Objective: Spinal cord injury (SCI) trials have historically underrepresented pediatric patients. There are limited pediatric data examining the influence of surgical timing on complications and mortality for children and adolescents who have sustained complete traumatic SCI.
Methods: The following multicenter cohort study used Trauma Quality Improvement Program data from 2010 to 2020. The authors identified pediatric patients (aged < 18 years) who sustained complete traumatic SCI and underwent surgical intervention within 7 days of admission. Propensity score matching was performed between patients who underwent surgery within 24 hours versus ≥ 24 hours. The authors then assessed differences for the following outcomes: major in-hospital complications, immobility-related complications, length of stay (LOS), and mortality.
Results: There were 837 patients with complete traumatic SCI managed across 297 trauma centers identified for study inclusion (70% underwent early surgery). After matching, 494 patients were available for analysis. Patients undergoing delayed surgery experienced longer ICU LOS (mean difference 3.74 days, 95% CI 0.91-6.57 days) and more major in-hospital complications (OR 1.77, 95% CI 1.16-2.73) and immobility-related complications (OR 2.09, 95% CI 1.25-3.56). There were no differences in mortality between groups. Younger age, non-White race, penetrating injuries, lower Glasgow Coma Scale score at admission, severe concomitant abdominal injuries, and motor vehicle collision injury mechanisms were associated with increased time to surgery.
Conclusions: The authors demonstrated an association between early surgery and shorter ICU LOS and reduced in-hospital complications. Future work is needed to quantify the impact of surgical timing on functional neurological outcomes and to explore upstream social determinants of health influencing timing of surgery.
Objective: Cerebral spinal fluid (CSF) diversion methods, including ventriculoperitoneal (VP) shunts, are the standard treatment for hydrocephalus. Hair clipping (HC) has been a routine neurosurgical practice of the great majority of neurosurgeons, due to the perception that this will either decrease the risk of shunt infection or allow for a faster, unimpeded opening and closing of the skin. The benefits of not cutting or clipping hair in terms of normalizing appearance and self-esteem are obvious. The purpose of this study was to assess whether the rate of shunt infection would differ between pediatric patients receiving operation via the hair-sparing (HS) approach versus HC.
Methods: A retrospective single-institution study comparing HS versus HC was conducted on pediatric patients undergoing long-term CSF shunt procedures at the Montreal Children's Hospital between August 2014 and April 2021. The primary outcome measure was shunt infection at 90 days and at long-term follow-up. Inclusion criteria were having at least 18 months of follow-up after long-term CSF shunt procedures, including insertions or revisions of VP shunts, ventriculoatrial shunts, cystoperitoneal shunts, subdural-peritoneal shunts, ventriculosubgaleal shunts, and ventriculosubgaleal reservoirs. Excluded procedures were those involving external ventricular drains, externalized shunts, Omaya reservoirs, endoscopic third ventriculostomies, and lumbar shunts.
Results: There were 434 CSF shunt procedures performed in 226 unique patients; 155 (35.71%) procedures were done using the HS approach versus 279 (64.29%) procedures via HC. At 90 days postoperatively, the infection rate was 1.29% in the HS group and 2.87% in the HC group, with an absolute risk difference of 1.58% (95% CI -1.07% to 4.23%, p = 0.24). At long-term follow-up (mean follow-up: 752 days and 716 days for the HS and HC groups, respectively), the rate of shunt infection remained at 1.29% for the HS group (no new infections) but rose to 4.66% for the HC group, with an absolute risk difference of 3.37% (95% CI 0.33%-6.41%, p = 0.03).
Conclusions: Performing CSF shunt procedures without cutting or clipping any hair has a very low risk of shunt infection, and certainly does not appear to increase the risk of infection (or malfunction) versus the hair removal approach. It is a safe alternative and should be considered due to its esthetic and psychological benefits regarding normalization of appearance and ease of resuming a normal life following shunt surgery.
Objective: Surgical intervention is commonly necessary for craniosynostosis. One of the preoperative concerns revolves around the cerebral venous drainage pattern and its potential involvement during surgery. Although there have been reports regarding venous drainage patterns in syndromic craniosynostosis, studies of nonsyndromic cases have been rare. In the present study, the aim was to study venous drainage patterns in nonsyndromic craniosynostosis.
Methods: Nonsyndromic cases at a single institute were retrospectively reviewed, and cerebral venous drainage in the posterior (transverse sinus [TS]) and anterior (cavernous sinus [CS] and para-CS [ParaCS]) venous routes was systematically investigated. The occipital sinus (OS) and emissary veins were also evaluated.
