Clinical Features and Management of Skull Base Fractures in the Pediatric Population: A Systematic Review.

Pediatric basilar skull fractures (BSFs) are a rare type of traumatic head injury that can cause debilitating complications without prompt treatment. Here, we sought to review the literature and characterize the clinical features, management, and outcomes of pediatric BSFs. We identified 21 relevant studies, excluding reviews, meta-analyses, and non-English articles. The incidence of pediatric BSFs ranged from 0.0001% to 7.3%, with falls from multi-level heights and traffic accidents being the primary causes (9/21). The median presentation age ranged from 3.2 to 12.8 years, and the mean age of patients across all studies was 8.68 years. Up to 55% of pediatric BSFs presented with intracranial hematoma/hemorrhage, along with pneumocephalus and edema. Cranial nerve palsies were a common complication (9/21), with the facial nerve injured most frequently (7/21). While delayed cranial nerve palsy was reported in a few studies (4/21), most resolved within three months post-admission. Other complications included CSF leaks (10/21) and meningitis (4/21). Management included IV fluids, antiemetics, and surgery (8/21) to treat the fracture directly, address a CSF leak, or achieve cranial nerve compression. Despite their rarity, pediatric skull base fractures are associated with clinical complications, including CSF leaks and cranial nerve palsies. Given that some of these complications may be delayed, patient education is critical.

Volumetric segmentation in the context of posterior fossa-related pathologies: a systematic review.

BACKGROUND: Segmentation tools continue to advance, evolving from manual contouring to deep learning. Researchers have utilized segmentation to study a myriad of posterior fossa-related conditions, such as Chiari malformation, trigeminal neuralgia, post-operative pediatric cerebellar mutism syndrome, and Crouzon syndrome. Herein, we present a summary of the current literature on segmentation of the posterior fossa. The review highlights the various segmentation techniques, and their respective strengths and weaknesses, employed along with objectives and outcomes of the various studies reported in the literature. METHODS: A literature search was conducted in PubMed, Embase, Cochrane, and Web of Science up to November 2023 for articles on segmentation techniques of posterior fossa. The two senior authors searched through databases based on the keywords of the article separately and then enrolled joint articles that met the inclusion and exclusion criteria. RESULTS: The initial search identified 2205 articles. After applying inclusion and exclusion criteria, 77 articles were selected for full-text review after screening of titles/abstracts. 52 articles were ultimately included in the review. Segmentation techniques included manual, semi-automated, and fully automated (atlas-based, convolutional neural networks). The most common pathology investigated was Chiari malformation. CONCLUSIONS: Various forms of segmentation techniques have been used to assess posterior fossa volumes/pathologies and each has its advantages and disadvantages. We discuss these nuances and summarize the current state of literature in the context of posterior fossa-associated pathologies.

Clear cell meningiomas-case presentation, review of radiographic identifiers, and treatment approaches.

Spinal clear cell meningiomas (CCMs) are a rare histological subtype of meningiomas that pose preoperative diagnostic challenges due to their radiographic similarities with other lesions. They are also more aggressive, exhibiting higher rates of recurrence, particularly in pediatric patients. Overcoming diagnostic challenges of these tumors can improve patient outcomes. In this report, we describe a case of a pediatric patient presenting with a lumbar CCM in whom we were able to obtain gross total resection. Our report reviews previously identified predictors of CCM recurrence, including the Ki-67 proliferation index, number of spinal segments involved, and hormonal influences related to age and sex. We describe the characteristic radiographic features that differentiate spinal CCMs from other tumors to improve pre-operative diagnosis. Furthermore, we provide our rationale for adjuvant therapy for pediatric patients to refine treatment protocols for these rare tumors.

STAT5b gain-of-function disease in a child with mycobacterial osteomyelitis of the skull: rare presentation of an emerging disease entity.

PURPOSE: STAT proteins play a key role in several cellular functions related to cell development, differentiation, proliferation, and survival. Persistent STAT activation due to somatic STAT5bN642H gain-of-function mutation is a rare mechanism of STAT dysregulation that results in hypereosinophilia, frequent infections, leukemias, and pulmonary diseases. Herein, we describe a case of a child with a rare early onset STAT5b gain-of-function disease treated with targeted JAK inhibition who developed a cranial Mycobacterium avium osteomyelitis. METHODS: A 3-year-old male with a known STAT5b gain-of-function mutation presented with a 10-day history of a firm, immobile, non-painful cranial mycobacterium mass with dural infiltration located anterior to the coronal suture. Stepwise management finalized with complete resection of the lesion with calvarial reconstruction. A case-based literature review was performed evaluating all patients with this mutation who developed cranial disease. RESULTS: The patient was symptom and lesion-free at 1 year since surgical resection and initiation of triple mycobacterial pharmacotherapy. Our literature review demonstrated the rarity of this disease, as well as other presentations of this disease in other patients. CONCLUSION: Patients with STAT5b gain-of-function mutations have attenuated Th1 responses and are treated with medications, such as JAK inhibitors, which further inhibit other STAT proteins that regulate immunity against rare infectious entities, such as mycobacterium. Our case highlights the importance of considering these rare infections in patients on JAK inhibitors and with STAT protein mutations. Possessing a clear mechanistic understanding of this genetic mutation, its downstream effect, and the consequences of treatment may enhance a physician's diagnostic and clinical management of similar patients in the future.

