Isolated cerebral cortical tears in children: aetiology, characterisation and differentiation from non-accidental head injury.

A wide spectrum of intracranial injuries has been described as complicating difficult birth, particularly following instrumental delivery. We describe five children in whom isolated cortical tears were observed on MRI. Four cases were characterised by a difficult instrumental delivery. None of the children developed long-term neurological sequelae. As far as we are aware, isolated cerebral cortical tears have not been reported previously although recognition of this injury pattern is important because of its possible misinterpretation as a marker of a non-accidental head injury. Other differential diagnoses that should be considered include cerebral infarcts, schizencephaly and accidental head injury. The importance of high-quality cross-sectional brain imaging in newborn infants with seizures is emphasised.

Profuse epistaxis following sphenoid surgery: a ruptured carotid artery pseudoaneurysm and its management.

OBJECTIVE: We report a rare case of iatrogenic pseudoaneurysm of the internal carotid artery secondary to endoscopic sphenoid surgery. METHOD: The management of this unusual complication and a review of the literature are presented. RESULTS: A 65-year-old woman presented with intractable epistaxis four days following endoscopic sphenoid sinus surgery. Initial, conservative measures were unsuccessful in controlling bleeding. The clinical picture of delayed, severe epistaxis after a sphenoid sinus exploration raised the possibility of injury to the internal carotid artery and subsequent formation of a false aneurysm. The patient's pseudoaneurysm was managed, without visualising it, by packing the sphenoid sinus (achieved by palpating 1 cm above the shoulder of the posterior choana) in order to gain control of the haemorrhage, followed by endovascular occlusion. CONCLUSION: An awareness of this rare complication is essential in order to manage this life-threatening condition efficiently.

Spinal subdural haematomas in children with non-accidental head injury.

OBJECTIVE: To examine the incidence of spinal pathology in infants with non-accidental head injury. METHODS: 18 infants with non-accidental head injury were investigated between 2000 and 2007 with dedicated MRI of the brain and spine. During the earlier years, the spine was imaged only when there were suspicious features on other imaging to suggest a spinal injury (seven cases). After 2005, all suspected cases of non-accidental head injury were routinely investigated with MRI of the whole spine in addition to the brain. The spinal imaging at initial investigation and at follow-up was reviewed. RESULTS: There was a high incidence (8/18 cases, 44%) of subdural collections in the spine. They were all clinically occult and in six cases large. All eight cases were associated with subdural haematomas in the supratentorial and infratentorial compartment. The signal characteristics were analysed and compared with those of the intracranial collections. One had a small epidural haematoma. Other depicted abnormalities and appearances at follow-up were also reviewed. CONCLUSION: There is a high incidence of previously unsuspected spinal subdural haematomas associated with intracranial collections in children with non-accidental head injury. Further work is required to evaluate the clinical implications.

Retreatment of previously embolized cerebral aneurysms: the risk of further coil embolization does not negate the advantage of the initial embolization.

BACKGROUND AND PURPOSE: A significant minority of aneurysms treated by endovascular means undergo additional subsequent therapy to treat aneurysm recurrence. Our study was undertaken to determine the risk of additional coil embolization of aneurysms recurring following endovascular therapy. MATERIALS AND METHODS: Patients were identified during a 10-year period from prospectively collated data bases at 2 different neuroscience institutions. Patient outcome was obtained from the data bases or the patient's neurosurgical records. Occlusion grade was assessed at the time of treatment and at follow-up angiography as complete, near-complete, or incomplete. RESULTS: Of a total of 1834 aneurysms in 1631 patients, 100 aneurysms in 99 patients treated between January 1996 and December 2005 required additional coiling because of an enlarging remnant and subtotal occlusion. This comprised 6% of the patients treated and 8% of the total followed. Thromboembolic events complicated 3 retreatment procedures, but all 3 patients remain independent. Ninety-five patients were followed for 8-103 months (mean, 42.3 months) by conventional or MR angiography. CONCLUSION: Coil embolization of aneurysm recurrences has a low complication rate and leads to satisfactory occlusion in most cases. The risk from additional coil embolization does not negate the advantage of the initial embolization.

Corpus callosum changes following shunting for hydrocephalus: case report and review of the literature.

Diffuse callosal signal changes can rarely occur following successful shunting for obstructive hydrocephalus. We report on a patient who underwent ventriculoperitoneal shunting for aqueductal stenosis and required two revisions for neurological deterioration and presumed shunt malfunction. Extensive changes involving the corpus callosum, periventricular white matter and optic chiasm were noted after the first, and were prominent after second shunt revision. Thus, post-shunting callosal changes may be associated with more extensive white matter disease, and may not imply wide pressure fluctuations. However, they need not prompt further intervention.

The 'unified hypothesis' of Geddes et al. is not supported by the data.

Inflicted head injury to the developing brain frequently results in serious disability. The pathogenesis of the neuraxial and ocular findings in infants believed to have suffered inflicted head injury remains the subject of considerable debate. Recent neuropathology studies of fatal cases of inflicted head injury and of a foetal/perinatal non-traumatic model have led to the proposal that there is a 'unified hypothesis', the essential feature of which is hypoxic brain swelling secondary to cervicomedullary injury. It has been suggested that less than violent forces may be involved and even that some cases may not be due to trauma at all. The purpose of this paper is to provide a critical review of the data upon which these suppositions are based on a background of what is already known. It is submitted that there are serious flaws in the methodology; the conclusions reached cannot logically be drawn from the data; and the 'unified hypothesis' is not supported by the evidence. On the basis of the data presented, it is also difficult to sustain the secondary hypothesis purporting to describe a minority cohort with 'infantile encephalopathy with subdural and retinal bleeding' of non-traumatic causation.

