Retinal haemorrhage in infants investigated for suspected maltreatment is strongly correlated with intracranial pathology

AIM

To test the two prevailing hypotheses regarding the aetiology of infant retinal haemorrhage: (a) traction forces exerted by the lens and/or corpus vitreum on the retina during infant shaking or (b) retinal vessel leakage secondary to intracranial pathology and raised intracranial pressure.

METHODS

Comparison of medical findings and reported type of trauma in infants investigated for suspected physical abuse with presence (n = 29) or non-presence of retinal haemorrhage (RH) (n = 119).

RESULTS

Intracranial pathology was recorded in 15 (13%) of the non-RH cases and in 27 (97%) of the RH cases (p < 0.0001). All 18 infants with bilateral RH had intracranial pathology. Of 27 infants subjected to witnessed or admitted shaking, two were in the group with RH. One had a single unilateral RH and no intracranial pathology. The other had bilateral RH and intracranial pathology with non-specific white matter changes, acute subdural and subarachnoid haemorrhages, and suspected cortical venous thrombosis. In 15 RH cases, there was no trauma reported and no findings other than RH and intracranial pathology. Accidental blunt head trauma was reported in 7 RH cases.

CONCLUSION

The present study indicates that RH in infants is secondary to intracranial pathology of non-specific aetiology.

Re-evaluation of medical findings in alleged shaken baby syndrome and abusive head trauma in Norwegian courts fails to support abuse diagnoses

AIM

The criteria for diagnosing abusive head trauma (AHT) are not well defined and this condition might be diagnosed on failing premises. Our aim was to review criminal AHT cases in Norwegian courts by scrutinising the underlying medical documentation.

METHODS

Cases were identified in the data registry for Norwegian courts from 2004 to 2015. Documentation was obtained from relevant health institutions. The medical co-authors first made independent evaluations of the documentation for each child, followed by a consensus evaluation.

RESULTS

A total of 17 children (11 boys) were identified, all diagnosed as AHT by court appointed experts, 15 were infants (mean age 2.6 months). A high proportion (41.2%) was born to immigrant parents and 31.3% were premature. The medical findings could be explained by alternative diagnoses in 16 of the 17 children; 8 boys (7 infants - mean age 2.9 months) had clinical and radiological characteristics compatible with external hydrocephalus complicated by chronic subdural haematoma. Six children (five infants with mean age 2.1 months) had a female preponderance and findings compatible with hypoxic ischaemic insults.

CONCLUSION

The medical condition in most children had not necessarily been caused by shaking or direct impact, as was originally concluded by the court experts.

Is external hydrocephalus a possible differential diagnosis when child abuse is suspected?

Background

Criteria for diagnosing abusive head trauma (AHT) or “shaken baby syndrome” are not well defined; consequently, these conditions might be diagnosed on failing premises.

Methods

The authors have collected a total of 28 infants, from the US (20) and Norway (8), suspected of having been violently shaken, and their caregivers had been suspected, investigated, prosecuted or convicted of having performed this action. Among 26 symptomatic infants, there were 18 boys (69%) and 8 girls (31%)—mean age 5.1 month, without age difference between genders.

Results

Twenty-one of 26 symptomatic children (81%) had a head circumference at or above the 90 percentile, and 18 had a head circumference at or above the 97 percentile. After macrocephaly, seizure was the most frequent initial symptom in 13 (50%) of the symptomatic infants. Seventeen (65%) of the symptomatic infants had bilateral retinal haemorrhages, and two had unilateral retinal haemorrhages. All infants had neuroimaging compatible with chronic subdural haematomas/hygromas as well as radiological characteristics compatible with benign external hydrocephalus (BEH).

Conclusions

BEH with subdural haematomas/hygromas in infants may sometimes be misdiagnosed as abusive head trauma. Based on the authors’ experience and findings of the study, the following measures are suggested to avoid this diagnostic pitfall: medical experts in infant abuse cases should be trained in recognising clinical and radiological BEH features, clinicians with neuro-paediatric experience should always be included in the expert teams and reliable information about the head circumference development from birth should always be available.

External Hydrocephalus as a Cause of Infant Subdural Hematoma: Epidemiological and Radiological Investigations of Infants Suspected of Being Abused

BACKGROUND

Acute subdural hematoma (ASDH) and chronic subdural hematoma (CSDH) in infants have been regarded as highly specific for abuse. Other causes of CSDH have not been investigated in a large population.

