Journal of neurosurgery. Pediatrics最新文献

Objective: The incidence of nonsyndromic multisuture craniosynostosis is rare, accounting for < 5% of cases. Concurrent isolated bilateral lambdoid and sagittal synostosis (BLSS), colloquially known as Mercedes-Benz pattern synostosis, constitutes < 1% of all craniosynostosis cases. Patients with BLSS benefit from surgical correction in infancy to correct the characteristic frontal bossing, a high forehead with significant downward sloping toward the occiput, a prominent occiput with a notable point, and occipital concavity that starts immediately below that region. However, due to its rarity, there is a paucity of literature describing the surgical management of BLSS. In this study, the authors evaluated a single institution's clinical experience treating this condition with early endoscopic strip craniectomy (ESC).

Methods: Medical records for patients with a diagnosis of concurrent sagittal and bilateral lambdoid synostosis who underwent ESC between 2006 and 2023 at a single institution were reviewed for demographic, operative, and follow-up data. Patients with additional fused sutures or other syndromic diagnoses were excluded as those cases constitute a distinct pathology from pure Mercedes-Benz synostosis. All patients with less than 1 year of follow-up were also excluded.

Results: Seven patients underwent early ESC as the primary treatment for Mercedes-Benz pattern synostosis. The mean age at surgery was 3.0 months (range 1.60-5.97 months). The mean operative time was 67 minutes, with a time under anesthesia of 155 minutes. There were no complications intra- or postoperatively. No patients required readmission within 30 days or a subsequent surgical procedure. The mean length of follow-up was 3.5 years.

Conclusions: Early endoscopic surgery is a safe and effective treatment for infants with Mercedes-Benz synostosis. Based on clinical criteria and limited imaging in some cases, the children have done extremely well with no need for additional surgery, but additional long-term follow-up is in process.

Objective: Neurosurgery, particularly pediatric neurosurgery, is associated with high malpractice risks due to the complexity of procedures and potential for severe complications. However, comprehensive reviews of medical malpractice cases specifically involving pediatric neurosurgeons are scarce. This study aimed to analyze trends in malpractice litigation within the pediatric neurosurgical field in the United States.

Methods: A search was conducted of the LexisNexis and Westlaw legal databases for medical malpractice cases involving pediatric neurosurgeons from 1979 to 2022. Cases were included if they involved a pediatric neurosurgical condition, a patient younger than 21 years of age, and at least one defendant who was a pediatric neurosurgeon. Fourteen cases met the inclusion criteria and were analyzed for clinical conditions, allegations, outcomes, and other relevant factors.

Results: Most cases originated from the southern United States, with spina bifida/tethered cord and subdural hematomas being the most cited conditions. Allegations predominantly focused on failure to diagnose or treat (57%, 8/14 cases) particularly in relation to hydrocephalus and spina bifida. Nine cases favored the defendant, 1 resulted in a plaintiff's verdict, and the outcome of 4 cases was unknown or a mixed verdict. Plaintiff age typically ranged from younger than 3 years to more than 13 years.

Conclusions: These findings highlight the prevalence of specific conditions such as spina bifida and hydrocephalus in malpractice cases involving pediatric neurosurgeons. While most cases favored the defendant, these conditions and the high acuity of pediatric neurosurgical care continue to present significant risks. Future research incorporating insurance provider data could offer further insights into malpractice trends in this field. This study provides a detailed overview of malpractice claims in pediatric neurosurgery, identifying key conditions and trends. Understanding these patterns is crucial for enhancing risk management and patient care in pediatric neurosurgery.

Objective: Although pediatric head trauma (PHT) is a critical public health issue, comprehensive research on the anatomical distribution and frequency of impact locations is lacking. The authors aimed to elucidate trends in the mechanisms and anatomical locations of PHT using clinical data across all injury severity levels.

