Pediatric head injuries: particularities and neurosurgical experience in a lower-middle income country

PURPOSE

To the best of our knowledge, this is the first study conducted in Tunisia on the neurosurgical management of child cranial trauma. The objectives of the present work were to identify the causes of pediatric head injuries, explore epidemiological and clinical specificities, and analyze the short- and long-term postoperative evolution.

METHODS

A retrospective review was conducted on one hundred children with head injuries over a five-year period at one of the largest neurosurgery departments in Tunisia. The collected data encompassed demographic information, clinical presentation features, neuroimaging characteristics, surgical management, complications, and outcomes.

RESULTS

Over a five-year period, we have found 118 children who have undergone surgery, representing an annual incidence of twenty-four children per year. The average age was 10 years. Falls emerged as the primary cause of childhood head injuries in our series, followed by road traffic accidents. The most frequently encountered initial sign was the loss of consciousness (52%), followed by headaches (28%), vomiting (25%), and seizures (8%). The average time between the accident and admission to the operating unit was 10 h. Various neurosurgeries were performed, with the evacuation of an epidural hematoma being the most common procedure. At a median follow-up of 24 months, the outcomes were favorable in 88% of cases.

CONCLUSION

The main prognostic factors for head trauma in children included age, circumstances of the accident, association with polytrauma, the initial Glasgow Coma Scale, the nature of the initial cerebral lesions, and the timeliness and quality of initial management.

Can we consider ventriculo-gallbladder shunt a first-line treatment in selected patients? Case report of a successful management

INTRODUCTION

Ventriculo-gallbladder shunt (VGS) has been recognized as a last-resort alternative to treat hydrocephalus when the peritoneum and/or other distal sites can no longer receive shunts. In some specific conditions, it may be conceded as a first-line treatment.

CASE PRESENTATION

We report the case of a 6-month-old girl with progressive post-hemorrhagic hydrocephalus who presented a concomitant chronic abdominal symptom. Specific investigations ruled out acute infection and led to the diagnosis of chronic appendicitis. Both problems were managed in a one-stage salvage procedure consisting of laparotomy sanctioning to treat the abdominal pathology and seize the opportunity to perform a VGS as a first option since the abdomen is prone to ventriculoperitoneal shunt (VPS) failure.

CONCLUSION

Only few cases have reported the use of VGS as the first option to handle uncommon complex cases due to abdominal or cerebrospinal fluid (CSF) conditions. We wish to draw attention to VGS as an effective procedure not only in children with multiple shunt failures but also as first-line management in some selected cases.

Apoplexy in pituitary metastasis revealing a lung carcinoma

Pituitary metastasis (PM) is an uncommon manifestation of systemic malignant tumours. It is the least common site of intracranial metastases. As PM has no clinical or radiological pathognomonic features, their diagnosis is challenging. Herein, we present a rare case of a PM unveiling lung cancer. A 60-year-old male with no medical history of malignancy was admitted with a sudden headache, retro-orbital pain, and a severe loss of both eyes' visual acuity. After proper investigations and endoscopic resection of the sellar mass, the diagnosis was confirmed to be pituitary metastasis of lung carcinoma. PM can be the initial presentation of an otherwise unknown malignancy. Their diagnosis and management are complex and depend on many factors. Endoscopic surgical resection provides histopathological proof, helps with symptomatic relief, and improves the quality of life but has no effect on survival.

Hydatid cyst in the third ventricle of the brain: case report of an exceptionally rare condition

Hydatid disease is an endemic zoonotic disease caused by the cestode Echinococcus multilocularis and Echinococcus granulosus. Intra-ventricular hydatid cysts are extremely rare. Even more rarely, and to the best of our knowledge, only three cases of third ventricle involvement have been reported. Herein, we present the fourth case of an intraventricular hydatid cyst in a pediatric patient located in the third ventricle. It is about a 7-year-old girl, of a rural origin, admitted for intracranial hypertension, deterioration of the general status, and weakness on the right side of her body. A cerebral magnetic resonance imaging (MRI) showed the presence of a rounded cystic formation in the third ventricle. The patient was operated through a transfrontal transventricular approach, and the cyst was removed. Postoperative course was uneventful. Hydatid disease should be considered part of the differential diagnosis for cystic lesions of the central nervous system, especially in endemic regions. Total removal of the cysts without rupture is a challenge, but best treatment remains an active nationwide prevention.

