Normal Brain MRIs Research Articles

Computationally optimized brain tumor classification using attention based GoogLeNet-style CNN

Early detection of diseases is a crucial step towards patient healthcare and recovery, especially, for low survival rate diseases like brain cancer. In recent years, deep learning models such as convolutional neural networks (CNNs) have been widely utilized for medical image classification owing to their proficiency in extracting local features. However, accurate classification of complex medical images necessitates capturing local and global features. This paper focuses on the classification of the three most prominent kinds of brain tumors, namely, glioma, meningioma and pituitary tumor, with the proposed CNN based on the structure of GoogLeNet. The proposed model uses an attention-based inception module (ABIM) embedded with attention mechanism of spatial attention and efficient channel attention. Attention helps CNN focus on features with more distinguishing power and ignores irrelevant features while the inception approach aids in extracting multiscale local features. ABIM incorporates attention with inception to generate better feature representation. The model training and testing are done on a publicly accessible Figshare dataset with 3064 brain MRI samples. The dataset comprises 1426, 708, and 930 MRI samples of glioma, meningioma, and pituitary tumors, respectively. In a five-fold cross-validation experiment, the proposed model achieved an average accuracy of 97.97% for glioma, 94.76% for meningioma, and 99.22% for pituitary tumors. The proposed CNN model surpasses existing models with an overall accuracy of 97.62%, while utilizing fewer parameters than its base model, GoogLeNet. The model is also evaluated on datasets from the Kaggle and Harvard medical repositories, and showed promising results in distinguishing between different tumor classes, and normal brain MRIs. These results demonstrate that our model not only outperforms other existing models in terms of accuracy but also has comparatively lower computational complexity, providing a robust tool to support healthcare professionals.

Examination of the Development and Asymmetry of the Cerebellum and Its Lobules in Individuals Aged 1-18 Years: A Retrospective MRI Study.

Developmental studies of cerebellar lobules were limited. To our knowledge, structural asymmetry has not been studied in immature cerebellar lobules in the 1-18 age group. This study investigated the effect of age and gender on the volumetric development and asymmetry of the global cerebellum and cerebellar lobules in children and adolescents. In this retrospective study, we included 670 individuals [376 (56.1%) males] aged 1-18years with normal brain MRIs between 2012 and 2021. volBrain CERES automatically segmented the right and left sides of the cerebellar lobules on three-dimensional T1-weighted MRIs. Volume and asymmetry data from individuals in 16 different age ranges were compared with SPSS (ver.28). The absolute volumetric development of the total cerebellum was consistent with the "S" development model in both sexes. The developmental trajectories of the cerebellar lobules were different from each other and showed sexual dimorphism. In the 1-18 age group, the absolute volumes of the total cerebellum and cerebellar lobules were significantly greater in males (p < 0.05). Absolute volumes of lobules IV, VIIB, VIIIA and VIIIB in the age groups had more gender differences. However, sexual dimorphism was insignificant in the cerebellum's total and lobular relative volume. Lobules IV, V, VI, VIIIA and VIIIB had left > right asymmetry and other lobules and total cerebellum had right > left asymmetry. This study confirmed the developmental heterogeneity and sexual dimorphism in the cerebellar lobules. It also provided volumetric data of the immature cerebellum to enable comparison in various neurological and neuropsychiatric diseases.

A novel classification method combining phase-field and DNN

This paper proposes a novel classification method. Firstly, we use the deep neural network (DNN) to classify the training set. After several iterations, we obtain the output vector Y. The component of the largest value in vector Y is represented as the label being classified, which we take as the output value. Because we chose the sigmoid function as our activation function, the output value is between 0 and 1. Therefore, the output value can represents the probability of the classified label by the DNN. Depending on the distribution of output values, we set tolerance values (Tol) that categorize similar output values as the same label in the DNN. If the output value is lower than Tol, we consider it categorically anomalous. Subsequently, we use the Phase-Field model to classify these anomalies and obtain better classification results. As this classification method combines Phase-Field model and DNN, we named it Phase-Field-DNN. In the numerical experiment using MNIST handwritten digit data set as experimental data, the classification accuracy of Phase-Field-DNN model is higher than that of Phase-Field model and DNN model through the analysis of the classification results of binary classification and multi-classification problems with this data. In addition, the model we proposed is used to classify the normal and abnormal brain MRIs, and the classification results are compared with those of others. After comparison, we find that our proposed model achieve the best classification results.

