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The imaging of subdural hematoma has evolved significantly. Computed tomography and MRI have supplanted other procedures and rendered most obsolete for the evaluation of intracranial pathology because of ease of use, tremendous soft tissue resolution, safety, and availability. Noncontrast computed tomography has become the accepted standard of care for the initial evaluation of patients with suspected subdural hematoma because of widespread availability, rapid acquisition time, and noninvasive nature. MRI offers important features in determining potential secondary causes of subdural hematoma, such as dural-based neoplasms.

INTRODUCTIONPatients with nontraumatic acute intracranial pathology benefit from neurointensivist care. Similarly, trauma patients with and without traumatic brain injury (TBI) fare better when treated by a dedicated trauma team. No study has yet evaluated the role of specialized neurocritical (NICU

Introduction Papilloedema is defined as swelling of the optic disc caused by raised intracranial pressure. Following a recent highly publicised court case, our paediatric and other services 1have experienced an unprecedented increase in referrals of children with ‘suspicious optic discs’. We aimed to evaluate the patient journey of all children presenting with suspected optic disc swelling and make recommendations for an integrated multidisciplinary pathway. Methods A retrospective case notes review in a single UK centre of all patients under 16 presenting with suspected optic disc swelling to Paediatric or Ophthalmology departments. Results During a 9 month period in 2016, 42 referrals concerning ‘suspicious’ optic discs were received. 39 (92%) of these were from community optometrists. Mean age was 11, ranging from 4–17 years old. 38 (90%) of these patients presented to Ophthalmic Emergency, of whom 18 were sent straight to paediatrics. The remainder came via their GP. 11 (61%) were sent for urgent MRI without seeing a paediatrician or ophthalmologist; 10 (91%) of these MRI scans were normal. 6 had ‘USS proven’ disc drusen. Only 3 children(11.5%) were found to have underlying pathology. Only 2 (5%) children had ‘true’ papilloedema related to intracranial pathology (1=astrocytoma, 1=idiopathic intracranial hypertension). Conclusions The large majority of children with a suspicion of a swollen optic disc raised by a community optometrist do not have any significant pathology. Increased referrals for suspicious optic discs creates a significant workload for paediatric and eye services and generates high levels of anxiety for the patient and family.

Aim To assess the prevalence of clinically urgent intracranial pathology (CUIP) in children visiting the emergency department with a complex febrile seizure (CFS). Methods Retrospective cohort review. We analysed the visits of patients for a CFS from January 2007 to December 2011 in seven paediatric emergency departments. Our main outcomes were the proportions of CUIP diagnosed between day 0 and 1 and within 30 days after the index visit. Results From 1 183 487 visits, 839 were for a CFS and 130 (15.5%) of these had a neuroimaging performed within 30 days (CT scan for 75 visits [8.9%], MRI for 30 visits [3.6%] and both for 25 visits [3.0%]). Three CUIP were diagnosed between day 0 and 1 (0.4% [CI-95%: 0.1-1.3]), 5 within 30 days after the index visit (0.7% [CI-95%: 0.2-1.7]) but none among the 630 visits of children presenting with a normal neurological clinical examination (0% [95% CI: 0.0-0.7]), nor among the 468 presenting only with multiple seizure (0% [95% CI: 0.0-1.0]). Conclusion In children with a CFS, CUIP is rare event in the subgroup of children with a normal neurological clinical examination and in those with brief generalised multiple seizures.

OBJECTIVE: The purpose of the current study was to investigate the prevalence of incidental paranasal sinus abnormalities on brain magnetic resonance imaging (MRI). We also aimed to assess the season, the age and sex-related differences in the frequencies of these abnormalities. METHODS: Paranasal sinus cavities of 839 patients who underwent brain MRI for suspected intracranial pathology were retrospectively evaluated for the presence of incidental abnormalities. Two study groups were established according to the season in which the MRI examinations were performed, and the prevalences of the incidental sinusal abnormalities in both winter and summer were calculated. The relation of the incidental sinusal abnormalities to age and sex were also analyzed. RESULTS: Of the 839 patients, 45.5% showed one or more sinusal abnormalities. The prevalence of the sinusal abnormalities was significantly higher in winter (50.6%) than in summer (40.3%) (p=0.003). While sphenoidal sinus lesions did not show significant seasonality (p>0.05), frontal, maxillary and ethmoidal sinus lesions were significantly more common in winter than in summer (p0.05). CONCLUSION: Paranasal sinus abnormality is a frequent incidental brain MRI finding which is more commonly detected in winter. Awareness of incidental paranasal sinus abnormalities and knowledge of its frequency contribute positively to clinical applications.

Perioperative management of pregnant patients, who require a neurosurgical intervention, poses several unique challenges for the neuroanesthetist. Besides the standard neuroanesthesia concerns, the delicate feto-maternal homeostasis has to be maintained, in order to achieve a good maternal outcome without compromising fetal safety. This may necessitate several modifications in the conventional neuroanesthesia technique and, often, a need to skillfully balance, competing or even contradictory clinical goals. Other pertinent dilemma that arises during management includes decisions regarding the optimal timing of neurosurgery, continuation or termination of pregnancy, optimal timing and mode of delivery, and possibility of a combined cesarean section and neurosurgery in patients with near-term pregnancy. Moreover, there are no well-established recommendations that can help to guide the management of these patients. Optimal perioperative management in these circumstances mandates an integrated understanding not only of neurosurgical anesthesia but also of the maternal physiological changes during pregnancy and their implications on feto-maternal homeostasis, intracranial pathology, and the neuroanesthesia technique, along with the pertinent perioperative fetal concerns and the effect of anesthetic drugs on feto-maternal physiology and cerebral homeostasis; importantly, a well-planned, individualized, and multidisciplinary approach is vital for a favorable outcome. The initial sections of this chapter provide an overview of the basic fundamentals; the latter sections describe the principles of anesthetic management for pregnant patients during a cranial surgery, a combined cesarean section and neurosurgery, spinal surgery, neuroendovascular procedure, and traumatic brain/spinal cord injury.

