Profile of Patients Receiving Computed Tomography Scans for Mild Traumatic Brain Injury in a Tertiary Care Hospital in Ethiopia.

BACKGROUND: Traumatic brain injury (TBI) is a leading contributor to emergency department (ED) mortalities in Ethiopia. Mild TBI patients comprise half of all TBI patients presenting for care in Ethiopia and have a high potential for recovery. As such, context-specific care-improving strategies may be highly impactful for this group of patients. OBJECTIVE: This study examines the presentation and disposition of mTBI patients who received a computed tomography scan of the head upon arrival at the largest teaching hospital in Ethiopia. METHODS: A retrospective cohort study was conducted from 2018 to2021 including patients >13 years old with a head injury and a Glasgow Coma Score of 13-15 who obtained a computed tomography scan of the head. Variables were collected from medical charts and single and multivariable analyses assessed outcomes of clinically important TBI (ciTBI) requiring a neurosurgical procedure or admission. RESULTS: A total of 193 patients were included. They were predominantly young men with no comorbidities, injured in road traffic accidents or by assault, had stable vital signs and were treated in lower-acuity ED areas. A minority demonstrated focal deficits, and 29.5% of patients had ciTBI. Most patients were discharged from the ED, but 13% were taken for operative neurosurgical procedures and 10.4% were admitted to the neurosurgery ward for observation. ED stays ranged from 8 hours to 10 days, as patients waited for CT availability, neurosurgical decision, or transportation. Female sex was independently protective of ciTBI. Self-referral status was independently protective against operative intervention. Female sex and self-referral status were independently protective of a disposition of admission and/or going to the operating room. CONCLUSIONS: This study characterizes the mTBI subgroup of head injury patients in Ethiopia's busiest ED: predominantly healthy young men with low-acuity presentations and only a fraction with abnormal neurological examinations. Nonetheless, about one-third had ciTBI and a minority were taken for neurosurgical procedures or admission, with female sex and self-referral identified as protective factors. Meanwhile, many patients stayed in the ED for days due to social or other nonmedical reasons. As TBI care in Ethiopia continues to improve, optimizing care for the mTBI subgroup is tantamount given their high recovery potential. This care will benefit from efficiently identifying those who need intervention or hospital level of care, and discharging those who do not.

Advances in myelin imaging with potential clinical application to pediatric imaging.

White matter development and myelination are critical processes in neurodevelopment. Myelinated white matter facilitates the rapid and coordinated brain messaging required for higher-order cognitive and behavioral processing. Whereas several neurological disorders such as multiple sclerosis are associated with gross white matter damage and demyelination, other disorders such as epilepsy may involve altered myelination in the efferent or afferent white matter pathways adjoining epileptic foci. Current MRI techniques including T1 weighting, T2 weighting, FLAIR, diffusion tensor imaging, and MR spectroscopy permit visualization of gross white matter abnormalities and evaluation of underlying white matter fiber architecture and integrity, but they provide only qualitative information regarding myelin content. Quantification of these myelin changes could provide new insight into disease severity and prognosis, reveal information regarding spatial location of foci or lesions and the associated affected neural systems, and create a metric to evaluate treatment efficacy. Multicomponent analysis of T1 and T2 relaxation data, or multicomponent relaxometry (MCR), is a quantitative imaging technique that is sensitive and specific to myelin content alteration. In the past, MCR has been associated with lengthy imaging times, but a new, faster MCR technique (mcDESPOT) has made quantitative analysis of myelin content more accessible for clinical research applications. The authors briefly summarize traditional white matter imaging techniques, describe MCR and mcDESPOT, and discuss current and future clinical applications of MCR, with a particular focus on pediatric epilepsy.

Validation of the Canadian CT Head Rule and the New Orleans Criteria for Mild Traumatic Brain Injury in Ethiopia.

