Lymphatic cells do not functionally integrate into 3D organotypic brain slice cultures, but aggregate around penetrating blood vessels.

Brain slice culture (BSC) is a well-known three-dimensional model of the brain. In this study, we use organotypic slices for studying neuro-lymphatic physiology, to directly test the longstanding assumption that the brain is not a hospitable milieu for typical lymphatic vessels. An additional objective is to model fluid egress through brain perivascular space systems and to visualize potential cellular interactions among cells in the leptomeninges including alterations of cellular geometry and number of processes. Immortalized lymphatic rat cell lines were used to seed organotypic brain slices. The brain slice model was characterized by monitoring morphologies, growth rates, degree of apoptosis, and transport properties of brain slices with or without a lymphatic component. The model was then challenged with fibroblast co-cultures, as a control cell that is not normally found in the brain. Immortalized lymphatic cells penetrated the brain slices within 2-4 days. Typical cell morphology is spindly with bipolar and tripolar forms well represented. Significantly more indigo carmine marker passed through lymphatic seeded BSCs compared to arachnoid BSCs. Significantly more indigo carmine passed through brain slices co-cultured with fibroblast compared to lymphatic and arachnoid BSCs alone. We have developed an organotypic model in which lymphatic cells are able to interact with parenchymal cells in the cerebrum. Their presence appears to alter the small molecule transport ability of whole-brain slices. Lymphatic cells decreased dye transport in BSCs, possibly by altering the perivascular space. Given their direct contact with the CSF, they may affect convectional and diffusional processes. Our model shows that a decrease in lymphatic cell growth may reduce the brain slice's transport capabilities.

Learning Curve Associated with ClearPoint Neuronavigation System: A Case Series.

BACKGROUND: The ClearPoint neuronavigation system affords real-time magnetic resonance imaging (MRI) guidance during stereotactic procedures. While such information confers potential clinical benefits, additional operative time may be needed. METHODS: We conducted a retrospective analysis of procedural time associated with ClearPoint Stereotaxis, with hypothesis that this procedural time is comparable with that associated with frame-based biopsy. RESULTS: Of the 52 patients evaluated, the total procedural time for ClearPoint stereotactic biopsy averaged 150.0 (±40.4) minutes, of which 111.5 (±16.5) minutes were dedicated to real-time MRI acquisition and trajectory adjustment. This procedural time is within the range of those reported for frame-based needle biopsies. Approximately 5 minutes of the procedural time is related to the mounting of the MRI-compatible stereotactic frame. Based on the procedural time, we estimate that four cases are required in the learning curve to achieve this efficiency. Efficient algorithms for distortion corrections and isocenter localization are keys to ClearPoint stereotaxis. Routine quality assurance/control after each MRI software update and institutional information technology maintenance also contribute to efficiency. Real-time MRI is essential for definitive diagnosis in select cases. CONCLUSIONS: ClearPoint stereotactic needle biopsy can be achieved in time frames comparable to frame-based stereotaxis. However, procedural efficiency requires 4 "learning curve" cases as well as vigilance in terms of MR distortion correction and information technology maintenance.

The effects of blood and blood products on the arachnoid cell.

After traumatic brain injury (TBI), large amounts of red blood cells and hemolytic products are deposited intracranially creating debris in the cerebrospinal fluid (CSF). This debris, which includes heme and bilirubin, is cleared via the arachnoid granulations and lymphatic systems. However, the mechanisms by which erythrocytes and their breakdown products interfere with normal CSF dynamics remain poorly defined. The purpose of this study was to model in vitro how blood breakdown products affect arachnoid cells at the CSF-blood barrier, and the extent to which the resorption of CSF into the venous drainage system is mechanically impaired following TBI. Arachnoid cells were grown to confluency on permeable membranes. Rates of growth and apoptosis were measured in the presence of blood and lysed blood, changes in transepithelial electrical resistance (TEER) was measured in the presence of blood and hemoglobin, and small molecule permeability was determined in the presence of blood, lysed blood, bilirubin, and biliverdin. These results were directly compared with an established rat brain endothelial cell line (RBEC4) co-cultured with rat brain astrocytes. We found that arachnoid cells grown in the presence of whole or lysed erythrocytes had significantly slower growth rates than controls. Bilirubin and biliverdin, despite their low solubilities, altered the paracellular transport of arachnoid cells more than the acute blood breakdown components of whole and lysed blood. Mannitol permeability was up to four times higher in biliverdin treatments than controls, and arachnoid membranes demonstrated significantly decreased small molecule permeabilities in the presence of whole and lysed blood. We conclude that short-term (<24 h) arachnoid cell transport and long-term (>5 days) arachnoid cell viability are affected by blood and blood breakdown products, with important consequences for CSF flow and blood clearance after TBI.

