Comprehensive characterization of intracranial hemorrhage in deep brain stimulation: a systematic review of literature from 1987 to 2023.

OBJECTIVE: Deep brain stimulation (DBS) is an effective treatment for medically refractory movement disorders and other neurological conditions. To comprehensively characterize the prevalence, locations, timing of detection, clinical effects, and risk factors of DBS-related intracranial hemorrhage (ICH), the authors performed a systematic review of the published literature. METHODS: PubMed, EMBASE, and Web of Science were searched using 2 concepts: cerebral hemorrhage and brain stimulation, with filters for English, human studies, and publication dates 1980-2023. The inclusion criteria were the use of DBS intervention for any human neurological condition, with documentation of hemorrhagic complications by location and clinical effect. Studies with non-DBS interventions, no documentation of hemorrhage outcome, patient cohorts of ≤ 10, and pediatric patients were excluded. The risk of bias was assessed using Centre for Evidence-Based Medicine Levels of Evidence. The authors performed proportional meta-analysis for ICH prevalence. RESULTS: A total of 63 studies, with 13,056 patients, met the inclusion criteria. The prevalence of ICH was 2.9% (fixed-effects model, 95% CI 2.62%-3.2%) per patient and 1.6% (random-effects model, 95% CI 1.34%-1.87%) per DBS lead, with 49.6% being symptomatic. The ICH rates did not change with time. ICH most commonly occurred around the DBS lead, with 16% at the entry point, 31% along the track, and 7% at the target. Microelectrode recording (MER) during DBS was associated with increased ICH rate compared to DBS without MER (3.5 ± 2.2 vs 2.1 ± 1.4; p[T ≤ t] 1-tail = 0.038). Other reported ICH risk factors include intraoperative systolic blood pressure > 140 mm Hg, sulcal DBS trajectories, and multiple microelectrode insertions. Sixty percent of ICH was detected at 24 hours postoperatively and 27% intraoperatively. The all-cause mortality rate of DBS was 0.4%, with ICH accounting for 22% of deaths. Single-surgeon DBS experience showed a weak inverse correlation (r = -0.27, p = 0.2189) between the rate of ICH per lead and the number of leads implanted per year. CONCLUSIONS: This study provides level III evidence that MER during DBS is a risk factor for ICH. Other risk factors include intraoperative systolic blood pressure > 140 mm Hg, sulcal trajectories, and multiple microelectrode insertions. Avoidance of these risk factors may decrease the rate of ICH.

Successful magnetic resonance-guided focused ultrasound treatment of tremor in patients with a skull density ratio of 0.4 or less.

OBJECTIVE: The use of magnetic resonance-guided focused ultrasound (MRgFUS) for the treatment of tremor-related disorders and other novel indications has been limited by guidelines advocating treatment of patients with a skull density ratio (SDR) above 0.45 ± 0.05 despite reports of successful outcomes in patients with a low SDR (LSDR). The authors' goal was to retrospectively analyze the sonication strategies, adverse effects, and clinical and imaging outcomes in patients with SDR ≤ 0.4 treated for tremor using MRgFUS. METHODS: Clinical outcomes and adverse effects were assessed at 3 and 12 months after MRgFUS. Outcomes and lesion location, volume, and shape characteristics (elongation and eccentricity) were compared between the SDR groups. RESULTS: A total of 102 consecutive patients were included in the analysis, of whom 39 had SDRs ≤ 0.4. No patient was excluded from treatment because of an LSDR, with the lowest being 0.22. Lesioning temperatures (> 52°C) and therapeutic ablations were achieved in all patients. There were no significant differences in clinical outcome, adverse effects, lesion location, and volume between the high SDR group and the LSDR group. SDR was significantly associated with total energy (rho = -0.459, p < 0.001), heating efficiency (rho = 0.605, p < 0.001), and peak temperature (rho = 0.222, p = 0.025). CONCLUSIONS: The authors' results show that treatment of tremor in patients with an LSDR using MRgFUS is technically possible, leading to a safe and lasting therapeutic effect. Limiting the number of sonications and adjusting the energy and duration to achieve the required temperature early during the treatment are suitable strategies in LSDR patients.

Trends and disparities in deep brain stimulation utilization in the United States: a Nationwide Inpatient Sample analysis from 1993 to 2017.

