Journal of neurosurgery. Pediatrics最新文献

Objective: Limited health literacy (HL) is associated with worse clinical outcomes across medical specialties. The association between limited HL and neurosurgical outcomes remains largely unknown. In this systematic review, the authors synthesized the existing literature on the association between limited patient and/or caregiver HL and neurosurgical outcomes.

Methods: A systematic search was conducted in PubMed, Embase, CINAHL, and JBI EBP from inception to February 12, 2025, following PRISMA guidelines. Study quality was assessed using the Newcastle-Ottawa Scale. The study design, sample size, population of interest, neurosurgical diagnoses/procedures, HL assessment used, pertinent findings, and related demographic factors were collected.

Results: The search yielded 698 article titles and abstracts, of which 37 underwent full-text review and 6 met inclusion criteria for this systematic review. These 6 studies included 695 neurosurgical patients and/or caregivers and used various methods to assess HL. Neurosurgical outcomes were grouped into the following categories: 1) delivery and timing of neurosurgical care, 2) hospital admission and discharge, and 3) quality of life (QOL) and well-being. Study results were split evenly across these 3 categories, with 2 studies that explored the delivery and timing of neurosurgical care, 2 that examined hospital admission and discharge, and 2 that investigated QOL and well-being. Study designs included 2 prospective observational studies, 3 cross-sectional studies, and 1 qualitative study. Sample sizes ranged from 27 to 300 patients, including pediatric, adult, and mixed (pediatric and adult) populations, as well as caregivers of pediatric and adult patients. All 6 studies were conducted outside the United States. Limited HL was found to be associated with delays in neurosurgical care, increased rates of discharge against medical advice, decreased patient independence, and worse psychological well-being.

Conclusions: This systematic review highlights the paucity of studies on neurosurgical outcomes among patients and/or caregivers with limited HL, while suggesting that limited HL is associated with worse neurosurgical outcomes. In addition, the lack of studies conducted in the US indicates a geographic gap in the literature. The authors provide a call to action and concrete steps to address the critical need for further research on HL to achieve more equitable neurosurgical care.

Objective: Traumatic brain injury (TBI) is a leading cause of acquired neurological disability in children of both sexes. Therapies that improve neurological disability in animal TBI models have universally failed in humans. Successful transition to clinical application should increase if experimental TBI models use animals that are more similar to humans and collect clinically relevant biomarkers. Porcine models of human disease are strong predictors of clinical efficacy. However, studies using immature swine of both sexes and serial collection of biological samples after TBI are lacking. In the authors' rat model of pediatric TBI, docosahexaenoic acid (DHA) improved outcomes and decreased white matter injury, neuroinflammation, and oxidative stress. The authors conducted a proof-of-concept study to evaluate the feasibility of obtaining serial blood, cerebrospinal fluid (CSF), and urine samples from piglets of both sexes after TBI using fluid percussion injury (FPI), and to assess the utility of these samples for measuring clinically relevant biomarkers in a preclinical pediatric TBI model.

Methods: After pilot testing of a CSF reservoir in cadaver piglets, the authors conducted FPI followed by reservoir placement in live 4-week-old male and female piglets.

Results: The authors succeeded in obtaining all 3 types of samples and measuring biomarkers of white matter injury, neuroinflammation, and oxidative stress. When inserted to an optimal depth of 10 mm, CSF reservoir function was preserved for 3-7 days despite normal piglet activity. Surgery-related mortality (occurring within 1 hour) was 3/36 piglets. One piglet had a quickly resolved scalp infection. FPI increased serum neurofilament light (NfL), a marker of axonal injury, at postinjury day (PID) 1 and 7 in males, blunted by DHA, although the sample size was small. At PID 3, FPI increased CSF interleukin (IL)-4, -8, -12, and -18. DHA abrogated the FPI-induced increase in IL-8 in males. FPI increased IL-12 in DHA-treated females but not control (coconut oil-treated) females. Female sex was associated with increased levels of 10 of the 13 CSF cytokines even in the absence of FPI. At PID 1, the authors observed markedly decreased CSF total antioxidant capacity, a measure of oxidative stress, in all groups.

