Cranial Magnetic Resonance Imaging Scans Research Articles

Pituitary Stalk Interruption Syndrome: Presentation of a Rare Case

AbstractPituitary stalk interruption syndrome is a congenital anomaly characterized by interrupted or thin pituitary stalk, hypoplastic or absent anterior pituitary, and an absent or ectopic posterior pituitary gland. The exact incidence rate of this syndrome is not known. However, the estimated incidence rate is 0.5/1,000,000 births. In this case report, we wanted to present a case of interrupted pituitary stalk syndrome, which presented with seizures and thyroid hormone deficiency. A 5-year-old female patient was admitted to our emergency department with vomiting, fever, and seizures with new onset. She had a twin who was ex-utero intrapartum in taken history. She was diagnosed with hypothyroidism and started on levothyroxine. Her height was in 25 to 50th percentile and her weight was in 10 to 25th percentile. She had mild mental retardation. On contrast-enhanced cranial magnetic resonance imaging scan, the pituitary stalk was absent, posterior pituitary was ectopic, and anterior pituitary was hypoplastic. The patient was diagnosed with interrupted pituitary stalk syndrome. After the symptoms were relieved, patient started on carbamazepine for epileptic seizures and hormone replacement therapy with levothyroxine and hydrocortisone. She was routinely followed up after the proper diagnosis. Leuprolide (gonadotropin-releasing hormone) and Norditropin (biosynthetic growth hormone) were added to medical therapy. Her height and weight were in 25th percentile after the long-term follow-up of approximately 10 years. On neurological examination, situation of mild mental retardation persisted. Pituitary stalk interruption syndrome is a very rare entity. However, radiologists should keep this syndrome in mind for patients who present with hypoglycemia, seizures, jaundice, cryptorchidism, and hypothyroidism in neonatal period and growth retardation with pituitary hormone deficiencies in childhood.

Recurrent pseudoprogression in isocitrate dehydrogenase 1 mutant glioblastoma

In a subset of glioblastoma (GBM) patients, the differentiation between tumor progression and tumor pseudoprogression (PsP) is challenging. This case describes a male patient suffering from isocitrate dehydrogenase 1 (IDH1) mutant GBM who demonstrated an increasing contrast-enhancing (CE) lesion on a cranial magnetic resonance imaging (cMRI) scan 8 months after radiochemotherapy. In accordance with the response assessment in neuro-oncology (RANO) criteria, the cMRI lesion was classified as recurrent tumor, although 18F-fluoroethyl-L-tyrosine positron emission tomography (18F-FET-PET) did not indicate vital tumor tissue. The patient underwent re-surgery but histopathology only revealed reactive and necrotic tissue, consistent with PsP. Nine weeks after complete resection of the CE lesion, a new lesion emerged that later regressed in the follow-up cMRI scans, thereby retrospectively establishing the diagnosis of recurrent PsP.

Magnetic resonance imaging in the diagnosis of white matter signal abnormalities.

Background White matter abnormalities (WMAs) pose a diagnostic challenge when trying to establish etiologic diagnoses. During childhood and adult years, genetic disorders, metabolic disorders and acquired conditions are included in differential diagnoses. To assist clinicians and radiologists, a structured algorithm using cranial magnetic resonance imaging (MRI) has been recommended to aid in establishing working diagnoses that facilitate appropriate biochemical and genetic investigations. This retrospective pilot study investigated the validity and diagnostic utility of this algorithm when applied to white matter signal abnormalities (WMSAs) reported on imaging studies of patients seen in our clinics. Methods The MRI algorithm was applied to 31 patients selected from patients attending the neurometabolic/neurogenetic/metabolic/neurology clinics at a tertiary care hospital. These patients varied in age from 5 months to 79 years old, and were reported to have WMSAs on cranial MRI scans. Twenty-one patients had confirmed WMA diagnoses and 10 patients had non-specific WMA diagnoses (etiology unknown). Two radiologists, blinded to confirmed diagnoses, used clinical abstracts and the WMSAs present on patient MRI scans to classify possible WMA diagnoses utilizing the algorithm. Results The MRI algorithm displayed a sensitivity of 100%, a specificity of 30.0% and a positive predicted value of 74.1%. Cohen's kappa statistic for inter-radiologist agreement was 0.733, suggesting "good" agreement between radiologists. Conclusions Although a high diagnostic utility was not observed, results suggest that this MRI algorithm has promise as a clinical tool for clinicians and radiologists. We discuss the benefits and limitations of this approach.

