Widespread, depth-dependent cortical microstructure alterations in pediatric focal epilepsy

OBJECTIVE

Tissue abnormalities in focal epilepsy may extend beyond the presumed focus. The underlying pathophysiology of these broader changes is unclear, and it is not known whether they result from ongoing disease processes or treatment-related side effects, or whether they emerge earlier. Few studies have focused on the period of onset for most focal epilepsies, childhood. Fewer still have utilized quantitative magnetic resonance imaging (MRI), which may provide a more sensitive and interpretable measure of tissue microstructural change. Here, we aimed to determine common spatial modes of changes in cortical architecture in children with heterogeneous drug-resistant focal epilepsy and, secondarily, whether changes were related to disease severity.

METHODS

To assess cortical microstructure, quantitative T1 and T2 relaxometry (qT1 and qT2) was measured in 43 children with drug-resistant focal epilepsy (age range = 4-18 years) and 46 typically developing children (age range = 2-18 years). We assessed depth-dependent qT1 and qT2 values across the neocortex, as well as their gradient of change across cortical depths. We also determined whether global changes seen in group analyses were driven by focal pathologies in individual patients. Finally, as a proof-of-concept, we trained a classifier using qT1 and qT2 gradient maps from patients with radiologically defined abnormalities (MRI positive) and healthy controls, and tested whether this could classify patients without reported radiological abnormalities (MRI negative).

RESULTS

We uncovered depth-dependent qT1 and qT2 increases in widespread cortical areas in patients, likely representing microstructural alterations in myelin or gliosis. Changes did not correlate with disease severity measures, suggesting they may represent antecedent neurobiological alterations. Using a classifier trained with MRI-positive patients and controls, sensitivity was 71.4% at 89.4% specificity on held-out MRI-negative patients.

SIGNIFICANCE

These findings suggest the presence of a potential imaging endophenotype of focal epilepsy, detectable irrespective of radiologically identified abnormalities.

Recommendations for neuroradiological examinations in children living with achondroplasia: a European Society of Pediatric Radiology and European Society of Neuroradiology opinion paper

Children living with achondroplasia are at an increased risk of developing neurological complications, which may be associated with acute and life-altering events. To remediate this risk, the timely acquisition of effective neuroimaging that can help to guide clinical management is essential. We propose imaging protocols and follow-up strategies for evaluating the neuroanatomy of these children and to effectively identify potential neurological complications, including compression at the cervicomedullary junction secondary to foramen magnum stenosis, spinal deformity and spinal canal stenosis. When compiling these recommendations, emphasis has been placed on reducing scan times and avoiding unnecessary radiation exposure. Standardized imaging protocols are important to ensure that clinically useful neuroimaging is performed in children living with achondroplasia and to ensure reproducibility in future clinical trials. The members of the European Society of Pediatric Radiology (ESPR) Neuroradiology Taskforce and European Society of Neuroradiology pediatric subcommittee, together with clinicians and surgeons with specific expertise in achondroplasia, wrote this opinion paper. The research committee of the ESPR also endorsed the final draft. The rationale for these recommendations is based on currently available literature, supplemented by best practice opinion from radiologists and clinicians with subject-specific expertise.

Metabolic patterns in brain 18F-fluorodeoxyglucose PET relate to aetiology in paediatric dystonia

There is a lack of imaging markers revealing the functional characteristics of different brain regions in paediatric dystonia. In this observational study, we assessed the utility of [18F]2-fluoro-2-deoxy-D-glucose (FDG)-PET in understanding dystonia pathophysiology by revealing specific resting awake brain glucose metabolism patterns in different childhood dystonia subgroups. PET scans from 267 children with dystonia being evaluated for possible deep brain stimulation surgery between September 2007 and February 2018 at Evelina London Children's Hospital (ELCH), UK, were examined. Scans without gross anatomical abnormality (e.g. large cysts, significant ventriculomegaly; n = 240) were analysed with Statistical Parametric Mapping (SPM12). Glucose metabolism patterns were examined in the 144/240 (60%) cases with the 10 commonest childhood-onset dystonias, focusing on nine anatomical regions. A group of 39 adult controls was used for comparisons. The genetic dystonias were associated with the following genes: TOR1A, THAP1, SGCE, KMT2B, HPRT1 (Lesch Nyhan disease), PANK2 and GCDH (Glutaric Aciduria type 1). The acquired cerebral palsy (CP) cases were divided into those related to prematurity (CP-Preterm), neonatal jaundice/kernicterus (CP-Kernicterus) and hypoxic-ischaemic encephalopathy (CP-Term). Each dystonia subgroup had distinct patterns of altered FDG-PET uptake. Focal glucose hypometabolism of the pallidi, putamina or both, was the commonest finding, except in PANK2, where basal ganglia metabolism appeared normal. HPRT1 uniquely showed glucose hypometabolism across all nine cerebral regions. Temporal lobe glucose hypometabolism was found in KMT2B, HPRT1 and CP-Kernicterus. Frontal lobe hypometabolism was found in SGCE, HPRT1 and PANK2. Thalamic and brainstem hypometabolism were seen only in HPRT1, CP-Preterm and CP-term dystonia cases. The combination of frontal and parietal lobe hypermetabolism was uniquely found in CP-term cases. PANK2 cases showed a distinct combination of parietal hypermetabolism with cerebellar hypometabolism but intact putaminal-pallidal glucose metabolism. HPRT1, PANK2, CP-kernicterus and CP-preterm cases had cerebellar and insula glucose hypometabolism as well as parietal glucose hypermetabolism. The study findings offer insights into the pathophysiology of dystonia and support the network theory for dystonia pathogenesis. 'Signature' patterns for each dystonia subgroup could be a useful biomarker to guide differential diagnosis and inform personalized management strategies.

