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Historically, the accuracy of imaging teeth by computed tomography (CT) has been suboptimal and deemed inadequate for surgical planning of orthognathic procedures. However, recent advances in CT hardware and software have significantly improved the accuracy of imaging occlusal anatomy. This technical note describes a quantitative means of evaluating the accuracy of CT-based modeling of teeth. Three-dimensional models of the dentition were created from a CT scan obtained of a craniomaxillofacial skeleton. Multiple reconstruction algorithms and modeling parameters were applied. The dentition of the same skeleton was scanned using a handheld optical scanning device to serve as the "gold standard." Semi-automated registrations of CT and optically acquired models were performed and deviation analysis was conducted. On average, the deviation of the CT model with the optical scan measured 0.19 to 0.25 mm across the various reconstruction and modeling parameters, with a mean of 0.22 mm. Computed tomography underestimated contours at cusp tips, while overestimating contours in occlusal groves. The use of bone reconstruction algorithms and decreased model smoothing resulted in more accurate models, though greater surface noise. Future studies evaluating the clinical effectiveness of CT-based occlusal splints should take this finding into account.

Background The trochlear nerve (the fourth cranial nerve) is the only cranial nerve that arises from the dorsal aspect of the midbrain. The nerve has a lengthy course making it highly susceptible to injury. It is also the smallest cranial nerve and is often difficult to identify on neuroimaging. Evidence acquisition High-resolution 3-dimensional skull base MRI allows for submillimeter isotropic acquisition and is optimal for cranial nerve evaluation. In this text, the detailed anatomy of the fourth cranial nerve applicable to imaging will be reviewed. Results Detailed anatomic knowledge of each segment of the trochlear nerve is necessary in patients with trochlear nerve palsy. A systematic approach to identification and assessment of each trochlear nerve segment is essential. Pathologic cases are provided for each segment. Conclusions A segmental approach to high-resolution 3-dimensional MRI for the study of the trochlear nerve is suggested.

Transcranial magnetic stimulation (TMS) is a newer noninvasive language mapping tool that is safe and well-tolerated by children. We examined the accuracy of TMS-derived language maps in a clinical cohort by comparing it against functional magnetic resonance imaging (MRI)–derived language map. The number of TMS-induced speech disruptions and the volume of activation during functional MRI tasks were localized to Brodmann areas for each modality in 40 patients with epilepsy or brain tumor. We examined the concordance between TMS- and functional MRI–derived language maps by deriving statistical performance metrics for TMS including sensitivity, specificity, accuracy, and diagnostic odds ratio. Brodmann areas 6, 44, and 9 in the frontal lobe and 22 and 40 in the temporal lobe were the most commonly identified language areas by both modalities. Overall accuracy of TMS compared to functional MRI in localizing language cortex was 71%, with a diagnostic odds ratio of 1.27 and higher sensitivity when identifying left hemisphere regions. TMS was more accurate in determining the dominant hemisphere for language with a diagnostic odds ratio of 6. This study is the first to examine the accuracy of the whole brain language map derived by TMS in the largest cohort examined to date. While this comparison against functional MRI confirmed that TMS reliably localizes cortical areas that are not essential for speech function, it demonstrated only slight concordance between TMS- and functional MRI–derived language areas. That the localization of specific language cortices by TMS demonstrated low accuracy reveals a potential need to use concordant tasks between the modalities and other avenues for further optimization of TMS parameters.

Cortical stimulation mapping is the gold standard for presurgical language mapping; however, it cannot be reliably performed in very young patients. Language mapping using noninvasive modalities is also challenging in very young patients. Although utility of language mapping using power of high-gamma in electrocorticographic recordings was demonstrated in adults and older children, there is a gap of knowledge in the ability of this procedure for localizing language-specific cortex in very young patients. We describe a case of a 2-year-old patient who, to our knowledge, is the youngest person to undergo successful high-gamma electrocorticographic presurgical language mapping for localization of the expressive language cortex (Broca area). The surgical plan was to resect a cortical tuber within the left inferior frontal gyrus and there was a strong concern about postoperative language deficit after resection. Presurgical language mapping using noninvasive modalities were attempted without success. Cortical stimulation mapping was not feasible in this patient. Therefore, high-gamma electrocorticography was the only viable option for language mapping, and it successfully localized the expressive language cortex. The patient underwent surgery for resection of the IFG tuber based on results of high-gamma electrocorticography and had no postoperative language deficit. High-gamma electrocorticography can be used for localizing language-specific cortex, especially Broca’s area, in very young patients.

Introduction Flat panel imaging for emergent large vessel occlusion can be acquired prior to mechanical thrombectomy (MT). In this study, we examined patients undergoing MT with computed tomography angiography (CTA) to determine agreement on the site of occlusion and CTA collateral score (CS). Methods Flat Panel CTA (FP-CTA) was acquired before MT. Time between CTA and FP-CTA acquisition, site of occlusion, and CS were reported. Significant CS change was defined as >2-point change, or any change to/from a malignant profile (CS = 0 to CS > 0, or vice versa). Results Eleven patients (mean age, 60.8 years; NIHSS, 17; 55.0% female) were included; IV tPA was administered to 7. Intra-reader occlusion site, dichotomous CS, and continuous CS correlation between CTA and FP-CTA were 96.6%, 90.0%, and 86.6%, respectively. Inter-reader correlation for occlusion site was 93% for CTA and 100% for FP-CTA; dichotomous CS correlation was 87% for both CTA and FP-CTA; correlation of continuous CS was 77% for CTA and 87% for FP-CTA. Conclusion Standard CTA and FP-CTA have high intra and inter-reader correlation determining site of occlusion and CS in ELVO setting. This angiographic tool may have potential applications for both triage and patient selection.

OBJECTIVE An ischemic stroke following an elective craniotomy in a child is perceived to be a rare event. However, to date there are few papers on this topic. The purpose of this study was to investigate the occurrence of stroke following elective intracranial surgery at a children’s hospital. METHODS The authors performed a retrospective review of all patients who developed a perioperative stroke following an elective craniotomy from 2010 through 2017. Data were collected using an institutional database that contained demographic, medical, radiological, and outcome variables. RESULTS A total of 1591 elective craniotomies were performed at the authors’ institution during the study period. Of these, 28 (1.8%) were followed by a perioperative stroke. Radiographic diagnosis of the infarction occurred at a median of 1.7 days (range 0–9 days) from the time of surgery, and neurological deficits were apparent within 24 hours of surgery in 18 patients (62.5%). Infarcts tended to occur adjacent to tumor resection sites (86% of cases), and in a unilateral (89%), unifocal (93%), and supratentorial (93%) location. Overall, 11 (39.3%) strokes were due to a perforating artery, 10 (35.7%) were due to a large vessel, 4 (14.3%) were venous, and 3 (10.7%) were related to hypoperfusion or embolic causes. Intraoperative MRI (iMRI) was used in 11 of the 28 cases, and 6 (55%) infarcts were not detected, all of which were deep. CONCLUSIONS The incidence of stroke following an elective craniotomy is low, with nearly all cases (86%) occurring after tumor resection. Perforator infarcts were most common but may be missed on iMRI. ABBREVIATIONS ACA = anterior cerebral artery; AChA = anterior choroidal artery; ACS NSQIP-P = American College of Surgeons National Surgical Quality Improvement Program–Pediatric; CVA = cerebrovascular accident; DWI = diffusion weighted imaging; iMRI = intraoperative MRI; MCA = middle cerebral artery; mRS = modified Rankin Scale; PCA = posterior cerebral artery.