Methods: The medical records of 146 PHT patients aged 0-14 years treated by the authors' neurosurgery department were analyzed, excluding cases of suspected abuse. Clinical data and injury mechanisms were reviewed, and 152 PHTs were assessed to identify the trauma frequencies for 17 different anatomical locations of the head. The authors compared actual to expected PHT hits per region based on area ratios to determine the regions more susceptible to PHT.

Results: Most PHTs were minor, without even subcutaneous hematomas. Radiological imaging was performed in 32.2% of patients, revealing abnormalities in 19.2% of those cases. Larger hematomas correlated with these abnormalities, although there was no correlation between vomiting and imaging findings. Notably, 65.7% of the traumas occurred within a horizontal band from the frontal to the occipital region, similar to the area covered by a sports headband. The high injury concentration in this area was particularly focused on the center-forehead region, where susceptibility was significant (p < 0.001). Children younger than 6 years of age had a greater bias toward specific PHT-prone regions. This diminished with age, suggesting changing PHT mechanisms as children mature.

Conclusions: Certain head regions are more prone to accidental PHT, with region-specific susceptibility varying by age. This study can facilitate the design of optimal pediatric head protection and support clinical assessment of injury patterns.

Objective: Hemispherotomy and posterior quadrant disconnection (PQD) are standard surgical treatments for medically intractable epilepsy in pediatric patients. However, the current academic literature is limited on their efficacy and safety in very young patients. This study evaluates the outcomes of patients ≤ 12 months of age who underwent hemispherotomy or PQD.

Methods: The authors retrospectively reviewed the medical records of patients ≤ 12 months of age who underwent epilepsy surgery at Washington University and St. Louis Children's Hospital from 2003 to 2023. Data on diagnosis, age at surgery, operative details, hospital length of stay, and complications were reported. The Engel classification and Gross Motor Function Classification System (GMFCS) were used to assess seizure and motor outcomes, respectively.

Results: A total of 14 patients who underwent either hemispherotomy (n = 12) or PQD (n = 2) were included. Overall, 57% had a diagnosis of hemimegaloencephaly, 29% had middle cerebral artery infarcts, and 14% had cortical development malformation. The mean age at surgery was 6 months, with the youngest child being 2 months of age. The mean estimated blood loss was 58% of the total blood volume. The mean duration of follow-up was 4.8 years. At 1 year postoperatively, seizure freedom was 75%. At the last follow-up, 54% of patients were free of disabling seizures (Engel class I), with 57% of this subgroup being completely seizure free (Engel class IA). Of the remaining patients, 23% experienced rare disabling seizures (Engel class II) and 23% experienced worthwhile improvement (Engel class III). At the last follow-up, 67% of patients had a GMFCS level of I or II (walking with no or some limitations) and 33% had a GMFCS level of IV (assisted self-mobility). There were no deaths or long-term postoperative complications.

Conclusions: Hemispherotomy and PQD in children ≤ 12 months of age are associated with meaningful seizure control and improved motor outcomes. These procedures should be considered for the treatment of medically refractory epilepsy, even in very young infants.

Objective: Nonsyndromic sagittal craniosynostosis is the most common form of craniosynostosis, and its management includes open cranial vault reconstruction (CVR) or minimally invasive techniques such as endoscopic suturectomy with helmet orthosis (ESO) and spring-assisted suturectomy (SAS). Delayed surgical referral can limit eligibility for minimally invasive techniques, which are associated with lower morbidity. Disparities in socioeconomic factors may contribute to later presentation, particularly for minority populations. This study explores the impact of sociodemographic variables, Area Deprivation Index (ADI), and Child Opportunity Index (COI) on referral timing, surgical timing, and the type of intervention performed.

Methods: The authors performed a retrospective review of children who underwent surgery for nonsyndromic single-suture sagittal craniosynostosis at a large urban referral center between 2015 and 2023. Patients were categorized into earlier referral (< 2 months) or later referral (≥ 2 months) cohorts and earlier surgery (< 6 months) or later surgery (≥ 6 months) cohorts. Demographics, socioeconomic indices (ADI, COI), and procedure type were compared between groups.

