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Saskia E. Luijnenburg, Patrick W. Hanlo, K. Sen Han, Wijnanda A. Kors, Theo D. Witkamp and Jonathan I. M. L. Verbeke

✓ The authors present the case of a 4-year-old boy in whom a medulloblastoma in the left cerebellar hemisphere was successfully resected with no signs of residual tumor on the postoperative magnetic resonance (MR) images. A second MR imaging study performed 1 month after surgery demonstrated an extensive, contrast-enhancing lesion in the left cerebellar hemisphere, which simulated massive recurrent tumor, and repeated surgery was considered. A third postoperative MR imaging study, performed for evaluation of the craniospinal axis 10 days after the second postoperative study, still showed some contrast enhancement in the left cerebellar hemisphere, but the lesion had almost disappeared. Postoperative hemicerebellar inflammation seemed to be the most likely explanation.

This case illustrates that early postoperative inflammation can mimic recurrent tumor on MR images obtained after resection of a medulloblastoma and caution should be taken in interpreting such images. Clinical history, neurological examination, laboratory findings, and repeated MR imaging studies can be helpful in evaluating the patient accurately.

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Paul H. Leliefeld, Rob H. J. M. Gooskens, Cees A. F. Tulleken, Luca Regli, Cuno S. P. M. Uiterwaal, K. Sen Han and L. Jaap Kappelle

Object

Clinical signs and symptoms of hydrocephalus can be clear and specific, but also subtle, nonspecific, or even absent. It may be difficult to decide whether shunt placement is indicated, especially in infants. Therefore, there is a need for the development of better noninvasive detection methods to distinguish between compensated and (slowly) progressive hydrocephalus. Early interference can reverse the cerebral damage, whereas the detection of a nonpathological state in infants with compensated hydrocephalus avoids the complications of unnecessary shunt procedures. Using MR imaging, the authors investigated cerebral blood flow (CBF) and apparent diffusion coefficients (ADCs) measured in infants with clinically compensated hydrocephalus.

Methods

The diagnosis of compensated hydrocephalus was made on the basis of clinical criteria, consisting of no signs or symptoms of increased intracranial pressure (ICP), measurement of a normal ICP, and standard MR imaging showing enlarged ventricles. Flow measurements through both internal carotid arteries and the basilar artery were considered to represent the total CBF. In addition, ADC values were assessed in 5 different regions of interest in the brain parenchyma using diffusion weighted imaging. Brain volumetric measurement was performed to express CBF in ml/100 cm3 brain/min, thus compensating for physiological CBF growth over time. Mean arterial blood pressure was manually measured to exclude this factor as a cause of a possible change in CBF. Intracranial pressure measurement was performed noninvasively using the Rotterdam Teletransducer.

Results

Eighteen infants with clinically compensated hydrocephalus were included. The mean CBF was 53.5 ml/100 cm3 of brain/min. The individual CBF values were graphically compared with age-related normal CBF values and fell in the normal range. Mean ADC value was 890.0 ×10−6 mm2/sec. Apparent diffusion coefficient values per region of interest were graphically compared with normal ADC values per region of interest and fell within the normal range.

Conclusions

In infants with hydrocephalus, normal CBF and low ADC values, as measured using MR imaging, are associated with compensated hydrocephalus and may support a conservative approach with respect to the decision on whether to place a shunt.

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Janneke Van Beijnum, Patrick W. Hanlo, K. Sen Han, W. Ludo Van Der Pol, Rudolf M. Verdaasdonk and Onno Van Nieuwenhuizen

✓ The authors present the case of a 2-year-old boy with bobble-head doll syndrome (BHDS) associated with a large suprasellar arachnoid cyst and enlarged ventricles, who was successfully treated with neuronavigated laser-assisted endoscopic ventriculocystocisternostomy.

The clinical history, surgical treatment, and clinical follow up of the patient are described. A navigated laser-assisted endoscopic ventriculocystocisternostomy of the suprasellar arachnoid cyst led to cessation of the head bobbing, and notable reduction of the cyst and ventricles was visible on the postoperative magnetic resonance images.

Caused by a suprasellar arachnoid cyst, BHDS can be successfully treated with navigated laser-assisted endoscopic ventriculocystocisternostomy. The advantages of this procedure are minimal invasiveness and facilitated guidance of the neuronavigation system to the target area when normal anatomical landmarks are not visible.

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Marike L. D. Broekman, Eelco W. Hoving, Kuan H. Kho, Lucienne Speleman, K. Sen Han and Patrick W. Hanlo

✓ Beckwith–Wiedemann syndrome (BWS) is a rare congenital syndrome characterized by gigantism, macroglossia, exophthalmos, postpartum hypoglycemia, and multiple midline defects such as omphalocele. The authors describe, to the best of their knowledge, the first case of a child in whom BWS was diagnosed and who was subsequently treated for a nasal encephalocele.

Because the authors believe that this feature might not be an incidental finding in patients with BWS, intranasal masses in these patients should be carefully differentiated, as complications might be severe.