The authors describe a case of unilateral abducens nerve palsy following perinatal stroke of the middle cerebral artery. A 1-year-old boy presented with left eye esotropia but no other ocular abnormalities. The patient's history, examination, and diagnostic tests were consistent with abducens nerve palsy. He underwent left medial rectus recession of 5.5 mm and left lateral rectus resection of 7 mm followed by patching. At 15 months after surgery, primary gaze by prism alternate cover testing revealed a 4 prism diopter (PD) esophoria (small angle in left gaze with essentially no action of lateral rectus) and 2 PD right hyperphoria. Ophthalmologic management of abducens nerve palsy entails addressing neurological sequelae in a timely manner, treating the esotropia and strabismic amblyopia to optimize visual system development. [ J Pediatr Ophthalmol Strabismus . 2020;57:e30–e33.]

Background Herpes Simplex Virus encephalitis (HSVE) is a devastating disease of all ages. Rigorous studies correlating viral load with neuroradiological and clinical severity have not been performed, particularly in neonates. Understanding these relationships may improve therapies. Objectives To correlate molecularly quantified HSV in cerebrospinal fluid (CSF) and disease severity. Study Design HSV loads (VL) were evaluated by real-time PCR from the CSF of 33 patients (20 neonates, 5 children, 8 adults) with HSVE. We studied relationships between CSF VL and structural and volumetric brain abnormalities (MRI); hospital morbidity; and discharge and long-term (>3 month) clinical outcomes. Results Initial CSF VL did not differ in neonates vs non-neonates (median 4.6 vs 5.1 log10 copies/mL, p = 0.75). Initial CSF VL was higher in neonates with HSV-2 vs HSV-1 (median 4.8 vs 3.2 log10 copies/mL, respectively, p = 0.02). Persistently detectable DNA in CSF despite acyclovir trended towards higher odds of unfavorable outcome at discharge for neonates [0.87 (CI 0.75–1), p = 0.07]. Initial VL correlated with higher CSF protein concentrations for the cohort and for neonates (p = 0.03 and 0.01, respectively), but not with lesion volume or subarachnoid exposure of involved brain (p all >0.05), hospital morbidity (p all >0.05), nor with higher odds of unfavorable discharge or long-term outcomes for the cohort [OR = 0.9(CI 0.5–1.6), p = 0.72; OR = 1.0(CI 0.5–1.8), p = 0.9] or for neonates [OR = 1.3(CI 0.5–3.3), p = 0.57; OR = 2.3(CI 0.7–8), p = 0.2]. Conclusions Initial HSV VL did not predict neuroradiological or clinical outcomes in patients with HSVE, suggesting host inflammatory factors contribute to disease in treated patients with good viral clearance.

BACKGROUND Pineoblastomas are rare, supratentorial, primitive neuroectodermal tumors. OBJECTIVE To document outcomes with multimodal therapy and evaluate the impact that the degree of surgical resection has on outcome. METHODS A departmental brain tumor database was queried to identify all patients with pathologically proven pineoblastoma who were treated from January 1997 to June 2015 at St. Jude Children's Research Hospital. For each patient, we recorded demographic, pathological, radiological, surgical, and clinical follow-up data. The effect of degree of surgical resection on survival outcomes was analyzed. RESULTS Forty-one patients (21 male, 20 female) treated for pineoblastoma were identified. The median age at diagnosis was 5.5 years (range 0.4-28.1) and the median follow-up was 34.5 months. Nineteen patients experienced tumor relapse with a median progression-free survival of 11.3 months, and 18 ultimately succumbed to their disease. Patients who died or experienced treatment failure were younger (median, 2.69 vs 6.5 years, P = .026) and more likely to have metastatic disease at diagnosis (12 [63.2%] vs 5 [22.7%], P = .012). When analyzing only patients 5 years of age or older with focal disease at presentation, those who had a gross total resection or near-total resection-compared with subtotal resection or biopsy-had greater overall survival (75.18 vs 48.57 months), with no patients dying as a result of their cancer. CONCLUSION Poor prognostic variables for children with pineoblastoma include young age, metastatic disease at presentation, and tumor relapse. For patients older than 5 years with focal disease, maximal tumor resection should be the goal.

Neonatal head ultrasound has a key role in triaging neonates with antenatal imaging or postnatal clinical concerns. This article will discuss key features of various intracranial pathologies of concern in term infants. It will also illustrate various congenital malformations.

Accurate assessment of motor function is critical, particularly in the context of presurgical functional mapping. There are a few noninvasive tools available for preoperative motor mapping in older children and adults undergoing surgery for brain tumor or refractory epilepsy including fMRI, magnetoencephalography (MEG), and transcranial magnetic stimulation (TMS).1,2 However, assessing motor function is challenging in very young children. Direct cortical stimulation, a standard procedure in adults, is associated with a high incidence of intraoperative seizures, and is often unsuccessful in young children.3,4 Alternately, noninvasive motor mapping using MEG and fMRI attempted during sleep or under sedation primarily localize the somatosensory cortex from which the location of motor cortex is inferred.5,6 Furthermore, these methods have a low success rate (∼25%) and have risks associated with sedation.6 However, TMS has the advantage of mapping the motor cortex directly without requiring sedation. We have previously reported on successful mapping of the motor cortex in young children aged between 17 and 35 months.7 Here we describe a case of an 11-month-old infant who is, to our knowledge, the youngest person to undergo successful presurgical motor mapping with TMS.

