Journal of neurosurgery. Pediatrics最新文献

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.

Objective: The aim of this study was to assess the effectiveness of a postoperative multimodal pain control protocol on perioperative pain scores in children undergoing decompression for Chiari type I malformation (CM-I).

Methods: This retrospective matched cohort study included patients < 21 years of age who underwent elective suboccipital craniectomy and C1 laminectomy for CM-I with or without duraplasty at a single center from January 2020 to July 2023. A standardized, multimodal postoperative pain protocol was implemented in August 2021 that did not use narcotic patient-controlled analgesia. Pre- and postprotocol cohorts were compared. The primary outcome was average perioperative pain score. Secondary outcomes included postoperative length of stay (LOS), narcotic usage, and antiemetic usage.

Results: Thirty-four children met the inclusion criteria (17 preprotocol, 17 postprotocol). Fifty-three percent were female (18/34). The mean patient age was 7.0 ± 5.0 years. After implementation of the pain protocol, noninferior average pain scores (p = 0.08) and less antiemetic administration (p = 0.048) were found across both surgery types. Equivalent inpatient LOS (p = 0.78), narcotic prescriptions at discharge (p = 0.73), and milliequivalents of morphine used (p = 0.55) were also found. Bone-only decompression was completed in 65% of patients (n = 22/34, 11 in each pre- and postprotocol group) with 12 of 34 undergoing duraplasty (6 in each pre- and postprotocol group). Patients who underwent posterior fossa decompression with duraplasty had a significantly longer LOS (p = 0.003), more overall narcotic usage (p = 0.015), and lower pain scores (p = 0.047) compared with those who underwent decompression without duraplasty.

Conclusions: Patients undergoing a CM-I decompression had noninferior postoperative pain control and required less antiemetic dosing after implementation of a multimodal pain protocol. Neurosurgeons should consider a postoperative multimodal pain regimen for their patients with CM-I who undergo decompression with or without duraplasty.

Objective: Ventricular shunt insertion is a common procedure in pediatric neurosurgical practice. In many areas of medicine there is a push toward rationalization of healthcare resources and a reduction in low-value tests or procedures. The intraoperative sampling of CSF at the time of shunt insertion is one traditional aspect of care that has not been rigorously evaluated. Additionally, the role of CSF cell counts and chemistry in predicting shunt dysfunction is often discussed but poorly studied. A recent meta-analysis found a correlation between elevated CSF protein levels and shunt failure in patients with tuberculous meningitis, but not other pathologies, which limits the generalizability of those findings to Western populations. The aims of this study were to assess the clinical utility of intraoperative CSF sampling during insertion of ventricular shunts and to describe any association of routine intraoperative CSF sample parameters with shunt failure or infection.

Methods: A retrospective review of a prospectively maintained surgical database covering 10 years of consecutive cases from a quaternary Australian pediatric neurosurgical center serving a population of 5.3 million was conducted. Statewide electronic medical records were reviewed to collate data on demographics, postoperative imaging, CSF biochemistry, instances of shunt failure, shunt revisions, and mortality. Patients undergoing insertion of a new ventricular shunt were included, while all cases of shunt revision were excluded.

Results: During the study period, 1485 shunt procedures were performed, of which 427 involved the placement of a new ventriculoperitoneal shunt system. The mean patient age was 5.2 years (range premature-18 years). Of the 427 cases, 377 (88%) underwent routine CSF sampling. The most common indications for shunt revision were proximal catheter obstruction (51/173, 29%), followed by infection (29/173, 17%) and valve blockage (23/173, 13%). During the study period, 3 patients with existing intracranial hardware had overt ventriculitis identified at the time of intraoperative sampling, resulting in shunt removal. One patient with an existing ventricular reservoir had a delayed clinically significant infection identified on intraoperative cultures. Elevated CSF protein levels were associated with shunt failure during follow-up (area under the curve 0.625). The identified cutoff of 300 mg/L was significantly associated with a reduced time to shunt failure in both univariate and multivariate analyses.