Cell growth of immortalized arachnoid cells in the presence of fibroblasts and blood products.

OBJECT: The pathophysiology of non-obstructive hydrocephalus involves alteration in cerebrospinal fluid (CSF) pathways. The exact mechanism is unknown, but as arachnoid CSF egress is a major route of CSF removal, damage or alteration to the growth of arachnoid cells may influence the rate of CSF absorption. We investigated the effect of soluble factors secreted by fibroblasts and the presence of blood products on arachnoid cell growth. METHODS: An immortalized arachnoid cell line was developed and cells were grown on semipermeable membranes in a culture chamber. Arachnoid cells were plated in Transwells®, with fibroblasts separated from the arachnoid cells. Cell phenotype was analyzed and cell growth rates were determined by manual counts. Similar experiments were conducted with biliverdin, bilirubin, as well as fibroblast challenge. DNA content in the cell cultures was then determined as corroborative data. Cell counts for the additional arachnoid cell lines were calculated at each day and represented the controls. RESULTS: Cell counts increased with each time point. Arachnoid cells in the three experimental conditions showed a statistically significant decrease in cell counts for each day when compared to the control group. Post hoc analysis showed differences between the control and experimental conditions but no significant difference between groups. The DNA content for each experimental condition was reduced at all time points when compared to the control arachnoid cells, but only became statistically significant at day 7. CONCLUSION: Inflammation and hemorrhage are two common conditions associated with the development of hydrocephalus. The arachnoid membrane is exposed to fibroblasts and blood products (bilirubin, biliverdin) in these conditions, and their effect on arachnoid cell growth was studied. We have shown that arachnoid cell growth decreases in the presence of fibroblasts, bilirubin, and biliverdin. Given its intimate relationship with CSF, it is possible that the decreased growth of arachnoid cells may affect absorption and thus contribute to the development of hydrocephalus.

Medication Adherence and Operating Room Efficiency for a Surgical Subspecialty.

The implementation of a 5-step reminder process and pharmacist consultation/visit improved medication adherence and reduced operative delays.

The influence of fibroblast on the arachnoid leptomeningeal cells in vitro.

OBJECTIVE: Fibroblast is pervasive in the setting of injury. Its invasion into the arachnoid tissue causes scarring, cortical adhesion of the brain, and obstruction of cerebrospinal fluid outflow. The purpose of this study is to determine the phenotypic and physiologic effects of fibroblasts on arachnoid in culture. METHODS: We studied the effects of fibroblast on the arachnoid cell growth, motility, phenotypic changes, and transport properties. Immortalized rat (Rattus norvegicus, Sprague Dawley breed) arachnoid cells were grown with fibroblast on opposite sides of polyethylene membranes or co-cultured in plastic wells. Arachnoid cell growth rate and DNA content, morphology, transport physiology, and extracellular matriceal content were determined in the presence of normal and irradiated fibroblast cells. RESULTS: When arachnoid cells were grown in the presence of fibroblasts, mannitol permeability increased and transepithelial electrical resistance (TEER) decreased. Arachnoid cell growth rate also significantly decreased. When arachnoid cells were grown in close proximity (i.e. on the same monolayer) with fibroblasts, the arachnoid cells were overrun by day 2, yet when physically separated, no significant change was seen in growth. Apoptosis increased markedly in arachnoid cultures in the presence of fibroblast. Fibroblast caused arachnoid cell to exhibit avoidance behavior, and irradiated fibroblast induced arachnoidal cells to move faster and exhibited greater directional changes. Subcellular glycosaminoglycan (GAG) content was significantly altered by fibroblast. INTERPRETATION: Fibroblasts influence arachnoid cell's mannitol transport likely via soluble factors. While the arachnoid cells did not change morphologically, cell growth was influenced. Over time, the cells had profound changes in transport and motility. The immortalized arachnoid cell/fibroblast culture system provides a unique model mimicking the pathologic event of leptomeningeal scarring.

Spontaneous frontal intradiploic meningoencephalocele.

