Surgical Outcome of Patients With Supratentorial Meningiomas Aged 80 Years or Older-Retrospective International Multicenter Study.

BACKGROUND AND OBJECTIVES: Demographic changes will lead to an increase in old patients, a population with significant risk of postoperative morbidity and mortality, requiring neurosurgery for meningiomas. This multicenter study aims to report neurofunctional status after resection of patients with supratentorial meningioma aged 80 years or older, to identify factors associated with outcome, and to validate a previously proposed decision support tool. METHODS: Neurofunctional status was assessed by the Karnofsky Performance Scale (KPS). Patients were categorized in poor (KPS ≤40), intermediate (KPS 50-70), and good (KPS ≥80) preoperative subgroups. Volumetric analyses of tumor and peritumoral brain edema (PTBE) were performed; volumes were scored as small (<10 cm 3 ), medium (10-50 cm 3 ), and large (>50 cm 3 ). RESULTS: The study population consisted of 262 patients, and the median age at surgery was 83.0 years. The median preoperative KPS was 70; 117 (44.7%) patients were allotted to the good, 113 (43.1%) to the intermediate, and 32 (12.2%) to the poor subgroup. The median tumor and PTBE volumes were 30.2 cm 3 and 27.3 cm 3 ; large PTBE volume correlated with poor preoperative KPS status ( P = .008). The 90-day and 1-year mortality rates were 9.0% and 13.2%, respectively. Within the first postoperative year, 101 (38.5%) patients improved, 87 (33.2%) were unchanged, and 74 (28.2%) were functionally worse (including deaths). Each year increase of age associated with 44% (23%-70%) increased risk of 90-day and 1-year mortality. In total, 111 (42.4%) patients suffered from surgery-associated complications. Maximum tumor diameter ≥5 cm (odds ratio 1.87 [1.12-3.13]) and large tumor volume (odds ratio 2.35 [1.01-5.50]) associated with increased risk of complications. Among patients with poor preoperative status and large PTBE, most (58.3%) benefited from surgery. CONCLUSION: Patients with poor preoperative neurofunctional status and large PTBE most often showed postoperative improvements. The decision support tool may be of help in identifying cases that most likely benefit from surgery.

Perioperative continuation or ultra-early resumption of antithrombotics in elective neurosurgical cranial procedures.

OBJECTIVE: Discontinuation of antithrombotics (AT) prior to elective cranial procedures is common practice, despite the higher risk of thromboembolic complications in these patients. The aim of this study was to investigate the risks and benefits of a new perioperative management protocol of continuation or ultra-early AT resumption in elective cranial procedures. METHODS: This study was an analysis of a prospectively collected cohort of patients undergoing elective cranial surgery with (AT group) and without (control group) AT. For extraaxial or shunt surgeries, acetylsalicylic acid (ASA) was continued perioperatively. For intraaxial pathologies, ASA was discontinued 2 days before surgery and resumed on postoperative day 3. All other AT were discontinued according to their pharmacokinetics, and resumed on postoperative day 3 after unremarkable postoperative imaging. Additionally, the authors performed a retrospective analysis of patients with AT who underwent surgery before implementation of this new AT management protocol (historical AT group). Primary and secondary outcomes were the incidence of hemorrhagic and thromboembolic complications within 3 months after surgery. RESULTS: Outcomes of 312 patients were analyzed (83 [27%] in the AT group, 106 [34%] in the control group, and 123 [39%] in the historical AT group). For all 3 patient groups, the most common type of surgery was craniotomy for intraaxial tumors (14 [17%] in the AT group, 28 [26%] in the control group, and 60 [49%] in the historical AT group). The most commonly used AT were ASA (38 [46%] in the AT group and 78 [63%] in the historical AT group), followed by non-vitamin K oral anticoagulants (32 [39%] in the AT group and 18 [15%] in the historical AT group). The total perioperative discontinuation time in the AT group was significantly shorter than in the historical AT group (median of 4 vs 16 days; p < 0.001). The rate of hemorrhagic complications was 4% (95% CI 1-10) (n = 3/83) in the AT group, 6% (95% CI 2-12) (n = 6/106) in the control group, and 7% (95% CI 3-13) (n = 9/123) in the historical AT group (p = 0.5). The rate of thromboembolic complications was 5% (95% CI 1-12) (n = 4/82) in the AT group, 8% (95% CI 3-15) (n = 8/104) in the control group, and 7% (95% CI 3-13) (n = 8/120) in the historical AT group (p = 0.7). CONCLUSIONS: The presented perioperative management protocol of continuation or ultra-early resumption of AT in elective cranial procedures does not seem to increase the hemorrhagic risk. Moreover, it appears to potentially protect patients from thromboembolic complications.

