Journal of neurosurgery. Pediatrics最新文献

Objective: The objective of this study was to discuss the characteristics of intracranial extension in patients with juvenile nasopharyngeal angiofibroma (JNA) and propose and an algorithm for its management.

Methods: A retrospective chart review of all patients with JNA who underwent operations between January 2013 and January 2023 was done, and those cases with intracranial extension categorized as stage IIIb, IVa, and IVb according to the Andrews modification of the Fisch staging classification were included in the study. Data were collected about age at presentation, symptoms, radiological findings, routes of intracranial extension, therapeutic management, and follow-up.

Results: Of 142 patients who underwent surgery for JNA, there were 40 (28.2%) cases with intracranial involvement. All patients were male with ages ranging from 10 to 26 years, with a mean age of 17 years at presentation. According to Andrews-Fisch classification, 28 patients presented with stage IIIb, 10 patients with stage IVa, and 2 patients with stage IVb. Parasellar involvement via the superior orbital fissure was the most frequent route of intracranial spread in patients with extensive involvement of the infratemporal fossa. All patients underwent surgery, and the most common approach was endoscope-assisted midface degloving. A total of 4 patients underwent craniotomy with an endoscope-assisted transfacial approach, which was single-stage surgery in 2 patients and a staged procedure in 2 patients. Blood transfusion was required in 53.6% of stage IIIb, 90% of stage IVa, and 100% of stage IVb patients. Residual tumor was present in 4 patients, and 3 patients developed recurrent disease. Postoperative radiotherapy was given to 5 patients. An algorithm for the surgical management of JNA with intracranial involvement was proposed on the basis of the authors' results.

Conclusions: In most cases, JNA with extradural intracranial extension can be completely excised with an endoscopic or endoscope-assisted transfacial approach, but a tumor with intracranial intradural extension requires tailored craniotomy along with a transfacial approach that can be done in single sitting or as a staged surgery. A small number of patients with gross cavernous extension receiving blood supply from a cavernous segment of the internal carotid artery are better suited for Gamma Knife or intensity-modulated radiation therapy of the residual lesion in the cavernous sinus.

Objective: Pediatric traumatic brain injury (TBI) represents a significant public health concern and source of resource utilization. The aim of this study was to establish the ability of the previously published pediatric Brain Injury Guidelines (pBIG) to identify patients with traumatic intracranial hemorrhage (ICH) who might not require routine repeat neuroimaging, neurosurgical consultation, or hospital admission in a large level I and level II trauma cohort.

Methods: Pediatric patients who presented with traumatic ICH between 2018 and 2022 at the included institutions were retrospectively reviewed and sorted into pBIG categories using clinical and radiographic criteria. Nonaccidental trauma was excluded. Repeat neuroimaging and results, neurosurgical intervention, length of stay (LOS), and 30-day mortality and re-presentation to healthcare were collected as outcomes.

Results: A cohort of 955 patients (median age 7.0 years, with 64.5% of patients being male) were included. Overall, 9.7% of patients had pBIG 1 injuries, 30.0% had pBIG 2 injuries, and 60.2% had pBIG 3 injuries. A total of 368 (38.5%) of patients underwent repeat neuroimaging, of whom 144 (39.1%) showed progression of hemorrhage. Neurosurgical intervention was performed in 129 (13.5%) patients, with 127 (98.4%) of them meeting pBIG 3 criteria on arrival. The two remaining patients met pBIG 2 criteria on arrival and then progressed to meet pBIG 3 criteria within 24 hours. Patient meeting pBIG 3 criteria were significantly more likely to have progression on repeat imaging, require neurosurgical intervention, and experience 30-day mortality (p < 0.001). Within the pBIG 3 cohort, there was not a significant relationship between progression on repeat imaging and the need for intervention (p = 0.61). Post hoc pairwise testing of individual radiographic pBIG groupings revealed pBIG 3 criteria for all categories except subarachnoid hemorrhage (SAH) to be predictive of need for neurosurgical intervention (p < 0.05).

Conclusions: Algorithmic management of mild TBI is beneficial to patient care. With zero and near-zero rates of neurosurgical intervention and mortality in patients with pBIG 1 and pBIG 2 injuries, respectively, the pBIG are valid in stratifying a larger and broader population of pediatric TBI patients. In contrast to other pBIG 3-defined compartment ICHs, "scattered" SAH does not correlate with need for neurosurgical intervention. However, these guidelines have the ability to safely improve care and decrease unnecessary resource utilization without negatively affecting patient outcomes. Utilization of guidelines of any sort are not intended to supersede clinical judgment. Prospective studies are needed.