Role of diffusion-weighted imaging for detecting bone marrow infiltration in skull in children with acute lymphoblastic leukemia.

We aimed to determine whether diffusion-weighted imaging (DWI) with apparent diffusion coefficient (ADC) measurement can detect skull bone marrow infiltration in newly diagnosed acute lymphoblastic leukemia (ALL) children before therapy and normalization in complete remission after treatment. Fifty-one newly diagnosed acute lymphoblastic leukemia (ALL) patients and 30 healthy age-matched subjects were included. Cranial magnetic resonance imaging (MRI) scans were reviewed, and skull marrow ADC values were compared before treatment and in complete remission after therapy. Skull marrow infiltration, manifested with abnormal DWI signals, was present in 37 patients (72.5%) before treatment. Of these, 23 (62.2%) showed scattered signal abnormalities and 14 (37.8%) showed a uniform abnormal signal pattern. Compared with the control group, ADC was significantly decreased in patients with ALL. DWI signal intensity and ADC normalized in patients with complete remission. DWI is a useful and noninvasive tool for detecting skull infiltration in ALL children before treatment and normalization at complete remission after therapy, and it is superior to conventional MRI in terms of conspicuity of these lesions. DWI could be used as an MRI biomarker for evaluation of treatment in ALL children.

Advantage in Bright-blood and Black-blood Magnetic Resonance Imaging with High-resolution for Analysis of Carotid Atherosclerotic Plaques.

Background:About 50% of the cerebral ischemia events are induced by intracranial and extracranial atherosclerosis. This study aimed to evaluate the feasibility and accuracy for displaying atherosclerotic plaques in carotid arteries and analyzing their ingredients by using high-resolution new magnetic resonance imaging (MRI) techniques.Methods:Totally, 49 patients suspected of extracranial carotid artery stenosis were subjected to cranial MRI scan and magnetic resonance angiography (MRA) examination on carotid arteries, and high-resolution bright-blood and black-blood MRI analysis was carried out within 1 week. Digital subtraction angiography (DSA) examination was carried out for 16 patients within 1 month.Results:Totally, 103 plaques were detected in the 49 patients, which were characterized by localized or diffusive thickening of the vessel wall, with the intrusion of crescent-shaped abnormal signal into lumens. Fibrous cap was displayed as isointensity in T1-weighted image (T1WI) and hyperintensities in proton density weighted image (PDWI) and T2-weighted image (T2WI), lipid core was displayed as isointensity or slight hyperintensities in T1WI, isointensity, hyperintensities or hypointensity in PDWI, and hypointensity in T2WI. Calcification in plaques was detected in 11 patients. Eight patients were detected with irregular plaque surface or ulcerative plaques, which were characterized by irregular intravascular space surface in the black-blood sequences, black hypointensity band was not detected in three-dimensional time-of-flight, or the hypointensity band was not continuous, and intrusion of hyperintensities into plaques can be detected. Bright-blood and black-blood techniques were highly correlated with the diagnosis of contrast-enhanced MRA in angiostenosis degree, Rs = 0.97, P < 0.001. In comparison to DSA, the sensitivity, specificity, and accuracy of MRI diagnosis of stenosis for ≥50% were 88.9%, 100%, and 97.9%, respectively.Conclusions:High-resolution bright-blood and black-blood sequential MRI analysis can accurately analyze ingredients in atherosclerotic plaques. Determined by DSA, MRI diagnosis of stenosis can correctly evaluate the serious degree of arteriostenosis.

Brain atrophy in cognitively impaired elderly: the importance of long-chain ω-3 fatty acids and B vitamin status in a randomized controlled trial