Due to technical limitations, small, distal, and tortuous intracranial pathology is sometimes out of reach of the current armamentarium of microcatheters designed for intracranial coil embolization. The Marathon microcatheter (Medtronic, Minneapolis, Minnesota, USA), designed specifically for the delivery of Onyx, is longer and more flexible than most coil delivery catheters. We report on nine patients (three with arteriovenous fistula, three with arteriovenous malformation, two with intracranial aneurysm, and one with tumor) where Marathon was used to deliver commercially available platinum coils. We also conducted laboratory compatibility testing and conclude that the Marathon can be used as a coil delivery catheter for Barricade coils (Blockade Medical, Irvine, California, USA) with diameter less than 0.012 in.

Intracranial causes of death trail in incidence behind cardiovascular and respiratory system pathologies in most deaths occurring in hospitals. When intracranial pathology becomes more important is in the forensic arena, where it is often supposed that in troublesome cases such as sudden and unexpected deaths or where there appears to be no anatomic cause of death revealed in the general autopsy, the cause must be in the brain. This hope is often dashed after a careful neuropathological examination. Intracranial causes of death are discussed here mostly within the context of the forensic exercise where complex processes may be involved such as: electrophysiological dysfunctions; disorders of respiratory control; dysfunction of the intracranial pressure/volume equilibrium.

Background: The presence of open fontanelle in infants plays a major role in the ability to image the brain with ultrasound. The premature infants are more prone for hypoxic-ischemic insults and complications, which on early diagnosis helps the neonatal brain to protect from further insults. Aims and Objectives: Evaluation of intracranial pathologies by transcranial neurosonography in neonates and infants, by dividing into three groups: Preterms before 34 weeks, after 34 weeks, and unrelated to gestational age. All preterms and neonates are scanned early to diagnose intracerebral hemorrhages, hypoxic-ischemic encephalopathy (HIE), infections, and congenital problems and later follow-up scans to identify its complications for the timely management of neonate. Materials and Methods: A total of 165 infants with clinical suspicion evaluated on neurosonogram for 2 years. The study was conducted in the Department of Radiology using multi-frequency convex probe, sector probe and small linear probe, and Doppler flow studies. The babies were screened in coronal, sagittal, parasagittal planes using anterior fontanelle, transtemporal as an acoustic windows, and additional views whenever necessary. Results: Positive sonographic findings identified in 120 patients. Some patients showed more than one sonographic findings. 75% of preterm babies presented with intraventricular hemorrhage and on follow-up scans showed communicating hydrocephalus in 75% and 16% porencephalic cysts. In HIE, 74% had cerebral edema followed by periventricular echo densities. 10 cases of periventricular leukomalacia with 2-3 mm cystic lesions resulting in cerebral palsy. All infections presented with echogenic sulci or meningeal thickening in 38%. Hydrocephalus being the common sequelae in 48%. In congenital anomalies, hydrocephalus predominates the study in 54% with other associated anomalies such as Dandy–Walker malformation. Conclusion: Neurosonography is a non-invasive, safe, cost effective and allows for the prediction of neurological development. It provides a clue to a wide range of pathology and spectrum of pathological imaging appearances encountered in neonates. It is an accurate and sensitive modality for early diagnosis and timely management.

Objective: To investigate the implication of a computed tomography scan for headache with non-localizing sign.Materials and methods: One hundred and thirty six patients with headache having non-localizing signs were included in this prospective study. Patients with age > 11 years, incomplete radiological or clinical data, recent/new onset headache, any immunosuppressive state, neurological deficits at the time of presentation, history of fever, trauma, any previous surgical intervention and any malignancy were excluded from the study.Results: Among the 136 patients, 73% were females and 27% were males with age range of 11- 76 years. Negative computed tomography scan was present in 91 (66.9 %) cases. Positive findings that significantly influenced the management were present in only 6 (4.4%) cases. Conclusion: Computed tomography in headache with non-localizing signs has a poor yield for a significant intracranial pathology. A careful and detailed assessment curtails the need for inadvertent imaging thus reducing the economic burden and health related hazards.Journal of Nepalgunj Medical College Vol.13(1) 2015: 2-4

