Dural sinus and internal jugular vein thrombosis complicating a blunt head injury in a pediatric patient

Introduction

Cerebral venous sinus thrombosis (CVST) following a blunt head trauma is a rare condition, described in the literature along with the lack of consensus regarding diagnosis and management.

Case summary

We present a case of a pediatric patient with a blunt head injury and epidural hematoma, who developed dural sinus and internal jugular vein thrombosis with fatal outcome.

Discussion

Most of reports show good outcome and recovery, but CVST might be related to poor recovery and even lead to death. The diagnosis and management of this condition are discussed based on a literature review.

Conclusion

It is important to keep a high degree of suspicion of CVST since early diagnosis may prevent potentially treatable catastrophic outcomes.     

Bilateral radial nerve compression neuropathy in the newborn

Purpose

This study aims to discuss the diagnosis and management of radial nerve compression neuropathy in the newborn.

Methods

A personal case is presented, followed by a review and analysis of clinically similar cases identified via a PubMed search of published medical literature.

Results

We report a case of a term newborn with bilateral radial neuropathy at the humerus level. Despite severe axonal involvement in the electrophysiological evaluation, the patient showed complete bilateral recovery after 3 months of follow-up.

Conclusions

Isolated radial nerve palsy is a rare event in the newborn. The condition does not require surgical treatment and usually proceeds to full and rapid spontaneous recovery.     

Grisel’s syndrome: a comprehensive review with focus on pathogenesis, natural history, and current treatment options

Introduction

Grisel’s syndrome (GS) is a rare otolaryngologic condition that involves rotatory subluxation of the atlanto-axial joint in the absence of trauma. Sir Charles Bell was the first to describe this condition in 1830. However, it was named after Pierre Grisel, a French ENT specialist who in 1930 described three such cases in children.

Methods

Using standard search engines, we reviewed the most recent literature regarding GS with special attention to its pathogenesis, natural history, and recent treatment options.

Results

Although defined over 80 years ago, the exact pathogenesis leading to GS is still not completely understood. Nevertheless, it occurs mainly as a complication of upper respiratory tract infections and/or surgical interventions in the head and neck. Most recent studies postulate that the spread of septic emboli from such infection nidus via the pharyngovertebral veins to the periodontoid vascular plexus could be the most likely cause. The diagnosis of GS is made by both clinical assessment as well as radiologic confirmation with either CT scan or MRI. Our review found out that most authors favor immobilization with a soft collar and antibiotics over surgical correction in the initial management of GS. Surgery is reserved for severe and refractory cases.

Conclusion

GS remains a rare, but potentially lethal children condition. Early diagnosis and treatment is crucial to its management and prognosis.     

Transorbital penetrating cerebral injury caused by a wooden stick: surgical nuances for removal of a foreign body lodged in cavernous sinus

Purpose

Penetrating head injury (PHI) is rare in civilian population and is mostly caused by low-velocity modes. A transorbital penetrating intracranial injury is very rare and more severe than traumatic brain injury.

Methods

We report a rare case of transorbital penetrating cranial injury caused by a wooden stick. The surgical strategy was planned as the wooden stick was lodged in the right cavernous sinus.

Results

The wooden stick was successfully removed. Patient made an uneventful recovery.

Conclusions

Transorbital penetrating injuries are uncommon form of injury and require a multidisciplinary approach. No attempt should be made to remove the foreign body without the backup of an operating room because of the possibility that the object may be tamponading an injured vessel. A careful planning and a strict adherence to basic perioperative principles can lead to a satisfactory outcome.     

Primary central neurocytoma of the mesencephalic tectum in a pediatric patient

Purpose

Neurocytomas are tumors or neuronal differentiation, typically located within the supratentorial ventricular system. The extraventricular location is uncommon. A limited number of cases involving the brainstem have been reported and may be misdiagnosed as brainstem gliomas. Furthermore, midbrain neurocytomas are extremely rare, and no similar cases in pediatric patients have been reported in the literature to date. Brainstem location of neurocytomas often precludes gross total removal of the lesion, and in these cases, adjuvant therapies may be helpful.

