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Ramesh Kumar, Frederic W. B. Deleyiannis, Corbett Wilkinson, and Brent R. O'Neill


The authors' goals in this study were to describe a series of dog attacks on children that required neurosurgical consultation and to better understand the pattern of injuries inflicted, the circumstances that place children at risk for attack, and the dog breeds involved. In addition, the authors review the surgical and medical management of these patients.


The authors performed a retrospective review of all children requiring neurosurgical consultation for dog bite at a regional Level 1 pediatric trauma center over a 15-year period.


A total of 124 children with dog bites to the head, face, and neck were evaluated in the emergency department. Of these, 17 children (13.7%) incurred injuries requiring neurosurgical consultation. Fifty-three percent of victims were female. The mean age at the time of attack was 30 months. Twelve (71%) of the attacks were perpetrated by the family pet, and 13 (76%) occurred at the patient's home. Breeds involved in the attacks included German Shepherd, Pit Bull, American Bulldog, large mixed breed, Labrador Retriever, and Akita, with German Shepherds and Akitas being the most frequently involved. Neurosurgical injuries included nondepressed skull fracture in 5, depressed skull fracture in 10, intracranial hemorrhage in 5, cerebral contusions in 4, dural laceration in 4, pneumocephalus in 5, clinically evident CSF leak in 3, spinal fracture with complete spinal cord injury in 1, stroke in 2, vascular injury in 2, and cranial nerve injury (hypoglossal and facial nerve) in 1. Prophylactic antibiotics were administered in 16 patients (94%). Only 1 patient had a confirmed infection involving the site of injury. Neurosurgical intervention was required in 10 patients (59%) and ranged in severity from debridement and closure of a complex scalp wound to decompressive craniectomy. Neurological deficits, all of which were considered catastrophic, developed in 3 patients (18%).


Dog attacks on children requiring neurosurgical consultation commonly involve the family pet, which is usually a large-breed dog with no history of prior aggression. Neurosurgical injuries often involve the cranial vault, with depressed skull fractures being the most common injury pattern. Most patients do not suffer a neurological deficit, although catastrophic neurological injury may occur. Prophylactic antibiotics are commonly used and surgical intervention is required in the majority of cases.

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Pankaj K. Singh, Mohit Agrawal, Dattaraj Sawarkar, Amandeep Kumar, Satish Verma, Ramesh Doddamani, P. Sarat Chandra, and Shashank S. Kale

Hangman’s fracture, also known as traumatic spondylolisthesis of the axis, causes widening of the neural canal and thus a low rate of neurological deficits. This low rate is one of the reasons it is neglected and patients present with late neurological deficits. In an effort to preserve motion at the C1–2 joint, the authors devised a new technique of bilateral C2 pedicle reconstruction. They describe the first two cases in the literature of an old hangman’s fracture with resorbed C2 pedicles due to chronic fracture, in which bilateral C2 pedicles were reconstructed. One of the two cases (case 2) is the first reported case of severe C2–3 spondyloptosis with C2 displaced up to the level of C4. Case 1 had a follow up of 21 months, while case 2 had a follow up of 12 months. Both patients experienced neurological improvement with evidence of fusion and artificial pedicle formation at last follow-up. Bilateral C2 pedicle reconstruction is a feasible technique that can be used with a good outcome in select patients.

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Venkatesh Shankar Madhugiri, Sudheer Kumar Gundamaneni, Vani Santosh, Barath Jagadisan, Gopalakrishnan Madhavan Sasidharan, Rathakrishnan V. Roopesh-Kumar, Awdhesh Kumar Yadav, Manish Singh, Ramesh Ananthakrishnan, Nisha Pariarath, and Niranjan Biswal

In this report the authors describe a rare case of a fulminant, pyogenic, necrotizing infection of the spinal cord and brain. Necrotizing lesions of the brain and spinal cord are usually infectious in origin and are associated with high rates of morbidity and death. Although the pathogens responsible have been identified in a few instances, the causal factors remain unknown in many cases. An 11-year-old girl developed acute, rapidly progressive paraplegia with bladder involvement and sensory loss below T-10. She had been treated recently for a Staphylococcus aureus infection of the knee joint precipitated by a penetrating injury with organic matter in the aftermath of a cyclone. Although appropriate antibiotic therapy was instituted, the spinal cord infection progressed to involve the entire spinal cord, brainstem, and brain. This fulminant course was marked by a rapid deterioration in the patient's clinical condition, ultimately leading to her death. Magnetic resonance imaging demonstrated a previously undescribed pattern of longitudinal enhancement along the spinal cord, as well as the white matter tracts in the brainstem and brain. The possible route of spread of infection along the neuraxis is postulated to be the potential space along the white matter tracts. Treatment is not standardized due to the rarity of the condition.

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Ravi Kumar, Ramesh Kumar, Grant W. Mallory, Jeffrey T. Jacob, David J. Daniels, Nicholas M. Wetjen, Andrew B. Foy, Brent R. O’Neill, and Michelle J. Clarke


Nonpowder guns, defined as spring- or gas-powered BB or pellet guns, can be dangerous weapons that are often marketed to children. In recent decades, advances in compressed-gas technology have led to a significant increase in the power and muzzle velocity of these weapons. The risk of intracranial injury in children due to nonpowder weapons is poorly documented.


A retrospective review was conducted at 3 institutions studying children 16 years or younger who had intracranial injuries secondary to nonpowder guns.


The authors reviewed 14 cases of intracranial injury in children from 3 institutions. Eleven (79%) of the 14 children were injured by BB guns, while 3 (21%) were injured by pellet guns. In 10 (71%) children, the injury was accidental. There was 1 recognized assault, but there were no suicide attempts; in the remaining 3 patients, the intention was indeterminate. There were no mortalities among the patients in this series. Ten (71%) of the children required operative intervention, and 6 (43%) were left with permanent neurological injuries, including epilepsy, cognitive deficits, hydrocephalus, diplopia, visual field cut, and blindness.


Nonpowder guns are weapons with the ability to penetrate a child’s skull and brain. Awareness should be raised among parents, children, and policy makers as to the risk posed by these weapons.

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Simon A. Hercules, Vengalathur Ganesan Ramesh, Srinivasan Paramasivan, Pari Kodiarasan, and Mohan Sampath Kumar

✓ An intraventricular glioma occupying all four ventricles of the brain in children is very uncommon. The authors report a unique case of a tetraventricular Grade II astrocytoma with evidence of extension into the basal cisterns in a 5-year-old boy who had a 1-month history of headache. There was no neurological deficit except bilateral papilledema.