Background: Deep brain stimulation (DBS) is an approved treatment option for Parkinson's Disease (PD), essential tremor (ET), dystonia, obsessive-compulsive disorder and epilepsy in the United States. There are disparities in access to DBS, and clear understanding of the contextual factors driving them is important. Previous studies aimed at understanding these factors have been limited by single indications or small cohort sizes. The aim of this study is to provide an updated and comprehensive analysis of DBS utilization for multiple indications to better understand the factors driving disparities in access. Methods: The United States based National Inpatient Sample (NIS) database was utilized to analyze the surgical volume and trends of procedures based on indication, using relevant ICD codes. Predictors of DBS use were analyzed using a logistic regression model. DBS-implanted patients in each indication were compared based on the patient-, hospital-, and outcome-related variables. Findings: Our analysis of 104,356 DBS discharges from 1993 to 2017 revealed that the most frequent indications for DBS were PD (67%), ET (24%), and dystonia (4%). Although the number of DBS procedures has consistently increased over the years, radiofrequency ablation utilization has significantly decreased to only a few patients per year since 2003. Negative predictors for DBS utilization in PD and ET cohorts included age increase and female sex, while African American status was a negative predictor across all cohorts. Significant differences in patient-, hospital-, and outcome-related variables between DBS indications were also determined. Interpretation: Demographic and socioeconomic-based disparities in DBS use are evident. Although racial disparities are present across all indications, other disparities such as age, sex, wealth, and insurance status are only relevant in certain indications. Funding: This work was supported by Alan & Susan Hudson Cornerstone Chair in Neurosurgery at University Health Network.

Spinal Cord Stimulation for Parkinson's Disease: A Systematic Review and Meta-Analysis of Pain and Motor Outcomes.

BACKGROUND: Spinal cord stimulation (SCS) has been investigated as a potential therapeutic option for managing refractory symptoms in patients with Parkinson's disease (PD). OBJECTIVE: This systematic review and meta-analysis aimed to evaluate the safety and efficacy of SCS in PD. METHOD: A comprehensive literature search was conducted on PubMed and Web of Science to identify SCS studies reporting Unified Parkinson Disease Rating Scale-III (UPDRS-III) or Visual Analogue Scale (VAS) score changes in PD cohorts with at least 3 patients and a follow-up period of at least 1 month. Treatment effect was measured as the mean change in outcome scores and analyzed using an inverse variance random-effects model. The risk of bias was assessed using the Newcastle-Ottawa Scale and funnel plots. RESULTS: A total of 11 studies comprising 76 patients were included. Nine studies involving 72 patients reported an estimated decrease of 4.43 points (95% confidence interval [CI]: 2.11; 6.75, p < 0.01) in UPDRS-III score, equivalent to a 14% reduction. The axial subscores in 48 patients decreased by 2.35 points (95% CI: 1.26; 3.45, p < 0.01, 20% reduction). The pooled effect size of five studies on back and leg pain VAS scores was calculated as 4.38 (95% CI: 2.67; 6.09, p < 0.001), equivalent to a 59% reduction. CONCLUSIONS: Our analysis suggests that SCS may provide significant motor and pain benefits for patients with PD, although the results should be interpreted with caution due to several potential limitations including study heterogeneity, open-label designs, small sample sizes, and the possibility of publication bias. Further research using larger sample sizes and placebo-/sham-controlled designs is needed to confirm effectiveness.

Essential Tremor - Deep Brain Stimulation vs. Focused Ultrasound.

INTRODUCTION: Essential Tremor (ET) is one of the most common tremor syndromes typically presented as action tremor, affecting mainly the upper limbs. In at least 30-50% of patients, tremor interferes with quality of life, does not respond to first-line therapies and/or intolerable adverse effects may occur. Therefore, surgery may be considered. AREAS COVERED: In this review, the authors discuss and compare unilateral ventral intermedius nucleus deep brain stimulation (VIM DBS) and bilateral DBS with Magnetic Resonance-guided Focused Ultrasound (MRgFUS) thalamotomy, which comprises focused acoustic energy generating ablation under real-time MRI guidance. Discussion includes their impact on tremor reduction and their potential complications. Finally, the authors provide their expert opinion. EXPERT OPINION: DBS is adjustable, potentially reversible and allows bilateral treatments; however, it is invasive requires hardware implantation, and has higher surgical risks. Instead, MRgFUS is less invasive, less expensive, and requires no hardware maintenance. Beyond these technical differences, the decision should also involve the patient, family, and caregivers.

