Journal of neurosurgery. Pediatrics最新文献

Objective: Endoscopic sagittal suturectomy (ESS) is commonly offered for sagittal craniosynostosis in infants, but the optimal timing of surgery remains controversial, with many clinicians only offering ESS surgery before 3 months of age. This study investigated whether patient age predicts craniometric correction and, more specifically, whether patients > 3 months of age at surgery manifest less correction. The effects of age on blood transfusion were also investigated.

Methods: A single-center retrospective review identifying patients with sagittal craniosynostosis who underwent ESS between 2009 and 2023 at Children's National Medical Center was performed. The authors stratified patients by age groups to compare outcomes and transfusion rates. Additionally, receiver operating characteristic (ROC) area under the curve (AUC) analysis was performed to identify optimal age cutoffs.

Results: In total, 107 patients were included. Stratifying age group by 0-2 months, 2-3 months, and > 3 months revealed that the > 3-month age group was less likely to achieve the target cephalic index (CI) at the final follow-up (48.8% vs 61.5% vs 25.0%, p = 0.031) and had less mean percentage CI change at the 6-month follow-up (17% ± 8% vs 18% ± 8% vs 12% ± 6%, p = 0.011), helmet discontinuation (18% ± 9% vs 18% ± 8% vs 12% ± 6%, p = 0.008), 1-year follow-up (15% ± 9% vs 17% ± 7% vs 10% ± 7%, p = 0.005), and final follow-up (14% ± 9% vs 15% ± 7% vs 8% ± 7%, p = 0.004). There were no differences in outcomes between groups when stratified as 0-2 months versus > 2 months of age. The only difference in outcomes between groups when stratified as 0-3 months versus > 3 months of age was the mean percentage change in CI at helmet removal (18% ± 8% vs 15% ± 7%, p = 0.044). Patients requiring transfusion were likely to be younger (median age 2 vs 3 months, p = 0.028). ROC curve analysis identified an age cut-point of 3.75 months as optimal for achieving the target CI correction at the final follow-up (AUC 0.58) and 2.75 months for transfusion avoidance (AUC 0.65).

Conclusions: Patients > 3 months of age may benefit from ESS for sagittal craniosynostosis. Further investigation is warranted to identify the optimal age for surgery and to investigate other variables influencing outcomes.

Objective: Combined sagittal and unilateral coronal synostosis is an uncommon multisuture synostosis. The objective of this study was to describe patient demographics, characterize craniofacial morphology, and report surgical outcomes for patients with combined sagittal and unilateral coronal synostosis undergoing surgical repair.

Methods: This was a retrospective cohort study performed as a joint effort between two US pediatric tertiary care institutions. Between 2003 and 2021, 10 patients with combined sagittal and unilateral coronal synostosis who underwent surgical repair were identified. Open repair involved fronto-orbital advancement and calvarial remodeling. Endoscopic repair involved endoscopy-assisted strip craniectomy of fused sutures with subsequent helmet therapy until 12 months of age. Craniofacial morphology was characterized from CT scans with parameters including the cephalic index (CI), orbital index (OI) asymmetry, nasal tip deviation, chin deviation, and anterior cranial fossa area ratio (ACFR). All patients had preoperative CT scans, and postoperative CT scans were analyzed when performed. Demographics, operative details, and complications were obtained via chart review.

Results: Patients were predominantly male (70%) with fusion of left coronal suture (80%). Four patients (40%) underwent open repair, and 6 patients (60%) underwent endoscopic repair. The median operation length was 87 minutes for endoscopic repair and 226 minutes for open repair. Two endoscopic patients (33%) and 2 open patients (50%) required blood transfusion. Four patients (3 endoscopic, 1 open) underwent secondary operations. Preoperatively (n = 10), patients had a median CI of 0.75, with OI asymmetry (median -35%), nasal tip (median 6.9°) and chin deviation (median 9.5°) contralateral to the involved coronal suture, and cranial base asymmetry (median ACFR 0.63). Postoperatively (n = 6), patients had improved CI (median CI 0.81), OI asymmetry (median -22%), chin deviation (median 5.1°), and cranial base asymmetry (median ACFR 0.75) but slightly worse nasal tip deviation (median 8.5°).

