UNASSIGNED: Drug testing typically follows a one-size-fits-all approach that is inadequate in some clinical scenarios, such as child maltreatment, neglect, and unintentional drug exposure. Results from immunoassay-based testing, which are non-specific, insensitive, and far from comprehensive, can lead to unintended consequences for children and their families.
UNASSIGNED: The objective of this retrospective case series study is to evaluate the utility of real-time (0-1 day) comprehensive drug testing as an alternative to immunoassay-based testing in the pediatric acute care setting.
UNASSIGNED: Comprehensive drug testing results obtained by mass spectrometry testing and associated medical data for all pediatric cases (0-12 years) at one institution from 2019 to 2022 were included in the analysis. The final case series (n = 7) included all cases from patients <3 years with comprehensive drug testing results that were inconsistent with medication history and/or toxicology results by immunoassay.
UNASSIGNED: Comprehensive drug testing by mass spectrometry was ordered for 174 urine and blood samples representing 97 patients (0-12 years) from 2019 to 2022. Of these, 76 cases were from patients <3 years old; results were consistent with medication history and confirmatory for immunoassay results (n = 34), consistent with medication history (n = 14), confirmatory for immunoassay results (n = 10), negative (n = 9), or medical history was incomplete (n = 2). The remaining 7 cases were included in the final case series.
UNASSIGNED: The cases highlight the value of real-time comprehensive drug testing in acute pediatric cases. Testing results can rule out toxic exposure from the diagnostic differential when negative, and lead to appropriate medical and social interventions when positive.

UNASSIGNED: Brain injuries caused by a tired bullet can range from headaches to severe brain injury and death. The question which poses a dilemma is whether extraction of retained bullets could decrease the late complications. This study aims to investigate the radiological findings, the neurological status of the patients, and different modalities of management for craniocerebral tired bullet injury.
UNASSIGNED: This study retrospectively reviewed 21 patients with a tired bullet injury to the brain who were admitted into our hospital over five years. All patients were assessed for the Glasgow outcome scale as outpatients.
UNASSIGNED: Of the 21 patients in the study, 11 (52.3%) were males, and 10 (47.6%) were females. The most common entry point of the bullet was frontal in 8 (38.0%) patients, followed by parietal in 7 (33.3%), and orbital in 5 (23.8%). The mortality rate was 23.8% (n = 5 patients). Bad outcomes were documented in patients with low GCS, with all patients who died having a GCS of (3-8). Bullet retrieval was performed for 7 of 21 patients, while all patients who were not candidates for emergency operation underwent local wound debridement. The GOS score was good [4 and 5] in 71.4% (15 of 21 patients).
UNASSIGNED: This study revealed that two-thirds of patients with tired bullet injury underwent conservative treatment with an excellent long-term outcome, particularly for patients with high GCS on admission. The mortality rate was high among children under 15 years and those with a GCS of 3-8.

Traumatic or iatrogenic sciatic nerve injury, but not superior gluteal nerve injury, is a well described complication after acetabular fractures. Most often, sciatic nerve injuries occur in fractures involving the posterior column/wall with a hip dislocation and posterior fracture displacement resulting in narrowing of the greater sciatic foramen and injuring the sciatic nerve passing through. In this case report, a case of abductor mechanism deficiency with positive Trendelenburg\'s sign after an acetabular fracture of the posterior column with hip dislocation is presented. Postoperative clinical and MRI examination revealed a neurogenic atrophy of gluteus medius and minimus muscles suggesting a superior gluteal nerve injury due to initial subtotal incarceration of the greater sciatic foramen by a displaced posterior fracture fragment. An additional mild sciatic nerve injury resolved in the early postoperative course, while intensive physiotherapy improved the patient\'s complaints and muscular atrophy caused by the superior gluteal nerve injury within 12 months. This case report intends to raise awareness for rare neurological complications after acetabular fractures for their early detection.

UNASSIGNED: There is little evidence on the factors influencing the decision to withdraw or continue life-sustaining treatment in the setting of severe traumatic brain injury in Japanese institutions. We investigated the factors associated with the withdrawal or withholding of life-sustaining treatment (WLST) for severe traumatic brain injury at a single Japanese institution.
UNASSIGNED: A total of 161 patients with severe traumatic brain injury were retrospectively reviewed. Patient characteristics and injury types were compared between patients with and without the WLST.
UNASSIGNED: Of the 161 patients, 87 (54%) died and 52 (32%) decided to undergo WLST. In 98% of the WLST cases, the decision was made within 24 h of admission. The mean duration between WLST and death was 2 days. The predicted probabilities for mortality and unfavorable outcomes were highest in patients with WLST within 24 h. Patients with WLST were older and had a higher frequency of falls on the ground, ischemic heart disease, and acute subdural hemorrhage than those without WLST.
UNASSIGNED: The decisions of almost all WLST cases were made within 24 h of admission for severe traumatic brain injury in a Japanese institution because of Japanese patients\' religious and cultural backgrounds.

