Isolated congenital facial nerve agenesis

An otherwise healthy 2 month old boy was referred to ENT for a congenital right facial palsy, with a birth history of difficult ventouse delivery. Initially, a traumatic cause was suspected, however subsequent MR 3D-FIESTA (T2 weighted) imaging demonstrated a right facial nerve agenesis with normal appearances of the remainder of the brain parenchyma, cranial nerves and parotid glands. There were no syndromic features or hearing difficulties. Isolated congenital nerve agenesis is a rare condition, with very few case reports available in the literature. Pre-natal 4D ultrasound imaging further supports the diagnosis. To our knowledge, this is the first published pre-natal ultrasound image of congenital facial nerve palsy. The infant has been referred for consideration of nerve reconstruction surgery, and is receiving multi-disciplinary input from ENT, Physiotherapy and Ophthalmology, the latter for prevention of exposure keratitis.

The (extended) achondroplasia foramen magnum score has good observer reliability

BACKGROUND

Achondroplasia is the most common skeletal dysplasia. A significant complication is foramen magnum stenosis. When severe, compression of the spinal cord may result in sleep apnea, sudden respiratory arrest and death. To avoid complications, surgical decompression of the craniocervical junction is offered in at-risk cases. However, practice varies among centres. To standardize magnetic resonance (MR) reporting, the achondroplasia foramen magnum score was recently developed. The reliability of the score has not been assessed.

OBJECTIVE

To assess the interobserver reliability of the achondroplasia foramen magnum score.

MATERIALS AND METHODS

Base of skull imaging of children with achondroplasia under the care of Sheffield Children's Hospital was retrospectively and independently reviewed by four observers using the achondroplasia foramen magnum score. Two-way random-effects intraclass coefficient (ICC) was used to assess inter- and intra-observer reliability.

RESULTS

Forty-nine eligible cases and five controls were included. Of these, 10 were scored normal, 17 had a median score of 1 (mild narrowing), 11 had a median score of 2 (effacement of cerebral spinal fluid), 10 had a score of 3 (compression of cord) and 6 had a median score of 4 (cord myelopathic change). Interobserver ICC was 0.72 (95% confidence interval = 0.62-0.81). Intra-observer ICC ranged from 0.60 to 0.86. Reasons for reader disagreement included flow void artefact, subtle T2 cord signal and myelopathic T2 cord change disproportionate to canal narrowing.

CONCLUSION

The achondroplasia foramen magnum score has good interobserver reliability. Imaging features leading to interobserver disagreement have been identified. Further research is required to prospectively validate the score against clinical outcomes.

Celiac Plexus Block to Treat Refractory Feed Induced Dystonia in Children with Severe Neurodisability: A Single Center Case Series

This observational study describes the procedure technique, safety outcomes, and patient responses to celiac plexus blockade (CPB) in children with severe neurodisability with refractory feed intolerance, feed induced pain or feed induced dystonia (FID).

Method

A review of the pathophysiological response to feeding in children with significant neurodisability and the effect on the neuroenteric system. A 2-stage CT-guided temporary celiac plexus blockade followed by neurolysis technique is described. We compile a case series of 5 patients with life limiting conditions and significant disability undergoing CPB in a single tertiary pediatric hospital.

Results

A total of 10 separate procedures in 5 children were completed. A positive outcome was observed in 3 out of 4 cases of pediatric FID. Two of the three patients on parenteral nutrition had improved feed tolerance postprocedure. All children tolerated the procedure well, no postprocedure complications were documented.

Conclusions

In selected cases, children with life-threatening feed induced dystonia or effective intestinal failure can be safely treated with celiac plexus blockade when other therapies have failed.

Rationale, design, and methods of a randomized, controlled, open-label clinical trial with open-label extension to investigate the safety of vosoritide in infants, and young children with achondroplasia at risk of requiring cervicomedullary decompression surgery

Achondroplasia causes narrowing of the foramen magnum and the spinal canal leading to increased mortality due to cervicomedullary compression in infants and significant morbidity due to spinal stenosis later in adulthood. Vosoritide is a C-natriuretic peptide analogue that has been shown to improve endochondral ossification in children with achondroplasia. The objective of this trial is to evaluate the safety of vosoritide and whether vosoritide can improve the growth of the foramen magnum and spinal canal in children that may require decompression surgery. An Achondroplasia Foramen Magnum Score will be used to identify infants at risk of requiring decompression surgery. This is a 2-year open label randomized controlled trial of vosoritide in infants with achondroplasia ages 0 to ≤12 months. Approximately 20 infants will be randomized 1:1 to either open label once daily subcutaneous vosoritide combined with standard of care or standard of care alone. The primary and secondary aims of the study are to evaluate the safety and efficacy of vosoritide in children with cervicomedullary compression at risk of requiring decompression surgery. The trial will be carried out in specialized skeletal dysplasia treatment centers with well established multidisciplinary care pathways and standardized approaches to the neurosurgical management of cervicomedually compression. After 2 years, infants randomized to standard of care alone will be eligible to switch to vosoritide plus standard of care for an additional 3 years. This pioneering trial hopes to address the important question as to whether treatment with vosoritide at an early age in infants at risk of requiring cervicomedullary decompression surgery is safe, and can improve growth at the foramen magnum and spinal canal alleviating stenosis. This in turn may reduce compression of surrounding structures including the neuraxis and spinal cord, which could alleviate future morbidity and mortality.Trial registrations: ClinicalTrials.gov, NCT04554940; EudraCT number, 2020-001055-40.

