Arachnoid cyst in the pediatric patient: What the radiologist needs to know

Arachnoid cysts are the most common incidentally discovered intracranial lesions on imaging and the most common cystic intracranial lesions. They may be developmental or secondary. A relative lack of recent literature and any comprehensive radiological review on arachnoid cysts has led to a general lack of awareness among radiologists of symptomatic or complicated arachnoid cysts. This is particularly concerning in pediatric patients. While arachnoid cysts are asymptomatic in most cases, they can cause clinical symptoms in a minority of cases, especially when they occur in unusual sites. These include intraventricular locations where they may cause hydrocephalus, the basal cisterns where they may compress cranial nerves, the cerebellopontine angle where they have to be differentiated from a number of cystic lesions, the cavum septum pellucidum or cavum velum interpositum, the choroid fissure where they can entrap the temporal horn and compress the hippocampus, the posterior fossa where they need to be differentiated from other posterior fossa cystic lesions, and within the spinal canal where there is a concern for cord or nerve root compression. Larger cysts are more prone to complications such as mass effect, hemorrhage, and rupture. Hemorrhage and rupture often present with acute symptoms. Ruptured cysts lose their characteristic imaging appearance and can mimic several ominous pathologies. It therefore becomes vital to accurately diagnose these cases as complications of pre-existing arachnoid cysts for appropriate management. A detailed review of all diagnostic imaging aspects of arachnoid cysts will help fill in the existing information void on this important entity.

ETMR-15. Central Nervous System Embryonal Tumor with EWSR1 translocation: Evolving changes in histology, sequencing, and epigenetics at relapse in 2 patients and potential treatment implications

INTRODUCTION: Histologically diagnosed embryonal tumors (ET) of the central nervous system (CNS) in the pediatric population represent a group of aggressive malignancies with historically poor prognoses. Immunohistochemistry (IHC) and cytogenetics refined tumor classification and improved treatment strategies. Modern advancements in molecular methods including methylation profiling provide further delineation of distinct ET subclasses. CASE DESCRIPTION: We present two cases with initial diagnosis of a CNS embryonal tumor with EWSR1 rearrangement. Relapsed tissue in both cases displayed acquisition of INI-1 loss consistent with atypical teratoid/rhabdoid tumor (AT/RT). The first case presented at 14 months of age with vomiting and altered mental status. Imaging revealed right frontal lobe hemorrhagic mass with signs of increased intracranial pressure; pathology returned as a CNS embryonal tumor with EWSR1-PLAGL1 translocation. Patient ultimately experienced multiple relapses with tumor sample each with INI-1 loss. The second case presented at 11 months of age with new onset seizures and was found to have right frontal tumor; pathology returned as CNS embryonal tumor with EWSR1-PLAGL1 translocation. Patient experienced recurrence in original tumor bed and pathology was consistent with malignant recurrence with INI-1 loss. Methylation profiling for diagnostic samples in both patients was consistent with ET not otherwise specified, while methylation profiling of relapsed tissue in both cases was consistent with AT/RT. EWSR1 translocation was persistent from diagnostic to relapsed samples. CONCLUSION/DISCUSSION: These cases illustrate the need for ongoing analysis in patients with CNS primitive neuroectodermal tumors and EWSR1 rearrangements, and the unique role of molecular studies in relapsed tissue. The emergence of treatment resistance in a subpopulation of cells more consistent with AT/RT suggests these patients could benefit from upfront and experimental treatment approaches for AT/RT.

Hypothermia as an Outcome Predictor Tool in Pediatric Trauma: A Propensity-Matched Analysis

OBJECTIVE

Hypothermia is an independent risk factor for mortality in adult trauma patients. Two small studies have shown similar results in pediatric trauma patients. Temperature is not included in any pediatric trauma assessment scores. This study sought to compare mortality and various descriptive outcomes between pediatric hypothermic and normothermic trauma patients.

METHODS

Data were obtained from the National Trauma Database from 2009 to 2012. Patients meeting inclusion criteria were stratified by presence of isolated head injury, head injury with multiple trauma, and absence of head injury. These groups were then subdivided into hypothermic (temperature ≤36°C) and normothermic groups. We used propensity score matching to 1:1 match hypothermic and normothermic patients. Mortality, neurosurgical interventions, endotracheal intubation, blood transfusion, length of stay, laparotomy, thoracotomy, conversion of cardiac rhythm, and time receiving mechanical ventilation were evaluated.