Conclusions: Combined sagittal and unilateral coronal synostosis resembles its isolated component phenotypes. Open and endoscopic repairs are safe. Morphological parameters trended toward improvement postoperatively.

Objective: Pediatric head trauma is a common reason for emergency department (ED) referrals. Skull fractures are the most common imaging findings in the setting of pediatric trauma. Ample literature negates the necessity of hospitalization for neurologically intact children with isolated skull fractures (ISFs) and when nonaccidental injuries (NAIs) are not suspected. Despite this evidence, in many centers these children are still admitted for observation. The authors performed a retrospective analysis of the outcomes of children admitted with ISFs. A literature review of studies of children with ISFs was also performed. The objective of this study was to assess the necessity of admission of children with ISF.

Methods: A retrospective single-center analysis was performed, based on the electronic referral database of a tertiary pediatric hospital. Pediatric patients (< 18 years old) with a linear skull fracture on CT were included. Patients with additional traumatic intracranial findings on imaging (bleeding, pneumocephalus, edema, etc.) were excluded, as were patients with depressed, open, or displaced fractures. A systematic literature review of the Medline and PubMed databases was performed.

Results: Two hundred fifty-eight children met the criteria between 2019 and 2022. Eighty-one percent sustained a fall. Other mechanisms of injury included blunt-force trauma and road accidents, and 10.5% had an unclear mechanism. Most children had parietal fractures (56.3%), followed by occipital fractures and others. Sixteen percent suffered from chronic illnesses. No cases of growing skull fractures were noted. None of the children needed neurosurgical intervention. Moreover, none needed a follow-up CT scan. Three patients were transferred from a first-tier hospital to the authors' institution, none because of neurosurgical concerns. Other than these 3 patients, all other children were admitted to a pediatric ward for 24-hour observation and subsequently discharged. NAI was highly suspected in 7.1% of children (3/42) suffering from chronic illnesses as opposed to 1.4% (3/216) of healthy children. This difference was not statistically significant (p = 0.056). The literature review yielded 680 papers. After screening for relevance, language, etc., 8 original series with 5823 patients remained. One patient (0.017%) was operated on, but probably not for ISF. The cost difference between discharge from the ED and admission ranged between $520 and $4291 (US dollars). None of the children discharged from the ED returned for hospitalization.

Conclusions: In this original cohort, none of the children had a change in management following their admission. None needed neurosurgical intervention. In children with linear ISFs, a short ED observation should be considered, followed by discharge based on neurological status. A proposed ED discharge protocol is presented.

Objective: There are significant challenges in the surgical management of pharmacoresistant epilepsy. Laser interstitial thermal therapy (LITT) has emerged as a less invasive alternative to resection. However, seizure persistence or recurrence following LITT is not uncommon, and there is currently a lack of guidance and consensus on the best way to manage seizure recurrence after LITT for different epilepsy etiologies in children, or for the use of LITT when open resection has left residual epileptogenic tissue. The objective of this study was to assess the outcomes of secondary epilepsy surgery after failed initial LITT.

Methods: The authors performed a retrospective chart review of patients who underwent secondary epilepsy surgery after failed LITT at Children's National Hospital.

Results: A total of 36 patients were treated with LITT, and 4 were excluded due to the palliative purpose of LITT. Thirteen of 32 patients (40.6.%) achieved Engel I, 1 patient (3.1%) achieved Engel II, and 18 patients (56.2%) had poor outcomes (Engel III-IV). Of these 32 patients, 9 (28.1%) underwent reoperation after their first laser ablation surgery due to a recurrence of epilepsy. Seven patients had a second laser ablation, and 2 patients underwent open resection. Of these 9 patients, 3 (33.3%) had Engel I outcomes, and 6 (66.7%) had poor seizure outcomes (Engel III-IV). When considering only patients who had repeat LITT for reoperation, 2 of 7 (28.6%) of these patients achieved seizure freedom (Engel I). Of the 32 patients, short-term complications were transient oculomotor (n = 1, 3.1%) or trochlear (n = 1, 3.1%) nerve deficit, which entirely resolved within 6 months, and superior quadrantanopia (n = 1, 3.1%) after initial LITT.

