Lipoblastomatosis Extended into the Lumbar Spinal Canal in a Child: A Case Report.

INTRODUCTION: Lipoblastoma and lipoblastomatosis are rare benign mesenchymal adipose tumors that originate from embryonic white adipocytes and occur most commonly in infancy and early childhood. Lipoblastomas occur in the extremities and trunk, including the retroperitoneum and peritoneal cavity. Therefore, infiltration into the spinal canal has rarely been reported. CASE PRESENTATION: A 4-year-old girl presented to our clinic because of difficulty sitting on the floor with her legs straight. She also complained of enuresis and constipation for the past 6 months with persistent headaches and back pain evoked by body anteflexion. A magnetic resonance imaging revealed a massive lesion of the psoas major muscle, retroperitoneal, and subcutaneous spaces, extending into the spinal epidural space between L2 and S1. The patient underwent surgery which resulted in gross total removal of the tumor from the spinal canal. The mass was yellowish, soft, lobulated, fatty, and easily removed from the surrounding structures. Pathology confirmed the diagnosis of lipoblastoma. The postoperative course was uneventful, and the patient was discharged without any signs of neurological deficit. CONCLUSION: We herein discuss a rare case of lipoblastoma extending into the spinal canal, resulting in neurological symptoms. Although this tumor is benign with no potential for metastasis, it is prone to local recurrence. Therefore, close postoperative observation should be performed.

Statistical and machine learning approaches to predict the necessity for computed tomography in children with mild traumatic brain injury.

BACKGROUND: Minor head trauma in children is a common reason for emergency department visits, but the risk of traumatic brain injury (TBI) in those children is very low. Therefore, physicians should consider the indication for computed tomography (CT) to avoid unnecessary radiation exposure to children. The purpose of this study was to statistically assess the differences between control and mild TBI (mTBI). In addition, we also investigate the feasibility of machine learning (ML) to predict the necessity of CT scans in children with mTBI. METHODS AND FINDINGS: The study enrolled 1100 children under the age of 2 years to assess pre-verbal children. Other inclusion and exclusion criteria were per the PECARN study. Data such as demographics, injury details, medical history, and neurological assessment were used for statistical evaluation and creation of the ML algorithm. The number of children with clinically important TBI (ciTBI), mTBI on CT, and controls was 28, 30, and 1042, respectively. Statistical significance between the control group and clinically significant TBI requiring hospitalization (csTBI: ciTBI+mTBI on CT) was demonstrated for all nonparametric predictors except severity of the injury mechanism. The comparison between the three groups also showed significance for all predictors (p<0.05). This study showed that supervised ML for predicting the need for CT scan can be generated with 95% accuracy. It also revealed the significance of each predictor in the decision tree, especially the "days of life." CONCLUSIONS: These results confirm the role and importance of each of the predictors mentioned in the PECARN study and show that ML could discriminate between children with csTBI and the control group.

Cerebellar hemorrhage in a newborn: a case report in association with suspected arterial dissection of the posterior inferior cerebellar artery.

We herein report a 5-day-old baby boy presented with a massive cerebellar hemorrhage due to suspected posterior inferior cerebellar artery (PICA) dissection. He was born by vacuum extraction at the gestational age of 41 weeks with 3370 g birth weight. On the fifth day of life, he developed dyspnea with worsening vital signs. CT of the head showed massive cerebellar hemorrhage and then transferred to our hospital. External ventricular drainages were emergently placed for his hydrocephalus on the first day of hospitalization, then cerebellar hematoma was evacuated with suboccipital craniotomy on day 11. Under microscopic observation, the left PICA was swollen with dark red discoloration at the caudal loop, being a confirmative finding of arterial dissection. By these findings, we suspected ruptured arterial dissection as a cause of cerebellar hemorrhage. The right PICA looked intact. He required a ventriculoperitoneal shunt on day 59 due to his persistent hydrocephalus, resulting in remarkable improvement of his neurological condition. An MRI, a CT angiography/venography, or blood tests showed no abnormalities such as tumors, vascular anomalies, or coagulopathies. We discuss the significantly rare case of cerebellar hematoma in a newborn, most likely caused by ruptured PICA dissection.

