Objectives: This study evaluates the diagnostic yield and utilization patterns of head and neck computed tomography angiography (CTAHN) in screening patients in the emergency department (ED) for blunt cerebrovascular injury. This study was conducted at a Level 1 trauma center serving a large geographical area with a high number of regional transfers. This study evaluates the prevalence of CTAHN overutilization in the ED and examines whether diagnostic yield correlates with adherence to the modified Denver criteria, transfer status, and trauma severity. Material and Methods: A retrospective chart review was conducted of patients presenting to the ED between January 01, 2021, and December 31, 2023. Patients over the age of 16 were included in this study if they presented with blunt traumatic injury and subsequently underwent CTAHN or neck CTA (CTAN) imaging during their ED evaluation. A multivariable regression analysis was performed to evaluate the association between CTA yield and factors including patient transfer status, trauma severity designation, and adherence to the modified Denver criteria. Results: A total of 643 patients met the inclusion criteria. A substantial proportion (74.2%) of CTAHN and CTAN examinations yielded negative results, with significant correlation to nonadherence to the modified Denver criteria. We found no significant association between CTAHN yield and transfer status or trauma level designation. Of the patients found to have trauma related actionable findings, 71.8% had adherence to the modified Denver criteria during triage screening. Conclusion: A high proportion of CTAHN and CTAN studies ordered from the ED yield low-value diagnostic results, with overutilization closely linked to nonadherence to the modified Denver criteria. Our findings carry important implications for quality improvement efforts, including unnecessary radiation exposure to patients and reduced efficiency in the ED. Enhanced guideline compliance may serve as a modifiable target to reduce diagnostic imaging overutilization.

Background:Spinal stress fractures are common among young athletes due to high-intensity training and repetitive spinal loading. Elderly individuals also exhibit high rates of spinal fractures, primarily due to age-related bone degeneration. This study aimed to compare fracture severity between pediatric patients experiencing high-energy mechanical injuries and geriatric patients sustaining low-energy injuries. Methods:This 10-year retrospective review included patients from a single center. Pediatric patients (<18 years) were included if they sustained injuries from exercise or motor vehicle collisions and were diagnosed with spinal stress fractures, spondylosis, spondylolisthesis, or spondylolysis. Geriatric patients (>60 years) were included if they had spinal injuries from ground-level falls. Fractures were graded using the arbeitsgemeinschaft für osteosynthesefragen (AO) thoracolumbar classification. Fisher's test, Welch's t-test, and the Mann-Whitney U-test were used to assess statistical differences. Results:Ninety patients were analyzed (47 pediatric, 43 geriatric). No significant difference was found in thoracolumbar grading levels between age groups (P = 0.244), but geriatric patients had significantly higher median injury severity (P = 0.005). All geriatric patients and 92% of pediatric patients had Type A (compression) fractures. A0 fractures were more common in pediatric (30%) than geriatric (7%) patients. A1 fractures occurred in 51% of geriatric and 49% of pediatric patients. A2 fractures were seen in 7% of geriatric patients only. A3 and A4 fractures were more prevalent in geriatric patients (23% and 12%, respectively) than in pediatric patients (16% and 5%). Conclusion:Thoracolumbar fracture patterns were similar between age groups, but elderly patients had more severe subtype injuries, likely reflecting the impact of age-related bone fragility.

Recurrence of tonsillar descent after successful surgical decompression for Chiari malformation type I (CMI) is very rare. Spontaneous intracranial hypotension (SIH) can mimic CMI by causing cerebellar tonsillar descent secondary to low cerebrospinal fluid (CSF) pressure in the thecal sac from a dural defect and CSF leak. We report a case of SIH secondary to spinal CSF leak in a pediatric patient with prior successful and uncomplicated Chiari decompression. The patient’s symptoms and radiographic findings initially mimicked CMI recurrence after 12 years of asymptomatic status; however, further clinical investigation suggested CSF leak and SIH as the cause. The patient was treated with an empirical epidural blood patch, which led to the resolution of symptoms, stabilization of tonsillar position, and syrinx regression. To the best of our knowledge, this is the first case of its kind describing cerebellar tonsillar descent due to spontaneous CSF hypotension in a patient more than a decade after successful surgical treatment for CMI.