Nontraumatic neck pain is a leading cause of disability, with nearly 50% of individuals experiencing ongoing or recurrent symptoms. Radiographs are appropriate as initial imaging for cervical or neck pain in the absence of "red flag" symptoms or if there are unchanging chronic symptoms; however, spondylotic changes are commonly identified and may result in both false-positive and false-negative findings. Noncontrast CT can be complementary to radiographs for evaluation of new or changing symptoms in the setting of prior cervical spine surgery or in the assessment of extent of ossification in the posterior longitudinal ligament. Noncontrast MRI is usually appropriate for assessment of new or increasing radiculopathy due to improved nerve root definition. MRI without and with contrast is usually appropriate in patients with new or increasing cervical or neck pain or radiculopathy in the setting of suspected infection or known malignancy. Imaging may be appropriate; however, it is not always indicated for evaluation of cervicogenic headache without neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Acute changes in mental status represent a broad collection of symptoms used to describe disorders in mentation and level of arousal, including the more narrowly defined diagnoses of delirium and psychosis. A wide range of precipitating factors may be responsible for symptom onset including infection, intoxication, and metabolic disorders. Neurologic causes that may be detected on neuroimaging include stroke, traumatic brain injury, nonconvulsive seizure, central nervous system infection, tumors, hydrocephalus, and inflammatory disorders. Not infrequently, two or more precipitating factors may be found. Neuroimaging with CT or MRI is usually appropriate if the clinical suspicion for an acute neurological cause is high, where the cause of symptoms is not found on initial assessment, and for patients whose symptoms do not respond appropriately to management. There was disagreement regarding the appropriateness of neuroimaging in cases where a suspected, nonneurologic cause is found on initial assessment. Neuroimaging with CT is usually appropriate for patients presenting with delirium, although the yield may be low in the absence of trauma or a focal neurological deficit. Neuroimaging with CT or MRI may be appropriate in the evaluation of new onset psychosis, although the yield may be low in the absence of a neurologic deficit. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Background and importance Presurgical mapping of eloquent cortex in young patients undergoing neurosurgery is critical for timely intervention, surgical planning, and minimizing postoperative deficits. However, invasive direct cortical stimulation has limited success in young children and noninvasive modalities, such as magnetoencephalography and functional MRI, require sedation, often precluding localization of critical language cortices. Transcranial magnetic stimulation (TMS), a noninvasive brain stimulation technique, is well suited to evaluate language areas in young children because it does not require the patient to remain still during mapping. Clinical presentation A 4-yr and 11-mo-old female patient diagnosed with epilepsia partialis continua of the right arm and face and right-sided weakness was evaluated at our institution. MRI findings and clinical examination led to the diagnosis of Rasmussen encephalitis involving left frontal lobe and insula. Language cortices were successfully identified in both hemispheres using TMS. The TMS findings aided in discussing with the family the risks of postsurgical deficits of left functional hemispherectomy, the definitive treatment for Rasmussen encephalitis. Postoperatively, the patient had intact speech and was seizure free. Conclusion We illustrate the feasibility and utility of TMS as a noninvasive functional mapping tool in this young child. The preoperative demonstration of bilateral language organization indicated a greater likelihood of preserved language functions postsurgery. We demonstrate that TMS is a safe and noninvasive tool to map language cortices in young children with serious epilepsy syndromes.

This article presents guidelines for imaging utilization in patients presenting with hearing loss or vertigo, symptoms that sometimes occur concurrently due to proximity of receptors and neural pathways responsible for hearing and balance. These guidelines take into account the superiority of CT in providing bony details and better soft-tissue resolution offered by MRI. It should be noted that a dedicated temporal bone CT rather than a head CT best achieves delineation of disease in many of these patients. Similarly, optimal assessment often requires a dedicated high-resolution protocol designed to assess temporal bone and internal auditory canals even though such a study will be requested and billed as a brain MRI. Angiographic techniques are helpful in some patients, especially in the setting of vertigo. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

OBJECTMalignant tumors of the brainstem, excluding classic diffuse intrinsic pontine gliomas (DIPGs), are a very rare, heterogeneous group of neoplasms that have been infrequently described in the literature. In this paper, the authors present their experiences with treating these unique cancers.METHODSA retrospective chart review was conducted to identify eligible cases over a 15-year period. All tumors involving the pons were, by consensus, felt not to be DIPGs based on their neuroimaging features. Demographic information, pathological specimens, neuroimaging characteristics, surgical and nonsurgical management plans, and survival data were gathered for analysis.RESULTSBetween January 2000 and December 2014, 29 patients were identified. The mean age at diagnosis was 8.4 years (range 2 months to 25 years), and 17 (59%) patients were male. The most common presenting signs and symptoms were cranial neuropathies (n = 24; 83%), hemiparesis (n = 12; 41%), and ataxia or gait disturbance (n = 10; 34%). There were 18 glial and 11 embryonal tumors. Of the glial tumors, 5 were radiation-induced and 1 was a malignant transformation of a previously known low-grade tumor. Surgical intervention consisted of biopsy alone in 12 patients and some degree of resection in another 15 patients. Two tumors were diagnosed postmortem. The median overall survival for all patients was 196 days (range 15 to 3999 days). There are currently 5 (17%) patients who are still alive: 1 with an anaplastic astrocytoma and the remaining with embryonal tumors.CONCLUSIONSIn general, malignant non-DIPG tumors of the brainstem carry a poor prognosis. However, maximal cytoreductive surgery may be an option for select patients with focal tumors. Long-term survival is possible in patients with nonmetastatic embryonal tumors after multimodal treatment, most importantly maximal resection.

Background Weakness of the sixth cranial nerve is the most common cause of an ocular motor cranial nerve palsy. It is often difficult to identify a corresponding abnormality on neuroimaging to correlate with the clinical examination. Evidence acquisition High-resolution 3D skull base magnetic resonance imaging (MRI) allows for visualization of the sixth nerve along much of its course and may increase sensitivity for abnormalities in regions that previously were challenging to evaluate. In this review, the authors share their experience with high-resolution imaging of the sixth nerve. Results For each segment, anatomic features visible on high-resolution imaging are described along with relevant pathologic entities. Conclusions We present a segmental approach to high-resolution 3D MRI for evaluation of the sixth nerve from the nuclear to the orbital segment.