Conclusions: Modified piglet FPI allowed serial collection of CSF, urine, and blood samples during the 1st week after surgery. The authors anticipate that this model will be useful for preclinical pharmacokinetic and efficacy studies that require longer term survival and serial biofluid collection after TBI.

Objective: The authors' objective was to assess the impact of telehealth on pediatric neurosurgical care access for underserved and rural populations in West Virginia. The authors explored how telehealth utilization varied over time, the socioeconomic benefits it provided to families, and its effect on visit completion rates compared with in-person appointments.

Methods: Clinic visits from January 1, 2017, to May 31, 2023, at the sole pediatric neurosurgery clinic in West Virginia were retrospectively reviewed. The data included three types of outpatient visits: in-person, telemedicine satellite clinic, and MyChart video appointments. Initial statistical analysis focused on visit completion rates, distance traveled, and time and cost savings for families. Additional geospatial analysis used heat density mapping to recognize regional utilization patterns, and community-level socioeconomic variables were analyzed for correlation with visit type utilization.

Results: Telehealth usage (telemedicine and MyChart) increased significantly during and after the COVID-19 pandemic. MyChart visits demonstrated the highest completion rates postpandemic. Telehealth visits saved families substantial travel time and cost, especially for those living more than 100 miles from the clinic. Geospatial analysis revealed that telemedicine usage was clustered in specific Appalachian regions, and in-person visits were more common among patients from economically distressed communities. Correlation analysis showed that higher poverty and unemployment rates were associated with in-person visit reliance, while telehealth adoption was lower in these populations.

Conclusions: Telehealth significantly enhances access to pediatric neurosurgical care for rural and economically disadvantaged families, reducing travel-related burdens and increasing visit adherence. However, economically distressed communities in Appalachia are less likely to use telehealth, possibly due to digital access issues or skepticism about remote care. Addressing these barriers is crucial to ensure equitable healthcare access. Further research should investigate structural and personal obstacles to telehealth uptake to improve service delivery for at-risk populations, ultimately fostering more inclusive and accessible healthcare options in remote areas.

Objective: Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to open resection for pediatric drug-resistant epilepsy (DRE). This systematic review and individual participant data meta-analysis aimed to identify independent predictors of seizure outcomes and operative and neurological complications following MRgLITT.

Methods: Uni- and multivariable mixed-effects Cox proportional-hazards regressions models were used to identify independent predictors of time to seizure recurrence following MRgLITT. Among patients with at least 12 months of follow-up, uni- and multivariable mixed-effects logistic regression analyses were conducted to ascertain the independent risk factors associated with seizure recurrence at last follow-up, operative complications, and postoperative neurological complications.

Results: A literature review identified 354 pediatric patients with a mean epilepsy duration of 7.5 (SD 5.3) years prior to MRgLITT. The mean age at seizure onset was 4.52 (SD 4.69) years, and focal seizures were more common (85.5%) than generalized seizures (14.5%). Lesions were detected on MRI in 82.1% of cases. The most common epilepsy etiologies were hypothalamic hamartoma (HH; 23.7%) and malformations of cortical development (23.7%). The mean follow-up duration after MRgLITT was 16.02 (SD 11.63) months. Engel class I outcomes were achieved in 57% of patients. In 205 cases where information was available regarding postoperative neurological complications, 35 patients (17.1%) experienced postoperative neurological complications, with hemiparesis as the most frequent complication (n = 16 patients). Of the 354 total patients who underwent MRgLITT, 8.2% underwent revision epilepsy surgery. No operative or clinical characteristics were associated with seizure recurrence. Seizure freedom probability was significantly higher among patients with HH compared to those with nonlesional MRI (p = 0.012). Patients with mesial temporal sclerosis experienced earlier seizure recurrence (p = 0.023), and an extratemporal surgical location was associated with longer seizure freedom probability (p = 0.034). Lesional MRI was associated with reduced odds of postoperative neurological complications (p = 0.031).

Conclusions: MRgLITT may be a safe and effective alternative option for pediatric DRE. Further prospective studies are warranted to elucidate MRgLITT strategies in pediatric DRE.

