CNS Abnormalities Research Articles

ARNOLD CHIARI-II MALFORMATION : A RARE CASE REPORT WITH PRENATAL SONOGRAPHIC FINDINGS.

Arnold chiari II malformation is a congenital CNS abnormality characterised by downward displacement of posterior fossa structures into spinal canal. This malformation is a causative factor of death in neonates and infants. A thorough understanding of the direct and indirect sonographic findings is necessary for the diagnosis of chiari II malformation in developing fetus.

Role of 3D / 4D Ultrasound in Assessment of Fetal CNS Congenital Anomalies

Background: Using contemporary ultrasound equipment, it is possible to diagnose CNS defects in prenatal life. Many CNS defects can be detected by ultrasound in the first and early second trimesters. 4D ultrasonography has a high sensitivity for detecting prenatal CNS abnormalities and is used to detect and diagnose some foetal CNS disorders.

Craniolacunia and the Development of the Fetal Calvaria: An Autopsy Series With Clinical and Histological Analysis.

Craniolacunia, also known as lückenschädel, is a congenital abnormality of the calvaria featuring well-circumscribed areas of marked thinning, interspersed with more-normal bone. It is most commonly associated with myelomeningocele and/or Chiari 2 malformation. Records, photographs, and histologic sections were reviewed from 13 autopsy cases with craniolacunia. To investigate normal calvarial development, 23 parietal bone samples from fetuses/infants of 16-42 weeks gestation were examined. Parietal bone development had reproducible morphologic stages. Bone thickness increased with gestational age, while osteoblast numbers decreased. Craniolacunia was mainly seen in neonates. Five patients had Chiari 2 malformation, 1 had hydrocephalus, and 2 had other structural CNS abnormalities. One had trisomy 18. Four had no congenital abnormalities. Two sustained intrapartum skull fractures. Histologic sections were available in 5 cases. Lacunae in term infants had architecture similar to normal calvaria at 16-20 weeks. Adjacent bone had age appropriate architecture but increased osteoblast numbers. This is the largest autopsy series of craniolacunia and first systematic histologic analysis of craniolacunia and the developing fetal calvaria. Decreased cerebrospinal fluid pressure, due to myelomeningocele or other structural abnormality, may promote craniolacunia development. The risk of intrapartum fracture through lacunae emphasizes the continued clinical relevance of this diagnosis.

Apert Syndrome with Agenesis of the Corpus Collosum - Case Report

Abstract Apert syndrome (Acrocephalosyndactylia type 1) belongs to the group of extremely rare congenital dysmorphic syndromes. It is characterized by craniostenosis with very early fusion of the skull and / or cranial base sutures, facial hypoplasia, symmetrical syndactyly of the fingers and toes and other systemic malformations. Multiple CNS abnormalities are common, but simultaneous occurrence of Apert syndrome and agenesis of corpus callosum is estimated about 10%. We present a male patient born after first, normal and controlled pregnancy and term, naturally birth, in which the Apert syndrome was diagnosed, based on the clinical presentation of the skull and face and syndactyly of fingers and toes. Neurological examination established generalized hypotonia and aggravated provocation of the primitive reflexes. Neurosonography showed complete agenesis of the corpus callosum, which makes this case a rare form of this syndrome. The head X-rays showed turricephalic skull shape and suture’s synostoses, which is demonstrated in more detail at computed tomography finding. The hands and feet X-rays showed bone synostosis of fingers and toes. The video-electroencephalogram recorded intermittent depression of electrocortical activity. There was conducted the multidisciplinary examination in order to examine the possibility of reconstructive and plastic surgical correction of the anomalies. The neurodevelopmental disorders in patients with Apert syndrome can be manifested by a variety of congenital malformations, but considering its rare occurrence, the significance of these abnormalities remains unknown.