OBJECT Cervicomedullary tumors (CMTs) represent a heterogeneous group of intrinsic neoplasms that are typically low grade and generally carry a good prognosis. This single-institution study was undertaken to document the outcomes and current treatment philosophy for these challenging neoplasms. METHODS The charts of all pediatric patients with CMTs who received treatment at St. Jude Children’s Research Hospital between January 1988 and May 2013 were retrospectively reviewed. Demographic, surgical, clinical, radiological, pathological, and survival data were collected. Treatment-free survival and overall survival were estimated, and predictors of recurrence were analyzed. RESULTS Thirty-one children (16 boys, 15 girls) with at least 12 months of follow-up data were identified. The median age at diagnosis was 6 years (range 7 months-17 years) and the median follow-up was 4.3 years. Low-grade tumors (Grade I or II) were present in 26 (84%) patients. Thirty patients underwent either a biopsy alone or resection, with the majority of patients undergoing biopsy only (n = 12, 39%) or subtotal resection (n = 14, 45%). Only 4 patients were treated solely with resection; 21 patients received radiotherapy alone or in combination with other treatments. Recurrent tumor developed in 14 children (45%) and 4 died as a result of their malignancy. A high-grade pathological type was the only independent variable that predicted recurrence. The 5- and 10-year treatment-free survival estimates are 64.7% and 45.3%, respectively. The 5- and 10-year overall survival estimate is 86.7%. CONCLUSIONS Children with CMTs typically have low-grade neoplasms and consequently long-term survival, but high risk of recurrence. Therapy should be directed at achieving local tumor control while preserving and even restoring neurological function.

Progeroid disorders overlapping with De Barsy syndrome (DBS) are collectively denoted as autosomal-recessive cutis laxa type 3 (ARCL3). They are caused by biallelic mutations in PYCR1 or ALDH18A1, encoding pyrroline-5-carboxylate reductase 1 and pyrroline-5-carboxylate synthase (P5CS), respectively, which both operate in the mitochondrial proline cycle. We report here on eight unrelated individuals born to non-consanguineous families clinically diagnosed with DBS or wrinkly skin syndrome. We found three heterozygous mutations in ALDH18A1 leading to amino acid substitutions of the same highly conserved residue, Arg138 in P5CS. A de novo origin was confirmed in all six probands for whom parental DNA was available Using fibroblasts from affected individuals and heterologous overexpression, we found that the P5CS-p.Arg138Trp protein was stable and able to interact with wild-type P5CS but showed an altered sub-mitochondrial distribution. A reduced size upon native gel electrophoresis indicated an alteration of the structure or composition of P5CS mutant complex. Furthermore, we found that the mutant cells had a reduced P5CS enzymatic activity leading to a delayed proline accumulation. In summary, recurrent de novo mutations, affecting the highly conserved residue Arg138 of P5 CS, cause an autosomal-dominant form of cutis laxa with progeroid features. Our data provide insights into the etiology of cutis laxa diseases and will have immediate impact on diagnostics and genetic counseling.

The development of high-quality intraoperative MRI (iMRI) capability has offered a major advance in the care of patients with complex intracranial disease. To date, this technology has been limited by the need for pin fixation of the calvaria. The authors report their preliminary experience with an MRI-compatible horseshoe headrest that allows for the following: 1) iMRI in patients too young for pin fixation; 2) iMRI in patients with large calvarial defects; 3) the ability to move the head during iMRI surgery; and 4) the use of neuronavigation in such cases. The authors report 2 cases of infants in whom the Visius Surgical Theatre horseshoe headrest (IMRIS Inc.) was used. Image quality was equivalent to that of pin fixation. The infants suffered no skin issues. The use of neuronavigation with the system remained accurate and could be updated with the new iMRI information. The Visius horseshoe headrest offers a technical advance in iMRI technology for infants, for patients with cranial defects or prior craniotomies in whom pin fixation may not be safe, or for patients in whom the need to move the head during surgery is required. The image quality of the system remains excellent, and the ability to merge new images to the neuronavigation system is helpful.

Objective To predict the postoperative language outcome using the support vector regression (SVR) and results of multimodal presurgical language mapping. Methods Eleven patients with epilepsy received presurgical language mapping using functional MRI (fMRI), magnetoencephalography (MEG), transcranial magnetic stimulation (TMS), and high-gamma electrocorticography (hgECoG), as well as pre- and postoperative neuropsychological evaluation of language. We constructed 15 (24–1) SVR models by considering the extent of resected language areas identified by all subsets of four modalities as input feature vector and the postoperative language outcome as output. We trained and cross-validated SVR models, and compared the cross-validation (CV) errors of all models for prediction of language outcome. Results Seven patients had some level of postoperative language decline and two of them had significant postoperative decline in naming. Some parts of language areas identified by four modalities were resected in these patients. We found that an SVR model consisting of fMRI, MEG, and hgECoG provided minimum CV error, although an SVR model consisting of fMRI and MEG was the optimal model that facilitated the best trade-off between model complexity and prediction accuracy. Conclusions A multimodal SVR can be used to predict the language outcome. Significance The developed multimodal SVR models in this study can be utilized to calculate the language outcomes of different resection plans prior to surgery and select the optimal surgical plan.

Tinnitus is the perception of sound in the absence of an external source. It is a common symptom that can be related to hearing loss and other benign causes. However, tinnitus may be disabling and can be the only symptom in a patient with a central nervous system process disorder. History and physical examination are crucial first steps to determine the need for imaging. CT and MRI are useful in the setting of pulsatile tinnitus to evaluate for an underlying vascular anomaly or abnormality. If there is concomitant asymmetric hearing loss, neurologic deficit, or head trauma, imaging should be guided by those respective ACR Appropriateness Criteria

Imaging of sinonasal pathology may occur for assessment of rhinosinusitis or mass lesions. Rhinosinusitis is prevalent in up to 16% of the US population with annual economic burdens estimated at 22 billion dollars. Rhinosinusitis is characterized as acute or chronic based on symptom duration; if four or more episodes occur annually, the term recurrent acute rhinosinusitis (RARS) is used. In acute uncomplicated rhinosinusitis when inflammatory change remains in the paranasal sinuses and nasal cavity, imaging may not be required. Distinction between viral or bacterial rhinosinusitis is a clinical diagnosis, and imaging should be interpreted in conjunction with clinical and endoscopic findings. Sinus CT imaging is appropriate per clinical judgment in associated complications including headache, facial pain, swelling, orbital proptosis, or cranial nerve palsies. In maxillary sinusitis, teeth may require assessment because 20% may be odontogenic in origin. MRI may be complementary in aggressive infections with intraocular/intracranial complications, invasive fungal sinusitis, or sinonasal masses. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

The most important clues to narrow differential diagnosis of benign bone tumors in the pediatric population include patient age, location of the lesion, number of lesions, type of matrix, margin features, and presence of periosteal reaction and extraosseous extension; a systemic imaging approach helps guide clinical management and prevent unnecessary patient anxiety and medical intervention.

Cortical Stimulation Mapping (CSM) and the Wada procedure have long been considered the gold standard for localizing motor and language-related cortical areas and for determining the language and memory-dominant hemisphere, respectively. In recent years, however, non-invasive methods such as magnetoencephalography (MEG), functional magnetic resonance imaging (fMRI), and transcranial magnetic stimulation (TMS) have emerged as promising alternatives to the aforementioned procedures, particularly in cases where the invasive localization of eloquent cortex has proven to be challenging. To illustrate this point, we will first introduce the evidence of the compatibility of invasive and non-invasive methods and subsequently outline the rationale and the conditions where the latter methods are applicable.