Methods

We report a case of a 16-year-old child who presented with signs and symptoms of increased intracranial pressure. The magnetic resonance imaging study demonstrated the presence of a primary mesencephalic tectum lesion causing obstructive hydrocephalus. The patient underwent emergent ventriculoperitoneal shunt implantation, resolving the hydrocephalus and the clinical symptoms. The lesion was partially removed through a suboccipital craniotomy and supracerebellar infratentorial approach to the mesencephalic tectum, without intraoperative complications.

Results

Histological examination of the lesion was consistent with the diagnosis of extraventricular neurocytoma. The patient was referred to the oncology department for additional treatment with Gamma Knife radiosurgery.

Conclusions

Although brainstem neurocytoma is rare, this case demonstrates that it should be included in the differential diagnosis of brainstem gliomas. Because of brainstem tumor location, complete surgical removal may be challenging or not possible, with a high risk of postoperative neurological deficits. Adjuvant therapies may prevent local tumor growth in cases of tumor remnants or recurrences following microsurgery in selected cases.     

Traumatic atlanto-occipital dislocation: do children and adolescents have better or worse outcomes than adults? A narrative review

Background

Traumatic atlanto-occipital dislocation is an uncommon, severely unstable pathology, which can lead to detrimental or even fatal neurological impairment. Specifically, children have consistently been reported to be more susceptible to this type of injury because of their disproportionately larger head, ligament laxity, and injury mechanisms. However, to date, rates of missed injury and outcomes including neurologic recovery of pediatric and adult populations following this insult have not been comparatively evaluated.

Methods

Standard search engines were used to investigate outcomes of traumatic atlanto-occipital dislocation in children and adolescents compared to adults.

Conclusions

Based on case reports and small series from the literature, it seems that children and adolescents tend to have a better likelihood of survival with the possibility of long-term neurological complications. Comparatively, adults who suffer traumatic atlanto-occipital dislocation either succumb to their injuries or survive with very little if any neurological complications.

     

Operative management of idiopathic spinal intradural arachnoid cysts in children: a systematic review

Background

Spinal intradural arachnoid cysts are rare with only a few patients reported so far. Idiopathic, traumatic, posthemorrhagic, and postinflammatory causes have been reported in the literature. Especially, idiopathic lesions, in which other possible etiological factors have been ruled out, seem to be rare.

Patients and Methods

We systematically reviewed the literature in regards to localization within the spinal canal, treatment options, complications, and outcome. Additionally, we present management strategies in two progressively symptomatic children less than 3 years of age with idiopathic intradural arachnoid cysts.

Results

In total, 21 pediatric cases including the presented cases have been analyzed. Anterior idiopathic spinal arachnoid cysts are predominantly located in the cervical spine in 87.5 % of all cases, whereas posterior cysts can be found at thoracic and thoracolumbar segments in 84.6 % of the patients. Most children presented with motor deficits (76.2 %). Twenty-five percent of anterior spinal arachnoid cysts caused back pain as the only presenting symptom. Open fenestration by a dorsal approach has been used in the vast majority of cases. No major surgical complications have been reported. Ninety-four percent of all patients did improve or showed no neurological deficits. Recurrence rate after successful surgical treatment was low (9.5 %).

Conclusion

Idiopathic spinal intradural arachnoid cysts can present with neurological deficits in children. Pathologies are predominantly located in the cervical spine anteriorly and in thoracic and thoracolumbar segments posteriorly to the spinal cord. In symptomatic cases, microsurgical excision and cyst wall fenestration via laminotomy are recommended. Our radiological, intraoperative, and pathological findings support the cerebrospinal fluid obstruction and vent mechanism theory of arachnoid cysts.     

Spinal epidural abscess from group A Streptococcus after varicella infection: a case report and review of the literature

Introduction

Spinal epidural abscess (SEA) is a very rare condition in pediatric patients. Varicella zoster infection could be a predisposing factor, and SEA should be suspected in patients with signs of secondary bacterial infection and even mild neurological signs.

Clinical case

We describe here a case of a 30-month-old girl with a history of remitting varicella infection, diagnosed for a lumbar epidural abscess and sacro-ileitis, secondary to group A Streptococcus (GAS).

Discussion

This is the third case of SEA from GAS reported in the literature in a pediatric population with varicella infection. We discuss here the clinical presentation and the diagnostic challenges for SEA in childhood through a review of the literature.     

