Journal of neurosurgery. Pediatrics最新文献

Objective: Electrode placement using robot-assisted stereoelectroencephalography (SEEG) has been proven a safe and accurate technique in children. As its use increases, understanding the impact of registration methods and patient-specific factors on placement accuracy is crucial. The aim of this study was to compare 4 registration methods and to evaluate factors associated with lead placement error.

Methods: This retrospective case series included pediatric patients who underwent robot-assisted SEEG from January 2019 to April 2022 at a single institution. Placement accuracy was assessed at both the inner skull table and the prespecified target using 4 registration techniques: 1) laser-based registration with a Mayfield skull clamp (laser), 2) a Leksell frame with bone fiducials (bone fiducials), 3) a Leksell frame with pins plus one bone fiducial (pins+fiducial), and 4) a frame-based registration with etched frame (frame-based). Accuracy differences were analyzed using Kruskal-Wallis and Wilcoxon tests. A stepwise multivariate linear regression model was used to evaluate predictors of error.

Results: Overall, 231 electrodes were placed in 22 patients (median age 15 years). The median error at the inner skull table was lowest with the pins+fiducial (0.6 mm) technique and highest with the laser (1.7 mm) technique. The target error was also lowest with pins+fiducial (1.1 mm) technique and highest with the laser (2.04 mm) technique. All group differences were statistically significant (p < 0.0001). Younger age (p = 0.0161) and increased bone thickness (p = 0.0304) were independently associated with error at the target and inner skull table, respectively. No clinical complications occurred, including hemorrhage, infection, or electrode malposition.

Conclusions: The registration technique used significantly affects robot-assisted SEEG accuracy in children. The use of frame-based approaches, especially using pins and a single fiducial, yielded the highest accuracy. Additional caution should be exercised in younger patients and with trajectories through thicker bone.

Objective: Posterior fossa decompression is the main surgical treatment for Chiari malformation type I (CM-I). The authors present findings on patient presentation, surgical methods, and postoperative complications from a large cohort of pediatric patients with the aim of utilizing this institutional experience to guide evidence-based management of pediatric CM-I.

Methods: A departmental operative database was queried for patients who underwent a posterior fossa decompression for CM-I between 1992 and 2021. The charts of identified patients were reviewed. Data regarding demographics, presentation, operative details, and complications were collected.

Results: A total of 510 patients were identified. The mean patient age was 10.2 ± 5.2 years, and 57% of patients were female. The most common presenting clinical symptoms or associated signs were exertional suboccipital headaches (65%), syringomyelia (55%), and scoliosis (18%). The mean cerebellar tonsillar descent was 14.2 ± 6.4 mm below the foramen magnum. At surgery, 20% of the patients with a preoperative syrinx had documented arachnoid veils obstructing the outflow tract of the fourth ventricle. Operatively, 99% of patients underwent cervical laminectomy; of these laminectomies, 89% were C1 only. Ninety-seven percent of all patients underwent suboccipital craniectomy with expansile duraplasty (PFDD), while 3% underwent bone-only decompression (PFD). Eighty-seven percent of the patients with PFDD received tonsillopexy and/or tonsillar resection. The median postoperative hospital stay was 2 days for PFD patients and 3 days for PFDD patients (p < 0.01). Postoperative complications developed in 12% of cases, with CSF leakage (5%) and aseptic meningitis (4%) being most common. CSF leakage and aseptic meningitis were also the most common reasons for early readmission after surgery. There were no intraoperative or postoperative deaths.

Conclusions: The authors demonstrate an institutional preference for PFDD and tonsillopexy. Exertional suboccipital pain and syringomyelia were the most common indications for surgery. Complications tended to be more common with PFDD. There was a significant difference in postoperative length of stay between patients who underwent PFD (median 2 days) versus PFDD (median 3 days). CSF leakage and aseptic meningitis were the most common reasons for readmission.

Objective: Patients with ventriculoperitoneal shunts have a lifelong risk of requiring revision procedures that may be time critical. Many of these patients reside distantly from neurosurgical services; however, the influence of this key sociodemographic factor on the outcomes of patients with ventriculoperitoneal shunts has not been previously studied. The Australasian Shunt Registry provides a rare opportunity to study the association of rurality with ventriculoperitoneal shunt outcomes across a large landmass with a broadly distributed population.

Methods: Data were extracted from the Australasian Shunt Registry for all patients aged ≤ 25 years who underwent first-time ventriculoperitoneal shunt insertion from December 2016 to October 2024. The patient's postcode of residence was matched to the corresponding Modified Monash Model (MM) rurality index for that region. The metropolitan cohort was defined as all patients with MM 1, and the rural/regional cohort included all patients with MM ≥ 2. The primary outcome of interest was time from ventriculoperitoneal shunt insertion to first shunt revision (shunt survival).