MRI without and with contrast is the most accurate imaging method to determine whether a process is intrinsic or extrinsic to a nerve of the brachial or lumbosacral plexus. However, there are no Current Procedural Terminology codes to correspond to imaging studies of the brachial or lumbar plexus discretely. This assessment uses "MRI of the brachial plexus" or "MRI of the lumbosacral plexus" as independent entities given that imaging acquisition for the respective plexus differs in sequences and planes compared with those of a routine neck, chest, spine, or pelvic MRI, yet acknowledges the potential variability of ordering practices across institutions. In patients unable to undergo MRI, CT offers the next highest level of anatomic evaluation. In oncologic patients, PET/CT imaging can identify the extent of tumor involvement and be beneficial to differentiate radiation plexitis from tumor recurrence but provides limited resolution of the plexus itself. The American College of Radiology Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision include an extensive analysis of current medical literature from peer-reviewed journals and the application of well-established methodologies (RAND/UCLA Appropriateness Method and Grading of Recommendations Assessment, Development, and Evaluation or GRADE) to rate the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances where evidence is lacking or equivocal, expert opinion may supplement the available evidence to recommend imaging or treatment.

Highlights • Developed and validated an overt continuous speech paradigm for use in fMRI. • The speech paradigm successfully identified the neural circuit of speech production. • The speech paradigm is effective in mapping disordered motor speech. • The fMRI paradigm will be useful for studying normal and disordered speech., We developed a task paradigm whereby subjects spoke aloud while minimizing head motion during functional MRI (fMRI) in order to better understand the neural circuitry involved in motor speech disorders due to dysfunction of the central nervous system. To validate our overt continuous speech paradigm, we mapped the speech production network (SPN) in typical speakers (n = 19, 10 females) and speakers with hypokinetic dysarthria as a manifestation of Parkinson disease (HKD; n = 21, 8 females) in fMRI. We then compared it with the SPN derived during overt speech production by 15O-water PET in the same group of typical speakers and another HKD cohort (n = 10, 2 females). The fMRI overt connected speech paradigm did not result in excessive motion artifacts and successfully identified the same brain areas demonstrated in the PET studies in the two cohorts. The SPN derived in fMRI demonstrated significant spatial overlap with the corresponding PET derived maps (typical speakers: r = 0.52; speakers with HKD: r = 0.43) and identified the components of the neural circuit of speech production belonging to the feedforward and feedback subsystems. The fMRI study in speakers with HKD identified significantly decreased activity in critical feedforward (bilateral dorsal premotor and motor cortices) and feedback (auditory and somatosensory areas) subsystems replicating previous PET study findings in this cohort. These results demonstrate that the overt connected speech paradigm is feasible during fMRI and can accurately localize the neural substrates of typical and disordered speech production. Our fMRI paradigm should prove useful for study of motor speech and voice disorders, including stuttering, apraxia of speech, dysarthria, and spasmodic dysphonia.

Object The objective of this systematic review and analysis was to answer the following question: What are the optimal treatment strategies for posthemorrhagic hydrocephalus (PHH) in premature infants? Methods Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to PHH. Two hundred thirteen abstracts were reviewed, after which 98 full-text publications that met inclusion criteria that had been determined a priori were selected and reviewed. Results Following a review process and an evidentiary analysis, 68 full-text articles were accepted for the evidentiary table and 30 publications were rejected. The evidentiary table was assembled linking recommendations to strength of evidence (Classes I–III). Conclusions There are 7 recommendations for the management of PHH in infants. Three recommendations reached Level I strength, which represents the highest degree of clinical certainty. There were two Level II and two Level III recommendations for the management of PHH. Recommendation Concerning Surgical Temporizing Measures: I. Ventricular access devices (VADs), external ventricular drains (EVDs), ventriculosubgaleal (VSG) shunts, or lumbar punctures (LPs) are treatment options in the management of PHH. Clinical judgment is required. Strength of Recommendation: Level II, moderate degree of clinical certainty. Recommendation Concerning Surgical Temporizing Measures: II. The evidence demonstrates that VSG shunts reduce the need for daily CSF aspiration compared with VADs. Strength of Recommendation: Level II, moderate degree of clinical certainty. Recommendation Concerning Routine Use of Serial Lumbar Puncture: The routine use of serial lumbar puncture is not recommended to reduce the need for shunt placement or to avoid the progression of hydrocephalus in premature infants. Strength of Recommendation: Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents: I. Intraventricular thrombolytic agents including tissue plasminogen activator (tPA), urokinase, or streptokinase are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Strength of Recommendation: Level I, high clinical certainty. Recommendation Concerning Nonsurgical Temporizing Agents. II. Acetazolamide and furosemide are not recommended as methods to reduce the need for shunt placement in premature infants with PHH. Strength of Recommendation: Level I, high clinical certainty. Recommendation Concerning Timing of Shunt Placement: There is insufficient evidence to recommend a specific weight or CSF parameter to direct the timing of shunt placement in premature infants with PHH. Clinical judgment is required. Strength of Recommendation: Level III, unclear clinical certainty. Recommendation Concerning Endoscopic Third Ventriculostomy: There is insufficient evidence to recommend the use of endoscopic third ventriculostomy (ETV) in premature infants with posthemorrhagic hydrocephalus. Strength of Recommendation: Level III, unclear clinical certainty.

Object The objective of this systematic review is to answer the following question: Does ventricle size after treatment have a predictive value in determining the effectiveness of surgical intervention in pediatric hydrocephalus? Methods The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were searched using MeSH headings and key words relevant to change in ventricle size after surgical intervention for hydrocephalus in children. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I–III). Results Six articles satisfied inclusion criteria for the evidentiary tables for this part of the guidelines. All were Class III retrospective studies. Conclusions Recommendation: There is insufficient evidence to recommend a specific change in ventricle size as a measurement of the effective treatment of hydrocephalus and as a measurement of the timing and effectiveness of treatments including ventriculoperitoneal shunts and third ventriculostomies. Strength of Recommendation: Level III, unclear clinical certainty.