Radiologic diagnosis of non-traumatic paediatric head and neck emergencies

Imaging plays a crucial role in evaluating paediatric patients with non-traumatic head and neck lesions in an emergency setting because clinical manifestations of these entities can overlap. For this reason, radiologists must be familiar with the clinical and imaging findings of prevalent paediatric head and neck emergencies. In this review, we present techniques and imaging clues for common complications of pathological processes in the paediatric head and neck, with a focus on the clinical scenario as a starting point for the radiologic approach.

Obstructive hydrocephalus due to an enlarged massa intermedia treated with endoscopic third ventriculostomy

The massa intermedia (MI) or interthalamic adhesion (ITA) is a band of tissue connecting the medial surfaces of the thalami and is present in the majority of healthy individuals. Its enlargement as well as its absence have been associated with some pathological states.We describe the first case report of a 3-year-old child presenting with obstructive hydrocephalus in the context of an enlarged massa intermedia. The patient's symptoms abated following an endoscopic third ventriculostomy.

Clinical Reasoning: A Teenage Girl With Progressive Hyperkinetic Movements, Seizures, and Encephalopathy

The "epilepsy-dyskinesia" spectrum is increasingly recognized in neurogenetic and neurometabolic conditions. It can be challenging to diagnose because of clinical and genetic heterogeneity, atypical or nonspecific presentations, and the rarity of each diagnostic entity. This is further complicated by the lack of sensitive or specific biomarkers for most nonenzymatic neurometabolic conditions. Nevertheless, clinical awareness and timely diagnosis are paramount to facilitate appropriate prognostication, counseling, and management.This report describes a case of a teenage girl who had presented at 14 months with a protracted illness manifesting as gastrointestinal upset and associated motor and cognitive regression. A choreoathetoid movement disorder, truncal ataxia, and microcephaly evolved after the acute phase. Neurometabolic and inflammatory investigations, EEG, brain MRI, muscle biopsy (including respiratory chain enzyme studies), and targeted genetic testing were unremarkable. A second distinct regression phase ensued at 14 years consisting of encephalopathy, multifocal motor seizures, absent deep tendon reflexes and worsening movements, gut dysmotility, and dysphagia. Video EEGs showed an evolving developmental and epileptic encephalopathy with multifocal seizures and nonepileptic movements. MRI of the brain revealed evolving and fluctuating patchy bihemispheric cortical changes, cerebellar atrophy with signal change, mild generalized brain volume loss, and abnormal lactate on MR spectroscopy. The article discusses the differential diagnostic approach and management options for patients presenting with neurologic regression, encephalopathy, seizures, and hyperkinetic movements. It also emphasizes the utility of next-generation sequencing in providing a rapid, efficient, cost-effective way of determining the underlying etiology of complex neurologic presentations.

Radiologic Evaluation Criteria for Chronic Subdural Hematomas: Recommendations for Clinical Trials

Embolization of the middle meningeal artery has gained substantial interest as a therapy for chronic subdural hematomas. For the results of the currently running chronic subdural hematoma trials to inform clinical practice, sufficient accuracy and matching definitions are necessary. We summarized the current practice in chronic subdural hematoma evaluation and derived suggestions on reporting standards using the {Nested} Knowledge AutoLit living review platform. On the basis of the most commonly reported data elements, we suggested a set of standardized image-based study end points for chronic subdural hematoma evaluation for future trials. The measurement methods and reporting standards as proposed in this article have been derived from published best practices and are endorsed by the European Society of Minimally Invasive Neurological Therapy's research committee. The standardization of radiologic outcome measures and measurement techniques in chronic subdural hematoma embolization trials would increase the impact and implication of each trial as well as facilitate data pooling for increased statistical power and, therefore, translation to clinical practice.

National audit of non-melanoma skin cancer excisions performed by plastic surgery in the UK

A national, multi-centre audit of non-melanoma skin cancer excisions by plastic surgery.

Guidelines for magnetic resonance imaging in pediatric head and neck pathologies: a multicentre international consensus paper

The use of standardized imaging protocols is paramount in order to facilitate comparable, reproducible images and, consequently, to optimize patient care. Standardized MR protocols are lacking when studying head and neck pathologies in the pediatric population. We propose an international, multicenter consensus paper focused on providing the best combination of acquisition time/technical requirements and image quality. Distinct protocols for different regions of the head and neck and, in some cases, for specific pathologies or clinical indications are recommended. This white paper is endorsed by several international scientific societies and it is the result of discussion, in consensus, among experts in pediatric head and neck imaging.

Clinical features, investigations, and outcomes of pediatric limbic encephalitis: A multicenter study

OBJECTIVES

To describe the clinical presentation, investigations, management, and disease course in pediatric autoimmune limbic encephalitis (LE).

METHODS

In this retrospective observational study, from the UK Childhood Neuroinflammatory Disease network, we identified children from six tertiary centers with LE <18 years old between 2008 and 2021. Clinical and paraclinical data were retrieved from medical records.