Results: At the conclusion of the study period, the Australasian Shunt Registry contained records for 5023 unique patients. After application of exclusion criteria, the resulting sample included 930 patients. The majority of these patients reside in a metropolitan MM1 area (617/930 [66%]). The cohorts were similar for demographic and clinical variables. The estimated mean shunt survival was 5.04 (95% CI 4.64-5.43) years for rural patients and 5.69 (95% CI 5.40-5.98) years for metropolitan patients (Wilcoxon test, p = 0.01). That effect remained statistically significant in the Cox proportional hazards model that included all variables that were significant on univariate analysis: a metropolitan address exerted a protective effect on overall shunt survival (HR 0.75, 95% CI 0.59-0.95, p = 0.02).

Conclusions: Rural/regional patients with ventriculoperitoneal shunts experienced reduced overall shunt survival when compared to metropolitan patients.

Objective: Chiari malformation (CM) involves a broad disease spectrum, where rare complex CM cases can be associated with craniocervical junction (CVJ) instability and require occipitocervical fusion. However, the natural progression of CVJ alignment in the general CM type I and 1.5 populations treated with posterior fossa decompression (PFD) remains insufficiently characterized. The authors aimed to compare CVJ alignment changes in patients who underwent PFD versus patients with CM who did not undergo surgery.

Methods: The authors conducted a retrospective cohort study at their institution of all patients diagnosed with CM I and 1.5 from 2000 to early 2023. Demographic, clinical, and surgical data were collected, along with preoperative and postoperative MRI measurements, including tonsillar herniation, brainstem descent, clivoaxial angle (CXA), and condylar-C2 sagittal vertical alignment (C-C2SVA).

Results: A total of 241 patients were included, with 201 undergoing PFD and 40 managed conservatively (controls). No significant differences were observed between groups in age at diagnosis, sex, or genetic diagnoses. In the PFD group, 55% underwent duraplasty and 45% underwent bone-only decompression. Baseline craniocervical alignment measurements showed a lower CXA in the PFD group (144.4° ± 13.4°) compared to controls (148.5° ± 14.2°) (p = 0.04) but no difference in C-C2SVA. Changes over time showed a small but significant decrease in CXA at < 1 year after surgery in the PFD group (-2.7°) compared to controls (-2.0°) (p = 0.008), but no differences were noted at 1-2 years. No differences in C-C2SVA were observed over time in either group.

Conclusions: PFD does not significantly impact craniocervical alignment or increase the risk of occipitocervical fusion in CM I and 1.5 patients. These findings support PFD as a safe first-line treatment, even in complex CM cases, and provide important information for patient education regarding the risks of surgery.

Objective: Use of an irrigating external intracranial drainage system has been an active and promising area of investigation in adult patients with intraventricular hemorrhage, ventriculitis, and chronic subdural hematoma. The objective of this study was to report on the safety and feasibility of an irrigating external intracranial drainage system for use in children.

Methods: Retrospective chart review was undertaken of the medical records of children who required an irrigating external intracranial drain (EID) at two children's hospitals for clearance of infection or blood from the ventricular system or extra-axial space. Irrigation parameters, CSF study results, adverse events during and after the course of irrigation, and ventricular peritoneal shunt outcomes up to 3 months postoperatively were assessed.

Results: Twelve patients younger than 18 years of age were treated between September 2023 and May 2025. Four patients were younger than 1 year of age (mean ± SD 4.72 ± 3.81 months), and 8 patients were between 4 and 18 years (mean 11.52 ± 4.33 years). Four patients required intracranial drainage for ventriculitis, 1 for intraventricular hemorrhage, 4 for postoperative clearance of blood following hemispherectomy or tumor resection, and 3 for subdural hematomas. The mean duration of irrigation was 6.45 ± 5.25 days. One patient had an adverse event during irrigation, which was a clinical seizure. Irrigation was stopped and the patient was treated with levetiracetam with no further seizures. This was the only patient who received irrigation using normal saline with vancomycin. All other patients received irrigation with lactated Ringer's solution without antibiotics. Seven patients had a ventriculoperitoneal shunt after treatment-5 of whom had a shunt on presentation-of which 2 required revisions for valve replacement within 3 months. All patients with ventricular pathology had stable ventricular configuration on follow-up imaging.

Conclusions: The use of an irrigating EID has potential utility for clearance of intracranial purulence and blood products in children. This is the first published series to delineate the safety and feasibility of this system in a group of children, 4 of whom were infants younger than 1 year of age.

Objective: Chiari decompression is the definitive treatment for symptomatic Chiari malformation type I (CM-I). In part 1 of this two-part series, operative management and perioperative complications were discussed. Presented here are the symptomatic outcomes from a large cohort of pediatric patients who underwent Chiari decompression.

