Central Nervous System Tumor With BCL6 Corepressor Internal Tandem Duplication: Treatment Course of a Long-term Survivor

Central nervous system (CNS) tumor with BCL6 corepressor (BCOR) internal tandem duplication (ITD) is a newly described CNS tumor, characterized by in-frame ITDs of the BCOR gene. There is no standard practice regarding the management of this tumor. We report the clinical course of a 6-year-old boy who presented to the hospital with worsening headaches. Computed tomography scan showed a large right-sided parietal supratentorial mass and brain magnetic resonance imaging confirmed a 6×8×6.7 cm lobulated, solid but heterogeneous mass in the right parieto-occipital region. While initial pathology suggested a WHO grade 3 anaplastic meningioma, additional investigation with molecular analysis confirmed the diagnosis of high-grade neuroepithelial tumor with BCOR exon 15 ITD. This diagnosis was renamed CNS tumor with BCOR ITD in the 2021 WHO CNS tumor classification. The patient received 54 Gy of focal radiation and has no evidence of disease recurrence after 48 months from the end of treatment. As this is a newly discovered entity with only a few previous reports in the scientific literature, this report presents a unique treatment for this CNS tumor compared with those previously described.

Pineal Parenchymal Tumor of Intermediate Differentiation and DICER1 Syndrome: A Case Report

DICER1 syndrome is a rare inherited tumor predisposition syndrome associated with an increased risk for several malignant and benign tumors. We present a patient with pineal parenchymal tumor of intermediate differentiation who was found to have a germline pathogenic variant in DICER1 gene. Pineoblastoma is a known DICER1-related tumor; however, the association between pineal parenchymal tumor of intermediate differentiation and DICER1 mutation is rare with only 1 recent large molecular study that has reported this association. This report adds to the evolving tumor spectrum of DICER1 and highlights the importance of molecular evaluation of pediatric brain tumors, for both therapeutic decisions and long-term surveillance.

A Rare Case of Type B Neonatal Pyruvate Carboxylase Enzyme Deficiency Presenting With Refractory Lactic Acidosis in the Early Neonatal Period

Pyruvate carboxylase (PC) enzyme deficiency is a rare genetic disorder inherited in an autosomal recessive (AR) manner. PC, a mitochondrial enzyme, converts pyruvate to oxaloacetate (OAA), which enters the tricarboxylic acid (TCA) cycle. Based on the tissue type, intermediate metabolites of the TCA cycle play a vital role in gluconeogenesis, lipogenesis, synthesis of nicotinamide adenine dinucleotide phosphate (NADPH), and neurotransmitter glutamate in the astrocytes. The severity of clinical presentation depends on the type of PC deficiency and on the residual enzyme activity. We present a term female infant admitted with refractory lactic acidosis that developed soon after birth. On biochemical evaluation, serum ammonia was 125 µmol/L; plasma amino acid analysis showed elevated citrulline, lysine, proline, decreased glutamine, and aspartic acid; urine organic acid analysis showed markedly increased lactic acid, and moderately elevated 3-hydroxy-butyric and acetoacetic acid. MRI brain demonstrated abnormal diffuse white matter edema, loculated and septate large cysts along the caudothalamic notch as well as lateral aspect of the frontal horn bilaterally. Magnetic resonance (MR) spectroscopy showed large amounts of lactate peak. Molecular genetic analysis showed two pathogenic variants in the PC gene confirming the diagnosis of PC enzyme deficiency. The infant was discharged home on palliative and hospice care, and she died on the 22^nd day after birth.