RESULTS

Twenty-five children fulfilling LE criteria were identified, with median age of 11 years (IQR 8, 14) and median follow-up of 24 months (IQR 18, 48). All children presented with seizures; 15/25 (60%) were admitted to intensive care. Neuroimaging demonstrated asymmetric mesial temporal changes in 8/25 (32%), and extra-limbic changes with claustrum involvement in 9/25 (38%). None were positive for LGI1/CASPR2 antibodies (Abs), 2/25 were positive for serum anti-NMDAR Abs, and 2/15 positive for anti-Hu Abs; one died from relapsing neuroblastoma. Two children had serum and CSF anti-GAD antibodies. Initial immune therapy included steroids in 23/25 (92%), intravenous immunoglobulin (IVIg) in 14/25 (56%), and plasma exchange in 7/25 (28%). The commonest second-line treatment was rituximab in 15/25 (60%). Median duration of hospital admission was 21 days (IQR 11, 30). At last follow-up, 13/25 (52%) had refractory seizures and 16/25 (64%) had memory impairment. Six children (24%) had modified Rankin Scale (mRS) scores ≥3. There was no significant difference in mRS, or long-term cognitive and epilepsy outcomes in those who received rituximab versus those who did not.

INTERPRETATION

A diagnosis of autoimmune LE was associated with significant morbidity and adverse outcomes in this pediatric cohort.

Acute Myelopathy in Childhood

Acute myelopathy presenting in childhood can be clinically classified based on the location of injury (with resulting spinal syndrome) or the cause (broadly traumatic or non-traumatic). Types of nontraumatic myelopathy include ischaemic, infectious, inflammatory, nutritional, and metabolic causes, some of which may be part of a systemic illness such as systemic lupus erythematosus or a demyelinating disease such as multiple sclerosis. Nonaccidental injury is an important consideration in cases of traumatic myelopathy, which may often be associated with other injuries. Assessment should include neuroimaging of the brain and spinal cord, with further investigations targeted based on the most likely differential diagnoses; for example, a child with suspected demyelinating disease may require specialist cerebrospinal fluid and serological testing. Management also will differ based on the cause of the myelopathy, with several of these treatments more efficacious with earlier initiation, necessitating prompt recognition, diagnosis, and treatment of children presenting with symptoms of a myelopathy. Important components of holistic care may include physiotherapy and occupational therapy, with multidisciplinary team involvement as required (for example psychological support or specialist bowel and bladder teams).

Persistent Trigeminal Artery: A Novel Imaging Finding in CHARGE Syndrome

BACKGROUND AND PURPOSE

Coloboma of the eye, Heart defects, Atresia of the choanae, Retardation of growth and/or development, Genital and/or urinary abnormalities, Ear abnormalities and deafness (CHARGE) syndrome is an autosomal dominant genetic disorder with evolving clinical diagnostic criteria. Recently, a number of additional anomalies have been described in this syndrome, which may aid in early diagnosis, particularly in incomplete phenotypes or atypical cases. The persistent trigeminal artery is an embryonic carotid-vertebral anastomosis, rarely seen in the healthy population, with a reported prevalence of 0.4%. Because we had observed the persistent trigeminal artery in patients with CHARGE syndrome, this study aimed to explore the prevalence of the persistent trigeminal artery in this syndrome.

MATERIALS AND METHODS

A retrospective study was performed at our tertiary center. MR imaging studies, clinical records, and genetic results were reviewed for patients diagnosed with CHARGE syndrome between 2006 and 2019. The prevalence of the persistent trigeminal artery in patients with CHARGE syndrome was recorded and compared with other established diagnostic criteria.

RESULTS

Twenty-five patients with CHARGE syndrome were included. The persistent trigeminal artery was demonstrated on MR imaging in 14/25 (56%) patients and was seen more frequently than 4 of 9 other established diagnostic criteria in our cohort. When individual major or minor diagnostic criteria were absent, the persistent trigeminal artery was still demonstrated on MR imaging in 52%-67% of these patients with CHARGE syndrome.

CONCLUSIONS

The prevalence of the persistent trigeminal artery in CHARGE syndrome of 56% is higher than that of some other established diagnostic criteria and much higher than that in the general population. The persistent trigeminal artery may be a useful addition to the expanding phenotype of CHARGE syndrome, supplementing other diagnostic criteria. Radiologists should be aware of this novel finding demonstrable on MR imaging.

POS1177 REVAMPING BIOLOGIC THERAPY DURING COVID-19

Background:

The COVID-19 pandemic has caught us all by surprise – from governments to individuals; the medical fraternity being no exception. It has affected all walks of life; with its immense contagiosity, diverse and intriguing pathogenesis and manifestations differing from other viruses. It has indeed left humanity in dark, unchartered waters; particularly in the early months of the pandemic.

Objectives:

This article shares the experience, in a Rheumatology department in a District General Hospital (DGH) in the United Kingdom, of managing patients on Biologic (b) and Targeted Synthetic (ts) DMARDs, in the midst of the COVID-19 Pandemic.

Methods:

All Rheumatology patients at the Princess Alexandra Hospital (PAH) in Harlow newly started on a biologic or targeted synthetic DMARD between 3rd July and 3rd Oct 2020 were identified. These patients had active inflammatory arthritis. Each patient was discussed in a dedicated Multi-Disciplinary Team (MDT) meeting and a consensus on treatment reached in-line with local and National guidelines.

Figure 1.

A slide presented at the Essex Rheumatology Association (ERA) meeting explaining the process adopted at the Rheumatology Department at Harlow during the peak of COVID-19 pandemic with new b/ts DMARD patients.

Results:

Of the 50 patients identified; 39 had Rheumatoid Arthritis, 6 had Ankylosing Spondylitis and 5 had Psoriatic Arthritis. Of these 50 patients, 5 patients decided against treatment during the stage of ‘Enhanced Verbal Consent’. These patients were flaring recurrently and were in regular contact with the department. However, they were afraid to start new Biologic treatment because of the risks of Covid-19. The breakdown of the biologic agents used in the remaining 45 patients were as follows: Adalimumab:11, Rituximab: 10, Etanercept: 9, Tofacitinib: 11, Tocilizumab SC: 3, Tocilizumab IV: 1, Sarilumab: 2, Secukinumab: 1, Infliximab: 1, Baricitinib: 1, Apremilast: 1

Figure 2.

