Open fetal surgery for ventricular-amniotic valve implantation in aqueductal stenosis-dependent severe fetal hydrocephalus - a case report with 7-year follow-up

Introduction Fetal ventriculomegaly is one of the most commonly diagnosed central nervous system (CNS) pathologies of the second trimester occurring with a frequency of 0.3-0.5/1000 births. Severe fetal ventriculomegaly (SVM) may necessitate intrauterine intervention. Most such interventions have been made percutaneously with ultrasound guidance insertion of a pigtail catheter, which sadly often became obstructed or migrated. Case presentation Our case report presents the possibility of ventriculo-amniotic valve implantation (VAVI) by classic hysterotomy in isolated severe fetal hydrocephalus (IVSM) due to aqueductal stenosis. The patient was operated on similarly to OFS MOMS criteria at 24+4/7 GA, with an initial lateral ventricular dimension of 22.5 mm. A female newborn was delivered by elective cesarean section at 31+1/7 GA due to PPROM (Apgar10' 8 pts., birth weight 1600 g), required CPAP, and removal of the drainage system due to infection and narrow lateral ventricles. Evans index (EI) gradual increase and clinical symptoms of high-pressure hydrocephalus after 10 days required a ventricle-peritoneal shunt (VPS) implantation. The newborn was discharged home after 28 days with stabile hydrocephalus (EI:0.59-0.6), in good clinical condition. The 7 year follow-up was complicated by epilepsy, VPS shunt infections, delay in motor and intellectual functions (mild to moderate), and symptoms of atypical autism, the phenotype possibly related to a variant in ZEB2 gene. Conclusion Intrauterine VAVI is a one-step procedure that is effective in draining CFS. The limitations of the method remain complications due to preterm labor and infection of the drainage system.

Development and Validation of a Pediatric MRI-Based Perianal Crohn Disease (PEMPAC) Index-A Report from the ImageKids Study

BACKGROUND

As part of the prospective multicenter ImageKids study, we aimed to develop and validate the pediatric MRI-based perianal Crohn disease (PEMPAC) index.

METHODS

Children with Crohn disease with any clinical perianal findings underwent pelvic magnetic resonance imaging at 21 sites globally. The site radiologist and 2 central radiologists provided a radiologist global assessment (RGA) on a 100 mm visual analog scale and scored the items selected by a Delphi group of 35 international radiologists and a review of the literature. Two weighted multivariable statistical models were constructed against the RGA.

RESULTS

Eighty children underwent 95 pelvic magnetic resonance imaging scans; 64 were used for derivation and 31 for validation. The following items were included: fistula number, location, length and T2 hyperintensity; abscesses; rectal wall involvement; and fistula branching. The last 2 items had negative beta scores and thus were excluded in a contending basic model. In the validation cohort, the full and the basic models had the same strong correlation with the RGA (r = 0.75; P < 0.01) and with the adult Van Assche index (VAI; r = 0.93 and 0.92; P < 0.001). The correlation of the VAI with the RGA was similar (r = 0.77; P < 0.01). The 2 models and the VAI had a similar ability to differentiate remission from active disease (area under the receiver operating characteristic curve, 0.91-0.94). The PEMPAC index had good responsiveness to change (area under the receiver operating characteristic curve, 0.89; 95% confidence interval, 0.69-1.00).

CONCLUSIONS

Using a blended judgmental and mathematical approach, we developed and validated an index for quantifying the severity of perianal disease in children with CD. The adult VAI may also be used with confidence in children.

The Assessment of the Usefulness of Prenatal Magnetic Resonance Imaging in the Diagnosis of Central Nervous System Defects

Central nervous system (CNS) abnormalities cause about 40% of infant deaths in the first year of life. In case of the detection of abnormalities by ultrasound, a pregnant woman should be offered prenatal magnetic resonance imaging (pMRI). The aims of our study were: (1) to evaluate the effectiveness of pMRI in the diagnosis of selected fetal CNS defects; and (2) to assess the possibility of replacing postnatal tests with prenatal magnetic resonance. The prospective and observational study was conducted between 2014 and 2017 at the University Hospital in Krakow. Patients with suspected CNS defects of the fetus were qualified for pMRI in the third trimester of pregnancy. Sixty patients were included in the study group. Prenatal MRI was characterized by low accuracy in the diagnosis of complex brain defects. Cohen’s kappa coefficient κ = 0.21 (95% CI 0.00–0.46). No evidence was found suggesting the replacement of postnatal tests with pMRI. MRI was characterized by low consistency of diagnoses in the case of complex brain defects. The possibility of replacing postnatal studies with pMRI was not supported.

Open fetal surgery for myelomeningocele - is there the learning curve at reduction mother and fetal morbidity?

OBJECTIVES

We aimed to show how increased experience of a surgery team in fMMC repair influences maternal and fetal/neonatal outcomes.

MATERIAL AND METHODS

We compare perinatal results of fMMC repair in our Fetal Surgery Center (FSC) in cohort groups for the early period (2005-2011 year; previous - PFSC, n = 46) and current period (2012-2015 year; current - CFSC, n = 74) to results of the randomized Management of Myelomeningocele Study (MOMS, 78 patients).

RESULTS

The maternal morbidity due to fMMC repair was low and there was no difference comparing CFSC to PFSC and MOMS. The frequency of iatrogenic preterm labor (iPTL) ≤ 30 weeks of gestation decreased from 34.1% in PFSC to 23.9% in CFSC. Iatrogenic preterm premature rupture of membranes (iPPROM) was a common complication after fMMC repair in all cohorts. The total reduction rate of hindbrain hernation (HH) was similar in CFSC - 90.3% and PFSC - 82.1%.

CONCLUSIONS

The increasing experience of our surgery team in fMMC repair majorly decreased the risk of iPTL.

Magnetisation transfer imaging revealed microstructural changes related to apathy symptoms after ischaemic stroke

OBJECTIVES

Apathy after stroke is common and has a negative impact on functional recovery. Neuroimaging correlates of poststroke apathy remain unclear. We aimed to investigate microstructural changes associated with the severity of poststroke apathy symptoms.

METHODS

We assessed 67 patients with cerebral ischaemia who underwent magnetisation transfer brain imaging 12-15 months after stroke. We used magnetisation transfer ratio (MTR) to represent microstructural integrity. We performed whole-brain voxel-based analysis and subsequent region of interest analysis to investigate the association between MTR and symptoms of poststroke apathy. To assess apathy symptoms, we used clinician-reported version of the Apathy Evaluation Scale.

RESULTS

Voxel-based analysis showed the association between symptoms of apathy and decreased MTR in areas overlapping with structures located in both hemispheres: left thalamus, bilateral hippocampus, bilateral fornix/stria terminalis, right amygdala, splenium of the corpus callosum, the retrolenticular part of left internal capsule and left sagittal stratum. In the region of interest analysis, only lower MTR in right fornix/stria terminalis was associated with greater poststroke apathy symptoms in a multivariate logistic model (odds ratio: 1.25, 95% CI: 1.09-1.46, p = 0.003). These associations were independent of depressive symptoms.

CONCLUSION

Magnetisation transfer brain imaging 12-15 months after stroke revealed changes in microstructural integrity associated with apathy symptoms in brain areas related to processing emotional information and reward valuation.

Prevalence and anatomical characteristics of developmental venous anomalies: an MRI study

PURPOSE

Developmental venous anomalies (DVAs) are extreme anatomical venous variations formed by multiple radiating medullary veins, which converge centripetally into a single collecting vein. Their coexistence with symptomatic cavernous malformations (CMs) has been reported in the literature. The aim of this study was to assess the characteristics of DVAs using MRI.

METHODS

A total of 6948 head MRIs of adult Caucasian patients were retrospectively analyzed to determine the number and locations of DVAs. We collected the data on the termination of the collecting vein, the prevalence of DVA-related CMs, and MRI FLAIR signal-hyperintensity corresponding to the location of the DVA.