UNASSIGNED: Craniopharyngiomas are benign tumours mainly confined to the cranial cavity in the suprasellar region.
UNASSIGNED: We present a rare case of an aggressive papillary craniopharyngioma with disseminated spinal intradural disease. A 67-year-old woman presented with a 4-month history of headache, visual disturbance, acute confusion and radicular leg pain. Previous history of breast carcinoma (ER ​+ ​PR ​+ ​HER2-) was noted. The importance of histological diagnosis prior to treatment of sellar or suprasellar lesions with atypical or aggressive features is explored.
UNASSIGNED: MRI demonstrated a partly solid and partly cystic pituitary mass lesion in the sellar and suprasellar region with chiasmal compression and hypothalamic involvement. The sella was mildly enlarged and there were no calcifications. Whole neuraxis MRI revealed intradural deposits involving the ventricular system, spinal cord and conus. Within a month, the lesion rapidly increased in size. The patient underwent a craniotomy and transventricular resection of the sellar and suprasellar mass. Cranial lesion histology favoured papillary craniopharyngioma, confirmed by BRAF V600 mutation. Lumbar puncture CSF cytology confirmed craniopharyngioma with BRAF mutation and no evidence of metastatic breast cancer.
UNASSIGNED: The patient remained confused postoperatively without focal neurological deficit and underwent palliative whole brain radiotherapy. She died 4 months later. A review of the literature identified 29 reports of ruptured craniopharyngioma.
UNASSIGNED: Ruptured craniopharyngioma presents with a suprasellar mass and drop lesions in the spinal canal, characteristics radiologically indistinguishable from metastatic disease. The importance of histological diagnoses in directing the management of these cases is highlighted.

UNASSIGNED: There is an ongoing debate whether Decompressive Craniectomy (DC) serves as an independent risk factor for the development of Post-traumatic Hydrocephalus (PTH).
UNASSIGNED: The aim of this systematic review and meta-analysis was to compare the incidence of PTH in TBI patients that underwent DC versus those that were managed without DC.
UNASSIGNED: The literature was systematically reviewed to identify studies with specific inclusion criteria: (1) Randomized Controlled Trials and observational studies with more than 10 patients in each study arm, (2) comparing the incidence of PTH, (3) in patients aged ≥15 years old, (4) that either underwent DC or received other treatment (non-DC). (5) Only studies in English were included and (6) no restrictions were applied on publication date. The pooled Odds Ratio (OR) and Confidence Interval (CI) were calculated. The quality of the included studies was assessed using the ROBINS and RoB 2.0 tools.
UNASSIGNED: Evidence from six articles was synthesized, incorporating data from 2522 patients. A statistically significant higher occurrence of PTH [OR (95% CI): 4.84 (2.51, 9.31); Pz ​< ​0.00001] was identified in patients undergoing DC for TBI when compared to those that were managed without DC. The same was true when only patients with severe TBI were included in the analysis [OR (95% CI): 2.87 (1.85, 4.43); Pz ​< ​0.00001].
UNASSIGNED: Our study has shown, within limitations, a clear association between DC and PTH. Further prospective studies, providing high-quality evidence, are needed to definitively establish any causative relationship between DC and PTH.

Susceptibility-weighted imaging (SWI) is a relatively new magnetic resonance imaging (MRI) technique used in the workup and diagnosis of brain pathologies. In the context of acute ischemic stroke (AIS), it is increasingly becoming useful in the diagnosis, treatment, and further management of these patients. An elderly man with metabolic syndrome presented to us with an acute onset of right sided body weakness and aphasia. Urgent imaging via MRI noted a left middle cerebral artery (MCA) occlusion. Diffusion-weighted imaging (DWI)/fluid attenuated inversion recovery (FLAIR) mismatch was noted with an acute infarct involving the left MCA territory; hence, treatment with intravenous (IV) thrombolysis was administered. On SWI, the prominent hypointense vessel sign was noted. Recanalization of the occluded left MCA was seen on diagnostic cerebral angiography post IV thrombolysis, however, the patient was noted to have early neurological deterioration (END) and poor early stage clinical outcome, despite repeat MRI showing recanalization of the left MCA occlusion and reversal of the prominent hypointense vessel sign on SWI. Presence of the prominent hypointense vessel sign on SWI in AIS patients is associated with poor clinical outcome, unsuccessful recanalization rates, END, poor early stage clinical outcome, and infarct core progression. Some studies have shown an association between this imaging sign and poor collateral circulation status. Therefore, this imaging sign could potentially prove to be a useful imaging biomarker. However, more studies are needed to validate this theory.

