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Background Rupture of infectious intracranial aneurysms (IIAs) is associated with a high likelihood of mortality. Endovascular treatment of IIAs via parent artery sacrifice offers good efficacy and outcomes; however, depending on the lesion’s location, neurologic deficit may result. Case description We describe a pediatric patient with ruptured IIAs off the left middle cerebral artery (MCA) treated with coil embolization and endovascular flow diversion using the Pipeline Flex Embolization Device (PED) with Shield technology. We chose to place a flow diverter because 1) there was a second, more distal IIA not amenable to direct coil embolization, 2) there was significant potential for aneurysm regrowth and need for retreatment, and 3) we believed the diseased parent MCA needed to be reconstructed. Conclusions In the setting of previous hemicraniectomy, PED-Shield gave us the option to discontinue dual antiplatelet therapy should the patient require further neurosurgical intervention. Our case supports a role for PED-Shield to address ruptured pseudoaneurysms.

Patient specific virtual surgical planning is a useful tool in craniofacial reconstruction. The aim of this paper is to quantify the surgical accuracy of polyetheretherketone (PEEK) cranial implant placement by comparing a computer tomography (CT)-based plan with the measured postoperative position.This is a retrospective case series. All patients who presented for evaluation and management of cranial defects at the University Health Sciences Center at San Antonio from June 2018 to July 2021 were eligible for the study. For each patient, we assessed accuracy by comparing the planned PEEK implant position, defined by a 3-dimensional mesh, to the measured postoperative position at multiple mesh vertices. The primary outcome variable in our study is the root mean square error (RMSE) between the planned position and the actual position of the implant.Twelve patients (7 men, 5 women, mean age: 25.6, median age: 30.5, range 6-74) were identified who underwent cranioplasty procedures with custom-made PEEK implants to reconstruct cranial defects. The RMSE of the vertex positions ranged between 0.66 and 3.1 millimeters (mm). Eleven of the twelve patients had an RMSE less than 2 mm. The Spearman rank-order correlation between the average error and the length and area of the implant were 0.59 (P = .04, significant) and 0.42 (P = .17, nonsignificant), respectively. The Pearson correlation between age and RMSE was -0.18 (P = .57), and not significant.Patient specific implant planning can design and guide the implant placement with a typical accuracy within 2 mm. This level of accuracy suggests that we can place implants accurately enough to achieve good patient aesthetics. The quantitative analysis suggests that the key to accurate placement is understanding the number and spatial distribution of plates and fixation.

Management of pediatric epidural hematoma (PEDH) ranges from observation to emergent craniotomy. Guidelines for management remain poorly defined. More so, serial CT imaging in the pediatric population is often an area of controversy given the concern for excessive radiation as well as increased costs. This work aims to further elucidate the need for serial imaging to surgical decision-making. A prospectively maintained single-institution trauma database was reviewed at a level-1 trauma center to identify patients 18 years old and younger presenting with PEDH over a 10-year period. Selected charts were reviewed for demographic information, mechanisms of injury, neurologic exam, radiographic findings, and treatment course. Surgical decisions were at the discretion of the neurosurgeon on call, often in discussion with a pediatric neurosurgeon. Two hundred and ten records with traumatic epidural hematomas were reviewed. Seventy-three (35%) were taken emergently for hematoma evacuation. Of these, 18 (25%) underwent repeat imaging prior to surgery. One hundred and thirty-seven (65%) were admitted for observation. Seventy-two patients (53%) did not undergo repeat imaging. Sixty-five (47%) admitted for conservative management had at least one repeat scan during their hospitalization. Indications for follow-up imaging during conservative management included routine follow-up (74%), initial scan in our system following transfer (17%), neurological decline (8%), and unknown (1%). Thirteen patients (9%) were taken for surgery in a delayed fashion following admission. Twelve patients who went to surgery in a delayed fashion demonstrated progression on follow-up imaging; however, increase in hematoma size on repeat imaging was the sole surgical indication in only four patients (3%). There were no deaths related to the epidural hemorrhage or postoperatively, regardless of management, and all patients recovered to their pre-trauma baseline. Given that isolated hematoma expansion accounted for an exceptionally small proportion of operative indications, this data suggests changes seen on CT should not be solely relied upon to dictate surgical management. The benefit of obtaining follow-up imaging must be strongly considered and weighed against the known deleterious effects of excessive radiation in pediatric patients, let alone its clinical utility.

Object Guidelines for the management of pediatric epidural hematoma (PEDH) remain poorly defined. Here we seek to characterize the disease course of PEDH in patients with presenting Glasgow Coma Scale (GCS) of 14+, and suggest high-risk characteristics for progression to surgery. Methods A prospectively maintained, single-institution, level-1 trauma hospital admission database was queried to identify patients ages 6 months to 18 years presenting with PEDH between 2006 and 2016. Selected charts were reviewed for clinical information and treatment. Head imaging was reviewed for hematoma size, location, fractures, and midline shift. Results Of 210 cases reviewed, 117 presented with a GCS of 14+. Of these, 24 required surgery while 93 were managed conservatively. Factors leading to surgery included decline in GCS (40%), size alone (21%), localizing neurological deficit (20%), progression on repeat imaging (12%), and other (7%). Hematomas involving the temporal lobe plus an adjacent lobe were more likely to proceed to surgery than those involving the temporal lobe alone (OR: 24.8, 95% CI (4.74, 129.26)). Hematomas in proximity to the superior sagittal and transverse sinuses proceeded to surgery in 33.3% and 37.5% of cases, respectively. Of the 93 patients with a thickness:biparietal skull diameter ratio of ≤0.15, 89 (95.7%) were managed conservatively. Conclusion In this single-institution experience, 21% of pediatric patients presenting with a GCS of 14+ proceeded to surgery. High-risk features include large hematoma thickness, proximity to the transverse sinus, and multilobar location. A thickness:biparietal skull diameter ratio less than 0.15 was highly unlikely to proceed to surgery.