Objective: Intraventricular baclofen (IVB) administration is used for the treatment of secondary dystonia associated with cerebral palsy (CP), but it has not been reported as a first-line infusion technique for spasticity. In this study, the authors report outcomes of patients with mixed or isolated spasticity treated with IVB administration.

Methods: A retrospective analysis was performed of consecutive patients treated with IVB between 2019 and 2023. Demographics, baseline clinical variables, and complications data were collected. The primary outcome of the study was the change in spasticity and dystonia as measured by the modified Ashworth Scale (MAS) and Barry-Albright Dystonia Scale (BADS) scores, respectively. Wilcoxon rank-sum tests were performed to compare the change in the pre- and postoperative scores.

Results: Fifteen patients were implanted with IVB pumps for spasticity related to CP between 2019 and 2023. The median change in the MAS score was 2 (interquartile range [IQR] = 1) and the median change in the BADS score was 1 (IQR = 2). The Wilcoxon rank-sum test revealed a statistically significant change in both scores following IVB pump placement (BADS z = 2.90, p = 0.003; MAS z = 3.2, p = 0.001). Three patients (20%) experienced minor perioperative complications, all of which were self-limiting and none required additional surgery.

Conclusions: This study reported on 15 cases of mixed or isolated spasticity and showed a relative improvement in the MAS and BADS scores after IVB pump placement. These results provide evidence that IVB can be a safe and effective treatment for spasticity-related CP in addition to dystonia. IVB may be advantageous when an intraventricular route of baclofen administration is preferred.

Objective: Functional MRI (fMRI) helps with the identification of eloquent cortex to assist with function preservation in patients who undergo epilepsy surgery. Language and memory tasks can even be used effectively in clinically involved pediatric patients. Most pediatric studies report on English speaking-only cohorts from English-dominant countries, yet languages other than English (LOEs) are increasingly prevalent in countries such as the US. This study evaluated the efficacy of pediatric fMRI for primarily bilingual patients with LOEs undergoing epilepsy surgery workups.

Methods: The authors reviewed patients who underwent epilepsy surgery workup at Seattle Children's Hospital and identified all patients who had valid verbal fluency fMRI tasks from 2007 to 2021, including the bilingual and LOE patients within this cohort who had LOE fMRI language scans. The percentage of LOE-bilingual patients and the LOEs were identified, and the LOE versus English activation in bilingual patients was compared.

Results: Of the 363 patients with epilepsy surgery workup who had successful verbal fluency fMRI tasks during 2007-2021, 63 (17%) were bilingual or LOE-only patients and 300 were monolingual English-language patients. Of the 63 patients, 18 were bilingual and had LOE plus English scans; 3 patients were fluent only in one non-English language and thus underwent LOE scans only; 30 were bilingual but chose to have only English language scans; and 12 additional patients had limited or questionable LOE proficiency and underwent English-only scans. Sixteen of 18 bilingual scans allowed reliable calculation for the language-related region of interest (ROI), and this study focused on the comparison of the first language and second language Broca's area and Wernicke's area ROI measurements. All patients had activation in both languages, with 100% concordance in terms of laterality for Broca's area ROIs and 94% concordance for Wernicke's area ROIs. However, while lateralization indices were largely concordant, variability in exact areas and extent of activation was noted.

Conclusions: This preliminary pediatric study suggests that language fMRI tasks can be completed effectively with bilingual and LOE pediatric patients as part of epilepsy surgery workups, regardless of the language spoken by the patient. Individual patient LOE and English activations were generally concordant in terms of lateralization, although exact areas of activation varied. Important future steps need to include larger samples, better pre-fMRI evaluation of bilingual proficiency, and standards for fMRI assessments with a diversity of patients, particularly bilingual pediatric patients.

Objective: Tumors in the ventral craniocervical junction (CCJ) pose unique challenges, particularly in children. The potential constraints with endoscopic approaches to tumors extending inferiorly and laterally and the risk of CSF leakage can be exacerbated in the pediatric population. Here, the authors present their experience with the extreme lateral transodontoid (ELTO) approach in children with large ventral CCJ tumors as an alternative or complement to anterior approaches.

Methods: This is a retrospective, single-center study of patients who underwent the ELTO approach from January 2021 to January 2024. Patients with at least 3 months of postoperative follow-up and postoperative MR images were included. Primary outcomes included extent of resection, intraoperative and postoperative complications, and neurological outcome.

