Hydrocephalus and Bobble-Head Doll SyndromeA 4-month-old female child presented to a neurosurgeon for evaluation of macrocephaly and abnormal head movements. The mother's pregnancy had no complications or known perinatal infections. The parents were unrelated, and there was no family history of congenital anomalies. Ultrasonography performed at 14 and 24 weeks of gestation had revealed moderate hydrocephalus. The patient was born at 38 weeks of gestation by cesarean delivery, with a birth weight of 4100 g, a length of 50 cm, and an occipitofrontal circumference (OFC) of 40 cm.Despite the macrocephaly, the patient's developmental milestone dates were normal. At age 3 months, she had an OFC of 48 cm and was already able to sit and support her neck, but on physical exam she demonstrated repetitive, rhythmic, vertical head movements (Video 1; available at www.jpeds.com). Hydrocephalus was evident on head computed tomography scan (Figure). After placement of a ventriculoperitoneal shunt, she showed an improvement in involuntary head movements (Video 2; available at www. jpeds.com).

Pneumocephalus is defined as the presence of air in the intracranial cavity, and this complication is rare after ventriculoperitoneal shunt (VPS) surgery. It can be caused by traumatic brain injury (TBI), surgical interventions, and anatomical or spontaneous malformation. We present a case of intraventricular pneumocephalus associated with the placement of a VPS. The patient was a 40-year-old man who had a VPS inserted 10-years ago due to hydrocephalus caused by TBI. He presented to the emergency room with complaints of headache, vomiting, rhinoliquorrhea, and fever. Computed tomography of the skull showed ventricular dilatation with intraventricular pneumocephalus. In a three-dimensional reconstruction, a bone defect was visualized with meningocele at the base of the skull that would explain the cerebrospinal fluid fistula. The meningocele was surgically corrected. After 14 days of antibiotic treatment, a new VPS was placed and the patient progressed satisfactorily. Pneumocephalus associated with VPS is a rare condition that can develop secondary to a combination of the shunt effect and an anatomical defect at the base of the skull. Excessively negative and persistent intracranial pressure of the shunt allows air to enter and fill the existing vacuum through the defect in the skull base. This bone defect may be congenital, due to traumatic brain injury, or a result of hydrocephalus itself. Computed tomography of the skull is an excellent investigation for the visualization of bone defects, and treatment involves a correction of the fistula. Pneumocephalus associated with VPS is rare. The presence of rhinoliquorrhea is a strong indication of the condition. Once the presence of a fistula is confirmed, it should be corrected to prevent worsening of the pneumocephalus.

Introduction: Spontaneous spinal epidural hematomas are a rare condition of spinal cord compression. We report a case of spontaneous spinal epidural hematoma in a child with neurological deficit. Case presentation: A 5-year-old male child with walking difficulty for 15 days. Clinical examination revealed spastic paraparesis and pyramidal signs. Magnetic resonance imaging of the cervical and thoracic spine showed extensive epidural hematoma (C7–T4) with significant medullary edema. Laminotomy was performed for decompression followed by drainage of the hematoma. Spontaneous spinal epidural hematoma usually occurs in the absence of identifiable etiology. The clinical presentation in children is nonspecific. The treatment is based on surgical decompression mainly by laminotomy performed within 48 hours of hematoma formation. Conclusion: In the case presented, the child remained paraparetic despite surgical decompression. The timing (>48 hours) of the surgical procedure probably influenced the poor prognosis.