Decompressive craniectomy for severe traumatic brain injury in children: analysis of long-term neuropsychological impairment and review of the literature.

OBJECTIVE: The effectiveness of decompressive craniectomy (DC) in the context of neurocritical care in adult patients has been recently under debate. The aim of our study was to evaluate the impact of decompressive craniectomy in severe traumatic brain injury (TBI) in children, focusing on short and long-term neurological and neuropsychological outcomes. METHODS: Retrospective review of the medical records of children admitted at a level I trauma center, between January 2012 and December 2015, submitted to DC due to severe TBI. Additionally, an extensive review of literature on this subject was carried out. RESULTS: Sixteen patients underwent DC for TBI at our institution during the evaluated period. 62.5% were males and the mean age was 12 years. Road traffic accident (RTA) was the main mechanism of trauma (62.5%). Average Glasgow Coma Scale (GCS) at admission was 5.2, whereas 75% of the patients presented with pathological pupillary reaction. Initial computed tomography (CT) showed skull fractures in 62.5% and acute subdural hemorrhage (ASH) in 56.3% of the patients. The mean intracranial pressure (ICP) was 27.2 mmHg prior to surgery, and the mean time window between admission and DC was 36.3 h. Unilateral DC was performed in 68.8% of the cases. The average Glasgow Outcome Scale (GOS) at 6-month follow-up was 3.7, whereas 70% of the survivors presented good recovery (GOS 4-5). Abnormal pupillary reaction at hospital admission increased 3-fold the risk of long-term neuropsychological disturbances. Follow-up evaluation revealed cognitive abnormality in 55.6% of the patients. The overall mortality at 6-month follow-up was 37.5%. CONCLUSION: The present study indicates towards a potential benefit of DC in children with severe TBI; nevertheless, our data demonstrated a high incidence of neuropsychological impairment in the long-term follow-up. Psychological and cognitive assessment should be computed in prognosis evaluation in future prospective studies.

The role of coagulopathy on clinical outcome following traumatic brain injury in children: analysis of 66 consecutive cases in a single center institution.

INTRODUCTION: Head injury is a significant economic, social, and medical problem in developing countries and remains one of the leading causes of pediatric morbidity and mortality. The association of traumatic brain injury and coagulopathy in children is linked with an increase in mortality and poor functional outcomes. However, its impact on long-term outcome has not been discussed in the literature so far. OBJECTIVES: The aim of this paper was to investigate the effect of coagulopathy diagnosed by routine laboratory tests on neurological outcome following traumatic brain injury in children. METHODS: A retrospective review was carried out using medical records of children with a traumatic brain injury admitted at a level I trauma center, between January 2013 and December 2016, submitted to any neurosurgical procedures. Statistical analysis was performed accordingly to identify factors predicting unfavorable or favorable outcomes at 1- and 6-month follow-ups. Data regarding age, gender, trauma mechanism, Glasgow Coma Scale at admission and at discharge, highest and lowest stable intracranial pressure, serum glucose and coagulation assessment, radiological findings, and length of stay were analyzed. RESULTS: We identified 66 children with surgical head trauma. Mean age was 10.9 years (ranges from 3 months to 17 years), with male predominance (77.3%). Common mechanisms were road traffic accidents (66.7%), falls (19.7%), and blunt trauma (10.6%). Brain edema was detected in 68.2% of the patients, surgical fractures or intracranial bleeding in 75.8%. ICP monitoring was performed in 24.2% of the patients, and of these, 18.7% underwent consecutive decompressive craniectomy. Mean length of in-patient treatment was 16.3 ± 28.2 days. At 1- and 6-month follow-ups, favorable outcome was detected in 71.2 and 78.7% of the patients, respectively. The mortality rate was 12.1%. Routine coagulation assessments such as prothrombin time, fibrinogen levels, and thrombocyte count upon admission were potential prognostic variables identified. CONCLUSIONS: The present study concluded that a trauma-related coagulopathy is an important predictor of unfavorable neurological outcome following TBI in pediatric patients. Initial GCS score, age, and neuroradiological findings, such as severe brain edema and different types of intracranial bleeding, correlated with GOS in the first 6 months following TBI. Sustained intracranial hypertension also predicted unfavorable outcome and death in this series.

Subthalamic nucleus lesion improves cell survival and functional recovery following dopaminergic cell transplantation in parkinsonian rats.

