A theoretical model of benign external hydrocephalus that predicts a predisposition towards extra-axial hemorrhage after minor head trauma

INTRODUCTION: There is controversy over whether there exists a predisposition towards bleeding into the subdural space in infants with benign external hydrocephalus (BEH) or other enlargement of the extra-axial space (e.g. subdural hygroma). The presumed etiology implicates shear forces in over-stretching the extra-axial blood vessels. We have created a model of the intracranial space that approximates certain aspects of BEH. Using this model, we predict situations where children with BEH will bleed into the extra-axial space when normal infants will not. METHODS: The cranial model consists of two spheres representing the brain and the skull. The distance between them represents the width of the extra-axial space. The spheres are concentric (with interspheric distance equal to N) in the normal condition and nonconcentric in BEH. In BEH, the distance between the two spheres varies from N to Q (0 < N 相似文献   

Improved diagnosis of subdural effusions in infants--importance of sonography and the noninvasive measurement of intracranial pressure

The detection of small frontal and high-parietal subdural effusions by ultrasound examination has some problems of methods. The diagnostic accuracy of the noninvasive investigation may be improved by using the following proceeding. The application of a short-focus transducer (focus-zone 1 to 4 cm) instead of the usual medium-focus transducer; The noninvasive measurement of intracranial pressure by aplanation-tonometry of the fontanelle. We report our results with this proceeding in 35 infants with liquid accumulation between cortex and cranium (27 infants with subdural effusions, 8 infants with enlarged subarachnoid spaces because of brain atrophy). The ultrasound features of a flattened superficial relief of brain-cortex and a wedge-shaped enlarged interhemispheric fissure are morphologic references to subdural effusions. Strong reflexions of the convexly arched superficial relief of brain-cortex, an enlarged interhemisphaeric fissure with parallel vertical bounds and enlarged lateral ventricles in the frontal parts with irregular outlines are signs for brain atrophy with enlarged subarachnoid spaces. If sonographic signs do not allow an accurate diagnosis, the noninvasive measurement of intracranial pressure bei aplanation-tonometry enables us to discriminate between subdural effusion and enlarged subarachnoid spaces by measuring a rised basic pressure and pathologic pressure waves (results from 26 long-term measurements in the above-mentioned 35 infants).     

Sonographic findings in bacterial meningitis in neonates and young infants

Cranial sonography plays an important role in the initial evaluation of infants with suspected bacterial meningitis and in monitoring for complications of the disease. Echogenic widening of the brain sulci, meningeal thickening and hyperemia suggest the diagnosis in an at-risk population. Sonography can identify the presence of extra-axial fluid collections, and color Doppler sonography can be very helpful in differentiating benign enlargement of subarachnoid spaces from subdural effusions. Intraventricular debris and stranding, and an irregular and echogenic ependyma are highly suggestive findings associated with ventriculitis. Sonography can play an important role in the detection of postinfectious hydrocephalus, in the determination of the level of obstruction, and in the evaluation of intracranial compliance. Focal or diffuse parenchymal involvement can represent parenchymal involvement by cerebritis, infarction, secondary hemorrhage or early abscess.     

Post-contrast FLAIR MR imaging of the brain in children: normal and abnormal intracranial enhancement

Objective To describe the normally enhancing intracranial structures on fluid-attenuated inversion recovery (FLAIR) MRI and evaluate the usefulness of postcontrast FLAIR images of the brain in the assessment of enhancing lesions by comparing postcontrast FLAIR imaging with postcontrast T1-weighted (T1-W) imaging in children.Materials and methods In 218 children, 249 pre- and postcontrast FLAIR MRI examinations of the brain were obtained consecutively between August 2001 and April 2002. The normally enhancing intracranial structures on FLAIR imaging were assessed in 77 MRI studies of 74 children who showed normal intracranial imaging findings. In 86 MRI studies in 68 children who showed enhancing intracranial lesions, lesion conspicuity on postcontrast FLAIR imaging was compared with that on postcontrast T1-W imaging for all lesions (n=107), intra-axial lesions (n=40), or extra-axial lesions (n=67).Results The normally enhancing intracranial structures on FLAIR MRI were the choroid plexus (99%, 76/77), pituitary stalk (84%, 65/77), pineal gland (71%, 55/77), dural sinuses (26%, 20/77), and cortical veins (9%, 7/77). Of all the enhancing lesions, lesion conspicuousness on postcontrast FLAIR imaging was better than postcontrast T1-weighted imaging in 42, equal in 28, and worse in 37. Of 40 intra-axial lesions, lesion conspicuousness on postcontrast FLAIR imaging was better in 6, equal in 10, and worse in 24. Of 67 extra-axial lesions, lesion conspicuity on postcontrast FLAIR imaging was better in 36, equal in 18, and worse in 13. Conspicuousness of extra-axial lesions was significantly better than that of intra-axial lesions on postcontrast FLAIR imaging (P<0.001).Conclusions The choroid plexus, pituitary stalk, pineal gland, dural sinuses, and cortical veins show normal enhancement on postcontrast FLAIR MRI in children, and postcontrast FLAIR imaging appears better than postcontrast T1-W imaging in the assessment of extra-axial enhancing lesions in children.Presented at the 46th Annual Meeting of the Society for Pediatric Radiology, San Francisco, California, USA, May 2003     