Rapid Versus Gradual Weaning of External Ventricular Drain: A Systematic Literature Review and Meta-analysis.

The insertion of an external ventricular drain (EVD) is one of the most common neurosurgical procedures. Whether the weaning method (gradual or rapid) influences the ventriculoperitoneal shunt (VPS) insertion rate has not been conclusively established. The aim of this study is to provide a systematic literature review and conduct a meta-analysis of studies comparing gradual with rapid EVD weaning regarding VPS insertion rate. Articles were identified by searching the Pubmed/Medline, Embase, and Web of Science databases throughout October 2022. Two independent researchers assessed the studies for inclusion and quality. We included randomized trials, prospective cohort studies, and retrospective cohort studies, which compared gradual and rapid EVD weaning. The primary outcome was VPS insertion rate, whereas secondary outcomes were EVD-associated infection (EVDAI) rate and length of stay in the hospital and intensive care unit (ICU). Four studies directly comparing rapid versus gradual EVD weaning, with 1337 patients suffering from subarachnoid hemorrhage, were identified and included in the meta-analysis. VPS insertion rate was 28.1% and 32.1% in patients with gradual and rapid EVD weaning, respectively (relative risk 0.85, 95% confidence interval 0.49-1.46, p = 0.56). Further, the EVDAI rate was comparable between the groups (gradual group 11.2%, rapid group 11.5%, relative risk 0.67, 95% confidence interval 0.24-1.89, p = 0.45), whereas length of stay in the ICU and hospital were significantly shorter in the rapid weaning group (2.7 and 3.6 days, respectively; p < 0.01). Rapid EVD weaning seems comparable to gradual EVD weaning concerning VPS insertion rates and EVDAI, whereas hospital and ICU length of stay is significantly reduced.

Intracranial Neuroendoscopy in Children and Adults: Where Do the Differences Lie?

BACKGROUND: Intraventricular neuroendoscopy has evolved into an essential adjunct in neurosurgery and is used across all age groups for various indications. However, studies comparing neuroendoscopic procedures between children and adults are scarce. The aim of this study is to compare various aspects between adults and children undergoing neuroendoscopy. METHODS: We retrospectively analyzed the data from consecutive patients dichotomized into 2 cohorts, pediatric (age <18 years) and adult (age ≥18 years) groups, in whom intracranial neuroendoscopy was performed between 2013 and 2020 (pediatric group) and 2010 and 2020 (adult group). RESULTS: Of 132 patients who underwent intracranial neuroendoscopic surgery, 47 (35.6%) were children and 85 (64.4%) were adults. The most common indications for the children and adults were intraventricular or paraventricular tumors (23.4%) and aqueduct stenosis (40%), respectively. Their clinical condition at the last follow-up was unchanged or improved for 90.5% of the children and 92.1% of the adults. An increased endoscopic third ventriculostomy success score was predictive of endoscopic third ventriculostomy success in the pediatric cohort (odds ratio, 1.073; P = 0.043). The postoperative rates of transient (pediatric, 23.4%; adult, 18.8%) and permanent (pediatric, 0%; adult, 1.2%) complications were comparable. The rate of secondary surgery was higher for the pediatric cohort (38.3%) than for the adult cohort (17.6%). CONCLUSIONS: The indications for neuroendoscopy vary between adults and children, although the long-term clinical outcome is comparable. The rate of secondary surgery is significantly higher for pediatric patients, especially for those aged <1 year. Because neuroendoscopy is considerably more frequent in pediatric patients, including pediatric neurosurgeons in adult neuroendoscopic cases could potentially help lower the complication rates and increase the success rates.

