1
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Hosseini EM, Zafarshamspour S, Ghasemi-Rad M, Benndorf G, Rasekhi A, Rafieossadat R. Endoluminal flow diversion as a primary treatment strategy for pediatric traumatic intracranial aneurysms: a case-based review of literature. Childs Nerv Syst 2024; 40:345-357. [PMID: 37750891 DOI: 10.1007/s00381-023-06161-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 09/18/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Traumatic intracranial aneurysms (TICAs) constitute a notable portion of pediatric intracranial aneurysms. Their unstable structure dictates a high incidence of rupture or mass effect from enlarging unruptured aneurysms, necessitating prompt diagnosis and treatment. TICAs often lack a true neck or are wide-necked, making them unsuitable for coil embolization and surgical clipping, and their fragile nature poses a risk of rupture during surgical and intrasaccular interventions. Endoluminal flow diverters (FD), deployed without requiring direct access to the aneurysmal sac, have emerged as an appealing sole treatment modality for TICAs. However, the clinical experience with this technique remains limited in the pediatric population. METHOD We describe the successful treatment of a paraclinoid TICA in a 4-year-old female using an endoluminal FD alone. Additionally, we conducted a literature review to assess the safety and effectiveness of this treatment modality in pediatric TICAs. RESULTS Endoluminal flow diversion led to complete aneurysm obliteration in our case, with no observed complication, at the 9-month follow-up. Our review of the previously reported pediatric TICAs managed by standalone flow diversion highlights this technique as safe, efficient, and promising as a sole treatment modality, particularly in the anterior circulation, with a high rate of persistent total obliteration and a low rate of complications. However, the requirement for long-term antiplatelet therapy with the possibility of frequent dose monitoring and adjustments warrants special attention when using endoluminal FDs. Until guidelines specifically addressing optimal antiplatelet therapy in children with intracranial FDs are formulated, adherence to existing protocols is imperative to avoid in-stent thrombosis. CONCLUSION Our literature review and personal experience indicate that endoluminal flow diversion can be a viable treatment approach for pediatric TICAs. However, prospective studies with extensive follow-ups are required to assess the durability of endoluminal FDs in treating pediatric TICAs, considering the long life expectancy of this demographic.
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Affiliation(s)
| | - Saber Zafarshamspour
- Department of Surgery, Rafsanjan University of Medical Sciences, Rafsanjan, Kerman, Iran
| | - Mohammad Ghasemi-Rad
- Department of Interventional Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Goetz Benndorf
- Department of Radiology, University Hospital Rigshospitalet, Copenhagen, Denmark
- Department of Radiology, Baylor College of Medicine, Houston, TX, USA
| | - Alireza Rasekhi
- Department of Radiology, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Reza Rafieossadat
- Department of Neurosurgery, Shiraz University of Medical Sciences, Shiraz, Iran.
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2
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Li J, Zhao H, Cao Z, Gu Z. Endoscopic Repair of Cerebrospinal Fluid Rhinorrhea Due to Trauma by a Bamboo Stick in a Pediatric Patient. J Craniofac Surg 2024; 35:e96-e98. [PMID: 37983104 DOI: 10.1097/scs.0000000000009894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 10/18/2023] [Indexed: 11/21/2023] Open
Abstract
Cerebrospinal fluid rhinorrhea (CSFR) is a condition in which the cerebrospinal fluid flows out of the nasal cavity due to rupture of the arachnoid, dura, and nasal membranes because of bone defects in the skull base. The authors report a rare case of CSFR in a 2-year-old girl who experienced trauma in the nasal cavity by a bamboo stick. She underwent endoscopic repair for the CSFR. During surgery, a bulged vesicle was observed at the left cribriform plate with a small amount of cerebrospinal fluid draining from the surrounding area. Postoperative recovery was good. Endoscopic CSFR repair in pediatric patients is minimally invasive, effective, and safe as demonstrated in this case. Prevention of CSFR in children is important. Parents and caretakers of children need to be more aware, and potentially dangerous objects should not be kept within reach of children.
