Revision rates of flow- versus pressure-regulated ventricular shunt valves for the treatment of hydrocephalus in neonates following germinal matrix haemorrhage-a retrospective review.

PURPOSE: Neonates with ventricular shunts inserted for hydrocephalus following germinal matrix haemorrhage (GMH) have high rates of shunt revision. The shunt valve plays a key role in regulating the function of the shunt. In this study, we aim to determine if the choice of flow-regulated or pressure-regulated valve used in the initial implantation of a shunt affects the rate of shunt revision. METHODS: A retrospective cohort comparison study was performed on 34 neonates with hydrocephalus following GMH who underwent placement of a ventricular shunt at the Queensland Children's Hospital from November 2014 to June 2020. The primary outcome examined was the need for revision or replacement of the ventricular shunt after successful initial placement within 2 years of implantation. The secondary outcome examined was the survival time of the shunt. RESULTS: 16 patients had placement of a flow-regulated valve, and 18 patients had placement of a pressure-regulated valve. 14 (87.5%) patients with flow-regulated valves required replacement during the follow-up period. 2 (18.18%) patients with a fixed pressure regulated underwent revision, while 2 (28.57%) programmable pressure-regulated shunts required revision. Patients that had a flow-regulated valve had a statistically significant higher rate of revision compared to those who had a pressure-regulated valve, (87.5% flow vs 22.22% pressure) with a P-value of < 0.001. Valve obstruction was also more common in patients with flow-regulated valves than pressure-regulated valves (4 vs 0) with a P-value of 0.010. Overall mean median survival time was 22.06 months, shunts with flow-regulated valves had a shorter median survival time of 3.19 months compared with over 24 months for pressure-regulated valves with a P-value of < 0.001. CONCLUSION: Our study suggests that the initial implantation of flow-regulated valves may carry an increased total rate of shunt revision and valve obstruction within the first 2 years following implantation compared to pressure-regulated valves in patients with hydrocephalus following GMH.

Endovascular treatment of trigeminal neuralgia with cranial autonomic symptoms due to a right-sided petrous ridge dAVF.

Dural arteriovenous fistula represents a rare cause of secondary Trigeminal Neuralgia. To date, there have been 18 reported cases of successful treatment of trigeminal neuralgia with endovascular embolization. Here we describe a unique case of a 51-year-old man with right-sided petrous ridge dural arteriovenous fistula causing ipsilateral V1 pain and cranial autonomic dysfunction. Cerebral angiography confirmed a Cognard type 3 right-sided tentorial dAVF supplied by an enlarged meningo-hypophpyseal vessel from the extradural ICA and by the middle meningeal artery. The fistula drains towards the midline via deep cerebral veins, the internal cerebral vein and the straight sinus with likely variceal compression of the right trigeminal nerve root entry zone. Transarterial Onyx embolization resulted in complete obliteration of the dural arteriovenous fistula with immediate resolution of facial pain and autonomic symptoms. After 24 months, the patient remains symptom-free and has no radiographic or clinical evidence of fistula recurrence. To date, there have been no other cases reported of trigeminal neuralgia with cranial autonomic symptoms or SUNCT syndrome due to a dural arteriovenous fistula. The presence of cranial autonomic symptoms with trigeminal neuralgia or a diagnosis of SUNCT should not deter endovascular treatments of dural arteriovenous fistulas or treatment of other compressive vascular lesions.

Chiari 1 malformation: age-based outcomes in a paediatric surgical cohort.

PURPOSE: Substantial evidence exists describing differences between paediatric and adult Chiari 1 malformation (CM1) patients. Differences in clinical presentation between very young (0-6 years old) and older (7-18 years old) paediatric patients is similarly well-established. However, progression on these findings with regard to surgical outcomes is limited. We aimed to establish whether inter-paediatric age group modifies surgical outcome for CM1 decompression. METHODS: Retrospective chart review was conducted for 65 patients receiving posterior fossa decompression between 2006 and 2018. Presenting features, surgical management, and outcome were evaluated and stratified into very young patients (0-6 years) or older patients (7-18 years). Outcomes were assessed using the Chicago Chiari Outcome Scale (CCOS), a validated 16-point framework for comparison. RESULTS: Very young patients (21 patients) scored significantly lower in surgical outcome overall compared with older patients (44 patients) (12.1 ± 3.2/16 vs 14.2 ± 1.6/16, p = 0.011), and across 3/4 CCOS subscores: non-pain symptoms, functionality, and complications. Very young patients also returned to theatre more commonly (47.6% vs 13.6%, p = 0.003), primarily for re-do decompression (7/10 patients, 70%). Finally, the presentation of very young patients differed to older patients with significantly more oropharyngeal (38.1% vs 9.0%, p = 0.014) and motor symptoms (47.6% vs 22.7%, p = 0.042). DISCUSSION: Very young patients (0-6 years) do not appear to respond as well to standard posterior fossa decompression, as their older (7-18 years) paediatric counterparts, in the absence of several baseline cohort characteristic differences. We hypothesise underlying anatomical differences may contribute to this finding.