BACKGROUND: There is a dearth of literature regarding prognostic and predictive factors for outcome following pediatric decompressive craniectomy (DC) performed after traumatic brain injury (TBI). The aim of this study was to develop a random forest machine learning algorithm to predict outcomes following DC in pediatric patients. METHODS: This multi-institutional retrospective study assessed the 6-month postoperative outcome in pediatric patients who underwent DC. We developed a machine learning model using classification random forest (CRF) and survival random forest (SRF) algorithms for prediction of outcomes. Data on clinical signs, radiographic studies, and laboratory studies were collected. Outcome measures for the CRF model were mortality and good or bad outcome based on Glasgow Outcome Scale at 6 months. A Glasgow Outcome Scale score of double dagger 4 indicated a good outcome. Outcome for the SRF model was mortality during the follow-up period. RESULTS: The study included 40 pediatric patients. Hospital mortality rate was 27.5%, and 75.8% of survivors had a good outcome at 6-month follow up. The CRF model for 6-month mortality had a receiver operating characteristic area under the curve of 0.984, whereas, 6-month good and bad outcomes had a receiver operating characteristic area under the curve of 0.873. The SRF model was trained at the 6-month time point with a receiver operating characteristic area under the curve of 0.921. CONCLUSIONS: CRF and SRF models successfully predicted 6-month outcomes and mortality following DC in pediatric patients with TBI. These results suggest that random forest models may be efficacious for predicting outcome in this patient population.

Background: Peripheral nerve surgeries require extensive practice to address anatomical variability and effectively manage neuropathy symptoms. While these procedures are increasingly performed by other surgical specialists, neurosurgeons bring unparalleled expertise in the central and peripheral nervous systems. Microscopic surgical techniques are essential for minimally invasive procedures, and cadaver-based education provides an invaluable medium for trainees to practice these techniques. However, few papers address these concepts in tandem. This study explores lesser-known peripheral nerve entrapments, highlights minimally invasive microscopic approaches, and advocates for cadaver-based training. Methods: Willed cadavers were embalmed through approved methods by the state anatomical board. For each decompression procedure, a 1–2 cm keyhole incision was made. Further methods are described in each nerve entrapment surgery below. Exploratory sessions with wider incisions were conducted either before or after the minimally invasive procedure to review anatomy or assess procedural success, respectively. Results: Neurosurgical medical education using cadavers allows trainees to practice techniques and enhance their skillset. Cadavers provide a valuable medium for exploring the relevant anatomy and visualizing the correct procedural steps after minimally invasive surgeries. Using microscopes for the procedures further facilitates detailed anatomical observation and technique refinement. Conclusions: Here, we show that cadaver-based medical education offers a realistic and controlled environment for exploring anatomical variability and refining surgical techniques. This method allows for a visual, mental, and tactile understanding, while performing minimally invasive procedures with a microscope on cadavers further enhances trainees’ proficiency, precision, and confidence, equipping them with the skills needed for improved surgical outcomes.

Background: Although uncommon, cerebellar contusions are associated with significant morbidity and mortality. Literature is lacking in the prognostic and morphological factors relating to their clinical picture and outcomes, especially within children. The objective of this study is to evaluate prognostic and anatomic factors in the clinical picture of cerebellar contusions, including effacement of the 4th ventricle and cisterna magna. Methods: This is a retrospective chart review over 11 years across two medical centers. Patients included were under 18 years who presented with a cerebellar contusion. Patients were stratified within the study group based on discharge Glasgow outcome scale (GOS) and reviewed for prognostic factors contributing to outcome. Mid sagittal area of the 4th ventricle and cisterna magna were measured using magnetic resonance imaging and compared within the groups. Results: A total of 21 patients met the study criteria, of which 16 (76.2%) were male, with an average patient age of 8.65 years. Poor outcome at discharge (GOS <4) was associated with decreased admission Glasgow coma scale (P = 0.003), admission motor response (P = 0.006), pupil reactivity (P = 0.014), presence of concomitant subarachnoid hemorrhage (P = 0.010), contusion volume (P < 0.001), and decreased area of the cisterna magna (P = 0.012). Patients with poor outcomes were also more likely to require surgical intervention (P = 0.042). Conclusion: There are multiple prognostic factors associated with the overall outcome following cerebellar contusions. The rate of good outcomes in this study was superior to that in previous studies in adults.