Head injury is the largest cause of mortality in paediatric trauma. Infants (

Background Central precocious puberty (CPP) is idiopathic in 90% of girls and 60% of boys, while some cases are caused by lesions of central nervous system (CNS), a condition often referred to as organic CPP. We aimed to analyze the etiology of organic CPP in a large cohort of girls and boys and determine gender-related differences. Methods Medical files of 256 girls and 120 boys diagnosed and treated for CPP in a single center in the last two decades were reviewed. Patients were classified into four groups with respect to previous history and MRI findings: (1) previously established CNS pathology at the time of diagnosis, (2) novel CNS pathology previously asymptomatic, (3) incidentalomas considered to be unrelated to CPP, and (4) completely normal MRI. Group 1 and 2 were considered as organic CPP whereas group 3 and 4 were considered as idiopathic CPP. Results Prevalence of CNS pathology was significantly higher in boys than girls (21.7% vs 6.2%). Previous CNS pathologies such as developmental anomaly of CNS, parenchymal injury, necrotic lesions and hydrocephalus were present in 3.5% of girls and 8.3% of boys. Prevalence of novel CNS pathology as determined by imaging among neurologically asymptomatic patients was 2.8% in girls and 14.5% in boys. The most common novel CNS pathologies in boys were hamartomas (5%) and suprasellar arachnoid cysts (3.3%); which were significantly lower in girls (0.8 and 0.8% respectively). Onset of organic CPP was before six years in girls, and seven years in boys. Conclusions Organic CPP was 3.5 times more common in boys compared to girls. It is possible to detect an underlying CNS pathology in one out of every five boys with CPP. Frequency and distribution of organic etiology also differ between girls and boys, hypothalamic hamartomas and suprasellar arachnoid cysts being more common in boys than girls. The likelihood of novel intracranial pathology associated with CPP is quite low in girls with an onset after six years of age and in boys with an onset after seven years of age.

Background and purpose Deciding whether or not to perform neuroimaging in primary headache is a dilemma for headache physicians. The aim of this study was to identify clinical predictors of incidental neuroimaging abnormalities in new patients with primary headache disorders. Methods This cross-sectional study was based on a prospective multicenter headache registry, and it classified 1,627 consecutive first-visit headache patients according to the third edition (beta version) of the International Classification of Headache Disorders (ICHD-3β). Primary headache patients who underwent neuroimaging were finally enrolled in the analysis. Serious intracranial pathology was defined as serious neuroimaging abnormalities with a high degree of medical urgency. Univariable and multivariable logistic regression analyses were conducted to identify factors associated with incidental neuroimaging abnormalities. Results Neuroimaging abnormalities were present in 170 (18.3%) of 927 eligible patients. In multivariable analysis, age ≥40 years [multivariable-adjusted odds ratio (aOR)=3.37, 95% CI=2.07-6.83], male sex (aOR=1.61, 95% CI=1.12-2.32), and age ≥50 years at headache onset (aOR=1.86, 95% CI=1.24-2.78) were associated with neuroimaging abnormalities. In univariable analyses, age ≥40 years was the only independent variable associated with serious neuroimaging abnormalities (OR=3.37, 95% CI=1.17-9.66), which were found in 34 patients (3.6%). These associations did not change after further adjustment for neuroimaging modality. Conclusions Incidental neuroimaging abnormalities were common and varied in a primary headache diagnosis. A small proportion of the patients incidentally had serious neuroimaging abnormalities, and they were predicted by age ≥40 years. These findings can be used to guide the performing of neuroimaging in primary headache disorders.

Introduction: The cavernous sinus (CS) lesions are difficult to identify on computed tomogram (CT) film, and the subtle changes may help in the diagnosis. The objective of the present study was to examine the para-cavernous adipose tissue in the CT scan in the Indian population. Material and Methods: The study included 100 patients of all age groups, who were examined using a 16 slice multidetector CT. The axial images were analyzed for the presence of adipose tissue on either side of the CS. The intracranial pathology and atrophic changes, if any, were noted. Results: The present study observed that 17% of the patients had intracranial pathologies. Among the 83% of patients with no pathology, paracavernous adipose tissue was observed in 85.5% and 89.2% over the right and left sides, respectively. It was observed that the paracavernous fat was visualized in higher frequency in elderly adults. It was visualized in all the patients (100%) of over 60 years. In some patients, with mass effect, the paracavernous fat was obliterated over the ipsilateral side, but it was visualized on the contralateral side. Discussion and Conclusion: The present study suggests that the CS lesions are difficult to identify on the CT scan, and the subtle signs may help in making a diagnosis. The para-CS adipose deposit is one among these subtle changes; if there is the presence of adipose tissue on one side and its absence on the other side, then pathology should be suspected.

Intracranial hemorrhage after traumatic brain injury (TBI) can be life threatening and requires prompt diagnosis. Computed tomography (CT) scans are a rapid and accurate way to evaluate for hemorrhage. In patients with mild and moderate TBI, however, in whom the incidence of intracranial pathology is low, scanning every patient with CT can be costly. The Food and Drug Administration recently approved a novel biomarker screen, the Banyan Trauma Indicator (BTI), to help streamline the decision for CT scanning in mild to moderate TBI. The BTI screen diagnoses intracranial lesions with a sensitivity and specificity of 97.5% and 99.6%, respectively. We performed cost analyses of the BTI screen to determine the threshold of cost-effectiveness, compared with application of clinical decision rules or routine CT scans, for cases of mild or moderate TBI. With a 0.104 probability of an intracranial lesion in mild TBI, the biomarker screen is cost-effective if the cost is $308.96 or below per test. In moderate TBI, because of the greater prevalence of intracranial lesions at 0.663, there is a lower need for screening, and BTI becomes cost-effective up to $73.41 per test.

‘Ping-pong’ fractures are depressed skull fractures in newborn infants that occur as inward buckling of the calvarial bones, forming a cup shape. These fractures are often associated with maintenance of bone continuity. These fractures may occur spontaneously during the intrauterine period or secondary to birth trauma. Currently, there is no standard protocol for the management of depressed skull fractures. Neurosurgical or non-surgical approaches may be administered depends on the severity of the fracture. Most untreated ping-pong fractures resolve spontaneously within 6 months. Therefore, it is recommended to reserve surgical elevation or non-surgical techniques for infants not demonstrating spontaneous resolution during this period. In addition, neurosurgical interventions are usually considered for cases with intracranial pathology or neurological deficits or for infants who do not respond to conservative treatment. Herein, we report a case of a newborn infant with a spontaneous intrauterine ping-pong fracture, which spontaneously resolved, without surgical or non-surgical intervention.

