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Cinalli G, Di Martino G, Russo C, Cristofano A, Picariello S, Cinalli MA, Mirone G, Mazio F, Quarantelli M, Spennato P, Covelli E. Jugular foramen stenosis in external hydrocephalus in infants. Childs Nerv Syst 2024:10.1007/s00381-024-06414-8. [PMID: 38642112 DOI: 10.1007/s00381-024-06414-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Accepted: 04/14/2024] [Indexed: 04/22/2024]
Abstract
OBJECTIVE To measure the size of jugular foramina in infants affected by external hydrocephalus (EH) and in a control group, to support the hypothesis that a jugular foramen (JF) stenosis may determine dural venous sinus alterations and increased venous outflow resistance as main pathophysiological factor. METHODS Minimum, maximum, and mean values of JF areas were measured in a series of phase-contrast magnetic resonance venous angiography (angio MRV PCA3D) performed on 81 infants affected by EH. Results were compared with a group of 54 controls. RESULTS Smaller JF area was significantly smaller in patients versus controls (43.1 ± 14.6 vs. 52.7 ± 17.8; p < 0.001) resulting in a significantly smaller mean JF areas in patients vs. controls (51.6 ± 15.8 vs. 57.0 ± 18.3; p = 0.043). In patients, smaller JF areas were significantly associated with higher venous obstruction grading score (VOGS) both on the right (p = 0.018) and on the left side (p = 0.005). Positional plagiocephaly (cranial vault asymmetry index > 3.5%) was more frequent among EH patients than controls (38/17) but the difference was not significant (p = 0.07). In the 38 plagiocephalic patients, JF area was smaller on the flattened side than the contralateral in a significant number of cases both in right (21/7) and left (9/1) plagiocephaly (p < 0.0005) as well as the mean area (48.2 + 16.4 mm2 vs. 57.5 + 20.7 mm2, p = 0.002) and VOGS was significantly higher on the plagiocephalic side than on the contralateral side (1.6 ± 1.1 vs. 1.1 ± 0.9, p = 0.019). CONCLUSION In this series of infants affected by EH, the mean size of the ostium of both JF resulted significantly smaller than controls. JF stenosis was significantly associated with higher degrees of venous obstruction on both sides, suggesting a direct extrinsic effect of JF size on dural sinus lumen and possible consequent effect on venous outflow resistance. Positional plagiocephaly, when present, was associated with a decreased JF area and increased VOGS on the flattened side.
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Affiliation(s)
- Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy.
| | - Giuliana Di Martino
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy
| | - Carmela Russo
- Pediatric Neuroradiology, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy
| | - Adriana Cristofano
- Pediatric Neuroradiology, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy
| | - Stefania Picariello
- Pediatric Neuro-Oncology, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy
| | | | - Giuseppe Mirone
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy
| | - Federica Mazio
- Pediatric Neuroradiology, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy
| | - Mario Quarantelli
- Biostructure and Bioimaging Institute, National Research Council, Naples, Italy
| | - Pietro Spennato
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy
| | - Eugenio Covelli
- Pediatric Neuroradiology, Santobono-Pausilipon Children's Hospital (AORN), Naples, Italy
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Skadorwa T, Skadorwa J, Wierzbieniec O. The Accuracy of Classification Systems in Nonsyndromic Sagittal Craniosynostosis. J Craniofac Surg 2024; 35:13-17. [PMID: 37639642 PMCID: PMC10749678 DOI: 10.1097/scs.0000000000009670] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 06/28/2023] [Indexed: 08/31/2023] Open
Abstract
Numerous classification systems of nonsyndromic sagittal craniosynostosis (NSC) are applied but none has gained a wide acceptance, since each classification is focused on distinct aspects. The aim of the study was to assess the accuracy of 4 classifications of NSC discussed in the literature by defining the associations among the classifications, individual features (sex, age, cranial index), and objective morphologic criteria (frontal bossing, retrocoronal constriction, sagittal ridge, and occipital bulleting). The study was conducted on anonymized thin-cut CT scans of 133 children with NSC 1 to 12 months old (mean age 5.42 mo). The type of cranial dysmorphology was assessed using 4 classification systems, focusing on skull shape, pattern of sagittal suture closure (Heuzé classification), deformation of skull vault (Sakamoto classification), and a single-dominant feature (David classification). Each patient was also independently investigated for the presence of morphologic criteria. A multivariate analysis was performed to explore the relations among the classifications and assess their accuracy. In the analyzed cohort sphenocephaly (38.3%), CFF type by Heuzé (30.8%), type I by Sakamoto (72.9%), and a central type by David (42.9%) were dominant findings. Regarding the morphologic criteria, frontal bossing was observed the most frequently (91.7%). The age of patients and cranial index differed significantly among the shapes of skull and David classifications ( P <0.001). The shape-based system showed the strongest correlation with other classifications and with measurable variables. Other classifications have much in common and some overlap, but none of them constitutes a standalone system to define all aspects of cranial dysmorphology in NSC.
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Affiliation(s)
- Tymon Skadorwa
- Department of Pediatric Neurosurgery, Bogdanowicz Memorial Hospital for Children
- Department of Descriptive and Clinical Anatomy, The Medical University of Warsaw
| | | | - Olga Wierzbieniec
- Department of Descriptive and Clinical Anatomy, The Medical University of Warsaw
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Garic D, McKinstry RC, Rutsohn J, Slomowitz R, Wolff J, MacIntyre LC, Weisenfeld LAH, Kim SH, Pandey J, St. John T, Estes AM, Schultz RT, Hazlett HC, Dager SR, Botteron KN, Styner M, Piven J, Shen MD. Enlarged Perivascular Spaces in Infancy and Autism Diagnosis, Cerebrospinal Fluid Volume, and Later Sleep Problems. JAMA Netw Open 2023; 6:e2348341. [PMID: 38113043 PMCID: PMC10731509 DOI: 10.1001/jamanetworkopen.2023.48341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 11/03/2023] [Indexed: 12/21/2023] Open
Abstract
Importance Perivascular spaces (PVS) and cerebrospinal fluid (CSF) are essential components of the glymphatic system, regulating brain homeostasis and clearing neural waste throughout the lifespan. Enlarged PVS have been implicated in neurological disorders and sleep problems in adults, and excessive CSF volume has been reported in infants who develop autism. Enlarged PVS have not been sufficiently studied longitudinally in infancy or in relation to autism outcomes or CSF volume. Objective To examine whether enlarged PVS are more prevalent in infants who develop autism compared with controls and whether they are associated with trajectories of extra-axial CSF volume (EA-CSF) and sleep problems in later childhood. Design, Setting, and Participants This prospective, longitudinal cohort study used data from the Infant Brain Imaging Study. Magnetic resonance images were acquired at ages 6, 12, and 24 months (2007-2017), with sleep questionnaires performed between ages 7 and 12 years (starting in 2018). Data were collected at 4 sites in North Carolina, Missouri, Pennsylvania, and Washington. Data were analyzed from March 2021 through August 2022. Exposure PVS (ie, fluid-filled channels that surround blood vessels in the brain) that are enlarged (ie, visible on magnetic resonance imaging). Main Outcomes and Measures Outcomes of interest were enlarged PVS and EA-CSF volume from 6 to 24 months, autism diagnosis at 24 months, sleep problems between ages 7 and 12 years. Results A total of 311 infants (197 [63.3%] male) were included: 47 infants at high familial likelihood for autism (ie, having an older sibling with autism) who were diagnosed with autism at age 24 months, 180 high likelihood infants not diagnosed with autism, and 84 low likelihood control infants not diagnosed with autism. Sleep measures at school-age were available for 109 participants. Of infants who developed autism, 21 (44.7%) had enlarged PVS at 24 months compared with 48 infants (26.7%) in the high likelihood but no autism diagnosis group (P = .02) and 22 infants in the control group (26.2%) (P = .03). Across all groups, enlarged PVS at 24 months was associated with greater EA-CSF volume from ages 6 to 24 months (β = 4.64; 95% CI, 0.58-8.72; P = .002) and more frequent night wakings at school-age (F = 7.76; η2 = 0.08; P = .006). Conclusions and Relevance These findings suggest that enlarged PVS emerged between ages 12 and 24 months in infants who developed autism. These results add to a growing body of evidence that, along with excessive CSF volume and sleep dysfunction, the glymphatic system could be dysregulated in infants who develop autism.
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Affiliation(s)
- Dea Garic
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Robert C. McKinstry
- Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, Missouri
| | - Joshua Rutsohn
- Department of Biostatistics, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | | | - Jason Wolff
- Department of Educational Psychology, University of Minnesota Twin Cities College of Education and Human Development, Minneapolis
| | - Leigh C. MacIntyre
- McGill Centre for Integrative Neuroscience, Montreal Neurological Institute-Hospital, McGill University, Montreal, Canada
| | - Leigh Anne H. Weisenfeld
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Sun Hyung Kim
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Juhi Pandey
- Center for Autism Research, Children’s Hospital of Philadelphia, University of Pennsylvania Perelman School of Medicine, Philadelphia
| | - Tanya St. John
- Department of Speech and Hearing Science, University of Washington, Seattle
- University of Washington Autism Center, University of Washington, Seattle
| | - Annette M. Estes
- Department of Speech and Hearing Science, University of Washington, Seattle
- University of Washington Autism Center, University of Washington, Seattle
| | - Robert T. Schultz
- University of Washington Autism Center, University of Washington, Seattle
| | - Heather C. Hazlett
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Stephen R. Dager
- Department of Radiology, University of Washington Medical Center, Seattle
| | - Kelly N. Botteron
- Department of Psychiatry, Washington University School of Medicine in St Louis, St Louis, Missouri
| | - Martin Styner
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Joseph Piven
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | - Mark D. Shen
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
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Skadorwa T, Wierzbieniec O, Sośnicka K, Podkowa K. Radiomorphologic profiles of nonsyndromic sagittal craniosynostosis. Childs Nerv Syst 2023; 39:3225-3233. [PMID: 37243812 PMCID: PMC10643241 DOI: 10.1007/s00381-023-05998-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/18/2023] [Indexed: 05/29/2023]
Abstract
PURPOSE Numerous classification systems of nonsyndromic sagittal craniosynostosis (NSC) are applied but none has gained a wide acceptance, since each classification is focused on distinct aspects of cranial dysmorphology. The goal of this study was to depict the most common combinations of radiomorphologic characteristics of NSC and to separate groups where the patients were morphologically similar to one another and at the same time significantly different from others. METHODS The study was conducted on anonymized thin-cut CT scans of 131 children with NSC aged 1-12 months (mean age 5.42 months). The type of cranial dysmorphology was assessed using four criteria: skull shape, pattern of sagittal suture fusion, morphologic features and cerebrospinal fluid (CSF) spaces alterations. After assigning the categories, an unsupervised k-modes clustering algorithm was applied to identify distinct patients clusters representing radiomorphologic profiles determined by investigated characteristics. RESULTS Cluster analysis revealed three distinct radiomorphologic profiles including the most common combinations of features. The profiles were not influenced by sex nor age but were significantly determined by skull shape (V = 0.58, P < 0.0001), morphologic features (V = 0.50, P < 0.0001) and pattern of sagittal suture fusion (V = 0.47, P < 0.0001). CSF alterations did not significantly correlate with the profiles (P = 0.3585). CONCLUSION NSC is a mosaic of radiologic and morphologic features. The internal diversity of NSC results in dissimilar groups of patients defined by unique combinations of radiomorphologic characteristics, from which the skull shape is the most differentiating factor. Radiomorphologic profiles support the idea of clinical trials targeted at more selective outcomes assessment.
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Affiliation(s)
- Tymon Skadorwa
- Department of Pediatric Neurosurgery, Bogdanowicz Memorial Hospital for Children, 4/24 Nieklanska St, 03924, Warsaw, Poland.