Increased brain atrophy rates are common in older people with cognitive impairment, particularly in those who eventually convert to Alzheimer disease. Plasma concentrations of omega-3 (ω-3) fatty acids and homocysteine are associated with the development of brain atrophy and dementia. We investigated whether plasma ω-3 fatty acid concentrations (eicosapentaenoic acid and docosahexaenoic acid) modify the treatment effect of homocysteine-lowering B vitamins on brain atrophy rates in a placebo-controlled trial (VITACOG). This retrospective analysis included 168 elderly people (≥70 y) with mild cognitive impairment, randomly assigned either to placebo (n = 83) or to daily high-dose B vitamin supplementation (folic acid, 0.8 mg; vitamin B-6, 20 mg; vitamin B-12, 0.5 mg) (n = 85). The subjects underwent cranial magnetic resonance imaging scans at baseline and 2 y later. The effect of the intervention was analyzed according to tertiles of baseline ω-3 fatty acid concentrations. There was a significant interaction (P = 0.024) between B vitamin treatment and plasma combined ω-3 fatty acids (eicosapentaenoic acid and docosahexaenoic acid) on brain atrophy rates. In subjects with high baseline ω-3 fatty acids (>590 μmol/L), B vitamin treatment slowed the mean atrophy rate by 40.0% compared with placebo (P = 0.023). B vitamin treatment had no significant effect on the rate of atrophy among subjects with low baseline ω-3 fatty acids (<390 μmol/L). High baseline ω-3 fatty acids were associated with a slower rate of brain atrophy in the B vitamin group but not in the placebo group. The beneficial effect of B vitamin treatment on brain atrophy was observed only in subjects with high plasma ω-3 fatty acids. It is also suggested that the beneficial effect of ω-3 fatty acids on brain atrophy may be confined to subjects with good B vitamin status. The results highlight the importance of identifying subgroups likely to benefit in clinical trials. This trial was registered at www.controlled-trials.com as ISRCTN94410159.

Dietary interventions as a neuroprotective therapy for the delay of the onset of cognitive decline in older adults: an umbrella review protocol.

Review question and Objective Are individual dietary interventions effective in delaying the onset of cognitive decline in older adults? The objective of this umbrella review is to determine the effectiveness of individual dietary interventions in delaying the onset of cognitive decline in older adults. Inclusion criteria Types of participants Inclusion criteria This umbrella review will consider systematic reviews of older adult humans with a mean age 60 years or older without clinically-diagnosed dementia/ Alzheimer's Disease at baseline, including those who have reported difficulties with memory (memory complainers) and/or with mild cognitive impairment as a result of the ageing process. Exclusion criteria The umbrella review will not include; participants with a mean age of less than 60 years participants with clinically-diagnosed dementia/ Alzheimer's Disease at baseline participants with cognitive impairment due to brain injury studies of participants with vascular dementia studies using animal models. Types of intervention(s) Inclusion criteria This umbrella review will consider systematic reviews that have evaluated the effects of administration of any dose of the individual dietary interventions listed below for any duration. Dietary interventions included in this review are alpha- lipoic acid acetyl-L-carnitine polyphenols choline inositol compounds omega-3 polyunsaturated fatty acids. Exclusion criteria This umbrella review will not consider systematic reviews of; combinations of individual dietary components or supplements vitamin supplements studies that combined drugs with a dietary intervention studies of whole of diet approaches. Types of outcomes Inclusion criteria Primary outcomes This umbrella review will consider systematic reviews that include the following primary outcome measures: cognitive function (as measured by psychometric tests). Cognitive function tests diagnostic of mild cognitive impairment and Alzheimer's Disease include, but are not limited to, Alzheimer’s Disease Assessment Subscale, Clinical Dementia Rating Scale, Cambridge Cognitive Examination, Mini Mental State Examination, Telephone Interview of Cognitive Status. Secondary outcomes This umbrella review will consider systematic reviews that include the following secondary outcome measures: analysis from brain imaging techniques including, volumetric cranial magnetic resonance imaging scan, uptake of the radioligand C-Pittsburgh compound B deposits in the brain by positron emission tomography TRUNCATED AT 350 WORDS

Migraine with Visual Aura: A Clinical Manifestation of Cerebrovascular Disorders in Childhood