BACKGROUND: Since 1976, 10 cases of intradiploic encephaloceles have been reported in the literature. This case is the first report of a spontaneous intradiploic meningoencephalocele of the frontal bone hypothesized to be secondary to distant head trauma. CASE DESCRIPTION: A 60-year-old female with a history of multiple traumatic head injuries as a child presenting with new onset generalized tonic-clonic seizures. Work-up revealed a right frontal epileptic focus. Imaging showed a right frontal intradiploic lesion. The patient underwent surgical resection, which during exploration was found to be an intradiploic encephalocele. She had an uneventful postoperative course with a resolution of seizures. CONCLUSIONS: The authors hypothesize that the rare nature of posttraumatic frontal intradiploic encephaloceles is due to the increased thickness of the frontal bone compared to the parietal bone.

Generation and preliminary characterization of immortalized cell line derived from rat lymphatic capillaries.

OBJECTIVE: Isolation of rodent endothelial cells from lymphatic capillaries with yields that allow extensive functional studies remains challenging due to low cell numbers, variable purity, and limited growth potential. The purpose of this study was the generation and preliminary characterization of rat lymphatic cell line with extended replicative capacity. This cell line is intended for in vitro studies of cellular transport in lymphatic endothelium and for in vivo experiments in rat animal models. METHODS: We created a novel rat lymphatic immortalized cell line, SV40-LEC, using retroviral gene transfer of SV40 large T antigen. We confirmed expression of characteristic markers and then examined its growth and transport properties. RESULTS: SV40-LECs demonstrated improved proliferative capacity, but retained morphological characteristics of lymphatic cells and expression of established lymphatic markers. The cells form capillary-like network in vitro. SV40-LEC monolayer has similar permeability to that of the primary initial lymphatics. Paracellular transport in SV40-LECs is limited for substances >70 kDa. Barrier properties of the SV40-LECs can be modulated by cyclic adenosine monophosphate and histamine, which are known to affect microvascular permeability. CONCLUSION: The SV40-LECs provide an excellent tool for in vitro studies of properties of lymphatic endothelium, and may be suitable for in vivo transplantation studies.

Arachnoid cells on culture plates and collagen scaffolds: phenotype and transport properties.

INTRODUCTION: The arachnoid tissue is a critical component of cerebrospinal fluid removal. Failure of that function results in hydrocephalus, a serious medical condition. The purpose of this study was to characterize arachnoid cell transport in culture and on three-dimensional collagen scaffold. METHODS: Arachnoid cells were harvested from rat brainstems and cultured onto bilayered bovine collagen scaffolds. Cell growth and phenotype (protein expression and morphometry) were determined. Permeability and hydraulic conductivity were quantified. RESULTS: Cells harvested from the anterior brainstem surface exhibited arachnoid cell phenotype (positive for vimentin, desmoplakin, and cytokeratin), readily penetrated the collagen scaffold, and doubled approximately every 2-3 days. The transepithelial electrical resistance value for a monolayer of cells was 160 Ω cm(2) and the permeability of indigo carmine was 6.7×10(-6)±1.1×10(-6) cm/s. Hydraulic conductivity of the collagen construct was 6.39 mL/min/mmHg/cm(2). CONCLUSION: Cells isolated from the anterior brain stem exhibited the same phenotype as those found in the native tissue and exhibited aspects of barrier function found in vivo. These studies suggest that an ex vivo model for the arachnoid granulation can be developed.

Congenital tumors of the central nervous system: the MCH experience.

INTRODUCTION: Congenital brain tumors in the younger pediatric population are rare lesions that are histologically distinct from those in the older pediatric population. Malignant histology is common, with persistently poor outcomes despite accessible neuroimaging and evolving adjuvant therapy. There remains scant literature about the natural history of these patients because of rarity and varied institutional experiences. METHODS: A retrospective review was performed of congenital brain tumor patients surgically treated at the Montreal Children's Hospital (MCH) over a 22-year period. Patients presenting in the first year of life were evaluated for demographic information, presenting symptoms, lesion location, and management. Analysis was by median rank test and chi(2) statistics. RESULTS: 13 cases of congenital brain tumors were identified: 5 supratentorial and 8 infratentorial. Median age (p = 0.93) and gender (p = 0.57) did not differ by location, and predominant histologies were choroid plexus papilloma and primitive neuroectodermal tumor. Seizure activity was exclusive to supratentorial lesions (40%, p = 0.03), with hypotonia observed only among infratentorial lesions (50%, p = 0.02). There was equal incidence of hydrocephalus (69%, p = 0.57) and increasing head circumference (38%, p = 0.27) by lesion location. Supratentorial lesions were treated by total resection (n = 3), subtotal resection (n = 1), and biopsy (n = 1). Infratentorial lesions were treated by total resection (n = 1), subtotal resection (n = 2), biopsy (n = 1), no operation (n = 2), and decompressive laminectomy for two spinal lesions. CONCLUSIONS: Congenital brain tumor patients represent fewer than 2% of patients treated at MCH. An evolving understanding of management objectives for these lesions requires understanding institutional experiences. Patients with supratentorial lesions frequently present with seizures, hydrocephalus, and macrocrania, and more frequently underwent total resection at surgery.

