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Meningiomas represent the most common benign histological tumor of the central nervous system. Usually, meningiomas are intracranial, showing a typical dural tail sign on brain MRI with Gadolinium, but occasionally they can infiltrate the skull or be sited extracranially. We present a systematic review of the literature on extracranial meningiomas of the head and neck, along with an emblematic case of primary extracranial meningioma (PEM), which provides further insights into PEM management. A literature search according to the PRISMA statement was conducted from 1979 to June 2021 using PubMed, Web of Science, Google Scholar, and Scopus databases, searching for relevant Mesh terms (primary extracranial meningioma) AND (head OR neck). Data for all patients were recorded when available, including age, sex, localization, histological grading, treatment, possible recurrence, and outcome. A total of 83 published studies were identified through PubMed, Google Scholar, and Scopus databases, together with additional references list searches from 1979 to date. A total of 49 papers were excluded, and 34 manuscripts were considered for this systematic review, including 213 patients. We also reported a case of a 45-year-old male with an extracranial neck psammomatous meningioma with sizes of 4 cm × 3 cm × 2 cm. Furthermore, whole-body 68Ga-DOTATOC PET/CT was performed, excluding tumor spread to other areas. Surgical resection of the tumor was accomplished, as well as skin flap reconstruction, obtaining radical removal and satisfying wound healing. PEMs could suggest an infiltrative and aggressive behavior, which has never found a histopathological correlation with a malignancy (low Ki-67, 68Ga-DOTATOC PET/CT should be considered in the patient’s global assessment. Surgical removal is a resolutive treatment, and the examination of frozen sections can confirm the benignity of the lesion, reducing the extension of the removal of healthy tissue surrounding the tumor.

Introduction Surgery is the primary treatment for Cushing's disease(CD). In cases with no biochemical remission after surgical resection or when recurrence occurs after a period of remission stereotactic radiosurgery (SRS) is used as alternative/adjuvant treatment. The aim of this study is to demonstrate the effectiveness of SRS and FSRS(Fractionated stereotactic radiosurgery) for the treatment of CD in a long term follow up. Methods This is a retrospective study in which 41 patient (36 females and 5 males) who underwent surgery for CD from 2009 to 2019 were included. Out of 41 cases, 34 cases had microadenomas while 7 had macroadenomas. These patients had recurrence or persistence of hypercortisolism post-operatively. After multidisciplinary evaluation, these patients were treated by CyberKnife (SRS & FSRS). Results Remission rate in our study was 60.97% with a median follow up period of 79.03 months. The median time to biochemical remission was 14 months. Tumour growth control was achieved in 95.12%. Hypopituitarism of different axes was seen in 34.14% patients. Secondary hypothyroidism was the most common pituitary insufficiency (34%) followed by secondary hypogonadism in 17%. Conclusion CyberKnife radiosurgery and hypofractionated radiosurgery can be used as an adjuvant treatment in patient with active disease and no biochemical remission after one or multiple surgical resections. Risk of radiation induced hypopituitarism and other complication is relatively low 34.14% and tumour growth control is significantly higher.

Purpose Computed tomography (CT) has been shown to change management in children on extracorporeal membrane oxygenation (ECMO). Although techniques have been described to transport these critically ill patients to the CT suite in the radiology department, transport out of the intensive care setting is not without risk, and using portable CT is a practical alternative. However, obtaining a CT pulmonary angiogram (CTPA) in a patient on veno-arterial (VA) ECMO presents unique challenges due to bypass of the cardiopulmonary system, which may lead to suboptimal opacification of the pulmonary arteries. Methods We describe a method to obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. Our solution involved temporary withholding ECMO and using the venous cannula to deliver a compact contrast bolus to the right atrium to adequately opacify the pulmonary arteries. Special attention was given to the delivery of the contrast bolus, which was given by hand injection, to ensure it coincided with image acquisition and minimized the time ECMO was withheld. Results We were able to successfully obtain a diagnostic CTPA study in an infant on VA ECMO in the intensive care unit using portable CT. Conclusion: This case demonstrates that in select instances CTPA in infants on VA ECMO can be achieved using a portable CT system.

