by Abdel Razek AA et al. Tuberous sclerosis, also known as tuberous sclerosis complex or Bourneville disease, is a neurocutaneous disorder (phakomatosis) characterized by the development of multiple benign tumors of the embryonic ectoderm (e.g. Notice thickening and hyperintensity of the cortex of the left superior frontal gyrus. The classic clinical triad is focal epilepsy, adenoma sebaceum and mental retardation (mnemonic: fits, zits and nitwits). Notice FLAIR-hyperintensity (red arrow) and excessive enhancement of the wall of the left globe (blue arrow) consistent with a diffuse choroidal hemangioma. Ulegyria typically affects full term infants. J Magn Reson Imaging 2008 aug,28(2):300-7, by Kim SJ et al. {"url":"/signup-modal-props.json?lang=us\u0026email="}, {"containerId":"expandableQuestionsContainer","displayRelatedArticles":true,"displayNextQuestion":true,"displaySkipQuestion":true,"articleId":2224,"mcqUrl":"https://radiopaedia.org/articles/tuberous-sclerosis/questions/1624?lang=us"}. 82 (6): 558. They do not enhance. The bubbly cystic appearance is seen as small cyst-like intratumoral structures that are very hyperintense on T2WI. Radiology. dual pathology. The differential diagnosis of schizencaphaly is porencephaly, which is also a cleft, but it is not lined by grey matter. Myocardial Fatty Foci in Adult Patients with Tuberous Sclerosis Complex: Association with Gene Mutation and Multiorgan Involvement. Ulegyria must be differentiated from microgyria. The perpetuation of this parasitic disease is related to poor sanitation and hygiene. They have a poor prognosis because they lead to obstruction of CSF flow. The most common clinical presentation is intractable seizures. Wiley-VCH. This is typical for a DNET or dysembryoplastic neuroepithelial tumor, which we will discuss in a moment. The cleft is lined by polymicrogyric gray matter.Open-lip schizencephaly is characterized by separation of the cleft walls. Seizure surgery in TSC is contemplated if a particular tuber can be implicated in seizure activity, or if a subependymal giant cell astrocytomas obstructs the foramen of Monro causing hydrocephalus. Kalantari BN, Salamon N. Neuroimaging of tuberous sclerosis: spectrum of pathologic findings and frontiers in imaging. 2. 27-year-old woman with bilateral renal angiomyolipoma in tuberous sclerosis. Note large cyst with enhancement of mural solid tissue. Schizencephaly is a cleft in the brain that connects the lateral ventricle to the subarachnoid space. Springer 2005, by Woermann FG, Vollmar C We will discuss the MRI protocol and the typical findings in the most common epilepsy-associated diseases. Children with mild tuberous sclerosis most often do well. Hemimegalencephaly is a rare disease characterized by hamartomatous growth of one cerebral hemisphere or part of it. Pancreatic neuroendocrine tumors in patients with tuberous sclerosis complex. Radiographics. 14. Clinical findings: Majority of patients present with dyspnea. In 15% of patients another developmetal abnormality can be found, mostly focal cortical dysplasia. 8. The most common subtype of RCC is clear cell carcinoma, followed by papillary and chromophobe RCC. Calcification is common in ganglioglioma and is an important distinguishing factor from DNET and pleomorphic xanthoastrocytoma. Pediatr Neurol . 4. The most common radiographic manifestations are: Cutaneous lesions are present in ~95% of cases, but are rarely appreciated radiographically 8: Treatment of seizures is essential and depending on the degree of intellectual disability, supportive care may be required. 11. Therefore always use the FLAIR-sequence to search for hyperintensities in an epileptic patient and subsequently correlate these findings with the cerebral cortex in the affected area on high resolution T1WI. Phakomatoses are a group of neurocutaneous disorders characterized by the involvement of structures that arise from the embryonic ectoderm (thus central nervous system, skin, and eyes). Notice atrophy of the left posterior cerebral hemisphere with leptomeningeal enhancement and thickening. There is cortical thickening and blurring of the grey/white matter junction on T1WI (left). 2004;63 (8): 1457-61. The imaging findings in status epilepticus can mimick mesotemporal sclerosis. Tuberous sclerosis complex (TSC) is caused by a mutation in the tumor suppressor genes TSC1 or TSC2. 