Magnetic resonance imaging of the brain in infants and children before and after cardiac surgery. A prospective study

We assessed the morphologic findings of the brain prospectively before and after cardiac surgery using magnetic resonance imaging. There were 12 patients with acyanotic and 6 with cyanotic heart disease. There were 2 deaths, and 1 patient did not have to undergo postoperative magnetic resonance imaging. The study group consisted of 15 patients completing both the preoperative and postoperative magnetic resonance imagings. All patients in the study group underwent moderate hypothermic cardiopulmonary bypass using a nonpulsatile membrane oxygenator. The mean (+/- SD) cardiopulmonary bypass time was 100 +/- 55 minutes. Ten of the preoperative studies were interpreted as normal. One third (5 of 15) of the patients showed ventriculomegaly and dilatation of the subarachnoid spaces on preoperative magnetic resonance images. Measurements of the preoperative and postoperative magnetic resonance images showed a postoperative increase in the bicaudate and third ventricular diameters. Four patients in the study group developed postoperative subdural hematomas. The subdural hematomas were small and caused no demonstrable mass effect on magnetic resonance imaging. One patient had a preoperative white matter infarction. There was 1 patient with a postoperative infarction.     

Idiopathic pericerebral swelling (external hydrocephalus) of infants]

Benign enlargement of the subarachnoid spaces was diagnosed in 41 infants on the basis of ultrasound and/or CT scan findings. 10 MHz transfontanellar ultrasonography is without doubt the most reliable investigation in this condition (skull-to-cortex distance greater than 5 mm). Patients with extracerebral collections due to a clearly identifiable pathologic process (e.g., prematurity, IUGR, neonatal distress, malnutrition) were excluded from the study. Macrocrania developed rapidly in 72% of patients, either as the single manifestation (30%) or with delayed motor development and hypotonia (30%). Other clinical patterns included evidence of intracranial hypertension (15%) and hypotonia without macrocrania (20%). The two main findings of this study were the high rate of familial forms and the severity of early hemorrhagic complications, i.e., spontaneous subdural hematoma (5/41 cases), with permanent neurologic impairment in some instances (2/5 cases). These complications call into question the benignity of this syndrome whose long-term outcome, particularly in terms of cognitive function, is as yet unknown.     

Subdural collection of intravenous fat emulsion in a neonate. Complication of central venous catheterization for total parenteral nutrition

An infected subdural collection of intravenous fat emulsion (Intralipid) was diagnosed in a 5-week-old premature infant who was receiving total parental nutrition (TPN) through a facial vein cutdown. This fluid was successfully drained and the infection, due to Staphylococcus epidermidis, was treated with vancomycin. We postulate that the subdural collection occurred as a result of septic thrombosis of the internal jugular vein with subsequent retrograde flow and infiltration of Intralipid from the bridging veins into the subdural space. This complication of central TPN has not been reported previously.     