BACKGROUND AND PURPOSE: Calcifications of the pineal, habenula, choroid plexus, and dura are often physiologic. In the modern CT era with thin-section images and multiplanar reformats, intracranial calcifications have become more conspicuous. We aimed to discover the CT prevalence of pineal region, choroid plexus, and dural calcifications in the first decade of life. MATERIALS AND METHODS: Five hundred head CTs from different patients (age range, 0–9 years) encountered during a consecutive 6-month period at a single academic children9s hospital were reviewed retrospectively after excluding examinations with artifacts and pineal region masses/hemorrhage. All studies were performed on a 320-detector CT, with 0.5-mm collimation and a 512 × 512 matrix. Five-millimeter reformatted axial, sagittal, and coronal images were analyzed for location and extent of intracranial calcifications. RESULTS: The mean age was 3.5 ± 5.7 years (range, 0–9 years). There were 285 males (57%) and 215 females (43%). Pineal calcifications were present in 5% (n = 25; age range, 3.2–8.9 years; median, 7 years). Habenular calcifications were found in 10% (n = 50; age range, 2.8–8.8 years; median, 7 years). Twelve percent (n = 58) had choroid plexus calcifications, (age range, 0.1–8.8 years). Dural calcifications were rare, present in 1% (n = 6; age range, 2.9–8.7 years). CONCLUSIONS: Physiologic intracranial calcifications may be found in the first decade, principally in children older than 5 years. Most epithalamic calcifications are habenular. Pineal and habenular calcifications were never present in children younger than 3 and 2 years, respectively. Choroid plexus calcifications may be present in the very young. Dural calcifications are rare.

We describe a 14-year-old boy with a pilocytic astrocytoma of the left caudate head. Preoperative localization MR imaging (MRI) was performed in the operating room, and spatial distortion was noted felt to be related to head positioning relative to the isocenter of the magnetic field. The distortion artifact was subtle enough to be difficult to detect, but large enough to change the location of the lesion potentially leading to a non-diagnostic stereotactic biopsy. Repeat imaging after changing the head position to allow scanning closer to the isocenter of the magnetic field showed decreased distortion, an improvement greater than that using the manufacturer's distortion correction algorithm on the initial images. Intraoperative MRI, and its requisite limitations in positioning, requires vigilance to detect possible distortion that could alter surgical outcomes if not identified and corrected prospectively.

BACKGROUND AND PURPOSE: High-field-strength intraoperative MR imaging has emerged as a powerful adjunct for resection of brain tumors. However, its exact role has not been firmly established. We sought to determine the impact of 3T-intraoperative MRI on the surgical management of childhood CNS tumors. MATERIALS AND METHODS: We evaluated patient data from a single academic children's hospital during a consecutive 24-month period after installation of a 3T-intraoperative MRI. Tumor location, histology, surgical approach, operating room time, presence and volume of residual tumor, need for tumor and non-tumor-related reoperation, and anesthesia- and MR imaging–related complications were evaluated. Comparison with pre-intraoperative MRI controls was performed. RESULTS: One hundred ninety-four patients underwent intraoperative MRI–guided surgery. Of these, 168 were 18 years or younger (mean, 8.9 ± 5.0 years; 108 males/60 females). There were 65 posterior fossa tumors. The most common tumors were pilocytic astrocytoma ( n = 31, 19%), low-grade glioma ( n = 31, 19%), and medulloblastoma ( n = 20, 12%). An average of 1.2 scanning sessions was performed per patient (maximum, 3). There were no MR imaging–related safety issues. Additional tumor was resected after scanning in 21% of patients. Among patients with a preoperative goal of gross total resection, 93% achieved this goal. The 30-day reoperation rate was

Hypoxic-ischemic injury (HII) continues to be an important cause of neonatal mortality and morbidity. In recent years, the role of magnetic resonance (MR) imaging has increased by providing early detection to initiate preventive measures and assess the severity of tissue injury, and it often serves as a prognostic indicator. However, because of the subtle findings and temporal variability of signal abnormalities, the imaging diagnosis often remains troublesome, particularly for trainees and general radiologists who do not often encounter these findings. The imaging manifestations between term and preterm infants differ significantly; the imaging findings in term neonates are discussed. Two main patterns of HII have been described in term neonates: peripheral and basal ganglia-thalamus, with the predominant pattern in an affected infant dependent on the duration and severity of the insult. The peripheral pattern occurs in the setting of mild hypoxia or ischemia of prolonged duration, with predominant findings in the cerebral cortex and subcortical white matter along the intervascular boundary zones. The basal ganglia-thalamus pattern is most often secondary to a more severe hypoxic or ischemic event of short duration and manifests with abnormal hyperintensity on T1-weighted images and hypointensity on T2-weighted images in the posterolateral putamen and ventrolateral thalamus. Associated loss of normal hyperintensity on T1-weighted images and hypointensity on T2-weighted images in the posterior limb of the internal capsule may be present. Restricted diffusion and evolution of imaging findings may be seen in each of these regions, depending on when images are obtained. Advanced imaging techniques, including MR spectroscopy, may add valuable information and specificity, with an abnormal lactate peak often serving as an indicator of HII in term neonates.

Advances in functional imaging have provided non-invasive techniques to probe brain organization of multiple constructs including language and memory. Because of high overall rates of agreements with older techniques, including Wada testing and cortical stimulation mapping (CSM), some have proposed that those approaches should be largely abandoned because of their invasiveness, and replaced with non-invasive functional imaging methods. High overall agreement, however, is based largely on concordant language lateralization in series dominated by cases of typical cerebral dominance. Advocating a universal switch from Wada testing and cortical stimulation mapping to fMRI or magnetoencephalography (MEG) ignores the differences in specific expertise across epilepsy centers, many of which often have greater skill with one approach rather than the other, and that Wada, CSM, fMRI, and MEG protocols vary across institutions resulting in different outcomes and reliability. Specific patient characteristics also affect whether Wada or CSM might influence surgical management, making it difficult to accept broad recommendations against currently useful clinical tools. Although the development of non-invasive techniques has diminished the frequency of more invasive approaches, advocating their use to replace Wada testing and CSM across all epilepsy surgery programs without consideration of the different skills, protocols, and expertise at any given center site is ill-advised.

Various methods of cross-sectional imaging are used for visualization of the cranial nerves, relying heavily on MR imaging. The success of the MR imaging sequences for visualization of cranial nerves depends on their anatomic context at the point of evaluation. The heterogeneity of opinion regarding optimal evaluation of the cranial nerves is partly a function of the complexity of cranial nerve anatomy. A variety of approaches are advocated and variations in equipment and terminology cloud the field. This article proposes a segmental classification and corresponding nomenclature for imaging evaluation of the cranial nerves and reviews technical considerations and applicable literature.