Objective: This study aimed to develop and evaluate an automated segmentation model for pediatric brain tumors in the posterior fossa region and the surrounding anatomy to facilitate 3D visualization of pediatric posterior fossa tumors for preoperative planning and patient education.

Methods: Annotations were created for a total of 29 pediatric posterior fossa tumor patients, and an additional cohort of 32 patients was included for only tumor segmentation. Six nnU-nets were trained for automatic semantic segmentation of the tumor, cerebrum, cerebellum, brainstem, ventricles, and venous structures. Performance metrics were set at a minimum Dice similarity coefficient (DSC) of 0.85 and a maximum 95th percentile Hausdorff distance (HD95) of 5 mm to ensure clinically relevant 3D visualization.

Results: The 6 networks created predictions for all patients in the test set. The median DSC and HD95 scores met the predefined performance criteria with median (IQR) DSC of 0.90 (0.093) for tumor segmentation, 0.97 (0.003) cerebrum, 0.97 (0.015) cerebellum, 0.91 (0.014) brainstem, 0.94 (0.038) ventricles, and 0.89 (0.077) venous structures. Overall high performance was found for automatic segmentation of the tumor and surrounding anatomy.

Conclusions: This study showed the successful development of an automatic segmentation algorithm tailored for pediatric posterior fossa tumors and relevant surrounding anatomy, enabling efficient 3D visualization for preoperative planning and patient education. This study provides a valuable basis for future research aimed at implementing advanced 3D visualization techniques for preoperative planning and patient education in pediatric neurosurgery.

Objective: Fever following hemispheric disconnection surgery is a well-known, although poorly understood, phenomenon resulting in frequent infectious workups. Prior studies have identified univariate relationships between post-hemispherotomy fever, seizure etiology, and use of an external ventricular drain for temporary CSF diversion. The aim of this study was to examine multivariate relationships between the occurrence of post-hemispherotomy fever, clinical characteristics, and CSF parameters.

Methods: A retrospective chart review was conducted for all patients who underwent hemispherotomy performed by a single surgeon at the Children's Hospital of Philadelphia from May 2017 to July 2024. Clinical characteristics, including seizure etiology, operative duration, estimated blood loss, age and weight at the time of surgery, and case chronology (i.e., surgeon experience) were abstracted. The daily maximum temperature (Tmax), antipyretic medication dosages, steroid regimen, and all blood and CSF laboratory values were recorded. Fever was defined as Tmax > 38.5°C on postoperative days 0-14. Associations between postoperative fever, clinical characteristics, and CSF parameters were assessed via multivariate logistic regression analysis.

Results: Seventy patients (35 male and 35 female, mean age 7.2 years) were included in the analysis. Postoperative fever occurred in 30 patients (42.9%). Fever was more common among patients with Rasmussen's encephalitis (RE; 8/11, 72.7%) and hemimegalencephaly (HME; 5/9, 55.6%), although neither etiology was significant in the multivariate analysis (p = 0.069 and p = 0.097, respectively). Fevers occurred more frequently at the beginning of the surgeon's career and declined with case chronology (OR 0.96, p = 0.047). Among patients for whom CSF laboratory testing was performed (52/70, 74.3%), a significant association was observed between the CSF protein level and postoperative fever (OR 1.002, p = 0.045).

Conclusions: The likelihood of fever following hemispherotomy declined with surgeon experience and was positively associated with an elevated CSF protein level. Fevers might also be more common in patients with certain seizure etiologies, specifically RE and HME.

Objective: The concept of spinal cord injury without radiographic abnormality (SCIWORA) was introduced in the 1980s. Unfortunately, the nomenclature creates confusion in the modern MRI-based era when applied to pediatric traumatic spinal injuries. The authors investigated the incidence and clinical characteristics of pediatric patients with true imaging-negative traumatic cervical spinal cord injuries (SCIs).

Methods: A prospective pediatric level I trauma center database at Primary Children's Hospital was queried to identify patients with cervical spine injuries tagged with "SCIWORA" or "transient spinal cord injury." Demographic and clinical data were analyzed retrospectively after applying the following inclusion criteria: patient age < 18 years, evidence of transient neuropraxia on neurological examination, cervical spine MRI available for review, Glasgow Coma Scale (GCS) score ≥ 8, no intracranial pressure monitoring during hospitalization, and no evidence of SCI on MRI.

