Review the causes of cerebral hemorrhage in the pediatric patient based on clinical cases. Stroke is a major cause of morbidity and mortality in children worldwide. The reported annual incidence ranges from 2.3 to 13 per 100,000 children per year in developed countries. In contrast to the adult, in children, diagnosis is not as straightforward, because when children present with acute neurological deficits, stroke is often not the first diagnosis considered by the medical providers. Neuroimaging is essential for diagnosis and differentiation of stroke from stroke mimics that can present similarly. Stroke in children can be ischemic or hemorrhagic, referring to the term hemorrhagic stroke as a intracerebral hemorrhage that is nontraumatic and whose most common etiology is secondary to a vascular malformation (Arteriovenous Malformation (AVM), Dural/Pial Arteriovenous Fistula (Dural AVF/Pial AVF), Cavernous Malformation, Vein of Galen Aneurysmal Malformation (VGAM), Developmental Venous Anomaly (DVA), Capillary telangiectasia, Sinus Pericranii, Aneurysms). The most commonly used classification of vascular malformation is based on angioarchitectural and histomorphological characteristics. To differentiate these classic types, in a first step, shunting lesions have to be discerned from nonshunting lesions, as well as other features of the vascular contribution that will be evaluated by image. We cannot forget the hemorrhage associated with coagulopathy, haematological disorders, brain tumors and cerebral sinovenous thrombosis (CSVT) which in the latter case can be found as venous infarction or hemorrhage; and other less common causes of hemorraghe in pediatrics as the intracranial aneurysms, in 15% of all pediatric aneurysms are secondary to an infection (micotic aneurysm). Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Rodríguez Garza Claudia, Guillen Gutierrez Cinthia, Elizondo Riojas Guillermo

Keywords: vascular malformations, hemorrhage, pediatric stroke

Atretic cephalocele is a rare disruption of neural tube closure. The reported incidence ranges from 1 in 3500 to 1 in 5000 live births. Is a small subscalp lesion that consist of dura, fibrous tissue, and dysplastic brain tissue. Its most common presentation it is a palpable midline parietal soft tissue mass, occasionally occipital, with a wide range of clinical presentations, the patient may have normal neurological development or have severe mental retardations, since it could be associated with multiple intracranial malformations including a fenestrated superior sagittal sinus (the most common), persistent falcine sinus, vertical embryonic positioning of the straight sinus, holoprosencephaly, hydrocephalus, eye anomalies, agenesis of the corpus callosum, among others, therefore is important to know about this condition as well as to identify its radiological characteristics using different diagnostic imaging methods to make a certain diagnostic. Transfontanellar brain ultrasound could be used as the first imaging method as it enables a non-invasive method, in addition the patients are not exposed to ionizing radiation, being the most consistent finding a subcutaneous, hypoechoic mass, with a solid fibrous tract connecting the extracranial lesion, through a small bony cranium defect, to the intracranial space; additionally in order to evaluate a further extension of the fibrous tract or the presence of other anomalies, CT or MRI can be performed, considering to the MRI as a better study because it can be used in pediatric population since there is no exposure to radiation. Main differential diagnoses of atretic cephalocele are sinus pericranii and dermoid cyst, other possible causes include haemangioma, sebaceous cyst, inclusion cyst, lipoma, tumors (Langerhans cell histiocytosis, sarcomas, etc.), bone and soft tissue infections and traumatic lesions. This educational poster pretends to review the radiological findings of two cases of patients with atretic cephalocele moreover a literature review since the published works regarding is limited and few case series or case reports have been documented. Read More

Meeting name: SPR 2022 Annual Meeting & Postgraduate Course , 2022

Authors: Ortega García Diana, Rodríguez Garza Claudia, Canales Nañez Sofìa, Terán Helda Estrella, Montemayor Martínez Alberto