We report a case of refractory post-operative cerebrospinal fluid leak from a posterior fossa operative site secondary to superior vena cava construction. The patient developed the leak after a posterior fossa craniotomy and resection of a cerebellar lung metastasis. The leak persisted despite conservative measures and lumbar drain insertion. Suspicion of superior vena cava obstruction was raised following clinical examination. She was managed with stenting of the superior vena cava, with cessation of leak.

OBJECTIVE: To examine levels of plasma osteopontin (OPN), a recently described neuroinflammatory biomarker, in children with abusive head trauma (AHT) compared with children with other types of traumatic brain injury (TBI). STUDY DESIGN: The study cohort comprised children aged

OBJECTIVEEvidence shows mixed efficacy of applying guidelines for the treatment of traumatic brain injury (TBI) in children. A multidisciplinary team at a children’s health system standardized intensive care unit–based TBI care using guidelines and best practices. The authors sought to investigate the impact of guideline implementation on outcomes.METHODSA multidisciplinary group developed a TBI care protocol based on published TBI treatment guidelines and consensus, which was implemented in March 2011. The authors retrospectively compared preimplementation outcomes (May 2009 to March 2011) and postimplementation outcomes (April 2011 to March 2014) among patients < 18 years of age admitted with severe TBI (Glasgow Coma Scale score ≤ 8) and potential survivability who underwent intracranial pressure (ICP) monitoring. Measures included mortality, hospital length of stay (LOS), ventilator LOS, critical ICP elevation time (percentage or total time that ICP was > 40 mm Hg), and survivor functionality at discharge (measured by the WeeFIM score). Data were analyzed using Student t-tests.RESULTSA total of 71 and 121 patients were included pre- and postimplementation, respectively. Mortality (32% vs 19%; p < 0.001) and length of critical ICP elevation (> 20 mm Hg; 26.3% vs 15%; p = 0.001) decreased after protocol implementation. WeeFIM discharge scores were not statistically different (57.6 vs 58.9; p = 0.9). Hospital LOS (median 19.6 days; p = 0.68) and ventilator LOS (median 10 days; p = 0.24) were unchanged.CONCLUSIONSA multidisciplinary effort to develop, disseminate, and implement an evidence-based TBI treatment protocol at a children’s hospital was associated with improved outcomes, including survival and reduced time of ICP elevation. This type of ICP-based protocol can serve as a guide for other institutions looking to reduce practice disparity in the treatment of severe TBI.

Objective: We report a 63 years old female who presented with confusion, urinary retention and gait disturbances.Method: CT head shows communicating hydrocephalus. Spinal MRI demonstrated an L5- S1...

To compare outcome between young [65 yrs] and old [65 yrs] patients of Parkinson's disease who underwent bilateral STN DBS a non-randomized retrospective study was done. 20 young (Young group) and 20 elderly (Old group) patients with matched baseline UPDRS were selected and followed up for 2 years after deep brain stimulation (DBS) surgery. The total and motor UPDRS, before, one year and two years after surgery was compared. PDQ39 a quality of life questionnaire and MMSE were also recorded. Zarit care burden interview (ZCBI) was used to analyse caregiver burden. Analysis of data was done using Mann-Whitney Test as the data was ordinal. The difference was not statistically significant at 1st and 2nd year of follow up in total and motor UPDRS. A significant reduction in Levodopa equivalent daily dose was seen in young and old group from preoperative period to 1stthen 2nd year of follow up. The difference was not statistically significant (P = 0.946) at 1st (P = 0.946) and at 2nd year (P = 0.989). Both the groups showed improvement in their PDQ39. The difference was not statistically significant at 1st (P = 0.636) and at 2nd year of follow up (P = 0.417). Caregiver burden (ZCBI) improved in both the groups and the difference was not statistically significant at 1st (P = 0.105) and at 2nd year of follow up (P = 0.078).In this study STN DBS didn't lead to any cognitive decline (MMSE) whatever is the age of patient during follow up. Bilateral STN DBS for Parkinson's disease is equally effective in young and elderly patients.

A 74 year old male presented with 1 month history of weakness in right upper limb and motor aphasia for 15 days. Magnetic resonance imaging (MRI) of the brain showed three discrete ring enhancing lesions. An image guided awake craniotomy and biopsy of a lesion was performed. The histopathological examination revealed it to be a grade III Oligodendroglioma. This was a rare case of multicentric high grade oligodendroglioma has never been reported in literature. We report such a case with relevant review of literature.