HGG-08. Lorlatinib for the treatment of ALK fusion positive infant high grade glioma

BACKGROUND: High grade gliomas (HGG) are very rare in the infant age group with approximately 800 cases diagnosed in the USA and Europe each year. Histologically, HGG in infants resemble HGG in older children and adults but have distinct molecular features like ALK, NTRK, MET and ROS1 fusions. HGG in infants have superior outcomes compared to older age groups (5-year overall survival >50%) when treated with a radiation sparing regimen. Here we present the unique treatment course for an infant with ALK fusion positive HGG, including molecularly targeted therapy. CASE DESCRIPTION: A 3-month-old African-American female presented with acute onset vomiting, right facial droop and focal seizures. MRI of the brain revealed a right frontal intraparenchymal mass. Upfront gross total resection (GTR) was performed and histologic diagnosis of epithelioid glioblastoma was made. The molecular analysis of the tumor showed ZNF397-ALK fusion. The patient was treated with a radiation sparing regimen consisting of Carboplatin 8 mg/kg x 2 days and Etoposide 3 mg/kg x 3 days for 6 cycles. The patient tolerated the chemotherapy and had no evidence of disease recurrence at the completion of chemotherapy. However, 8 months after completion of therapy, she had a localized relapse and underwent a second GTR. Repeat molecular analysis confirmed the presence of ZNF 397-ALK fusion. She was started on Lorlatinib at 95 mg/m2/day once a day. She continued on the medication for 15 months and had no evidence of disease at the end of 15 months. During the course of her treatment, she had excessive weight gain (CTCAE grade-3) despite dose reduction. CONCLUSION: Infant high grade gliomas have a high prevalence of gene fusions including ALK fusions. This case shows that these fusions may be amenable to molecularly targeted treatments and should be studied in prospective clinical trials.

Does Severity of Brain Injury on Magnetic Resonance Imaging Predict Short-Term Outcome in Neonates Who Received Therapeutic Hypothermia?

OBJECTIVE

 The National Institute of Child Health and Human Development (NICHD) magnetic resonance imaging (MRI) pattern of brain injury is a known biomarker of childhood outcome following therapeutic hypothermia for neonatal hypoxic-ischemic encephalopathy (HIE). However, usefulness of this classification has not been evaluated to predict short-term outcomes. The study aimed to test the hypothesis that infants with NICHD MRI pattern of severe hypoxic-ischemic brain injury will be sicker with more severe asphyxia-induced multiorgan dysfunction resulting in prolonged length of stay (LOS) following therapeutic hypothermia. We also evaluated the role of other risk factors which may prolong LOS.

STUDY DESIGN

 We retrospectively reviewed the medical records of 71 consecutively cooled neonates to examine the ability of MRI patterns of brain injury to predict the LOS. A neuroradiologist masked to outcomes classified the patterns of brain injury on MRI as per NICHD. Pattern 2A (basal ganglia thalamic, internal capsule, or watershed infarction), 2B (2A with cerebral lesions), and 3 (hemispheric devastation) of brain injury was deemed "severe injury."

RESULTS

 Out of 71 infants, 59 surviving infants had both MRI and LOS data. LOS was higher for infants who had Apgar's score of ≤5 at 10 minutes, severe HIE, seizures, coagulopathy, or needed vasopressors or inhaled nitric oxide, or had persistent feeding difficulty, or remained intubated following cooling. However, median LOS did not differ between the infants with and without MRI pattern of severe injury (15 days, interquartile range [IQR]: 9-28 vs. 12 days, IQR: 10-20; p = 0.4294). On multivariate linear regression analysis, only persistent feeding difficulty (β coefficient = 11, p = 0.001; or LOS = 11 days longer if had feeding difficulty) and ventilator days (β coefficient 1.7, p < 0.001; or LOS increased 1.7 times for each day of ventilator support) but not the severity of brain injury predicted LOS.

CONCLUSION

 Unlike neurodevelopmental outcome, LOS is not related to severity of brain injury as defined by the NICHD.

KEY POINTS

· The NICHD pattern of brain injury on MRI predicts neurodevelopmental outcome following hypothermia treatment for neonatal HIE.. · LOS did not differ between the infants with and without MRI patterns of severe injury.. · The severity of brain injury as defined by the NICHD was not predictive of the LOS following therapeutic hypothermia..