BACKGROUND: Traumatic brain injury (TBI) is a major public health problem worldwide. Although computed tomography (CT) scans are often used for TBI workup, clinicians in low-income countries are limited by fewer radiographic resources. The Canadian CT Head Rule (CCHR) and the New Orleans Criteria (NOC) are widely used screening tools to rule out clinically important brain injury without CT imaging. Although these tools are well validated in studies from upper- and middle-income countries, it is important to study these tools in low-income countries. This study sought to validate the CCHR and NOC in a tertiary teaching hospital population in Addis Ababa, Ethiopia. METHODS: This single-center retrospective cohort study included patients older than 13 years presenting from December 2018 to July 2021 with a head injury and a Glasgow Coma Scale score of 13-15. Retrospective chart review collected demographic, clinical, radiographic, and hospital course variables. Proportion tables were constructed to determine the sensitivity and specificity of these tools. RESULTS: A total of 193 patients were included. Both tools showed 100% sensitivity for identifying patients requiring neurosurgical intervention and abnormal CT scans. The specificity for the CCHR was 41.5% and 26.5% for the NOC. Male gender, falling accidents, and headaches had the strongest association with abnormal CT findings. CONCLUSIONS: The NOC and the CCHR are highly sensitive screening tools that can help rule out clinically important brain injury in mild TBI patients without a head CT in an urban Ethiopian population. Their implementation in this low-resource setting may help spare a significant number of CT scans.

Frailty Measured by the Risk Analysis Index Predicts Nonhome Discharge and Mortality After Resection in Refractory Epilepsy: Analysis of 1236 Patients From a Prospective Surgical Registry, 2012 to 2020.

BACKGROUND: Risk stratification of epilepsy surgery patients remains difficult. The Risk Analysis Index (RAI) is a frailty measurement that augments preoperative risk stratification. OBJECTIVE: To evaluate RAI's discriminative threshold for nonhome discharge disposition (NHD) and mortality (or discharge to hospice within 30 days of operation) in epilepsy surgery patients. METHODS: Patients were queried from the American College of Surgeons-National Surgical Quality Improvement Program database (2012-2020) using diagnosis/procedure codes. Linear-by-linear trend tests assessed RAI's relationship with NHD and mortality. Discriminatory accuracy was assessed by C-statistics (95% CI) in receiver operating characteristic curve analysis. RESULTS: Epilepsy resections (N = 1236) were grouped into temporal lobe (60.4%, N = 747) and nontemporal lobe (39.6%, N = 489) procedures. Patients were stratified by RAI tier: 76.5% robust (RAI 0-20), 16.2% normal (RAI 21-30), 6.6% frail (RAI 31-40), and 0.8% severely frail (RAI 41 and above). The NHD rate was 18.0% (N = 222) and positively associated with increasing RAI tier: 12.5% robust, 34.0% normal, 38.3% frail, and 50.0% severely frail ( P < .001). RAI had robust predictive discrimination for NHD in overall cohort (C-statistic 0.71), temporal lobe (C-statistic 0.70), and nontemporal lobe (C-statistic 0.71) cohorts. The mortality rate was 2.7% (N = 33) and significantly associated with RAI frailty: 1.1% robust, 8.0% normal, 6.2% frail, and 20.0% severely frail ( P < .001). RAI had excellent predictive discrimination for mortality in overall cohort (C-statistic 0.78), temporal lobe (C-statistic 0.80), and nontemporal lobe (C-statistic 0.74) cohorts. CONCLUSION: The RAI frailty score predicts mortality and NHD after epilepsy surgery. This is accomplished with a user-friendly calculator: https://nsgyfrailtyoutcomeslab.shinyapps.io/epilepsy/ .

Baseline frailty status, not advanced patient age, predicts epilepsy surgery outcomes: An analysis of 696 patients from the NSQIP database.