Objective: cEEG is an emerging technology for which there are no clear guidelines for patient selection or length of monitoring. The purpose of this study was to identify subgroups of pediatric patients with high incidence of seizures. Study Design: We conducted a retrospective study on 517 children monitored by cEEG in the intensive care unit (ICU) of a children's hospital. The children were stratified using an age threshold selection method. Using regression modeling, we analyzed significant risk factors for increased seizure risk in younger and older children. Using two alternative correction procedures, we also considered a relevant comparison group to mitigate selection bias and to provide a perspective for our findings. Results: We discovered an approximate risk threshold of 14 months: below this threshold, the seizure risk increases dramatically. The older children had an overall seizure rate of 18%, and previous seizures were the only significant risk factor. In contrast, the younger children had an overall seizure rate of 45%, and the seizures were significantly associated with hypoxic-ischemic encephalopathy (HIE; p = 0.007), intracranial hemorrhage (ICH; p = 0.005), and central nervous system (CNS) infection (p = 0.02). Children with HIE, ICH, or CNS infection accounted for 61% of all seizure patients diagnosed through cEEG under 14 months. Conclusions: An extremely high incidence of seizures prevails among critically ill children under 14 months, particularly those with HIE, ICH, or CNS infection.

Spinal ependymoma commonly presents as an intramedullary tumor. We present a rare case of multicentric intradural extramedullary spinal ependymoma. A 59 years old female presented to us with spastic quadriparesis for 10 months. Magnetic resonance imaging of the spinal cord showed discretely located enhancing tumor masses from at C1-C2, C6-C7, and D4 to L3 level. Subtotal resection of the symptomatic tumor at C6-C7 and D7-D9 was done. The patient underwent radiotherapy with 50.4 Gy. At follow-up of 11 months, patient is doing well. The relevant literature is reviewed.

Poor workflow associated with physician rounding can produce inefficiencies that decrease time for essential activities, delay clinical decisions, and reduce staff and patient satisfaction. Workflow and provider resources were not optimized when a pediatric intensive care unit increased by 22,000 square feet (to 33,000) and by nine beds (to 30). Lean methods (focusing on essential processes) and scenario analysis were used to develop and implement a patient-centric standardized rounding process, which we hypothesize would lead to improved rounding efficiency, decrease required physician resources, improve satisfaction, and enhance throughput.Human factors techniques and statistical tools were used to collect and analyze observational data for 11 rounding events before and 12 rounding events after process redesign. Actions included: 1) recording rounding events, times, and patient interactions and classifying them as essential, nonessential, or nonvalue added; 2) comparing rounding duration and time per patient to determine the impact on efficiency; 3) analyzing discharge orders for timeliness; 4) conducting staff surveys to assess improvements in communication and care coordination; and 5) analyzing customer satisfaction data to evaluate impact on patient experience.Thirty-bed pediatric intensive care unit in a children's hospital with academic affiliation.Eight attending pediatric intensivists and their physician rounding teams.Eight attending physician-led teams were observed for 11 rounding events before and 12 rounding events after implementation of a standardized lean rounding process focusing on essential processes.Total rounding time decreased significantly (157 ± 35 mins before vs. 121 ± 20 mins after), through a reduction in time spent on nonessential (53 ± 30 vs. 9 ± 6 mins) activities. The previous process required three attending physicians for an average of 157 mins (7.55 attending physician man-hours), while the new process required two attending physicians for an average of 121 mins (4.03 attending physician man-hours). Cumulative distribution of completed patient rounds by hour of day showed an improvement from 40% to 80% of patients rounded by 9:30 AM. Discharge data showed pediatric intensive care unit patients were discharged an average of 58.05 mins sooner (p.05). Staff surveys showed a significant increase in satisfaction with the new process (including increased efficiency, improved physician identification, and clearer understanding of process). Customer satisfaction scores showed improvement after implementing the new process.Implementation of a lean-focused, patient-centric rounding structure stressing essential processes was associated with increased timeliness and efficiency of rounds, improved staff and customer satisfaction, improved throughput, and reduced attending physician man-hours.

