Nearly one quarter of patients who underwent resection of a medulloblastoma developed symptoms of CMS, of which 92% were judged to be of moderate or severe intensity. Brainstem invasion by tumor was the only risk factor that correlated positively with CMS occurrence; there was a negative correlation with cerebellar hemisphere tumor location. As more radical resections are attempted for medulloblastoma, the potential for increased morbidity must be carefully weighed against prognostic factors, especially in patients with brainstem invasion.

Abusive head trauma (AHT) is the leading cause of fatal head injuries in children younger than 2 years. A multidisciplinary team bases this diagnosis on history, physical examination, imaging and laboratory findings. Because the etiology of the injury is multifactorial (shaking, shaking and impact, impact, etc.) the current best and inclusive term is AHT. There is no controversy concerning the medical validity of the existence of AHT, with multiple components including subdural hematoma, intracranial and spinal changes, complex retinal hemorrhages, and rib and other fractures that are inconsistent with the provided mechanism of trauma. The workup must exclude medical diseases that can mimic AHT. However, the courtroom has become a forum for speculative theories that cannot be reconciled with generally accepted medical literature. There is no reliable medical evidence that the following processes are causative in the constellation of injuries of AHT: cerebral sinovenous thrombosis, hypoxic-ischemic injury, lumbar puncture or dysphagic choking/vomiting. There is no substantiation, at a time remote from birth, that an asymptomatic birth-related subdural hemorrhage can result in rebleeding and sudden collapse. Further, a diagnosis of AHT is a medical conclusion, not a legal determination of the intent of the perpetrator or a diagnosis of murder. We hope that this consensus document reduces confusion by recommending to judges and jurors the tools necessary to distinguish genuine evidence-based opinions of the relevant medical community from legal arguments or etiological speculations that are unwarranted by the clinical findings, medical evidence and evidence-based literature.

ABSTRACT. Objective. Abusive head injuries among infants (shaken infant or shaken impact syndrome) represent a devastating form of child abuse; an effective prevention program that reduces the incidence of abusive head injuries could save both lives and the costs of caring for victims. We wished to determine whether a comprehensive, regional, hospital-based, parent education program, administered at the time of the child's birth, could be successfully implemented and to examine its impact on the incidence of abusive head injuries among infants <36 months of age.Methods. All hospitals that provide maternity care in an 8-county region of western New York State participated in a comprehensive regional program of parent education about violent infant shaking. The program was administered to parents of all newborn infants before the infant's discharge from the hospital. The hospitals were asked to provide both parents (mothers and, whenever possible, fathers or father figures) with information describing the dangers of violent infant shaking and providing alternative responses to persistent infant crying and to have both parents sign voluntarily a commitment statement (CS) affirming their receipt and understanding of the materials. Program compliance was assessed by documenting the number of CSs signed by parents and returned by participating hospitals. Follow-up telephone interviews were conducted with a randomized 10% subset of parents, 7 months after the child's birth, to assess parents' recall of the information. Finally, the regional incidence of abusive head injuries among infants and children <36 months of age during the program (study group) was contrasted with the incidence during the 6 preceding years (historical control group) and with statewide incidence rates for the Commonwealth of Pennsylvania during the control and study periods, using Poisson regression analyses with a type I error rate of 0.05.Results. During the first 5. C affey 1,2 first used the term whiplash-shaken infant syndrome to describe the association of intracranial injuries, retinal hemorrhage, and certain long bone fractures attributable to child abuse among infants (the majority Ͻ1 year of age). Other terms for this condition include shaken baby syndrome or shaken infant syndrome, shaken impact syndrome, 3 infant shaken impact syndrome, 4 infant whiplash-shake injury syndrome, 5 abusive head trauma, 6 and inflicted, nonaccidental, or intentional head injury. Shaken infant syndrome is the most widely used and recognized term, although shaking alone may not account for all injuries. 3 Whatever the terminology and pathogenesis, abusive head injuries among infants represent one of the most severe forms of child abuse, with 13 to 30% mortality rates 4,5,7,8 and significant neurologic impairments in at least one half of the survivors. 9 The economic costs of abusive head injuries are significant; initial inpatient hospitalization costs average $18 000 to $70 000 per child, and average ongoing medical costs can exceed $300 000 per child. [10...