Kronik Böbrek Hastalığına Merkezi Sinir Sistemi Cevabı

Özetİnsan nüfusunun yaşlanması nedeniyle kronik böbrek hastalığı (KBH) gibi hastalıkların prevalansı her geçen yıl artmaktadır. Kronik böbrek hastalığı, böbrek yapı ve işlevini etkileyen heterojen bozuklukları ifade eden genel bir terimdir. Glomerüler filtrasyonda azalmayı takriben böbreğin sıvı-solüt dengesini ayarlama yeteneğinde, metabolik ve endokrin fonksiyonlarında kronik ve progresif bozulma durumu olarak tanımlanabilmektedir. KBH sıklıkla yaşlıları etkilemektedir. Yaşın ilerlemesiyle birlikte böbreklerde birtakım yapısal ve fonksiyonel değişiklikler ortaya çıkar. Dolayısıyla, gelecekte hafif ve orta dereceli KBH’dan muzdarip hasta sayısının artması beklenmektedir. KBH, kalp ve beyin gibi diğer organlara zarar veren derin metabolik ve hemodinamik değişikliklere yolaçar. Merkezi sinir sistemi anormallikleri ve bilişsel eksiklik, KBH’nın şiddeti ile ilerlemekte ve çoğunlukla hemodiyaliz hastaları arasında ortaya çıkmaktadır. Ayrıca bireyleri sosyo-ekonomik yönden de etkilemektedir. Hastalarda KBH risk faktörlerinin erken tanınması temel noktayı oluşturmaktadır. Bu nedenle, risk altındaki gruplarda uygulanacak olası önleyici ve koruyucu tedavilerin tespiti ve hastalığın tedavisi için bu mekanizmaların incelenmesi gerekmektedir. Bu derleme, ilgili mekanizmalar hakkında mevcut bilgileri sunmaktadır.

Late amniocentesis: better late than never? A single referral centre experience.

Several congenital abnormalities present late in pregnancy necessitating invasive testing to rule out genetic/infectious causes at late gestation. Not many studies have described the indications/safety of a late gestation amniocentesis. All records of amniocentesis performed beyond 24weeks were reviewed and evaluated for indications, positive yield and complications. About 187 women had an amniocentesis after 24weeks for various indications with CNS abnormalities beingthe commonest. The total yield of positive findings was 14.60% (22/150; excluding 2 VOUS). CNS, multiple system involvement and skeletal system anormalities yielded maximum results. About 32.05% abnormalities could have potentially been detected at the time of a routine anomaly scan. Amongst all the deliveries, 2.1% delivered spontaneously within a week of the procedure and about 5.4% delivered spontaneously within a month of the procedure. The study emphasises the need for additional accreditation (FMF, ISUOG) of sonographers to ensure the detection of anomalies at the routine 18-20weeks scan. Inspite of a normal mid-trimester scan, central nervous system and gastrointestinal abnormalities presented more commonly after 24weeks. The high positive yield in our study highlights the importance of testing even in late pregnancy beyond the legal age of termination. The test could clearly stratify the pregnancies with a poor outcome whilst reassuring the others. The procedure itself did not lead to a neonatal death due to prematurity.

Prevalence of Homeless Mentally Ill Patient along with their Clinical Presentation at Government Setup in Western Uttar Pradesh State of India

Context: Homeless persons lack socioeconomic support which is instrumental in affecting both their physical as well as psychological health. A number of destitute persons are often brought to specialized psychiatric centres in view of their dilapidating physical and psychological health.Aim: To study the prevalence and clinical presentation among the destitute persons admitted to a specialized psychiatric care centre.Materials & Methods: A total of 100 destitute persons admitted to a specialized psychiatric care centre were included in the study as a retrospective chart review. Demographic profile and clinical presentations were noted. The classification of psychiatric illnesses was done as per international classification of diseases (ICD)-10 classification. Data has been represented in frequencies (number) and percentages.Results: Age of patients ranged from 15 to 75 years. Mean age of patients was 40.70 ± 13.99 years. Majority (62%) were males and Hindus (57%). Poor personal hygiene (79%), abnormal behavior (52%) and self-muttering (44%) were the most common presenting complaints. On mental status examination, irrelevant speech (85%), restricted/perplexed affect (93%), impaired judgement (98.8%), impaired attention and concentration (90.7%) and impaired memory (80%) were the major findings. CNS and GI abnormalities were seen in 9% and 2% patients. Almost all (99%) had non-cooperative attitude, inadequate skin/nail care (94%). Majority (56%) had thin to very thin built and psychomotor agitation (55%). Unspecified nonorganic psychosis (44%) was the most common psychiatric illness followed by paranoid schizophrenia (10%) and organic delirium (6%). In 28% cases, the psychiatric illness could not be established clearly, and were kept under observation.Conclusion: Destitute persons have a huge burden of psychiatric illness that had affected their physical health too.

Perinatal and Fetal Autopsies in Neuropathology: How I do it.

