Reyna De La Garza Karla,  Salinas Puente Estefany,  Mercado Flores Mariana,  Rodríguez Garza Claudia,  Maya Garcia Haziel,  Montemayor Martinez Alberto

Final Pr. ID: Poster #: CR-030

Encephalitis is a rare neurological disease which a viral infection or an autoinmune disorder can cause. Regardless of the etiology, the presentation is widely varied with symptoms stemming from headaches to hallucinations to cardiac dysrhythmias. A diagnosis is most commonly reached through an elimination process, due to the vague nature of the symptoms.
The purpose of this case is to showcase a patient in which the classical imaging findings of an autoimmune encephailits were absent, in favor of an atypical presentation.
A 19-year-old female began with an episode of auditory hallucinations accompanied by a headache, all resolved without treatment. A week later she developed irrational fear as well as nausea and seizures. Visual hallucinations followed, with an altered state of consciousness, memory loss, and a fever of over 100°F. She was admitted into emergency care, where a head CT scan was performed, which revealed a generalized and diffuse decrease in density of the white matter, corresponding to cerebral edema. Spinal fluid revealed a high protein count, with normal glucose and white blood cell count. An electroencephalogram resulted in the presence of theta brain waves with the absence of an epileptogenic area, which indicates a disfunctional neurological state. The patient developed respiratory distress requiring intubation and was admitted into the intensive care unit with a new treatment of antiviral medicine, with the new diagnostic suspicion of encephalitis. A contrast-enhanced thoracoabdominal CT was performed, which revealed a right adnexal theratoma, guiding the diagnostic suspicion to an anti-NMDA induced encephalitis, for which a brain contrast-enhanced MRI was performed, with no classical findings present such as hippocampal atrophy and temporal lobe hyperintensity; instead the T2-based sequences showed cystic oval lesions in the frontal, temporal and occipital lobe, as well as diffuse hyperintensity of white matter, susceptibility weighted sequences showed focal round hypointesities corresponding to microhemorrhages distributed through the entirety of the white matter, and the gadolinium-enhanced sequence showed avid enhancement of the cystic lesions. A second spinal fluid test revealed antibodies against NMDA receptors and immunoglobulin treatment was administered with a poor response from the patient who presented heart failure shortly after and died. Read More

Authors:  Reyna De La Garza Karla , Salinas Puente Estefany , Mercado Flores Mariana , Rodríguez Garza Claudia , Maya Garcia Haziel , Montemayor Martinez Alberto

Keywords:  encephalitis, autoimmune, neuroradiology

Bhatia Aashim,  Henry M.,  Feygin Tamara,  Christian Cindy

Final Pr. ID: Poster #: EDU-065

Abusive head trauma is associated with high morbidity and mortality. The evidence-based identification, care, and protection of infants and young children who are victims of AHT is critical. A diagnosis of AHT is made after careful consideration of the history provided, constellation of injuries identified, in conjunction with any additional diagnostic evaluation, as appropriate. This multidisciplinary educational module will focus on the evidence-based evaluation of intracranial findings when abusive head trauma (AHT) is a consideration, highlighting the importance of collaboration between child abuse pediatricians (CAPs) and pediatric neuroradiologists.

Framing the discussion with multiple cases, we will (1) describe the varied clinical presentations of abusive head trauma, (2) describe a general approach to the medical evaluation of abnormal intracranial findings when abuse is a concern; (3) present the differential diagnosis including traumatic and medical causes; (4) discuss appropriate imaging evaluation including neuroimaging (brain, spine) and skeletal imaging approaches; (5) report imaging findings found more commonly in AHT; (6) underscore the importance of collaboration between child abuse pediatricians and neuroradiologists; (7) highlight key literature, including the 2018 SPR-supported AHT consensus statement, to reference in practice, and, finally; (8) discuss consideration of language to include in imaging reports when abuse is a concern.

Following completion of the educational module, the learner will be familiar with the medical and imaging evaluations when AHT is considered, be able to describe imaging findings that are more commonly associated with AHT, and be familiar with references from the literature for self-study. Read More

Authors:  Bhatia Aashim , Henry M. , Feygin Tamara , Christian Cindy

Keywords:  Child Maltreatment, Abusive Head Trauma, Neuroradiology

Gokli Ami,  Shekdar Karuna,  Reid Janet

Final Pr. ID: Paper #: 174

Both neuroradiologists and pediatric radiologists require unique skills to confidently manage pediatric neuroradiology cases either in a community setting, or in a specialized pediatric tertiary care hospital. We conducted a needs assessment of pediatric radiologists to define their neuroradiology subspecialty training experience and identify perceived skills and knowledge gaps as well as their attitudes toward a customized pediatric neuroradiology curriculum. Read More

Authors:  Gokli Ami , Shekdar Karuna , Reid Janet

Keywords:  Needs assessment, pediatric neuroradiology, training

Mirza Eushaa,  Aziz Sumaiya,  Ajilogba Kaseem,  Delf Jonathan,  Dickinson Fiona,  Samanta Rajib,  Patel Ushma,  Swienton David,  Sharaf Ahmed

Final Pr. ID: Poster #: CR-044

Case:

We present the case of a 3 year old male patient who presented to ED with right sided weakness and facial drooling post fall with head injury. On examination, there was residual right sided weakness with poor eye contact and communicative difficulties.

