Carbon fibre instrumentation for scoliosis surgery in children with spinal cord intramedullary tumours: a novel technical note.

INTRODUCTION: Scoliosis in children is the most common spinal deformity seen by general practitioners, paediatricians and spinal surgeons. Progressive scoliosis can result in the development of a worsening deformity and cosmesis. Patients usually present with aesthetic concerns. Progressive scoliosis that fails conservative management may require or be offered surgical intervention. Intramedullary tumours may be associated with scoliosis. Management of patients with these dual pathologies can be challenging. Classical scoliosis instrumentation utilising titanium implants impairs post-operative MRI evaluation with metal artefacts. Carbon fibre instrumentations has the potential to reduce the imaging metal artefacts but has not been described in scoliosis correction. METHODS: Surgical technical note describing correction of scoliosis in two adolescents' with intradural tumours utilising carbon fibre implants. RESULTS: We developed a hybrid approach where we initially used titanium implants to manipulate the deformity then replaced the construct with carbon fibre implants in the same setting to maintain the deformity correction with good follow up outlook. CONCLUSION: Our technique is robust, safe and replicable. It enabled appropriate post-operative MRI evaluation of the neural structures with a reduced risk of metal artefacts.

Clinical Application of Shear Wave Elastography for Assisting Brain Tumor Resection.

BACKGROUND: The clinical outcomes for brain tumor resection have been shown to be significantly improved with increased extent of resection. To achieve this, neurosurgeons employ different intra-operative tools to improve the extent of resection of brain tumors, including ultrasound, CT, and MRI. Young's modulus (YM) of brain tumors have been shown to be different from normal brain but the accuracy of SWE in assisting brain tumor resection has not been reported. AIMS: To determine the accuracy of SWE in detecting brain tumor residual using post-operative MRI scan as "gold standard". METHODS: Thirty-four patients (aged 1-62 years, M:F = 15:20) with brain tumors were recruited into the study. The intraoperative SWE scans were performed using Aixplorer® (SuperSonic Imagine, France) using a sector transducer (SE12-3) and a linear transducer (SL15-4) with a bandwidth of 3 to 12 MHz and 4 to 15 MHz, respectively, using the SWE mode. The scans were performed prior, during and after brain tumor resection. The presence of residual tumor was determined by the surgeon, ultrasound (US) B-mode and SWE. This was compared with the presence of residual tumor on post-operative MRI scan. RESULTS: The YM of the brain tumors correlated significantly with surgeons' findings (ρ = 0.845, p < 0.001). The sensitivities of residual tumor detection by the surgeon, US B-mode and SWE were 36%, 73%, and 94%, respectively, while their specificities were 100%, 63%, and 77%, respectively. There was no significant difference between detection of residual tumor by SWE, US B-mode, and MRI. SWE and MRI were significantly better than the surgeon's detection of residual tumor (p = 0.001 and p < 0.001, respectively). CONCLUSIONS: SWE had a higher sensitivity in detecting residual tumor than the surgeons (94% vs. 36%). However, the surgeons had a higher specificity than SWE (100% vs. 77%). Therefore, using SWE in combination with surgeon's opinion may optimize the detection of residual tumor, and hence improve the extent of brain tumor resection.

Ruptured intra-cranial arachnoid cysts: a case series from a single UK institution.

INTRODUCTION: Intracranial arachnoid cysts are a common incidental finding; however presentation with cyst rupture is a recognised complication. Patients are advised to avoid contact sports to reduce the risk of cyst rupture but the risk of rupture is not currently known. The aim of this study is to describe a single institution's experience of managing ruptured intra-cranial arachnoid cysts. METHOD: A retrospective case note review of all patients admitted to a single institution with a ruptured intra-cranial arachnoid cyst between 2005 and 2016 (inclusive). Medical records were reviewed for demographics, history of trauma, surgical treatment and radiological evidence of cyst rupture. RESULTS: Fourteen patients were identified for inclusion with an average age of 23.4 years (range 7-57) and 10 (71%) were male. Nine patients (64%) had a documented history of head trauma. Eleven patients (78.6%) required neurosurgical intervention which included hygroma/haematoma evacuation only (n = 5), haematoma evacuation with cyst fenestration (n = 4) and cyst fenestration/shunting only (n = 2). Twelve patients (85%) experienced full recovery and the remaining two had persisting headaches or neurological symptoms. DISCUSSION: Cyst rupture remains an uncommon cause for presentation with arachnoid cysts. However the majority are associated with head trauma and thus current advice to avoid contact sports seems justified.

