MRI of fatal course of acute hemorrhagic leukoencephalitis in a child with SARS-CoV-2 omicron BA 2.0 infection.

We present a pediatric case of acute hemorrhagic leukoencephalitis associated with SARS-CoV-2 Omicron BA 2.0 infection. A previously healthy girl presented with ataxia and diplopia three weeks after the COVID-19 confirmation from a nasopharyngeal swab. Acute and symmetrical motor weakness and drowsiness ensued within the following 3 days. She then became spastic tetraplegic. MRI revealed multifocal lesions in the cerebral white matter, basal ganglia, and brainstem, with hemorrhagic changes confirmed with T1-hyperintensity and hypointensity on susceptibility-weighted images. Peripheral areas of decreased diffusion, increased blood flow, and rim contrast enhancement were noted in the majority of lesions. She was treated with a combination of intravenous immunoglobulin and methylprednisolone pulse therapy. Neurological deterioration ensued with coma, ataxic respiratory pattern and decerebrate posture. Repeated MRI performed on day 31 revealed progression of abnormalities, hemorrhages and brain herniation. Despite the administration of plasma exchange, she died two months after admission.

Quantitative Analysis for the Delineation of the Subthalamic Nuclei on Three-Dimensional Stereotactic MRI Before Deep Brain Stimulation Surgery for Medication-Refractory Parkinson's Disease.

Delineation of the subthalamic nuclei (STN) on MRI is critical for deep brain stimulation (DBS) surgery in patients with Parkinson's disease (PD). We propose this retrospective cohort study for quantitative analysis of MR signal-to-noise ratio (SNR), contrast, and signal difference-to-noise ratio (SDNR) of the STN on pre-operative three-dimensional (3D) stereotactic MRI in patients with medication-refractory PD. Forty-five consecutive patients with medication-refractory PD who underwent STN-DBS surgery in our hospital from January 2018 to June 2021 were included in this study. All patients had whole-brain 3D MRI, including T2-weighted imaging (T2WI), T2-weighted fluid-attenuated inversion recovery (FLAIR), and susceptibility-weighted imaging (SWI), at 3.0 T scanner for stereotactic navigation. The signal intensities of the STN, corona radiata, and background noise were obtained after placing regions of interest (ROIs) on corresponding structures. Quantitative comparisons of SNR, contrast, and SDNR of the STN between MR pulse sequences, including the T2WI, FLAIR, and SWI. Subgroup analysis regarding patients' sex, age, and duration of treatment. We used one-way repeated measures analysis of variance for quantitative comparisons of SNR, contrast, and SDNR of the STN between different MR pulse sequences, and we also used the dependent t-test for the post hoc tests. In addition, we used Mann-Whitney U test for subgroup analyses. Both the contrast (0.33 ± 0.07) and SDNR (98.65 ± 51.37) were highest on FLAIR (all p < 0.001). The SNR was highest on SWI (276.16 ± 115.5), and both the SNR (94.23 ± 31.63) and SDNR (32.14 ± 17.23) were lowest on T2WI. Subgroup analyses demonstrated significantly lower SDNR on SWI for patients receiving medication treatment for ≥13 years (p = 0.003). In conclusion, on 3D stereotactic MRI of medication-refractory PD patients, the contrast and SDNR for the STN are highest on FLAIR, suggesting the optimal delineation of STN on FLAIR.

Spectrum of neuroimaging mimics in children with COVID-19 infection.

Coronavirus disease 2019 (COVID-19), caused by SARS-CoV-2, has affected over 200 million people globally (including over 30 million people in the United States), with children comprising 12.9% of reported cases in the United States. In children, COVID-19 infection appears to be associated with mild respiratory symptoms; however, serious neurological complications may occur in conjunction with multisystem inflammatory syndrome. A wide spectrum of neurological diseases have been observed in children with COVID-19 infection including encephalitis, acute necrotizing encephalopathy, acute disseminated encephalomyelitis, cytotoxic lesion of the callosal splenium, posterior reversible encephalopathy syndrome, venous sinus thrombosis, vasculitis and infarction, Guillain-Barré syndrome, transverse myelitis, and myositis. This review describes the characteristic magnetic resonance neuroimaging features of these diseases and their differentiations from other imaging mimics. In addition, we review the possible pathophysiology underlying the association between these diseases and COVID-19-infection. As new SARS-CoV-2 variants emerge and COVID-19 infection continues to spread worldwide, pediatricians, radiologists, and first-line care givers should be aware of possible neurological diseases associated with COVID-19 infection when these reported neuroimaging patterns are observed in children during this pandemic.