Visualisation of fetal meconium on post-mortem magnetic resonance imaging scans: a retrospective observational study

Background

Less invasive techniques for fetal post-mortems are increasingly used to correlate with parental wishes. With the use of post-mortem magnetic resonance imaging (MRI), normal appearance of the organs must be established.

Purpose

To investigate the after death appearance of the fetal meconium throughout gestation using the hyperintense appearance of meconium on T1 weighted MRI.

Material and Methods

This was a retrospective study that took place in a tertiary referral centre radiology department. Sixty-two fetal body post-mortem MRI scans (January 2014 to May 2018) between 12 and 41 weeks gestation were reviewed. Signal intensity of meconium at the rectum, sigmoid colon, splenic flexure and hepatic flexure was evaluated and correlated with gestational age. Interrater reliability was calculated.

Results

Meconium did not consistently have high signal intensity on T1 scans and was not always obvious. Rectal meconium had the highest intensity, and the more proximal the bowel the lower the intensity. The meconium had higher intensity at earlier gestations. Interrater reliability for rectal meconium gradings was excellent.

Conclusion

This study provides the first published primary research on the appearance of fetal meconium on post-mortem MRI. Overall, results were variable and suggest an alteration of bowel contents after death, but further investigation is needed to effectively inform practice.

Benefits and Limitations of the Minimally Invasive Postmortem: A Review of an Innovative Service Development

INTRODUCTION

Pediatric postmortem (PM) rates have significantly declined, creating a need for effective minimally invasive alternatives to correlate with parental wishes. We review the use of a minimally invasive fetal and neonatal PM service further to preliminary findings published in 2015.

MATERIALS AND METHODS

Cases taken from the mortuary electronic database from 2012 to 2017 are analyzed. The minimally invasive service consisted primarily of external examination, magnetic resonance imaging (MRI), and placental examination. Any significant conditions found noted. All pathology reports include a Relevant Condition at Death (ReCoDe) obstetric classification. Reports analyzed to determine which aspects of the service provided positive information.

RESULTS

Of 1498 perinatal postmortems, 105 (7%) were PM MRI, of which 75.24% were intrauterine fetal deaths. Relevant conditions were identified in 94 cases (89.52%), and ReCoDe categories in 80 cases (76.19%). Moreover, 90% of cases had a ReCoDe condition, with 10% unclassified. Seven cases had more than 1 ReCoDe. Main conditions related to placenta (32.5%) and umbilical cord (27.5%). The most informative elements were placental examination and MRI.

CONCLUSION

Minimally invasive PMs are a viable alternative to traditional autopsy when this option is refused. However, further case analysis is needed to determine potential bias toward certain classification codes.

Biometric analysis of the foetal meconium pattern using T1 weighted 2D gradient echo MRI

Objectives:

Foetal MRI is used to assess abnormalities after ultrasonography. Bowel anomalies are a significant cause of neonatal morbidity, however there are little data concerning its normal appearance on antenatal MRI. This study aims to investigate the pattern of meconium accumulation throughout gestation using its hyperintense appearance on T₁ weighted scans and add to the current published data.

Methods:

This was a retrospective cohort study in a tertiary referral clinical MRI centre. Foetal body MRI scans of varying gestational ages were obtained dating between October 2011 and March 2018. The bowel was visualised on T₁ weighted images. The length of the meconium and the width of the meconium at the rectum, sigmoid colon, splenic flexure and hepatic flexure was measured. Presence or absence of meconium in the small bowel was noted. Inter- and intrarater reliability was assessed.

Results:

181 foetal body scans were reviewed. 52 were excluded and 129 analysed. Visualisation of the meconium in the large bowel became increasingly proximal with later gestations, and small bowel visualisation was greater at earlier gestations. There was statistically significant strong (r = 0.6–0.8) or very strong (r = 0.8–1.0) positive correlation of length and width with increasing gestation. Interrater reliability was moderate to excellent (r = 0.4–1.0).

Conclusion:

This study provides new information regarding the pattern of meconium accumulation throughout gestation. With care, the results can be used in clinical practice to aid diagnosis of bowel pathology.

Advances in knowledge:

The findings of this study provide further information concerning the normal accumulation of foetal meconium on MR imaging, an area where current research is limited.

Functional mRNA analysis reveals aberrant splicing caused by novel intronic mutation in WDR45 in NBIA patient

WDR45 gene-associated neurodegeneration with brain iron accumulation (NBIA), referred to as beta-propeller protein-associated neurodegeneration (BPAN), is a rare disorder that presents with a very nonspecific clinical phenotype in children constituting global developmental delay. This case report illustrates the power of a combination of trio exome sequencing, in silico splicing analysis, and mRNA analysis to provide sufficient evidence for pathogenicity of a relatively intronic variant in WDR45, and in so doing, find a genetic diagnosis for a 6-year-old patient with developmental delay and seizures, a diagnosis which may otherwise have only been found once the characteristic MRI patterns of the disease became more obvious in young adulthood.

