Archives of Pediatric Neurosurgery

Multilevel Spinal Cord Injuries in Children with SCIWORA Syndrome

Wed, 16 Sep 2026 00:00:00 -0300

Background: The unique anatomical and physiological features of the pediatric spine predispose children to a distinct form of spinal cord trauma known as SCIWORA (Spinal Cord Injury Without Radiographic Abnormality). This condition occurs predominantly in children and is characterized by clinical evidence of spinal cord injury in the absence of detectable abnormalities on conventional imaging modalities, including plain radiography and MRI. Recent studies indicate that multilevel spinal cord involvement in pediatric SCIWORA cases may be more frequent than previously recognized, and some patients may ultimately require surgical management.

Methods: A retrospective analysis was performed on 80 children aged 4–18 years who were treated for SCIWORA at the Pediatric Neurosurgery Department in Omsk between 2008 and 2022. The mechanisms of injury were evaluated, and neurological status was assessed using the Frankel scale to determine the severity of neurological deficits. Injury severity was additionally classified according to the criteria proposed by Zwimpfer T.J. (1990). All patients underwent spinal radiography in two standard projections as well as MRI examination. In twenty-eight cases, electromyography (EMG) studies were performed.

Results: In two patients, clinical manifestations of L4–L5 radiculopathy were observed despite the absence of lumbar spinal trauma. All patients demonstrated favorable outcomes following conservative treatment.

Conclusions: Pediatric SCIWORA remains a relatively rare yet potentially severe form of spinal cord injury. In children with SCIWORA syndrome, multifocal spinal cord involvement is possible, and the degree of neurological recovery largely depends on the presence and severity of MRI-detected abnormalities

Red Flags in Pediatric Head Trauma: A Multicenter Analysis of Predictors of Intracranial Injury

Wed, 16 Sep 2026 00:00:00 -0300

Background: Pediatric traumatic brain injury (TBI) is a leading cause of childhood mortality. The early identification of variables that predict adverse outcomes may help refine clinical decisions. This study aimed to determine the variables associated with poor outcomes in pediatric TBI.

Methods: A retrospective multicenter study was conducted in pediatric patients with TBI admitted at a public and a private reference center in Minas Gerais, Brazil. Nineteen demographic and clinical variables were assessed as predictors of intracranial hemorrhage, skull fracture, neurosurgical intervention, and mortality using multivariable logistic regression.

Results: A total of 3,049 patients were evaluated (58.9% male) from 2019 to 2020. The mean age was 5.6 years (SD 5.3; median 3.6). Falls were the most frequent mechanism of trauma (84%), and a cranial tomography was performed in 37.4% of cases. Intracranial hemorrhage was associated with severe TBI (OR 63), periorbital ecchymosis (OR 7.07), and traffic-accident (OR 5.05). Skull fracture was associated with retromastoid ecchymosis (OR 22.8), severe TBI (OR 16.3), and post-traumatic seizure (OR 9.05). Severe TBI (OR 50.2), anisocoria (OR 6.44), and abusive head trauma (OR 4.32) were related to neurosurgical intervention.

Conclusions: This large multicenter study reinforces the importance of TBI severity, as assessed by the Glasgow Coma Scale, as well as the role of abusive head trauma as a predictor of poor outcomes. The development of novel algorithms should be encouraged to improve care for pediatric trauma.

Skull fractures following head trauma in the first year of life: epidemiology, mechanisms and outcomes

Wed, 16 Sep 2026 00:00:00 -0300

Introduction: Head trauma during infancy represents a distinctive clinical entity due to the rapid developmental changes in the first year of life. Skull fractures are a clinically relevant marker of traumatic head injury in infants and frequently prompt hospital admission and specialist evaluation. Understanding mechanisms and clinical characteristics is essential for improving diagnostic assessment and prevention strategies.

Materials and Methods: This retrospective study included infants <12 months admitted to our Institution between 2021 and 2025, diagnosed with a skull fracture. Birth-related trauma was excluded. Demographic, radiological, and clinical data were analyzed. Trauma mechanisms were classified as accidental, non-accidental, medical condition–related, or other. Accidental mechanisms were further subdivided according to the circumstances of the fall.