Intraventricular meningiomas are rare in the pediatric population. These tumors are often large in size and aggressive in behavior when they occur in children. The management of these tumors is a surgical challenge.

Pediatric acute liver failure is often accompanied by hepatic encephalopathy, cerebral edema, and raised intracranial pressure. Elevated intracranial pressure can be managed more effectively with intracranial monitoring, but acute-liver-failure-associated coagulopathy is often considered a contraindication for invasive monitoring due to risk for intracranial bleeding. We reviewed our experience with use of early intracranial pressure monitoring in acute liver failure in children listed for liver transplantation.Retrospective review of all intubated pediatric acute liver failure patients with grade III and grade IV encephalopathy requiring intracranial pressure monitoring and evaluated for potential liver transplant who were identified from an institutional liver transplant patient database from 1999 to 2009.None.A total of 14 patients were identified who met the inclusion criteria. Their ages ranged from 7 months to 20 yrs. Diagnoses of acute liver failure were infectious (three), drug-induced (seven), autoimmune hepatitis (two), and indeterminate (two). Grade III and IV encephalopathy was seen in ten (71%) and four (29%) patients, respectively. Computed tomography scans before intracranial pressure monitor placement showed cerebral edema in five (35.7%) patients. Before intracranial pressure monitor placement, fresh frozen plasma, vitamin K, and activated recombinant factor VIIa were given to all 14 patients, with significant improvement in coagulopathy (p.04). The initial intracranial pressure ranged from 5 to 50 cm H2O; the intracranial pressure was significantly higher in patients with cerebral edema by computed tomography (p.05). Eleven of 14 (78%) patients received hypertonic saline, and three (22%) received mannitol for elevated intracranial pressure. Eight of 14 (56%) monitored patients were managed to liver transplant, with 100% surviving neurologically intact. Four of 14 (28%) patients had spontaneous recovery without liver transplant. Two of 14 (14%) patients died due to multiple organ failure before transplant. One patient had a small 9-mm intracranial hemorrhage but survived after receiving a liver transplant. No patient developed intracranial infection.In our series of patients, intracranial pressure monitoring had a low complication rate and was associated with a high survival rate despite severe hepatic encephalopathy and cerebral edema in the setting of pediatric acute liver failure. In our experience, monitoring of intracranial pressure allowed interventions to treat increased intracranial pressure and provided additional information regarding central nervous system injury before liver transplant. Further study is warranted to confirm if monitoring allows more directed intracranial pressure therapy and improves survival in pediatric acute liver failure.

A physician group in a pediatric intensive care unit faced challenges when moving to a larger unit. Challenges included increased time for rounds, nonbillable attending physician hours, poor communication with pediatric intensive care unit staff, and meeting resident physician duty hours and teaching requirements. The purpose of this analysis was to identify waste and opportunities for improvement to improve physician efficiency.Human factor (observational data collection) techniques were used to capture60 hrs of rounding data. Twelve attending physicians and their rounding teams were shadowed to capture rounds on 130 pediatric intensive care unit patients. Rounding events, times, and patient interactions were recorded. Lean methods and scenario analysis were used to analyze the data and identify opportunities for improvement. Rounding events were categorized to determine value-added and nonvalue-added activities. Value-added activities were subclassified as essential or nonessential to morning rounds.Thirty-bed pediatric intensive care unit in a children's hospital with academic affiliation. PATIENTS OR SUBJECTS: Eight attending pediatric intensivists and their physician rounding teams.Eight attending physician-led rounding teams were observed for 12 rounding events and a total of 130 patient contacts.Large variation existed in the rounding process. Nonessential activities was highly correlated with physician preference and created a wide range in rounding time per patient. Essential activities showed the least variation and represents a "lean process." Scenario analysis was used to determine the impact of removing waste and reallocating the nonessential activities outside of rounds. Results of the analysis indicated that rounds could be reduced by 42% and that plan of care completion would be timelier (decreased from a mean of 157 to 82 mins).In a large physician group, essential activities showed the least variation. Practice variation focused on minimizing nonessential activities could have dramatic impacts on standardizing practice. Further study is indicated to determine whether standardizing rounds to focus on essential activities can lead to more effective processes that require fewer resources while improving outcomes for all stakeholders.