Reversible Cerebral Vasoconstriction Syndrome and Sickle Cell Disease: A Case Report

Reversible cerebral vasoconstriction syndrome (RCVS), is rare in the pediatric population and is characterized by severe headaches and other neurologic symptoms. We present a case of RCVS occurring concomitantly with posterior reversible encephalopathy syndrome in an 8-year-old African American child with sickle cell disease (HbSS). Imaging studies including computed tomography, magnetic resonance imaging and cerebral angiography of the brain showed acute hemorrhagic stroke and a beaded appearance of peripheral cerebral vessels. In this report, we focus on the typical features of RCVS and discuss the underlying risk factors that may increase the risk in patients with HbSS disease.

RARE-53. PINEAL PARENCHYMAL TUMOR OF INTERMEDIATE DIFFERENTIATION (PPTID) AND DICER1 SYNDROME: A CASE REPORT

BACKGROUND

DICER1 syndrome is a rare inherited tumor predisposition syndrome linked to an increased risk of several malignancies. Affected individuals most commonly develop pleuropulmonary blastoma (PPB) and ovarian sex cord-stromal tumors. Brain tumors in these patients are rare, however; the increased frequency of pineoblastoma in this population has been established. Traditionally, pineal parenchymal tumors of intermediate differentiation (PPTIDs) have not been associated with DICER1 syndrome, with research suggesting alternative mutations driving tumorigenesis. These tumors are pathologically and clinically diverse, with long-term surveillance based on therapeutic interventions. Here we describe a case of a germline DICER1 mutation in a patient with a PPTID, suggesting that this mutation is not limited to pineoblastoma as previously reported. CASE: We describe a 19 year-old female with a WHO grade III PPTID treated with multimodal therapy including surgery, craniospinal irradiation (CSI) and chemotherapy. She was noted to have a thyroid mass at diagnosis and was subsequently diagnosed with a benign thyroid nodule, followed most recently by a cataract with pathology concerning for medulloepithelioma of the ciliary body. Due to the known association between medulloepithelioma and DICER1 syndrome, targeted germline sequencing was obtained and confirmed a pathogenic heterozygous mutation.

CONCLUSION

To our knowledge this is the first report of a PPTID in a patient with DICER1 syndrome. This association highlights the clinical implications of molecular evaluation in pediatric brain tumors, for both immediate therapeutic decisions and long-term surveillance.

Pneumocephalus in a Pediatric Patient with Glioma Receiving Trametinib

The mitogen-activated protein kinase (MAPK) pathway consists of the Ras/Raf/MEK/ERK signaling cascade, and its upregulation plays a major role in the pathogenesis of pediatric astrocytomas and molecular inhibitors of this pathway including trametinib and dabrafenib have been tested in early-phase clinical trials and used by pediatric oncologists in children with BRAF-mutated gliomas. We report a clinical case where a child with progressive BRAF-mutated glioma developed an uncommon and difficult to manage complication - pneumocephalus from intracranial air entry and trapping through dehisced surgical wounds and preexisting skull burr holes. The patient's wound breakdown coincided with skin toxicity from MEK inhibitor therapy. With increasing use of targeted molecular inhibitors in pediatric neuro-oncology, this case illustrates the potentially complicated course of MEK inhibitor therapy in patients with scalp surgical wounds and burr holes that were placed within few weeks from initiation of drug therapy, especially if patients have additional factors that can contribute to poor wound healing such as use of steroids and malnutrition.

Monozygotic twins with neuroblastoma MS have a similar molecular profile: a case of twin-to-twin metastasis

Fetoplacental neuroblastoma metastasis has been postulated as a mechanism accounting for concordant cases where one twin develops a primary tumour and the second twin manifests the disease without an identifiable primary site. These tumours may originate and spread concomitantly due to the same genetic background shared by monozygotic twins. This study investigated the molecular profile of stage MS neuroblastoma presenting concomitantly in monozygotic twins. Comparative genomic hybridisation (aCGH) was done for each of the twin liver tumour and peripheral blood samples at diagnosis. Comparison of copy-number variation (CNV) regions revealed a set of CNVs that were common to both tumour specimens and not apparent in the blood. The CNV signature in both twins’ tumours was highly similar, suggesting a common clonal origin. Additional findings included large deletion of chromosome 10 and amplification of chromosome 17. Notably, both liver samples had amplification of a short region involving DEIN (chromosome 4q34.1). Similar CNVs strongly support a common clonal origin and metastatic spread from one twin to the other. DEIN is a long-coding RNA (IncRNA) that has been found highly expressed in stage MS neuroblastoma and is likely involved in biological processes such as cell migration and metastasis.