Results: A total of 89 nonsyndromic cases were evaluated, including 12 right coronal synostosis (RCS), 14 left coronal synostosis (LCS), 15 bilateral coronal synostosis (BCS), 36 sagittal synostosis, 6 metopic synostosis, and 6 combined metopic-sagittal synostosis cases. All venous studies were performed using MR venography. There was a significant difference among all six groups in TS dominance (p = 0.0108). In unilateral coronal synostosis (UCS; including RCS and LCS) cases, 76.9% had TS dominance on the opposite side of the synostotic suture (20 of 26 UCS, including 10 of 12 RCS and 10 of 14 LCS). There was a significant difference in the incidence of OS, with the highest incidence observed in the BCS group (33.3%, p = 0.027). CS/ParaCS venous drainage was observed in 94.4% of cases on the right side and 95.5% on the left side, showing no significant difference among the groups on both sides. No visible emissary vein was observed in any of the groups.
Conclusions: A significantly higher predominance of left TS was found in RCS cases, in contrast with the typical right-side predominance seen in the normal population. In addition, the majority of UCS cases exhibited TS dominance on the opposite side of the synostotic suture. Furthermore, the present results showed a significant difference in the prevalence of OS, which was predominantly observed in BCS cases. These findings could be explained by the induction effect on venous sinuses by the compensatory growth of the skull according to Virchow's law, suggesting that synostotic sutures induce compensatory skull expansion in regions farthest (diagonally) from the affected sutures, thereby enlarging nearby venous sinuses.
Objective: Pediatric cerebral vasospasm (PCV) is associated with aneurysmal subarachnoid hemorrhage (aSAH), but aSAH is uncommon in children. No universal guidelines exist for PCV management. The authors sought to assess variations in practice patterns in pediatric aSAH and PCV management.
Methods: A REDCap survey was circulated by the AANS/CNS Pediatric Section and the Pediatric Neurocritical Care Research Group assessing PCV management practices.
Results: A total of 58 responses were received. The proportion of responses received from each region ranged from 19% in the Northeast to 28% in the Midwest. Of all respondents, 88% reported practicing at academic institutions. Neurosurgeons constituted 79% of respondents, and intensivists 17%; 85% primarily managed children. Most providers treated 1-3 aSAHs annually and a minority (21%) reported protocolized aSAH management at their centers. PCV prevention used permissive hypertension (90%), chemoprophylaxis (86%), and strict fluid-volume management (83%). PCV was typically assessed using serial neurological examination (60%) and transcranial Doppler (TCD) studies (72%). Treatment of PCV included permissive hypertension (50%) and endovascular interventions (81% intraarterial verapamil, 35% nitroprusside, and 67% angioplasty). Balloon angioplasty was more common than stent retriever-plasty.
Conclusions: Pediatric PCV is rare and primarily treated by specialists at academic institutions. Although some elements of management are commonly used, wide variability exists in the strategies used for PCV prevention, detection, and treatment. Management strategies for pediatric PCV may be extrapolations from adult paradigms, but standardized guidelines are lacking. Prioritization should be given to the development of such guidance to enable the development of more robust evidence-based practices in the future.
Objective: The objective of this study was to describe the technical aspects and postnatal neurosurgical outcomes of a prenatal, 3-miniport fetoscopic myelomeningocele (MMC) repair technique providing a multilayered closure using cryopreserved decellularized human umbilical cord (HUC) matrix allograft for duraplasty.
Methods: The authors conducted a subanalysis of an ongoing prospective cohort study analyzing the neurosurgical outcomes of 57 of 92 consecutive patients who underwent multilayered fetoscopic surgical MMC repair using HUC matrix allograft for duraplasty at their institution from December 2016 to March 2022, including more than 24 months of postnatal follow-up.
Results: Of 92 patients who underwent fetoscopic MMC repair, 88 had duraplasty using cryopreserved HUC matrix allograft. Fifty-seven patients had at least 24 months of follow-up data. The mean gestational age at the time of surgical repair was 24.8 ± 0.7 weeks. The average operative time from skin incision to closure was 260 ± 43.4 minutes, in which 79% of this time was used for the fetoscopic portion. No patient required intraoperative emergency delivery. At birth, there were no cases of CSF leak or complete wound dehiscence. Six (11.5%) of 52 patients experienced superficial wound dehiscence, and only 2 (3.5%) required surgical revision. At 30 months, 54.8% of patients were noted to be independent ambulators, 35.5% were therapeutic ambulators, and 9.7% remained wheelchair users in this subset of patients. The rate of hydrocephalus requiring CSF diversion was 35.3%, and 84.3% of patients had complete reversal of hindbrain herniation at birth. Eight (15.7%) of 51 patients had spinal inclusion cysts noted on routine follow-up spinal imaging, but only 2 (3.9%) required surgical intervention due to radiological progression without neurological symptoms.