Prediction of Malignant Transformation of WHO II Astrocytoma Using Mathematical Models Incorporating Apparent Diffusion Coefficient and Contrast Enhancement.

Using only increasing contrast enhancement as a marker of malignant transformation (MT) in gliomas has low specificity and may affect interpretation of clinical outcomes. Therefore we developed a mathematical model to predict MT of low-grade gliomas (LGGs) by considering areas of reduced apparent diffusion coefficient (ADC) with increased contrast enhancement. Patients with contrast-enhancing LGGs who had contemporaneous ADC and histopathology were retrospectively analyzed. Multiple clinical factors and imaging factors (contrast-enhancement size, whole-tumor size, and ADC) were assessed for association with MT. Patients were split into training and validation groups for the development of a predictive model using logistic regression which was assessed with receiver operating characteristic analysis. Among 132 patients, (median age 46.5 years), 106 patients (64 MT) were assigned to the training group and 26 (20 MT) to the validation group. The predictive model comprised age (P = 0.110), radiotherapy (P = 0.168), contrast-enhancement size (P = 0.015), and ADC (P < 0.001). The predictive model (area-under-the-curve [AUC] 0.87) outperformed ADC (AUC 0.85) and contrast-enhancement size (AUC 0.67). The model had an accuracy of 84% for the training group and 85% respectively for the validation group. Our model incorporating ADC and contrast-enhancement size predicted MT in contrast-enhancing LGGs.

Brain Abscess Apparent Diffusion Coefficient is Associated With Microbial Culture Yields.

BACKGROUND: Obtaining pus for microbial cultures is one of the surgical aims in patients with brain abscess. Predictors of microbial yields are necessary as they help in treatment planning. PURPOSE: To investigate the relationship between microbial culture yields of brain abscesses and their apparent diffusion coefficient (ADC) values and clinical characteristics. STUDY TYPE: Retrospective. SUBJECTS: Eighty-four patients diagnosed with brain abscess by surgery and histopathology (59 with positive abscess cultures). FIELD STRENGTH/SEQUENCE: Diffusion-weighted, T2-weigthed, and contrast-enhanced T1-weighted imaging at 1.5 T and 3 T. ASSESSMENT: Contrast-enhanced T1-weighted images were co-registered to ADC maps. Three neuroradiologists determined abscess imaging characteristics (distribution, location, and ventricular rupture), and two measured abscess volumes and ADC values. Clinical characteristics collected included sex, age, fever, underlying diseases, infection sources, white blood cell count, percentage of segmented neutrophils, C-reactive protein level, regimen and duration of empirical antibiotics, and types of surgery. STATISTICAL TESTS: Interobserver differences were assessed with Fleiss kappa and intraclass correlation coefficients. The differences in clinical and imaging factors between the positive and negative culture groups were compared with Chi-square analysis or Student's t test. All factors were subjected to multivariable logistic regression analysis to assess their associations with microbial culture yields, and factors with statistical significance were evaluated with receiver operating characteristic curve analysis to assess their diagnostic performance in discriminating the two groups. RESULTS: Mean ADC (×10-6  mm2 /s) of culture-negative abscesses (841 ± 173) was significantly higher (P < 0.05) than that of culture-positive abscesses (536 ± 90). On multivariable analysis, mean ADC was the only significant factor (P < 0.05) related to culture yields. With 660 as the cutoff value, the sensitivity, specificity, and accuracy of ADC for discriminating culture yields were 93.2%, 88.0%, and 91.7%, respectively. DATA CONCLUSION: ADC could be used to discriminate between culture-positive and culture-negative abscesses. EVIDENCE LEVEL: 4 TECHNICAL EFFICACY: Stage 2.

