A human importin-ß-related disorder: Syndromic thoracic aortic aneurysm caused by bi-allelic loss-of-function variants in IPO8.

Importin 8, encoded by IPO8, is a ubiquitously expressed member of the importin-ß protein family that translocates cargo molecules such as proteins, RNAs, and ribonucleoprotein complexes into the nucleus in a RanGTP-dependent manner. Current knowledge of the cargoes of importin 8 is limited, but TGF-ß signaling components such as SMAD1-4 have been suggested to be among them. Here, we report that bi-allelic loss-of-function variants in IPO8 cause a syndromic form of thoracic aortic aneurysm (TAA) with clinical overlap with Loeys-Dietz and Shprintzen-Goldberg syndromes. Seven individuals from six unrelated families showed a consistent phenotype with early-onset TAA, motor developmental delay, connective tissue findings, and craniofacial dysmorphic features. A C57BL/6N Ipo8 knockout mouse model recapitulates TAA development from 8-12 weeks onward in both sexes but most prominently shows ascending aorta dilatation with a propensity for dissection in males. Compliance assays suggest augmented passive stiffness of the ascending aorta in male Ipo8-/- mice throughout life. Immunohistological investigation of mutant aortic walls reveals elastic fiber disorganization and fragmentation along with a signature of increased TGF-ß signaling, as evidenced by nuclear pSmad2 accumulation. RT-qPCR assays of the aortic wall in male Ipo8-/- mice demonstrate decreased Smad6/7 and increased Mmp2 and Ccn2 (Ctgf) expression, reinforcing a role for dysregulation of the TGF-ß signaling pathway in TAA development. Because importin 8 is the most downstream TGF-ß-related effector implicated in TAA pathogenesis so far, it offers opportunities for future mechanistic studies and represents a candidate drug target for TAA.

Papilloedema: a highly specific predictor of raised intracranial pressure in a complex neurosurgical paediatric cohort.

PURPOSE: Papilloedema is recognised as an indicator of raised intracranial pressure, although there is a paucity of literature describing the utility of fundoscopy in screening for raised ICP in children with craniofacial synostosis, particularly young children. We sought to investigate the association of optic disc morphology with ICP in children, and to define the sensitivity and specificity of papilloedema as a clinical indicator of raised ICP and determine if age, or underlying conditions impact the findings. METHOD: Retrospective analysis of all patients undergoing ICP monitoring at a designated paediatric neurosurgical and craniofacial unit in the United Kingdom between October 2009 and October 2018. The fundoscopy findings and ICP monitoring data were analysed for 31 children with craniosynostosis and 29 children without craniosynostosis. RESULTS: All children who had papilloedema had raised ICP confirmed with monitoring. Across the 60-patient cohort, confirmed papilloedema on fundoscopy had Positive Predictive Value (PPV) of 1.00, Negative Predictive Value (NPV) of 0.64 with sensitivity 48% and specificity 100% for the presence of raised ICP (p = < 0.0001). In the craniosynostosis group, PPV was 1.00, NPV was 0.39, sensitivity 48% and specificity 100% (p = < 0.03). There is no correlation between severity of optic disc swelling using Frisen grading and elevation of ICP. Age did not affect the presence of papilloedema in those with raised ICP. CONCLUSION: The presence of papilloedema is a strong indicator of raised ICP in a child, regardless of underlying aetiology. Detailed fundoscopy can prevent the need for further investigations including imaging-related radiation and invasive CSF pressure monitoring.

Seizures as presentation of shunt malfunction: tertiary paediatric neurosurgery experience.

