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Abstract: We describe a case of hemiconvulsion–hemiplegia–epilepsy (HHE) syndrome documented by longitudinal magnetic resonance imaging (MRI). A two-year and nine-month-old boy had a prolonged hemiconvulsion during fever followed by right hemiparesis. Seven days later the imaging abnormality on T2 and diffusion-weighted images (DWI) was limited to the white matter of the left hemisphere. One month later severe gliosis and unilateral brain atrophy were already evident. MRI is useful in the early stages of prolonged seizures and T2 and DWI abnormalities appear to be well correlated with parenchymal damage that results from sustained ictal activity. The neuroradiological findings in our case and in the few HHE patients reported in the literature seem to be very characteristic and, if confirmed in larger series, could permit an early diagnosis. [Copyright &y& Elsevier]

Objective To present a case of LBSL with neonatal onset and with rapid progression and to review the literature focused on LBSL with early onset (before one year of age). Methods We report a case of an infant admitted at our Child Neurology Unit in November 2014 with LBSL, investigated with blood and cerebrospinal spinal fluid (CSF) tests, brain and spinal magnetic resonance imaging (MRI). Results The patient was admitted at our hospital at 2 months of age because of severe hypotonia. She had regular antenatal and perinatal story. At birth physical and neurological examination were normal. At two weeks of age nystagmus was noticed and after few weeks, she started to be hyporeactive and hypotonic. At our examination she had severe and diffuse hypotonia, brisk reflex at legs and nystagmus. CSF examination showed an increased lactate (7.4 mmol/L, range 1.2–2.2 mmol/L). Cerebral (including spectroscopy) and spinal MRI showed changes in white matter consistent with LBSL. Two weeks later she developed respiratory arrest and needed mechanical ventilatory support. Steroid therapy was administered without results. Genetic test is in progress. Conclusion LBSL is a rare disease described for the first time in 2003 by Van der Knaap et al. as a mild disorder with childhood and adolescent onset and slow progression. In the Literature we found two cases with neonatal onset, rapid deterioration and death respectively at 2 and 3 year of age and 16 cases with onset before 12 months (mean 8 months) and early death in 6/16 cases. We add to the pertinent literature a new case of LBSL with neonatal onset having a rapid and deteriorating course. This condition should be suspected in neonates or infants with leukoencephalopathy on brain MRI and lactic acidosis in CSF. Spinal MRI and specific genetic tests are needed to confirm the diagnosis. [ABSTRACT FROM AUTHOR]

Objective Given the rarity of this condition, especially in children, there is a paucity of literature reporting large case series of paediatric anti-N-methyl-D-aspartate receptor encephalitis. Our goal is to contribute to define the features of paediatric anti-N-methyl-D-aspartate receptor encephalitis. Methods We describe a new nationwide case series of 20 children (50% females), referred by 13 Italian centers. Results Mean age at onset was 8 years (range 3–17). Prodromal symptoms were reported in 31.6%; onset was with neurological symptoms in 70%, and with behavioral/psychiatric disturbances in 30%. Most patients developed a severe clinical picture (90%), and 41% experienced medical complications; children 12–18 years old seemed to be more severe and symptomatic than younger patients. All children received first-line immune therapy; second-line treatment was administered to 45%. Relapses occurred in 15%. Most patients recovered substantially (80%); this rate was higher among older patients, and in those receiving first immune therapy within 1 month. Conclusion Our case series confirms a symptomatologic core of paediatric anti-N-methyl-D-aspartate receptor encephalitis, even though displaying some distinctive features that may be explained by a specific genetic background or by the limited number of the patients. The growing incidence of this condition, the relative age-dependent variability of its manifestations, the availability of immunotherapy and the possible better outcome with early treatment impose a high index of clinical suspicion be maintained. Paediatricians should consider this diagnosis for children presenting with neurological and/or behavioral or psychiatric disturbances, regardless of age and gender, especially in the absence of data suggesting other specific etiologies. Other authors: F. Beccaria, L. Giunta, C. Boniver, M.G. Natali Sora, N. Zamponi. [ABSTRACT FROM AUTHOR]

