Effects of Mediterranean diet or mindfulness-based stress reduction on fetal and neonatal brain development: a secondary analysis of a randomized clinical trial.

BACKGROUND: Maternal suboptimal nutrition and high stress levels are associated with adverse fetal and infant neurodevelopment. OBJECTIVE: This study aimed to investigate if structured lifestyle interventions involving a Mediterranean diet or mindfulness-based stress reduction during pregnancy are associated with differences in fetal and neonatal brain development. STUDY DESIGN: This was a secondary analysis of the randomized clinical trial Improving Mothers for a Better Prenatal Care Trial Barcelona that was conducted in Barcelona, Spain, from 2017 to 2020. Participants with singleton pregnancies were randomly allocated into 3 groups, namely Mediterranean diet intervention, stress reduction program, or usual care. Participants in the Mediterranean diet group received monthly individual sessions and free provision of extra-virgin olive oil and walnuts. Pregnant women in the stress reduction group underwent an 8-week mindfulness-based stress reduction program adapted for pregnancy. Magnetic resonance imaging of 90 fetal brains was performed at 36 to 39 weeks of gestation and the Neonatal Neurobehavioral Assessment Scale was completed for 692 newborns at 1 to 3 months. Fetal outcomes were the total brain volume and lobular or regional volumes obtained from a 3-dimensional reconstruction and semiautomatic segmentation of magnetic resonance images. Neonatal outcomes were the 6 clusters scores of the Neonatal Neurobehavioral Assessment Scale. Multiple regression analyses were conducted to assess the association between the interventions and the fetal and neonatal outcomes. RESULTS: When compared with the usual care group, the offspring exposed to a maternal Mediterranean diet had a larger total fetal brain volume (mean, 284.11 cm3; standard deviation, 23.92 cm3 vs 294.01 cm3; standard deviation, 26.29 cm3; P=.04), corpus callosum (mean, 1.16 cm3; standard deviation, 0.19 cm3 vs 1.26 cm3; standard deviation, 0.22 cm3; P=.03), and right frontal lobe (44.20; standard deviation, 4.09 cm3 vs 46.60; standard deviation, 4.69 cm3; P=.02) volumes based on magnetic resonance imaging measures and higher scores in the Neonatal Neurobehavioral Assessment Scale clusters of autonomic stability (mean, 7.4; standard deviation, 0.9 vs 7.6; standard deviation, 0.7; P=.04), social interaction (mean, 7.5; standard deviation, 1.5 vs 7.8; standard deviation, 1.3; P=.03), and range of state (mean, 4.3; standard deviation, 1.3 vs 4.5; standard deviation, 1.0; P=.04). When compared with the usual care group, offspring from the stress reduction group had larger fetal left anterior cingulate gyri volume (1.63; standard deviation, 0.32 m3 vs 1.79; standard deviation, 0.30 cm3; P=.03) based on magnetic resonance imaging and higher scores in the Neonatal Neurobehavioral Assessment Scale for regulation of state (mean, 6.0; standard deviation, 1.8 vs 6.5; standard deviation, 1.5; P<.01). CONCLUSION: Maternal structured lifestyle interventions involving the promotion of a Mediterranean diet or stress reduction during pregnancy were associated with changes in fetal and neonatal brain development.

Decompressive hemicraniectomy in pediatric malignant arterial ischemic stroke: a case-based review.

