Pediatric fibrocartilaginous embolism inducing paralysis.

BACKGROUND: Fibrocartilaginous embolism (FCE) is a rare cause of pediatric ischemic myelopathy. The pathology is thought to result from fragmentation with embolization into the microvasculature of the radicular artery often secondary to high axial force. While most cases arise in the setting of vigorous activity, our case reveals that FCE can also occur during relative physical inactivity. Additionally, while a majority of cases are associated with neck or back pain, our case also reveals that FCE can present without concurrent pain episodes. We describe a rare case of spinal cord infarction (SCI) likely due to FCE in a 14 year old male. Our patient was sitting with his feet elevated, playing a video game, when he developed sudden difficulty moving his arms. Initially presenting with a negative MRI scan and la belle indifference, our patient was suspected to exhibit functional quadraparesis secondary to psychosomatization/adjustment disorder. Repeat MR imaging 7 days later revealed typical findings for FCE with SCI (irregular, pencil-like T2 hyperintensity in the ventral cervical/upper thoracic cord and owl's eye pattern on axial images). Six months later, the diagnosis of FCE remains predominant. Our patient continues to improve with occupational and physical therapy. Ambulatory efforts and bladder function continue to progress. To improve functional gains, the patient is being considered for a chemodenervation procedure. CONCLUSION: Our case reveals that FCE can occur during physical inactivity and present without concurrent pain. Outcome regarding pediatric fibrocartilaginous embolism is highly variant; however, the two largest outcomes reported were either patient death or discharge.

Mature Teratoma Confined to the Posterior Fossa.

Mature teratomas located solely in the posterior fossa are rare. We describe a girl who presented with hydrocephalus caused by a posterior fossa tumor that was ultimately diagnosed as a mature teratoma following complete extirpation. Unusual imaging characteristics which produced confusion preoperatively were, however, very consistent with mature teratomas that are encountered in the gonads. Immature elements were universally absent; therefore, extirpation was curative. Hydrocephalus is unlikely to resolve after tumor removal, and cerebrospinal fluid diversion may be required.

Google Trends™ and Quality of Information Analyses of Google™ Searches Pertaining to Concussion.

Sports-related concussions occur with high incidence in the United States. Google Trends™ (GT) analyses indicate changes of public interest in a topic over time, and can be correlated with incidence of health events such as concussion. Internet searches represent a primary means of patient education for many health topics, including concussion; however, the quality of medical information yielded by internet searches is variable and frequently of an inappropriate reading level. This study therefore aims to describe GT over time and evaluate the quality and readability of information produced by Google™ searches of the term "concussion." We identified a strong negative correlation from 2009 to 2016 between GT scores and total number of American high school football participants (R 2 = 0.8553) and participants per school (R 2 = 0.9533). Between 2004 and 2020, the monthly GT popularity score were variable (p = 3.193E-08), with September having the greatest scores, correlating with the height of American tackle football season. Applying five validated quality assessment scoring systems at two time points, it was confirmed that different sources yielded varying quality of information. Academic and non-profit healthcare sources demonstrated the highest quality metrics across two time points. There was significant variability of scores among the different scoring systems, however. The majority of searches at both time points yielded information that was rated as "fair" to "poor" in quality. Applying six readability tests, we revealed that only a single commercial website offered information written at or below the American Medical Association- recommended 6th-grade level for healthcare information. In summary, GT data analyses suggest that searches correlate with the American tackle football season and increased between 2009 and 2016, given that public interest in concussion increased and annual participation in football decreased. The quality of information yielded by Google™ searches and readability are inadequate, indicating the need for significant improvement.

Employing Google Trends to Assess Concussion Search Popularity, Seasonality, and Association With High School Sports Participation.

