To evaluate multimodal magnetic resonance imaging (MRI) characteristics in pediatric patients diagnosed with posterior reversible encephalopathy syndrome (PRES). Read More

Meeting name: IPR 2016 Conjoint Meeting & Exhibition , 2016

Authors: Mcgovern Jonathan, Zuccoli Giulio, Goyal Rakesh

Keywords: PRES, MRI, ASL, Perfusion

An 11-year-old female presented with 3-weeks history of intractable vomiting, nausea, blurred vision, vertical nystagmus and ataxia with gait instability. A CT scan revealed a small calcification at the left craniocervical junction (CJJ) and mild effacement of the fourth ventricle (Figure). MRI showed a partially-enhancing medulla oblongata lesion and a non-enhancing cystic exophytic lesion abutting the left pre-medullary cistern. There was avid thick enhancement along the ventrolateral surface of the medulla oblongata. No restricted diffusion was present. MR spectroscopy demonstrated decreased NAA and elevated lactates. Based on imaging findings, a brainstem glioma with exophytic component was suspected. The CBC, CMP, ESR and CRP were normal. The patient underwent suboccipital craniectomy with C1 laminectomy, and an exophytic pale gray mass was identified. Multiple specimens were taken, and frozen diagnosis showed only necrosis. The cyst wall was resected. Resection of the brainstem component was limited by neurophysiology. Histologically, the lesion consisted of a fibrous cyst wall lined by columnar to pseudostratified columnar epithelium, findings reflecting a neuroenteric cyst. No glial tissue was identified. Gram stain and Grocott stain were negative for bacterial and fungal specimens. An empiric treatment with wide spectrum antibiotic was started. Follow-up MRI demonstrated near complete resolution of edema in the medulla oblongata, and substantial decrease in enhancement in anterolateral exophytic component and patient has substantially improved clinically. In retrospect, a sinus tract extended from the cystic lesion at the craniocervical junction into the brainstem causing edema, inflammation and enhancement which resolved once the cyst was surgically decompressed. <b>Conclusion</b>: This case shows a neuroenteric cyst connected to the brainstem, through a sinus tract leading to chronic inflammation and infection, resulting in imaging findings resembling a brainstem glioma. Surgical decompression of the cyst and antibiotic treatment resulted in resolution of the brainstem lesion. Read More

Meeting name: SPR 2018 Annual Meeting & Postgraduate Course , 2018

Authors: Ly Juan Domingo, Subramanian Subramanian, Rajan Deepa, Greene Stephanie, Zuccoli Giulio

Keywords: Neurenteric, magnetic resonance imaging MRI, glioma

Pediatric cervical spine trauma, although rare with an incidence of only 1-2%, can have very high morbidity and mortality. The leading causes are motor vehicle collision, sports related injury and child abuse in infants. The incidence of upper cervical spine injury is more common in children than adults due to differences in biomechanics, with the pediatric head size being proportionally larger when compared to adults. Although conventional radiographs remain the standard initial imaging evaluation, CT has become an important modality to detect bony injury and subtle signs of underlying ligamentous injury and hemorrhage (although consideration must be made for the increased radiation exposure). The presence of ligamentous injury, dens synchondrosis fracture, spinal cord evaluation, and spinal cord injury without radiographic abnormality (SCIWORA), meanwhile, are better evaluated with MRI. We will review the normal appearance of the pediatric cervical spine including normal measurements on radiographs and CT, including the importance of the basion-dens interval, powers ratio, and atlanto-occipital distance with illustrations. The normal development of the cervical spine as well as CT and MRI anatomy of cervical spine ligaments will be reviewed with illustrations. Imaging findings of atlanto-occipital and atlanto-axial distraction and pediatric cervical spine fractures including clay shoveler's fracture and dens synchondrosis fractures will be illustrated with CT and MRI. Finally, a review of clinical decision criteria for pediatric cervical spine trauma and imaging approach will be presented. The importance of obtaining MRI in children under 5 years and appropriate use of imaging will also be discussed. Image 1: Sagittal CT image demonstrates increased basion to dens distance and normal atlanto-dental interval, consistent with atlanto-occipital dissociation. Image 2: T2-weighted sagittal MR image demonstrates injuries to the tectorial and posterior atlanto-occipital membranes with atlanto-occipital dissociation. There is associated epidural hemorrhage. Image 3: Sagittal CT reconstruction demonstrates a powers ratio greater than 1, raising suspicion for anterior atlanto-occipital dissociation. Read More

Meeting name: SPR 2018 Annual Meeting & Postgraduate Course , 2018

Authors: Akbari Yasmin, Subramanian Subramanian, Furtado Andre, Panigrahy Ashok, Zuccoli Giulio

Keywords: Spine, Trauma, Pediatric

Transfontanelle cranial ultrasound is widely used in the neonatal setting to screen for abnormalities, particularly in the neonatal and cardiac intensive care unit settings. Radiologists and sonographers are typically very familiar with the ultrasound appearance of germinal matrix hemorrhage in premature infants. However, other abnormalities can also be very well seen sonographically, but may be underappreciated and therefore underreported. Under recognition may delay appropriate therapy these infants. The purpose of this educational review is to demonstrate the sonographic findings in a variety of neonatal intracranial abnormities including ischemia, hemorrhage, as well as developmental and anatomical anomalies, and to compare them with what may be the more familiar cross sectional appearance, including CT and MRI. Read More

Meeting name: SPR 2017 Annual Meeting & Categorical Course , 2017

Authors: Squires Judy, Zuccoli Giulio, Lynda Flom, Subramanian Subramanian, Panigrahy Ashok

Keywords: MRI, Ultrasound