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Affiliation(s)
- Jiani Li
- Department of Otolaryngology-Head and Neck Surgery, Shengjing Hospital of China Medical University, Shenyang, Liaoning, China
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3
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Johns JD, Pittman C, Briggs SE. Temporal Bone Trauma. Otolaryngol Clin North Am 2023; 56:1055-1067. [PMID: 37385862 DOI: 10.1016/j.otc.2023.05.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
Temporal bone trauma represents a potentially underrecognized condition during head injuries and remains an important consideration during the evaluation of these patients. The temporal bone contains many critical neurovascular structures in addition to the primary organs of the auditory and vestibular systems that may be violated during these injuries. Despite the lack of consensus guidelines on the management of these injuries, this review highlights the current literature regarding the diagnosis and management of temporal bone trauma and its potential complications.
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Affiliation(s)
- James Dixon Johns
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Gorman Building, 1st Floor, 3800 Reservoir Road NW, Washington DC 20007, USA; Department of Otolaryngology-Head and Neck Surgery, MedStar Washington Hospital Center, 106 Irving Street Northwest, Suite 2700, Washington, DC 20010, USA
| | - Corinne Pittman
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Gorman Building, 1st Floor, 3800 Reservoir Road NW, Washington DC 20007, USA; Department of Otolaryngology-Head and Neck Surgery, MedStar Washington Hospital Center, 106 Irving Street Northwest, Suite 2700, Washington, DC 20010, USA
| | - Selena E Briggs
- Department of Otolaryngology-Head and Neck Surgery, MedStar Georgetown University Hospital, Gorman Building, 1st Floor, 3800 Reservoir Road NW, Washington DC 20007, USA; Department of Otolaryngology-Head and Neck Surgery, MedStar Washington Hospital Center, 106 Irving Street Northwest, Suite 2700, Washington, DC 20010, USA.
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4
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McAvoy M, Hopper RA, Lee A, Ellenbogen RG, Susarla SM. Pediatric Cranial Vault and Skull Base Fractures. Oral Maxillofac Surg Clin North Am 2023; 35:597-606. [PMID: 37442667 DOI: 10.1016/j.coms.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Abstract
Cranial vault and skull base fractures in children are distinctly different from those seen in adults. Pediatric skull fractures have the benefit of greater capacity to remodel; however, the developing pediatric brain and craniofacial skeleton present unique challenges to diagnosis, natural history, and management. This article discusses the role of surgical treatment of these fractures, its indications, and techniques.
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Affiliation(s)
- Malia McAvoy
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Richard A Hopper
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Amy Lee
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Richard G Ellenbogen
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA
| | - Srinivas M Susarla
- Department of Neurosurgery; Division of Plastic Surgery, Department of Surgery, University of Washington School of Medicine, Craniofacial Center, Seattle Children's Hospital, Seattle, WA, USA.
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5
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Belhumeur V, Leblanc PA, Crevier L. Cerebrospinal fluid external leak after penetrating trauma in a neurologic intact infant patient: a case report. Childs Nerv Syst 2022; 38:1647-1649. [PMID: 35019999 DOI: 10.1007/s00381-021-05440-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 12/27/2021] [Indexed: 11/03/2022]
Abstract
Cranial cerebrospinal fluid (CSF) leak is an extremely rare complication of blunt head trauma causing skull fractures, especially fractures involving the skull base. We present the case of a 10-month-old male who received glass fragments on the midline and posterior tier of his anterior fontanelle producing a cranial cerebrospinal fluid leak without any skull fracture or symptoms. Neurologic exam was completely normal and a superficial stitch wound repair was performed. He was observed for 24 h, had no antibiotic, and left with a 1-week outpatient neurosurgical follow-up. The patient had no negative outcome. Cerebrospinal fluid leak should be included in the differential diagnosis of a head trauma in a patient with open fontanelles. No similar case was found in literature.
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Affiliation(s)
- Vincent Belhumeur
- Faculty of Medicine, Department of Emergency Medicine, Université Laval, Quebec, QC, Canada.