BACKGROUND Preinjury employment status may contribute to disparity, injury risk, and recovery patterns following mild traumatic brain injury (MTBI). OBJECTIVE To characterize associations between preinjury unemployment, prior comorbidities, and outcomes following MTBI. METHODS MTBI patients from TRACK-TBI Pilot with complete six-month outcomes were extracted. Preinjury unemployment, comorbidities, injury factors, and intracranial pathology were considered. Multivariable regression was performed for employment and outcomes, correcting for demographic and injury factors. Mean-differences (B) and 95% CIs are reported. Statistical significance was assessed at p < 0.05. RESULTS 162 MTBI patients were aged 39.8±15.4-years and 24.6% -unemployed. Unemployed patients demonstrated increased psychiatric comorbidities (45.0% -vs.- 23.8%; p = 0.010), drug use (52.5% -vs.- 21.3%; p < 0.001), smoking (62.5% -vs.- 27.0%; p < 0.001), prior TBI (78.4% -vs.- 55.0%; p = 0.012), and lower education (15.0% -vs.- 45.1% college degree; p = 0.003). On multivariable analysis, unemployment associated with decreased six-month functional outcome (Glasgow Outcome Scale-Extended: B = - 0.50, 95% CI [- 0.88, - 0.11]), increased psychiatric disturbance (Brief Symptom Inventory-18: B = 6.22 [2.33, 10.10]), postconcussional symptoms (Rivermead Questionnaire: B = 4.91 [0.38, 9.44]), and post-traumatic stress disorder (PTSD Checklist-Civilian: B = 5.99 [0.76, 11.22]). No differences were observed for cognitive measures or satisfaction with life. CONCLUSIONS Unemployed patients are at risk for preinjury psychosocial comorbidities, poorer six-month functional recovery and increased psychiatric/postconcussional/PTSD symptoms. Resource allocation and return precautions should be implemented to mitigate and/or prevent the decline of at-risk patients.

The goal of this review is to outline the prevalence and significance of occipital headaches in children and how they relate to neuroimaging findings. We seek to evaluate the concern that occipital headaches in children are indicative of secondary headache pathology by reviewing the yield of neuroimaging in pediatric patients with occipital headache location. Occipital headaches are a common presentation of primary headache disorders in children, seen in 7–16% of children presenting for evaluation of headache and in up to 20% of children diagnosed with migraine in the emergency department. Review of recent literature confirms that in and of itself, occipital location of headache in a child with recurrent headache and a normal physical examination should not be regarded as worrisome. Headaches with associated signs on neurologic examination should be investigated for a secondary cause, regardless of headache location. Occipital headaches that do not meet criteria for a primary headache disorder should be evaluated for site-specific occipital headache conditions. Neuroimaging for recurrent headache in children who have normal neurological examinations has an overall low yield (0–4.1%) for actionable findings in recent studies. Importantly, an abnormal neurologic examination often predicts the presence of neuroimaging abnormalities. In the absence of an atypical history or abnormalities on clinical examination, occipital headaches in children are no more likely to be associated with intracranial pathology than headaches in other locations. If the child’s headaches are otherwise consistent with migraine or another primary headache disorder, and the neurologic examination is normal, the yield of neuroimaging is low, and imaging can generally be deferred.

BACKGROUND Patients who present for a trauma workup often have a head computed tomography (CT) performed to identify intracranial pathology. Facial fractures are routinely identified in these patients, and further imaging is the norm with dedicated facial CT scans. Additional imaging increases radiation doses; however, it is unclear if additional operative fractures are identified. The aim of this study was to examine differences between these 2 CT imaging modalities. METHODS A retrospective review of all operative facial trauma patients receiving both head and facial scans at a single institution was performed (1999-2012). Identified fracture patterns were compared between the head and facial CT scans of each patient to determine if the results correlated. Demographic information and injury mechanism were compared. RESULTS A total of 307 patients receiving both types of CT scan underwent facial fracture repair. In the 106 patients (35%) with differences identified fractures between the scans, 151 additional operative fractures were found through dedicated facial imaging: nasal fractures (58 vs 15; P < 0.001), midface fractures (69 vs 34; P < 0.001), zygoma fractures (51 vs 21; P < 0.001), and orbital fractures (90 vs 51; P < 0.001). No differences in demographics or mechanisms of injury were observed between groups. CONCLUSIONS Standard head CT scans alone failed to identify a significant number of operative facial fractures compared with facial CT in 35% of patients. Dedicated facial CT scans should be considered for patients with known or suspected facial fractures, even if a head scan has been performed previously.

Objective: Computed tomography (CT) of the brain can allow rapid assessment of intracranial pathology after traumatic brain injury (TBI). Frequently in paediatric TBI, CT imaging can fail to display the classical features of severe brain injury with raised intracranial pressure. The objective of this study was to determine early CT brain features that influence intracranial or systemic physiological trends following paediatric TBI.