Objectives:A firm understanding of anatomy is foundational for all medical students and residents. As opportunities for cadaveric study dwindle, we propose a simplified perfusion model for formalin fixed cadavers that allow for endoscopic neuroanatomical study and procedural practice. This model is easily accessible, cost effective, and valuable in medical training.Materials and Methods:Cadavers were fixed through accepted methods that included formalin injection into the cranial vault. The perfusion system was set up using a series of catheters, tubing, and pressurized saline bag that forced saline into the various neuroanatomical spaces chosen for study.Results:A neuroendoscope was subsequently introduced to explore and identify relevant neuroanatomical structures as well as to perform a 3rd ventriculostomy and filum sectioning.Conclusion:Using formalin fixed cadavers for neuroendoscopic studies and procedural practice is a cost effective, multipurpose tool that can provide medical trainees with a strong understanding of anatomy as well as procedural practice.

Introduction: Most people who are infected with the novel severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are asymptomatic or present with mild upper respiratory symptoms. This is especially true in the pediatric population; however, rarely, a massive cytokine storm can develop, causing multisystem inflammatory syndrome associated with COVID (MIS-C). Furthermore, children may also suffer from acute ischemic strokes secondary to SARS-CoV-2 infection. Case Presentation: Here, we present a 2-year-old male who was admitted to the hospital with MIS-C and evidence of a previous SARS-CoV-2 infection. On postadmission day 2, the patient was in cardiogenic shock, had acute kidney injury, liver dysfunction, and metabolic acidosis. He had concurrent altered mental status, and his computed tomography scan showed ischemic infarcts in the territory of the right middle cerebral artery and superior cerebellar artery bilaterally. Magnetic resonance angiography confirmed occlusion of the right middle cerebral artery and right superior cerebellar artery. He underwent an emergent decompressive craniectomy due to rapid deterioration and cerebral edema. After the procedure, he continued to improve and was discharged with moderate disability that improved during outpatient rehab. Conclusion: Though rare in children, SARS-CoV-2 can lead to AIS, especially in the presence of underlying risk factors such as MIS-C and hypercoagulopathy. AIS can be associated with severe mortality and morbidity; however, even in this severe case of AIS, the patient was successfully treated with a decompressive craniectomy.

Objective: Although accessory sutures are considered to be relatively rare, the consequences of a missed diagnosis are profound. Distinguishing between accessory sutures and cranial fractures can be difficult, especially in cases of suspected non-accidental trauma. High-resolution imaging is the best way to discern between two- and three-dimensional computerized tomography (3D CT) is considered the preferred method for evaluation. The goal of this study was to determine the impact of 3D CT scans in distinguishing between accessory sutures and cranial fractures in suspected child abuse cases in a rural community and the importance of early detection in such cases, as well as call attention to the consequences of initial misinterpretation. Materials and methods: The researchers conducted a retrospective chart review of all pediatric patients diagnosed with cranial fractures (265 in total) at University Medical Center between May 30, 2016, and May 30, 2021. Initial computed tomography (CT) scans and subsequent 3D CT scans were evaluated for each patient that fit the inclusion criteria, 13 in total. Patients were then categorized into two groups based on the final diagnosis on the radiology report: accessory cranial suture or cranial fracture. Once these patients were identified, the etiology and structural components of each were evaluated, and the key differences were highlighted. Results: Our results showed that, of the 11 cases of suspected non-accidental trauma, six were finally diagnosed with accessory sutures with the use of 3D CT scans, and of those six, four were diagnosed with cranial fractures from the initial CT scan report due to a similar presentation and asymmetric nature. Conclusion: Discerning between fracture and accessory suture is essential in evaluating pediatric patients presenting with signs of cranial fracture due to the increased risk of misinterpretation that can lead to severe legal consequences considering that cranial suture variants may mimic intentional injury and be mistaken for child abuse, causing significant distress for patients and their families.

