmed schizencephaly and intractable seizures. The evaluation methods included a medical history assessment, a neurological examination and magnetic resonance imaging (MRI). Continuous intracranial video-electroencephalogram (vEEG) monitoring with surface electrodes and deep electrodes was evaluated to confirm the epileptogenic zones associated with the schizencephalic lesions. Cortical electrical stimulation was performed to evaluate the neurophysiology of the relevant brain regions. Epileptic focus resection was performed close to the schizencephalic cleft according to the results of intracranial EEG and stimulation while preserving neurological functions. MRI revealed bilateral open lip schizencephaly in one patient and closed lip schizencephaly in the other patient. The epileptogenic zones were localized close to the schizencephalic clefts. The seizure outcome was Engel's class Ia in both patients at 1-year follow-up. No significant neurological deficits were found, and their activities of daily life were significantly improved. We conclude that abnormal cortex near the schizencephalic clefts may display an extrinsic epileptogenicity. Accurate localization of the epileptogenic zones using intracranial EEG and electrical stimulation can lead to a seizure-free outcome in patients with refractory epilepsy associated with schizencephaly.

Right Homonymous Hemianopia: A Clinical Case Report of Schizencephaly

Purpose

To report a case of a 56-year-old male with right homonymous hemianopia.

Methods

Retrospective descriptive study of a case report based on information from clinical records, patient observation and analysis of complementary diagnostic tests.

Results

An asymptomatic 56-year-old male presented to our hospital for a routine ophthalmic examination. The best-corrected visual acuity was 20/20 in the right eye (RE) and in the left eye (LE). Pupillary function, intraocular pressure, external segment examinations and slit-lamp biomicroscopy were normal, bilaterally. Fundoscopy showed a cup-to-disc (C/D) ratio in the RE of 0.3 and of 0.4 in the LE. Retinal nerve fiber layer (RNFL) thickness measured by spectral domain optical coherence tomography revealed thinning of the superior, temporal and nasal RNFL in the RE and thinning of the superior, inferior and temporal RNFL in the LE. Automated static perimetry showed right homonymous hemianopia. Brain computed tomography (CT) showed an open-lip schizencephaly with a significant reduction of the left brain parenchyma.

Conclusions

Despite the large visual defect, the patient was unaware of it and had an active professional life. This is an interesting case because despite the extensive morphological abnormalities seen on brain CT there is a relatively small functional repercussion.

Prenatal Diagnosis and Postnatal Outcome of Schizencephaly

The aim of this study was to present our experience with 5 cases of fetal schizencephaly in terms of prenatal diagnostic features, and postnatal outcome. The database of prenatal diagnosis unit was searched for antenatally diagnosed cases with schizencephaly. Maternal characteristics, ultrasonography, prenatal-postnatal magnetic resonance imaging (MRI) findings, and postnatal outcome were noted. Of 5 cases, 2 had definitive prenatal diagnoses on ultrasound and 3 cases were diagnosed by fetal MRI. All cases had cerebral cortical migration anomalies including polymicrogyria, subependymal heterotopia, and lissencephaly, and 2 cases had additional extracranial malformations. Three cases showed regression of the cerebral clefts on follow-up postnatal MRIs. Three cases had moderate to severe psychomotor retardation, and 1 case needed repeated ventriculoperitoneal shunt operation due to hydrocephaly. Prenatal diagnosis of schizencephaly with ultrasonography is not straightforward and required further evaluation with fetal MRI. Additional cerebral anomalies worsen the prognosis of schizencephaly.

Malformations of cortical development and epilepsy

Malformations of cortical development (MCDs) are an important cause of epilepsy and an extremely interesting group of disorders from the perspective of brain development and its perturbations. Many new MCDs have been described in recent years as a result of improvements in imaging, genetic testing, and understanding of the effects of mutations on the ability of their protein products to correctly function within the molecular pathways by which the brain functions. In this review, most of the major MCDs are reviewed from a clinical, embryological, and genetic perspective. The most recent literature regarding clinical diagnosis, mechanisms of development, and future paths of research are discussed.