Magnetic resonance-guided focused ultrasound for the treatment of tremor.

INTRODUCTION: Magnetic resonance-guided focused ultrasound (MRgFUS) is an emerging treatment for tremor and other movement disorders. An incisionless therapy, it is becoming increasingly common worldwide. However, given MRgFUS' relative novelty, there remain limited data on its benefits and adverse effects. AREAS COVERED: We review the current state of evidence of MRgFUS for tremor, highlight its challenges, and discuss future perspectives. EXPERT OPINION: Essential tremor (ET) has been the major indication for MRgFUS since a milestone randomized controlled trial (RCT) in 2016, with substantial evidence attesting to the efficacy and acceptable safety profile of this treatment. Patients with other tremor etiologies are also being treated with MRgFUS, with studies - including an RCT - suggesting parkinsonian tremor in particular responds well to this intervention. Additionally, targets other than the ventral intermediate nucleus, such as the subthalamic nucleus and internal segment of the globus pallidus, have been reported to improve parkinsonian symptoms beyond tremor, including rigidity and bradykinesia. Although MRgFUS is encumbered by certain unique technical challenges, it nevertheless offers significant advantages compared to alternative neurosurgical interventions for tremor. The fast-growing interest in this treatment modality will likely lead to further scientific and technological advancements that could optimize and expand its therapeutic potential.

Connectomic neuromodulation for Alzheimer's disease: A systematic review and meta-analysis of invasive and non-invasive techniques.

Deep brain stimulation (DBS) and non-invasive neuromodulation are currently being investigated for treating network dysfunction in Alzheimer's Disease (AD). However, due to heterogeneity in techniques and targets, the cognitive outcome and brain network connectivity remain unknown. We performed a systematic review, meta-analysis, and normative functional connectivity to determine the cognitive outcome and brain networks of DBS and non-invasive neuromodulation in AD. PubMed, Embase, and Web of Science were searched using three concepts: dementia, brain connectome, and brain stimulation, with filters for English, human studies, and publication dates 1980-2021. Additional records from clinicaltrials.gov were added. Inclusion criteria were AD study with DBS or non-invasive neuromodulation and a cognitive outcome. Exclusion criteria were less than 3-months follow-up, severe dementia, and focused ultrasound intervention. Bias was assessed using Centre for Evidence-Based Medicine levels of evidence. We performed meta-analysis, with subgroup analysis based on type and age at neuromodulation. To determine the patterns of neuromodulation-induced brain network activation, we performed normative functional connectivity using rsfMRI of 1000 healthy subjects. Six studies, with 242 AD patients, met inclusion criteria. On fixed-effect meta-analysis, non-invasive neuromodulation favored baseline, with effect size -0.40(95% [CI], -0.73, -0.06, p = 0.02), while that of DBS was 0.11(95% [CI] -0.34, 0.56, p = 0.63), in favor of DBS. In patients ≥65 years old, DBS improved cognitive outcome, 0.95(95% [CI] 0.31, 1.58, p = 0.004), whereas in patients <65 years old baseline was favored, -0.17(95% [CI] -0.93, 0.58, p = 0.65). Functional connectivity regions were in the default mode (DMN), salience (SN), central executive (CEN) networks, and Papez circuit. The subgenual cingulate and anterior limb of internal capsule (ALIC) showed connectivity to all targets of neuromodulation. This meta-analysis provides level II evidence of a difference in response of AD patients to DBS, based on age at intervention. Brain stimulation in AD may modulate DMN, SN, CEN, and Papez circuit, with the subgenual cingulate and ALIC as potential targets.

Idiopathic Parkinson's disease and chronic pain in the era of deep brain stimulation: a systematic review and meta-analysis.