In-hospital outcomes of neonates with hypoxic-ischemic encephalopathy receiving extracorporeal membrane oxygenation

OBJECTIVE

To determine in-hospital outcomes of neonates with hypoxic ischemic encephalopathy (HIE) requiring extracorporeal membrane oxygenation (ECMO).

STUDY DESIGN

Single-center retrospective study from 2005 to 2016 of neonates ≥35 weeks gestation with moderate/severe HIE, requiring ECMO for persistent pulmonary hypertension of newborn (PPHN).

RESULTS

Our cohort (n = 20) received therapeutic hypothermia for moderate (n = 12), severe (n = 5), or undocumented severity (n = 3) of HIE. During ECMO, 30% (n = 6) infants developed intracranial hemorrhage at a median (IQR) duration of 24 (20) hours. Sixteen (80%) infants survived to discharge, among which 15 had MRI performed; 47% (n = 7) had normal MRI, 20% (n = 3) had intracranial hemorrhage and 13% (n = 2), 13% (n = 2) and 7% (n = 1) had NICHD stage 1, 2, and 3 pattern of brain injury respectively.

CONCLUSIONS

In this high-risk population of neonates, use of ECMO was safe and efficacious as demonstrated by survival and outcomes.

Neuroimaging in Autoimmune and Neuroinflammation-Related Epilepsies

Autoimmune encephalitis is increasingly recognized as a cause of new onset altered mental status and seizures with a wide range of neuroimaging findings. We will describe the neuroimaging findings in autoimmune and neuroinflammation-related epilepsies.

Endoscopic posterior interhemispheric complete corpus callosotomy

Traditionally corpus callosotomy is done through a craniotomy centered at the coronal suture, with the aid of a microscope. This involves dissecting through the interhemispheric fissure below the falx to reach the corpus callosum. The authors describe a posterior interhemispheric approach to complete corpus callosotomy with an endoscope, which bypasses the need to perform interhemispheric dissection because the falx is generally close to the corpus callosum in this region.

Apparent diffusion coefficient mapping in medulloblastoma predicts non-infiltrative surgical planes

INTRODUCTION

An appropriate surgical approach for posterior fossa lesions is to start tumor removal from areas with a defined plane to where tumor is infiltrating the brainstem or peduncles. This surgical approach minimizes risk of damage to eloquent areas. Although magnetic resonance imaging (MRI) is the current standard preoperative imaging obtained for diagnosis and surgical planning of pediatric posterior fossa tumors, it offers limited information on the infiltrative planes between tumor and normal structures in patients with medulloblastomas. Because medulloblastomas demonstrate diffusion restriction on apparent diffusion coefficient map (ADC map) sequences, we investigated the role of ADC map in predicting infiltrative and non-infiltrative planes along the brain stem and/or cerebellar peduncles by medulloblastomas prior to surgery.

METHODS

Thirty-four pediatric patients with pathologically confirmed medulloblastomas underwent surgical resection at our facility from 2004 to 2012. An experienced pediatric neuroradiologist reviewed the brain MRIs/ADC map, assessing the planes between the tumor and cerebellar peduncles/brain stem. An independent evaluator documented surgical findings from operative reports for comparison to the radiographic findings. The radiographic findings were statistically compared to the documented intraoperative findings to determine predictive value of the test in identifying tumor infiltration of the brain stem cerebellar peduncles.