Quantitative assessment of cerebrospinal fluid flow and volume in enlargement of the subarachnoid spaces of infancy using MRI.

The etiology of enlarged subarachnoid spaces of infancy is unknown; however, there is radiologic similarity with normal pressure hydrocephalus. Adults with normal pressure hydrocephalus have been shown to have altered cerebrospinal (CSF) flow through the cerebral aqueduct. To explore potential similarity between enlarged subarachnoid spaces of infancy and normal pressure hydrocephalus, we compared MRI-measured CSF flow through the cerebral aqueduct in infants with enlarged subarachnoid spaces of infancy to infants with normal brain MRIs. This was an IRB approved retrospective study. Clinical brain MRI examinations including axial T2 imaging and phase contrast through the aqueduct were reviewed for infants with enlarged subarachnoid spaces of infancy and for infants with a qualitatively normal brain MRI. The brain and CSF volumes were segmented using a semi-automatic technique (Analyze 12.0) and CSF flow parameters were measured (cvi42, 5.14). All data was assessed for significant differences while controlling for age and sex using analysis of covariance (ANCOVA). Twenty-two patients with enlarged subarachnoid spaces (mean age 9.0months, 19 males) and 15 patients with normal brain MRI (mean age 18.9months, 8 females) were included. Volumes of the subarachnoid space (P < 0.001), lateral (P < 0.001), and third ventricles (P < 0.001) were significantly larger in infants with enlarged subarachnoid spaces of infancy. Aqueductal stroke volume significantly increased with age (P = 0.005), regardless of group. CSF volumes were significantly larger in infants with enlarged subarachnoid spaces of infancy versus infants with a normal MRI; however, there was no significant difference in CSF flow parameters between the two groups.

Vitamin D status and latitude predict brain lesions in adrenoleukodystrophy.

Approximately 40% of boys with X-linked adrenoleukodystrophy (ALD) develop inflammatory demyelinating brain lesions (cerebral ALD, cALD) and are at risk for death or severe disability. Risk factors for cALD are poorly understood. Our objective was to evaluate whether vitamin D status, which influences immune function, is associated with risk for cALD. We used two independent cohorts to assess whether low vitamin D status is correlated with cALD. We used complementary proxies for vitamin D status: plasma 25-hydroxyvitamin D levels and latitude. In our first cohort, we measured 25-hydroxyvitamin D in biobanked plasma samples from ALD boys with initially normal brain MRIs followed at two expert centers. In a second cohort, we measured latitude (using home ZIP code) among ALD boys identified in a national administrative database (PHIS) covering 51 US pediatric hospitals. We used logistic regression models to estimate the odds of developing cALD in each cohort. In the first cohort, we identified 20 ALD boys with a total of 53 plasma sample timepoints who met inclusion criteria; 50% (n = 10) subsequently developed cALD. Average 25-hydroxyvitamin D levels were lower among boys who developed cALD than those who did not (median 28.9 vs 36.6 ng/ml); p = 0.019. For each 10 ng/mL decrease in 25-hydroxyvitamin D, the odds ratio for developing cALD was 6.94; p = 0.044. In the second cohort, we identified 230 ALD boys across 28 states; 57% of boys (n = 132) developed cALD. Each 2° increase in latitude conferred an odds ratio of 1.17 (95% confidence interval, 1.01, 1.35); p = 0.036 for developing cALD. Using independent cohorts, we found that ALD boys with lower pre-morbid plasma levels of 25-hydroxyvitamin D, or more northerly latitude of residence, were more likely to develop cALD. These findings offer complementary lines of evidence that vitamin D and/or ultraviolet light exposure influence cALD risk.

Rapid brain MRI protocols result in comparable differential diagnoses versus a full brain protocol in most canine and feline cases.