Urgent CT Head revealed a focal, well defined hypo-attenuation in the left basal ganglia (Figure 1).

Subsequent MRI Head and Angiogram demonstrated an anomalous origin of the left middle cerebral artery (MCA) and lenticulostriate arteries on Time of Flight (TOF) angiographic images. The left internal cerebral artery (ICA) gives off the left posterior communicating artery which loops back on it giving off a very small MCA and forming a large, odd looking A1 anterior cerebral artery (ACA) (Figure 2). The left lenticulostriate arteries arise on the horizontal segment of the loop which forms the A1 ACA (Figure 2).

The left perforator territory demonstrates high T2/FLAIR signal with diffusion restriction involving the left putamen and upper aspect of the left caudate nucleus as seen on CT (Figure 3).

The patient was initiated on antiplatelet therapy with aspirin. He subsequently represented two months later with transient left sided weakness. Neurological examination was grossly normal apart from a slow gate.

Repeat MRI demonstrated reduction in the extent of the previous T2 signal abnormality within the left putamen consistent with expected evolution of previous infarct (Figure 4).

Dual antiplatelet therapy with the addition of clopidogrel was initiated. Subsequent clinical follow up found improvement in his verbal ability and eye contact.

Discussion:

There are numerous reported anatomical variants involving the MCA, such as a duplicated, accessory and fenestration, which are related to the embryological development of the MCA (1-3). Recently, twig-like MCA’s have been reported which are likely thought to be a secondary consequence to developmental stenosis of the proximal MCA (4). There are currently no case reports describing the anomalous distal ICA, ACA and MCA findings such as those in our case report. We hypothesise that the patient clinical symptoms are likely due to the anomalous origin and tortuosity of the lenticulostriate arteries resulting in hypoperfusion and ischaemia (5). Clinical improvement was demonstrated after initiating antiplatelet therapy. Moreover, interestingly despite the small calibre MCA there was no evidence of ischaemia within this territory. Read More

Authors:  Mirza Eushaa , Aziz Sumaiya , Ajilogba Kaseem , Delf Jonathan , Dickinson Fiona , Samanta Rajib , Patel Ushma , Swienton David , Sharaf Ahmed

Keywords:  Pediatric Neuroradiology, Pediatric Stroke

Holz Emily,  Fisher Paul

Final Pr. ID: Poster #: CR-050

Neurocysticercosis (NCC) is the result of infection of the nervous system by the larvae of Taenia solium—the pork tapeworm. It is endemic in regions of Latin America, Sub-Saharan Africa, and Asia, however, is also of concern in non-endemic regions as a result of immigration and travel to endemic regions. NCC is a major cause of seizures, however disease presentation varies based on the number, growth, and location of lesions as well as the inflammatory response of the host. In addition to seizures, other common clinical manifestations are headaches, intracranial hypertension, focal deficits, and altered mental status. Case Presentation: A 13-year old female with a history of intermittent headaches presented to the emergency department with severe headache, nausea and vomiting, and altered mental status. Upon evaluation, the patient had a Glasgow Coma Scale score of 8, indicative of a severe level of brain injury. A brain MRI revealed a non-enhancing “cystic” ovoid lesion filling much of the third ventricle. A subsequent CT revealed a scolex (anterior end of the tapeworm) with obstructive hydrocephalus at the level of the third ventricle and cerebral aqueduct. NCC has 3 stages—vesicular, colloidal or granular, and calcified—each with characteristic findings on imaging. In the vesicular stage, imaging shows cysts with central hyperdensity on CT representing the scolex. In the colloidal or granular stage, imaging shows cysts with surrounding enhancement and edema, and in the calcified stage, calcifications are visible. In this case, the patient appeared to be at the end of the vesicular stage, transitioning into the colloidal or granular stage as there was evidence of a scolex on CT and a cystic lesion with interstitial edema, however it was non-enhancing. Additionally, in NCC parenchymal lesions are most common, and with antiparasitic treatment, have a generally benign prognosis. Extraparenchymal disease, which includes ventricular cysts as seen in this patient, is less common and is not benign, often resulting in obstructive hydrocephalus, also evident in this patient, and may even result in death. Based on imaging findings, the patient underwent fenestration of the cyst and biopsy, which revealed fragments of a parasitic organism. NCC can result in life-threatening consequences including hydrocephalus, herniation, and edema, so while treatment generally consists of anti-inflammatory and antiparasitic medications, surgery may be indicated in some patients. Read More

Authors:  Holz Emily , Fisher Paul

Keywords:  Pediatric Neuroradiology, Hydrocephalus, Brain MRI

Rana Abhilasha,  Mansfield Kori,  Radder Shrinivas,  Razzaq Sania,  Jayappa Sateesh,  Charles Glasier,  Ramakrishnaiah Raghu,  Murphy Janice