RESULTS

At least one DVA was identified in 7.46% of the patients. The prevalence decreased with age, with a Pearson correlation coefficient of - 0.7328. A total of 599 DVAs were identified. Multiple DVAs were found in 10.92% of the patients with DVAs. The DVAs were identified more often in the supratentorial region (73.12%, p < 0.0001), and the most common location was the frontal lobe (35.23%). The collecting vein usually drained into the superficial cerebral veins (68.78%). CMs were observed in 4.14% of the patients with DVAs, and the prevalence showed a positive correlation with age. Signal-intensity abnormalities were identified in the vicinity of 5.18% DVAs.

CONCLUSION

Knowledge about characteristics of DVAs and associated anomalies is essential for neuroradiologists and neurosurgeons. The large number of currently available diagnostic studies enables us to assess anatomical variants on a great number of subjects.

FUNCTIONAL NEUROMARKERS OF COGNITIVE IMPAIRMENT IN VASCULAR DEMENTIA: A CASE STUDY

Early diagnosis and monitoring of disease progression in patients with Vascular Dementia (VaD) have become vital in clinical practice, as disease modifying treatments for VaD become available. The goal of our research was to study cognitive impairment in a patient at an early stage of VaD. We evaluated latencies of the P3 GO and NOGO components of event-related potentials (ERPs), elicited in cued GO/NOGO tasks, as potential neuromarkers of cognitive im- pairment, as suggested by previous research. The patient, a right-handed, 53-year-old male with a college edu- cation, suffered a transient ischemic attack (TIA) in 2011. During this attack, which lasted for a few minutes, he was confused and had trouble speaking, trouble seeing in both eyes, difficulty walking, problems with balance and coordination, and strange behavior. Se - ven years later, in 2018, he was assessed using the HBI methodol- ogy, which consisted of recording (1) a 19-channel EEG in resting state (with eyes open and eyes closed), and (2) a cued GO/NOGO task, and then comparing the results with EEG spectra and Event- Related Potentials (ERPs) data from normative and patient data - bases. The patient died in 2019. Post-mortem studies confirmed cortical microhaemorrhages neuropathological criteria for VaD. We did not found deposits of hyperphosphorylated tau (HPτ) and Aβ, which fulfil the neuropathological criteria for AD. The parietal-temporal-occipital EEG power was significantly higher in all conditions in this subject in comparison to healthy controls, indicating idling of the corresponding areas. The amplitude and la- tency of the P3 GO wave were found to be intact in the subject, in- dicating normal posterior cortical functioning in the cognitive task. The latency of the P3 GO wave was found to be significantly higher in the subject, indicating impairment of engagement operations. In a GO/NOGO task, ERPs provide a useful tool for assessment of brain functioning in clinical settings.

The Use of Indomethacin with Complete Amniotic Fluid Replacement and Classic Hysterotomy for the Reduction of Perinatal Complications of Intrauterine Myelomeningocele Repair

OBJECTIVE

This study presented outcomes of classical hysterotomy with modified antiprostaglandin therapy for intrauterine repair of foetal myelomeningocele (fMMC) performed in a single perinatal centre.

STUDY DESIGN

Forty-nine pregnant women diagnosed with fMMC underwent classic hysterotomy with anti-prostaglandin management, complete amniotic fluid replacement and high dose indomethacin application.

RESULTS

The average gestational age (GA) at delivery was 34.4 ± 3.4 weeks, with no births before 30 weeks GA. There were 2 foetal deaths. Complete reversal of hindbrain herniation (HH), assessed in magnetic resonance imaging at 30-31 weeks GA was found in 72% of foetuses (mostly with HH grade I prior to fMMC repair). Our protocol resulted in rare use of magnesium sulphate (6%), low incidence of chorioamniotic membrane separation - chorioamniotic membrane separation (6%), preterm premature rupture of membranes - preterm premature rupture of membranes (pPROM; 15%) and preterm labour - preterm labour (PTL; 17%). The postoperative wound continuity of the uterus was usually stable (in 72% of patients), with low frequency of scar thinning (23%).

CONCLUSION

Our protocol results in rare use of tocolytics, and the low occurrences of CMS, pPROM and PTL in relation to other study cohorts: Management of Myelomeningocele Study, Children's Hospital of Philadelphia, and Vanderbilt University Medical Centre.

HEALTH-RELATED QUALITY OF LIFE OF A PATIENT FOLLOWING NEUROSURGERY ON GLIOBLASTOMA MULTIFORME (GBM)

Health-related quality of life (HRQoL) plays a role as a patient-centered meaningful endpoint, assessing the direct clinical benefit for a patient. The inclusion of HRQoL measurements in a glioma patient may provide important data to inform clinicians on treatment decision-making. The aim of the study was to evaluate cognitive decline and HRQoL in the clinical care of a patient following neurosurgery on of glioblastoma multiforme (GBM). A 69-year-old female developed malignant brain glioma in the right temporal-occipital area; this being confirmed by CT and MR study and neuropathological findings. She had complained of headaches, dizziness, nausea, vomiting as well as attention and memory loss, and anxiety, sadness and a slowing down in the performance of daily activities. The symptoms rapidly became worse and she was referred to a neurosurgery department for consultation. She was successfully neurosurgically operated on. She was examined with the use of ne uro psycho logical tests three times: the first examination was conducted before the neurosurgical operation, the second two weeks after, and the third half year after the neurosurgical operation. In the first examination by the standard Polish version of the Mindstreams™ Interactive Computer Tests disturbances for all the tested cognitive functions occurred. The greatest changes were to occur however in the areas of visual-spatial functions. attention, executive functions and memory. In the second test, a return to the norm was achieved for the disturbed cognitive and executive functions. In the third examination (half a year after the neurosurgical operation), the cognitive and executive functions were still not bad, but had slightly decreased. Similar trend was observed in HRQoL. A significant difference in the health profile between the 1 st and 2 nd as well as between 1 st and 3 rd examination was detected for the eight SF-36 domains - HRQoL was improved. While only slight but no significant changes occurred between 2 nd and 3 rd examination. HRQoL was still not bad, but had slightly decreased. The patient after the neurosurgical operation of glioblastoma multiforme (GBM) is capable of carrying out daily activities, but shows some level of reduced complains for functional capacity, pain, general health and vitality, emotional and social functioning for mental health which has led to the impaired HRQoL.

Brain Maturation-Differences in Biochemical Composition of Fetal and Child's Brain

INTRODUCTION

The aim of this study was to evaluate differences in ¹H MRS spectra of the brain of fetuses and children from 6 to 11 years of age.

MATERIAL AND METHODS

21 healthy fetuses in the third trimester and 22 children were examined using the proton nuclear magnetic resonance. The relative metabolite concentrations to the sum of all metabolites were calculated.

RESULTS

In the ¹H MRS spectra of the brain from fetuses and children, there are the same characteristic peaks: N-acetylaspartate (NAA), creatine (Cr), choline (Cho), and myo-inositol (mI). NAA/Σ, NAA/Cr, and Cr/Σ concentrations are significantly higher and Cho/Σ, Cho/Cr, mI/Σ, and mI/Cr are significantly lower in children than in the fetuses.

CONCLUSIONS

It was found that the brain metabolism changes from fetal life to childhood. The results of this study may provide a valuable basis for further research on brain maturation and "healthy aging."

