Sonographic appearance of the ventriculus terminalis cyst in the neonatal spinal cord.

The ventriculus terminalis or "fifth ventricle" is an ependyma-lined residual lumen of the caudal portion of the spinal cord (the conus medullaris). We present the cases of three neonates with asymptomatic cystic dilatation of the ventriculus terminalis as seen on spinal sonography. Over a 4 year period (1996-1999), we prospectively found three cases in which spinal sonograms demonstrated cystic dilatation of the ventriculus terminalis of the conus medullaris in normal term neonates. Sonograms of the lumbosacral spine of two of the infants demonstrated cystic dilatation of the ventriculus terminalis of the conus medullaris. The third infant had cystic dilatation at the distal tip of the conus medullaris at the origin of the filum terminale. No other abnormalities were noted. The three infants have remained asymptomatic during clinical follow-up periods of up to 3 years. Cystic dilatation of the ventriculus terminalis is an unusual but normal anatomic variant of the conus medullaris that can be visualized on spinal sonograms in neonates.

Neck pain. Primary care work-up of acute and chronic symptoms.

Acute or chronic neck pain can arise from degenerative processes, musculoskeletal trauma, or structural changes. For all patients presenting with neck pain, determining the presence of radiculopathy or myelopathy is an important step in initial assessment. Depending on the duration of pain, the work-up should include appropriate use of traditional and advanced imaging studies. For cases that do not suggest traumatic, structural, or rheumatologic origins, alternate considerations should include stress, depression, and--because of its increased incidence in older persons--cancer. Nonsteroidal anti-inflammatory agents, mild oral analgesics, and short-term corticosteroid therapy are the mainstays of treatment, although physical therapy and traction can be helpful for some patients. The presence of a herniated disk, cord compression (severe stenosis), tumor, or other structural lesion may require surgical decompression.

Down syndrome: imaging of multiorgan involvement.

Down syndrome (trisomy 21) has many manifestations that affect multiple organ systems, and we describe the wide array of imaging findings. Common cardiovascular and gastrointestinal entities are congenital heart disease (atrioventricular canal), bowel atresias (duodenal and anal), and Hirschsprungs disease. Children with Down syndrome have an 18-20 fold increased incidence of leukemia. Pulmonary hypoplasia, lung cysts, and pig bronchus (origin of the right upper lobe bronchus from the trachea) have been described. Neurologic findings include mineralizing vasculopathy of the basal ganglia, Moyamoya disease, and cerebellar/vermian hypoplasia. Musculoskeletal manifestations are numerous and include eleven ribs, hypersegmented sternum, abnormal pelvis, joint laxity/dislocations, and DDH (developmental dysplasia of the hip). Of special importance is the "triple jeopardy" of the upper cervical spine (atlanoaxial subluxation, hypoplastic posterior arch of C1, and atlantooccipital instability) and the resulting controversial cervical spine radiographic screening of children with Down syndrome. Knowledge of the many anomalies associated with Down syndrome can aid the clinician, not only in diagnosing abnormalities in these patients, but also in counseling families for potential problems that can occur in these children.

Lobar emphysema due to anomalous aortic origin of the left pulmonary artery.

The unusual case of an infant with aortic origin of the left pulmonary artery is presented. The patient developed a rare complication of lobar emphysema due to bronchial compression from the enlarged right pulmonary artery. Operative anastomosis of the left pulmonary artery to the pulmonary trunk was successful, with subsequent resolution of the lobar emphysema.

The effect of osteotomy on bowing and height in children with X-linked hypophosphatemia.

The clinical records of 40 patients with X-linked hypophosphatemia who were treated and followed for at least 36 months were examined retrospectively. The patients were divided into those treated with medication only (group A) and those treated with medication and surgery (group B). At follow-up, significant improvement in bowing angles was noted for group B patients compared with those treated medically. There was, however, no improvement in the height of children in group A, and there was a significant decrease in height among the children treated surgically (group B). Neither height nor bowing angles of femurs or tibias at presentation predicted the need for future osteotomies. However, children who eventually needed surgery were found to be obese at presentation significantly more frequently than children who did not require osteotomy.

Occult spinal dysraphism in neonates: assessment of high-risk cutaneous stigmata on sonography.