- Department of Descriptive and Clinical Anatomy, The Medical University of Warsaw, 5 Chalubinskiego St, 02004, Warsaw, Poland.
| | - Olga Wierzbieniec
- Department of Descriptive and Clinical Anatomy, The Medical University of Warsaw, 5 Chalubinskiego St, 02004, Warsaw, Poland
| | - Kamila Sośnicka
- Department of Descriptive and Clinical Anatomy, The Medical University of Warsaw, 5 Chalubinskiego St, 02004, Warsaw, Poland
| | - Klaudia Podkowa
- Department of Descriptive and Clinical Anatomy, The Medical University of Warsaw, 5 Chalubinskiego St, 02004, Warsaw, Poland
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Songsaeng D, Nava-apisak P, Wongsripuemtet J, Kingchan S, Angkoondittaphong P, Phawaphutanon P, Supratak A. The Diagnostic Accuracy of Artificial Intelligence in Radiological Markers of Normal-Pressure Hydrocephalus (NPH) on Non-Contrast CT Scans of the Brain. Diagnostics (Basel) 2023; 13:2840. [PMID: 37685378 PMCID: PMC10486480 DOI: 10.3390/diagnostics13172840] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/08/2023] [Accepted: 08/23/2023] [Indexed: 09/10/2023] Open
Abstract
Diagnosing normal-pressure hydrocephalus (NPH) via non-contrast computed tomography (CT) brain scans is presently a formidable task due to the lack of universally agreed-upon standards for radiographic parameter measurement. A variety of radiological parameters, such as Evans' index, narrow sulci at high parietal convexity, Sylvian fissures' dilation, focally enlarged sulci, and more, are currently measured by radiologists. This study aimed to enhance NPH diagnosis by comparing the accuracy, sensitivity, specificity, and predictive values of radiological parameters, as evaluated by radiologists and AI methods, utilizing cerebrospinal fluid volumetry. Results revealed a sensitivity of 77.14% for radiologists and 99.05% for AI, with specificities of 98.21% and 57.14%, respectively, in diagnosing NPH. Radiologists demonstrated NPV, PPV, and an accuracy of 82.09%, 97.59%, and 88.02%, while AI reported 98.46%, 68.42%, and 77.42%, respectively. ROC curves exhibited an area under the curve of 0.954 for radiologists and 0.784 for AI, signifying the diagnostic index for NPH. In conclusion, although radiologists exhibited superior sensitivity, specificity, and accuracy in diagnosing NPH, AI served as an effective initial screening mechanism for potential NPH cases, potentially easing the radiologists' burden. Given the ongoing AI advancements, it is plausible that AI could eventually match or exceed radiologists' diagnostic prowess in identifying hydrocephalus.
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Affiliation(s)
- Dittapong Songsaeng
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (D.S.)
| | - Poonsuta Nava-apisak
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (D.S.)
| | - Jittsupa Wongsripuemtet
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (D.S.)
| | - Siripra Kingchan
- Faculty of Information and Communication Technology, Mahidol University, Salaya, Nakhon Pathom 73170, Thailand
| | - Phuriwat Angkoondittaphong
- Faculty of Information and Communication Technology, Mahidol University, Salaya, Nakhon Pathom 73170, Thailand
| | - Phattaranan Phawaphutanon
- Department of Radiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok 10700, Thailand; (D.S.)
| | - Akara Supratak
- Faculty of Information and Communication Technology, Mahidol University, Salaya, Nakhon Pathom 73170, Thailand
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Thiblin I, Andersson J, Wester K, Högberg G, Högberg U. Retinal haemorrhage in infants investigated for suspected maltreatment is strongly correlated with intracranial pathology. Acta Paediatr 2022; 111:800-808. [PMID: 34617346 DOI: 10.1111/apa.16139] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2021] [Revised: 10/01/2021] [Accepted: 10/05/2021] [Indexed: 01/14/2023]
Abstract
AIM To test the two prevailing hypotheses regarding the aetiology of infant retinal haemorrhage: (a) traction forces exerted by the lens and/or corpus vitreum on the retina during infant shaking or (b) retinal vessel leakage secondary to intracranial pathology and raised intracranial pressure. METHODS Comparison of medical findings and reported type of trauma in infants investigated for suspected physical abuse with presence (n = 29) or non-presence of retinal haemorrhage (RH) (n = 119). RESULTS Intracranial pathology was recorded in 15 (13%) of the non-RH cases and in 27 (97%) of the RH cases (p < 0.0001). All 18 infants with bilateral RH had intracranial pathology. Of 27 infants subjected to witnessed or admitted shaking, two were in the group with RH. One had a single unilateral RH and no intracranial pathology. The other had bilateral RH and intracranial pathology with non-specific white matter changes, acute subdural and subarachnoid haemorrhages, and suspected cortical venous thrombosis. In 15 RH cases, there was no trauma reported and no findings other than RH and intracranial pathology. Accidental blunt head trauma was reported in 7 RH cases. CONCLUSION The present study indicates that RH in infants is secondary to intracranial pathology of non-specific aetiology.
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Affiliation(s)
- Ingemar Thiblin
- Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Jacob Andersson
- Department of Surgical Sciences Uppsala University Uppsala Sweden
| | - Knut Wester
- Department of Clinical Medicine K1 University of Bergen Bergen Norway
| | | | - Ulf Högberg
- Department of Women's and Children's Health Uppsala University Uppsala Sweden
- Department of Epidemiology and Global Health Umeå University Umeå Sweden
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Yu K, Yi M, Cui R, Gong T, Dong C, Gao X, Zhao J, Li M. Computed Tomography Measurement and Evaluation of the Subarachnoid Space Over Cerebral Convexities in Infants Aged 1-24 Months. J Child Neurol 2021; 36:447-452. [PMID: 33331188 DOI: 10.1177/0883073820977998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A widened subarachnoid space might be pathologic, potentially pathologic, or simply a normal developmental variant. However, the definition of a normal subarachnoid space width in infants remains unclear, especially on computed tomography (CT) images. To determine the physiological subarachnoid space width among infants aged 1-24 months, its upper limit, and changes with age, we measured the cerebrospinal fluid width on 538 CT images. Measurements were obtained at fixed planes and fixed positions to prevent variance and increase comparability between patients. We observed an asymmetry in the cerebrospinal fluid width of the temporal region. The width increased in all positions until 4-6 months of age, after which it began to decrease, reaching a relatively stable range in infants aged 13-24 months. We suggest considering the 95th percentile of the cerebrospinal fluid width as the upper limit. The correlation between age and the subarachnoid space width should be considered during clinical diagnosing.
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Affiliation(s)
- Ke Yu
- Department of Radiology, Jinan Children's Hospital, Jinan, Shandong, China
| | - Minggang Yi
- Department of Radiology, Jinan Children's Hospital, Jinan, Shandong, China
| | - Ruodi Cui
- Department of Radiology, Jinan Children's Hospital, Jinan, Shandong, China
| | - Tao Gong
- 159394Shandong Medical Imaging Research Institute, Jinan, Shandong, China
| | - Chunhua Dong
- Department of Radiology, Jinan Children's Hospital, Jinan, Shandong, China
| | - Xin Gao
- Department of Radiology, Jinan Children's Hospital, Jinan, Shandong, China
| | - Jianshe Zhao
- Department of Radiology, Jinan Children's Hospital, Jinan, Shandong, China
| | - Min Li
- Department of Nuclear Medicine, 205371960th Hospital of PLA, Jinan, Shandong, China
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Abstract
Enlarged subarachnoid spaces are a common finding in infants and young children imaged for macrocephaly or an enlarging head circumference, and benign enlargement of the subarachnoid spaces is often diagnosed. Infrequently, presumed "spontaneous" subdural hemorrhages or subdural collections might complicate these enlarged subarachnoid spaces. Children with large bilateral subdural collections might also present for imaging with macrocephaly. Each scenario potentially raises concerns for prior injury because subdural hemorrhage is a frequent finding in children with abusive head trauma.
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Affiliation(s)
- Marguerite M Caré
- Division of Pediatric Neuroradiology, Department of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave., Cincinnati, OH, 45229, USA.
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Abstract
PURPOSE Multiple names within the literature refer to a clinical picture affecting infants and consisting of a large or fast growing head circumference with enlarged cortical subarachnoid spaces (CSAS) while cranial sutures are open. This myriad of terms demonstrates the confusion about the entity, that may even group together different etiological processes. In this review, we aim to shed light on this matter in an effort to restate the defining features of the clinical picture and sum the evidence and current understanding of its pathophysiology and related imaging findings. METHODS Extensive and updated review of the literature with special focus on defining features, clinical history with long term evaluation and pathophysiological process. RESULTS Functional and molecular CSF studies as well as clinical evidence challenges the common pathophysiological theory based on non-functional arachnoid villi. Conversely, there is increasing evidence supporting cerebro-venous system abnormalities as the main pathophysiological factor. Additionally, long term cohorts studies show that it may have subtle but irreversible neurodevelopmental consequences. CONCLUSION Subarachnomegaly is an age-related condition of the infancy with radiological enlargement of CSAS and often self limiting course. However, considering the evidence on pathophysiology as outlined herein and long term outcome reports, further research effort is needed to assess the consequences of venous outflow impairment and enlarged CSAS and how this relates to imaging findings and neurodevelopment test results later in life.
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Affiliation(s)
- Laura V. Sainz
- grid.5801.c0000 0001 2156 2780Institute of Neuroinformatics, ETH, Zürich, Switzerland ,grid.411544.10000 0001 0196 8249Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Tübingen, Germany
| | - Martin U. Schuhmann
- grid.411544.10000 0001 0196 8249Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Tübingen, Germany
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Cinalli G, di Martino G, Russo C, Mazio F, Nastro A, Mirone G, Ruggiero C, Aliberti F, Cascone D, Covelli E, Spennato P. Dural venous sinus anatomy in children with external hydrocephalus: analysis of a series of 97 patients. Childs Nerv Syst 2021; 37:3021-3032. [PMID: 34430999 PMCID: PMC8510989 DOI: 10.1007/s00381-021-05322-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 08/03/2021] [Indexed: 11/15/2022]
Abstract
PURPOSE To evaluate the anatomical variations of dural venous sinuses in children with external hydrocephalus, proposing a radiological grading of progressive anatomic restriction to venous outflow based on brain phase-contrast magnetic resonance venography (PC-MRV); to evaluate the correlation between positional plagiocephaly and dural sinuses patency; and to compare these findings with a control group to ascertain the role of anatomical restriction to venous outflow in the pathophysiology of external hydrocephalus. METHODS Brain MRI and PC MRV were performed in 97 children (76 males, 21 females) diagnosed with external hydrocephalus at an average age of 8.22 months. Reduction of patency of the dural sinuses was graded as 1 (stenosis), 2 (complete stop) and 3 (complete agenesis) for each transverse/sigmoid sinus and sagittal sinus. Anatomical restriction was graded for each patient from 0 (symmetric anatomy of patent dural sinuses) through 6 (bilateral agenesis of both transverse sinuses). Ventricular and subarachnoid spaces were measured above the intercommissural plane using segmentation software. Positional plagiocephaly (PP) and/or asymmetric tentorial insertion (ATI) was correlated with the presence and grading of venous sinus obstruction. These results were compared with a retrospective control group of 75 patients (35 males, 40 females). RESULTS Both the rate (84.53% vs 25.33%) and the grading (mean 2.59 vs mean 0.45) of anomalies of dural sinuses were significantly higher in case group than in control group. In the case group, sinus anomalies were asymmetric in 59 cases (right-left ratio 1/1) and symmetric in 22. A significant association was detected between the grading of venous drainage alterations and diagnosis of disease and between the severity of vascular anomalies and the widening of subarachnoid space (SAS). Postural plagiocephaly (39.1% vs 21.3%) and asymmetric tentorial insertion (35.4% vs 17.3%) were significantly more frequent in the case group than in the control group. When sinus anomalies occurred in plagiocephalic children, the obstruction grading was significantly higher on the flattened side (p ≤ 0.001). CONCLUSION Decreased patency of the dural sinuses and consequent increased venous outflow resistance may play a role in the pathophysiology of external hydrocephalus in the first 3 years of life. In plagiocephalic children, calvarial flattening may impact on the homolateral dural sinus patency, with a possible effect on the anatomy of dural sinuses and venous drainage in the first months of life.