Clinical and patient-reported outcome after patient-specific 3D printer-assisted cranioplasty.

Various cranioplasty techniques exist for the reconstruction of cranial bone defects. Patient-specific implants can be produced in-house using a recently developed 3D printer-assisted cranioplasty technique. However, the resulting cosmetic outcomes from the patient's perspective are underreported. With our case series, we aim to present the clinical outcome, morbidity rate, patient-reported cosmetic results, and cost-effectiveness of patient-specific3D printer-assisted cranioplasty technique. This is a consecutive retrospective case series of adult patients undergoing cranioplasty using the patient-specific 3D printer-assisted technique. As primary endpoint, the functional outcome based on modified Rankin scale (mRS) at discharge and follow-up was assessed. A prospective telephone survey was conducted to collect and provide patient-reported outcomes. Thirty-one patients underwent patient-specific 3D printer-assisted cranioplasty, mostly to reconstruct frontotemporoparietal (61.3%) and frontotemporal defects with orbital involvement (19.4%). Good functional outcome (mRS ≤ 2) at discharge and during the last follow-up was achieved in 54.8% (n = 17) and 58.1% (n = 18) patients. Overall, the rate of clinically relevant surgery-related complications was 35.5% (n = 11). Postoperative epidural hematoma/collection (16.1%) and infections (12.9%) were the most frequent complications. Permanent morbidity occurred in one patient (3.2%) with postoperative acute ipsilateral vision loss after frontotemporal cranioplasty with orbital involvement. No surgery-related mortality occurred. The mean patient-reported cosmetic satisfaction score was 7.8 ± 1.5, with 80% of patients reporting satisfying or very satisfying cosmetic results. No significant differences were seen between the different defect localization regarding the cosmetic outcome. The mean manufacturing costs of a patient-specific 3D printer-assisted implant ranged from 748 to 1129 USD. Based on our case series, patient-specific 3D printer-assisted cranioplasty is cost-effective and leads to satisfying cosmetic results, especially in large defects and/or defects with complex geometry.

The Role of Active or Passive Drainage after Evacuation of Chronic Subdural Hematoma: An Analysis of Two Randomized Controlled Trials (cSDH-Drain-Trial and TOSCAN Trial).

The evacuation of a chronic subdural hematoma (cSDH) is one of the most common procedures in neurosurgery. The aim of this study was to assess the influence of drainage suction in the surgical treatment of cSDH on the recurrence rate. Post hoc analysis was conducted on two randomized controlled trials (cSDH-Drain-Trial and TOSCAN trial) stratifying a total of 581 patients into active or passive drain type. Of the 581 patients, 359 (61.8%) and 220 (37.9%) were stratified into the active and passive drainage groups, respectively. The reoperation rate following postoperative recurrence was 23.1% and 14.1% in the active and passive drainage groups, respectively (p < 0.011). After propensity score matching, the differences in recurrence rate remained significant (26.6% versus 15.6%, p = 0.012). However, the functional outcome (mRS) at 6−12 months did not differ significantly (median [IQR]) between the 2 groups (passive drainage group 0.00 [0.00, 2.00], active drainage group 1.00 [0.00, 2.00], p = 0.431). Mortality was comparable between the groups (passive drainage group 12 (5.5%), active drainage group 20 (5.6%), p = 0.968). In the univariate analysis, active drainage, short (<48 h) duration of drainage, and early (<48 h) postoperative mobilization were significantly associated with a higher recurrence rate. However, the multivariate logistic regression model could not confirm that any of these parameters were significantly associated with recurrence. Our post hoc analysis proposes that using a passive instead of an active drain might be associated with a reduced recurrence rate after evacuation of a cSDH. We suggest gathering further evidence by means of a randomized controlled trial.

Resection of brain lesions with a neuroendoscopic ultrasonic aspirator - a systematic literature review.