Spinal clear cell meningioma without dural attachment: a case report and literature review

Clear cell meningiomas (CCM) are a very rare histologic subtype of meningioma usually affecting younger patients. The reported data on spinal CCM are extremely rare. Until today, only 89 cases have been reported. Furthermore, CCM without dural attachment is even rarer since only 19 cases have been reported in English literature. In this article, we present the twentieth case of a spinal CCM without dural attachment. Our patient was a 58-year-old female who was presented with pain in her lower back and bilateral sciatica for 6 months. Magnetic resonance imaging showed an intra-dural well-demarcated lesion at L3. Via a posterior approach, total resection was possible due to the lack of dural adhesion of the tumor. Histologic diagnosis was clear cell meningioma.

A case report of a Cerebellopontine angle lipoma revealed by vertigo

Cerebellopontine angle (CPA) lipoma is an extremely rare lesion representing only 0.1% of all the CPA tumors. We present a case of a 56-year-old woman with a 6-month history of vertigo. Cerebral MRI showed a left CPA lipoma. The patient was managed conservatively.

Remote cerebellar hemorrhage after the evacuation of a subdural hematoma: a case report

Remote intracranial hemorrhage is postoperative bleeding that occurs away from the surgical site. Remote cerebellar hemorrhage (RCH) is a cerebellar hemorrhage that may occur in 0.04-0.8% of cases after supratentorial and spinal procedures. We report a case of a 73-year-old male who developed signs of increased intracranial pressure two days after the evacuation of a subdural hematoma. Brain computed tomography showed RCH with the “zebra sign” and triventricular hydrocephalus that indicated the placement of external ventricle drain in emergency. Therefore, surgeons must pay special attention to this rare postoperative complication because it can be devastating in terms of patient outcome especially due to its possible complications requiring surgical treatment.

Congenital Glioblastoma: Lessons Learned from a Rare Case with Unusual Presentation

Congenital glioblastomas are uncommon tumors of infancy with unique molecular features and usually better prognosis compared to their pediatric and adult counterparts. A 15-day old newborn harboring a congenital glioblastoma undiagnosed at pregnancy presented to our emergencies with rapid neurological deterioration. Radiological investigations revealed an 8 by 9 cm space occupying and enhancing lesion in the left temporoparietooccipital region with intratumoral hemorrhage. The patient was immediately transferred to the operative theater and was operated in a poor condition. Unfortunately he showed no improvement post-operatively and died within two days in the intensive care unit. As such presentation is unique; we present the case and review the relevant literature concerning the potential pitfalls in diagnosis, management strategies and improvements in outcome.

Epidural Venous Angioma Presenting with Spinal Cord Compression in a 42-Year-Old Woman with Previous History of Ovarian Malignancy

BACKGROUND

Venous angioma is an extremely rare vascular malformation of the epidural space. To the best of our knowledge, only 5 cases have been documented to date and none has been reported in the setting of a previous malignancy.

CASE DESCRIPTION

We report the case of a 42-year-old woman with a previous history of ovarian cancer, treated by surgery plus chemotherapy; who presented with signs of spinal cord compression for 3 weeks. Magnetic resonance imaging showed an intensely enhancing epidural mass at the T2-T6 level causing major spinal cord compression, for which urgent surgery was indicated. During surgery, the tumor was extremely hemorrhagic and the hemostasis was hazardous. Blood loss was estimated at 1.5 L, causing hemodynamic instability and requiring intensive resuscitation with fluids and blood transfusions. Gross total resection was achieved and the pathologic examination confirmed the diagnosis of venous angioma. The patient recovered quickly postoperatively and was able to walk independently within 2 weeks of starting intensive rehabilitation. She was symptom free with no clinical or radiologic evidence of recurrence at 1 year follow-up.

CONCLUSIONS

Venous angioma should be included in the differential diagnosis of spinal epidural masses even in case of previous malignancy. Subtle imaging features should alert clinicians to this rare yet potentially life-threatening condition. Surgery remains the cornerstone of the treatment and can result in remarkable recovery.

