OBJECTIVE 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. METHODS 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. RESULTS 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%). CONCLUSIONS 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.

Objective: We reviewed our experience with open fetal surgical myelomeningocele repair to assess the efficacy of a new modification of the hysterotomy closure technique regarding hysterotomy complication rates at the time of cesarean delivery. Methods: A modification of the standard hysterotomy closure was performed on all patients undergoing prenatal myelomeningocele repair. The closure consisted of an interrupted full-thickness #0 polydioxanone (PDS) retention suture as well as a running #0 PDS suture to re-approximate the myometrial edges, and the modification was a third imbricating layer resulting in serosal-to-serosal apposition. A standard omental patch was placed per our routine. Both operative reports and verbal descriptions of hysterotomy from delivering obstetricians were reviewed. Results: A total of 49 patients underwent prenatal repair of myelomeningocele, 43 having adequate follow-up for evaluation. Of those, 95.4% had completely intact hysterotomy closures, with only 1 partial dehiscence (2.3%) and 1 thinned scar (2.3%). There were no instances of uterine rupture. Discussion: In patients undergoing this modified hysterotomy closure technique, a much lower than expected complication rate was observed. This simple modified closure technique may improve hysterotomy healing and reduce obstetric morbidity.

Programmable Intrathecal (IT) drug delivery systems are being increasingly used with radiation therapy for cancer treatment and palliation. Ionizing radiation is assumed to cause dysfunction of the programmable IT device. However, the dose limit and safety of the IT drug delivery device used concurrently with radiotherapy have not been extensively documented. Here we report a patient who underwent the implantation of an IT pump during radiotherapy. This device was subsequently directly exposed to radiation. Estimated cumulative doses to the pump were in the range of 1.28 to 9.98 Gy. The IT pump exposed to this high-dose radiation did not pose any risk to the patient or the environment. The device was queried during and after the completion of treatment and found to be functioning without fault. This is the first case description about the successful function of an IT drug delivery device directly exposed to ionizing radiation.

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Multidisciplinary care in the era of COVID mitigation presented a unique opportunity to evolve a multidisciplinary Telehealth experience at the Children’s Hospital Colorado. We describe our experience in developing unique programming to remain in compliance with an experience as recommended by the Parameters of Care while integrating information technology accessible via the electronic health record, multimedia adjuncts, and the integration of multiple institutional participants in creating a platform to offer care via Telehealth. Visit structure, planning, implementation, and advantages and disadvantages of the programming are discussed.

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OBJECTIVEPlacement of a cerebrospinal fluid diversion device (i.e., shunt) is a routine pediatric neurosurgical procedure, often performed in the first weeks of life for treatment of congenital hydrocephalus. In the postoperative period, shunt placement may be complicated by subdural, catheter tract, parenchymal, and intraventricular hemorrhages. The authors observed a subset of infants and neonates who developed multifocal intraparenchymal hemorrhages (MIPH) following shunt placement and sought to determine any predisposing perioperative variables.METHODSA retrospective review of the electronic medical record at a tertiary-care children’s hospital was performed for the period 1998–2015. Inclusion criteria consisted of shunt placement, age < 30 days, and available pre- and postoperative brain imaging. The following data were collected and analyzed for each case: ventricular size ratios, laboratory values, clinical presentation, shunt and valve type, and operative timing and approach.RESULTSA total of 121 neonates met the inclusion criteria for the study, and 11 patients (9.1%) had MIPH following shunt placement. The preoperative frontal and occipital horn ratio (FOR) was significantly higher in the patients with MIPH than in those without (0.65 vs 0.57, p < 0.001). The change in FOR (∆FOR) after shunt placement was significantly greater in the MIPH group (0.14 vs 0.08, p = 0.04). Among neonates who developed MIPH, aqueductal stenosis was the most common etiology (45%). The type of shunt valve was associated with incidence of MIPH (p < 0.001). Preoperative clinical parameters, including head circumference, bulging fontanelle, and coagulopathy, were not significantly associated with development of MIPH.CONCLUSIONSMIPH represents an underrecognized complication of neonatal shunted hydrocephalus. Markers of severity of ventriculomegaly (FOR) and ventricular response to CSF diversion (∆FOR) were significantly associated with occurrence of MIPH. Choice of shunt and etiology of hydrocephalus were also significantly associated with MIPH. After adjusting for corrected age, etiology of hydrocephalus, and shunt setting, the authors found that ∆FOR after shunting was still associated with MIPH. A prospective study of MIPH prevention strategies and assessment of possible implications for patient outcomes is needed.

A 9-year-old male presented to the Children’s Colorado Emergency Department (ED) after losing consciousness and falling face-first onto a sidewalk while being escorted from a 4th of July parade. He had a mild headache and nausea that worsened as the parade progressed. En route to the hospital, his temperature was 105℉ and he had a tonic-clonic seizure. He had had a head injury one week prior. He had been jumping on a trampoline with siblings when his sister landed on his head. There was no loss of consciousness and he denied headache or nausea afterward. Computed tomography (CT) of his head (not shown) had been reportedly negative. By the time he arrived at the ED this time, he was awake but still had a headache and nausea. On examination, he had nuchal rigidity with gait ataxia and positive Romberg testing. Head CT (Fig. 1A) showed a focal linear hyperdensity in the region of the left Sylvian fissure. There was concern for subarachnoid hemorrhage (SAH) given his two recent head injuries. Later, the same hyperdensity was retrospectively noted on his previous CT. Subsequent magnetic resonance imaging with angiography (MRI/MRA) (Fig. 1B) revealed the hyperdensity to be a large left temporal lobe developmental venous anomaly (DVA). There was no aneurysm. By the next morning, the patient’s symptoms and findings had all resolved. It was thought that he had suffered acute hyperthermia. Developmental venous anomalies of the brain are congenital abnormalities that arise from incomplete development of the venous system. They can be found in up to 2.6 % of autopsy studies and are thought to be harmless. They can be associated with sporadic cerebral cavernous malformations. Rare cases of hemorrhage have been reported, but usually in association with cavernous malformations. As DVAs provide venous drainage to the brain, it is important not to damage them during resection of cavernous malformations. The Sylvian fissure is a common place for both posttraumatic and aneurysmal SAH. Sometimes, after trauma, it is unclear whether SAH resulted from the trauma or from aneurysmal rupture. As shown in this report, however, hyperdensity in the region of the Sylvian fissure on CT may not represent SAH. In certain circumstances, if further imaging is being contemplated to search for the source of SAH, providers may consider MRI/MRA with contrast versus CT or catheter angiography, as other lesions will be better seen on MR imaging.