Fetal and perinatal autopsies are useful to identify the accurate cause of death and in the process recognize disorders which may require counselling for future pregnancies. Abnormalities of the CNS are an important cause of fetal loss and perinatal deaths. Most of these are structural abnormalities of the CNS, however a smaller portion show changes pertaining to prematurity, infections and even congenital tumors. In this review we evaluate CNS abnormalities of the fetus and the newborn as detected in autopsy series. We also describe our experience in a tertiary care hospital with a specialized neonatology unit over the last 8 years and discuss some of the newer methods like virtual autopsy.

Clinical characteristics and genetic analysis of a neonate with Smith-Magenis syndrome

To explore the clinical features and genetic etiology for a neonate with Smith-Magenis syndrome (SMS). Copy number variation sequencing (CNV-seq) was applied to the neonate and his parents, and the genotype-phenotype correlation was analyzed. On the second day after birth, the neonate had presented with pathological jaundice and immunodeficiency. Cranial MRI revealed ventricular enlargement and enlargement of cisterna magna. At 3 months, the infant has presented with square face, prominent forehead, deep-set eyes, hypertelorism, palpebral fissure upward and button noses. Genetic testing showed that he had carried a 2.9 Mb deletion in 17p11.2 region, seq[GRCh37] del(17)(p11.2)(chr17:16 836 379-19 880 992). The same deletion was not found in either parent. SMS is mostly diagnosed in child and adulthood, but rarely in neonates. For neonates with SMS, the neurological and behavioral abnormalities have not been shown, but pathological jaundice, CNS abnormalities and immune deficiency may be the characteristics, which require attention of neonatal physicians.

PHACOSIT: A sitting phacoemulsification technique for patients unable to lie down flat during cataract surgery

Phacoemulsification is routinely performed with the patient lying supine on the surgical table with his or her head flat and facing the overhead microscope. This routine technique can be a challenge in medical conditions such as kyphosis, scoliosis, orthopnea, Meniere’s disease, and CNS abnormality. Some cardiovascular and respiratory conditions make the patients breathless when they lie down, whereas other neurological and spinal problem patients are also equally uncomfortable. The only reasonable solution to conduct surgery on a patient who cannot lie down flat on the operating table is to position them face to face in a sitting position. We describe an innovative phacoemulsification technique in a sitting position called “phacosit” in an 80-year-old wheelchair-bound female patient who was denied cataract surgery by other eye surgeons owing to her medical condition.

Children Undergoing Laryngeal Surgery for Obstructive Sleep Apnea: NSQIP Analysis of Length of Stay, Readmissions, and Reoperations.

No national study to date has specifically evaluated the predictive variables associated with extended hospitalization and other postoperative complications following laryngeal surgery in children with obstructive sleep apnea (OSA). The goals of this study were to identify perioperative risk factors and provide a descriptive analysis of surgical outcomes in these children using the National Surgical Quality Improvement Program-Pediatrics (NSQIP-P) database. Patients aged 0 to 18 years who underwent laryngeal surgery with a postoperative diagnosis of OSA were queried via the 2014-2018 NSQIP-P database using Current Procedural Terminology code 31541. Variables collected included age, sex, ethnicity, body mass index (BMI), medical comorbidities, American Society of Anesthesiologists (ASA) physical classification, operative time, and concurrent procedures. Endpoints of interest were length of stay, unplanned reoperation, readmission, reintubation, and postoperative complications. Univariate and multivariate linear regression analyses were performed. A total of 181 cases were identified (57.5% male and 42.5% female, mean age 4.36 years, range 14 days-17.7 years). Body mass index (P = .015, OR = 0.96), structural CNS abnormality (P = .034, OR = 1.95), preoperative oxygen supplementation (P = .043, OR = 1.28), operative time (P = .019, OR = 1.84, 95% CI = 1.28-2.54), and concurrent procedure (P < .001, OR = 2.21) were all independently associated with LOS. Postoperative complications had no significantly associated variables, with an overall low incidence of readmission (5.0%), reoperation (1.7%), and reintubation (1.1%). In this data set, children with OSA undergoing laryngeal surgery experienced minimal postoperative complications. Recognition of the factors associated with increased LOS could lead to improvement in the quality of care for children with OSA.

Tetrahydrobiopterin and Its Multiple Roles in Neuropsychological Disorders.

