Fetal trauma: brain imaging in four neonates

The purpose of this paper is to describe brain pathology in neonates after major traffic trauma in utero during the third trimester. Our patient cohort consisted of four neonates born by emergency cesarean section after car accident in the third trimester of pregnancy. The median gestational age (n=4) was 36 weeks (range: 30–38). Immediate post-natal and follow-up brain imaging consisted of cranial ultrasound (n=4), computed tomography (CT) (n=1) and post-mortem magnetic resonance imaging (MRI) (n=1). Pathology findings were correlated with the imaging findings (n=3). Cranial ultrasound demonstrated a huge subarachnoidal hemorrhage (n=1), subdural hematoma (n=1), brain edema with inversion of the diastolic flow (n=1) and severe ischemic changes (n=1). In one case, CT demonstrated the presence and extension of the subarachnoidal hemorrhage, a parietal fracture and a limited intraventricular hemorrhage. Cerebellar hemorrhage and a small cerebral frontal contusion were seen on post-mortem MRI in a child with a major subarachnoidal hemorrhage on ultrasound. None of these four children survived (three children died within 2 days and one child died after 1 month). Blunt abdominal trauma during pregnancy can cause fetal cranial injury. In our cases, skull fracture, intracranial hemorrhage and hypoxic-ischemic encephalopathy were encountered.     

Uncommon magnetic resonance imaging observation of lumbar subdural hematoma with cranial origin

A patient with a history of pain, paresthesias, and weakness in both legs is reported. Magnetic resonance imaging (MRI) of the lumbar spine demonstrated subacute subdural hematoma. Brain MRI obtained 1 day later because of progressive headache showed hemorrhagic cortical metastasis and extensive subdural hematoma. It is hypothesized that the lumbar hematoma originated from the intracranial bleeding, which was substantiated by the observation of a thin hemorrhagic collection connecting cranial and lumbar hematomas on MRI. Cranial origin should be included in the differential diagnosis of spontaneous spinal subdural hematomas.     

Computed tomographic evolution of post-traumatic subdural hygroma in young adults

Summary The authors report on two cases of post-traumatic subdural hygroma that were encountered in young adults. Serial computed tomograms were taken immediately following trauma and for more than 4 weeks thereafter. In the case of a 28-year-old man with a skull fracture, an initial CT scan revealed a thin crescentic subdural collection in the right frontal area. A successive CT scan on the 36th postoperative day revealed developed subdural hygroma, and the CSF-like fluid was surgically evacuated. In the second case, involving an 18-year-old man, a very thin bifrontal subdural collection was found on the initial CT scan, and on the 15th post-traumatic day CT scan demonstrated a bifrontal subdural hygroma. No surgical treatment was carried out, and the follow-up CT scan on the 29th post-traumatic day demonstrated no change in size. The two young patients were slightly symptomatic during the period involved, and the repeat unenchanced CT scans showed subdural lesions of less than brain density, even in the chronic stage.     

Spontaneous intracranial hypotension: use of unenhanced MRI

We report a case of spontaneous intracranial hypotension diagnosed with unenhanced cranial MRI, showing laminar subdural fluid and engorgement of the hypophysis and perisellar sinuses. Cerebrospinal fluid pressure was low. MRI was normal after resolution of symptoms. Prior reports emphasise the enhancing pachymeninges seen in this syndrome. We maintain that, when subdural collections and perisellar engorgement are detected on unenhanced MRI in the proper clinical setting, contrast enhancement may not be necessary for the diagnosis. Received: 23 June 1999 Accepted: 13 August 1999     

Subdural enhancement on postoperative spinal MRI after resection of posterior cranial fossa tumours