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Affiliation(s)
- Giuseppe Cinalli
- Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children's Hospital, Via Mario Fiore n. 6, 80129, Naples, Italy.
| | - Giuliana di Martino
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Carmela Russo
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Federica Mazio
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Anna Nastro
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Giuseppe Mirone
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Claudio Ruggiero
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Ferdinando Aliberti
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Daniele Cascone
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Eugenio Covelli
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neuroradiology Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
| | - Pietro Spennato
- grid.415247.10000 0004 1756 8081Department of Pediatric Neurosciences, Pediatric Neurosurgery Unit, Santobono-Pausilipon Children’s Hospital, Via Mario Fiore n. 6, 80129 Naples, Italy
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11
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Gergelé L, Manet R, Kolias A, Czosnyka M, Lalou A, Smielewski P, Hutchinson PJ, Czosnyka ZH. External Hydrocephalus After Traumatic Brain Injury: Retrospective Study of 102 Patients. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:35-38. [PMID: 33839814 DOI: 10.1007/978-3-030-59436-7_8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
INTRODUCTION External hydrocephalus (EH) refers to impairment of extra-axial cerebrospinal fluid flow with enlargement of the subarachnoid space (SAS) and concomitant raised intracranial pressure (ICP). It is often confused with a subdural hygroma and overlooked, particularly when there is no ventricular enlargement. In this study, we aimed to describe the epidemiology of EH in a large population of adults with traumatic brain injury (TBI). METHODS This observational, retrospective cohort study was conducted in adult patients who were admitted with TBI to the Department of Clinical Neuroscience at Addenbrooke's Hospital (Cambridge, UK) over a period of 3 years (2014-2017). Patients were included in the study if they had ICP monitoring and at least three CT scans within the first 21 days to assess SAS evolution. Patients who underwent a decompressive craniectomy were excluded. SAS was assessed individually on each CT scan by two independent investigators. ICP data were analysed with ICM+ software (Cambridge Enterprise Ltd., Cambridge, UK). Short-term and 6-month outcomes were examined. The groups of patients with and without EH were compared. RESULTS Of the 102 patients included in the study, 30.4% developed EH after a delay of 2.98 ± 2.4 days. The initial Glasgow Coma Scale (GCS) scores did not differ between patients with and without EH. Subarachnoid haemorrhage was found to be the main risk factor for EH. Patients with EH required a significantly longer period of mechanical ventilation (+6.9 days), were more likely to have a tracheostomy (55% versus 33%), and had a longer stay in the intensive care unit (+8.5 days). ICP was higher during the 48 h after diagnosis of EH than during the previous 48 h. EH survivors had a lower mean Glasgow Outcome Scale Extended (GOS-E) score (4.6 versus 5.9, P = 0.031) and were more likely to receive a permanent shunt for secondary hydrocephalus (17.4% versus 1.8%, odds ratio 7.1). CONCLUSION In adults with TBI, EH remains insufficiently understood and probably underdiagnosed. This study showed that it is a frequent complication of TBI, with significant clinical consequences.
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Affiliation(s)
- Laurent Gergelé
- Intensive Care Unit, Ramsay Santé
- , Hôpital Privé de la Loire, Saint Etienne, France. .,Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| | - Romain Manet
- Department of Neurosurgery B, Hôpital P. Wertheimer, Hospices Civiles de Lyon, Lyon, France
| | - A Kolias
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - A Lalou
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Zofia H Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neuroscience, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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12
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Ma W, Li XJ, Li W, Xiao L, Ji XJ, Xu Y. MRI findings of central nervous system involvement in children with haemophagocytic lymphohistiocytosis: correlation with clinical biochemical tests. Clin Radiol 2020; 76:159.e9-159.e17. [PMID: 33036779 DOI: 10.1016/j.crad.2020.09.009] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2020] [Accepted: 09/09/2020] [Indexed: 11/16/2022]
Abstract
AIM To investigate the brain magnetic resonance imaging (MRI) features of children with haemophagocytic lymphohistiocytosis (HLH) with central nervous system (CNS) involvement, and to investigate the correlation with clinical biochemical tests. MATERIAL AND METHODS Clinical and MRI data were collected from 118 children with HLH-CNS between January 2012 and June 2019. Patients were grouped according to their MRI findings, and statistical methods were used to test for correlations between the MRI findings and biochemical variables. RESULTS Patients were divided into three groups, including normal appearance (Group 1, 17/118), diffuse parenchymal volume loss (Group 2, 44/118), and brain parenchyma lesions (Group 3, 57/118) containing three subtypes of brain lesions and HLH-CNS complications. Comparing biochemical values among the three groups revealed a significant difference for all values (p<0.05), except for cell counts in the cerebrospinal fluid (CSF). A pairwise comparison further showed significant inter-group differences for most of the variables. Spearman's rank correlation coefficient also demonstrated that CSF cell counts (r=0.193, p=0.036), CSF microprotein content (r=0.379, p<0.001), serum aspartate aminotransferase (AST; r=0.521, p<0.001), serum lactate dehydrogenase (LDH; r=0.514, p<0.001) and activated partial thromboplastin time (APTT; r=0.326, p<0.001) correlated positively with the MRI groups, while platelet count (PLT; r=-0.633, p<0.001) and plasma fibrinogen (FIB; r=-0.258, p=0.005) correlated negatively. CONCLUSION Classification of brain MRI findings of HLH-CNS correlates well with the results of several key biochemical tests. Brain MRI is a promising method to elucidate illness severity and clinical outcomes.
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Affiliation(s)
- W Ma
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - X J Li
- Department of Neurology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - W Li
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - L Xiao
- Clinical Laboratory, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - X J Ji
- Department of Ultrasound, Children's Hospital of Chongqing Medical University, Chongqing, China
| | - Y Xu
- Department of Radiology, Children's Hospital of Chongqing Medical University, Chongqing, China.
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13
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Murphy VA, Shen MD, Kim SH, Cornea E, Styner M, Gilmore JH. Extra-axial Cerebrospinal Fluid Relationships to Infant Brain Structure, Cognitive Development, and Risk for Schizophrenia. BIOLOGICAL PSYCHIATRY: COGNITIVE NEUROSCIENCE AND NEUROIMAGING 2020; 5:651-659. [PMID: 32457022 DOI: 10.1016/j.bpsc.2020.03.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 03/13/2020] [Accepted: 03/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Increased volume of extra-axial cerebrospinal fluid (EA-CSF) is associated with autism spectrum disorder diagnosis in young children. However, little is known about EA-CSF development in typically developing (TD) children or in children at risk for schizophrenia (SCZHR). METHODS 3T magnetic resonance imaging scans were obtained in TD children (n = 105) and in SCZHR children (n = 38) at 1 and 2 years of age. EA-CSF volume and several measures of brain structure were generated, including global tissue volumes, cortical thickness, and surface area. Cognitive and motor abilities at 1 and 2 years of age were assessed using the Mullen Scales of Early Learning. RESULTS In the TD children, EA-CSF volume was positively associated with total brain volume, gray and white matter volumes, and total surface area at 1 and 2 years of age. In contrast, EA-CSF volume was negatively associated with average cortical thickness. Lower motor ability was associated with increased EA-CSF volume at 1 year of age. EA-CSF was not significantly increased in SCZHR children compared with TD children. CONCLUSIONS EA-CSF volume is positively associated with overall brain size and cortical surface area but negatively associated with cortical thickness. Increased EA-CSF is associated with delayed motor development at 1 year of age, similar to studies of children at risk for autism, suggesting that increased EA-CSF may be an early biomarker of abnormal brain development in infancy. Infants in the SCZHR group did not exhibit significantly increased EA-CSF, suggesting that increased EA-CSF could be specific to neurodevelopmental disorders with an earlier onset, such as autism.
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Affiliation(s)
- Veronica A Murphy
- Curriculum in Neuroscience, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Mark D Shen
- Carolina Institute for Developmental Disabilities, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina; Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Sun Hyung Kim
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Emil Cornea
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Martin Styner
- Department of Computer Science, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina; Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - John H Gilmore
- Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina.
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14
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Rudisill SS, Wang JT, Jaimes C, Mongerson CRL, Hansen AR, Jennings RW, Bajic D. Neurologic Injury and Brain Growth in the Setting of Long-Gap Esophageal Atresia Perioperative Critical Care: A Pilot Study. Brain Sci 2019; 9:E383. [PMID: 31861169 PMCID: PMC6955668 DOI: 10.3390/brainsci9120383] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2019] [Revised: 12/11/2019] [Accepted: 12/14/2019] [Indexed: 12/14/2022] Open
Abstract
We previously showed that infants born with long-gap esophageal atresia (LGEA) demonstrate clinically significant brain MRI findings following repair with the Foker process. The current pilot study sought to identify any pre-existing (PRE-Foker process) signs of brain injury and to characterize brain and corpus callosum (CC) growth. Preterm and full-term infants (n = 3/group) underwent non-sedated brain MRI twice: before (PRE-Foker scan) and after (POST-Foker scan) completion of perioperative care. A neuroradiologist reported on qualitative brain findings. The research team quantified intracranial space, brain, cerebrospinal fluid (CSF), and CC volumes. We report novel qualitative brain findings in preterm and full-term infants born with LGEA before undergoing Foker process. Patients had a unique hospital course, as assessed by secondary clinical end-point measures. Despite increased total body weight and absolute intracranial and brain volumes (cm3) between scans, normalized brain volume was decreased in 5/6 patients, implying delayed brain growth. This was accompanied by both an absolute and relative CSF volume increase. In addition to qualitative findings of CC abnormalities in 3/6 infants, normative CC size (% brain volume) was consistently smaller in all infants, suggesting delayed or abnormal CC maturation. A future larger study group is warranted to determine the impact on the neurodevelopmental outcomes of infants born with LGEA.
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Affiliation(s)
- Samuel S. Rudisill
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.S.R.); (J.T.W.); (C.R.L.M.)
| | - Jue T. Wang
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.S.R.); (J.T.W.); (C.R.L.M.)
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
| | - Camilo Jaimes
- Department of Radiology, Division of Neuroradiology, Boston Children’s Hospital, and Department of Radiology, Harvard Medical School, Boston, MA 02115, USA;
| | - Chandler R. L. Mongerson
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.S.R.); (J.T.W.); (C.R.L.M.)
| | - Anne R. Hansen
- Department of Pediatrics, Division of Neonatal Medicine, Boston Children’s Hospital, and Department of Pediatrics, Harvard Medical School, Boston, MA 02115, USA;
| | - Russell W. Jennings
- Department of Surgery, Boston Children’s Hospital, and Department of Surgery, Harvard Medical School, Boston, MA 02115, USA;
- Esophageal and Airway Treatment Center, Boston Children’s Hospital, Boston, MA 02115, USA
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children’s Hospital, Boston, MA 02115, USA; (S.S.R.); (J.T.W.); (C.R.L.M.)
- Department of Anaesthesia, Harvard Medical School, Boston, MA 02115, USA
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15
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Wester K. Two Infant Boys Misdiagnosed as "Shaken Baby" and Their Twin Sisters: A Cautionary Tale. Pediatr Neurol 2019; 97:3-11. [PMID: 31147228 DOI: 10.1016/j.pediatrneurol.2019.02.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/06/2019] [Accepted: 02/27/2019] [Indexed: 12/13/2022]
Affiliation(s)
- Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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16
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Zahl SM, Egge A, Helseth E, Wester K. Clinical, Radiological, and Demographic Details of Benign External Hydrocephalus: A Population-Based Study. Pediatr Neurol 2019; 96:53-57. [PMID: 30808532 DOI: 10.1016/j.pediatrneurol.2019.01.015] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Revised: 01/16/2019] [Accepted: 01/22/2019] [Indexed: 10/27/2022]
Abstract
BACKGROUND Benign external hydrocephalus has an incidence of about 0.4 per 1000 live births. It affects infants and is characterized by an increasing head circumference and typical neuroimaging findings. Previously published studies on benign external hydrocephalus often contain groups of few and selected patients. METHODS This is a follow-up of a recently published article reporting the incidence of benign external hydrocephalus. This retrospective and population-based study covers two large health regions in Norway, over a 10-year period (1994 to 2003). Infants with increasing head circumference, combined with typical radiological findings of enlarged subarachnoid spaces, were included. Information about head circumference development, neuroimaging findings, and birth delivery methods, as well as demographic details, was retrieved from the hospital medical records. RESULTS A total of 176 children with benign external hydrocephalus were included, 86.4% being boys. At birth, the head circumference was close to normal. Mean age for when the head circumference reached abnormal values, i.e., crossing two percentiles or reaching the 97.5 percentile, was 3.4 months; none was older than seven months. Around four of five children had dilated lateral ventricles in addition to enlarged subarachnoid spaces. The neuroimaging findings tended to normalize after age 12 months. About half of the patients ended up with head circumferences at or above the 97.5 percentile. CONCLUSIONS Most infants with benign external hydrocephalus are born with a normal head circumference that increases too fast and reaches abnormally high values before age six months. This age and gender distribution is very similar to that described for infant subdural hemorrhage.