SLC35A2-related congenital disorder of glycosylation: Defining the phenotype

We aim to further delineate the phenotype associated with pathogenic variants in the SLC35A2 gene, and review all published literature to-date. This gene is located on the X chromosome and encodes a UDP-galactose transporter. Pathogenic variants in SLC35A2 cause a congenital disorder of glycosylation. The condition is rare, and less than twenty patients have been reported to-date. The phenotype is complex and has not been fully defined. Here, we present a series of five patients with de novo pathogenic variants in SLC35A2. The patients' phenotype includes developmental and epileptic encephalopathy with hypsarrhythmia, facial dysmorphism, severe intellectual disability, skeletal abnormalities, congenital cardiac disease and cortical visual impairment. Developmental and epileptic encephalopathy with hypsarrhythmia is present in most patients with SLC35A2 variants, and is drug-resistant in the majority of cases. Adrenocorticotropic hormone therapy may achieve partial or complete remission of seizures, but the effect is usually temporary. Isoelectric focusing of transferrins may be normal after infancy, therefore a congenital disorder of glycosylation should still be considered as a diagnosis in the presence of a suggestive phenotype. We also provide evidence that cortical visual impairment is part of the phenotypic spectrum.

Surfer's exostosis in a child who does not surf

Surfer's exostoses are more commonly seen in adults who frequently participate in aquatic activities with repeated exposed to cold water and wind. However, this entity has not been previously reported in the pediatric population. Most patients can be managed conservatively, particularly considering that surgical removal of external auditory canal exostosis can be challenging.

Outcomes following 'mini' percutaneous nephrolithotomy for renal calculi in children. A single-centre study

INTRODUCTION

This retrospective review was undertaken to identify the postoperative outcomes of children undergoing 'mini' percutaneous nephrolithotomy (MPCNL) at a single institution.

OBJECTIVE

Outcomes measured included: percentage of stone clearance, postoperative analgesia requirements, the need for intraoperative or postoperative blood transfusion, length of stay and morbidity.

STUDY DESIGN

A total of 46 patients were reviewed over a two-and-a-half-year period; the mean age was 7.3 years (range: 1-16 years). The MPCNL was performed with a radiological-guided peripheral puncture, followed by dilatation of the nephrostomy tract to a maximum Amplatz sheath size of 16-French; an 11-French nephroscope was used. Stone disintegration was achieved either with pneumatic or laser lithotripsy.

RESULTS

Complete stone clearance was achieved in 35/46 children (76%). The remaining 11 children had a stone clearance rate of over 80%. No patients required intraoperative/postoperative blood transfusion. A total of 39% of patients were managed on simple/non-opiate based analgesia, with 54% requiring opioid analgesia postoperatively for less than 24 h. There were no procedure-related complications and no mortalities. The mean length of stay was 2.24 days.

DISCUSSION

The management of urolithiasis can be challenging in children. The use of percutaneous nephrolithotomy, is becoming increasingly popular in the treatment of paediatric urolithiasis. The stone clearance rate in children undergoing standard PCNL, has been reported to be 50-98% in the literature [1,2,3,4]. Samad et al. [2] in 2006, reported their experience in 188 consecutive PCNLs, using a 17Fr or 26Fr nephroscope. Their largest sub group included children aged >5-16 yrs. Within this group, 57% were treated with a 17Fr nephroscope and 43% with the 26Fr nephroscope, achieving stone clearance of only 47% with PCNL monotherapy. In this group the transfusion rate was 3% [2]. Badawy et al., reported their experience of 60 children in 1999, using a 26 or 28Fr Amplatz sheath. They reported an 83.3% stone clearance with single session PCNL, with only one procedure being abandoned due to intraoperative bleeding requiring blood transfusion [3]. In 2007, Bilen et al. reported their experience and compared the use of 26Fr, 20Fr and 14Fr (mini) PCNL. Stone size, previous surgery and the mean haemoglobin drop postoperatively did not change between the groups, however the blood transfusion rate was higher in the 26Fr and 20Fr Amplatz sheath groups. The stone clearance was highest in the 'mini PCNL' group at 90%, compared to 69.5% in the 26Fr and 80% in the 20Fr group [4]. MPCNL has become increasingly popular over recent years, with stone clearance reported as 80-85% [5-7] following a single session of MPCNL as monotherapy. In 2012, Yan et al. reported 85.2% stone clearance with mini PCNL monotherapy (tract size 14-16Fr), with no children requiring blood transfusion [6]. Zeng et al. reported their experience of 331 renal units in children, with stone clearance rates reaching 80.4% and a blood transfusion rate of 3.1% [8]. In our centre, we do not perform postoperative haemoglobin levels as a matter of routine and any investigations are performed on an intention to treat principle. Bilen et al. reported no blood transfusions being required in their cohort of patients undergoing MPCNL [4] and this is supported by Yan et al. [6].