A case of Sotos syndrome with subduroperitoneal shunt

The authors present a case of Sotos syndrome with increasing severity of subdural hygroma from the age of 5 months, which was managed with a subduroperitoneal shunt at 10 months of age. The patient had been followed up until 30 months of age with continuing improvement of symptoms. The patient initially presented with dolichocephaly accompanied by macrocrania, early tooth development, repeated pneumonia infections and developmental retardation concerning crawling, sitting, walking and speaking at 5 months of age. Magnetic resonance imaging (MRI) demonstrated partial hypoplasia of the corpus callosum and bifrontal subdural hygroma. The patient underwent subduroperitoneal shunting at 10 months of age with partial improvement of symptoms. At 18 months of age, the patient showed increased irritability and sweating, and development of spinal kyphosis, which resulted from shunt malfunction as shown in the shuntogram. The appearance of cervical syringomyelia was also seen in the MRI. After shunt revision, the irritability, sweating and kyphosis improved along with disappearance of the syringomyelia. The authors describe a case of Sotos syndrome with subduroperitoneal shunt that showed syringomyelia which developed with shunt malfunction but disappeared after shunt revision. We emphasize the importance of active management such as subduroperitoneal shunting to drain the cerebrospinal fluid in the Sotos syndrome.     

Outcome following subdural haemorrhages in infancy.

Subdural haemorrhages (SDH) are associated with significant neurodisability in affected individuals. The incidence of SDH in infants is between 12 and 25 cases per 100,000 children and most detected SDH are due to physical abuse. In the infant brain, SDH are caused by tearing of the bridging veins in the subdural space and may result in significant brain injury. The challenge of assessing outcome in infants with SDH is evaluating whether SDH or other accompanying brain insults are instrumental in the neurodevelopmental outcome.     

Outcome following subdural haemorrhages in infancy

Subdural haemorrhages (SDH) are associated with significant neurodisability in affected individuals. The incidence of SDH in infants is between 12 and 25 cases per 100,000 children and most detected SDH are due to physical abuse. In the infant brain, SDH are caused by tearing of the bridging veins in the subdural space and may result in significant brain injury. The challenge of assessing outcome in infants with SDH is evaluating whether SDH or other accompanying brain insults are instrumental in the neurodevelopmental outcome.     

Risk factors in long-term sequelae of central nervous system prophylaxis in successfully treated children with acute lymphocytic leukemia

Seventy-two successfully treated patients with acute lymphocytic leukemia, all in first complete remission and all off therapy, who had received CNS prophylaxis (radiotherapy, 2,400 rad, plus intrathecal methotrexate), were studied by computed tomography (CT) of the brain, EEGs, and neurologic evaluations 3 to 9 years after the end of prophylaxis. Thirty-five patients showed CT brain scan abnormalities: intracranial calcifications (twelve); widening of the subarachnoid spaces (eight); isolated dilatation of ventricular spaces (three) and with frontal periventricular hypodensity (two); dilatation of ventricular and subarachnoid spaces (nine); and a hypodense area (one). Only 17 patients showed aspecific EEG abnormalities which were never linked to CT scan findings. None of our patients presented major motor deficits at the neurologic examination. A stepwise logistic regression technique showed that age less than 5 years at the time of prophylaxis was the most important risk factor (p = 0.008) of CT brain scan abnormalities followed by neurets (p = 0.037) and sex (p = 0.10). Furthermore, the multivariate analysis pointed out that the interactions between these variables were not significant and the effects were only of the first order.     

MRI in children with mental retardation

BACKGROUND: In mental retardation (MR) an aetiological diagnosis is not always obtained despite a detailed history, physical examination and metabolic or genetic investigations. In some of these patients, MRI is recommended and may identify subtle abnormal brain findings. OBJECTIVE: We reviewed the cerebral MRI of children with non-specific mental retardation in an attempt to establish a neuroanatomical picture of this disorder. MATERIALS AND METHODS: Thirty children with non-specific MR were selected to undergo cerebral MRI. The examination included supratentorial axial slices, mid-sagittal images and posterior fossa coronal images. Brain malformations, midline and cerebellar abnormalities were studied. RESULTS: In 27 of 30 patients, the neuroimaging evaluation revealed a relatively high incidence of cerebral and posterior fossa abnormalities. The most frequent were: dysplasia of the corpus callosum (46%; hypoplasia, short corpus callosum and vertical splenium), partially opened septum pellucidum and/or cavum vergae (33%), ventriculomegaly (33%), cerebral cortical dysplasia (23%), subarachnoid space enlargement (16.6%), vermian hypoplasia (33%), cerebellar and/or vermian disorganised folia (20%), and subarachnoid spaces enlargement in the posterior fossa (20%). Other anomalies were: enlarged Virchow-Robin spaces (10%), white matter anomalies (10%) and cerebellar or vermian atrophy. CONCLUSIONS: MRI has shown a high incidence of subtle cerebral abnormalities and unexpected minor forms of cerebellar cortical dysplasia. Even if most of these abnormalities are considered as subtle markers of brain dysgenesis, their role in the pathogenesis of mental retardation needs further investigation.     