Neurological and endocrinological manifestations of 49 children with intracranial pure germinoma at initial diagnosis in Taiwan.

BACKGROUND: Intracranial pure germinoma is a rare extragonadal neoplasm. Affected patients may have motor impairment, visual disturbance, neurological signs, and endocrine disorder, depending on the size and location of the tumor. This study investigated and analyzed patients' demographic data and neuroimaging, clinical, laboratory, and endocrinological findings. METHODS: We performed a retrospective chart review of 49 children diagnosed with pure germinoma in Taiwan from 1990 to 2018. The initial clinical presentation, tumor markers (beta-hCG, alpha fetoprotein, and carcinoembryonic antigen), pituitary function, and brain images were reviewed and analyzed. RESULTS: This study included 49 patients (37 boys and 12 girls). Their ages ranged from 7.5 to 17.9 years, and the mean age at diagnosis was 13.6 years. Initial symptoms included visual disturbance (n = 23, 47.9%), motor impairment (n = 20, 40.8%), polyuria (n = 20, 40.8%), headache (n = 17, 34.7%), dizziness or vertigo (n = 14, 28.6%), nausea/vomiting (n = 13, 26.5%), and short stature (n = 8, 18.2%). Laboratory data indicated growth hormone deficiency or low IGF-1 levels (n = 18, 85.7%), adrenal insufficiency (n = 21, 77.8%), central diabetes insipidus (n = 27, 55.1%), central hypothyroidism (n = 15, 48.4%), and hypogonadotropic hypogonadism (n = 4, 44.4%). CONCLUSION: Intracranial pure germinomas may initially manifest as neurological symptoms or endocrinological findings at diagnosis. As endocrinologic presentation is related to delayed diagnosis, clinicians should be aware of patients with such complaints. Laboratory data should be surveyed carefully, and neuroimaging must be considered if the result is abnormal.

Rhombencephalitis in Children: Diffusion Magnetic Resonance Imaging (MRI) Correlation With Clinical Outcomes.

In children with rhombencephalitis, neuroimaging abnormalities have been infrequently correlated with clinical outcome. We investigated whether magnetic resonance (MR) neuroimaging studies could predict clinical outcomes and disturbance of consciousness in patients with rhombencephalitis. We retrospectively analyzed the MR studies of 19 pediatric patients with rhombencephalitis (median age: 4.2 years, range 0.5-17; sex: 32% male). Fluid-attenuated inversion recovery imaging and diffusion-weighted imaging findings were graded to create imaging scores according to the extent of imaging abnormality. Clinical outcomes in the first week and 12th month were graded by using Glasgow Outcome Scale scores (1-5) and dichotomized to unfavorable or favorable outcome. Correlations of the imaging scores with the clinical outcomes and with disturbance of consciousness were assessed by using multivariate logistic regression analysis. No significant correlation was found between fluid-attenuated inversion recovery score or diffusion-weighted imaging score (P = .608, P = .132, respectively) and disturbance of consciousness. In the first week, the unfavorable outcome group (n = 11) had significantly higher diffusion-weighted imaging score than did the favorable outcome group (n = 8) (Mann-Whitney U test, P = .005). Multivariate logistic regression analysis showed that the diffusion-weighted imaging score (odds ratio, 18.182; 95% confidence interval: 1.36, 243.01; P = .028) was significantly associated with unfavorable outcome. In the 12th month, the fluid-attenuated inversion recovery score or diffusion-weighted imaging score (P = .994, P = .997, respectively) were not significantly associated with unfavorable outcome. Patients with rhombencephalitis who have a higher diffusion-weighted imaging score are more likely to have an unfavorable 1-week clinical outcome.

Arterial spin-labeling magnetic resonance imaging of brain maturation in early childhood: Mathematical model fitting to assess age-dependent change of cerebral blood flow.

