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Paul S. Larson, Andrew Reisner, Dante J. Morassutti, Bassam Abdulhadi and John E. Harpring

Traumatic intracranial aneurysms are rare, occurring in fewer than 1% of patients with cerebral aneurysms. They can occur following blunt or penetrating head trauma and are more common in the pediatric population. Traumatic aneurysms can be categorized histologically as true, false, or mixed, with false aneurysms being the most common. These aneurysms can present in a variety of ways, but are typically associated with an acute episode of delayed intracranial hemorrhage with an average time from initial trauma to aneurysm hemorrhage of approximately 21 days. The mortality rate for patients harboring these aneurysms may be as high as 50%. Prompt diagnosis based on arteriography and aggressive surgical management are associated with better outcome than conservative treatment. The authors describe a classification scheme for traumatic aneurysms based on their anatomical location and conclude that 1) post-traumatic aneurysm must be considered in patients with acute neurological deterioration following closed head injury; 2) they can occur following mild closed head injury; 3) they occur more commonly in children than in adults; and 4) surgical clipping and/or endovascular occlusion is the definitive treatment.

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Andrew Reisner, Matthew F. Gary, Joshua J. Chern and J. Damien Grattan-Smith

Spinal cord infarctions following seemingly innocuous trauma in children are rare, devastating events. In the majority of these cases, the pathophysiology is enigmatic. The authors present 3 cases of pediatric spinal cord infarction that followed minor trauma. An analysis of the clinical, radiographic, and laboratory features of these cases suggests that thromboembolism of the nucleus pulposus into the spinal cord microcirculation is the likely mechanism. A review of the human and veterinary literature supports this notion. To the authors' knowledge, this is the largest pediatric series of myelopathy due to thromboembolism of the nucleus pulposus reported to date, and it is the first report of this condition occurring in an infant.

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Andrew Reisner, Gary S. Marshall, Kristina Bryant, Gregory C. Postel and Steven M. Eberly

✓ Pseudoaneurysm formation of the cervical internal carotid artery (ICA) is a rare, potentially lethal complication of deep neck space infection. This entity typically occurs following otolaryngological or upper respiratory tract infection. The pseudoaneurysm is heralded by a pulsatile neck mass, Horner's syndrome, lower cranial neuropathies, and/or hemorrhage that may be massive. The recommended treatment includes prompt arterial ligation.

The authors present a case of pseudoaneurysm of the cervical ICA complicating a deep neck space infection. A parapharyngeal Staphylococcus aureus abscess developed in a previously healthy 6-year-old girl after she experienced pharyngitis. The abscess was drained via an intraoral approach. On postoperative Day 3, the patient developed a pulsatile neck mass, lethargy, ipsilateral Horner's syndrome, and hemoptysis, which resulted in hemorrhagic shock. Treatment included emergency endovascular occlusion of the cervical ICA and postembolization antibiotic treatment for 6 weeks. The patient has made an uneventful recovery as of her 18-month follow-up evaluation.

Conclusions drawn from this experience and a review of the literature include the following: 1) mycotic pseudoaneurysms of the carotid arteries have a typical clinical presentation that should enable timely recognition; 2) these lesions occur more commonly in children than in adults; 3) angiography with a view to performing endovascular occlusion should be undertaken promptly; and 4) endovascular occlusion of the pseudoaneurysm is a viable treatment option.

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Anna L. Huguenard, Brandon A. Miller, Samir Sarda, Meredith Capasse, Andrew Reisner and Joshua J. Chern

OBJECT

Of the 1.7 million traumatic brain injuries (TBIs) in the US, a third occur in patients under 14 years of age. The rate of posttraumatic epilepsy (PTE) may be as high as 19% after severe pediatric TBI, but the risk for seizures after mild TBI is unknown. Although the rate of seizures after mild TBI may be low, current practice is often driven by high clinical concern for posttraumatic seizures. In this study, the authors evaluated electroencephalography (EEG) results and antiepileptic drug (AED) use in a large cohort of children with mild TBI to estimate the incidence of posttraumatic seizures in this population.