Breakdown of the various b/ts DMARD agents newly started in the 45 patients between 3/7/20 - 3/10/20 at PA Hospital, Harlow, UK

Conclusion:

The over-riding principle that guided the Department during the COVID crisis was: primum non nocere (first, do no harm). The adherence to the Case Based Discussions (CBDs) positively impacted on decision making, ensuring safe initiation of Biologic DMARDs even during the height of the pandemic. This is vital to achieve early disease remission. The MDT meetings comprising Doctors, Specialist Pharmacist and Nurse Specialists ensured prompt risk stratification of individual patients. It gave patients the opportunity to be part of the decision-making - evident in the five of the fifty patients, who opted to defer the start date of their treatments. The choice of the new Biologic agent was based on the latest National COVID-19 guidelines. The agents with the shortest half-life were selected. Moreover, patients for Rituximab were given one pulsed infusion, as opposed to two infusions. Only one of the 45 patients started on a Biologic agent over this period, either was tested positive or had symptoms suggestive of COVID-19.

References:

[1]https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7261974

[2]https://rmdopen.bmj.com/content/6/2/e001314

[3]https://www.nejm.org/doi/full/10.1056/nejmc2009567

[4]https://www.jrheum.org/content/early/2020/05/13/jrheum.200527

[5]https://www.uptodate.com/contents/coronavirus-disease-2019-covid-19-care-of-adult-patients-with-systemic-rheumatic-disease

[6]www.england.nhs.uk/clinical-guide-rheumatology-patients-v1-19-march-2020.pdf

[7]https://www.rheumatology.org.uk/practice-quality/covid-19-guidance

[8]https://www.nice.org.uk/guidance/ng167/chapter/4-Treatment-considerations

[9]https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-doctors/decision-making-and-consent

Acknowledgements:

We acknowledge the whole Rheumatology Dept at Harlow for their sincere team work during the COVID-19 pandemic – Sabaa Naz (Rheumatology Pharmacist), Mona Kamal Zou (Biologics Nurse Specialist), Lily Robinson (DMARD Nurse Specialist), Mary Surendran (Osteoporosis Nurse Specialist), Janet Bell (Secretary to Dr Ahmed) and Claire Stroud (Secretary to Dr Farrow).

Disclosure of Interests:

None declared.

408 Hand Trauma Consent

Background

Consenting patients for procedures is a regular process for a trainee surgeon. The process of consent has come under scrutiny in recent years due to inadequacies highlighted by legal cases. With over 1.36 million patients attending A&E per year with hand trauma, this is the most common acute referral to Plastic surgeons.

Aim

To review current local practice by auditing risks and complications from hand trauma consent forms.

To develop and implement a standardised pre-printed label including relevant risks and complications for hand trauma.

Method

Sample of hand trauma related consent forms audited assessing and comparing the risks and complications sections to a standardised set agreed locally by Consultant Plastic surgeons, cross referenced with literature.

Standardised label including relevant risks and complications put into practice then re-audit their use.

Results

Use of the new standardised label demonstrated an elimination of omissions and increased adherence to 100% for all the relevant risks and complications.

Conclusions

Significant improvements in the process of consent were achieved through the development and implementation of a standardised risk and complications label. This ensures standards from the GMC and RCS guidelines are satisfied; positively impacting on service provision by improving the quality of the consent process.

Systemic Inflammation Is Associated With Neurologic Involvement in Pediatric Inflammatory Multisystem Syndrome Associated With SARS-CoV-2

Objective

Pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) is a severe immune-mediated disorder. We aim to report the neurologic features of children with PIMS-TS.

Methods

We identified children presenting to a large children's hospital with PIMS-TS from March to June 2020 and performed a retrospective medical note review, identifying clinical and investigative features alongside short-term outcome of children presenting with neurologic symptoms.

Results

Seventy-five patients with PIMS-TS were identified, 9 (12%) had neurologic involvement: altered conciseness (3), behavioral changes (3), focal neurology deficits (2), persistent headaches (2), hallucinations (2), excessive sleepiness (1), and new-onset focal seizures (1). Four patients had cranial images abnormalities. At 3-month follow-up, 1 child had died, 1 had hemiparesis, 3 had behavioral changes, and 4 completely recovered. Systemic inflammatory and prothrombotic markers were higher in patients with neurologic involvement (mean highest CRP 267 vs 202 mg/L, p = 0.05; procalcitonin 30.65 vs 13.11 μg/L, p = 0.04; fibrinogen 7.04 vs 6.17 g/L, p = 0.07; d-dimers 19.68 vs 7.35 mg/L, p = 0.005). Among patients with neurologic involvement, these markers were higher in those without full recovery at 3 months (ferritin 2284 vs 283 μg/L, p = 0.05; d-dimers 30.34 vs 6.37 mg/L, p = 0.04). Patients with and without neurologic involvement shared similar risk factors for PIMS-TS (Black, Asian and Minority Ethnic ethnicity 78% vs 70%, obese/overweight 56% vs 42%).

Conclusions

Broad neurologic features were found in 12% patients with PIMS-TS. By 3-month follow-up, half of these surviving children had recovered fully without neurologic impairment. Significantly higher systemic inflammatory markers were identified in children with neurologic involvement and in those who had not recovered fully.