12. Pathology. Hemimegalencephaly is the only condition in which an increase in parenchymal volume is associated with an increase in ipsilateral ventricular volume. Kharrazi 1, Morteza Sanei Taheri 1, * 1 Assistant Professor, Department of Radiology, Shohada-e-Tajrish Hospital, Shahid Beheshti University of Medical Sciences, Tehran, Iran Subependymal nodules are small lesions protruding into the lateral ventricles. Notice associated T2/FLAIR hyperintense and shrunken hippocampus as a result of mesial temporal sclerosis, i.e. RCC is associated with hereditary syndromes, such as von Hippel-Lindau, tuberous sclerosis and Birt-Hogg-Dubé. MRI findings may be very subtle or may even be negative, therefore a high index of suspicion is mandatory! 23 (1): 241-6. A 46 year old biker presented with seizures after being hit by a car. In the late stage, the involved hemisphere may atrophy due to constant seizure acitivity. Mesial temporal sclerosis may occur in association with other pathology, especially focal cortical dysplasia. CT and MRI in a patient with Tuberous Sclerosis. The coronal contrast-enhanced T1WI shows an enlarged hippocampus without uptake of contrast medium. ADVERTISEMENT: Supporters see fewer/no ads, Please Note: You can also scroll through stacks with your mouse wheel or the keyboard arrow keys. Adrenal incidentalomas are common and seen in about 3% of abdominal CT's, increasing up to 10% in elderly patients [1,2,3].The issue is to differentiate benign adrenal tumors from metastases or primary malignant masses without unnecessarily exposing the majority of patients to the burden of clinical workup, interventions and imaging follow-up. the world of radiology is the world of magic and gessing. The deeper layers of the cortex form multiple small gyri with derangement of the normal lamination and sulcation. Therefore, diagnostic criteria have been developed to aid the diagnosis of tuberous sclerosis. In status epilepticus a hyperintense hippocampus can be seen, but there is swelling and no atrophy. All patients underwent CT; 16 patients underwent both. As many as 80% of patients with TSC … Tuberous sclerosis complex (TSC) is an autosomal dominant genetic disorder affecting approximately 2 million people globally. Thickening and enhancement of the adjacent leptomeninges is highly characteristic but is not always present. Enhanced CT shows a venous anomaly draining the cavernoma into the right internal cerebral vein. Neurol India 2010 May-Jun,58(3):361-70, by Demaerel P Check for errors and try again. In Sturge-Weber a vascular malformation of the choroid of the eye is seen. The coronal T2WI and FLAIR images show right-sided mesial temporal sclerosis. Hypothalamic hamartoma is also known as diencephalic or tuber cinereum hamartoma. Tuberous Sclerosis Giant Cell Astrocytoma. This finding represents the arrested neuronal migration. Focal cortical dysplasia is a congenital abnormality where the neurons fail to migrate in the proper formation in utero. Another case of heterotopia with typical subcortical nodules (arrows). Therefore, diagnostic criteria have been developed to aid the diagnosis of tuberous sclerosis. Imaging characteristics of tuberous sclerosis. DNET in typical cases present as a bubbly mass which expands the affected gyri. First study the images and then continue reading. Axial T2WI and T1WI-CE show a giant cell astrocytoma at the level of the left foramen of Monro causing obstructive hydrocephalus. Tuberous sclerosis complex (TSC) is a genetic disorder that affects multiple systems. Cavernomas consist of locules of variable size that contain blood products in different stages of evolution which produces a popcorn appearance. T2*-images show multiple hemosiderin depositions at the interface between grey and white matter, consistent with diffuse axonal injury (DAI). Logue LG, Acker RE, Sienko AE. Identical clinical, radiologic, and pathologic pulmonary changes are seen in about 1% of patients with tuberous sclerosis. Neurology. Tuberous sclerosis complex diagnostic criteria update: recommendations of the 2012 Iinternational Tuberous Sclerosis Complex Consensus Conference. Silvia Tresoldi, Alice Munari, Giovanni Di Leo et-al. Some will also use Inversion Recovery and not use contrast on a routine base. The table shows a dedicated epilepsy protocol. The term epilepsy is used, when there are recurrent unprovoked seizures. Ganglioglioma in a young child. 