Purpose: Less than 5% of children who present to the emergency department (ED) with a chief complaint of a headache will have an intracranial finding. Despite this low prevalence, large numbers of children who present to the ED undergo diagnostic imaging with Computed Tomography (CT) or Magnetic Resonance Imaging (MRI). This relatively low yield in imaging neurologically normal patients has implications for resource utilization and exposure to ionizing radiation as well as un-necessary sedation. The goal of this study is to describe the utilization of head CT or MRI among pediatric ED …

Children presenting in later childhood with isolated, acquired, comitant non-accommodative esotropia (ANAET) form an unusual clinical group whose evaluation, treatment, and prognosis are unclear. We identified 9 such patients with no evidence of intracranial pathology whose outcomes following standard bilateral medial rectus recessions were excellent.

Pial arteriovenous malformations (AVMs) of the brain are vascular abnormalities located in the subpial space that consist of direct communications from artery to vein via intervening nidus. AVMs are the most common intracranial pathology and frequent cause of intracranial hemorrhage in children. Moreover, the epidemiology and clinical findings particular to chil- dren with AVMs can be ascribed to the distinct angioarchitecture of pediatric AVMs. However, the natural history and treatment of pediatric AVMs is relatively unknown. In this article, we review current knowledge of pediatric pial AVMs.

Head CT after out-of-hospital cardiac arrest is often obtained to evaluate intracranial pathology. Among children admitted to the PICU following pediatric out-of-hospital cardiac arrest, we hypothesized that loss of gray-white matter differentiation and basilar cistern and sulcal effacement are associated with mortality and unfavorable neurologic outcome.Retrospective, cohort study.Single, tertiary-care center PICU.Seventy-eight patients less than 18 years old who survived out-of-hospital cardiac arrest to PICU admission and had a head CT within 24 hours of return of spontaneous circulation were evaluated from July 2005 through May 2012.None.Median time to head CT from return of spontaneous circulation was 3.3 hours (1.0, 6.0). Median patient age was 2.3 years (0.4, 9.5). Thirty-nine patients (50%) survived, of whom 29 (74%) had favorable neurologic outcome. Nonsurvivors were more likely than survivors to have 1) loss of gray-white matter differentiation (Hounsfield unit ratios, 0.96 [0.88, 1.07] vs 1.1 [1.07, 1.2]; p0.001), 2) basilar cistern effacement (93% vs 7%; p = 0.001; positive predictive value, 94%; negative predictive value, 59%), and 3) sulcal effacement (100% vs 0%; p ≤ 0.001; positive predictive value, 100%; negative predictive value, 68%). All patients with poor gray-white matter differentiation or sulcal effacement had unfavorable neurologic outcomes. Only one patient with basilar cistern effacement had favorable outcome.Loss of gray-white matter differentiation and basilar cistern effacement and sulcal effacement are associated with poor outcome after pediatric out-of-hospital cardiac arrest. Select patients may have favorable outcomes despite these findings.

Objectives/Hypothesis To determine the pediatric age groups viable for nasoseptal flap (NSF) reconstruction of endoscopic endonasal approaches (EEA) to intracranial pathology of suprasella neoplasms. Study Design Retrospective cohort study. Methods Retrospective review of 16 pediatric patients who underwent EEA with NSF reconstruction for a suprasellar defect from 2012 to 2014. Radioanatomic analysis was utilized to assess feasibility of NSF reconstruction of suprasellar neoplasms approached via EEA. Computed tomography (CT) measurements for defect size and potential flap coverage were measured by preoperative maxillofacial CT. Radiographic measurements and surgical outcomes were compared to determine if flap size would be sufficient to cover said defects in two pediatric age groups: those >10 years of age (mean age 14 years) and those 10 years of age population, and this was not due to insufficient flap coverage. Average potential flap length and width are sufficient to cover average suprasellar defect length and width in both age groups (P

BACKGROUND: Neurosurgeons have preferred to perform the stereotactic biopsy for pathologic diagnosis when the intracranial pathology located eloquent areas and deep sites of the brain.AIM: To get a higher ratio of definite pathologic diagnosis during stereotactic biopsy and develop practical method.MATERIAL AND METHODS: We determined at least two different target points and two different trajectories to take brain biopsy during stereotactic biopsy. It is a different way from the conventional stereotactic biopsy method in which one point has been selected to take a biopsy. We separated our patients into two groups, group 1 (N=10), and group 2 (N= 19). We chose one target to take a biopsy in group 1, and two different targets and two different trajectories in group 2. In group 2, one patient underwent craniotomy due to hemorrhage at the site of the biopsy during tissue biting. However, none of the patients in both groups suffered any neurological complication related biopsy procedure.RESULTS: In group 1, two of 10 cases, and, in group 2, fourteen of 19 cases had positive biopsy harvesting. These results showed statistically significant difference between group 1 and group 2 (P

A unilaterally fixed mydriasis, also known as a 'blown pupil,' is considered an ominous sign concerning for intracranial pathology. Causes of anisocoria can range from benign to immediately life-threatening. When a patient presents with anisocoria, the concern for a fatal diagnosis leads the clinician to obtain numerous tests, many of which may be unnecessary. The authors present a case of a healthy woman in her 30s who presented with an acute unilateral mydriasis likely secondary to inadvertent contact with a scopolamine patch. On examination, she had no other neurological deficits. Further investigation did not reveal any abnormality. In the event of a patient with an isolated mydriasis in an otherwise healthy and conversant patient with no other neurological deficits, it is essential to rule out other causes before pursuing aggressive and unnecessary testing and treatment.