OBJECTIVE: In this study, we evaluated the incidence of dorsal cutaneous stigmata in a healthy neonate population; we also assessed whether specific types of cutaneous stigmata are associated with underlying spinal dysraphism. SUBJECTS AND METHODS: From July 1993 through December 1996, we prospectively examined term neonates with dorsal cutaneous stigmata. Each neonate underwent spinal sonography and clinical assessment of the cutaneous stigmata. Incidence of dorsal cutaneous stigmata in a healthy neonatal population was determined by dividing the number of neonates with cutaneous stigmata by the total number of neonates examined. RESULTS: The incidence of cutaneous stigmata in the healthy neonate study population was 4.8%. We examined 207 neonates with 216 cutaneous stigmata, the most common of which was the simple midline dimple (74%). None of the neonates with only a simple midline dimple had spinal dysraphism. Of the 207 neonates we examined, 16 had spinal dysraphism. Clinical examination revealed 180 dimples and 36 other types of cutaneous stigmata (e.g., hemangiomas, hairy patches, masses, tails, lesions). Fourteen (39%) of 36 other cutaneous stigmata were positive for spinal dysraphism. Eight (40%) of 20 atypical dimples were positive for spinal dysraphism. Three were large clefts (>5 mm); the remaining five cases were seen in combination with other lesions and were all located more than 2.5 cm from the anus. Six (67%) of the nine neonates with multiple cutaneous stigmata had spinal dysraphism. CONCLUSION: Simple midline dimples are the most commonly encountered dorsal cutaneous stigmata in neonates and indicate low risk for spinal dysraphism. Only atypical dimples are associated with a high risk for spinal dysraphism, particularly those that are large (>5 mm), high on the back (>2.5 cm from the anus), or appear in combination with other lesions. High-risk cutaneous stigmata in neonates include hemangiomas, upraised lesions (i.e., masses, tails, and hairy patches), and multiple cutaneous stigmata.

Hyperdense posterior falx in the neonate.

OBJECTIVE: Hyperdense posterior falx and/or torcula on unenhanced CT scans is associated with sagittal sinus thrombosis in adults. However, the validity of this finding in newborns is unknown. MATERIALS AND METHODS: A prospective review was performed from September 1995 to November 1996, evaluating head CT scans of infants during their first week of life. RESULTS: Eleven neonatal head CT scans revealed a hyperdense posterior falx, suggestive of sagittal sinus thrombosis. Further imaging (7 ultrasound and 4 magnetic resonance imaging examinations) revealed no evidence of venous thrombosis in 10 of the 11 infants. CONCLUSION: Predominantly unmyelinated neonatal brain and increased hematocrit of neonatal blood probably contribute to the false impression of hyperdense posterior falx/torcula on neonatal head CT scans.

History of the operating microscope: from magnifying glass to microneurosurgery.

The advent of the microscope in the operating room revolutionized neurosurgery. We traced the origin and evolution of this important invention from the first magnifying lens to its practical application in neurosurgery. The concept of magnification evolved from unexplained observations in ancient times to the invention of the microscope by the late 16th century. In the subsequent 3 centuries, scientists made technical advances that greatly improved the power and utility of the microscope. By the early 20th century, otolaryngologists became the first surgeons to use the microscope in clinical surgery. After World War II, ophthalmologists and vascular and plastic surgeons began using the microscope in the operating room, making further technical improvements. It was a relatively small group of pioneering neurosurgeons in the late 1950s and 1960s who transformed microneurosurgery from a revolutionary and unorthodox "experiment" into the standard of care in much of modern neurosurgery.

Elevated laminin concentrations in lung secretions of preterm infants supported by mechanical ventilation are correlated with radiographic abnormalities.

OBJECTIVE: The objective of this study was to test the hypothesis that the presence of laminin in neonatal tracheal aspirates would be indicative of damage to the structural integrity of the basal laminae of the lung caused by barotrauma and hyperoxia. We predicted that disruption of the basal laminae would be a critical determinant of lung injury and fibrotic repair in the preterm infant whose lungs were ventilated with supplemental oxygen. STUDY DESIGN: The study group consisted of 23 premature infants in the neonatal intensive care unit whose lungs were ventilated by supplemental oxygen. We quantitated concentrations of laminin and fibronectin from sequential tracheal aspirates by enzyme-linked immunosorbent assays. A two-way analysis of variance was used to compare laminin and fibronectin concentrations in infants with and without radiographic evidence of coarse pulmonary markings indicative of fibrotic repair of lung injury. RESULTS: The concentrations of laminin, but not fibronectin, were significantly higher throughout the first 5 weeks of life in infants with abnormal chest radiographs at 36 weeks after conception. The concentrations of laminin in infant serum were approximately 1/30 that of tracheal aspirate laminin concentrations, suggesting that little if any of the laminin detected in the tracheal aspirates was derived from the serum. CONCLUSIONS: Increased concentrations of laminin in tracheal aspirates may be an indication of lung injury and fibrotic repair in the preterm infant.