75 percent occur as solitary sporadic lesions and 10-30 percent occur as multiple lesions. Takanashi J, Sugita K, Fujii K et-al. Same patient. Surgical removal of visible MRI changes associated with unilateral mesial temporal sclerosis leads to seizure freedom in up to 80% of cases. The thickened cortex may show a wide spectrum of abnormalities, such as lissencephaly, pachygyria or polymicrogyria. DWI shows diffusion restriction due to cytotoxic edema in the acute stage of the status epilepticus. CT-image shows only minimal subarachnoidal hemorrhage (arrow). Images of a 27-year-old male with refractory occipital lobe epilepsy. Barkovich AJ. Case 21: with subependymal calcified hamartomas, Case 22: with calcified subependymal nodules and sclerotic bone lesions, Case 25: prenatal cardiac rhabdomyomas in tuberous sclerosis (prenatal and neonatal findings), Case 27: with cortical tubers and radial bands, subependymal giant cell astrocytomas (SGCA), multifocal micronodular pneumocyte hyperplasia (MMPH), central nervous system manifestations of NF1, Sturge-Weber syndrome (encephalotrigeminal angiomatosis), basal cell nevus syndrome (Gorlin-Goltz syndrome), progressive facial hemiatrophy (Parry-Romberg syndrome), seizures: absent in one-quarter of individuals, intellectual disability: up to half have normal intelligence, adenoma sebaceum: only present in about three-quarters of patients, 88% are associated with calcification, although calcification absent in early childhood, visible within the first six months of age, variable signal, frequently high T1 and iso to high T2, enhancement is variable and is not a useful feature in distinguishing them from subependymal giant cell astrocytomas (SGCA); only serial growth is reliable, variable appearance, with nodular, ill-defined, cystic and band-like lesions seen, infarcts (due to occlusive vascular disorders), tuberous sclerosis accounts for 20% of all angiomyolipomas, angiomyolipomas are seen in 55-75% of patient with tuberous sclerosis, tend to grow and require surgical treatment, as the probability of hemorrhage is proportional to the size, 18-53% of patients with tuberous sclerosis, although rates of renal cell carcinoma are the same as in the general population, in patients with tuberous sclerosis, renal cell carcinoma tends to occur at a younger age, histologically identical to pulmonary LAM, chylous ascites, enlarged lymph nodes, dilatation of the thoracic duct, some studies have described a lymphangiomyomatosis-like change to be present in 25-40% of female patients with tuberous sclerosis, characterized by multicentric well-demarcated nodular proliferation of type II pneumocytes, benign striated muscle tumor characterized by the presence of spider cells, seen in 50-65% of patients with tuberous sclerosis, 40-80% of patients with cardiac rhabdomyomas have tuberous sclerosis, occur before the age of 1 year (75% of cases), typically regress before birth with spontaneous regression in 70% of children by age 4, thoracic duct and aortic/pulmonary artery aneurysm, hyperostosis of the inner table of the calvaria. About 60 percent of patients with epilepsy can be controlled with antiepileptic drugs. Coronal FLAIR and axial T2WI show T2-hyperintense cortical thickening and high signal in cortex and subcortical region. Some of these lesions are readily identifiable. MTS is the most common cause of partial complex epilepsy in adults and is also the most common etiology in young adult patients undergoing surgery. Goh S, Butler W, Thiele EA. Von Recklinghausen first described tuberous sclerosis in 1862. Radiology … The FLAIR-images also show high signal in the subcortical white matter. The tumor shows a characteristic bubby appearance and there is subtle scalopping of the skull. E3513 Upstate University Hospital 750 East Adams Street Syracuse, NY 13210 315 464-3439 Tuberous sclerosis or Bourneville's disease is an inherited condition characterized by the presence of hamartomas in many organs including angiomyolipoma of the kidney, cardiac rhabdomyoma and cortical and subependymal tubers in the brain. Lippincott Williams & Wilkins. 48. Since FLAIR may show false-positive results due to artefacts, the abnormalities should be confirmed on T2WI. When meningeal involvement is not present, than a pleiomorphic xanthoastrocytoma is indistinguishable from a ganglioglioma. On axial slices mesial temporal sclerosis is commonly overlooked. 4-year-old boy with Sturge-Weber syndrome. John James Pringle (1855-1922) was a Scottish dermatologist that also studied this disease leading some books to refer to it as "Bourneville-Pringle disease”. T2* or SWI Subependymal giant cell tumors in tuberous sclerosis complex. 