Keywords: ATRETIC CEPHALOCELE, CYST, SCALP MASS

Intracranial hemorrhage (ICH) and ischemic brain injury are rare in the fetus. The most common location of hemorrhage in the fetus is intraventricular and is related to prematurity. Intracranial hemorrhage in the fetus can be intra or extra-axial and its recognition is important because of its complications and poor outcome. The causes of fetal intracranial hemorrhage are idiopathic, maternal, and of the fetus; maternal causes vary, and the main is trauma. Domestic violence increases during pregnancy, placing the mother and the fetus at risk for injury. Features of central nervous system nonaccidental trauma in pediatric patients are well established, however, there are not too many examples in the literature of these imaging findings in the fetal stage. The purpose of this case is to demonstrate the features of intracranial hemorrhage and ischemic brain injury caused by nonaccidental trauma during pregnancy and the evolution after birth. The subject of this case report is a 36-week gestation product referred because of severe ventriculomegaly detected during an obstetric ultrasound; a fetal MRI was performed which showed an acute to subacute hemispheric bilateral subdural hematoma, infratentorial subdural hemorrhage, retroclival hematoma, subarachnoid hemorrhage, ventriculomegaly, brain edema, and midline shift. The patient was born at 38 weeks through C-section with no respiratory effort and a 4 points APGAR score, he was intubated and spent 38 days in the NICU, during his stay a postnatal transfontanelar ultrasound and a brain MRI were performed and showed persistence of the supratentorial and infratentorial subdural hematomas bigger in size with an epidural component, retroclival hematoma, subarachnoid hemorrhage, brain edema, midline shift, uncal herniation and hemispheric ischemic vascular event. The etiology of this extensive and atypical presentation hemorrhage was inquired including coagulation and genetic disorders, and the medical background of the parents which came out normal; after thorough interrogation, the mother revealed trauma related to domestic violence. In our case, we will show that the localization and features of nonaccidental trauma of the central nervous system in the fetal stage are similar to the pediatric stage. Read More

Meeting name: SPR 2023 Annual Meeting & Postgraduate Course , 2023

Authors: Salinas Puente Estefany, Blanqueto Fuentes David, Rodríguez Garza Claudia, Dávila Escamilla Ivan, Montemayor Martínez Alberto

Keywords: Fetal, Trauma, Head

Myelination it's a dynamic process through which a lipoprotein sheath that covers the axons develops. It begins at the 4th month of gestation and reaches its maximum at 24 months and occurs from caudal to rostral, from dorsal to ventral, from central to peripheral <b>Normal myelination by MRI </b> Sequences <b>T1 </b>key sequence to evaluate myelination &lt;1 year. The signal reflects the presence of proteins <b>T2 </b>key sequence to evaluate myelination 1 and 2 years As the myelin sheaths thicken the surrounding interstitial water moves <b>FLAIR, DP, DTI </b>complementary sequences <b>T1WI</b> <b>RN </b>Brain stem, optical tracts, anterior commissure, ventral thalamus, posterior limb of the internal capsule, rolandic and perirolandic gyrus <b>2 months </b>deep white matter and anterior limb of internal capsule <b>4 months</b> Splenium, optical radiations become more evident, cerebellar white matter <b>6 months</b> Genu, body and splenus of the corpus callosum <b>8 months </b>U fibers in occipital lobes progressing slowly to frontal and temporal at one year of age. <b>10-12 months </b>Appearance of myelination with adult pattern in T1WI <b>T2WI RN </b>Dorsal brain stem, posterior limb of the internal capsule, ventral thalamus, perirolandic gyrus <b>2 months </b>Posterior internal capsule arm, semiovale centrum and optical tracts <b>4 months </b>Optical radiation and subcortical white matter <b>6 months </b>Splenium <b>8 months </b>Genu, body and splenic corpus callosum, anterior arm of the internal capsule <b>12 months </b>cerebellar white matter and occipital subcortical U fibers <b>18 months </b>Frontal white matter. Some residual hyperintense signals around the trigons of the lateral ventricles <b>36 months </b>Myelination appearance with adult pattern in T2WI <b>Myelination Terminal Zones</b> Normal variant of development Zones of incomplete myelination Hyperintense, bilateral and symmetric foci in dorsolateral WM to the atrium of the lateral ventricle <b>Abnormal Patterns</b> <b>Delayed myelination </b>Situations in which myelination is slow but present.Usually bilateral and symmetric <b>Hypermyelination </b>Rare pathology, it can be local or generalized. Sturge Webber, epilepsy and late sequelae of perinatal hypoxia. <b>Hypomyelinization </b>Permanent deficit of the myelin deposit. Unlike the delay of myelination these do not present myelination over time It can be seen as normal myelination in T1 but with deficit in T2 <b>White matter diseases</b> <b>Demyelinating diseases</b> They are acquired and have destruction of normal myelin <b>Demyelinating diseases </b>Hereditary enzyme deficiency that causes abnormal myelin formation, destruction or turnover Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Guillen Gutierrez Cinthia, Rodriguez Garza Claudia, Elizondo Riojas Guillermo, Hernández Grimaldo Edgar, Garza Acosta Andrea

