Prognostic and morphological factors in pediatric cerebellar contusions.

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 4th 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 4th 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.

Stoma Retraction in Super-Morbidly Obese Patient Leading to Class IV Midline Wound: A Cautionary Tale.

Stoma creation is often necessary for fecal diversion in general surgery. The creation of stomas involves mobilization of either the large or small intestine through the abdominal wall to allow for the passage of waste that traverses the intestinal tract. Among the complications of stoma creation, particularly in obese patients, is stoma retraction, whereby the stoma retracts greater than 5 mm from the skin. This is often accompanied by extensive dermal dehiscence, which can lead to significant leakage resulting in infection. Here, we present the case of a super-morbidly obese female patient with an end ileostomy following total colectomy in which abdominal closure was not initially achieved. The stoma became retracted and dehisced leading to continued contamination of the open abdomen, necessitating multiple abdominal washouts. Injection of 300 units of botulinum toxin A (BTA) was administered into the abdominal wall muscles later the day of her index operation. An Abdominal Wall Reapproximation Anchor (ABRA) dynamic tissue system (DTS) was utilized successfully in subsequent operations for primary myofascial closure. Heavy continuous contamination of the midline wound through the subcutaneous cleft between the retracted ileostomy and midline surgical wound was treated with intensive wound care, strict bed rest, nothing to eat or drink (NPO), and total parenteral nutrition (TPN). Post-operative stoma complications occur frequently, and stoma retraction is commonly encountered, especially in the obese. The patient presented in this case study had multiple risk factors which led to a complicated treatment course. Successful primary myofascial closure and complete healing of the midline surgical wound highlights the importance of a patient-tailored multimodal approach.