Background: Decompressive craniectomy (DC) can be utilized in the management of severe traumatic brain injury (TBI). It remains unclear if timing of DC affects pediatric patient outcomes. Further, the literature is limited in the risk assessment and prevention of complications that can occur post DC. Methods: This is a retrospective review over a 10-year period across two medical centers of patients ages 1 month–18 years who underwent DC for TBI. Patients were stratified as acute (24 h) based on timing to DC. Primary outcomes were Glasgow outcome scale (GOS) at discharge and 6-month follow-up as well as complication rates. Results: A total of 47 patients fit the inclusion criteria: 26 (55.3%) were male with a mean age of 7.87 ± 5.87 years. Overall, mortality was 31.9% (n = 15). When evaluating timing to DC, 36 (76.6%) patients were acute, and 11 (23.4%) were subacute. Acute DC patients presented with a lower Glasgow coma scale (5.02 ± 2.97) compared to subacute (8.45 ± 4.91) (P = 0.030). Timing of DC was not associated with GOS at discharge (P = 0.938), 3-month follow-up (P = 0.225), 6-month follow-up (P = 0.074), or complication rate (P = 0.505). The rate of posttraumatic hydrocephalus following DC for both groups was 6.4% (n = 3). Conclusion: Although patients selected for the early DC had more severe injuries at presentation, there was no difference in outcomes. The optimal timing of DC requires a multifactorial approach considered on a case-by-case basis.

Background: Pediatric cranioplasty is associated with a high rate of complications, including bone resorption (BR) in 20–50% of cases. We aimed to evaluate factors contributing to BR, including the effect of the timing of cranioplasty and the use of post-surgical drains. Methods: This is a dual institution retrospective review of all patients under 18 years old who underwent a cranioplasty following a decompressive craniectomy (DC) for the treatment of traumatic brain injury between 2011 and 2021. Early cranioplasty was defined as within 30 days after DC and late cranioplasty as >30 days. Patients were grouped by BR and separately by timing to cranioplasty. Groups were compared based on the Glasgow Outcome Scale (GOS) and postoperative drain usage. Results: A total of 30 patients were included in the study. The mean age was 7.39 (standard deviation = 6.52) and 60% were male. The median time to cranioplasty was 13 days (interquartile range = 10–17). BR was present in 16.7% of cases. A subgaleal drain was utilized in 93.3% and an external ventricular drain (EVD) in 63.3% of patients following cranioplasty. Drain usage was not associated with BR and timing to cranioplasty was not associated with discharge or 6-month GOS. Conclusion: This study demonstrates that early cranioplasty following DC may have similar outcomes to late cranioplasty. Post-surgical EVDs and subgaleal drains did not increase the incidence of BR, suggesting their importance in the postoperative management of these patients.

Background The aim of this study was to assess deformational plagiocephaly’s (DP) predictive value in neglect and physical abuse (nonaccidental trauma [NAT]) within the pediatric population. In addition, we sought to characterize the prevalence of DP and NAT for our hospital’s mostly rural catchment area. Methods Data on hospitalized patients diagnosed with NAT and/or neglect between 2012 and 2018 were collected via retrospective chart review. All enrolled children were younger than the age of 4 years at the time of diagnosis, and those without legible head computed tomographies or magnetic resonance images during their initial hospitalization were excluded. Utilizing neuroimaging, we calculated the cranial vault asymmetry index (CVAI) and cranial index for each patient to assess for DP. Differences between the two groups were assessed using Wilcoxon’s rank-sum test for continuous variables and Fisher’s exact test for categorical variables. A p-value of 0.05 or less was considered statistically significant. All analyses were conducted using SAS 9.4 (Cary, North Carolina, United States). Results The prevalence of DP within the combined cohort of NAT and neglect patients is 21%, similar to that reported in the literature for the general population (20–50%). There was no significance between the prevalence of DP and a history of NAT (p > 0.1) or neglect (p > 0.1). Furthermore, there was no correlation between CVAI and characteristics of initial presentation or history of trauma for either NAT (p-values: 0.359 and 0.250, respectively) or neglect groups (p-values: 0.116 and 0.770, respectively). Conclusion While there are many limitations to this study, our results suggest that abused children are no more likely to have history of DP than the general population, and the degree of DP is not associated with severity of trauma history or initial presentation. We hope the results of this study promote future investigations for unique and subtle predictive factors of child abuse/neglect.