The development of minimally invasive neuroendoscopy has advanced in recent years. The introduction of the neuroendoscopic ultrasonic aspirator (NUA) increased the treatment spectrum of neuroendoscopy. This review aimed to present a systematic overview of the extent of resection, lesion characteristics, technical aspects, complications, and clinical outcomes related to using the NUA. Articles were identified by searching the PubMed/Medline, Embase, and Web of Science database through June 2022 with restriction to the last 20 years. We included case series, case reports, clinical trials, controlled clinical trials, meta-analyses, randomized controlled trials, reviews, and systematic reviews written in English. Studies reporting on endonasal approach or hematoma evacuation using the NUA were excluded. The references of the identified studies were reviewed as well. Nine full-text articles were included in the analysis, with a total of 40 patients who underwent surgery for a brain tumor using NUA. The most common underlying pathology treated by NUA was colloid cyst (17.5%), pilocytic astrocytoma (12.5%), subependymal giant cell astrocytoma (7.5%), subependymoma (7.5%), and craniopharyngioma (7.5%). Complete or near-total resection was achieved in 62.5%. The most frequently reported postoperative complication was secondary hydrocephalus (10%), meningitis/-encephalitis (7.5%), cognitive impairment (7.5%), and subdural hygroma (7.5%). In one case (2.5%), surgery-related death occurred due to a severe course of meningoencephalitis. According to the preliminary data, NUA seems to be a safe and efficient minimally invasive alternative to conventional microscopic resection of brain tumors. Further studies to investigate advantages and disadvantages of using the NUA are needed.

Transitional Care in Pediatric Brain Tumor Patients: A Systematic Literature Review.

BACKGROUND: Due to advances in the treatment of pediatric brain tumors (PBT), an increasing number of patients are experiencing the transition from the pediatric to the adult health care system. This requires efficient transitional models. METHODS: We systematically reviewed the literature regarding PBT concerning different transitional models and aspects of the transitional period. For this purpose, PubMed, Medline, and Embase databases were searched systematically through January 2022. RESULTS: We reviewed a total of 304 studies, of which 15 were ultimately included. We identified five transition models described within the literature, while the most frequently mentioned ones were the "adult caregiver model" (45.5%), "joint caregiver model" (45.5%), "continued caregiver model" (27.3%), and the "specialized clinic model" (27.3%). During the transition, the most frequent challenges mentioned by the patients were the lack of knowledge about the disease by the adult health care professionals (62.5%) and the difficulty of establishing a new relationship with the new physician, environment, or hospital (37.5%). CONCLUSIONS: An efficient transitional model is mandatory for patients with PBT. Continuity in the treatment and care of the patient and their family is essential. For this purpose, in patients with PBT, the "continued caregiver model", and for NF1 and TSC patients, the "specialized clinic model" seems optimal to offer continuity of care. If such models are unavailable, efficient communication with patients, families, and specialists in a multidisciplinary network is even more critical.

A standardized model for in vitro testing of sutures and patches for watertight dural closure.

OBJECTIVE: CSF leaks are common complications of spinal and cranial surgeries. Several dural grafts and suture techniques are available to achieve watertight dural closure, but the effectiveness of these techniques remains unclear. The authors developed a standardized in vitro model to test available grafts and suture techniques alone or in combination to find the technique with the most watertight dural closure. METHODS: A fluid chamber with a dural fixation device, infusion pump, pressure gauge, and porcine pericardium as a dural equivalent was assembled to provide the reusable device for testing. The authors performed dural closure in 4 different fashions, as follows: A) using running versus simple interrupted suture technique and different suture materials to close a 3-cm incision; B) selecting commonly used sealants and dural patches in combination with a running suture; C) performing duraplasty (1.5 × 1.5-cm square defect) with different dural substitutes in a stand-alone fashion; and D) performing duraplasty with different dural substitutes in a double-layer fashion. Each technique was tested 6 times. The hydrostatic burst pressure (BP) was measured and compared using the Kruskal-Wallis test or the Mann-Whitney U-test. Values are reported as mean ± SD. RESULTS: There was no significant difference between the running and simple interrupted suture technique (p = 0.79). Adding a patch or sealant to a suture resulted in a 1.7- to 14-fold higher BP compared to solitary suture closure (36.2 ± 24.27 cm H2O and 4.58 ± 1.41 cm H2O, respectively; p < 0.001). The highest BP was achieved by adding DuraSeal or TachoSil (82.33 ± 12.72 cm H2O and 74.17 ± 12.64 cm H2O, respectively). For closing a square defect, using a double-layer duraplasty significantly increased BP by a factor of 4-12 compared to a single-layer duraplasty (31.71 ± 12.62 cm H2O vs 4.19 ± 0.88 cm H2O, respectively; p < 0.001). The highest BP was achieved with the combination of Lyomesh and TachoSil (43.67 ± 11.45 cm H2O). CONCLUSIONS: A standardized in vitro model helps to objectify the watertightness of dural closure. It allows testing of sutures and dural grafts alone or in combination. In the authors' testing, a running 6-0 monofilament polypropylene suture combined with DuraSeal or TachoSil was the technique achieving the highest BP. For the duraplasty of square defects, the double-layer technique showed the highest efficacy.