Carbon dioxide (CO2) angiography in children.

BACKGROUND: When iodinated contrast material is contraindicated, carbon dioxide (CO2) gas can be injected intravascularly to produce high-quality digital subtraction angiograms. OBJECTIVE: CO2 angiography, although previously described in adults, has never before been reported in children. MATERIALS AND METHODS: We present three children with renal transplants who required renal angiography. Because of elevated creatinine levels, iodinated contrast was not used to search for possible renal artery stenosis. Instead, CO2 angiography was used to evaluate the renal artery anastomosis. RESULTS: In all three cases, the renal artery anastomosis was clearly visualized using CO2 angiography and showed no evidence of renal artery stenosis. CONCLUSION: Digital CO2 angiography is an effective method for pediatric renal angiography. The technique can easily be adapted for virtually any angiographic laboratory capable of digital subtraction imaging. Digital CO2 angiography also lacks the risks of a conventional iodinated contrast medium, namely nephrotoxicity, allergic reaction and volume overload.

Hiatus/paraesophageal hernias in neonatal Marfan syndrome.

We report on an infant with neonatal Marfan syndrome (NMS) and hiatus/paraesophageal hernia who presented to a university hospital with an unusual early complication of this connective tissue disorder. An abnormal course of the nasogastric tube was noted on the first day of life by a radiograph of the chest and abdomen performed for bloody gastric drainage. The question of esophageal perforation was raised. Subsequent contrast study demonstrated a large hiatus/paraesophageal hernia with pronounced gastroesophageal reflux (GER). A part of the hernia was positioned posterior and to the right of the gastroesophageal junction (GEJ), presumably the location of the nasogastric tube as noted on the initial films. Although characterized by cardiac/aortic abnormalities, NMS can be a difficult diagnosis and should be considered in any infant with hiatus/ paraesophageal hernia with or without GER.

Neurosonographic diagnosis of thalamic/basal ganglia vasculopathy in trisomy 13--an important diagnostic aid.

We performed a retrospective review of all the infants diagnosed with trisomy 13 in our institution from 1982 to 1995 and evaluated the neurosonographic findings along with their clinical information and cytogenetic analysis. Nine babies were admitted with trisomy 13. Sonography of the head was performed on 4 patients, and demonstrated in all of them a linear, branching, echogenic pattern in the thalamus/basal ganglia. Doppler evaluation of the thalamus/basal ganglia was performed in 3 of the 4 cases and confirmed these linear echogenicities to be of vascular origin. This is the first study to evaluated the occurrence of this finding in a specific syndrome, namely trisomy 13.

Equine-related neurosurgical trauma: a prospective series of 30 patients.

Thirty million Americans ride horses; 50,000 of these riders are treated in emergency rooms annually. Equestrian activities are uniquely dangerous because the participant is unrestrained, often helmetless, and riding large, unpredictable animals capable of 40-mph speeds and kicking with up to 1 ton of force. Neurologic injuries in equestrians constitute the majority of severe injuries and fatalities. We prospectively studied all patients admitted to the University of Kentucky Medical Center with equine-related neurosurgical trauma from July 1992 to January 1996. Eighteen of 30 patients were male. Age ranged from 3 to 64 years. Five patients died (17%), and two suffered permanent paralysis. There were 24 head injuries (80%) and 9 spinal injuries (30%). The majority of injuries (60%) were caused by ejection or fall from the horse. Twelve patients (40%) were kicked by a horse, and four patients sustained crush injuries. Six patients underwent craniotomy, three had operative spinal stabilization, and five required ventriculostomy. Eleven patients (37%) were professional riders. Twenty-four patients (80%) were not wearing helmets, including all fatalities and craniotomy patients. Our data show that equine-related neurosurgical injuries can be severe and fatal because of the significant size, force, and unpredictability of these animals as well as the lack of proper headgear. We recommend that helmets be worn at all times around horses because a significant number of our patients (33%) were injured as bystanders. Risk of serious injury appears to be a function of cumulative exposure to horses, not level of expertise. Experience is not protective; helmets are.

