Journal of neurosurgery. Pediatrics最新文献

Objective: Limited data exist regarding the outcomes of early decompressive craniectomy (DC) in pediatric patients who have sustained severe traumatic brain injury (TBI). In this study, using data from the Approaches and Decisions in Acute Pediatric TBI Trial (ADAPT), the authors' primary hypothesis was that there was no significant difference in long-term outcomes in children who underwent early versus late DC following severe TBI.

Methods: All pediatric patients with severe TBI who underwent DC within the first 7 days of their ICU stay were included in this study. Early DC was defined as a DC performed within 24 hours of admission. Late DC was defined as DC performed after 24 hours. A propensity score-matching methodology was used to analyze the results.

Results: Of the 1000 enrolled patients in the ADAPT, 273 patients qualified for this study. Propensity score matching created 44 pairs of patients. Pair-matched analysis showed no significant difference in in-hospital mortality (5 [11.4%] vs 6 [13.6%], p > 0.99), 30-day mortality (4 [9.1%] vs 5 [11.4%], p > 0.99), and 60-day mortality (6 [13.6%] vs 5 [11.4%], p > 0.99) between the early and the late groups. The 6-month Glasgow Outcome Scale-Extended (GOS-E) score (favorable scores 1-4: 14 [42.4%] vs 10 [27.8%], p = 0.306) between the groups was similar. There were no significant differences identified between the groups regarding the ICU stay (median [95% CI] 15 [13-21] vs 15 [13-22] days, p = 0.558). There was a significant difference between early and late DC in hospital length of stay (median [95% CI] 24 [18-30] vs 31 [19-39] days, p = 0.049).

Conclusions: Early DC did not show any significant long-term benefit in terms of mortality or GOS-E score but resulted in a shorter hospital length of stay.

Objective: Cerebral cavernous malformations (CCMs) are groups of blood vessels that develop abnormally in both the brain and/or spinal cord. Currently, MRI and/or CT are the primary methods for assessing CCMs. Plasma-based biomarkers could serve as a complement to standard imaging techniques by providing a quantitative and molecular-based technique to detect disease at lower cost. Therefore, the authors evaluated cell division cycle 42 binding protein beta (CDC42BPB) as a potential novel plasma biomarker for CCMs.

Methods: Plasma samples were obtained from patients with pathological analysis-confirmed CCM (n = 10, age 1-16 years) and compared to controls (n = 24, age 1-19 years). The protein levels were measured using the Olink Proximity Extension Assay. Findings were confirmed with ELISA. CDC42BPB expression was further analyzed with Western blot and immunohistochemistry analysis in patient-derived primary cells and CCM tissues, respectively.

Results: CCM patients exhibited significantly higher CDC42BPB plasma levels compared to controls (approximately 6-fold greater expression, p = 0.004). Furthermore, the high CDC42BPB plasma expression was concordant with the protein levels in CCM tissues and patient-derived primary cells.

Conclusions: The authors present data supporting the measurement of CDC42BPB plasma level as a putative biomarker for CCMs. These findings have implications relevant to improving diagnosis, follow-up, and molecular pathophysiological analysis.

Objective: Up to 30% of children with focal epilepsy have drug-resistant epilepsy and may be candidates for epilepsy surgery. Intraoperative electrocorticography (iECoG) is a method to acutely delineate the epileptogenic zone during epilepsy resections, but its effectiveness is debated. The authors assessed the association between iECoG findings and seizure outcomes in pediatric epilepsy patients undergoing resective epilepsy surgery.

Methods: The authors conducted a retrospective cohort analysis of 115 patients at UPMC Children's Hospital of Pittsburgh who underwent resective epilepsy surgery for focal epilepsy. They assigned patients to subgroups based on the extent of resection in concordance with iECoG findings. Patients in group A had postresection iECoG without epileptiform activity at the margins. Patients in group B had persistent epileptiform activity on postresection iECoG and underwent an extended resection. Patients in group C had persistent epileptiform activity on postresection iECoG, but further resection was contraindicated due to involvement of eloquent cortex.

Results: The primary outcome was seizure freedom at 1 year (Engel class I), which was achieved in 64% (n = 74) of all patients; however, there was no statistically significant difference in seizure freedom or antiseizure medication reduction between the three groups. Notably, there was also no significant relationship between patient group and transient or long-term postoperative complications, such as unexpected postoperative deficits, infection, or symptomatic intracranial hemorrhage.

Conclusions: The authors found no statistically significant difference between groups A, B, and C regarding postoperative seizure reduction and freedom. While iECoG provides a biomarker for the purposes of resection, in this cohort, iECoG findings were not associated with postoperative seizure freedom.

