8 y/o male with seizure

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Doctor's Information

Name : Morteza
Family : Sanei Taheri
Affiliation :Radiology Department,Shohada Tajrish Hospital,SBMU
Academic Degree : Associate Professor of Radiology
Email : This email address is being protected from spambots. You need JavaScript enabled to view it.
Resident : Mirhadi Razavian

Case Section

Pediatric Radiology

Patient's Information

Gender : Male
Age : 8

Clinical Summary

A 8 y/o male with seizure

Imaging Findings

MRI demonstrates schizencephaly at left frontotemporoparietal lobes , pachygyria , absent septum pellusidum .

Differential Diagnosis

Differential diagnosis
• focal cortical dysplasia
o sometimes may have a cleft on the cortical surface that does not extend completely to the ventricular surface
• heterotopic grey matter
o closed lip schizencephaly can mimic a band of grey matter heterotopia. Assessing the ventricular outline will often demonstrate a slight cleft whereas periventricular grey matter will usually bulge into the ventricle.
• porencephaly
o a zone of encephalomalacia that extends from the cortical surface to the ventricular surface but is lined by gliotic white matter, not grey matter
o it is worth noting that some authors would refer to schizencephaly as 'true porencephaly'.

Final Diagnosis

Schizencephaly

Discussion (Related Text)

Schizencephaly is a rare cortical malformation that manifests as a grey matter-lined cleft extending from the ependyma to the pia mater. schizencephaly is reserved for clefts lined by grey matter (polymicrogyria) thought to represent a true malformation, whereas porencephaly implies an encephaloclastic event (e.g. ischaemia). Epidemiology
Schizencephaly is rare with an estimated incidence of ~1.5:100,000 live births. It is almost always sporadic, although a few familial cases have been described 6. There is no known gender predilection 6.
Interestingly schizencephaly appears to be overrepresented in abandoned or adopted children, raising the possibility that in untero insults (e.g. cocaine and other 'street drugs') may be a risk factor 6.
Clinical presentation
The abnormality is increasingly detected at antenatal ultrasound, especially when it is of the open-lip variety.
In general developmental delay, motor disturbance correlate with the degree of anatomical abnormality, especially when clefts are present bilaterality. Seizures are relatively common, although the severity and prevalence of seizures do not appear to be dependent on the anatomical extent of involvement.
Pathology
A cleft extends from the ependymal surface of brain to the pia mater, and the two layers meet in the cleft: the so-called pial-ependymal seam 5. The grey matter that lines the cleft is abnormal, usually representing polymicrogyria.
Radiographic features
Schizencephaly can sometimes be bilateral, and is divided into two morphological types:
• open lip
o the cleft walls are separated and filled with CSF
o most common form in bilateral cases 6
• closed lip
o the cleft walls are in apposition
o most common form in unilateral cases
Most often the cleft involves the posterior frontal or parietal lobes (70%), and although large clefts can extend to involve the temporal or occipital lobes, isolated involvement of these lobes is uncommon 6.
It is frequently associated (50-90%) 6 with other cerebral anomalies:
• septooptic dysplasia
• grey matter heterotopia
• absent septum pellucidum
Ultrasound
Increasingly, schizencephaly is being diagnosed antenatally or post partum with cranial ultrasound. Closed lip schizencephaly is difficult to identify, whereas open lip forms can, if large, be readily seen (see article on fetal schizencephaly).
MRI
MRI is the imaging modality of choice, and enables identification of the pial-ependymal cleft visualisation of cortical dyplasia and heterotropic gray matter.
• closed lip (type I): seen as nipple-like out-pouching at the ependymal surface
• open lip (type II): heterotopic gray matter lined CSF cleft seen extending from ventricular to cortical surface .

References

• 1. Brant WE, Helms CA. Fundamentals of diagnostic radiology. Lippincott Williams & Wilkins. (2007) ISBN:0781761352. Read it at Google Books - Find it at Amazon
• 2. Osborn AG. Diagnostic neuroradiology. Mosby Inc. (1994) ISBN:0801674867. Read it at Google Books - Find it at Amazon
• 3. Oh KY, Kennedy AM, Frias AE et-al. Fetal schizencephaly: pre- and postnatal imaging with a review of the clinical manifestations. Radiographics. 25 (3): 647-57. doi:10.1148/rg.253045103 - Pubmed citation
• 4. Ketonen L, Hiwatashi A, Sidhu R. Pediatric brain and spine, an atlas of MRI and spectroscopy. Springer Verlag. (2005) ISBN:3540213406. Read it at Google Books - Find it at Amazon
• 5. Barkovich AJ, Norman D. MR imaging of schizencephaly. AJR Am J Roentgenol. 1988;150 (6): 1391-6. AJR Am J Roentgenol (abstract) - Pubmed citation
• 6. Sarnat HB. Malformations of the nervous system. Elsevier Science Health Science div. (2008) ISBN:0444518967. Read it at Google Books - Find it at Amazon