Evaluation of brain disease in veterinary patients uses a wide variety of MRI sequences. A shortened protocol that maintains consistency of interpretation would reduce radiologist reporting time, patient anesthetic time, and client cost. The aims of this retrospective, methods comparison, observer agreement study were to evaluate whether abbreviated MRI protocols alter differential diagnoses and recommendations compared to our institution's standard protocol; evaluate interobserver agreement on standard brain MRIs; and assess whether differential diagnoses change after postcontrast images. Normal and pathologic canine and feline brain MRIs were retrieved from hospital archives. Three protocols were created from each: a 5-sequence noncontrast enhanced Fast Brain Protocol 1 (FBP1); a 6-sequence contrast-enhanced Fast Brain Protocol 2 (FBP2); and an 11-sequence standard brain protocol (SBP). Three blinded veterinary radiologists interpreted FBP images for 98 cases (1 reader/case) and SBP images for 20 cases (3 readers/case). A fourth observer compared these interpretations to the original MRI reports (OMR). Overall agreement between FBPs and OMR was good (k=0.75) and comparable to interobserver agreement for multiple reviews of SBP cases. Postcontrast images substantially altered conclusions in 17/97 cases (17.5%), as well as improved interobserver agreement compared to noncontrast studies. The conclusions reached with shortened brain protocols were comparable to those of a full brain study. The findings supported the use of a 6-sequence brain MRI protocol (sagittal T2-weighted [T2w] TSE; transverse T2w turbo spin echo fluid-attenuated inversion recovery, T2*-weighted gradient recalled echo, T1-weighted spin echo, and diffusion weighted imaging/apparent diffusion coefficient; and postcontrast transverse T1-weighted spin echo) for dogs and cats with suspected intracranial disease.

Use of deep learning in the MRI diagnosis of Chiari malformation type I

PurposeTo train deep learning convolutional neural network (CNN) models for classification of clinically significant Chiari malformation type I (CM1) on MRI to assist clinicians in diagnosis and decision making.MethodsA retrospective MRI dataset of patients diagnosed with CM1 and healthy individuals with normal brain MRIs from the period January 2010 to May 2020 was used to train ResNet50 and VGG19 CNN models to automatically classify images as CM1 or normal. A total of 101 patients diagnosed with CM1 requiring surgery and 111 patients with normal brain MRIs were included (median age 30 with an interquartile range of 23–43; 81 women with CM1). Isotropic volume transformation, image cropping, skull stripping, and data augmentation were employed to optimize model accuracy. K-fold cross validation was used to calculate sensitivity, specificity, and the area under receiver operating characteristic curve (AUC) for model evaluation.ResultsThe VGG19 model with data augmentation achieved a sensitivity of 97.1% and a specificity of 97.4% with an AUC of 0.99. The ResNet50 model achieved a sensitivity of 94.0% and a specificity of 94.4% with an AUC of 0.98.ConclusionsVGG19 and ResNet50 CNN models can be trained to automatically detect clinically significant CM1 on MRI with a high sensitivity and specificity. These models have the potential to be developed into clinical support tools in diagnosing CM1.

Functional brain connectivity in ex utero premature infants compared to in utero fetuses

Brain structural changes in premature infants appear before term age. Functional differences between premature infants and healthy fetuses during this period have yet to be explored. Here, we examined brain connectivity using resting state functional MRI in 25 very premature infants (VPT; gestational age at birth <32 weeks) and 25 healthy fetuses with structurally normal brain MRIs. Resting state data were evaluated using seed-based correlation analysis and network-based statistics using 23 regions of interest (ROIs) per hemisphere. Functional connectivity strength, the Pearson correlation between blood oxygenation level dependent signals over time across all ROIs, was compared between groups. In both cohorts, connectivity between homotopic ROIs showed a decreasing medial to lateral gradient. The cingulate cortex, medial temporal lobe and the basal ganglia shared the strongest connections. In premature infants, connections involving superior temporal, hippocampal, and occipital areas, among others, were stronger compared to fetuses. Premature infants showed stronger connectivity in sensory input and stress-related areas suggesting that extra-uterine environment exposure alters the development of select neural networks in the absence of structural brain injury.