OBJECTIVE: This investigation employs 2004-2020 Google Trends data to correlate concussion search popularity and high school sports participation while assessing search seasonality and factors associated with search escalation. BACKGROUND: Events linked to concussions, from news to entertainment, altered public perception of concussions and discouraged high-risk activities. Such sentiment likely promoted high school football's 2004-2018 8% decrease in participation, despite simultaneous 8% increase for sports overall. Google Trends (GT) analysis calculates distinct subjects' popularity scores (0-100) by normalizing Google search frequency with other subjects in the same topic. With 35% of patients researching their conditions using Google, tracking concussion popularity scores allows robust analysis of event-driven fluctuation, seasonal variation, and sports impact. DESIGN/METHODS: Worldwide GT analysis was conducted for the disease topic "Concussion" with the categorical filter "Health" from 2004 to 2020. This period's monthly popularity scores with annual averages and annual high school sports participation data were subsequently obtained from Google Trends and the National Federation of State High School Associations, respectively. RESULTS: Concurrence of significant score changes with CTE studies' publication, release of 2015 film Concussion, and the COVID-19 pandemic validates GT's measurement of public interest. From 2006 to 2016, Pearson's correlation coefficients demonstrated strong negative correlation between GT popularity scores for "Concussion" with total number of high school football participants overall (R2 = 0.8553) and participants per school (R2 = 0.9533). Confirming football-related seasonality, one-way ANOVA regression analysis concluded 2004-2020's mean change in month-specific popularity score is not the same (p = 3.193E-08), and months during football season had statistically significant variability (September: p = 4.389E-05) with elevated average z-scores. CONCLUSIONS: Coupled with ANOVA regression and normalized analyses, strong negative correlations between concussion popularity score and high school football participation produce quantitative measures of a long-suspected relationship. Tracking concussion popularity and seasonality with Google Trends provides insight into how, when, and why patients are educating themselves online.

Comparison of spring-mediated cranioplasty to minimally invasive strip craniectomy and barrel staving for early treatment of sagittal craniosynostosis.

The treatment of sagittal craniosynostosis has evolved from early strip craniectomy to total cranial vault remodeling and now back to attempts at minimally invasive correction. To optimize outcomes while minimizing morbidity, we currently use 2 methods of reconstruction in patients younger than 9 months: spring-mediated cranioplasty (SMC) and minimally invasive strip craniectomy with parietal barrel staving (SCPB). The purpose of this study was to compare the safety and efficacy of the 2 methods. Hospital records of our first 7 SMCs and our last 7 SCPBs were analyzed for demographics, the type of operation performed, estimated blood loss, transfusion requirements, operative time, length of stay in the intensive care unit, length of hospital stay, preoperative cephalic index, postoperative cephalic index, and complications. The techniques were then compared using analysis of variance.All 14 patients successfully underwent cranial vault remodeling with significant improvement in cephalic index. Demographics, length of stay in the intensive care unit (P = 0.15), preoperative cephalic index (P = 0.86), and postoperative cephalic index (P = 0.64) were similar between SMC and SCPB. Spring-mediated cranioplasty had statistically significantly shorter operative time (P = 0.002), less estimated blood loss (P < 0.001), and shorter length of hospital stay (P = 0.009) as compared with SCPB. Complications included 1 spring dislodgment in an SMC that did not require additional management and 1 undercorrection in the SCPB group. Both SMC and SCPB are safe, effective means of treating sagittal craniosynostosis. Spring-mediated cranioplasty has become our predominant means of treatment of scaphocephaly in patients younger than 9 months because of its improved morbidity profile.

Comparative analysis of tranexamic acid use in minimally invasive versus open craniosynostosis procedures.

BACKGROUND: Intraoperatively administered tranexamic acid (TXA) lessens blood loss during orthopedic and cardiovascular surgery. Its use for craniosynostosis surgery warrants investigation. Therefore, we analyzed our use of TXA during minimally invasive (MI) and open craniosynostosis procedures. METHODS: Fifty-six patients were retrospectively studied: 20 in the MI group, 10 receiving TXA; 36 in the open group, 16 receiving TXA. Study variables were weight-adjusted estimated blood loss (EBL) and calculated blood loss (CBL), transfusion and incidence, transfusion volume, and complications. Calculated blood loss was determined by a novel formula based on red cell mass. RESULTS: In the MI group, median EBL was significantly lower for TXA recipients (9.62 vs 15.94 mL/kg, P = 0.0231), whereas median CBL was not (36.59 vs 34.12 mL/kg, P = 0.7976). Transfusion incidences were 80% TXA versus 100% control (P = 0.4737). Median transfusion volume trended lower (10.76 vs 19.43 mL/kg, P = 0.0723).In the open group, median EBL and CBL for TXA recipients were lower but not significantly different than for nonrecipients (21.86 vs 23.40 mL/kg, P = 0.7416; 53.54 vs 80.13; P = 0.3137). All patients had a transfusion. Median transfusion volume for TXA recipients versus nonrecipients was 34.01 versus 40.35 mL/kg (P = 0.3137). Tranexamic acid greatly minimized the range of EBL and CBL in both surgical groups. There was a significant correlation between the CBL and EBL (P < 0.0001). There were no adverse events. CONCLUSIONS: Intraoperative TXA administration is safe with modest benefit suggested, especially in the MI group. Calculated blood loss correlated well with EBL at lower blood loss volumes, implicating it as a potential measurement of true blood loss.