Intracranial hemorrhage (ICH) from an intracranial aneurysm or arteriovenous malformation is a grave complication of pregnancy and is responsible for 5 to 12% of all maternal deaths. We critically analyzed 154 cases of verified ICH during pregnancy from an identified intracranial lesion, including 2 patients treated at our institution and 152 cases previously reported in the literature in English. Aneurysms were responsible for ICH in 77% of patients, and arteriovenous malformations in 23%. Hemorrhage occurred antepartum in 92% of patients and postpartum in 8%. Women with angiomatous hemorrhage were younger than those with aneurysmal hemorrhage; however, in contrast to previous reports, we found no differences between angiomatous and aneurysmal hemorrhage with respect to parity or gestational age at the time of the initial hemorrhage. Hypertension and/or albuminuria were present at some time during the pregnancy in 34% of patients with documentation, which sometimes made it difficult to differentiate angiomatous or aneurysmal ICH from that associated with eclampsia. In a logistic regression analysis, surgical management of aneurysms, but not arteriovenous malformations, was associated with significantly lower maternal and fetal mortality, independent of other covariants. For those patients with a lesion not operated on, cesarean delivery afforded no better maternal or fetal outcome than did vaginal delivery. We conclude that the decision to operate after ICH during pregnancy should be based upon neurosurgical principles, whereas the method of delivery should be based upon obstetrical considerations. The perioperative and anesthetic management of the pregnant patient with a neurosurgical complication is discussed.

Much confusion still exists concerning the pathological definitions and clinical significance of double spinal cord malformations. Traditional terms used to describe the two main forms of these rare malformations, diastematomyelia and diplomyelia, add to the confusion by their inconsistent usage, ambiguities, and implications of their dissimilar embryogenesis. Based on the detailed radiographic and surgical findings of 39 cases of double cord malformations and the autopsy data on two other cases, this study endorses a new classification for double cord malformations and proposes a unified theory of embryogenesis for all their variant forms and features. The new classification recommends the term split cord malformation (SCM) for all double spinal cords. A Type I SCM consists of two hemicords, each contained within its own dural tube and separated by a dura-sheathed rigid osseocartilaginous median septum. A Type II SCM consists of two hemicords housed in a single dural tube separated by a nonrigid, fibrous median septum. These two essential features necessary for typing, the state of the dural tube and the nature of the median septum, do not ever overlap between the two main forms and can always be demonstrated by imaging studies so that accurate preoperative typing is always possible. All other associated structures in SCM such as paramedian nerve roots, myelomeningoceles manqué, and centromedian vascular structures frequently do overlap between types and are not reliable typing criteria. The unified theory of embryogenesis proposes that all variant types of SCMs have a common embryogenetic mechanism. Basic to this mechanism is the formation of adhesions between ecto- and endoderm, leading to an accessory neurenteric canal around which condenses an endomesenchymal tract that bisects the developing notochord and causes formation of two hemineural plates. The altered state of the emerging split neural tube and the subsequent ontogenetic fates of the constituent components of the endomesenchymal tract ultimately determine the configuration and orientation of the hemicords, the nature of the median septum, the coexistence of various vascular, lipomatous, neural, and fibrous oddities within the median cleft, the high association with open myelodysplastic and cutaneous lesions, and the seemingly unlikely relationship with fore and midgut anomalies. The multiple facets of this theory are presented in increasing complexity against the background of known embryological facts and theories; the validity of each facet is tested by comparing structures and phenomena predicted by the facet with actual radiographic, surgical, and histopathological findings of these 41 cases of SCM.