PURPOSE: Malignant stroke is a life-threatening emergency, with a high mortality rate (1-3). Despite strong evidence showing decreased morbidity and mortality in the adult population, decompressive hemicraniectomy (DCH) has been scarcely reported in the pediatric stroke population, and its indication remains controversial, while it could be a potential lifesaving option. METHODS AND RESULTS: We performed an extensive literature review on pediatric malignant arterial ischemic stroke (pmAIS) and selected 26 articles reporting 97 cases. Gathering the data together, a 67% mortality rate is observed without decompressive therapy, contrasting with a 95.4% survival rate with it. The median modified Rankin score (mRS) is 2.1 after surgery with a mean follow-up of 31.8 months. For the 33% of children who survived without surgery, the mRS is 3 at a mean follow-up of 19 months. As an illustrative case, we report on a 2-year-old girl who presented a cardioembolic right middle cerebral artery stroke with subsequent malignant edema and ongoing cerebral transtentorial herniation in the course of a severe myocarditis requiring ECMO support. A DCH was done 32 h after symptom onset. At the age of 5 years, she exhibits an mRS of 3. CONCLUSION: Pediatric stroke with malignant edema is a severe condition with high mortality rate if left untreated and often long-lasting consequences. DCH might minimize the vicious circle of cerebral swelling, increasing intracranial pressure and brain ischemia. Our literature review underscores DCH as an efficient therapeutic measure management of pmAIS even when performed after a significant delay; however, long-lasting morbidities remain high.

Robot-assisted, real-time, MRI-guided laser interstitial thermal therapy for pediatric patients with hypothalamic hamartoma: surgical technique, pitfalls, and initial results.

OBJECTIVE: Real-time, MRI-guided laser interstitial thermal therapy (MRgLITT) has been reported as a safe and effective technique for the treatment of epileptogenic foci in children and adults. After the recent approval of MRgLITT by the European Medicines Agency in April 2018, the authors began to use it for the treatment of hypothalamic hamartomas (HHs) in pediatric patients with the assistance of a robotic arm. In this study, the authors report their initial experience describing the surgical technique, accuracy of the robotic arm, safety, and efficacy. METHODS: The laser fiber was placed with the assistance of the stereotactic robotic arm. The accuracy of the robotic arm for this procedure was calculated by comparing the intraoperative MRI to the preoperative plan. Common demographic and seizure characteristics of the patients, laser ablation details, complications, and short-term seizure outcomes were prospectively collected. RESULTS: Sixteen procedures (11 first ablations and 5 reablations) were performed in 11 patients between 15 months and 17 years of age (mean age 6.4 years) with drug-resistant epilepsy related to HHs. The mean target point localization error was 1.69 mm. No laser fiber needed to be repositioned. The mean laser power used per procedure was 4.29 W. The trajectory of the laser fiber was accidentally ablated in 2 patients, provoking transient hemiparesis in one of these patients. One patient experienced postoperative somnolence and syndrome of inappropriate antidiuretic hormone secretion, and 2 patients had transient oculomotor (cranial nerve III) palsy. Fifty-four percent of the patients were seizure free after the first ablation (mean follow-up 22 months, range 15-33 months). All 5 patients who experienced an epilepsy relapse underwent a second treatment, and 4 remain seizure free at least 5 months after reablation. CONCLUSIONS: In the authors' experience, the robotic arm was sufficiently accurate for laser fiber insertion, even in very young patients. MRgLITT appears to be an effective treatment for selected cases of HH. MRgLITT for HH is a minimally invasive procedure with appealing safety features, as it allows delivery of energy precisely under real-time MRI control. Nonetheless, complications may occur, especially in voluminous HHs. The amount of delivered energy and the catheter cooling system must be closely monitored during the procedure. A larger sample size and longer follow-up duration are needed to judge the efficacy and safety of MRgLITT for HH more rigorously. This initial experience was very promising.

Cefalohematoma neonatal infectat per Escherichia coli I meningitis asèptica / Cefalohematoma neonatal infectado por escherichia coli y meningitis aséptica / Escherichia coli-infected neonatal cephalohematoma and aseptic meningitis