Langerhans cell histiocytosis in a patient with stage 4 neuroblastoma receiving oral fenretinide.

Langerhans cell histiocytosis (LCH) has previously been reported in association with other malignancies. The pathogenesis of LCH and its relationship to other malignancies is poorly understood. We present a novel case of a child who developed an LCH bone lesion while receiving a Phase I protocol therapy with oral fenretinide/Lym-X-Sorb (4-HPR/LXS) powder for neuroblastoma.

Machine Learning in Modeling High School Sport Concussion Symptom Resolve.

INTRODUCTION: Concussion prevalence in sport is well recognized, so too is the challenge of clinical and return-to-play management for an injury with an inherent indeterminant time course of resolve. A clear, valid insight into the anticipated resolution time could assist in planning treatment intervention. PURPOSE: This study implemented a supervised machine learning-based approach in modeling estimated symptom resolve time in high school athletes who incurred a concussion during sport activity. METHODS: We examined the efficacy of 10 classification algorithms using machine learning for the prediction of symptom resolution time (within 7, 14, or 28 d), with a data set representing 3 yr of concussions suffered by high school student-athletes in football (most concussion incidents) and other contact sports. RESULTS: The most prevalent sport-related concussion reported symptom was headache (94.9%), followed by dizziness (74.3%) and difficulty concentrating (61.1%). For all three category thresholds of predicted symptom resolution time, single-factor ANOVA revealed statistically significant performance differences across the 10 classification models for all learners at a 95% confidence interval (P = 0.000). Naïve Bayes and Random Forest with either 100 or 500 trees were the top-performing learners with an area under the receiver operating characteristic curve performance ranging between 0.656 and 0.742 (0.0-1.0 scale). CONCLUSIONS: Considering the limitations of these data specific to symptom presentation and resolve, supervised machine learning demonstrated efficacy, while warranting further exploration, in developing symptom-based prediction models for practical estimation of sport-related concussion recovery in enhancing clinical decision support.

Critical assessment of pediatric neurosurgery patient/parent educational information obtained via the Internet.

OBJECTIVE The Internet is used frequently by patients and family members to acquire information about pediatric neurosurgical conditions. The sources, nature, accuracy, and usefulness of this information have not been examined recently. The authors analyzed the results from searches of 10 common pediatric neurosurgical terms using a novel scoring test to assess the value of the educational information obtained. METHODS Google and Bing searches were performed for 10 common pediatric neurosurgical topics (concussion, craniosynostosis, hydrocephalus, pediatric brain tumor, pediatric Chiari malformation, pediatric epilepsy surgery, pediatric neurosurgery, plagiocephaly, spina bifida, and tethered spinal cord). The first 10 "hits" obtained with each search engine were analyzed using the Currency, Relevance, Authority, Accuracy, and Purpose (CRAAP) test, which assigns a numerical score in each of 5 domains. Agreement between results was assessed for 1) concurrent searches with Google and Bing; 2) Google searches over time (6 months apart); 3) Google searches using mobile and PC platforms concurrently; and 4) searches using privacy settings. Readability was assessed with an online analytical tool. RESULTS Google and Bing searches yielded information with similar CRAAP scores (mean 72% and 75%, respectively), but with frequently differing results (58% concordance/matching results). There was a high level of agreement (72% concordance) over time for Google searches and also between searches using general and privacy settings (92% concordance). Government sources scored the best in both CRAAP score and readability. Hospitals and universities were the most prevalent sources, but these sources had the lowest CRAAP scores, due in part to an abundance of self-marketing. The CRAAP scores for mobile and desktop platforms did not differ significantly (p = 0.49). CONCLUSIONS Google and Bing searches yielded useful educational information, using either mobile or PC platforms. Most information was relevant and accurate; however, the depth and breadth of information was variable. Search results over a 6-month period were moderately stable. Pediatric neurosurgery practices and neurosurgical professional organization websites were inferior (less current, less accurate, less authoritative, and less purposeful) to governmental and encyclopedia-type resources such as Wikipedia. This presents an opportunity for pediatric neurosurgeons to participate in the creation of better online patient/parent educational material.