Progressive brainstem compression in an infant with neurocutaneous melanosis and Dandy-Walker complex following ventriculoperitoneal shunt placement for hydrocephalus. Case report.

Neurocutaneous melanosis (NM) coexisting with the Dandy-Walker complex (DWC) is a rare condition, with fewer than 15 cases reported in the literature. The authors present a case of an infant with NM and DWC suffering from progressive brainstem compression following ventriculoperitoneal (VP) shunt placement for hydrocephalus. This 1-year-old boy with congenital melanocytic nevi had met normal developmental milestones until the age of 11 months, when he began regressing in ambulation and language function. Intractable vomiting had developed 1 week later. Magnetic resonance (MR) imaging of the brain revealed DWC with hydrocephalus, and spinal MR images demonstrated a proliferative process within the meninges, consistent with NM. The patient underwent right frontal VP shunt placement resulting in immediate symptom relief, but 3 weeks later became irritable, increasingly lethargic, unable to pull to stand, and unable to tolerate solid food without choking. Due to these symptoms and intractable vomiting, the patient presented to the authors' institution. Brain MR imaging revealed a new-onset diffuse cystic process with anterior and posterior brainstem compression, marked kinking of the cervicomedullary junction, melanocyte pigmentation of the left temporal lobe, diffuse leptomeningeal enhancement, and no evidence of hydrocephalus. Consistent with these imaging findings, the degree of brainstem involvement upon gross visualization predictably deterred resection attempts beyond those necessary for biopsy. Pathological examination revealed diffuse melanocytosis, and the family decided not to pursue aggressive measures postoperatively. This report indicates the potential for rapid intracranial manifestation of diffuse melanocytosis in NM patients. Although the prognosis is poor, early neurosurgical involvement in these patients may provide tissue diagnosis and the potential for decompression if the process is caught early in its course.

Utilization of recombinant activated factor VII for intracranial hematoma evacuation in coagulopathic nonhemophilic neurosurgical patients with normal international normalized ratios.

BACKGROUND: Recombinant activated Factor VII (rFVIIa) has recently gained popularity for rapid reversal of coagulopathy during operative neurosurgery. Patients undergoing chronic subdural hematoma (CSDH) or epidural hematoma (EDH) evacuation often have their coagulation status judged by preoperative international normalized ratio (INR). We present our experience in two patients with significant clinical coagulopathy who were successfully reversed with rFVIIa in the setting of normal INR. METHODS: Patient one was a 79-year-old man with history of prostate cancer and three previous operative left CSDH evacuations, each complicated by coagulopathic bleeding, who presented with new-onset left EDH. Patient two was a 27-year-old woman with relapsed acute myelogenous leukemia with bilateral CSDH and mass effect on MRI. Neither patient had hemophilia, and preoperative INR was 1.2 in each case. Both patients underwent evacuation in the operating room, preceded by rFVIIa administration. RESULTS: Patient one underwent removal of his previous craniotomy flap followed by EDH evacuation. In patient two, coagulopathic bleeding upon surgical approach necessitated an additional dose of rFVIIa. Burrhole evacuation was well-tolerated with visible brain re-expansion following irrigation. Each case occurred with minimal blood loss and relatively easy hemostasis, with postoperative CT and clinical course revealing adequate evacuation. Neither patient experienced thromboembolic complications or required re-operation. CONCLUSION: These two patients are the first to be examined for the use of rFVIIa for reversal of clinical coagulopathy in the setting of normal INR. Our experience suggests that normal INR should not be a deterrent for patients to receive rFVIIa in the setting of strong neurosurgical suspicion for underlying clinical coagulopathy.

A lateral cervical lipomyelomeningocele associated with diplomyelia.

