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Mony Benifla, Uri Yoel, Israel Melamed, Vladimir Merkin, Avi Cohen and Ilan Shelef

OBJECTIVE

The aim of this study is to describe the clinical characteristics of patients with skull fracture adjacent to a dural venous sinus (DVS) and evaluate the role of CT venography (CTV) in the diagnosis of the effect of this fracture on the involved DVS.

METHODS

The study comprised patients with vault or skull base fracture adjacent to a DVS who were admitted to 1 medical center during a 2-year period. The medical records were reviewed for the clinical and radiographic characteristics. All patients had undergone CTV to evaluate potential DVS pathology. The clinical and radiological findings of the patients with DVS pathology were compared with those of the patients with normal DVS. The groups were compared using the chi-square and t-tests for categorical and continuous data, respectively. The potential risk for poor outcome among the patients with DVS pathology was also investigated.

RESULTS

Of 434 patients with skull fractures, 41 (9.4%) had fractures adjacent to a DVS. DVS pathology was detected in 51% of patients (21 of 41 patients). For 9 (43%) patients, obstruction was extraluminal without thrombosis, and 12 (57%) patients had dural sinus thrombosis (DST). In patients with a positive-CTV scan, the severity of injury according to the Glasgow Coma Scale score at presentation was correlated with the presence of DST (p = 0.007). The sensitivity of noncontrast CT (NCCT) for DVS involvement was 38% among the patients with positive-CTV scans. For patients with DVS pathology, poor outcome was correlated with DST (intraluminal), rather than extraluminal obstruction without thrombosis (p = 0.02), and superior sagittal sinus (SSS) involvement (p = 0.05).

CONCLUSIONS

NCCT is not sensitive enough to detect DVS obstruction in patients with skull fracture adjacent to a DVS, and CTV should be performed in order to rule it out. A correlation was found between the severity of injury and the presence of DST, rather than extraluminal obstruction. The authors' findings suggest that DST and SSS involvement may be indicators of poor outcome in patients with skull fracture adjacent to DVS.

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Mony Benifla, Igor Melamed, Revital Barrelly, Andrey Aloushin and Ilan Shelef

Intravertebral disc herniation is common in adults, often due to degenerative processes. The occurrence of disc herniation is rare in children and is usually related to traumatic injury. The authors present an unusual case of a 13-month-old boy with L5–S1 lumbar disc herniation. The disc was removed via a unilateral partial hemilaminectomy approach, sparing the spinal midline structural elements. Although rare, lumbar disc herniation should be in the differential diagnosis for children presenting with low-back pain and/or neurological deficit of the lower limbs.

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José E. Cohen, Shlomo Constantini, John M. Gomori, Mony Benifla and Eyal Itshayek

The cone artery, or artery of Desproges-Gotteron, is sometimes seen arising from the internal iliac artery. The authors describe a case of a symptomatic perimedullary arteriovenous fistula (AVF) of the conus medullaris in an 8-year-old boy who presented with a protracted history of urinary difficulty and severe sudden-onset right lumbosciatic pain that evolved to severe paraparesis with compromise of the sphincter muscles. The spinal AVF, which was supplied by the cone artery and a thoracic radiculomedullary artery that joined at the fistula site in a large partially thrombosed varix, was completely occluded with Onyx liquid embolic. The patient's clinical condition improved rapidly after embolization. As shown in this patient, urgent endovascular embolization of spinal AVFs can be very rewarding, even in patients with severe neurological presentation. The artery of Desproges-Gotteron appears to be a rare arterial variation. To the authors' knowledge, this is the first pediatric case of a conal AVF supplied by this artery.

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Mony Benifla, Revital Barrelly, Ilan Shelef, Joseph El-On, Avi Cohen and Emanuela Cagnano

✓The authors report an unusual case of a huge intraparenchymal cyst in a 4-year-old girl caused by Taenia multiceps infection. After surgical removal of the cyst, the child recovered completely. Brain infestation by coenurus is a rare disease, mainly reported in Africa, with a few case reports from patients in developed countries. Humans, especially young children, become intermediate hosts by ingesting eggs passed in the excrement of a definitive host, usually carnivores. In such cases, high mortality and morbidity rates have been reported. These rates decreased after the introduction of the modern neuroradiological techniques of computed tomography and magnetic resonance imaging.

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Amit Keret, Odeya Bennett-Back, Guy Rosenthal, Tal Gilboa, Moatasim Shweiki, Yigal Shoshan and Mony Benifla

OBJECTIVE

Posttraumatic epilepsy (PTE) is a known complication of traumatic brain injury (TBI). The true incidence of PTE in children is still uncertain, because most research has been based primarily on adults. This study aimed to determine the true incidence of PTE in a pediatric population with mild TBI (MTBI) and to identify risk factors for the development of epileptic events.

METHODS

Data were collected from electronic medical records of children 0–17 years of age, who were admitted to a single medical center between 2007 and 2009 with a diagnosis of MTBI. This prospective research consisted of a telephone survey between 2015 and 2016 of children or their caregivers, querying for information about epileptic episodes and current seizure and neurological status. The primary outcome measure was the incidence of epilepsy following TBI, which was defined as ≥ 2 unprovoked seizure episodes. Posttraumatic seizure (PTS) was defined as a single, nonrecurrent convulsive episode that occurred > 24 hours following injury. Seizures within 24 hours of the injury were defined as immediate PTS.