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Affiliation(s)
- Sverre Morten Zahl
- Department of Clinical Medicine K1, University of Bergen, Norway; Department of Ear, Nose and Throat, Aalesund Hospital, Aalesund, Norway.
| | - Arild Egge
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway; Faculty of Medicine, University of Oslo, Norway
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Norway; Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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17
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Sainz LV, Zipfel J, Kerscher SR, Weichselbaum A, Bevot A, Schuhmann MU. Cerebro-venous hypertension: a frequent cause of so-called "external hydrocephalus" in infants. Childs Nerv Syst 2019; 35:251-256. [PMID: 30474714 DOI: 10.1007/s00381-018-4007-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 11/18/2018] [Indexed: 11/25/2022]
Abstract
INTRODUCTION External hydrocephalus (eHC) is commonly defined as a subtype of infant "hydrocephalus" consisting of macrocepahly associated with enlarged subarachnoid space and no or mild ventriculomegaly. This status is thought to be related to impaired CSF absorption because of arachnoid villi immaturity. However, other factors like the venous system might be involved in the development of the clinical picture. METHODS All patients diagnosed with eHC received prospectively contrast-enhanced 3D MR phlebography. Venous sis abnormalities were graded depending on the number of affected sinus segments and type. External CSF space volume was quantified planimetrically. RESULTS Seventeen patients with the typical clinical feature of eHC were included. In 15, venous sinus abnormalities were found. There was a significant correlation between the volume of the widened cortical subarachnoid space (CSAS) and the number of venous sinus segments affected. Conversely, ventricular volume was not correlated. CONCLUSION These results support the hypothesis that impaired venous outflow plays a major role in external hydrocephalus development. Raised venous pressure increases intracranial pressure accelerating head growth, resulting in an enlargement of the cortical subarachnoid space. Increased venous pressure increases the capillary bed pressure and brain turgor preventing ventricular space to enlarge forcing displacement of ventricular CSF to the subarachnoid space. As a result, ventriculomegaly is rarely found. The descriptive term "external hydrocephalus" implying a primary etiology within the CSF system is misleading and this work supports the notion that venous hypertension is the leading cause of the clinical picture.
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Affiliation(s)
- Laura V Sainz
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Tuebingen, Germany.
- Department of Neurosurgery, University Hospital Fundación Jiménez Díaz of Madrid, Madrid, Spain.
| | - Julian Zipfel
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Tuebingen, Germany
| | - Susanne R Kerscher
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Tuebingen, Germany
| | - Annette Weichselbaum
- Department of Pediatric Neurology, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Andrea Bevot
- Department of Pediatric Neurology, University Children's Hospital of Tuebingen, Tuebingen, Germany
| | - Martin U Schuhmann
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tuebingen, Tuebingen, Germany
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18
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Baron J, Mastrolia SA, Shelef I, Tirosh D, Mijalovsky A, Ben-Harush Y, Hershkovitz R. Fetal wide subarachnoid space and its outcome in cases of macrocephaly without ventriculomegaly. J Matern Fetal Neonatal Med 2019; 33:2570-2575. [PMID: 30513033 DOI: 10.1080/14767058.2018.1555805] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: To examine the occurrence and outcomes of fetuses with wide subarachnoid space (WSS) without ventriculomegaly in pregnant women with fetal macrocephaly as a sole diagnosis.Study design: A retrospective study was performed, analyzing patients with fetal macrocephaly between the years 2008 and 2018. All these patients underwent MRI, in order to detect brain anomalies. In the absence of any other brain abnormality, they were evaluated for WSS and their offspring's database was followed for at least two years after birth.Results: Ten patients were found to be carrying fetuses with macrocephaly, nine of them were diagnosed with WSS without ventriculomegaly prior to delivery. Following at least two years of follow up, all patients did not present significant neurodevelopmental abnormalities, apart from one child that had a genetic mutation of 15q21.2-22.31 deletion with other anomalies that were not diagnosed prenatally.Conclusions: We present herein for the first time in the literature a cohort of patients with a prenatal diagnosis of WSS without ventriculomegaly in fetuses with macrocephaly. Our data show that, in the presence of normal anomaly scan and normal chromosomal study, there is a low chance for significant neurodevelopmental abnormalities in fetuses with WSS without ventriculomegaly.
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Affiliation(s)
- Joel Baron
- US Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Salvatore Andrea Mastrolia
- US Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel.,Department of Obstetrics and Gynecology, Ospedale dei Bambini "Vittore Buzzi", University of Milano, Milano, Italy
| | - Ilan Shelef
- Radiology Department, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Dan Tirosh
- US Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Analia Mijalovsky
- Children's Neurodevelopment Unit, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Yigal Ben-Harush
- US Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
| | - Reli Hershkovitz
- US Unit, Department of Obstetrics and Gynecology, Soroka University Medical Center, Ben Gurion University of the Negev, Be'er Sheva, Israel
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19
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Zahl SM, Egge A, Helseth E, Skarbø AB, Wester K. Quality of life and physician-reported developmental, cognitive, and social problems in children with benign external hydrocephalus-long-term follow-up. Childs Nerv Syst 2019; 35:245-250. [PMID: 30523438 PMCID: PMC6351505 DOI: 10.1007/s00381-018-4016-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Accepted: 11/28/2018] [Indexed: 12/04/2022]
Abstract
INTRODUCTION Benign external hydrocephalus (BEH) is characterized by too rapidly increasing head circumference in infants, combined with typical neuroimaging findings. Psychomotor developmental delay is typically seen during the first few years of life; after that, the children's development assumedly normalizes. However, little is known about the long-term effects of BEH. METHODS In this retrospective population-based study, children diagnosed with BEH during the years 1994-2003 in Southern Norway were asked to participate. Included patients (age 8-18 years old) and their parents answered the PedsQL questionnaire. The patient's family physicians contributed by giving information from medical records, with special emphasis on developmental, cognitive, and social function. RESULTS One hundred seventy-six children were identified with BEH. One hundred three patients and 86 parents completed the PedsQL questionnaire. Supplemental medical information for 142 of the patients was received, mainly from their family physicians. Children and adolescents with BEH score themselves better than the normative mean on health-related quality of life, while the parents score their BEH children within the normative mean, except for the school functioning subgroup, where they score significantly lower. Various developmental, physical, and social problems are reported, like mental retardation, speech problems, epilepsy, motor impairment, psychiatric disorders, and cognitive difficulties. Among these patients, there is a discrepancy in some areas between the child-reported and parent-reported quality of life. CONCLUSIONS Children and adolescents who were diagnosed with BEH during infancy generally do well. However, for some patients, there appear to be various developmental, social, and cognitive problems, and they seem to struggle more in school than their healthy peers.
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Affiliation(s)
- Sverre Morten Zahl
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway.
- Department of Ear, Nose and Throat, Aalesund Hospital, N-6026, Aalesund, Norway.
| | - Arild Egge
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
| | - Eirik Helseth
- Department of Neurosurgery, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Anne-Britt Skarbø
- Department of Clinical Neurosciences for Children, Oslo University Hospital, Oslo, Norway
| | - Knut Wester
- Department of Clinical Medicine K1, University of Bergen, Bergen, Norway
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway
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Mongerson CRL, Wilcox SL, Goins SM, Pier DB, Zurakowski D, Jennings RW, Bajic D. Infant Brain Structural MRI Analysis in the Context of Thoracic Non-cardiac Surgery and Critical Care. Front Pediatr 2019; 7:315. [PMID: 31428593 PMCID: PMC6688189 DOI: 10.3389/fped.2019.00315] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 07/11/2019] [Indexed: 01/20/2023] Open
Abstract
Objective: To determine brain magnetic resonance imaging (MRI) measures of cerebrospinal fluid (CSF) and whole brain volume of full-term and premature infants following surgical treatment for thoracic non-cardiac congenital anomalies requiring critical care. Methods: Full-term (n = 13) and pre-term (n = 13) patients with long-gap esophageal atresia, and full-term naïve controls (n = 19) < 1 year corrected age, underwent non-sedated brain MRI following completion of thoracic non-cardiac surgery and critical care treatment. Qualitative MRI findings were reviewed and reported by a pediatric neuroradiologist and neurologist. Several linear brain metrics were measured using structural T1-weighted images, while T2-weighted images were required for segmentation of total CSF and whole brain tissue using the Morphologically Adaptive Neonatal Tissue Segmentation (MANTiS) tool. Group differences in absolute (mm, cm3) and normalized (%) data were analyzed using a univariate general linear model with age at scan as a covariate. Mean normalized values were assessed using one-way ANOVA. Results: Qualitative brain findings suggest brain atrophy in both full-term and pre-term patients. Both linear and volumetric MRI analyses confirmed significantly greater total CSF and extra-axial space, and decreased whole brain size in both full-term and pre-term patients compared to naïve controls. Although linear analysis suggests greater ventricular volumes in all patients, volumetric analysis showed that normalized ventricular volumes were higher only in premature patients compared to controls. Discussion: Linear brain metrics paralleled volumetric MRI analysis of total CSF and extra-axial space, but not ventricular size. Full-term infants appear to demonstrate similar brain vulnerability in the context of life-saving thoracic non-cardiac surgery requiring critical care as premature infants.
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Affiliation(s)
- Chandler R L Mongerson
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Sophie L Wilcox
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Stacy M Goins
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Danielle B Pier
- Massachusetts General Hospital Child Neurology, Boston, MA, United States.,Harvard Medical School, Harvard University, Boston, MA, United States
| | - David Zurakowski
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Harvard Medical School, Harvard University, Boston, MA, United States
| | - Russell W Jennings
- Harvard Medical School, Harvard University, Boston, MA, United States.,Department of Surgery, Boston Children's Hospital, Boston, MA, United States
| | - Dusica Bajic
- Department of Anesthesiology, Critical Care and Pain Medicine, Boston Children's Hospital, Boston, MA, United States.,Massachusetts General Hospital Child Neurology, Boston, MA, United States
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21
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Abstract
BACKGROUND There is currently a renaissance of interest in the many functions of cerebrospinal fluid (CSF). Altered flow of CSF, for example, has been shown to impair the clearance of pathogenic inflammatory proteins involved in neurodegenerative diseases, such as amyloid-β. In addition, the role of CSF in the newly discovered lymphatic system of the brain has become a prominently researched area in clinical neuroscience, as CSF serves as a conduit between the central nervous system and immune system. MAIN BODY This article will review the importance of CSF in regulating normal brain development and function, from the prenatal period throughout the lifespan, and highlight recent research that CSF abnormalities in autism spectrum disorder (ASD) are present in infancy, are detectable by conventional structural MRI, and could serve as an early indicator of altered neurodevelopment. CONCLUSION The identification of early CSF abnormalities in children with ASD, along with emerging knowledge of the underlying pathogenic mechanisms, has the potential to serve as early stratification biomarkers that separate children with ASD into biological subtypes that share a common pathophysiology. Such subtypes could help parse the phenotypic heterogeneity of ASD and map on to targeted, biologically based treatments.
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Affiliation(s)
- Mark D Shen
- Carolina Institute for Developmental Disabilities, Department of Psychiatry, and the UNC Intellectual and Developmental Disabilities Research Center, University of North Carolina at Chapel Hill School of Medicine, Campus Box 3367, Chapel Hill, NC, 27599-3367, USA.