The expanding phenotype of COL4A1 and COL4A2 mutations: clinical data on 13 newly identified families and a review of the literature

Two proα1(IV) chains, encoded by COL4A1, form trimers that contain, in addition, a proα2(IV) chain encoded by COL4A2 and are the major component of the basement membrane in many tissues. Since 2005, COL4A1 mutations have been known as an autosomal dominant cause of hereditary porencephaly. COL4A1 and COL4A2 mutations have been reported with a broader spectrum of cerebrovascular, renal, ophthalmological, cardiac, and muscular abnormalities, indicated as "COL4A1 mutation-related disorders." Genetic counseling is challenging because of broad phenotypic variation and reduced penetrance. At the Erasmus University Medical Center, diagnostic DNA analysis of both COL4A1 and COL4A2 in 183 index patients was performed between 2005 and 2013. In total, 21 COL4A1 and 3 COL4A2 mutations were identified, mostly in children with porencephaly or other patterns of parenchymal hemorrhage, with a high de novo mutation rate of 40% (10/24). The observations in 13 novel families harboring either COL4A1 or COL4A2 mutations prompted us to review the clinical spectrum. We observed recognizable phenotypic patterns and propose a screening protocol at diagnosis. Our data underscore the importance of COL4A1 and COL4A2 mutations in cerebrovascular disease, also in sporadic patients. Follow-up data on symptomatic and asymptomatic mutation carriers are needed for prognosis and appropriate surveillance.

Schizencephaly-diagnostics and clinical dilemmas

BACKGROUND

Schizencephaly is an uncommon congenital disorder of cerebral cortical development. The defect is characterized by the presence of a cleft in the brain extending from the surface of the pia mater to the cerebral ventricles. The margins of the cleft are lined with heterotropic, dysplastic gray matter. The causes of schizencephaly are heterogeneous and can include teratogens, prenatal infection, maternal trauma, or EMX2 mutations.

METHOD

In the present paper, the authors described difficulties in employing diagnostic imaging in differentiating between type II (open-lip) schizencephaly and much more common intracranial fluid spaces of a different origin (arachnoid cysts and hydrocephalus).

RESULT

In all the three cases, the treatment consisted in implantation of a shunt system; nevertheless, it should be emphasized that a surgical intervention in the third presented case (type II schizencephaly) aimed at relieving the symptoms of intracranial hypertension-a directly life-threatening condition-since shunting is not a method of treating schizencephaly itself.

CONCLUSIONS

Although proper interpretation of the character of intracranial fluid spaces is of significance for further therapeutic management, yet, the key decision as to the surgical intervention is made based on clinical presentation, predominantly on symptoms of intracranial hypertension.

Polymicrogyria: a common and heterogeneous malformation of cortical development

Polymicrogyria (PMG) is one of the most common malformations of cortical development. It is characterized by overfolding of the cerebral cortex and abnormal cortical layering. It is a highly heterogeneous malformation with variable clinical and imaging features, pathological findings, and etiologies. It may occur as an isolated cortical malformation, or in association with other malformations within the brain or body as part of a multiple congenital anomaly syndrome. Polymicrogyria shows variable topographic patterns with the bilateral perisylvian pattern being most common. Schizencephaly is a subtype of PMG in which the overfolded cortex lines full-thickness clefts connecting the subarachnoid space with the cerebral ventricles. Both genetic and non-genetic causes of PMG have been identified. Non-genetic causes include congenital cytomegalovirus infection and in utero ischemia. Genetic causes include metabolic conditions such as peroxisomal disorders and the 22q11.2 and 1p36 continguous gene deletion syndromes. Mutations in over 30 genes have been found in association with PMG, especially mutations in the tubulin family of genes. Mutations in the (PI3K)-AKT pathway have been found in association PMG and megalencephaly. Despite recent genetic advances, the mechanisms by which polymicrogyric cortex forms and causes of the majority of cases remain unknown, making diagnostic and prenatal testing and genetic counseling challenging. This review summarizes the clinical, imaging, pathologic, and etiologic features of PMG, highlighting recent genetic advances.