Cerebral vascular pathology mostly gets manifest in early adulthood. Bleeding, epileptic seizure, and focal neurologic deficits are the most common clinical presentations leading to the diagnosis. We present two children with migraine headache and visual aura as first symptoms. Case 1: A 7-year-old girl suffers from classical clinical symptoms of a migraine with visual aura. Cranial magnetic resonance imaging (MRI) scan revealed a large arteriovenous (AV) malformation in the right occipital lobe without signs of bleeding. As there were no epileptic seizures and just minimal restriction in the visual field, a watchful-waiting approach was preferred. In the 7 year follow-up, the clinical manifestation remained stable with variable amount of migraine attacks. Though the follow-up MRI showed an unchanged overall size of the AV malformation, the venous drainage and shunt volume raised and thereby the risk of bleeding. The possible and also risky therapeutic options versus further watchful-waiting approach are actually discussed with the family. Case 2: A 10-year-old boy suffers, since he is 7 years old, from left-sided temporal-parietal headache with visual aura and vertigo. As the frequency of the attacks significant rose (2-4 attacks/week), the boy sought medical advice. Cranial MRI and the following angiography showed a giant intracranial aneurysm of the cavernous part of the internal carotid (two aneurysm “pockets” with 1.5 cm diameter each) with local compression especially of the left optic nerve. Hints for an aneurysm associated illness or familiar burden were not found. After a positive occlusion test, a combined neuroradiological and neurosurgical approach with coiling and clipping of the left internal carotid was realized without complications. Conclusion: In children suffering from migraine with visual aura, which presents less often than migraine without aura, a cranial MRI should be considered, as it may be the first clinical sign of rare cerebrovascular disorders.

P16.34 * BEVACIZUMAB TREATMENT FOR ACOUSTIC NEURINOMA IN NEUROFIBROMATOSIS TYPE 2: A CASE REPORT

Neurofibromatosis type 2 (NF2) is a dominantly inherited genetic condition. Unlike patients with sporadic tumours, NF2 patients often have multiple meningiomas, acoustic neurinomas and ependymomas. The multiplicity of tumours make surgery and radiation therapy for all tumours impracticable. In effect, bilateral acoustic neurinomas are the hallmark of this disease and these tumours cause progressive hearing loss in most patients. Neovascularization is necessary for tumour growth and is driven by tumour produced angiogenic factors such as vascular endothelial growth factor (VEGF). Bevacizumab is a humanized monoclonal antibody that neutralizes the activity of VEGF. Recent data showed that VEGF is produced by schwannoma tumour cells. Also, bevacizumab treatment, in patients with NF2 who were considered poor candidates for surgery and radiation therapy, was followed by clinically meaningful hearing improvement and tumour-volume reduction. We report the case of a 39 years old woman with sudden rightsided hearing loss. Magnetic resonance imaging (MRI) revealed multiple meningiomas and neurinomas (C2 and L5 lesions) and a right side acoustic neurinoma of 26x24 mm, confirming the diagnosis of NF2. Bevacizumab was given as an infusion every 2 weeks at a dose of 5.0 mg/kg body weight. Before the treatment, the patient has a thorough medical evaluation including blood pressure, urine analysis, liver and kidney function tests, coagulation status and history of thrombosis, hemoglobin, leukocyte count and thrombocyte count. Three months after the start of therapy the patient has reported an hearing response with progressive improvement in audiometry, word recognition and face-to-face conversation. Six months after the start of therapy, the right acoustic neurinoma had regressed and, also, mitigation of brain stem compression was clearly visible on the cranial MRI scans. The patient, after 12 months, continued to be treated with bevacizumab. In our experience no toxic effects drug-related has been seen; anyway, the absence of many common toxic effects of bevacizumab in our patient may have reflected her youth and the lack of other medical conditions. The exact mechanism of the action of bevacizumab on acoustic neurinomas remains to be elucidated. The drug may also suppress growth of tumour Schwann cells directly, a possibility that can be tested in vitro in future studies. The encouraging results with bevacizumab suggest consideration of a prospective clinical trial for progressive NF2-related acoustic neurinomas, especially for patients with imminent total hearing loss.

Relationship of age with the size of the interventricular foramina and aqueductus sylvii: a morphometric evaluation

Objectives:The ventricular system is an essential part of the brain. Various pathologies directly or indirectly affect the size of this system. Morphometric analysis of the cerebral ventricular system is important for evaluating changes due to growth, aging, and intrinsic and extrinsic pathologies. The aim of this study was to evaluate the normative data for the interventricular foramina and cerebral aqueduct with regard to surgery and clinical situations.Methods:Cranial magnetic resonance imaging (MRI) scans of 128 healthy subjects (63 female subjects, 65 male subjects; 2–63 years old) were individually reviewed. The right and left interventricular foramina lengths and diameters and the cerebral aqueduct length and diameter were statistically evaluated and compared between sexes and among age groups.Results:There were no significant differences among the age groups in either sex (P > 0·05). Additionally, there was no correlation between age and measurement parameters (P > 0·05).Discussion:We did not observe any changes in interventricular foramina or cerebral aqueduct measurements in healthy subjects from a wide range of age groups. Such changes should be useful for diagnosing diseases that affect the ventricular system and planning surgical procedures, especially those involving the ventricular system.