Traumatic brain injury (TBI) is a major cause of death and disability in the United States. Time to treatment is often related to patient outcome. Access to cerebral imaging data in a timely manner is a vital component of patient care. Current methods of detecting and quantifying intracranial pathology can be time-consuming and require careful review of 2D/3D patient images by a radiologist. Additional time is needed for image protocoling, acquisition, and processing. These steps often occur in series, adding more time to the process and potentially delaying time-dependent management decisions for patients with traumatic brain injury. Our team adapted machine learning and computer vision methods to develop a technique that rapidly and automatically detects CT-identifiable lesions. Specifically, we use scale invariant feature transform (SIFT) 1 and deep convolutional neural networks (CNN) 2 to identify important image features that can distinguish TBI lesions from background data. Our learning algorithm is a linear support vector machine (SVM) 3 . Further, we also employ tools from topological data analysis (TDA) for gleaning insights into the correlation patterns between healthy and pathological data. The technique was validated using 409 CT scans of the brain, acquired via the Progesterone for the Treatment of Traumatic Brain Injury phase III clinical trial (ProTECT_III) which studied patients with moderate to severe TBI 4 . CT data were annotated by a central radiologist and included patients with positive and negative scans. Additionally, the largest lesion on each positive scan was manually segmented. We reserved 80% of the data for training the SVM and used the remaining 20% for testing. Preliminary results are promising with 92.55% prediction accuracy (sensitivity = 91.15%, specificity = 93.45%), indicating the potential usefulness of this technique in clinical scenarios.

Harvey Cushing is widely regarded as one of the forefathers of neurosurgery, and is primarily associated with his work on intracranial pathology. However, he had a clinical and academic interest in peripheral nerve surgery. Through the courtesy of the Alan Mason Chesney Medical Archives, the surgical records of the Johns Hopkins Hospital from 1896 to 1912 were reviewed. The records of a single patient undergoing brachial plexus exploration and cervical rib resection were selected for detailed review. The operative report and accompanying illustrations demonstrate Cushing’s interest in adding approaches to the pathology of the brachial plexus to his operative armamentarium.

The chapter begins by analyzing the conviction and exoneration of Kenneth Marsh. Then, as the chapter explains current medical understanding of shaken baby syndrome (SBS), it becomes clear that we have lost sight of previously known facts concerning infant intracranial pathology and anatomy, and that natural conditions have been mischaracterized as the result of inflicted trauma. Research has discredited each of the indicators of SBS. Specifically, thin-film subdural hemorrhage (SDH; bleeding in the membrane surrounding the brain) has not been demonstrated to be the result of traumatic rupture of bridging veins caused by shaking, but is more likely to originate as a function of immaturity. Encephalopathy (disease, damage, or malfunction of the brain) is not due to traumatic shearing of the nerve fibers of the brain, but is due to a secondary cascade of events, including brain swelling and lack of blood and oxygen supply, and is not specific for trauma and certainly not for abuse. Retinal hemorrhages (bleeding in the retina) occur in normal births and have many other natural causes in infants, one being part of the same secondary cascade. In addition, biomechanics have shown that shaking produces less acceleration than a short fall, supporting the alternative explanation often given by defendants: the infant was injured by a short fall. Though doctors, including the leading advocates of SBS, are shifting their views in several jurisdictions internationally, defendants still face prosecution and conviction based on the old SBS tenets, and attorneys and courts must be aware of current science in order to ensure fair trials and just verdicts.

To determine the yield of neuroimaging in children presenting to the emergency department with acute ataxia in the post–varicella vaccine era, we conducted a cross-sectional study between 1995 and 2013 at a single pediatric tertiary care center. We included children aged 1-18 years evaluated for acute ataxia of

Introduction: Although one third of febrile seizures are complex, a consensus has still not been reached on how to manage them, as is the case with simple febrile seizures. The objective of this study is to estimate the usefulness of complementary examinations and the risk of associated serious intracranial pathology. Patients and methods: A retrospective review was conducted from 2003 until 2011 on patients from 6 months to 6 years presenting with a complex febrile seizure admitted to a tertiary care hospital, excluding the cases with previous neurological disease. Epidemiological and clinic variables were collected, as well as complementary tests and complications. Results: We found 65 patients (31 females and 34 males), of whom 44 had repeated seizures in the first 24 hours, with 15 having focal seizures. The vast majority (90%) of the recurrences occurred before 15 hours. The mean age was 20.7 months and temperature was 39.1 ± 0.12 °C. None of the patients had severe intracranial pathology. The electroencephalogram gave no helpful information for the diagnosis. Neuroimaging was normal in all studied cases. Conclusions: The incidence of complications in complex febrile seizure in our series did not justify the systematic admission or the systematic study with complementary tests when the neurological examination was normal. The routine electroencephalogram does not appear to be justified. Resumen: Introducción: Un tercio de las crisis febriles son complejas. Su manejo no ha suscitado un consenso como en el caso de las crisis febriles simples. El objetivo de este estudio es estimar la rentabilidad de los exámenes complementarios y el riesgo de enfermedad intracraneal grave asociada. Pacientes y métodos: Estudio retrospectivo desde el año 2003 hasta el 2011 de los pacientes ingresados en un hospital de tercer nivel con criterios de convulsión febril compleja de 6 meses a 6 años, excluyendo los casos con afección neurológica previa. De los pacientes seleccionados, se recogieron variables epidemiológicas, clínicas, pruebas complementarias y complicaciones. Resultados: Se encontró a 65 pacientes (31 mujeres y 34 varones) de los cuales 44 tuvieron crisis repetidas en las primeras 24 h y 15 presentaron crisis focales. El 90% de la recurrencia ocurrió antes de 15 h. La edad media fue de 20,7 meses y la temperatura fue de 39,1 ± 0,12 °C. En ningún paciente se encontró afección intracraneal grave durante su ingreso. El electroencefalograma no ofreció información de ayuda para su diagnostico. La neuroimagen fue normal en todos los casos estudiados. Conclusiones: La incidencia de complicaciones en la convulsión febril compleja en nuestra serie no justificó el ingreso ni el estudio sistemático con pruebas complementarias cuando la exploración neurológica era normal. El electroencefalograma de rutina no parece estar justificado.