We report a case of a neonate with complex spinal dysraphism and associated anomalies of the axial skeleton. Based on the clinical presentation and radiographic findings, and recent advances in the understanding of human embryogenesis, we formulate a hypothesis that such a presentation is the result of failure of normal gastrulation. A 1-day-old male neonate presented with multiple right-sided anomalies, including hypoplastic right face and decreased movement of the right upper extremity. Radiographic studies demonstrated absent right cervical hemivertebrae, right cervical lipomyelomeningocele, and cervical diplomyelia with right hemicord terminating in a blind pouch. Anterior and posterior cervical and thoracic fusion with instrumentation was performed at the age of 3 years, and on follow-up the patient had improvement in right upper extremity strength. Complex spinal dysraphism is a pathological process that occurs during different stages in human development. We describe a case involving a rare lateral lipomyelomeningocele in the cervical-thoracic area.

Basicranial diplomyelia: an extension of the split cord malformation theory. Case report.

Basicranial diastematomyelia is an extremely rare congenital disorder. A review of the literature indicates only one reported case of basicranial diastematomyelia in which an osseous peg divided the brainstem in two. The authors present the first reported case of basicranial diplomyelia split by a fibrous band and correlate its pathogenesis with that of split cord malformation (SCM). The patient described in the present report had a fibrous stalk dividing the brainstem, and therefore the condition was categorized as a diplomyelia, or SCM Type II. Because the occipital dermatomes behave similarly to the spinal dermatomes early in development, they may be subject to the same embryonic error that results in SCM. The authors propose that the mechanism leading to SCM is the same as that found in basicranial split malformations and that the theory explaining it be modified to include the posterior fossa.

A morphometric, neuroanatomical, and behavioral study on the effects of geometric constraint on the growing brain: the methyl 2-cyanoacrylate craniosynostosis model.

OBJECT: The effects of premature sutural synostosis on the developing brain remain unknown. A model of craniosynostosis in the perinatal rat was used to investigate the morphological and cytoarchitectural changes in the maturing brain as well as the neurobehavioral outcome. METHODS: A total of 56 perinatal rats, eight in each subgroup, were used in this study. Hypothermic arrest was induced in the rats and methyl 2-cyanocrylate was applied across the sagittal, coronal, and lambdoidal sutures at postnatal Days 0, 3, and 7. Sham rats underwent similar hypothermic arrest and application of methyl 2-cyanoacrylate but at a site different from the sutural lines. Age-matched rats that did not undergo any procedure were included as normal controls. Serial gross measurements were obtained to chart calvarial growth and computerized tomography scanning was performed to calculate mean calvarial volumes. At postnatal Day 30, the brains were fixed in situ and detailed morphological and cytoarchitectural analysis was conducted. There were no statistical differences in any of the analyses between sham rats and normal age-matched controls. In contrast, calvarial growth rates (analysis of variance, p < 0.05), mean brain weights (t-test, p < 0.01), and anterior-posterior and lateral diameter measurements (t-test, p < 0.01) were different for all synostotic rats compared with sham controls. On cytoarchitectural surveys, focal areas of nodular heterotopia and differences in cell density at the pyramidal cell layer were noted (t-test, p < 0.01). Open field testing also demonstrated excessive exploratory behavior in the synostosed animals. CONCLUSIONS: Early pan-calvarial sutural synostosis in the perinatal rat after administration of methyl 2-cyanoacrylate is associated with morphometrical and cytoarchitectural changes in the developing brain.

Ewing's sarcoma of the cavernous sinus: case report.

OBJECTIVE AND IMPORTANCE: The Ewing's sarcoma (ES) family of tumors is a relatively rare entity, presenting most commonly in children. While the most common sites for this group of tumors are the trunk and the extremities, this case is unique in that we describe a long-term follow-up with an ES presenting in the cavernous sinus. CLINICAL PRESENTATION: We report the case of a 13-year-old girl presenting with the symptoms of classic orbital apex syndrome. Magnetic resonance imaging disclosed a cavernous sinus mass engulfing the optic nerve and extending into the superior orbital fissure. INTERVENTION: Evaluation of this patient included intracranial magnetic resonance imaging angiography and biopsy of the cavernous sinus mass lesion. Histopathological findings yielded a diagnosis of ES. Further work-up demonstrated that the patient's thyroid was also involved. The tumor was treated with radiation therapy to both sites and, subsequently, after confirmed metastases to other sites, 11 cycles of doxorubicin-based chemotherapy, as well as bone marrow transplantation. However, the patient succumbed to the illness 18 months after her initial diagnosis. CONCLUSION: The cavernous sinus is an unusual site for ES, but given the vascularity and the frequency of this tumor in childhood, the diagnosis should be entertained. This patient with an ES of cavernous sinus may be the first reported case with a long-term follow-up in the literature.