Results: Six children underwent 8 ELTO approaches (2 children underwent bilateral ELTO). The median age was 8 years (range 3-17 years), with a mean follow-up of 15.8 months. Diagnoses included classic chordoma (n = 3), poorly differentiated chordoma (n = 2), and high-grade undifferentiated sarcoma (n = 1). Gross-total resection (GTR) was achieved in all cases. One patient developed thrombosis of the third segment of the vertebral artery without symptoms or signs of ischemia. One patient with hydrocephalus and significant dysphagia due to bilateral cranial nerve XII palsy at diagnosis and worsening left vocal cord paralysis after the resection required ventriculoperitoneal shunt placement as well as a tracheostomy and gastrostomy after tumor resection. One patient required revision of the occipitocervical fixation due to new onset of dysphagia 4 months after tumor resection, without additional consequences.

Conclusions: The ELTO approach is safe and feasible in children with large tumors of the ventral craniocervical junction. GTR was achieved in all the patients, and there were no significant complications or new neurological deficits due to the approach.

Objective: The authors aimed to describe a low-cost and easily reproducible alteration of the Bruner and Tulipan procedure to preserve uterine muscular fibers. They conducted a retrospective cohort study of 10 pregnant women whose fetuses developed lumbosacral myelomeningocele (MM). The MM was repaired through a fetal neurosurgical procedure using a tubular single-port endoscope-assisted technique.

Methods: This study was conducted at the Santa Joana Hospital and São Paulo Hospital between January 2020 and June 2023. The procedure consisted of tubular retraction of circular fibers from the uterine body without excision of the uterine wall. Tubular devices with progressively larger diameters were used for retraction without cutting the uterine muscular fibers, and a 25-mm-diameter tubular retractor was used to allow endoscope-assisted closure of the MM using microsurgical techniques.

Results: The average birth age was 36 weeks 3 days. Defect repair was possible in all cases. The mean surgical time was 130 minutes. Two of the patients developed hydrocephalus. One patient underwent a ventriculoperitoneal shunt, and the other underwent endoscopic third ventriculostomy with choroid plexus coagulation.

Conclusions: This procedure avoids excision of the uterine wall, promotes a workspace for microsurgical techniques assisted by endoscopy, and is possibly the first step for future single-port correction using robotic techniques.

Objective: This study aimed to investigate the burden of CSF shunt failure and false alarms on pediatric patients with hydrocephalus, their caregivers, and the healthcare system.

Methods: This retrospective longitudinal study examined pediatric patients who underwent CSF shunt procedures at Auckland City Hospital from January 2014 to December 2019. The study included patients aged 18 years or younger living within the hospital's catchment area. Clinical encounters were recorded from the date of their first shunt insertion until November 1, 2023. Data collected included patient demographics, hospital admissions, acute and elective shunt-related imaging, clinic visits, surgery times, and symptom characteristics. Shunt-related admissions were categorized as either shunt failures or false alarms.

Results: The cohort comprised 73 patients with follow-up periods ranging from 4 to 18 years. By the 1st year, 71% had been rehospitalized for shunt-related concerns, with 59% experiencing at least 1 false alarm and 38% experiencing at least 1 shunt failure. By the 4th year, 88% of patients had been rehospitalized for shunt-related concerns, 42% had experienced at least 3 false alarms, 60% had at least 1 shunt failure, and 25% had at least 3 shunt failures. The average accumulated hospital stay was 1 month for shunt failures and 2 weeks for false alarms, compared with 22 days for all other admissions. Frequent clinic interactions from multiple specialties highlighted the complex care needs of these patients. The timing of shunt failure or false alarm, but not symptom duration, significantly predicted their overall frequency.

Conclusions: This study details the chronic burden and complex care requirements for pediatric patients with CSF shunts. Shunt-related concerns significantly and disproportionately contribute to the patients' total hospital interactions. The findings highlight the immediate clinical need for novel technologies to enable long-term and accurate detection of shunt failure to optimize patient care. Future efforts should focus on improving shunt systems to lower failure rates.

Objective: Spinal epidural abscesses (SEAs) are rare infections in children but can lead to significant neurological sequelae. The authors sought to describe the presentation, management, and outcomes of children with these infections at their institution.

Methods: This was a retrospective study of pediatric patients admitted with SEA to a quaternary children's hospital between 2013 and 2023. Clinical characteristics including laboratory, surgical, and antimicrobial data were collected and analyzed.

