Giant middle cerebral aneurysm presenting as hemiathetosis in a child and its spontaneous thrombosis.

A 10-year-old girl presented with a 6-week history of gradually increasing, abnormal movements and weakness of the right upper and lower limbs. There were no features of raised intracranial pressure. Computed tomography scan and magnetic resonance imaging (MRI) of the brain showed the features of a partially thrombosed giant middle cerebral artery aneurysm, located deep in the left lentiform region and compressing the basal ganglia and the mesencephalon. The angiogram confirmed the aneurysm and its origin from the main trunk of the artery with occlusion of all the branches. A direct approach was unsuitable for the treatment of the aneurysm, so an embolization procedure to occlude the neck of the aneurysm was considered. During the waiting period, the patient improved and became asymptomatic. Follow-up MRI showed complete thrombosis of the aneurysm and eventually, reduction in its size and mass effect. The hemiathetosis may have been the result of direct pressure on the basal ganglia by the aneurysm. The spontaneous intra-aneurysmal thrombosis may have been due to the massive size of the aneurysm and its narrow neck.

Folic acid supplementation in low birth weight infants.

Low birth weight infants (246) entered a trial to folic acid supplementation from 3 weeks to 12 months of age. The folic acid group had significantly higher mean hemoglobin levels at 6 and 9 months of age but the differences were only about 0.5 gm/dl, there was no significant difference in hematocrit, and in both groups of infants the mean hemoglobin levels were higher than those of normal birth weight infants. The differences in hemoglobin, although statistically significant, are of uncertain clinical significance. Median red cell folate levels remained within the normal adult range in both groups of infants. A minority of infants in the untreated group had low red cell folate levels but this was usually temporary, corrected by dietary folate, and not associated with low hemoglobin. Weight gain was not affected by folic acid supplementation. The infants in this trial were fed with a milk preparation containing 3.5 microgram/100 ml of folic acid which is a similar concentration to that of human milk and we recommend that the folate content of milks fed to low birth weight infants should not fall below this level. We do not have sufficient grounds to recommend routine folic acid supplements for all low birth weight infants throughout the first year of life but there is a possibility that their folate intake may sometimes be suboptimal.

Diagnosis and management of folate deficiency in low birthweight infants.

Significant folate deficiency in 14 out of 37 preterm infants of birthweights 2.0 kg or less was found to be reliably and most conveniently diagnosed by abnormal morphological changes in peripheral blood and confirmed by the response to folic acid. Deficiency appeared to be more common in light-for-dates infants including the smaller of twins. Neither the clinical status nor the levels of haemoglobin or erythrocyte folate was a reliable guide to the presence of megaloblastic erythropoiesis in the very young preterm infant. 100-200 microgram folic acid a day, orally or IM, may be required to ensure an optimal haematological response, and this would be appropriate for therapeutic trial if the diagnosis is in doubt. This amount would also replenish tissue folate stores; larger doses are likely to exceed the requirements of small infants.