Unusual Case of Posterior Fossa Extradural Hematoma in a Child: Review of the Literature.

INTRODUCTION: Posterior fossa extradural hematoma (PFEH) is a rare pathology often due to nuchal region trauma. In children, PFEH causes rapid decline of the neurological status also for brain stem compression. Early brain computed tomography (CT) scan is necessary suspicious for PFEH. Most patients need surgical evacuation. CASE PRESENTATION: In this article, we present a 5-year-old patient arrived for meningitis that came out in favor of PFEH after an accurate history record. DISCUSSION/CONCLUSION: Accurate anamnestic records, especially in pediatric patients, prevent from misleading clinic and neurological presentation. Brain CT scan is an indispensable diagnostic tool in order to promptly recognize and treat PFEH considering that rapid cognitive impairment of patients raises the risk of mortality and morbidity.

Modern Treatment of Brain Arteriovenous Malformations Using Preoperative Planning Based on Navigated Transcranial Magnetic Stimulation: A Revisitation of the Concept of Eloquence.

BACKGROUND: Navigated transcranial magnetic stimulation (nTMS) provides a reliable identification of "eloquent" cortical brain areas. Moreover, it can be used for diffusion tensor imaging fiber tracking of eloquent subcortical tracts. We describe the use of nTMS-based cortical mapping and diffusion tensor imaging fiber tracking for defining the "eloquence" of areas surrounding brain arteriovenous malformations (BAVMs), aiming to improve patient stratification and treatment. METHODS: We collected data of BAVMs suspected to be in eloquent areas treated between 2017 and 2019, and submitted to nTMS-based reconstruction of motor, language, and visual pathways for the definition of the eloquence of the surrounding brain areas. We describe the nTMS-based approach and analyze its impact on patient stratification and allocation to treatment in comparison with the standard assessment of eloquence based on anatomical landmarks. RESULTS: Ten patients were included in the study. Preliminarily, 9 BAVMs were suspected to be located in an eloquent area. After nTMS-based mapping, only 5 BAVMs were confirmed to be close to eloquent structures, thus leading to a change of the score for eloquence and of the final BAVMs grading in 60% of patients. Treatment was customized according to nTMS information, and no cases of neurological worsening were observed. Radiological obliteration was complete in 7 cases microsurgically treated, and accounted for about 70% in the remaining 3 patients 1 year after radiosurgical treatment. CONCLUSIONS: The nTMS-based information allows an accurate stratification and allocation of patients with BAVMs to the most effective treatment according to a modern, customized, neurophysiological identification of the adjacent eloquent brain networks.