Paraneoplastic limbic encephalitis in a patient with extensive disease small-cell lung cancer

Paraneoplastic limbic encephalitis (PLE) is a rare disorder infrequently accompanying malignancy, coexisting in ~50% of the cases with small-cell lung cancer (SCLC). The pathomechanism of PLE is considered to be immune-mediated, with production of specific anti-Hu antibodies and activation of T-cells directed against onconeural antigens present on both tumor cells and neurons. We herein report the case of a 50-year-old male patient who, prior to being diagnosed with SCLC, presented with typical symptoms of PLE (seizures, subacute cognitive dysfunction with severe memory impairment, anxiety and hallucinations). The initial brain magnetic resonance imaging examination revealed mild enlargement and hyperintensity of the hippocampal gyri bilaterally, with narrowed temporal horns of the lateral ventricles; the findings of the cerebrospinal fluid examination were compatible with the diagnosis of lymphocytic meningitis. Due to the suspected infectious origin of the disease, treatment with acyclovir and antibiotics was initially applied. However, following subsequent diagnosis of the underlying SCLC and the presence of antineuronal anti-Hu antibodies in the patient's serum, the diagnosis of PLE accompanying extensive-disease (ED) SCLC was confirmed. In addition to the standard cytotoxic therapy, throughout the course of his disease the patient also continued treatment with valproic acid (VPA) as prophylaxis for the initial seizures. VPA is known to be a potent histone deacetylase inhibitor that may reverse epigenetic changes in tumor cells and potentially improve the outcome of cancer patients. The patient succumbed to the disease 25 months after the diagnosis of malignancy; such a long course is observed in only ~5% of patients with ED SCLC. Therefore, it was hypothesized that the accompanying paraneoplasia and treatment with VPA may have improved the outcome in this patient.

APPLICATION OF FUNCTIONAL NEUROMARKERS FOR CONSTRUCTING PROTOCOLS OF NEUROTHERAPY AND MONITORING THE SUCCESS OF TREATMENT IN CHRONIC CROSSED TRANSCORTICAL SENSORY APHASIA: A CASE STUDY

Background. The goal of the study was threefold: 1) to evaluate QEEG/ERPs in­dexes of functional brain impairment after a stroke associated with chronic crossed transcortical sensory aphasia, 2) to construct a neu­rotherapy protocol to compensate for this functional damage, and 3) to assess the changes in the functional neuromarkers induced by the neurotherapy sessions. Case study. A 72-year-old, strongly right-handed woman with atrial fibrillation sud­denly developed cerebral embolism of the right middle cerebral artery. She was treated conservatively, and the left hemiparesis, and aphasia – in a moderate degree, consequently existed. A CT-scan showed a large infarct lesion partially parallel to Wernicke’s area. After one year of ineffective aphasia therapy we constructed an experimental neuro­therapy protocol (TMS combined with comprehensive aphasia therapy) on the basis of an assessment of the spontaneous QEEG and event-related potentials (ERPs) in the cued GO/NOGO. The patient was assessed before and after the neurotherapy sessions by the same methodology. Conclusions.It was found that before the TMS treatment the temporal area (T6) generates a strong P2 wave in response to visual stimulus indicating a hyper-sensitivity of the neurons located at temporal areas of the right hemisphere. This was connected with crossed transcortical sensory aphasia found within the aphasia profile in the Polish version of the Western Aphasia Battery (K-WAB). The TMS sessions reduced this hyper-sensitivity substantially. The patient speech returned to the norm, she was to return to social life.

KIF5A de novo mutation associated with myoclonic seizures and neonatal onset progressive leukoencephalopathy

The KIF5A gene (OMIM 602821) encodes a neuron-specific kinesin heavy chain involved in intracellular transport of mitochondria and other cargoes. KIF5A protein comprises the N terminal motor domain, the stalk domain and the C-terminal cargo binding domain. The binding between KIF5A and its cargoes is mediated by kinesin adaptor proteins such as TRAK1 and TRAK2. Numerous missense KIF5A mutations in the motor and stalk domains cause spastic paraplegia type 10 (SPG10, OMIM 604187). Conversely, the role of loss-of-function mutations, especially those affecting the cargo binding domain, is unclear. We describe a novel de novo KIF5A p.Ser974fs/c.2921delC mutation found by whole exome sequencing in a patient with a congenital severe disease characterized by myoclonic seizures and progressive leukoencephalopathy. Since this phenotype differs considerably from the KIF5A/SPG10 disease spectrum we propose that the KIF5A p.Ser974fs and possibly other mutations which lead to truncation of the C-terminal tail of the protein cause a novel disorder. We speculate that the unique effect of the C-terminal truncating KIF5A mutations may result from the previously described complex role of this protein domain in binding of the TRAK2 and possibly other kinesin adaptor protein(s).

Relationship between Proton Magnetic Resonance Spectroscopy of Frontoinsular Gray Matter and Neurodevelopmental Outcomes in Very Low Birth Weight Children at the Age of 4

Very low birth weight is associated with long term neurodevelopmental complications. Macroscopic brain abnormalities in prematurity survivors have been investigated in several studies. However, there is limited data regarding local cerebral metabolic status and neurodevelopmental outcomes. The purpose of this study was to characterize the relationship between proton magnetic resonance spectra in basal ganglia, frontal white matter and frontoinsular gray matter, neurodevelopmental outcomes assessed with the Leiter scale and the Developmental Test of Visual Perception and selected socioeconomic variables in a cohort of very low birth weight children at the age of four. Children were divided in three groups based on the severity of neurodevelopmental impairment. There were no differences in spectroscopy in basal ganglia and frontal white matter between the groups. Lower concentrations of N-acetylaspartate (NAA), choline (Cho) and myoinositol (mI) were observed in the frontoinsular cortex of the left hemisphere in children with neurodevelopmental impairment compared to children with normal neurodevelopmental outcomes. Higher parental education, daycare attendance and breastfeeding after birth were associated with more favorable neurodevelopmental prognosis, whereas rural residence was more prevalent in children with moderate and severe impairment. Our study demonstrates the role of long term neurometabolic disruption in the left frontoinsular cortex and selected socioeconomic variables in determination of neurodevelopmental prognosis in prematurity survivors.

Augmentative and Alternative Communication (AAC) for a patient with a nonfluent/agrammatic variant of PPA in the mutism stage

INTRODUCTION

The paper presents an example of the successful administration of the Augmentative and Alternative Communication (AAC) system. Such an approach is of particular significance in cases of patients with speech and language deterioration, which is observed in a nonfluent/agrammatic variant of primary progressive aphasia (PPA-G). Regaining the ability to communicate with others proves to be very important for the patients' self-esteem and enables them to restore previously broken social bonds.

CASE HISTORY

The patient A.G., aged 73, a right-handed woman, had been a teacher of Polish before suffering from speech disorders of the PPA-G type. As the disease progressed, her communication deteriorated and finally she developed mutism. The patient was given a clinical and imaging-supported diagnosis of an isolated nonfluent/ agrammatic variant of primary progressive aphasia (PPA-G). The Augmentative and Alternative Communication (AAC) system specially designed for her needs was introduced to help the patient to regain the possibility to communicate. After 20 sessions of training with the use of simple equipment she was again able to communicate non-verbally with her son and with the staff of the nursing home. At the same time, a considerable improvements in her social functioning, including daily activities, was observed.

CONCLUSIONS

Loss of the ability to communicate with others has a serious impact upon a patient's quality of life, and often results in withdrawal and an inability to lead an independent life. The introduction of the Augmentative and Alternative Communication (AAC) system proves to be a great help, not only for regaining the ability to communicate, but also for the restoration of social bonds. In consequence, the previously mute patient begins to show signs of social cooperation.

[Familial case of oral-facial-digital syndrome type 1 (OFD 1)]

Ciliopathies are phenotypically and genetically heterogeneous disorders that share ciliary dysfunction as a common pathological mechanism. Ciliary dysfunction results in a broad range of malformations including renal, hepatic and pancreatic cysts, visceral abnormalities, retinal degeneration, anosmia, cerebellar or other brain anomalies, polydactyly, bronchiectasis and infertility. The paper presents a familial case of oral-facial-digital syndrome type 1 in 14 year old girl suspected to polycystic kidney disease.