Objective: Responsive neuromodulation with the Responsive Neurostimulation (RNS) System is an important treatment option for pediatric patients with drug-resistant epilepsy. Early reports on seizure reduction and safety have been encouraging, but there is a need for greater understanding of evolving indications, treatment approaches, and outcomes in this population. The authors report patient characteristics, adverse events, seizure outcoames, quality-of-life outcomes, and programming details for young patients treated at their institution, focusing on pediatric outcomes.

Methods: A retrospective review of all patients treated in the Massachusetts General Hospital Pediatric RNS Clinic between August 2020 and January 2025 was conducted. Clinical characteristics, seizure frequency, and programming parameters were collected for each patient. Primary outcome was seizure response at 12 months after implantation. Secondary outcomes included seizure response at last follow-up, change in antiseizure medications at last follow-up, responses to a questionnaire focused on quality of life at last follow-up, and adverse surgical or stimulation-related events.

Results: Thirty-two patients underwent RNS implantation (63% female, mean [range] age 15 [6-28] years) with a median follow-up of 24 months, including 27 children ≤ 18 years (47% female) with median follow-up 22 months. RNS targets were bilateral thalamic (n = 24), cortical (n = 3), hippocampal (n = 2), and corticothalamic (n = 3). No surgical complications occurred. Stimulation-related adverse effects occurred in 44% of patients (36% pediatric). Among patients with at least 1 year of follow-up (n = 24 [19 pediatric]), the responder rate at 12 months was 79% (74% pediatric), with median 78% seizure reduction (p = 0.0003) (pediatric 73%, p = 0.0097). At last follow-up, the responder rate was 92% (89% pediatric), with 91% median seizure reduction (p = 0.0002) (pediatric 90%, p = 9.9 × 10-8); 54% of patients were super responders (53% pediatric). No clinical characteristics evaluated were significantly different between responders and nonresponders. Patients reported significant improvements in quality of life across categories related to physical activities and activities of daily living (p = 0.003, pediatric p = 0.009), cognition and school (p = 0.0006, pediatric p = 0.001), social and mood (p = 0.03, pediatric p = 0.05), and seizures (p = 1.8 × 10-6, pediatric p = 1.3 × 10-5).

Conclusions: The authors' cohort of young patients with severe drug-resistant epilepsy from a variety of etiologies experienced comparable improvements in seizure control at 12 months to that reported in adults at 9 years. Patients also reported improvements in quality of life. These robust outcomes may be due to empirical targeting of patient-specific seizure networks and rapid escalation of therapy to higher treatment parameters.

Objective: There has been a trend toward opioid-sparing anesthesia in recent years, for which the long-term impact on the incidence of chronic postsurgical pain (CPSP) has not been elucidated. Therefore, the primary objective of this study was to determine if a change in opioid-sparing intraoperative management influenced the rate of CPSP in children who underwent posterior spinal fusion (PSF) for adolescent idiopathic scoliosis (AIS).

Methods: This retrospective cohort was derived from the electronic medical records at Texas Children's Hospital from patients who underwent PSF for AIS from January 1, 2012, through July 2, 2024. The primary outcome was the incidence of CPSP at the 12-week follow-up visit and requiring regular use of nonopioid analgesics. Secondary outcomes included hospital length of stay (LOS) and postoperative opioid consumption expressed as oral morphine equivalents (OME) per kilogram. The exposure was the use of an opioid as a continuous infusion during the intraoperative period.

Results: The authors identified 774 patients who met inclusion criteria, of whom 162 (20.9%) reported CPSP with continued analgesic use at 12 weeks postoperatively. The incidence of CPSP was not associated with the use of opioids as a continuous infusion intraoperatively when compared with nonopioid infusion management (OR 1.32, 95% CI 0.87-1.99; p = 0.19). Opioid infusion was associated with a reduced LOS (mean 4.4 vs 4.1 days, p < 0.001; Cohen's d = -0.28; 95% CI -0.43 to -0.13) and increased total postoperative opioid consumption (mean 4.9 vs 3.9 mg/kg OME p < 0.001; Cohen's d = 0.35, 95% CI 0.20-0.50) when compared with nonopioid infusion management. Preoperative back pain and female sex were independently associated with CPSP (OR 2.03, 95% CI 1.39-2.96, p < 0.001 and OR 1.93, 95% CI 1.17-3.19; p = 0.01, respectively).

Conclusions: The findings of this study suggest that intraoperative opioid administration by continuous infusion after PSF for AIS was not associated with an increased risk of CPSP. Continuous opioid infusion was associated with significantly increased postoperative opioid use. Preoperative back pain and female sex were independently associated with CPSP at 12 weeks.

Objective: Mechanisms and patterns of severe traumatic brain injury (TBI) in infants and toddlers are different from adults and even from older children, but there is no taxonomy of injuries that can provide a basis for individualized care. The current project was undertaken as a proof of concept to demonstrate that a taxonomy can be constructed with clinical correlations.

