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Gladstone Airewele, Geoffrey Miller, Charles McCluggage and Murali Chintagumpala

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Spontaneous regression of a diffuse brainstem lesion in the neonate

Report of two cases and review of the literature

Willard Darrell Thompson Jr. and Edward J. Kosnik

P The authors present two cases of diffuse brainstem lesions that regressed without treatment. Two newborns presented with cranial nerve palsies and limb weakness at birth. Magnetic resonance (MR) images obtained in the 1st week of life revealed a large, expansive pontomedullary lesion in each patient. Findings of clinical and imaging examinations were highly consistent with the characteristics of diffuse brainstem glioma. After consultation with the parents of both infants, all parties agreed to forgo the treatment modalities available at the time. Neither patient underwent surgery, radiation treatment, or chemotherapy; both underwent routine neurological and MR imaging examinations. Within weeks the patient in Case 1 started to improve clinically and at 4 years of age has reached nearly all developmental milestones. Serial MR images demonstrated a steady decrease in the size of the lesion. The patient in Case 2 improved in a similar manner and is now 10 years old. The findings from these two cases should encourage families and clinicians to consider that a subcategory of diffuse lesions may exist, particularly in the neonatal period. It must be stressed, however, that nearly all patients with diffuse brainstem lesions experience a poor outcome, regardless of tumor grade or treatment. Brainstem gliomas, spontaneous regression of central nervous system tumors, and the differential diagnoses of brainstem lesions are discussed.

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Edward J. Kosnik

✓ The technique of harvesting the ligamentum nuchae and its use in posterior fossa surgery are discussed. By using this technique the author has avoided postoperative cerebrospinal fluid leakage in more than 200 procedures.

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Pediatric neck injuries

A clinical study

Stephen A. Hill, Carole A. Miller, Edward J. Kosnik and William E. Hunt

✓ This review of pediatric neck injuries includes patients admitted to Children's Hospital of Columbus, Ohio, during the period 1969 to 1979. The 122 patients with neck injuries constituted 1.4% of the total neurosurgical admissions during this time. Forty-eight patients had cervical strains; 74 had involvement of the spinal column; and 27 had neurological deficits. The injuries reached their peak incidence during the summer months, with motor-vehicle accidents accounting for 31%, diving injuries and falls from a height 20% each, football injuries 8%, other sports 11%, and miscellaneous 10%.

There is a clear division of patients into a group aged 8 years or less with exclusively upper cervical injuries, and an older group with pancervical injuries. In the younger children, the injuries involved soft tissue (subluxation was seen more frequently than fracture), and tended to occur through subchondral growth plates, with a more reliable union than similar bone injuries. In the older children, the pattern and etiology of injury are the same as in adults. The entire cervical axis is at risk, and there is a tendency to fracture bone rather than cartilaginous structures.

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Edward J. Kosnik, Carl P. Boesel, Janet Bay and Martin P. Sayers

✓ A series of 18 primitive neuroectodermal tumors in children (15 cerebral and three spinal) is reported. These are highly malignant neoplasms, both histologically and clinically. They are rapidly growing tumors, with a brief duration of symptoms and a rapidly progressive course. Forty percent of the patients were alive at 6 months, only 10% at 1 year, and all patients had died within 2 years following diagnosis.

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Edward J. Kosnik and William E. Hunt

✓ Elevation of systemic arterial pressure in seven patients with intracranial arterial aneurysms has been shown to be effective in alleviating ischemic symptoms attributed to cerebral vasospasm. Autoregulation is at least partially lost in patients with cerebral hemodynamic crisis. Blood volume expansion was used to augment vasopressors in maintenance of systemic hypertension. The management of these cases is discussed. Caution in the use of this technique is advised, since the regimen is not without risk.

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Edward J. Kosnik, John N. Meagher and Lowell R. Quenemoen

✓ An unusual case is presented of an intradiploic encephalocele surrounding a cerebrospinal fluid cyst. The relationship of this developmental anomaly to the more commonly encountered midline encephalocele and isolated reports of temporal bone encephaloceles are discussed.

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Richard C. Dewey, Edward J. Kosnik and Martin P. Sayers

✓ The authors present an x-ray film method to ascertain the function of ventricular shunts in hydrocephalic patients. No special equipment is required. Representative x-ray films and analysis of results in 131 determinations are presented.

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Edward J. Kosnik, William E. Hunt and Carole A. Miller

✓ The history, physical findings, and treatment of dural arteriovenous malformations are reviewed. The importance of completely identifying and obliterating the fistula, even at the expense of obliterating major venous sinuses, is emphasized. Failure of surgical treatment usually is the result of mistaking the more obvious dilated feeding vessels for the lesion itself.