Functional Magnetic Resonance Imaging in Pediatrics

Functional magnetic resonance imaging (fMRI) allows non-invasive assessment of human brain function in vivo by detecting blood flow differences. In this review, we want to illustrate the background and different aspects of performing functional magnetic resonance imaging (fMRI) in the pediatric age group. An overview over current and future applications of fMRI will be given, and typical problems, pitfalls, and benefits of doing fMRI in the pediatric age group are discussed. We conclude that fMRI can successfully be applied in children and holds great promise for both research and clinical purposes

Loud Clicking Sounds Associated with Rapid Soft Palate Muscle Contractions

An 8-year-old boy was seen by his primary care pediatrician with a chief complaint of intermittent rapid vibrations of the epiglottis that began several weeks prior. Intraoral examination revealed rapid, symmetrical bilateral contractions of the soft palate muscles (velum), accompanied by clicking sounds audible to physician (objective tinnitus) and patient. The patient was able to volitionally control the initiation and cessation of the palatal movements. The child\u27s mother stated that there had been no clicking noises heard while the boy was sound asleep. Palatal clonus was tentatively diagnosed as the cause of the problem. A normal magnetic resonance imaging study with contrast enhancement confirmed that there was no anatomical basis for the localized movement disorder.Palatal myoclonus is an uncommon localized intraoral movement disorder. There are 2 distinct types, and our patient was diagnosed with the essential palatal myoclonus type. This type is characteristically associated with clicking tinnitus, heard by the affected person as well as those in close proximity. The clicking noise is not continuous, ceases during sleep, and is not lifelong

Issues Concerning the Treatment of a Child with a Craniopharyngioma

The case being presented is that of a 6-year-old boy with craniopharyngioma. The discussion centers on the controversy regarding the optimal therapy for craniopharyngioma: surgery alone, radiotherapy alone, or combined therapy using both surgery and radiation. This patient was treated with biopsy and radiotherapy and the reasons for that decision are discussed

Endoscopic Access to the Infratemporal Fossa and Skull Base: A Cadaveric Study

OBJECTIVES: To demonstrate that the regions of the infratemporal fossa and skull base at the level of the foramen ovale can be visualized endoscopically and that structures can be manipulated within these regions using endoscopic instruments. METHODS: Cadaveric dissection of 3 human cadavers using an endoscopic optical dissector. In all, 6 endoscopic infratemporal fossa and skull base approaches were performed. SETTING: Human temporal bone laboratory. RESULTS: A Gillies incision was coupled with a lateral brow incision, and then subperiosteal planes were developed. Endoscopic visualization and instrumentation was then performed. The infratemporal fossa was readily identified. The skull base at the level of the foramen ovale and the branches of the third division of the trigeminal nerve were seen distinctly. A probe was placed with ease within the foramen ovale itself. CONCLUSIONS: Endoscopic access to the infratemporal fossa is readily accomplished, with excellent visualization and instrumentation ability. This novel technique provides access to this remote region for evaluation, possible biopsy, and potential treatment of infratemporal fossa lesions

Glossopharyngeal schwannoma in childhood: Case report and treatment strategy

Glossopharyngeal (that is, cranial nerve IX) schwannomas are extremely rare nerve sheath tumors that frequently mimic the more common vestibular schwannoma in their clinical as well as radiographic presentation. Although rare in adults, this tumor has not been reported in a child. The authors report the case of a 10-year-old boy who presented with several months of unilateral hearing loss. He was found to have a large right cerebellopontine angle tumor. Given the boy\u27s primary complaint of hearing loss and the appearance of the lesion on imaging, the tumor was initially believed to be a schwannoma of the vestibular nerve. It was found intraoperatively, however, to originate from the glossopharyngeal nerve. To the authors\u27 knowledge, this is the first reported case of a glossopharyngeal schwannoma in a child

Atlanto-occipital Subluxation in a Neonate with Down’s Syndrome: Case Report and Review of the Literature

Atlantooccipital subluxation (AOS) occurs in up to 63% of patients with Down’s syndrome. However, presenting symptoms and the age at which pre-operative screening becomes necessary have not been clearly delineated. Recently, a 16-day-old female with Down’s syndrome and AOS presented to our institution. Following patent ductus arteriosus ligation, her neurological examination revealed trace movement, few spontaneous respirations, and left lower extremity clonus. Cervical spine radiographs revealed significant AOS. She was reduced and underwent a fusion from the occiput to C2. She gradually regained full strength and sensation. This case is the youngest example of AOS related to Down’s syndrome described. It emphasizes the need for preopera-tive screening of all patients with Down’s syndrome