Tetrahydrobiopterin (BH4) is a multifunctional co-factor of various enzymes and a substantial amount of studies have shown BH4 as a key regulator in the synthesis of neurotransmitters such as serotonin, nor-epinephrine as well as dopamine. The imbalance of BH4 may affect neurotransmitter production which can lead to many abnormalities in CNS. This article reviews the role of BH4 in neurodegenerative and neurodevelopmental disorders. We focus on the therapeutic potential of BH4 in various brain diseases that involves neurotransmitters and attempt to address how the modulation of BH4 may provide a novel strategy in various neuropsychological conditions.

Neuroradiological signs of encephalopathy in children with autism spectrum disorders associated with genetic folate deficiency

The results of five meta‑analyzes indicate the association of autism spectrum disorders (ASD) with genetic deficiency of the folate cycle (GDFC) in children. In such cases, specific encephalopathy is formed with predominant immune‑dependent pathways of pathogenesis, the radiological signs of which are insufficiently studied.&#x0D; Objective —— to describe the typical neuroimaging signs of encephalopathy in children with GDFC suffering from ASD, and to find correlations between clinical signs, mechanisms of nervous system damage and neuroimaging data to optimize the algorithm of diagnosis, monitoring and treatment.&#x0D; Methods and subjects. The retrospective analysis of medical data of 225 children aged 2 to 9 years with GDFC, in which there were clinical manifestations of ASD (183 boys and 42 girls). The diagnosis of ASD was made by child psychiatrists according to the criteria of DSM‑IV‑TR (Diagnostic and Statistical Manual of mental disorders) and ICD‑10 (The International Statistical Classification of Diseases and Related Health Problems). Pathogenic polymorphic variants of folate cycle genes were determined by PCR with restriction. Neuroimaging was performed by MRI of the brain in conventional modes (T1‑ and T2‑weighted, FLAIR) on tomographs with a magnetic induction of 1.5 T. To study the associations between the indicators, the odds ratio (OR) and the 95 % confidence interval (95 % SI) were used.&#x0D; Results. There are 5 main groups of neuroimaging signs characteristic of leukoencephalopathy, temporal mesial sclerosis, PANS/PITANDS/PANDAS, congenital CMV neuroinfection and postnatal encephalitis, mild congenital CNS abnormalities. Neuroimaging signs are closely associated with the results of special laboratory tests that characterize the known immune‑dependent mechanisms of CNS damage, and with the emergence of relevant clinical syndromes, consistent with modern concepts of major infectious or autoimmune lesions of the nervous system in immunosuppressed patients. Laboratory‑radiological‑clinical complexes (virus‑induced temporal mesial sclerosis, autoimmune limbic encephalitis, autoimmune subcortical encephalitis, autoimmune or virus‑induced demyelinating lesions of the cerebral hemispheres and mild congenital malformations) have been identified.&#x0D; Conclusions. Encephalopathy in children with ASD associated with GDFC has a complex pathogenesis and is the result of combining a number of immune‑dependent forms of CNS damage in different ways in different patients, leading to a heterogeneous clinic‑radiological phenotype.&#x0D;

28580 Diffuse capillary malformation with overgrowth and phakomatosis pigmentovascularis type II in a newborn

The most common vascular lesion in pediatric patients is a capillary malformation (CM). CMs can be localized, diffuse, or found in association with vascular malformation syndromes. Diffuse capillary malformation with overgrowth (DCMO) describes a widespread capillary malformation associated with nonprogressive, proportional enlargement of soft or bony tissue. In contrast, phakomatosis pigmentovascularis (PPV) is a rare congenital syndrome associated with vascular anomalies, often a nevus flammeus, and melanocytic lesions. Of the five subtypes, type II is the most common and presents with a nevus flammeus and dermal melanocytosis. Herein, we discuss a unique case of a two-day-old female infant who presented with extensive vascular malformations, limb hemihypertrophy, and melanocytic nevi suspicious for both DCMO and PPV type II. The team was consulted for evaluation of a two-day-old female infant born with right leg and left knee capillary malformations and right-sided leg hemihypertrophy. On examination, the infant was further noted to have two isolated CMs on her forehead and lip and dermal melanocytosis on her buttock. There was no deep lymphatic or venous malformations noted on her right leg ultrasound; therefore, Klippel-Trenaunay syndrome was less probable. The patient’s both conditions warranted periodic follow-up with pediatric specialists, as DMCO necessitates limb-length monitoring and PPV can be associated with CNS and ocular abnormalities. As both diseases themselves are rare, the patient’s presentation made her disease a diagnostic challenge. Dermatologists should be aware of the rare, concomitant presentation of DCMO and PPV and should be aware of the needed referrals and follow-up.