AIM: Patients with a background of cerebrospinal fluid (CSF)-diverting shunts are frequently investigated for shunt malfunction when presenting with seizures. However, there is very limited evidence in the literature regarding the association of seizures and shunt malfunction. We sought to determine the incidence of shunt malfunction in our cohort of shunted paediatric patients presenting with seizures, and the utility of seizures as a marker of shunt malfunction. METHODS: We retrospectively identified all shunted patients presenting with seizures, as well as all patients undergoing shunt revision following a presentation with seizures from our hospital database over a 14-year period from 2009 to 2023. Data gathered included demographics, de novo seizures or change in pattern of seizures, the aetiology of hydrocephalus and the segment of shunt requiring revision. Exclusion criteria included infected cases requiring shunt externalisation. A literature review of all papers discussing seizures as a presentation of shunt malfunction was also carried out. RESULTS: Overall, over a 14-year period of study, 338 shunted patients presented with seizures and were referred as suspected shunt malfunction with 10 having confirmed shunt malfunction requiring revision (2.9%). This group represented 6.2% of 161 cases of shunt revision carried out during the 14-year period of study. Post-haemorrhagic hydrocephalus secondary to prematurity was the commonest aetiology of shunted hydrocephalus presenting with seizures. Out of 10 patients presenting with seizures with shunt malfunction, 4 presented with de novo seizures, while 6 presented with a change in seizure pattern or frequency in already known epileptic patients. Shunt revision surgeries included 5 distal catheter, 2 proximal catheter, 1 proximal catheter-valve, 1 valve only and 1 case of whole shunt change. CONCLUSION: Our data supports that seizures are rare manifestation of shunt malfunction and can present either de novo or with a change in seizure frequency in already-known epileptic patients.

Evaluation of incidence and outcomes of compressive extradural haematoma-related infarcts in the paediatric population.

INTRODUCTION: Traumatic extradural haematoma (EDH) is one of the neurosurgical emergencies in the paediatric population. One of the rare complications of extradural haematoma is adjacent parenchymal infarct from the compressive effect of haematoma leading to further morbidity. We aimed to evaluate the incidence and outcomes of this rare complication in paediatric trauma patients. METHODS: We undertook a retrospective review of all operative extradural haematoma cases in single centre paediatric neurosurgical unit between the years 2008 and 2024. Cases with postoperative imaging were analysed for demographics, age, sex, dimensions of haematoma and underlying infarct, pre-operative GCS and pupillary abnormality and time interval from scan to surgery. Infarct was defined as well-defined parenchymal hypodensity corresponding to vascular territory and not attributable to contusions on postoperative CT head performed at 24-72 h. All patients suspected of stroke had further MRI brain for evaluation. Statistical analysis was then performed comparing groups with and without infarct. RESULTS: Overall, 115 cases of extradural haematoma were identified during the study period. Eighty cases had adequate postoperative imaging to allow assessment for infarcts; 7.5% demonstrated evidence of infarct underlying extradural haematoma. Mean age in the infarct group was 1.8 years (M:F ratio 2:1) with mean EDH dimensions of 77 mm × 31.4 mm × 79.7 mm). Mean age in the non-infarct group was 8.6 years (M:F ratio 2:1) with mean EDH dimensions of (57.5 mm × 19.6 mm × 62.6 mm). Children with infarcts were significantly younger with larger haematoma dimensions and had a higher proportion of pupillary abnormalities. There was no significant difference in pre-operative GCS and scan-to-surgery time-lapse between the groups with and without infarct. CONCLUSION: Compressive effect of EDH can lead to underlying parenchymal infarct. Children with extradural haematoma-related infarct were younger with larger haematoma size and a higher proportion of pupillary abnormalities.

Retroflexed dens in paediatric Chiari 1 patients and implications: Single centre retrospective study.