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Shen MD, Nordahl CW, Li DD, Lee A, Angkustsiri K, Emerson RW, Rogers SJ, Ozonoff S, Amaral DG. Extra-axial cerebrospinal fluid in high-risk and normal-risk children with autism aged 2-4 years: a case-control study. Lancet Psychiatry 2018; 5:895-904. [PMID: 30270033 PMCID: PMC6223655 DOI: 10.1016/s2215-0366(18)30294-3] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2017] [Revised: 07/16/2018] [Accepted: 07/17/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND We previously showed, in two separate cohorts, that high-risk infants who were later diagnosed with autism spectrum disorder had abnormally high extra-axial cerebrospinal fluid (CSF) volume from age 6-24 months. The presence of increased extra-axial CSF volume preceded the onset of behavioural symptoms of autism and was predictive of a later diagnosis of autism spectrum disorder. In this study, we aimed to establish whether increased extra-axial CSF volume is found in a large, independent sample of children diagnosed with autism spectrum disorder, whether extra-axial CSF remains abnormally increased beyond infancy, and whether it is present in both normal-risk and high-risk children with autism. METHODS In this case-control MRI study, children with autism spectrum disorder or with typical development aged 2-4 years were recruited from the community to the UC Davis MIND Institute Autism Phenome Project, based in Sacramento, CA, USA. The autism spectrum disorder group comprised children with autism spectrum disorder who were either normal risk (ie, from simplex families) or high risk (ie, from multiplex families). Measurements of extra-axial CSF volume, brain volume, head circumference, sleep problems, and familial risk status were derived from MRI and behavioural assessments. We applied a previously validated machine learning algorithm based on extra-axial CSF volume, brain volume, age, and sex to the current dataset. FINDINGS Between July 20, 2007, and Dec 13, 2012, 159 children with autism spectrum disorder (132 male, 27 female) and 77 with typical development (49 male, 28 female) underwent MRI scans. The autism spectrum disorder group had an average of 15·1% more extra-axial CSF than controls after accounting for differences in brain volume, weight, age, and sex (least-squares mean 116·74 cm3 [SE 3·33] in autism group vs 101·40 cm3 [3·93] in typical development group; p=0·007; Cohen's d = 0·39). Subgroups of normal-risk (n=132) and high-risk (n=27) children with autism spectrum disorder had nearly identical extra-axial CSF volumes (p=0·78), and both subgroups had significantly greater volumes than controls. Both extra-axial CSF volume (p=0·004) and brain volume (p<0·0001) uniquely contributed to enlarged head circumference in the autism spectrum disorder group (p=0·04). Increased extra-axial CSF volume was associated with greater sleep disturbances (p=0·03) and lower non-verbal ability (p=0·04). The machine learning algorithm correctly predicted autism spectrum disorder diagnosis with a positive predictive value of 83% (95% CI 76·2-88·3). INTERPRETATION Increased extra-axial CSF volume is a reliable brain anomaly that has now been found in three independent cohorts, comprising both high-risk and normal-risk children with autism spectrum disorder. Increased extra-axial CSF volume is detectable using conventional structural MRI scans from infancy through to age 3 years. These results suggest that increased extra-axial CSF volume could be an early stratification biomarker of a biologically based subtype of autism that might share a common underlying pathophysiology. FUNDING US National Institutes of Health.
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Affiliation(s)
- Mark D Shen
- The Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA; Carolina Institute for Developmental Disabilities and Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA.
| | - Christine W Nordahl
- The Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA; Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA
| | - Deana D Li
- The Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA; Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA
| | - Aaron Lee
- The Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA; Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA
| | - Kathleen Angkustsiri
- The Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA; Department of Pediatrics, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA
| | - Robert W Emerson
- Carolina Institute for Developmental Disabilities and Department of Psychiatry, University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, NC, USA
| | - Sally J Rogers
- The Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA; Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA
| | - Sally Ozonoff
- The Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA; Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA
| | - David G Amaral
- The Medical Investigation of Neurodevelopmental Disorders (MIND) Institute, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA; Department of Psychiatry and Behavioral Sciences, UC Davis School of Medicine, University of California-Davis, Sacramento, CA, USA
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Tan AP, Mankad K, Gonçalves FG, Talenti G, Alexia E. Macrocephaly: Solving the Diagnostic Dilemma. Top Magn Reson Imaging 2018; 27:197-217. [PMID: 30086108 DOI: 10.1097/rmr.0000000000000170] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Macrocephaly is a relatively common clinical condition affecting up to 5% of the pediatric population. It is defined as an abnormally large head with an occipitofrontal circumference greater than 2 standard deviations above the mean for a given age and sex. Megalencephaly refers exclusively to brain overgrowth exceeding twice the standard deviation. Macrocephaly can be isolated and benign or may be the first indication of an underlying congenital, genetic, or acquired disorder, whereas megalencephaly is more often syndromic. Megalencephaly can be divided into 2 subtypes: metabolic and developmental, caused by genetic defects in cellular metabolism and alterations in signaling pathways, respectively. Neuroimaging plays an important role in the evaluation of macrocephaly, especially in the metabolic subtype which may not be overtly apparent clinically. This article outlines the diverse etiologies of macrocephaly, delineates their clinical and radiographic features, and suggests a clinicoradiological algorithm for evaluation.
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Affiliation(s)
- Ai Peng Tan
- Department of Diagnostic Radiology, National University Health System, Singapore, Singapore
| | - Kshitij Mankad
- Great Ormond Street Hospital for Children NHS Foundation Trust, London, United Kingdom
| | | | - Giacomo Talenti
- Neuroradiology Unit, Padua University Hospital, Padua, Italy
| | - Egloff Alexia
- Perinatal Imaging and Health Department, St Thomas' Hospital, London, United Kingdom
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The Child With Macrocephaly: Differential Diagnosis and Neuroimaging Findings. AJR Am J Roentgenol 2018; 210:848-859. [DOI: 10.2214/ajr.17.18693] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Increased Extra-axial Cerebrospinal Fluid in High-Risk Infants Who Later Develop Autism. Biol Psychiatry 2017; 82:186-193. [PMID: 28392081 PMCID: PMC5531051 DOI: 10.1016/j.biopsych.2017.02.1095] [Citation(s) in RCA: 116] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2016] [Revised: 02/01/2017] [Accepted: 02/02/2017] [Indexed: 11/21/2022]
Abstract
BACKGROUND We previously reported that infants who developed autism spectrum disorder (ASD) had increased cerebrospinal fluid (CSF) in the subarachnoid space (i.e., extra-axial CSF) from 6 to 24 months of age. We attempted to confirm and extend this finding in a larger independent sample. METHODS A longitudinal magnetic resonance imaging study of infants at risk for ASD was carried out on 343 infants, who underwent neuroimaging at 6, 12, and 24 months. Of these infants, 221 were at high risk for ASD because of an older sibling with ASD, and 122 were at low risk with no family history of ASD. A total of 47 infants were diagnosed with ASD at 24 months and were compared with 174 high-risk and 122 low-risk infants without ASD. RESULTS Infants who developed ASD had significantly greater extra-axial CSF volume at 6 months compared with both comparison groups without ASD (18% greater than high-risk infants without ASD; Cohen's d = 0.54). Extra-axial CSF volume remained elevated through 24 months (d = 0.46). Infants with more severe autism symptoms had an even greater volume of extra-axial CSF from 6 to 24 months (24% greater at 6 months, d = 0.70; 15% greater at 24 months, d = 0.70). Extra-axial CSF volume at 6 months predicted which high-risk infants would be diagnosed with ASD at 24 months with an overall accuracy of 69% and corresponding 66% sensitivity and 68% specificity, which was fully cross-validated in a separate sample. CONCLUSIONS This study confirms and extends previous findings that increased extra-axial CSF is detectable at 6 months in high-risk infants who develop ASD. Future studies will address whether this anomaly is a contributing factor to the etiology of ASD or an early risk marker for ASD.
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Hussain ZB, Hussain AB, Mitchell P. Extra-axial cerebrospinal fluid spaces in children with benign external hydrocephalus: A case-control study. Neuroradiol J 2017; 30:410-417. [PMID: 28691570 DOI: 10.1177/1971400917719298] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background The distinction between normal and pathological extra-axial cerebrospinal fluid (CSF) spaces is unclear, with the use of the term benign external hydrocephalus (BEH) not being well defined in clinical practice. This study aimed to establish a distribution of metrics of the subarachnoid space in a population of children diagnosed as normal, and investigate the clinical use of the term BEH. Methods A retrospective case-control study on magnetic resonance image scans was performed on 150 children diagnosed as normal and 10 children diagnosed with BEH. Measurements were taken in the axial plane for CSF width (CSFW), and interhemispheric width (IHW). Results Normal controls had a mean age of 11.1 ± 7.6 months (78 male, 72 female) and the BEH sample had a mean age of 10.6 ± 7.8 months (six male, four female). Mean CSFW was 7.96 ± 4.79 mm in the BEH sample compared to 4.58 ± 2.25 mm in the normal sample ( p < 0.05). Mean IHW was 6.30 ± 2.79 mm in the BEH sample compared to 3.89 ± 1.83 mm in the normal sample ( p < 0.05). However, a substantial overlap between the two distributions of CSFW was found, with 50% of BEH patients lying within a single standard deviation of the mean of normal individuals. Conclusion The absence of diagnostic criteria for BEH means reporting is variable. Patients being diagnosed with BEH who have no other clinical defects may represent the extreme of the normal population rather than a distinct clinical entity.
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27
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Whitehead MT, Lee B, McCarron A, Fricke ST, Vezina G. Reduced subarachnoid fluid diffusion in enlarged subarachnoid spaces of infancy. Neuroradiol J 2017; 30:418-424. [PMID: 28195509 DOI: 10.1177/1971400916689803] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Background and purpose Enlargement of the subarachnoid spaces in infancy (ESSI) is a common cause of macrocephaly without proven explanation. We have observed subarachnoid diffusion to be decreased in these patients. We aim to quantify the diffusivity of ventricular and subarachnoid cerebrospinal fluid in ESSI patients, to determine if diffusion characteristics deviate from normocephalic infants, and to propose a unique mechanism for ESSI. Materials and methods 227 consecutive brain magnetic resonance exams from different macrocephalic children were retrospectively reviewed after institutional review board waiver. Patients with noncommunicating hydrocephalus, substantial ventriculomegaly, atrophy, structural bone and/parenchymal abnormalities, abnormal brain signal, hemorrhages, meningitis, and normal imaging were excluded. A total of 53 exams from macrocephalic patients and 21 normocephalic subjects were analyzed. Mean quantitative apparent diffusion coefficient (ADC) values were obtained from the ventricular frontal horn and frontal subarachnoid spaces. The subarachnoid:ventricular ADC ratios were compared using a Mann-Whitney U-test. Results The mean age was 13 +/-8 months (macrocephalic cohort) and 13 +/- 6 months (normocephalic cohort). The subarachnoid fluid mean ADC was 2.50+/-0.26 × 10-3 mm2/s in the macrocephalic group and 2.84+/-0.29 × 10-3 mm2/s in the normocephalic group. The ventricular fluid mean ADC was 2.97+/-0.37 × 10-3 mm2/s and 2.74 +/-0.32 × 10-6 mm2/s, respectively. The mean quantitative ADC ratios in the macrocephalic group were 0.85, significantly smaller than the normocephalic group (1) ( z = -6.3; p = 0). Conclusion Subarachnoid space fluid diffusivity is reduced in patients with enlarged subarachnoid spaces of infancy. We propose insufficient frontotemporal capillary protein resorption to be the initiating factor in ESSI, leading to unbalanced osmotic/hydrostatic pressures, and secondary congestion.