Nontraumatic orbital roof encephalocele.

Intraorbital meningoencephaloceles occur most commonly as a complication of traumatic orbital roof fractures. Nontraumatic congenital orbital meningoncephaloceles are very rare, with most secondary to destructive processes affecting the orbit and primary skull defects. Treatment for intraorbital meningoencephaloceles is surgical repair, involving the excision of herniated brain parenchyma and meninges and reconstruction of the osseous defect. Most congenital lesions present in infancy with obvious globe and orbital deformities; we report an orbital meningoencephalocele in a 3-year-old girl who presented with ptosis.

Inappropriate use of infant seating devices increases risks of injury.

PURPOSE: The purpose of our study was to investigate the epidemiology and resulting injuries following falls sustained by infants seated in a variety of seating devices. METHODS: A retrospective chart review of a cohort of infants less than 12 months old who presented to our institution from 1991 to 2010 after a fall from various seating devices was performed. RESULTS: Two hundred five infants were identified, including 146 patients who were admitted to our institution (1991-2010) and 59 patients who were seen and discharged from the ED (2008-2010). Mean age of admitted infants was younger (3.5 vs. 5.3 months). Two patients (1%) required surgery for a depressed skull fracture. Overall, 18% had an intra-cranial hemorrhage. More patients requiring an admission secondary to their injuries fell from a table or counter (42% vs. 27%). CONCLUSION: Falls sustained by children seated in a variety of devices are frequent. Failure to restrain children in seating devices or improperly placing them on a table/counter is associated with more significant injuries. In order to minimize such injuries, it is important to educate caregivers of the risk in utilizing such seating devices.

Nonendoscopic, minimally invasive calvarial vault remodeling without postoperative helmeting for sagittal synostosis.

OBJECT: Multiple surgical procedures have been described for the management of isolated nonsyndromic sagittal synostosis. Minimally invasive techniques have been recently emphasized, but these techniques necessitate the use of an endoscope and postoperative helmeting. The authors assert that a safe and effective, more "minimalistic" approach is possible, avoiding the use of endoscopic visualization and routine postoperative application of a cranial orthosis. METHODS: A single-institution cohort analysis was performed on 18 cases involving infants treated for isolated nonsyndromic sagittal synostosis between 2008 and 2010 using a nonendoscopic, minimally invasive calvarial vault remodeling (CVR) procedure without postoperative helmeting. The surgical technique is described. Variables analyzed were: age at time of surgery, sex, estimated blood loss (EBL), operative time, intraoperative complications, postoperative complications, length of stay, pre- and postoperative cephalic index (CI), clinical impressions, and results of a 5-question nonstandardized questionnaire administered to patient caregivers regarding outcome. RESULTS: Eleven male and 7 female infants (mean age 2.3 months) were included in the study. The mean duration of follow-up was 16.4 months (range 6-38 months). The mean procedural time was 111 minutes (range 44-161 minutes). The mean length of stay was 2.3 days (range 2-3 days). The mean EBL in all 18 patients was 101.4 ml (range 30-475 ml). One patient had significant bone bleeding resulting in an EBL of 475 ml. Excluding this patient, the mean EBL was 79.4 ml (range 30-150 ml). There were no deaths or intraoperative complications; one patient had a superficial wound infection. The mean CI was 69 preoperatively versus 79 postoperatively, a statistically significant difference (p < 0.0001). Two patients were offered helmeting for suboptimal surgical outcome; one family declined and the single helmeted patient showed improvement at 2 months. No patient has undergone further surgery for correction of primary deformity, secondary deformities, or bony irregularities. Complete questionnaire data were available for 14 (78%) of the 18 patients; 86% of the respondents were pleased with the cosmetic outcome, 92% were happy to have avoided helmeting, 72% were doubtful that helmeting would have provided more significant correction, and 86% were doubtful that further surgery would be necessary. Small, palpable, aesthetically insignificant skull irregularities were reported by family members in 6 cases (43%). CONCLUSIONS: The authors present a nonendoscopic, minimally invasive CVR procedure without postoperative helmeting. Their small series demonstrates this to be a safe and efficacious procedure for isolated nonsyndromic sagittal synostosis, with improvements in CI at a mean follow-up of 16.1 months, commensurate with other techniques, and with overall high family satisfaction. Use of a CVR cranial orthosis in a delayed fashion can be effective for the infrequent patient in whom this approach results in suboptimal correction.

