Neuroradiological Imaging Techniques in Pediatric...
Transcript of Neuroradiological Imaging Techniques in Pediatric...
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Neuroradiological Imaging
Techniques in Pediatric Neurology
Rajan Patel, MD
Director, Pediatric Neuroimaging
Assistant Professor, Division of Neuroradiology
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DISCLOSURE
• No financial disclosure.
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LEARNING OBJECTIVES
• Overview of different imaging modalities in Pediatric Neuroradiology
• To learn the basic differences in CT & MRI of the Brain in Pediatrics as compare to adults.
• Brief discussion of role of imaging in Hypoxic Ischemic Encephalopathy(HIE), Seizure, Metabolic Disorders
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IMAGING MODALITIES
• USG: – Brain: Evaluate for IVH, hydrocephalus for preterm and
newborn (<6 months)
– Spine: Spinal Dysraphism, concern for tethered cord
• CT: – Brain: Screening exam in acute setting/ER with
neurological deficit, Trauma, suspected child abuse
• MR: – Neurological deficit, Developmental delay, Suspected
congenital abnormality, Metabolic Disorders.
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• No radiation
• Can be performed at bed-side
• Non-invasive
• Requires no sedations
• Relatively inexpensive
• No contraindications
Head Ultrasound – Why?
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Head Ultrasound - Limitations
• Operator dependent
• Age of child
– Can’t be performed once anterior fontanelle closed.
• Limited evaluation for early parenchymal
abnormalities
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Head Ultrasound - Indications
• Germinal matrix hemorrhage - Preterm infants
• Periventricular Leukomalacia (PVL)
• Macrocephaly
• Follow up hydrocephalus
• Concern for presence of vascular
anomalies – Vein of Galen Malformation
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Watershed Zones: Pre-term Vs. Full term
Chao, C. et al. Neonatal Hypoxic-Ischemic Encephalopathy: Multimodality Imaging Findings. RadioGraphics 2006.
Pre-Term Full Term
• Penetrating arteries
that arise from the
surface of the brain
and extend toward
lateral ventricles.
• Lack of collaterals.
• Vessels start to grow
from the lateral
ventricles outward
toward the surface.
• Moves the
watershed area
more peripherally.
• Difficulty with auto
regulation in
response to hypoxia
or ischemia.
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• Mild to moderate HIE: – Blood flow is shunted from the watershed areas to
the more hypervascular areas of the brain including the basal ganglia, thalamus, brainstem.
– Classic periventricular WM findings in preterm and deep WM in full term.
• Severe HIE: – Deep brain structures such as basal ganglia
involvement.
Patterns of brain injury in HIE
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HIE in the Pre-term
• Neuroimaging findings of the HIE depend on the severity of the insult:
– Mild to moderate HIE: • Germinal matrix hemorrhage
• Intraventricular hemorrhage (IVH)
• Periventricular Leukomalacia (PVL)
– Severe HIE: • Injuries involving the deep gray matter structures (basal
ganglia) or brainstem, which are similar to findings of HII in term infants
Huang BY, Castillo M. Hypoxic-Ischemic Brain Injury: Imaging Findings from Birth to Adulthood. Radiographics 2008
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Sagittal Coronal
Grade I: Hemorrhage confined to caudothalamic groove
Germinal Matrix Hemorrhage and IVH
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Sagittal Coronal
Grade II: Grade I + extension into the lateral ventricles without hydrocephalus
Germinal Matrix Hemorrhage and IVH
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Sagittal Coronal
Grade III: Grade II with hydrocephalus
Germinal Matrix Hemorrhage and IVH
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Sagittal Coronal
Grade IV: Grade III + extension into the adjacent
parenchyma/hemorrhagic venous infarcts
Germinal Matrix Hemorrhage and IVH
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• 5% of infants born before 32 weeks and 15-20% of infants born before 28 weeks will develop cerebral palsy(1).
• PVL is an important prognostic sign as more than 50% of infants with exhibit some form of cerebral palsy or cognitive/behavioral deficit(2).
• 2 Types of PVL:
• Focal PVL will be more associated with cerebral palsy
• Diffuse PVL will be more associated with cognitive/behavioral deficit
1. Huang BY, Castillo M. Hypoxic-Ischemic Brain Injury: Imaging Findings from Birth to Adulthood. Radiographics 2008 2. Volpe J. Cerebral White Matter Injury of the Premature Infant- More Common Than You Think. AJP 2003; 112; 176-180.