Neurological involvement in children with E. coli O104:H4-induced hemolytic uremic syndrome

The aim of this study was to analyze the neurological involvement and outcome in pediatric patients with hemolytic uremic syndrome (HUS) during the 2011 epidemic caused by Escherichia coli O104:H4. Clinical data and data from magnetic resonance imaging (MRI) scans and electroencephalography (EEG) during the acute phase of the disease and during follow-up at 3 and 6 months were analyzed in 50 patients. Twenty-five of these patients underwent neuropsychological testing (WISC IV) during follow-up. Neurological involvement (stupor or coma, seizures, visual disturbances, paresis, myocloni) was initially observed in 14/50 (28%) patients. One patient died. EEG abnormalities were more frequent in patients with neurological involvement than in those without (12/14 vs. 13/25, respectively). Cranial MRI scans were analyzed in nine patients with neurological involvement, of whom five showed abnormal findings. At the 3- and 6-month follow-ups, EEG abnormalities were found in 14/40 (35%) and 7/36 (19%) patients, respectively, whereas 28/42 (67%) and 17/39 (44%) patients, respectively, complained about on-going reduced performance. Neuropsychological testing showed a slightly lower global intelligence quotient in patients with neurological involvement versus those without (113.4 ± 2.8 vs. 119.4 ± 1.8, respectively). Neurological involvement was frequent in our cohort. Accordingly, the incidence of pathological EEG findings was high, even in patients without clinical signs of neurological involvement. Nevertheless, major neurological sequelae were rare, and neuropsychological outcome was favorable after 6 months.

Combined visual and motor evoked potentials predict multiple sclerosis disability after 20 years

Background: The development of predictors of multiple sclerosis (MS) disability is difficult due to the complex interplay of pathophysiological and adaptive processes. Objective: The purpose of this study was to investigate whether combined evoked potential (EP)-measures allow prediction of MS disability after 20 years. Methods: We examined 28 patients with clinically definite MS according to Poser’s criteria with Expanded Disability Status Scale (EDSS) scores, combined visual and motor EPs at entry (T0), 6 (T1), 12 (T2) and 24 (T3) months, and a cranial magnetic resonance imaging (MRI) scan at T0 and T2. EDSS testing was repeated at year 14 (T4) and year 20 (T5). Spearman rank correlation was used. We performed a multivariable regression analysis to examine predictive relationships of the sum of z-transformed EP latencies (s-EPT0) and other baseline variables with EDSST5. Results: We found that s-EPT0 correlated with EDSST5 (rho=0.72, p<0.0001) and ΔEDSST5-T0 (rho=0.50, p=0.006). Backward selection resulted in the prediction model: E (EDSST5)=3.91–2.22×therapy+0.079×age+0.057×s-EPT0 (Model 1, R2=0.58) with therapy as binary variable (1=any disease-modifying therapy between T3 and T5, 0=no therapy). Neither EDSST0 nor T2-lesion or gadolinium (Gd)-enhancing lesion quantities at T0 improved prediction of EDSST5. The area under the receiver operating characteristic (ROC) curve was 0.89 for model 1. Conclusions: These results further support a role for combined EP-measures as predictors of long-term disability in MS.

Increased Arterial Diameters in the Posterior Cerebral Circulation in Men with Fabry Disease

A high load of white matter lesions and enlarged basilar arteries have been shown in selected patients with Fabry disease, a disorder associated with an increased stroke risk. We studied a large cohort of patients with Fabry disease to differentially investigate white matter lesion load and cerebral artery diameters. We retrospectively analyzed cranial magnetic resonance imaging scans of 87 consecutive Fabry patients, 20 patients with ischemic stroke, and 36 controls. We determined the white matter lesion load applying the Fazekas score on fluid-attenuated inversion recovery sequences and measured the diameters of cerebral arteries on 3D-reconstructions of the time-of-flight-MR-angiography scans. Data of different Fabry patient subgroups (males – females; normal – impaired renal function) were compared with data of patients with stroke and controls. A history of stroke or transient ischemic attacks was present in 4/30 males (13%) and 5/57 (9%) females with Fabry disease, all in the anterior circulation. Only one man with Fabry disease showed confluent cerebral white matter lesions in the Fazekas score assessment (1%). Male Fabry patients had a larger basilar artery (p<0.01) and posterior cerebral artery diameter (p<0.05) compared to male controls. This was independent of disease severity as measured by renal function and did not lead to changes in arterial blood flow properties. A basilar artery diameter of >3.2 mm distinguished between men with Fabry disease and controls (sensitivity: 87%, specificity: 86%, p<0.001), but not from stroke patients. Enlarged arterial diameters of the posterior circulation are present only in men with Fabry disease independent of disease severity.