CONCLUSION

Mini PCNL is an effective and safe procedure for the treatment of paediatric renal stones. In the present series, all children achieved greater than 80% stone clearance, none received a blood transfusion (intra/postoperatively) and there were no mortalities. Postoperative pain was managed with simple analgesia in 39%; however, the majority required opiate analgesia for less than 24 hours.

Thoracic Kyphosis is Now Uncommon Amongst Children and Adolescents with Cystic Fibrosis

Historically, thoracic kyphosis has been reported to be common amongst patients with cystic fibrosis (CF). The mechanisms leading to the development of this abnormality of the chest wall are not fully understood. In order to explore the prevalence of the condition amongst children with CF in the early twenty-first century and to explore factors that might be contributing to its development, a retrospective cross sectional study was undertaken in a regional CF unit. Data were obtained from 74 children with CF aged 8-16 years attending for their annual review. Thoracic kyphosis was measured from lateral chest X-ray using an alternative Cobb method. Lung function, disease severity, and nutritional status were also recorded. Correlations between measures were explored using a multiple linear regression model. The range of Cobb angles measured was 5.4-44.3° with thoracic kyphosis identified in only two subjects. There was no correlation between age and thoracic kyphosis, however, there was a significant correlation between lung function and thoracic kyphosis (p = 0.004). Regression coefficient (b) was -0.26 (95% CI: -0.44, -0.08). The prevalence of thoracic kyphosis is significantly less amongst children with CF than previously reported. This appears likely to be associated with the overall improvements in pulmonary status. Studies of older populations may bring further understanding of increasing thoracic kyphosis in people with CF.

Blue rubber bleb naevus syndrome and Chiari malformation: high risk of peroperative haemorrhage

Blue rubber bleb naevus syndrome is an uncommon disorder whereby patients possess cutaneous vascular malformations. Cranial malformations have been rarely reported in the literature. We report the first ever case of a patient with blue rubber bleb naevus syndrome (BRBNS), who was found to have a symptomatic Chiari malformation and prominent subcutaneous vascular malformations in communication with the intracranial venous sinuses. In our case, a routine operation for Chiari malformation was complicated by significant blood loss. The operative hazards are presented along with suggested peri-operative management strategies when carrying out neurosurgical operations on patients with BRBNS. A brief literature review is included.

Dynamic pelvic floor ultrasound for lower urinary tract symptoms in children--initial report on normative values

PURPOSE

Lower urinary tract symptoms (LUTS) are common in children. The aim of this study was to determine normal values for pelvic floor movement in asymptomatic controls to allow comparison with symptomatic children with dysfunctional voiding (DV) in the next phase of the study.

MATERIAL AND METHODS

One hundred children between the ages of 5-17 years were recruited prospectively as controls. All were asked to perform a voluntary pelvic floor contraction manoeuvre with a full bladder. All scans were performed on a Vivid I GE ultrasound machine with a 4-9 MHz curvilinear probe. M Mode was used to determine the direction of pelvic floor (levator plate-LP) movement, the distance in cms and the endurance in seconds. Each measurement was taken 3 times.

RESULTS

Six children were unable to understand and perform the manoeuvre and were excluded. The median age was 10 years (range 4-17). The median LP movement was 0.3 cm (range 0.1-1.6) and cranial in 86/94 (91%). The median endurance time was 5.8 s (range 2.3-15.5). For the (n = 59) younger children aged 4-11, the 95% normal reference range for LP movement was 0.1 cm-1.4 cm and for endurance was 2.5-13.5 s. For the (n = 33) older children aged 12-17, the 95% normal reference range for LP movement was 0.2 cm-1.2 cm and for endurance was 2.3-15.5 s. There was a significant correlation (Pearson r = 0.39, P = 0.001) between average LP movement and endurance.

CONCLUSIONS

This study gives the normal reference ranges for the variables measured. A further study is currently underway examining the same variables in children with dysfunctional voiding (DV) and comparing these with the reference range.

Paediatric post-septal and pre-septal cellulitis: 10 years' experience at a tertiary-level children's hospital

OBJECTIVE

To assess the incidence and complications of pre-septal (pre-SC) and post-septal (post-SC) cellulitis over 10 years. Pre-SC and post-SC are also known as periorbital and orbital cellulitis, respectively.

METHODS

Retrospective analysis of CT scans. Data included the presence of pre-SC and post-SC, paranasal sinus disease (PNS) and complications.

RESULTS

Among 125 patients scanned for these suspected diagnoses, 67 had both pre-SC and post-SC, 37 had pre-SC and 4 had post-SC; there were 17 normal scans. 110 patients had PNS. 68/71 (96%) patients with post-SC had PNS. Post-SC complications included orbital and/or subperiosteal abscess (50/71: 30 medial orbital, 10 superomedial, 3 lateral, 2 anteromedial, 2 inferomedial, 1 superior, 1 anterosuperior and 1 not specified), cavernous sinus thrombosis (CST) (1), superior ophthalmic vein (SOV) thrombosis (4) and subdural frontal empyema (2); 1 patient had SOV and CST and subdural empyema.