Keywords: Development, white matter

Cystic fibrosis (CF) is caused by autosomal-recessive mutations in the CF transmembrane regulator (CFTR) gene. Results in production of abnormally viscous mucus and secretions in the lungs of patients It is the most common genetic disorder leading to chronic pulmonary disease in children. In the lung, the cystic fibrosis transmembrane regulator (CFTR) is a protein responsible for efflux of chloride and inhibition of the sodium channel's activity which controls the influx of sodium. Pulmonary manifestations of CF includes Bronchiectasis Pneumothorax Recurrent bacterial infection Pulmonary arterial hypertension <b>Chest XRAY: </b>is inferior to CT for the assessment of patients with known bronchiectasis. Nevertheless, radiography remains a useful modality for assessing the pulmonary complications associated with bronchiectasis, because of its low cost, availability, low radiation dose, and speed of acquisition <b>Brasfield scoring system</b> The score is based on conventional chest radiographic findings and has been reported to have good correlation with pulmonary function. There is a maximum score of 25 with points subtracted based on the score from each of the following categories: <b>Air trapping:</b> generalized pulmonary overdistension (sternal bowing, depression of diaphragms, or thoracic kyphosis) <b>Linear markings </b>Linear opacification due to prominence of bronchi; may be seen as parallel line densities, branching, or “end-on” circular densities (bronchial wall thickening) <b>Nodular cystic lesions: </b>multiple discrete rounded densities ≥0.5 cm in diameter, with either radiopaque or radiolucent centers (bronchiectasis); does not refer to irregular linear markings; confluent nodules not classified as large lesion <b>Large lesions:</b> segmental or lobar atelectasis or consolidation, including acute pneumonia. <b>General severity: </b>impression of overall severity on chest x-ray <b>HRCT</b> has become indispensable in the monitoring of CF patients and is used to guide therapy and assess response to treatment, as it not only correlates with lung function tests. Scans are repeated every 6 to 18 months depending on the clinical course. <b>BHALLA SCORE SYSTEM</b> Bhalla system can assess the degree of lung involvement and the evolution of the damages caused by lung disease based on various radiological findings. It values Bronchiectasias Peribronchial thickening Extent of bronchiectasias Extent of mucous plugs Abscesses or sacculations Bronchial generations affected Number of bullae Extent of emphysema Collapse or consolidation Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Guillen Gutierrez Cinthia, Rodriguez Garza Claudia, Elizondo Riojas Guillermo, Hernández Grimaldo Edgar, Garza Acosta Andrea

Keywords: Chest CT, Chest Xray, Education

Vascular abnormalities are commonly observed in pediatric patients, with an estimated prevalence of at least 4.5%. The current classification scheme for vascular anomalies was developed in 2014 by ISSVA (International Society for the Study of Vascular Abnormalities) and is based on the work of Mulliken and Glowacki of 1982. This classification emphasizes the fundamental difference between vascular tumors and vascular malformations. The diagnosis of vascular abnormalities is based on clinical history and physical examination. <b>US: </b>Screening, proper characterization <b>TC: </b>It allows assessing the extent of the lesion and the relationship with adjacent structures <b>MRI: </b>It's the ideal imaging study and reflects its histological composition. The most commons anomalies are: <b>Hemangiomas:</b> The most frequent vascular tumors are lobed and highly vascular lesions. They have significant enhancement to the administration of contrast medium, but only moderate T2 hyperintensity that reflects their highly cellular nature. <b>Venous Malformation:</b> Malformed venous channels with slow blood flow with thrombosis and flebolite formation Important, often heterogeneous and peripheral enhancement with central progression. Hyperintense T2 signal reflects low cellularity <b>Lymphatic malformations:</b> Dilated lymphatic channels and cysts. They can be macro or microcystic Macrocystic variants appear as cysts with a very bright T2 signal and minimal enhancement (if any), bleeding is a common complication with liquid-liquid level formation. <b>Arteriovenous Malformations:</b> The main finding is empty flow due to high flow, which infiltrate the tissues without evidence of a free mass. There may be a mild enhancement and T2 hyperintensity that reflects tissue edema <b>Treatment: </b> In most cases, conservative treatment is recommended, but when a patient suffers from clinical complications sclerotherapy of the nidus becomes mandatory. A multidisciplinary approach is needed. <b>Sclerosing agents</b> <b>Alcohol 98%: </b>Strong endothelial damage, high response rate, less expensive, easy to obtain. Painful during the procedure, high complication rate, penetrative effect on the deep vascular layer <b>Ethanolamine oleate: </b>Excellent thrombogenic effect, chemical damage to the vascular wall, less toxic effect than absolute ethanol. It can induce acute renal failure due to hemolytic effect, less endothelial damage than absolute ethanol. <b>Polidocanol: </b>Overhydration of endothelial cells, almost painless procedure. May induce reversible cardiac arrest Read More

Meeting name: SPR 2020 Annual Meeting & Postgraduate Course , 2020

Authors: Guillen Gutierrez Cinthia, Rodriguez Garza Claudia, De Luna Vega Raul, Hernández Grimaldo Edgar, Elizondo Riojas Guillermo

Keywords: Hemangioma, Lymphatic Malformation, Venous Malformation

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

Meeting name: SPR 2024 Annual Meeting & Postgraduate Course , 2024

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