OBJECTIVE: Preoperative risk stratification of patients undergoing epilepsy surgery remains challenging. Recently, the efforts to look beyond age alone as an outcomes predictor has resulted in the development of measures of physiological reserve, or 'frailty indices.' The most frequently cited index in neurosurgery is the 11-item or 5-item modified frailty index (mFI11 or mFI-5). The present study aimed to use a large national registry to evaluate the effect of frailty (as measured by mFI-5 versus age on postoperative outcomes of patients undergoing epilepsy surgery. METHODS: The National Surgical Quality Improvement Program (NSQIP) database, overseen by the American College of Surgeons (ACS), was used to extract data for patients undergoing epilepsy surgery from 2015 to 2019. Univariate and multivariate analyses for age and mFI-5 were performed for the following 30-day outcomes of extended length of hospital stay (eLOS) and non-home discharge (NHD). The effect sizes were summarized by odds ratio and associated 95 % confidence intervals. Receiver operating characteristic (ROC) curve analysis, including area under the curve (AUC), was used to quantify the discrimination. RESULTS: Univariate and multivariate analyses demonstrated that frailty statuses from mFI-5, not age, were significantly predictive of eLOS and NHD. On ROC curve analysis, mFI-5 was a stronger predictor of eLOS (C = 0.59, 95 % CI 0.54-0.64, p < 0.001) and NHD (C = 0.69, 95 % CI 0.64-0.76, p < 0.001) than age (C = 0.53, 95 % CI 0.48-0.58, p = 0.21 and C = 0.53, 95 % CI 0.46-0.59, p = 0.44, respectively). CONCLUSION: Frailty, not age, is an independent risk factor for poor postoperative outcomes, particularly eLOS and NHD, in patients undergoing epilepsy surgery. Usage of mFI-5 for preoperative risk stratification of epilepsy surgery patients can help in prognostication.

An In Vitro Study of Magnetic Field Interference with an Electronic Shunt Programmer.

BACKGROUND: Programmable shunts play a valuable role in the treatment of hydrocephalus. However, the use of magnets in programming these valves has caused obstacles in today's magnetized world. Previous studies have reported problems with magnetic toys and electronics unintentionally reprogramming shunt valves. This study investigated how an Apple Watch can interfere with the Codman CERTAS Plus electronic programmer. METHODS: In this in vitro study, we tested the magnetic field emitted by Apple Watch Series 3, 4, 5, and 6 using an electromagnetic field tester at distances of 0-50 mm. We conducted 20 trials of shunt programming and shunt setting reading with and without each watch. RESULTS: All 4 watches generated significant magnetic fields. Maximum magnetic fields were Series 3, 165.73 millitesla (mT); Series 4, 144.91 mT; Series 5, 131.09 mT; and Series 6, 130.68 mT. All 4 watches interfered with the programmer's ability to correctly read and program the valve setting. CONCLUSIONS: The Codman CERTAS Plus electronic programmer detects the magnetic field emitted from an Apple Watch and mistakes it for the valve, rendering programming difficult. These smartwatches and similar electronic devices should be kept away from the programmer and not worn by health care providers to avoid inappropriate readings and setting changes.

Myelin water fraction changes in febrile seizures.

OBJECTIVE: The objective of this feasibility study was to investigate whether myelin water fraction (MWF) patterns can differentiate children presenting with febrile seizures who will go on to develop nonfebrile epilepsy from those who will not. PATIENTS AND METHODS: As part of a prospective study of myelination patterns in pediatric epilepsy, seven subjects with febrile seizures underwent magnetic resonance imaging (MRI) including the following standard sequences-T1-weighted, T2-weighted, fluid-attenuated inversion recovery (FLAIR)-and an additional experimental sequence, multicomponent-derived equilibrium single-pulse observation of T1 and T2 (mcDESPOT) to quantify MWF. For each of these subjects, MWF maps were derived and compared with an age-matched population-averaged MWF atlas. RESULTS: All seven subjects (<5 years old) initially presented with febrile seizures. Of the seven, four had complex seizures and three had simple seizures. All of the children with simple febrile seizures had higher MWF compared with model-derived controls and did not develop epilepsy. All of the children with complex febrile seizures had lower MWF than their model-derived control, and two of these subjects later developed epilepsy. CONCLUSION: This is the first study in which MWF maps were used to study children with febrile *seizures. This data suggests that relatively higher or stable MWF compared with normative data indicates a lower risk of nonfebrile epilepsy while relatively lower MWF may indicate a pathological condition that could lead to nonfebrile epilepsy.

