Diffuse axonal injury on magnetic resonance imaging and its relation to neurological outcomes in pediatric traumatic brain injury.

OBJECTIVE: Diffuse axonal injury (DAI), a frequent consequence of pediatric traumatic brain injury (TBI), presents challenges in predicting long-term recovery. This study investigates the relationship between the severity of DAI and neurological outcomes in children. METHODS: We conducted a retrospective analysis of 51 pediatric TBI patients diagnosed with DAI using Adam's classification. Neurological function was assessed at 2, 3, and 6 weeks, and 12 months post-injury using the Pediatric Glasgow Outcome Scale-Extended (PGOSE). RESULTS: PGOSE scores significantly improved over time across all DAI grades, suggesting substantial recovery potential even in initially severe cases. Despite indicating extensive injury, patients with DAI grades II and III demonstrated significant improvement, achieving a good recovery by 12 months. Although the initial Glasgow Coma Scale (GCS) score did not show a statistically significant association with long-term outcomes in our limited sample, these findings suggest that the severity of DAI alone may not fully predict eventual recovery. CONCLUSIONS: Our study highlights the potential for significant neurological recovery in pediatric patients with DAI, emphasizing the importance of long-term follow-up and individualized rehabilitation programs. Further research with larger cohorts and extended follow-up periods is crucial to refine our understanding of the complex relationships between DAI severity, injury mechanisms, and long-term neurological outcomes in children.

Spinal Gunshot Wound With an Air Rifle: A Case Report.

Spinal gunshot injuries are one of the most serious injuries that can cause morbidity and mortality. We report a case of a nine-year-old boy, referred to our emergency department from another hospital, with lower limb weakness after being shot by an air gun in his back. After extensive investigation, it appeared that a foreign body representing the bullet was found in his spinal canal; the patient was taken to the operating room for surgical decompression and removal of foreign bodies. After that, the patient started to show partial improvement in his neurological deficits and is to be continued on physiotherapy.

Clinical characterization of pediatric supratentorial tumors and prediction of pituitary insufficiency in two tertiary centers in Saudi Arabia.

Background: Post-operative pituitary insufficiency (PI) occurs in children with supra-tentorial tumors (STT) because of surgery or the mass effect of the tumor. We assessed the prevalence and clinical characteristics of STTs and predicted postoperative PI in our patients. Methods: This retrospective cohort study included children who underwent surgery for STT in two tertiary hospitals in Saudi Arabia (2009-2019). We focused on clinical, radiological, and histopathological features of STTs. We also used a linear regression model to predict post-operative PI. Results: The study included 55 children (1-18 years, mean: 9.5 ± 4.9 years, 32 [54%] females) with an initial presentation of STT that required surgery excluding recurrent episodes. The calculated period prevalence of STT was 18.2%, and the prevalence of postoperative PI was 58.2% (n = 32/55). The most common symptoms were headache and visual disturbances, and 20% patients had preoperative symptoms of PI. Baseline preoperative investigations for PI were performed in 60% of patients, and dynamic tests were conducted in only seven patients. A residual cortisol deficiency was presumed in 24 (43.7%) patients and 18 (32.7%) patients who developed central diabetes insipidus (DI) post-operatively. Overall, the brain imaging correlated well with the histopathological diagnosis (kappa = 0.48; P < .001). Craniopharyngioma (n = 15/55, 27.3%) was the commonest STT. Predictive factors for a postoperative residual PI included age (10.9 ± 4.8 years; p-value = .027), female gender (p-value = .016 [OR = 8.31; 95% CI (1.48-46.71)], presentation with headache (P value = .039 [OR = 9.27; 95% CI (1.12-76.72)]), and visual disturbances (p-value = .044 [OR = 5.07; 95% CI (1.04-24.61)]. Conclusion: STTs commonly occurred in our study population, and females were more prone to develop a residual PI. On-time surveillance of an intact endocrine system during the perioperative period is essential for the prediction and early management of PI.

A rare cerebellar vermis high-grade neuroepithelial tumor: Radiological-pathological correlation.

Neuroepithelial tumors, formerly known as primitive neuroectodermal tumors of the central nervous system, are reclassified under embryonal tumors in the 2016 WHO Classification of Tumors of the Central Nervous System. The tumor has two known genetic alterations: HGNET-MN1 and HGNET-BCOR. Previously, radiological features of the tumor have been reported as large, intra-axial lesions in the cerebral or cerebellar hemisphere, which presents mild adjacent edema. Here, we report the first case of high-grade neuroepithelial tumor not elsewhere classified (HGNET-NEC) arising from the cerebellar vermis, demonstrating good outcomes in clinical follow-up when compared with previously known types.

Management of ventriculo-gallbladder shunt in the presence of gallstones.

