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Ibrahim H. Al-Ahmed, Mohamed Boughamoura, Peter Dirks, Abhaya V. Kulkarni, James T. Rutka and James M. Drake

Object

Neurenteric cysts (NCs) are endothelium-lined structures of presumed endodermal origin. There have been few pediatric series of intracranial NCs reported previously. The authors present their experience in the management of these lesions.

Methods

A retrospective chart review of all cases of NCs identified between 1977 and 2007 was carried out. Demographics, details of clinical presentation, surgical therapy, and outcome data were extracted.

Results

Eleven cases were identified, involving 6 girls and 5 boys. The patients' average age was 4.6 years (range 1 day–14 years). Limb weakness was the most common presenting symptom. The location of the cysts was cervical in 2 cases, cervicothoracic in 4 cases, and thoracic in 3 cases. One cyst was anterior to the pons with extension to the left cerebellopontine angle and 1 cyst was at the craniocervical junction. Five patients had an apparently complete initial excision, with 1 recurrence. Four patients were initially treated with incomplete excision and/or cyst drainage, usually into an Ommaya reservoir. A neonate with a large cervicothoracic cyst died of multiple congenital anomalies without any intervention. All other patients were alive at last follow-up. One patient with a radiologically identified presumed cyst, which remained stable, was simply followed up. Several patients required multiple procedures and 1 patient developed hydrocephalus after aseptic meningitis and was treated with CSF shunting.

Conclusions

Neurenteric cysts are rare in the pediatric population. Total resection, if possible, provides the best long-term outcome. Incomplete excision may lead to multiple procedures, including cyst drainage, but can lead to long-term stability.

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Sanjay Gupta, Shobhan Vachhrajani, Abhaya V. Kulkarni, Michael D. Taylor, Peter Dirks, James M. Drake and James T. Rutka

Object

Extraaxial infections of the CNS, including subdural empyema and epidural abscess, are rare but potentially life-threatening conditions. Symptoms are usually progressive, and early diagnosis is therefore important. Early intervention with appropriate treatment offers the best opportunity for eradicating the infection and promoting maximal neurological recovery.

Methods

The medical records of children with extraaxial CNS infection over the last 24 years at the Hospital for Sick Children were analyzed. Only those patients with radiological and/or operative confirmation of the diagnosis of subdural empyema or epidural abscess were included in the study. Demographic and clinical data were collected to determine the outcomes after such infections and factors that predict for such outcomes.

Results

The authors identified 70 children who fulfilled the inclusion criteria. Sinusitis was the most common etiology and was seen in 38 patients. All of these patients were older than 7 years of age at diagnosis. Subdural empyemas were diagnosed in 13 patients following bacterial meningitis, and they were found primarily in infants within the 1st year of life. Other etiological factors included otogenic infection (4 cases), postneurosurgical infection (7 cases), and hematogenous spread of infection (7 cases including 6 cases of spinal epidural abscess). Streptococcus anginosus and Staphylococcus aureus were the most common pathogens identified. Sixty-four patients (91.4%) underwent at least 1 neurosurgical procedure. Seizures and cerebral edema from cortical vein thrombosis were the most common complications.

Conclusions

Due to variable etiology, identification of the responsible microorganism through neurosurgical drainage followed by long-term intravenous antibiotics remains the mainstay in treating extraaxial CNS infections. Optimal outcome is achieved with early diagnosis and therapy.

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Deanna Sasaki-Adams, Abhaya Kulkarni, James Rutka, Peter Dirks, Michael Taylor and James M. Drake

✓Osteogenesis imperfecta (OI) is a rare genetic disorder characterized by disruption of normal collagen formation resulting in varying degrees of skeletal vulnerability, ligamentous laxity, and scleral discoloration. Children with OI may suffer from complex neurosurgical problems affecting the brain and spine. The authors sought to determine the neurosurgical implications of OI in a cohort of patients treated at a quaternary care center for pediatrics.

The authors reviewed the case histories of 10 children with OI treated by the neurosurgical service at the Hospital for Sick Children in Toronto between January 1988 and March 2007. The cases of 4 of these children are highlighted in the article. The most common neurosurgical conditions encountered in this cohort included macrocephaly in 5 patients, subdural hematoma in 3 patients, epidural hematoma in 2 patients, and hydrocephalus in 3 patients. Basilar invagination and spinal fractures were observed in 20% of the cohort. Although some patients could be treated nonoperatively, several required craniotomy for clot evacuation, decompression, and spinal fixation for fracture or basilar invagination, and cerebrospinal fluid shunt insertion.

Neurosurgical conditions affecting patients with OI include macrocephaly, the development of an acute intracranial hematoma after often minimal trauma, the development of chronic subdural fluid collections that may require drainage, hydrocephalus (both communicating and noncommunicating), basilar invagination, and subaxial spinal fractures. Surgery may be complicated in some children because of the underlying bone fragility and bleeding diathesis commonly observed in patients with OI.

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Raafat R. Yahya, Peter Dirks, Robin Humphreys, James T. Rutka, Michael Taylor and James M. Drake

Object

Television tipover has recently been recognized as a significant cause of injury in children, and head injury accounts for most of the associated deaths. The authors reviewed their experience with children who sustained head injury from falling televisions.

Methods

Children admitted with the diagnosis of head injury related to falling televisions since 1992 were identified from the authors' trauma database, and a retrospective review of the medical records was performed.

Eighteen patients were identified: 13 boys and five girls whose ages ranged from 12 months to 10 years (mean 44 months). The admission Glasgow Coma Scale (GCS) score was 15 in 10 patients. Only three patients had a GCS score of 8 or less (one patient had a score of 4). Neurological examinations were normal in 10 patients; three had cranial nerve deficits and three had otorrhea, otorrhagia, or hemotympanum. Radiological abnormalities included 16 skull fractures, three epidural hematomas, three small subdural hematomas, one intracranial hemorrhage, and three venous obstructions of the transverse—sigmoid sinus. The mean hospital stay was 8.9 days (range 2–39 days). Follow up at 0.2 to 68 months (mean 13.4 months) revealed severe neurological deficits in one patient and cranial nerve deficits of cranial nerves six, seven, or eight in six patients.

Conclusions

Falling televisions result in significant head injuries in children, with substantial short- and long-term sequelae. This injury is easily preventable through simple measures taken by both the manufacturers and caregivers.