Prospective study of myelin water fraction changes after mild traumatic brain injury in collegiate contact sports.

OBJECTIVE: Mild traumatic brain injury (mTBI) in athletes, including concussion, is increasingly being found to have long-term sequelae. Current imaging techniques have not been able to identify early damage caused by mTBI that is predictive of long-term symptoms or chronic traumatic encephalopathy. In this preliminary feasibility study, the authors investigated the use of an emerging magnetic resonance imaging (MRI) technique, multicomponent driven equilibrium single pulse observation of T1 and T2 (mcDESPOT), in visualizing acute and chronic white matter changes after mTBI in collegiate football and rugby players. METHODS: This study was a nonrandomized, nonblinded prospective trial designed to quantify changes in the myelin water fraction (MWF), used as a surrogate MRI measure of myelin content, in a group of male collegiate football and rugby players, classified here as a contact sport player (CSP) cohort, at the time of mTBI diagnosis and 3 months after injury when the acute symptoms of the injury had resolved. In addition, differences in the MWF between the CSP cohort and a control cohort of noncontact sport players (NCSPs) were quantified. T-tests and a threshold-free cluster enhancement (TFCE) statistical analysis technique were used to identify brain structures with significant changes in the MWF between the CSP and NCSP cohorts and between immediately postinjury and follow-up images obtained in the CSP cohort. RESULTS: Brain MR images of 12 right-handed male CSPs were analyzed and compared with brain images of 10 right-handed male NCSPs from the same institution. A comparison of CSP and NCSP baseline images using TFCE showed significantly higher MWFs in the bilateral basal ganglia, anterior and posterior corpora callosa, left corticospinal tract, and left anterior and superior temporal lobe (p < 0.05). At the 3-month follow-up examination, images from the CSP cohort still showed significantly higher MWFs than those identified on baseline images from the NCSP cohort in the bilateral basal ganglia, anterior and posterior corpora callosa, and left anterior temporal lobe, and also in the bilateral corticospinal tracts, parahippocampal gyrus, and bilateral juxtapositional (previously known as supplemental motor) areas (p < 0.05). In the CSP cohort, a t-test comparing the MWF at the time of injury and 3 months later showed a significant increase in the overall MWF at follow-up (p < 0.005). These increases were greatest in the bilateral basal ganglia and deep white matter. MWF decreases were seen in more superficial white matter (p < 0.005). CONCLUSIONS: In this preliminary study, MWF was found to be increased in the brains of CSPs compared with the brains of controls, suggesting acute/chronic MWF alterations in CSPs from previous injuries. Increases in the MWF were also demonstrated in the brains of CSPs 3 months after the players sustained an mTBI. The full clinical significance of an increased MWF and whether this reflects axon neuropathology or disorderly remyelination leading to hypermyelination has yet to be determined.

Delayed osteomyelitis resulting from an extension injury of the cervical spine: case report.

Osteomyelitis of the cervical spine is an exceedingly rare lesion in pediatric practice and is caused by a variety of mechanisms. The authors present a case in which cervical osteomyelitis presented in a delayed manner after the patient experienced a stable cervical extension injury at the C4-5 level. On review of the original images, the authors noted a likely perforation in the retropharyngeal space. This case highlights the risk of retropharyngeal injury in cervical trauma, with the seldom-seen complication of osteomyelitis as a result.