INTRODUCCIÓ: Un cefalohematoma és una col·lecció de sang sota el periosti del crani secundària a un traumatisme del part. Afecta entre l'1% I el 2% dels nadons nascuts per un part vaginal I entre el 3% I el 4% dels nascuts mitjançant un part instrumentat. Solen ser benignes I autolimitats, I es resolen espontàniament al cap d'unes setmanes, però alguns casos poden anar acompanyats d'anèmia, hiperbilirubinèmia o fractura cranial, complicar-se amb una calcificació o, rarament, infectar-se. CAS CLINIC: Nounat a terme de 9 dies de vida amb un cefalohematoma present des del naixement que va augmentar de mida després de tenir febre I infectar-se per Escherichia coli, suposadament per l'extensió d'una bacterièmia, I que es va acompanyar d'una meningitis asèptica (pleocitosi) que es va considerar secundària a una osteomielitis per contigüitat. El pacient es va tractar amb antibiòtics I desbridament quirúrgic, I no va tenir seqüeles. COMENTARIS: Cal tenir present que els cefalohematomes, tot I que habitualment tenen un curs autolimitat I una bona evolució, són un lloc potencial d'infecció, I que cal sospitar I descartar la infecció en un pacient amb febre I l'existència prèvia d'un cefalohematoma. S'han descrit casos de meningitis associats a cefalohematoma, però, fins on sabem, només un de meningitis asèptica com el descrit I que es va considerar, a diferència del que presentem, secundària a un retard en la recollida del líquid cefaloraquidi després d'iniciada l'antibioteràpia

INTRODUCCIÓN: Un cefalohematoma es una colección de sangre debajo del periostio del cráneo secundaria a un traumatismo del parto. Afecta a entre el 1% y el 2% de los neonatos nacidos mediante un parto vaginal y a entre el 3% y el 4% de los nacidos mediante un parto instrumentado. Suelen ser benignos, autolimitados y resolverse espontáneamente en semanas, pero en algunos casos se pueden acompañar de anemia, hiperbilirrubinemia o fractura craneal, complicarse con una calcificación o, raramente, infectarse. CASO CLÍNICO: Recién nacido a término de 9 días de vida con un cefalohematoma presente desde el nacimiento que aumentó de tamaño tres haber tenido fiebre e infectarse por Escherichia coli, supuestamente por la extensión de una bacteriemia, y que se acompañó de una meningitis aséptica (pleocitosis) que se consideró secundaria a una osteomielitis por contigüidad. El paciente se trató con antibióticos y desbridamiento quirúrgico y no tuvo secuelas. COMENTARIOS: Debemos tener en cuenta que los cefalohematomas, a pesar de que habitualmente tienen un curso autolimitado y una buena evolución, son un lugar potencial de infección, y que hay que sospechar y descartar la infección en un paciente con fiebre y la existencia de un cefalohematoma previo. Se han descrito algunos casos de meningitis asociados a cefalohematoma, pero hasta donde sabemos solo uno de meningitis aséptica como el descrito y que se consideró, a diferencia del que presentamos, secundaria a un retraso en la recogida del líquido cefalorraquídeo tras el inicio de la antibioterapia

INTRODUCTION: A cephalohematoma is a collection of blood below the periosteum of the skull due to birth trauma. It affects 1-2% of spontaneous vaginal deliveries and 3-4% of instrument-assisted deliveries. It is usually a self-limiting, benign condition which resorbs within weeks. A small proportion of cases can be accompanied by anemia, hyperbilirubinemia or a skull fracture, or be complicated by calcification or rarely by infection. CASE REPORT: 9-day-old full term neonate with a cephalohematoma present at birth that enlarged after the cephalohematoma got infected by Escherichia coli during a septic episode. Aseptic meningitis (pleocytosis) was assumed to be due to contiguous osteomyelitis. The patient was successfully treated with antibiotics and surgical debridement and showed no sequelae. COMMENTS: Clinicians should be aware that even though cephalohematomas are usually a benign, self-limiting condition, they are a potential site of infection. Infection must be suspected and ruled out in a patient with fever and a pre-existing cephalohematoma. A few cases of meningitis accompanying an infected cephalohematoma have been reported, although, to our knowledge, there is only one report of an associated aseptic meningitis. In contrast to the patient we present, in the other reported case lumbar puncture was performed 24 hours after onset of antibiotic treatment, which was suggested as the reason for the cerebrospinal fluid to be sterile

Autoinflammatory diseases in childhood, part 1: monogenic syndromes.