Diagnosis and treatment of vein of Galen aneurysmal malformations

Introduction

Vein of Galen aneurysmal malformations (VGAM) are rare but clinically significant intracranial arteriovenous shunt lesions that most often present in neonates and infants.

Methods

Retrospective clinical data were collected for patients evaluated with a diagnosis of VGAM from 1994 to 2007.

Results

Thirteen patients with VGAM were evaluated from 1994 to 2007. Seven patients presented emergently with medically intractable cardiac failure, and six were treated in the first 2 weeks of life. Five children treated after this period (1.5–31 months of age) manifested enlarging head circumference, abnormal development, or subarachnoid hemorrhage. Eleven patients were managed endovascularly. Four disease or procedure-related complications occurred. Two complications were associated with poor outcome, both of which occurred in patients treated at less than 2 weeks of age. Two other patients experienced transient neurological deficits with no evidence of permanent sequelae. Outcome in the six patients treated emergently in the first 2 weeks of life included two patients who developed normally, one with mild to moderate neurological deficits, one with severe neurological deficits, and two deaths. Outcome in the five older patients (treated between 1.5 and 31 months) was considerably better than in the group treated early and included three with normal outcome and two with mild neurological deficits.

Conclusions

Contemporary endovascular techniques remain the preferred treatment for VGAM in all age groups. Early diagnosis and multimodality treatment are essential for the best management and treatment of the complex constellation of clinical problems often arising from this disorder.     

Traumatic extradural hematoma in childhood

Objective

This study was undertaken to assess the clinical and radiological characteristics of children with traumatic extradural hematoma (TEDH), and factors affecting the initial neurological status and outcome.

Methods

Medical records of 269 consecutive children with TEDH from 2005 to 2012 were retrospectively reviewed, factors affecting the initial neurological status and outcomes were explored using univariate and multivariate analysis.

Results

There were 166 boys and 103 girls (average age: 7.0 years). Fall from a height (59 %) was the most common mechanism of head injury. With increasing age, an increase of motor-vehicle accident and assault was noted. Among the children 85.5 % experienced a Glasgow Coma Scale (GCS) of 13–15, 9.7 % with GCS 9–12, and 4.8 % with GCS 3–8. The main clinical manifestations were headache, vomiting and nausea, and conscious disturbance. The main locations were the temporal, temporoparietal, and frontal regions. The 97.4 % saw a favorable outcome, whereas 2.6 % had a poor outcome (overall mortality: 1.1 %).

Conclusion

Many factors influenced the prognosis; the most important factors affecting prognosis were the initial neurological condition and secondary brain edema, while the initial neurological status were associated with pupillary abnormality, clinical progression, the number and volume of TEDH, and midline shift. Although the outcome was excellent in most cases, early diagnosis and surgical evacuation before irreversible brain damage was important to lower mortality for those massive TEDHs.     

Multilevel thoracic hemangioma with spinal cord compression in a pediatric patient: case report and review of the literature

Purpose

Vertebral hemangiomas are common benign vascular tumors of the spine. It is very rare for these lesions to symptomatically compress neural elements. If spinal cord compression does occur, it usually involves only a single level. Multilevel vertebral hemangiomas causing symptomatic spinal cord compression have never been reported in the pediatric population to the best of our knowledge.

Methods

We report the case of a 15-year-old boy presenting with progressive paraparesis due to thoracic spinal cord compression from a multilevel thoracic hemangioma (T5–T10) with epidural extension.

Results

Because of his progressive neurological deficit, he was initially treated with urgent multilevel decompressive laminectomies from T4 to T11. This was to be followed by radiotherapy for residual tumor, but the patient was unfortunately lost to follow-up. He re-presented 3 years later with recurrent paraparesis and progressive disease. This was treated with urgent radiotherapy with good response. As of 6 months follow-up, he has made an excellent neurological recovery.

Conclusions

In this report, we present the first case of a child with multilevel vertebral hemangiomas causing symptomatic spinal cord compression and review the literature to detail the pathophysiology, management, and treatment of other cases of spinal cord compression by vertebral hemangiomas.     