Traumatic Frontal Epidural Hematoma Caused by Multiple Arterial Injuries in the Anterior Fossa.

BACKGROUND: This case report illustrates the need to evaluate the possibility of multiple arterial sources when presented with a frontal epidural hematoma associated with facial trauma. CASE DESCRIPTION: The patient presented after being struck in the face by a baseball. Computed tomography of the brain revealed a large frontal epidural hematoma. Intraoperatively, bleeding from a frontal branch of the middle meningeal artery was encountered and cauterized, and the hematoma was removed. Routine follow-up imaging performed the next day showed a residual frontal hematoma; however, the epidural hematoma was in a more medial location than the initial hematoma. The patient was taken back to the operating room; after frontal lobe retraction and extensive exploration, a different source of bleeding from posterior ethmoidal artery feeders was encountered. After the second operation, the patient's hematoma did not recur, and he was discharged home with no neurologic deficits 3 days later. CONCLUSIONS: We report a case of an epidural hematoma caused by 2 distinct arterial feeders. We discuss radiologic review and operative management of anterior fossa epidural hematomas and stress the importance of considering arterial bleeding from sources other than the middle meningeal artery in anterior fossa epidural hematomas. We discuss the utility of preoperative angiography for these patients and reinforce the need for acute postoperative imaging to ensure successful operative and patient outcomes.

Risk factors for baclofen pump infection in children: a multivariate analysis.

OBJECTIVE Intrathecal baclofen infusion systems to manage severe spasticity and dystonia are associated with higher infection rates in children than in adults. Factors unique to this population, such as poor nutrition and physical limitations for pump placement, have been hypothesized as the reasons for this disparity. The authors assessed potential risk factors for infection in a multivariate analysis. METHODS Patients who underwent implantation of a programmable pump and intrathecal catheter for baclofen infusion at a single center between January 1, 2000, and March 1, 2012, were identified in this retrospective cohort study. The primary end point was infection. Potential risk factors investigated included preoperative (i.e., demographics, body mass index [BMI], gastrostomy tube, tracheostomy, previous spinal fusion), intraoperative (i.e., surgeon, antibiotics, pump size, catheter location), and postoperative (i.e., wound dehiscence, CSF leak, and number of revisions) factors. Univariate analysis was performed, and a multivariate logistic regression model was created to identify independent risk factors for infection. RESULTS A total of 254 patients were evaluated. The overall infection rate was 9.8%. Univariate analysis identified young age, shorter height, lower weight, dehiscence, CSF leak, and number of revisions within 6 months of pump placement as significantly associated with infection. Multivariate analysis identified young age, dehiscence, and number of revisions as independent risk factors for infection. CONCLUSIONS Young age, wound dehiscence, and number of revisions were independent risk factors for infection in this pediatric cohort. A low BMI and the presence of either a gastrostomy or tracheostomy were not associated with infection and may not be contraindications for this procedure.

A case of Cushing ulcer in an 8-month-old patient with medulloblastoma.

The authors present the first case of a Cushing ulcer in an infant with medulloblastoma who, despite being administered stress ulcer prophylaxis, worsened after corticosteroids were initiated. An 8-month-old boy presented with progressive vomiting, lethargy, and decreased oral intake. Imaging revealed a heterogeneous fourth ventricular mass. Preoperatively, the patient was started on dexamethasone. The patient underwent an uncomplicated external ventricular drain placement and suboccipital craniotomy for resection of the lesion. The results of the pathological analysis were consistent with medulloblastoma. Postoperatively, the patient had melanotic stools, which were reported to be occurring for months prior to presentation. Two proximal duodenal bulb ulcers were found and required definitive surgical repair. The patient recovered from the acute postsurgical course after continued stress ulcer prophylaxis and is currently undergoing chemotherapy.

Complex Chiari Malformations in Children: Diagnosis and Management.

