Preserved Limbic White Matter Predicts Favorable 2-Year Outcomes in Neonatal Hypoxic-Ischemic Encephalopathy.

The opioid crisis is promoting illicit fentanyl and other opioid overdose in children. One complication, leukoencephalopathy, is described in a variety of resultant syndromes, including chasing the dragon leukoencephalopathy syndrome; cerebellar, hippocampal, and basal nuclei transient edema with restricted diffusion syndrome; acute toxic leukoencephalopathy; and pediatric opioid use–associated neurotoxicity with cerebellar edema (POUNCE) syndrome. Because each syndrome is rare, the nature and extent of difference between these syndromes is unclear. However, recently reported pediatric patients appear to have the characteristics of POUNCE, which include cerebellar edema, altered mental status, and cardiorespiratory depression due to opioid toxicity. Early detection and intervention may be necessary to achieve immediate and long‐term recovery. There is a paucity of pediatric literature to guide care in severely affected patients, which appear to threaten life due to increased intracranial pressure. The 2023 Annual Meeting of the Child Neurology Society Neurocritical Care Special Interest Group members discussed recent patients with POUNCE (one of the three discussed cases is not included due to planned inclusion in another article) in whose consciousness was temporarily reduced with good recovery. With a show of hands, about a fourth of 40 attendees from different US institutions reported directly caring for a child with POUNCE. The format of the meeting was a round table moderated open discussion among all attendees. The group discussed the utility of external ventricular drain placement and intracranial pressure monitoring to guide medical management of patients with posterior fossa mass effect and reduced consciousness. The central concern and related solutions further focused on communication barriers between care services, including the need to foster collaborative working relationships between medical and surgical teams through regular structured meetings for case reviews. One evolving element further illuminated in the discussion was the medical provider promoting the need for extra ventricular drain but the neurosurgical member promoting caution against rushing toward this intervention without focal brainstem findings on current exam. The risk discussed for extra ventricular drain placement included worsening or precipitation of upward cerebellar herniation, while the cons of waiting were missing the window for reducing intracranial pressure and patient deterioration.