Correction of anterior open bite is a frequently encountered and challenging problem for the craniomaxillofacial surgeon and orthodontist. Accurate clinical evaluation, including cephalometric assessment, is paramount for establishing the diagnosis and appropriate treatment plan. The purposes of this technical note were to discuss the basic geometric principles involved in the surgical correction of skeletal anterior open bites and to offer a simple mathematical model for predicting the amount of posterior maxillary impaction with concomitant mandibular rotation required to establish an adequate overbite. Using standard geometric principles, a mathematical model was created to demonstrate the relationship between the magnitude of the open bite and the magnitude of the rotational movements required for correction. This model was then validated using a clinical case. In summary, the amount of open bite closure for a given amount of posterior maxillary impaction depends on anatomic variables, which can be obtained from a lateral cephalogram. The clinical implication of this relationship is as follows: patients with small mandibles and steep mandibular occlusal planes will require greater amounts of posterior impaction.

Commissural white matter fibers comprising the callosal splenium are diverse. Subsections of the splenium myelinate at different times, in a centrolineal manner. The aims of this study are to depict the normal callosal splenium myelination pattern and to distinguish the transient age-related mid splenium hypointensity from pathology. We reviewed 131 consecutive brain MRIs in patients between ages 3 and 6 months from a single academic children’s hospital. Patients that were preterm, hydrocephalic, and/or had volume loss were excluded. Fifty total MR exams that included T1-weighted MR imaging (T1WI), T2-weighted MR imaging (T2WI), and diffusion tensor imaging (DTI) were reviewed. Regions of callosal splenium myelination manifested by T1 and T2 shortening were evaluated. Tractography was performed with seeds placed over the posterior, mid, and anterior splenium to define the origin, destination, and course of traversing fibers. Splenium signal varied significantly from 3 to 6 months, with distinct age-related trends. On T1WI, the splenium was hypointense at 3 months (12/13), centrally hypointense/peripherally hyperintense at 4 months (15/16), and hyperintense at 6 months (10/11). Tractography revealed three distinct white matter tract populations: medial occipital (posterior); precuneus, posterior cingulate, and medial temporal (middle); and postcentral gyri (anterior). Specific commissural fiber components of the splenium myelinate at different times. The transient developmental mid splenium hypointensity on T1WI corresponds to tracts from the associative cortex, principally the precuneus. Heterogeneous splenium signal alteration in patients ages 3–6 months is a normal developmental phenomenon that should not be confused with pathologic lesions.

Intramedullary spinal cord neoplasms (ISCN) in children provide diagnostic, treatment and management dilemmas. Resection results in the best chance for disease control, but the greatest risk of neurologic deficit. We hypothesize that diffusion tensor imaging (DTI) and diffusion tensor-fiber tracking (DT-FT) can help characterize margins of pediatric ISCN to aid in surgical planning. This HIPAA compliant retrospective study was performed after Institutional Review Board approval. Patients with ISCN from a single tertiary care pediatric institution were identified, and patients with preoperative DTI were evaluated. Ten patients (eight males and two females) with ISCN with preoperative DTI were identified. The mean age was 11.1 ± 6.2 years (range, 2–18 years). Eight tumors demonstrated DTI and DT-FT evidence of splayed cord tracts, and two demonstrated evidence of infiltration of cord tracts. The eight patients with splayed tracts underwent resection, with seven achieving gross-total resection and one subtotal resection. The two patients with infiltration of white matter tracts underwent biopsy of their lesion. DTI of pediatric ISCN can aid in defining the margins of the tumor and relationship to the intrinsic white matter structures of the spinal cord. Splaying and displacement of fiber tracts appears to predict a discrete margin to the tumor and resectability, whereas infiltration of the white matter tracts suggests biopsy may be more advisable.

Objective The widely accepted h -index depends on the citation analysis source and does not consider the authorship position, the journal's impact factor (IF), or the age of the paper or author. We investigated these factors in citation statistics of academic neurosurgeons. Methods An uncorrected h- index and the m- quotient, which corrects for career length, were calculated by the use of Scopus and Google Scholar. In a subset of neurosurgeons, we computed the contemporary h- index ( hc) , which accounts for the age of the publications; the authorship value (AV), weighted by author position; and the journal IF. An "overall' average for AV and IF including most of an author's publications and an average for publications comprising the h- index (" h- index core") were calculated. Results When we used Google Scholar, the mean h -index was significantly greater than that calculated when we used Scopus ( P = 0.0030). m- quotient and hc- index increased with academic rank, with an m- quotient >1 achieved by 69% of chairmen and 48% of professors. The effect of AV was greatest on the greater h- indices. The average IF for the h- index core was greater than the overall IF, which did not correlate with academic rank. Few neurosurgeons consistently publish in high-impact journals. Conclusion Google Scholar tends to inflate the h- index. The m -quotient and hc- index allow comparisons of researchers across time. Although average journal IF did not differ significantly among neurosurgeons academic ranks, it should be noted for individuals who consistently publish in high-impact journals. We recommend the creation of individual bibliometric profiles to better compare the academic productivity of neurosurgeons.

Background and purposeHigher admission serum glucose levels have been associated with poor outcomes in patients with acute ischemic stroke (AIS) treated with IV thrombolysis. We sought to evaluate the association of admission serum glucose with early outcomes of patients with emergent large vessel occlusion (ELVO) treated with mechanical thrombectomy (MT).MethodsConsecutive AIS patients due to ELVO treated with MT in three tertiary stroke centers were evaluated. The following outcomes were documented using standard definitions: symptomatic intracranial hemorrhage (sICH), complete reperfusion, mortality, functional independence (modified Rankin Scale (mRS) score of 0–2), and functional improvement (shift in mRS score) at 3 months. The association of admission serum glucose and admission hyperglycemia (>140 mg/dL) with outcomes was evaluated using univariable and multivariable binary and ordinal logistic regression models.Results231 AIS patients with ELVO (mean age 62±14 years, 51% men, median admission National Institute of Health Stroke Scale score 16 points (IQR 12–21), median admission serum glucose 125 mg/dL (IQR 104–162)) were treated with MT. Admission hyperglycemia was associated with a lower likelihood of functional improvement (common OR 0.53; 95% CI 0.31 to 0.97; p=0.027) and higher odds of 3 month mortality (OR 2.76; 95% CI 1.40 to 5.44; p=0.004) in multivariable analyses adjusting for potential confounders. A 10 mg/dL increase in admission blood glucose was associated with a higher likelihood of sICH (OR 1.07; 95% CI 1.01 to 1.13; p=0.033) and 3 month mortality (OR 1.07; 95% CI 1.02 to 1.12; p=0.004) in multivariable models. There was no association between admission serum glucose or hyperglycemia and complete reperfusion.ConclusionsHigher admission serum glucose and admission hyperglycemia are independent predictors of adverse outcomes in ELVO patients treated with MT.