OBJECTIVE: Pain is the most common nonmotor symptom of Parkinson's disease (PD) and is often undertreated. Deep brain stimulation (DBS) effectively mitigates the motor symptoms of this multisystem neurodegenerative disease; however, its therapeutic effect on nonmotor symptoms, especially pain, remains inconclusive. While there is a critical need to help this large PD patient population, guidelines for managing this significant disease burden are absent. Herein, the authors systematically reviewed the literature and conducted a meta-analysis to study the influence of traditional (subthalamic nucleus [STN] and globus pallidus internus [GPi]) DBS on chronic pain in patients with PD. METHODS: The authors performed a systematic review of the literature and a meta-analysis following PRISMA guidelines. Risk of bias was assessed using the levels of evidence established by the Oxford Centre for Evidence-Based Medicine. Inclusion criteria were articles written in English, published in a peer-reviewed scholarly journal, and about studies conducting an intervention for PD-related pain in no fewer than 5 subjects. RESULTS: Twenty-six studies were identified and included in this meta-analysis. Significant interstudy heterogeneity was detected (Cochran's Q test p < 0.05), supporting the use of the random-effects model. The random-effects model estimated the effect size of DBS for the treatment of idiopathic pain as 1.31 (95% CI 0.84-1.79). The DBS-on intervention improved pain scores by 40% as compared to the control state (preoperative baseline or DBS off). CONCLUSIONS: The results indicated that traditional STN and GPi DBS can have a favorable impact on pain control and improve pain scores by 40% from baseline in PD patients experiencing chronic pain. Further trials are needed to identify the subtype of PD patients whose pain benefits from DBS and to identify the mechanisms by which DBS improves pain in PD patients.

Infratemporal Fossa Vascular Anatomy Pertinent to Percutaneous Access to the Foramen Ovale for Treatment of Trigeminal Neuralgia: A Comparison of Cadaveric Dissection and Computed Tomography Analysis.

BACKGROUND: Trigeminal neuralgia may be treated via percutaneous access to the foramen ovale (FO). Vascular complications associated with the needle trajectory can result in serious morbidity and mortality. This study aimed to correlate the vascular relationships of the FO at the skull base via cadaveric dissections and computed tomography (CT). METHODS: Two fresh cadaver heads were injected with red and blue latex to delineate arteries and veins. Neck and infratemporal fossa dissections were carried out to delineate the vascular relationships of the FO. High-resolution head CT images of adult patients undergoing neurosurgical evaluations or procedures were analyzed for distances and sizes of skull base foramina in the infratemporal fossa. RESULTS: Three infratemporal fossa dissections (2 cadaveric specimens) were performed. Mean distance of FO to internal carotid artery was 2.4 ± 0.12 cm, and mean distance of FO to middle meningeal artery was 0.8 ± 0.16 cm. Head CT images of 52 patients (104 sides) with 1-mm axial slice thickness were analyzed. Area of the FO was 31.1 ± 9.6 mm2. Distance of FO to internal carotid artery was 1.70 ± 0.31 cm, and distance of FO to middle meningeal artery was 0.73 ± 0.61 cm. CONCLUSIONS: Cadaveric delineation of vascular structures in the infratemporal fossa correlates with head CT imaging and may be used to accurately plan percutaneous access to the FO. Inadvertent puncture of the extracranial internal carotid artery is nearly impossible with good technique. The most likely source of percutaneous vascular injury is the middle meningeal artery and distal branches of the maxillary artery.

Deep brain stimulation targets in epilepsy: Systematic review and meta-analysis of anterior and centromedian thalamic nuclei and hippocampus.

Deep brain stimulation (DBS) is a neuromodulatory treatment used in patients with drug-resistant epilepsy (DRE). The primary goal of this systematic review and meta-analysis is to describe recent advancements in the field of DBS for epilepsy, to compare the results of published trials, and to clarify the clinical utility of DBS in DRE. A systematic literature search was performed by two independent authors. Forty-four articles were included in the meta-analysis (23 for anterior thalamic nucleus [ANT], 8 for centromedian thalamic nucleus [CMT], and 13 for hippocampus) with a total of 527 patients. The mean seizure reduction after stimulation of the ANT, CMT, and hippocampus in our meta-analysis was 60.8%, 73.4%, and 67.8%, respectively. DBS is an effective and safe therapy in patients with DRE. Based on the results of randomized controlled trials and larger clinical series, the best evidence exists for DBS of the anterior thalamic nucleus. Further randomized trials are required to clarify the role of CMT and hippocampal stimulation. Our analysis suggests more efficient deep brain stimulation of ANT for focal seizures, wider use of CMT for generalized seizures, and hippocampal DBS for temporal lobe seizures. Factors associated with clinical outcome after DBS for epilepsy are electrode location, stimulation parameters, type of epilepsy, and longer time of stimulation. Recent advancements in anatomical targeting, functional neuroimaging, responsive neurostimulation, and sensing of local field potentials could potentially lead to improved outcomes after DBS for epilepsy and reduced sudden, unexpected death of patients with epilepsy. Biomarkers are needed for successful patient selection, targeting of electrodes and optimization of stimulation parameters.