CMET-14. BRAIN METASTASES: A NEW PATHOPHYSIOLOGY, A NEW TREATMENT PARADIGM, AND, PERHAPS, A NEW PROGNOSIS

Abstract INTRODUCTION Brain metastases are widely held to reach the CNS through the blood stream. We provide evidence that the initial site of most CNS metastases is the CSF, with subsequent invasion of brain parenchyma. We also model the therapeutic implications of this novel hypothesis. METHODS Two neuro-radiologists independently assessed whether brain metastases were contiguous with CSF spaces in 200 consecutive patients using pre-treatment MRI. CSF was examined for malignant cells in 66 newly diagnosed, previously untreated patients. We contoured normal brain MRIs of 3 patients to calculate the percentage of brain within 5 mm of a CSF space. We queried an international neoplastic meningitis database to document response of brain metastases to intra-CSF chemotherapy. RESULTS Mean age was 64.2. One hundred patients were male; 143 had lung cancer, 15 melanoma, 12 gastrointestinal, 11 breast, 9 renal, 7 bladder. Mean number of metastases was 4.63. Eighty-five percent of metastases touched a CSF space. In 67% of patients, all metastases touched a CSF space. Neither histology, number or size of metastases, nor patient age predicted contiguity with CSF spaces. In our consecutive subset of patients, 44% (10/23) with one, 46% (5/11) with two, 63% (5/8) with three, and 71% (17/24) with &gt;3 metastases had malignant cells in the CSF (R2=0.93, p=0.037). Five of 7 patients with both brain and CSF metastases receiving only IT chemotherapy experienced a substantial reduction in the size of at least some metastases. Up to 75% of the brain parenchyma lies within 5 mm of CSF spaces. CONCLUSIONS Our data suggest that brain metastases may access the CNS through the CSF rather than the bloodstream. IT chemotherapy may treat brain metastases. We suggest that the CSF should be monitored in all patients with, or at risk for, brain metastases. True cures may require treatment of the CSF space.

Wallerian Degeneration of the Cerebral Peduncle and Association with Motor Outcome in Childhood Stroke

BackgroundTo evaluate the presence of Wallerian degeneration and its relationship with sensorimotor deficits following childhood-onset arterial ischemic stroke (AIS). MethodsChildren surviving unilateral AIS older than one month of age were assessed for severity of sensorimotor neurological deficit with the Pediatric Stroke Outcome Measure at least one year post stroke (mean follow-up = 2.9 years, S.D. = ±1.6). The area (mm3) of each cerebral peduncle was measured on T2-weighted magnetic resonance images to calculate an Asymmetry Index (AI). The AI between patients with childhood stroke (cases) and controls (children with normal MRI) was compared. In the stroke group, the AI between patients with good and poor motor outcome, and the correlation between the AI and motor outcome was calculated. ResultsAsymmetry was compared in 52 children with stroke (cases) and 20 controls (normal brain MRIs). The AI was greater in patients with stroke (mean = 6.8%, S.D. = ±5.9) compared with controls (mean = 3.4%, S.D. = ±3.5, P < 0.02). Patients with poor outcome had an AI of 10% or greater compared with patients with good outcome (mean 10.4 versus 4, P < 0.001), and the AI was moderately correlated with motor deficit severity (r = 0.582, P = 0.001). ConclusionsAsymmetry of the cerebral peduncle is a feasible method of assessing Wallerian degeneration in children with unilateral AIS. The degree of asymmetry in the cerebral peduncles was moderately correlated with neurological outcome severity and reflects the degree of motor deficit in children following stroke.

Should Spinal MRI Be Routinely Performed in Patients With Clinically Isolated Optic Neuritis?

Should Spinal MRI Be Routinely Performed in Patients With Clinically Isolated Optic Neuritis?

Thalamic volume and dimensions on MRI in the pediatric population: Normative values and correlations: (A cross sectional study)

BackgroundDiagnoses of thalamic atrophy in children are based on experts’ judgments. No normative measures exist for aiding objective diagnoses. Our aim was to determine normative two-dimensions(2D) and volume measurements of the thalamus in normally developing children. MethodsMRI images of 245 patients were retrospectively collected. Only participants with normal brain MRIs were included in this cross-sectional study. Anterior-posterior (AP), transverse (T), and craniocaudal (C) diameters were measured. Volumetric masks of the thalamus were manually drawn, whereas volumetric measurements of the brain were automated. Results124 patients were male (50.6%). We tabulated our measurements from birth until 18 years old. No significant differences in the thalamus measurements are found between the two hemispheres nor between sexes. The most remarkable increase in the thalamus volume and AP dimension is noted in the first four years of life, following which the values seem to stabilize. Craniocaudal diameters seem to increase in the first year of life, whereas transverse diameters increase until the age of 14 before plateauing. ConclusionWe report normative values of the thalamus in 2D and 3D from birth until 18 years of age. A rapid increase in the thalamic size is noted during the first four years of life followed by stabilization.