Results: Two hundred four children, 29.4% of whom were female, met the study inclusion criteria. Among these children, 50.0% underwent CVR, 36.3% SAS, and 13.7% ESO. Patients in the later surgery cohort were significantly more likely to be non-White (29.1%, p < 0.01), non-English speaking (13.9%, p < 0.01), and publicly insured or uninsured (59.5%, p < 0.01). Non-White patients were referred later (93 vs 45 days, p < 0.001), disproportionately older at surgery (207 vs 148 days, p < 0.001), and more likely to undergo CVR (69.2%, p < 0.001). Distance to the hospital, median household income, ADI, and COI were not significant predictors of the type of surgery performed.

Conclusions: This study highlights disparities in access to minimally invasive craniosynostosis surgery, particularly among non-White, non-English speaking, and socioeconomically disadvantaged children in the state of Georgia. Targeted efforts in community education are needed to reduce this disparity and strive toward equitable access to care.

Objective: Although total corpus callosotomy (TCC) is attempted for better seizure control in patients with drug-resistant generalized seizures and intellectual disability, some surgeons may avoid TCC for fear of postoperative neurocognitive sequelae. The present study aimed to identify the predictors of favorable or unfavorable seizure outcomes and evaluate the postoperative changes in cognitive function after TCC.

Methods: The authors retrospectively reviewed the clinical records of consecutive patients who underwent TCC to palliate generalized seizures between 2010 and 2022 in the Department of Neurosurgery, Hiroshima University Hospital and had a minimum follow-up of 2 years. The inclusion criteria were 1) age at surgery ≥ 5 years, 2) preoperative IQ score ≤ 50; and 3) 1- or 2-stage TCC. A multivariable logistic regression analysis was performed to determine the predictors of seizure outcome after TCC. The changes in IQ were compared between the favorable and unfavorable seizure outcome groups.

Results: The authors included 40 patients. Favorable seizure outcomes (> 75% reduction in seizure frequency, severity, or both) were obtained after TCC in 29 (72.5%) and 23 (57.5%) patients at 1 year and 2 years postoperatively, respectively. Multivariable logistic regression analysis revealed that interictal electroencephalography showing multiple independent spike foci (MISF) was an independent predictive factor of an unfavorable seizure outcome at 2 years after TCC (p = 0.0270; OR 6.48, 95% CI 1.24-33.96). ΔIQ from preoperatively to 1 year postoperatively was significantly higher in the favorable seizure outcome group (median 0, range -1 to +14) than in the unfavorable seizure outcome group (median -6, range -14 to -5; p = 0.0042). From 1 to 2 years postoperatively, there was no decline in IQ in either group and no difference in ΔIQ between the two groups.

Conclusions: The authors found that MISF is a predictor of unfavorable seizure outcome after TCC. Unfavorable seizure outcomes are associated with postoperative aggravation in cognitive function. The cognitive deterioration may be due in part to the surgical intervention itself. Thus, appropriate selection of the candidates for TCC is desired.

Objective: The authors provide an updated analysis of inpatient healthcare utilization, associated costs, and mortality trends for pediatric hydrocephalus in the US from 2006 to 2019. The goals were to describe patient, hospital, and hospitalization characteristics and determine factors associated with mortality.

Methods: This cross-sectional study used 2006, 2009, 2012, 2016, and 2019 data from the Healthcare Cost and Utilization Project Kids' Inpatient Database, which collects nationally representative weighted data samples of pediatric hospital discharges. Admissions related to hydrocephalus were categorized as being associated with permanent cerebrospinal fluid (CSF) diversion (including CSF shunt management and endoscopic third ventriculostomy [ETV] with or without choroid plexus cauterization [CPC]) or unrelated to permanent CSF diversion.