Laser interstitial thermal therapy for the treatment of insular lesions: A systematic review.

Background: The surgical treatment of insular lesions has been historically associated with high morbidity. Laser interstitial thermal therapy (LITT) has been increasingly used in the treatment of insular lesions, commonly neoplastic or epileptogenic. Stereotaxis is used to guide laser probes to the insula where real-time magnetic resonance thermometry defines lesion creation. There is an absence of previously published reviews on insular LITT, despite a rapid uptake in use, making further study imperative. Methods: Here we present a systematic review of the PubMed and Scopus databases, examining the reported clinical indications, outcomes, and adverse effects of insular LITT. Results: A review of the literature revealed 10 retrospective studies reporting on 53 patients (43 pediatric and 10 adults) that were treated with insular LITT. 87% of cases were for the treatment of epilepsy, with 89% of patients achieving seizure outcomes of Engle I-III following treatment. The other 13% of cases reported on insular tumors and radiological improvement was seen in all cases following treatment. All but one study reported adverse events following LITT with a rate of 37%. The most common adverse events were transient hemiparesis (29%) and transient aphasia (6%). One patient experienced an intracerebral hemorrhage, which required a decompressive hemicraniectomy, with subsequent full recovery. Conclusion: This systematic review highlights the suitability of LITT for the treatment of both insular seizure foci and insular tumors. Despite the growing use of this technique, prospective studies remain absent in the literature. Future work should directly evaluate the efficacy of LITT with randomized and controlled trials.

Patient Acceptability of the Use of Advanced Practice Providers in an Outpatient Neurosurgery Clinic.

Introduction Increasing demands for healthcare manpower has necessitated the utilization of advanced practice providers (APPs). The effect of APPs in primary care has been well-characterized but is less studied in surgical subspecialties. The objective of this study is to assess the patient acceptability of APPs in an outpatient neurosurgery setting. Methods We conducted a prospective, survey-based study among 78 adult patients in the neurosurgical outpatient clinic. The survey consisted of 10 questions assessing the hypothetical acceptability of care provided by neurosurgeons and APPs. These were compared as pre-specified dyads, with patients blinded to dyad composition. The data were analyzed with Chi-square tests. Results Patients preferred to see their neurosurgeon for their first clinic visit even with a longer lag time (29% acceptability difference, p = 0.012). Patients also preferred to see the neurosurgeon for their first postoperative visit (20% difference, p = 0.009). For all visits, patients preferred to see an APP if the clinic visit would be on time, rather than see the surgeon with a significant delay (30% difference, p = 0.0002). If their visit was scheduled with an APP, patients preferred that the neurosurgeon review their treatment plan before they left the clinic (15% difference, p = 0.04). Overall, seeing an APP was acceptable if patients were informed ahead of time (37% difference, p < 0.0001). Conclusions Team-based care utilizing APPs is acceptable to patients. Patients had strong preferences for seeing their surgeon for the first neurosurgical clinic visit and first post-operative visit. Patients were satisfied with seeing an APP if they could be seen more expeditiously. Patients also preferred to know ahead of time if they were going to see an APP.

Deep Brain Stimulation for Multiple Sclerosis Tremor: A Meta-Analysis.

OBJECTIVES: To examine the effect of deep brain stimulation (DBS) on multiple sclerosis (MS)-tremor, as measured by a normalized scale of tremor severity, with a meta-analysis of the published literature. METHODS: Medline and EBSCO Host (January, 1998 to June, 2018) were systematically reviewed with librarian guidance, using the keywords "Deep brain stimulation" and "multiple sclerosis." Bibliographies and experts in the field were also consulted to identify missed articles. All therapeutic studies on DBS for MS-tremor, reported in the English language, within the study period were included. Papers that reported outcomes without a measure of central tendency and/or distribution were excluded. The papers were read in their entirety and graded for risk of bias according to the American Academy of Neurology (AAN) standards. To maximize statistical power, papers using different stimulation targets were grouped together. Outcomes were reported with the Fahn-Tolosa-Marin scale (FTM), the Bain-Finchley scale (CRS) and 3- and 4-point tremor severity scales and normalized with a Hedges g. RESULTS: The search produced 13 studies suitable for meta-analysis. The random-effects meta-analysis showed that DBS improved the Hedges standardized mean tremor score by 2.86 (95%CI 2.03-3.70, p < .00001). Heterogeneity was high, with an I2 of 84%, suggesting that random effects model is more appropriate. Adverse event rates varied from 8% to 50%. CONCLUSIONS: This meta-analysis provides level III evidence that DBS may improve MS-related tremor as measured by standardized tremor severity scales.