| | | | - Louis Crevier
- Division of Neurosurgery, Department of Surgery, CHU de Québec, Université Laval, Quebec, Canada
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Eisinger RS, Sorrentino ZA, Cutler C, Azab M, Pierre K, Lucke-Wold B, Murad GJ. Clinical risk factors associated with cerebrospinal fluid leak in facial trauma: A retrospective analysis. Clin Neurol Neurosurg 2022; 217:107276. [PMID: 35526511 DOI: 10.1016/j.clineuro.2022.107276] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 04/22/2022] [Accepted: 04/27/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVE Cerebrospinal fluid (CSF) leak occurs most commonly following skull fracture, with a CSF leakage complicating up to 2% of all head traumas. This study aims to identify demographic and injury characteristics correlated with the highest risk of CSF leak in patients with known facial fractures. METHODS Retrospective data was collected from a previously described trauma registry from 2010 to 2019. Patients over 18 years old with any type of facial fracture, known CSF leak status, available neuroimaging, and hospital admission were included. Chi-Square analysis for demographic and injury characteristic data were utilized. RESULTS A total of 79 patients with CSF leak and 4907 patients without CSF leak were included in the database. Patients with CSF leak tended to be younger than those without CSF leak (38.45 +/- 0.28 vs 44.08 +/- 0.28, M +/- SE, p = 0.0197). CSF leak depended on the mechanism of injury (MOI; X2 =27.02, df=2, p = 0.0000013), with CSF leak rates highest in penetrating injuries (4.87%) and motor vehicle accidents (1.78%) compared to blunt injuries (0.95%); age did not significantly differ between the MOI groups (p = 0.11). CSF leak was also more common in patients with a lower Glasgow coma scale (GCS; 7.95 +/- 0.58 vs 12.21 +/- 0.10, p = 10-15), LeFort type 2&3 and pan-facial fractures compared to all other facial fracture types (8.9% vs 1.2%, p = 10-15), and radiographic midline shift (29.4% vs 9.1%, p = 10-15). There was a trend towards a higher proportion of males in those with CSF leak compared to those without (83.3% vs 73.7% males, p = 0.073), and in patients with prolonged loss of consciousness (LOC; 9.43% with LOC > 1 h vs 2.69% LOC < 1 h, p = 0.056). CONCLUSION Facial fractures often present with CSF leak, and certain demographic and injury risk factors including younger age, worse GCS score, evidence of midline shift, and certain mechanisms of injury (penetrating and motor vehicle) are correlated with increased risk and warrant close screening and follow-up for CSF leak detection. LeFort type 2&3 and pan-facial fractures are at high risk of CSF leak.
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Affiliation(s)
| | | | | | | | - Kevin Pierre
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Brandon Lucke-Wold
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA.
| | - Gregory Ja Murad
- University of Florida College of Medicine, Gainesville, FL, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
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Kim TG, Sin EG. A Case of Penetrating Brain Injury Followed by Delayed Cerebrospinal Fluid Leakage. Korean J Neurotrauma 2021; 17:168-173. [PMID: 34760829 PMCID: PMC8558028 DOI: 10.13004/kjnt.2021.17.e29] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/15/2021] [Accepted: 09/22/2021] [Indexed: 11/15/2022] Open
Abstract
Although penetrating brain injury is rare, it is associated with high morbidity and mortality. In several studies, even if very few patients arrive at the hospital alive, half of them eventually die, and the other half have significant neurological sequelae. Cerebrospinal fluid (CSF) leakage caused by traumatic brain injury is common. Therefore, we should be aware of the complications, prognosis, and follow-up strategies of penetrating brain injuries. A 55-year-old man was brought to our hospital with diffuse cerebral contusion and skull fracture. Three weeks after successful surgery, the patient returned with a large amount of pneumocephalus and pneumoventricle caused by delayed CSF leakage. Fortunately, the patient was discharged without neurological deficits after reoperation. In the urgent situation of penetrating brain injury, the treatment and prognosis vary depending on the initial actions and clinical factors. In addition, we should be aware that a variety of complications, as well as CSF leakage, can occur in patients with penetrating brain injuries.