CONCLUSION

71/125 (57%) patients had post-SC. 50/125 (40%) patients imaged for pre-SC/post-SC had orbital abscess; 44/50 (88%) of these involved the medial orbit. Patients can develop solely superior or inferior abscesses that are difficult to identify by axial imaging alone, hence coronal reformatted imaging is essential. 5/125 (4%) patients developed major complications (SOV/CST/empyema), hence imaging review of the head and cavernous sinus region is essential. A diagnosis of post-SC on CT should alert the radiologist because this diagnosis can be associated with an increased incidence (5/71, 7%) of complications.

ADVANCES IN KNOWLEDGE

We recommend that all patients with a suspected diagnosis of post-SC should undergo CT scan (post-contrast orbits and post-contrast head, with multiplanar reformats and a careful review of the SOV and the cavernous sinus). Particular attention should be paid to exclude intracranial complications including subdural empyema and cerebral abscess. As soon as a diagnosis of post-SC is made, in addition to informing the referring clinical team, urgent opinion should be sought from ear, nose and throat (ENT), neurology and ophthalmology with a view to urgently drain of the paranasal sinuses`.

CT of the neonatal head

Computed tomography (CT) is used less often than other techniques on neonatal units. However, in the acute setting, CT can be invaluable in diagnosing or excluding potentially life-threatening conditions and guiding initial management in neonates. Common indications for scanning include trauma, suspected non-accidental injury, infection, or an acute hypoxic or metabolic event. The aim of this review is to provide an overview of the normal neonatal head at CT and compare this to the common pathological abnormalities. Several key features of each condition will be highlighted. It is important to note that some pathological conditions can have overlapping features at CT and, therefore, the clinical history and additional investigations are also of key importance in determining the diagnosis.

Craniospinal abnormalities and neurologic complications of osteogenesis imperfecta: imaging overview

Osteogenesis imperfecta is a rare genetic disorder that leads to progressive skeletal deformities due to deficits in type I collagen, the main pathophysiologic effect of the disease. In addition, it may lead to a wide range of associated neurologic abnormalities: The central nervous system is usually involved because of softening of bone at the base of the skull, with resultant upward migration of the upper cervical spine and odontoid process into the skull base. Upward migration of the spine may cause compression of the brainstem, mechanical impingement of the spinal canal with restriction of cerebrospinal fluid circulation, and impingement of the cranial nerves. Osteogenesis imperfecta also may directly involve neurovascular structures, leading to cavernous fistulas of the carotid artery, dissection of the cervical arteries, and cerebral aneurysms. The brain parenchyma is frequently affected by the disease, with manifestations including cerebral atrophy, communicating hydrocephalus, and cerebellar hypoplasia. The imaging features of the disorder vary as widely as its clinical manifestations, depending on the severity of disease. Severe forms accompanied by debilitating skeletal fractures and progressive neurologic impairments may lead to perinatal death, whereas milder asymptomatic forms might cause only a modest reduction in life span. The most important advance in medical therapy for osteogenesis imperfecta has been the introduction of bisphosphonate therapy to slow the resorption of bone in patients with moderate to severe forms of the disease (ie, type III or IV). In some patients, neurosurgery may be necessary to correct the effects of severe basilar invagination by the odontoid process.

Management of isolated syringomyelia in the paediatric population--a review of imaging and follow-up in a single centre

OBJECTIVE

To assess the natural history of isolated syringomyelia in children.

METHODS

MRI reports from February 2007 to August 2011 mentioning syrinx were identified on Sheffield Children's PACS database. Scans with syringes having an AP diameter of > 1 mm and extending over at least two vertebral bodies were reviewed. Patients with an identifiable cause such as a Chiari malformation were then excluded.

RESULTS

Thirty-nine patients were included with a mean age at diagnosis of 10.6 years. The average syrinx AP diameter was 3.30 mm. The rostrocaudal length of the syringes varied between 2 and 19 vertebral bodies. Twenty-seven out of 39 syringes were thoracic in origin. There were 3 and 6 syringes involving the cervicothoracic and thoracolumbar regions, respectively, with 3 involving the cervical area only. Eleven out of 39 (Group I) patients were found "incidentally" during work-up for adolescent idiopathic scoliosis and these were considered as a separate group. These patients did not have any significant symptoms and were discharged following their scoliosis correction surgery. Syrinx was incidental in 14 further patients (Group II). Of the 14 patients, 11 remained asymptomatic with no change in syrinx morphology throughout follow up. Of the 14 patients, 3 were lost to follow-up. Of the 39 patients, 14 (Group III) presented with progressive back pain without any obvious clinical cause. Of the 14, 10 either improved or remained the same. Of the 14 patients, 3 underwent lumbar puncture, 1/14 having myelography. All 4/14 patients reported significant pain reduction on follow up following intervention.

CONCLUSION

Idiopathic syrinx is a benign pathology, which can be managed expectantly. Most cases remain stable or improve over time. In a small minority who have progressive back pain, we have found that lumbar puncture may be helpful in reducing symptoms.