Congenital neuroblastoma presenting with paraplegia following spinal puncture in a neonate. Case report and review of the literature

Neuroblastoma is the most common intraspinal solid tumor of childhood. Neurological deterioration due to an intratumoral hemorrhage following a spinal puncture is extremely rare. We report on the case of a 23-day-old neonate who was admitted to our institution for the onset of a paraplegia following a diagnostic lumbar puncture. The MRI showed an epidural tumor with massive intratumoral hemorrhage. Operatively and with histologic confirmation, the mass was determined to be a neuroblastoma. Following surgery, neurological function improved.

Plagiocephaly due to Frontosphenoidal Suture Synostosis: Report of 2 Cases and Literature Review

BACKGROUND/AIMS

The most common cause of anterior plagiocephaly is the fusion of the unilateral coronal suture. In some rare cases, however, the fusion of the frontosphenoidal suture may lead to a resembling pattern with specific clinical and radiological features. The aim of the present study is to further enlighten this entity as it is misdiagnosed most of the time.

METHODS

A report of 2 cases of plagiocephaly due to frontosphenoidal synostosis with a review of the literature.

RESULTS

One female and one male baby were identified. The mean age at presentation was 11.5 months (range: 1-22). Head circumference was normal in each patient. The two fusions were on the left side. Unilateral frontal flattening and recession of the supraorbital rim were the most important physical findings. Computed tomography confirmed the patency of the frontoparietal suture and the closure of the frontosphenoidal suture. Fronto-orbital advancement was performed in both cases with good cosmetic outcome.

CONCLUSION

Frontosphenoidal synostosis should be suspected and carefully searched when dealing with plagiocephaly with patent coronal suture. Good outcome requires a prompt diagnosis and early correction.

Metastatic sacrococcygeal yolk sac tumor: A misleading diagnosis

Sacrococcygeal yolk sac tumor (YST) is an extremely rare malignant extra-gonadal germ-cell tumor, which usually succeeds to the degeneration of more common benign teratoma. We describe here an unprecedented case of conus medullaris compression by a spinal metastasis from a pure sacrococcygeal YST in a 1½ years old girl, which was misdiagnosed initially as an anal fissure and stress the need of a meticulous clinical examination and further screening in young patients presenting with sphincter disturbances.

Atypical teratoid rhabdoid tumor of the lateral ventricle

Atypical teratoid/rhabdoid tumors (AT/RTs) are rare and highly malignant embryonal central nervous system neoplasms, usually seen in very young children with rapid fatal outcome despite aggressive treatment. They are most commonly located in the posterior fossa. Intraventricular location is extremely rare. To the best of our knowledge, only 4 cases of lateral ventricle location were reported in the literature. We report the fifth case of lateral ventricle AT/RT in a 2-month-old male who presented with rapid increase of his head circumference. Brain computed tomography scan and magnetic resonance imaging showed heterogeneous huge mass within the left lateral ventricle extending to the parieto-occipital parenchyma and markedly enhancing by contrast. The baby underwent left transparietal approach with complete removal of the tumor. Histological examination confirmed the diagnosis of AT/RT. An aggressive chemotherapy was administrated postoperatively. The outcome is good without neurological deficit or recurrence after 3 years and half of follow-up.

Primary pure and nonsecreting embryonal carcinoma of the anterior third ventricle: a case report

Central nervous system germ cell tumors (GCTs) account for less than 5% of primary brain tumors in children and adolescents but continue to attract much attention. To the best of our knowledge, a primary pure and nonsecreting embryonal carcinoma of the anterior third ventricle has never been previously reported. A 15-year-old boy presented with signs of increased intracranial pressure for the past 2 weeks complicated by 2 episodes of generalized tonic-clonic seizures 1 day before admission. Neurological examination was normal, and funduscopic examination disclosed a grade II papilledema bilaterally. CT and MRI revealed a well-demarcated and enhancing mass within the anterior third ventricle associated with a left lateral ventricle hydrocephalus. There was no evidence of tumor within the pineal or suprasellar region, and systemic and cerebrospinal fluid evaluation demonstrated normal levels of α-fetoprotein and human chorionic gonadotropin. Radical surgery was advised, and total tumor resection was achieved via a transcallosal transforaminal approach. The postoperative course was uneventful, and the final histological diagnosis was a pure embryonal carcinoma. Further screening showed no other location, and adjunctive high-dose chemotherapy was administered. The patient has been symptom free with no clinical or radiological sign of progression at the most recent follow-up examination 2 years after surgery. Primary pure and nonsecreting embryonal carcinoma can develop within the anterior third ventricle and should be considered in the differential diagnosis of anterior third ventricular masses especially in young patients. Accurate identification, radical surgery and high-dose chemotherapy can result in better tumor control and improve the postoperative outcome.