Imaging pitfalls in paediatric posterior fossa neoplastic and non-neoplastic lesions

Paediatric posterior fossa lesions can have much overlap in their clinical and radiological presentation. There are, however, a number of key imaging features that can help the reading radiologist to distinguish tumours from important tumour mimics which are often inflammatory or metabolic entities. This pictorial review provides a number of important cases that proved challenging on imaging and illustrates some common pitfalls when interpreting lesions in the posterior fossa in children. Not everything that is abnormal will be a tumour, but often other causes are overlooked and misinterpreted as tumours, leading to great morbidity for that child. This article highlights some lesions that were mistaken as tumours and will introduce the reader to less commonly seen pathologies which are important to consider on a differential list for this location.

Evaluation of DISORDER: Retrospective Image Motion Correction for Volumetric Brain MRI in a Pediatric Setting

BACKGROUND AND PURPOSE

Head motion causes image degradation in brain MR imaging examinations, negatively impacting image quality, especially in pediatric populations. Here, we used a retrospective motion correction technique in children and assessed image quality improvement for 3D MR imaging acquisitions.

MATERIALS AND METHODS

We prospectively acquired brain MR imaging at 3T using 3D sequences, T1-weighted MPRAGE, T2-weighted TSE, and FLAIR in 32 unsedated children, including 7 with epilepsy (age range, 2-18 years). We implemented a novel motion correction technique through a modification of k-space data acquisition: Distributed and Incoherent Sample Orders for Reconstruction Deblurring by using Encoding Redundancy (DISORDER). For each participant and technique, we obtained 3 reconstructions as acquired (Aq), after DISORDER motion correction (Di), and Di with additional outlier rejection (DiOut). We analyzed 288 images quantitatively, measuring 2 objective no-reference image quality metrics: gradient entropy (GE) and MPRAGE white matter (WM) homogeneity. As a qualitative metric, we presented blinded and randomized images to 2 expert neuroradiologists who scored them for clinical readability.

RESULTS

Both image quality metrics improved after motion correction for all modalities, and improvement correlated with the amount of intrascan motion. Neuroradiologists also considered the motion corrected images as of higher quality (Wilcoxon z = -3.164 for MPRAGE; z = -2.066 for TSE; z = -2.645 for FLAIR; all P < .05).

CONCLUSIONS

Retrospective image motion correction with DISORDER increased image quality both from an objective and qualitative perspective. In 75% of sessions, at least 1 sequence was improved by this approach, indicating the benefit of this technique in unsedated children for both clinical and research environments.

Achondroplasia Foramen Magnum Score: screening infants for stenosis

BACKGROUND

Achondroplasia is associated with foramen magnum stenosis (FMS) and significant risk of morbidity and sudden death in infants. A sensitive and reliable method of detecting infants who require decompressive surgery is required. This study aims to describe the incidence and severity of FMS in an unselected, sequential series of infants using a novel MRI score and retrospectively correlate severity with clinical examination and cardiorespiratory sleep (CRS) studies.

METHODS

The Achondroplasia Foramen Magnum Score (AFMS) was developed and scores were retrospectively correlated with clinical and CRS data over a 3-year period.

RESULTS

Of 36 infants (M:F, 18:18), 2 (5.6%) did not have FMS (AFMS0); 13 (36.1%) had FMS with preservation of the cerebrospinal fluid (CSF) spaces (AFMS1); 3 (8.3%) had FMS with loss of the CSF space but no spinal cord distortion (AFMS2); 13 (36.1%) had FMS with flattening of the cervical cord without signal change (AFMS3); and 5 (13.9%) had FMS resulting in cervical cord signal change (AFMS4). Mean Total Apnea and Hypopnea Index (TAHI) for AFMS0-4 was 3.4, 6.41, 2.97, 10.5 and 25.8, respectively. Severe TAHI had a specificity of 89% but only a 59% sensitivity for AFMS3-4. Neurological examination was normal in 34/36 (94%) patients. Overall, 9/36 (25%) infants required neurosurgery with minimal surgical complications.

CONCLUSIONS

Clinical examination and CRS have a low sensitivity for predicting the effects of foramen stenosis on the spinal cord. Routine screening with MRI using AFMS can aid in detecting early spinal cord changes and has the potential to reduce infant morbidity and mortality.

Idiopathic Hypertrophic Pachymeningitis: Does Earlier Treatment Improve Outcome?

Background/goal: Hypertrophic pachymeningitis is a rare chronic inflammatory disorder characterized by marked fibrous thickening of the cerebral and/or spinal dura mater. This condition has largely been reported in adults, but there are very few reports in children. Methods: We describe a 14-year-old boy with idiopathic hypertrophic pachymeningitis, who presented with deteriorating vision on a background of severe headache. We evaluated pediatric cases of hypertrophic pachymeningitis and compared treatments and their relation to outcomes. Results: There are only eleven pediatric cases of hypertrophic pachymeningitis reported in the literature. In the patients treated with steroids either at presentation or subsequent relapses, a good response was reported. In the cases with delayed initiation of steroid treatment, this was often related to an incomplete recovery. In our patient, this delay may have contributed to his poor visual outcome. Conclusions: Early initiation of steroid treatment in children with idiopathic hypertrophic pachymeningitis may improve outcomes.

