0:01

This is a CT scan on a one-month-old child

0:04

that had a seizure that came in

0:05

from an outside institution.

0:06

Now, seizures in a newborn are highly concerning.

0:11

It could be related to infections,

0:13

it could be related to trauma,

0:15

it could be related to congenital abnormalities,

0:18

could be related to infantile spasms,

0:20

which are a type of seizure that

0:21

needs to be treated right away.

0:23

So, it's obviously something we want

0:26

to pay close attention to.

0:28

And on this image,

0:30

we're seeing this area of bright signal here in

0:33

the left frontal lobe and in the

0:36

left posterior frontal lobe.

0:38

There's some abnormality in the ventricle.

0:42

And at an outside institution that

0:45

doesn't often deal with children,

0:47

there was a concern for these representing

0:51

parenchymal hemorrhages,

0:54

and as well as intraventricular blood products and.

0:59

And the concern was raised for child abuse.

1:03

And that's not unreasonable because they often

1:07

say child abuse is something you don't want to

1:09

not think about it, you don't want to miss it.

1:12

But let's look closer.

1:14

We're not seeing any edema.

1:16

This is superficial.

1:17

So that is where you can sometimes get a

1:19

traumatic injury. But these deeper findings,

1:22

it's not where you normally would

1:23

get a traumatic injury.

1:25

So, what might this be? Well, we perform an MRI,

1:32

and at first glance,

1:34

the brain tranchema looks fairly normal,

1:37

because in a newborn,

1:40

this child being one month old,

1:42

the white matter normally is bright

1:44

on T2-weighted imaging.

1:45

So there's a high water content because it's not

1:47

myelinated. So now we look a little closer.

1:52

This area here is.

1:54

There's some dark signal and probably

1:57

some cortical thickening that.

2:00

Corresponds with this area of bright

2:01

signal here on the CT scan.

2:04

So, what else? Well, again,

2:08

we may see something similar here in the

2:12

posterior aspect of the left frontal lobe that

2:15

corresponds with this area here on the CT scan.

2:19

We see this finding here in the lateral

2:22

ventricle that corresponds with this

2:24

area here the CT scan.

2:26

So now, none of these things in the MR.

2:28

Are looking like hemorrhage or trauma,

2:31

but we still need to figure out what's going

2:33

on because we're still not seeing.

2:35

We're seeing a couple of abnormalities.

2:38

I don't think we have the full picture yet.

2:40

I'm going to look at T1-weighted image,

2:43

and you can see,

2:44

actually multifocal areas of signal abnormality

2:46

on T1-weighted imaging.

2:49

So while we can barely see some of

2:52

these abnormalities on T2,

2:53

now that we look at them,

2:54

we see these hypo intense areas,

2:57

it becomes very obvious on T1.

2:59

One weighted imaging.

3:01

So in T1-weighted imaging, we're seeing,

3:03

not only are we seeing multifocal

3:04

areas of signal abnormality,

3:06

if we look go from the periphery,

3:08

where it's fanned out and it comes

3:10

in tapers as it comes in,

3:13

these look like the morphology of

3:14

type two b cortical dysplasia,

3:17

and that morphology comes from the migration

3:20

along the pathway from the germinal

3:22

matrix out to the periphery.

3:24

And normally, in tuber sclerosis complex,

3:28

we expect to see the areas of dysplasia or

3:31

cortical tubers as hyperintense

3:33

on T2 and FLAIR imaging.

3:35

But here

3:37

the hyperintense signal is not able to be

3:41

clearly identified in a background

3:43

of unmyelinated brain. Similarly,

3:46

in older individuals,

3:47

where there's a myelinated brain that's

3:49

hyperintense on T1-weighted imaging.

3:53

signal of the areas of dysplasia,

3:55

but in this patient who has an unmyelinated

3:58

brain, we can see.

3:59

Neonatal tuberous sclerosis complex

4:03

can look very different.