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Affiliation(s)
- Tae Geon Kim
- Department of Neurosurgery, Konyang University Hospital, Daejeon, Korea
| | - Eui Gyu Sin
- Department of Neurosurgery, Konyang University Hospital, Daejeon, Korea
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8
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Predisposing conditions for bacterial meningitis in children: what radiologists need to know. Jpn J Radiol 2021; 40:1-18. [PMID: 34432172 PMCID: PMC8732808 DOI: 10.1007/s11604-021-01191-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2021] [Accepted: 08/13/2021] [Indexed: 11/24/2022]
Abstract
A variety of underlying diseases can predispose infants and children to bacterial meningitis (BM). For the diagnosis, treatment, and prevention of its recurrence, radiologists should be familiar with its predisposing conditions so that they can suggest the appropriate imaging approach. Predisposing conditions of BM can be broadly classified into two categories: infection spread from the adjacent tissue to the cerebrospinal fluid (CSF) space and immunodeficiency. Diseases in the former category are further divided according to regardless of whether there is a structural defect between the CSF space and the adjacent tissue. When a structural defect is suspected in a patient with BM, computed tomography (CT) of the head and magnetic resonance (MR) imaging are first-line imaging examinations. Radionuclide cisternography should be implemented as a second-line step to identify the CSF leak site. In patients with suspected parameningeal infection without any structural defect, such as sinusitis or otitis media/mastoiditis, CT or MR images can identify not only the disease itself but also the associated intracranial complications. The purpose of this article is to discuss the diagnostic approach and imaging findings associated with the variety of conditions predisposing patients to recurrent BM, focusing on the role of radiology in their management.
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9
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Hoffman H, Otite FO, Chin LS. Venous Injury in Patients with Blunt Traumatic Brain Injury: Retrospective Analysis of a National Cohort. Neurocrit Care 2021; 36:116-122. [PMID: 34244919 DOI: 10.1007/s12028-021-01265-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 04/23/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND Cerebral venous injury (CVI) includes injury to a dural venous sinus or major vein and leads to poorer outcomes for patients with blunt traumatic brain injury (TBI). We sought to identify the incidence, associated factors, and outcomes associated with CVI in a large national cohort. METHODS Adult patients with blunt TBI were identified from the National Trauma Databank (2013-2017). Outcomes included inpatient mortality, discharge disposition, stroke, length of stay (LOS), intensive care unit LOS, and duration of mechanical ventilation. Multivariate regression models were used to identify the association between exposure variables and CVI, as well as each outcome. RESULTS There were 619,659 patients with blunt TBI who met the inclusion criteria. CVI occurred in 1792 (0.3%) patients. Mixed intracranial injury type had the strongest association with CVI (odds ratio [OR] 2.89, 95% confidence interval [CI] 2.38-3.50), followed by isolated TBI (OR 1.76, 95% CI 1.54-2.02) and skull fracture (OR 1.72, 95% CI 1.55-1.91). CVI was associated with increased odds of mortality (OR 1.38, 95% CI 1.19-1.60), nonroutine discharge (OR 1.26, 95% CI 1.12-1.40), and stroke (OR 1.95, 95% CI 1.33-2.86). It was also associated with longer LOS (β 2.02, 95% CI 1.55-2.50) and intensive care unit LOS (β 0.14, 95% CI 0.13-0.16). Among locations of venous injury, superior sagittal sinus injury had significant associations with mortality (OR 2.93, 95% CI 1.62-5.30) and nonroutine discharge disposition (OR 1.94, 95% CI 1.12-3.35), whereas the others did not. CONCLUSIONS We identified a 0.3% incidence of CVI in all-comers with blunt TBI as well as several injury-related variables that may be used to guide investigation for dural venous sinus injury. CVI was associated with poorer outcomes, with superior sagittal sinus injury having the strongest association.
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Affiliation(s)
- Haydn Hoffman
- Department of Neurosurgery, State University of New York Upstate Medical University, 750 E. Adams St., Syracuse, NY, 13210, USA.
| | - Fadar O Otite
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Lawrence S Chin
- Department of Neurosurgery, State University of New York Upstate Medical University, 750 E. Adams St., Syracuse, NY, 13210, USA
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10
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[Top ten pediatric radiological emergencies]. Radiologe 2020; 60:981-998. [PMID: 32995968 DOI: 10.1007/s00117-020-00744-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pediatric emergencies encompass a wide range of different findings. These include injuries to the child's body due to high-energy trauma or abuse, unclear limitations of consciousness and primarily unspecific abdominal or thoracic pain as well as swallowing or inhalation of foreign bodies. Detailed knowledge of the various imaging methods and the correct application are important. This article gives an overview of the significance of imaging techniques for emergency diagnostics in childhood and adolescence.