RESULTS

Data from 3,011,482 patients were obtained. There were 414,562 patients who met the inclusion criteria. In all patients meeting inclusion criteria, hypothermia was a significant risk factor in all outcomes measured. Following stratification and 1:1 matching, in all groups, hypothermia was associated with increased mortality (P < 0.0001), increased rate of endotracheal intubation (P < 0.0002), increased need for blood transfusion (P < 0.0025), and conversion of cardiac rhythm (P < 0.0027).

CONCLUSION

Hypothermia has been shown to be a significant prognostic indicator in the pediatric trauma patient with further potential application. Future studies are indicated to evaluate the incorporation of hypothermia into the Pediatric Trauma Score not only to help predict injury severity and mortality but also to improve appropriate and expeditious patient transfer to pediatric trauma centers and potentially facilitate earlier intervention.

Management of an odontoid synchondrosis fracture causing chronic translational anterior atlanto-axial subluxation in a child with autism: case report

The authors report an unusual case of an odontoid synchondrosis fracture causing chronic translational anterior atlanto-axial subluxation and present a discussion of the unique management of this case. Traumatic translational anterior atlanto-axial subluxation is a rare manifestation within pediatrics. Patients with preexisting abnormalities in ligamentous or bony structures may present with unusual symptomatology, which could result in delay of treatment. A 6-year-old male patient with autism who presented with acute respiratory arrest was noted to have an odontoid synchondrosis fracture and severe anterior translational atlanto-axial subluxation. Initial attempts at reduction with halo traction were tried for first-line treatment. However, because of concern regarding possible inadvertent worsening of the impingement, the presence of comorbid macrocephaly, and possible instability with only C1-2 fusion, a posterior C1 laminectomy was performed. Further release of the C1-2 complex and odontoid peg from extensive fibrous tissue allowed for complete reduction. Acute injuries of the C1-2 complex may not present as expected, and the presence of pain is not a reliable symptom. Halo traction is an appropriate initial treatment, but some patients may require surgical realignment and stabilization.

Radiological and clinical predictors of scoliosis in patients with Chiari malformation type I and spinal cord syrinx from the Park-Reeves Syringomyelia Research Consortium

OBJECTIVE

Scoliosis is frequently a presenting sign of Chiari malformation type I (CM-I) with syrinx. The authors' goal was to define scoliosis in this population and describe how radiological characteristics of CM-I and syrinx relate to the presence and severity of scoliosis.

METHODS

A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°).

RESULTS

Based on available imaging of patients with CM-I and syrinx, 260 of 825 patients (31%) had a clear diagnosis of scoliosis based on radiographs or coronal MRI. Forty-nine patients (5.9%) did not have scoliosis, and in 516 (63%) patients, a clear determination of the presence or absence of scoliosis could not be made. Comparison of patients with and those without a definite scoliosis diagnosis indicated that scoliosis was associated with wider syrinxes (8.7 vs 6.3 mm, OR 1.25, p < 0.001), longer syrinxes (10.3 vs 6.2 levels, OR 1.18, p < 0.001), syrinxes with their rostral extent located in the cervical spine (94% vs 80%, OR 3.91, p = 0.001), and holocord syrinxes (50% vs 16%, OR 5.61, p < 0.001). Multivariable regression analysis revealed syrinx length and the presence of holocord syrinx to be independent predictors of scoliosis in this patient cohort. Scoliosis was not associated with sex, age at CM-I diagnosis, tonsil position, pB-C2 distance (measured perpendicular distance from the ventral dura to a line drawn from the basion to the posterior-inferior aspect of C2), clivoaxial angle, or frontal-occipital horn ratio. Average curve magnitude was 29.9°, and 37.7% of patients had a left thoracic curve. Older age at CM-I or syrinx diagnosis (p < 0.0001) was associated with greater curve magnitude whereas there was no association between syrinx dimensions and curve magnitude.