Venous Manometry as an Adjunct for Diagnosis and Multimodal Management of Intracranial Hypertension due to Meningioma Compressing Sigmoid Sinus.

Intracranial venous hypertension is a rare presentation of meningiomas in the transverse-sigmoid sinus region. We describe a case of a young patient presenting with intracranial hypertension due to a meningioma causing compression of the dominant sigmoid sinus. We were able to document the cerebral venous pressure gradient across the lesion confirming our hypothesis that compression of the sigmoid sinus from the meningioma was the cause of intracranial hypertension. The patient is a 17-year-old male who presented with intracranial hypertension due to meningioma at the right dominant sigmoid sinus, which was treated by a Simpson grade IV surgical resection followed by stereotactic radiosurgery. Following treatment, his papilledema resolved and he remains symptom-free at 18 months. In conclusion, venous manometry is a useful adjunct to diagnose intracranial hypertension in non-idiopathic causes of intracranial hypertension. A multimodal management approach of intracranial hypertension due to outflow obstruction from the dominant sinus led to an excellent recovery on follow up.

Neurogenesis in Neurodegenerative Diseases: Role of MFG-E8.

Neurodegenerative diseases are devastating medical conditions with no effective treatments. Restoration of impaired neurogenesis represents a promising therapeutic strategy for neurodegenerative diseases. Milk fat globule-epidermal growth factor-factor VIII (MFG-E8) is a secretory glycoprotein that plays a wide range of cellular functions including phagocytosis of apoptotic cells, anti-inflammation, tissue regeneration, and homeostasis. The beneficial role of MFG-E8 has been shown in cerebral ischemia (stroke), neurodegenerative diseases such as Alzheimer's disease and Parkinson's disease, and traumatic brain injury. In stroke, MFG-E8 promotes neural stem cell proliferation and their migration toward the ischemic brain tissues. These novel functions of MFG-E8 are primarily mediated through its receptor αvß3-integrin. Here, we focus on the pivotal role of MFG-E8 in protecting against neuronal diseases by promoting neurogenesis. We also discuss the mechanisms of MFG-E8-mediated neural stem/progenitor cell (NSPC) proliferation and migration, and the potential of MFG-E8 for neural stem cell niche maintenance via angiogenesis. We propose further investigation of the molecular pathways for MFG-E8 signaling in NSPC and effective strategies for MFG-E8 delivery across the blood-brain barrier, which will help develop MFG-E8 as a future drug candidate for the bedside management of neurodegenerative diseases.

Post-partum posterior reversible encephalopathy syndrome requiring decompressive craniectomy: case report and review of the literature.

Posterior reversible encephalopathy syndrome (PRES) is an uncommon but potentially devastating syndrome if not recognized and treated appropriately. As the name implies, recognition of the condition and proper management may reverse the clinical and radiological findings. However, diagnosis is not always straightforward. We present the case of a 24-year-old female who was 4 days post-partum and presented with headache, neck pain, and new-onset seizures. She had undergone epidural anesthesia during labor, and initial imaging was suggestive of intracranial hypotension versus pachymeningitis. Despite initial conservative therapy including anti-epileptic drugs, magnesium therapy, empiric antibiotics, and Trendelenburg positioning, the patient continued to deteriorate. Follow-up imaging was suggestive of PRES with signs of intracranial hypertension. The patient underwent a decompressive suboccipital craniectomy for refractory and severe PRES and later fully recovered. This case highlights the sometimes difficult diagnosis of PRES, possible association with pregnancy, eclampsia/preeclampsia and/or cerebrospinal fluid drainage, and the rare but life-saving need for decompression in severe cases.

Growing Skull Fracture: Case Report after Rottweiler Bite and Review of the Literature.

Growing skull fracture remains a rare but clinically significant complication of traumatic skull fractures in children less than 3 years of age. Dog attacks on children commonly cause head and neck injuries. We report the first case of growing skull fracture caused by a Rottweiler bite in a 21 days old neonate. Early diagnosis and surgical repair resulted in excellent outcome.