CONCLUSIONS

Molecular testing in daughters of known OFD1 mutation carriers and mothers of affected daughters seems to be reasonable. Not each case of policystic kidney disease which looks like autosomal dominant policystic kiedney disease is actually the above disease. The insight into the pathogenesis of ciliopathies is mandatory for understanding these combined congenital anomaly syndromes of seemingly unrelated symptoms of hepatorenal and pancreatic fibrocystic disease. Close interdisciplinary approach is mandatory in terms of efficient and reliable diagnostic and therapeutic interventions in patients presenting with ciliopathies.

Generalized seizures as the first manifestation of multihormonal pituitary hormone deficiency causing normovolemic hyponatremia

Patient: Female, 14

Final Diagnosis: Multiple pituitary hormone deficiency

Symptoms: Hyponatremia

Medication: —

Clinical Procedure: Endovascular embolectomy

Specialty: Endocrinology and Metabolic

Objective: Patient complains/malpractice

Comparison of prenatal and postnatal treatments of spina bifida in Poland--a non-randomized, single-center study

OBJECTIVE

The aim of this study was a comparison of the outcomes of intrauterine myelomeningocele (MMC) repairs (IUMR) in type II Chiari malformation (II CM) fetuses with clinical data of newborns and infants operated on postnatally.

METHODS

The study group (SG) comprised 46 pregnant women whose type II CM children underwent IUMR, while 47 pregnant women whose type II CM children were operated on postnatally constituted the control group (CG). A total of 24 SG and 20 CG patients reached the endpoint of the study.

RESULTS

High incidence of prelabor rupture of membranes (24 (52.2%), CI: 3.74 (1.69-8.26) (p < 0.001) was noted in the group of prenatal surgeries as compared to controls. The need for ventriculoperitoneal shunt implantation was statistically significantly lower (p < 0.008) in the group of children after IUMR as compared to controls (5 (27.8%) and 16 (80%), respectively, CI: 0.35 (0.16-0.75). None of the postnatally treated CG children can walk without adaptive equipment. In contrast, two children from the SG (2 (11.1%) CI: 1.86 (1.00-3.48) p < 0.05) are able to walk independently.

CONCLUSIONS

Prenatal MMC closure significantly lowers further adverse evolution of the II CM. Further studies are needed, especially on preventive measures for preterm labor and iatrogenic preterm prelabor rupture of membranes (iPPRM) in the postoperative course of IUMR.

[Prenatal MRI as a method of controlling fetal pathology]

BACKGROUND

It has been shown that MRI offers the possibility of more detailed assessment of fetal pathology than sonography. It is used not only to diagnose but also to follow up some prenatal diseases. It is a basis of in utero treatment and the tool of monitoring its efficacy The purpose of the study was to present the authors' experience with prenatal MRI as a method of follow-up of fetal pathology and of monitoring invasive fetal therapy

MATERIAL AND METHODS

The study group consisted of 31 fetuses that underwent two MRI examinations. The first exams were performed at the gestational age of 19-28 weeks (mean: 23.6 weeks), the follow-up between week 20 and 37 (mean: 30.5). The MRI examinations were performed using 1.5 T scanners. SSFSE/T2-weighted images, TSE/ or GRE/T1-weighted images, DWI, FIESTA, EPIGRE were performed.

RESULTS

In 5 cases MRI allowed to exclude a suspected pathology: brain anomaly in a healthy fetus, septo-optic dysplasia in a healthy fetus, right-sided CDH in case of a left-sided pathology pentalogy of Cantrell, lack of bladder in a fetus with a small, thick-walled bladder In 4 cases an additional pathology was detected on MRI: CCAM/ pulmonary sequestration with self-regression, cerebellar hypoplasia, rhombencephalosynapsis, tethered cord with syringohydromyelia. In 4 cases MRI was used just to follow-up and showed evolution of the disease in 2 cases: regression of intracerebral hemorrhage, progression of kidney disease. Finally, in 18 cases MRI was performed before and after an open fetal surgery of myelomeningocele showing good outcome in 10 cases and a wide spectrum of complications in 8 neonates: from edema of the transplant only in 4 to recurrent MC in 1.

CONCLUSIONS

Maternal uterus constitutes a natural "incubator" for the fetus--it is easier and safer to perform diagnostic procedure in utero than in a seriously ill newborn. MRI is a method of choice in the diagnosis and of follow-up in cases of open fetal surgery.

Diagnostic problems in case of twin pregnancies: US vs. MRI study

AIM

To present an experience with twin pregnancies underlining the impact of magnetic resonance imaging (MRI) on diagnosis and management.

METHODS

There were 17 cases of twin pregnancies: nine monochorionic [including four monochorionic diamniotic and five monochorionic monoamniotic (conjoined twins)] and eight dichorionic. The MRI examinations were performed between 19 and 39 weeks of gestational age in two centers using 1.5 T scanners (GE Signa Excite and GE Signa HDxt; GE Healthcare, Waukesha, WI, USA), always after ultrasound (US). In the first period of our activity, SSFSE sequence in T2-weighted images (SSFSE/T2WI) was the main diagnostic tool supported by TSE or GRE T1-weighted images (T1WI). After upgrading the scanners, diffusion-weighted imaging (DWI), steady-state free precession (FIESTA), and echoplanar GRE imaging (EPIGRE) became available.

RESULTS

In 11 cases (64.7%), MRI was superior to US and supplied additional information, including two cases in which pathology of the second twin suspected on US was ruled out on the basis of MRI. In six cases (35.3%) MRI confirmed US diagnosis and brought no new data.

CONCLUSION

MRI offers more detailed assessment of fetal pathology in cases of twin pregnancies, including conjoined twins, in which sonographic evaluation is more difficult than in single cases.

Embryonal tumor with abundant neuropil and true rosettes: an autopsy case-based update and review of the literature

INTRODUCTION

Embryonal tumor with abundant neuropil and true rosettes (ETANTR) is a rare subtype of primitive neuroectodermal tumors first reported in 2000. It is rare among the group of embryonal central nervous system tumors with approximately 50 reported cases. ETANTR has been suggested to be a separate entity among this group of tumors.

CASE REPORT

Herein, we present only the second autopsy case of ETANTR, which occurred in a 17-month-old boy, and was located in the brainstem. The tumor was inoperable, and despite chemotherapy, the child died 3 months after initial hospitalization. A brain only autopsy was performed.

DISCUSSION

Neuropathological and neuroimaging examinations suggest ETANTR grew by expansion rather than invasion distorting anatomical structures of the posterior fossa. We suggest that the characteristic histopathological picture of the tumor is the result of multifocal and dispersed germinative activity surrounded by mature neuropil-like areas.

CONCLUSION

ETANTR is a pediatric tumor occurring in children under 4 with a significantly poor prognosis with more cases and research required to characterize this rare embryonal tumor.

[Dysraphic spinal defekt - from diagnostics to therapy]

Congenital malformations comprise all cases of abnormal fetal develop. ment. Among the most serious ano malies - those of the central nervous system (CNS) - the most common are disrafic disorders, i.e. malformations of neural tube closure. This study is an approach to the problem of congenital malformation diagnostics, in the context of modern prenatal treatment and prognosis.

Evaluation of differentiated neurotherapy programs for a patient after severe TBI and long term coma using event-related potentials

BACKGROUND

This article examines the effectiveness of differentiated rehabilitation programs for a patient with frontal syndrome after severe TBI and long-term coma. We hypothesized that there would be a small response to relative beta training, and a good response to rTMS, applied to regulate the dynamics of brain function.