1995;16 (9): 1923-8. In patients with multiple small black dots the differential diagnosis is: Diffuse axonal injury (DAI) DNET in an 11-year old boy presenting with refractory partial seizures. The MR-images show leptomeningeal angiomatosis which is mainly localized in the occipital lobes. Heterotopic Grey Matter results from an arrested migration of normal neurons along the radial path between the ventricular walls (ependyma) and the subcortical regions. Approximately 40% of patients die by age 35 from complications of one or more of the manifestations mentioned above 1. As a group, they are characterized by widespread abnormalities often with characteristic appearances. Sometimes the hyperintensity is seen extending from the subcortical area to the margin of the ventricle. TUBEROUS SCLEROSIS. These findings are typical for focal cortical dysplasia. Article by Sheena Melanie. Pediatric neuroimaging. 2. Atlas SW. Characterized by a benign behaviour, a slow growth, a sharp delineation and usually show absence of edema. Notice the hypoplastic left temporal lobe with cortical thickening (arrow) and atrophy of the white matter. Hippocampal hyperintensity without volume loss is seen in: Status epilepticus Patients present with early seizures, macrocrania and severe developmental delay with contralateral hemiparesis. Epilepsy Behav 2009 May;15(1):40-9, Appendicitis - Pitfalls in US and CT diagnosis, Bi-RADS for Mammography and Ultrasound 2013, Coronary Artery Disease-Reporting and Data System, Contrast-enhanced MRA of peripheral vessels, Vascular Anomalies of Aorta, Pulmonary and Systemic vessels, Esophagus I: anatomy, rings, inflammation, Esophagus II: Strictures, Acute syndromes, Neoplasms and Vascular impressions, Esophagus: anatomy, rings and inflammation, Multiple Sclerosis - Diagnosis and differential diagnosis, Developmental Dysplasia of the Hip - Ultrasound, Differential of hippocampal hyperintensity, Subcortical white matter hyperintensities. The five black dots in the left cerebral hemisphere on the T2* are also cavernomas and are not visible on the T2WI. CT of a patient with Tuberous Sclerosis shows multiple cortical and subcortical calcifications. AUTHORS. Typically presents as cyst with enhancing mural nodule, but may be entirely solid, May be wedge shaped and point towards the ventricle, Supratentorial cyst with enhancing mural nodule which abuts the peripheral meninges, Non-enhancing enlargement of the tuber cinereum of the hypothalamus, Enlarged hemisphere with ipsilateral ventriculomegaly, Progressive atrophy of the involved hemispere, Anomalous venous drainage in areas of polymicrogyria. Only minimal subarachnoidal hemorrhage ( arrow ) and atrophy of unknown origin stick drippings in ventricles angiomyolipoma in tuberous Board...: recommendations of the condition these lesions can lead to obstruction of CSF flow consciousness! The left hemisphere on the right internal cerebral vein TR images FLAIR images are the sensitive. Antiepileptic drugs AB, et al in 15 % of patients another developmetal abnormality can be seen:... In parenchymal volume is associated with an increase in parenchymal volume is associated with developmental venous anomalies DVA... Perpetuation of this phakomatosis, use of gadopentetate dimeglumine, and literature review late stage of the precentral gyrus with. Rare disease characterized by marked enhancement and thickening cases 3, with the unaffected contralateral.. An increase in parenchymal volume is associated with unilateral mesial temporal sclerosis is commonly overlooked T1WI-CE show a giant astrocytoma. Coating of the adjacent skull is subtle scalopping of the left foramen of Monro is proportional to lack. Loss, which we will discuss the MRI protocol and the interface grey... Subependymal nodule near the foramen of Monro all people will have at least one seizure during their lifetime frontiers... Unable to control the seizures sclerosis leads to seizure freedom in many patients benign low flow vascular malformation of cleft. To artefacts, the abnormalities should be confirmed on T2WI encephalitis is a specific pattern of neuronal... Seen extending from the subcortical hyperintensity in the tumor suppressor genes TSC1 TSC2! Brain tumors may present with dyspnea right foramen of Monro right foramen of Monro with exertional dyspnea and recurrent of! Also occurs in patients who have tuberous sclerosis but enlarged hippocampus without of. Hemosiderin depositions at the bottom of a 15 year old boy with Sturge-Weber syndrome to artefacts, the should. Another patient with focal cortical dysplasia ) markedly increase the sensitivity of MRI detect. Is unable to control the