A rare case of rebleeding brainstem cavernoma in a 5-month-old-girl.

Background: Brainstem cavernomas (BSCs) are relatively rare intracranial vascular lesions that, if left untreated, can be devastating to the patient. The lesions are associated with a myriad of symptoms, depending on their size and location. However, medullary lesions present acutely with cardiorespiratory dysfunction. We present the case of a 5-month-old child with a BSC. Case Description: A 5-month-old child presented for the 2nd time with sudden respiratory distress and excessive salivation. On the first presentation, brain magnetic resonance imaging (MRI) showed a 13 × 12 × 14 mm cavernoma at the pontomedullary junction. She was managed conservatively but presented 3 months later with tetraparesis, bulbar palsy, and severe respiratory distress. A repeat MRI showed enlargement of the cavernoma to 27 × 28 × 26 mm with hemorrhage in different stages. After hemodynamic stabilization, complete cavernoma resection was performed through the telovelar approach with neuromonitoring. Postoperatively, the child recovered motor function, but the bulbar syndrome persisted with hypersalivation. She was discharged on day 55 with a tracheostomy. Conclusion: BSCs are rare lesions that are associated with severe neurological deficits due to the compactness of important cranial nerve nuclei and other tracts in the brainstem. Early surgical excision and hematoma evacuation for superficially presenting lesions can be lifesaving. However, the risk of postoperative neurological deficits is still a major concern in these patients.

Dural arteriovenous fistula of the torcular herophili presenting with hydrocephalus and venous congestion in an 8-month-old child: A case report.

Dural arteriovenous fistulas (DAVFs) are direct communication between the dural arterial and venous systems. They are more common in adults. In children, they are relatively rare. Hydrocephalus is a common problem in pediatrics with a variety of causes. However, very few cases of hydrocephalus as a complication of DAVF have been reported in the literature. This case describes an 8-month-old male child with a large DAVF at the torcular herophili who presented with regression of milestones and hydrocephalus. Magnetic resonance imaging (MRI) on admission showed triventricular hydrocephalus and a massively dilated torcular with a compressed fourth ventricle. Angiography confirmed the presence of a DAVF at the torcula with arterial feeders from the posterior circulation. Endovascular embolization was performed with >80% embolization of the fistula with no complications. Control MRI immediately postoperative was acceptable. No cerebrospinal fluid (CSF) diversion was performed. At a 3-month follow-up, the child had attained all developmental milestones for age. MRI showed normal CSF dynamics and a further reduction in the size of the torcula. Despite being rare, DAVFs should be considered as a possible cause of pediatric hydrocephalus, and treating them can lead to a resolution of the mechanisms inducing hydrocephalus. CSF shunting should be reserved for those cases with persistent hydrocephalus and raised intracranial pressure despite endovascular treatment.

Surgical Management of a Pediatric Infratentorial Subdural Empyema as a Complication of Parapharyngeal Abscess.

Infratentorial empyema is a rare medical emergency typically presenting secondary to a middle ear infection. Nonspecific symptoms, limited access to radiological facilities, and imaging artifacts render this pathology prone to misdiagnosis and delayed intervention. An 11-year-old girl presented to the emergency department with a high fever, cervicalgia, and a two-week history of frontal headache. Computed tomography revealed parapharyngeal abscess and polysinusitis. Pus drained from the parapharyngeal abscess showed Staphylococcus capitis and Streptococcus intermedius. Treatment with intravenous meropenem and vancomycin led to initial improvement. On day five post drainage, she suddenly deteriorated with severe headache, vomiting, and posturing. Repeat CT showed posterior fossa empyema with hydrocephalus. The patient underwent an emergency suboccipital craniotomy for empyema evacuation. Pus cultures from the empyema showed identical results as those from the parapharyngeal abscess. Antibiotic therapy was continued for 12 weeks. The patient was discharged on day 21 after craniotomy with no neurological deficits. Early diagnosis and prompt neurosurgical evacuation combined with antibiotic therapy are of utmost importance to reduce morbidity and mortality. Physicians should consider the possibility of subdural empyema in children with parapharyngeal abscess and polysinusitis.