Characteristics and Outcomes of Critically Ill Pediatric Patients with Posterior Reversible Encephalopathy Syndrome.

BACKGROUND/OBJECTIVE: Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiologic entity, typically manifesting as reversible neurological symptoms and signs of white matter edema on magnetic resonance imaging. PRES has been widely described in adults. Studies of PRES in children are mostly limited to case series and case controls. METHODS: Retrospective chart review of patients under 21 years with PRES admitted at a tertiary children's hospital from 2011 to 2016. They were compared to controls matched for age and mortality risk using the Pediatric Index of Mortality-2 score. RESULTS: Sixteen cases of PRES were identified in 13 patients (ages 5-17 years, 46% male). PRES presented with altered mental status (75%), seizures (77%), headache (31%), and vision changes (23%). In patients who recovered (n = 11), median days to symptom resolution was three (range 1-8). PRES patients had a higher mortality rate (15% vs. 5%, p < 0.05) and higher mean length of stay (13.1 vs. 4.6 days) and were more likely to have autoimmune disease (p < 0.05), immunosuppression (p < 0.05), and anemia (p < 0.05). No PRES patients were diagnosed with epilepsy by last known follow-up, and all of whom had been started on an antiepileptic drug were discontinued within 13 months. Sepsis was suspected in 53% of PRES patients and 59% of controls (p = 1.00). All PRES patients had stage II hypertension, versus 41% of controls (p < 0.05). Average creatinine in PRES was 2.35 mg/dL compared to 0.90 mg/dL in controls (p < 0.05). PRES patients had lower serum calcium (p < 0.05). After correcting for albumin, no association between PRES and hypocalcemia remained. PRES patients had a higher length of stay (13.1 vs. 4.6 days, p < 0.05) and mortality rate (15% vs. 3%, p < 0.05). CONCLUSIONS: Immunosuppression, autoimmune disease, renal insufficiency, anemia, and hypertension are associated with PRES after controlling for mortality risk in critically ill children. There was no association between corrected serum calcium and sepsis with PRES.

A case of bronchial granular cell tumor in a pediatric patient.

Only nine cases of bronchial granular cell tumor have previously been reported in pediatric patients. We present a 15-year-old girl with acute-onset right shoulder pain, discovered to have a granular cell tumor causing bronchial stenosis and a cavitating post-obstructive right upper lobe pneumonia. The patient was treated with lobectomy. Bronchial granular cell tumors are benign neoplasms that typically present with recurrent pneumonia. Imaging may demonstrate an endobronchial lesion or an associated post-obstructive opacity, but diagnosis requires tissue sampling. To our knowledge, this is the tenth case of bronchial granular cell tumor in a pediatric patient to be reported since 1926.

Location of the vertebral artery at C1 in children: how far out laterally can one safely dissect?

BACKGROUND: There is little information available on the anatomic location of the vertebral artery in pediatric patients undergoing a posterior cervical arthrodesis involving the first cervical vertebra (C1). The purpose of this study was to define how far laterally one can safely dissect posteriorly without risk to the vertebral artery in pediatric patients. METHODS: A subset of computed tomography angiograms of the neck that had been previously obtained in patients at our institution was evaluated. The location of the vertebral artery was identified on both the right and the left side at the vertebral artery groove. RESULTS: A total of 549 patients were included. The vertebral artery was an average of 13.97 mm (standard deviation, 1.89 mm) from the midline. Ninety-seven percent of the vertebral arteries were more than 1 cm lateral to the midline, and none were less than 8 mm from the midline. There was a significant difference among the age groups in the location of the vertebral artery, with the vertebral artery closer to the midline in younger patients (p < 0.001). In patients eight years of age or older, the average distance from the midline equaled the value reported for adults. CONCLUSIONS: Patients under the age of eight years had vertebral arteries that were significantly closer to the midline compared with those of older patients; nonetheless, 97% of the vertebral arteries in the younger patients were more than 1 cm lateral to the midline. CLINICAL RELEVANCE: Increased care must be taken when dissecting out laterally on C1 in younger patients, as the vertebral artery tends to be closer to the midline than has been described in adults.