Progress in the Management of Paediatric-Onset Multiple Sclerosis

Considerable progress has been made in the understanding and treatment of paediatric-onset multiple sclerosis (POMS); how this has translated into more effective care is less well understood. Here, we evaluate how recent advances have affected patient management and outcomes with a retrospective review of POMS patients managed at two paediatric neuroimmunology centres. Two cohorts, seen within a decade, were compared to investigate associations between management approaches and outcomes. Demographic, clinical and neurocognitive data were extracted from case notes and analysed. Of 51 patients, 24 were seen during the period 2007-2010 and 27 during the period 2015-2016. Median age at onset was 13.7 years; time from symptom onset to diagnosis was 9 months. Disease-modifying therapies were commenced in 19 earlier-cohort and 24 later-cohort patients. Median time from diagnosis to treatment was 9 months for earlier vs. 3.5 months in later patients (p = 0.013). A wider variety of treatments were used in the later cohort (four medications earlier vs. seven in the later and two clinical trials), with increased quality of life and neurocognitive monitoring (8% vs. 48% completed PedsQL quality of life inventory; 58% vs. 89% completed neurocognitive assessment). In both cohorts, patients were responsive to disease-modifying therapy (mean annualised relapse rate pre-treatment 2.7 vs. 1.7, mean post-treatment 0.74 vs. 0.37 in earlier vs. later cohorts). In conclusion, over the years, POMS patients were treated sooner with a wider variety of medications and monitored more comprehensively. However, this hugely uncontrolled cohort did not allow us to identify key determinants for the improvements observed.

Perioperative intravenous contrast administration and the incidence of acute kidney injury after major gastrointestinal surgery: prospective, multicentre cohort study

BACKGROUND

This study aimed to determine the impact of preoperative exposure to intravenous contrast for CT and the risk of developing postoperative acute kidney injury (AKI) in patients undergoing major gastrointestinal surgery.

METHODS

This prospective, multicentre cohort study included adults undergoing gastrointestinal resection, stoma reversal or liver resection. Both elective and emergency procedures were included. Preoperative exposure to intravenous contrast was defined as exposure to contrast administered for the purposes of CT up to 7 days before surgery. The primary endpoint was the rate of AKI within 7 days. Propensity score-matched models were adjusted for patient, disease and operative variables. In a sensitivity analysis, a propensity score-matched model explored the association between preoperative exposure to contrast and AKI in the first 48 h after surgery.

RESULTS

A total of 5378 patients were included across 173 centres. Overall, 1249 patients (23·2 per cent) received intravenous contrast. The overall rate of AKI within 7 days of surgery was 13·4 per cent (718 of 5378). In the propensity score-matched model, preoperative exposure to contrast was not associated with AKI within 7 days (odds ratio (OR) 0·95, 95 per cent c.i. 0·73 to 1·21; P = 0·669). The sensitivity analysis showed no association between preoperative contrast administration and AKI within 48 h after operation (OR 1·09, 0·84 to 1·41; P = 0·498).

CONCLUSION

There was no association between preoperative intravenous contrast administered for CT up to 7 days before surgery and postoperative AKI. Risk of contrast-induced nephropathy should not be used as a reason to avoid contrast-enhanced CT.

Intravenous thrombolysis for large vessel or distal occlusions presenting with mild stroke severity

BACKGROUND AND PURPOSE

We investigated the effectiveness of intravenous thrombolysis (IVT) in acute ischaemic stroke (AIS) patients with large vessel or distal occlusions and mild neurological deficits, defined as National Institutes of Health Stroke Scale scores < 6 points.

METHODS

The primary efficacy outcome was 3-month functional independence (FI) [modified Rankin Scale (mRS) scores 0-2] that was compared between patients with and without IVT treatment. Other efficacy outcomes of interest included 3-month favorable functional outcome (mRS scores 0-1) and mRS score distribution at discharge and at 3 months. The safety outcomes comprised all-cause 3-month mortality, symptomatic intracranial hemorrhage (ICH), asymptomatic ICH and severe systemic bleeding.

RESULTS

We evaluated 336 AIS patients with large vessel or distal occlusions and mild stroke severity (mean age 63 ± 15 years, 45% women). Patients treated with IVT (n = 162) had higher FI (85.6% vs. 74.8%, P = 0.027) with lower mRS scores at hospital discharge (P = 0.034) compared with the remaining patients. No differences were detected in any of the safety outcomes including symptomatic ICH, asymptomatic ICH, severe systemic bleeding and 3-month mortality. IVT was associated with higher likelihood of 3-month FI [odds ratio (OR), 2.19; 95% confidence intervals (CI), 1.09-4.42], 3-month favorable functional outcome (OR, 1.99; 95% CI, 1.10-3.57), functional improvement at discharge [common OR (per 1-point decrease in mRS score), 2.94; 95% CI, 1.67-5.26)] and at 3 months (common OR, 1.72; 95% CI, 1.06-2.86) on multivariable logistic regression models adjusting for potential confounders, including mechanical thrombectomy.

CONCLUSIONS

Intravenous thrombolysis is independently associated with higher odds of improved discharge and 3-month functional outcomes in AIS patients with large vessel or distal occlusions and mild stroke severity. IVT appears not to increase the risk of systemic or symptomatic intracranial bleeding.

Temporal bone and intracranial abnormalities in syndromic causes of hearing loss: an updated guide

PURPOSE

To describe in detail the temporal bone and brain findings in both common and rare syndromic causes of hearing loss, with the purpose of broadening among radiologists and enhance the current understanding of distinct imaging features in paediatric patients with syndromic hearing loss.

METHODS

A detailed search of electronic databases has been conducted, including PubMed, Ovid Medline, Scopus, Cochrane Library, Google Scholar, National Institute for Health and Care Excellence (NICE), Embase, and PsycINFO.

RESULTS

Syndromic causes of hearing loss are characterised by different and sometimes specific abnormalities in the temporal bone.

CONCLUSION

A complete knowledge of the image findings in the temporal bones, brain, skull and other body regions is critical for the optimal assessment and management of these patients.