RESULTS

Twenty-six patients had preoperative ADC mapping completed and thereby, met inclusion criteria. Mean age at time of surgery was 8.3 ± 4.6 years. Positive predictive value of ADC maps to predict tumor invasion of the brain stem and cerebellar peduncles ranged from 69 to 88 %; negative predictive values ranged from 70 to 89 %. Sensitivity approached 93 % while specificity approached 78 %.

CONCLUSIONS

ADC maps are valuable in predicting the infiltrative and non-infiltrative planes along the tumor and brain stem interface in medulloblastomas. Inclusion and evaluation of ADC maps in preoperative evaluation can assist in surgical resection planning in patients with medulloblastoma.

Childhood posterior reversible encephalopathy syndrome: Magnetic resonance imaging findings with emphasis on increased leptomeningeal FLAIR signal

PURPOSE

Posterior reversible encephalopathy syndrome (PRES) is a clinico-radiologic syndrome characterized clinically by headache, seizures, and altered sensorium and radiological changes which are usually reversible. The purpose of this study was to describe the spectrum of magnetic resonance imaging (MRI) findings in childhood PRES, to determine the common etiologies for childhood PRES, and to have an insight into the pathophysiology of PRES.

METHODS

The MRI results of 20 clinically diagnosed cases of PRES between July 2011 and June 2013 were reviewed. The final diagnosis of PRES was based on the clinical presentation and the MRI features at the time of presentation, which resolved on the follow-up imaging. The medical records of the patients were reviewed to determine the underlying medical disease.

RESULTS

Eight out of the 20 patients included in the study were on cyclosporine or tacrolimus based immunosuppressant therapy for kidney transplant. Four patients had severe hypertension at presentation. The most common MRI finding was high T2-fluid-attenuated inversion recovery (FLAIR) signal in the cortex and subcortical white matter of both cerebral hemispheres, particularly in the parietal and occipital lobes (n=16). The second most common MRI finding was increased leptomeningeal FLAIR signal (n=7). Out of seven patients with leptomeningeal signal, five demonstrated leptomeningeal enhancement as well. Four out of these seven patients had no other parenchymal findings.

CONCLUSION

Childhood PRES is commonly seen in the setting of immunosuppressant therapy for kidney transplant, severe hypertension and cancer treatment. There was high incidence of increased leptomeningeal FLAIR signal and leptomeningeal enhancement in our study. It supports the current theory of endothelial injury with increased microvascular permeability as the potential pathophysiology of PRES. Also, absence of elevated blood pressure in majority of the patients in our study supports the theory of direct endothelial injury by some agents leading to vasogenic edema.

Ornithine transcarbamylase deficiency presenting with acute reversible cortical blindness

Acute focal neurologic deficits are a rare but known presentation of ornithine transcarbamylase deficiency, particularly in females. We describe here a 6-year-old girl with newly diagnosed ornithine transcarbamylase deficiency who presents with an episode of acute cortical blindness lasting for 72 hours in the absence of hyperammonemia. Her symptoms were associated with a subcortical low-intensity lesion with overlying cortical hyperintensity on fluid-attenuated inversion recovery magnetic resonance imaging (MRI) of the occipital lobes. Acute reversible vision loss with these MRI findings is an unusual finding in patients with ornithine transcarbamylase deficiency. Our findings suggest a role for oxidative stress and aberrant glutamine metabolism in the acute clinical features of ornithine transcarbamylase deficiency even in the absence of hyperammonemia.

Diffuse intrinsic pontine glioma biopsy: a single institution experience

Tumor biopsy is rarely performed in diffuse intrinsic pontine glioma (DIPG) due to the presumed risk of surgical complications, although data on the surgery related morbidity of DIPG biopsy is sparse. We performed a retrospective review on 22 consecutive cases of DIPG diagnosed from 2002 to 2012 at Children's Hospital of Michigan, 15 of which underwent biopsy. Transient new or worsening neurological deficits were observed in three of 15 cases following surgery. No surgery related mortality or permanent deficit was observed, and the mean overall survival was 10.4 ± 3.8 months. Undergoing biopsy did not adversely affect the outcome.