The encephalopathic child

Encephalopathy is a common paediatric emergency associated with a high risk of morbidity, mortality and long term neurodevelopmental delay in survivors. Prompt diagnosis of the cause of encephalopathy enables the paediatrician to deliver specific medical or surgical treatment that will facilitate a better short and long term outcome. Diagnostic imaging plays a pivotal role in diagnosis. Encephalopathy has many causes. The differential diagnosis includes non accidental injury, trauma, metabolic syndromes, meningo-encephalitis, toxins, hypoxia, demyelination, stroke, haemorrhage and tumours. We describe an approach that helps us formulate an imaging strategy using US, CT and MRI that facilitates patient care.

Childhood moyamoya disease and moyamoya syndrome: a pictorial review

Moyamoya disease is an uncommon chronic cerebrovasculopathy, characterized by progressive stenosis of the terminal portion of the internal carotid artery and its main branches, in association with the development of compensatory collateral vessels at the base of the brain. The etiology is unknown, and was originally considered exclusive to East Asia, with particular prevalence in Japan. Moyamoya disease is increasingly diagnosed throughout the world, and represents an important cause of childhood stroke in Western countries. In some cases, similar angiographic features are evident in children with other medical conditions, such as sickle cell disease and Down syndrome. In these instances, the term "moyamoya syndrome" is used. Diagnosing the vasculopathy, excluding possible associated conditions, and planning treatment and follow-up imaging comprise important aspects of clinical management. We review the key imaging features of childhood moyamoya disease and syndrome, present examples of its associations, and discuss new neuroradiologic methods that may be useful in management.

Intracranial non-Langerhans cell histiocytosis presenting as an isolated intraparenchymal lesion

Non-Langerhans cell histiocytosis in the absence of cutaneous or other organ involvement is very rare. A Caucasian boy age 3 years 11 months presented with episodes of recurrent right-side seizures over 2 weeks. Brain CT and MR imaging showed a single enhancing left frontal lobe lesion. Stereotactic biopsy was performed and histological examination showed diffuse infiltrate of macrophages with foamy cytoplasm. Four months later there was recurrence of seizure activity despite anti-epileptic medication and a repeat MR scan showed a persistent enhancing lesion in the left frontal lobe. Histological examination of the resection specimen resembled juvenile xanthogranuloma (JXG) involving the central nervous system. In the absence of skin lesions a diagnosis of non-Langerhans cell histiocytosis was made. The child made a full recovery following surgery with resolution of his symptoms.

Role of imaging in the diagnosis of acute bacterial meningitis and its complications

Acute bacterial meningitis is a common neurological emergency and a leading cause of death and neurological disability worldwide. Diagnosis is based on clinical and microbiological findings with neuroimaging in the form of CT reserved for those with specific adverse clinical features or when an underlying cause such as mastoiditis is suspected. MRI is extremely useful for detecting and monitoring the complications of meningitis. These can be remembered by the mnemonic HACTIVE (hydrocephalus, abscess, cerebritis/cranial nerve lesion, thrombosis, infarct, ventriculitis/vasculopathy and extra-axial collection). Diffusion weighted imaging (DWI) and magnetic resonance spectroscopy (MRS) are useful to distinguish abscess from other ring enhancing lesions.

Fluoroscopy-guided insertion of nasojejunal tubes in children - setting local diagnostic reference levels

BACKGROUND

Little is known about the radiation burden from fluoroscopy-guided insertions of nasojejunal tubes (NJTs) in children. There are no recommended or published standards of diagnostic reference levels (DRLs) available.

OBJECTIVE

To establish reference dose area product (DAP) levels for the fluoroscopy-guided insertion of nasojejunal tubes as a basis for setting DRLs for children. In addition, we wanted to assess our local practice and determine the success and complication rates associated with this procedure.

MATERIALS AND METHODS

Children who had NJT insertion procedures were identified retrospectively from the fluoroscopy database. The age of the child at the time of the procedure, DAP, screening time, outcome of the procedure, and any complications were recorded for each procedure. As the radiation dose depends on the size of the child, the children were assigned to three different age groups. The sample size, mean, median and third-quartile DAPs were calculated for each group. The third-quartile values were used to establish the DRLs.

RESULTS

Of 186 procedures performed, 172 were successful on the first attempt. These were performed in a total of 43 children with 60% having multiple insertions over time. The third-quartile DAPs were as follows for each age group: 0-12 months, 2.6 cGy cm(2); 1-7 years, 2.45 cGy cm(2); >8 years, 14.6 cGy cm(2). High DAP readings were obtained in the 0-12 months (n = 4) and >8 years (n = 2) age groups. No immediate complications were recorded.

CONCLUSION

Fluoroscopy-guided insertion of NJTs is a highly successful procedure in a selected population of children and is associated with a low complication rate. The radiation dose per procedure is relatively low.

Congenital nasal piriform aperture stenosis with vestibular abnormality

We present a neonate with congenital nasal piriform aperture stenosis associated with an abnormal vestibular aperture. Radiological evaluation with CT is essential to confirm the diagnosis and delineate the anatomy for surgical planning. Extension of the scan field of view to include the petrous temporal bone is essential to identify associated abnormalities of the vestibule.

