Novel Predictive Markers on Computed Tomography for Predicting Early Epidural Hematoma Growth in Pediatric Patients.

Objective Epidural hematoma (EDH), most often caused by rupture of the middle meningeal artery secondary to head trauma with fracture of the temporal bone, is a potentially fatal condition that can lead to elevated intracranial pressure, herniation, and death within hours following the inciting traumatic incident, unless surgical evacuation is accomplished. Several markers have been found to be associated with hematoma expansion in intracerebral hemorrhage (ICH) patients, including: the CT Blend Sign, Swirl Sign, and Black Hole Sign. This study aims to examine these markers, along with intradural air close to or in the region of an EDH and/or close to a significant fracture, fractures involving the skull base, and complicated (i.e., comminuted or displaced) fractures for possible associations to EDH growth in the pediatric population. Predicting hematoma growth is a crucial part of patient management, as surgery can be a life-saving intervention. Methods Scans from all pediatric patients with EDH from 2012 to 2019 across two separate health systems were examined and measurements were taken to determine whether these additional factors are of predictive value. Specifications such as length, transverse, and height measurements were taken from CT images. Statistical Analysis The average percent change in the hematoma measurements was used to determine which predictive factors were associated with a "noteworthy increase," namely, an increase of greater than 25%. Additionally, the average percent change in hematoma size was evaluated for patients whose original imaging showed either all three CT signs or intradural air in all three specified locations. Results Most of the proposed markers were associated with EDH growth in this cohort. The established CT signs were also supported. This is notable, as most of the research on these signs has been in adult populations rather than pediatric. Conclusions Adding these novel imaging signs could aid in the decision to operate on versus observe PEDH patients, thereby preventing unnecessary procedures or preserving brain function quickly when surgery is indicated. This study serves as a starting point for several other investigations into the validity of the proposed markers as well as a reevaluation of the current signs in the pediatric population.

Symptomatic pancreatic body endometrial cyst requiring en bloc distal pancreatectomy.

Pancreatic endometriosis is an extremely rare condition, with only a few cases described in the literature. Definitive diagnosis is often difficult to elucidate and will almost always require biopsy or surgical resection. We present a case of a female in her early thirties with a well-known history of widespread endometriosis presenting with vague epigastric pain. CT imaging showed an 11 cm well-circumscribed simple-appearing cyst in the lessor sac. Its origin could not be determined preoperatively but it appeared to involve the parenchyma of the body of the pancreas. Due to the associated pain and indeterminate nature, subtotal surgical resection of the extrapancreatic cyst was performed with the intrapancreatic cyst being managed by a cystogastrostomy to the adjacent stomach in a planned pancreas-sparing procedure following intraoperative confirmation it was arising within the pancreas. Pathological evaluation of the resected cyst confirmed it to be an endometrial cyst. The cystogastrostomy anastomosis subsequently obstructed a few weeks postoperatively and symptoms recurred from cyst enlargement. Redo robotic resection with resection of the remnant cyst, cystogastrostomy and en bloc spleen-preserving distal pancreatectomy was performed. The patient had an uneventful recovery. She has had no recurrence of cyst or symptoms since. A procedure video is included in the report.

Atypical cutaneous and musculoskeletal manifestation of SARS-CoV-2: 'COVID-19 toes' and spasticity in a 48-year-old woman.

Establishing accurate symptomatology associated with novel diseases such as COVID-19 is a crucial component of early identification and screening. This case report identifies an adult patient with a history of clotting dysfunction presenting with rare cutaneous manifestations of COVID-19, known as 'COVID-19 toes'', previously described predominantly in children. Additionally, this patient presented with possible COVID-associated muscle spasticity of the lower limbs, as well as a prolonged and atypical timeline of COVID-19 infection. The rare occurrence of 'COVID-19 toes'' in this adult patient suggests that her medical history could have predisposed her to this symptom. This supports the coagulopathic hypothesis of this manifestation of COVID-19 and provides possible screening questions for patients with a similar history who might be exposed to the virus. Additionally, nervous system complaints associated with this disease are rare and understudied, so this novel symptom may also provide insight into this aspect of SARS-CoV-2.

Association between Foramen Size and Febrile Seizure Status in the Pediatric Population: A Two-Center Retrospective Analysis.

Objective Febrile seizures have been shown to occur in 2 to 5% of children between the ages of 6 months and 5 years, making them the most common seizures of childhood. Multiple risk factors for febrile seizures have been identified; however, no investigation has been conducted to explore foramen size and associated venous drainage as a potential risk factor for experiencing febrile seizures. Of particular interest are the parietal foramen and the condylar canal, which conduct the parietal emissary vein and the occipital emissary vein, respectively. Emissary veins lack valves, allowing them to play a crucial role in selective brain cooling via a bidirectional flow of blood from the head's evaporating surface. Narrowed cranial apertures conducting these veins may lead to reduced cerebral venous outflow and delayed brain cooling, creating favorable conditions for a febrile event. This study seeks to explore the association between cranial aperture area and febrile seizure status. Methods A retrospective cross-sectional medical record review study from January 2011 to December 2017 was conducted at a 500-bed academic hospital and a 977-bed private hospital in Lubbock, Texas, United States. A total of 101 complex febrile seizure patients were compared with a similarly aged group of 75 trauma patients representing the normal population. Parietal foramen area and condylar canal area were electronically measured and defined as having "normal" or "below normal" area. Statistical Analysis Independent t -tests were used to compare foramen and canal areas by febrile seizure status. Logistic regression analyses were conducted to determine the association of small cranial aperture area with febrile seizure status. Results Below normal parietal foramen area had a strong association with febrile seizures in our patient population. Male sex, white race, and complete vaccination status were also found to have significant associations with febrile seizure status. Conclusion Our findings indicated that narrowed parietal foramen may be considered as a risk factor for febrile seizure development.

Bilateral Cephalohematoma With Sagittal Synostosis and Scaphocephaly.

Inappropriate fusion of the cranial sutures leads to craniosynostosis and the subsequent skull rigidity can cause many developmental and structural problems. Cephalohematoma is a subperiosteal collection of blood commonly associated with birth trauma or instrument-assisted delivery and is one of the most frequently reported fetal injuries in Caesarian section procedures. There have been very few cases reported of patients with both scaphocephaly due to sagittal craniosynostosis and cephalohematoma and no reports of scaphocephaly with bilateral cephalohematoma as of the date of this report. The current literature suggests that the two conditions are potentially associated, either through mechanical pathways involving trauma or through a complex interplay of growth factors. The authors present a case of bilateral cephalohematoma with scaphocephaly secondary to progressive sagittal craniosynostosis.