Results: A total of 156 infants were included. Accidental trauma accounted for 89.7% of cases; 4.5% were classified as non-accidental trauma. The fractures were mostly parietal (72.4%); intracranial hemorrhage occurred in 43.6%. Seventeen patients (10.9%) required neurosurgical intervention; 24 (15.4%) required intensive care admission. Fundoscopic abnormalities were identified in six infants, predominantly in cases of non-accidental trauma. Analysis by developmental age groups demonstrated clear age-related patterns of injury mechanisms, with caregiver-related falls predominating during the first months of life and supervision-related injuries increasing with the onset of mobility.

Conclusions: Head trauma resulting in skull fractures during the first year of life demonstrates distinct developmental patterns of injury. These findings highlight the importance of developmental context in clinical assessment and suggest that many injuries may be preventable through targeted caregiver education and improved domestic safety measures.

Systematic Inflammation Index as Predictors of CT Findings in Pediatric Traumatic Brain Injury: A Retrospective Study

Eleni Romeo, George A. Alexiou, Spyridon Voulgaris — Wed, 16 Sep 2026 00:00:00 -0300

Background: Pediatric traumatic brain injury (TBI) is a common cause of emergency department (ED) visits. Although head computed tomography (CT) remains the gold standard for the acute evaluation of TBI, it is associated with ionizing radiation exposure. The aim of this study was to evaluate the association between SII and head CT positivity in pediatric patients with TBI.

Methods: This retrospective study included children aged ≤18 years presenting to the emergency department with TBI who underwent head CT. Demographic, clinical, and laboratory data were collected, and SII was calculated from complete blood count parameters. The primary outcome was CT positivity. ROC curve analysis was performed to assess diagnostic performance.

Results: A total of 52 pediatric patients (mean age 13.1 ± 3.4 years) were included, of whom 33 (63.5%) had a positive head CT scan. Median SII was significantly higher in CT-positive patients compared with CT-negative patients [1891 (646–2892) vs 1128 (428–1712); p = 0.025]. ROC analysis demonstrated moderate discriminative ability of SII for predicting CT positivity (AUC 0.687, 95% CI 0.543–0.832). Using the Youden index, the optimal SII cut-off value was 1837.7, yielding a sensitivity of 51.5% and specificity of 89.5%. In multivariable analysis adjusted for age and GCS, SII was not independently associated with CT positivity (p = 0.118).

Conclusions: SII was associated with CT positivity in univariable analysis but not after adjustment, suggesting a potential role as an exploratory adjunctive biomarker. Larger prospective multicenter studies are warranted to clarify the potential role of SII as an adjunct to clinical decision rules in pediatric TBI.

Decompressive craniectomy in children and adolescents with severe traumatic brain injury: a systematic review.

Wed, 16 Sep 2026 00:00:00 -0300

Introduction/Background: Decompressive craniectomy (DC) is a neurosurgical technique employed in pediatric patients with severe traumatic brain injury (sTBI). However, consensus remains lacking regarding the specific criteria for its indication. The objective of this study is to synthesize data concerning the clinical and CT scan criteria for performing DC in children and adolescents with sTBI.

Methodology: This systematic review analyzed scientific studies indexed in the MEDLINE database via the PubMed platform. The search included studies published between 2015 and 2025 that involved children and adolescents (under 18 years of age) with sTBI treated with DC. This review is registered in the International Prospective Register of Systematic Reviews (PROSPERO: CRD420251159406).

Results: Eighteen manuscripts describing the clinical and tomographic criteria for DC indication were included. In a combined sample of 916 children, pupillary abnormalities (162/343; 47.2%) were identified as a primary clinical factor guiding surgical decisions. CT imaging revealed post-traumatic intracranial mass lesions associated with midline shift (MLS), further justifying the procedure. Invasive intracranial pressure monitoring (ICPm) was utilized in 48.6% (386/794) of cases, and the overall mortality rate was 24% (220/916).