Hydrocephalus is a prevalent health problem that is frequently encountered by paediatric neurosurgeons during infancy and childhood. We report a case of an 11-year-old boy with high cerebrospinal fluid protein hydrocephalus secondary to optic glioma that required a ventriculoperitoneal (VP) shunt. The patient had multiple failures of VP shunt and developed massive ascites. Alternatively, the hydrocephalus was treated by ventriculo-gallbladder (VG) shunt in the presence of sludge which was removed from the gallbladder before placement of the shunt. After VG shunt insertion, the patient expressed signs of infection with elevated liver profile, which emphasised the presence of gallstones. While the shunt was kept in its place without any complications, the gallstones were successfully removed by an endoscopic retrograde cholangiopancreatography. In conclusion, the presence of sludge is not a contraindication for VG shunt placement, and, if the VG shunt was complicated with gallstones, it could be treated without the need for cholecystectomy.

Split Cord Malformation: Presentation, Management, and Surgical Outcome.

BACKGROUND: Split cord malformation (SCM) is a rare anomaly characterized by a split along the midline of the cord, which divides it into 2 symmetric or nonsymmetric entities. SCM surgical indications and outcomes are still debatable, the signs and symptoms are generally nonspecific and are commonly associated with other anomalies and deficits. METHODS: We retrospectively searched the hospital database at King Abdulaziz Medical City, Riyadh, Saudi Arabia for patients with SCM between 1998 and 2018. Descriptive statistics were used to present categorical data as percentages and frequencies. RESULTS: A total of 25 patients were included in this series. The mean age of patients at the time of diagnosis was 4.4 years. A total of 18 patients (72%) underwent surgical correction. The mean difference between the age at diagnosis and the age at correction was 7 months. All patients underwent intraoperative neurophysiologic monitoring. Postoperative complications were minimal. Cerebrospinal fluid leakage was noted in 2 patients, transient urinary retention was noted in 1 patient, and transient unilateral leg paresis was noted in 1 patient. Most patients (n = 15, 83%), were discharged within 19 days after surgery, and 81% showed improvement postoperatively. Over the long-term follow-up, none of the patients developed new urologic or neurologic deficits. CONCLUSIONS: Most patients with SCM present during childhood. Postoperative complications after SCM corrective surgery are generally minimal, and the overall outcomes, mainly including partial or complete symptomatic improvement and/or symptom stability and hydronephrosis resolution, were favorable.

Cervical spine clearance in unconscious pediatric trauma patients: a level l trauma center experience.

PURPOSE: To radiographically assess cervical spine clearance in unconscious pediatric trauma patients. METHODS: A retrospective cohort study was conducted to review pediatric patients with suspected cervical spinal injuries between 2005 and 2018 at King Abdulaziz Medical City (KAMC), Riyadh, Saudi Arabia. All pediatric patients aged 15 years and less, who sustained trauma (motor vehicle accident, pedestrian, fall, all-terrain vehicle accident, and sports injures) and were intubated at the scene or in the emergency department, were included. RESULTS: A total of 62 patients were included. The average age for children was 8 ± 3.9 years. The average Glasgow coma scale (GCS) for children at initial trauma was 7.6 + 3.7. The average injury severity score (ISS) was 24.1 + 17.7. The most frequent abnormal finding identified on CT scan was cervical spine straightening (N = 8; 13.1%). A total of 13 children had abnormal MRI findings, with the most common injury being ligamentous in nature (N = 13; 46.42%). The sensitivity and specificity of CT scan in cervical spine clearance in unconscious children are 84.8% and 100%, respectively. CONCLUSION: Utilizing CT scans in clearing the cervical spine is of paramount importance to promptly detect possible injuries. The role of MRI in cervical spine clearance still cannot be undervalued, especially when the clinical suspicion for injury is high.

Intraoperative Triggered Electromyography Recordings from the External Urethral Sphincter Muscles During Spine Surgeries.

INTRODUCTION: Bowel and bladder function are at risk during tumor resection and other surgeries of the conus, cauda equina, and nerve roots. This study demonstrates the ability to acquire triggered electromyography (t-EMG) from the external urethral sphincter (EUS) muscles by utilizing a urethral catheter with an electrode attached. METHODS: A retrospective analysis of neurophysiological monitoring data from two medical centers was performed. Seven intradural tumors and three tethered cord release surgeries that used urethral sphincter electrodes to record t-EMG were included in the analysis. The patients consisted of five females and five males with ages ranging from eight months to 67 years (median: 49 years). Our neuromonitoring paradigm included upper and lower extremity somatosensory evoked potentials (SSEPs) and transcranial electrical motor evoked potentials (TCeMEPs), as well as spontaneous and triggered electromyography (EMG) from the external anal sphincter (EAS), EUS muscles and lower extremity muscles bilaterally. A catheter with urethral electrodes attached was used for recording spontaneous electromyography (s-EMG), t-EMG, and TCeMEPs from the skeletal muscle of the EUS. Train of four (TOF) was also recorded from the abductor hallucis muscle as well for monitoring the level of muscle relaxant. RESULTS: We were able to successfully record t-EMG responses from the EUS muscles in all patients (100%). It is worthy to note that only one patient presented preoperatively with bladder incontinence, urgency, and frequency. Almost immediately in the postoperative phase, the patient's frequency and urgency improved, and the bladder function normalized within two weeks of having the tumor removed. CONCLUSIONS: In this small series, we were able to acquire t-EMG in 100% of patients when recorded from the EUS using a urethral catheter with electrodes built into it. T-EMGs can be attempted in surgeries that put the function of the pelvic floor at risk. More study is needed to establish better statistical methods, better modality efficacy, and a better understanding of intraoperative countermeasures that may be employed when an alert is encountered to prevent impending neurological sequelae.