Autoinflammatory diseases constitute a family of disorders defined by aberrant stimulation of inflammatory pathways without involving antigen-directed autoimmunity. They may be divided into monogenic and polygenic types. Monogenic autoinflammatory syndromes are those with identified genetic mutations, such as familial Mediterranean fever, tumor necrosis factor receptor-associated periodic fever syndrome (TRAPS), mevalonate kinase deficiency or hyperimmunoglobulin D syndrome, cryopyrin-associated periodic fever syndromes (CAPS), pyogenic arthritis pyoderma gangrenosum and acne (PAPA) syndrome, interleukin-10 and interleukin-10 receptor deficiencies, adenosine deaminase 2 deficiency and pediatric sarcoidosis. Those without an identified genetic mutation are known as polygenic and include systemic-onset juvenile idiopathic arthritis, idiopathic recurrent acute pericarditis, Behçet syndrome, chronic recurrent multifocal osteomyelitis and inflammatory bowel disease among others. Autoinflammatory disorders are defined by repeating episodes or persistent fever, rash, serositis, lymphadenopathy, arthritis and increased acute phase reactants, and thus may mimic infections clinically. Most monogenic autoinflammatory syndromes present in childhood. However, because of their infrequency, diverse and nonspecific presentation, and the relatively new genetic recognition, diagnosis is usually delayed. In this article, which is Part 1 of a two-part series, the authors update monogenic autoinflammatory diseases in children with special emphasis on imaging features that may help establish the correct diagnosis.

Autoinflammatory diseases in childhood, part 2: polygenic syndromes.

Autoinflammatory diseases are a family of disorders characterized by aberrant stimulation of inflammatory pathways without involvement of antigen-directed autoimmunity. They can be further divided in monogenic and polygenic types. Those without an identified genetic mutation are known as polygenic and include systemic-onset juvenile idiopathic arthritis, idiopathic recurrent acute pericarditis, Behçet syndrome, chronic recurrent multifocal osteomyelitis and inflammatory bowel disease among others. Autoinflammatory diseases are characterized by recurrent flares or persistent systemic inflammation and fever, as well as lymphadenopathy and cutaneous, abdominal, thoracic and articular symptoms. Although these syndromes can mimic infections clinically, the inflammatory lesions in autoinflammatory disorders are aseptic. However, because of their infrequency, varied and nonspecific presentation, and the new genetic identification, diagnosis is usually delayed. In this article, which is Part 2 of a two-part series, the authors review the main polygenic autoinflammatory diseases that can be seen in childhood, with special emphasis wherever applicable on imaging features that may help establish the correct diagnosis. However, the major role of imaging is to delineate organ involvement and disease extent.

Connective Tissue Disorders in Childhood: Are They All the Same?

Systemic connective tissue disorders are characterized by the presence of autoantibodies and multiorgan system involvement. Juvenile systemic lupus erythematosus with or without associated antiphospholipid syndrome; juvenile dermatomyositis; sclerodermiform syndromes, including systemic and localized sclerodermas and eosinophilic fasciitis; mixed connective tissue disease; and Sjögren syndrome are the disorders that affect children most frequently. Diagnosis is difficult, because the clinical presentation of patients is diverse, from mild to severe disease. In addition, all organs may be affected. However, a variety of imaging techniques are now available to investigate rheumatic disease in children. These imaging modalities offer the potential for earlier diagnosis and improved assessment of therapeutic response. This article reviews the main connective tissue disorders that affect children, highlighting their key imaging features on images acquired with different diagnostic imaging modalities and correlating these features with clinical and pathologic findings, when available. ©RSNA, 2019.

Imaging Evaluation of Pediatric Parotid Gland Abnormalities.