Predicting factors for electrocardiographic findings in patients with tramadol-induced seizure.

BACKGROUND: Seizure and electrocardiographic (ECG) abnormalities are of the most common complications of tramadol toxicity. OBJECTIVE: This study aimed to show the prevalence and predictive value of various factors for ECG findings in patients with tramadol-induced seizures. METHOD: In a descriptive cross-sectional study, 146 patients with tramadol-induced seizures referred to Poursina Hospital, Guilan, Iran, between June and November 2018 were enrolled. The clinical manifestations, such as blood pressure, respiratory rate, and pulse rate (PR), and ECG parameters, including PR interval, QRS duration, R wave in aVR lead, and corrected QT interval, were assessed. Appropriate statistical tests were used to analyze the data. RESULTS: We showed that tramadol dose was significantly higher in patients with abnormal ECG findings compared with those with normal ECG pattern both upon admission (p = 0.001) and after 6 hours of admission (p = 0.001). The results found the predictive value of tramadol dose for abnormal ECG patterns upon admission (odds ratio (OR) 1.014, 95 percent CI 1.008 to 1.020) and 6 hours later (OR 1.008, 95 percent CI 1.003 to 1.013) in these patients. In addition, it was revealed that PR was a strong predictor of abnormal ECG findings in patients with tramadol-induced seizures upon admission (OR 1.085, 95 percent CI 1.038 to 1.134). Nevertheless, age only predicted abnormal findings 6 hours later (OR 1.104, 95 percent CI 1.019 to 1.195). CONCLUSION: Tramadol dose, age, PR, and seizures frequency could be used as indicators of abnormal ECG findings in patients with tramadol-induced seizures. KEY POINTS: The results of our study showed a high prevalence of sinus tachycardia, terminal S and R waves in aVR lead terminal S wave, and the combination of these abnormalities in this subset of patients.

Propionibacterium acnes Infection in Disc Material and Different Antibiotic Susceptibility in Patients With Lumbar Disc Herniation.

BACKGROUND: Low back pain is an important, worldwide clinical problem from which human populations are suffering. It has been suggested that Propionibacterium acnes is associated with low back pain. The objective of this clinical study is to evaluate the P. acnes infection in the disc material and antibiotic susceptibility in patients with disc herniation. METHODS: A total of 120 patients with disc herniation surgery were enrolled in the study. The samples were excited during discectomy and then cultured in both anaerobic and aerobic incubations. Minimum inhibitory concentration (MIC) was performed for determination of antibiotic susceptibility. RESULTS: Of 120 samples, 60 (50%) samples were positive for microorganisms. Disc herniation was at the level of L4-L5 in 63 cases and L5-S1 in 57 cases. CONCLUSIONS: According to the results and presence of P. acnes in more than 35% of the cultured samples, the presence of P. acnes in lumbar disc herniation is a suspected element leading to this condition. After analysis of the antibiotics, the lowest MIC value was identified for amoxicillin, ciprofloxacin, erythromycin, rifampicin, tetracycline, vancomycin; the moderate MIC value was for fusidic acid; and the highest MIC value was for gentamicin and trimethoprim.

Spontaneous Epidural Hematoma of Cervical Spine.

Spontaneous cervical epidural hematoma is an uncommon cause of acute spinal cord compression. This is a rare idiopathic condition that leads to acute onset of neurologic deficits, which if not recognized early can have catastrophic consequences. Acute cervical epidural hematoma is definitely a condition of neurologic emergency. Although it is a rare condition, it must be considered in nontraumatic patients with sudden onset of neurologic deficits. Patients with spontaneous spinal epidural hematoma typically present with acute onset of severe back pain, and they rapidly develop signs of compression of the spinal cord or cauda equina. Here, we present a case of a 31-year-old man who presented with acute onset of neck pain with radicular component with progressive neurologic deficit. Emergent magnetic resonance imaging revealed cervical extradural hematoma with cord compression that was promptly evacuated. Functional recovery was achieved within 48 hours. The level of preoperative neurologic deficit and its severity, as well as operative interval, are important factors significantly affecting the postoperative outcome.

Ligamentum Flavum Hematoma Presented with Low Back Pain: A Case Report and Review of the Literature.

A 61-year-old woman with no past medical history presented with low back pain and radicular pain in the right lower extremity. Magnetic resonance imaging of the lumbar spine showed a heterogeneous intensity mass in the lateral recess of the spinal canal at the L4-5 disk level. Postoperatively, her radicular pain resolved within a few days with excellent low back pain relief. Ligamentum flavum hematoma is a rare differential diagnosis for cystic lesions in the lumbar spine that can be removed simply by surgery with excellent relief of symptoms and improvement in strength of the right lower extremity and increased sensitivity.

Meningioma in Fourth Ventricle of Brain: A Case Report and Literature Review.

Meningiomas are benign tumors origin from central nervous system. They usually involve cephalic, paravertebral soft tissues, skin and in rare cases in the ear, temporal bone, mandible, foot, lung, and mediastinum. In this case, we report an unusual case of meningioma which placed in the fourth ventricle. A 14-year-old man with seizure and headache referred to our ward. The magnetic resonance imaging reported bilateral acoustic neuroma and fourth ventricle meningioma. The patient was scheduled for total tumor resection and the histopathology revealed psammomatous type of meningioma. The patient discharged with good general status.