Prenatal diagnosis of arachnoid cysts: a case series and systematic review.

INTRODUCTION: Primary cysts are believed to arise from the splitting of the arachnoid membrane during prenatal development and can be diagnosed in utero. Prenatal diagnosis is uncommon; therefore, the evidence base for counselling expectant mothers is limited. The purpose of this article is to present a case series and review the current literature on prenatally diagnosed arachnoid cysts. METHOD: A keyword search of hospital electronic records was performed for all patients with a prenatally diagnosed arachnoid cyst at a tertiary neurosurgical centre. Case notes were reviewed for all patients diagnosed between 2005 and 2017. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to structure a systematic review of all English language articles published up to May 2018. RESULTS: A total of eight eligible patients were identified from our own records and 123 from the literature. Sixty-eight per cent of patients had a normal outcome. Sixty-three per cent of patients underwent surgical intervention which was not associated with abnormal outcome. The diagnosis of syndromic/genetic diagnosis (p < 0.001) and the presence of other intra-cranial anatomical abnormalities (p = 0.05) were significant predictors of abnormal outcome. CONCLUSION: The pathogenesis and prognosis of a prenatal arachnoid cyst diagnosis remain unclear. These results suggest favourable outcomes from simple cysts without associated abnormalities and expectant mothers should be counselled accordingly. A wider prospective review is required to better established evidence-based practice.

Paediatric brain abscesses: a single centre experience.

Introduction: Brain parenchymal abscesses are relatively infrequent but potentially serious infections in the paediatric population. Surgical intervention in addition to a prolonged administration of antibiotics is generally appropriate management. This study presents our centre's experience of managing such patients in the context of relevant literature. Method: A single-centre retrospective case note review was conducted over a 15 year period (2003-2017). Patients were selected from electronic hospital records using ICD10 code G06.0. Patients < 18 years of age with a confirmed intra-parenchymal abscess were included. Patient records were reviewed for abscess location, microbiology results, surgical intervention, and outcome using the Glasgow Outcome Score at 3 months. Results: Twenty-four patients were identified (mean age: 7.4 ± 5.3 years, male n = 11). Twelve (50.0%) patients had an abscess in the frontal lobe and Streptococcus was the most common causative microorganism (n = 15). Nineteen patients (79.2%) had an identifiable source which included: ENT infections, congenital cardiac malformations, recent dental surgery and meningitis. All 24 patients underwent surgery with 20 patients having a total of 32 aspirations between them and the other 4 having craniotomy and excision. Twenty patients had 3 month follow-up data of which 18 patients scored GOS: 5, one was GOS: 4 and one was GOS: 3. Conclusions: Brain parenchymal abscess remains an uncommon pathology in the paediatric population. The majority of patients have a preceding infection with Streptococcus as the most common causative organism. Antimicrobial therapy should be selected accordingly. All of our patients underwent surgical intervention and received intravenous antibiotics with favourable outcome and no mortality.

Natural History of Intracranial Arachnoid Cysts.

BACKGROUND: Intracranial arachnoid cysts are a common incidental finding. Most of these remain asymptomatic with surgical intervention being reserved for those cysts causing symptoms from mass effect or hydrocephalus. It is not properly understood why cysts enlarge nor is it possible to predict in which cysts this will occur. The aim of this study is to review the natural history of incidental arachnoid cysts. METHODS: A retrospective case review was conducted of all patients diagnosed with an arachnoid cyst between 2007 and 2016. Case notes and radiology reports were reviewed for demographics, symptoms, and changes in cyst sizes. RESULTS: Four hundred and eighty-five patients were diagnosed with an arachnoid cyst during this time period; of these, 425 (87.6%) were asymptomatic. Patients with symptomatic cysts were significantly younger and more likely to have associated hydrocephalus. The most common indications for imaging which resulted in the diagnosis of the cyst were headaches (n = 106), stroke (n = 51), and seizures (n = 41). The cyst size remained stable or reduced in 147 patients (99.3%) with follow-up imaging (n = 148), and the enlarging cyst remained asymptomatic. CONCLUSIONS: Asymptomatic arachnoid cysts have a low rate of cyst enlargement on follow-up imaging, which supports not routinely imaging these patients. However, serial imaging and surgery may still be indicated in asymptomatic patients at risk of obstructive hydrocephalus which, in this series, was only seen in the pediatric population. A better understanding of the natural history of intracranial arachnoid cysts allows for more efficient follow-up planning.