Modeling genetic epileptic encephalopathies using brain organoids

Developmental and epileptic encephalopathies (DEE) are a group of disorders associated with intractable seizures, brain development, and functional abnormalities, and in some cases, premature death. Pathogenic human germline biallelic mutations in tumor suppressor WW domain‐containing oxidoreductase (WWOX) are associated with a relatively mild autosomal recessive spinocerebellar ataxia‐12 (SCAR12) and a more severe early infantile WWOX‐related epileptic encephalopathy (WOREE). In this study, we generated an in vitro model for DEEs, using the devastating WOREE syndrome as a prototype, by establishing brain organoids from CRISPR‐engineered human ES cells and from patient‐derived iPSCs. Using these models, we discovered dramatic cellular and molecular CNS abnormalities, including neural population changes, cortical differentiation malfunctions, and Wnt pathway and DNA damage response impairment. Furthermore, we provide a proof of concept that ectopic WWOX expression could potentially rescue these phenotypes. Our findings underscore the utility of modeling childhood epileptic encephalopathies using brain organoids and their use as a unique platform to test possible therapeutic intervention strategies.

Detection rate of fetal CNS anomalies by first and second trimester ultrasound screening

Objectives: The aim of this study was to detect CNS abnormalities in the first and second trimester by ultrasound. Methods: This cross-sectional study was performed on pregnant women who referred to the radiology department of Imam Reza and Valiasr hospitals in Tehran-Iran during 2019-2020. After obtaining informed consent, pregnant women were screened in the first trimester at week 13-13 and then in the second trimester at week 18-20 by a 5-8 MHz Ultrasound Transducer. Each ultrasound included examination of the fetal brain and vertebrae at the axial coronal and sagittal planes in the most important anatomical areas, including the trans-thalamic (TT) or the trans-ventricular (TV) plane, transverse cerebellar, and vertebral canal plan. Ultrasound of the first and second trimesters of all mothers was performed. Information of all pregnant mothers was collected and recorded. Data analysis was performed using SPSS software version 25. Results: In this study, 2234 pregnant women were included in the study. The total rate of detected anomalies was found to be 1.3%. The rate of abnormalities detected in the first trimester was far less than in the second trimester. The prevalence of CNS anomalies in the population under 30 years of age was also found 0.9%, while it was 1.6% in the population over 30 years of age. Conclusion: Second-trimester ultrasound is the method of choice in diagnosing central nervous system abnormalities. However, first-trimester ultrasound is the diagnostic method for structural abnormalities of the skull.

Incidental Finding Prevalences in 3-Tesla Brain and Spine MRI of Military Pilot Applicants.

INTRODUCTION: Incidental findings in brain and spine MRI are common. In aerospace medicine, pilot selection may be affected by improved sensitivity of modern MRI devices. We investigated the occurrence of medically unfit rates caused by incidental findings in military pilot applicants using a 3-Tesla scanner as compared to the outcomes of a lower field strength 1-Tesla device based on similar screening protocols.METHODS: A total of 3315 military pilot applicants were assessed by a standardized German Air Force Imaging Screening Protocol and retrospectively subdivided into two cohorts, one of which was assessed by 1-Tesla MRI (2012-2015; N 1782), while in the second cohort (2016-2019; N 1808), a 3-Tesla MRI was used. Cohorts were statistically analyzed relating to three entities of incidental findings: 1) intervertebral disc displacements, 2) intracerebral vessel malformations, and 3) other abnormal findings in the brain.RESULTS: Pooled prevalences of incidental findings in medically unfit applicants significantly increased by use of 3-Tesla MRI as compared to lower resolution 1-Tesla MRI. Regarding the spine, prevalences more than doubled (1.46 vs. 4.99%; P < 0.05) for intervertebral disc displacements. Similarly, prevalences of cerebral vessel malformations as well as other abnormal CNS incidental findings considerably increased by use of 3-Tesla MRI (0.28 vs. 1.67%; P < 0.05, and 5.12 vs. 9.80%; P < 0.05). Effect sizes and correlations were substantial in all conditions analyzed (Cohens d > 0.8; Pearsons r > 0.75).CONCLUSIONS: Our data suggest a strong dependency of incidental cerebrospinal findings on image resolution and sensitivity of MRI devices used for screening, which is enhanced by refined imaging protocols and followed by increased medical unfit rates in prospective aviators. Adjusted strategies in the assessment of such lesions are needed to redefine their natural history and physiological impact, and to optimize screening protocols for future pilot selection.Snksen S-E, Khn SR, Nobl H-J, Knopf H, Ehling J, Jakobs FM, Frischmuth J, Weber F. Incidental finding prevalences in 3-Tesla brain and spine MRI of military pilot applicants. Aerosp Med Hum Perform. 2021; 92(3):146152.