Final Pr. ID: Poster #: EDU-028

Dandy-Walker continuum is a group of posterior-fossa malformations which presents as posterior-fossa cyst with variable degree of vermian hypoplasia on antenatal ultrasound. However, evaluation of posterior fossa is limited on antenatal ultrasound. Fetal MRI provides excellent evaluation of posterior fossa including cerebellar vermis and biometric measurements for accurate characterization of Dandy-Walker Continuum which includes classic Dandy-Walker malformation, Vermian hypoplasia, Blake pouch cyst and Mega cisterna magna (in the order of severity).
In this pictorial review we will provide a step-wise approach for accurate characterization of Dandy-Walker continuum on fetal MRI through various case-based illustrations, biometric measurements (tegmentovermian angle, vermian and lateral ventricle size) and position of 4th ventricle choroid plexus. Associated findings like ventriculomegaly, corpus callosal agenesis, cortical migrational anomalies will also be demonstrated. This will aid pediatric radiologists in providing accurate antenatal diagnosis of Dandy-Walker continuum which is helpful for post-natal management as severe cases require immediate shunting and milder cases require only follow-up. Read More

Authors:  Rana Abhilasha , Mansfield Kori , Radder Shrinivas , Razzaq Sania , Jayappa Sateesh , Charles Glasier , Ramakrishnaiah Raghu , Murphy Janice

Keywords:  Fetal Magnetic Resonance Imaging, Dandy-Walker Continuum, Neuroradiology

Shukla Neal,  Kim Joseph,  Hammer Matthew,  Tu Long,  Rao Balaji

Final Pr. ID: Poster #: CR-051

Reversible cerebral vasoconstriction syndrome (RCVS) is commonly seen in middle-aged patients. This syndrome is characterized by thunderclap headaches which may not be apparent or recognized in pediatric patients, posing a challenge in diagnosis. Several medications have been associated with the development of RCVS, though they are not reliably known to cause it: highlighting the potential influence of other underlying predisposing factors. RCVS is self-limiting with treatment focused on reducing the degree of vasoconstriction.
A 7-year-old male patient with a medical history of B-cell acute lymphoblastic lymphoma, currently undergoing treatment with intrathecal methotrexate, cytarabine, and IV vincristine was admitted to our institution for acute perforated appendicitis. On the second day of hospitalization, the patient developed left arm weakness which prompted evaluation with MRI/MRA brain. Imaging revealed restricted diffusion in the left superior frontal gyrus with corresponding low ADC values and mild T2/FLAIR signal suggestive of an acute ischemic infarct. Vascular imaging showed a beaded appearance of the supraclinoid ICA, ACA and MCA bilaterally. Transcranial doppler study of the arteries confirmed elevated velocities consistent with multifocal stenoses. Initial differential diagnoses included acute ischemic infarct secondary to vasculitis with infectious causes considered due to the patient’s neutropenic state. Although, there was no evidence of vasculitis in other regions of the body and a primary CNS vasculitis typically presents with bilateral infarcts. Methotrexate leukoencephalopathy was also considered, although it typically affects white matter, primarily in the centrum semiovale. Posterior reversible encephalopathy syndrome was another possibility, but the absence of cerebral microhemorrhages argued against this. Given the vascular and ischemic findings, RCVS was ultimately suspected. A follow-up MRI performed several days later revealed a new infarct in the right frontal lobe. Notably, repeat CTA imaging showed complete resolution of the arterial stenoses, further supporting the diagnosis of RCVS.
This case illustrates the diagnostic challenge of RCVS in a pediatric patient with comorbidities that initially pointed towards a neoplastic or infectious etiology. Although not performed in the presented case, vessel wall MRI may be a useful tool in differentiating between arterial narrowing from vasculitis versus RCVS or atherosclerosis. Read More

