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Osmotic demyelination syndrome is an acute demyelination process that usually occurs several days following an osmotic stress. This syndrome is rare in adults (0.4% to 0.56%) and even more uncommon in children. We performed a review of all reported pediatric osmotic demyelination syndrome patients from 1960 to 2018. Among all 106 cases, 49 presented with isolated central pontine myelinolysis, 30 with isolated extrapontine myelinolysis, and 27 with combined central pontine myelinolysis and extrapontine myelinolysis. There was no gender preponderance, and the highest prevalence was noted between the ages one and five years. Magnetic resonance imaging remains the diagnostic modality of choice, and diffusion tensor imaging is now increasingly used for prognostication in osmotic demyelination syndrome. Sixty percent of the children had a complete neurological recovery. Current management of osmotic demyelination syndrome in children consists of supportive medical care, steroids, and intravenous immunoglobulin. Our review of the literature supports the hypothesis that steroids and immunoglobulins are potentially helpful, although additional controlled studies are needed.

Apparent life-threatening events (ALTEs), often accompanied by choking, have been hypothesized to cause subdural hemorrhages (SDH), retinal hemorrhages, and brain injury. If the choking/ALTE hypothesis were true, children who present with ALTE and SDH would have fewer extracranial injuries suspicious for abuse than those with SDH and no ALTE. We aimed to compare the prevalence of suspicious extracranial injuries in children who have ALTE-associated SDH to those with non-ALTE SDH.We performed a 5-year retrospective case-control study of children2 years of age with SDH evaluated by the Child Abuse Pediatrics program at a children's hospital. Subjects were classified as ALTE-associated SDH and non-ALTE SDH on the basis of ALTE definitions as proposed by the authors of the choking/ALTE hypothesis. The 2 groups were compared for the prevalence of suspicious extracranial injuries.Of 170 study subjects, 64 had an ALTE-associated SDH and 106 had non-ALTE SDH. ALTE-associated SDH subjects were nearly 5 times more likely to have at least one suspicious extracranial injury (odds ratio [OR] 4.8, 95% confidence interval [CI] 1.9-12.1) and were more likely to have individual types of suspicious extracranial injuries, including retinoschisis (OR 4.1, 95% CI 1.6-10.2), high-specificity bruising (OR 2.6, 95% CI 1.3-4.9), and internal abdominal injury (3.5, 95% CI 1.2-9.9). Subjects with ALTE-associated SDH were also significantly more likely to die or have persistent neurologic impairment. All 10 subjects with a dysphagic-choking type ALTE had at least 1 suspicious extracranial injury.ALTEs are not supported as causative mechanisms for findings concerning abusive head trauma.

1. Rose N. Gelineau-Morel, MD* 2. Timothy P. Zinkus, MD† 3. Jean-Baptiste Le Pichon, MD, PhD* 1. *Division of Neurology and 2. †Division of Radiology, Children’s Mercy Hospital, Kansas City, MO * Abbreviations: AAP: : American Academy of Pediatrics AHT : : abusive head trauma CDC: : Centers for Disease Control and Prevention Child SCAT5: : Child Sport Concussion Assessment Tool CISG: : Concussion in Sport Group CT: : computed tomography DAI: : diffuse axonal injury FLAIR: : fluid-attenuated inversion recovery GCS: : Glasgow Coma Scale MRI: : magnetic resonance imaging mTBI: : mild traumatic brain injury TBI: : traumatic brain injury There is still a considerable amount of confusion when it comes to managing concussions. An excessive number of head computed tomographic scans are being obtained for concussions, resulting in unnecessary exposure to ionizing radiation. Clinicians should be aware of the most recent guidelines for the management of concussion, including the need for imaging, and should be able to differentiate mild from moderate and severe traumatic brain injury. After completing this article, readers should be able to: 1. Differentiate a mild from a moderate or severe traumatic brain injury (TBI). 2. Acutely manage a child with a TBI, including deciding when further imaging is necessary. 3. Manage a child with a postconcussion syndrome and identify when referral to a specialist is necessary. Traumatic brain injury (TBI) is the leading cause of death or severe disability in children older than 1 year. (1)(2) In a report to Congress published by the Centers for Disease Control and Prevention (CDC) in 2018, (3) the CDC reported the public health burden of TBIs. They noted that 640,000 emergency department visits and 18,000 hospital stays were directly related to TBI. The etiology of TBI varies among age groups. In the 0- to 4-year-old age group, the most common cause of TBI is falls. On the other hand, in the 15- to 24-year-old age group the distribution of injuries caused by …

