Copyright ©The Author(s) 2016.
World J Clin Pediatr. Aug 8, 2016; 5(3): 262-272
Published online Aug 8, 2016. doi: 10.5409/wjcp.v5.i3.262
Table 1 Summarizes the reports of intracranial incidental findings in children on brain magnetic resonance imaging[5-22]
Ref.CountryStudy objective /conclusion
Yilmaz et al[5]TurkeyTo evaluate clinical significance of MRI abnormality in children with headache/
Despite the high rate of IFs, the yield is non-contributory to diagnosis and therapy
Bayram et al[6]TurkeyTo describe the prevalence of WML detected on MRI in children with headaches/ Non-specific WML may be seen in children with headache. In the absence of benefit, repeated MRI studies are unwarranted. It should be tailored according to clinical course
Graf et al[7]United StatesStudied the frequency and consequences of IFs on non-acute pediatric headache/
The frequency and types of all IFs were generally comparable to previous studies
Schwedt et al[8]United StatesTo study the frequency of “benign” abnormalities in children with headache, compare it with the frequency of MRI findings that dictate a change in patient management/
About 20% children with headache have benign findings that do not result in a change in management which rarely occurred in 1.2% of children in this study
Koirala[9]NepalTo evaluate the yield of MRI findings in patients with seizure/
The majority of abnormalities on MRI included hippocampal sclerosis and T2 hyperintensity
Kalnin et al[10]United StatesTo characterize IFs association with seizure onset and to standardize a classification system/
The MRI and a standardized scoring system demonstrated a higher rate of IFs than previously reported. MRI parameters need to expand the definition of significant IFs
Gupta et al[11]United StatesTo test the hypothesis that children with developmental delay are more likely to have incidental findings than are the children with normal development status/
Authors reported a higher prevalence of IFs in children with developmental delay as compared with those with normal development status
Seki et al[12]JapanTo report prevalence of IFs in healthy children and to suggest an ethical and practical management protocol/
The prevalence of IFs was high but those requiring further MRI was low. Evaluating equivocal findings was the most difficult part of IFs management
Gupta et al[13]United StatesTo elucidate the prevalence of incidental findings in a general pediatric neurology practice/
Authors reported a high prevalence of and a low rate of referrals in comparison to previous studies. This study may help guide management decisions and discussions
Potchen et al[14]MalawiTo collect normative magnetic resonance imaging data for clinical and research applications/
Incidental brain magnetic resonance abnormalities are common in Malawian children
Kim et al[15]United StatesTo elucidate the prevalence of incidental findings in a healthy pediatric population/
Frequency of important IFs was not high. But, awareness of neurologic status, the presence and variety of IFs are of vital importance for research and welfare of the child
Incidental findings in pediatric specialty clinic other than neurology
Oh et al[16]South KoreaTo investigated the clinical characteristics of children in whom Rathke’s cleft cysts were incidentally discovered and the treatment response with endocrinopathy/
Rathke’s cleft cysts less than 20 mm expressing cystic intensity can be treated medically
Rachmiel et al[17]CanadaTo assess IFs in children with congenital hypothyroidism compared to 38 healthy controls/
Both groups had a similar incidence of structural abnormalities. There was no association between those findings and neurocognitive function
Whitehead et al[18]United StatesThe prevalence of pineal cysts in children who have had high-resolution 3T brain MRI/
Characteristic-appearing pineal cysts are benign findings. In lack of no referable comprehensive symptoms, no follow-up is required
Mogensen et al[19]DenmarkTo evaluate the outcome of brain MRI in girls referred with early signs of puberty/
Girls with central precocious puberty should have a brain MRI
Perret et al[20]SwitzerlandThe prevalence and management options of incidentally found mass lesions at pediatric clinic/
A subgroup of lesions such as tectal glioma and dysembryoplastic neuroepithelial tumor can be monitored conservatively
Jordan et al[21]United StatesThe prevalence of incidental findings on brain MRI in children with sickle cell disease/
IFs were present in 6.6% patients and a potentially serious or urgent finding was 0.6%