Pediatric sports-related concussion produces cerebral blood flow alterations.

OBJECTIVES: The pathophysiology of sports-related concussion (SRC) is incompletely understood. Human adult and experimental animal investigations have revealed structural axonal injuries, decreases in the neuronal metabolite N-acetyl aspartate, and reduced cerebral blood flow (CBF) after SRC and minor traumatic brain injury. The authors of this investigation explore these possibilities after pediatric SRC. PATIENTS AND METHODS: Twelve children, ages 11 to 15 years, who experienced SRC were evaluated by ImPACT neurocognitive testing, T1 and susceptibility weighted MRI, diffusion tensor imaging, proton magnetic resonance spectroscopy, and phase contrast angiography at <72 hours, 14 days, and 30 days or greater after concussion. A similar number of age- and gender-matched controls were evaluated at a single time point. RESULTS: ImPACT results confirmed statistically significant differences in initial total symptom score and reaction time between the SRC and control groups, resolving by 14 days for total symptom score and 30 days for reaction time. No evidence of structural injury was found on qualitative review of MRI. No decreases in neuronal metabolite N-acetyl aspartate or elevation of lactic acid were detected by proton magnetic resonance spectroscopy. Statistically significant alterations in CBF were documented in the SRC group, with reduction in CBF predominating (38 vs 48 mL/100 g per minute; P = .027). Improvement toward control values occurred in only 27% of the participants at 14 days and 64% at >30 days after SRC. CONCLUSIONS: Pediatric SRC is primarily a physiologic injury, affecting CBF significantly without evidence of measurable structural, metabolic neuronal or axonal injury. Further study of CBF mechanisms is needed to explain patterns of recovery.

Cutaneous vascular anomalies associated with neural tube defects: nomenclature and pathology revisited.

BACKGROUND: Lumbosacral cutaneous vascular anomalies associated with neural tube defects are frequently described in the literature as "hemangiomas." The classification system for pediatric vascular anomalies developed by the International Society for the Study of Vascular Anomalies provides a framework to accurately diagnose these lesions. OBJECTIVE: To apply this classification to vascular cutaneous anomalies overlying myelodysplasias. METHODS: A retrospective analysis of patients with neural tube defects and lumbosacral cutaneous vascular lesions was performed. All eligible patients had detailed histopathologic analysis of skin and spinal cord/placode lesions. Clinical and radiologic features were analyzed. Conventional histology and GLUT-1 immunostaining were performed to differentiate infantile capillary hemangiomas from capillary vascular malformations. RESULTS: Ten cases with cutaneous lesions associated with neural tube defects were reviewed. Five lesions were diagnosed as infantile capillary hemangiomas based upon histology and positive GLUT-1 endothelial reactivity. These lesions had a strong association with dermal sinus tracts. No reoperations were required for residual intraspinal vascular lesions, and overlying cutaneous vascular anomalies involuted with time. The remaining 5 lesions were diagnosed as capillary malformations. These occurred with both open and closed neural tube defects, did not involute, and demonstrated enlargement and darkening due to vascular congestion. CONCLUSION: The International Society for the Study of Vascular Anomalies scheme should be used to describe the cutaneous vascular lesions associated with neural tube defects: infantile capillary hemangiomas and capillary malformations. We advocate that these lesions be described as "vascular anomalies" or "stains" pending accurate diagnosis by clinical, histological, and immunohistochemical evaluations.