Clinical and radiological outcomes following surgical treatment for intra-cranial arachnoid cysts.

OBJECTIVES: Intra-cranial arachnoid cysts are benign lesions which are usually incidental, however can produce neurological symptoms due to mass effect as they enlarge. Controversy still exists regarding the optimal option for the surgical management of these cysts. These options are neuroendoscopic fenestrations, microsurgical fenestrations +/- marsupialisation and insertion of a cysto-peritoneal shunt. PATIENTS AND METHODS: A retrospective case note review of all patients with intra-cranial arachnoid cysts treated surgically at a single UK neurosurgical centre over a 15 year period. Data on clinical presentations and outcomes was collected from the patient notes and the pre- and post-operative cyst volumes were calculated by creating 3-dimensional volumetric models. RESULTS: Eighty-two patients were identified of which 45 were treated endoscopically, 34 microscopically and 3 underwent cysto-peritoneal shunting. The most common cyst location was the middle fossa (n = 25). Amongst the symptomatic patients, improvement or resolution of symptoms was seen in 35 out of 40 cysts treated endoscopically (88%), 28 out of 32 treated microsurgically (88%) and 3 out of 3 treated by shunting (100%, p = 0.79). The reoperation rate was not significantly different between the endoscopic and microsurgical groups (24.4% vs 14.7%, p = 0.49). The endoscopic and shunted groups had a shorter length of stay than the microsurgical group (3.0 vs 3.0 vs 4.5 days, p = 0.04). All three treatment modalities had a similar percentage reduction in cyst volume after surgery (30.0 vs 41.7 vs 30.9%, p = 0.98). CONCLUSIONS: This cohort series shows that endoscopic and microsurgical approaches to treat intracranial arachnoid cysts produce comparable clinical and radiological outcomes. Endoscopic fenestration is associated with a shorter length of stay as would be expected from a minimally invasive procedure.

Further characterization of changes in axial strain elastograms due to the presence of slippery tumor boundaries.

Elastography measures tissue strain, which can be interpreted under certain simplifying assumptions to be representative of the underlying stiffness distribution. This is useful in cancer diagnosis where tumors tend to have a different stiffness to healthy tissue and has also shown potential to provide indication of the degree of bonding at tumor-tissue boundaries, which is clinically useful because of its dependence on tumor pathology. We consider the changes in axial strain for the case of a symmetrical model undergoing uniaxial compression, studied by characterizing changes in tumor contrast transfer efficiency (CTE), inclusion to background strain contrast and strain contrast generated by slip motion, as a function of Young's modulus contrast and applied strain. We present results from a finite element simulation and an evaluation of these results using tissue-mimicking phantoms. The simulation results show that a discontinuity in displacement data at the tumor boundary, caused by the surrounding tissue slipping past the tumor, creates a halo of "pseudostrain" across the tumor boundary. Mobile tumors also appear stiffer on elastograms than adhered tumors, to the extent that tumors that have the same Young's modulus as the background may in fact be visible as low-strain regions, or those that are softer than the background may appear to be stiffer than the background. Tumor mobility also causes characteristic strain heterogeneity within the tumor, which exhibits low strain close to the slippery boundary and increasing strain toward the center of the tumor. These results were reproduced in phantom experiments. In addition, phantom experiments demonstrated that when fluid lubrication is present at the boundary, these effects become applied strain-dependent as well as modulus-dependent, in a systematic and characteristic manner. The knowledge generated by this study is expected to aid interpretation of clinical strain elastograms by helping to avoid misinterpretation as well as provide additional diagnostic criteria stated in the paper and stimulate further research into the application of elastography to tumor mobility assessment.

Long subcutaneous tunnelling reduces infection rates in paediatric external ventricular drains.