Maternal obesity and severe preeclampsia among immigrant women: a mediation analysis

Background

Severe preeclampsia is known to be associated with both maternal place of birth and obesity. However, the role of prepregnancy obesity has not been well elucidated on the causal pathway between maternal origin and severe preeclampsia. We aimed to test for and quantify a mediation effect of obesity in this association.

Methods

A secondary analysis of the PreCARE prospective French cohort of pregnant women (n = 9,579). Adjusted path analysis logistic regression models tested for a mediation effect of obesity in the association between maternal place of birth and severe preeclampsia. Adjusted odds ratios and 95% confidence intervals for the total exposure-outcome association and for the direct and indirect/obesity-mediated components were calculated in addition to an estimate of the indirect/obesity-mediated effect.

Results

95 (0.99%) women developed severe preeclampsia: 47.6% were non-European immigrants, 16.3% were born in Sub-Saharan Africa, and 12.6% were obese. Obesity was both associated with Sub-Saharan African place of birth and severe preeclampsia. Women from Sub-Saharan Africa had an increased risk of severe preeclampsia compared to European-born mothers (aOR 2.53, 95% CI 1.39-4.58). The obesity-mediated effect of the association was 18% (aOR 1.18, 95%CI 1.03-1.35).

Conclusions

Sub-Saharan African immigrant women have a two-fold higher risk of developing severe preeclampsia as compared to European-born women, one-fifth of which is mediated by prepregnancy obesity. Our results provide estimates of the benefit of decreasing obesity among at-risk women.

Key messages

Obesity, a modifiable risk factor, is a target for interventions to prevent severe preeclampsia among immigrant women from Sub-Saharan Africa. Future investigations should focus on better elucidating the role of other modifiable mediators such as interaction with the health care system and quality of prenatal care.

Defective tubulin detyrosination causes structural brain abnormalities with cognitive deficiency in humans and mice

Reversible detyrosination of tubulin, the building block of microtubules, is crucial for neuronal physiology. Enzymes responsible for detyrosination were recently identified as complexes of vasohibins (VASHs) one or two with small VASH-binding protein (SVBP). Here we report three consanguineous families, each containing multiple individuals with biallelic inactivation of SVBP caused by truncating variants (p.Q28* and p.K13Nfs*18). Affected individuals show brain abnormalities with microcephaly, intellectual disability and delayed gross motor and speech development. Immunoblot testing in cells with pathogenic SVBP variants demonstrated that the encoded proteins were unstable and non-functional, resulting in a complete loss of VASH detyrosination activity. Svbp knockout mice exhibit drastic accumulation of tyrosinated tubulin and a reduction of detyrosinated tubulin in brain tissue. Similar alterations in tubulin tyrosination levels were observed in cultured neurons and associated with defects in axonal differentiation and architecture. Morphological analysis of the Svbp knockout mouse brains by anatomical magnetic resonance imaging showed a broad impact of SVBP loss, with a 7% brain volume decrease, numerous structural defects and a 30% reduction of some white matter tracts. Svbp knockout mice display behavioural defects, including mild hyperactivity, lower anxiety and impaired social behaviour. They do not, however, show prominent memory defects. Thus, SVBP-deficient mice recapitulate several features observed in human patients. Altogether, our data demonstrate that deleterious variants in SVBP cause this neurodevelopmental pathology, by leading to a major change in brain tubulin tyrosination and alteration of microtubule dynamics and neuron physiology.

Hypothalamic malformations in patients with X-linked deafness and incomplete partition type 3

Patients with X-linked deafness carry mutations in the POU3F4 gene and have pathognomonic inner ear malformations characterised by symmetrical incomplete partition type 3 (absent modiolus and lamina spiralis but preserved interscalar septum in a normal-sized cochlea) and large internal auditory meatus (IAM) with an increased risk of gusher during stapes surgery. We describe a range of fairly characteristic malformations in the hypothalamus of some patients with this rare condition, ranging from subtle asymmetric appearance and thickening of the tuber cinereum to more marked hypothalamic enlargement. We discuss the role of POU3F4 in the normal development of both the inner ear and hypothalamus and the proposed pathophysiology of incomplete partition type 3.

Short-lasting retroorbital pain attacks as a form of ictal epileptic headache: Case report

Background and objectives

Ictal epileptic headache is a rare form of painful seizure, habitually consisting of migrainous or tension-type headache. We describe a case of a patient with short-lasting, severe retroorbital pain attacks caused by frontal lobe epilepsy.

Case report

A 25-year-old male patient presented with recurrent attacks of paroxysmal, short-lasting, excruciating left periorbital and facial pain mainly occurring from sleep. After intracranial EEG exploration and resection of a right prefrontal focal cortical dysplasia, long-term seizure and headache remission was obtained.

Discussion

Our case extends the clinical and neuroanatomical spectrum of ictal epileptic headache and suggests that long-term remission can be obtained by resective epilepsy surgery. It also reinforces the role of the prefrontal cortex in the pain matrix and pain generation.

Conclusion

Despite its rarity, ictal epileptic headache should be suspected in selected patients, particularly those with other ictal symptoms and signs, history of epileptic seizures, or neuroimaging abnormalities.

Palatine tonsil SUVmax on FDG PET-CT as a discriminator between benign and malignant tonsils in patients with and without head and neck squamous cell carcinoma of unknown primary

AIM

To analyse the maximum standardised uptake value (SUVmax) ratio between tonsils in patients with and without tonsillar carcinoma to determine useful diagnostic thresholds.