Intracranial pressure based decision making: Prediction of suspected increased intracranial pressure with machine learning.

BACKGROUND: Repeated invasive intracranial pressure (ICP) monitoring is desirable because many neurosurgical pathologies are associated with elevated ICP. On the other hand, it could become a risk for children to repeat sedation, anesthesia, or radiation exposure. As a non-invasive method, measurements of optic nerve sheath diameter (ONSD) has been revealed to accurately predict increased ICP. However, no studies have indicated a relationship among age, brain, and ventricular parameters in normal children, nor a prediction of increased ICP with artificial intelligence. METHODS AND FINDINGS: This study enrolled 400 normal children for control and 75 children with signs of increased ICP between 2009 and 2019. Measurements of the parameters including ONSD on CT were obtained. A supervised machine learning was applied to predict suspected increased ICP based on CT measurements. A linear correlation was shown between ln(age) and mean ONSD (mONSD) in normal children, revealing mONSD = 0.36ln(age)+2.26 (R2 = 0.60). This study revealed a linear correlation of mONSD measured on CT with ln(age) and the width of the brain, not the width of the ventricles in 400 normal children based on the univariate analyses. Additionally, the multivariate analyses revealed minimum bicaudate nuclei distance was also associated with mONSD. The results of the group comparison between control and suspected increased ICP revealed a statistical significance in mONSD and the width of the ventricles. The study indicated that supervised machine learning application could be applied to predict suspected increased ICP in children, with an accuracy of 94% for training, 91% for test. CONCLUSIONS: This study clarified three issues regarding ONSD and ICP. Mean ONSD measured on CT was correlated with ln(age) and the width of the brain, not the width of the ventricles in 400 normal children based on the univariate analyses. The multivariate analyses revealed minimum bicaudate nuclei distance was also associated with mONSD. Mean ONSD and the width of ventricles were statistically significant in children with signs of elevated ICP. Finally, the study showed that machine learning could be used to predict children with suspected increased ICP.

Recurrent Shoulder Tip Pain After Ventriculoperitoneal Shunt Placement Associated with Infectious Peritonitis with Propionibacterium acnes; A Case Report and Review of the Literature.

Ventriculoperitoneal (VP) shunt placement is commonly performed for the treatment of hydrocephalus, and several complications of this procedure are well known. Radiating shoulder tip pain after VP shunt placement has been reported as an unusual complication in a few cases, associated with dislocation of the peritoneal catheter. We described the case of a 9-year-old girl who presented with recurrent radiating shoulder tip pain after VP shunt placement. The pain recurred after peritoneal catheter repositioning because of peritoneal inflammation and adhesion due to peritonitis with Propionibacterium acnes (P. acnes). This bacterium was isolated using 16S ribosomal RNA gene polymerase chain reaction (16S rRNA gene PCR), and anaerobic and prolonged culture tests. After antibacterial treatment, ventriculoarterial (VA) shunt placement was successfully performed. Hemidiaphragm irritation by the peritoneal catheter leads to radiating shoulder tip pain, and peritoneal inflammation and adhesion caused by infectious peritonitis may cause recurrence of this despite catheter repositioning. Clinicians should be aware of shoulder pain as a complication of VP shunt placement, and should consider VA shunt placement as an alternative treatment if this symptom recurs after catheter repositioning. Furthermore, 16S rRNA gene PCR and anaerobic and prolonged culture tests should be considered to detect P. acnes infection.

Severe posterior reversible encephalopathy syndrome resolved with craniectomy.

Posterior reversible encephalopathy syndrome (PRES) has been thought to be a benign disease, but recently severe cases have been reported with increasing recognition. A 3-year-old girl with congenital nephrotic syndrome had rapidly progressed to coma. Computed tomography (CT) of the head showed striking swelling of the brainstem and transtentorial herniation. Emergency decompressive craniectomy was performed. Consecutively, blood pressure was optimally controlled. The patient gradually recovered to the previous state before onset of PRES. Rapid improvement of clinical symptoms and rapid resolution of abnormal findings on serial CT led to diagnosis of PRES. In severe PRES with unstable vital signs, surgical intervention should be considered as well as appropriate blood pressure management.