CASE REPORT

M. L-S, age 26, suffered from anosognosia, executive dysfunction, and behavioral changes, after a skiing accident and prolonged coma, rendering him unable to function independently in many situations of everyday life. Only slight progress was made after traditional rehabilitation. The patient took part in 20 sessions of relative beta training (program A) and later in 20 sessions of rTMS (program B); both programs were combined with behavioral training. We used standardized neuropsychological testing, as well as ERPs before the experiment, after the completion of program A, and again after the completion of program B. As hypothesized, patient M.L-S showed small improvements in executive dysfunction and behavioral disorders after the conclusion of program A, and major improvement after program B. Similarly, in physiological changes the patient showed small improvement after relative beta training and a significant improvement of the P300 NOGO component after the rTMS program.

CONCLUSIONS

The rTMS program produced larger physiological and behavioral changes than did relative beta training. A combination of different neurotherapeutical approaches (such as neurofeedback, rTMS, tDCS) can be suggested for similar severe cases of TBI. ERPs can be used to assess functional brain changes induced by neurotherapeutical programs.

A case of "borrowed identity syndrome" after severe traumatic brain injury

BACKGROUND

It is well known that traumatic brain injury often changes the way the patient perceives reality, which often means a distortion of the perception of self and the world. The purpose of this article is to understand the processes of identity change after traumatic brain injury.

CASE REPORT

We describe progressive deterioration in personal identity in a former physician who had sustained a serious head injury (1998), resulting in focal injuries to the right frontal and temporal areas. He regained consciousness after 63 days in coma and 98 days of post-traumatic amnesia, but has since displayed a persistent loss of autobiographical memory, self-image, and emotional bonds to family and significant others. Qualitative 'life-story' interviewing was undertaken to explore the mental state of a patient whose subjective, "first person" identity has been disengaged, despite the retention of significant amounts of objective, "third person" information about himself and his personal history (though this was also lost at a later stage in the patient's deterioration). Identity change in our patient was characterized by a dynamic and convoluted process of contraction, expansion and tentative balance. Our patient tends to cling to the self of others, borrowing their identities at least for the period he is able to remember. Identity is closely connected with the processes of memory.

CONCLUSIONS

The results will be examined in relation to the microgenetic theory of brain function. The brain mechanisms that may account for these impairments are discussed. Findings from this study have important implications for the delivery of person-focused rehabilitation.

Persistent notochordal canal imitating compression fracture--plain film, CT and MR appearance

BACKGROUND

Persistent notochordal canal is a rare developmental anomaly, typically restricted to 1 or 2 vertebral levels, and only in exceptional cases extending over a longer segment. It is usually asymptomatic and discovered incidentally.

CASE REPORT

A 30-year-old woman reported to our department for control lumbar spine plain films. About 2 years before, after minor trauma, she had been misdiagnosed on radiograms in another hospital as having a compression L5 vertebra fracture. The assessment of current plain films and analysis of previous radiograms delivered indicated the need for taking a developmental anomaly into consideration. Based on CT and MR of lumbar spine performed, a final diagnosis of a persistent notochordal canal was established.

CONCLUSIONS

In spite of its rare occurrence, the characteristic features of a persistent notochordal canal should be known by radiologists, particularly to avoid misinterpretation in post-traumatic patients.

Speech intelligibility in cerebral palsy children attending an art therapy program

BACKGROUND

Dysarthia is a common sequela of cerebral palsy (CP), directly affecting both the intelligibility of speech and the child's psycho-social adjustment. Speech therapy focused exclusively on the articulatory organs does not always help CP children to speak more intelligibly. The program of art therapy described here has proven to be helpful for these children.

MATERIAL/METHODS

From among all the CP children enrolled in our art therapy program from 2005 to 2009, we selected a group of 14 boys and girls (average age 15.3) with severe dysarthria at baseline but no other language or cognitive disturbances. Our retrospective study was based on results from the Auditory Dysarthria Scale and neuropsychological tests for fluency, administered routinely over the 4 months of art therapy.

RESULTS

All 14 children in the study group showed some degree of improvement after art therapy in all tested parameters. On the Auditory Dysarthia Scale, highly significant improvements were noted in overall intelligibility (p<0.0001), with significant improvement (p<0.001) in volume, tempo, and control of pauses. The least improvement was noted in the most purely motor parameters. All 14 children also exhibited significant improvement in fluency.

CONCLUSIONS

Art therapy improves the intelligibility of speech in children with cerebral palsy, even when language functions are not as such the object of therapeutic intervention.

[The role of MRI in the assessment of the cardiac anatomy and function]

This paper discusses the role of MRI in the assessment of the cardiac anatomy and function. Cardiac MRI offers the possibility of precise quantitative heart evaluation (also in measuring the volume and mass of the heart ventricles). It is characterised by high reproducibility compared with that of echocardiography. For the assessment of the heart and the great vessels the Spin Echo and Fast Spin Echo sequences are used. The observation of the heart function is possible in Gradient Echo sequences, in the cine mode. Contrast enhancement sequences allow the assessment of the heart perfusion, the detection and scope of ischaemic area and post-infarction scar as well as the differentiation between necrotic tissue from stunned muscle. In many cardiac conditions MRI may play an important role. They include ischaemic heart disease, cardiomyopathies, cardiac defects and less common pathologies such as tumours, sarcoidosis, amyloidosis and haemochromatosis. The use of cardiac MRI in the diagnostics of those conditions is discussed.

[Three-dimentiolanl moving-table MR angiography in diagnostic of peripheral arteria diseases]

PURPOSE

The aim of this study was to present the method of three-dimentional contrast-enhanced moving-table MR angiography, on the basis of own experience.

METHOD

The 1,5T MR system with moving-table option was used to examin pelvic and peripheral arteries of lower extremities. The body coil was used. The large region of interest was divided into three segments: TOP--pelvis, MID--thight and BOT--leg. MR aquisitions were performed in coronal plane after injection of contrast, given by the automatic two-chamber syringe. Programm IVI were used to obtain 3D reconstructions.

CONCLUSION

Three-dimentional contrast-enhanced moving-table MR angiography is accurate, noninvasive diagnostic method for evaluation of peripheral arterial diseases of lower extremities and allows to choose an adequate method of treatment.

Brain development of the human fetus in magnetic resonance imaging

INTRODUCTION

Ultrasonography is the first step in the in vivo evaluation of fetal central nervous system. However, it is not always easy--or even possible--to carry out this examination because of maternal obesity, oligo- or ahydramnios or fetal position. Magnetic resonance imaging becomes then the only method of assessment. Recognition of cerebral and cerebellar abnormalities requires detailed knowledge of normal development and morphology of the fetal brain.

AIM

To show the sequence of fetal brain maturation on MR images on the basis of own material and equipment.

MATERIAL AND METHOD

Seventy five fetuses without cerebral abnormalities were selected for the analysis of T2-weighted images of the brain obtained with use of GE Signa 1.5T scanners. No maternal sedation was used. Single-Shot Fast Spin Echo sequence (SSFSE) was applied in T2-weighted images in axial, sagittal and coronal planes in all fetuses. Fast Spoiled Gradient Echo (FSPGR) T1-weighted images were also obtained.

RESULTS

The sequence of fetal brain maturation during the second half of pregnancy was elaborated and discussed.

CONCLUSIONS

Magnetic resonance imaging is the most useful method of the evaluation of normal fetal brain development. It should be used as an additional tool in every case of diagnostic difficulties or uncertainty.