INTRODUCTION: Chiari 1 malformation and hind brain hernia can be associated with skull base and craniocervical anomalies. One of the more recently associated anomalies is a retroverted or retroflexed odontoid process or dens. We conducted a retrospective study of our operated symptomatic and conservatively managed asymptomatic Chiari cohort to assess the impact of dens retroflexion on rate of revision or cerebrospinal fluid diversion following primary foramen magnum decompression (FMD). METHODS: We undertook a retrospective study of all foramen magnum decompression (FMD) cases for Chiari type 1 malformation performed over a 15-year period in a single tertiary paediatric neurosurgical unit. For comparison, non-operated asymptomatic Chiari cases were considered as reference cohort. Information gathered included: demographics, age, sex, length of cerebellar tonsils below McRae's line, pB-C2 distance (a line drawn perpendicular to one drawn between the basion and the posterior aspect of the C2 body), angle of retroflexion (angle formed between a line drawn through the odontoid synchondrosis and its intersection with a line drawn from the tip of the odontoid process) and angle of retroversion (angle formed between the line drawn from the base of C2 and its intersection with a line drawn from the tip of the odontoid process). Grade of retroflexion was measured using pre-operative mid-sagittal MR images and classified as grade 0 (> 90°), grade 1 (85°-89°); grade 2 (80°-84°) and grade 3 (< 80°). The rates for redo surgery or need for cerebrospinal fluid (CSF) diversion were obtained from clinical records and compared in the operated and non-operated groups. RESULTS: One hundred twenty-six Chiari 1 patients were included in this study with adequate imaging. Sixty-five patients were in the non-operated asymptomatic cohort with 61 patients in the operated symptomatic cohort. Mean age of non-operated cohort was 10.2 years with M:F ratio (30:35). Mean cerebellar tonsillar length below McRae's line was 10.3 mm. 7.7% of this cohort had associated syrinx. Mean angles of retroversion and retroflexion were 76 and 78°, respectively. Retroflexion grades included (9.2% grade 1, 35% grade 2 and 52.3% grade 3). pB-C2 distance was 6.8 mm. Mean age of operated cohort was 11.3 years, with M:F ratio (21:40). Mean cerebellar tonsillar length below McRae's line was 15 mm. 45.9% of this cohort had associated syrinx. Mean angles of retroversion and retroflexion were 73 and 74.5°, respectively. Retroflexion grades included (4.9% grade 1, 16.5% grade 2 and 78.6% grade 3). pB-C2 distance was 6.9 mm. No association was identified between retroflexion grade and rate of revision or CSF diversion following primary foramen magnum decompression. CONCLUSION: The operated Chiari 1 cohort had more retroflexed dens, longer tonsils and associated syrinx compared to the non-operated asymptomatic cohort.

Middle fossa arachnoid cyst fenestration for ruptured cysts associated with subdural collections: paediatric neurosurgery tertiary unit experience.

INTRODUCTION: Arachnoid cysts are commonly encountered benign cystic structures and often come to attention as incidental findings following cranial imaging. Surgical intervention rates vary in different studies; however, rupture of cyst and subdural collection with mass effect are some of the indications for surgical intervention. In this study, we aimed to evaluate our operated cohort of middle fossa arachnoid cysts to determine the rate of traumatic subdural collection in this cohort and further assess outcomes. METHODS: A retrospective review of all consecutive operated middle cranial fossa arachnoid cysts was carried out for the period 2010 to 2024. Demographics including age, sex, Galassi type, surgical technique for fenestration, preceding history of trauma, presence of papilloedema, and complications following surgery were extracted. Indication for surgery included papilloedema and headaches or increasing head circumference or rupture and subdural collections. Arachnoid cysts managed with CSF diversion as primary surgery were excluded. RESULTS: Over the study period, 21 fenestrations of the arachnoid cysts were carried out in 19 patients with mean age of 7 years and M:F ratio of 2.2:1 (laterality: 9 right-sided and 10 left-sided). These included seven Galassi 2 and twelve Galassi 3 arachnoid cysts. At presentation, 10 had papilloedema, 5 with no papilloedema, and 4 with no available ophthalmological assessment. Fenestration of cyst included 12 microscopic, 6 endoscopic, and 3 combined approaches. Of the operated cohort, 8 were due to rupture of arachnoid cyst and subdural collections causing mass effect. Of 8 cases of ruptured arachnoid cyst with subdural collections, 75% had clear history of preceding head injury in the context of accidental or sports-related injuries. Two patients required redo-fenestration (10.5%), 1 patient required temporary lumbar drain (5.2%), and 2 patients required cysto-peritoneal shunts (10.5%). CONCLUSION: Rupture of arachnoid cysts and subdural collections although rare can be associated with head injury in majority of cases. All operated cases belonged to grade 2 and 3 Galassi.

Endoscopic third ventriculostomy for hydrocephalus after craniovertebral decompression for Chiari malformation type I: technical nuances and surgical pitfalls.