Authors:  Shukla Neal , Kim Joseph , Hammer Matthew , Tu Long , Rao Balaji

Keywords:  RCVS, Acute Lymphoblastic Leukemia, Neuroradiology

Kuehne Alexander,  Chen Danling,  Hwang James,  Ehrlich Lauren,  Lisse Sean

Final Pr. ID: Poster #: CR-046

Meningoceles in the cranium occur when an osseous defect in the skull base allows for the protrusion or herniation of the meninges into the extracranial compartment. Meningoceles vary in severity and may be asymptomatic or complicated by meningitis, brain abscess, pneumocephalus, or cerebrospinal fluid leak. Meningoceles can be congenital, traumatic, iatrogenic (such as in sinus or craniofacial surgery), spontaneous (due to increased intracranial pressure) or idiopathic. The most common sites of meningoceles in the skull base are the cribriform plate, sphenoid sinus, perisellar region, and tegmen tympani or mastoideum. Accurate and timely detection is essential for avoiding complications of meningoceles. Localization of the site of the meningoceles and assessment of their size and composition is accomplished through a variety of imaging techniques, such as with CT or MR myelography. Surgical repair of meningoceles may be accomplished through both open and endoscopic approaches.
A 2-year-old male patient with a past medical history of febrile seizures and postinfectious hydrocephalus requiring ventriculoperitoneal shunt placement and multiple shunt revisions initially presented with emesis and lethargy concerning for shunt malfunction. MRI showed a fluid-signal intensity located adjacent to the petrous portion of the right temporal bone, extending caudally to the right upper neck, which raised concern for cerebrospinal fluid (CSF) leak. Lumbar puncture was notable for an elevated CSF opening pressure of 40 cm H2O. CT myelogram confirmed a small (7mm) meningocele protruding through an osseous defect in the right jugular foramen, which completely opacified with intrathecally-injected contrast. Delayed images obtained following two hours further demonstrated subtle contrast enhancement surrounding the right jugular vein in the upper neck, raising concern for a slow CSF leak from the meningocele. Due to elevated CSF opening pressure, shunt malfunction was theorized to be the cause of the patient’s emesis and lethargy. Shunt was revised and patient was subsequently able to be discharged. Repeat follow up imaging demonstrated stabile size of patient’s meningocele. Due to small size, and resolution of patient’s symptoms following shunt revision, patient’s meningocele will be followed with recurrent MR imaging. Read More

Authors:  Kuehne Alexander , Chen Danling , Hwang James , Ehrlich Lauren , Lisse Sean

Keywords:  CSF, MRI, Neuroradiology

Lee Justine,  Patel Roshni,  Bell Lena,  O'neill Kimberly,  Cohen Benjamin

Final Pr. ID: Poster #: EDU-068

Myelin oligodendrocyte glycoprotein (MOG) antibody-associated disease (MOGAD) is a condition in which serum antibodies are targeted against central nervous system (CNS) myelin-forming oligodendrocytes, resulting in an acquired monophasic or relapsing-remitting CNS demyelination. The histopathology and imaging manifestations of MOGAD differ from that of other demyelinating disorders, such as Multiple Sclerosis or Neuromyelitis Optica Spectrum Disorders. Age dependent MOGAD presentations have also been reported, in which pediatric patients often present with acute disseminated encephalitis (ADEM) or brain lesions, followed by optic neuritis, among others. This contrasts with that of the typical adult presentation of optic neuritis, followed by transverse myelitis and a smaller proportion presenting with ADEM. Our educational exhibit will showcase the CT and MR imaging spectrum of pediatric MOGAD in patients at our institution, including: 1) ADEM, 2) transverse myelitis, 3) optic neuritis, and 4) other atypical manifestations, including ophthalmologic findings of papilledema.

We also discuss the concurrent finding of elevated intracranial pressure (ICP) in our cases, its presumed pathophysiology in the setting of MOGAD, and brief discussion of the current literature in which little is known about how elevated ICP affects MOGAD disease presentation, prognosis, and management. Interestingly, despite markedly elevated lumbar puncture opening pressures in our pediatric MOG patients, our patients did not demonstrate classic imaging findings of intracranial hypertension, such as those seen in idiopathic intracranial hypertension. This finding is both clinically and radiologically significant, as clinicians aim to better understand the purported disease course, manage MOG-associated intracranial hypertension, and stratify risk in patients demonstrating elevated lumbar puncture opening pressures on admission. Our exhibit will add a neuroradiology imaging component to the literature as we strive to comprehensively understand pediatric MOGAD in the subset of patients who demonstrate associated elevated intracranial pressures. Read More

Authors:  Lee Justine , Patel Roshni , Bell Lena , O'neill Kimberly , Cohen Benjamin

Keywords:  Demyelination, Neuroradiology, Pediatric Neuroradiology

Lara Nunez Denny,  Harder Sheri,  Tshuma Makabongwe,  Azma Roxana

Final Pr. ID: Poster #: CR-056

Fulminant demyelinating diseases include acute disseminated encephalomyelitis (ADEM), myelin oligodendrocyte glycoprotein antibody associated disease (MOGAD), multiple sclerosis (MS) and neuromyelitis optica-spectrum disorders (NMOSD), among others.
The purpose of this case report is to present the evolving MRI/MRS findings in a patient with fulminant MS.

A seven year old female presented with a 3 day history of progressive encephalopathy, gait disturbance and urinary incontinence. She had a recent viral upper respiratory tract infection. Interestingly, family history revealed the diagnosis of multiple sclerosis in the patient’s mother. Brain MRI revealed extensive T2/FLAIR hyperintense lesions, predominantly related to the cerebral and cerebellar white matter, with associated incomplete rim and central enhancement and marginal diffusion restriction. MRS showed decreased NAA, elevated choline and a prominent lactate peak. Accompanying bilateral anterior optic neuritis and papillitis was noted with T2 hyperintensity, enhancement and diffusion restriction.
Immune suppressive treatment was initiated. Short interval serial follow up demonstrated progressive confluence of the lesions with increasing edema. While overall enhancement and diffusion restriction decreased, there was a new leading edge of diffusion restriction and enhancement, mainly in the bifrontal region. A persistent inflammatory signature was demonstrated on MRS. Subsequent follow up demonstrated some cerebral volume loss with resolving edema, enhancement and diffusion restriction.
An extensive autoimmune panel was negative, including aquaporin 4 antibodies, NMO and MOG antibodies. Although CSF was sent for oligoclonal bands (OCBs), the sample volume was inadequate for testing on the first lumbar puncture (LP). OCBs were not identified on subsequent LP obtained after initiation of treatment.