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Affiliation(s)
- Matthew T Whitehead
- 1 Department of Radiology, Children's National Medical Center, USA.,2 The George Washington University School of Medicine, USA
| | - Bonmyong Lee
- 3 Department of Radiology, The Johns Hopkins Medical Institute, USA
| | - Audrey McCarron
- 1 Department of Radiology, Children's National Medical Center, USA
| | - Stanley T Fricke
- 1 Department of Radiology, Children's National Medical Center, USA.,2 The George Washington University School of Medicine, USA
| | - Gilbert Vezina
- 1 Department of Radiology, Children's National Medical Center, USA.,2 The George Washington University School of Medicine, USA
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Corbacioglu Esmer A, Yuksel A, Aksu Uzunhan T, Demir O, Sarac Sivrikoz T, Aydinli N. Evaluation of fetal subarachnoid space using transabdominal ultrasonography and normal values during pregnancy. SPRINGERPLUS 2016; 5:1439. [PMID: 27652015 PMCID: PMC5005224 DOI: 10.1186/s40064-016-3121-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/04/2016] [Accepted: 08/22/2016] [Indexed: 11/18/2022]
Abstract
Objectives To determine the feasibility of evaluating the subarachnoid space by measuring two novel sonographic parameters in axial section using transabdominal ultrasound, in addition to the parameters previously defined in coronal section, and to construct a normal range for the subarachnoid space width in singleton healthy fetuses. Methods Healthy pregnant women between 20 and 29 weeks were scanned using transabdominal ultrasound. Four variables were measured for the evaluation of subarachnoid space width; sinocortical width and anterior craniocortical width in coronal plane, and lateral and posterior craniocortical width in axial plane. Result The data of 154 patients were recorded. SCW could be measured in 87.6 % (135) of fetuses, while the same figure was 77.9 % (120), 96.1 % (151) and 98.1 % (148) for anterior, lateral and posterolateral CCW, respectively. The SCW and anterior CCW did not display a significant correlation with gestational age and head circumference. The mean of SCW was 1.55 ± 0.41 mm with a range of 0.85–3.87 mm. The mean anterior CCW was 1.63 ± 0.39 mm with a range of 0.85–2.82 mm. A linear regression line was plotted between gestational age and lateral CCW (r = 0.707; p < 0.0001) and posterolateral CCW (r = 0.437; p < 0.0001), and nomograms for these parameters are constructed. Conclusion This study presents a novel approach for the in utero evaluation of the subarachnoid space with two measurements in axial plane using transabdominal ultrasound. The nomograms will be helpful when there is a suspicion of subarachnoid space dilatation during routine cranial scan.
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Affiliation(s)
- Aytul Corbacioglu Esmer
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Kanuni Sultan Suleyman Research and Teaching Hospital, Istanbul, Turkey
| | - Atil Yuksel
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Tugce Aksu Uzunhan
- Division of Pediatric Neurology, Department of Pediatrics, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Omer Demir
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Tugba Sarac Sivrikoz
- Division of Maternal Fetal Medicine, Department of Obstetrics and Gynecology, Istanbul University Faculty of Medicine, Istanbul, Turkey
| | - Nur Aydinli
- Division of Pediatric Neurology, Department of Pediatrics, Istanbul University Faculty of Medicine, Istanbul, Turkey
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A hypothesis of traumatic subdural effusion associated with communicating hydrocephalus in infants and its management. J Craniofac Surg 2015; 26:435-7. [PMID: 25675020 DOI: 10.1097/scs.0000000000001329] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
We report a case with both traumatic subdural effusion (TSE) and associated hydrocephalus. A collapse of the sinuses is known to be present in some infants with external hydrocephalus, but collapsed sinuses have not been previously described in patients with TSE and associated hydrocephalus. Therefore, a preoperative magnetic resonance imaging venography was performed, with thrombosis in the left transverse and sigmoid sinuses identified. The infant was treated with subdural peritoneostomy. We hypothesized that an occlusive cerebral venous sinus thrombosis may well be the culprit, or an exacerbating factor for TSE associated with hydrocephalus.
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Marino MA, Morabito R, Vinci S, Germanò A, Briguglio M, Alafaci C, Mormina E, Longo M, Granata F. Benign external hydrocephalus in infants. A single centre experience and literature review. Neuroradiol J 2014; 27:245-50. [PMID: 24750715 DOI: 10.15274/nrj-2014-10020] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2013] [Accepted: 01/29/2014] [Indexed: 11/12/2022] Open
Abstract
External hydrocephalus (EH) is a benign clinical entity in which macrocephaly is associated with an increase in volume of the subarachnoid space, especially overlying both frontal lobes, and a normal or only slight increase in volume of the lateral ventricles. Several pathogenic hypotheses have been proposed but the most accredited theory seems to be delayed maturation of the arachnoid villi. There is a consensus that this is a benign entity, correlated to a familial predisposition and, in some cases, inheritance. CT and MRI are very important to make a diagnosis but also to establish the prognosis in patients who encounter the rare complications such as subdural haematomas. In conclusion, CT and MRI can provide a highly accurate diagnosis in these patients, allowing a preliminary assessment of the prognosis, particularly regarding the enlarged subarachnoid space limits and the "cortical vein" sign which can predict a further complication. These results are obtained with the same examination performed in a standard CT or MRI study of the brain and no injection of contrast medium is needed.
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Affiliation(s)
- Maria Adele Marino
- Neuroradiology Unit, Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina; Messina, Italy -
| | - Rosa Morabito
- Neuroradiology Unit, Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina; Messina, Italy
| | - Sergio Vinci
- Neuroradiology Unit, Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina; Messina, Italy
| | - Antonino Germanò
- Department of Neurosciences, Psychiatric and Anaesthesiological Sciences, Neurosurgery Unit, University of Messina; Messina, Italy
| | - Marilena Briguglio
- National Research Council of Italy (CNR), Institute of Clinical Physiology (IFC), University of Messina; Messina, Italy
| | - Concetta Alafaci
- Department of Neurosciences, Psychiatric and Anaesthesiological Sciences, Neurosurgery Unit, University of Messina; Messina, Italy
| | - Enricomaria Mormina
- Neuroradiology Unit, Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina; Messina, Italy
| | - Marcello Longo
- Neuroradiology Unit, Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina; Messina, Italy
| | - Francesca Granata
- Neuroradiology Unit, Department of Biomedical Sciences and Morphologic and Functional Imaging, University of Messina; Messina, Italy
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Mattei TA, Sambhara D, Bond BJ, Lin J. Clinical outcomes of temporary shunting for infants with cerebral pseudomeningocele. Childs Nerv Syst 2014; 30:283-91. [PMID: 23881425 DOI: 10.1007/s00381-013-2230-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2013] [Accepted: 07/08/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE Although in the case of subdural collections temporary shunting has been suggested as a viable alternative for definitive drainage of the accumulated fluid until restoration of the normal CSF dynamics, there is no agreement on the best management strategy for pseudomeningocele. METHODS The authors performed a retrospective chart review in order to evaluate the clinical outcomes of infants temporarily shunted for pseudomeningocele without encephalocele at our institution (The University of Illinois at Peoria/Illinois Neurological Institute) in the period from 2004 to 2012. The epidemiological characteristics, clinical management, and final outcomes of such subpopulation were compared with a control group which received temporary shunting for subdural hematomas (SDH) during the same period. RESULTS Four patients (100% male) ranging in age from 8.9 to 27.1 months (mean = 13.88) with pseudomeningocele and 17 patients (64.7% male) ranging in age from 1.9 to 11.8 months (mean = 4.15) with SDH were identified. Although the initial management included sequential percutaneous subdural tapping in 82% of the patients, all children ultimately failed such strategy, requiring either subdural-peritoneal (81% of the cases) or subgaleal-peritoneal (19% of the cases) shunting. The mean implant duration was 201 days for the pseudomeningocele group and 384 days for the SDH one. Mean post-shunt hospitalization was 2 days for patients with pseudomeningocele and 4 days for patients with SDH. There was no statistical difference in terms of complications, length of hospitalization post-shunting, or clinical outcomes between the patients with pseudomeningocele and those with SDH. CONCLUSIONS Temporary shunting of infants with pseudo-meningocele constitutes a viable therapeutic alternative with favorable clinical outcomes and a low risk of shunt dependency similar to those of children with SDH.
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Affiliation(s)
- Tobias A Mattei
- Department of Neurosurgery, Illinois Neurological Institute (INI), University of Illinois College of Medicine at Peoria (UICOMP), 530 NE Glen Oak, 61637, Peoria, IL, USA,
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Greiner MV, Richards TJ, Care MM, Leach JL. Prevalence of subdural collections in children with macrocrania. AJNR Am J Neuroradiol 2013; 34:2373-8. [PMID: 23868166 DOI: 10.3174/ajnr.a3588] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The relationship between enlarged subarachnoid spaces and subdural collections is poorly understood and creates challenges for clinicians investigating the etiology of subdural collections. The purpose of this study was to determine the prevalence of subdural collections on cross sectional imaging in children with macrocephaly correlating with subarachnoid space enlargement. MATERIALS AND METHODS The radiology information system of a large pediatric medical center was reviewed for "macrocrania" and "macrocephaly" on reports of cranial MRI/CT examinations in children <24 months of age, over a 24-month period. Head circumference was obtained from the clinical record. Studies were reviewed blindly for subdural collection presence and subarachnoid space size. Children with prior cranial surgery, parenchymal abnormalities, hydrocephalus, or conditions predisposing to parenchymal volume loss were excluded. Chart review was performed on those with subdural collections. RESULTS Imaging from 177 children with enlarged head circumference was reviewed. Nine were excluded, for a final cohort of 168 subjects (108 with enlarged subarachnoid space). Subdural collections were identified in 6 (3.6%), all with enlarged subarachnoid space (6/108, 5.6%). In 4, subdural collections were small, homogeneous, and nonhemorrhagic. In 2, the collections were complex (septations or hemorrhage). Two children were reported as victims of child abuse (both with complex collections). No definitive etiology was established in the other cases. CONCLUSIONS The prevalence of subdural collections in imaged children with macrocrania was 3.6%, all occurring in children with enlarged subarachnoid space. Our results suggest that enlarged subarachnoid space can be associated with some subdural collections in this cohort. Despite this, we believe that unexpected subdural collections in children should receive close clinical evaluation for underlying causes, including abusive head trauma.
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Affiliation(s)
- M V Greiner
- Department of Pediatrics, Mayerson Center for Safe and Healthy Children
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Shen MD, Nordahl CW, Young GS, Wootton-Gorges SL, Lee A, Liston SE, Harrington KR, Ozonoff S, Amaral DG. Early brain enlargement and elevated extra-axial fluid in infants who develop autism spectrum disorder. ACTA ACUST UNITED AC 2013; 136:2825-35. [PMID: 23838695 DOI: 10.1093/brain/awt166] [Citation(s) in RCA: 193] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Prospective studies of infants at risk for autism spectrum disorder have provided important clues about the early behavioural symptoms of autism spectrum disorder. Diagnosis of autism spectrum disorder, however, is not currently made until at least 18 months of age. There is substantially less research on potential brain-based differences in the period between 6 and 12 months of age. Our objective in the current study was to use magnetic resonance imaging to identify any consistently observable brain anomalies in 6-9 month old infants who would later develop autism spectrum disorder. We conducted a prospective infant sibling study with longitudinal magnetic resonance imaging scans at three time points (6-9, 12-15, and 18-24 months of age), in conjunction with intensive behavioural assessments. Fifty-five infants (33 'high-risk' infants having an older sibling with autism spectrum disorder and 22 'low-risk' infants having no relatives with autism spectrum disorder) were imaged at 6-9 months; 43 of these (27 high-risk and 16 low-risk) were imaged at 12-15 months; and 42 (26 high-risk and 16 low-risk) were imaged again at 18-24 months. Infants were classified as meeting criteria for autism spectrum disorder, other developmental delays, or typical development at 24 months or later (mean age at outcome: 32.5 months). Compared with the other two groups, infants who developed autism spectrum disorder (n = 10) had significantly greater extra-axial fluid at 6-9 months, which persisted and remained elevated at 12-15 and 18-24 months. Extra-axial fluid is characterized by excessive cerebrospinal fluid in the subarachnoid space, particularly over the frontal lobes. The amount of extra-axial fluid detected as early as 6 months was predictive of more severe autism spectrum disorder symptoms at the time of outcome. Infants who developed autism spectrum disorder also had significantly larger total cerebral volumes at both 12-15 and 18-24 months of age. This is the first magnetic resonance imaging study to prospectively evaluate brain growth trajectories from infancy in children who develop autism spectrum disorder. The presence of excessive extra-axial fluid detected as early as 6 months and the lack of resolution by 24 months is a hitherto unreported brain anomaly in infants who later develop autism spectrum disorder. This is also the first magnetic resonance imaging evidence of brain enlargement in autism before age 2. These findings raise the potential for the use of structural magnetic resonance imaging to aid in the early detection of children at risk for autism spectrum disorder or other neurodevelopmental disorders.