PURPOSE

The purpose of this study was to investigate to what extent external hydrocephalus is present in infants with ASDH and CSDH undergoing evaluation for abuse.

MATERIAL AND METHODS

Eighty-five infants suspected of being abused, with ASDH (n = 16) or CSDH (n = 69), were reviewed regarding age, risk factor profiles, craniocortical width (CCW), sinocortical width (SCW), frontal interhemispheric width (IHW), subarachnoid space width (SSW), and head circumference (HC). In infants with unilateral subdural hematoma (SDH), correlations between contralateral SSW and ipsilateral CCW and SDH width were investigated.

RESULTS

Infants with CSDH had significantly lower mortality, were more often premature and male, and had significantly higher CCW, SCW, IHW, and SSW than infants with ASDH (P < 0.05). Ipsilateral CCW (R = 0.92, P < 0.001) and SDH width (R = 0.81, P < 0.01) correlated with contralateral SSW. Increased HC was more prevalent in infants with CSDH (71%) than in infants with ASDH (14%) (P < 0.01). Forty-two infants, all with CSDH, had at least one of CCW, SCW, or IHW ≥95^th percentile. Twenty infants, all with CSDH, had CCW, SCW, and IHW >5 mm, in addition to increased HC.

CONCLUSION

A substantial proportion of infants with CSDH who had been suspected of being abused had findings suggesting external hydrocephalus.

Thrombosis is not a marker of bridging vein rupture in infants with alleged abusive head trauma

Aim

Thrombosis of bridging veins has been suggested to be a marker of bridging vein rupture, and thus AHT, in infants with subdural haematoma.

Methods

This is a non‐systematic review based on Pubmed search, secondary reference tracking and authors’ own article collections.

Results

Radiological studies asserting that imaging signs of cortical vein thrombosis were indicative of traumatic bridging vein rupture were unreliable as they lacked pathological verification of either thrombosis or rupture, and paid little regard to medical conditions other than trauma. Autopsy attempts at confirmation of ruptured bridging veins as the origin of SDH were fraught with difficulty. Moreover, microscopic anatomy demonstrated alternative non‐traumatic sources of a clot in or around bridging veins. Objective pathological observations did not support the hypothesis that a radiological finding of bridging vein thrombosis was the result of traumatic rupture by AHT. No biomechanical models have produced reliable and reproducible data to demonstrate that shaking alone can be a cause of bridging vein rupture.

Conclusion

There is no conclusive evidence supporting the hypothesis that diagnostic imaging showing thrombosed bridging veins in infants correlates with bridging vein rupture. Hence, there is no literature support for the use of thrombosis as a marker for AHT.

Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures

AIM

Specific birth-related fractures have been studied; underestimates might be a problem. We aimed to assess all fractures diagnosed as birth-related as well as other neonatal fractures.

METHODS

A population-based study on all infants born in Sweden 1997-2014; data were retrieved from the Swedish Health Registers (10th version of International Classification of Diseases. Outcome measures were birth-related fractures (ICD-10 P-codes) and other neonatal fractures (ICD-10 S-codes).

RESULTS

The overall fracture incidence was 2.9 per 1000 live birth (N = 5336); 92.6% had P-codes and 7.4% (S-codes). Some birth-related fractures were diagnosed beyond the neonatal period. Other neonatal fractures could have been birth-related. Clavicle fracture (88.8%) was associated with adverse maternal and infant anthropometrics and birth complications. The few neonates with rib fractures all had concomitant clavicle fracture. For skull fractures, a minor part was birth-related and most were associated with accidents. Half of the long bone fractures were associated with accidents. Birth-related femur fractures were associated with bone fragility risk factors. Five infants with abuse diagnoses had fractures: skull (4), long bone (2) and rib (1).

CONCLUSION

Birth-related and other neonatal fractures are rarely diagnosed. Difficult birth is the main contributor to birth-related fracture and accidents to other neonatal fractures.

Examining perinatal subdural haematoma as an aetiology of extra-axial hygroma and chronic subdural haematoma

AIM

Benign external hydrocephalus (BEH), hygroma and chronic subdural haematoma are extra-axial fluid collections in infants. MRI studies have shown that almost half of all new-borns have perinatal subdural blood, generally referred to as subdural haematoma (SDH) or perinatal SDH. Epidemiologically there are striking similarities between chronic SDH and BEH in infants.

METHODS

Discussion of pathophysiological mechanisms for BEH and chronic SDH, based on existing literature.