In malignant brain tumours which may disseminate staging, usually by cranial and spinal MRI is necessary. If MRI is performed in the postoperative period pitfalls should be considered. Nonspecific subdural contrast enhancement on spinal staging MRI is rarely reported after resection of posterior fossa tumours, which may be mistaken for dissemination of malignancy. We investigated the frequency of spinal subdural enhancement after posterior cranial fossa neurosurgery in children. We reviewed 53 postoperative spinal MRI studies performed for staging of paediatric malignant brain tumours, mainly infratentorial primitive neuroectodermal tumours 2–40 days after surgery. There was contrast enhancement in the spinal subdural space in seven cases. This was not seen in any of eight patients who had been operated upon for a supratentorial tumour. After resection of 45 posterior cranial fossa tumours the frequency of subdural enhancement was 15.5%. MRI showing subdural enhancement was obtained up to 25 days postoperatively. No patient with subdural enhancement had cerebrospinal fluid (CSF) examinations positive for tumour cells or developed dissemination of disease in the CSF. Because the characteristic appearances of subdural contrast enhancement, appropriate interpretation is possible; diagnosis of neoplastic meningitis should rarely be impeded. Because of the striking similarity to that in patients with a low CSF-pressure syndrome and in view of the fact that only resection of tumours of the posterior cranial fossa, usually associated with obstructive hydrocephalus, was followed by this type of enhancement one might suggest that rapid changes in CSF pressure are implicated, rather the effects of blood introduced into the spinal canal at surgery.     

Cranial epidural empyema with osteomyelitis caused by actinomyces, CT, and MRI appearance

Actinomycosis is an uncommon cause of intracranial infection. Epidural empyema represents about 6% of CNS actinomycotic lesions. A case of an epidural empyema with parietal bone osteomyelitis caused by Actinomyces israelii is presented. Relevant neuroimaging features were bone erosions and a multiloculated collection with annular contrast enhancing on CT. Postoperative MRI revealed extensive involvement of the neighbor dura, falx, and subdural space. MRI was crucial to follow-up the response to antibiotic treatment.     

The two-in-one model: a new variation of the arteriovenous malformation model in swine

We report a new variation of the well-established experimental arteriovenous malformation (AVM) model in swine. To provide high flow through the rete mirabile (nidus, RM) and thereby to reduce the rate of spontaneous thrombosis of the AVM, we performed an end-to-end anastomosis of the left common carotid artery (CCA) and the external jugular vein (EJV) microsurgically in three micropigs. After 1 and 4 months the animals underwent angiograms of the CCA and vertebral artery (VA). In all cases the diversion of the blood through the RM was patent, up to the 4 months follow-up. We observed an arteriovenous fistula (arteriovenous pseudomalformation, pAVF) between the VA and the EJV in each case at both 1 and 4 months. This modification of the well-known AVM model in the micropig could be used to monitor long-term changes after embolisation, avoiding the naturally high rate of spontaneous thrombosis. This two-in-one model is thus well suited for preclinical testing of embolic materials. Received: 2 December 1999 Accepted: 31 August 2000     

Infantile acute subdural hemorrhage probably caused by injury to the diploic channels

A 6-month-old, previously healthy boy hit the right frontal region of his head against the corner of a plastic toy box. At presentation, a small area with scalp discoloration was noted in the right frontal region. Head computed tomography at the level of discoloration revealed an intracranial hematoma, 5 mm in maximal thickness, below the coronal suture. In addition, there were bony bridges connecting the frontal and parietal bones. Furthermore, a linear crack was found in the diploe of the frontal bone in contact with the coronal suture. Cerebral MRI confirmed linear hyperintensity between the inner tables. We assumed that a kind of ping-pong ball fracture was caused by the head blow, centering on the coronal suture, resulting in rupture of contacting diploic channels and tear of the dura mater, and forming a subdural hematoma. Acute subdural hemorrhage may be caused by an insignificant blow to the coronal suture in infantile patients with underdeveloped cranial bones and sutures, accompanied by subtle external findings.     

Foot drop due to cranial gunshot wound

OBJECTIVE: We present a case of foot drop from hemorrhagic contusion after cranial gunshot, which has never been reported. METHODS: A 21-year-old man was admitted with inability of dorsiflexion 1 day after a tangential gunshot wound of the scalp. The scalp skin was cut by the rifle bullet. He had foot drop and his neurological examination was normal except for weakness at dorsiflexion of the right foot. Pathological reflexes and sensation failure were not detected. T1- and T2-weighted magnetic resonance images showed hyperintense contusion at the right superior frontal gyrus and mild subdural hemorrhage. Peripheral nervous system examination was electrophysiologically normal. Motor-evoked potentials showed the location of the lesion at the motor cortex because no electrical record was obtained from the right anterior tibial and extensor digitorum brevis muscles, and there was a normal record on the left. Six months later, the patient's neurological examination was uneventful. CONCLUSION: When a cranial gunshot wound injury victim presents with foot drop, the central causes should be included in the differential diagnosis list.     