Ceiling Fan-Related Head Injuries in Children: A Queensland Neurosurgical Experience.

INTRODUCTION: Ceiling fans are a widespread energy-efficient appliance required for managing the sweltering weather extremes encountered in northern Australian states including Queensland. Ceiling fans are also a rare cause of serious head injury in children requiring neurosurgical intervention. There is limited available evidence on the presentation, mechanism, and management of these injuries. METHODS: A retrospective analysis of children who suffered ceiling fan injuries admitted to the Queensland Children's Hospital, a level-1 paediatric trauma hospital in Brisbane, Queensland, under the neurosurgery unit from November 2014 to July 2018 was performed. RESULTS: Seventeen children (64.7% male) with a mean age of 4.24 years (range 0.66-7.25) sustained ceiling fan injuries requiring neurosurgical management during this period. Children were injured following being accidentally lifted or thrown into the ceiling fan path; jumping, playing, climbing, or being pushed from a bunk bed; or climbing on other furniture. All patients suffered skull fractures (88.2% depressed), and 65% suffered extra-axial or intracerebral haemorrhage. Operative management was required in 76.5% of the patients. No patients suffered adverse outcomes, and no complications, including infections, were recorded. CONCLUSIONS: Despite their rarity, paediatric ceiling fan injuries requiring neurosurgical management are a cause of significant morbidity. Surgical management targeted elevation of depressed fractures and washout of open fractures rather than evacuation of intracranial collections. Almost all included patients required transfer with associated social and economic implications. Such injuries are largely preventable with improved supervision and safety awareness. Hazard modification may be extended to regulatory changes or improved ceiling fan design.

Case Report of an Anterior Thoracic Myelomeningocele: A Multidisciplinary Approach to Surgical Management.

BACKGROUND: Cervicothoracic myelomeningocele (MMC) is a rare entity with only 2 reported cases in the literature of anterior thoracic MMC. CASE DESCRIPTION: We report a third case in a 3-year-old boy. MMC was diagnosed during antenatal screening and later warranted surgical intervention. Despite being asymptomatic, radiologic surveillance demonstrated worsening syringomyelia, tonsillar descent, and cord signal change concerning for myelomalacia. Preoperative management involved respiratory assessment for pulmonary compromise, general pediatric consultation, gait analysis by physiotherapy, and serial imaging by radiology. Surgical management involved an anterior thoracotomy approach by cardiothoracic surgeons, repair of the MMC by neurosurgeons, and bone graft to ameliorate the bony defect in the vertebral body by orthopaedic surgeons. Postoperative care involved 4 days in the intensive care unit and 14 days on the pediatric neurosurgical ward. At 3-year follow-up, there was radiologic improvement of syringomyelia, tonsillar descent, and kyphoscoliosis with no neurological or pulmonary complications. CONCLUSIONS: This case highlights the unique multidisciplinary surgical management of the rare entity of anterior thoracic MMC without scoliosis correction for radiologic progression.

Traumatic brain injuries in a paediatric neurosurgical unit: A Queensland experience.