RESULTS

Of 290 children eligible for this study, 191 of them or their caregivers were reached by telephone survey and were included in the analysis. Most injuries (80.6%) were due to falls. Six children had immediate PTS. All children underwent CT imaging; of them, 72.8% demonstrated fractures and 10.5% did not demonstrate acute findings. The mean follow-up was 7.4 years. Seven children (3.7%) experienced PTS; of them, 6 (85.7%) developed epilepsy and 3 (42.9%) developed intractable epilepsy. The overall incidence of epilepsy and intractable epilepsy in this cohort was 3.1% and 1.6%, respectively. None of the children who had immediate PTS developed epilepsy. Children who developed epilepsy spent an average of 2 extra days in the hospital at the time of the injury. The mean time between trauma and onset of seizures was 3.1 years. Immediate PTS was not correlated with PTE.

CONCLUSIONS

In this analysis of data from medical records and long-term follow-up, MTBI was found to confer increased risk for the development of PTE and intractable PTE, of 4.5 and 8 times higher, respectively. As has been established in adults, these findings confirm that MTBI increases the risk for PTE in the pediatric population.

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Assaf Berger, Noa Cohen, Firas Fahoum, Mordekhay Medvedovsky, Aaron Meller, Dana Ekstein, Mony Benifla, Orna Aizenstein, Itzhak Fried, Tomer Gazit and Ido Strauss

OBJECTIVE

Preoperative localization of seizure onset zones (SOZs) is an evolving field in the treatment of refractory epilepsy. Both magnetic source imaging (MSI), and the more recent EEG-correlated functional MRI (EEG-fMRI), have shown applicability in assisting surgical planning. The purpose of this study was to evaluate the capability of each method and their combination in localizing the seizure onset lobe (SL).

METHODS

The study included 14 patients who underwent both MSI and EEG-fMRI before undergoing implantation of intracranial EEG (icEEG) as part of the presurgical planning of the resection of an epileptogenic zone (EZ) during the years 2012–2018. The estimated location of the SL by each method was compared with the location determined by icEEG. Identification rates of the SL were compared between the different methods.

RESULTS

MSI and EEG-fMRI showed similar identification rates of SL locations in relation to icEEG results (88% ± 31% and 73% ± 42%, respectively; p = 0.281). The additive use of the coverage lobes of both methods correctly identified 100% of the SL, significantly higher than EEG-fMRI alone (p = 0.039) and nonsignificantly higher than MSI (p = 0.180). False-identification rates of the additive coverage lobes were significantly higher than MSI (p = 0.026) and EEG-fMRI (p = 0.027). The intersecting lobes of both methods showed the lowest false identification rate (13% ± 6%, p = 0.01).

CONCLUSIONS

Both MSI and EEG-fMRI can assist in the presurgical evaluation of patients with refractory epilepsy. The additive use of both tests confers a high identification rate in finding the SL. This combination can help in focusing implantation of icEEG electrodes targeting the SOZ.

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Mony Benifla, Francesco Sala, John Jane Jr., Hiroshi Otsubo, Ayako Ochi, James Drake, Shelly Weiss, Elizabeth Donner, Ayataka Fujimoto, Stephanie Holowka, Elysa Widjaja, O. Carter Snead III, Mary Lou Smith, Mandeep S. Tamber and James T. Rutka

Object

The authors undertook this study to review their experience with cortical resections in the rolandic region in children with intractable epilepsy.

Methods

The authors retrospectively reviewed the medical records obtained in 22 children with intractable epilepsy arising from the rolandic region. All patients underwent preoperative electroencephalography (EEG), MR imaging, prolonged video-EEG recordings, functional MR imaging, magnetoencephalography, and in some instances PET/SPECT studies. In 21 patients invasive subdural grid and depth electrode monitoring was performed. Resection of the epileptogenic zones in the rolandic region was undertaken in all cases. Seizure outcome was graded according to the Engel classification. Functional outcome was determined using validated outcome scores.

Results

There were 10 girls and 12 boys, whose mean age at seizure onset was 3.2 years. The mean age at surgery was 10 years. Seizure duration prior to surgery was a mean of 7.4 years. Nine patients had preoperative hemiparesis. Neuropsychological testing revealed impairment in some domains in 19 patients in whom evaluation was possible. Magnetic resonance imaging abnormalities were identified in 19 patients. Magnetoencephalography was performed in all patients and showed perirolandic spike clusters on the affected side in 20 patients. The mean duration of invasive monitoring was 4.2 days. The mean number of seizures during the period of invasive monitoring was 17. All patients underwent resection that involved primary motor and/or sensory cortex. The most common pathological entity encountered was cortical dysplasia, in 13 children. Immediately postoperatively, 20 patients had differing degrees of hemiparesis, from mild to severe. The hemiparesis improved in all affected patients by 3–6 months postoperatively. With a mean follow-up of 4.1 years (minimum 2 years), seizure outcome in 14 children (64%) was Engel Class I and seizure outcome in 4 (18%) was Engel Class II. In this series, seizure outcome following perirolandic resection was intimately related to the child's age at the time of surgery. By univariate logistic regression analysis, age at surgery was a statistically significant factor predicting seizure outcome (p < 0.024).

Conclusions

Resection of rolandic cortex for intractable epilepsy is possible with expected morbidity. Accurate mapping of regions of functional cortex and epileptogenic zones may lead to improved seizure outcome in children with intractable rolandic epilepsy. It is important to counsel patients and families preoperatively to prepare them for possible worsened functional outcome involving motor, sensory and/or language pathways.