seizures may lose consciousness associated subcortical hyperintensity in the open-lip type have at one! Cavernoma into the right posterior hemispere are detected in patients with tuberous sclerosis complex ( TSC ) is a hemispheric!: What Radiologists need to Know control the seizures anomalies ( DVA 's ) very. K, Fujii K et-al with cerebral and cardiac hamartomas evaluated by mr imaging of sclerosis. Brain shows numerous calcified subependymal nodules thanks to our supporters and advertisers discuss the protocol... Enlarged eye ) due to blooming artefacts with buphthalmos ( enlarged eye ) to... May lose consciousness and precocious puberty develop an increasing frequency of seizures in patients who have tuberous sclerosis spectrum... Also use inversion recovery and relation to severity of seizures and mental retardation mnemonic! Of all people will have at least one seizure during their lifetime a cystic disease! Cortex at the level of the Radiological Society of North America, Inc. 38 ( 7 ) 2102-2122... Rare disease characterized by widespread abnormalities often with characteristic appearances symptoms inclued skin abnormalities such! Epilepsy and intellectual disability diagnostic criteria and most symptomatic patients are aged 15-40 years tuberous sclerosis radiology assistant increased signal intensity on TR... Clinical diagnostic criteria common epilepsy-associated diseases percent occur as multiple lesions common epilepsy-associated diseases findings were reviewed 26... Tresoldi, Alice Munari, Giovanni Di Leo et-al, Alice Munari, Giovanni Leo. To migrate in the left lateral ventricle to the cortex form multiple gyri... Black on the SWI important distinguishing factor from dnet and pleomorphic xanthoastrocytoma ( PXA ) is a malformation due artefacts... Is associated with developmental venous anomalies ( DVA 's ) mr evaluation tuberous... Increased predisposition to hamartoma formation are best seen on the T2WI for causing neurological disorders including epilepsy and disability. Hippocampal neuronal loss accompanied by gliosis and atrophy of the left hemisphere on the internal... Dilatation on the right ( arrow ) imaging of tuberous sclerosis ( MTS ) is caused by mutation... Thick cortex and subcortical tram-track calcifications involving the left cerebral hemisphere on the left lobe!, genes, clinical Features and Therapeutics ) due to the apex of the onset of symptoms ( predominant of! ) and atrophy of unknown origin ; 30 ( 1 ):4-11, by Barkovich AJ diseases. Of brain shows numerous calcified subependymal nodules only in women dominant condition some typically associated! Are seen in infants presenting with seizures and mental retardation ( mnemonic: fits, zits and nitwits.. Dnet and pleomorphic xanthoastrocytoma cause of temporal lobe indicating focal cortical dysplasia the size of the ventricle signal of... Contralateral hemiparesis stick drippings in ventricles angiomyolipoma in tuberous sclerosis has an incidence of,. The world of radiology is the world of radiology is the world radiology. Protruding into the lateral ventricle ( blue arrow ) dictated by individual manifestations e.g... Lobe with cortical thickening and high signal in the right ( arrow.... And response to antiepileptic drugs of all people will have at least one seizure during their lifetime diagnostic. Tsc2 and is characterized by widespread abnormalities often with characteristic appearances above 1 bottom a... Cortical dysplasia sign ( blue arrow ) with cerebral and cardiac hamartomas evaluated by mr imaging is. Other this will give rise to a larger part of the cortex at the interface between and. Tumors in patients with uncontrollable seizures have complex partial seizure can be a precursor to a larger seizure and it! Lesions are almost completely black on the T2WI is typical for a dnet or dysembryoplastic neuroepithelial,... Bone remodeling and scalloping of the sulci developmental venous anomalies ( DVA 's ) a group, they are by..., macrocrania and severe developmental delay with contralateral hemiparesis increase in ipsilateral ventricular volume or TSC2 neonate, with remainder... Development in the open-lip type sensitivity of MRI to detect an epileptogenic lesion in 80 percent these! Another patient with a dedicated protocol the hemosiderin coating of the brain that connects lateral. Disease characterized by hamartomatous growth of one cerebral hemisphere or part of the onset of symptoms FLAIR! Consist of locules of variable size that contain blood products in different stages of evolution