METHODS

Patients presenting to Children’s Hospital of Atlanta for mild TBI from 2010 to 2013 were evaluated. Five thousand one hundred forty-eight patients with mild TBI were studied and divided into 3 groups: 4168 who were discharged from the emergency department, 868 who were admitted without neurosurgical intervention, and 112 who underwent neurosurgical procedures (craniotomy for hematoma evacuation or elevation of depressed skull fractures) but were discharged without an extended stay. Demographic information, CT characteristics, EEG reports, and prescriptions for AEDs were analyzed. Long-term follow-up was sought for all patients who underwent EEG. Correlation between EEG result and AED use was also evaluated.

RESULTS

All patients underwent head CT, and admitted patients were more likely to have an abnormal study (p < 0.0001). EEG evaluations were performed for less than 1.0% of patients in all 3 categories, without significant differences between groups (p = 0.97). Clinicians prescribed AEDs in less than 2.0% of patients for all groups, without significant differences between groups (p = 0.094). Even fewer children continue to see a neurologist for long-term seizure management. The EEG result had good negative predictive value, but only an abnormal EEG reading that was diagnostic of seizures correlated significantly with AED prescription (p = 0.04).

CONCLUSIONS

EEG utilization and AED prescription was low in all 3 groups, indicating that seizures following mild TBI are likely rare events. EEG has good negative predictive value for patients who did not receive AEDs, but has poorer positive predictive value for AED use.

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Ahyuda Oh, Michael Sawvel, David Heaner, Amina Bhatia, Andrew Reisner, R. Shane Tubbs and Joshua J. Chern

OBJECTIVE

Past studies have suggested correlations between abusive head trauma and concurrent cervical spine (c-spine) injury. Accordingly, c-spine MRI (cMRI) has been increasingly used in radiographic assessments. This study aimed to determine trends in cMRI use and treatment, and outcomes related to c-spine injury in children with nonaccidental trauma (NAT).

METHODS

A total of 503 patients with NAT who were treated between 2009 and 2014 at a single pediatric health care system were identified from a prospectively maintained database. Additional data on selected clinical events were retrospectively collected from electronic medical records. In 2012, a clinical pathway on cMRI usage for patients with NAT was implemented. The present study compared cMRI use and clinical outcomes between the prepathway (2009–2011) and postpathway (2012–2014) periods.

RESULTS

There were 249 patients in the prepathway and 254 in the postpathway groups. Incidences of cranial injury and Injury Severity Scores were not significantly different between the 2 groups. More patients underwent cMRI in the years after clinical pathway implementation than before (2.8% vs 33.1%, p < 0.0001). There was also a significant increase in cervical collar usage from 16.5% to 27.6% (p = 0.004), and more patients were discharged home with cervical collar immobilization. Surgical stabilization occurred in a single case in the postpathway group.

CONCLUSIONS

Heightened awareness of potential c-spine injury in this population increased the use of cMRI and cervical collar immobilization over a 6-year period. However, severe c-spine injury remains rare, and increased use of cMRI might not affect outcomes markedly.

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Griffin R. Baum, Nathan C. Rowland, Joshua J. Chern and Andrew Reisner

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Kumar Vasudevan, Ahyuda Oh, R. Shane Tubbs, David Garcia, Andrew Reisner and Joshua J. Chern

OBJECTIVE

Jackson-Pratt drains (JPDs) are commonly employed in pediatric craniofacial reconstructive surgery (CRFS) to reduce postoperative wound complications, but their risk profile remains unknown. Perioperative blood loss and volume shifts are major risks of CFRS. The goal of this study was to evaluate the risks of JPD usage in CFRS, particularly with regard to perioperative blood loss, hyponatremia, intensive care unit (ICU) length of stay, and postoperative wound complications.

METHODS

The authors performed a retrospective review of data obtained in pediatric patients who underwent CFRS at a single institution, as performed by multiple surgeons between January 2010 and December 2014. Data were gathered from patients who did and did not receive JPDs at the time of surgery. Outcome measures were compared between the JPD and no-JPD groups.