PERIVENTRICULAR LEUKOMALACIA (PVL)
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Coronal Coronal Axial T2
PERIVENTRICULAR LEUKOMALACIA (PVL)
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Spine Ultrasound
• Best in newborn/early infancy
• Limited value after 6 months due to ossification
of bony elements
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Spine Ultrasound - Indications
• Evaluation of lumbosacral stigmata known
to be associated with spinal dysraphism – Midline or paramedian soft tissue masses
– Hair tufts
– Hemangiomas
– Paramedian, Deep sacral dimples
• Evaluation of suspected defects such as
Cord Tethering, Diastematomyelia, Syrinx
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Spine Ultrasound - Indications
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Spine Ultrasound - Indications
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Pediatrics CT HEAD
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Radiation Risk
http://apps.who.int/iris/bitstream/10665/205033/1/9789241510349_eng.pdf?ua=1
http://www.acr.org/Quality-Safety/Appropriateness-Criteria
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Radiation Risk
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Radiation Risk
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Radiation Risk
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Radiation Risk
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Decreased Dose
• kVp>mA>collimation.
– Increase mA with age.
• 0 to 2 years 135.
• 2-3 years 180.
• 3-6 years 210.
• > 6 years 240
• Low dose CT for shunt evaluation, PNS, Temporal bone
• Use other alternatives if possible such as MRI for shunt evaluation.
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Unique about Pediatrics CT HEAD
• White matter is difficult to evaluate in the neonate – Better evaluated with US and MR
• Marked white matter hypodensity until age of 2 months
• Basal ganglia indistinct until 4 months
• Cortex should be well seen no matter what age • Hyperdense dural venous sinuses in neonates from
increased hematocrits
• Prominence of the subarachnoid spaces – Normal or macrocephalic
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3 week old with Seizure
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7 week old with Fever
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3 year old with Seizure
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3 week old with Seizure
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Question
3 year old with Seizure, Weakness
Which side is abnormal?
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3 week old with Altered consciousness
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3 week old with Fever, Seizure
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14 month old with macrocephaly
- Normal or Abnormal
- Which compartment fluid is located?
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6 month old with macrocephaly
- Normal or Abnormal
- Which compartment fluid is located?
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Case 1
- Normal or Abnormal
- Which compartment fluid is located?
Case 2
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Anterior Extra-axial Fluid
• Subarachnoid versus Subdural
• Subarachnoid – Symmetric
– Vessels (bridging veins) coarse through
– No mass effect
• Subdural – Asymmetric
– Vessels displaced towards cortex
– Underlying mass effect.
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4 months, Girl with 1st time seizure & 5 mins
of passing out, CPR by Dad
• Social History: - Wanted child – only child - Socially well adjusted family
• No History of trauma
• Unclear diagnosis! - Epilepsy? – Strong family history - Cardiac problem? - Metabolic etiology?
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• Clinical examination: – Bruise on the both sides of
chest
– H/o CPR by Dad at home
4 months, Girl with 1st time seizure & 5 mins
of passing out, CPR by Dad
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Disease/Accident
Abuse
Seizure without trauma
Socially well adjusted family
CT report: Normal
No report of trauma
Disease/accident vs. Abuse
- a question of balance?
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4 months, Girl with 1st time seizure & 5 mins
of passing out, CPR by Dad
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CT report: Clear!
- Bilat. SDH suggesting
violent, recurring trauma
Positive Retinal Hemorrhage
Disease/accident vs. Abuse
- a question of balance?
Seizure without trauma
Socially well adjusted family
Disease/Accident
Abuse
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HU
85
0
45
Weeks
1 2 3 4
Normal Brain
SDH: Time course Vs. Change of attenuation(HU)
Adapted from K. Ericson
CSF
5
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Child Abuse
• Retinal haemorrhages
• Acute on chronic SDH
• Cerebral edema
• Speaks in very strong favour
Reiber: Fatal falls in Childhood. Am J Forensic Med & Pathol 1993:3;201-207
Shaken Baby Syndrome (> 95 %)
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Bridging Veins
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SHAKEN BABY SYNDROME
• Repeated accelerations – decelerations
• Brain comes in motion relative to the skull and meninges.