4:04

There's different imaging sequences

4:05

you look for in this patient.

4:08

This highlights that you see dysplasia

4:11

very well on T1-weighted imaging,

4:13

and it's much more subtle on T2-weighted

4:16

imaging. Similarly, these subependymal nodules,

4:19

if we look closely,

4:20

we can see them on T1 and T2-weighted

4:22

imaging. And we look here,

4:25

we can see at least three separate

4:26

nodules adjacent to one another.

4:29

So this patient has tuberous sclerosis complex and

4:36

no signs of trauma, no signs of hemorrhage.

4:39

Now,

4:40

what does it look like when they grow older?

4:43

So this is the patient several years later.

4:46

These areas that we saw of hyperintense signal.

4:50

We can barely see an abnormality on T2

4:53

to begin with. As they get older,

4:55

the hyperintense signal is able to be identified

4:58

in the background of the.

5:00

Rest of the brain as it myelinates.

5:02

This area here,

5:03

this area of dysplasia is very obvious

5:06

in the myelinated background. 93 00:03:51,626 --> 00:03:53,298 We don't really see the hyperintense

3:53

signal of the areas of dysplasia,

3:55

but in this patient who has an unmyelinated

3:58

brain, we can see.

3:59

Neonatal tuberous sclerosis complex

4:03

can look very different.

4:04

There's different imaging sequences

4:05

you look for in this patient.

4:08

This highlights that you see dysplasia

4:11

very well on T1-weighted imaging,

4:13

and it's much more subtle on T2-weighted

4:16

imaging. Similarly, these subependymal nodules,

4:19

if we look closely,

4:20

we can see them on T1 and T2-weighted

4:22

imaging. And we look here,

4:25

we can see at least three separate

4:26

nodules adjacent to one another.

4:29

So this patient has tuberous sclerosis complex and

4:36

no signs of trauma, no signs of hemorrhage.

4:39

Now,

4:40

what does it look like when they grow older?

4:43

So this is the patient several years later.

4:46

These areas that we saw of hyperintense signal.

4:50

We can barely see an abnormality on T2

4:53

to begin with. As they get older,

4:55

the hyperintense signal is able to be identified

4:58

in the background of the.

5:00

Rest of the brain as it myelinates.

5:02

This area here,

5:03

this area of dysplasia is very obvious

5:06

in the myelinated background.

5:08

It's very subtle on the earlier image,

5:13

and we can see these subependymal nodules.

5:16

So this just goes to show that these areas of

5:20

dysplasia not only do they change in their

5:24

imaging appearance on a given sequence,

5:27

they change in which sequence you can actually

5:29

see them on. As the child grew older,

5:33

we can't see the areas of dysplasia stand

5:36

out on T1-weighted imaging,

5:37

except for maybe right here,

5:39

all the rest of the areas, you see it at most,

5:42

because the higher water content

5:43

is being hypo intense,

5:45

whereas earlier they were hyperintense.

5:47

They didn't necessarily change

5:49

significant intrinsically,

5:51

but it's the relative appearance

5:52

compared to the background.

5:54

All of these little areas here that

5:57

we see in the right hemisphere.

5:59

Frontal lobe is hyperintense.

6:01

We're not seeing them on the current study

6:04

because the white matter surrounding

6:06

it has myelinated,

6:07

and myelinated white matter is hyperintense on T1

6:10

weighted imaging due to the

6:11

proteolipids of myelin.

6:13

So this just goes to show

6:15

that both in a newborn,

6:16

you need to be very cautious in interpreting

6:20

findings of suspected intracranial hemorrhage.

6:23

We need to be aware of the imaging findings

6:26

of neonatal tuberous sclerosis complex,

6:28

and in this case,

6:29

it shows that T1-weighted imaging

6:31

is the most effective.

6:33

And we can see the evolution as the brain myelinates.

6:37

T2-weighted and FLAIR imaging become

6:39

more relevant than T1.