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Affiliation(s)
- Mark D Shen
- The Medical Investigation of Neurodevelopmental Disorders Institute and Department of Psychiatry and Behavioural Sciences, UC Davis School of Medicine, University of California, Davis, Sacramento, CA 95817, USA
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Piatt JH. A pitfall in the diagnosis of child abuse: external hydrocephalus, subdural hematoma, and retinal hemorrhages. Neurosurg Focus 2012; 7:e4. [PMID: 16918219 DOI: 10.3171/foc.1999.7.4.6] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
External hydrocephalus has been associated with subdural hematomas in infancy, and the hematomas have been noted to be secondary to minor trauma or have even been described as spontaneous. The author reports the case of an infant with external hydrocephalus who developed retinal as well as subdural hemorrhages after sustaining a minor head injury. Although retinal hemorrhage in infancy has been considered virtually pathognomonic of child abuse, in the setting of external hydrocephalus a more cautious interpretation may be appropriate.
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Affiliation(s)
- J H Piatt
- Departments of Neurosurgery and Pediatrics. Oregon Health Sciences University, Portland, Oregon
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Tsuang FY, Huang APH, Tsai YH, Chen JY, Lee JE, Tu YK, Wang KC. Treatment of patients with traumatic subdural effusion and concomitant hydrocephalus. J Neurosurg 2012; 116:558-65. [DOI: 10.3171/2011.10.jns11711] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Traumatic subdural effusion (TSE) is a common sequela of traumatic brain injury. Surgical intervention is suggested only when TSE exerts mass effect. The authors have found that many patients with TSE exerting mass effect have concomitant hydrocephalus. Patient experiencing this occurrence were studied, and the pathogenesis of this phenomenon was discussed in the context of recent advances in the understanding of CSF circulation.
Methods
During a 2-year period, the authors' institution treated 14 patients with TSE who developed hydrocephalus, after 1 of the patients suffered subdural drainage and other 13 received subdural peritoneal shunt (SPSs). Thirteen of those who had SPSs received programmable ventriculoperitoneal shunts (VPSs) for the hydrocephalus. The clinical characteristics as well as the imaging and operative findings of these patients were reviewed.
Results
All patients with symptomatic TSE exerting mass effect received SPSs. All of these patients had a modified Frontal Horn Index of more than 0.33 at presentation, and high opening pressure on durotomy. Following a brief period (4–7 days) of clinical improvement, the condition of all patients deteriorated due to hydrocephalus. Programmable VPSs were inserted with the initial pressure set at approximately 8–10 cm H2O according to opening pressure at ventriculostomy. Shunt valve pressure was gradually decreased to 5–7 cm H2O, according to clinical and radiological follow-up.
Conclusions
Elevated modified Frontal Horn Index in patients with TSE is suggestive of concomitant hydrocephalus. The authors propose that tearing of the dura-arachnoid plane following trauma contributes to TSE and may also impede CSF circulation, causing hydrocephalus. Shunt pressure was adjusted to relative low pressure, indicating the old age of the patients and poor reexpansion of brain parenchyma after the mass effect. Subdural peritoneal shunts and VPSs are indicated in those patients with TSE exerting mass effect with concomitant hydrocephalus.
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Affiliation(s)
- Fon-Yih Tsuang
- 1Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei
- 5Institute of Clinical Neuroscience, National Taiwan University, Taipei; and
| | - Abel Po-Hao Huang
- 2Department of Surgery, National Taiwan University Hospital, Yun-Lin Branch, Yun-Lin
- 5Institute of Clinical Neuroscience, National Taiwan University, Taipei; and
| | - Yi-Hsin Tsai
- 3Department of Traumatology,
- 5Institute of Clinical Neuroscience, National Taiwan University, Taipei; and
| | - Jo-Yu Chen
- 4Department of Medical Imaging, and
- 5Institute of Clinical Neuroscience, National Taiwan University, Taipei; and
| | - Jing-Er Lee
- 6Department of Neurology, Zhuchi Buddhist Hospital, Taipei, Taiwan
| | - Yong-Kwang Tu
- 1Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei
- 5Institute of Clinical Neuroscience, National Taiwan University, Taipei; and
| | - Kuo-Chuan Wang
- 1Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei
- 5Institute of Clinical Neuroscience, National Taiwan University, Taipei; and
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External hydrocephalus in infants: six cases with MR venogram and flow quantification correlation. Childs Nerv Syst 2011; 27:2087-96. [PMID: 21833725 DOI: 10.1007/s00381-011-1549-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2011] [Accepted: 07/29/2011] [Indexed: 10/17/2022]
Abstract
PURPOSE The cause of external hydrocephalus in infants is largely unknown. However, familial macrocephaly and delayed maturation of the arachnoid granulations are thought to play a part in the idiopathic cases. Secondary cases of external hydrocephalus are associated with hemorrhage, meningitis, and elevated venous pressure. Recently, elevated venous pressure has been shown to be a much more common cause of communicating hydrocephalus in children than previously thought. The purpose of this study is to investigate venous pressure as a cause of external hydrocephalus. METHODS Six children with external hydrocephalus underwent an MRI examination including MR venography and MR flow quantification techniques. A chart review was performed to correlate the clinical findings with the MR findings. Six children with normal head circumferences and growth profile served as controls. RESULTS The net aqueduct flow in both normal and hydrocephalic children was into the ventricles. There was a spectrum of blood flow findings in the infants with hydrocephalus. (1) Those with normal arterial inflow showed venous outflow stenoses or anomalies. (2) Those with normal MR venograms tended to have elevated cerebral blood inflow. CONCLUSIONS The absorption of CSF in infants is into the capillary bed of the deep white matter rather than the arachnoid granulations. Absorption into a capillary bed depends on hydrostatic pressure. Similar to older children with communicating hydrocephalus, the infants in this cohort with external hydrocephalus showed evidence of an elevation in venous pressure. Elevated venous pressure may be a much more common cause of external hydrocephalus than previously recognized.
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Ghosh PS, Ghosh D. Subdural hematoma in infants without accidental or nonaccidental injury: benign external hydrocephalus, a risk factor. Clin Pediatr (Phila) 2011; 50:897-903. [PMID: 21576186 DOI: 10.1177/0009922811406435] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Benign external hydrocephalus (BEH) is considered a self-limiting condition in infants. Subdural hematoma (SDH) in infants without a history of trauma indicates nonaccidental injury (NAI). The authors studied whether SDH can complicate BEH without apparent trauma. Out of 45 children younger than 3 years with nontraumatic SDH, 9 (7 boys) with mean age 6 months had BEH as risk factor. Symptoms included increasing head size (8), fussiness, and irritability (3). Three had up-gaze restriction, 1 axial hypotonia, and 6 normal examination. Neuroimaging showed prominent extra-axial spaces; SDH was bilateral (6), subacute (5). Other etiological workup for SDH was negative except NAI in 1. Two required evacuation of SDH and subdural-peritoneal shunt; others managed conservatively. Development was normal in 8 on follow-up. On follow-up imaging of 8, SDH completely resolved in 3, markedly reduced in 3, and remained stable in 2. BEH is a risk factor for SDH in infants, thus not always benign.
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Zahl SM, Egge A, Helseth E, Wester K. Benign external hydrocephalus: a review, with emphasis on management. Neurosurg Rev 2011; 34:417-32. [PMID: 21647596 PMCID: PMC3171652 DOI: 10.1007/s10143-011-0327-4] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 04/18/2011] [Accepted: 05/01/2011] [Indexed: 11/10/2022]
Abstract
Benign external hydrocephalus in infants, characterized by macrocephaly and typical neuroimaging findings, is considered as a self-limiting condition and is therefore rarely treated. This review concerns all aspects of this condition: etiology, neuroimaging, symptoms and clinical findings, treatment, and outcome, with emphasis on management. The review is based on a systematic search in the Pubmed and Web of Science databases. The search covered various forms of hydrocephalus, extracerebral fluid, and macrocephaly. Studies reporting small children with idiopathic external hydrocephalus were included, mostly focusing on the studies reporting a long-term outcome. A total of 147 studies are included, the majority however with a limited methodological quality. Several theories regarding pathophysiology and various symptoms, signs, and clinical findings underscore the heterogeneity of the condition. Neuroimaging is important in the differentiation between external hydrocephalus and similar conditions. A transient delay of psychomotor development is commonly seen during childhood. A long-term outcome is scarcely reported, and the results are varying. Although most children with external hydrocephalus seem to do well both initially and in the long term, a substantial number of patients show temporary or permanent psychomotor delay. To verify that this truly is a benign condition, we suggest that future research on external hydrocephalus should focus on the long-term effects of surgical treatment as opposed to conservative management.
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Affiliation(s)
- Sverre Morten Zahl
- Department of Neurosurgery, Haukeland University Hospital, Bergen, Norway.
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Orešković D, Klarica M. Development of hydrocephalus and classical hypothesis of cerebrospinal fluid hydrodynamics: facts and illusions. Prog Neurobiol 2011; 94:238-58. [PMID: 21641963 DOI: 10.1016/j.pneurobio.2011.05.005] [Citation(s) in RCA: 88] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Revised: 05/13/2011] [Accepted: 05/18/2011] [Indexed: 11/30/2022]
Abstract
According to the classical hypothesis of the cerebrospinal fluid (CSF) hydrodynamics, CSF is produced inside the brain ventricles, than it circulates like a slow river toward the cortical subarachnoid space, and finally it is absorbed into the venous sinuses. Some pathological conditions, primarily hydrocephalus, have also been interpreted based on this hypothesis. The development of hydrocephalus is explained as an imbalance between CSF formation and absorption, where more CSF is formed than is absorbed, which results in an abnormal increase in the CSF volume inside the cranial CSF spaces. It is believed that the reason for the imbalance is the obstruction of the CSF pathways between the site of CSF formation and the site of its absorption, which diminishes or prevents CSF outflow from the cranium. In spite of the general acceptance of the classical hypothesis, there are a considerable number of experimental results that do not support such a hypothesis and the generally accepted pathophysiology of hydrocephalus. A recently proposed new working hypothesis suggests that osmotic and hydrostatic forces at the central nervous system microvessels are crucial for the regulation of interstial fluid and CSF volume which constitute a functional unit. Based on that hypothesis, the generally accepted mechanisms of hydrocephalus development are not plausible. Therefore, the recent understanding of the correlation between CSF physiology and the development of hydrocephalus has been thoroughly presented, analyzed and evaluated, and new insights into hydrocephalus etiopathology have been proposed, which are in accordance with the experimental data and the new working hypothesis.
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Affiliation(s)
- D Orešković
- Ruđer Bošković Institute, Department of Molecular Biology, Bijenička 54, 10 000 Zagreb, Croatia.
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40
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Yew AY, Maher CO, Muraszko KM, Garton HJL. Long-term health status in benign external hydrocephalus. Pediatr Neurosurg 2011; 47:1-6. [PMID: 21778677 DOI: 10.1159/000322357] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 04/19/2010] [Indexed: 11/19/2022]
Abstract
PURPOSE Benign external hydrocephalus (BEH) is characterized by excess cerebrospinal fluid in the frontal subarachnoid spaces in infants evaluated for macrocephaly. We sought to describe the natural history of this disorder, specifically its clinical presentation, disease course and long-term health status impact using the validated, disease-specific Hydrocephalus Outcome Questionnaire (HOQ). METHODS An inception cohort of children >5 and <18 years old, with a history of BEH was assembled by ICD-9 and a key word search of medical and radiology records. Review confirmed the diagnosis of BEH, excluded major medical comorbidities and assessed presentation, radiographic features and head size/growth velocity. The HOQ was administered by mail. RESULTS We identified 99 patients, 5-12 years old (55% males). Twenty were born prematurely, 12 with <33 weeks gestation. Children presented at an average age of 9 ± 4.8 months (mean ± SD). The presenting complaint was macrocephaly in 65 cases. Other presenting findings were positional head shape deformity and torticollis; 10% had a family history of macrocephaly. Developmental delay was present in 21% of patients (4% verbal, 20% gross motor, 4% fine motor delay). Four patients had small subdural hematomas, none with suspicion of a non-accidental trauma. During clinical reassessment over a mean follow-up of 13 months, the average head percentile was stable and none of the patients developed new subdural hematomas. Gross motor delay resolved in 15/20 and fine motor delay in 4/4 patients. Verbal delay resolved in 2/4 patients, but interestingly, was newly detected in 6 other children. None of the patients required cerebrospinal fluid shunting. The response rate to the HOQ was 25% (median age 7 years, 74% females). The average overall HOQ score was 0.75 ± 0.24 versus 0.68 ± 0.19 for a previously published cohort of shunted hydrocephalic children. CONCLUSIONS BEH patients in this series generally saw resolution of presenting motor developmental delays; however, new verbal delays were detected in a non-trivial number of patients. Quality of life measurements suggest some reduction in health status, but less so than is seen with shunted hydrocephalus.