CONCLUSIONS

Syrinx characteristics, but not tonsil position, were related to the presence of scoliosis in patients with CM-I, and there was an independent association of syrinx length and holocord syrinx with scoliosis. Further study is needed to evaluate the nature of the relationship between syrinx and scoliosis in patients with CM-I.

Abnormal elastin and collagen deposition is present in extracranial arteriovenous malformations: A comparison to intracranial disease

BACKGROUND

Vascular malformations are characterized by anomalous vascular channels with fragile walls and a propensity to bleed. Arteriovenous malformations (AVMs) in particular have disorganized vascular spaces with intervening fibrosis. Characterization of the structural abnormalities of these vessels has not been comprehensively evaluated. We hypothesize that AVMs are likely to demonstrate altered elastic and collagen fiber organization and distribution, reflecting their fragility, vascular instability, and abnormal development.

METHODS

Fifteen AVMs were histologically evaluated by H&E, elastin and trichrome staining. To identify potential differences between extracranial and intracranial AVMs, 5 AVMs were harvested from the brain (n=5) and 10 from extracranial sites involving the skin and deep soft tissue (n=10).

RESULTS

The elastin staining demonstrated reduplication, fragmentation and disruption of internal elastic lamina as well as irregular thickness, and inconsistent vascular density of all AVM specimens. Trichrome staining revealed thickening of the intimal layers of AVM arteries and demonstrated an irregular thickness of venous walls within the malformation and some areas of medial degeneration. Intracranial AVMs are characterized by more intramural inflammation with predominant neutrophil and lymphocyte infiltration. In contrast, extracranial AVMs display more extravascular inflammation with mast cell and neutrophil infiltration. Microvascular proliferations intervening between larger blood vessels were also noted in both types of AVMs, but more obvious in extracranial AVMs.

CONCLUSION

These observed histologic anomalies of AVMs demonstrate disorganized deposition of elastin and collagen that point to the clinically observed vascular instability and fragility of these lesions.

Disconnective Hemispherotomy for Medically Intractable Status Epilepticus in an 8-Year-Old Child

We report here the unusual case of an 8-year-old child with left hemispheric focal epilepsy secondary to a perinatal infarction who presented with new onset absence seizures and eventual nonconvulsive status epilepticus that was refractory to medical management. Following review at our multidisciplinary Epilepsy Surgery conference, the patient underwent disconnective surgical hemispherotomy with immediate cessation of his seizures; and has remained seizure-free at 4 months following surgery. In this context, we present here an overview of hemispherectomy and related procedures, including peri-insular disconnective hemispherotomy, and we discuss the efficacy of surgery for challenging hemispheric epilepsies.

Intracranial glioblastoma with drop metastases to the spine after stereotactic biopsy

BACKGROUND

Glioblastoma (GBM) is the most common primary intracranial tumor, but metastases are rarely reported. Previous reports have documented the occurrence of drop metastases to the spine. However, few of these reports have demonstrated the occurrence of spinal metastases after biopsy with stable intracranial disease. Here we present such a case.

CASE DESCRIPTION

We present a case of GBM metastatic to the spinal cord after a stereotactic biopsy with stable intracranial disease. To our knowledge, this occurrence has only been reported in one previous case.

CONCLUSION

We propose that traversing the lateral ventricle at the time of biopsy contributed to cerebrospinal fluid seeding with tumor cells and subsequent development of spinal disease.

The current state of non-accidental head injury in Arkansas

Child maltreatment syndrome (CMS) and non-accidental head injury (NAHI) are frequent causes of death and disability with national incidences reported as high as 24.6 per 100,000 children. At this time the true incidence of CMS is unknown in Arkansas. The purpose of this review is to illustrate the severity of non-accidental head injury and increase awareness in the state of Arkansas. This paper is the first in a planned series to determine the incidence, risk factors, presentation, best effective treatment strategies and outcomes of CMS and NAHI in Arkansas.