Results: Each year, there were approximately 30,000-32,000 hydrocephalus-related admissions, resulting in 331,000-526,000 hospital days and US$3.4-5.0 billion charges, for pediatric patients. In 2019, hydrocephalus accounted for 0.5% of all pediatric hospital admissions, 1.4% of all pediatric hospital days, and 2.4% of all pediatric hospital charges in the US. The median (IQR) length of stay across all hydrocephalus-related admissions decreased from 4 (2-15) days in 2006 to 3 (2-9) days in 2019. CSF shunt-related admissions decreased from 11,111 in 2006 to 7959 in 2016; notably, admissions for CSF shunt malfunctions/revisions decreased over time (12,327 in 2006 to 5960 in 2019). In 2019, hospital stays were shorter (4.99 vs 6.69 days) and charges were lower (US$108 million vs US$128 million) in patients who underwent ETV or ETV+CPC compared to those who had initial shunt placement, respectively. However, these unadjusted differences likely reflect baseline patient selection rather than inherent procedural superiority. Patients admitted for periventricular-intraventricular hemorrhage of prematurity (pIVH) had longer hospital stays (p < 0.001) and higher mean costs than others. Compared with survivors, children who died were younger, had pIVH, had a birth-related admission, were self-paying, and were admitted to a nonchildren's hospital (p < 0.05).

Conclusions: Pediatric hydrocephalus continues to pose a heavy burden in the US. Despite advancements in management, it remains associated with high costs, significant hospital utilization, and substantial morbidity and mortality. ETV admissions were associated with shorter hospital stays and lower costs, and pIVH was associated with particularly high resource utilization and markedly higher in-hospital mortality. Future efforts should focus on reducing mortality and improving care delivery for high-risk subgroups, particularly those with pIVH and birth-related etiologies.

Objective: Rasmussen's encephalitis (RE) affects the structure and function of one cerebral hemisphere, typically during childhood. Hemispherotomy is a surgical treatment that functionally disconnects the affected hemisphere. The cognitive consequences of surgery and the potential for postoperative recovery remain poorly understood, however, due to their complex and multifactorial nature. This study aimed to examine the long-term cognitive outcomes of patients with RE following hemispherotomy and identify the clinical factors influencing recovery.

Methods: Forty-four patients who underwent childhood hemispherotomy for RE (28 girls, 23 with left RE) were included in this retrospective study. Neuropsychological assessments were conducted during postoperative follow-up, and verbal (VIQ) and nonverbal (performance IQ [PIQ]) IQ scores from the most recent evaluation were analyzed. The impact of age at seizure onset (ASO), age at hemispherotomy, preoperative epilepsy duration, side of hemispherotomy, age at neuropsychological evaluation, and postoperative follow-up duration on intellectual efficiency scores was assessed using partial least squares analysis.

Results: The mean ASO was 5.9 years, the mean age at hemispherotomy was 9.6 years, the mean epilepsy duration was 3.7 years, and the mean postoperative follow-up duration was 9.5 years. After hemispherotomy, 91% of patients were seizure free (Engel class I), and 86% were no longer receiving antiepileptic medication. Patients who underwent hemispherotomy of the language-dominant hemisphere (Hdom) had lower VIQ scores but higher PIQ scores compared to those with hemispherotomy of the nondominant hemisphere (Hnondom). Results showed that higher VIQ was significantly associated with several clinical factors, including a shorter epilepsy duration before surgery, a younger age at surgery, and hemispherotomy of the nondominant hemisphere for language. In contrast, no clear link was found between clinical variables and PIQ.

Conclusions: In RE, early hemispherotomy performed soon after disease onset appears to be associated with better long-term intellectual outcomes. Verbal functions can be recovered following hemispherotomy of the dominant hemisphere, highlighting the preferential reorganization of language in postoperative cognitive recovery. These findings underscore the critical importance of early surgical decision-making in optimizing patient care and maximizing postoperative recovery.