Affiliation:
1. Division of Child Neurology University of North Carolina School of Medicine Chapel Hill North Carolina USA
2. Division of Neurosurgery University of North Carolina School of Medicine Chapel Hill North Carolina USA
3. Division of Child Neurology Nemours Children's Health Wilmington Delaware USA
4. Department of Pediatrics Northwestern University Feinberg School of Medicine Chicago Illinois USA
5. Section of Neurology, Ann and Robert H. Lurie Children's Hospital of Chicago Chicago Illinois USA
Abstract
AbstractObjectiveThe Child Neurology Society 2023 Annual Meeting Neurocritical Care Special Interest Group discussed pediatric opioid use–associated neurotoxicity with cerebellar edema (POUNCE). Inspired by the discussion and the suspicion of an underrecognized severe form of the disorder, we provide a case series and literature review on this important and emerging topic.MethodsThe meeting was moderated by coauthor DSM, with formal presentation by coauthor AG, and supplemented with a supporting case by coauthor VLB. The attendees, by show of hand, were queried for experience with direct care of children in the critical care unit with neurotoxicity from opioid exposure. These meeting elements informed our literature review and case series.ResultsA key focus of the meeting was the importance of interdisciplinary communication regarding POUNCE, emphasizing the necessity for neurosurgical assessment due to mass effect. Approximately 10 of 40 attendees, representing different US hospitals, reported caring for children with opioid neurotoxicity and concern for increased intracranial pressure. Described during the meeting was a 2‐year‐old girl with opioid exposure, rapidly worsening neurological exam, and transforaminal herniation concerning for severe POUNCE syndrome and impact on brain networks by resting‐state functional magnetic resonanance imaging (rs‐MRI). After surgical decompression did not improve her neurological function, she underwent rs‐MRI, electroencephalogram, and MRI. The networks indicated better neurological function than the exam, consistent with outcome. In contrast, the second patient, was an 11‐month‐old boy with fentanyl exposure who was treated for opioid overdose and closely monitored clinically. He did not require surgical intervention and has recovered well.InterpretationThese patients add to the few publications documenting the management of POUNCE, which may require urgent posterior cranial fossa decompression, and highlight the potential for good outcomes. Additionally, this is the first report documenting rs‐fMRI for this condition, which was consistent with the patient's outcome.