Epidural spinal cord compression in a patient with blue rubber bleb nevus syndrome

Blue rubber bleb nevus syndrome (BRBNS) can present with vascular malformations throughout the body, especially in the gastrointestinal tract. Spinal cord compression from these lesions is rare, particularly in the pediatric population. The authors report a case of BRBNS involving an 18-year-old female patient who presented with back pain and an epidural thoracic mass with cord compression. She underwent an uncomplicated thoracic laminectomy and decompression, with removal of what appeared to be a venous malformation. Postoperatively her pain improved, and imaging revealed resolution of cord compression. Pathological analysis highlighted dilated venous channels with myxoid degeneration in the wall with clot, characteristic of BRBNS. The early age of presentation and location are unique based on the literature search of BRBNS. The present report highlights the multiplicity of venous malformations in BRBNS, and the management of this case.

Posterior reversible encephalopathy and cerebral vasoconstriction in a patient with hemolytic uremic syndrome

BACKGROUND

We report a patient with hemolytic uremic syndrome who presented with radiological manifestations suggestive of posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome.

PATIENT

A 13-year-old girl presented with fever and bloody diarrhea and progressed to develop hemolytic uremic syndrome. She subsequently developed encephalopathy, aphasia, and right-sided weakness.

RESULTS

Brain magnetic resonance imaging showed presence of vasogenic edema in the left frontal lobe, in addition to T2 and fluid-attenuated inversion recovery changes in white matter bilaterally, compatible with posterior reversible encephalopathy syndrome. Magnetic resonance angiography showed beading of the cerebral vessels. Neurological deficits reversed 8 days after symptom onset, with resolution of the beading pattern on follow-up magnetic resonance angiography after 3 weeks, suggesting reversible cerebral vasoconstriction syndrome.

CONCLUSIONS

Both posterior reversible encephalopathy syndrome and reversible cerebral vasoconstriction syndrome may represent manifestations of similar underlying pathophysiologic mechanisms. Recognition of the co-existence of these processes in patients with hemolytic uremic syndrome may aid in judicious management of these patients and avoidance of inappropriate therapeutic interventions.

Histiocytic necrotizing lymphadenitis (Kikuchi-Fujimoto disease) with CNS involvement in a child

We describe the case of a 9-year-old boy with encephalitis associated with histiocytic necrotizing lymphadenitis (HNL), also known as Kikuchi-Fujimoto disease. The child presented with unilateral cervical lymphadenopathy and fever that evolved to encephalitis in 3 weeks. Brain MRI showed bilateral temporal lobe hyperintense signal on T2 and FLAIR, hyperintense FLAIR signal in the periaqueductal gray matter, medial walls of the third ventricle, and mammillary bodies, multiple diffusion restriction foci in a central perivascular distribution and central perivascular enhancement. The perivascular distribution and nodularity of the diffusion restriction seen in this case has not been previously reported in HNL encephalitis.

Cerebral infarct in pediatric neuro-Behçet's disease

Behçet's disease is a multisystem inflammatory vasculitic disorder with a chronic course for which the etiology is unknown. The central nervous system can be affected in 5% to 30% of all Behçet patients, yet it has been rarely reported in children or in Western countries. We describe a 14-year-old girl with Behçet's disease that presented initially as a cerebral infarct without venous sinus thrombosis.

Magnetic resonance imaging (MRI) in penile metastases of extragenitourinary cancers

BACKGROUND

The aim of present study is to evaluate the efficacy of magnetic resonance imaging (MRI) in different types of penile metastases.

MATERIALS AND METHODS

In this report, we present three cases of penile metastases that have been developed secondary to extragenitourinary malignancies. Two of them did not have any primary malignancy history.

RESULTS

Penile biopsies were performed in all patients and metastatic penile tumours were found due to extragenitourinary malignancies. Penile MRI was performed before biopsies. The findings of MRI were correlated with histopathologic diagnosis. Moreover, penile MRI was found to be more sensitive in the evaluation of the lesions than ultrasonography.