PURPOSE: Hydrocephalus after craniovertebral decompression (CVD) for Chiari I malformation (CM-1) is a well-recognised complication. The mainstay of management involves medical management with high-dose steroids and/or acetazolamide, repeated lumbar punctures, external ventricular drainage (EVD) or insertion of a ventriculoperitoneal shunt (VPS). Endoscopic third ventriculostomy (ETV) has only been used a handful of times to treat this type of hydrocephalus with controversial outcomes. Not much is known about this or the technical nuances of this procedure. We report our experience. METHODS: All children who underwent ETV to treat hydrocephalus post CVD done for CM-1 were identified from a prospectively kept database. RESULTS: Three children were identified (13F, 11F, 13F). The average time to presentation of hydrocephalus was 8 days after craniovertebral decompression. Two were successfully treated with ETV with brain imaging showing a reduction in the size of the ventricles post-operatively and not requiring any further cerebrospinal fluid drainage. In one patient, the procedure had to be abandoned after the peel away catheter was introduced into the right ventricle because CSF egressed under high pressure with ventricle walls collapse resulting in an obstructed view. This child ultimately required a VPS. CONCLUSION: ETV can be used to successfully treat post CVD hydrocephalus in CM-1 patients depending on the aetiology of the hydrocephalus. There are technical and anatomical commonalities between these cases which make it more challenging than an ETV performed in "typical" obstructive hydrocephalus. We describe our experience and review the cases previously reported in the literature.

Endoscopic fenestration of the superior medullary velum for the treatment of a trapped fourth ventricle-technical note.

A trapped fourth ventricle is a clinic-radiological entity characterised by progressive neurological symptoms due to an enlargement of the fourth ventricle secondary to obstruction to its outflow. This condition is most commonly observed in ex-preterm patients shunted for a post-haemorrhagic or post-infective hydrocephalus. Until the introduction of endoscopic aqueductoplasty and stent placement, through a supratentorial or an infratentorial approach, treatment of trapped fourth ventricle entailed high rates of complications, repeated procedures and consequent morbidity. We describe the first case of successful treatment of trapped fourth ventricle by fenestration of superior medullary velum through an infratentorial approach in a 20-month-old child with a functional supratentorial ventriculoperitoneal shunt and an aqueductal anatomy not favourable for stenting. To the best of our knowledge, this is the first reported case of utilisation of this technique in a patient with a trapped fourth ventricle, and we wish to highlight this new alternative approach in cases where conventional aqueductoplasty and stenting may not be feasible.

Clinical features and outcome in pediatric arteriovenous malformation: institutional multimodality treatment.

PURPOSE: Intracranial arteriovenous-malformation (AVM) is a relatively rare condition in pediatrics, yet is a major cause of spontaneous intracranial hemorrhage with a risk of fatal hemorrhage reported to be between 4 and 29%. Little is known about vessel morphology and optimum treatment modalities including multimodality combination therapy and prognosis in children. METHODS: A retrospective review of all children presenting to our institution from 2006 to 2020 that had an AVM was undertaken. RESULTS: A total of 50 children were identified with median age of 11 (range 1-16) years. The mean follow-up was 7.6 years. Forty-one children presented as an emergency and of those, 40 had hemorrhage identified on initial brain imaging. The average nidus size was 25 mm, drainage was superficial in 51% of cases, and located in eloquent cortex in 56%. The supplemental Spetzler-Martin grading indicated 78% (39/50) were grade 4 and above (moderate to high risk). Primary treatment modalities included embolization in 50% (25) or SRS in 30% (15) and surgery in 20% (10).The AVM was obliterated on follow-up DSA in 66% children. Three children had post-treatment hemorrhage, two related to embolization and one the day following SRS, giving a re-bleed rate of 6%. The GOSE was available for 32 children at long term follow and 94% had a good outcome (GOSE 5-8). Two children died due to acute hemorrhage (4%). CONCLUSION: The majority of children with AVM present with hemorrhage. The rebleed rate during definitive treatment is low at 6% over the study period. The selective use of the 3 modalities of treatment has significantly reduced mortality and severe disability.

The role of surgery in relieving calcified shunt site-related pain in patients with functioning VP shunt.