Parotid gland lesions in children can be divided into benign or malignant. The age of the patient helps narrow the differential diagnosis, with vascular and congenital lesions being more frequent in the 1st year of life, while solid tumors are more frequent in older children. Inflammatory disease usually has rapid onset in comparison with that of neoplastic or congenital processes, which have more gradual clinical evolution. Currently, multiple imaging techniques are available to study the parotid region, such as US, CT, and MRI. However, it is still a challenge to distinguish nonmalignant lesions from malignant ones. US is the first-line diagnostic approach in children to characterize the morphology and vascularity of these lesions. CT in children may be indicated for evaluation of abscesses or sialolithiasis. MRI is the imaging modality of choice for investigating the nature of the lesion and its extent. In addition to complete and detailed clinical information, knowledge of parotid gland anatomy and characteristic radiologic features of parotid disorders is essential for optimal radiologic evaluation and avoiding unnecessary interventional diagnostic procedures or treatment. This article illustrates a variety of entities (congenital, inflammatory, vascular, neoplastic) that can occur in the parotid gland, highlighting the most frequent radiologic patterns of manifestation and correlating them with clinical, surgical, and pathologic findings. ©RSNA, 2018.

Adrenoleucodistrofia ligada al X con patrón radiológico atípico / X-linked adrenoleukodystrophy with an atypical radiological pattern

Introducción. La adrenoleucodistrofia ligada al X (ALD-X) es la enfermedad peroxisómica más frecuente. Se debe a una mutación en el gen ABCD1. La pérdida de la función de ABCD1 provoca una betaoxidación inefectiva de los ácidos grasos de cadena muy larga, lo que provoca la acumulación de estos ácidos grasos. La alteración típica en la neuroimagen en la forma cerebral es la desmielinización periventricular simétrica y de localización posterior. Caso clínico. Niño de 10 años, con hemiparesia espástica derecha y deterioro cognitivo subagudo. La resonancia magnética cerebral mostró afectación asimétrica de la sustancia blanca en la región frontoparietotemporal izquierda, y en la tomografía axial computarizada se visualizaban calcificaciones. Se confirmó ALD-X mediante la elevación de los niveles de ácidos grasos de cadena muy larga, y se encontró una variante patogénica en el gen ABCD1. Conclusiones. La desmielinización asimétrica con calcificaciones raramente se ha descrito en la ALD-X, y estos hallazgos podrían retrasar el diagnóstico. Esta presentación excepcional se debería considerar siempre en niños con inicio subagudo de síntomas motores y regresión cognitiva o del comportamiento

Introduction. X-linked adrenoleukodystrophy (X-ALD) is the most frequent peroxisomal disease. It is due to a mutation in the ABCD1 gene. The loss of functioning of ABCD1 triggers ineffective beta oxidation of very long-chain fatty acids, which gives rise to an accumulation of these fatty acids. The typical alteration revealed in neuroimaging scans in the cerebral form is symmetrical periventricular demyelination with posterior location. Case report. We report the case of a 10-year-old boy with right spastic hemiparesis and subacute cognitive impairment. Magnetic resonance imaging of the brain showed symmetrical involvement of the white matter in the left frontoparietotemporal region, and calcifications were observed in the computerised axial tomography scan. X-ALD was confirmed by means of the elevated levels of very long-chain fatty acids, and a pathogenic variant was found in the ABCD1 gene. Conclusions. Symmetrical demyelination with calcifications has rarely been reported in X-ALD, and these findings could delay diagnosis. This exceptional presentation should always be taken into consideration in children with subacute onset of motor symptoms and cognitive or behavioural regression

Central nervous system malformation associated with methamphetamine abuse during pregnancy.