GLOBUS PALLIDUS HIGH–SIGNAL LESIONS: A PREDOMINANT MRI FINDING IN CHILDREN WITH NEUROFIBROMATOSIS TYPE 1

IntroductionLesions of the brain recognised as unidentified bright objects (UBOs) are commonly observed as areas of increased T2–weighted signal intensity on Magnetic resonance imaging (MRI) in children with neurofibromatosis type...

Brain and lung metastasis of Bartholin’s gland adenoid cystic carcinoma: a case report

IntroductionAdenoid cystic carcinoma of Bartholin’s gland is a very rare disease.Case presentationA 48-year-old premenopausal woman of Caucasian origin was delivered adjuvant pelvic and inguinal radiotherapy after prior complete left Bartholin’s gland tumor excision and inguinal lymph node dissection for adenoid cystic carcinoma of Bartholin’s gland with one metastatic inguinal lymph node.Two years after primary treatment, she presented to the Emergency Room with acute headache, hypoacousia, decrease in visual acuity, and a decrease in right leg muscle strength. A cranial magnetic resonance imaging scan demonstrated three cystic brain lesions with associated perifocal edema. Chest and abdomen computed tomography scans and a magnetic resonance imaging scan of the pelvis did not find any metastatic or residual disease elsewhere. A physical examination found no local recurrence.Stereotactic brain biopsies with pathology examination revealed the presence of adenoid cystic carcinoma metastasis. She thus received 30Gy of brain radiotherapy but, three months later, the brain lesions did not decrease in size and left mid lobular lung lesions appeared on her chest computed tomography scan. A mid left lobe lung excision was undertaken followed by chemotherapy consisting of six cycles of cyclophosphamide, adriamycin and cisplatin. Five months after beginning chemotherapy, the brain disease progressed and our patient died.ConclusionOur case report shows the difficulty in managing brain and lung metastasis of Bartholin’s gland adenoid cystic carcinoma as no consensus on the optimal treatment exists.

Schizophrenia and mega cisterna magna: case report

Mega cisterna magna (MCM) is a developmental malformation of the posterior fossa, morphologically vermis and cerebellar hemispheres are intact. Although the relationship between this anomaly and psychiatric disorders is emphasized, its nature has not fully understood. In this article, we report a case of schizophrenia detected mega cisterna magna. A 35-year-old, married, housewife, graduated from primary school, female patient was brought to our clinic by her relatives with complaints of disorganized and inappropriate speech, strange behavior. She had auditory and visual hallucinations, delusions of reference and persecution. Neurological examination and EEG examination were normal, but mega cisterna magna was disclosed in her cranial magnetic resonance imaging scan. The relationship between psychosis and clinical significance of MCM has not defined completely yet. The role of the cerebellum in schizophrenia has been highlighted by Andreasen’s hypothesis of ‘cognitive dysmetria’. This hypothesis suggests that cerebellum has a role in general dyscoordination of sensorimotor and mental processes which are seen in schizophrenic patients. Schizophrenic patients are known to have problems about memory and verbal fluency, too. In the context of this case, the relationship of schizophrenia with cerebellar anomalies was reviewed. Key words:

Globus pallidus high-signal lesions: A predominant MRI finding in children with neurofibromatosis type 1