Conclusion: In children and adolescents victims of sTBI, pupillary abnormalities coupled with CT evidence of acute intracranial lesions, mass effect, and MLS are key indicators for DC, whether or not invasive ICPm is employed.

Assessment of Intracranial Pressure in Pediatric Traumatic Brain Injury: Methods, Evidence, and Clinical Implications

Adriano Keijiro Maeda, Zeferino Demartini Junior — Wed, 16 Sep 2026 00:00:00 -0300

Background: Pediatric traumatic brain injury (TBI) is one of the leading causes of disability and early mortality, constituting a global public health problem. Even mild TBI can cause neurological deterioration due to secondary brain injury, usually associated with elevated intracranial pressure (ICP) compromising cerebral perfusion. Early identification and appropriate management of intracranial hypertension are therefore fundamental in the care of this population.

Methods: A narrative review of the literature was conducted to identify and synthesize current evidence on ICP monitoring methods in children and adolescents, encompassing original articles, systematic reviews, meta-analyses, and clinical guidelines.

Results: ICPM is an essential tool for preventing secondary brain injuries, guiding therapeutic interventions, and maintaining ICP and cerebral perfusion pressure within target ranges. Invasive methods, particularly the external ventricular drain, remain the gold standard for accuracy and allow direct therapeutic intervention, but carry risks of infection and hemorrhage. Intraparenchymal sensors offer a safer alternative with comparable accuracy. Noninvasive methods, including optic nerve sheath diameter ultrasonography, transcranial Doppler, and skull surface extensometry, demonstrate reasonable ability to detect intracranial hypertension and are particularly useful for triage, screening, and follow-up, though they do not yet replace invasive monitoring in critical clinical decisions.

Conclusions: The choice of ICP monitoring method should be individualized, balancing accuracy, safety, available resources, and the patient's clinical context. In severe TBI, invasive methods remain indispensable, whereas noninvasive approaches play a complementary role, particularly when invasive access is contraindicated or unavailable. Integrating multiple monitoring strategies may optimize ICP assessment in the pediatric population.

Clinical and tomographic criteria for neurosurgical approaches in children with severe traumatic brain injury: A systematic review

Wed, 16 Sep 2026 00:00:00 -0300

Background: Severe traumatic brain injury (sTBI) remains a major cause of mortality and disability in children worldwide. Intracranial pressure monitoring (ICPm) and decompressive craniectomy (DC) are commonly employed in the management of pediatric sTBI, the clinical and radiological criteria guiding these interventions remain heterogeneous.

Methods: A systematic review was conducted according to PRISMA 2020 guidelines. PubMed, Scopus, Web of Science, and LILACS were searched in March 2026 for studies published within the last 10 years. Eligible studies included pediatric patients (<18 years) with severe TBI (Glasgow Coma Scale [GCS] <9) and reported quantitative clinical or tomographic criteria for neurosurgical interventions.

Results: From 2,763 retrieved records, 21 studies met the inclusion criteria, including 10 focused on ICPm and 11 on DC. ICPm was primarily indicated in patients with GCS≤8 and abnormal computed tomography findings, particularly brain swelling and high Marshall scores. Intracranial hypertension thresholds varied between 15 and 20 mmHg, with some age-adjusted approaches. For DC, the most frequent radiological findings were acute subdural hematoma, midline shift, diffuse cerebral edema, and signs of herniation. Lower GCS scores and pupillary abnormalities were consistently associated with worse outcomes. While ICP-guided management and DC were associated with improved physiological control and, in some studies, better functional outcomes, consistent reductions in mortality were not demonstrated.

Conclusions: Current evidence reveals substantial heterogeneity in the clinical and tomographic criteria used for ICPm and DC in pediatric sTBI. Standardized prospective multicenter studies are needed to define optimal indications and improve outcome prediction.