CONCLUSION

MRI can be accepted as a reliable non-invasive method for the evaluation of the extent of penile metastases and involvement of tunica albuginea or urethral.

Xanthoma disseminatum of the central nervous system and cranium

Xanthoma disseminatum is a rare normolipemic histiocytic disorder of non-Langerhans cell origin. It is a chronic systemic disease with a benign course, characterized by disseminated, yellow-orange-colored papules on the face, flexures, and mucosal membranes. We report 3 patients with xanthoma disseminatum, who presented primarily with central nervous system disease and a multitude of imaging findings throughout the craniospinal axis.

West Nile virus infection

OBJECTIVE

Our objective is to present a brief review of the clinical aspects of West Nile virus infection with emphasis on the spectrum of MRI findings.

CONCLUSION

West Nile virus infection has become endemic in the United States and radiologists should become aware of the diverse imaging appearances in the central nervous system.

Buerger's disease with multisystem involvement. A case report and a review of the literature

Buerger's disease is a recurrent inflammatory, nonatherosclerotic vasoocclusive disease, which typically affects small and medium-sized arteries, veins, and nerves of the upper and lower extremities. Systemic manifestations involving cerebral, mesenteric, and coronary arteries are exceptional. Moreover, multisystem involvement of 2 or more organs is extremely rare. The authors present a case of Buerger's disease in a patient who subsequently developed cerebral and bowel infarcts as well as cavernomatous transformation of the portal vein. Therefore, Buerger's disease, although rare, does have a chronic aggressive nature in some patients.

Isolated Late Penile Metastasis of an Adenocarcinoma of the Rectum

Penile metastatic tumors are relatively infrequent and very rare compared to extraurogenital tumor metastasis. We present an interesting rare occurrence of a late penile metastasis on an adenocarcinoma of the rectum.

Marked migration of sternotomy wires: a case report

This case report of sternal dehiscence, complicated by pronounced migration of fractured sternotomy wires, demonstrates the utility of computerized tomography (CT) in the precise localization of the wire fragments. Although CT is not typically used to evaluate sternal wire abnormalities, selected cases of sternal dehiscence can benefit from this detailed survey. A review of the literature regarding complications was also performed.

Sinonasal ossifying fibroma with fluid-fluid levels on MR images

Ossifying fibroma is a rare benign neoplasm that usually affects mandibular and maxillary bones. In this report, we present a case of sinonasal ossifying fibroma with fluid-fluid levels and posterior extension toward the torus tubarius on MR images.

Accuracy of skeletal age assessment in children from birth to 6 years of age with the ultrasonographic version of the Greulich-Pyle atlas

OBJECTIVES

For the evaluation of skeletal age, the methods of Greulich-Pyle and Tanner-Whitehouse are generally used in clinical practice. Our investigation was undertaken to determine whether the ultrasonographic version of the Greulich-Pyle atlas is capable of assessing skeletal age. If so, we aimed to describe the standards for the ultrasonographic version of the Greulich-Pyle atlas for each year during the first 6 years of life.

METHODS

Ninety-seven subjects underwent left hand and wrist radiography and ultrasonographic examination for bone age assessment during a 1.5-year study. Estimated bone ages derived from the plain radiography and "hand and wrist ultrasonography charts" interpreted by use of the Greulich-Pyle atlas were compared statistically.

RESULTS

The estimated bone ages from plain radiography and hand and wrist ultrasonography charts interpreted by use of the Greulich-Pyle atlas were significantly correlated; 71.1% of male patients had the same age in both methods, and in 84.4% of patients, the difference was less than 6 months. In 65.5% of female patients, both methods revealed the same age, and in 88.5% of them, the difference was less then 6 months.

CONCLUSIONS

The ultrasonographic version of the Greulich-Pyle atlas can be used to estimate bone age even in ultrasonography departments. This method is highly correlated and a valid alternative to plain radiography for bone age estimation. This enables estimation of skeletal age in ultrasonography departments easily without exposing the patient to radiation.