PURPOSE: The aim of this study is to report the efficacy of long subcutaneous tunnelling of external ventricular drains in reducing rates of infection and catheter displacement in a paediatric population. METHODS: In children requiring external ventricular drainage, a long-tunnelled drain was placed and managed according to a locally agreed guideline. End points were novel CSF infection incurred during the time of drainage and re-operation to re-site displaced catheters. Data were compared to other published series. RESULTS: One hundred eighty-one long-tunnelled external ventricular drains (LTEVDs) were inserted. The mean age was 6.6 years (range 0-15.5 years). Reasons for insertion included intraventricular haemorrhage (47 %), infection (27 %), tumour-related hydrocephalus (7.2 %), as a temporising measure (17 %) and trauma (2.2 %). The overall new infection rate for LTEVD was 2.76 %. If the 48 cases where LTEVDs were inserted to treat an existing infection are excluded, the infection rate was 3.8 % (5/133). The mean duration of insertion was 10 days (range 0-42 days). Four LTEVDs (2.2 %) were inadvertently dislodged, requiring reinsertion. Thirteen patients required removal of EVD alone. There was a significant difference (p < 0.05) when comparing our infection rate to 14 publications of infection rates in short-tunnelled EVDs; however, there was no difference when comparing our data to three publications using LTEVDs. CONCLUSION: The use of an antibiotic-impregnated LTEVD, managed according to a predefined guideline, is associated with significantly reduced infection and displacement rates when compared with contemporary series. It is suggested that this reduction is of both clinical and economic benefits.

A novel technique of detecting MRI-negative lesion in focal symptomatic epilepsy: intraoperative ShearWave elastography.

Focal symptomatic epilepsy is the most common form of epilepsy that can often be cured with surgery. A small proportion of patients with focal symptomatic epilepsy do not have identifiable lesions on magnetic resonance imaging (MRI). The most common pathology in this group is type II focal cortical dysplasia (FCD), which is a subtype of malformative brain lesion associated with medication-resistant epilepsy. We present a patient with MRI-negative focal symptomatic epilepsy who underwent invasive electrode recordings. At the time of surgery, a novel ultrasound-based technique called ShearWave Elastography (SWE) was performed. A 0.5 cc lesion was demonstrated on SWE but was absent on B-mode ultrasound and 3-T MRI. Electroencephalography (EEG), positron emission tomography (PET), and magnetoencephalography (MEG) scans demonstrated an abnormality in the right frontal region. On the basis of this finding, a depth electrode was implanted into the lesion. Surgical resection and histology confirmed the lesion to be type IIb FCD. A PowerPoint slide summarizing this article is available for download in the Supporting Information section here.

Lack of uniformity in the clinical assessment of children with lipomyelomeningocele: a review of the literature and recommendations for the future.

OBJECTIVE: An objective clinical assessment tool whose accuracy and reproducibility can be validated is essential for the initial evaluation, selection for surgery and surveillance of children with lipomyelomeningocele (LMMC). The aim of this study was to analyse the large number of such tools presently in use and recommend an alternative that could lead to greater uniformity between different series and greater consistency in the assessment of individual patients. METHODS: A systematic review of the literature between January 1980 and December 2010 was undertaken and details of how the children in each series were assessed and the degree to which age was taken into account recorded. RESULTS: Thirty-six different assessment tools were used in 40 different publications. None was validated in all aspects. Objective measures were used most in urological assessments but rarely in other domains. Age-specific assessments were used in only 10 % of publications. CONCLUSION: This study confirmed that the assessment tools for evaluation of children with LMMC are inconsistent, often vague and poorly validated. This compromises the ability of clinicians who care for them to compare studies across centres for both treated and untreated children. We have sought to highlight those criteria which are relevant, measurable and reproducible and which might be combined into an easily applied assessment.

Preoperative embolisation of choroid plexus tumours in children: part I-does the reduction of perioperative blood loss affect the safety of subsequent surgery?

OBJECTIVE: Operative management of choroid plexus tumours is hindered by excessive bleeding and significant CSF production. Our aim was to assess whether the use of preoperative embolisation would increase the safety of surgery by reducing the perioperative blood loss and achieve higher rates of resection of the tumour. METHODS: Between 1996 and 2009, 30 patients (mean age 2.25 years) with choroid plexus tumours (24 papillomas, 6 carcinomas) were treated. Fifteen of them underwent preoperative super-selective embolisation of the feeding vessels with histoacryl glue. The perioperative blood loss as a percentage of estimated blood volume loss (EBV) was recorded together with mortality and morbidity of the two groups (embolised, EMB+ vs. not, EMB-). RESULTS: The embolisation was successful in 13/15 (86.6 %) patients. This manoeuvre rendered the tumour relatively avascular making the operative field "less hazardous" as reported by the surgeon. In addition, higher gross total resection rate was achieved (100 vs. 41 %; p = 0.001) at the first operative attempt in the EMB+ group. The percentage EBV loss was 96 % in EMB- group vs. 224 % in EMB+ group (p = 0.038). CONCLUSION: Our observations with regards to preoperative embolisation of choroid plexus tumours show an acceptable safety profile for the endovascular technique. At the same time, it renders the operative treatment of the tumours safer by reducing perioperative blood loss resulting in a high gross total resection rate. In summary, we suggest that preoperative embolisation is a useful adjunct that should be considered prior to surgical resection in managing these patients.