Paget-Schroetter syndrome in a non athlete - a case report

A young male waiter presented with left shoulder pain, with ultrasound showing thrombosis of the left subclavian vein. After exclusion of hypercoagulability, a dynamic MRI upper limb venogram was performed, confirming Paget-Schroetter syndrome (PSS). Our case is unusual as Paget Schroetter syndrome are seldom reported in non athletes. This is also the first report to show dynamic MRI images of PSS.     

Posterior cranial fossa dural arteriovenous malformation with a varix mimicking a thrombosed aneurysm: case report

Summary Dural arteriovenous malformations (AVMs) in the posterior cranial fossa are relatively infrequent. Intradural haemorrhage is one of their specific complications. Angiographic demonstration of varices or aneurysmal structures is one of the hallmarks of severe cases. We report a patient with posterior cranial fossa dural AVM associated with a varix mimicking a thrombosed aneurysm on CT and MRI. Internal carotid and vertebral angiography failed to demonstrate an aneurysm, but external carotid injection revealed a dural AVM affecting the sigmoid sinus, and a varix. The AVM was completely eliminated by embolization. When a dural AVM is suspected clinically selctive angiography should be performed to confirm the diagnosis even when CT or MRI do not show dilated vessels.     

Neuroimaging features of spontaneous intracranial hypotension

We reviewed the cranial MRI and radionuclide cisternograms of four adults with postural headache indicating spontaneous intracranial hypotension (SIH). All four underwent clinical and radiological follow-up. MRI showed diffuse, thin meningeal enhancement; bilateral subdural fluid collections; and morphological abnormalities secondary to “sagging” of the brain. Radionuclide cisternography revealed direct or indirect signs of leakage of cerebrospinal fluid (CSF) along the spinal axis, and the symptoms resolved after the leak treated by epidural injection of blood at a level indicated by the cisternogram. The diffuse meningeal enhancement decreased but persisted on follow-up MRI, although the patients were asymptomatic. All morphologic abnormalities resolved during 3–5 months follow-up. Received: 24 August 1998 Accepted: 27 April 1999     

Hippocampal malrotation with normal corpus callosum in a child with Opitz syndrome

We present cranial magnetic resonance imaging (MRI) findings in a 6-year-old boy with Opitz syndrome. The electroencephalogram revealed epileptiform abnormalities in both frontal regions. MRI showed normal callosal development, but a rounded shape of the left hippocampus due to malrotation. The temporal horn was slightly dilated on the left side. These features were consistent with isolated hippocampal malrotation.     

High-resolution cranial ultrasound in the shaken-baby syndrome

With limited near-field resolution and accessible acoustic windows, sonography has not been advocated for assessing central nervous system injuries in the shaken-baby syndrome. Our purpose was to correlate high-resolution ultrasonographic characteristics of central nervous system injuries in whiplash injuries and the shaken-baby-syndrome with MRI and CT. Ultrasonographic images of 13 infants, aged 2–12 months, with whiplash or shaking cranial trauma were reviewed and compared with MRI in 10 and CT in 10. Five patients had serial ultrasonography and MRI or CT follow-up from 1 to 4 months after the initial injury. With ultrasonography we identified 20 subdural haematomas. MRI and CT in 15 of these showed that four were hyperechoic in the acute stage, three were mildly echogenic in the subacute stage, and that one subacute and seven chronic lesions were echo-free. Five patients had acute focal or diffuse echogenic cortical oedema which evolved into subacute subcortical hyperechoic haemorrhage in four, and well-defined chronic sonolucent cystic or noncystic encephalomalacia was seen at follow-up in two. Using ultrasonography we were unable to detect two posterior cranial fossa subdural haematomas or subarachnoid haemorrhage in the basal cisterns in three cases, but did show blood in the interhemispheric cistern and convexity sulci in two. Ultrasonography has limitations in demonstrating abnormalities remote from the high cerebral convexities but may be a useful adjunct to CT and MRI in monitoring the progression of central nervous system injuries in infants receiving intensive care. Received: 25 October 2000 Accepted: 25 October 2000     

Giant subdural empyema in an infant

Summary A giant subdural empyema was found to be the cause of a large head in a two month old female child referred for cranial sonography. The sonographic features of the subdural empyema as illustrated by this case are: (1) The presence of an extra-axial space occupying lesion with mass effect. (2) Its fluid nature with mobile echogenic debris within. (3) Its large extent from frontal to occipital region, and (4) Its thick medial echogenic wall. A total of 250 ml of pus was evacuated from the empyema and the child was doing well on follow up at four months of age.     