Color Doppler sonography of orbital and vertebral arteries in migraineurs without aura

PURPOSE

The objective of this study was to investigate whether the retrobulbar hemodynamics in the ophthalmic (OA), posterior ciliary (PCA), central retinal (CRA), and vertebral (VA) arteries are affected in migraineurs without aura.

METHODS

The eyes of migraineurs without aura and those of healthy control subjects were evaluated during both headache and headache-free periods. Retrobulbar and vertebral blood flow velocities in the OA, PCA, CRA, and the extracranial part of the VA were measured bilaterally using color Doppler sonography. The peak systolic and end-diastolic flow velocities and the pulsatility (PI) and resistance (RI) indices were determined for all arteries.

RESULTS

In total, we enrolled 30 migraineurs and 31 healthy control subjects. Statistically significant differences between headache-free migraineurs and control subjects were observed in the PI and RI of both right and left PCAs and in the RI of both right and left CRAs. The PI and RI of the left VA of the migraineurs were significantly lower during both headache and headache-free periods than were those of the control subjects. Among the migraineurs, the peak systolic and end-diastolic velocities of the left VA were increased during headache periods relative to those found during the headache-free periods.

CONCLUSIONS

The retrobulbar circulation and flow hemodynamics in the left VA may be altered in both headache and headache-free periods in migraineurs without aura. The differences found between migraineurs and control subjects may implicate autonomic dysfunction in migraineurs.

Imaging in the diagnosis of symptomatic forearm muscle herniation

Muscle herniation can be defined as protrusion of a portion of muscle through an acquired or congenital defect of enclosing fascia. Although it is usually a cosmetic problem, it can lead to local pain and tenderness after prolonged exertion. In this report, we present a case of flexor digitorum superficialis muscle herniation in a 58-year-old man. The radiographic, ultrasonographic and magnetic resonance imaging findings are described with dynamic examination, permitting demonstration of muscle herniation through the fascial defect during muscle contraction.

Ultrasonographic findings in pediatric fractures

The aim of this study was to document and analyze ultrasonographic (US) findings in different types of pediatric fractures. Thirty-nine patients, aged between 1 and 14 years, with a fracture were included in the study. Patients were classified as complete or incomplete fractures. Greenstick fractures, torus fractures and plastic deformations were considered as incomplete fractures. Ultrasonographic findings (subperiosteal hematoma, bending, cortical disruption, and reverberating echo) were analysed for each type of fracture. Subperiosteal hematoma was present in all patients in the study. Bending sign was present in all patients in the incomplete fracture group, but not present in complete fractures. Cortical disruption and reverberating echo were present in all patients with complete and greenstick fractures. In conclusion, whether the fracture is complete or incomplete, subperiosteal hematoma, together with a cortical disruption, bending sign, or reverberating echo shown on US can confirm the fracture diagnosis in children.

Magnetic resonance imaging of the intratemporal facial nerve in idiopathic peripheral facial palsy

The aim of this study was to investigate the prevalence of facial nerve involvement with gadolinium-enhanced magnetic resonance imaging (Gd-MRI) in patients with idiopathic peripheral facial palsy (IPFP), and to discuss the localization and the pattern of enhancement. A total of 13 patients (9 female, 4 male) with IFPF were included in this study. Topographic tests and electromyography (EMG) were performed, and MRI was taken. Ten subjects whose cranial MRIs were taken for nonorganic pathology served as the control group. Twelve of 13 paralytic facial nerves had enhancement on postcontrast images. Two facial nerves of the control group demonstrated enhancement. We found a correlation between the enhancement of the facial nerve and the time for recovery. The average time from the onset of facial palsy to the recovery in patients with enhancement was 14 weeks, whereas it was 6 weeks in patient with no enhancement. Finally, all patients had complete recovery of the facial nerve function. We concluded that contrast enhancement of the paralytic facial nerve can be a radiological sign of a neural inflammation and may indicate a prolonged recovery.