Methods: A departmental operative database was queried for patients who underwent Chiari decompression between 1992 and 2021; 510 patients were identified. Data regarding patient outcomes were collected.

Results: Seventy-three percent of patients with exertional suboccipital headaches and 67% of patients with central sleep apnea reported improvement, while 77% of patients with syringomyelia and postoperative imaging exhibited a reduction in the length or diameter of the syrinx after decompressive surgery. Among the 32 patients with syringomyelia as an indication for repeat surgery, 18 (56%) had structural causes of syrinx formation or persistence identified on preoperative imaging and all had structural causes identified intraoperatively. Postoperative complications requiring readmission after revision surgery occurred in 18% of patients, slightly higher than with primary Chiari decompression (11%), although the most common complications remained CSF leakage and aseptic meningitis. Nine percent of patients required repeat decompression due to worsening or new Chiari symptoms or persistent syringomyelia, with a median time to repeat surgery of 17 months.

Conclusions: The authors present an institutional experience with Chiari decompression. Both initial and revision decompressive surgeries were predominantly performed as posterior fossa decompression with duraplasty and tonsillopexy and demonstrated high rates of postoperative symptomatic and radiographic improvement. Revision surgery was necessary in < 10% of patients, most commonly due to syrinx persistence or formation secondary to intradural scarring from the initial surgery.

Objective: Vagus nerve stimulation (VNS) is an established adjunctive therapy for drug-resistant epilepsy (DRE). However, evidence regarding its efficacy in children with structural and nonstructural etiologies of epilepsy remains limited. Herein, the authors aimed to explore the effectiveness of VNS in patients with either etiology.

Methods: In this retrospective single-center study, authors evaluated children (ages 2-18 years) with DRE due to nonlesional monogenic epilepsies (MEs) or malformations of cortical development (MCDs) who had undergone VNS device implantation between 2008 and 2024 and had ≥ 6 months of follow-up. Patients with tuberous sclerosis complex were excluded. Clinical, genetic, neuroimaging, VNS programming, and outcome data were extracted from medical records. The primary outcome was the responder rate, defined as > 50% seizure reduction from baseline at 6 months, 12 months, and the last follow-up, in the two groups.

Results: Of 336 VNS device recipients, 64 children with ME (n = 44) or MCD (n = 20) met the study inclusion criteria. The median follow-up was 3.5-4.0 years. The responder rate in the ME versus MCD group at 6 months, 1 year, and the last follow-up was 38.6% versus 42.1% (p = 0.77), 45.7% versus 44.4% (p = 0.46), and 47.6% versus 63.2% (p = 0.64), respectively. The SCN1A-related Dravet syndrome (SCN1A-DS) subgroup (n = 12) had a responder rate (50.0%) comparable to that of the non-SCN1A-DS ME group (43.7%) at the last follow-up. The frequency of status epilepticus decreased significantly in both groups (p = 0.03). VNS was well tolerated, with mild to moderate side effects reported in < 5% patients. No clinical variable, including age at seizure onset, epilepsy duration, or age at VNS device implantation predicted seizure outcomes.

Conclusions: VNS therapy was noted to have a similar responder rate in children with DRE due to MEs or MCDs. Both groups experienced meaningful benefits, with a small proportion of patients experiencing mild side effects.

Objective: Socioeconomic factors such as income and community type have been shown to correlate with outcomes in adult neuro-oncological care. In pediatric populations, fewer conclusions have been drawn on the effects of factors such as race, sex, and insurance status on survival due to the relative rarity of such cases. This analysis used the National Cancer Institute's Surveillance, Epidemiology, and End Results (SEER) program database to evaluate differences in outcomes for factors influencing survival in both pediatric and adult CNS malignancies.

Methods: From the SEER research November 2020 (1975-2018) dataset, 29,865 patients with malignant CNS tumors (identified by International Classification of Diseases for Oncology, 3rd ed., code) diagnosed between 1990 and 2018 and directly causing patient deaths were selected. Data were collected on age at diagnosis, sex, race, median household income (in 2019 US dollars), community type (rural-urban continuum), and survival (in months). This cohort was separated into pediatric (ages 0-19 years, n = 1509) and adult (ages ≥ 20 years, n = 28,356) subgroups, and independent survival analysis was conducted by income, community type, sex, and race. Kaplan-Meier curves were visualized for each comparison.

Results: Log-rank analysis of survival in the pediatric cohort showed greater mortality rates in females (p = 0.0224). The same analysis in the adult cohort showed greater mortality rates in lower income groups, more rural community settings, females, and patients categorized as White (p < 0.0001 for all comparisons).

Conclusions: Unlike in the adult population, income, community setting, and race were not associated with significant differences in survival in the pediatric population, prompting further investigation into healthcare delivery differences between pediatric and adult populations. Further study should focus on the cause of these discrepancies to improve equity in neurosurgical care.