Table 2 Clinical demography of intracranial incidental findings on pediatric brain magnetic resonance imaging evaluated at general neurology clinic and at research center[5-15]
Ref.Clinical demographics
Girls n (%) with MRI
Study- settingReason for MRINo. ofsubjectNo. ofMRI (%)Mean age(range) year
Yilmaz et al[5]Pediatric neurologyHead pain449288 (64)111.2 (NA)189 (58)
Bayram et al[6]941527 (61)212.1 (4-16)NA
Graf et al[7]40091 (23)210.8 (3-18)NA
Schwedt et al[8]681218 (32)212.1 (2-18)3126 (52)
Koirala[9]Pediatric and adult neurologySeizure36c36 (100)3NA (1-16)NA
Kalnin et al[10]Radiology349281 (81)9.7 (6-14)143 (51)
Gupta et al[11]Pediatric neurologyDevelopmental delay2185771 (35)7.6 (NA )433 (56)
Gupta et al[13]General1618666 (41)9.8 (0-21)280 (42)
Seki et al[12]Research InstituteHealthy children39589 (25)1NA (5-8)53 (44)
Kim et al[15]Radiology225198 (88)111.2 (1 mo-18)126 (56)
Potchen et al[14]Community-based10268 (71)112.1 (9-14)54 (55)
Table 3 Clinical demography of children with intracranial incidental findings on pediatric brain magnetic resonance imaging studies at pediatric specialty clinic other than neurology[16-21]
Ref.Study-settingReason for MRINo. of subjectNo. of MRI (%)Clinical demographics
Mean age(range) yearGirls n (%) with MRI
Oh et al[16]EndocrinologyRathke’s cleft cysts34126 (76)NA (4-18)17 (65)
Rachmiel et al[17]EndocrinologyCongenital hypothyroidism68230 (100)12.5 (10-15)16 (55)
Whitehead et al[18]RadiologyPineal cyst100100 (100)6.8 (1 mo-17)52 (52)
Mogensen et al[19]EndocrinologyEarly puberty229207 (100)3NA (6-9)207 (100)
Perret et al[20]OncologyPrimary brain tumor4335335 (100)7.6 (0-18)132 (39)
Jordan et al[21]Neurology researchSickle cell disease953953 (100)9.2 (5-15)460 (48)
Table 4 Lists three most commonly reported intracranial incidental findings on brain magnetic resonance in various pediatric-settings[5-19]
Ref.Three most common intracranial IFs, n (%)Comment or serious finding
Yilmaz et al[5]White-matter hyperintensity 14 (4.3) Old infarcts 4 (1.2), and CM I 3 (0.9)2 (0.6%) malignant tumor and 1 hydrocephalus, 0.3% IFs were relevant to headache
Bayram et al[6]Supratentorial non-specific WMC 23 (4.4)All patients with IFs had normal development and no seizures or head trauma
Graf et al[7]CM I 6 (15), arachnid cysts 6 (15), brain stem parenchymal abnormality, 4 (10)Brain stem IFs included Dandy-Walker variant, cerebellar calcification, and tectal plate hyperintensity
Schwedt et al[8]CM I 11 (4.6), nonspecific white matter abnormalities 7 (2.9), venous angiomas and arachnoid cyst each 5 (2.5)Discovery of 4 tumors, 4 old infarcts, 3 CM I, and 2 moyamoya required a change in management
Koirala[9]Hippocampal sclerosis, T2 hyperintense foci in various distributions, both 4 (21) each, cortical atrophy 3 (16)Study focus was IFs in patient with seizure. The lesions were better detected by MRI than computerized tomography
Kalnin et al[10]Ventricular enlargement 143 (51), leukomalacia/gliosis 64 (23), heterotopias and cortical dysplasia 33 (12)Temporal lobe lesions were detected 15%, a higher frequency than in previous studies
Gupta et al[11]Variant signal intensity 30 (18), WMC changes 23 (13), and PVL, 10 (6)IFs were reported in children with developmental delay as to those with normal development status
Seki et al[12]Cavum septi pellucid 6 (15) and Pineal cyst 2 (5 ), Enlarged perivascular spaces 1 (2.5)Focus of the study was reporting of extracranial IFs in healthy children
Gupta et al[13]CM I and cerebellar ectopia, 16 (3.5), Arachnoid cysts, 12 (1.8)White matter changes were the most common IFs classified under normal-variants
Potchen et al[14]PVW matter changes/gliosis 6 (6), mild diffuse atrophy 4 (4), and Empty sella 3 (3)Incidental findings were unassociated with age, sex, antenatal problems, or febrile seizures
Kim et al[15]Focal white matter lesion 3 (1.3), arachnoid cyst, frontal venous angioma, and mega cisterna magna, all three 2 (0.9) eachIFs were detected on 225 conventional research in a cohort of neurologically healthy children
IFs in pediatric specialty clinics other than neurology
Oh et al[16]Low signal intensities on T1-WI and high signal intensities on T2-WI 26 (73)Incidence of hypointensity on T1-WI was higher in patients with Rathke’s cleft cysts
Rachmiel et al[17]Prominent VR perivascular spaces, cerebellar ectopia, and abnormalities in sella region all 3 (7.9) eachThe comparative study found no IFs association with clinical and cognitive abnormalities