[Myoinositol trends in HMRS brain spectrum of patients with hepatic encephalopathy]

Hepatic encephalopathy (HE) comprises a complex set of neuropsychiatric abnormalities upon primary hepatic dysfunction. Ammonia and other nitrogen-based compounds are thought to be essential etiological factors when dysmetabolized in the liver, they provoke highly undesirable neuroglial transmission in the central nervous system (CNS). Proton MR spectroscopy (HMRS) is a noninvasive in vivo method of analyzing the metabolic spectrum of neuronal tissue and its pathological changes even before overt clinical symptoms occur and can be seen in morphological MR examination. Myoinositol (ml) is one of the metabolites that can be identified with HMRS. It is considered a glial marker, directly involved in compensation processes to overcome toxic effects of hepatic metabolites which had crossed the brain-blood barrier. Thus, ml may be a crucial prognostic factor for patients with HE. The goal of the present paper was to selectively investigate ml trends upon the MR brain spectrum. 36 male participants were enrolled in the study: 20 patients (mean age 58.2 years) with clinical symptoms suggestive of HE in the course of either chronic viral hepatitis or post-viral liver cirrhosis, and 16 men (mean age 51.3 years) with normal liver function (control group). Brain MR examinations were performed in all participants, followed by HMRS in single voxel spectroscopy (SVS) technique from occipital gray matter of right (Voxel 1) and left (Voxel 2) cerebral hemispheres. MR data were acquired with a 1.5 T GE Signa Excite scanner. ml peak height was normalized with respect to creatine. A statistically significant decrease in ml/Cr ratio has been appreciated in the MR spectra of HE patients. The mean ml/Cr ratio for HE patients was 0.75, and was 0.93 for the control group, and, for alpha = 0.05, the observed differences between ml/Cr ratio mean values appeared to be statistically significant.

[Usefulness of proton MR spectroscopy for determining diagnosis and treatment outcome in unipolar depressive disorder]

PURPOSE

The aim of the study was to evaluate the usefulness of proton MR spectroscopy for determining the biochemical abnormalities in acute episode of depression and after regression of the disease in course of unipolar depressive disorder.

MATERIAL AND METHODS

Forty one patients (age 18-55 years) with known unipolar depressive disorder (a Hamilton Depression Rating Scale of 16 or greater) were evaluated by the means of HMRS during acute episode of depression and after positive therapeutic response (at least 50% reduced Hamilton score for at least 4 consecutive weeks). All patients underwent single-volume 1H MRS (TR=1500 ms, TE=35 ms) using a 1.5T scanner. Four brain areas were analyzed: both frontal lobes and both hippocampi.

RESULTS

In the acute fase of the disease patients had statistically significant increases in Cho/Cr levels in right hippocampus area and increases in ml/Cr levels in left frontal lobes relative to controls. After positive therapeutic response no significant abnormalities were found.

CONCLUSION

These results suggest that abnormal increased brain metabolites should reverse after treatment. In the time of new imaging technics we hope that in the future 1H MRS may be helpful for determining the accuracy of the diagnosis and can improved prediction of therapeutic response in unipolar depression.

[The influence of MRI examination on prenatal guidance and therapeutic decisions in fetuses with central nervous system defects]

PURPOSE

The aim of this study was the evaluation of diagnostic and prognostic value of prenatal US and MRI in fetuses with central nervous system abnormalities, and of the influence of incorporating MRI to diagnostic algorithm on the therapeutic decisions.

MATERIALS AND METHODS

123 pregnant women (16-40 weeks' gestation) underwent MRI due to abnormal appearance of fetal central nervous system in US (using Voluson-Kretz 730PRO). MRI has been performed on a 1.5-T Excite (GE), using a phased-array body coil, with T2-weighted sequences (SSFSET2) and orthogonal scans. The MRI findings have been compared to those from prenatal US. The influence of MRI examination in prenatal diagnostic on decisions concerning termination of pregnancy, method of delivery and neurosurgical intervention after birth was assessed.

RESULTS

Among 123 fetuses with central nervous system abnormalities, 11 neonates died after birth (in 6 cases pathologic examination was performed), in 67 cases the MR findings were correlated with the results of the neonatal evaluation, all other cases have not been verified. Almost in 70% of the cases, MRI findings complemented the US diagnosis, in 22 cases changed it with respect to central nervous system defects, and in 18 cases--with respect to other system/organ abnormalities. In a few cases US failed to provide a correct diagnosis. In 3 cases, the MRI findings have not been confirmed with postnatal evaluation.

CONCLUSIONS

Prenatal MRI in congenital central nervous system defects allows to obtain much more important therapeutic data and complement or correct the fetal sonographic diagnosis. Prenatal MRI allows to plan gynaecological, neonatal, neurosurgical treatment, and to predict neurological defects. It also improves prenatal guidance.

[Fetal ventriculomegaly secondary to germinal matrix hemorrhage--case report]

A germinal matrix is an area of the fetal brain where neuroblasts proliferate till the 20th week of gestation after which their migration takes place. Germinal matrix hemorrhage (GMH) is a frequent cause of fetal ventriculomegaly or hydrocephalus, yet the pathophysiological conditions of GMH remain unclear. A case of fetal ventriculomegaly resulting from GMH has been reported in the article. A prenatal ultrasonographic examination (US) carried out in the 30th week of gestation revealed enlarged ventricles. Utero magnetic resonance imaging (MRI) performed in the 34th week of gestation demonstrated asymetric ventriculomegaly and the changes suggesting the occurance of GMH and ependymal intraventricular hemorrhage. Fetal ventriculomegaly and hydrocephalus are commonly detected by ultrasonographic examination, but it is often difficult to determine the causes of the diseases by US. In these cases MRI allows to establish the final diagnosis.

Pituitary enlargement in patients with PROP1 gene inactivating mutation represents cystic hyperplasia of the intermediate pituitary lobe. Histopathology and over 10 years follow-up of two patients

Patients with a PROP1 inactivating mutation present combined pituitary hormone deficiency (CPHD) and pituitary maldevelopment. A retrospective analysis of 31 CPHD patients with a PROP1 mutation revealed two individuals, aged 18 and 4.5 years, who had undergone subtotal surgery to remove pituitary tumors, 16.8 x 12 mm and 9 x 10 x 12 mm in size. Histological reassessment of tissue samples revealed epithelial cells, partially oxyphilic, forming gland-like microcystic structures, most of them filled with eosinophilic colloid. These structures were directly linked with fragments of the posterior lobe. Neither atypia nor any traces of proliferation activity (Ki-67 LI=0%) were noted. Immunohistochemistry showed the presence of all hormonal phenotypes of cells. These findings corresponded to the intermediate lobe of the pituitary gland. For this type of pathology we propose the term 'cystic hyperplasia of the intermediate pituitary lobe' and suggest PROP1 gene assessment in patients with CPHD in order to avoid unnecessary neurosurgical interventions.

Neuropsychological diagnosis and treatment after closed-head injury in a patient with a psychiatric history of schizophrenia

BACKGROUND

Despite recent interest in the brain/mind problem and possible organic correlates of mental disease, relatively few case studies have examined the problem concretely. The present paper describes a 66-year-old male patient with a long history of schizophrenia, whose psychotic symptoms displayed qualitative and quantitative changes after a closed-head injury.

CASE REPORT

After a very disturbed childhood and youth, including several jail terms, the patient was diagnosed with schizophrenia in the early 1960s and frequently thereafter hospitalized. Visual hallucinations were the dominant symptom, and art therapy provided some relief, which led to a successful artistic career. In 1989, while actively hallucinating, he suffered a mild TBI in a pedestrian accident. Despite findings of organic dysfunction, he did not receive full neuropsychological diagnosis and treatment until four years later, when he presented with symptoms of perseveration, hemispatial neglect, and disturbances of working memory. The patient then received an individual program of neuropsychological rehabilitation, while his treating psychiatrist gradually withdrew psychotropic medication. After a year of therapy there was marked improvement of both neuropsychological and psychiatric symptoms. At the same time, he began to paint in a completely different style.

CONCLUSIONS

The case described here shows that the pathomechanisms of schizophrenia and neurobehavioral disturbances resulting from organic brain damage are not after all unrelated. Microgenetic theory can provide a basis for explaining the course of symptoms in this and similar cases, as we re-think the brain-mind relationship.