PURPOSE: Shunt calcification is a known late sequela of ventriculoperitoneal (VP) shunt insertion and is associated with shunt malfunction. However, in some patients, while shunt functionality is preserved despite calcification of the catheters, they experience nociceptive symptoms. In this paper, the authors present their surgical experience in managing patients with a functional VP shunt and experiencing pain secondary to shunt calcification. METHODS: We analysed outcomes of patients presenting with pain at the level of a calcified shunt who underwent surgical untethering of the calcified catheter from the soft tissues. This procedure was commenced by the senior author in 2015. Patients were collected prospectively from the databases of two institutions. Evidence of shunt calcification was confirmed on neuroimaging. RESULTS: Seven patients, two male and five female, were included. The mean age at untethering was 13.5 years. The mean time interval between primary shunt surgery and symptom onset was 12 years (range 6-16 years). The commonest site of tethering was the neck (50%) followed by abdomen and chest (both 25%). Six patients underwent untethering of the catheter from soft tissues. One patient had removal of a redundant segment of calcified shunt left in situ during a previous revision. All patients experienced pain relief following shunt untethering. CONCLUSION: Untethering of calcified VP shunt catheters from soft tissue can be considered an effective treatment of shunt site pain and offered to patients presenting with a functional VP shunt.

ERF-related craniosynostosis and surgical management in the paediatric cohort.

INTRODUCTION: ERF mutation is one of the most recently identified genetic aberrations associated with syndromic craniosynostosis. Data on the pattern of craniosynostosis, surgical management of ERF-related craniosynostosis and outcomes is limited. We report on our single-centre experience in paediatric cohort of patients with syndromic craniosynostosis secondary to ERF mutation. METHODS: A retrospective review of all paediatric craniofacial cases was performed over an 8-year period (2014-2022). All patients with genetically confirm ERF-related craniosynostosis were identified, and clinical parameters including, age, sex, pattern of craniosynostosis, associated tonsillar herniation and follow-up period were further analysed from electronic clinical and imaging systems. All patients were selected and discussed in multidisciplinary craniofacial meeting (composed of neurosurgical, maxillofacial, plastics and genetics teams) prior to any surgical intervention. RESULTS: Overall, 10 patients with ERF-related craniosynostosis were identified with a male-to-female ratio of 4:1 with mean age at the time of surgery of 21.6 months with a mean follow-up period of 5.2 years. ERF-confirmed cases led to variable craniosynostosis pattern with multi-sutural synostosis with concurrent sagittal and bilateral lambdoid involvement as the most common pattern (7/10). No patient pre-operatively had evidence of papilloedema on ophthalmological assessment. Eight out of 10 patients had associated low-lying tonsils/hind brain hernia pre-operatively. Eight out of 10 patients required surgery which included 2 fronto-orbital advancement, 3 calvarial remodelling, 2 posterior calvarial remodelling/release and 1 insertion of ventriculoperitoneal shunt. CONCLUSION: Involvement of sagittal and lambdoid sutures is the most common pattern of craniosynostosis. ERF-related craniosynostosis can have variable pattern of suture fusion, and management of each patient requires unique surgical planning and execution based on clinical needs for the optimal outcomes.

A rare case of inferior vena cava occlusion secondary to abdominal pseudocyst associated with ventriculoperitoneal shunt-case report and review of literature.

BACKGROUND AND IMPORTANCE: Abdominal pseudocyst (APC) is an uncommon but well-recognised complication of ventriculo-peritoneal (VP) shunt. Diagnosis is based on clinical features of shunt malfunction, including headaches, vomiting and drowsiness, and abdominal swelling. APCs can grow to large sizes resulting in compression of abdominal viscera; however, inferior vena cava (IVC) compression is extremely rare, and only one other case associated with VP shunt had been reported. CLINICAL PRESENTATION: We report a case of a 12-year-old girl with a background of open myelomeningocoele repair, kyphoscoliosis and right-sided VP shunt in situ who presented with bilateral lower limb swelling and abdominal distension. She exhibited no features of raised intracranial pressure but had bilateral pitting oedema up to the groin. Abdominal ultrasound and CT scan showed a massive septated pseudocyst (20 × 18 × 8 cm) compressing the IVC. The APC was drained, and the shunt was externalised, with conversion to a ventriculo-atrial (VA) shunt 1 week later after cultures of the cystic fluid, cerebrospinal fluid and shunt tube came back sterile. The patient remained well with no recurrence of the abdominal fluid and no VA shunt complication at 36-month follow-up. CONCLUSION: This patient had specific risk factors for development of a massive APC and the subsequent IVC compression, including prior surgeries, spinal deformity, abnormal abdominal anatomy and poor abdominal muscle tone and sensation. Early recognition of this complication and prompt alleviation of the mass effect of IVC compression can prevent long-term neurological and vascular sequalae.