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Affiliation(s)
- Andrew Y Yew
- Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, MI, USA
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41
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Gallini F, Baranello G, Serrao F, Alfieri P, Cota F, Maggio L, Tamburrini G, Romagnoli C, Mercuri E. External hydrocephalus in discordant birth weight twins: a case report. J Matern Fetal Neonatal Med 2010; 24:337-40. [PMID: 20608805 DOI: 10.3109/14767058.2010.497566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The term "external hydrocephalus (EH)" is used to describe excessively rapid head growth in infants who are found to have enlarged subarachnoid spaces and little or no ventricular enlargement. EH has not yet been described in discordant birth weight twins. We report the cases of two sets of discordant twins with normal neonatal course and normal neonatal brain ultrasound scans who developed an EH in the first months after birth and had a mild neurodevelopmental delay. Our findings suggest that EH may be part of neurologic morbidity in discordant birth weight twins and represents one of the potential complications to look for in the follow-up of these infants.
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Affiliation(s)
- Francesca Gallini
- Division of Neonatology, Department of Pediatrics, Catholic University of the Sacred Heart, Rome, Italy
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Ando S, Otani M, Moritake K. Usefulness of spinal drainage for post-traumatic external hydrocephalus: report of two cases. J Clin Neurosci 2010; 4:236-40. [PMID: 18638961 DOI: 10.1016/s0967-5868(97)90079-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/1994] [Accepted: 02/28/1995] [Indexed: 10/26/2022]
Abstract
An 8-year-old girl presented with symptoms of increased intracranial pressure on the 18th day after removal of an occipital epidural haematoma. A 69-year-old woman exhibited the same symptoms on the 6th day after the removal of a left frontal subdural haematoma. Computed tomography (CT) revealed that both patients were suffering from external hydrocephalus. Spinal drainage, maintained for 18 days in the former case and for 7 days in the latter, not only relieved those symptoms but also cured the external hydrocephalus. Recurrence of external hydrocephalus has not been observed in either case for several years since discontinuation of spinal drainage. Usefulness of spinal drainage for post-traumatic external hydrocephalus is discussed.
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Affiliation(s)
- S Ando
- Department of Neurosurgery, Unnan General Hospital, Shimane Prefecture, Japan
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43
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Abstract
Prenatal ultrasound has concentrated on readily visible cerebral structures including head size, shape, ventricles, CSP (cavum septi pellucidi), cerebellar size/vermian presence and cisterna magna. However, apart from these easily visible structures it is important to evaluate the brain itself. Patients who initially appear to have mild isolated findings such as borderline ventriculomegaly in fact can have many more subtle findings that significantly alter prognosis and management that can be detected on detailed examination of the brain. There has been rapid evolution in imaging these foetuses, especially with neurosonography and MRI, and a revolution in understanding the underlying genetic and biochemical mechanisms. There is increasing emphasis to detect cortical abnormalities as early as possible. This article reviews development of the cerebral cortex, the classification, aetiologies and clinical manifestations of cortical disorders, normal and abnormal appearances at ultrasound and MRI, and approaches to investigation.
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Affiliation(s)
- Ants Toi
- Department of Medical Imaging, Mount Sinai Hospital and University Health Network, University of Toronto, Toronto, Ontario, Canada.
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44
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Affiliation(s)
- Murat Kocaoglu
- Department of Radiology, Gulhane Military Medical School, Etlik, Ankara, Turkey.
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45
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Hellbusch LC. Benign extracerebral fluid collections in infancy: clinical presentation and long-term follow-up. J Neurosurg 2009; 107:119-25. [PMID: 18459883 DOI: 10.3171/ped-07/08/119] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Benign extracerebral fluid collections are common in infants, but there are unanswered questions regarding presentation and long-term outcome. This study was undertaken to establish head size at birth, head size at presentation, head growth over time, history of presentation, indications for surgery, and long-term results. METHODS Cases of benign extracerebral fluid collections in infancy were retrospectively reviewed. Data pertaining to clinical presentation, progress, and long-term follow-up were evaluated. Patients were divided into two groups on the basis of the presence or absence of increased signal intensity of fluid in the extracerebral space on T1-weighted magnetic resonance images. Group 1 consisted of 39 patients who had benign extracerebral fluid collections without any subdural collections. Group 2 consisted of nine patients who had a chronic subdural hematoma or hygroma without a history of trauma and had generous subarachnoid spaces and/or a history of premature birth. Patients were observed for an average of 49 months. RESULTS Group 1 included 39 patients (ages at presentation 3-12 months); the most common presentation in this group was macrocephaly (28 cases). Of those Group 1 cases in which data regarding gestational age at birth were available, 15 births were either severely or mildly premature and 14 were full term. Of those Group 1 patients with adequate data, 14 had an occipitofrontal circumference (OFC) in the 50th to 98th percentile at birth and two had OFCs greater than the 98th percentile. Measurements obtained at 24 months of age were available for 18 Group 1 patients: OFC was at approximately the 98th percentile in eight (all eight born at full term) and more than 1 cm larger than the 98th percentile in 10. Head growth in Group 1 patients continued to decrease, approaching the 98th percentile after 24 months of age. Only three of the 39 patients in Group 1 required shunt placement. Of the 33 Group 1 patients for whom long-term follow-up was available, 30 were developing normally, and three had mild developmental delays. Group 2 included nine patients (ages at presentation 3-7 months); the most common presentations were large head (three patients) and seizures (three patients). Data concerning gestational age at birth were available in eight Group 2 cases: birth was severely premature in four and gestation was full term in four. Five Group 2 patients were treated surgically-two with subduroperitoneal (SDP) shunt placement, two with subdural punctures, and one with subdural punctures and SDP shunt placement. Adequate follow-up information was available in eight of nine Group 2 cases; all eight patients were found to be developing normally. CONCLUSIONS Group 1 patients usually had a normal head size at birth, they rarely required shunt placement, their head growth eventually leveled off toward the 98th percentile line, and their outcomes were generally good. Although five of nine Group 2 patients required subdural punctures and/or SDP shunt placement, that group of patients also developed well. Infants with nontraumatic subdural hematomas or hygromas, presumably associated with benign extracerebral fluid collections, can often experience significant resolutions of the hematoma or hygroma within several months without surgical treatment.
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Affiliation(s)
- Leslie C Hellbusch
- Department of Surgery (Neurosurgery), Nebraska Medical Center, Omaha, Nebraska 68114, USA.
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Whyte C, Eshkar N. Images from headache: external hydrocephalus due to cryptococcal meningitis. Headache 2007; 47:1447-8. [PMID: 18052954 DOI: 10.1111/j.1526-4610.2007.00940.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Chad Whyte
- New Jersey Neuroscience Institute-Neurology, Edison, NJ, USA
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47
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Vertinsky AT, Barnes PD. Macrocephaly, increased intracranial pressure, and hydrocephalus in the infant and young child. Top Magn Reson Imaging 2007; 18:31-51. [PMID: 17607142 DOI: 10.1097/rmr.0b013e3180d0a753] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Macrocephaly, increased intracranial pressure, and hydrocephalus are common related conditions that lead to cross-sectional imaging of the infant and young child. Imaging plays a central role in establishing the diagnosis and guiding disposition and treatment of these patients. In this review, a general overview is provided, and the more common causes of hydrocephalus are presented, including posthemorrhage, postinfection, developmental malformations, and masses. Imaging guidelines are also outlined for initial evaluation and follow-up, along with a discussion of the imaging features of shunt malfunction.
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Paciorkowski AR, Greenstein RM. When is enlargement of the subarachnoid spaces not benign? A genetic perspective. Pediatr Neurol 2007; 37:1-7. [PMID: 17628215 DOI: 10.1016/j.pediatrneurol.2007.04.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2006] [Revised: 03/14/2007] [Accepted: 04/13/2007] [Indexed: 02/06/2023]
Abstract
Enlargement of the subarachnoid spaces is occasionally encountered during neuroimaging of children. This enlargement is generally regarded as a nonpathologic process that resolves uneventfully. However, there are several genetic disorders in which enlargement of the subarachnoid spaces can be an early sign, or the feature of an associated syndrome, that may aid in the underlying diagnosis. Recognizing subarachnoid space enlargement in these circumstances requires an understanding of the normal physiology of the subarachnoid space at different time points in a child's neurodevelopment. This article reviews the events shaping the subarachnoid space, both during normal physiologic maturation and in specific genetic disorders.
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Affiliation(s)
- Alex R Paciorkowski
- Department of Genetics and Developmental Biology, Division of Human Genetics, University of Connecticut Health Center, West Hartford, Connecticut 06119, USA.
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49
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Wilson RK, Williams MA. Evidence that congenital hydrocephalus is a precursor to idiopathic normal pressure hydrocephalus in only a subset of patients. J Neurol Neurosurg Psychiatry 2007; 78:508-11. [PMID: 17202229 PMCID: PMC2117818 DOI: 10.1136/jnnp.2006.108761] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To identify the proportion of patients in a large idiopathic normal pressure hydrocephalus (INPH) cohort with large head circumference (HC) who presumably have congenital hydrocephalus that has not become clinically apparent until late in life. METHODS HC was measured in 158 patients diagnosed with communicating INPH and assigned to HC centile range adjusted for height and sex. The proportion of patients with INPH and HC above the 97th, 90th or 50th centiles was compared with the proportion expected in a normal population. RESULTS The proportion of patients with HC >90th centile was significantly larger than would be expected in a normal distribution (19.6% vs 10%, p = 0.0001), as was the proportion of patients with HC >97th centile (8.9% vs 3%, p = 0.0001). The relative association between INPH and HC >97th centile was nearly tripled (relative association 2.95; CI 1.36 to 6.41), but the relative association between INPH and HC >50th centile was not significantly higher than predicted (relative association 1.13; CI 0.95 to 1.34). CONCLUSION A significantly larger proportion of elderly adults with INPH have a HC greater than the 90th or 97th centile than predicted by population norms, supporting the concept that compensated congenital hydrocephalus that does not become symptomatic until late in life is one aetiology of INPH, but is not responsible for all INPH. The mechanism that leads to the development of INPH in most patients remains elusive.
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Affiliation(s)
- Robin K Wilson
- Adult Hydrocephalus Program, Department of Neurology, Johns Hopkins Hospital, Baltimore, Maryland 21287, USA.
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50
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Abstract
BACKGROUND Nonaccidental head trauma in infants is the leading cause of infant death from injury. RESULTS AND DISCUSSION Clinical features that suggest inflicted head trauma include the triad of the so-called shaken baby syndrome, consisting of retinal hemorrhage, subdural, and/or subarachnoid hemorrhage in an infant with little signs of external trauma. Studies have shown that, in general, the average short fall in the home is extremely unlikely to produce either subdural or retinal hemorrhage, although focal injuries such as skull fractures and epidural hemorrhage may be seen. Acceleration/deceleration, especially of the rotational type, is believed to be the most probable mechanism of injury in cases of nonaccidental head trauma. Damage to the cervicomedullary junction and the respiratory centers, with subsequent hypoxia and intracerebral edema, has also been implicated. After the initial trauma and hemorrhage, loss of cerebral autoregulation, breakdown of the blood-brain barrier, and disruption of ionic homeostasis occur, leading to brain edema and cytotoxicity. Cellular damage can involve large volumes of tissue, without respecting vascular territories. CONCLUSION Overall, a satisfactory biomechanical model is lacking, and the criminal nature of abusive injury makes it difficult to perform systematic, controlled studies. Unfortunately, outcomes are poor, and the rate of repeated abusive episodes is high. Future research should focus on the development of a satisfactory research model and on prevention strategies.
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Affiliation(s)
- Paula Gerber
- Barrow Neurological Institute, Phoenix, AZ 85013, USA.
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