Endoscopic and Endoscopically-Assisted Resection of Intraventricular Lesions Using a Neuroendoscopic Ultrasonic Aspirator.

The development of minimally invasive neuroendoscopy has advanced in recent years. The introduction of the neuroendoscopic ultrasonic aspirator (NUA) broadened the treatment spectrum of neuroendoscopy. We aim to describe our experience with the use of NUA for the resection of intraventricular lesions. Here, we present consecutive retrospective case series of adult and pediatric patients undergoing resection of an intraventricular lesion with a NUA (Endoscopic Neurosurgical Pen, Söring GmbH, Quickborn, Germany) between January 2019 and April 2020. Eight patients between the age of 0.5 and 73 years underwent surgery using NUA and were included in this study. In four patients, an endoscopic assisted (EA) resection of the lesion was undertaken, while in four patients, the lesion was removed using purely endoscopic (PE) resection. In all cases, gross/near total resection was achieved. The average blood loss was 142.5 ± 90.4 mL (range 50-300 mL). Transient morbidity was seen in four patients (50%), while permanent morbidity or mortality did not occur. The NUA seems to be a safe and valuable tool for the minimally invasive resection of intraventricular lesions in selected cases. The type, size, consistency, and vascularization of the lesion limit at times the purely endoscopic use of the NUA.

Does the discontinuation time of antiplatelet or anticoagulation treatment affect hemorrhagic complications in patients undergoing craniotomy for neurovascular lesions?

BACKGROUND: The number of patients treated with platelet inhibitors (PI) and/or anticoagulants (AC) in neurosurgery is increasing. The aim of this study was to analyse the effect of PI/AC discontinuation time on hemorrhagic events after craniotomy for neurovascular pathologies. METHODS: The 30-day postoperative bleeding rates were retrospectively compared between short (≤5 days) and long (>5 days) discontinuation time of PI/AC before and after surgery. Kaplan-Meier survival analysis comparing time to postoperative bleeding and the effect of PI/AC discontinuation time on bleeding rates were analysed. Potential risk factors for postoperative bleeding were further analysed in uni- and multivariate analysis. RESULTS: Out of 215 consecutive patients undergoing craniotomy for neurovascular lesions between January 2009 and April 2019, 23.3% were treated with PI/AC. Of these 36% (n = 18) and 20.8% (n = 10) were included in the short pre- and postoperative discontinuation group, respectively. Bleeding rates were comparable between the pre- and postoperative short and long discontinuation groups (preoperative 11.1% vs 10%, p = .659; postoperative 0% vs 13.2%, p = .566). In-hospital mortality rates and time to bleed of the groups were comparable as well. Similarly, the rate for thromboembolic events was not significantly affected by the pre- or postoperative discontinuation time of PI/AC. After multivariate analysis preoperative bleeding of the lesion was significantly associated with postoperative bleeding. CONCLUSIONS: Patients with short discontinuation time of PI/AC treatment undergoing craniotomy for the treatment of neurovascular lesions do not appear to have increased rates of postoperative bleeding.

Mortality and Outcome in Elderly Patients Undergoing Emergent or Elective Cranial Surgery.