Intraosseous schwannoma of the cervical vertebral body: A case report and review of the literature.

Intraosseous schwannomas (IOS) of non-sacral vertebra are extremely rare; only 14 cases were reported previously. We described a case of IOS involving a cervical vertebral body, successfully treated by surgical resection, with a review of the literature and discussion of this extremely rare tumour.

Imaging of HSV-tk Reporter gene expression: comparison between [18F]FEAU, [18F]FFEAU, and other imaging probes.

UNLABELLED: Herpes virus type 1 thymidine kinase (HSV1-tk) and the mutant HSV1-sr39tk are the 2 most widely used "reporter genes" for radiotracer-based imaging. Two pyrimidine nucleoside analogs, [18F]FEAU (1-(2'-deoxy-2'-fluoro-beta-d-arabinofuranosyl)-5-ethyluridine) and [18F]FFEAU (1-(2'-deoxy-2'-fluoro-beta-d-arabinofuranosyl)-5-(2-fluoroethyl)uridine), have generated recent interest as potential new probes for imaging HSV1-tk and HSV1-sr39tk gene expression. METHODS: We compared [18F]FEAU and [18F]FFEAU with a series of other pyrimidine nucleoside derivatives (including 1-(2'-deoxy-2'-fluoro-beta-d-arabinofuranosyl)-5-iodouridine [FIAU]) and with acycloguanosine analogs using a stable HSV1-tk transduced cell line (RG2TK+) and wild-type RG2 cells. RESULTS: The in vitro accumulation data and the calculated and normalized clearance constant, nKi, as well as sensitivity and selectivity indices indicated that 2 pyrimidine nucleoside probes, [18F]FEAU and [18F]FFEAU, had the best uptake characteristics. These probes were selected for further dynamic PET studies in nude rats bearing subcutaneous RG2TK+ and RG2 tumors. The 2-h postinjection [18F]FEAU uptake levels were 3.3% +/- 1.0% and 0.28% +/- 0.07% dose/cm3 in subcutaneous RG2TK+ and RG2 tumors, respectively, and 2.3% +/- 0.2% and 0.19% +/- 0.01% dose/cm3, respectively, for [18F]FFEAU. The corresponding RG2TK+/RG2 uptake ratios were 11.5 +/- 1.5 and 12.2 +/- 1.4, respectively. The inherent problem of comparing different radiolabeled pyrimidine nucleoside and guanosine-based probes for imaging HSV1-tk expression using different transduced cell lines and assay systems in the absence of an independent thymidine kinase-enzyme assay is discussed. CONCLUSION: For HSV1-tk reporter systems that require a 1- to 4-h PET paradigm, HSV1-tk-[18F]FEAU is the current top contender.

Apnea caused by mesial temporal lobe mass lesions in infants: report of 3 cases.

Apnea as an isolated manifestation of seizures is well described in neonates but is only occasionally observed in infants. This article reports 3 infants presenting with apneic events as the main manifestation of seizure, documented by video electroencephalogram, all with mesial temporal lobe lesions. The 3 infants, after normal pregnancy and delivery at term, showed the first apnea at the age of 4 to 10 months. Although the interictal electroencephalogram result was often normal, ictal video electroencephalogram in all infants showed focal rhythmic discharges with or without generalization. Magnetic resonance imaging showed an inferior mesial temporal lobe mass lesion in all infants. All patients underwent lesion removal, and they are seizure free with normal psychomotor development.

Proliferation-dependent changes in amino acid transport and glucose metabolism in glioma cell lines.