PURPOSE: To determine the trajectory of age-dependent cerebral blood flow (CBF) change in infants and young children by fitting mathematical models to the imaging data. METHODS: In this retrospective study, we reviewed the arterial spin-labeling imaging studies of 49 typically developing infants and young children at postmenstrual age (PMA) ranging from 38 to 194 weeks. All patients had normal structural MR imaging. Coregistration and gray matter segmentation were performed to extract whole-brain CBF values. Regional CBF values were obtained using manual region-of-interest placement. Curve estimation regression procedures with the corrected Akaike information criterion (AICc) were performed to determine the mathematical model best fitting the relationship between the CBF (whole-brain and regional measurements) and PMA of the patients. RESULTS: Whole-brain CBF trajectory was best fitted by a cubic model (AICc = 215.95; R2 = 0.566; P < .001). Whole-brain CBF at 1, 6, 12, and 24 months was estimated to be 36, 52, 58, and 55 mL/100 g/min, respectively. Regional CBF trajectory was also best fitted by a cubic model in the frontal (AICc = 233.63; R2 = 0.442; P < .001), parietal (AICc = 229.18; R2 = 0.614; P < .001), basal ganglion (AICc = 239.39; R2 = 0.178; P = .043), temporal (AICc = 236.01; R2 = 0.441; P < .001), and occipital (AICc = 236.46; R2 = 0.475; P < .001) regions. CONCLUSIONS: In early childhood, the trajectory of CBF change was nonlinear and best fitted by the cubic model for the whole brain and all brain regions.

Arterial spin-labeling perfusion imaging of childhood encephalitis: correlation with seizure and clinical outcome.

PURPOSE: In childhood encephalitis, perfusion abnormalities have been infrequently reported to associate with clinical status. We investigated whether perfusion abnormalities correlated with seizure and clinical outcome in encephalitis. METHODS: We retrospectively analyzed the MR studies of 77 pediatric patients with encephalitis. Pseudo-continuous arterial spin-labeling (ASL) imaging was performed on a 3-T scanner. The patients were divided into five groups according to ASL perfusion imaging pattern: normal perfusion (NP), focal hypoperfusion (Lf), extreme global hypoperfusion (LE), focal hyperperfusion (Hf), and extreme global hyperperfusion (HE). Clinical outcome at 3 weeks was dichotomized to unfavorable or favorable outcome according to the Glasgow outcome scale. Multivariate logistic regression was conducted to predict unfavorable outcome and presence of seizure separately, based on explanatory variables including age, sex, and ASL pattern. RESULTS: Twenty-seven (35%) patients were designated as in group Hf, five (7%) in group Lf, 11 (14%) in group LE, none in group HE, and 34 (44%) in group NP. Multivariate logistic regression analysis showed that ASL pattern was significantly associated with unfavorable outcome (P = 0.005) and with presence of seizure (P = 0.005). For ASL pattern, group LE was 17.31 times as likely to have an unfavorable outcome as group NP (odds ratio confidence interval [CI] 3.084, 97.105; P = 0.001). Group Hf was 6.383 times as likely to have seizure as group NP (CI 1.765, 23.083; P = 0.005). CONCLUSIONS: In childhood encephalitis, patients with extreme global hypoperfusion had poor neurological outcome and those with focal hypoperfusion were more likely to have seizure.

Arterial spin-labeling perfusion imaging of children with subdural hemorrhage: Perfusion abnormalities in abusive head trauma.

BACKGROUND AND PURPOSE: Perfusion abnormalities have not been well described in children with subdural hemorrhage (SDH). We investigated whether patients with abusive head trauma (AHT+) had more perfusion abnormalities than those without (AHT-). MATERIALS AND METHODS: We reviewed the perfusion MR studies of 12 infants with SDH and 21 controls. The perfusion images were obtained using a pseudo-continuous arterial spin-labeling sequence with volumetric fast spin-echo readout. An MR perfusion scoring system (0-6 points) was devised to facilitate appraisal of the extent of abnormalities. An asymmetry index (AI) was calculated for each region of perfusion abnormality. Comparison of perfusion scores across the AHT+, AHT-, and control groups was performed. The AIs of the hypoperfused lesions and hyperperfused lesions in patients were separately compared with those of the controls. The neurological outcomes of the patients were associated with imaging abnormalities. RESULTS: Perfusion abnormalities were found in five (83%) of six AHT+ patients and in one (17%) of six AHT- patients. The AHT+ group recorded a significantly higher perfusion score than did both the AHT- group and the controls. Four patients with hypoperfused lesions exhibited significantly lower AI (P=.002) than did the controls, and three patients with hyperperfused lesions had significantly higher AI (P=.006) than did the controls. Of the four patients with hypoperfused lesions, two expired and one experienced hemiparesis. CONCLUSIONS: Patients with AHT have higher perfusion abnormality scores than patients with other causes of SDH and controls. Moreover, hypoperfusion may suggest a poor clinical outcome.