Pre-operative embolisation of choroid plexus tumours in children. Part II. Observations on the effects on CSF production.

OBJECTIVE: Choroid plexus tumours are one of the few causes of hydrocephalus secondary to increased CSF production. Operative treatment aided by pre-op embolisation is being used in our institution as a primary option of treatment. Our aim was firstly to quantify the effects of embolisation on CSF production and secondly to assess whether the use of pre-operative embolisation would lead to reduction of CSF production thus reducing the need for CSF diversion procedures in the perioperative and long term. METHODS: From 1996 till 2009, 30 patients (mean age, 2.25 years) underwent surgical treatment for 24 choroid plexus papillomas and 6 choroid plexus carcinomas. Thirteen underwent pre-operative super-selective embolisation of the feeding vessels with Histoacryl glue. The need for CSF diversion-external ventricular drain (EVD)/shunt-was recorded together with the daily CSF production between the two groups (embolised: EMB+ vs. not embolised: EMB-) RESULTS: The embolisation was successful in 13 of 15 (86.6 %) patients. The average post-op daily CSF production between the EMB+ and EMB- groups was (67 vs. 135 ml/day; p = 0.005). EVD days in situ post-operatively was 7.9 vs. 12.1 (p = 0.033). However, the need for permanent CSF diversion was similar in both groups (five vs. six). CONCLUSION: We have established the safety of pre-operative embolisation as an adjunct to operative treatment of choroid plexus tumours. As we expected, this technique, by removing the tumour's blood supply, reduces the rate of CSF production. This has had a positive impact on the post-operative management of these patients. We cannot say the same for the need of permanent CSF diversion in our study.

Slip elastography: a novel method for visualising and characterizing adherence between two surfaces in contact.

Identification of the anatomical location and mechanical properties such as adherence at the tissue tumour interface may be of clinical benefit in determination of tumour resectability and prognosis. There are currently no imaging modalities in routine clinical practice that can provide this information. This paper presents the development of a new imaging technique based on ultrasound elastography, called slip elastography, for determination of the anatomical location and measurement of the adherence between two surfaces. The theoretical basis of slip and its definition in relation to shear are described. In vitro testing with gelatine phantoms to determine the optimal parameters for shear strain estimation and slip boundary measurement and to test reliability are also described. The results suggest that slip elastography can reliably identify the anatomical location of a slip boundary and can measure the externally applied axial force required to initiate slip at that boundary in vitro. The vector based shear strain estimator was the most robust and worked with minimal angular dependence with minimal non-slip shearing artefact.

Suprasellar arachnoid cyst resulting in the syndrome of inappropriate antidiuretic hormone secretion.

The syndrome of inappropriate antidiuretic hormone secretion (SIADH) is occasionally seen after hypothalamic injury or dysfunction, although it typically occurs in association with other endocrine disturbances. It is has never been described as a presenting feature of a suprasellar arachnoid cyst (SAC) in the pediatric population. The authors describe the case of an enlarging SAC resulting in SIADH as the only presenting feature, with an otherwise normal hypothalamic-pituitary axis. An SAC was diagnosed in utero in this 5-month-old girl who had a normal functioning hypothalamic-pituitary axis on presentation. Because of cyst enlargement and hydrocephalus, the patient was scheduled for surgery; however, preoperative labs revealed SIADH. After stabilizing the serum sodium concentration with fluid restriction and the administration of 3% sodium chloride, the patient underwent endoscopic cyst fenestration. Postoperatively, she had complete resolution of the SIADH. Syndrome of inappropriate antidiuretic hormone secretion as the presenting symptom of an SAC has not been previously described. In the aforementioned patient, the proposed mechanism for SIADH was enlargement of the suprasellar arachnoid cyst causing compression of the supraoptic and paraventricular nuclei and thus overstimulating the secretion of arginine vasopressin, which resulted in SIADH. The association of SIADH with an SAC is reportable, as is the resolution of the SIADH via cyst fenestration. The authors suggest that SIADH is an uncommon presenting feature of SACs and that syndrome resolution is possible with cyst decompression.

Surgical management of supratentorial ependymomas.