A method for placing Heschl gyrus depth electrodes

A wide range of devices is used to obtain intracranial electrocorticography recordings in patients with medically refractory epilepsy, including subdural strip and grid electrodes and depth electrodes. Penetrating depth electrodes are required to access some brain regions, and 1 target site that presents a particular technical challenge is the first transverse temporal gyrus, or Heschl gyrus (HG). The HG is located within the supratemporal plane and has an oblique orientation relative to the sagittal and coronal planes. Large and small branches of the middle cerebral artery abut the pial surface of the HG and must be avoided when planning the electrode trajectory. Auditory cortex is located within the HG, and there are functional connections between this dorsal temporal lobe region and medial sites commonly implicated in the pathophysiology of temporal lobe epilepsy. At some surgical centers, depth electrodes are routinely placed within the supratemporal plane, and the HG, in patients who require intracranial electrocorticography monitoring for presumed temporal lobe epilepsy. Information from these recordings is reported to facilitate the identification of seizure patterns in patients with or without auditory auras. To date, only one implantation method has been reported to be safe and effective for placing HG electrodes in a large series of patients undergoing epilepsy surgery. This well-established approach involves inserting the electrodes from a lateral trajectory while using stereoscopic stereotactic angiography to avoid vascular injury. In this report, the authors describe an alternative method for implantation. They use frameless stereotaxy and an oblique insertion trajectory that does not require angiography and allows for the simultaneous placement of subdural grid arrays. Results in 19 patients demonstrate the safety and efficacy of the method.

Rachipagus parasite associated with myelocystocele and diastematomyelia

A case of parasitic rachipagus associated with myelocystocele, diastematomyelia and teratoma is presented. The parasite was successfully removed, and the spinal canal was reconstructed using bone harvested from the parasite.

[Unspecific abdominal complaints: diagnosis with szintigraphy]

This case report describes a 65-year old man with symptomatic abdominal and pelvic splenosis. 50 Years ago he has had splenectomy after a road traffic accident. Ultrasound and CT revealed a bulky mass in the iliac fossa and multifocal intraabdominal nodules suggesting peritoneal carcinomatosis. Scintigraphy with Tc-99m-labelled heat damaged red blood cells led to definitive diagnosis. RBC-scintigraphy is a specific, easy performable diagnostic tool. It is cost-effective and can avoid other diagnostic procedures or explorative surgery.

[Experiences with follow-up investigations of oral vaccination campaigns against rabies in foxes in Saxony with special emphasis on a standardised serology]

An 8-year experience with organisation and standardisation of follow-up investigations within oral vaccination campaigns against rabies in foxes (OVF) in Saxony is summarised. With respect to OVF, the number of diagnostic tests performed during the years 1992-2000 on foxes amounts to a total of 52,226 Fluorescence antibody-(FAT), 7,551 marker-(TC) and 11,645 serological tests. The mean bait-uptake and the mean immunisation rate in foxes ranged between 78-86% and 60-89%, respectively. Based on the seroconversion rates of the years 1997-2000 observed in vaccination areas and in areas where vaccination was already finished, experience with a standardised serology under routine conditions is presented and discussed. Furthermore, recommendations concerning organisation and logistics of sampling are given.

Recombinant human superoxide dismutase enhances the effect of inhaled nitric oxide in persistent pulmonary hypertension

We investigated the pulmonary vascular effects of superoxide dismutase (SOD) alone and in combination with inhaled nitric oxide (iNO) in newborn lambs with persistent pulmonary hypertension (PPHN) following prenatal ligation of the ductus arteriosus. In in vitro experiments, pretreatment with SOD significantly enhanced vascular relaxation in response to the NO donor S-nitrosyl-acetylpenicillamine (SNAP) in fifth-generation pulmonary arteries isolated from lambs with PPHN. In vivo treatment of fully instrumented newborn lambs with a single intratracheal dose of recombinant human CuZn SOD (rhSOD; 5 mg/kg) produced selective dilation of the pulmonary circulation. Further studies, of the combination of rhSOD and iNO, showed enhancement of the pulmonary vascular effects of iNO after brief periods of inhalation of 5 ppm and 80 ppm NO. We conclude that rhSOD reduces pulmonary vascular resistance and facilitates the action of iNO in a lamb model of PPHN. This suggests that rhSOD may prove to be an effective adjunctive treatment for newborns with PPHN.