Prevalence, knowledge and attitudes of healthcare professionals toward herbal medication use in pregnancy

Tumor necrosis factor-alpha inhibitors (TNFα-I) are biological agents used in the treatment of rheumatologic disorders. TNFα-I have been associated with demyelinating disorders mimicking multiple sclerosis. The goal of this report is to illustrate cases of myelopathy which developed during the use of TNFα-I.We describe the clinical, neuroimaging and laboratory features of 4 cases of myelopathy associated with TNFα-I.The mean period of TNFα-I exposure was 27 [12–36] months. Three of the four patients exhibited active inflammatory myelopathy as the spinal cord MRI lesions enhanced with gadolinium and CSF pleocytosis or oligoclonal bands were present. All patients had normal brain MRIs at the time of presentation.TNFα-I may play a role in the development of myelopathies in absence of brain involvement or other features of demyelinating disease. TNFα-I associated myelopathy should be considered in patients with history of treatment with TNFα-I who exhibit symptoms of myelopathy.

TNF-alpha inhibitor associated myelopathies: A neurological complication in patients with rheumatologic disorders

ObjectivesTumor necrosis factor-alpha inhibitors (TNFα-I) are biological agents used in the treatment of rheumatologic disorders. TNFα-I have been associated with demyelinating disorders mimicking multiple sclerosis. The goal of this report is to illustrate cases of myelopathy which developed during the use of TNFα-I. MethodsWe describe the clinical, neuroimaging and laboratory features of 4 cases of myelopathy associated with TNFα-I. ResultsThe mean period of TNFα-I exposure was 27 [12–36] months. Three of the four patients exhibited active inflammatory myelopathy as the spinal cord MRI lesions enhanced with gadolinium and CSF pleocytosis or oligoclonal bands were present. All patients had normal brain MRIs at the time of presentation. ConclusionsTNFα-I may play a role in the development of myelopathies in absence of brain involvement or other features of demyelinating disease. TNFα-I associated myelopathy should be considered in patients with history of treatment with TNFα-I who exhibit symptoms of myelopathy.

Acute Ataxia in Childhood: 11-Year Experience at a Major Pediatric Neurology Referral Center.

We categorized the causes of acute ataxia in the pediatric population-referred to the Division of Neurology-at a large, urban pediatric medical center. Of the 120 cases identified over the past 11 years, post-infectious cerebellar ataxia was the most commonly diagnosed (59%), followed by drug intoxication, opsoclonus-myoclonus ataxia syndrome, episodic ataxia, acute cerebellitis, cerebellar stroke, ADEM, meningitis, cerebral vein thrombosis, Leigh's disease, Miller-Fisher syndrome, and concussion. Among the patients with post-infectious cerebellar ataxia, 85% were 1-6 years old and all had a history of antecedent viral illness. CSF pleocytosis was present in 40% of patients; all had normal brain MRIs. The majority (91%) recovered within 30 days. We conclude that post-infectious cerebellar ataxia remains the most common cause of acute ataxia in childhood and that it carries a good prognosis. We also differentiate acute post-infectious cerebellar ataxia from other causes with similar presentations.