A case report of a pediatric traumatic aneurysm with arteriovenous (A-V) fistula CASE-BASED UPDATE

Background

Traumatic intracranial aneurysms (TICAs) are rare, representing less than 5 % of all intracranial aneurysms. Most TICAs are located within the anterior circulation, and less than 10 % of TICAs occur in the posterior circulation. Histopathologically, most TICAs are false aneurysms and have a high risk of rupture or re-bleeding. When they are discovered, careful observation or treatment may be required. Once they are enlarged, they have a high risk of rupture, and immediate treatment is essential.

Case report

For the first time in the literature, we report a rare case of an 8-year-old boy with a TICA in anterior inferior cerebellar artery (AICA) and arteriovenous (A-V) fistula after severe head trauma. Trapping of AICA and resection of the aneurysm was performed. Postoperatively, he has peripheral facial palsy but is otherwise neurologically normal.

Conclusion

Surgical treatment for traumatic aneurysms is challenging because most of TICAs are histopathologically pseudoaneurysms. It may be technically difficult to perform direct surgery of aneurysms especially located in the posterior circulation, but when the treatment is successful, the outcome was favorable.     

Intramedullary spinal cord abscess as complication of lumbar puncture: a case-based update

Introduction

Although lumbar puncture (LP) is a relatively straightforward procedure and is usually associated with low morbidity, rare and significant neurological complications can occur. Intramedullary spinal cord abscess (ISCA) after lumbar puncture is one of these serious complications; however, this complication has not yet been reported in children.

Case report

After 27 days in another medical facility, a 1-year-old girl was admitted to our hospital with a diagnosis of fever of unknown origin. Prior to the second admission, she had undergone multiple traumatic LP attempts. The patient was referred to our institution with progressive and ascending weakness. Three days later, this weakness involved all of the patient’s four limbs. A LP was performed and showed purulent cerebrospinal fluid (CSF). An emergent spinal magnetic resonance imaging was performed and revealed an intramedullary lesion extending from the T2 to L3 level. Broad-spectrum antibiotics and steroids were administered to the patient, and a T2–L3 laminectomy was performed. The postoperative course was uneventful, but a neurologic deficit, including lower limb paralysis, remained.

Conclusion

The index of suspicion for a pyogenic infection of the intramedullary space should be higher if progressive flaccid paralysis develops within a few days after a lumbar procedure. Nevertheless, the diagnosis may be challenging due to the rarity of this condition. Any misdiagnosis or delay of adequate treatment may lead to unfavorable outcomes.     

One size fits all: or horses for courses? Recovery-based care in specialist mental health services

Introduction

The ??recovery approach?? to the management of severe mental health problems has become a guiding vision of service provision amongst many practitioners, researchers, and policy makers as well as service users.

Method

This qualitative pilot study explored the meaning of ??recovery?? with users of three specialist mental health services (eating disorders, dual diagnosis, and forensic) in 18 semi-structured interviews.

Results

The relevance of themes identified in mainstream recovery literature was confirmed; however, the interpretation and relative weight of these themes appeared to be affected by factors that were specific to the diagnosis and treatment context. ??Clinical?? recovery themes were also seen as important, as were aspects of care that reflect core human values, such as kindness.     

The association of neural axis and craniovertebral junction anomalies with scoliosis in Rubinstein–Taybi syndrome

Object

Rubinstein–Taybi syndrome (RSTS) is a rare condition with characteristic genetic and clinical features. The presence of variable vertebral and neural axis abnormalities has been reported in the literature. We describe the possible association of multiple different spinal anomalies in these patients.

Results

The radiological exams of two RSTS patients (a female and male of 11 and 13 years) have been reviewed. Both patients presented the simultaneous association of craniovertebral junction bony abnormalities (occipito-C1 condyle subluxation and posterior C2–C3 arches fusion), Chiari I malformation, spinal cord syrinx, low-lying conus medullaris, and scoliosis.

Conclusion

An association of different spinal cord anomalies is possible in RSTS patients and has to be investigated with a comprehensive neuroimaging study in order to address the proper treatment and prevent the development of neurologic deficits.     

“Rabbit Ear” scalp deformity caused by massive subdural effusion in infant following bilateral bur-hole drainage failure: successfully managed with subduro-peritoneal shunt

Introduction

Subdural effusion in an infant is a rare clinical scenario which may be secondary to a variety of etiologies. Massive subdural effusion is an extremely rare complication of head injury.