Characterization of virus-induced interferon-gamma responses in mice previously infected with murine cytomegalovirus

These studies demonstrate that in vitro stimulation of spleen cells from murine cytomegalovirus (MCMV) immune mice with MCMV-infected fibroblasts induces production of interferon (IFN)-gamma. This response is specific to MCMV, is not generalized to heterologous viruses, and also is not H-2 restricted. Both early and late CMV antigens induce IFN-gamma. In in vitro cell depletion and direct cell selection experiments, T lymphocytes were responsible for IFN-gamma production. Although both CD4 and CD8 cells appear to be required to induce the response, the cell subset that releases the IFN-gamma is not yet undefined. In vivo, this IFN-gamma response appears early after acute infection and persists > or =1 year. The response is not seen in T cell-deficient mice. Thus, previous MCMV infection results in a virus-specific IFN-gamma response in spleen cells exposed to MCMV antigens. The pathophysiologic significance of these observations is now under study.

Cell wall active antifungal compounds produced by the marine fungus Hypoxylon oceanicum LL-15G256. III. Biological properties of 15G256 gamma

15G256 gamma is a cyclic lipopeptide antifungal agent discovered in a mechanism of action screen for cell wall acting antifungal agents. The compound shows moderate activity in both greenhouse tests against plant disease caused by pathogenic fungi and in in vitro tests against human fungal pathogens. Microscopic examination of treated fungi suggests that the compound acts by the inhibition of cell wall biosynthesis. However, in vitro inhibition of Neurospora crassa glucan and chitin synthase were only observed at high drug concentrations suggesting that 15G256 gamma may act on a novel cell wall target.

Training in community psychiatry: new opportunities

The authors describe the impact on training that accompanied an assignment of senior (PGY-4) residents to work one-half day each week for a six month period at a community-based agency concerned with the care of persons with severe and persistent mental illness who were formerly homeless. As the goals and methods of psychiatric training are rethought and adapt to programmatic shifts and economic pressures, new opportunities open up to move treatment and training to the "front lines" in the community where an innovative therapeutic armamentarium for persons with severe and chronic mental illness is developing.

High-performance liquid chromatographic determination of tazobactam and piperacillin in human plasma and urine

A high-performance liquid chromatographic (HPLC) method with ultraviolet (UV) absorbance was developed for the analysis of piperacillin-tazobactam (tazocillin), in plasma and urine. The detection was performed at 218 nm for tazobactam and 222 nm for piperacillin. The procedure for assay of these two compounds in plasma and of piperacillin in urine involves the addition of an internal standard (ceftazidime for tazobactam and benzylpenicillin for piperacillin) followed by a treatment of the samples with acetonitrile and chloroform. To quantify tazobactam in urine, diluted samples were analysed using a column-switching technique without internal standard. The HPLC column, LiChrosorb RP-select B, was equilibrated with an eluent mixture composed of acetonitrile-ammonium acetate (pH 5). The proposed technique is reproducible, selective, and reliable. The method has been validated, and stability tests under various conditions have been performed. Linear detector responses were observed for the calibration curve standards in the ranges 5-60 micrograms/ml for tazobactam, and 1-100 micrograms/ml for piperacillin and spans what is currently though to be the clinically relevant range for tazocillin concentrations in body fluids. The limit of quantification was 3 micrograms/ml for tazobactam and 0.5 microgram/ml for piperacillin in plasma and urine. Extraction recoveries from plasma proved to be more than 85%. Precision, expressed as C.V., was in the range 0.4-18%.

[Use of pit and fissure sealants in private practice: the Quebec situation]

This paper presents data collected in March of 1989 from a sample of dentists practicing in the province of Quebec. A survey was mailed to dentists in order to determine to what degree sealants are used and the various characteristics relative to the dentists in question. Other questions related to how dentists obtained information about sealants, the difficulties encountered with their application and the problems relative to their use by the dental profession. The results indicate that nearly three quarters of Quebec dentists use sealants at least sometimes. This level of usage is comparable to American findings. A dentist is more likely to use sealants, if he is a recent graduate, a female dentist, and in a child-oriented group practice. A high proportion of dentists (2/3) use sealants selectively (in less than 25% of their patients). According to the dentists surveyed, the main obstacle to using sealants is the lack of coverage by the government dental program and the public's ignorance of the benefits of sealants. Most dentists who admitted never trying sealants, reported that they simply preferred to place an amalgam filling. In general, dentists knew the indications for sealants and had a positive attitude relative to their use.