Results: A total of 22,909 patients were entered into the trauma database from 2005 to 2022. Of the 226 patients who met the initial search criteria, 21 met the final inclusion criteria. Eighteen patients (85.7%) were male, and the mean age was 13.66 ± 2.48 years. The median GCS score was 15 (IQR 13-15). Neurological deficits noted on presentation included sensory, motor, and rectal tone loss in 19 (90.5%), 19 (90.5%), and 1 (4.8%) patient, respectively. The most common mechanism of injury was American football (10 patients, 47.6%), followed by wrestling (4, 19.0%) and motor vehicle collisions (2, 9.5%). The mean hospital stay was 1.81 ± 0.98 days (range 1-5 days), with 3 (14.3%) patients admitted to the pediatric ICU for 1.33 ± 0.58 days on average. All 21 patients were initially managed with a rigid cervical orthosis worn for 1-42 days (mean 4.57 ± 5.42 days). Neurological symptoms completely resolved by discharge in 16 (76.2%) patients. The time necessary for neurological recovery was 1-15 days (mean 2.24 ± 3.34 days). No patient required surgery or prolonged collar usage.

Conclusions: In this cohort, patients with MRI-negative neuropraxic cervical SCI were predominantly adolescent male athletes who recovered from their injuries within a few days without surgery or prolonged use of cervical collars. The authors assert that the term "transient spinal neuropraxia in pediatric patients" (T-SNIPP) is more appropriate to describe these injuries in the modern, MRI-based era of pediatric trauma care.

Objective: Traumatic spinal cord injury (SCI) in children and adolescents is uncommon but represents a substantial source of morbidity. Due in part to its rarity, there are few pediatric-specific studies on this topic. Therefore, the aim of this study was to assess demographics, injury mechanisms, treatment characteristics, and neurological outcomes in a cohort of pediatric patients with traumatic SCI, and to determine patient and injury factors associated with neurological recovery after injury.

Methods: In this retrospective observational cohort study, children and adolescents with traumatic SCI presenting to a quaternary children's hospital from January 2000 to December 2020 were identified. Patients with spinal column injury without evidence of spinal cord involvement, such as fracture and ligamentous injury alone, were excluded. Neurological examinations were abstracted from clinical notes at admission, discharge, and 3- to 4-month and 12-month follow-up time points, and the grade of injury was assessed per the American Spinal Injury Association Impairment Scale (AIS). Univariate logistic regression was used to identify associations between demographic, injury, and treatment variables with improvement of ≥ 1 AIS grade at 12 months.

Results: Seventy-five patients (45 male, mean age 10.4 years) with traumatic SCI were included in the analysis. The injury mechanism was most often motor vehicle collision (MVC; n = 35, 46.7%), followed by sports and recreation injuries (n = 23, 30.7%) and falls (n = 9, 12%). There were 36 patients (48%) with concomitant nonspinal injuries, including 24 (32%) with traumatic brain injury. Overall, 15 patients (20%) died in the hospital at a median of 1 day (IQR 1-2 days) after injury, most of which were associated with MVC, concomitant head injury, and/or craniocervical junction (CCJ) dissociation. Surgical intervention was performed for 30 patients (40%). Of the 47 patients with AIS grades A-D who survived to the 1-year follow-up, 34 (72%) improved by ≥ 1 AIS grade and 11 (23%) improved by ≥ 2 AIS grades by 12 months. A higher injury severity score (OR 0.86, 95% CI 0.77-0.93) and spinal cord hemorrhage on MRI (OR 0.09, 95% CI 0.01-0.58) were associated with lower odds of improvement.

Conclusions: Mortality was relatively common after pediatric SCI and was associated with CCJ dissociation or concomitant nonspinal injuries. Among surviving patients who were admitted to the hospital with neurological impairment, a majority experienced improvement by ≥ 1 AIS grade at the 12-month follow-up.