Nonpathologic ventriculomegaly in the premature intrauterine growth retarded infant.

OBJECTIVE: To determine any neurosonographic differences between premature intrauterine growth retarded (IUGR) neonates and premature appropriate for gestational age (AGA) infants. STUDY DESIGN: We retrospectively reviewed the head sonograms of 36 premature IUGR infants and 32 premature AGA matched controls. RESULTS: Seven of the 36 (19%) IUGR infant head sonograms revealed mild ventriculomegaly with no evidence of hemorrhage or ischemia. Only one of the 32 control scans (3%) had similar findings. Mild ventriculomegaly in the IUGR infant versus the AGA control neonate was statistically significant (p value of 0.05). Follow-up head sonograms (4 to 12 weeks after the initial head sonogram) revealed resolution of the mild ventriculomegaly in five of the seven IUGR infants. Clinically, all of the IUGR infants with mild ventriculomegaly were asymptomatic during their stay in the nursery and in clinical follow-up ranging from 3 to 5 years. CONCLUSION: Mild ventriculomegaly on the head sonograms of asymptomatic premature IUGR infants (with no associated hemorrhage or ischemic change) should be recognized as a transient, nonpathologic finding.

Relation of gastric distention to prostaglandin therapy in neonates.

PURPOSE: To evaluate the short-term gastric effects of prostaglandin therapy in neonates. MATERIALS AND METHODS: The authors retrospectively reviewed the radiographs of nine neonates with congenital heart disease who received prostaglandins during the 1st week of life. Eighteen matched control infants (nine healthy neonates and nine infants with noncyanotic congenital heart disease) who did not receive prostaglandins were also evaluated. RESULTS: Within 48 hours of initial prostaglandin therapy, persistent (>3 days) gastric distention was noted in four of nine infants. No infants developed feeding intolerance during the 1st week of life; two of nine infants (both with initial asymptomatic gastric distention) developed feeding intolerance with prolonged prostaglandin therapy. In all cases, gastric distention resolved with cessation of prostaglandins. The radiographs of the control infants were unremarkable (P < .01). CONCLUSION: Persistent, asymptomatic gastric distention can be seen in neonates within 48 hours of initiation of prostaglandin therapy. Intervention is not warranted; this finding resolves with cessation of prostaglandins. Early gastric distention may be predictive of feeding intolerance in infants who receive prolonged prostaglandin therapy.

Symptomatic spinal intradural arachnoid cyst development after lumbar myelography. Case report and review of the literature.

STUDY DESIGN: This case report describes the unique occurrence of acquired intradural spinal arachnoid cyst after lumbar puncture, which was proven radiographically and surgically. OBJECTIVES: To review and explore complications of lumbar puncture in the context of subsequent cyst development and to review the incidence, presentation, pathogenesis, and management of spinal intradural arachnoid cysts. SUMMARY OF BACKGROUND DATA: The etiology of the spinal intradural arachnoid cyst remains obscure; some such cysts are ascribed anecdotally to previous trauma or arachnoiditis, whereas the majority are idiopathic and assumed by many authors to be congenital. METHODS: A 20-Year-old woman with back and leg pain underwent lumbar myelography that yielded normal results with no evidence of arachnoid cyst at that time. Within 5 months, clinical symptoms of cauda equina compression and an S1 radiculopathy developed. Subsequent myelography and magnetic resonance imaging revealed a lumbar spinal arachnoid cyst. There was no history of intervening trauma or arachnoiditis. The lumbar puncture was thought to be the cause of the arachnoid cyst. RESULTS: A laminectomy was performed with complete excision of the arachnoid cyst. The patient had an unremarkable postoperative course with excellent relief of her symptoms. CONCLUSIONS: This case provides supporting evidence for the traumatic etiology of spinal intradural arachnoid cyst. The development of an intradural spinal arachnoid cyst should be included as a possible complication of lumbar puncture.