[In vivo retention of KOH soluble and firmly bound fluoride in demineralized dental enamel]

Cylindrical enamel blocks with initial carious lesions were treated for one hour with Duraphat or Fluor-Protector. After removal of the fluoride varnishes the enamel blocks were kept in the mouths of 3 probands for 5 days. Plaque was allowed to accumulate on half of the enamel cylinders, while the other half was kept clean. Part of the enamel cylinders were retained as fluoridated controls. Compared with Duraphat the application of Fluor-Protector resulted in a significantly higher uptake of KOH soluble and firmly bound fluoride. During the 5 days of the experiment the amount of KOH soluble fluorides decreased in both groups. In the presence of plaque the fluoride loss was higher. The amount of firmly bound fluoride increased both in the plaque covered and in the clean enamel. The durable cariostatic effect of fluoridated varnishes seems to be due to the slow dissolution of Ca F2-like precipitates on the enamel surface and the concomitant fluoride uptake in the underlying demineralized enamel.

The immunohistochemical distribution of collagens type IV, V, VI and of laminin in the human oral mucosa

The distribution of collagens type V (form AB2) and VI was investigated on cryostat sections of normal human oral mucosa by indirect immunofluorescence. For comparison, antibodies to fragments of type IV collagen and laminin were also used to delineate basement membrane containing structures. All antibodies used were raised against human proteins. Type V collagen appeared as a microfibrillar structure throughout the interstitium, apparently touching but not being present within epithelial or vascular basement membranes. Microfibrils in blood vessel walls were limited to the intimal layer. Pericellular areas were not specifically stained. Type VI collagen appeared as an almost amorphous stromal structure becoming more prominent and more fibrillar in the upper connective tissue papillae. Intense staining was observed in the media of blood vessels and around smooth muscle cells. A possible role of type VI collagen in tissue stabilization may be expected from this ubiquitous and abundant distribution. The findings identify types V and VI collagen as important structures in the oral mucosa and serve as a basis for understanding morbid changes.

Oral and dental development in X chromosome aneuploidy

Though frequently noted, orofacial anomalies in poly X syndromes have been seldom reviewed. In a study of patients with an X chromosome aneuploidy (XXXXX, XXXX, XXXXY, XXXY) the following facial and dental defects were found to be characteristic features of these syndromes: mainly bifid uvula and macroglossia, enamel defects, dental taurodontism and abnormal roots. These observations are discussed in the light of the possible role of X-linked genes.

[Sonography of the thyroid gland. Volume determination and morphologic correlation of echo and tissue structures]

The volume of 15 autopsied thyroid glands was determined by fluid displacement and compared with their sonographically obtained stereometric volumes. Maximum variation was 8.6%. Thyroid volumes were measured by ultrasound in 100 volunteers between ages 15 and 36. Total mean value was 19.8 ml. with a mean value of 22.1 ml. in the male group and 17.8 ml. in the female group. 20 volunteers had an additional scintigraphic examination. The thyroid volumes estimated by scintiscanning differed up to 85% with the volume measurements from sonography. Sonography scans were obtained from 6 autopsied thyroid glands and compared with the corresponding tissue slices. Tissue structures were reproduced with great accuracy by ultrasound.

[Endocarditis caused by Candida parapsilosis (para-krusei)]

This paper describes a case of Candida Parapsilosis endocarditis in a patient with a mitral valve prosthesis implanted two years previously. This history started with a cerebrovascular accident associated with pyrexia. A complex medico-surgical therapeutic approach controlled the infection. This consisted of systemic and local (immersion of the prosthesis) antifungal therapy, bathing the left heart chambers in 5 p. 100 iodine solution and two valve replacements at 8 months intervals. The second surgery was not related to recurrence of the candida infection but to a perivalvular leak attributed to the insertion of the prosthesis into tissues inflamed by recent infection. Despite the improvement in the prognosis of fungal infection due to an early surgical approach, it is still essential to try and prevent the disease, the mortality rate still being over 80 p. 100. It is essential to be very careful when using intravenous catheters and aerosols; the indications of antibiotherapy must also be respected.