265 Hemivertebra: systematic review of cases with cytogenetic abnormalities, associated anomalies and proposed prenatal management

To identify cases of hemivertebra with abnormal cytogenetic studies and assess for other associated anomalies in order to provide more accurate patient counseling and prenatal management. This systematic review was conducted using PubMed (including Cochrane database) and Ovid Medline from inception through November 2019. Studies were deemed eligible for inclusion if hemivertebra with abnormal cytogenetic studies was identified in the fetal, neonatal, or infant period. Studies that described other vertebral anomalies were excluded. We identified 17 cases of hemivertebra with cytogenetic abnormalities among a total of 324 cases (5%) in our review. These include partial tetrasomy 4q, mosaic trisomy 4, mosaic trisomy 7, mosaic trisomy 9, mosaic trisomy 18q, mosaic trisomy 18; trisomy 7, trisomy 15q with monosomy 6q, partial trisomy 22; duplication of 2p; 4p- deletion, 17p deletion, 18p deletion, 18q22.2 deletion, 22q13.3 deletion; ring chromosome 21, and Fanconi’s anemia. 29% (5/17) were diagnosed prenatally, 47% (8/17) at birth, and 18% (3/17) postnatally. All cases had prenatally or postnatally diagnosed associated anomalies. 29% (5/17) had associated anomalies identified prenatally, including ear anomalies, CNS abnormalities, micrognathia, congenital heart defects, renal anomalies, clubfeet, and fetal growth restriction. Postnatally diagnosed anomalies commonly included: CNS (41%, 7/17), cardiac (53%, 9/17), skeletal (71%, 12/17) and genitourinary (59%,10/17). Hemivertebra with abnormal cytogenetic testing was always associated with malformations from other organ systems that could be missed by prenatal ultrasound alone. Those include CNS, cardiovascular, musculoskeletal, and genitourinary anomalies. Fetal echocardiogram is recommended due to the considerable association with congenital heart defects. Fetal neurosonography or MRI should be considered. Of those receiving genetic testing, karyotype or SNP microarray should be considered due to the common presence of mosaicism.

The care of the concussed pediatric patient prior to presentation to primary care pediatrician versus concussion specialists: Implications for management

Objective Absent adequate randomized control trials to inform appropriate treatment for concussion in pediatric patients, guidelines have been developed based on expert opinion and observational data that may not apply to all groups. This study examines differences in the previous clinical care between concussed patients who present in pediatric practice and specialty clinics. Differences found might influence treatment recommendations for each setting. Study design Prospective data collected from a pediatric practice in 2011 to 2013 were compared to chart review data from two specialty clinics between 2015 and 2017. In all three groups patients 11–19 years of age with an ICD9 billing code for concussion were included if they met the 4th International Consensus definition of concussion. Patients were excluded if hospitalized or had abnormal CNS imaging. Results The time between injury and presentation was substantially longer in specialty clinic patients versus those seen in the primary pediatric care office. (median 10 vs. 2 days-p &lt; 0.001) Primary care patients presenting had higher rates of immediate rest after injury, 61.4% vs 27.9% (p &lt; 0.001). More specialty clinic patients had been seen in the emergency departments prior to presentation (47.5% vs. 18.8% p &lt; 0.001) regardless of rest status at presentation to the office. Conclusion Several differences in previous clinical care between the groups were found. These included the time of presentation from injury, rates of cognitive rest both immediate and non-immediate, and emergency department visits. These differences may have implications for management recommendations. Accordingly, the appropriate treatment for patients seen by the primary pediatric care physicians may be different from those referred to specialty care. Given these findings randomized controlled trails should be conducted independently in both groups of patients.

Devic's disease: A rare case presentation

We report a case of a young patient with sudden drop in vision and lower limb weakness. On examination was found to have left eye disc edema and abnormal CNS function. On further investigation, the patient was diagnosed to have optic neuritis with associated transverse myelitis-a syndrome referred to neuromyelitis optica or Devic's Disease. This case emphasizes the need for timely intervention to prevent permanent vision loss.