INTRODUCTION: Supratentorial ependymomas are rare neoplasms accounting for just ten to 15 new cases in the UK per year. This article discusses the surgical management of these tumours. MATERIALS AND METHODS: We present our experience over the past 12 years looking, in particular, at the location, histological grading, postoperative complications, survival and progression-free survival. A literature review of publications discussing the surgical management of ependymoma over the past 10 years is then presented. RESULTS: The data shows that complete surgical resection confers a significant survival advantage. There appears to be conflicting data with respect to prognosis when comparing supratentorial to infratentorial ependymoma. CONCLUSION: The authors suggest complete excision and advocate, where appropriate, the use of pre and intra-operative functional mapping and second-look surgery. The trade off neurological deficit in the pursuit of complete surgical excision in some instances should be considered.

Presurgical functional mapping with functional MRI.

PURPOSE OF REVIEW: The present article describes current indications for functional MRI in the preoperative planning of neurosurgical patients. Functional MRI continues to have an expanding role. RECENT FINDINGS: There are three main categories of patients who commonly undergo preoperative functional MRI. Patients with lesions close to eloquent cortex can benefit from preoperative functional MRI to assess resectability and reduce the possibility of functional deficit. The second group are those patients who have functional MRI as part of their preoperative planning to localize language dominance and for functional localization of memory. The final group are those patients in whom attempts are made to image and localize abnormal brain function. This has a specific application in the field of epilepsy surgery (electroencephalographic-correlated functional MRI). These three roles require different spatial resolutions. Advances in multimodality imaging are enabling more accurate localization of function intraoperatively. SUMMARY: It is hoped that the increasing use of functional MRI in combination with both preoperative and intraoperative imaging modalities may reduce the risk of neurological deficit while improving completeness of resection. Electroencephalographic-correlated functional MRI may provide an additional method for localization of epileptogenic foci.

Toward reducing shunt placement rates in patients with myelomeningocele.

OBJECT: The prevalence of shunt-dependent hydrocephalus in patients with myelomeningocele has been reported to be in the region of 85%, and shunt-related complications are a significant cause of morbidity and mortality in these patients. Since 1997 the authors have adopted a stringent policy with respect to shunt placement in patients with myelomeningocele, reserving this treatment for those with symptomatic hydrocephalus, severe ventricular dilation at the time of presentation, and/or unequivocal progressive ventriculomegaly after primary closure. They report their experience. METHODS: The authors reviewed all cases of myelomeningocele involving patients who presented to their institution over a 10-year period. They excluded cases in which the primary closure was carried out at another institution or in which there was not at least 12 months of clinical and imaging follow-up. Data regarding shunt insertion shunt-related complications, and clinical outcome were obtained from a review of the clinical records and analyzed. RESULTS: Fifty-four cases satisfied the inclusion criteria for this study. Shunt insertion was performed in 28 of these cases (51.9%). CONCLUSIONS: Applying more stringent guidelines for shunt placement, permitting moderate ventricular dilation, and accepting some mild increase in ventricular size after myelomeningocele closure has resulted in a reduced rate of shunt placement compared with previous series. The rate is comparable to that reported following in utero closure of myelomeningocele.

Scedosporium apiospermum brain abscess treated with surgery and voriconazole. Case report.

Scedosporium apiospermum is a fungus found in the soil and in contaminated water. Common cutaneous manifestations include Madura foot, a painless swelling on the sole of the foot. Invasive infection is usually associated with immunosuppression. The authors present a 16-month-old immunocompetent boy who had a near-drowning event. Following this, he was severely disabled with spastic quadriparesis. Early computerized tomography scans revealed diffuse hypoxic injury. Magnetic resonance images obtained 3 months after the initial event demonstrated multiple ring-enhancing lesions in the brain. Aspiration of the lesion was performed. Scedosporium apiospermum, the asexual form of Pseudallescheria boydii, was cultured. Conventional antifungal agents were commenced, with minimal effect. The child was subsequently treated with a new antifungal agent, voriconazole, a broad-spectrum triazole antifungal agent with good penetration into the cerebrospinal fluid. The patient improved, with a good radiological outcome and a moderate clinical outcome. The authors review the use of voriconazole for central nervous system infections and review the literature on S. apiospermum associated with near drowning.

Osteosarcoma and fibrosarcoma caused by postoperative radiotherapy for a pituitary adenoma. Case report.

Sarcomatous change is a rare complication of postoperative radiotherapy for pituitary adenomas. The authors report on what they believe to be the first case in which fibrosarcoma and, later, osteosarcoma developed during a 14-year period following surgery and radiotherapy for a nonsecreting pituitary macroadenoma.