Pediatric MS is defined when the onset is before the age of 16 with less than 1% of patients presenting under the age of 10. Marburg variant is a rare, rapidly progressive, fulminant form of multiple sclerosis with high morbidity and mortality rates. Fulminant ADEM typically presents as a monophasic demyelinating disease and is often preceded by a viral or bacterial infection. In this case, the patient fulfilled Mc Donald diagnostic criteria 2024 for MS with initial typical MS lesions in ≥4 central nervous system topographies. Read More

Authors:  Lara Nunez Denny , Harder Sheri , Tshuma Makabongwe , Azma Roxana

Keywords:  Brain MRI, Pediatric Neuroradiology

Trofimova Anna,  Reddy Kartik,  Bajaj Manish,  Goldman-yassen Adam

Final Pr. ID: Poster #: EDU-046

A broad spectrum of intracranial cysts and cystic-appearing lesions exist with unique imaging and pathologic characteristics. Some cysts have a predilection for certain intracranial locations, which, in combination with specific imaging features, can help point towards a particular pathology and, in some cases, associated syndromes. Herein, we describe a pattern-based approach for evaluation of intracranial cysts and cystic lesions in order to narrow the differential diagnosis and assist in diagnosing an associated syndrome. Cyst pathologies to be discussed include: Arachnoid cysts, dermoid/epidermoid cysts, subependymal cysts, connatal cysts, cystic encephalomalacia, neuroglial cyst, perivascular spaces, choroid plexus cysts, and choroidal fissure cysts. Syndromes and conditions to be discussed include: Aicardi Syndrome (interhemispheric cysts), congenital muscular dystrophy (cerebellar cysts), congenital CMV (anterior temporal cysts), Zellweger syndrome (caudothalamic groove cysts), Glutaric Aciduria type 1 (middle cranial fossa cysts), and trisomy 18 (choroid plexus cysts). By being familiar with the pattern-based approach to characterization of the intracranial cystic lesions, radiologists can hone their differential diagnoses and differentiate benign/incidental lesions from ones that signify a broader pathology. Read More

Authors:  Trofimova Anna , Reddy Kartik , Bajaj Manish , Goldman-yassen Adam

Keywords:  Cyst, Brain, Neuroradiology

Lewis Heidi,  Kucera Jennifer

Final Pr. ID: Poster #: EDU-038

The pediatric orbit presents a wide spectrum of possible abnormalities which differ significantly from those seen in adults. Evaluation of the various pediatric orbital abnormalities depends on radiologic assessment with different imaging techniques to aid in diagnosis. The purpose of this exhibit is to describe and differentiate the more commonly encountered pediatric orbital abnormalities using a multimodality approach. Read More

Authors:  Lewis Heidi , Kucera Jennifer

Keywords:  Orbit, Neuroradiology, Head and Neck

Shah Summit,  Rusin Jerome,  Krishnamurthy Rajesh,  Adler Brent H.

Final Pr. ID: Poster #: SCI-052

RADPEER has been criticized for lack of clinical implications, yet few studies have compared RADPEER to alternative peer-review systems or correlated peer review scores with changes in patient management. We aimed to implement a pediatric subspecialty over-read program and compare RADPEER to a Clinical Outcomes Scale, which graded impact on patient outcomes. Read More

Authors:  Shah Summit , Rusin Jerome , Krishnamurthy Rajesh , Adler Brent H.

Keywords:  Quality, Safety, Neuroradiology

Park Seungweon,  Sarma Asha,  Dewan Michael,  Leschied Jessica,  Greene Elton,  Pruthi Sumit,  Martin Dann,  Foust Alexandra

Final Pr. ID: Poster #: EDU-081

Spinal cord lipomas are rare benign tumors of adipose tissue that have a range of presentations and management based on size, location, and embryogenesis. Importantly, the intradural lipomatous tissue can act as a tethering lesion placing the cord at risk of vascular compromise, particularly during periods of growth. Since spinal lipomas cause progressive disease and symptoms, early recognition and treatment in the pediatric population is beneficial. Neurosurgical literature supports further classification of spinal lipomas as dorsal, transitional, terminal, and chaotic based on location and imaging features for risk stratification, surgical planning, and prognostication. Although categorization for the purpose of guiding surgical management is based on imaging features, there currently is lack of representation of this classification system for spinal cord lipomas in the radiology literature.