Objective:There are limited data evaluating the effect of post mechanical thrombectomy (MT) blood pressure (BP) levels on early outcomes of patients with large vessel occlusions (LVO). We sought to investigate the association of BP course following MT with early outcomes in LVO.Methods:Consecutive patients with LVO treated with MT during a 3-year period were evaluated. Hourly systolic BP (SBP) and diastolic BP (DBP) values were recorded for 24 hours following MT and maximum SBP and DBP levels were identified. LVO patients with complete reperfusion following MT were stratified in 3 groups based on post-MT achieved BP goals: Results:A total of 217 acute ischemic stroke patients with LVO were prospectively evaluated. A 10 mm Hg increment in maximum SBP documented during the first 24 hours post MT was independently (p = 0.001) associated with a lower likelihood of 3-month functional independence (odds ratio [OR] 0.70; 95% confidence interval [CI] 0.56–0.87) and a higher odds of 3-month mortality (OR 1.49; 95% CI 1.18–1.88) after adjusting for potential confounders. In addition, achieving a BP goal of p = 0.010) in comparison to permissive hypertension.Conclusions:High maximum SBP levels following MT are independently associated with increased likelihood of 3-month mortality and functional dependence in LVO patients. Moderate BP control is also related to lower odds of 3-month mortality in comparison to permissive hypertension.

In 1976 an infant boy initially presented with a choroidal vein of Galen malformation (cVOGM). Craniotomy and clipping of the anterior cerebral artery and posterior choroidal arteries was performed, which was reported in the literature 40 years ago. The patient remained asymptomatic until age 42 when he re-presented with an isolated intraventricular hemorrhage. Angiography demonstrated cVOGM with venous sinus occlusive disease leading to venous hypertension and subsequent intraventricular hemorrhage. The angiogram also demonstrated a ‘pseudo-nidus’ composed of multiple arterial-to-arterial anastomoses that had developed as a result of the original surgical treatment. We embolized a portion of the lesion to reduce the venous hypertension. The patient has been asymptomatic for more than 2 years. To our knowledge, this is the first reported case of a symptomatic neonatal VOGM treated with open surgery that required embolization as an adult for a delayed hemorrhagic presentation.

Cerebellar tumors are the most common group of solid tumors in children. MR imaging provides an important role in characterization of these lesions, surgical planning, and postsurgical surveillance. Preoperative imaging can help predict the histologic subtype of tumors, which can provide guidance for surgical planning. Beyond histology, pediatric brain tumors are undergoing new classification schemes based on genetic features. Intraoperative MR imaging has emerged as an important tool in the surgical management of pediatric brain tumors. Effective understanding of the imaging features of pediatric cerebellar tumors can benefit communication with neurosurgeons and neuro-oncologists and can improve patient management.

Background Tics and Tourette syndrome are common problems evaluated by both the general pediatrician and pediatric neurologist. The common comorbidities of tics are well known, but the severe neurological complications are rare and may not be appreciated. Methods This is a retrospective case series and literature review. Results We present here four adolescents with Tourette syndrome who had severe neurological complications secondary to motor tics. We provide the history, neurological examination, and radiological findings in addition to a review of previously reported cases of vascular and cervical cord complications associated with violent motor tics. Conclusions We highlight the importance of recognizing the presenting signs of these complications early and the need to vigorously treat violent motor tics to prevent significant neurological complications.

Background and purposeHigh admission blood pressure (BP) levels have been associated with lower recanalization rates after endovascular treatment (EVT) for patients with acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). We sought to evaluate the association of admission BP with early outcomes in patients with ELVO treated with EVT.MethodsConsecutive patients with AIS presenting with ELVO in a tertiary stroke center during a 4-year period were prospectively evaluated. Admission systolic blood pressure (SBP) and diastolic blood pressure (DBP) were measured using automated cuff recordings. A blinded neuroradiologist calculated the final infarct volume (FIV) using standardized ABC/2 methodology. A favorable functional outcome (FFO) at 3 months was defined as modified Rankin Scale score of 0–2.ResultsOur study population consisted of 116 patients with AIS (mean age 63±13 years, median NIH Stroke Scale score 17 points (IQR 14–21), median FIV 30 cm3 (IQR 8–94)). Higher admission SBP correlated with higher FIV (r +0.225; p=0.020). Patients with FFO had lower admission SBP (151±24 mm Hg vs 165±28 mm Hg; p=0.010), while admission SBP levels were higher in patients who died during hospitalization (169±34 mm Hg vs 156±24 mm Hg; p=0.043). A 10 mm Hg increment in admission SBP was independently (p=0.010) associated with an increase of 12 cm3 in FIV (95% CI 3 to 21) in multiple linear regression models adjusting for potential confounders. A 10 mm Hg increment in admission SBP was independently (p=0.012) associated with a lower likelihood of FFO at 3 months (OR 0.64; 95% CI 0.45 to 0.91) in multiple logistic regression models adjusting for potential confounders.ConclusionsHigher admission SBP is an independent predictor of increased FIV and lower likelihood of 3-month FFO in patients with ELVO treated with EVT.

Melanotic neuroectodermal tumor of infancy (MNTI) is a rare lesion that typically manifests in the first year of life, most commonly involving the facial bones. We present 2 infants with MNTI involving the posterior skull with associated compression of the superior sagittal sinus (SSS). A review of the anatomical locations of MNTI is offered, and the implications of SSS involvement are described. This represents the first known description of MNTI with involvement of the posterior SSS.

Advances in handheld computing now allow review of DICOM datasets from remote locations. As the diagnostic ability of this tool is unproven, we evaluated the ability to diagnose acute appendicitis on abdominal CT using a mobile DICOM viewer. This HIPAA compliant study was IRB-approved. Twenty-five abdominal CT studies from patients with RLQ pain were interpreted on a handheld device (iPhone) using a DICOM viewer (OsiriX mobile) by five radiologists. All patients had surgical confirmation of acute appendicitis or follow-up confirming no acute appendicitis. Studies were evaluated for the ability to find the appendix, maximum appendiceal diameter, presence of an appendicolith, periappendiceal stranding and fluid, abscess, and an assessment of the diagnosis of acute appendicitis. Results were compared to PACS workstation. Fifteen cases of acute appendicitis were correctly identified on 98% of interpretations, with no false-positives. Eight appendicoliths were correctly identified on 88% of interpretations. Three abscesses were correctly identified by all readers. Handheld device measurement of appendiceal diameter had a mean 8.6% larger than PACS measurements (p = 0.035). Evaluation for acute appendicitis on abdominal CT studies using a portable device DICOM viewer can be performed with good concordance to reads performed on PACS workstations.