Conclusions: A laparotomy-assisted, 3-miniport fetoscopic approach for prenatal MMC multilayered repair offers excellent access and visualization for an effective watertight closure. The use of HUC matrix allograft as a dural substitute was shown to be effective with a low rate of neurosurgical postnatal complications.
Objective: Studies have shown a high prevalence of sleep-disordered breathing (SDB) among children with myelomeningocele (MMC), but there are few published data on the longitudinal care of these patients. The objective of this study was to determine the effectiveness of standard treatments for SDB in children with MMC.
Methods: The authors analyzed records from three multidisciplinary spina bifida clinics to identify all patients with both MMC and SDB diagnosed by polysomnography (PSG). The primary outcome of this study was a change in apnea-hypopnea index (AHI; the number of apneic or hypopneic events per hour of sleep) before and after clinically recommended SDB treatments. Clinical and demographic variables were recorded and evaluated for possible association with posttreatment improvement of AHI. Analysis included change in AHI (a continuous variable) and whether SDB improved (defined as an AHI < 2.5 or decrease of AHI by ≥ 50% from baseline).
Results: Seventy-one eligible patients (aged 2 days-21 years, 52% male) had an initial AHI > 2.5 and had follow-up PSG after treatment for SDB. The mean AHI decreased from 20.5 (SD 21.6) at baseline to 11.6 (SD 15.7) after treatment (p = 0.0006). Children treated with supplemental oxygen and with continuous positive airway pressure had improvement on PSG (18 of 25 and 12 of 18, respectively). Children treated with adenotonsillectomy were less likely to improve (7 of 19). Forty-one patients (58%) improved from a baseline AHI > 2.5 to an AHI < 2.5 after treatment.
Conclusions: Children with MMC and SDB who undergo standard SDB treatments guided by pediatric sleep medicine physicians show improvement in PSG parameters after treatment.
Objective: The exact association between the frequently present anomalous intracranial venous vasculature, emissary collaterals, ventriculomegaly, and increased intracranial pressure (ICP) in children with Apert and Crouzon syndromes remains an enigma. This study aimed to evaluate the association between the aberrant venous system and ventricle size and increased ICP, and to assess the development of the venous structures over time.
Methods: This retrospective cohort study included all patients with Apert or Crouzon syndrome with available CT venography (CTV) scans of the brain. Anomalous venous vasculature was assessed by the total collateral score (TCS), which scored 9 intra- and extracranial venous structures (TCS range 0-16). Ventricle size (fronto-occipital horn ratio [FOHR]) was measured on the same scan. The presence of increased ICP, a shunt, tonsillar herniation, and head circumference were extracted from electronic patient records and were used as secondary covariates. Subsequent CTV scans were scored when available.
Results: Ninety patients were included in this study. The mean TCS was 7.5 ± 2.5, and was comparable for patients with Apert and Crouzon syndromes (mean 8.0 and 7.3, respectively). The presence of an extra abnormal venous structure was associated with an increase of the FOHR of 3.2% (p < 0.01). After dividing the venous structures into intra- and extracranial, a similar association between both and the FOHR was found (4.1% and 2.3%, respectively; p < 0.01). The TCS was similar for patients with normal and increased ICP at the time of the scan. Sixteen patients had dual CTV scans. The median time between both scans was 3.2 years. The presence of collaterals remained stable over time (median ΔTCS = 0.3). Seven patients with functioning shunts also maintained high TCSs (median TCS = 9).
Conclusions: In patients with Apert and Crouzon syndromes, a close relationship between venous collaterals and ventricle size was observed, in which a more extensive aberrant venous drainage pattern, both intra- and extracranial, was associated with larger ventricles. Preliminary longitudinal data suggested that the presence of venous collaterals remained constant over time despite effective treatment of increased ICP, indicating reliance on these collaterals even in cases of normal ICP. The authors hypothesize that this dependence on collateral drainage is the result of their aberrant internal venous anatomy and predisposes individuals to increased ICP.
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