With increasing use of sophisticated brain and spinal imaging, more children are being referred to pediatric neurosurgeons for unexpected findings on MRI.

A report, recently published in the April 2015 issue of Pediatrics discussed the incidence of such findings and the challenges this presents for clinicians.

The most common incidental findings referred for neurosurgical input were pineal cysts, arachnoid cysts, Chiari malformations and Tarlov (perineural) cysts.

Other findings considered to be incidental were:

• Benign enlargement of the subarachnoid space:  This is considered a transient developmental “macrocephaly” occurring in mid-infancy that typically resolves later in childhood.
• Brain tumors:  Most of these are benign glial tumors with favorable natural history, but none-the-less, warrant observation and repeat imaging over time.
• AVM’s:  Although considered “incidental” in the paper, the authors further go on to note that such a finding does pose a lifelong risk for hemorrhage at arterial pressures.
• Cavernous hemangiomas and Developmental venous malformations:  Each of these are typically considered more benign lesions.
• Telangiactasias are believed to pose no risk for hemorrhage and are not an uncommon finding in children being imaged.
• Pituitary abnormalities:  The authors state that these are so common as to be dubbed “Pituitary Incidentaloma”.

MRI use in the United States is much greater than in most other developed countries. According to the Organization for Economic Cooperation and Development, in 2010 there were 97.7 MRI per 1000 population ordered in the US as compared to 40 per 1000 in Canada.  The US rate for 2013 showed a further increased utilization to 106.8.

The challenges faced by a point of entry physician are primarily 2-fold:

• Many clinicians fear missing a significant lesion and often feel “pressure” from parents to order such imaging, despite a neurologic exam that is normal.
• Some of the findings noted above do pose a risk, thus can be significant and in these cases it becomes paramount to distinguish between the more versus the less benign findings.

It is expected that as demand for imaging by the general public increases, coupled with improving resolution capability of various imaging modalities, the likelihood of encountering incidental findings will continue to increase.

Click link for the complete paper. Incidental Brain and Spine Findings on MRI in Children