RESULTS

Perinatal SDH is common, and we hypothesise that this condition in some infants develop into extra-axial fluid collections, known as hygroma, BEH or chronic subdural haematoma. The mechanism seems to be an intradural bleeding that creates an obstructive layer preventing normal CSF absorption. The site where the bleeding originates from and those areas enveloped in blood from the primary damaged area are prone to later rebleeds, seen as 'acute on chronic' haematomas. With steady production of CSF and the blockage, increased intracranial pressure drives the accelerated skull growth seen in many of these children.

CONCLUSION

Perinatal SDH hampers CSF absorption, possibly leading to BEH and chronic SDH, with a high risk of false accusations of abuse. Close monitoring of head circumference could prove vital in detecting children with this condition.

Anxiety and Depression in Patients with Intracranial Arachnoid Cysts-A Prospective Study

BACKGROUND

Arachnoid cysts yield cognitive deficits that are normalized after surgical cyst decompression.

OBJECTIVE

The present study aimed to investigate whether arachnoid cysts also affect symptoms of anxiety and depression, and if surgical cyst decompression leads to reduction of these symptoms.

METHODS

Twenty-two adult patients (13 men and 9 women) with symptomatic temporal or frontal cysts were included in this questionnaire (Hospital Anxiety and Depression Scale [HADS])-based prospective study. The mean time between answering the preoperative questionnaire and surgery was 37 days. The patients answered the same HADS questionnaire 3-6 months postoperatively.

RESULTS

Preoperatively, both patients with frontal (N = 4) and patients with temporal (N = 18) cyst had higher mean HADS anxiety scores than those found in the general population. For patients with temporal cyst, there was a significant or near-significant difference in anxiety and depression scores and the combined scores between those with right-sided cysts and those with left-sided cysts. Postoperatively, the HADS scores normalized and were no longer different from those of the general population. The difference in scores between patients with right and left temporal cyst also disappeared.

CONCLUSIONS

Patients with arachnoid cyst have higher levels of anxiety and depression than do the general population and these scores were normalized after decompressive cyst surgery. We further found a hemispheric asymmetry: patients with a right temporal cyst showed higher anxiety, depression, and combined scores than did patients with a left temporal cyst. Also, this disparity normalized after cyst decompression. Thus, arachnoid cysts seem to affect not only cognition but also the level of affective symptoms.

Medical diagnoses among infants at entry in out-of-home care: A Swedish population-register study

BACKGROUND AND AIMS

Identification of child abuse involves a medical investigation and assessment of problems related to social environment and upbringing and might necessitate out-of-home care. The objective of this study was to analyse infants placed in out-of-home care in Sweden by incidence, medical diagnoses, and perinatal factors.

METHODS

This was a population-based register study of infants born in Sweden 1997 to 2014. Data were retrieved from registers at the Swedish National Board of Health and Welfare and Statistics Sweden. Outcome measures were out-of-home care categories: (a) "Problems Related to Social Environment/Upbringing", (b) "Abuse diagnoses without SDH (subdural haemorrhage), RH (retinal haemorrhage), rib fracture, or long bone fracture", and (c) "SDH, RH, rib fracture, or long bone fracture." As a reference population, we randomly selected infants without medical diagnoses born the same year.

RESULTS

Overall incidence of out-of-home care was 402 per 100 000. For subcategories (a), (b), and (c), the incidences were 14.8 (n = 273), 3.77 (n = 70), and 9.83 (n = 182) per 100 000, respectively. During the study period, the first remained unchanged; the latter two have been increasing. Compared with other reasons for out-of-home care, children in category (c), "SDH, RH, rib fracture, or long bone fracture", had increased odds of being boys (adjusted odds ratio [aOR] 1.60; 95% confidence interval [CI], 1.08-2.38) and decreased odds of having a mother being single (aOR 0.49; 95% CI, 0.32-0.75) and a smoker (aOR 0.60; 95% CI, 0.37-0.96). Compared with the reference population, children in this category were more often twin born (7.7% versus 2.8%), preterm (18.5% versus 5.5%), and small-for-gestational age (5.2% versus 2.1%).

CONCLUSION

SDH, RH, rib fracture, or long bone fracture constitute a minor part of medical diagnoses for infants entered in out-of-home care, but have been increasing, both in numbers and proportion. Overdiagnosis of abuse might be a possible reason but cannot be ascertained by this study design.