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11
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Pediatric Frontal Bone and Sinus Fractures: Cause, Characteristics, and a Treatment Algorithm. Plast Reconstr Surg 2020; 145:1012-1023. [PMID: 32221225 DOI: 10.1097/prs.0000000000006645] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND The purpose of this study was to assess the incidence, cause, characteristics, presentation, and management of pediatric frontal bone fractures. METHODS A retrospective cohort review was performed on all patients younger than 15 years with frontal fractures that presented to a single institution from 1998 to 2010. Charts and computed tomographic images were reviewed, and frontal bone fractures were classified into three types based on anatomical fracture characteristics. Fracture cause, patient demographics, management, concomitant injuries, and complications were recorded. Primary outcomes were defined by fracture type and predictors of operative management and length of stay. RESULTS A total of 174 patients with frontal bone fractures met the authors' inclusion criteria. The mean age of the patient sample was 7.19 ± 4.27 years. Among these patients, 52, 47, and 75 patients were classified as having type I, II, and III fractures, respectively. A total of 14, 9, and 24 patients with type I, II, and III fractures underwent operative management, respectively. All children with evidence of nasofrontal outflow tract involvement and obstruction underwent cranialization (n = 11). CONCLUSIONS The authors recommend that type I fractures be managed according to the usual neurosurgical guidelines. Type II fractures can be managed operatively according to the usual pediatric orbital roof and frontal sinus fracture indications (e.g., significantly displaced posterior table fractures with associated neurologic indications). Lastly, type III fractures can be managed operatively as for type I and II indications and for evidence of nasofrontal outflow tract involvement. The authors recommend cranialization in children with nasofrontal outflow tract involvement. CLINICAL QUESTION/LEVEL OF EVIDENCE Risk, II.
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Bokhari R, You E, Bakhaidar M, Bajunaid K, Lasry O, Zeiler FA, Marcoux J, Baeesa S. Dural Venous Sinus Thrombosis in Patients Presenting with Blunt Traumatic Brain Injuries and Skull Fractures: A Systematic Review and Meta-Analysis. World Neurosurg 2020; 142:495-505.e3. [PMID: 32615287 DOI: 10.1016/j.wneu.2020.06.117] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Revised: 06/14/2020] [Accepted: 06/16/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Dural venous sinus thrombosis (DVST) is an increasingly recognized complication of blunt traumatic brain injury (TBI) and skull fractures. However, data concerning epidemiology and clinical significance of DVST are unclear. Determining the disease burden in patients with TBI is an important first step to guide future studies assessing the natural course of traumatic DVST or the effects of its treatment. Therefore, we performed to our knowledge the first systematic review and meta-analysis evaluating the prevalence of DVST in patients with TBI and skull fractures. METHODS MEDLINE and Embase databases were systematically searched for relevant studies published up to March 2018. All studies that assessed the prevalence of DVST among patients with TBI who underwent a vascular imaging study were included. The primary outcome was the presence or absence of DVST on imaging. A random-effects meta-analysis was used to pool studies. RESULTS Our systematic review yielded 638 articles, and 13 articles met inclusion criteria. In patients with skull fractures adjacent to a venous sinus, the prevalence was 26.2% (95% confidence interval = 19.4%-34.4%). This elevated risk was similar between adult (pooled estimate 23.8%; 95% CI = 16.2%-33.5%) and pediatric (pooled estimate 31.3%; 95% CI = 19.1%-46.9%) populations. CONCLUSIONS We found an unexpectedly high and consistent frequency of DVST among patients with skull fractures regardless of age group or severity of brain injury. These findings are important and highlight the need for further understanding the natural history of DVST and providing better guidelines on its management.
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Affiliation(s)
- Rakan Bokhari
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada
| | - Eunice You
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada
| | - Mohamad Bakhaidar
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia; Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada
| | - Khalid Bajunaid
- Department of Surgery, Faculty of Medicine, University of Jeddah, Jeddah, Saudi Arabia
| | - Oliver Lasry
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada; Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Frederick A Zeiler
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada; Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Judith Marcoux
- Department of Neurology and Neurosurgery, Montreal Neurological Hospital and Institute, McGill University, Montreal, Quebec, Canada
| | - Saleh Baeesa
- Division of Neurosurgery, Department of Surgery, Faculty of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.