MR CSF Flow Examination as a Non-Invasive Method of Determining Shunt-Independent Hydrocephalus in Children with Implanted Ventriculoperitoneal Shunt

The study discusses the value of MR examination of CSF flow through the cranial part of the ventriculoperitoneal shunt in the evaluation of shunt-dependent hydrocephalus. Sixteen patients aged eight to 18 years were examined in the course of many years of treatment using the ventriculoperitoneal shunt. No clinical manifestations of shunt obstruction had been observed in any of the patients prior to MR examination. A Signa Horizon 1.5T (GEMS) unit was used. Axial and sagittal T1- and T2-weighted images were performed to find the ventriculoperitoneal shunt canal. A 2D CINE/GR/PC sequence was performed in the plane perpendicular to the shunt canal. CSF-flow was calculated by the Flow Analysis program. Patients were divided into two groups: 1) no CSF-flow was noted in five children indicating shunt-independent hydrocephalus; 2) CSF-flow was present (average flow volume from 0.1 to 1.9 ml/min) in 11 children, distinguishing the group with shunt-dependent hydrocephalus. Conclusions: 1) MR CSF flow examination will establish the absence or presence of CSF flow and determine its direction and velocity. 2) With no clinical manifestations of shunt impatency the absence of flow in the shunt canal found in MR CSF flow examination may indicate shunt-independent hydrocephalus. 3) When the CSF flow in the shunt is found in MR shunt-dependent hydrocephalus is diagnosed.

[MRI brain imaging data in children with cavum septi pellucidi and vergae]

BACKGROUND

Cavum septum pellucidum (CSP) is commonly known marker of neurodevelopmental brain malformation. In MR imaging it is seen either as an isolated finding or with association of others developmental brain changes e.g. cavum vergae (CV).

AIM OF THE STUDY

was to assess the frequency of CSP and CV associated with others brain developmental malformations in children. We also classified clinical syndromes in children with these structural brain malformations.

MATERIAL AND METHODS

The study was performed on 55 children, hospitalised in the Department of Pediatric Neurology, Jagiellonian University in Krakow, between 1998-2006 with diagnosed CSP and/or CV in MRI. There were 29 girls and 26 boys aged 4 months-16 years old. Clinical history, clinical status and neurological findings in physical examination were main indication to perform brain MRI. MRI scans was done in SE T1, FSE T2, PD, FLAIR, IR T1 sequences, 3 and 5 mm depth, in vertical, frontal and axial surfaces, performed on 1,5 T machine Signa Horizon HiSpeed General Electric.

RESULTS

There were 38 children with CSP, 12 children with CSP and CV, and 5 with CV. In 18/55 children (33%) CSP was isolated, but in 37/55 children (67%) CSP was coexisted with other brain structural malformations. The average age of diagnosis in isolated CSP was 10 years old, in coexisting malformation was 5 years. In half of the children, the reason of neuroimaging was epilepsy, in this 6/18 patient with isolated CSP or CV. 58% of the study group had a normal mental development, but 35% of children with additional brain malformation and 11% of children with isolated CSP and CV were mentally retarded.

CONCLUSION

1. The majority of the children with CSP and CV had also coexisting brain malformations diagnosed in MRI. 2. CSP and CV coexisting with large brain malformation e.g. dysplasia septo-optica and agenesis of corpus callosum. were diagnosed earlier. 4. Mental retardation was diagnosed in 1/3 children with different structural brain malformation but also in 11% of children with CSP and CV as well.

[Usefulness of MR CSF flow examination in children with hydrocephalus]

BACKGROUND

MR examination allows the determination of the absence or presence of CSF-flow as well as its direction and velocity.

THE AIM OF THE STUDY

is the presentation of the value of MR examination CSF-flow and its usefulness in diagnosis of hydrocephalus in children. MR CSF-flow examination may be performed in the cerebral aqueduct of Sylvius and in the drain of the ventriculo-peritoneal shunt.

METHODS

The examination big in classical MR examination: axial and sagittal T1-weighted scans (TR 500, TE 12) and T2-weighted scans (TR 5000, TE 100). The CSF flow examination is performed in 2D CINE/GR/PC (TR 33, TE 9.1, FA 30 degrees, FOV 12 x 12 cm, slice thickness 5 mm, acquisition matrix 256 x 192) in the plane perpendicular to the examined structure. The gating sequence is compatible with the patient's heart rate. Two regions of interest is established: area of flow (ROI 1) and the area of background (ROI 2). CSF flow is calculated using Flow Analysis software. CSF-flow in CINE phase-contrast technique is used to qualitative assessment of flow.

CONCLUSIONS

MR examination allows the determination of the absence or presence of CSF-flow and its direction and velocity in the cerebral aqueduct of Sylvius and in the drain of the ventriculo-peritoneal shunt. This examination enables the differentiation between the shunt-dependent and shunt-independent type of hydrocephalus, which is of great significance in clinical management of patients after a shunt implantation.

[Results of control MRI examinations performed due to radiological indication--preliminary report]

INTRODUCTION

MR is very important examination of central nervous system in children in the evaluation of differences dependent of sex and age as well as in the diagnostics. Radiological indications are important in many cases to perform a control study, to evaluate a dynamic changes or to establish the diagnosis.

THE AIM

The aim of this study was to examine the results of control MRI examination in children with neurologic syndromes.

MATERIAL AND METHODS

In the year 2006 control MRI was performed in 22 cases since it was advised after previous MRI examinations in children hospitalized in the Department of Pediatric Neurology UJ CM in Kraków. The group of children aged 4-18 years (mean 12 years) consisted of 14 boys and 8 girls. The commonest clinical diagnoses were epilepsy, encephalopathies, hemiparesis, cranial neuropathies, headache, anizocoria, vertigo, paraparesis and NF I.

RESULTS

Repeated MRI in 14 children did not revealed significant changes, independently from clinical changes. In 3 patients positive changes or regres of pathological foci were observed within the subarachnoid hemorrhage. In 3 children MRI revealed progressive changes, within in the child with NFI, and in patient with pyramidolextrapyramidal syndrome which progressed from hemiparesis to quadriplegia and also in a child with disseminated symptoms, such as ataxia, piramidal syndrome and cranial nerve palsies. In 2 other children the repeated MRI helped to establish the final diagnosis. The evolution of neuroradiological changes in the first child with the history of hemiparesis indicated ischemia as a cause of neurological syndrome. The other patient with cranial neuropathies of VII, VIII and XII nerves associated with intellectual impairment was diagnosed with CADASIL only with the help of control MRI examination.

CONCLUSIONS

In 9% children the second MRI which helped to analyze evolution of changes was important to establish the final diagnosis. The control MRI examination in 64% children did not revealed significant changes independently of clinical changes, such as recovery or aggravation of symptoms, what explains the decision to repeat MR examination in unclear cases.

[MRI of fetal central nervous system malformations]

Ultrasonography is the method of choice for prenatal malformation screening, but it does not always provide sufficient information for correct diagnosis or adequate abnormality evaluation. Fetal magnetic resonance imaging (MRI) is considered a valuable second line imaging tool for confirmation, completion and correction of complex fetal ultrasonography findings. Fetal MRI has proven its value in pathologies of the central nervous system. MR imaging's role includes nor only confirming or excluding possible lesions, but also defining their full extent, aiding in their characterization, and demonstrating other associated abnormalities. The article describes the most common anomalies of CNS discover by fetal MR.

[Trigeminalgia caused by neurovascular compression in 12 years old girl]

Trigeminalgia is one of the most frequent clinical problems, common in adults but also found in children. In this paper we described a case of 12 years old girl with symptomatic trigeminalgia caused by neurovascular compression, hospitalized in the Department of Pediatric Neurology Jagiellonian University in Kraków. It creates a very difficult diagnostic problem. The girl was first unsuccessfully treated with carbamazepine and afterwards the surgery of neurovascular decompression was performed. We emphasis the crucial role of MR and MRA in cases refractory to classic pharmacotherapy.