Clinical, Radiological, and Demographic Details of Benign External Hydrocephalus: A Population-Based Study

BACKGROUND

Benign external hydrocephalus has an incidence of about 0.4 per 1000 live births. It affects infants and is characterized by an increasing head circumference and typical neuroimaging findings. Previously published studies on benign external hydrocephalus often contain groups of few and selected patients.

METHODS

This is a follow-up of a recently published article reporting the incidence of benign external hydrocephalus. This retrospective and population-based study covers two large health regions in Norway, over a 10-year period (1994 to 2003). Infants with increasing head circumference, combined with typical radiological findings of enlarged subarachnoid spaces, were included. Information about head circumference development, neuroimaging findings, and birth delivery methods, as well as demographic details, was retrieved from the hospital medical records.

RESULTS

A total of 176 children with benign external hydrocephalus were included, 86.4% being boys. At birth, the head circumference was close to normal. Mean age for when the head circumference reached abnormal values, i.e., crossing two percentiles or reaching the 97.5 percentile, was 3.4 months; none was older than seven months. Around four of five children had dilated lateral ventricles in addition to enlarged subarachnoid spaces. The neuroimaging findings tended to normalize after age 12 months. About half of the patients ended up with head circumferences at or above the 97.5 percentile.

CONCLUSIONS

Most infants with benign external hydrocephalus are born with a normal head circumference that increases too fast and reaches abnormally high values before age six months. This age and gender distribution is very similar to that described for infant subdural hemorrhage.

Quality of life and physician-reported developmental, cognitive, and social problems in children with benign external hydrocephalus-long-term follow-up

INTRODUCTION

Benign external hydrocephalus (BEH) is characterized by too rapidly increasing head circumference in infants, combined with typical neuroimaging findings. Psychomotor developmental delay is typically seen during the first few years of life; after that, the children's development assumedly normalizes. However, little is known about the long-term effects of BEH.

METHODS

In this retrospective population-based study, children diagnosed with BEH during the years 1994-2003 in Southern Norway were asked to participate. Included patients (age 8-18 years old) and their parents answered the PedsQL questionnaire. The patient's family physicians contributed by giving information from medical records, with special emphasis on developmental, cognitive, and social function.

RESULTS

One hundred seventy-six children were identified with BEH. One hundred three patients and 86 parents completed the PedsQL questionnaire. Supplemental medical information for 142 of the patients was received, mainly from their family physicians. Children and adolescents with BEH score themselves better than the normative mean on health-related quality of life, while the parents score their BEH children within the normative mean, except for the school functioning subgroup, where they score significantly lower. Various developmental, physical, and social problems are reported, like mental retardation, speech problems, epilepsy, motor impairment, psychiatric disorders, and cognitive difficulties. Among these patients, there is a discrepancy in some areas between the child-reported and parent-reported quality of life.

CONCLUSIONS

Children and adolescents who were diagnosed with BEH during infancy generally do well. However, for some patients, there appear to be various developmental, social, and cognitive problems, and they seem to struggle more in school than their healthy peers.

Cortical Plasticity After Surgical Tendon Transfer in Tetraplegics

Background: Developmental cortical plasticity with reorganization of cerebral cortex, has been known to occur in young and adult animals after permanent, restricted elimination of afferent (visual or somatosensory) input. In animals, cortical representation of unaffected muscles or sensory areas has been shown to invade the neighboring cortex when this is deprived of its normal sensory input or motor functions. Some studies indicate that similar cortical plasticity may take place in adult humans. Methods: In patients with a high cervical spinal cord injury leaving the patient without any movements of the fingers, we performed fMRI studies of the cortical representation of an elbow flexor muscle before and after a surgical procedure that changed its function to a thumb flexor, thus providing the patient with a useful grip. Results: Preoperatively, the elbow flexion movement was elicited from a cortical area corresponding with the "elbow area" in healthy individuals. Despite the fact that an elbow flexor was used for the post-operative key-grip, this movement in the tetraplegic patients was elicited from a similar brain region as in healthy controls (the "hand area"). This supports our hypothesis that control of that muscle shifts from a brain region typically associated with elbow movement, to one typically associated with wrist movements. Conclusion: The findings presented here show with fMRI that the human cortex is capable of reorganizing itself spatially after a relatively acute change in the periphery.

Epidemiology of Benign External Hydrocephalus in Norway-A Population-Based Study

BACKGROUND

Benign external hydrocephalus is defined as a rapidly increasing head circumference (occipitofrontal circumference) with characteristic radiological findings of increased subarachnoid cerebrospinal fluid spaces on neuroimaging. The incidence of benign external hydrocephalus has not been previously reported, and there is no available information on the ratio of benign external hydrocephalus in the population of hydrocephalic children.