Pediatric Rhabdoid Meningioma with Extension to the Heart: A First Case Report and Literature Review.

BACKGROUND: Meningiomas are the most common benign intracranial neoplasms in adults, but they have a lower incidence in children. Rhabdoid meningioma is a rare subtype of meningioma and is classified as World Health Organization grade III. CASE DESCRIPTION: We present a very rare case of a 9-year-old boy who presented to our institution with a history of headache, dizziness, and vomiting without neurologic deficit. The investigation showed a posterior fossa tumor with hemorrhage inside and hydrocephalus. He underwent tumor resection, and pathology showed rhabdoid meningioma. The patient had extensive recurrence after only 5 months, including extension to the neck, mediastinal veins, and heart. He was treated surgically and received adjuvant chemotherapy followed by radiation therapy. CONCLUSIONS: Rhabdoid meningioma is a malignant subtype of meningioma that occurs very rarely in pediatric patients. Additionally, rhabdoid meningioma, when it does occur in pediatric patients, has a high tendency to recur. Radical surgical resection with adjuvant radiotherapy is essential to prolonging survival. This is the first case with extracranial extension to the mediastinal veins and heart.

Primary Giant Cerebral Hydatid Cyst in an 8-year-old Girl.

Echinococcosis, also called hydatid disease, is a parasitic disease that passes from animals to humans. Literature reports suggest very rare cases of cerebral hydatid cysts. Brain involvement with hydatid disease occurs in 1%-2% of all Echinococcus infections. In this report, we aim to emphasize the presentation of such an isolated primary cerebral hydatid cyst, discuss its radiological features, Emergency department management, inpatient medical management, referral to neurosurgery, consequent operative procedures, postoperative care, and outcome.

Benefit of Intraoperative Neurophysiological Monitoring in a Pediatric Patient with Spinal Dysmorphism, Split Cord Malformation, and Scoliosis.

Intraoperative neurophysiological monitoring (IONM) consists of a group of neurodiagnostic techniques that assess the nervous system's functional integrity during surgical operations. A retrospective analysis of a pediatric female patient was conducted who underwent 12 operations for the correction of scoliosis, tethered cord, and split spinal cord wherein IONM played an important role. From age 3 to 6, she underwent six procedures including a release of the tethered cord, resection of the filum terminale, removal of a T11-T12 bony spur, release of L3 adhesions, repair of subcutaneous meningocele, and correction of scoliosis with a vertical expandable prosthetic titanium rod (VEPTR) technique without the use of IONM. However, a multimodality IONM protocol with somatosensory evoked potentials, transcranial electrical motor evoked potentials (TCeMEP), and an electromyogram was utilized during the later procedures. At age 6 (the seventh procedure), a VEPTR expansion was performed, with loss and recovery of the lower extremity motor evoked potentials. The postoperative magnetic resonance imaging (MRI) showed a partial split cord malformation with retethering of the spinal cord. We repaired her split cord malformation and tethered cord while employing IONM. Using IONM for her operation was crucial because a sudden significant loss of TCeMEP resulted in a cancellation of the procedure; the MRI showed a thick remnant attached to the spinal cord. If the procedure was performed without IONM, we could have missed the underlying pathology, an error that may have resulted in paraplegia. We strongly recommend using IONM during high-risk surgical procedures to help significantly reduce the risk of permanent postoperative complications.

Sacral Dimple.

A 5-month-old boy, the product of a normal, spontaneous, uncomplicated vaginal delivery, presented to a peripheral hospital with a 2-month history of recurrent fever, vomiting, seizures, and progressive lower limb weakness. He was discovered to have hydrocephalus secondary to a posterior fossa lesion. An external ventricular drain was inserted, and he was transferred to our hospital. Upon presentation, his head circumference was 45 cm (in the 90th percentile), pupils were equally reactive, and he was quadriparetic with the left side being weaker than the right. Spinal examination revealed a sacral dimple with purulent discharge on digital pressure. Magnetic resonance imaging revealed a brain abscess, a spinal dermoid cyst, and dermal sinus. He underwent craniotomy and abscess evacuation followed by untethering of the spinal cord, resection of the dermoid, and the skin sinus. He tolerated the procedure well, and his weakness improved. The antibiotic course was completed, and the external ventricular drain was removed. Follow-up after 2 years showed a normal neurologic examination.