BACKGROUND:Traumatic brain injury (TBI) is the leading cause of mortality and morbidity in children. Previous studies evaluated outcomes of adult patients; however, few assessed outcomes of pediatric TBI patients presenting with herniation. This study investigated outcome data in pediatric patients presenting with TBI and cerebral herniation and the interventional strategies used for each patient in a rural community. METHODS:A dual-institution retrospective review of 50 pediatric patients presenting with TBI and cerebral herniation from January 2011 to December 2020 was conducted. Mechanism of injury; herniation based on radiology findings; admission, presurgery, and postsurgery Glasgow Coma Scale scores; intracranial pressure values; discharge Glasgow Outcome Scale scores; length of stay; intensive care unit length of stay; procedures performed; and 30-day mortality/morbidity were collected for each patient. RESULTS:Although a nonsurgical approach led to better outcomes (29.4% vs. 48.4% mortality rate), early intervention with decompressive craniectomy improved morbidity in patients with severe TBI and cerebral herniation. Male patients presenting with TBI complicated by herniation were more likely to have a fatal outcome compared with female patients (51.6% vs. 26.3%). Behavior and age at injury may play a role in these differences. CONCLUSIONS:TBI remains a serious concern in the pediatric population with no clear guidelines on the optimal treatment. This study highlights the advantage of integrating more aggressive surgical intervention, such as decompressive craniectomy, in rural communities earlier in the hospital course. Future studies should explore additional factors that could contribute to outcomes in this patient population.

Background: Pediatric cranioplasty is associated with a high rate of complications, including bone resorption (BR) in 20–50% of cases. We aimed to evaluate factors contributing to BR, including the effect of the timing of cranioplasty and the use of post-surgical drains. Methods: This is a dual institution retrospective review of all patients under 18 years old who underwent a cranioplasty following a decompressive craniectomy (DC) for the treatment of traumatic brain injury between 2011 and 2021. Early cranioplasty was defined as within 30 days after DC and late cranioplasty as >30 days. Patients were grouped by BR and separately by timing to cranioplasty. Groups were compared based on the Glasgow Outcome Scale (GOS) and postoperative drain usage. Results: A total of 30 patients were included in the study. The mean age was 7.39 (standard deviation = 6.52) and 60% were male. The median time to cranioplasty was 13 days (interquartile range = 10–17). BR was present in 16.7% of cases. A subgaleal drain was utilized in 93.3% and an external ventricular drain (EVD) in 63.3% of patients following cranioplasty. Drain usage was not associated with BR and timing to cranioplasty was not associated with discharge or 6-month GOS. Conclusion: This study demonstrates that early cranioplasty following DC may have similar outcomes to late cranioplasty. Post-surgical EVDs and subgaleal drains did not increase the incidence of BR, suggesting their importance in the postoperative management of these patients.

Background: Following disc herniations, fragments migrate into the anterior epidural space within the lumbar spine. Although the volume of this area has been previously described in the adult population, the volume is relatively unknown within children.Objectives: Investigate the relative volume in the lumbar anterior epidural space within the growing spine by using imaging studies.Study Design: Retrospective chart review.Setting: University Medical Center in Lubbock Texas. A teaching hospital affiliated with Texas Tech University Health Sciences Center.Methods: We conducted a retrospective review of the charts of pediatric patients seen at our institution from 2018 through 2020. Charts chosen for our investigation contained computed tomography imaging of the lumber spine, showing no deformities. Thirty patients were stratified equally among 3 age groups, 2-5 years old, 10-12 years old, and 16-18 years old. The anterior epidural space was measured in each patient 3 times using the previously reported method used by Teske et al (1). Results were compared with a combination of analysis of variance (ANOVA) and single tail paired t test.Results: There was a statistically significant difference in the anterior epidural space size among age groups at all levels of the lumbar spine. When comparing only 2 groups together, the younger age group had anterior epidural space sizes significantly smaller than the other age group for all levels of the lumbar spine. The 10-12 age group had a significantly smaller space in the anterior epidural space than the 16-18-year olds only at the level of L2, L4, and L5 (P = 0.048,0.039, and 0.031, respectively). Within the 16-18-year age group, the anterior epidural space was significantly different between L4 and L3 and L2 and L3 (P < 0.001 and P = 0.019, respectively).Limitations: Our study is limited by its retrospective nature and the sample size of the patient groups. Furthermore, the use of computed tomography imaging and not making physical measurements limits our accuracy.Conclusion: The volume of the anterior epidural space is smaller in the pediatric population than the adult population. The inability of herniated discs to fit within the epidural space in children and adolescents could potentially be the cause of the increased failure of conservative treatment for pediatric lumbar disc herniations.