Objective To describe the natural history of sporadic and familial hemiplegic migraines (SHM and FHM) with onset in the pediatric age. Methods Retrospective observational study of 28 cases, visiting 9 Italian Centers for Juvenile Headache, diagnosed as SHM or FHM (ICHD-III b version, 2013) with onset under 16 years and with a longitudinal follow-up. Results 28 cases (17 females, 11 males): 23 SHM (14 females, 9 male), 5 FHM (3 females, 2 male). Family history was positive for migraine without aura (5/28) or with aura non hemiplegic (8/28). Triggering factors were found in 13/28 cases. Age at HM onset: mean 10.1 y, range 4–16 y (5/28 cases under 6 y). Mean duration of aura was 11h 13' (range 5′–48 h). Between HM attacks, neurologic examination was normal in 26/28 cases. At follow-up: mean age 16.9 y (range 6.5–47 y), mean duration of follow-up 8.1 y (range 2.5–38 y). The frequency of attacks ranged from 2 per month to less than 1 per year (mean 5–6 every year). During follow-up, FHM and SHM cases showed some differences: in cases with SHM attacks were less frequent but more severe while FHM patients had less intense but more frequent attacks and also a longer duration of disease. Preventive therapy for HM was prescribed to 12/28 cases. Conclusion In the Literature data on the natural history of HM are quite limited, particularly in children. In the majority of our cases, the frequency and the type of attacks were quite variable, and in less than half of the cases trigger factors were identified. The majority of our patients had a good prognosis, even in cases with early onset of HM and/or prolonged and/or severe HM attacks. The natural history of SHM seems to differ from the FHM. [ABSTRACT FROM AUTHOR]

Objective To present a case of congenital gluteal muscles absence associated with renal ectopia, without spina bifida occulta. Methods A 3-years-old child was referred to our child Neurology Unit for motor delay and walking difficulties. Familial and pregnancy history were unremarkable except for right renal ectopia diagnosed with antenatal ultrasound. At birth, he presented flexed hips and lower limbs rigidity. He started walking at 19 months. Neurological examination (28 months) showed waddling gait, gluteal muscles hypoplasia and lumbar hyperlordosis. Laboratory findings, imaging and electrophysiological exams were performed. Results At 28 months of age the child underwent electromyography (with needle of 50 mm) that showed absence of voluntary activity in the territory of gluteal muscles, with normal response in the regions of vastus medialis and sural triceps and normal nerve conduction studies. Laboratory findings (creatine phosphokinase and transaminases) were normal. Musculoskeletal and pelvis magnetic resonance imaging (MRI) revealed a complete, symmetrical fibroadipose replacement of gluteus, gracilis, semitendinosus, semimembranosus and biceps femoris muscles, anterior legs muscles were normal. Spinal magnetic resonance excluded spina bifida occulta. Right kidney was ectopic. Conclusion Bilateral symmetrical congenital absence of muscles is rare, other than Eagle-Barrett syndrome. So far, only three cases of congenital absence of gluteal muscles have been reported and they all had spina bifida occulta. To the best of our knowledge, our case is the first report of congenital absence of gluteal muscles without spinal dysraphism. The only remarkable finding was the kidney ectopia, never described in association with gluteus' agenesis by previous Literature. This association could be explained by a disruption of normal embryologic migration of mesodermal cells during gestational age. Muscular MRI and extensive electromyography should be considered in the diagnostic work-up of children with motor delay and walking difficulties and with clinical suspicion of neuromuscular disorders. [ABSTRACT FROM AUTHOR]