Amino acid imaging is increasingly being used for assessment of brain tumor malignancy, extent of disease, and prognosis. This study explores the relationship between proliferative activity, amino acid transport, and glucose metabolism in three glioma cell lines (U87, Hs683, C6) at different phases of growth in culture. Growth phase was characterized by direct cell counting, proliferation index determined by flow cytometry, and [(3)H]thymidine (TdR) accumulation, and was compared with the uptake of two non-metabolized amino acids ([(14)C]aminocyclopentane carboxylic acid (ACPC) and [(14)C]aminoisobutyric acid (AIB)), and [(18)F]fluorodeoxyglucose (FDG). Highly significant relationships between cell number (density), proliferation index, and TdR accumulation rate were observed in all cell lines ( r>0.99). Influx ( K(1)) of both ACPC and AIB was directly related to cell density, and inversely related to the proliferation index and TdR accumulation in all cell lines. The volume of distribution ( V(d)) for ACPC and AIB was lowest during rapid growth and highest during the near-plateau growth phase in all cell lines. FDG accumulation in Hs683 and C6 cells was unaffected by proliferation rate, growth phase, and cell density, whereas FDG accumulation was correlated with TdR accumulation, growth phase, and cell density in U87 cells. This study demonstrates that proliferation rate and glucose metabolism are not necessarily co-related in all glioma cell lines. The values of K(1) and V(d) for ACPC and AIB under different growth conditions suggest that these tumor cell lines can up-regulate amino acid transporters in their cell membranes when their growth conditions become adverse and less than optimal.

Assessment of treatment response by autoradiography with (14)C-aminocyclopentane carboxylic acid, (67)Ga-DTPA, and (18)F-FDG in a herpes simplex virus thymidine kinase/ganciclovir brain tumor model.

UNLABELLED: Assessments of herpes simplex virus 1 thymidine kinase (HSV-tk)/ganciclovir (GCV) treatment response, early in the course of therapy, are important in the evaluation and clinical management of patients. This study addresses whether imaging amino acid transport, glucose utilization, and passive vascular permeability provides an early indication of treatment response and can predict long-term outcome. METHODS: Fischer 344 rats with intracerebral HSV-tk transduced RG2TK+ xenografts were studied. GCV-treated (50 mg/kg twice daily) and saline-treated control animals were compared; triple-label quantitative autoradiography was performed 3 d after initiating treatment, and long-term survival was determined. Autoradiograms of (18)F-FDG, (67)Ga-diethylenetriaminepentaacetic acid ((67)Ga-DTPA), and (14)C-aminocyclopentane carboxylic acid ((14)C-ACPC) were obtained; measurements of (14)C-ACPC and (67)Ga-DTPA plasma clearance (K(1)), (14)C-ACPC transport ( partial differential K(1)), relative glucose utililization (R), and normalized radioactivity (% dose/g) were obtained in tumor and brain tissues. Adjacent sections were stained to detect apoptotic cells, microvessels, and type L neutral amino acid transporter in tumor and normal brain. RESULTS: GCV treatment reduced partial differential K(1) and % dose/g of (14)C-ACPC in RG2TK+ xenografts to approximately 30% of that in nontreated animals (from 34 +/- 9 [mean +/- SD] to 9.5 +/- 2.7 microL/min/g and from 0.28 +/- 0.09 to 0.11 +/- 0.04 % dose/g, respectively). GCV had a significant but substantially smaller effect than toxicity on glucose utilization and little or no effect on passive vascular permeability of RG2TK+ xenografts. These differences could not be explained by differences in plasma amino acid or glucose concentration at the time of the study. Histology revealed a large fraction of dead tumor cells and only a sparse distribution of apoptotic cells in GCV-treated tumors. Many CD34-positive endothelial cells in GCV-treated tumors showed only weak or marginal LAT1 staining, whereas CD98 staining remained unchanged. Survival was significantly increased by GCV treatment from 18 +/- 4 to 56 +/- 17 d. CONCLUSION: (14)C-ACPC influx, K(1)(ACPC), facilitated transport, partial differential K(1)(ACPC), and % dose/g (ACPC) are good indicators of early treatment response after HSV-tk/GCV gene therapy. The parametric images and changes in K(1)(ACPC), partial differential K(1)(ACPC), and % dose/g (ACPC) are substantial and are better than the corresponding measures obtained in the same animals and in the same tissue (tumor) regions with (67)Ga-DTPA and (18)F-FDG. Amino acid transport imaging may be a good surrogate paradigm to monitor treatment response of brain tumors.