Neuroimaging of nonaccidental head trauma: pitfalls and controversies

Although certain neuroimaging appearances are highly suggestive of abuse, radiological findings are often nonspecific. The objective of this review is to discuss pitfalls, controversies, and mimics occurring in neuroimaging of nonaccidental head trauma in order to allow the reader to establish an increased level of comfort in distinguishing between nonaccidental and accidental head trauma. Specific topics discussed include risk factors, general biomechanics and imaging strategies in nonaccidental head trauma, followed by the characteristics of skull fractures, normal prominent tentorium and falx versus subdural hematoma, birth trauma versus nonaccidental head trauma, hyperacute versus acute on chronic subdural hematomas, expanded subarachnoid space versus subdural hemorrhage, controversy regarding subdural hematomas associated with benign enlarged subarachnoid spaces, controversy regarding hypoxia as a cause of subdural hematoma and/or retinal hemorrhages without trauma, controversy regarding the significance of retinal hemorrhages related to nonaccidental head trauma, controversy regarding the significance of subdural hematomas in general, and pitfalls of glutaric aciduria type 1 and hemophagocytic lymphohistiocytosis mimicking nonaccidental head trauma.     

Subdural hematoma in a teenager related to roller-coaster ride.

Reports about neurological injury related to roller-coaster rides mostly involve adults; we present a case of subdural hematoma in a pediatric patient presented 14 days after a roller-coaster ride. These rides show extreme up-and-down, to-and-fro, and rotatory acceleration/deceleration forces that could produce tensile and shearing stresses with tearing of bridging cerebral veins resulting in subdural hemorrhage. Pediatricians should consider roller-coaster riding a modern cause of subdural hematoma, as well as a possible cause of unexplained neurologic events in otherwise healthy adolescents.     

A postmortem view on "pure" subdural hemorrhages in infants and toddlers

In the last years, the discussion concerning the causes of infantile subdural hemorrhages became controversial. Many authors still suppose that child abuse is the predominant cause of such cases. On the other hand, reports presenting series of accidental cases were published, and the fear of an overdiagnosis of the shaken baby syndrome has been expressed. Our autopsy material concerning all lethal head injuries of infants and toddlers from 2 decades was reviewed. 17 of these 64 cases were characterized by the following: history of no trauma or only an insignificant event; children found dead or apnoic or in coma; no skull fractures; no focal brain injury; ruptures of several bridging veins but only minimal subdural bleeding. 11 victims were infants (1st year of life) and either 3 were 2 years resp. 3 - 6 years old; 50 % off all lethal head injuries of infants were of this type, while only 25 % resp. 10 % of the following age groups. None of these 17 cases was a result of a minor accident witnessed by unrelated persons. Abuse could be ascertained with a high degree of probability in most cases and remained quite likely in the others. Two different types of subdural hemorrhages should be kept from another: a) patients suffering a moderate head injury from a minor accident which results in a subdural bleeding (from a small intracranial lesion) often do not deteriorate soon after the impact, develop a hemorrhage of significant volume, respond well to therapy and have a good prognosis. b) cases with a history of no or only of an insignificant trauma, infants dead or nearly dead on clinical presentation, often a poor outcome in cases of survival. There is typically no significant subdural bleeding despite multiple bridging vein ruptures in the majority of these cases: the subdural hemorrhage is here only a visible sign of a much more serious and general cerebral alteration, resulting in a rapid increase of intracranial pressure (often complicated by respiratory arrest) which prevents a signifant bleeding into the subdural space. This combination of findings is typically found in victims of massive events (car occupants in high-velocity crashes) and not compatible with a supposition of a minor fall causing this.     