Novel Michael addition products of bis(amino acidato)metal(II) complexes: synthesis, characterization, dye degradation, and oxidation properties

Michael addition reactions of bis(amino acidato)metal(II) complexes (metal = copper, nickel, zinc; amino acid = glycine, dl-alanine, l-alanine) with acrylonitrile have been carried out under various experimental conditions in the absence of a base, resulting in mono- and disubstituted products in high yield, including partially hydrolyzed products. A reaction mechanism for the Michael addition on the nitrogen atom of the coordinated amino acid moiety, replacing the amino hydrogen atom(s), is proposed. All of the products have been characterized by Fourier transform infrared spectroscopy, electron paramagnetic resonance spectra, and elemental and electrochemical analyses. The single-crystal structures of bis( N-cyanoethylglycinato)copper(II) monohydrate ( 1a), diaquabis( N-cyanoethylglycinato)nickel(II), aquabis( N, N-dicyanoethylglycinato)copper(II) ( 2a), and bis[( N-propionamido- N-cyanoethyl)glycinato]copper(II) dihydrate ( 4a) have been confirmed by X-ray diffraction techniques. The products 1a, 2a, 4a, and bis( N-propionamidoglycinato)copper(II) monohydrate ( 3a) have been used as catalysts for the degradation of a phenol red dye and mild oxidation of various organic substrates in the presence of hydrogen peroxide. The monosubstituted complexes have been found to catalyze the reactions to a greater extent than the disubstituted complexes.

Diagnostic difficulties in the management of H-type tracheoesophageal fistula

PURPOSE

To evaluate the diagnostic difficulties and pitfalls in establishing the diagnosis of congenital H-type tracheoesophageal fistula.

MATERIAL AND METHODS

A retrospective review of all cases of H-type tracheoesophageal fistula that were diagnosed in a single unit over a 6-year period. The variables assessed were age at presentation, presenting symptoms, time to diagnosis, investigations, and time to surgical repair of H-type fistula. The investigations leading to a definitive diagnosis are assessed and discussed.

RESULTS

Between 1998 and 2004, five cases of H-type tracheoesophageal fistula presented to our unit. All cases had an upper gastrointestinal contrast study/tube esophagogram. In addition, four cases had a chest radiograph, three cases had a bronchoscopy, and one case an esophagoscopy. The median delay from the time of first presentation to diagnosis of H-type tracheoesophageal fistula was 14 days (7-58 days). Median age at surgery was 15 days (8-60 days).

CONCLUSION

Although symptoms are usually present from birth, the diagnosis of H-type fistula is difficult and often delayed. The various diagnostic techniques are not entirely reliable and fistula identification can be elusive. The authors present recommendations for the diagnostic work-up, which may increase the diagnostic potential and avoid unnecessary delays in the diagnosis and management of H fistula.

Idiopathic maxillary antral mucocele in a child: a rare presentation

We report a case of a large maxillary sinus mucocele in a 14-year-old girl presenting with epiphora, proptosis and dental pain. This was marsupialized endoscopically, with complete resolution of symptoms over three months' follow up. The literature is reviewed.

Short-course chemotherapy for paediatric respiratory tuberculosis: 5-year report

This report presents the 5-year follow-up of 137 children with respiratory tuberculosis enrolled in a randomised clinical trial of two different anti-tuberculosis regimens 9HR and 2HRZ3/4RH2. Both regimens had similar cure rates, with low relapse rates and mortality. Of 134 children followed up to 5 years, 86% had normal radiographs, with more sequelae in the 9HR group (15% vs. 1.5%, P < 0.01). One patient relapsed and there was one accidental death. Short-course chemotherapy in children is safe, effective and well tolerated, and leads to excellent long-term results, with a small proportion of children left with radiological sequelae.

Anterior spinal cord infarction owing to possible fibrocartilaginous embolism

Anterior spinal artery syndrome is characterised by acute flaccid quadriparesis or paraparesis, disturbance of pain and temperature sensation, and loss of sphincter control. Fibrocartilaginous embolism is a rarely recognised, but important cause of spinal cord infarction. Fibrocartilaginous embolisation usually occurs after minor trauma without major bony lesions, typically with an intervening symptom-free interval and progressive 'stroke-in-evolution' course. There is evidence that the embolus originates from the intervertebral disc, but the mechanism whereby disc fragments enter the spinal vessels is not well understood. We describe the evolution of MRI findings in a case of anterior spinal artery territory infarction thought to be secondary to fibrocartilaginous embolism.

Spontaneous occlusion of post-traumatic splenic pseudoaneurysm: report of two cases in children

Conservative therapy for splenic injuries is widely advocated. The advantages of conservative therapy for splenic injuries include the preservation of splenic immune function, prevention of overwhelming post-splenectomy sepsis, and avoidance of laparotomy and its associated early and late complications. Pseudoaneurysms of the splenic artery branch are encountered because of the prevalence of conservative management and widespread use of imaging techniques in the follow-up of these cases. We report two cases of post-traumatic splenic pseudoaneurysm in children which thrombosed spontaneously, one during the diagnostic angiogram examination and another on follow-up studies.