• Torn bridging veins
• Subdural haematoma
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HEAD TRAUMA
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Pediatrics MRI HEAD
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• T1 – WM increases relative to GM
Newborn 2 year old
2 year old Newborn
• T2 – WM decreases relative to GM
White Matter Myelination
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White Matter Myelination
Posterior to Anterior
Central to Peripheral
Caudal to Cranial
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ANATOMIC REGION T1 T2
Middle Cerebellar Peduncle,
Posterior Limb of IC, Birth Birth – 2 Month
Deep Cerebellar WM (DCW) Birth – 3 Month 3 – 5 Month
Anterior Limb of IC 2 - 3 Month 8 - 11 Month
Splenium, Corpus Callosum 3 - 4 Month 4 - 6 Month
Genu, Corpus Callosum 4 - 6 Month 6 - 8 Month
Frontal White Matter, Central 4 - 6 Month 11 - 14 Month
Frontal White Matter, Peripheral 6 - 11 Month 14 - 18 Month
Simplified Pattern Approach
Barkovich et al. “Normal maturation of the neonatal and infant brain:MRI at 1.5 T” Radiology 1988;166: 173.
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ANATOMIC REGION T1 T2
Middle Cerebellar Peduncle,
Posterior Limb of IC, Birth Birth – 2 Month
Deep Cerebellar WM (DCW) Birth – 3 Month 3 – 5 Month
Anterior Limb of IC 2 - 3 Month 8 - 11 Month
Splenium, Corpus Callosum 3 - 4 Month 4 - 6 Month
Genu, Corpus Callosum 4 - 6 Month 6 - 8 Month
Frontal White Matter, Central 4 - 6 Month 11 - 14 Month
Frontal White Matter, Peripheral 6 - 11 Month 14 - 18 Month
Simplified Pattern Approach
Up to 6 months: Use T1-W; Use T2-W > 6 months
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ANATOMIC REGION T1 T2
Middle Cerebellar Peduncle,
Posterior Limb of IC, Birth Birth – 2 Month
Deep Cerebellar WM (DCW) Birth – 3 Month 3 – 5 Month
Anterior Limb of IC 2 - 3 Month 8 - 11 Month
Splenium, Corpus Callosum 3 - 4 Month 4 - 6 Month
Genu, Corpus Callosum 4 - 6 Month 6 - 8 Month
Frontal White Matter, Central 4 - 6 Month 11 - 14 Month
Frontal White Matter, Peripheral 6 - 11 Month 14 - 18 Month
Simplified Pattern Approach
Up to 6 months: Use T1-W; Use T2-W > 6 months
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ANATOMIC REGION T1 T2
Middle Cerebellar Peduncle,
Posterior Limb of IC, Birth Birth – 2 Month
Deep Cerebellar WM (DCW) Birth – 3 Month 3 – 5 Month
Anterior Limb of IC 2 - 3 Month 8 - 11 Month
Splenium, Corpus Callosum 3 - 4 Month 4 - 6 Month
Genu, Corpus Callosum 4 - 6 Month 6 - 8 Month
Frontal White Matter, Central 4 - 6 Month 11 - 14 Month
Frontal White Matter, Peripheral 6 - 11 Month 14 - 18 Month
Simplified Pattern Approach
Up to 6 months: Use T1-W; Use T2-W > 6 months
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T1 Weighted Sequence
MCP, DCW Splenium
Genu
3 months 4 months 6 months 8-11 months
T2 Weighted Sequence
6 months 8 months
Splenium
Genu
11 months
ALIC
14-18 months 14-18 months
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• To identify possible epileptic focus
– MRI, MEG, SPECT/PET
• To confirm lateralization
– fMRI, WADA testing
Role of imaging in Epilepsy
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• Imaging MUST BE acquired on a 3T scanner.
• High resolution T2-weighted coronal oblique images
• 3D T1-weighted MPRAGE volumetric images
• Coronal FLAIR images
MRI: EPILEPSY PROTOCOL
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1.5 T, Coronal T2 Oblique Images
WHY 3T?
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3 T, Coronal T2 Oblique Images
WHY 3T?
• Abnormally thickened right insular cortex
• Abnormally thickened superior temporal gyrus
• Right temporal subependymal heterotopia.