Combined C-arm fluoroscopy and C-arm cone beam computed tomography for the evaluation of patients with possible intrathecal baclofen delivery system malfunctions.

BACKGROUND: Evaluating intrathecal baclofen (ITB) delivery systems for potential malfunction can be challenging. The catheter systems are prone to myriad complications that are frequently difficult to ascertain by conventional imaging techniques. Newer imaging technologies and their combinations can be used to identify such problems, define surgical indications, and focus operative planning. C-arm fluoroscopy and C-arm cone beam CT performed in one imaging session represents one such combination that has great utility. OBJECTIVE: We present a case series of ITB catheter evaluations using combined C-arm fluoroscopy (CF) and C-arm cone beam CT (CCBCT). METHODS: We retrospectively analyzed 7 pediatric patients who underwent ITB catheter systems evaluations by the use of combined CF and CCBCT. Study variables included indications for evaluation, imaging results, interventions, correlation of surgical findings with imaging, and clinical outcome. RESULTS: Three patients had intact and patent catheter systems. Four patients demonstrated various problems of the catheter systems, including disconnection, microfracture, fracture with segment migration, and subdural migration. Dosage adjustments improved all patients with normal studies. Surgery was guided by the imaging, and all operative patients improved after targeted interventions. Intraoperative findings correlated perfectly with imaging. CONCLUSION: Combined CF and CCBCT proved highly effective in the evaluation of our patients with potential ITB system malfunctions. This technique is advocated for such evaluations because it accurately defines problems with connectivity, integrity, and position of catheter systems. When surgical intervention is required, this information aids in operative planning.

Intracranial migration of a fractured intrathecal catheter from a baclofen pump system: case report and analysis of possible causes.

OBJECTIVE: This case report describes a new complication associated with a baclofen pump in which its fractured intrathecal catheter migrated into the patient's ventricular system. A thecal model was developed to evaluate catheter buoyancy in artificial cerebrospinal fluid (CSF). The literature was reviewed to identify possible mechanical and physiologic causes of catheter migration. CLINICAL PRESENTATION: A 16-year-old boy with cerebral palsy presented with cervical pain, nausea, and vomiting. He was known to have a nonfunctioning baclofen pump with a 1-piece intrathecal catheter. Imaging studies showed mild ventriculomegaly and a fractured segment of the intrathecal catheter that extended from the cervical subarachnoid space into the third and fourth ventricles. INTERVENTION: The patient had complete symptom resolution after undergoing urgent surgical removal of the catheter segment. Manufacturer analysis of the retrieved catheter revealed a crushed, jagged proximal end. In an experimental thecal sac model, catheter segments in lengths of 0.5 to 89 cm were denser than the artificial CSF and, therefore, did not float in the thecal sac. This finding negates the role of buoyancy in migration. Review of the literature advocates for caudocranial CSF flow patterns as a plausible mechanism for migration. CONCLUSION: This complication alerts surgeons to the migration risk of loose intrathecal catheter segments into the ventricular system. CSF flow patterns and mechanical processes, but not material properties of the catheter, are likely causes.

Hypothalamic-opticochiasmatic gliomas mimicking craniopharyngiomas.

The differential diagnosis of suprasellar masses in the pediatric age group includes craniopharyngiomas and hypothalamic-opticochiasmatic gliomas (HOCGs). These tumors frequently display unique features on computed tomography and magnetic resonance imaging. We review two cases of pediatric suprasellar HOCGs with preoperative imaging characteristics resembling those of craniopharyngioma. HOCGs mimicking craniopharyngiomas represent a diagnostic and operative challenge to the pediatric neurosurgeon. Although an accurate leading pathologic diagnosis can frequently be made with preoperative neuroimaging, the neurosurgeon must be prepared for discovery of another tumor type and have plans to proceed accordingly.