METHODS

This study is retrospective and population-based study, geographically covering two health regions in the southern half of Norway with a total mean population of 3.34 million in the ten-year study period, constituting approximately 75% of the Norwegian population. Children with a head circumference crossing two percentiles, or greater than the 97.5th percentile, and with typical imaging findings of enlarged frontal subarachnoid spaces with or without enlarged ventricles were included. Children were excluded if they had a history of head trauma, intracranial hemorrhage, central nervous system infection, other known causes of hydrocephalus, or were born preterm defined as birth before 37 weeks of gestation.

RESULTS

A total of 176 children fitting the criteria were identified, giving an incidence of 0.4 per 1000 live births. One hundred fifty-two (86.4%) of the patients were male, and mean age at referral was 7.3 months. Increasing head circumference was the main reason for referral in 158 (89.8%) patients and the only finding in 60 (34.1%) patients. Thirty-seven (21%) children had normal ventricles on imaging; the remainder had increased ventricular size. The incidence of pediatric hydrocephalus in Norway is reported to be 0.75 per 1000 live births, thus benign external hydrocephalus accounts for approximately 50% of hydrocephalic conditions in this population.

CONCLUSIONS

The incidence of benign external hydrocephalus was found to be 0.4 per 1000 live births in this population.

Neurocognitive and psychosocial function in children with benign external hydrocephalus (BEH)-a long-term follow-up study

INTRODUCTION

Long-term impact of benign external hydrocephalus (BEH) on cognition is largely unknown, and indication for neurosurgical CSF diversion procedure is debated. This study reports neuropsychological and psychosocial function in operated and non-operated BEH children.

METHODS

Eighty-six children (76 males) between 8 and 18 years (mean 13.9) diagnosed with BEH before 12 months were included, of whom 30.2 % were operated. Participants completed neuropsychological tests and questionnaires covering quality of life (PedsQL) and executive function (BRIEF).

RESULTS

Both operated and non-operated BEH children performed significantly below normative means on several neuropsychological tests. The children scored themselves higher than the norm average on PedsQL; however, the parents reported life quality comparable to other children. Operated children performed poorer compared with non-operated children on tests of psychomotor speed, attention span, executive function, motor speed and coordination, and on the BRIEF subscale Monitoring. Operated children, but not their parents, reported more problems on PedsQL subscale School than non-operated children.

DISCUSSION

Children with BEH display long-term subtle neurocognitive difficulties. Non-operated children performed significantly better on some neuropsychological measures and reported less psychosocial problems. This difference may be caused by a selection bias: neurosurgical intervention was more likely in children with clinically more pronounced symptoms.

An Ethiopian Training Program in Neurosurgery with Norwegian Support

After a 4-year planning period, a joint Ethiopian/Norwegian training program in neurosurgery was started in June 2006. The collaborating partners were Addis Ababa University; Department of Surgery, Tikur Anbessa Specialized Hospital; University of Bergen; Haukeland University Hospital; and Myungsung Christian Medical Center, a Korean missionary hospital in Addis Ababa, Ethiopia. A memorandum of understanding was signed at dean/chief executive officer levels. Although other initiatives have been involved in supporting neurosurgery in Addis Ababa during the same period, this institutionally founded program has been the main external contributor to neurosurgical capacity building through the education of 21 Ethiopian neurosurgeons, and in supporting a sustainable environment for neurosurgical training within a network of 5 centers in Addis Ababa. This article gives an account of the strategies underlying the program planning, the history of the program, and on the experience gained by it. Finally, ethical problems and challenges encountered in the program are discussed.

Neurological Fallacies Leading to Malpractice: A Case Studies Approach

A young woman presents with an intracranial arachnoid cyst. Another is diagnosed with migraine headache. An elderly man awakens with a stroke. And a baby delivered vaginally after 2 hours of questionable electronic fetal monitoring patterns grows up to have cerebral palsy. These seemingly disparate cases share a common underlying theme: medical myths. Myths that may lead not only to misdiagnosis and treatment harms but to seemingly never-ending medical malpractice lawsuits, potentially culminating in a settlement or judgment against an unsuspecting neurologist. This article provides a case studies approach exposing the fallacies and highlighting proper management of these common neurologic presentations.