Background. Missed or delayed detection of progressive neuronal damage after traumatic brain injury (TBI) may have negative impact on the outcome. We investigated whether routine follow-up CT is beneficial in sedated and mechanically ventilated trauma patients.Methods. The study design is a retrospective chart review. A routine follow-up cCT was performed 6 hours after the admission scan. We defined 2 groups of patients, group I: patients with equal or recurrent pathologies and group II: patients with new findings or progression of known pathologies.Results. A progression of intracranial injury was found in 63 patients (42%) and 18 patients (12%) had new findings in cCT 2 (group II). In group II a change in therapy was found in 44 out of 81 patients (54%). 55 patients with progression or new findings on the second cCT had no clinical signs of neurological deterioration. Of those 24 patients (44%) had therapeutic consequences due to the results of the follow-up cCT.Conclusion. We found new diagnosis or progression of intracranial pathology in 54% of the patients. In 54% of patients with new findings and progression of pathology, therapy was changed due to the results of follow-up cCT. In trauma patients who are sedated and ventilated for different reasons a routine follow-up CT is beneficial.

INTRODUCTION Patients undergoing stereotactic radiosurgery (SRS) for intracranial pathology have two treatment options: frame-based (FB) versus masked (MB). There is sparse information on a patient’s experience between the two types and to what extent a patient’s diagnosis will predict their SRS experience. METHODS A retrospective analysis of patients who completed a questionnaire of their experience after SRS using the Gamma Knife Icon was completed. RESULTS Fifty-eight patients completed the questionnaire, 60% were FB and 40% MB. The average age was 63.3 + 15.3 years, 40% were male. Of the patients treated with a FB technique, 51% didn’t find SRS to be uncomfortable. Comparatively, 91% of MB patients didn’t find SRS to be uncomfortable. Patients who underwent FB treatment rated their pain of frame placement on a visual analog scale (VAS) 1–3, 24%, VAS 4–6, 46%, VAS 7–10, 30%. Eight patients answered that they didn’t tolerate the procedure as expected, most of which were treated using a FB method (87%). Compared to previous surgery or SRS, five patients found their experience of SRS wasn’t tolerable, while 93% of patients would consider repeat SRS. All patients treated felt adequately informed about the procedure. The patient experience of discomfort during SRS and their evaluation of pain during frame placement between patients treated for benign versus malignant lesions (discomfort: 59% vs. 22%, respectively and median VAS pain: 6 + 2.67, 4.5 + 1.99, respectively) determined a benign diagnosis had more discomfort during SRS compared to a malignant diagnosis. Pain during frame placement was similar for both diagnoses. CONCLUSION Patients experienced frame-based SRS as more uncomfortable than mask-based treatment. Benign pathologies appeared to have more discomfort compared to malignant pathologies. All patients of both techniques felt adequately informed about their procedure.

Background: Preterm neonates have a higher mortality and morbidity because of their greater risk for intracranial hemorrhage (ICH), hypoxic ischemic encephalopathy(HIE) which can lead to poor neurodevelopmental outcomes. The present study was conducted to evaluate neonates with clinically suspected intracranial pathology by neurosonography.Methods: Included neonates were those with clinically suspected intracranial pathology admitted to neonatal intensive care unit of the Bharati Vidyapeeth Medical College and Hospital (Deemed to be University), Sangli from October 2018 till December 2018. First cranial neurosonography was done between first and third day, second between 7th and 10th day of birth. HIE also known as Periventricular leukomalacia (PVL) grading was done using the De Varies et al, grading. Severity of ICH was graded according to Papile and Burstein classification(1978).Results: Of the total 60 neonates, 61.7% were preterm and rest at term. Mean APGAR score at 1 minute was 8.6 (range 5 to 10) and at 5 minutes was 9.58 (range 8 to 10). Mean ventricular index at the first assessment was 26.78% and 26.89% at the second assessment. Grade 1 HIE was found in 17 neonates on first assessment, and two had grade 2 HIE. Second assessment revealed grade 1 HIE in 20 neonates and grade 2 in two. First assessment revealed two neonates with grade 1 and grade 2 ICH, out of which one grade 2 ICH worsened to grade 3. Two neonates were found to have corpus callosal agenesis.Conclusions: Transcranial neurosonography stands as an excellent and reliable investigation of choice for neonates to detect HIE,ICH and intracranial congenital anomalies.