Background: Decompressive craniectomy (DC) can be utilized in the management of severe traumatic brain injury (TBI). It remains unclear if timing of DC affects pediatric patient outcomes. Further, the literature is limited in the risk assessment and prevention of complications that can occur post DC. Methods: This is a retrospective review over a 10-year period across two medical centers of patients ages 1 month–18 years who underwent DC for TBI. Patients were stratified as acute (<24 h) and subacute (>24 h) based on timing to DC. Primary outcomes were Glasgow outcome scale (GOS) at discharge and 6-month follow-up as well as complication rates. Results: A total of 47 patients fit the inclusion criteria: 26 (55.3%) were male with a mean age of 7.87 ± 5.87 years. Overall, mortality was 31.9% ( n = 15). When evaluating timing to DC, 36 (76.6%) patients were acute, and 11 (23.4%) were subacute. Acute DC patients presented with a lower Glasgow coma scale (5.02 ± 2.97) compared to subacute (8.45 ± 4.91) ( P = 0.030). Timing of DC was not associated with GOS at discharge ( P = 0.938), 3-month follow-up ( P = 0.225), 6-month follow-up ( P = 0.074), or complication rate ( P = 0.505). The rate of posttraumatic hydrocephalus following DC for both groups was 6.4% ( n = 3). Conclusion: Although patients selected for the early DC had more severe injuries at presentation, there was no difference in outcomes. The optimal timing of DC requires a multifactorial approach considered on a case-by-case basis.

Introduction: Craniosynostosis is a common pediatric presentation in which the premature fusion of one or more cranial sutures results in a misshapen skull. This birth defect is often associated with comorbidities due to structural impacts on nearby anatomical features. While there is some evidence for a male predominance among craniosynostosis patients, little has been investigated regarding sex differences in comorbidities of this condition. This study seeks to explore potential sexual dimorphisms in craniosynostosis patients at the time of presentation. Methods: We conducted a retrospective, cross-sectional review of male and female non-syndromic craniosynostosis (NSC) patients between the ages of 1 month and 9 years that were evaluated at a 500-bed academic hospital or a 977-bed private hospital in Lubbock, TX, USA. Common comorbidities including ophthalmologic diagnoses, developmental delays, obstructive sleep apnea, chronic otitis media, hearing loss, chronic headaches, and seizure disorders were evaluated. The NSC cohort was compared to a similarly aged trauma group that represented the normal population. Results: 175 NSC patients fit the inclusion criteria, of which 109 (62%) were male. A diagnosis of craniosynostosis was significantly associated with ophthalmological diagnoses (p < 0.0001), chronic otitis media (p < 0.0001), developmental delays (p < 0.0001), and hearing loss (p = 0.0047). Male NSC patients were less likely to present with ophthalmological diagnoses (p = 0.0010) or hearing loss (p = 0.0052) than females. Conclusions: Our findings expand on current literature evaluating possible comorbidities of NSC, particularly supporting the association with ophthalmological diagnoses, chronic otitis media, developmental delays, and hearing loss. We also report sex differences in ophthalmological diagnoses and hearing loss for NSC patients. These findings can serve to educate physicians of symptoms requiring prompt recognition and management in these patients.

OBJECTIVE:Chiari I malformation (CM-1), traditionally defined as a descent of the cerebellar tonsils by 5 mm or more, is surgically managed via posterior fossa decompression. However, there is currently no clear radiologic or symptomatic selection criteria for surgical intervention to indicate which patients may see the most improvement following decompression.METHODS:This retrospective pilot study included 22 patients who had symptomatic CM-1 managed via surgical decompression and 22 patients who had nonoperative management of CM-1. Tonsillar motion was assessed using phase-contrast magnetic resonance imaging and 2-dimensional fast imaging employing steady-state acquisition. Both quantitative and qualitative results that best described the CM-1 anatomy, radiologic measurements, and tonsillar motion were obtained and analyzed.RESULTS:Statistical analysis suggested that clinical symptoms differ based on tonsillar motion (P = 0.0044). Surgical patients had significantly more tonsillar motion than nonsurgical patients (P = 0.0010). Among the patients who underwent suboccipital decompression, the presurgery to postsurgery change in clinical symptoms was statistically significant (P < 0.0001), with all clinical symptoms showing decreased prevalence postsurgery. Anterior flow (P = 0.0004) and posterior flow (P < 0.0001) had significant negative associations with tonsillar motion.CONCLUSIONS:Tonsillar motion correlated positively with increased clinical symptoms of CM-1. Furthermore, tonsillar motion was associated with impaired cerebrospinal fluid flow that manifested in increased clinical symptoms. We recommend use of 2-dimensional fast imaging employing steady-state acquisition and assessment of cerebrospinal fluid flow as an adjunct to both clinical judgement and magnetic resonance imaging when selecting patients with CM-1 who would best benefit from surgical decompression.