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13
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Hejrati N, Ebel F, Guzman R, Soleman J. Posttraumatic cerebrovascular injuries in children. A systematic review. Childs Nerv Syst 2020; 36:251-262. [PMID: 31901968 DOI: 10.1007/s00381-019-04482-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 12/17/2019] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Posttraumatic craniocervical vascular injuries in pediatric traumatic brain injury (TBI) are rare, and children-specific, evidence-based standards on screening and therapy of posttraumatic carotid-cavernous fistula (CCF), craniocervical artery dissections (CCAD), traumatic aneurysms (TA), and posttraumatic sinus venous thrombosis (SVT) is lacking. The aim of this review is to summarize the data on epidemiology, clinical presentation, and treatment of these traumatic lesions in a systematic manner. METHODS We performed a systematic PubMed search for records of CCF, CCAD, TA, and SVT related to pediatric TBI published until June 2019. RESULTS After screening 2439 records, 42 were included in the quantitative analysis. Incidences for CCAD in blunt TBI were 0.21% (range 0.02-6.82%). 11.7% (range 1.69-15.58%) of pediatric aneurysms were found to be traumatic of origin, whereas 38.2% (range 36.84-40%) of all pediatric SVT were due to blunt TBI. For all of the posttraumatic cerebrovascular pathologies, we found a clear male predominance with 68.75% in CCF, 63.4% in CCAD, 60% in TA, and 58.33% in SVT. Clinical presentation did not differ from the adult population with exception of young child. While there is only recommendation for the therapy of CCAD and SVT in the pediatric population, no such recommendation exists for the treatment of CCF's and TA's, and data from randomized controlled trials is lacking. CONCLUSION While these results show that posttraumatic CCF, CCAD, TA, and SVT are rarely encountered in children, misdiagnosis may have potentially drastic consequences due to a longer lifetime burden in the pediatric population. Awareness, early recognition, and prompt initiation of the appropriate therapy are essential to avoid morbidity and mortality. Further studies should focus on the development of clinical and radiological screening criteria of posttraumatic vascular lesions in children.
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Affiliation(s)
- Nader Hejrati
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.
| | - Florian Ebel
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland
| | - Raphael Guzman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Spitalstrasse 33, Basel, 4056, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
| | - Jehuda Soleman
- Department of Neurosurgery, University Hospital of Basel, Spitalstrasse 21, 4031, Basel, Switzerland.,Division of Pediatric Neurosurgery, University Children's Hospital of Basel, Spitalstrasse 33, Basel, 4056, Switzerland.,Faculty of Medicine, University of Basel, Basel, Switzerland
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Dallas J, Mercer E, Reynolds RA, Wellons JC, Shannon CN, Bonfield CM. Should ondansetron use be a reason to admit children with isolated, nondisplaced, linear skull fractures? J Neurosurg Pediatr 2019; 25:284-290. [PMID: 31835245 DOI: 10.3171/2019.9.peds19203] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 09/30/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Isolated, nondisplaced skull fractures (ISFs) are a common result of pediatric head trauma. They rarely require surgical intervention; however, many patients with these injuries are still admitted to the hospital for observation. This retrospective study investigates predictors of vomiting and ondansetron use following pediatric ISFs and the role that these factors play in the need for admission and emergency department (ED) revisits. METHODS The authors identified pediatric patients (< 18 years old) with a linear ISF who had presented to the ED of a single tertiary care center between 2008 and 2018. Patients with intracranial hemorrhage, significant fracture displacement, or other traumatic injuries were excluded. Outcomes included vomiting, ondansetron use, admission, and revisit following ED discharge. Both univariable and multivariable analyses were used to determine significant predictors of each outcome (p < 0.05). RESULTS Overall, 518 patients were included in this study. The median patient age was 9.98 months, and a majority of the patients (59%) were male. The most common fracture locations were parietal (n = 293 [57%]) and occipital (n = 144 [28%]). Among the entire patient cohort, 124 patients (24%) had documented vomiting, and 64 of these patients (52%) received ondansetron. In a multivariable analysis, one of the most significant predictors of vomiting was occipital fracture location (OR 4.05, p < 0.001). In turn, and as expected, both vomiting (OR 14.42, p < 0.001) and occipital fracture location (OR 2.66, p = 0.017) were associated with increased rates of ondansetron use. A total of 229 patients (44%) were admitted to the hospital, with vomiting as the most common indication for admission (n = 59 [26%]). Moreover, 4.1% of the patients had ED revisits following initial discharge, and the most common reason was vomiting (11/21 [52%]). However, in the multivariable analysis, ondansetron use at initial presentation (and not vomiting) was the sole predictor of revisit following initial ED discharge (OR 5.05, p = 0.009). CONCLUSIONS In this study, older patients and those with occipital fractures were more likely to present with vomiting and to be treated with ondansetron. Additionally, ondansetron use at initial presentation was found to be a significant predictor of revisits following ED discharge. Ondansetron could be masking recurrent vomiting in ED patients, and this should be considered when deciding which patients to observe further or discharge.