From Sinus Infection to Subdural Empyema: A Pediatric Epileptic Case with Imaging Challenges and Misdiagnosis

Wed, 16 Sep 2026 00:00:00 -0300

Past, Present and Future of the Treatment of Traumatic Brain Injury in Children and Adolescents

José Carlos Esteves Veiga , Jose Roberto Tude Melo — Wed, 16 Sep 2026 00:00:00 -0300

Historical Background

The first clinical evidence of Traumatic Brain Injury (TBI) was discovered in prehistoric Tanzania, with findings dating back to approximately 2 million years BC in the pre-historic period, in Tanzania, apparently due to a crocodile bite demonstrating cranial fractures [1]. The earliest written records appear in the Edwin Smith Papyrus (Ancient Egypt, ~3000–2500 BC), which described head injuries, skull fractures, and neurological symptoms, establishing the first known classification of TBI severity. There were 27 head injury cases of which 13 were fractures with neurological involvement. The Edwin Smith Papyrus is still preserved at the New York Academy of Medicine in New York City [1,2]. The recognition that children require distinct treatment from adults is a much more recent achievement. Initially based solely on the presence or absence of skull fractures, later shifting toward the neurological deficits observed. For centuries, injured children were treated merely as "small adults," with identical therapeutic approaches and no recognition of the physiological peculiarities of the developing brain [3,4].

Historically, the lack of pediatric-specific protocols was one of the greatest challenges in caring for children with TBI. Decisions on performing CT scans or invasive intracranial pressure (ICP) monitoring were based on extrapolations from adult studies, which often led to unnecessary radiation exposure in children or, on the other hand, delayed diagnosis of intracranial lesions. Furthermore, the absence of evidence-based guidelines for the pediatric ICU meant that practices such as deep sedation, hyperventilation, and barbiturate coma therapy were used inconsistently, with significant variation among institutions and a lack of clear target parameters [4,5,6].

Present

In the present, specific protocols have transformed pediatric neurotrauma care. The PECARN (Pediatric Emergency Care Applied Research Network) [7] rule represents a milestone: a rigorously validated clinical decision rule that allows clinicians to safely identify children at low risk of clinically significant TBI, avoiding unnecessary CT scans and their associated radiation. Developed from a large multicenter cohort (over 42,000 children), the PECARN rule has high sensitivity and an excellent negative predictive value, substantially reducing radiation exposure in the pediatric population [7]. In the ICU setting, the publication of evidence-based guidelines, such as those from the Brain Trauma Foundation [8], standardized the management of severe pediatric TBI. Current recommendations encompass multimodal neuromonitoring (ICP, brain tissue oxygenation — PbtO2, and continuous electroencephalography), strict thermal control, maintenance of adequate cerebral perfusion pressure (CPP) with age-adjusted targets, hyperosmolar therapy (mannitol), and, in selected cases, decompressive craniectomy. The recognition that the immature brain has a distinct neurometabolic cascade post-trauma including prolonged ionic flux, mitochondrial dysfunction, and increased vulnerability to excitotoxicity has also driven the development of age-appropriate neuroprotective strategies [4,5,8].

FUTURE

The future focuses on Precision Medicine, with the integration of serum and neuroimaging biomarkers aimed at personalized diagnosis and prognosis [9,10]. Biomarkers such as GFAP (Glial Fibrillary Acidic Protein), UCH-L1 (Ubiquitin C-terminal Hydrolase L1), NfL (Neurofilament Light Chain), and a panel of inflammatory cytokines are being validated to stratify lesion severity, predict outcome, and guide therapeutic decisions without relying exclusively on clinical and conventional imaging criteria. Together with advances in genomics and pharmacogenomics, the goal is to develop individualized neuroprotective drugs that modulate specific pathways — such as the neuroinflammatory cascade, oxidative stress, and apoptosis — in a manner tailored to each patient's genetic profile [3,9,10]. Artificial Intelligence (AI) — particularly Machine Learning algorithms — emerges as a transformative tool. Predictive models fed by continuous ICP, PbtO2, and multimodal hemodynamic data are being developed for real-time monitoring, capable of anticipating episodes of intracranial hypertension and cerebral hypoperfusion minutes before they occur, enabling proactive rather than merely reactive interventions [8,9].