Spinal cord compression secondary to vertebral echinococcosis

We describe a patient with progressive lower limb weakness and paresthesia 3 days after falling from a considerable height. Magnetic resonance imaging and computed tomography revealed collapsed Th2 and Th3 vertebrae. A tuberculous (TB) spondylitis was suspected, and anti-TB medication was started however with no clinical improvement. She was referred to our center and operated. A 3 level discectomy and 2 level corpectomy were performed with iliac bone grafting and anterior plating via an anterior cervical approach. The patient developed an esophagocutaneous fistula that was repaired and cured. The biopsy specimen showed a hydatid cyst of the vertebra as the cause of the lesion. After the result, she was started on oral albendazole. At follow-up nearly 4 months after surgery, the patient had regained significant power in her lower limbs with a muscular strength of 5/5 in both legs, thus making it possible to walk without support.

Outcome in patients undergoing surgery for spinal injury in an Ethiopian hospital

OBJECT

The objective of this study was to investigate epidemiology and outcome after surgical treatment for spinal injuries in Ethiopia.

METHODS

Medical records of patients who underwent surgery for spine injuries at Myungsung Christian Medical Center in Addis Ababa, Ethiopia, between January 2008 and September 2012 were reviewed retrospectively. Assessment of outcome and complications was determined from patient consultations and phone interviews.

RESULTS

A total of 146 patients were included (129 males, 17 females). Their mean age was 31.7 years (range 15–81 years). The leading cause of injury was motor vehicle accidents (54.1%), and this was followed by falls (26.7%). The most common injury sites were lumbar (41.1%) and cervical (34.2%) regions of the spine. In 21.2% of patients, no neurological deficit was present before surgery, 46.6% had incomplete spinal cord injury (American Spinal Injury Association [ASIA] Impairment Scale [AIS] Grade B-D), and 32.2% had complete spinal cord injury (AIS Grade A). Follow-up was hampered by suboptimal infrastructure, but information regarding outcome was successfully obtained for 110 patients (75.3%). At follow-up (mean 22.9 months; range 2–57 months), 25 patients (17.1%) were confirmed dead and 85 patients (58.2%) were alive; 49 patients (33.6%) underwent physical examination. At least 8 of the 47 patients (17.0%) with a complete injury and 29 of the 68 patients (42.6%) with an incomplete injury showed neurological improvement. The reported incidences of pressure wounds, recurrent urinary tract infections, pneumonia, and thromboembolic events were 22.5%, 13.5%, 5.6%, and 1.1%, respectively.

CONCLUSIONS

Patients showed surprisingly good recovery considering the limited resources. Surgical treatment for spine injuries in Ethiopia is considered beneficial.

Reference Ranges for Head Circumference in Ethiopian Children 0-2 Years of Age

BACKGROUND

Head circumference (HC) charts are important for early detection of hydrocephalus during childhood. In low-income countries where population-based HC charts are rarely available, hydrocephalus occurs more commonly than in developed countries, and is usually not diagnosed early enough to prevent severe brain damage. This applies to Ethiopia as well. The World Health Organization (WHO) has provided standard HC charts advocated for global use, but recent studies cast doubts whether these charts are equally applicable in various populations. The aim of the study was therefore to establish reference ranges for early childhood HC in Ethiopia.

METHODS

In this prospective, observational cross-sectional study, measurements of HC were collected from healthy children of different ethnicities between birth and 24 months, in health centers situated in 5 Ethiopian cities. Reference ranges for HC were estimated using the LMS method and compared with those recommended by WHO.

RESULTS

A total of 4019 children were included. Overall, 6.7% of boys and 7.1% of girls were above the +2 standard deviation (SD) of the WHO reference ranges, whereas the corresponding figures below -2 SD were 2.8% and 2.1%. Similarly, the +2 SD lines of the Ethiopian reference curves were considerably higher than those of the WHO growth standards, whereas the median and -2 SD lines were more comparable.

CONCLUSIONS

Ethiopian HC reference ranges for children from birth to 24 months of age were found to differ significantly from those established by WHO and should correspondingly be considered as the first choice for screening for hydrocephalus in that population.

Prehospital use of cervical collars in trauma patients: a critical review

The cervical collar has been routinely used for trauma patients for more than 30 years and is a hallmark of state-of-the-art prehospital trauma care. However, the existing evidence for this practice is limited: Randomized, controlled trials are largely missing, and there are uncertain effects on mortality, neurological injury, and spinal stability. Even more concerning, there is a growing body of evidence and opinion against the use of collars. It has been argued that collars cause more harm than good, and that we should simply stop using them. In this critical review, we discuss the pros and cons of collar use in trauma patients and reflect on how we can move our clinical practice forward. Conclusively, we propose a safe, effective strategy for prehospital spinal immobilization that does not include routine use of collars.