Intracystic hemorrhage of the middle fossa arachnoid cyst and subdural hematoma caused by ruptured middle cerebral artery aneurysm.

We report a case of a cerebral aneurysm arising from the bifurcation of the left middle cerebral artery that ruptured into a left middle cranial fossa arachnoid cyst, associated with acute subdural hematoma. We discuss the relationships of aneurysm, arachnoid cyst, and subdural hematoma.     

颅底及颈段脊髓血管畸形的介入检查

目的 :为介入栓塞治疗及手术治疗提供重要依据 ,从而防止误诊、漏诊病例的发生。方法 :对我院近期 3 0例疑有颅底及颈段脊髓血管畸形患者的临床表现、MRI影像特点、介入检查资料进行分析。结果 :3 0例患者均具有颅底及颈段脊髓血管畸形的临床表现及磁共振影像特点 ,经行选择性全脊髓血管造影、必要时行全脑血管造影证实 2 9例为颅底及颈段脊髓血管畸形 (其中 2 7例畸形团来自颈部血管供血及胸段脊髓血管等多支血管供血 ;2例来自颈外动脉系统供血 )。另外 1例开始被误诊为颅底及颈段脊髓血管畸形 ,后进行全脑血管造影发现为由颈内动脉原始听动脉供血的硬脑膜动静脉瘘向脊髓髓周静脉引流而造成MRI的留空信号。结论 :为了防止误诊及漏诊病例的发生 ,应对双侧的锁骨下动脉、椎动脉、肋颈干、甲状颈干、上胸段肋间动脉或全脊髓血管及颈外动脉进行造影检查 ,必要时还应进行全脑血管造影。     

Gyral abnormalities in the early stage of superior sagittal sinus thrombosis

We report computed tomography (CT) features in a case of segmental thrombosis of the superior sagittal sinus. On the initial cranial CT scan, both frontal cortices showed focal areas of slightly increased attenuation. The lesions were isointense on magnetic resonance (MR) images no matter what pulse sequence was used, except on fluid-attenuated inversion recovery images, which showed curvilinear sulcal hyperintensity. On postcontrast T1-weighted images, curvilinearly enhancing structures were apparent in both frontal cortical sulci. No lesion appeared on follow-up CT or in MR images. We speculated that the areas of slightly increased attenuation in the cortices represented blood congestion in the cortical veins, venules and capillaries without serum leakage. Cranial CT images should be carefully interpreted to avoid overlooking subtle lesions.     

Spontaneous intracranial hypotension: clinical and neuroimaging findings in six cases with literature review

Spontaneous intracranial hypotension (SIH) is an uncommon but increasingly recognized syndrome. Orthostatic headache with typical findings on magnetic resonance imaging (MRI) are the key to diagnosis. Delayed diagnosis of this condition may subject patients to unnecessary procedures and prolong morbidity. We describe six patients with SIH and outline the important clinical and neuroimaging findings. They were all relatively young, 20-54 years old, with clearly orthostatic headache, minimal neurological signs (only abducent nerve paresis in two) and diffuse pachymeningeal gadolinium enhancement on brain MRI, while two of them presented subdural hygromas. Spinal MRI was helpful in detecting a cervical cerebrospinal fluid leak in three patients and dilatation of the vertebral venous plexus with extradural fluid collection in another. Conservative management resulted in rapid resolution of symptoms in five patients (10 days-3 weeks) and in one who developed cerebral venous sinus thrombosis, the condition resolved in 2 months. However, this rapid clinical improvement was not accompanied by an analogous regression of the brain MR findings that persisted on a longer follow-up. Along with recent literature data, our patients further point out that SIH, to be correctly diagnosed, necessitates increased alertness by the attending physician, in the evaluation of headaches.     

动脉栓塞治疗男性先天性盆腔动静脉畸形一例

报道1例长期原因不明肉眼血尿多囊肾患者。影像检查显示两侧盆区动静脉畸形(CPAVM)。经超选择栓塞髂内动脉8支分支血尿治愈,随访6个月,血尿无复发。文献复习表明CPAVM发病甚少,形态多样。介入治疗是有效的微创方法。