Hematogenous pasteurella haemolytica brain abscess

Pasteurella infections are common in domestic animals and very rare in human. We report a hematogenously acquired Pasteurella haemolytica brain abscess, mimicking brain tumor on magnetic resonance imaging, in an 18-year-old female patient known with cardiac interventricular communication, without recent history of animal contact. The outcome was good after abscess complete removal and antimicrobials therapy for 6 weeks. To the best of our knowledge, this is the first reported case of P. haemolytica brain abscess.

Hematogenous pasteurella haemolytica brain abscess

Pasteurella infections are common in domestic animals and very rare in human. We report a hematogenously acquired Pasteurella haemolytica brain abscess, mimicking brain tumor on magnetic resonance imaging, in an 18-year-old female patient known with cardiac interventricular communication, without recent history of animal contact. The outcome was good after abscess complete removal and antimicrobials therapy for 6 weeks. To the best of our knowledge, this is the first reported case of P. haemolytica brain abscess.

[Pseudo-tumoral neuro-Behçet's disease]

INTRODUCTION

Clinical involvement of the central nervous system occurs in about 10 to 30 percent of patients with Behçet's disease. Neurological pseudo tumoral presentation is rare.

CASE REPORT

We report a case of pseudo tumoral neuro-Behçet disease in a 38-year-old man, with past history of facial and dorsal folliculitis, who presented suddenly headache, right hemiplegia, aphasia and disturbed consciousness. Neuroradiological investigations showed a pseudo tumoral lesion in the left capsulo-thalamic region extending to the homolateral peduncle. The patient improved with steroid and immunosuppresseur therapy.

CONCLUSION

The clinical and radiological presentation of neuro-Behçet's disease can mimic a brain tumor.

[Vermian epidermoid cyst revealed by head injury]

Vermian epidermoid cyst developing in the fourth ventricle is very rare. We report a case observed in a 24-year-old man, who presented severe headache, dizziness and a blurred vision following head injury. Examination revealed a discrete gait disturbance. Cerebral CT-scan showed a large hypodense lesion of the posterior fossa without contrast enhancement. MRI demonstrated the vermian location of this lesion which displaced the roof of the fourth ventricle upward and the brainstem forward. A suboccipital approach allowed total removal of a well-encapsulated epidermoid cyst, non adherent to the floor of the fourth ventricle. The postoperative course was uneventful.

Calcifications post-nucléorthèse, un problème toujours d’actualité?

INTRODUCTION

Intradiscal injection of triamcinolone hexacetonide, used to treat sciatica caused by herniated discs was discontinued after discovery that it was followed in some cases by epidural calcification.

OBSERVATION

Ten years after an intradiscal injection at L4-L5, a 40 year-old man developed voluminous perivertebral, bilateral foraminal and intraductal calcifications that compressed the dural sheath. After preliminary excision, these calcifications recurred and required further excision, followed by posterior lateral grafting and osteosynthesis.

DISCUSSION

Calcifications following intradiscal injections are symptomatic in 14 to 68% of cases. They require radical surgical treatment to avoid recurrence.

[A symptomatic choroid plexus cyst in the lateral ventricle]

Choroid plexus cyst is generally small and a relatively common finding at autopsy. Huge and symptomatic cysts are rare. Few cases are reported in the literature. We report one case of symptomatic choroid plexus cyst of the right lateral ventricle in a six month baby who presented with epilepsy. Cerebral CT scan and MRI showed a large cyst in the right lateral ventricle compressing the adjacent structures. Total removal of the cyst has been performed by a parieto-temporal approach. The course was uneventful.

[A rare cause of multiple lacunae of the cranial vault and temporal bone in adults: histiocytosis X]

Histiocytosis X is an uncommon disease. Temporal bone involvement is a frequent head and neck manifestation. Most patients are under fifteen years of age. The authors report a case of a bilateral extensive temporal involvement complicated with vertigo and peripheric facial palsy. CT plays a dominant role in the diagnosis because of the ability to identify bone destruction, soft tissue involvement and intra-cranial histiocytosis more accurately.