Maze learning in patients with intracranial arachnoid cysts

BACKGROUND

The temporal lobe is of importance for visuospatial orientation. Intracranial arachnoid cysts have a predilection for the temporal fossa, and might therefore affect visuospatial orientation. The aim was to find out whether temporal cysts affect maze learning and if surgical cyst decompression improves maze performance.

METHODS

Forty-five patients with a temporal arachnoid cyst and 17 control patients with cervical disc disease were tested in a labyrinth route in the hospital corridors the day before surgery and at least 3 months postoperatively.

RESULTS

Thirty-five cyst patients (78 %) experienced postoperative improvement of their preoperative complaints. The cyst patients spent significantly longer time than the controls navigating through the maze in the preoperative test, 161 s and 127 s, respectively, but there was no difference in number of errors between the two groups. However, the cyst patients improved significantly in the postoperative test, both with regards to number of errors they made and time spent, contrary to the control patients, whose postoperative performance equalled that of the preoperative test. For the cyst patients, postoperative improvement in the labyrinth test correlated with the clinical outcome-but not the neuroradiological outcome-after the operation.

CONCLUSIONS

Thus, temporal arachnoid cysts may affect visuospatial orientation and learning in a reversible manner.

Quantitative proteomics comparison of arachnoid cyst fluid and cerebrospinal fluid collected perioperatively from arachnoid cyst patients

BACKGROUND

There is little knowledge concerning the content and the mechanisms of filling of arachnoid cysts. The aim of this study was to compare the protein content of arachnoid cysts and cerebrospinal fluid by quantitative proteomics to increase the understanding of arachnoid cysts.

METHODS

Arachnoid cyst fluid and cerebrospinal fluid from five patients were analyzed by quantitative proteomics in two separate experiments.In a label-free experiment arachnoid cyst fluid and cerebrospinal fluid samples from individual patients were trypsin digested and analyzed by Orbitrap mass spectrometry in a label-free manner followed by data analysis using the Progenesis software.In the second proteomics experiment, a patient sample pooling strategy was followed by MARS-14 immunodepletion of high abundant proteins, trypsin digestion, iTRAQ labelling, and peptide separation by mix-phase chromatography followed by Orbitrap mass spectrometry analysis. The results from these analyzes were compared to previously published mRNA microarray data obtained from arachnoid membranes.

RESULTS

We quantified 348 proteins by the label-free individual patient approach and 1425 proteins in the iTRAQ experiment using a pool from five patients of arachnoid cyst fluid and cerebrospinal fluid. This is by far the largest number of arachnoid cyst fluid proteins ever identified, and the first large-scale quantitative comparison between the protein content of arachnoid cyst fluid and cerebrospinal fluid from the same patients at the same time. Consistently in both experiment, we found 22 proteins with significantly increased abundance in arachnoid cysts compared to cerebrospinal fluid and 24 proteins with significantly decreased abundance. We did not observe any molecular weight gradient over the arachnoid cyst membrane. Of the 46 proteins we identified as differentially abundant in our study, 45 were also detected from the mRNA expression level study. None of them were previously reported as differentially expressed. We did not quantify any of the proteins corresponding to gene products from the ten genes previously reported as differentially abundant between arachnoid cysts and control arachnoid membranes.

CONCLUSIONS

From our experiments, the protein content of arachnoid cyst fluid and cerebrospinal fluid appears to be similar. There were, however, proteins that were significantly differentially abundant between arachnoid cyst fluid and cerebrospinal fluid. This could reflect the possibility that these proteins are affected by the filling mechanism of arachnoid cysts or are shed from the membranes into arachnoid cyst fluid. Our results do not support the proposed filling mechanisms of oncotic pressure or valves.