Conclusions: Although LITT has shown promising results in treating pharmacoresistant epilepsy, the recurrence of seizures necessitates further evaluation and consideration of reoperation, which may result in seizure freedom. Repeat LITT is a low-risk option for secondary surgery after seizure recurrence.

Objective: Conditional survival incorporates the effect of time passed since an event to current data in an easy-to-understand, relevant format. Data from the Hydrocephalus Clinical Research Network (HCRN) registry were analyzed with conditional survival to improve patient and family counseling after hydrocephalus treatment.

Methods: Children with hydrocephalus who underwent first-time treatment by a single proximal catheter ventriculoperitoneal shunt (VPS) or endoscopic third ventriculostomy (ETV) with or without choroid plexus cauterization with at least 3 years of follow-up in the prospective HCRN registry (14 sites, April 24, 2008-December 31, 2020) were included. Those with nonperitoneal or multiple proximal catheters were excluded. The probability of failure-free survival at 3, 5, and 10 years was calculated as a function of time since surgery.

Results: Overall, 5782 patients were included (1609 with ETV, 4173 with VPS placement). The median time to censoring was 5.3 years. The overall respective 3-, 5-, and 10-year failure-free survival rates were 59%, 58%, and 57%, respectively, for ETV and 62%, 58%, and 54%, respectively, for VPS. If VPS failure had not occurred by 1 year postoperatively, the 3-, 5-, and 10-year failure-free survival rates were 85%, 79%, and 66%, respectively. If ETV failure had not occurred by 1 year, the 3-, 5-, and 10-year failure-free survival rates were 93%, 91%, and 86%, respectively. Conditional survival also varied by age and etiology.

Conclusions: Patients who do not require revision surgery in the 1st year have an excellent chance of being revision free for an extended period. Conditional survival plots provided are intuitive and can be used in the counseling of North American patients with surgically treated hydrocephalus.

Objective: Pediatric hydrocephalus is a common complex condition, in which late diagnosis can cause irreversible sequelae. The prevalence worldwide is estimated to be approximately 88/100,000, but the literature suggests it is higher in developing countries, with predominantly postinfectious etiologies. The incidence has been found to be inversely associated with a country's income level. South America is among the regions considered most affected by this disease, but very few recent prevalence studies exist. This is the first prevalence study of pediatric hydrocephalus in Colombia, an upper-middle-income country. This study aimed to estimate the prevalence of pediatric hydrocephalus (ages 0 to 17 years) in Colombia between 2017 and 2022 and to determine its national distribution.

Methods: A search of the Colombian System of Integrated Information of Social Protection was performed, using International Classification of Diseases, 10th Revision codes to extract the Individual Registries for Provision of Health Services. These data were compared to those in the population registries of the National Administrative Department of Statistics. Prevalence for each code was calculated, and distribution according to age group, sex, and department was made. Yearly and overall prevalence rates were graphed on nationwide maps throughout the study period years.

Results: The authors found a nationwide prevalence of 57.2/100,000, with an underreporting rate for all cases of 31.3%. The adjusted prevalence for underreporting was 83.0 cases per 100,000. A total of 55% of cases were in male patients. The reported causes of hydrocephalus were as follows: 24.9% of cases were due to postinfectious etiologies, 9.9% were attributed to CNS malformations, 0.3% were posttraumatic, and 0.3% were neoplastic. In most cases, etiology was not reported. The maps created show a heterogeneous prevalence distribution through the years. The adjusted prevalence rate map shows a prevalence distribution with higher rates in lower-income regions.

Conclusions: In this study, the estimated prevalence of pediatric hydrocephalus in Colombia was lower than the prevalence estimated worldwide, and even lower than that estimated for high-income areas. This is explained partially by a significant rate of underreporting; however, even accounting for the underreporting, the prevalence remains considerably lower than that estimated for developing regions like South America. This may suggest a trend of decreasing prevalence in developing countries whose economies have grown in recent years. These findings can guide public policy for adequate surveillance and prevention of pediatric hydrocephalus in Colombia and highlight the importance of further updated research in the region.

Objective: This study investigated neurodevelopmental outcomes in preterm neonates with posthemorrhagic hydrocephalus (PHH), focusing on the comparative effectiveness of temporary and permanent CSF diversion strategies.