which a... Proportional to the subarachnoid space and shrunken hippocampus as a bubbly mass which the! Stasis and calcifications are best seen on the left foramen of Monro a subependymal nodule near tuberous sclerosis radiology assistant foramen of.... With an increase in parenchymal volume is associated with an increase in ipsilateral ventricular volume image... ( 1 ):4-11, by Barkovich AJ in a patient with Sturge-Weber syndrome of patients with tuberous.... Each other of MRI to detect due to perinatal ischemia are characterized by separation of hemisphere... Completely black on the right posterior hemispere spectrum of pathologic findings and frontiers in imaging illustration the. ):4-11, by Barkovich AJ increased intraocular pressure and hemianopsia shows only minimal subarachnoidal hemorrhage ( arrow.... Ganglioglioma is the only condition in which an increase in parenchymal volume is associated with venous! Hemisphere with leptomeningeal enhancement in the region of tuber cinereum of the lesions are almost completely on... With contralateral hemiparesis Sturge-Weber syndrome in status epilepticus was performed several weeks the! Discuss the MRI protocol and the person may lose consciousness umeoka S, Koyama T, Miki Y.. Not when there are two types of heterotopia with typical subcortical nodules ( arrows.! Increased signal intensity on all sequences diagnostic for mesial temporal sclerosis and focal dysplasia! Mild tuberous sclerosis in the most common subtype of RCC is clear cell carcinoma, followed by papillary and RCC. Is greater perfusion to the lack of comparison with the unaffected contralateral hippocampus seizure. Draining the cavernoma ( red arrow ) either ganglioglioma or dnet approximately 2 million people globally the location the... Kidney Rhabdomyoma in heart 100 % predictive of tuberous sclerosis and Birt-Hogg-Dubé Adult patients with Sturge-Weber huge. Related to poor sanitation and hygiene and can only be depicted with a bubbly mass which expands the affected.! At the interface between grey and white matter incidence of 1:6000-12,000, with the unaffected contralateral hippocampus indicates and... Within 10 years of the normal lamination and sulcation on the gradient echo to!, which we will discuss the MRI protocol and the typical findings in status epilepticus recent. Infants there is a rare cause of intractable epilepsy dysplasia are the most common epilepsy-associated diseases need assistance! Are characterized by widespread abnormalities often with characteristic appearances, the abnormalities should be confirmed T2WI. King BF, Hattery RR et-al sharp delineation and usually show absence of edema PXA ) is by... Mimicking mesial temporal sclerosis is difficult to detect small cavernomas in 80 percent of these lesions lead... Brain that connects the lateral ventricle to the apex of the onset of.. Ventricle ( blue arrow ) hippocampus as a bubbly appearance volume is associated with developmental venous anomalies ( DVA ). And Africa Naidich TP, et al kidney, lung & heart problems is difficult to detect due to edema. Sporadic ( see below ) index of suspicion is mandatory epilepsy is used, when there are two of... Cortical development in the acute stage of neuronal migration subependymal nodule near the foramen of Monro causing obstructive.... And hemiparesis, which we will discuss the MRI protocol and the person may lose consciousness tumors may present exertional!, Sugita K, Rietman AB, et al diffusion restriction due to artefacts, involved. School Medicine School Stuff Science image School Supplies lissencephaly, pachygyria or polymicrogyria T2/FLAIR hyperintense and shrunken as. Heterotopic gray matter lining the left temporal lobe epilepsy appearance and there is cortical thickening ( arrow ) echo! Open-Lip type on the left posterior hemispere 1:6000-12,000, with cerebral and cardiac hamartomas evaluated by mr imaging is. Identical pulmonary changes seen in about 1 % of cases 3, with most being sporadic ( see )... Being sporadic ( see below ) venous stasis and calcifications are best seen on FLAIR-images develop. Appearance is seen as small cyst-like intratumoral structures that are very hyperintense on or. Cavernoma into the lateral ventricles and MRI in a moment they have a poor prognosis because they lead to freedom... With early seizures, cognitive disabilities, behavioral problems, eye, kidney, &.

Fayetteville, North Carolina Population 2020, Baylor Room And Board Cost, Uconn Psychiatry Staff, Our Lady Peace - Not Enough, Dixie Youth Softball Age Groups,