[Results of cerebral angiography performed after neuroradiological indications in children with CNS diseases]

INTRODUCTION

Despite of the constant progress in the imaging of vessels, cerebral angiography characterises with the best specificity and sensitivity in detection of arterial, arteriovenous malformations and aneurysms.

THE AIM

The aim of this study was to compare the results of cerebral angiography and other neuro-radiologic methods in cases suggesting the probability of vascular malformations in children with neurologic syndroms. MATHERIAL AND MEHTODS: In the year 2006 cerebral angiography was performed in 20 children since it was advised after radiological examinations in children hospitalized in the Department of Pediatric Neurology UJ CM in Krakó w. The group of children aged 3-17 years (mean 11 years) consisted of 11 girls and 9 boys. The commonest clinical diagnoses were epilepsy, less common cranial neuropathies, migraine, hemiparesis and agiomatosis of skin. Before cerebral angiography was indicated, other radiological examinations were performed, within CT in 7 cases, CTA in one, MRI in 17 children and MRA in 5. In some children other examinations were also performed, within transcranial doppler evaluation of cerebral blood flow, EEG, video EEG, lumbar puncture and ultrasound eye evaluation.

RESULTS

The pathological changes were detected in 5 CT examinations, 1 CTA, 7 MRI and in 4 MRA, suggesting cerebral vascular malformations. Cerebral angiography excluded vascular malformations in 15 children. In 5 children angiography confirmed however the presence of vascular pathology. In 2 of them arterial hypoplasia in the posterior circulation was detected, in 2 cases supratentorial artery hypoplasia and a single venous cerebellar malformation. Children were diagnosed with migraine with aura in two cases, within one with paresis of the right leg and single cases with skin angiomatosis, syncope and sleep myoclonus.

CONCLUSIONS

Cerebral angiography allowed to exclude vascular pathology in 75% of children, in whom previous neuroradiological examinations suggested such pathology. It was important for their quality of life. In 25% of patients angiography confirmed results of previous neuroradiological tests detecting vascular pathology. MR with contrast medium is more sensitive than angiography in detection of venous angiomas.

[Brain MRI data in children with so called primary generalized seizures]

INTRODUCTION

Diagnosis of primary generalised seizures may be not precise because difficulties exist with the assessment of information of focal onset of these seizures.

THE AIM

The aim was to examine if the careful searching for partial component of seizures is necessary in children with so called primary generalized seizures.

MATERIAL AND METHODS

The examined group included 45 children aged 6 month to 18 year (mean 11 year) within 19 girls and 26 boys, hospitalized during the year 2006 in the Department of Pediatric Neurology UJ CM in Krakow. The history indicated the primary generalized character of seizures. The tonic-clonic seizures were observed in 39 children, myoclonic in 3, infantile spasms in 1 and absence in other 2. In 6 patients familiar epilepsy was diagnosed in first-degree cousins. Neuropediatric examination was normal apart from 4 children with dysmorphic features of the face. Intellectual development was normal in 43 children, however it was close to the lower range in one and mildly delayed in the other one. Generalized paroxysmal bioelectric activity was detected in 43 children and in 2 children EEG pattern was normal. MRI was performed in SE T1, FSE T2, PD, FLAIR and IR T1 sequences with 3 or 5 millimetre thickness of layer in the sagital, coronal and transversal plane, using a 1.5 T signa horizon HiSpeed General Electric. These examinations were performed in the Voxel MR Laboratory in University Children's Hospital in Krakow.

RESULTS

MRI results were normal in 14/45 children and in others pathological. In 9/45 MR revealed subarachnoidal cyst, in 8 lateral ventricles asymmetry, in 5 mild demyelination, in 9 subarachnoid space and lateral ventricles dilatation. In 2/45 children brain tumors (hamartoma of the hypothalamus and DNET of the temporal lobe), in 1 gliosis of the occipital lobe were revealed, however other insignificant changes were also observed. Dual or multiple MRI pathology was revealed in 14 children. In17/45 children abnormalities were localized.

CONCLUSIONS

Existence of focal pathology in MRI of 38% children with the history of so called primary generalized seizures suggested the necessity of more careful searching for partial component of seizures.

[MRI and MRA data in children with migraine with aura]

INTRODUCTION

One of indications to perform structural MRI and MRA is migraine with aura. Results may influence migraine management.

THE AIM

THE AIM of this study was an assessment of MRI and MRA results in children with symptoms of migraine with aura and also the analysis if MR results influence migraine management.

MATERIALS AND METHODS

During the year 2006, 20 children with migraine were hospitalized in the Department of Pediatric Neurology Jagiellonian University Krakow. There were 11 girls and 9 boys, aged 6-18 years (mean 13,7 years) with symptoms of migraine with aura. In 12 of them visual, in 9 sensory, in 6 dysphasic and in 3 motor aura was present. In 7 children two or more aura types coexisted. In 9 cases family history of migraine was positive. MRI was performed in all children, while additional MRA in 18 children and digital cerebral angiography in 1 of them. MRI was performed in SE T1, FSE T2, PD, FLAIR and IR T1 sequences with 3 or 5 millimetre thickness of slices, in the sagital, coronal and transversal plane, using a 1,5 T system (HiSpeed GE). 3D TOF techniques were used to perform MRA.

RESULTS

Results of MRI were normal in 11/20. In other children brain pathology was detected, within lateral ventricular asymmetry (2), demyelination (2), dilatation of CSF spaces (2) and vascular malformation (2). Isolated pathology, such as a calcification of the pineal gland and focal demyelination of vascular origin were detected in individual children. MRA in 16 children did not revealed pathology, however in 2 other children slight asymmetry of distal insular branches of middle cerebral arteries was detected. Aneurysm of the right anterior communicans artery was suspected in one child and it was confirmed by MRA. In one case digital angiography confirmed described on MRI result left vertebral and cerebral posterior arteries hypoplasia and also revealed collaterals in the posterior skull cavity.

CONCLUSIONS

Detection of vascular pathology in 20 % of patients with migraine with aura using MRI and MRA is an argument to perform both examinations in such patients.

Neuropsychological features of rapidly progressive dementia in a patient with an atypical presentation of Creutzfeldt-Jakob Disease

BACKGROUND

Creutzfeldt-Jakob Disease (CJD) is a degenerative disease of the brain, characterized by rapid and irreversible decline, with dementia, ataxia, myoclonus, and other neurological and neurobehavioral disorders associated with rapidly progressive spongiform encephalopathy. The mode of transmission and basic pathomechanism remain unclear. The clinical picture of CJD is highly diverse, producing a number of variants.

MATERIAL AND METHODS

The patient to be described is a 68-year-old Polish female, JR, clinically diagnosed with CJD. The article presents the case history in detail, with particular emphasis on neuropsychological testing, which was initiated when the patient was still lucid and capable of cooperation. The first presenting symptom was agraphia, followed by hemianopsia and other vision disorders, culminating in visual hallucinations. As the progress of the disease accelerated there was rapidly progressive dementia, aphasia developing to organic mutism, myoclonus, hyperkinesia, ultimately loss of all verbal contact or voluntary movement.

RESULTS

JR's neuropsychological parameters declined in a period of less than 3 months from near normal to levels characteristic of severe dementia.

CONCLUSIONS

The clinical picture here presented is consistent with that of the Heidenhain variant of CJD, with spongiform encephalopathy beginning in the right occipital lobe. Several features of the case remain atypical, however, including the absence of the most common genetic mutation and the patient's long survival after onset.

[Optimizing computed tomography diagnosis in retrobulbar orbit tumors]

CT is still one of the most commonly applied diagnostic procedure in cases of suspected neoplastic lesions in the retrobulbar region. Orbit tumors are rare, however due to their localisation close to the organ of sight, they make a serious clinical problem. The authors analysed retrospectively 127 tumors (interview, ophthalmological examination, CT, surgical procedure, histopathologic findings) with the aim of improving CT diagnostics.