A 71-year-old female patient presented with an intracranial mass. Her past medical history included multiple surgical procedures, including total abdominal hysterectomy (TAH), radical trachelectomy...

Chiari I malformation, defined as herniation of the cerebellar tonsils at least 5 mm below the foramen magnum, can result from congenital or acquired pathology. While the mechanism is not well understood, an association between Chiari I and cystic fibrosis has been described in the literature. The lifelong respiratory status management necessitated by cystic fibrosis creates a greater risk of Chiari symptomatology as well as post-operative CSF-related complications in the setting of duraplasty secondary to recurrent transient increases in intracranial pressure. We will review the literature, describe our experience with these patients, and propose bony decompression as an approach to treatment. A retrospective review of pediatric patients treated at our institution with both cystic fibrosis and Chiari I was performed. Since our first case in 2016, our department has evaluated four patients carrying that dual diagnosis. All four underwent posterior fossa decompression surgery. Two patients had incidental pathology. Two symptomatic patients exhibited headaches and/or coordination difficulty. Half of the patients had associated syringomyelia. All patients were offered posterior fossa decompression utilizing intraoperative ultrasound. All four patients underwent posterior fossa decompression without duraplasty. Average operative time was 128 min. There were no complications post-operatively. Average hospital stay was 3.8 days. Average surgical length of stay was 2.3 days. Morbidity and mortality were 0%. The longest follow-up to date is 20 months. The two asymptomatic patients remained so post-operatively. The child with headaches and imbalance had complete resolution of his symptoms after surgery, as did the toddler with headaches. Both patients with syringomyelia demonstrated significant decrease in the size of their syrinxes on imaging performed at least 3 months post-operatively. Based on the literature and our experience, we recommend considering posterior fossa decompression without duraplasty as treatment for pediatric cystic fibrosis patients with Chiari I malformation. This approach can be effective for symptomatic and prophylactic cases in this particular patient demographic because their comorbidities predispose them to Chiari pathology and symptomatology as well as certain post-operative complications.

Posterior fossa syndrome (PFS) is a well-known sequela of midline posterior fossa tumor resection. Patients typically exhibit transient behavioral, motor, and oculomotor disturbances that resolve within a few weeks to several months after surgery. The underlying pathophysiology of PFS is not completely understood, but contemporary literature has implicated injury to the dentate nucleus and/or exiting dentatothalamocortical fiber bundles as a causative factor. The authors present a case of a young male who developed a delayed variant of PFS typified by motor deficits and demonstrated diffusion restriction in the ipsilateral superior cerebellar peduncle. Because the correlation between PFS and the superior cerebellar peduncle injury is poorly described in the literature, particularly with regard to relevant radiographic imaging, the authors of this report hope their findings will contribute to that insufficient body of evidence.

Background/Aims: As a preoperative planning tool, conventional magnetic resonance (MR) imaging may have limited value in differentiating tumors from white matter tracts. MR diffusion tensor imaging (MRDTI) has become a useful tool for evaluating white matter tracts in relation to surrounding structures and has been used in surgical planning for brain tumors involving white matter. We investigated the use of DTI of the optic nerves in surgical planning for pediatric suprasellar tumors. Methods: We present findings in 10 pediatric control patients and 2 cases of pediatric suprasellar tumors in which a routine 6-direction DTI of the brain was performed at 3 T. Postprocessing permitted the study of the diffusion tensor parameters, as well as the tractography, of the optic nerves. Results: The control patients demonstrated the optimization of the technique and permitted the quantitation of fractional anisotropy and apparent diffusion coefficient values. The tumor cases demonstrated the utility of optic nerve DTI to differentiate between optic nerves and suprasellar/chiasmatic brain tumors. Conclusions: A routine 6-direction DTI of the pediatric brain at 3 T permits a detailed DTI study of the optic nerves. Optic nerve tractography can be used to aid in the evaluation and treatment of pediatric brain tumors in the area of the optic chiasm.

Tethered cord syndrome describes a condition of multisystem end organ dysfunction due to fixation of the spinal cord. This systematic review focuses on the closed skin variant of this condition, occult spinal dysraphism. The embryology, pathophysiology, presentation, and classification of occult spinal dysraphism are explained to develop a simple framework for discussions regarding this often confusing condition. Following Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines, we synthesized urologic outcome data after tethered cord release in children from 17 studies performed over the past 25 years. These results prompted several conclusions. First, the different subgroups and different nomenclature of tethered cord syndrome are often confused, making interpretation of results difficult. Second, untethering has a positive effect on urologic symptoms and urodynamics parameters. Third, timing of untethering is important: early intervention prevents significant long-term traction aiming to avoid irreversible neurologic damage. Fourth, pediatric urologists and neurosurgeons have an important role in diagnosing and treating this condition and should work closely as part of a multidisciplinary team.

The imaging findings of pilocytic astrocytomas are classically described as a cyst with an enhancing mural nodule. We report 2 unusual cases of multicystic cerebellar midline masses that were proven to be pilocytic astrocytomas. The uniqueness of the imaging features in these cases may represent an important variant of pilocytic astrocytomas. Recognition of this variant may prevent an unnecessary workup to exclude other etiologies such as parasitic infection (ie, cysticercosis) or cystic metastatic disease.