Craniofacial abnormalities in a murine knock-out model of mucopolysaccharidosis I H: a computed tomography and anatomic study.

The genetic mucopolysaccharidoses are a group of lysosomal storage diseases in which mucopolysaccharides (glycosaminoglycans) accumulate as the result of a malfunction or lack of a lysosomal degradation enzyme. There are currently seven known forms of mucopolysaccharidoses. Type I results from an enzymatic deficiency of alpha-L-iduronidase. There are three subtypes of mucopolysaccharidoses I that are commonly recognized: Hurler syndrome, Hurler-Scheie syndrome, and Scheie syndrome. Of the three subtypes, Hurler syndrome has the most severe clinical picture. Craniofacial anomalies and cognitive impairment are some of the more pronounced features of Hurler syndrome. Hurler syndrome has been described in cats, dogs, mice, and human beings and is inherited as an autosomal recessive trait. The biochemical nature of the disease is preserved across species lines. Clinically, the disease has similar effects in human beings and animals. It has been difficult to reverse the phenotype of the disease even with replacement of the defective alpha-L-iduronidase enzyme. The purpose of this study is to characterize the cranio-facial differences in the murine knock-out model of Hurler syndrome objectively. Twenty-three measurements were taken from computed tomographic scans in a coronal and sagittal plane on 24 black C57/B6 knock-out Hurler syndrome mice. The seven statistically significant measurements are width of the cervical canal, height of the foramen magnum, width between the external auditory canals, width of the skull base at the mandibular condyles, midocular distance, spread of the mandibular condyles, and width of the zygoma at the maxilla. This information now provides researchers with objective data from living Hurler syndrome-affected mice that will allow them to follow therapies directed at improving craniofacial outcomes for any therapy over time.

Pediatric intracranial complications of central venous catheter placement.

Central venous catheters are essential in the medical management of critically ill pediatric patients. Medical practitioners should be aware of the potential for misplacement of these devices as such complications may result in serious injury and possible death. Catheter malpositioning is not limited to any particular site and may have far-reaching consequences that affect a single or multiple organ systems. We present two cases where central venous catheter positioning led to complications that resulted in intracranial pathology which was fatal in one case.

The Seldinger technique for insertion of difficult to place ventricular catheters.

BACKGROUND: Multiloculated ventricular hydrocephalus is a difficult pathology for neurosurgeons to treat. Not only are the shunts for this condition prone to malfunction, but they are also difficult to place. METHODS: The Seldinger technique is used in combination with a rigid scope with a working channel. A soft filiform wire or a thick suture is inserted through the channel. The scope is withdrawn and a ventricular catheter is slid down the wire. The remainder of the shunt is inserted in the usual fashion. RESULTS: We have not encountered any neurologic compromise from this technique. No bleeding was encountered with the described technique. CONCLUSION: The Seldinger technique with appropriate types of guide wires and in combination with an endoscope is a useful technique for difficult to place shunts.

Radiology of nonaccidental trauma.

The long-term outlook for infants subjected to nonaccidental trauma is bleak. In a retrospective study with a mean 9-year follow-up, Duhaime et al [63] noted the relationship between acute factors on presentation and the long-term outcome. Infants who were unresponsive on presentation remained vegetative or severely impaired at follow-up. Most of the infants who required intubations were severely impaired at follow-up. In those with acute seizures, 60% were severely impaired, and an equal number had moderately severe to good outcome. Less than 6 months of age at the time of insult resulted in severe disability in most infants. CT findings of diffuse hypodensity or loss of gray-white differentiation led to severe disability at follow-up. Focal areas of hypodensity or contusion had an equal probability of good outcome or severe disability. Child abuse unfortunately is prevalent in our society, and as physicians our profession requires that we help our patients. When dealing with one of our most vulnerable group of patients, it is imperative when a child with injury is examined that physicians keep in their differential child abuse. This article has provided information in regards to radiographic studies that assist a physician in diagnosing child abuse. The importance of this not only is in providing appropriate care, but far more importantly in protecting a child or his or her siblings from future abuse.