Acute torticollis due to non-traumatic atlanto-axial subluxation (AAS) is often seen in children presenting with inflammatory conditions of the upper respiratory tract and the neck. Grisel's syndrome is the eponym given to this condition. These patients may present earlier in the disease process without evident subluxation. Thus, early recognition of the condition with prompt commencement of appropriate conservative treatment could halt the progression into Grisel's syndrome. The purpose of this study is to address the importance of early recognition of inflammatory torticollis that can be treated successfully by conservative methods. A retrospective review was made of the case files and radiological investigations of 13 children with fever and torticollis who were treated in the neurosurgery unit of Hamad General Hospital in Qatar, over a two-year period from July 1996 to July 1998. The children were aged between three and 12 years with a male to female ratio of 3:1. All patients arrived at the hospital within 48 hours of onset of torticollis and almost all had manifestations of upper respiratory tract or head and neck infections. Radiological examination by cervical spine X-rays, computerized tomography (CT) or magnetic resonance images (MRI) revealed that only three cases out of 13 had AAS. All patients underwent conservative treatment that included rest, neck collar, simple analgesics and antibiotics, where appropriate. A muscle relaxant was used in nine cases and Halter traction was applied to the three with AAS. All patients responded well to treatment and none required surgical intervention for AAS. We conclude that the majority of children presenting acutely with inflammatory torticollis have rotational deformity only without AAS. Progression to the latter, i.e. Grisel's syndrome, may be aborted should the diagnosis be made early and conservative treatment initiated in time. On the other hand, delay in diagnosis would deprive these children an opportunity of receiving effective conservative treatment.

Bony decompression is useful in the management of head trauma. Careful selection of cases and appropriate radiological assessment are important and will guide decision for either craniotomy or craniectomy.

Over the last decade there has been an increasing awareness that psychosocial problems may persist in patients who have made apparently good recoveries after aneurysmal subarachnoid haemorrhage (ASAH). The caregivers of these patients are often relatives and it is becoming apparent that these carers frequently suffer psychosocial stress with associated morbidity. Previous studies have looked primarily at patients and few have included carers. We exclusively studied carers using simple validated questionnaires. We measured the effect on general and psychosocial health of the carers of patients treated for ASAH, 2-3 years after discharge. The majority of the carers (88.1%) were close relatives; 53.8% were experiencing social or emotional stress and 46.4% of these felt completely overwhelmed. The level of stress correlated positively with management complications, but not site of aneurysm or other aspects of treatment. We conclude that there is an argument for priority assistance for those carers predicted to be vulnerable to stress.

IMPORTANCETrials often assess primary outcomes of traumatic brain injury at 6 months. Longer-term data are needed to assess outcomes for patients receiving surgical vs medical treatment for traumatic intracranial hypertension. OBJECTIVE To evaluate 24-month outcomes for patients with traumatic intracranial hypertension treated with decompressive craniectomy or standard medical care.DESIGN, SETTING, AND PARTICIPANTS Prespecified secondary analysis of the Randomized Evaluation of Surgery With Craniectomy for Uncontrollable Elevation of Intracranial Pressure (RESCUEicp) randomized clinical trial data was performed for patients with traumatic intracranial hypertension (>25 mm Hg) from 52 centers in 20 countries. Enrollment occurred between January 2004 and March 2014. Data were analyzed between 2018 and 2021. Eligibility criteria were age 10 to 65 years, traumatic brain injury (confirmed via computed tomography), intracranial pressure monitoring, and sustained and refractory elevated intracranial pressure for 1 to 12 hours despite pressure-controlling measures. Exclusion criteria were bilateral fixed and dilated pupils, bleeding diathesis, or unsurvivable injury.INTERVENTIONS Patients were randomly assigned 1:1 to receive a decompressive craniectomy with standard care (surgical group) or to ongoing medical treatment with the option to add barbiturate infusion (medical group). MAIN OUTCOMES AND MEASURESThe primary outcome was measured with the 8-point Extended Glasgow Outcome Scale (1 indicates death and 8 denotes upper good recovery), and the 6-to 24-month outcome trajectory was examined. RESULTSThis study enrolled 408 patients: 206 in the surgical group and 202 in the medical group. The mean (SD) age was 32.3 (13.2) and 34.8 (13.7) years, respectively, and the study population was predominantly male (165 [81.7%] and 156 [80.0%], respectively). At 24 months, patients in the surgical group had reduced mortality (61 [33.5%] vs 94 [54.0%]; absolute difference, −20.5 [95% CI, −30.8 to −10.2]) and higher rates of vegetative state (absolute difference, 4.3 [95% CI, 0.0 to 8.6]), lower or upper moderate disability (4.7 [−0.9 to 10.3] vs 2.8 [−4.2 to 9.8]), and lower or upper severe disability (2.2 [−5.4 to 9.8] vs 6.5 [1.8 to 11.2]; χ 2 7 = 24.20, P = .001). For every 100 individualstreatedsurgically,21additionalpatientssurvivedat24months;4wereinavegetativestate, 2 had lower and 7 had upper severe disability, and 5 had lower and 3 had upper moderate disability, respectively. Rates of lower and upper good recovery were similar for the surgical and medical groups (20 [11.0%] vs 19 [10.9%]), and significant differences in net improvement (Ն1 grade) were observed between 6 and 24 months (55 [30.0%] vs 25 [14.0%]; χ 2 2 = 13.27, P = .001).CONCLUSIONS AND RELEVANCE At 24 months, patients with surgically treated posttraumatic refractory intracranial hypertension had a sustained reduction in mortality and higher rates of vegetative state, severe disability, and moderate disability. Patients in the surgical group were more likely to...

Structural lesions are common and diverse in pediatric seizures. Significant proportion of these patients may benefit from surgery, and these benefits override financial and sociocultural considerations.