Conclusions: It may be reasonable to consider omission of routine intraoperative CSF sampling at the time of shunt insertion in patients without existing intracranial hardware. Elevated CSF protein levels are associated with a reduced time to shunt failure in a dose-dependent manner.

Objective: CSF leaks are a significant source of patient morbidity following intradural spine surgeries. Watertight dural closure is crucial during these procedures to minimize the risk of a CSF leak. This study reports postoperative outcomes and changes in patient management after switching to penetrating titanium clips for dural closure in a large cohort of pediatric patients receiving a tethered cord release (TCR) or a selective dorsal rhizotomy (SDR).

Methods: An IRB-approved retrospective review was conducted of the medical charts of all patients who underwent thoracolumbar dorsal midline dural closure with the AnastoClip GC Closure System during the 7 years between May 22, 2017, and May 21, 2024. Selected data such as evidence of a CSF leak and postoperative length of stay were collected.

Results: A total of 290 patients were treated with AnastoClips GC for dural closure. Of these patients, 232 (80.0%) underwent a TCR only, 52 (17.9%) received an SDR, and 6 (2.1%) underwent a complex TCR. The mean duration between surgery and last follow-up was 7.96 months (range 0.27-54.57 months). One patient, who received a simple TCR, experienced a transient pseudomeningocele without headache, emesis, or visible leak that resolved without surgical intervention within 8 weeks. Three (1%) patients had positional headaches without other evidence of a CSF leak, all limited to the initial 2 weeks of postoperative care. Six (2%) patients had delayed wound healing, 2 of whom underwent operative wound revisions. As of January 1, 2021, patients no longer had to lie flat postoperatively. While 60.6% of TCR patients were discharged from the hospital on POD 1 (none on POD 0) prior to this date, 87.5% of patients were discharged from the hospital on either POD 0 (3.1%) or POD 1 (84.4%) afterward. Similarly, 50% of SDR patients were discharged on POD 2 or 3 after the need for lying flat postoperatively was removed versus 21% before the protocol change.

Conclusions: AnastoClip GC Closure System titanium clips are safe and effective for dural closure in both TCR and SDR, with rare complications. Their efficacy has prompted us to remove flat bed rest requirements for postoperative patients, significantly reducing the length of stay, and has opened the door to making simple TCRs a same-day surgery.

Objective: The natural history of cephaloceles is not well understood. The goal of this study was to better understand the natural history of fetal cephaloceles from prenatal diagnosis to the postnatal period.

Methods: Between January 2013 and April 2023, all patients evaluated with a cephalocele at the Center for Fetal Diagnosis and Treatment were identified. All patients underwent prenatal and postnatal MRI. Demographic and imaging covariates were obtained from the electronic medical record. Volumetric analyses were performed to determine the percentage of neural tissue within the cephalocele. Progressive herniation was defined as an increase in cephalocele absolute neural tissue volume ≥ 5% or new herniation of an additional intracranial structure into the cephalocele.

Results: A total of 25 patients met the inclusion criteria. Of these patients, 6 (24%) exhibited progressive cephalocele herniation from the prenatal to postnatal MRI. The median sac volume was 2.2 mL (mean 6.2 mL, range 0.3-40.5 mL). The median change in brain volume in the patients with cephalocele progression was a decrease of 1.5% (mean -7.3%, range -36.4% to 3.1%). Cephalocele sac volume at the time of fetal imaging was predictive of progressive herniation, which persisted on multivariate analysis when controlling for gestational age, sex, and percentage of herniated neural tissue. While 44% of the patients had ventriculomegaly, 56% ultimately required permanent CSF diversion.

Conclusions: Progressive neural herniation from the fetal to postnatal period is not commonly seen in fetal cephaloceles. Sac volume is associated with an increased risk of progressive herniation into the cephalocele.