Staphylococcus aureus infectious endocarditis has a high mortality, major causes of death being cardiac failure, systemic embolism, and sepsis. Pseudoaneurysms, a rare complication of this infection, are not invariably fatal with appropriate treatment. A previously healthy 32-year-old man was found to have multiple cerebral infarctions, and infectious endocarditis with mitral valve vegetation was diagnosed by echocardiography. Because methicillin-resistant Staphylococcus aureus (MRSA) was identified from blood cultures, vancomycin was administered. Massive intracerebral hemorrhage in the left temporo-occipital lobe occurred in the patient on the 3rd day after admission, and the hematoma was completely removed surgically. Another hemorrhage was identified in the right occipital region on the 7th hospital day, which led the patient deep coma. Blood cultures on the 10th day were negative for MRSA; however, imaging studies revealed pseudoaneurysms in the superior mesenteric, hepatic, and left popliteal arteries 3 weeks after admission. No surgical indication was applied to these pseudoaneurysms because the patient remained comatose. On the 78th day after admission, the patient\'s blood pressure suddenly dropped and he died. Autopsy demonstrated massive bleeding in the abdominal cavity caused by rupture of the superior mesenteric artery pseudoaneurysm. Our patient\'s clinical course was fulminant, his endocarditis being complicated by cerebral infarctions, intracranial hemorrhages, and multiple pseudoaneurysms within 3 weeks of admission. In retrospect, he may have survived if emergency resection of the mitral valve vegetation had been performed on the first or second day of admission; however, the in-hospital mortality rate after such surgery is high.

Bronchopulmonary cancer muscle metastases are uncommon, especially when they are visible. They can impact any muscle in the body, but the psoas, diaphragmatic, and paravertebral muscles have a clear advantage. We present a case of lateral pterygoid muscle metastasis of squamous cell carcinoma of the lung in a 70-year-old habitual smoker (40 packs per year) presents headaches more marked on the right and progressively worsening. A complementary brain MRI revealed a well-limited oval formation with irregular contours in hypo signal T1 hyper signal T2 heterogeneous, with area of central necrosis of the right pterygoid muscle, which was revealed to be a secondary location of bronchopulmonary malignancy after further examination (CT scan of the cervico-thoraco-abdomino-pelvic region, TEP scan, and biopsy). Moreover, muscle metastases are rarely revealing of primary cancer.

UNASSIGNED: Although some immunocompetent patients have developed invasive aspergillosis, the vast majority of cases are seen in immunocompromised patients. COVID-19 infection has been proposed to cause immune dysfunction or suppression, which predisposes patients to fungal co-infections such as mucormycosis and aspergillosis.
UNASSIGNED: A 58-year-old woman was admitted to the hospital with confusion, dysarthria, and loss of consciousness. The patient had a 1-month prior history of severe COVID-19 infection. A computerized tomography (CT) scan and a magnetic resonance imaging (MRI) revealed an intraventricular lesion with perilesional edema and a significant midline shift, which was initially thought to be an intraventricular tumor. Following a posterior parietal craniotomy, the lesion was resected via a transcortical approach from the posterior parietal region to the right lateral ventricle. Histopathological findings confirmed intraventricular aspergillosis (IVA). The patient was treated with intravenous amphotericin B for two months and discharged with oral variconazole for 4 months.
UNASSIGNED: Covid-19 infections can result in- dissemination of fungal diseases such as aspergillosis. As a minor component of cerebral aspergillosis with a poor prognosis, intraventricular aspergillosis necessitates prompt treatment, which includes surgical resection and the administration of anti-fungal medications.
UNASSIGNED: Infection with COVID-19 causes immune dysfunction, which leads to fungal co-infection, including CNS aspergillosis. As a result, all COVID-19 patients who present with acute neurologic symptoms should have CNS aspergillosis considered in their differential diagnosis.