Chiari malformation Type 1 (CMI) is traditionally characterized as a descent of the cerebellar tonsils more than 5mm below the foramen magnum. In some patients with CMI, there is aberrant pulsatile movement of the tonsils downward during cardiac systole which can affect cerebrospinal fluid (CSF) flow at the foramen magnum. Here, we present an 18-year-old female patient with CMI who presented with worsening symptoms of her CMI. Magnetic resonance imaging (MRI) at this time indicated an increase in cerebellar tonsil movement and decreased CSF flow at the foramen magnum. At her follow-up appointment, she had complete resolution of the aberrant motion of her tonsils and CSF flow returned to baseline without surgical intervention. Her symptoms also improved during this time, and she is now able to be followed by her primary care physician. The increased pulsatile movement of cerebellar tonsils in patients with CMI has been linked to diminished CSF flow at the foramen magnum and symptom severity. Spontaneous resolution of CMI is rare and has only ever been documented as ascension of the cerebellar tonsils. This case describes restoration of normal tonsil movement and baseline CSF flow corresponding with a resolution of symptoms where a complete resolution in tonsillar ectopia was not present.

Choroid plexectomy is a debated surgical intervention for the treatment of hydranencephaly and chronic infected hydrocephalus. We present a case of a 2-year-old with multiple shunt revisions and hydrocephalus secondary to a pilocytic astrocytoma. He presented with new somnolence, vomiting, and abdominal distension 5 months post subtotal tumor resection, with a history of shunt revisions and infections related to his chemotherapy-induced low white blood cell count. He underwent choroid plexus coagulation and resection. Three years post choroid plexectomy, the patient continues to meet neurodevelopmental milestones and is shunt independent. While ventricular shunt placement is the most common course of treatment, choroid plexectomy should be considered as an alternative treatment of hydrocephalus secondary to other neurological disorders, especially when the patient is immunocompromised, to avoid the recurrent infections seen with shunt placement.

Objective Epidural hematoma (EDH), most often caused by rupture of the middle meningeal artery secondary to head trauma with fracture of the temporal bone, is a potentially fatal condition that can lead to elevated intracranial pressure, herniation, and death within hours following the inciting traumatic incident, unless surgical evacuation is accomplished. Several markers have been found to be associated with hematoma expansion in intracerebral hemorrhage (ICH) patients, including: the CT Blend Sign, Swirl Sign, and Black Hole Sign. This study aims to examine these markers, along with intradural air close to or in the region of an EDH and/or close to a significant fracture, fractures involving the skull base, and complicated (i.e., comminuted or displaced) fractures for possible associations to EDH growth in the pediatric population. Predicting hematoma growth is a crucial part of patient management, as surgery can be a life-saving intervention. Methods Scans from all pediatric patients with EDH from 2012 to 2019 across two separate health systems were examined and measurements were taken to determine whether these additional factors are of predictive value. Specifications such as length, transverse, and height measurements were taken from CT images. Statistical Analysis The average percent change in the hematoma measurements was used to determine which predictive factors were associated with a "noteworthy increase," namely, an increase of greater than 25%. Additionally, the average percent change in hematoma size was evaluated for patients whose original imaging showed either all three CT signs or intradural air in all three specified locations. Results Most of the proposed markers were associated with EDH growth in this cohort. The established CT signs were also supported. This is notable, as most of the research on these signs has been in adult populations rather than pediatric. Conclusions Adding these novel imaging signs could aid in the decision to operate on versus observe PEDH patients, thereby preventing unnecessary procedures or preserving brain function quickly when surgery is indicated. This study serves as a starting point for several other investigations into the validity of the proposed markers as well as a reevaluation of the current signs in the pediatric population.

Pigmented epithelioid melanocytomas (PEMs) are low-grade, intermediate-type borderline melanocytic tumors with limited metastatic potential. To date, PEMs have been treated via gross-total resections. Postoperative recurrence and mortality are rare. This case highlights a unique presentation of a PEM that involved bone destruction and intradural infiltration, which required a subtotal resection. To the authors' knowledge, this is the first report of a PEM extending through the dura and necessitating subtotal resection, which is contrary to the standard of care, gross-total resection. Surveillance imaging 10 months after resection remained negative for clinical and radiological recurrence.