Endoscopic fenestration of middle fossa arachnoid cysts: a technical description and case series

BACKGROUND: Arachnoid cysts are intra-arachnoidal cerebrospinal fluid collections most frequently seen in the middle cranial fossa. The optimal method of treatment for symptomatic arachnoid cysts remains controversial and includes cyst shunting, open craniotomy and endoscopic fenestration. All these techniques, however, have been associated with the development of postoperative subdural fluid collections. We describe a new endoscopic transcortical technique that attempts to avoid this complication. METHODS: Six patients with middle cranial fossa arachnoid cysts were treated with endoscopic fenestration at our institution between January 2002 and December 2005. Three cases were approached directly through the cyst, while the other 3 were approached by passing the endoscope through the rim of adjacent cortex. RESULTS: All six endoscopic fenestrations were successful in treating the arachnoid cysts. Among the 3 patients treated via a direct cyst entry, 2 cases developed significant subdural hygromas, 1 of which required aspiration. On the other hand, 1 of the 3 cases treated using a transcortical technique developed an insignificant postoperative extra-axial collection that resolved at 3 months without intervention. CONCLUSION: Endoscopic fenestration is an effective treatment for symptomatic arachnoid cysts. Endoscopic fenestration via a transcortical approach attempts to minimize cerebrospinal fluid drainage into the subdural space, avoiding the development of significant postoperative extra-axial collections, while promoting flow into the basal cisterns.     

Damage patterns in severe child abuse with and without fatal sequelae

In 62 battered children with involvement of the central nervous system clinically 3 patterns of impact to the skull, brain and its coverings could be distinguished: In 22 babies (mean age 6 months) the brain was damaged mainly by violent shaking. Many of those infants were in shock and epileptic status on admission. Retinal, subarachnoidal, and later subdural bleedings were recognizable. At first, all patients survived, but later 3 of them died in a vegetative state. Retinal bleedings are prompted by subarachnoidal hemorrhage due to shearing of bridging veins and by compression of the chest which immediately is followed by raise of venous pressure in the upper half of the body and by arteriospasms, leading to endothelial damage and increase of vascular permeability (Purtscher's disease). Both mechanisms result in severe retinal hemorrhage which might intrude into the vitreous body (Terson-syndrome). The consequences of violent shaking for the child might be disastrous mental retardation, microcephaly, spasticity, and epilepsies. The child might turn blind on one or both eyes; the visual failure is due to retinal scar formation, retinal detachment and fibrous organisation within the vitreous body on the one hand, due to raised intracranial pressure on the other hand, adding further damage to the visual pathway. In 19 children whose mean age was 13 months massive impact on the skull resulted in major brain damage: acute subdural hematoma, contusional bleedings, compound, diastatic or impression fractures. Ten of them died immediately or were picked up dead from home by different emergency services.(ABSTRACT TRUNCATED AT 250 WORDS)     

Benign subdural collections of infancy.

During the past two years we studied six infants with subdural collections of fluid. All patients had macrocrania and excessive transillumination of the head. Rapid head growth was common but five patients were otherwise asymptomatic. Subdural taps performed on five children confirmed the presence of abnormal fluid over the cerebral convexities. Subdural fluid in four patients was compatible with effusion and in another with a hematoma. Computerized tomographic evaluation of all infants showed ventricular enlargement, wide cerebral sulci, decreased density in the anterior temporal regions, large sylvian cisterns, prominent interhemispheric fissures, and decreased density over the cerebral convexities. The CT findings resembled cerebral atrophy but psychomotor development and neurologic examinations have been norma.     

Accidental drainage of a cerebral hydatid cyst into the peritoneal cavity

Intracranial hydatidosis is more common in children than in adults. The most severe complication is anaphylactic response after direct rupture into the subarachnoid spaces. We report a case of brain hydatid cyst that was accidentally drained into the peritoneal cavity and was not complicated by an anaphylactic response or dissemination.     

Multiple thoracic vertebral compression fractures caused by non-accidental injury: case report with radiological–pathological correlation

We report a 21-month-old boy with multiple contiguous thoracic vertebral compression fractures involving eight vertebral bodies, attributable to non-accidental injury. No subluxation was associated, however, there was extensive injury to the upper cervical and lower lumbar regions of the spinal cord. Anterosuperior beaking, thought to represent a previous injury, was evident in a mid-lumbar vertebra. Clinical examination revealed bilateral retinal hemorrhages and retinoschisis. Death occurred as a result of severe brain edema with bilateral subdural and subarachnoid hemorrhages. Radiological-pathological correlation is presented.