Diffusion-Weighted Imaging of Periventricular Leukomalacia in Very Young Children: Assessment of Peritrigonal Stripe of Restricted Diffusion.

Purpose In periventricular leukomalacia (PVL), apparent diffusion coefficient (ADC) reduction, normally shown as dark stripe in the peritrigonal (PT) white matter, may be incomplete. We assessed the PT dark stripe to differentiate between PVL patients and control subjects. Patients and Methods We reviewed the magnetic resonance studies of 27 neonates and young children with PVL and 67 control subjects to assess the PT dark stripe on ADC maps. In PVL patients, the assessment was referred to the location of PVL lesion on fluid-attenuated inversion recovery (FLAIR) imaging. In the controls, the PT region or the location corresponding to FLAIR hyperintensity was evaluated for the dark stripe. We compared the prevalence of the dark stripe on ADC map and the PT FLAIR hyperintensity between the PVL and the control subjects. Results On ADC map, complete PT dark stripe was present in 67 (100%) of 67 controls but only in 4 (14.8%) of 27 PVL patients (p-value < 0.01), with sensitivity of 0.85, specificity of 1.0, and accuracy of 0.96. PT FLAIR hyperintensity was present in 44 (65.7%) of 67 controls and in 18 (66.7%) of 27 PVL patients (p = 0.920). Conclusion PVL patients can be differentiated from the control subjects with PT dark stripe on ADC map.

Arterial spin-labeling perfusion imaging of childhood meningitis: a case series.

INTRODUCTION: Conventional magnetic resonance imaging (MRI), which is mainly used to detect complications, is ineffective in determining the neurological status of patients with meningitis. Hemodynamic change in the brain may be more indicative of the neurological status but few imaging studies have verified this. Arterial spin-labeling (ASL) perfusion, a noninvasive MR method requiring no contrast agent injection, can be used to measure cerebral blood flow (CBF). CASE REPORTS: We describe three pediatric patients with meningitis, who all showed regions of increased CBF on perfusion imaging. One patient, presenting with headache and conscious disturbance, had CBF changes in the frontal, temporal, and occipital regions. The other two patients, presenting with hallucinations, memory deficits, and seizures, had CBF changes in the frontal and temporal regions. CONCLUSION: ASL perfusion imaging may be helpful in assessing patients with meningitis, demonstrating CBF changes more strongly correlating with the neurological status, and detecting active brain abnormalities.

Kimura's disease: clinical and imaging parameters for the prediction of disease recurrence.

Kimura's disease is a rare chronic inflammatory disorder with a high rate of recurrence. The clinical and imaging features of Kimura's disease have been documented in the literature, but the relationship between these features and disease recurrence is still unclear. We conclude that disease duration of greater than 5 years, bilateral involvement, a lesion diameter of greater than 3 cm, a blood eosinophil count greater than 20%, and ill-defined lesions are predictive factors for the recurrence of Kimura's disease.

Craniocervical arterial dissection: a cause of childhood arterial ischemic stroke in Taiwan.