MATERIALS AND METHODS

Positron-emission tomography (PET)/computed tomography (CT) examinations of patients with suspected head and neck squamous cell carcinoma (SCC) and controls from April 2013 to September 2016 were reviewed retrospectively. Tonsillar SUVmax ratios (ipsilateral/contralateral for malignant tonsils, maximum/minimum for patients without [controls]) were calculated and used to construct a receiver operating characteristic (ROC) curve.

RESULTS

Twenty-five patients had tonsillar carcinoma (mean SUVmax ratio of 2, range 0.89-5.4) and 86 patients acted as controls (mean SUVmax ratio of 1.1, range 1-1.5). Using the ROC, the most accurate SUVmax ratio for identifying malignancy was >1.2 (77% sensitivity, 86% specificity). A potentially more clinically useful SUVmax ratio is ≥1.6 with 62% sensitivity and 100% specificity.

CONCLUSION

An SUVmax ratio between tonsils of ≥1.6 is highly suspicious for SCC and could be used to direct site of biopsy. Some malignant tonsils had normal FDG uptake; therefore, PET/CT should not be used to exclude tonsillar cancer. Minor asymmetrical uptake is frequently seen in non-malignant tonsils and does not necessarily require further investigation. Due to the single centre nature of this study and the recognised variation in SUV measurements between PET scans, other centres may need to develop their own cut-offs.

Motec Wrist Arthroplasty: 4 Years of Promising Results

BACKGROUND

The Motec cementless modular metal-on-metal ball-and-socket wrist arthroplasty is an implant with promising intermediate results. An alternative to primary wrist fusion, total wrist arthroplasty is an option for active patients, who wish to retain their wrist function. It is indicated in cases of degenerative osteoarthritis, post-traumatic arthritis and rheumatoid (inflammatory) arthritis.

METHODS

A prospective review of patient demographics, pre and post-operative Disabilities of the Arm Shoulder and Hand (DASH), MAYO scores, range of movements and grip strengths. All complications in follow up were recorded across the 4 year period.

RESULTS

25 implants on 23 patients over 5.5 years, mean age 61; 8 females and 15 male. 10 patients with SLAC, 3 SNAC, 5 inflammatory and 7 patients with generalized osteoarthritis. The patients showed significant improvements of MAYO and DASH scores post-operatively, as well as the flexion/extension arc and grip strengths. There was just one case of implant loosening- the radial screw after a wound infection, which was revised with a longer screw. Two implants were converted to Motec fusion due to pain. One implant was dislocated and relocated. The remaining patients have had good wrist function. Only 6 patients were unable to return to work.

CONCLUSIONS

Similar to published studies, this series shows the Motec implant to be a good motion preserving alternative to total wrist fusion.

Cerebral vasculopathy in childhood neurofibromatosis type 2: cause for concern?

Unlike adult neurofibromatosis type 2 (NF2), which presents with symptoms related to bilateral vestibular schwannomas, children with NF2 most frequently present with ocular, dermatological, and neurological symptoms. Arteriopathy, a well-established feature in neurofibromatosis type 1, is not a widely recognized feature of NF2. Here we report three children with NF2 with cerebral arteriopathy and/or arterial ischaemic stroke. Bevacizumab, a vascular endothethial growth factor inhibitor, is an established treatment for rapidly growing vestibular schwannomas; however, it carries a risk of both ischaemic and haemorrhagic stroke. Thus, the role of screening and risk to benefit ratio of bevacizumab in NF2 merit further consideration. WHAT THIS PAPER ADDS: Children with neurofibromatosis type 2 (NF2) may be at increased risk of cerebral vasculopathy and arterial ischaemic stroke. Targeted magnetic resonance angiography should be performed in children with NF2 who are being considered for bevacizumab therapy.

Rudiment resorption as a response to starvation during larval development in the sea urchin Strongylocentrotus droebachiensis

Phenotypic flexibility (reversible phenotypic change) enables organisms to couple internal, ontogenetic responses with external, environmental cues. Phenotypic flexibility also provides organisms with the capacity to buffer stereotypical internal, developmental processes from unpredictable external, ecological events. Echinoids exhibit dramatic phenotypic flexibility in response to variation in exogenous nutrient supplies. The extent to which echinoids display this flexibility has been explored incompletely and research hitherto has been conducted predominantly on larval structures and morphologies. We investigated experimentally the extent to which the primordial juvenile, the developing rudiment, can exhibit the first phase in phenotypic flexibility among individuals. We report for the first time on rudiment regression and complete resorption as a response to starvation during larval development in the sea urchin Strongylocentrotus droebachiensis (O.F. Müller, 1776) and identify a developmental “window of opportunity” within which this can occur. Based on our observations and previous suggestions, we speculate that sea urchin rudiments might provide means of buffering development during unfavorable conditions.

Neurometabolic Disorders of the Newborn

There is an extensive and diverse set of medical conditions affecting the neonatal brain within the spectrum of neurometabolic disorders. As such, their clinical presentations can be rather nonspecific, and can often mimic acquired entities such as hypoxic-ischemic encephalopathy and sepsis. Similarly, the radiological findings in these entities can also be frequently nonspecific, but a more detailed analysis of imaging findings (especially magnetic resonance imaging) alongside the relevant clinical details can be a rewarding experience, thus enabling a timely and targeted diagnosis. Early diagnosis of an underlying neurometabolic disorder is vital, as some of these entities are potentially treatable, and laboratory and genetic testing can be precisely targeted. Further, their detection helps with counselling families for future pregnancies. We present a review of neurometabolic disorders specific to the newborns with a focus on how neuroimaging findings match their clinical presentation patterns.