This article describes the diagnosis and management of patients with complex Chiari malformations. This group of patients cannot be categorized as a Chiari 1 or 1.5 because the pathology and progression of their disease is unique. The authors discuss how to diagnose and treat patients with complex Chiari malformations, particularly with regard to discerning which patients would benefit from a simple Chiari decompression versus Chiari decompression with occipitocervical fusion.

Risk factors for infection and the effect of an institutional shunt protocol on the incidence of ventricular access device infections in preterm infants.

OBJECT: Intraventricular hemorrhage in premature infants often leads to progressive ventricular dilation and the need for ventricular reservoir placement. Unfortunately, these reservoirs have a higher rate of infection than ventriculoperitoneal shunts in premature babies. The authors analyzed the risk factors for infection in this population and studied whether the implementation of an institutional protocol for shunt placement had a corollary effect on ventricular access device (VAD) infection rates in premature neonates with intraventricular hemorrhage. METHODS: The authors conducted a retrospective cohort review of consecutive premature neonates in whom VADs were inserted in the operating room at Primary Children's Hospital between June 2003 and June 2011 to identify risk factors for infection. Medical records were reviewed for information on infection (culture proven or eroded hardware at 90 days), gestational age at birth, weight, gestational age at surgery, intrathecal antibiotics, hemorrhage, death, and surgeon. The institution used a pilot protocol for shunt infection reduction in 2006-2007, and then the full Hydrocephalus Clinical Research Network protocol from June 2007 to 2011, and the rates of infection during these periods were analyzed. Confounding factors such as sepsis, necrotizing enterocolitis, and a history of meningitis were also analyzed. RESULTS: The overall infection rate was 10.5% (11 patients) in the 105 patients identified. Gestational age at procedure was a significant risk factor for infection (p=0.05). Meningitis was significantly associated with infection, with 63% of the infected group having had prior meningitis compared with 7% for the noninfected group (p<0.001). Concurrent with the implementation of the protocol to reduce shunt infection, the VAD infection rate decreased from 14.7% to 5.4% (p=0.2). CONCLUSIONS: Gestational age at procedure and previous meningitis were significant risk factors for VAD infections. In addition, the implementation of an institutional standardized shunt protocol for ventriculoperitoneal shunts may have altered the operating room team's behavior, indicated by a nonmandated use of intrathecal antibiotics in VAD surgeries, contributing to a reduced VAD infection rate. Although the observed difference was not statistically significant with the small sample size, the authors believe that these findings deserve further study.

Programmable shunts and headphones: Are they safe together?

OBJECT: Programmable shunts have a valuable role in the treatment of patients with hydrocephalus, but because a magnet is used to change valve settings, interactions with external magnets may reprogram these shunts. Previous studies have demonstrated the ability of magnetic toys and iPads to erroneously reprogram shunts. Headphones are even more ubiquitous, and they contain an electromagnet for sound projection that sits on the head very close to the shunt valve. This study is the first to look at the magnetic field emissions of headphones and their effect on reprogrammable shunt valves to ascertain whether headphones are safe for patients with these shunts to wear. METHODS: In this in vitro study of the magnetic properties of headphones and their interactions with 3 different programmable shunts, the authors evaluated Apple earbuds, Beats by Dr. Dre, and Bose QuietComfort Acoustic Noise Cancelling headphones. Each headphone was tested for electromagnetic field emissions using a direct current gaussmeter. The following valves were evaluated: Codman Hakim programmable valve, Medtronic Strata II valve, and Aesculap proGAV. Each valve was tested at distances of 0 to 50 mm (in 5-mm increments) from each headphone. The exposure time at each distance was 1 minute, and 3 trials were performed to confirm results at each valve setting and distance. RESULTS: All 3 headphones generated magnetic fields greater than the respective shunt manufacturer's recommended strength of exposure, but these fields did not persist beyond 5 mm. By 2 cm, the fields levels were below 20 G, well below the Medtronic recommendation of 90 G and the Codman recommendation of 80 G. Because the mechanism for the proGAV is different, there is no recommended gauss level. There was no change in gauss-level emissions by the headphones with changes in frequency and amplitude. Both the Strata and Codman-Hakim valves were reprogrammed by direct contact (distance 0 mm) with the Bose headphones. When a rotation component was added, all 3 headphones reprogrammed the Strata and Codman-Hakim valves at 0 mm. At all distances above 0 mm, the headphones did not affect the shunts. The proGAV valve was not affected by headphones at any distance. CONCLUSIONS: Although all the headphones studied generated significant gauss fields at distances less than 5 mm, the programmable valve settings only changed at a distance of 0 mm (i.e., with direct contact). Given the subcutaneous location of the valve, the authors conclude that is highly unlikely that commercially available or customary headphones can contribute to the reprogramming of shunts.