BACKGROUND/PURPOSE: To describe the clinical characteristics and imaging findings of craniocervical dissection in childhood ischemic stroke, in a tertiary medical center. METHODS: In this retrospective study, we investigated children (aged 1 month to 18 years) with symptoms and radiographic confirmation of ischemic stroke from January 1996 to January 2007. Stroke work-up included neuroimaging (magnetic resonance imaging, computed tomography, conventional angiography, and magnetic resonance angiography), cardiac assessment, prothrombotic assays, immunoassays, infection screening, and metabolic screening. RESULTS: Among 95 children with arterial ischemic stroke, arterial dissection was identified as the underlying risk factor in nine patients (7 boys and 2 girls; age range, 1.9 17.2 years). All the patients had focal neurological signs and two had warning symptoms. A history of trauma was noted in two patients and another two had stroke during physical exertion. The other five patients had spontaneous dissection. Six patients had anterior circulation arterial dissection. Three patients had posterior circulation arterial dissection, and the most common location was in the vertebral artery. Antiplatelet treatment was given to five patients and anticoagulants to one. Endovascular treatment was given to one patient with dissecting aneurysm. One patient died at the acute stage and another seven had neurological deficits after 9 months to 8 years follow-up. The ninth patient had no residual neurological impairment. No patients had recurrent stroke. CONCLUSION: Arterial dissection should be considered in childhood ischemic stroke. Spontaneous arterial dissection is an important factor in this group. Early investigation and treatment can improve the outcome.

Treatment of cerebellopontine angle tumors in children: a single institution's experience.

The authors discuss the current management for cerebellopontine angle (CPA) tumors in children. CPA tumors accounted for 1% to 3% of intracranial tumors in children. There had been much controversy with the management of these tumors. A total of 29 eligible patients were enrolled to the study and 5 patients had multiple lesions at diagnosis. Eight patients with tumors exclusively confined in the CPA. Sixteen patients with tumors occurred predominantly within CPA and 5 arising from the vicinity and growing mainly into the CPA. Twelve tumors were located in the right CPA (41%) and 5 (17%) on the left. Thirteen of the 29 patients developed hydrocephalus and 3 required placement of a shunt. Lesions of the CPAs were divided into those native to the angle and those extending to the angle from adjacent structures. Gross total removal was achieved in 9 cases, subtotal in 14, and 2 had biopsies only. Four patients were diagnosed with pontine glioma solely by magnetic resonance imaging without histologic confirmation. Two died soon after the operation. Ten patients died with a mortality rate of 34.5%. The median follow-up in this study was 38 months (range: 4 to 225 mo). The CPA is a rare location for lesions in children, with clear predominance on the right side. Although low-grade lesions are more frequent, the histology varies widely and is limited by the lack of radiologic-pathologic correlation.

Seizures in childhood ischemic stroke in Taiwan.

In this retrospective study, we collected clinical and radiographic data on children (age range, 1 month to 18 years) with symptoms and radiographic confirmation of seizure after ischemic stroke for the period of January 1996 to July 2006. Thirty-nine out of 94 children with ischemic stroke had poststroke seizures. Thirty-three out of 39 children with poststroke seizures had new onset seizures but only data of 28 were available. Infection was the most common etiology in the early poststroke seizure group (52.4%) but not in the late poststroke seizure group (0%). Infarction involving arterial ischemic stroke of anterior circulation were the most common in both the early poststroke seizure (61.9%) and the late poststroke seizure group (57.1%). Epilepsy was the most common sequelae in both the early poststroke seizure (38.1%) and late poststroke seizure group (100%). Children who had initial focal neurological sign (100% vs. 38.1%; P=0.007) or the focal cortical dysfunction on EEG (85.7% vs. 33.3%; P=0.029) were prone to develop late poststroke seizures. Late poststroke seizures had a high risk of developing poststroke epilepsy (100% vs. 38.1%; P=0.007). We conclude that seizures commonly occur in childhood ischemic stroke. Most poststroke seizures developed at an early stage. Infection was the most common etiology that caused early poststroke seizures in childhood ischemic stroke. Initial focal neurological signs and focal cortical dysfunction on EEG are risk factors for developing epilepsy. Poststroke seizures did not affect mortality, but there was a significant difference in normal outcome and epilepsy between those with or without poststroke seizures.

Hemorrhagic stroke associated with pulmonary edema and catastrophic cardiac failure.