INTRODUCTION: Prenatal methamphetamine exposure is related to prematurity, fetal growth restriction, neurobehavioral effects and long-term motor and cognitive sequelae. PATIENT PRESENTATION: We report the case of a newborn from a Filipina with no prenatal care with a complex brain malformation. Methamphetamine was identified in maternal and neonatal urine and in maternal hair, raising our suspicion of methamphetamine as a cause of this malformation. DISCUSSION: Methamphetamine abuse is a growing problem worldwide. There are little data on its effect on the fetus. To our knowledge, no fetal brain abnormalities have been associated with its use. In our case, the lack of antenatal control does not allow us to date when this malformation appeared. CONCLUSION: The aim of our report is to generate awareness of the possible association between methamphetamine abuse during pregnancy and central nervous system malformations.

Urethral catheter-related bladder wall lesions simulating inflammatory pseudotumor in a neonate.

BACKGROUND: Inflammatory pseudotumors of the bladder are rare in newborns. Considering the potential for malignancy, invasive diagnostic assessment and therapeutic surgical excision have been described as the approach of choice. CASE REPORT: We present a case of urethral catheter-related injury causing multifocal lesions simulating inflammatory pseudotumors of the bladder, diagnosed in a newborn presenting with persistent priapism. This case is distinct by virtue of its very rapid spontaneous regression of the bladder wall lesions within 4 days. CONCLUSIONS: Our neonatal case, along with previously described pediatric pseudotumor of the bladder, show the potential for spontaneous regression of these lesions and emphasizes the importance of balancing the potential risks and benefits of aggressive diagnostic or therapeutic interventions. Frequent diagnostic imaging and close follow-up should be considered as an alternative in young pediatric populations.

Human Metapneumovirus in the Cerebrospinal Fluid of a Patient With Acute Encephalitis.

OBJECTIVE: To report, to our knowledge, the first case of detection of human metapneumovirus in the cerebrospinal fluid of a patient during acute encephalitis. DESIGN: Case report. SETTING: University hospital. PATIENT: A 10-year-old girl with acute encephalitis. RESULTS: Human metapneumovirus was detected in cerebrospinal fluid and nasal-wash specimens during the initial phase of mild encephalitis. Abrupt clinical deterioration was associated with the presence of multiple areas of demyelination and cortical abnormalities. Demyelinated areas improved after immunomodulatory therapy, but cortical lesions spread in both hemispheres. Surprisingly, clinical worsening occurred when the virus became undetectable in cerebrospinal fluid. CONCLUSIONS: The detection of human metapneumovirus in cerebrospinal fluid strongly suggests its causative role in acute encephalitis. The evolution of the clinical and radiological features provided insight into the pathogenesis of human metapneumovirus encephalitis.

Ultrasound findings on patients with juvenile idiopathic arthritis in clinical remission.

OBJECTIVE: To assess whether children with juvenile idiopathic arthritis (JIA) in clinical remission show pathologic findings on either gray-scale or power Doppler ultrasound of their joints. METHODS: Children with JIA were eligible if they were in clinical remission for at least 3 months, as defined by the absence of clinically active joints and serologic markers of inflammation. Gray-scale as well as power Doppler ultrasonography of the wrist, knee, and ankle were carried out on previously affected joints and unaffected contralateral joints. Images were read by 2 independent readers. Findings were categorized as 1) structural abnormalities in the case of synovial thickening or increased joint fluid on gray-scale ultrasound or 2) power Doppler positive in the case of an abnormal power Doppler signal. RESULTS: The study cohort consisted of 28 patients. Eight of 14 patients with previous wrist involvement had pathologic gray-scale findings, and 3 of these 14 patients also had pathologic Doppler findings in the wrist. None of the 20 patients with past knee involvement had pathologic gray-scale or Doppler findings in the knee. Six of 15 patients with previous ankle involvement had pathologic gray-scale findings and 1 of the 15 patients had pathologic Doppler findings in the tibiotalar joint. CONCLUSION: This study demonstrates that some patients who meet clinical criteria for remission continue to show ongoing pathology on joint ultrasound, which may be suggestive of persistent inflammation.