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INTRODUCTION AND IMPORTANCE: Colonic ventriculoperitoneal shunt (VPS) migration with trans-anal protrusion remains uncommon. Patients may be asymptomatic, and diagnosis may only be made on visualization of the prolapsed catheter from the anus. This unique case of early post-operative trans-anal shunt protrusion highlight the possibility of this rare complication specially when shunt revision accompanies bowel surgery. CASE PRESENTATION: The authors present a case of early postoperative colonic shunt migration in a thirteen-year-old female with who underwent Malone Antegrade Continence Enema (MACE) with concomitant revision of the distal part of the peritoneal catheter. She presented two weeks post operatively with shunt catheter protruding from the anus. This was noticed by her carer and she was asymptomatic on her presentation. CLINICAL DISCUSSION: Delayed post-operative shunt related bowel perforation and trans-anal shunt protrusion is an uncommon complication after ventriculoperitoneal shunting. Most cases present months after surgery and majority are asymptomatic on presentation. The exact pathophysiology is not established, and mechanisms have been proposed. Early post -operative trans-anal shunt protrusion is rare and suggests inadvertent occult bowel injury especially when shunt placement or revision accompanies extensive bowel surgery. CONCLUSION: The authors recommended shunt imaging within the first two to three weeks after shunt revision in patient who undergo concomitant bowel surgery with risk of inadvertent bowel injury to identify early colonic migration and avoid its potentially fatal sequelae.

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BACKGROUND: Endodermal cysts of the oculomotor nerve are rare presentations. Only case reports are available to help guide clinicians with managing this rare entity. CASE DESCRIPTION: A 3-year-old boy presented with an acute on chronic left oculomotor nerve palsy due to a left interpeduncular cistern cyst found on magnetic resonance imaging. He underwent a left pterional craniotomy and fenestration of the histologically proven endodermal cyst and had initial improvement at the 2-month review. He subsequently developed clinical and radiologic evidence of recurrence and was treated surgically with a refenestration and insertion of a cysto-subarachnoid shunt through a trans-sylvian approach. At 6-month follow-up, there was complete resolution of the oculomotor nerve palsy with interval development of oculomotor synkinesis. CONCLUSIONS: Magnetic resonance imaging is an essential modality in the follow-up of these patients postoperatively in the setting of unchanged or deteriorated neurology. Fenestration of the cyst is appropriate first-line surgical management; however, a cysto-subarachnoid shunt is a safe consideration in recurrent, symptomatic cysts and provides sustained symptom resolution.

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BACKGROUND: Optic pathway gliomas and glioblastomas remain a rare entity within the infant population. CASE DESCRIPTION: We outline the case of a 6-month-old female who presented with failure to thrive, nystagmus and features of raised intracranial pressure. Subsequent magnetic resonance imaging demonstrated an infiltrating tumor radiating from the optic nerves bilaterally. She underwent emergent ventriculoperitoneal shunting and biopsy. Histology confirmed a World Health Organization grade IV glioblastoma. CONCLUSIONS: The patient remained clinically and radiologically stable at 1 year. Optic pathway glioblastoma in this population is a previously undescribed entity that requires multidisciplinary input to guide ongoing therapy.

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BACKGROUND: Intracranial hypotension secondary to spontaneous spinal cerebrospinal fluid (CSF) fistula is a rare condition that can have serious sequelae. Early diagnosis and treatment can be challenging. CASE DESCRIPTION: We present the case of a 17-year-old male who presented with a history of sudden-onset, postural headaches associated with upper thoracic back pain. Magnetic resonance imaging (MRI) demonstrated a thoracic extradural fluid collection and slumping of the brain within the posterior fossa. The patient was initially managed with a period of bed rest, followed by a thoracic epidural blood patch. Symptoms recurred and subsequent operative exploration found a large arachnoid cyst with CSF egress through a linear split in the axilla of the right T7 nerve root. The arachnoid cyst was resected, and the defect was closed primarily. All symptoms completely resolved. MRI at 3 months postoperatively demonstrated normal spinal configuration and resolution of brain sagging. CONCLUSIONS: Spontaneous CSF leaks are a rare cause of postural headache. Although epidural blood patching is an easy and safe intervention, early serial imaging to ascertain the evolution of the pathology may identify cases that are amenable to early surgical management.

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Traumatic brain injury (TBI) from penetrating or closed forces to the cranium can result in a range of forms of neural damage, which culminate in mortality or impart mild to significant neurological disability. In this regard, diffuse axonal injury (DAI) is a major neuronal pathophenotype of TBI and is associated with a complex set of cytoskeletal changes. The neurofilament triplet proteins are key structural cytoskeletal elements, which may also be important contributors to the tensile strength of axons. This has significant implications with respect to how axons may respond to TBI. It is not known, however, whether neurofilament compaction and the cytoskeletal changes that evolve following axonal injury represent a component of a protective mechanism following damage, or whether they serve to augment degeneration and progression to secondary axotomy. Here we review the structure and role of neurofilament proteins in normal neuronal function. We also discuss the processes that characterize DAI and the resultant alterations in neurofilaments, highlighting potential clues to a possible protective or degenerative influence of specific neurofilament alterations within injured neurons. The potential utility of neurofilament assays as biomarkers for axonal injury is also discussed. Insights into the complex alterations in neurofilaments will contribute to future efforts in developing therapeutic strategies to prevent, ameliorate or reverse neuronal degeneration in the central nervous system (CNS) following traumatic injury.