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Affiliation(s)
- Jonathan Dallas
- 1Vanderbilt University School of Medicine
- 3Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | | | - Rebecca A Reynolds
- 2Department of Neurosurgery, Vanderbilt University Medical Center; and
- 3Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - John C Wellons
- 2Department of Neurosurgery, Vanderbilt University Medical Center; and
- 3Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Chevis N Shannon
- 2Department of Neurosurgery, Vanderbilt University Medical Center; and
- 3Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
| | - Christopher M Bonfield
- 2Department of Neurosurgery, Vanderbilt University Medical Center; and
- 3Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee
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Varshneya K, Rodrigues AJ, Medress ZA, Stienen MN, Grant GA, Ratliff JK, Veeravagu A. Risks, costs, and outcomes of cerebrospinal fluid leaks after pediatric skull fractures: a MarketScan analysis between 2007 and 2015. Neurosurg Focus 2019; 47:E10. [DOI: 10.3171/2019.8.focus19543] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Accepted: 08/20/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVESkull fractures are common after blunt pediatric head trauma. CSF leaks are a rare but serious complication of skull fractures; however, little evidence exists on the risk of developing a CSF leak following skull fracture in the pediatric population. In this epidemiological study, the authors investigated the risk factors of CSF leaks and their impact on pediatric skull fracture outcomes.METHODSThe authors queried the MarketScan database (2007–2015), identifying pediatric patients (age < 18 years) with a diagnosis of skull fracture and CSF leak. Skull fractures were disaggregated by location (base, vault, facial) and severity (open, closed, multiple, concomitant cerebral or vascular injury). Descriptive statistics and hypothesis testing were used to compare baseline characteristics, complications, quality metrics, and costs.RESULTSThe authors identified 13,861 pediatric patients admitted with a skull fracture, of whom 1.46% (n = 202) developed a CSF leak. Among patients with a skull fracture and a CSF leak, 118 (58.4%) presented with otorrhea and 84 (41.6%) presented with rhinorrhea. Patients who developed CSF leaks were older (10.4 years vs 8.7 years, p < 0.0001) and more commonly had skull base (n = 183) and multiple (n = 22) skull fractures (p < 0.05). These patients also more frequently underwent a neurosurgical intervention (24.8% vs 9.6%, p < 0.0001). Compared with the non–CSF leak population, patients with a CSF leak had longer average hospitalizations (9.6 days vs 3.7 days, p < 0.0001) and higher rates of neurological deficits (5.0% vs 0.7%, p < 0.0001; OR 7.0; 95% CI 3.6–13.6), meningitis (5.5% vs 0.3%, p < 0.0001; OR 22.4; 95% CI 11.2–44.9), nonroutine discharge (6.9% vs 2.5%, p < 0.0001; OR 2.9; 95% CI 1.7–5.0), and readmission (24.7% vs 8.5%, p < 0.0001; OR 3.4; 95% CI 2.5–4.7). Total costs at 90 days for patients with a CSF leak averaged $81,206, compared with $32,831 for patients without a CSF leak (p < 0.0001).CONCLUSIONSThe authors found that CSF leaks occurred in 1.46% of pediatric patients with skull fractures and that skull fractures were associated with significantly increased rates of neurosurgical intervention and risks of meningitis, hospital readmission, and neurological deficits at 90 days. Pediatric patients with skull fractures also experienced longer average hospitalizations and greater healthcare costs at presentation and at 90 days.