Neuroimaging for non-accidental head injury in childhood: a proposed protocol.

Non-accidental head injury (NAHI) is a major cause of neurological disability and death during infancy. Radiological imaging plays a crucial role in evaluating craniospinal injury, both for guiding medical management and the forensic aspects of abusive trauma. The damage sustained is varied, complex and may be accompanied by an evolving pattern of brain injury secondary to a cascade of metabolic and physiological derangements. Regrettably, many cases are poorly or incompletely evaluated leading to diagnostic errors and difficulties in executing subsequent child care or criminal proceedings. It is evident, from cases referred to the authors, that imaging protocols for NAHI are lacking (or only loosely adhered to, if present) in many centres throughout the U.K. Future research in this field will also be hampered if there is a lack of consistent and reliable radiological data. There is no nationally agreed protocol for imaging NAHI. We propose such a protocol, based upon a wide experience in the medical management of child abuse and extensive involvement in the medicolegal aspects of NAHI.

Delayed reconfiguration of a Guglielmi detachable coil mass associated with late occlusion of an adjacent aneurysm and parent vessel.

We present a case of asymptomatic, progressive, late occlusion of the left superior cerebellar artery (SCA) and an aneurysm arising from the junction of the SCA and basilar artery after embolization of an adjacent aneurysm arising between the left posterior cerebral artery and the left SCA. The delayed occlusion was associated with reconfiguration of the Guglielmi detachable coils at the neck of the treated aneurysm.

Amphetamine abuse and intracranial haemorrhage.

Amphetamines taken by any route can cause cerebral vasculitis and intracranial haemorrhage. 8 cases were seen in a neurosurgical unit over 3.5 years. The published work indicates that those who experience these complications, mainly young adults, have poor outcomes.

Coil embolization of cerebral aneurysms in patients with sickling disorders.

In patients with sickle cell disease cerebral aneurysm formation is thought to be a complication of recurrent red cell sickling, and multiple aneurysms have been reported in these patients. Management of patients with suspected cerebral aneurysm has traditionally involved cerebral vessel angiography followed by craniotomy and aneurysmal clipping. In patients without sickle cell disease, non-operative intervention in the form of endovascular coil embolization is increasingly being used to ablate aneurysms, but has not thus far been reported in patients with sickle cell disease. We report two patients with sickling disorders who have undergone coil embolization of cerebral aneurysms with good functional and radiological outcomes. These patients illustrate that endovascular coiling is useful in the treatment of cerebral aneurysms associated with sickling disorders, although, as with surgical intervention, preparation with exchange transfusion is appropriate.

Post-procedure migration of Guglielmi detachable coils and Mechanical detachable spirals.

We describe a previously unreported complication of the use of Guglielmi detachable coils and Mechanical detachable spirals in endovascular treatment of intracranial aneurysms. We document four cases in which migration of part of a coil into the parent artery occurred after completion of the procedure. Possible mechanisms are discussed.

Constructive interference in steady-state 3D Fourier-transform MRI in the management of hydrocephalus and third ventriculostomy.

We describe the use of three-dimensional Fourier transform constructive imaging in the steady state (CISS) MRI in the assessment of patients with hydrocephalus. We have found it of value both as a diagnostic investigation and in the follow-up of patients treated by third ventriculostomy.

Endovascular management of complete vertebral artery dissection presenting with subarachnoid haemorrhage.

SUMMARY: Spontaneous vertebral artery (VA) dissection may involve the intradural segment of the VA and result in subarachnoid haemorrhage (SAH). These lesions are frequently associated with recurrent SAH, and have a high mortality. Prior to the development of endovascular techniques the majority of these lesions were treated surgically. In cases where the dissection involved the posterior inferior cerebellar artery (PICA) origin surgery was associated with significant complications including recurrent SAH from retrograde VA flow into the dissected segment above the surgical clip. We describe two cases of complete VA dissection in which the entire intradural VA was sacrificed to prevent recurrent SAH. The first case tolerated planned left PICA occlusion without developing a significant neurological deficit. The second case had infarcted the right PICA territory at presentation.

Pachymeningitis in Wegener's granulomatosis.

A case of Wegener's granulomatosis is described in which meningeal thickening and enhancement was demonstrated on MR imaging. The diagnosis was suggested by the clinical picture, imaging findings and a positive anti-neutrophil cytoplasmic antibody; and confirmed by biopsy of ethmoidal tissue.

Hypertrophic olivary degeneration: case report in a child.

We report a case of hypertrophic olivary degeneration (HOD) detected by MRI, in a 14-year-old girl, 13 months after surgical excision of a brainstem cavernous malformation. As in vivo diagnosis of this condition has only become possible with the advent of MRI, the number of reported cases remains relatively small and they are almost exclusively in adults. Many radiologists and particularly paediatric radiologists, may therefore be unfamiliar with this entity. To our knowledge, this is the first specific report of HOD diagnosed by MRI in a child.

Ruptured fusiform cerebral aneurysm in a neonate.

An 11-day-old male infant presented with subarachnoid and intraventricular haemorrhage caused by a ruptured intracranial aneurysm. Magnetic resonance (MR) angiogram and digital subtraction angiography (DSA) revealed a fusiform aneurysm 10 mm in diameter supplied by the proximal segment of the anterior cerebral artery (A1), with both distal segments (A2) arising from the aneurysm. The right A1 was aplastic. There have been 13 previous case reports of neonatal cerebral artery aneurysms, but only 1 of these has been fusiform. None of the earlier reports has mentioned dysplastic segments or other anomalies of the circle of Willis.

Transmural migration of an intracavernous carotid detachable balloon used to control surgically induced haemorrhage.

We report a case in which a balloon detached in the carotid siphon for control of iatrogenic bleeding migrated to the oesophagus. We discuss the pathophysiology.