Differences Between the Infant and Adolescent Brain

Identifying the pathophysiological differences of TBI between infants and adolescents is essential for appropriate clinical management. At the extremes of childhood, the cranial and cerebral characteristics are profoundly distinct, directly influencing the response to trauma.

The Brain and Skull of the Infant (0 to 2 Years) [3,4,6]

Cranial Compliance: The infant's skull has open fontanelles and non-fused sutures, providing a natural expansibility that can mask classic signs of intracranial hypertension for longer periods. Paradoxically, this same compliance makes the brain more vulnerable to contrecoup injuries and parenchymal deformation during impacts.

Trauma Mechanics: The disproportionately large head relative to the body, combined with weak cervical musculature, predisposes infants to high-energy acceleration-deceleration injuries (angular acceleration), such as those seen in abusive head trauma (shaken baby syndrome). The immature, highly aqueous brain (with reduced myelin) undergoes greater deformation under shear stress.

Vulnerability to Hypovolemia: The total blood volume in an infant is significantly lower in absolute terms compared to adolescents. Intracranial hemorrhage or even extensive subgaleal hematomas can rapidly lead to hypovolemic shock — a phenomenon rarely seen in older children or adults after an isolated head injury.

The Brain and Skull of the Adolescent

Monro-Kellie Doctrine: the skull becomes a rigid, non-expandable compartment. Hence, the Monro-Kellie doctrine applies fully: the sum of intracranial volumes is constant, and any increase in one component must be compensated by the displacement of another; once compensation is exhausted, ICP rises exponentially.
Diffuse Axonal Injury (DAI): The adolescent brain is more myelinated, creating a higher density interface between gray and white matter. Acceleration/deceleration and rotational forces promote severe diffuse axonal injury from shear forces; a mechanism strongly associated with unfavorable neurological outcomes.
Malignant Brain Swelling: Adolescents are particularly prone to "malignant brain swelling," a phenomenon of acute hyperemia (vascular congestion) followed by diffuse cytotoxic edema, often refractory to conventional treatment. The management priority in this age group is strict ICP control through staged protocols that combine sedation, hyperosmolar therapy, moderate hyperventilation, and in extreme cases, decompressive craniectomy [7,8,10].

In summary, while in the infant the open skull offers some degree of protection against rapid increases in ICP but increases susceptibility to traumatic vascular and hypovolemic lesions, in the adolescent the rigid skull imposes the Monro-Kellie doctrine, with higher risk of diffuse axonal injury and malignant swelling that require aggressive ICP management. Understanding these differences is fundamental to tailoring care at each stage of development.

Final Remarks

The guidelines and consensus references that underpin the current management of TBI in children and adolescents are primarily derived from multicenter studies and systematic reviews, such as those by Kochanek et al. (2019) [8], the Brain Trauma Foundation pediatric guidelines, the PECARN studies led by Kuppermann et al. (2009) [7] for head CT decision rules, Giza and Hovda (2014) [5] for the neurometabolic cascade of concussion, and the recent reviews by Mayer et al. (2025) [10] and Chiollaz et al (2025) [9] on biomarkers and precision medicine in pediatric TBI.

Pediatric Neurotraumatology: A Scientific Body of Knowledge in Permanent Construction

Jose Roberto Tude Melo — Wed, 16 Sep 2026 00:00:00 -0300

I would like to thank all colleagues and researchers who submitted their valuable scientific contributions, helping to partially fill some of the gaps in our knowledge. I am equally grateful for the gaps that will remain open even after reading these manuscripts, as they sustain the ongoing desire for knowledge and remind us that knowledge is always under construction. For Nietzsche, absolute certainties revealed an inability to engage in reflection and openness to multiple perspectives and could even be associated with illusions. I conclude this editorial by wishing readers an enriching experience with the articles in this special issue on TBI in the pediatric population, and by inviting them to engage in reflection, and even disillusionment—in the spirit of Nietzschean thought.