Posterior Calvarial Distraction in older paediatric population: single centre paediatric neurosurgery craniofacial unit outcomes.

PURPOSE: Posterior calvarial distraction (PCD) is a safe and effective technique used to increase cranial vault volume and therefore reduce intracranial pressure in children with complex craniosynostosis. Optimal timing and method used for PCD is controversial. This procedure is usually performed in children younger than 2 years. Literature regarding calvarial distraction in older children is sparse and limited. We report our single-centre experience with PCD in children aged 6 and above to outline the applications, benefits and challenges of employing this technique in an older paediatric population. METHODS: A retrospective analysis of a database on craniofacial cases from 2006 to 2021 was performed. Patients undergoing PCD were identified and children aged 6 and above at the time of operation were included. Data on demographics and clinical outcomes were obtained from electronic records and relevant imaging was reviewed. All cases were reviewed prior to a decision for surgery by the multidisciplinary craniofacial team (composed of neurosurgery, maxillofacial and plastics teams) and underwent surgery in our paediatric craniofacial centre. RESULTS: Overall, 98 PCD cases were identified during the study period, of which 20 cases were identified as having undergone PCD at age 6 or above with mean age of 8.8 years (range 6-18). The most common indication was pansynostosis associated with raised intracranial pressure. Four cases had calvarial remodelling previously and represented with symptoms of raised intracranial pressure sometime after their initial surgery requiring PCD as rescue procedure. Average duration of inpatient stay was 5.85 days. The average duration of follow-up was 3.5 years (0.3 to 11 years). Mean distraction distance achieved was 22.5 mm (18-29 mm). Five patients experienced complications related to wound infection or distractor. Follow-up assessment in all patients demonstrated evidence of vault expansion and symptomatic improvement and resolution of intracranial pressure signs. Comparison with younger cohort did not reveal any difference in any parameters except lower rate of transfusion in the older cohort compared to young cohort (5% vs 38%). CONCLUSION: Posterior calvarial distraction in older children is safe and effective for vault expansion and treatment of raised intracranial pressure in selected cases. A multidisciplinary craniofacial team approach is crucial for appropriate case selection and management in order to optimise outcomes.

A Simple Method for Eye Protection During Prone Positioning for Craniofacial Surgery.

Surgery in the prone position risks vision loss due to a number of factors. Craniofacial surgery poses an even greater risk due to the anatomical and physiological makeup of these patients. Here, we describe a novel method of providing protection from direct pressure on the globe during prone positioning for craniofacial procedures and our protocol for improving safety and reducing the risk of postoperative vision loss.

Nervous system involvement in Pfeiffer syndrome.

Pfeiffer syndrome (PS) is a rare autosomal dominant craniofacial disorder characterized by primary craniosynostosis, midface hypoplasia, and extremities' abnormalities including syndactyly. The purpose of this article was to review the current knowledge regarding how PS affects the nervous system. Methodologically, we conducted a systematic review of the existing literature concerning involvement of the nervous system in PS. Multiple-suture synostosis is common, and it is the premature fusion and abnormal growth of the facial skeleton's bones that cause the characteristic facial features of these patients. Brain abnormalities in PS can be primary or secondary. Primary anomalies are specific developmental brain defects including disorders of the white matter. Secondary anomalies are the result of skull deformity and include intracranial hypertension, hydrocephalus, and Chiari type I malformation. Spinal anomalies in PS patients include fusion of vertebrae, "butterfly" vertebra, and sacrococcygeal extension. Different features have been observed in different types of this syndrome. Cloverleaf skull deformity characterizes PS type II. The main neurological abnormalities are mental retardation, learning difficulties, and seizures. The tricky neurological examination in severely affected patients makes difficult the early diagnosis of neurological and neurosurgical complications. Prenatal diagnosis of PS is possible either molecularly or by sonography, and the differential diagnosis includes other craniosynostosis syndromes. Knowing how PS affects the nervous system is important, not only for understanding its pathogenesis and determining its prognosis but also for the guidance of decision-making in the various critical steps of its management. The latter necessitates an experienced multidisciplinary team.

Supratentorial vs infratentorial posterior calvarial distraction osteogenesis for the increase of ICV in children with syndromic or multi-suture craniosynostosis: a retrospective cohort study.