Objective: While the association of a syrinx with a tethered spinal cord in the context of VACTERL (vertebral defects [V], imperforate anus or anal atresia [A], cardiac malformations [C], tracheoesophageal defects [T] with or without esophageal atresia [E], renal anomalies [R], and limb defects [L]) association is known, the incidence of idiopathic syrinxes among these patients has not previously been reported. The authors aimed to characterize the incidence of syrinxes and the pattern of congenital anomalies in pediatric patients with VACTERL association, with a specific focus on the presence of idiopathic syrinxes in this population.

Methods: An institutional database was retrospectively queried for all pediatric patients with VACTERL association. Patients were assessed for the presence of a syrinx. Those with no accompanying lesion to which the syrinx could be ascribed were designated idiopathic. Descriptive statistics and qualitative analyses characterized the clinical presentation and outcomes of this population.

Results: The authors retrospectively identified 186 patients between 1993 and 2023 with VACTERL association. Of these 186 patients, 141 (75.8%) had a tethered spinal cord and 44 (23.7%) had a syrinx. Most syrinxes could be ascribed to the presence of a tethered spinal cord and/or Chiari malformation; however, 4 (9.1%) of the 44 appeared idiopathic, suggesting the incidence of idiopathic syrinxes in this patient population may be as high as 2.2% (4/186). Most patients remained asymptomatic aside from a single patient who presented with mild gait dysfunction that resolved over time. All syrinxes were managed conservatively, and all but one decreased or remained stable in size on follow-up imaging.

Conclusions: Although limited, current estimates suggest the general incidence of an idiopathic syrinx is between 5.6 and 8.4 per 100,000 people; these findings in a pediatric cohort with VACTERL association suggest an incidence of 2200 per 100,000 (i.e., 2.2%). Thus, an idiopathic syrinx may be 200-400 times as prevalent in the pediatric VACTERL population.

Objective: Patients with drug-resistant epilepsy (DRE) are often referred for phase II evaluation with stereo-electroencephalography (SEEG) to identify a seizure onset zone for guiding definitive treatment. For patients without a focal seizure onset zone, neuromodulation targeting the thalamic nuclei-specifically the centromedian nucleus, anterior nucleus of the thalamus, and pulvinar nucleus-may be considered. Currently, thalamic nuclei selection is based mainly on the location of seizure onset, without a detailed evaluation of their network involvement. This study aimed to prospectively assess the involvement of thalamic nuclei in seizure propagation during the SEEG evaluation in pediatric patients with DRE.

Methods: This prospective study investigated the placement of thalamic electrodes during the SEEG phase II evaluation in pediatric patients. Following a phase I presurgical evaluation, patients were presented at a comprehensive epilepsy conference, where recommendations for SEEG evaluation were made. In cases in which neuromodulation was a potential outcome, thalamic nuclei were prospectively selected in 10 patients based on a preimplantation hypothesis. During the SEEG evaluation, electrical activity recorded from the thalamic electrodes was analyzed. If the patient went on to undergo neuromodulation, the recorded data guided the thalamic target selection.

Results: Ten patients underwent implantation of 14 thalamic electrodes during SEEG implantation. No surgical complications were associated with either the placement or removal of these electrodes. Video-EEG analysis performed during the interictal period was unremarkable in 4 patients and revealed network spikes in 6 patients. These networks describe brain regions that may be connected structurally and functionally. Electrographic seizure onsets in thalamic contacts were simultaneous with cortical onset in 3 patients, early in 5, late in 1, and not involved in 1 patient. Seventy-two of the 109 seizures (66%) captured during SEEG involved thalamic contacts. Seven patients underwent neuromodulation after SEEG revealed an extensive network, rather than a focal onset, which precluded focal surgical resection. In all 7 of these patients, thalamic SEEG results were instrumental in guiding final neuromodulation targets chosen for implantation.

Conclusions: In pediatric patients without a single resectable focus as a cause of their DRE, thalamic implantation during phase II SEEG evaluation is both safe and effective for assessing thalamic nuclear network involvement. This information could be instrumental in selecting thalamic nuclei for neuromodulation, allowing for a more individualized approach to treatment.