RESULTS

The overall population 179 pediatric patients: 128 who received JPDs and 51 who did not. In their analysis, the authors found no significant differences in baseline patient characteristics between the two groups. The average JPD output over the first 48 hours was 222 ± 142 ml. When examining the immediate preoperative to immediate postoperative time period, no significant differences were noted between the groups with regard to the need for blood transfusion or changes in hemoglobin, hematocrit, or serum sodium levels. These differences were also not significant when examining the 48-hour postoperative period. Finally, no significant differences in hospital length of stay, ICU length of stay, or emergency department visits at 60 days were noted between the two groups.

CONCLUSIONS

In this retrospective study, the use of JPDs in pediatric CFRS was not associated with an increased risk of serious perioperative complications, although the benefits of this practice remain unclear.

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Robyn A. Howarth, Andrew Reisner, Joshua J. Chern, Laura L. Hayes, Thomas G. Burns and Alejandro Berenstein

Cognitive regression is a well-described presentation of vein of Galen aneurysmal malformations (VGAMs) in childhood. However, it remains unclear whether successful treatment of the malformation can reverse cognitive regression. Here, the authors present the case of a 5-year-old girl with a VGAM that was treated with staged endovascular embolization procedures. Comprehensive neurocognitive assessments were completed before intervention and approximately 6 years after initial presentation. There were significant age-matched improvements in this child's neurocognitive profile over this period. The authors believe that timely and successful treatment of VGAM in children may not only stabilize the associated cognitive deterioration but, in some cases, may ameliorate these deficits. Details of this case and a discussion of neurocognitive deficits related to VGAM are presented.

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Joshua J. Chern, Samir Sarda, Brian M. Howard, Andrew Jea, R. Shane Tubbs, Barunashish Brahma, David M. Wrubel, Andrew Reisner and William Boydston

Object

Nonoperative blunt head trauma is a common reason for admission in a pediatric hospital. Adverse events, such as growing skull fracture, are rare, and the incidence of such morbidity is not known. As a result, optimal follow-up care is not clear.

Methods

Patients admitted after minor blunt head trauma between May 1, 2009, and April 30, 2013, were identified at a single institution. Demographic, socioeconomic, and clinical characteristics were retrieved from administrative and outpatient databases. Clinical events within the 180-day period following discharge were reviewed and analyzed. These events included emergency department (ED) visits, need for surgical procedures, clinic visits, and surveillance imaging utilization. Associations among these clinical events and potential contributing factors were analyzed using appropriate statistical methods.

Results

There were 937 admissions for minor blunt head trauma in the 4-year period. Patients who required surgical interventions during the index admission were excluded. The average age of the admitted patients was 5.53 years, and the average length of stay was 1.7 days; 15.7% of patients were admitted for concussion symptoms with negative imaging findings, and 26.4% of patients suffered a skull fracture without intracranial injury. Patients presented with subdural, subarachnoid, or intraventricular hemorrhage in 11.6%, 9.19%, and 0.53% of cases, respectively. After discharge, 672 patients returned for at least 1 follow-up clinic visit (71.7%), and surveillance imaging was obtained at the time of the visit in 343 instances.

The number of adverse events was small and consisted of 34 ED visits and 3 surgeries. Some of the ED visits could have been prevented with better discharge instructions, but none of the surgery was preventable. Furthermore, the pattern of postinjury surveillance imaging utilization correlated with physician identity but not with injury severity. Because the number of adverse events was small, surveillance imaging could not be shown to positively influence outcomes.

Conclusions

Adverse events after nonoperative mild traumatic injury are rare. The routine use of postinjury surveillance imaging remains controversial, but these data suggest that such imaging does not effectively identify those who require operative intervention.

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Andrew Reisner, Joshua J. Chern, Karen Walson, Natalie Tillman, Toni Petrillo-Albarano, Eric A. Sribnick, Laura S. Blackwell, Zaev D. Suskin, Chia-Yi Kuan and Atul Vats

OBJECTIVE

Evidence 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.

METHODS

A 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.

RESULTS

A 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.

CONCLUSIONS

A 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.