Case report

Authors report a rare case of progressive massive subdural effusion which, despite bilateral bur-hole placement and drainage, failed and presented with visual deterioration and massive bulge of the scalp at bur-hole sites, producing a rabbit ear appearance in a 10-month-old infant. Ultimately, cystoperitoneal shunt was carried out in a desperate attempt to prevent impending rupture of scalp sutures at sites of previous bur-hole placement. This was followed by not only complete resolution of hygroma but also visual recovery. The patient is doing well at 6 months following shunt, regaining normal vision and appropriate developmental milestones. A MRI scan of the brain was carried out at last follow-up, which revealed mild ventriculomegaly with the rest of the brain being unremarkable, and subduro-peritoneal shunt in situ. Such a case has not been reported in the literature till date.

Discussion

Subdural effusion usually runs a self-limiting course. Though neurosurgical intervention is occasionally needed, different methods of surgical procedure for management include bur hole alone, bur holes with subdural drain placement, twist drill craniotomy with drain, and even craniotomy. Various methods of management are discussed along with a review of pertinent literature.     

Intervertebral disc calcification with neurological symptoms in children: report of conservative treatment in two cases

Purpose

Intervertebral calcifications are rare in the paediatric population. Two cases of children with symptomatic intervertebral calcifications responsible for spinal cord compression and neurological compromise are presented.

Methods

The data of two children treated conservatively for a symptomatic intervertebral calcification responsible for spinal cord compression and neurological compromise were retrospectively reviewed.

Results

Frontal and lateral radiographs are usually sufficient to determine the presence and extent of the calcified cervical disc protrusion. Conservative treatment with antalgics and bracing was applied in both cases. The two patients were completely free of symptoms 4 weeks after initial treatment. Magnetic resonance imaging screening showed a complete vertebral canal clearance at final follow-up.

Conclusion

Despite the lack of significance due to the small number of patients, conservative treatment should be considered in children with moderate neurological symptoms due to calcified disc protrusion.     

Spontaneous Subdural Fluid Collection Following Aneurysmal Subarachnoid Hemorrhage: Subdural Hygroma or External Hydrocephalus?

Background

Subdural fluid collections (hygromas and effusions) in adults are usually seen following head trauma or overdrainage of cerebrospinal fluid (CSF) after CSF diversion procedures. We report an unusual case of subdural fluid collection that developed spontaneously 5 days after an aneurysmal subarachnoid hemorrhage (SAH). This patient neither had permanent CSF diversion procedure nor history of significant head trauma during her clinical course.

Methods

This study is a Case report of the patient suffering from an SAH.

Results

A 71-year-old woman suffered an SAH from a ruptured right-sided posterior communicating artery aneurysm. Computed tomography (CT) demonstrated diffuse SAH and signs of early hydrocephalus that did not require treatment. The aneurysm was treated with endovascular coil occlusion without any complications. Throughout her hospital course, she remained alert without neurological deficits. A large subdural fluid collection was discovered incidentally during a routine CT scan of the brain 5 days after the SAH. The patient remained asymptomatic; therefore, the collection was treated conservatively. It resolved spontaneously at five days after the initial diagnosis.

Conclusion

Subdural fluid collections following SAH can occur as a result of head trauma, external hydrocephalus, or as a treatment complication of CSF shunting and craniotomies. It is critical to differentiate simple hygromas from external hydrocephalus since their response to CSF diversion is entirely different.     

Isolated intracranial Rosai–Dorfman disease in a child,a case report and review of the literature

Background

Rosai–Dorfman disease (RDD), otherwise known as sinus histiocytosis with massive lymphadenopathy (SHML), usually affects young adults and commonly presents with massive painless cervical lymphadenopathy. Extranodal disease is present in a third of patients, and it is recognised that this can involve the central nervous system. Intracranial RDD is rare in adults and fewer than 10 paediatric cases have been reported.

Case

A 10-year-old boy with isolated intracranial RDD presents with a painless forehead mass. The management is discussed and the literature reviewed.

Conclusion

This case of isolated intracranial RDD highlights the importance of considering RDD in the differential of paediatric intracranial mass lesions and outlines the diagnostic and treatment challenges faced when managing this rare condition.