Introduction. Meningiomas are rare tumors in children, in whom the intracranial pathology is dominated by craniopharyngiomas and medulloblastomas. Cystic meningiomas are also rare, as is their intraosseous location. Intraosseous meningiomas are ectopic meningiomas. Their diagnosis is rarely done preoperatively. We report a case of cystic intraosseous meningioma managed in our department. Observation. Mr. ON, 16 years old, presented progressively a right temporal tumefaction causing an aesthetic prejudice. This tumefaction raised the flag of the right ear. It was covered by normal skin and there was moderate right hypo acoustics. CT scan showed a right sphenotemporal lesion with hyperdense contours and hypodense contents. It repressed the brain without invading it but affected the anatomic structures of the ear. Surgical procedure allowed for almost complete excision of the lesion. Histology of the operative specimen concluded to an intraosseous meningothelial meningioma. After a 4-year follow-up, the tumor residue remained stable. Conclusion. In addition to the diagnostic difficulty, we faced two other therapeutic difficulties. The first is that complete excision was not possible to avoid compromising a hearing always good. The second difficulty was related to the age of the patient who did not allow us to consider the cranial plasty before the end of the growth.

Bilateral abducens nerve palsy due to closed head trauma is exceedingly rare. We present the case of a 51-year-old woman with posttraumatic bilateral abducens nerve palsy and persistent deficits at 1-year follow-up. This case demonstrates a rare example of cranial nerve palsy in the setting of a closed head injury without intracranial pathology.

The basic neurologic history and exam for the interventional radiologist performing intracranial procedures need not be exhaustive and will not supplant that by neurologic specialist. It should include a pertinent history, focused neurologic exam, and a brief physical exam. The interventional radiologist should be familiar with the grading scales commonly used for patients with intracranial pathology to understand the severity and prognosis of various pathologies. The goal of the examination is to mitigate risk, direct the evaluation, aid in medical decision making, and allow the establishment of an appropriate physician-patient relationship.

Parturients with intracranial lesions are often assumed to have increased intracranial pressure, even in the absence of clinical and radiographic signs. The risk of herniation after an inadvertent dural puncture is frequently cited as a contraindication to neuraxial anesthesia. This article reviews the relevant literature on the use of neuraxial anesthesia in parturients with known intracranial pathology, and proposes a framework and recommendations for assessing risk of neurologic deterioration, with epidural analgesia or anesthesia, or planned or inadvertent dural puncture. The authors illustrate these concepts with numerous case examples and provide guidance for the practicing anesthesiologist in determining the safety of neuraxial anesthesia.

Introduction: Delayed vasospasm has traditionally been considered the most important determinant of poor outcome after subarachnoid haemorrhage (SAH). Consequently, most of the research and therapies are directed towards reducing the incidence of vasospasm (VSP). To date, however, clinical trials based on this strategy have not delivered a definitive treatment for preventing or reducing brain injury after SAH. This fact has caused a paradigm shift in research, which now focuses on early brain injury (EBI) occurring in the first 72 hours after SAH. It has also changed the idea of VSP's role in brain damage, and suggests the need for re-evaluating the pathophysiological process of SAH. Development: This review examines the current state of knowledge on the pathophysiological mechanisms associated with EBI and summarises the diagnostic options currently available. Conclusion: It seems that the research approach needs to be changed, so that investigators will focus on prevention of EBI, reduction of secondary brain complications and ultimately, the optimisation neurological outcome. Resumen: Introducción: El vasoespasmo (VSP) ha sido tradicionalmente considerado como el principal determinante de mal pronóstico tras sufrir una hemorragia subaracnoidea (HSA). Como consecuencia, la mayoría de las líneas de investigación y los tratamientos están dirigidos hacia la reducción de la incidencia de dicho VSP. Hasta la fecha, sin embargo, los resultados de los ensayos clínicos basados en esta estrategia no se han traducido en un tratamiento definitivo capaz de prevenir o mejorar la lesión cerebral tras una HSA.Este hecho ha provocado un cambio de paradigma en el interés investigativo, focalizándolo hacia la lesión cerebral precoz (LCP), que se produce en las primeras 72 horas tras la HSA. Así mismo, ha modificado la visión que se tenía de la responsabilidad del VSP sobre el daño cerebral y sugiere la necesidad de una re-evaluación del proceso fisiopatológico de la HSA. Desarrollo: Esta revisión examina el estado actual del conocimiento de los mecanismos fisiopatológicos relacionados con la LCP y resume las opciones diagnósticas disponibles en la actualidad. Conclusión: Parece necesario cambiar la dirección en la investigación de esta enfermedad, centrándose en la prevención de la LCP, la reducción de las complicaciones cerebrales secundarias y en última instancia, la optimización de los resultados neurológicos. Keywords: Biomarkers, CT perfusion, Early brain injury, Subarachnoid haemorrhage, Vasospasm, Palabras clave: Hemorragia subaracnoidea, Lesión cerebral precoz, Marcadores biológicos, Tomografía computarizada de perfusión, Vasoespasmo

A sensitive and specific triage of patients with primary or secondary headache is a major concern in evaluating pediatric headache patients. History and physical examination are the major tools for differentiating primary headache disorders from symptomatic headaches caused by defined pathologies. If the criteria of the International Headache Society for a primary headache disorder are met, no further investigations are necessary. However, physicians should be familiar with subtle signs in history and physical examination that raise suspicion of intracranial pathology. These features, also named "red flags" and "relatively red flags," are outlined in detail in this review. Any red flag should prompt neuroimaging. In case of relatively red flags, a more restrained approach can be appropriate depending on the individual setting. Excessive concerns of patients and parents regarding an underlying pathology can constitute an indication for neuroimaging. Offering neuroimaging implicates the important issues of incidental findings and of "false reassurance." These risks should be discussed with patients and parents before the investigation. In any pediatric headache patient, regular clinical reevaluations should be warranted, even if neuroimaging is normal. The value of clinical follow-up examinations for a reasonable and reliable assessment of the patients cannot be overestimated.