Objective To present a case carrying a chromosomal rearrangement of the 6p25.3 locus and diagnosed with Moyamoya syndrome. Methods A Caucasian 4 years-and-9-months-old girl was admitted to a peripheral hospital for vomiting and acute left hemiparesis, followed by left arm clonic seizures, aphasia and confusion. Phenytoin stopped the crisis, but hemiparesis persisted. EEG documented widespread slow waves, mainly on the right hemisphere. Computed tomography (third day) showed hypodensity of the entire right hemisphere. Past history was characterized by prematurity (born at 32 g.w.), cardiac defects (atrial septal defect, patent ductus arteriosus), surgically corrected at 3 years old. High resolution karyotype showed this rearrangement: 46, XX, der(6)dup(6) (p24p23)del(6)(p25). Cognitive level was borderline. On day 4 the girl was transferred to our Child Neurology Unit where she underwent a complete workup. Results Echocardiogram: normal; carotid doppler ultrasound: bilateral stenosis of internal carotid arteries; brain magnetic resonance imaging (MRI): ischemic areas in territories supplied by right middle and anterior cerebral arteries; brain angio-MRI: bilateral multiple stenosis of anterior and posterior cerebral arteries and collateral circulation consistent with Moyamoya syndrome. Therefore, after a digital angiography, the patient underwent an encephalo-duro-arterial-myo-sinangiosis. The post-operative period was uneventful. Conclusion Moyamoya syndrome is known to be associated to some genetic conditions (such as Neurofibromatosis type 1, Alagille syndrome and Trisomy 21). To date, only one pediatric case with Moyamoya syndrome and chromosomal rearrangement of 6p25.3 has been reported, similar to our patient. Therefore, all patients presenting with a chromosomal rearrangement involving the 6p25.3 locus should be studied with brain angio-MRI; moreover this genetic region should be investigated to identify possible disease-specific genes for Moyamoya syndrome. [ABSTRACT FROM AUTHOR]

OBJECTIVE: To clarify the most frequent modalities of use of plasma exchange (PE) in pediatric anti-N-methyl-d-aspartate receptor (anti-NMDAR) encephalitis and to establish the most effective association with other immunotherapies. METHODS: Systematic literature review on PE in pediatric anti-NMDAR encephalitis (2007-2015). RESULTS: Seventy-one articles were included (mostly retrospective), reporting a total of 242 subjects (73.2%, 93/127 females; median age at onset 12years, range 1-18). Median time to immunotherapy was 21days (range 0-190). In most cases, PE was given with steroids and IVIG (69.5%, 89/128), or steroids only (18%, 23/128); in a minority, it was associated with IVIG only (7%, 9/128), or was the only first-line treatment (5.5%, 7/128). In 54.5% (65/119), PE was the third treatment after steroids and IVIG, in 31.1% (37/119) the second after steroids or IVIG; only in 14.3% (17/119) was it the first treatment. Second-line immunotherapies were administered in 71.9% (100/139). Higher rates of full/substantial recovery at follow-up were observed with immunotherapy given ?30days from onset (69.4%, 25/36) compared to later (59.2%, 16/27), and when PE was associated with steroids (66.7%, 70/105) rather than not (46.7%, 7/15). Significant adverse reactions to PE were reported in 6 patients. CONCLUSION: Our review disclosed a paucity of quality data on PE in pediatric anti-NMDAR encephalitis. PE use in this condition has been increasingly reported, most often with steroids and IVIG. Despite the limited number of patients, our data seem to confirm the trend towards a better outcome when PE was administered early, and when given with steroids. [ABSTRACT FROM AUTHOR]

Our aim was to investigate clinical picture, differential diagnosis between epileptic seizures and movement disorder and the significance of EEG patterns in paediatric anti- N-methyl-d-aspartate receptor (NMDAr) antibodies encephalitis. We reviewed clinical history, time course of the disease and EEG records. Clinical suspicion was confirmed by cell-based assay for detection of NMDAr antibodies in the serum and CSF in 3 and in serum in 1 of the patients. Four patients had the diagnosis of anti-NMDAr antibodies encephalitis in our Institution between 2007 and 2012 (the last three since 2011). All presented with movement disorders, epileptic seizures or seldom psychiatric disturbance, rapidly associated to abnormal sleep-wake cycle, hyporesponsivity and catatonia, followed by autonomic nervous system imbalance. In the acute phase epileptic seizures were clinically suspected in all patients but the EEG showed clear electro-clinical patterns in only one patient, one other receiving antiepileptic treatment before EEG recording had electrical seizure patterns. EEG recordings showed some similarities between the four subjects in the corresponding disease phases. Extensive diagnostic testing failed to detect neoplasms in all. All patients showed a marked improvement at follow up. Anti NMDAr antibodies encephalitis is increasingly recognised in the paediatric population. With respect to adults, movement disorder, seizures and rapid development of hyporesponsivity predominate at onset over discrete psychiatric symptoms. EEG features although not specific might help to suspect the disease in the early stages and aid in the differentiation between epileptic and non epileptic manifestations, with implications for treatment. [Copyright &y& Elsevier]