Introduction:Lesions of the brain, recognized as unidentified bright objects (UBOs), are commonly observed as areas of increased T2-weighted signal intensity on magnetic resonance imaging (MRI) in children with neurofibromatosis type 1 (NF1). Identification of these lesions is not currently encompassed in the National Institute of Health (NIH) diagnostic criteria for NF1.Objective:We aimed to determine the prevalence of UBOs in children with NF1 and identify areas of the brain that are commonly affected by these lesions, allowing us to evaluate whether UBOs should be included in the diagnostic criteria for the diagnosis of NF1.Materials and Methods:We reviewed the cranial MRI scans of 22 children who had been diagnosed with sporadic or familial NF1 in accordance with the criteria established by NIH. UBOs were present in 81% of the children with NF1.Results:These lesions have a predilection for specific areas of the brain, including the globus pallidus (72%), cerebellum (66%), brainstem (27%) and cerebral hemispheres (16%). The prevalence of UBOs identified varied significantly with age and sex; they were infrequent in children less than 4 years of age but were common in those aged between 4 and 12 years of age. UBOs were more commonly seen in males (66.6%) compared with females (33.3%). Repeat MRI scan on a subset of these patients with UBOs did not show any significant changes despite a worsening in clinical symptoms.Conclusion and Discussion:We have shown that UBOs are a common finding in children with NF1, and are most prevalent between the ages of 4 and 12 years. Many sites of the brain are affected by these lesions, most notably the globus pallidus and the cerebellum. Further research must be conducted to elucidate the significance of UBOs in patients with NF1 and whether these lesions have any utility in the clinical detection of NF1.

Abusive head trauma: Report of 3 cases

Abusive head trauma (AHT) is perpetrated when an infant or young child is shaken violently by an abuser, resulting in injuries to various intracranial structures, historically called "shaken baby syndrome" (SBS). Three cases of AHT with different constellations of clinical symptoms are presented here. Case 1- Three-month-old female infant was admitted with recurrent seizures, drowsiness, and low grade fever. Ophthalmologic examination revealed retinal hemorrhages (RH) in the left eye. Computed tomography of cranium showed left frontal intra-parenchymal subdural hematoma (SDH). Case 2- Twelve-month-old male infant was admitted with a history of favoring left leg. Ophthalmologic examination revealed RH in the right eye. Cranial magnetic resonance imaging (MRI) revealed subacute SDH in the right frontoparietal region. Case 3- Three-month-old male infant was admitted with irritability and seizures. Ophthalmologic examination revealed bilateral disseminated RH. Cranial MRI scan showed bilateral frontoparietal subacute SDH. All cases were reported to Child Protective Services, who decided not to remove children from homes, but evaluated psychosocial risks and developed a safety plan, including home visits and family education. Physicians must be aware of possibility of AHT in infants presenting both subtle and overt neurologic symptoms. It is important to provide training on AHT to staff involved in the management of these cases.

Brain abscess in a recent immigrant

A 7-year-old boy who has recently immigrated from India presented with two episodes of focal seizure over a 3-month period. A cranial magnetic resonance imaging scan showed a ring-enhancing lesion in his cerebral cortex. He was diagnosed with a pyogenic brain abscess following resection of the lesion and also had positive serology to Taenia solium (which causes neurocysticercosis). We briefly review these two diseases and discuss the important diagnostic issues.

Metastatic pituitary carcinoma in a patient with acromegaly: a case report

IntroductionAsymptomatic pituitary abnormalities occur in about 10% of cranial magnetic resonance imaging scans, but metastatic carcinoma of the pituitary gland is rare: 133 cases have been reported. Two thirds secreted either prolactin or adrenocorticotropic hormone, and another 24% were non-secreting.Case presentationA 42-year-old Caucasian man lived for 30 years after the diagnosis of a pituitary tumor whose clinical and biochemical features were those of acromegaly and hypogonadism. Radiotherapy, totaling 7300 rad, was administered to the sella over two courses. Growth hormone levels normalized, but he developed both thyroid and adrenal insufficiency, and replacement therapy was commenced. Fourteen years later, growth hormone levels again became elevated, and bromocriptine was commenced but led to side effects that could not be tolerated. An attempted surgical intervention failed, and octreotide and pergolide were used in succession. Twenty-seven years after the diagnosis, a mass from an excisional biopsy of below the angle of the mandible proved to be metastatic pituitary carcinoma. Immunohistochemical staining was positive for synaptophysin, growth hormone, and prolactin. One year later, an octreotide scan showed uptake at the sella, neck, and spleen. Our patient declined further active oncology treatment.ConclusionsMetastatic pituitary carcinoma associated with acromegaly is particularly rare. To the best of our knowledge, this is the eighth such case and is the first report of growth hormone and prolactin present in the metastatic mass.