Isolated extracranial recurrence of anaplastic ependymoma

Anaplastic ependymoma is a malignant glial tumor thought to arise from radial glial cells of the ventricular zone. Because ependymoma is frequently encountered within ventricular spaces, they are prone to leptomeningeal dissemination. Metastatic extracranial ependymoma has been reported, but in the context of progressive intracranial disease. We report on a boy who developed isolated extracranial recurrence of his anaplastic ependymoma, initially at the scalp and later metastases to cervical lymph nodes. The location of tumor recurrence proximate to the surgical site suggested surgical seeding. This case demonstrates an unusual site of recurrence of anaplastic ependymoma and highlights a previously underappreciated surgical complication

Symptomatic Lumbar Stenosis Following Fusion Using Sublaminar Hooks. Case Report.

A case of postfusion lumbar stenosis caused by the presence of sublaminar hooks is described. The patient was a 52-year-old man who 11 years previously had undergone lumbar fusion with Harrington rod instrumentation for a traumatic L-2 vertebral body fracture. Postoperatively, he developed progressive low-back pain, neurogenic claudication, and significant lower-extremity weakness and atrophy. Upon radiological examination, he was found to have high-grade lumbar stenosis at the level of the caudal sublaminar hooks. The instrumentation was removed and the area of radiological stenosis decompressed. Clinically, both the patient\u27s pain and motor deficits resolved and, on postoperative imaging, the stenosis was relieved. Thus, despite other areas of persisting pathology, it is concluded that the stenosis occurring at the level of the caudal sublaminar hooks contributed to the patient\u27s symptoms. Although not a common cause of postfusion stenosis, the presence of instrumentation in the proximity of neural elements must be considered as an etiology for neurological dysfunction

Inadvertent Hyponatremia Leading to Acute Cerebral Edema and Early Evidence of Herniation

INTRODUCTION: For years, the maintenance of normal or supranormal serum sodium (Na) concentrations has been believed to be beneficial in brain injuries. Recently published guidelines for cerebral trauma recommend the use of hypertonic saline to achieve hypernatremia for the management of increased intracranial pressure and these standards are generally practiced across most diseases in neurocritical care including stroke, hemorrhage and tumors. Severe hyponatremia has long been known to be detrimental, but objective evidence for the harm of mild hyponatremia as a secondary injury has been scarce. DESCRIPTION OF CASE: In this case report, we describe a child with aneurysmal subarachnoid hemorrhage who had a sudden, inadvertent decrease in serum Na (128 meq/l) that was associated with a deterioration of her neurological examination and evidence of early transtentorial herniation on emergent brain CT scan. These findings were quickly reversed after the serum Na was corrected. DISCUSSION: This report emphasizes that close monitoring of serum Na and osmolarity in acute head injured children is important, and provides evidence that alterations of these parameters is a substantial risk for cerebral edema in children with evolving brain injuries and briefly reviews the literature regarding the risks of hyponatremia in children

Pediatric Incidental Brain Tumors: a Growing Treatment Dilemma

OBJECT: Rising numbers of MRI studies performed during evaluations for pediatric disorders have contributed to a significant increase in the number of incidentally found brain tumors. Currently, there is very little literature on the nature of and the preferred treatment for these incidental brain tumors. In this paper the authors review their experience diagnosing and treating these lesions in children as well as the current literature on this topic. METHODS: Records from 2 centers were reviewed for incidentally found brain tumors, treatment approaches, and outcomes for both surgical and nonsurgical cohorts. RESULTS: Forty-seven children (30 males and 17 females) with a mean age of 8.6 years were found to have incidental brain lesions suspected to be neoplasms. Twenty-five underwent surgery and 22 were observed. Two children in the observation group required surgery at a later stage. Tumor pathology in 24 patients was benign. Only 3 patients had high-grade tumors. All nonsurgically treated lesions were presumed to be low-grade tumors and were followed up for 25 ± 20 months. CONCLUSIONS: The discovery of incidental brain tumors on MRI in children poses an increasing challenge. Additional studies are needed to determine the significance as well as the optimal management strategies in this situation