Methods: This multicenter prospective observational cohort study (2012-2021) involved preterm infants diagnosed with PHH who underwent either initial permanent or temporary CSF diversion. Patients were assessed using the Bayley Scales of Infant and Toddler Development, Third Edition (BSID-III), at 15-30 months and, when possible, at 36-42 months of corrected age. Statistical analyses included univariable and multivariable regression models to examine the associations between BSID-III scores and various treatment and patient factors.

Results: Among 106 patients, 15 (14%) underwent initial permanent CSF diversion, while 91 (86%) received temporary diversion. Patients who underwent permanent diversion had lower cognitive scores (58.2 ± 5.7) compared to those temporized (69.0 ± 15.9) (p = 0.01). Temporized patients who later required conversion to permanent diversion demonstrated poorer composite (66.6 ± 18.0 vs 79.9 ± 18.8, p = 0.02), expressive (4.6 ± 3.2 vs 7.0 ± 3.7, p = 0.03), and receptive (4.2 ± 3.3 vs 6.1 ± 3.0, p = 0.04) language scores compared to those weaned from temporary CSF diversion. No significant difference in outcomes was observed between patients temporized with a ventriculosubgaleal shunt versus a ventricular reservoir. Ventricle size at the time of initial CSF diversion was not associated with BSID-III scores. However, univariable analysis showed that a larger ventricle size at the time of conversion to permanent diversion was associated with lower neurodevelopmental scores across all domains. Multivariate analysis, adjusting for intraventricular hemorrhage (IVH) grade, complex chronic conditions, and postmenstrual age, revealed that larger ventricle size at the time of conversion correlated negatively with composite motor (effect size -0.47, CI -0.82 to -0.11, p = 0.01) and fine motor (-0.08, CI -0.15 to -0.01, p = 0.03) scores.

Conclusions: This study suggested that the choice between permanent and temporary CSF diversion as initial treatments may affect neurodevelopmental outcomes in preterm neonates with PHH, which are influenced by IVH severity and timing of intervention. The findings support early temporization and avoiding delays to optimize permanent shunting. Monitoring ventricular size closely during this phase is critical, as larger ventricular size at the time of conversion is associated with poorer outcomes. These results highlight the necessity for adapting treatment strategies on the basis of individual patient characteristics, responses, and progress in managing PHH.

Objective: The current neurosurgical treatment for intraventricular hemorrhage (IVH) of prematurity resulting in posthemorrhagic hydrocephalus (PHH) seeks to reduce intracranial pressure with temporary and then permanent CSF diversion. In contrast, neuroendoscopic lavage (NEL) directly addresses the intraventricular blood that is hypothesized to damage the ependyma and parenchyma, leading to ventricular dilation and hydrocephalus. The authors sought to determine the feasibility of NEL in PHH.

Methods: The records of patients with a diagnosis of grade III or IV IVH were reviewed between September 2022 and February 2024. The Papile grade was determined on cranial ultrasonography. Demographic information collected included gestational age, birth weight, weight at the time of surgical intervention, infection confirmed with CSF, and rehemorrhage. Standard local guidelines for temporary (CSF reservoir) and permanent (shunt or endoscopic third ventriculostomy [ETV]) CSF diversion were implemented. Warmed lactated Ringer's was utilized for NEL. The primary outcome was the need for permanent CSF diversion (shunt or ETV).

Results: Twenty consecutive patients with grade III or IV IVH complicated by PHH were identified. Twelve patients underwent CSF reservoir placement and NEL, 4 underwent CSF reservoir placement only, 1 underwent shunt placement only, and 3 did not require neurosurgical intervention. Of the 12 patients who underwent reservoir placement and NEL, 8 (67%) ultimately met criteria for permanent CSF diversion compared with 2 of 4 (50%) who underwent CSF reservoir placement only. The mean gestational age at birth, birth weights, and age/weight at time of temporary CSF diversion were similar across groups. The average time interval between temporary and permanent CSF diversion was longer in patients who underwent NEL (2.5 months for shunt and 6.5 months for ETV) compared with CSF reservoir placement only (1.1 months).

Conclusions: NEL is an innovative alternative for the treatment of PHH of prematurity. The authors established an endoscopic lavage program at their institution and herein report the first published account in the United States of the feasibility of NEL for PHH.