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CAUSE 0-2 2-20 21-40 41-60 >61
Cerebral
Hypoxia X
Inborn error of
Metabolism X
Congenital
Malformation X X
Infection X X
Phakomatosis X X
Primary seizures X
MTS X X
Vascular
Malformation X X
Post-traumatic
Epilepsy X X X X
Tumor X X X
Stroke X X
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MALFORMATION OF CORTICAL
DEVELOPEMENT
• Malformation due to abnormal neuronal and glial proliferation
- Focal cortical dysplasia
- Hemimegalancephaly
- Neoplasm (DNET, Ganglioglioma)
• Malformation due to abnormal neuronal migration
- Lissencephaly
- Heterotopias
• Malformation due to abnormal late migration and organization
- Polymicrogyria
- Schizencephaly
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MALFORMATION OF CORTICAL
DEVELOPEMENT
• Malformation due to abnormal neuronal and glial proliferation
- Focal cortical dysplasia
- Hemimegalancephaly
- Neoplasm (DNET, Ganglioglioma)
• Malformation due to abnormal neuronal migration
- Lissencephaly
- Heterotopias
• Malformation due to abnormal late migration and organization
- Polymicrogyria
- Schizencephaly
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• Key MRI Features of FCD:
– Abnormal gyral pattern
FCD: KEY MR IMAGING FINDINGS
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• Key MRI Features of FCD:
– Abnormal gyral pattern
– Increased cortical thickness
– Increased cortical signal
FCD: KEY MR IMAGING FINDINGS
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• Key MRI Features of FCD:
– Abnormal gyral pattern
– Increased cortical thickness
– Increased cortical signal
– Blurring of gray matter / white matter
junction
– Increased white matter signal
FCD: KEY MR IMAGING FINDINGS
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• Key MRI Features of FCD:
– Abnormal gyral pattern
– Increased cortical thickness
– Increased cortical signal
– Blurring of gray matter / white matter
junction
– Increased white matter signal
– ‘Transmantle’ signal changes
FCD: KEY MR IMAGING FINDINGS
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Mesial Temporal Sclerosis(MTS)
Coronal T2
• Left hippocampus T2 hyperintensity
• Left hippocampal atrophy
• Compensatory enlargement of the adjacent temporal horn
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Clinical Data
Imaging Lab
Tests
Genetic Tests
Pediatric Metabolic Disorders
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Clinical Data
Imaging Lab
Tests
Genetic Tests
Pediatric Metabolic Disorders
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MRI based approach to Pediatric Metabolic Ds.
1) Disorders of Hypomyelination
2) Disorders affecting subcortical WM
3) Disorders affecting periventricular + deep WM
4) Disorders affecting combined WM and GM
5) Disorders affecting GM with some WM
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*Disorders of Hypomyelination*
• Pelizaeus–Merzbacher disease (PMD)
• Fucosidosis
• Sialic acid storage disorder
• Hypomyelination with atrophy of the basal ganglia and cerebellum
• Hypomyelination, hypodontia, hypogonadotropic hypogonadism
• Hypomyelination and congenital cataract
• Hypomyelination with monocarboxylate transporter-8 deficiency
• Folate receptor defect
• Tremor-ataxia with central hypomyelination
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2y/M, Hypotonia,Developmental Delay
Markedly delayed myelination of the cerebral white matter on T2.
T1 T2
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*Disorders affecting
Predominantly Subcortical WM*
• Megalencephalic Leukoencephalopathy with
Cysts (MLC) / Van der Knaap Disease
• Vanishing White Matter Disease
• Galactosemia
• Aicardi-Goutieres Syndrome
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Vanishing White Matter Ds. (Childhood ataxia with central hypomyelination)
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Megalencephalic Leukoencephalopathy
with Cysts (MLC) / Van der Knaap Disease
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*Disorders affecting Predominantly
Periventricular + Deep WM*
• X-linked ALD
• Metachromatic Leukodystrophy
• Mucopolysaccharidoses (MPS)
• Lowe Syndrome
• Cockayne Syndrome
• X-linked Charcot-Marie-Tooth Syndrome
• Leukoencephalopathy with Brainstem and
Spinal cord involvement (LBSL)
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X-Linked Adrenoleukodystrophy (ALD)
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Metachromatic Leukodystrophy
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*Disorders affecting
Combined White and Gray Matter*
• Alexander Disease
• Canavan Disease
• Krabbe Disease
• Maple Syrup Urine Disease (MSUD)
• GM1/GM2 Gangliosidosis
• Organic Acidopathies
• e.g. Propionic acidemia, Glutaric aciduria type I, Methylmalonic acidemia, L-2-hydroxyglutaric aciduria
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Alexander Disease
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Canavan Disease
13 months old, increased head circumference
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Canavan Disease
Elevated NAA : Creatine ratio 2.72
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*Disorders affecting
Predominantly Gray Matter with some WM*
• Mitochondrial Disorders
• Leigh Syndrome
• Kearns-Sayre Syndrome
• Mitochondrial Encephalopathy, Lactic
Acidosis, Stroke like symptoms (MELAS)
• Urea Cycle Disorders
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Leigh Syndrome
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SUMMARY
• Use helpful resources if any uncertainty regarding which imaging study to order in pediatric patients. – ACR appropriate criteria, Call Radiologists
• Significant difference in appearance of CT Head (up to 6 months) & MRI of head (up to 2 year) as compared to adults.
• Learn from your colleagues.
i.e. multidisciplinary conferences