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children with a broad injury spectrum and associated continuum in the level of care required. A dearth of data exists regarding children requiring inpatient neurosurgical admission following TBI. A retrospective study of children 0-16 years-old admitted to the neurosurgical unit of a level-1 paediatric trauma hospital in Queensland, Australia following TBI was conducted focusing on the demographics, clinical characteristics, and management of these patients to guide those involved in their management, and identify areas for improvement in injury prevention and trauma system management. Over 48 months, 671 patients were identified (62.6% male) with median age 5.0 years, the majority transferred from peripheral centres. Falls (47.2%) and traffic accidents (21.5%) were the most common mechanisms. Non-displaced skull fracture was the most common injury. Moderate or severe TBI (GCS 3-12) was seen in 14.8% of whom were more likely to require surgery, intensive care, or suffer polytrauma. Clinically significant TBI, defined as moderate/severe TBI, polytrauma, death, requiring neurosurgery, intensive care admission, intubation, or admission three or more nights was detected in 57.97% with higher rates in transferred patients (62.9%) versus primary presentations (50.6%). Mechanisms involving low kinetic forces especially low-height falls and children with non-surgical pathology were less likely to meet criteria for clinically significant TBI. Opportunity exists to optimise triage and transfer practices within the trauma network to minimise the economic and social implications of over-triage with many children requiring only brief observation.

Neurological injuries from skateboards in paediatric and adolescent populations: injury types and severity.

BACKGROUND: Skateboarding is a popular recreation among children and adolescents. Injuries that result in presentation to emergency departments are varied including head injuries. The study aims to assess the type and severity of neurological damage to the brain and spine in children from injuries incurred while using a skateboard. METHODS: After obtaining Ethics approval, a retrospective case review was performed of all admissions to all Brisbane, Australia public hospital neurosurgery departments of children 18 years and less who experienced injuries to the brain and spine for the years 2010-2014. RESULTS: There were 51 skateboard-related admissions over the study period of which 94% were male. The mean age was 14.3 years. The Injury Severity Score (ISS) ranged from 1 to 38 with a mean of 11.4. A total of 70.5% of the ISS scores fell within the minor or moderate categories and 29.5% fell within the serious and severe categories. There were no ISS scores in the critical category. A total of 16 skull vault fractures and 14 skull base fractures were recorded. There were 13 extradural haematomas of which five were evacuated by craniotomy and one of whom experienced hemiplegia. There was a spinal cord injury with paraplegia. A range of other neurological complications occurred. There were no deaths. CONCLUSION: Uncommon but serious neurological morbidity accompanies skateboard use. Concerns remain about the level of helmet use and choice of unsafe locations for skateboarding.

Chiari I malformation with significant motor and autonomic dysfunction in an infant.

Quadriparesis and cardiovascular instability are not symptoms commonly associated with Chiari I malformation diagnoses, less so in a 3-month-old toddler. Chiari I malformations have a wide array of symptoms, varying with regard to both the nature of onset and the age of the patient presenting. This variation is illustrated in this report, presenting a novel description of a set of symptoms in a particularly young patient, a case lacking the common insidious nature of Chiari I malformation symptoms. Acute onset of cardiovascular instability, global hypertonia, hyperreflexia, and proximal upper limb weakness in a 3-month-old toddler are discussed. Parallels between the presented case and previous case reports are few, however some key features are distinguishable among similar cases. A successful posterior fossa craniectomy allowed the acutely unwell toddler to become a healthy, fully functional child. We believe this case contributes to elucidating the rare presentations of a curious pathology.

The effect of age on the quality of life of patients living with stomas: a pilot study.

BACKGROUND: The formation of a stoma is associated with important effects on quality of life (QOL). The objective of this prospective pilot study was to assess the effect of age on QOL after stoma formation. METHODS: Forty-nine patients requiring stoma formation had their QOL assessed by completion of the SF-36 v2 (SF-36v-1999 QualityMetric, Inc.) QOL questionnaire at three time points (preoperatively, at 6 months and at 12 months postoperatively). RESULTS: There was evidence of a difference in mental function according to age (P = 0.05) with younger patients continuing to improve in QOL to 12 months, whereas older patients started higher but any improvement in their QOL over time was too small to be shown. Physical function of QOL improved over time in both younger and older patients, but the pattern of change differed. Older patients started higher but reached their maximum QOL by 6 months, whereas younger patients continued to improve. There was also evidence of a difference related to presentation with acute presentations starting lower in terms of QOL than elective presentations and showing an increase in QOL at both 6 and 12 months. No difference in change in QOL could be shown for type of stoma, sex or reversal. CONCLUSIONS: There was evidence that age and presentation are factors that influence changes in the QOL of stoma patients. Studies have shown that a stoma nurse specialist may help to increase QOL. Therefore, stoma therapy should be targeted at older patients who require more physical and mental support in adjusting to life with a stoma.