1. Isadore Tarantino, MD* 2. Rachel Lieberman, MD* 3. Timothy Zinkus, MD† 4. Paul Grabb, MD‡ 1. *Department of Pediatrics, 2. †Department of Radiology, 3. ‡Department of Neurosurgery, Children's Mercy Hospitals and Clinics, Kansas City, MO A previously healthy 19-month-old girl presents for evaluation of an enlarging mass over her lumbosacral region. The child and her family recently immigrated to the United States from Ethiopia, where the girl was born. The girl’s mother reports that the mass has been present since birth but was very small at that time. During the subsequent 19 months, the mass has continued to enlarge until it is easily noticeable under her clothing. The girl is reportedly developmentally normal and has no bowel or bladder dysfunction. Her mother is unsure whether the mass is painful because the girl does not cry when she lies on her back. The girl has had no fevers, no overlying redness of the skin covering or surrounding the mass, and no drainage from the mass. Due to inability to receive proper medical care in Ethiopia, she was brought to our emergency department for evaluation of the mass. On physical examination the girl is thin, but well nourished. The mass is entirely covered by skin and sits midline over the lumbosacral region. It measures approximately 7×6×4 cm (Fig 1). The mass is mobile and fluid-filled, with only minimal tenderness to palpation. There is no overlying skin discoloration, and no abnormal cutaneous markings. The girl demonstrates the ability to walk normally, with appropriate lower-extremity muscle tone and intact lower-extremity sensation. Figure 1. Midline lumbosacral mass measuring approximately 7×6×4 cm. Initial ultrasonography performed in the emergency department reveals a large, irregular, cystic structure in the subcutaneous tissue with a tail extending deeper toward the spine. The girl is admitted to the hospital for further evaluation, and magnetic resonance imaging …

OBJECTIVEChildren who have subdural hematomas (SDHs) with no or minimal neurological symptoms (SDH-mild symptoms) often present a forensic challenge. Nonabusive causes of SDH, including birth-related SDH, benign enlargement of the subarachnoid spaces (BESS), and other proposed causes have been offered as etiologies. These alternative causes do not provide explanations for concomitant suspicious injuries (CSIs). If SDH with mild symptoms in young children are frequently caused by these alternative causes, children with SDH-mild symptoms should be more likely to have no other CSIs than those who have SDH with severe symptoms (SDH-severe symptoms). Additionally, if SDH with mild symptoms is caused by something other than abuse, the location and distribution of the SDH may be different than an SDH caused by abuse. The objectives of this study were to determine the prevalence of other CSIs in patients who present with SDH-mild symptoms and to compare that prevalence to patients with SDH-severe symptoms. Additionally, this study sought to compare the locations and distributions of SDH between the two groups. Finally, given the data supporting BESS as a potential cause of SDH in young children, the authors sought to evaluate the associations of BESS with SDH-mild symptoms and with other CSIs.METHODSThe authors performed a 5-year retrospective case-control study of patients younger than 2 years of age with SDH evaluated by a Child Abuse Pediatrics program. Patients were classified as having SDH-mild symptoms (cases) or SDH-severe symptoms (controls). The two groups were compared for the prevalence of other CSIs. Additionally, the locations and distribution of SDH were compared between the two groups. The presence of BESS was evaluated for associations with symptoms and other CSIs.RESULTSOf 149 patients, 43 presented with SDH-mild symptoms and 106 with SDH-severe symptoms. Patients with SDH-mild symptoms were less likely to have other CSIs (odds ratio [OR] 0.2, 95% confidence interval [CI] 0.08–0.5) and less likely to have severe retinal hemorrhages (OR 0.08, 95% CI 0.03–0.3). However, 60.5% of patients with SDH-mild symptoms had other CSIs. There was no difference between the groups regarding the location and distribution of SDH. Of the entire study cohort, 34 (22.8%) had BESS, and BESS was present in 17 (39.5%) of the SDH-mild symptoms group and 17 (16%) of the SDH-severe symptoms group (OR 3.4, 95% CI 1.5–7.6). The presence of BESS was significantly associated with a lower chance of other CSIs (OR 0.1, 95% CI 0.05–0.3). However, 17 patients had BESS and other CSIs. Of these 17, 6 had BESS and SDH-mild symptoms.CONCLUSIONSThe high occurrence of other CSIs in patients with SDH-mild symptoms and a similar high occurrence in patients with BESS (including those with SDH-mild symptoms) indicate that such children benefit from a full evaluation for abuse.

The fossa navicularis is a notch-like bone defect in the basiocciput that has been hitherto considered as an anatomical variant of the clivus and not previously described as a potential source of clival or skull base pathology. We report the imaging findings in a 5-year-old child who presented acutely with a retropharyngeal abscess and osteomyelitis of the clivus. Imaging after treatment revealed a "notch-like" defect in the anterior clivus consistent with a fossa navicularis. Based on these appearances, we postulate that the lymphoid tissue of the pharyngeal tonsil residing in the fossa navicularis served as a route through which infection spread and subsequently developed into clival osteomyelitis, which is a rare diagnosis. This case is unique, and we believe that the presence of this variant in young children may be important and is not merely an anatomical curiosity.