Subthalamic nucleus (STN) modulation is currently the gold standard in the treatment of Parkinson's disease (PD) cases refractory to medication. Cell transplantation is a tissue-restorative approach and is a promising strategy in the treatment of PD. One of the obstacles to overcome in cell therapy is the poor dopaminergic cell survival. Our experiment investigates the impact of a partial subthalamotomy prior to ventral mesencephalic (VM) embryonic cell transplantation on dopaminergic cell survival and functional outcome. Unilateral dopamine depletion was carried out in rats, via medial forebrain bundle (MFB) injection of 6-hydroxydopamine, and half of the animals went on to receive unilateral excitotoxic lesions of the STN/Zone Incerta (ZI) causing partial lesion of these structures on the same side as the MFB lesion. All MFB-lesioned animals, with or without the STN/ZI lesion, received striatal ipsilateral embryonic VM cell grafts. The data suggest that the STN/ZI lesion could boost the dopamine cell survival in the grafts by 2.6-fold compared with the control grafted-only group. Moreover, performance on the drug-induced rotation and the spontaneous behavior tests were ameliorated on the STN/ZI-lesioned group to a significantly greater extent than the grafted-only group. These data suggest that the STN/ZI partial lesion optimized the striatal environment, promoting an improvement in cell survival. Further studies are needed to see whether the synergy between STN modulation via deep brain stimulation and cell therapy might have clinical applications in the management of PD.

Epidermoid cyst mimicking an intrinsic brainstem tumor.

OBJECTIVE: To describe an atypical clinical and radiological presentation of a brainstem epidermoid cyst in a child and to provide a review of the medical literature on brainstem epidermoid cysts in children. MATERIAL AND METHOD: Review of medical records and operative notes of an unusual case of a patient with a brainstem epidermoid cyst. MEDLINE literature search using the terms brainstem, epidermoid cyst and children. RESULTS: Gross total resection of the cyst was achieved. The patient had an uneventful recovery. CONCLUSION: Epidermoid cysts are rare tumors of the brain and children. The management of these tumors can be quite challenging. A good clinical and neuroradiological evaluation pre-operatively is fundamental for a successful surgical treatment. Surgical resection should be as radical as possible without putting the patient's neurological status into risk.

The success of endoscopic third ventriculostomy in children: analysis of prognostic factors.

OBJECTIVE: The treatment of hydrocephalus in children with endoscopic third ventriculostomy (ETV) has particular features and is associated with different success rates (SR). The aim of this study was to identify putative factors that could influence the outcome of ETV in children. METHODS: Clinical data of 114 consecutive patients under 18 years of age who underwent 116 consecutive ETVs from January 2000 to January 2010 were reviewed. Data were analyzed with regards to clinical and radiological SR. The actual long-term SR was compared to that predicted by the ETV Success Score (ETVSS) model. RESULTS: The study group included 49 males (43%) and 65 females (57%) with a mean age of 6.17 ± 1.02 years (ranging from 11 days to 18 years) at surgery. Concerning the etiology of hydrocephalus, tumors and aqueductal stenosis (AS) were the most frequently observed, with each occurring in 33 cases (29%), followed by malformations in 24 (21%), cystic lesions in 6 (5%) and other etiologies in 18 patients (16%). The overall SR at the first ETV attempt was 80% (91/114), compared to 74.8% (variance 14.35, 95% CI 69.37-78.22) predicted by the ETVSS. Regarding age, SR was 58% in patients under 6 months of age, 65% in children between 6 months and 1 year, and 86% in children older than 1 year. SR for AS and hydrocephalus associated with posterior fossa tumors were 88 and 90%, respectively. Unsatisfactory results were related to previous intraventricular hemorrhage and infection. The overall complication rate in this series was 13%. CONCLUSION: ETV is safe and effective in children. In this series, the age of the patient and etiology of hydrocephalus were related to SR. Also, the ETVSS was accurate to predict outcome. In a long-term follow-up, surgical experience was statistically significant in reducing complications.

Multiple cranial burr holes as an alternative treatment for total scalp avulsion.

BACKGROUND: Total scalp avulsion is a devastating injury in clinical practice. It often occurs in female adults, being rare in children. The standard treatment for scalp avulsion is microsurgical replantation, when feasible. Coverage becomes a major problem when replantation fails or is contraindicated, resulting in significant morbidity and requiring multiple procedures. In this article, in addition to reviewing the literature, we report a historical method for obtaining skin coverage after failure of replantation. METHODS: The authors report a case of a 10-year-old girl who had her scalp totally avulsed by an agricultural machine, including her right auricle. Microsurgery scalp replantation was attempted immediately after fluid resuscitation. The surgery failed probably due to the long time interval between trauma and surgery, which resulted in total ischemic time of 11 h and consequently made vascular microanastomosis impracticable. Multiple trephination of the calvarium was performed in order to expose the diploe. After 4 weeks, granulation tissue from the holes began to cover the defect, allowing the formation of a vascular bed suitable for skin grafting. CONCLUSIONS: Total scalp avulsion in children is seldom reported in the literature. Therefore, its management is both difficult and challenging. The exposure of the diploe with multiple burr holes is a safe and effective method for treating this injury. It may be considered, along with skin grafting, a good therapeutic alternative to be used when microsurgical replantation fails or is not feasible.