The aim of this exhibit is to educate pediatric radiologists about this classification system for spinal cord lipomas. Relevant anatomy and embryogenesis will be reviewed, and case-based examples will be used to illustrate relevant imaging features of each type of spinal lipoma. Findings impacting surgical planning and prognosis will be specifically highlighted. Read More

Authors:  Park Seungweon , Sarma Asha , Dewan Michael , Leschied Jessica , Greene Elton , Pruthi Sumit , Martin Dann , Foust Alexandra

Keywords:  spinal lipoma, embryogenesis, neuroradiology

Rana Abhilasha,  Mansfield Kori,  Radder Shrinivas,  Razzaq Sania,  Jayappa Sateesh,  Charles Glasier,  Ramakrishnaiah Raghu,  Murphy Janice

Final Pr. ID: Poster #: EDU-025

Ultrasound is the initial modality for assessment of fetal anatomy. Fetal ventriculomegaly is detected in 1% of antenatal ultrasounds, further evaluation may be limited due to head position, acoustic shadow from skull bones and lack of contrast resolution. By overcoming these limitations fetal MRI plays an important role in diagnostic work-up of ventriculomegaly and aids in further characterization of associated anomalies. It is important for pediatric radiologists to be aware of various causes of ventriculomegaly, associated central nervous system and other anomalies as accurate antenatal diagnosis aids in determining further management (fetal surgery, mode of delivery, post-natal treatment).
This educational exhibit will provide comprehensive review of role of fetal MRI in ventriculomegaly including fetal MRI sequences, broad spectrum of ventriculomegaly cases (rare syndromic cases- Neu Laxova, Aicardi syndrome; cebocephaly, holoprosencephaly, migrational anomalies, hydranencephaly, unilateral lateral ventriculomegaly, aqueductal stenosis, interhemispheric cyst, Chiari-2, intracranial hemorrhage), classification of ventriculomegaly (classified as developmental, obstructive and destructive with ex-vacuo ventricular dilatation) and associated anomalies (facial, spinal, limb, gastrointestinal, genitourinary). A comprehensive understanding of ventriculomegaly and associated anomalies on fetal MRI will aid the pediatric radiologists in arriving at accurate diagnosis. Read More

Authors:  Rana Abhilasha , Mansfield Kori , Radder Shrinivas , Razzaq Sania , Jayappa Sateesh , Charles Glasier , Ramakrishnaiah Raghu , Murphy Janice

Keywords:  Fetal MRI, Ventriculomegaly, Neuroradiology

Hammer Matthew,  Kim Joseph,  Shukla Neal,  Tu Long,  Rao Balaji

Final Pr. ID: Poster #: CR-053

Septo-optic dysplasia is a rare condition with an estimated prevalence of 1 in 10,000-50,000 live births. Characteristic features include optic nerve hypoplasia, septum pellucidum absence, and hypothalamic-pituitary dysfunction; at least two features are needed to make the diagnosis. The disease has phenotypic variation, with only 30% of patients exhibiting the full triad of findings. In newborns, the disease can be suspected in the setting of hypoglycemia, jaundice, microphallus, and ocular abnormality. We present multiple cases of septo-optic dysplasia.

Case 1: A newborn term female was found to have hyperbilirubinemia and hypoglycemia shortly after birth. Subsequent MRI brain without contrast showed right temporal open lip schizencephaly, a large right middle cranial fossa arachnoid cyst, and dysplasia of the bilateral optic nerves. Upon follow-up, the patient reached her growth milestones but had vision deficits.

Case 2: A 12-year-old boy presented with concern for delayed growth. Per his parents, he had a remote history of septo-optic dysplasia, but outside imaging was not available for review. Subsequent MRI brain and orbits with and without contrast showed open-lip right frontal schizencephaly, bilateral hypoplastic optic nerves, a hypoplastic pituitary gland with an ectopic posterior pituitary, and a left middle cranial fossa arachnoid cyst. X-ray of the hand and wrist showed a 5-year delayed skeletal age. Lab values were consistent with panhypopituitarism, and the patient was started on growth hormone. Follow up imaging when the patient was 18 years old showed congruent skeletal and chronological age.

Case 3: A 14-year-old boy who had been wearing glasses since he was 4 years old presented for worsening vision. On fundoscopic exam, bilateral optic nerve hypoplasia was noted. Follow-up MRI brain with contrast showed an absent septum pellucidum and bilateral optic nerve hypoplasia without brain parenchymal abnormality. The patient was referred to endocrinology for further workup.

Overall, septo-optic dysplasia remains a rare condition with variable phenotypic expression and morbidity for patients. Since the disease is part of a larger spectrum, it should remain on the differential for young patients with pituitary dysfunction and/or vision abnormalities. Timely diagnosis allows for faster treatment and appropriate management of hypopituitarism and brain parenchymal abnormalities. Read More

Authors:  Hammer Matthew , Kim Joseph , Shukla Neal , Tu Long , Rao Balaji

Keywords:  Septo-Optic Dysplasia, Neuroradiology

Shah Isha,  Joshi Priscilla

Final Pr. ID: Poster #: EDU-082

The dengue virus, an RNA virus from the Flaviviridae family, is typically considered non-neurotropic. Dengue encephalitis is caused by four strains DENV1 to DENV4. While the dengue virus generally does not affect the nervous system, DENV2 and DENV3 can be neurotropic. Symptoms of dengue encephalitis include headaches, seizures, and changes in consciousness.