HuA and tristetraprolin are induced following T cell activation and display distinct but overlapping RNA binding specificities

AU-rich elements found in the 3'-untranslated regions of cytokine and proto-oncogene transcripts regulate mRNA degradation and function as binding sites for the mRNA-stabilizing protein HuA and the mRNA-destabilizing protein tristetraprolin. Experiments were performed to evaluate the expression of HuA and tristetraprolin in purified human T lymphocytes and to evaluate the ability of these proteins to recognize specific AU-rich sequences. HuA is a predominantly nuclear protein that can also be found in the cytoplasm of resting T lymphocytes. Within 1 h after stimulation of T lymphocytes with anti-T cell receptor antibodies or a combination of a phorbol myristate acetate and ionomycin, an increase in cytoplasmic HuA RNA-binding activity was observed. Although absent in resting cells, cytoplasmic tristetraprolin protein was detected 3-6 h following activation. HuA recognized specific AU-rich sequences found in c-jun or c-myc mRNA that were poorly recognized by tristetraprolin. In contrast, tristetraprolin recognized an AU-rich sequence in interleukin-2 mRNA that was poorly recognized by HuA. Both HuA and tristetraprolin, however, recognized AU-rich sequences from c-fos, interleukin-3, tumor necrosis factor-alpha, and granulocyte/macrophage colony-stimulating factor mRNA. HuA may transiently stabilize a subset of AU-rich element-containing transcripts following T lymphocyte activation, and tristetraprolin may subsequently mediate their degradation.

Concerted dephosphorylation of the transcription factor NFAT1 induces a conformational switch that regulates transcriptional activity

NFAT transcription factors are highly phosphorylated proteins that are regulated by the calcium-dependent phosphatase calcineurin. We show by mass spectrometry that NFAT1 is phosphorylated on fourteen conserved phosphoserine residues in its regulatory domain, thirteen of which are dephosphorylated upon stimulation. Dephosphorylation of all thirteen residues is required to mask a nuclear export signal (NES), cause full exposure of a nuclear localization signal (NLS), and promote transcriptional activity. An inducible phosphorylation site in the transactivation domain contributes to transcriptional activity. Our data suggest that dephosphorylation promotes NFAT1 activation by increasing the probability of an active conformation, in a manner analogous to that by which depolarization increases the open probability of voltage-gated ion channels. This conformational switch paradigm may explain modification-induced functional changes in other heavily phosphorylated proteins.

Rational treatment of empyema in children

HYPOTHESIS

Efficacious and cost-effective treatment of pediatric empyema can be accomplished following a protocol based on its radiographic appearance. Therapeutic modalities include thoracostomy tube drainage (TTD) with or without fibrinolytic therapy (FT) and video-assisted thoracoscopic debridement (VATD).

DESIGN

Retrospective case series.

SETTING

Tertiary referral center.

RESULTS

From 1995 through 1999, 31 children were treated ranging in age from 11 months to 18 years (mean age, 5.1 years). Twenty-seven (87.1%) underwent TTD; of these, 22 (81.5%) received FT with urokinase. The TTD failed in 4 children (14.8%) who required salvage VATD. Primary VATD was performed in another 4 children (12.9%). The mean length of stay was 14.6 days (TTD, 14.1 days; salvage VATD, 20. 0 days; primary VATD, 11.5 days), ranging from 8.0 to 30.0 days. Complications included readmission for fever (2 patients [6.5%]) and gastrointestinal bleeding (1 patient [3.2%]). There were no anaphylactic reactions or bleeding episodes due to urokinase. Two patients (7.4%) treated with TTD and FT developed an air leak that resolved spontaneously. The mean hospital charges were $78,832 (TTD with or without FT, $75,450; salvage VATD, $107,476; primary VATD, $69,634). The procedural charges were highest for salvage VATD.

CONCLUSIONS

Most cases of pediatric empyema can be treated by TTD with or without FT. This therapy is safe and effective for children with nascent disease. Primary VATD is preferred in children with advanced disease. Cost-effectiveness could be further improved through better prediction of those patients likely to fail TTD and require salvage VATD. An algorithmic approach based on findings from computed tomography or (better) ultrasonography of the chest may be the best way to make this distinction and rationalize care.

Use of arm veins for lower extremity arterial bypass--results, anatomical features and technical considerations

Forty lower limb bypasses using arm veins were performed on 37 patients. The indications for surgery were limb threat in 50% of cases, graft failure in 33%, aneurysms in 10% and claudication in 7%. Saphenous veins were absent because of prior use in 73% of cases, and because they were unsuitable in 27%. A single vein was used in 48%, 2 veins in 40% and 3 veins in 12% of cases. Seventy-four per cent of cases had a single-vessel run-off below the distal anastomosis. Eighty-two per cent of the distal anastomoses were to infrapopliteal arteries. The primary and secondary rates of these 40 bypasses at a mean follow-up of 14 months (range 1-40 months) were 74% and 90%, respectively. Limb salvage was 94%. Peri-operative morbidity and mortality were 23% and 3%, respectively. The anatomical and technical aspects of harvesting arm veins are critical to the success of this procedure and will be emphasised. We have found arm veins to be a durable source of accessible autogenous grafts for lower limb revascularisation in the absence of suitable saphenous veins.