Background: Although uncommon, cerebellar contusions are associated with significant morbidity and mortality. Literature is lacking in the prognostic and morphological factors relating to their clinical picture and outcomes, especially within children. The objective of this study is to evaluate prognostic and anatomic factors in the clinical picture of cerebellar contusions, including effacement of the 4^th ventricle and cisterna magna. Methods: This is a retrospective chart review over 11 years across two medical centers. Patients included were under 18 years who presented with a cerebellar contusion. Patients were stratified within the study group based on discharge Glasgow outcome scale (GOS) and reviewed for prognostic factors contributing to outcome. Mid sagittal area of the 4^th ventricle and cisterna magna were measured using magnetic resonance imaging and compared within the groups. Results: A total of 21 patients met the study criteria, of which 16 (76.2%) were male, with an average patient age of 8.65 years. Poor outcome at discharge (GOS <4) was associated with decreased admission Glasgow coma scale (P = 0.003), admission motor response (P = 0.006), pupil reactivity (P = 0.014), presence of concomitant subarachnoid hemorrhage (P = 0.010), contusion volume (P < 0.001), and decreased area of the cisterna magna (P = 0.012). Patients with poor outcomes were also more likely to require surgical intervention (P = 0.042). Conclusion: There are multiple prognostic factors associated with the overall outcome following cerebellar contusions. The rate of good outcomes in this study was superior to that in previous studies in adults.

Background: Peripheral nerve surgeries require extensive practice to address anatomical variability and effectively manage neuropathy symptoms. While these procedures are increasingly performed by other surgical specialists, neurosurgeons bring unparalleled expertise in the central and peripheral nervous systems. Microscopic surgical techniques are essential for minimally invasive procedures, and cadaver-based education provides an invaluable medium for trainees to practice these techniques. However, few papers address these concepts in tandem. This study explores lesser-known peripheral nerve entrapments, highlights minimally invasive microscopic approaches, and advocates for cadaver-based training. Methods: Willed cadavers were embalmed through approved methods by the state anatomical board. For each decompression procedure, a 1–2 cm keyhole incision was made. Further methods are described in each nerve entrapment surgery below. Exploratory sessions with wider incisions were conducted either before or after the minimally invasive procedure to review anatomy or assess procedural success, respectively. Results: Neurosurgical medical education using cadavers allows trainees to practice techniques and enhance their skillset. Cadavers provide a valuable medium for exploring the relevant anatomy and visualizing the correct procedural steps after minimally invasive surgeries. Using microscopes for the procedures further facilitates detailed anatomical observation and technique refinement. Conclusions: Here, we show that cadaver-based medical education offers a realistic and controlled environment for exploring anatomical variability and refining surgical techniques. This method allows for a visual, mental, and tactile understanding, while performing minimally invasive procedures with a microscope on cadavers further enhances trainees’ proficiency, precision, and confidence, equipping them with the skills needed for improved surgical outcomes.

Recurrence of tonsillar descent after successful surgical decompression for Chiari malformation type I (CMI) is very rare. Spontaneous intracranial hypotension (SIH) can mimic CMI by causing cerebellar tonsillar descent secondary to low cerebrospinal fluid (CSF) pressure in the thecal sac from a dural defect and CSF leak. We report a case of SIH secondary to spinal CSF leak in a pediatric patient with prior successful and uncomplicated Chiari decompression. The patient’s symptoms and radiographic findings initially mimicked CMI recurrence after 12 years of asymptomatic status; however, further clinical investigation suggested CSF leak and SIH as the cause. The patient was treated with an empirical epidural blood patch, which led to the resolution of symptoms, stabilization of tonsillar position, and syrinx regression. To the best of our knowledge, this is the first case of its kind describing cerebellar tonsillar descent due to spontaneous CSF hypotension in a patient more than a decade after successful surgical treatment for CMI.