Mogensen et al[19]Arachnoid cysts 5 (9.2), of which one patient had hydrocephalusIncidental findings were unrelated to early puberty
Table 5 Summarizes incidentally found “serious lesions” on pediatric brain magnetic resonance imaging
Ref.The context in which brain MRI was orderedWorsening course
Yilmaz et al[5]Children mean age 11.2 yr presented for headache evaluationMalignant brain tumor and hydrocephalusChiari I malformation I; Relevant to headacheTissue type of tumor in study was unspecified
Schwedt et al[8]Children mean age 12.1 yr presented for headache evaluationTumors, moyamoya disease, and demyelinating diseaseArteriovenous malformation and intracerebral hemorrhageStudy focus was “benign” imaging abnormalities, no further information for serious lesion other than pineal tumor was available
Kalnin et al[10]Children mean age 9.7 yr presented for the first onset seizureNoneTemporal lobe lesionsVarious Epileptic abnormalities1 have been associated with pediatric brain MRI
Potchen et al[14]Community-based children mean age 12.1 yrGranulomas with gliosisEmpty sella and vermian atrophyCalcified granulomas caused by neurocysticercosis or tuberculosis occurs in the endemic part of the world
Mogensen et al[19]All girls, mean age unavailable, presented for early puberty evaluation to endocrine clinicPontine and pineal tumor, and hypothalamic pilocytic astrocytomaHydrocephalus, cortical dysplasia, and chiari II malformationA high frequency a pathological brain findings occurred in 6-8 yr old girls with precocious puberty
2Perret et al[20]Incidentally found mass lesions management in children mean age 7.6 yr in oncologyLow-grade glioma, craniopharyngioma, ependymoma, and CPPMedulloblastoma and fibrillary astrocytomaDysembryoplastic neuroepithelial tumor and tectal glioma can be monitored conservatively
Jordan, et al[21]Children mean age 9.2 yr with sickle cell disease in neurology researchChiari I malformation with large spinal cord syrinx3Possible tectal glioma, Possible tumor vs dysplasiaAmongst 6.6% incidental findings identified, 0.6% children with sickle cell disease had potentially serious or urgent finding
Table 6 A proposal for a common clinical profile of intracranial incidental findings on pediatric brain magnetic resonance imaging
Clinical implication
Discovery of the unexpected incidental findingsRevealing during investigation enhances the patients or parents anxiety. The evidence-based knowledge will provide an additional confidence for the practicing physicians
Type of the incidental findingsVarieties of white matter changes are reported. However, these usually do not initiate a neurologic consultation. Chiari type I malformation, arachnoid cyst, and pineal cyst, all continued to be a common source of concern for some physicians
Distribution of incidental findingsAttention to the distribution of findings is a useful tool in deciding the clinical importance of such findings. A midline lesion particularly in the posterior fossa and hippocampal location is likely to have a serious clinical implication
The clinical context in which MRI was performedThis is probably the single most important step in understating the clinical implication of incidental findings (Table 6). This is particularly important when the child was referred to neurology after revealing the incidental finding on brain MRI
Table 7 Summarizes the neurosurgical intervention and their outcome in children with incidentally discovered serious lesions
Ref.Incidentally found serious findingsNo. ofpatientsSurgical procedure performedOutcome
Schwedt et al[8]Chiari type I malformation3Surgical decompressionHeadache relieved in 2 patients after surgery
Jordan et al[21]Chiari I malformation with spinal cord syrinx2Surgical decompressionNeurologic stable
Perret et al[20]Pilocystic astrocytoma2Primary subtotal resectionStable disease
Craniopharyngioma1Primary total resectionComplete remission
Anaplastic ependymoma1Primary total resection, radio-chemotherapyComplete remission
Choroid plexus papilloma1Primary total resectionComplete remission
Medulloblastoma1Delayed subtotal resection, radio-chemotherapyNeurologic stable
Fibrillary astrocytoma1Delayed total resectionComplete remission
Mature teratoma1Delayed subtotal resectionNeurologic stable
Desmoplastic ganglioglioma1Primary total resectionComplete remission
Mogensen et al[19]Pilocytic astrocytoma1HypophysectomyPatients developed pan hypopituitarism after surgery
Yilmaz et al[5]Medulloblastoma1Urgent surgery for space occupying lesionHeadache relieved after surgery