Results: Fourteen patients (median age 3.7 years) had SEAs. Thirteen (93%) patients developed the infection in the outpatient setting, and of these 10 (77%) were evaluated by a medical provider prior to the encounter when the diagnosis was made. The most common causative pathogen was Staphylococcus aureus. Thirteen (93%) of 14 patients underwent a surgical procedure, and patients were treated with antibiotics for a median of 38 days. Eleven (79%) of 14 patients received enteral antibiotics for part of their treatment course. All patients recovered with no neurological sequelae.

Conclusions: SEAs are rare infections, but good outcomes can be obtained with prompt antimicrobial and surgical management. Enteral antibiotics should be considered as part of therapy. Larger multicenter studies are needed to determine the optimal antibiotic duration and route, and which patients should undergo neurosurgical intervention versus interventional radiology drainage or medical management alone.

Objective: The Endoscopic Third Ventriculostomy Success Score (ETVSS) is a useful decision-making heuristic when considering the probability of surgical success, defined traditionally as no repeat cerebrospinal fluid diversion surgery needed within 6 months. Nonetheless, the performance of the logistic regression (LR) model in the original 2009 study was modest, with an area under the receiver operating characteristic curve (AUROC) of 0.68. The authors sought to use a larger dataset to develop more accurate machine learning (ML) models to predict endoscopic third ventriculostomy (ETV) success and also to perform the largest validation of the ETVSS to date.

Methods: The authors queried the MarketScan national database for the years 2005-2022 to identify patients < 18 years of age who underwent first-time ETV and subsequently had at least 6 months of continuous enrollment in the database. The authors collected data on predictors matching the original ETVSS: age, etiology of hydrocephalus, and history of any previous shunt placement. Next, they used 6 ML algorithms-LR, support vector classifier, random forest, k-nearest neighbors, Extreme Gradient Boosted Regression (XGBoost), and naive Bayes-to develop predictive models. Finally, the authors used nested cross-validation to assess the models' comparative performances on unseen data.

Results: The authors identified 2047 patients who met inclusion criteria, and 1261 (61.6%) underwent successful ETV. The performances of most ML models were similar to that of the original ETVSS, which had an AUROC of 0.693 on the validation set and 0.661 (95% CI 0.600-0.722) on the test set. The authors' new LR model performed comparably with AUROCs of 0.693 on both the validation and test sets, with 95% CI 0.633-0.754 on the test set. Among the more complex ML algorithms, XGBoost performed best, with AUROCs of 0.683 and 0.672 (95% CI 0.609-0.734) on the validation and test sets, respectively.

Conclusions: This is the largest external validation of the ETVSS, and it confirms modest performance. More sophisticated ML algorithms do not meaningfully improve predictive performance compared to ETVSS; this underscores the need for higher utility, novelty, and dimensionality of input data rather than changes in modeling strategies.

Objective: Corpus callosotomy is an effective treatment for atonic seizures in patients with medically refractory epilepsy. A large modern series of corpus callosotomies performed via open craniotomy highlights the importance of establishing contemporary complication rates for this operation as a benchmark for comparison with newer methodologies. The authors' study, therefore, examined operative factors and complication rates for a sample of patients who underwent open microsurgical craniotomy for corpus callosotomy to determine current metrics regarding safety and effectiveness for this procedure.

Methods: The authors retrospectively reviewed institutional data for patients who underwent first-time open callosotomy from 2005 to 2022. Demographic and clinical variables were collected and analyzed with a focus on operative factors and complication rates.

Results: A total of 105 patients were included in the study (mean [range] age 9.39 [0.67-24.17] years); 58.1% (n = 61) were male. One surgeon performed a majority of the operations (n = 80 [76.20%]); 2 other surgeons performed the remaining surgical procedures (21.9% and 1.90%, respectively). In total, 66 complete, 38 subtotal (anterior 70%-99%), and 1 posterior (40%) callosotomies were performed. Blood loss was available for 102 (97.1%) patients (mean [range] 96.67 [10-500] ml). The mean [range] operative time was calculated as 226.76 (45-386) minutes in 76 (72.4%) patients by excluding those patients who underwent concurrent vagal nerve stimulator placement or revision. The operative complication rate was determined to be 6.7% and was comprised of 3 cases of transient pseudomeningocele, 3 wound infections, and 1 delayed intraparenchymal hemorrhage. No venous infarcts were observed on postoperative MRI.

Conclusions: This is the largest single-center series of open callosotomy patients thus far in the literature and describes important updated metrics to help evaluate new techniques being developed for the surgical treatment of atonic seizures in medically intractable epilepsy.