Elevations in MR Measurements of Whole Brain and Regional Cerebral Blood Flow and Oxygen Extraction Fraction Suggest Cerebral Metabolic Stress in Children with Sickle Cell Disease Unaffected By Overt Stroke

Positron emission tomography (PET) studies have shown that the brain increases cerebral blood flow (CBF) and oxygen extraction fraction (OEF, the fraction of oxygen brain tissue extracts from blood) when oxygen delivery is compromised in adult ischemic stroke. Children with sickle cell disease (SCD) have higher CBF compared to healthy children, suggesting that autoregulatory mechanisms, compensating for compromised oxygen delivery, may underlie the pathophysiology of ischemic stroke in SCD. Until now, evaluation of cerebral oxygen metabolism in children with SCD has been limited to measurement of CBF due to the radiation risks of PET. We used a MR sequence that measures voxel-wise OEF to test our hypothesis that children with sickle cell disease will have elevated whole brain and regional OEF when compared to typically developing, sibling controls without SCD.Thirty-six participants, 8 controls and 28 with SCD (26 HbSS and 2 HbSB0), ages 5-21 years, were recruited from St. Louis Children's Hospital. Participants underwent brain MRI with measurement of CBF via pseudo-continuous arterial spin labeling and OEF via a novel processing of asymmetric spin echo sequence that measures tissue deoxyhemoglobin. CBF and OEF maps were individually co-registered to corresponding T1 images with FMRIB's Linear Image Registration Tool, and gray and white matter were segmented with FMRIB's Automated Segmentation Tool. Visual inspection identified a region of high OEF within the deep white matter of the frontal and parietal lobes in the majority of subjects (figure 1 a,b). OEF maps from control and SCD participants were coregistered and averaged into a single map, and then an OEF threshold of 47.5% was applied to demarcate this "high OEF region" (figure 1c). Hemoglobin (Hb) and hematocrit were obtained in SCD participants, while these values were assumed for the controls. Arterial oxygen content (CaO2) was calculated as 1.36 x Hb x SpO2. Comparisons were made with a Mann-Whitney U test or Student's t-test. Bivariate correlations were tested with Kendall's tau b. Bonferroni correction was used in determining significance. Multivariate linear regression modeling with block entry described covariates associated with CBF.The control and SCD cohorts did not differ in age, gender or SpO2. SCD participants demonstrated higher whole brain, gray matter and white matter CBF and OEF when compared to controls (table 1, figure 1a-b), but there was no difference in whole brain or segmented measures of CBF and OEF between SCD participants with structurally normal brain MRIs (n=16) and silent infarcts (n=12). SCD participants' OEF was higher within the "high OEF region" when compared to controls (table 1), but the regional OEF did not differ between SCD participants with structurally normal brain MRIs versus silent infarcts. Whole brain CBF negatively correlated with age (b = -0.554, p < 0.001), while whole brain OEF did not (b= 0.014, p = 0.921). Lower CaO2 correlated with higher whole brain CBF (b = -0.329, p < 0.016) and higher whole brain OEF (b = -0.587, p < 0.001). CaO2 remained a predictor (β = -0.38, p = 0.009) of CBF when controlling for age (β = -0.63, p < 0.001).We report the first whole brain, segmented and regional analysis of oxygen metabolism, including CBF and OEF, in a pediatric SCD cohort unaffected by overt stroke. Elevation in both CBF and OEF in response to low arterial oxygen content suggests children with SCD are chronically compensating to meet the brain's metabolic demands. OEF is more elevated in children with SCD when compared to healthy controls within the "high OEF region," which coincides with previously reported locations of silent infarcts. We propose that the "high OEF region" provides a tissue signature of vulnerable, metabolically stressed brain that is at risk for future stroke. [Display omitted] [Display omitted] DisclosuresFields:Neurophage: Equity Ownership, Membership on an entity's Board of Directors or advisory committees.

Long-lasting TMS motor threshold elevation in mild traumatic brain injury

Mild traumatic brain injury (mTBI) is very common, and part of the patients experience persistent symptoms. These may be caused by diffuse neuronal damage and could therefore affect cortical excitability. The motor threshold (MT), measured by transcranial magnetic stimulation (TMS), is a measure of cortical excitability and cortico-spinal tract integrity. We used navigated TMS (nTMS) and electromyography to determine subjects' left hemisphere MTs. Nineteen subjects with mTBI (11 with persistent symptoms and eight fully recovered) and nine healthy controls were tested. The injuries had occurred on average 5 years earlier. All participants had normal brain MRIs, that is, no signs of injury. None used centrally acting medication. The mean MT in controls was 43.0% (SD 2.5) of maximum stimulator output. The mTBI subjects mean MT was 53.4% (SD 9.7), being higher than the controls' threshold. Subjective recovery did not correlate with MT. The results show chronic MT elevation in a sample of subjects with symptomatic or recovered mTBI. This suggests that mTBI may be compensated, although not fully recovered, years after the injury. While the cause for MT elevation cannot be concluded from these preliminary observations, possible explanations include decreased cortical excitability and impaired subcortical conduction.