Management of Chiari I Deformity in Children and Adolescents: A Report from the Consensus Taskforce of the Brazilian Society of Pediatric Neurosurgery

Much controversy remains on the current management of Chiari I deformity (CID) in children, with many clinical, surgical and ethic-legal implications. The Brazilian Society of Pediatric Neurosurgery (SBNPed, in the Portuguese acronym) has put together a panel of experts to analyze updated published data on the medical literature about this matter and come up with several recommendations for pediatric neurosurgeons and allied health professionals when dealing with CID. Their conclusions are reported herein, along with the respective scientific background.

Neuroendoscopic surgery in children: an analysis of 200 consecutive procedures.

OBJECTIVE: Neuroendoscopic surgery in children has particular features and is associated with different success rates (SR). The aim of this study was to identify putative factors that could influence the outcome in pediatric patients. METHODS: Clinical data of 177 patients under 18 years of age submitted to 200 consecutive neuroendoscopic procedures from January 2000 to January 2010 were reviewed. RESULTS: The overall success rate was 77%. Out of the patients with successful outcomes, 46% were under six months, 68% were between six months and one year of age, and 85% older than one year. Neuroendoscopic techniques provide very good results for a wide number of indications in children. Tumor-related cerebrospinal fluid (CSF) circulation problems and aqueductal stenosis seem to be particularly well suited to neuroendoscopic treatment regardless of the patient's age. CONCLUSION: Patients' age and etiology of hydrocephalus were associated with a different outcome. In all cases, surgical experience is extremely important to reduce complications.

Neuroendoscopic surgery in children: an analysis of 200 consecutive procedures / Neuroendoscopia em crianças: uma análise de 200 procedimentos consecutivos

Neuroendoscopic surgery in children has particular features and is associated with different success rates (SR). The aim of this study was to identify putative factors that could influence the outcome in pediatric patients.

Clinical data of 177 patients under 18 years of age submitted to 200 consecutive neuroendoscopic procedures from January 2000 to January 2010 were reviewed. The overall success rate was 77%. Out of the patients with successful outcomes, 46% were under six months, 68% were between six months and one year of age, and 85% older than one year. Neuroendoscopic techniques provide very good results for a wide number of indications in children. Tumor-related cerebrospinal fluid (CSF) circulation problems and aqueductal stenosis seem to be particularly well suited to neuroendoscopic treatment regardless of the patient's age. Patients' age and etiology of hydrocephalus were associated with a different outcome. In all cases, surgical experience is extremely important to reduce complications. .

A cirurgia neuroendoscópica em crianças apresenta particularidades e está associada a diferentes taxas de sucesso (TS). O objetivo deste estudo consistiu em identificar fatores que pudessem influir no resultado do tratamento em pacientes pediátricos. Dados clínicos de 177 pacientes com idade inferior a 18 anos submetidos a 200 procedimentos neuroendoscópicos consecutivos entre janeiro de 2000 e janeiro de 2010 foram revisados. A taxa de sucesso global foi de 77%. Os pacientes com idade inferior a seis meses apresentaram taxa de sucesso de 46%; pacientes entre seis meses e um ano de vida obtiveram êxito em 68% dos casos; dentre os maiores de um ano, 85% dos procedimentos foram bem-sucedidos. Técnicas neuroendoscópicas proporcionam muito bons resultados para uma grande variedade de indicações em crianças. Independentemente da faixa etária, o tratamento endoscópico apresenta-se particularmente adequado para problemas da circulação liquórica relacionados a tumores e à estenose aquedutal. A faixa etária dos pacientes e a etiologia da hidrocefalia estão associadas a diferentes resultados. Em todos os casos, experiência neurocirúrgica é extremamente importante para a redução das complicações. .

Penetrating cardiac injuries: a 13-year retrospective evaluation from a Brazilian trauma center.

To present our experience with penetrating cardiac injuries. We have retrospectively reviewed the records of 70 victims of penetrating cardiac injuries. A logistic regression has been performed in order to determine the association between death and clinical predictors. Penetrating injuries consisted of 43 stab wounds (61.4%) and 27 (38.6%) gunshot injuries (P=0.72). There were 63 (90%) male and 7 female (10%, P<0.001) victims. The mean age was 27.36+/-11.51, ranging from 3 to 65 years. The overall mortality was 32.9%, 47.8% for gunshot wounds and 52.2% for stab wounds (P=0.266). Eight victims (11.4%) had associated intra-thoracic great vessel injuries and 17 (24.3%) presented associated intra-abdominal organ injuries. The incidence of injured chamber was: right ventricle 37.1%, right atrium 27.1%, left ventricle 25.7%, and left atrium 5.7%. Non-survivors had lower systolic blood pressure (37.50+/-39.18 mmHg) than survivors (79.04+/-41.04 mmHg; P<0.001) upon arrival at the hospital. Thirteen non-survival (56.5%) and 10 (21.3%) survival victims had systolic blood pressure (SBP)