In dengue encephalitis, areas most commonly affected are the basal ganglia, thalamus, brainstem, cerebellum, cortical white matter, periventricular white matter, and cortical gray matter. On T2-weighted and FLAIR sequences, these areas appear hyperintense, while on T1-weighted images, the lesions may be iso- or hypointense. Micro-hemorrhages show as blooming on susceptibility-weighted MRI. MRI is essential for the initial assessment of suspected dengue encephalitis and for patients with dengue fever experiencing worsening neurological symptoms.

Our presentation highlights the need to understand the relevant imaging findings and possible causes of neurological issues in dengue-infected patients, as this is crucial for accurate diagnosis and effective treatment, leading to better outcomes. Read More

Authors:  Shah Isha , Joshi Priscilla

Keywords:  Neuroradiology, Infection, Pediatric Imaging

Mceniery Jane,  Corness Jonathan

Final Pr. ID: Poster #: CR-015

To report an unusual case of synchoronous primary brain tumours of two different histological subtypes in the posterior fossa of a 13 year old girl. Read More

Authors:  Mceniery Jane , Corness Jonathan

Keywords:  Neuroradiology, Oncology, MRI

Creeden Sean,  Dahmoush Hisham,  Guimaraes Carolina

Final Pr. ID: Poster #: EDU-079

Brainstem anomalies pose a diagnostic challenge for trainees to even the most advanced in their practice. Our exhibit aims to provide a comprehensive review of these rare disorders which are being diagnosed earlier and more frequently utilizing advanced imaging and genetic sequencing techniques. Representative images of these disorders with key distinguishing features will be presented. Familiarity with these conditions will benefit practicing radiologists, radiologists in training, and our clinical colleagues. Read More

Authors:  Creeden Sean , Dahmoush Hisham , Guimaraes Carolina

Keywords:  fetal imaging, neuroradiology, MRI

Kuehne Alexander,  Chen Danling,  Hwang James,  Tu Long,  Ehrlich Lauren,  Lisse Sean

Final Pr. ID: Poster #: CR-055

Parechovirus infection is a recognized cause of childhood meningoencephalitis with distinctive neuroimaging findings. Human parechovirus (HPeV) is a single-RNA virus from the Picornaviridae viral family transmitted through respiratory or gastrointestinal contact. While the clinical presentation of parechovirus infection usually manifests as mild, self-limiting symptoms, in rare cases, the virus may infect the central nervous system and result in seizures, encephalopathy, and permanent neurologic disability. Pediatric patients younger than two years of age are at greatest risk for central nervous system (CNS) infection. CNS viral infection may be confirmed by lumbar puncture. Typical imaging features of parechovirus encephalitis on brain MR imaging include a diffuse pattern of restricted diffusion involving the subcortical and deep periventricular white matter, predominantly within the frontoparietal region, with additional involvement of the corpus callosum and the bilateral thalami. The differential diagnosis of similar radiologic presentations includes other causes of viral encephalitides (such as rotavirus, chikingunya, and HSV), hypoxic-ischemic encephalopathy, leukodystrophy, and rare genetic metabolic disorders.
A two-week-old male patient without significant past medical history presented to the pediatrician with irritability and increased work of breathing. Within a day, the patient developed worsening tachypnea, increased grunting, pallor, lethargy, and exanthem of the chest and neck. The patient presented to the hospital and was intubated for respiratory distress. Continuous electroencephalography recorded during inpatient admission was notable for abnormal ictal burden consistent with status epilepticus. Brain MR imaging was obtained, and demonstrated the characteristic imaging findings of parechovirus infection of diffuse abnormal restricted diffusion throughout the bilateral subcortical and periventricular white matter, corpus callosum, and thalami, with sparing of the cortex. HPeV RNA was positive in PCR assays of cerebrospinal fluid, serum, and stool. Patient received 2 doses of intravenous immunoglobulin. Unfortunately, there is no current further treatment for parechovirus infection and our patient ended up succumbing to the disease. We hope that this case presentation highlights the unique imaging feature characteristics of parechovirus and can help include this rare infection on the differential for pediatric radiologists moving forward. Read More

Authors:  Kuehne Alexander , Chen Danling , Hwang James , Tu Long , Ehrlich Lauren , Lisse Sean

Keywords:  Meningitis, Infection, Neuroradiology

Soker Tom,  Wien Michael

Final Pr. ID: Poster #: EDU-062

Objectives:
To review normal neonatal brain anatomy as seen on ultrasound.
To review the pathophysiology of common brain injuries in premature neonates.
To detail the utility of ultrasound and MRI in evaluation of common neonatal brain injuries.