Plasma glial fibrillary acidic protein levels in children with sickle cell disease

To determine if glial fibrillary acidic protein (GFAP) is associated with brain injury in children with sickle cell disease (SCD), we measured plasma GFAP among cross-sectional groups of unselected children with SCD, subsets of children with SCD and normal brain MRI or MRI evidence of cerebral infarct, healthy pediatric controls, and adults with brain injury. Children with SCD had higher plasma GFAP than healthy pediatric controls (mean concentrations 0.14 ± 0.37 vs. 0.07 ± 0.08 ng/mL; P 5 0.003); also, 16.0% (16/100) of children with SCD and cerebral infarct had GFAP elevations above the 95th percentile of healthy pediatric controls (P 5 0.04). Although not statistically significant, children with SCD and cerebral infarct had more elevated GFAP levels than with SCD and no infarct (16/100, 16.0% vs. 14/168, 8.3%; P 5 0.07). Children with SCD and acute brain ischemia had a higher proportion of elevated GFAP than SCD children with normal MRI (3/6, 50% vs.8.3%; P 5 0.01). GFAP was associated with elevated systolic blood pressure in the preceding year and correlated positively with white blood cell count and negatively with age and performance IQ. Plasma GFAP is elevated among children with SCD and may be associated with subclinical brain injury.

Congenital nasal pyriform aperture stenosis: Feeding evaluation and management

Purpose We identified four patients with congenital nasal pyriform aperture stenosis (CNPAS) with feeding and respiratory difficulties. While feeding difficulties have been described in infants with other causes of nasal obstruction (e.g., choanal atresia), little attention has been focused on feeding in infants with CNPAS. Findings All four patients were treated with nasal steroids and nasal saline and two underwent surgical repair of the CNPAS at 2 months of age. Except for gastroesophageal reflux in one patient, upper gastrointestinal tract (UGI) contrast studies were normal in all patients. Three patients underwent bedside swallow evaluations, two of whom participated in videoflouroscopic swallow studies (VFSS) because of limited oral intake or respiratory problems during feeding. These three patients presented with intact oral-motor coordination at rest and during non-nutritive sucking, and nasal whistling, nasal congestion, or breathing difficulties/desaturations with oral feeding. On VFSS, one infant had trace aspiration with thin and thick liquids. Three patients required supplemental feeding during the first year of life. All three patients with normal brain MRIs were successful oral feeders by 16 months of age, the fourth is undergoing feeding therapy at 24 months of age. Summary Feeding problems are common in infants with CNPAS and supplemental feedings may be needed even after management of airway difficulties. Infants with CNPAS should undergo comprehensive feeding/swallowing evaluations which may include bedside swallow evaluations and VFSSs. The prognosis for transitioning to total oral feedings is good and related to the extent of the airway obstruction and presence of other comorbidities.

Isolated labyrinthine infarction as a harbinger of anterior inferior cerebellar artery territory infarction with normal diffusion-weighted brain MRI

Objectives This paper aims to determine the frequency of isolated labyrinthine infarction as an initial manifestation of anterior inferior cerebellar artery (AICA) territory infarction and discuss its clinical implication. Methods We studied 54 consecutive patients with AICA infarction diagnosed by brain MRI from the acute stroke registry. Results We identified 4 patients (7.4%) with AICA territory infarction who initially presented with vertigo and hearing loss mimicking acute labyrinthitis and subsequently suffered from delayed neurological deficits. All patients had normal brain MRIs including diffusion-weighted images at the time of isolated audiovestibular loss, but all subsequently exhibited acute infarct(s) in the AICA territory on follow-up brain MRIs when they developed additional neurological deficits. Conclusion Labyrinthine infarction may be a warning sign of impending pontocerebellar infarction in the AICA territory. Our results indicate that even a classical peripheral presentation, e.g., acute hearing loss, and acute vertigo with unidirectional nystagmus, may be a manifestation of ischemic stroke in the posterior circulation.