OBJECTIVE: Due to the aging population, the number of elderly patients in need of cranial surgery for various neurosurgical pathologies is growing. We sought to compare mortality and outcome of elderly patients undergoing cranial surgery with a younger population. METHODS: This was a retrospective analysis of adult patients undergoing craniotomy or craniectomy for various indications. Patients were allocated to 4 age groups (<65 years, 65-74 years, 75-84 years, ≥85 years; groups 1-4, respectively). Primary outcome was 30-day mortality rate, whereas secondary outcome measurements were clinical outcome measured by the modified Rankin Scale score, morbidity (bleeding, infection, and thromboembolic complications), length of stay (LOS), and discharge location. RESULTS: We included 838 consecutive patients. Overall, 30-day mortality was 5.0% (n = 42), showing significant difference between the groups (2.8%, 7.3%, 7.5%, and 22.7% groups 1-4, respectively; P < 0.001). Mortality remained statistically significantly different between the groups also after stratification for elective or emergent surgery. Cumulative 30-day mortality-free rate was significantly different between the groups as well (log rank test χ2 = 24.58, P < 0.001). Elderly patients showed significantly greater rates of bleeding (P = 0.003), longer LOS (P < 0.001), more discharges to rehabilitation facilities (P = 0.008), and a trend toward worst modified Rankin Scale score at follow-up (P = 0.08). After multivariate regression analysis, age (≥75 years) and lower preoperative Glasgow Coma Scale score (<14) were significantly associated with greater mortality rates, whereas postoperative thrombosis prophylaxis was a protective factor for mortality. CONCLUSIONS: In patients undergoing craniotomy or craniectomy, advanced age seems to be associated with greater mortality and bleeding rates, longer LOS, and more discharge to rehabilitation facilities.

Burr hole trepanation and insertion of a subperiosteal drain for chronic subdural haematoma: how I do it.

BACKGROUND: Burr hole trepanation (BHT) is the most commonly used surgical method for the treatment of chronic subdural haematoma (cSDH). METHOD: We give a brief overview on the indication for surgical treatment of cSDH, the surgical technique of BHT, and specific perioperative considerations. In particular, we emphasise on the technique of a subperiosteal drain placement. CONCLUSION: BHT is a valid option to treat chronic subdural haematoma. Careful surgical technique and placement of a subperiosteal drain is required to minimise complications and improve outcome.

Melanotic neuroectodermal tumor of infancy to the skull: case-based review.

BACKGROUND: Melanotic neuroectodermal tumor of infancy (MNTI) is a rare tumor, which usually occurs in infants under the age of one. Early diagnosis and radical surgery seem to be critical for long-term cure. CASE PRESENTATION: We describe a case of a 4-month-old boy with a MNTI to the skull. The mass was first noticed at 4 month of age and grew very rapidly over a time of 2 weeks. Initially, a fine needle biopsy ruled out a sarcoma and led to the diagnosis. The tumor originated from the sphenoid wing and infiltrated the frontotemporal bone, the lateral wall of the right orbit, and the underlying dura mater. A total excision of the tumor, including the adjacent bone and dura, was achieved. Reconstruction of the bone was performed using absorbable plates and Tutobone. Histology confirmed the initial diagnosis, while molecular diagnosis showed high conformity of the MNTI with medulloblastoma group 3. The patient recovered well, while the reconstruction led to a good cosmetic result. A local recurrence occurred leading to a single-dose chemotherapy with Vincristine and a second surgery after 15 weeks. Thereafter, the patient developed recurrent large pseudomeningocele, which was treated by multiple shunt procedures and finally reconstruction of the bone using Palacos. Radiological follow-up 3 months after the second resection showed no tumor recurrence. CONCLUSION: Radical surgery for MNTI is to date the gold standard since it seems to minimize recurrence rates. Because of the rapid and destructive growth within the bone, reconstruction is necessary, which can be very challenging in infants.

Posttraumatic cerebrovascular injuries in children. A systematic review.

INTRODUCTION: Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner. METHODS: We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019. RESULTS: After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF's and TA's, and data from randomized controlled trials is lacking. CONCLUSION: While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children.