Cerebral arteriovenous fistula (AVF) is a vascular malformation that is rare in the pediatric population. Older children with cerebral AVF tend to present with neurologic problems related to intracranial venous hypertension or intracranial hemorrhage. Cardiac and pulmonary complications following acute neurologic injury such as subarachnoid hemorrhage are common in adults, but are rarely reported in children. However, complications have been reported in cases of enterovirus 71 rhombencephalitis in infants and children and can cause high morbidity and mortality. Here, we report a 14-year-old boy who presented with cardiac failure associated with pulmonary edema following cerebral hemorrhagic stroke due to AVF. After aggressive investigation and management, we intervened before significant hypoxia and hypotension developed, potentially reducing the risk of long-term adverse neurologic consequences in this patient.

Clinical experience of childhood hypertensive encephalopathy over an eight year period.

BACKGROUND: Hypertensive encephalopathy is an uncommon neurological syndrome in children, usually with reversible clinical and neuroimaging findings. Little is known about the precipitating factors, clinical presentations, neuroimaging findings and outcomes of childhood hypertensive encephalopathy in Taiwan. METHODS: To characterize this syndrome, we retrospectively analyzed 12 children with hypertensive encephalopathy in a tertiary institution from 1998 through 2005. We investigated the precipitating factors, clinical findings, courses, neuroimaging characteristics and outcomes. RESULTS: Twelve patients (10 boys and 2 girls) with hypertensive encephalopathy were identified. Post-streptococcal glomerulonephritis was the most common precipitating underlying disease. Common clinical presentations included mental change (100%), seizure (91.6%), headache (66.6%), nausea or vomiting (75%), and blurred vision (41.6%). Brain imaging studies showed vasogenic edema over the bilateral parietal, occipital and parasagittal regions, or the cerebellum. All patients had a reversible clinical course. CONCLUSION: Hypertensive encephalopathy is predominant in males, and mental change is the most common clinical presentation. Renal origin is a common precipitating factor. A characteristic lesion of hypertensive encephalopathy is occipitoparietal region edema. The overall clinical outcome is good after prompt treatment.

Intramedullary spinal arteriovenous malformation in a boy of familial cerebral cavernous hemangioma.

OBJECT: The coexistence of spinal arteriovenous malformation (AVM) and a familial cerebral cavernous hemangioma (CCH) is extremely rare. METHODS: A 9-year-old boy suddenly developed severe paraplegia and urinary dysfunction. Spinal magnetic resonance imaging (MRI) scan revealed a cervical and upper thoracic intramedullary lesion. Due to acute neurological dysfunction, the patient underwent emergency surgical exploration. An intramedullary vascular lesion was found and excised. Pathologically, AVM was noted. After the surgery, the boy was ambulatory with left lower limb stiffness. MRI scan of the brain revealed multiple cerebral cavernous hemangioma. Symptomatic multiple CCH in his mother and grandmother were also noted. CONCLUSIONS: We concluded that the presence of spinal AVM should be suspected if the patient with familial CCH develops the signs of space-occupying lesion of the spinal cord, facilitating early diagnosis of the spinal AVM.

Endovascular covered stent reconstruction improved the outcomes of acute carotid blowout syndrome. Experiences at a single institute.

SUMMARY: Carotid blowout is a devastating complication in patients with head and neck cancer, commonly encountered as a delayed complication of radiation therapy. The clinical outcomes in patients with carotid blowout are discouraging; even transarterial embolization has been performed to control the acute massive bleeding. In recent years, covered stents have been reported as an alternative treatment producing favorable results. In this study, 13 consecutive patients with acute carotid blowout syndrome were treated at our institute by covered-stent reconstruction between December 2005 and December 2007. The median posthemorrhagic survival period after reconstruction (187 days) was more than that reported in patients treated only with transarterial embolization (26 days). Though the estimated mortality was about 54%, those who survived showed favorable outcomes, and only one transit complication of acute in-stent thrombosis occurred. Thus, endovascular covered-stent reconstruction is a safe and effective approach to manage acute carotid blowout syndrome.