PURPOSE: Craniosynostosis is the premature and pathological fusion of calvarial sutures. One modality of surgical treatment of syndromic craniosynostosis is posterior calvarial distraction (PCD). This can be either supratentorial or infratentorial. Currently, supratentorial PCD may be regarded as safer but produces a smaller increase in calvarial volume compared to infratentorial PCD. This study quantifies and compares the effectiveness of supratentorial and infratentorial PCD to help guide surgical decision-making. METHODS: The CT and/or MRI scans of 47 cases of craniosynostosis who underwent PCD from the Birmingham Children's Hospital (BCH) were converted to sagittal series multi-planar reformatted (MPR) scans for the manual calculation of ICV. The 47 cases were classified as having undergone either supratentorial or infratentorial PCD using lateral plain film radiographs, with 28 and 32 pairs of pre- and post-operative CT/MRI scans reviewed respectively. RESULTS: A statistically significant difference between supratentorial and infratentorial PCD was observed for the increase in supratentorial volume (STV) (P = 0.0458) and total intracranial volume (TICV) (P = 0.0437), but not for the increase in infratentorial volume (ITV) (P = 0.0697). The relationship for each volume trended towards convergence but was not achieved before the physical limit of 30 mm distraction had been reached. Intraclass correlation coefficient values for agreement of MRI and CT scans for STV, ITV and total ICV were 0.852, 0.864 and 0.854 respectively. CONCLUSION: Our evidence suggests that supratentorial PCD is more effective for increasing ICV in a clinical setting. CT and MRI imaging modalities are acceptably clinically interchangeable for calculating ICV in craniosynostosis.

Chyloperitoneum following open myelomeningocele repair: dealing with an extremely rare finding.

PURPOSE: Chyloperitoneum is an extremely rare finding following myelomeningocele (MMC) repair in neonates. We aimed to describe the characteristics of such a case and explore its clinical significance. CASE REPORT: A male baby born at term with open MMC and hydrocephalus underwent MMC repair surgery with rotational flaps on the first postnatal day. The procedure was uneventful. Three days later, he underwent a right ventriculoperitoneal shunt (VPS) insertion. On opening the peritoneum, a remarkable amount of yellowish opaque fluid was observed. Chyloperitoneum was suspected, but the VPS procedure was completed as planned. Biochemical analysis was consistent with that of chyle. DISCUSSION: Neonatal chylous ascites is a rare condition; hence, available data on pathophysiology and therapy in the literature are scarce. It is postulated that the MMC repair in neonates causes abdominal tautness, which leads to rupture of small lymphatics and raised intraportal pressure. The combination of these two processes results in extravasation of chyle from the gastrointestinal tract. Presence of chyloperitoneum is not a contraindication for VPS insertion. CONCLUSION: Chyloperitoneum is an extremely rare sequela of MMC repair in neonates. Pediatric neurosurgeons should be aware of it, especially when a VPS procedure is to follow a repair, in order to know how to deal with it and avoid unnecessary abandonment of the shunt.

Paediatric spondylodiscitis: a 10-year single institution experience in management and clinical outcomes.

PURPOSE: Discitis in the paediatric population poses diagnostic challenges due to non-specific presenting symptoms and difficulty with expressing pain in non-communicating children. Discitis remains a relatively rare condition in the paediatric population and previous reports are limited to small cohorts. In this article, we report our experience in management of discitis over a 10-year period and review the literature on this topic. METHODS: We retrospectively reviewed cases of paediatric discitis/spondylodiscitis over a 10-year period between 2008 and 2018 managed in our regional paediatric neurosurgery unit. Relevant demographic information, microbiological data, blood investigation profile, antibiotic treatment duration and clinical outcomes were interrogated from clinical notes and electronic databases and further analysed. RESULTS: Overall, 21 cases of paediatric discitis were identified from year 2008 to 2018 with a female to male ratio of 1.3:1. The mean age at presentation was 4.3 years (range 1 to 15 years). Overall, there were 19 cases of lumbosacral/lumbar, 1 thoracic and 1 cervical discitis. The mean duration of follow-up was 20 months (range 6 to 69 months). The most common presenting features were back pain and refusal to walk/sit or weight bear. Erythrocyte sedimentation rate (ESR) was found to be more sensitive than C-reactive protein (CRP) (sensitivity 78% versus 38%) in our cohort. Computer tomography (CT)-guided biopsy was performed in five cases and only one of these was positive (20%). All patients were treated with intravenous antibiotics with resolution of discitis. CONCLUSIONS: Presentation of discitis in children can be non-specific and requires high index of suspicion. CT-guided biopsy in our cohort revealed a low rate of positive cultures. Despite negative blood cultures and CT-guided biopsy results, empirical intravenous antibiotics were effective in treating discitis successfully. In our cohort, low yield of CT-guided biopsy does not support its use on each case and this may be reserved for cases resistant to antimicrobial therapy or concerns regarding other pathology mimicking infection. Better understanding and awareness of this condition and its pathophysiology can lead to timely imaging, diagnosis and treatment.