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16
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Northam W, Chandran A, Quinsey C, Abumoussa A, Flores A, Elton S. Pediatric nonoperative skull fractures: delayed complications and factors associated with clinic and imaging utilization. J Neurosurg Pediatr 2019; 24:489-497. [PMID: 31470399 DOI: 10.3171/2019.5.peds18739] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 05/22/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Skull fractures represent a common source of morbidity in the pediatric trauma population. This study characterizes the type of follow-up that these patients receive and discusses predictive factors for follow-up. METHODS The authors reviewed cases of nonoperative pediatric skull fractures at a single academic hospital between 2007 and 2017. Clinical patient and radiological fractures were recorded. Recommended neurosurgical follow-up, follow-up appointments, imaging studies, and fracture-related complications were recorded. Statistical analyses were performed to identify predictors for outpatient follow-up and imaging. RESULTS The study included 414 patients, whose mean age was 5.2 years; 37.2% were female, and the median length of stay was 1 day (IQR 0.9-4 days). During 438 clinic visits and a median follow-up period of 8 weeks (IQR 4-12, range 1-144 weeks), 231 imaging studies were obtained, mostly head CT scans (55%). A total of 283 patients were given recommendations to attend follow-up in the clinic, and 86% were seen. Only 12 complications were detected, including 7 growing skull fractures, 2 traumatic encephaloceles, and 3 cases of hearing loss. Primary care physician (PCP) status and insurance status were associated with a recommendation of follow-up, actual follow-up compliance, and the decision to order outpatient imaging in patients both with and without intracranial hemorrhage. PCP status remained an independent predictor in each of these analyses. Follow-up compliance was not associated with a patient's distance from home. Among patients without intracranial hemorrhage, a follow-up recommendation and actual follow-up compliance were associated with pneumocephalus and other polytraumatic injuries, and outpatient imaging was associated with a bilateral fracture. No complications were found in patients with linear fractures above the skull base in those without an intracranial hemorrhage. CONCLUSIONS Pediatric nonoperative skull fractures drive a large expenditure of clinic and imaging resources to detect a relatively small profile of complications. Understanding the factors underlying the decision for clinic follow-up and additional imaging can decrease future costs, resource utilization, and radiation exposure. Factors related to injury severity and socioeconomic indicators were associated with outpatient imaging, the decision to follow up patients in the clinic, and patients' subsequent attendance. Socioeconomic status (PCP and insurance) may affect access to appropriate neurosurgical follow-up and deserves future research attention. Patients with no intracranial hemorrhage and with a linear fracture above the skull base do not appear to be at risk for delayed complications and could be candidates for reduced follow-up and imaging.
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Affiliation(s)
| | - Avinash Chandran
- 2Matthew Gfeller Sport-Related TBI Research Center, Department of Exercise and Sport Science; and
| | | | | | - Alex Flores
- 3School of Medicine, University of North Carolina, Chapel Hill, North Carolina
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Yang LH, Wang WF, Zhang SH, Fan ZX, Xiao JQ. Neuromuscular electrical stimulation on hearing loss caused by skull base fracture: A protocol for systematic review of randomized controlled trial. Medicine (Baltimore) 2019; 98:e14650. [PMID: 30813207 PMCID: PMC6408040 DOI: 10.1097/md.0000000000014650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND This systematic review aims to investigate the effectiveness and safety of neuromuscular electrical stimulation (NMES) on hearing loss (HL) caused by skull base fracture (SBF). METHODS We will retrieve the following electronic databases of Cochrane Library, PUBMED, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Allied and Complementary Medicine Database, and Chinese Biomedical Literature Database from the inception to January 1, 2019 for relevant RCTs of NMES for HL caused by SBF. Two experienced authors will independently perform the study selection, data extraction, and methodology quality assessment. A 3rd author will solve any disagreements between 2 authors through discussion. RESULTS This study will provide a high-quality synthesis of latest evidence of NMES for HL caused by SBF from comprehensive assessments, including hearing loss evaluation, hearing threshold, quality of life, and any relevant adverse events. CONCLUSION The expected results of this systematic review will provide the up-to-date evidence to assess the effectiveness and safety of NEMS for patients with HL caused by SBF. ETHICS AND DISSEMINATION The results of this study will be disseminated through publication in a peer-reviewed journal or will be presented at an associated conference meeting. This study will not use individual patient data, thus, the ethical approval is not needed. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019120195.
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Affiliation(s)
| | - Wei-feng Wang
- Department of Neurosurgery, First Affiliated Hospital of Jiamusi University
| | - Shu-hong Zhang
- Department of Biology, Basic Medicine School of Jiamusi University, Jiamusi
| | | | - Jian-qi Xiao
- Department of Neurosurgery, The First Hospital of Qiqihar City, Qiqihar, China
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