Fundamentals of the neurologic examination for patients undergoing central nervous system interventional procedures.

The basic neurologic history and exam for the interventional radiologist performing intracranial procedures need not be exhaustive and will not supplant that by neurologic specialist. It should include a pertinent history, focused neurologic exam, and a brief physical exam. The interventional radiologist should be familiar with the grading scales commonly used for patients with intracranial pathology to understand the severity and prognosis of various pathologies. The goal of the examination is to mitigate risk, direct the evaluation, aid in medical decision making, and allow the establishment of an appropriate physician-patient relationship.

The safety and feasibility of outpatient carotid endarterectomy.

BACKGROUND: Carotid endarterectomy (CEA) is one of the most commonly performed and studied surgical procedures for extracranial ischemic disease. OBJECTIVE: The authors reviewed the outcome of 39 consecutive carotid endarterectomy procedures performed by a single surgeon with emphasis on the safety of discharging patients the same day of the procedure. METHODS: Retrospective analysis was performed over a two-year period on patients who were admitted as outpatients and underwent CEA. Following CEA, patients were observed for 4-6h in the recovery room and Duplex ultrasonography was completed to assess the endarterectomy repair. Determination was then made whether patients could be safely discharged home. RESULTS: Over a two year period, CEA was performed 39 times in 37 outpatients. Twenty-five patients (64%) were discharged within 6h of surgery completion. The remaining 14 patients (36%) were admitted to the hospital for varying reasons. Six patients (43%) stayed either due to personal preference or the lack of supervision at home and six other patients (43%) stayed because of mild hemodynamic instability. Of the two remaining patients, one was admitted for chest pain and the other for a small wound hematoma. No patients developed postoperative neurologic deficits. Two-tailed Fisher test analysis of collected variables revealed that patients who had general anesthesia were more likely to be admitted (p<0.02). CONCLUSION: Patients undergoing CEA can be safely discharged the same day after a brief period of postoperative observation. One factor that may predict the need for postoperative admission is the use of general anesthesia.

Successful endovascular treatment of a holo-hemispheric cerebral arteriovenous fistula in an infant.

A cerebral arteriovenous fistula (CAVF) is a rare abnormality representing only 4.7% of all cerebral arteriovenous malformations. In this report a unique case is presented of a giant holo-hemispheric CAVF in an infant who presented with congestive heart failure and was successfully treated endovascularly with transarterial and transvenous embolization. A 4-day-old girl presented with lethargy and poor feeding and was found to be in congestive heart failure secondary to a large left hemispheric vascular malformation. Embolization was performed via a transarterial route on days of life (DOL) 11 and 18, a transvenous route on DOL 54 and a final transarterial treatment on DOL 76. After all treatment the patient was discharged home on minimal cardiac medications. At 2-year follow-up the patient had moderate motor delays and mild speech delays, but she continued to meet milestones and her cardiac failure was completely resolved. This case demonstrates one of the largest CAVFs treated successfully in the neonatal population.