Paediatric developmental venous anomalies (DVAs): how often do they bleed and where?

INTRODUCTION: Developmental venous anomalies (DVAs) are anomalies of venous drainage and considered a low-flow malformation. Studies evaluating natural history and risk factors for intracranial haemorrhage in the paediatric population are rare. We evaluate clinical and radiological features, risk factors and outcomes of paediatric DVAs. METHODS: A retrospective study was conducted over a 10-year period between 2004 and 2014. Medical records, imaging and prospective databases were reviewed. Three-hundred-and-three radiological studies in total were evaluated. RESULTS: Fifty-two children (20 boys and 32 girls [median age: 6 years] were identified with DVAs. Their age distribution was as follows: 1.9% neonates (< 1 month), 11.5% infants (1 month to 1 year), 30.8% 1-5 years, 30.8% 5-12 years and 25% 12-16 years. The majority (92.3%) presented with asymptomatic DVAs identified incidentally. Overall, anatomical distribution revealed predilection for frontal region (42.3%) with other common sites being posterior fossa (17.3%) and basal ganglia (13.5%). Temporal (11.5%), parietal (9.6%) and occipital (5.8%) were the remainder. Associated cavernous malformations (CMs) were present in 3/52 (5.8%), and no DVAs were associated with aneurysms or arteriovenous malformations (AVMs). Three patients had more than one DVA. There were three deaths unrelated to DVAs over median follow-up of 3.8 years. Four patients (7.7%) suffered DVA-related intracranial haemorrhage presenting with neurological deficits. The ages of the children with DVA-related haemorrhages were 21 days, 2 years and 6 months, 7 years and 1 month and 11 years and 7 months. Left-sided DVA haemorrhages predominated (3/4, 75%). The relative risk of a cerebellar DVA haemorrhage compared to its supratentorial counterpart was 5.35 (OR 6.8, 95% CI 0.8-58). DISCUSSION: DVA-related haemorrhage is sevenfold greater in our paediatric cohort compared to adults and is significantly associated with cerebellar location and cavernous malformations. There were no haemorrhages over a median period of 3.8 years of prospective follow-up.

Spontaneous neonatal subdural haemorrhage: always non-accidental injury?

In any neonate or infant presenting with an acute onset of encephalopathy, and/or retinal haemorrhages with no history of major trauma and imaging showing subdural haemorrhage (SDH), the diagnostic priority is to exclude a non-accidental injury (NAI), given the association of these clinical features with the shaken baby syndrome. However, other causes of SDH may present in a similar manner in neonates and infants, in particular vascular lesions such as aneurysms. A four week old neonate presenting with seizures and retinal haemorrhages, was diagnosed with an acute subdural haemorrhage (ASDH) on imaging with significant midline shift needing surgical evacuation. As there was some blood extending into the left sylvian fissure, further imaging was considered before surgical intervention. This showed a distally located middle cerebral artery aneurysm, which was successfully treated and the neonate made a remarkable recovery. We present a case of a neonate presenting with spontaneous acute subdural haematoma in the absence of classical diffuse subarachnoid haemorrhage, intracerebral haemorrhage or intraventricular haemorrhage, secondary to a ruptured middle cerebral artery aneurysm. The distribution of aneurysms in the neonatal age group is different to adults, with middle cerebral artery aneurysms and more distally located peripheral aneurysms being more common. Vigilance should be borne to exclude the aforementioned as causes for this presentation especially prior to undertaking surgical intervention.