Methods: Data were taken from the American College of Surgeons Trauma Quality Improvement Program for the years 2014 through 2022. Inclusion criteria were an age < 2 years and Abbreviated Injury Scale head score of 4, 5, or 6. Latent class analysis (LCA) was performed based on covariates reflecting socioeconomic status, access to definitive care, mechanism of injury, severity of injury, and pathology.

Results: There were 3735 cases meeting study inclusion criteria. Overall mortality among cases with a known outcome was 19%, and 70% of discharges were routine. Intracranial monitoring was coded for 28% of cases. An LCA model with 4 classes was studied. The mortality rates of the 4 classes were highly distinct at 2%, 13%, 37%, and 65%, respectively. The routine discharge rates were similarly distinct at 92%, 66%, 41%, and 12%, respectively. The rates of intracranial monitoring varied much more narrowly between 26% and 39%.

Conclusions: A scheme for classifying injuries based on LCA had powerful associations with outcomes and proves that a clinically meaningful taxonomy of severe TBI in the very young is possible. The fact that 25% of cases with the best prognosis underwent intracranial monitoring and only 37% of cases with the worst prognosis did so demonstrates the need for an evidence-based taxonomy to guide individualized care. Large-scale prospective study may define categories that are conceptually accessible rather than latent and that guide therapies as well as predict outcomes.

Objective: Despite improvements in rates of hydrocephalus with prenatal repair of myelomeningocele (MMC), a significant number of children still require CSF diversion. While previous studies have focused on uncovering predictors of future hydrocephalus, differences in timing and presentation of MMC-associated hydrocephalus following pre- and postnatal surgery are not well-characterized. This study aimed to determine how age, head size, and ventricle size differ at hydrocephalus presentation in patients treated with pre- and postnatal surgery for MMC.

Methods: The Hydrocephalus Clinical Research Network Core Data Project was queried to identify patients with MMC who underwent pre- or postnatal repair and required permanent CSF diversion-by shunting or endoscopic third ventriculostomy, with or without choroid plexus cauterization-between April 2008 and June 2024. The primary variable of interest was chronological age at the primary CSF diversion procedure. Secondary variables of interest included absolute head circumference (HC), HC percentile/z-score, and frontal-occipital horn ratio (FOHR).

Results: One thousand forty-four patients from 14 centers were included: 125 (12%) underwent prenatal MMC repair and 919 (88%) underwent postnatal MMC closure. The median patient age at primary CSF diversion procedure was 4.1 months in the prenatal MMC repair cohort versus 0.6 months in the postnatal closure cohort (p < 0.001). Absolute HC (45.0 vs 38.0 cm, p < 0.001), HC percentile (> 99.9 vs 97.0, p < 0.001), HC z-score (3.4 vs 1.9, p < 0.001), and FOHR (0.60 vs 0.56, p < 0.001) were greater in the pre- versus postnatal surgery cohort. Linear mixed models adjusting for treatment center and time period in which CSF diversion was performed revealed that patients with MMC treated prenatally underwent CSF diversion 3.02 (95% CI 0.39-5.64) months later (p = 0.024) and had greater HC z-scores (+1.27, 95% CI 0.81-1.73; p < 0.001), but similar FOHRs (-1.08, 95% CI -5.07 to 2.90; p = 0.593) compared to those treated postnatally.

Conclusions: Patients developing hydrocephalus following prenatal MMC repair undergo CSF diversion later and have larger heads than those developing hydrocephalus following postnatal MMC closure; however, FOHRs are similar between groups. The disparity between HC and FOHR may suggest the presence of increased overall brain parenchymal and/or extra-axial volume in children receiving prenatal MMC repair, although further study is required. These findings may inform prenatal counseling and follow-up timing for patients with MMC.

Craniopagus twins, particularly the total vertical type II variant, represent one of the rarest and most complex congenital malformations, with significant surgical challenges. This technical note presents the successful staged separation of craniopagus twins at 3 years 9 months of age, the oldest known to be separated to date. The twins shared a prominent circumferential venous sinus, requiring a novel surgical strategy. Advanced imaging, 3D modeling, and virtual reality planning in the metaverse-between Brazil and the United Kingdom-guided the 7 staged surgeries. Initially, partial separations focused on the more vulnerable twin. However, arteriographic evidence of venous dependency led to a paradigm shift, in which the authors performed the final stages on the other twin to preserve critical venous outflow. This innovative approach allowed division of the shared venous sinus without neurological compromise. The final separation, completed in 2 stages over 31 hours, resulted in successful independent circulations and recovery. This case highlights the importance of individualized surgical planning, collaborative international simulation, and the potential for adapting separation protocols based on venous architecture.