Table of contents:
US evaluation of the neonatal brain
–Review standard views
–Review normal neonatal brain anatomy
Pathophysiology of Germinal Matrix Hemorrhage (GMH)
Review of ultrasound and MRI findings in GMH
–Initial injuries, and how they evolve over time
–Sample cases and mimics
Pathophysiology of Periventricular Leukomalacia (PVL)
Review ultrasound and MRI findings in PVL
–Initial injuries, and how they evolve over time
–Sample cases
Summary and key facts Read More

Authors:  Soker Tom , Wien Michael

Keywords:  Germinal Matrix Hemorrhage, Brain Ultrasound, Pediatric Neuroradiology

Mansfield Kori,  Rana Abhilasha,  Radder Shrinivas,  Razzaq Sania,  Charles Glasier,  Murphy Janice,  Jayappa Sateesh,  Ramakrishnaiah Raghu

Final Pr. ID: Poster #: EDU-064

Introduction: Radiology residents typically receive limited exposure to dental radiology during their training. However, they frequently encounter dental pathologies while scanning the brain or maxillofacial regions for other clinical purposes. Understanding basic principles of dental radiology is essential for accurately assessing maxillo-facial computed topography (CT) scans, as these pathologies can go under-recognized and potentially have significant impact on diagnosis and treatment. Purpose: This study aims to highlight the importance of dental radiology knowledge for radiology residents and fellows. By recognizing dental pathologies in imaging studies, radiologists can contribute to better management and care of pediatric patients. Discussion: This will be a pictorial educational exhibit obtaining cases from the teaching database at a pediatric tertiary care hospital. We will present cases in a pictorial format, primarily focusing on conventional CT, orthopantomograms (OPG), and cone-beam computed topography (CBCT). The discussion will cover various dental pathologies encountered, including: Impacted Dental Prosthesis: Leading to maleruption of the teeth, a dentist’s perspective; Prosthesis Malfunction: Identifying signs of failure and the implications for patient care; Post-Maxillofacial Surgery Complications: Examining alterations due to mechanical stress on the mandible, leading to exostosis and other lesions; Dental issues in Syndromes affecting the Faciocranium: Dental issues in well-known syndromes such as Pierre Robin, hemifacial microsomia, Goldenhar syndrome, etcetera; Unexpected Findings: Perforation of the mandibular fossa into the middle cranial fossa as a sequalae of juvenile inflammatory arthritis and trauma. Read More

Authors:  Mansfield Kori , Rana Abhilasha , Radder Shrinivas , Razzaq Sania , Charles Glasier , Murphy Janice , Jayappa Sateesh , Ramakrishnaiah Raghu

Keywords:  Computed Tomography, Neuroradiology, Diagnostic Accuracy

Mendoza Venegas Diego,  Herrera Ernesto,  Rodríguez Garza Claudia,  Elizondo Riojas Guillermo

Final Pr. ID: Poster #: CR-054

Mitochondrial Encephalomyopathy with Lactic Acidosis and Stroke-like Episodes (MELAS) is a rare mitochondrial disorder primarily affecting children and young adults, typically presenting between the ages of 2 and 40. It is characterized by tRNA mutations that lead to deficiencies in respiratory chain protein complexes, resulting in disrupted intracellular energy production and impaired cellular function. Common clinical manifestations include stroke-like episodes, hemiparesis, seizures, recurrent headaches, and muscle weakness, with progressive cerebral atrophy and cognitive decline occurring over time. Diagnosis often relies on magnetic resonance imaging (MRI), which frequently shows cortical lesions that do not follow vascular territories.
This case report details an 11-year-old girl who presented in early 2023 with severe new-onset headaches and blurred vision. After multiple consultations with pediatricians and neurologists, a brain MRI was ordered, revealing chronic stroke-like lesions in various regions, predominantly in the posterior brain, along with calcified basal ganglia and a lactate doublet on spectroscopy. Lactic acidosis was detected, and genetic testing confirmed MELAS syndrome due to a mutation in the MT-TL1 gene (m.3243A>G). Following her diagnosis, she began treatment with Coenzyme Q10, L-Arginine, and L-Carnitine. However, earlier this year, she was hospitalized again due to right-sided hemiparesis. A follow-up MRI showed a new stroke-like lesion in the left precentral gyrus, characterized by cortical diffusion restriction and high signal intensity on the FLAIR sequence, exemplifying the characteristic migrating stroke-like lesions associated with MELAS. In conclusion, this case highlights the critical importance of early recognition and diagnosis of MELAS, a rare mitochondrial disorder characterized by complex neurological manifestations. Key MRI findings, including stroke-like lesions that migrate without adhering to vascular territories, a lactate doublet on MR spectroscopy, and calcified basal ganglia, are vital for diagnosis. Ultimately, confirming the diagnosis through genetic testing is essential for effective management and treatment. Read More

Authors:  Mendoza Venegas Diego , Herrera Ernesto , Rodríguez Garza Claudia , Elizondo Riojas Guillermo

Keywords:  Mitochondrial Disease, Neuroradiology, Brain MRI