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Toe walking, stuttering, wetting bed. CT, MRI, catscan reports suggest cyst in posterior fossa, positive Babinski sign. Anything to worry?

DOCTOR OF THE MONTH - Feb 2013
Feb 2013
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I have a four year old son who has been through a lot recently and I'm hoping to get another opinion.

He has always been a toe walker, but in January we (teachers, PT, and parents) noticed a sharp change in the frequency and severity of the toe walking. In addition, he started stuttering, wetting the bed (2/week about), and chewing on everything (sleeves, blankets...). I originally was thinking it was just a phase, but now I'm wondering if it's related to our current issues. He fractured his nose in February by tripping and falling face first into a ski ball game. They did a CT and it broke pretty straight and we avoided surgery. (Not sure if that's at all related to any of this, but thought I'd included it since it was within the timeline). A week after the break I noticed a large dent in the top of his head. We had an xray and catscan done and we were referred to a nuerosurgeon and she indicated that the dent is nothing and it's likely always been there. I strongly disagree that's it has always been there as I think myself or someone else would have noticed a dent this size. I also have noticed that since finding this dent, the dent has gotten smaller. I tend to think that if it really was the shape of his head all along it wouldn't change. The catscan also showed a cyst on his brain (left posterior fossa), no where near this dent. During his nuero exam she seemed to think the cyst was nothing to be concerned about, but she did note that he exhibited a positive babinski sign every time on his left foot and occasionally on his right. She ordered an MRI of his brain and spine. The MRI showed prominent ventricles, but no signs of hydrocephalus. She is currently out of town and I'm anxious to get answers and I'm wondering a few things...

In addition to wondering your thoughts on if any of this is related and getting your general input on what this might be I'm also wondering if a positive babinski sign ever mean nothing? Meaning, can you have it and still have a perfectly normal brain function?

Thank you
Posted Tue, 23 Apr 2013 in Brain and Spine
 
 
Answered by Dr. E Venkata Ramana 4 hours later
Hi XXXXXXX

Thank you for your query on Healthcare Magic.

I went through the history of your 4 year old child.

1.Toe walking is a concerning symptom in a 4 year old child and it may some
time associated with spasticity of the lower limbs. So spinal cord abnormalities,
and other neuro problems have to be investigated further.

2.Stuttering, wetting of the bed, chewing everything are due to one phase of the
child development and are more related to his behavoir related problems. And
they may not related to his problem of toe walking.

If it is thought related, bed wetting may be related to toe walking as both can be associated with an underlying spinal problem sometimes.

3.Coming to the dent, if it is not correlated with the injury, it may be a normal
thing if it is not associated with any pressure symtoms of the brain.

And some times if there is any hematoma (contusion) formed due to head injury, there will be a dent underlying the hematoma.

4.The cyst in posterior fossa on CT scan may be a cystic hygroma, which is a
normal variant and usually it wont cause any symptoms of brain dysfunction.

5.But positive Babinski sign is abnormal and it is indicative of an upper motor
neuron problem like brain, and spinal cord lesions.

6.The MRI is suggestive of prominent ventricles, even though there is no
hydrocephalus. But the cause for the prominent ventricles has to be evaluated.

My advise is :

a. To evaluate for any neurological abnormality for his toe walking.

b. To look into the causes of ventricular prominence on his MRI.

c. To examine the complete nervous system of the child by a Pediatric neurologist.

d. To look for the causes of his positive Babinski sign.

e. To manage his behavioral and developmental problems like stuttering,
chewing, and bed wetting with the opinion of Pediatrician and a Psychiatrist.

Therefore I advise you to take a Pediatric neurologist consultation for complete assessment of the child nervous system in addition to the Neuro surgeon consultation.

Hope I have answered your query, if you have any clarification please fee free to consult me.

Regards.
Above answer was peer-reviewed by
 
Follow-up: Toe walking, stuttering, wetting bed. CT, MRI, catscan reports suggest cyst in posterior fossa, positive Babinski sign. Anything to worry? 7 hours later
Thank you. Just to be clear...

1. There is always a cause of a positive babinski sign, right? It is never an incedental finding, correct? And I should press the doctors for a cause and not settle for "it's no big deal?" or could it actually be no big deal?

2. Do prominent ventricles always have a cause or is that just how some people are? And are prominent ventricles at all related to a positive babinski?

Thanks!

 
 
Answered by Dr. E Venkata Ramana 25 minutes later
Hi XXXXXXX

You are welcome,

And thank you for getting back.

My answers to your querie are :
1.

Positive Babinski sign is abnormal in a child after the age started to walk.

It is indicative of an associated upper motor neuron problem.

And in addition to this abnormal sign, an upper motor neuron problem will present with the other signs like exaggerated knee, ankle jerks, increased tone, and some times clonus.

But consistent presence of the positive Babinski sign is significant and suggestive of abnormality.

But in the setting of having toe walking, this sign should be looked of its consistent presence and to be investigated further or referred to a Pediatric neurologist.

2.

'Prominent ventricles' is a finding, but the causes of this prominence has to be looked, and presence of any signs of brain atrophy to be seen and a detailed history since birth to know any corresponding neurological symptoms.

Prominent ventricles are related to a positive Babinski sign, if the prominence is secondary to brain atrophy.

Without the signs of brain or cerabral atrophy or any brain involvement, simple presence of prominent ventricles may not be related to the positive Babinski sign.

Hope my explaination may clarify your concerns and doubts regarding your son.

Still if you have any clarification, please fee free to get back.

Regards.
Above answer was peer-reviewed by
 
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