Margaret Keymakh

BACKGROUND AND IMPORTANCE: Cranioplasty, the surgical repair of cranial defects, aims to restore the structural integrity and aesthetic appearance of the skull. The choice of implant material is crucial and influenced by factors such as fit, risk of infection, and postoperative monitoring. Pediatric patients pose unique challenges in cranioplasty because of ongoing skull growth, bone resorption, and higher complication rates. This case report highlights the use of ClearFit ^© (Longeviti Neuro Solutions), a polymethyl methacrylate–based sonolucent implant, as a novel approach to pediatric cranioplasty with sonolucent properties to enhance postoperative imaging and monitoring capabilities, compatible with ultrasound monitoring. CLINICAL PRESENTATION: A 2-year-old male patient with a traumatic brain injury and resulting sunken cranial defect underwent cranioplasty using a ClearFit implant (the youngest reported use of this technology to-date). The implant demonstrated successful integration and a favorable surgical outcome. One year after surgery, the polymethyl methacrylate–based sonolucent implant yields good clinical outcomes without postsurgical complication, allowing postoperative monitoring without radiation exposure even after fontanelle closure. When used alongside porous polyethylene strips, it may also support ongoing skull growth. CONCLUSION: This case supports the use of ClearFit as a viable option over traditional materials—particularly in young patients who may be at a higher risk of bone resorption with autologous grafts and will need postoperative intracranial monitoring.

BACKGROUND AND OBJECTIVES: Moyamoya disease (MMD) is a rare cerebrovascular disorder discovered in Japan, characterized by progressive internal carotid artery stenosis and fragile collateral vessel formation. Diagnosis relies on imaging, with Suzuki staging commonly used to classify disease severity. There is limited literature on MMD in non-Asian, non-White populations. This study evaluated clinical factors associated with disease presentation, severity, treatment, and progression, with a novel focus on longitudinal changes in Suzuki stage. METHODS: A retrospective cohort study was conducted using electronic medical records. Clinical data, including demographics, Suzuki stages, surgical interventions, stroke frequency, and outcomes, were collected and analyzed. RESULTS: Of 114 patients diagnosed with MMD, 89 were from underrepresented populations in Moyamoya literature. Imaging from 91 patients showed Suzuki scores following a bell-curve distribution. Higher initial Suzuki scores were significantly associated with an increased likelihood of surgery ( P < .001). In a subcohort of 71 patients with at least 2 Suzuki scores 1 year apart, scores remained largely stable, although a weak, nonsignificant trend toward worsening was seen in nonsurgical patients ( P = .14). Notably, Mann-Whitney U analysis revealed a significant difference in Suzuki stage changes, with nonsurgical patients showing greater radiographic progression and surgically treated patients exhibiting stability or improvement ( P < .05). No significant correlation was found between changes in Suzuki stage and functional outcomes or stroke events. CONCLUSION: This study expands understanding of MMD in a diverse, non-Asian population and supports Suzuki staging as a reliable tool for disease assessment and surgical planning. Surgical intervention appears to slow radiographic progression, supporting its role in management. Further prospective studies are needed to refine Suzuki staging in monitoring disease trajectory and guiding treatment.

Pediatric basilar skull fractures (BSFs) are a rare type of traumatic head injury that can cause debilitating complications without prompt treatment. Here, we sought to review the literature and characterize the clinical features, management, and outcomes of pediatric BSFs. We identified 21 relevant studies, excluding reviews, meta-analyses, and non-English articles. The incidence of pediatric BSFs ranged from 0.0001% to 7.3%, with falls from multi-level heights and traffic accidents being the primary causes (9/21). The median presentation age ranged from 3.2 to 12.8 years, and the mean age of patients across all studies was 8.68 years. Up to 55% of pediatric BSFs presented with intracranial hematoma/hemorrhage, along with pneumocephalus and edema. Cranial nerve palsies were a common complication (9/21), with the facial nerve injured most frequently (7/21). While delayed cranial nerve palsy was reported in a few studies (4/21), most resolved within three months post-admission. Other complications included CSF leaks (10/21) and meningitis (4/21). Management included IV fluids, antiemetics, and surgery (8/21) to treat the fracture directly, address a CSF leak, or achieve cranial nerve compression. Despite their rarity, pediatric skull base fractures are associated with clinical complications, including CSF leaks and cranial nerve palsies. Given that some of these complications may be delayed, patient education is critical.

Spinal clear cell meningiomas (CCMs) are a rare histological subtype of meningiomas that pose preoperative diagnostic challenges due to their radiographic similarities with other lesions. They are also more aggressive, exhibiting higher rates of recurrence, particularly in pediatric patients. Overcoming diagnostic challenges of these tumors can improve patient outcomes. In this report, we describe a case of a pediatric patient presenting with a lumbar CCM in whom we were able to obtain gross total resection. Our report reviews previously identified predictors of CCM recurrence, including the Ki-67 proliferation index, number of spinal segments involved, and hormonal influences related to age and sex. We describe the characteristic radiographic features that differentiate spinal CCMs from other tumors to improve pre-operative diagnosis. Furthermore, we provide our rationale for adjuvant therapy for pediatric patients to refine treatment protocols for these rare tumors.