Influence of cell-to-cell variability on spatial pattern formation

Many spatial patterns in biology arise through differentiation of selected cells within a tissue, which is regulated by a genetic network. This is specified by its structure, parameterisation and the noise on its components and reactions. The latter, in particular, is not well examined because it is rather difficult to trace. The authors use suitable local mathematical measures based on the Voronoi diagram of experimentally determined positions of epidermal plant hairs (trichomes) to examine the variability or noise in pattern formation. Although trichome initiation is a highly regulated process, the authors show that the experimentally observed trichome pattern is substantially disturbed by cell-to-cell variations. Using computer simulations, they find that the rates concerning the availability of the protein complex that triggers trichome formation plays a significant role in noise-induced variations of the pattern. The focus on the effects of cell noise yields further insights into pattern formation of trichomes. The authors expect that similar strategies can contribute to the understanding of other differentiation processes by elucidating the role of naturally occurring fluctuations in the concentration of cellular components or their properties.

Neurotrauma outside the high-income setting: a review of audit and data-collection strategies

OBJECTIVE

To review the sparse literature that exists on the topic of head injury assessment and management outside high-income settings and attempt to: 1) identify strengths and weaknesses of the currently published clinical data relating to head injuries in lower-income countries; and 2) consider specific objectives for future head injury research in the resource-limited setting. If levels of excellence in neurosurgery are to be sustainably achieved outside high-income countries, there must be good systems of research and audit in place both to identify where development is needed and to evaluate the efficacy of development projects already in progress.

METHODS

We performed a MEDLINE search of publications between 1980 and 2010 by using the search terms head injuries/craniocerebral trauma/neurotrauma and developing world/developing nations. Information was extracted and compared between publications by using our local head injury evaluation and audit database (OxHEAD) as a quality standard.

RESULTS

The issue of traumatic brain injury management in low-income countries is underrepresented in the international literature relative to the scale of the problem. However, epidemiologic data generally are better reported than data relating to in-hospital care and follow-up, which suffers as a result of heterogeneous data collection and categorization techniques.

CONCLUSION

The use of standardized scoring systems and outcome measures is likely to improve the comparability of data between studies. A multicenter collaborative approach towards data collection in resource-limited settings may be the most efficient and productive strategy for future research.

A novel CD44v6 targeting antibody fragment with improved tumor-to-blood ratio

The chimeric monoclonal antibody U36 (cMAb U36) recognizes the CD44v6 antigen. Its potential as a radioimmunotargeting agent, as well as its safety, has been shown in previous studies in head and neck cancer patients. However, intact MAbs have long circulation time in the blood and tumor targeting may also be hampered due to the slow and incomplete diffusion into solid tumors. In comparison, smaller monovalent Fab' and divalent F(ab')2 fragments are expected to exhibit shorter circulating half-lives, better tumor penetration and are thus more likely to yield better imaging results. In this study, novel F(ab')2 and Fab' fragments from cMAb U36 were radiolabeled with 125I and the characteristics of the conjugates in vitro were examined. The biodistribution of the conjugates were then evaluated in nude mice bearing CD44v6-expressing xenograft tumors. Furthermore, the penetration depth and distribution in tumor tissue was assessed by autoradiography in selected tumor samples. The in vitro experiments showed that the conjugates were stable and had intact affinity to CD44v6. The biodistribution study demonstrated superior tumor-to-blood ratio for the novel cMAb U36 fragment 125I-F(ab')2 compared with both the intact MAb and the monovalent fragment form. Autoradiography also revealed better tumor penetration for 125I-F(ab')2. This study demonstrates that the use of antibody fragments may improve radioimmunotargeting and possibly improve the management of head and neck malignancies.

Benign external hydrocephalus: a review, with emphasis on management

Benign external hydrocephalus in infants, characterized by macrocephaly and typical neuroimaging findings, is considered as a self-limiting condition and is therefore rarely treated. This review concerns all aspects of this condition: etiology, neuroimaging, symptoms and clinical findings, treatment, and outcome, with emphasis on management. The review is based on a systematic search in the Pubmed and Web of Science databases. The search covered various forms of hydrocephalus, extracerebral fluid, and macrocephaly. Studies reporting small children with idiopathic external hydrocephalus were included, mostly focusing on the studies reporting a long-term outcome. A total of 147 studies are included, the majority however with a limited methodological quality. Several theories regarding pathophysiology and various symptoms, signs, and clinical findings underscore the heterogeneity of the condition. Neuroimaging is important in the differentiation between external hydrocephalus and similar conditions. A transient delay of psychomotor development is commonly seen during childhood. A long-term outcome is scarcely reported, and the results are varying. Although most children with external hydrocephalus seem to do well both initially and in the long term, a substantial number of patients show temporary or permanent psychomotor delay. To verify that this truly is a benign condition, we suggest that future research on external hydrocephalus should focus on the long-term effects of surgical treatment as opposed to conservative management.