Journal of neurosurgery. Pediatrics最新文献

Objective: The Matsushima grading system is widely used to evaluate angiographic revascularization outcomes after pial synangiosis for moyamoya vasculopathy by quantifying collateral ingrowth. The authors hypothesized that the orbital grading system (OGS), a new scale developed for adults to measure collateral ingrowth, would provide greater consistency and interrater reliability. They aimed to compare the performance of these scales for the first time in the pediatric population.

Methods: The authors performed a retrospective analysis of patients with moyamoya vasculopathy with follow-up catheter angiography after indirect revascularization at a single major pediatric center from 2006 to 2023. An interrater reliability analysis was performed using 5 raters with varying levels of training, who provided scores for 30 blinded cases. Fleiss' kappa coefficient (κ) was calculated as a measure of agreement beyond chance.

Results: A total of 101 patients with a median age of 9 years, of predominantly female sex (56.4%) who were mostly affected by moyamoya disease (71.3%) were included. A total of 158 cerebral hemispheres were treated with pial synangiosis (57 patients had bilateral surgeries). Most hemispheres were categorized as Suzuki stage 3 or above (82.9%). At a median of 12.4 months postoperatively, collateral growth was classified as Matsushima grade A in 57.6%, B in 24.1%, C in 14.6%, and as borderline grades in 3.8%. The OGS scores were grade 0 in 7.0%, grade 1 in 8.9%, grade 2 in 43.7%, and grade 3 in 40.5%. Interrater agreement evaluation revealed that the OGS had a superior κ value compared with the Matsushima scale (0.51 vs 0.15, p < 0.001).

Conclusions: The OGS had higher interrater agreement rates than the Matsushima scale for identifying postoperative collateral ingrowth in children after pial synangiosis. This scale provides a more consistent method for evaluating angiographic outcomes after indirect revascularization in the pediatric population.

Objective: Endoscopic third ventriculostomy (ETV), an alternative to ventriculoperitoneal shunt (VPS) placement, is associated with a higher risk of early failure, sometimes necessitating subsequent VPS insertion. The authors evaluated the impact of ETV prior to VPS placement on the risk of VPS failure by using the Hydrocephalus Clinical Research Network (HCRN) Core Data Project.

Methods: The authors retrospectively reviewed prospectively collected data from the HCRN Core Data Project (registry) on all children who underwent VPS surgery between April 2008 and July 2023. Children who had undergone VPS placement as initial treatment for hydrocephalus were compared with those who had undergone ETV prior to VPS insertion. The primary outcome was initial VPS survival, with failure defined as any subsequent hydrocephalus procedure. Kaplan-Meier and Cox proportional hazards analyses were performed to assess the effect of prior ETV, controlling for age at the first permanent procedure (ETV or VPS placement), hydrocephalus etiology, and complex chronic conditions (CCCs).

Results: VPS placement was performed in 6206 children, of whom 642 underwent VPS placement after failed ETV. VPS insertion after ETV improved shunt survival at 1 year (74.3% vs 67.8%, p < 0.001). Unadjusted analysis showed improved VPS survival after ETV (HR 0.78, 95% CI 0.68-0.90, p = 0.001). Corrected age ≥ 30 days at the time of the first permanent procedure, choroid plexus cauterization, etiology of hydrocephalus other than intraventricular hemorrhage of prematurity, and the absence of a CCC were also associated with improved shunt survival on univariable analysis. Multivariable analysis revealed that hydrocephalus etiology, the absence of a CCC, corrected age ≥ 30 days at the time of the first permanent procedure, and ETV prior to VPS insertion (HR 0.85, 95% CI 0.74-0.98) remained associated with shunt survival (all p < 0.05).

Conclusions: This analysis demonstrates an association between ETV prior to VPS placement and improved VPS survival, even when controlling for age, comorbid conditions, and hydrocephalus etiology. Further work is needed to understand the mechanism of this effect.

Objective: The Hydrocephalus Clinical Research Network-Quality (HCRNq) was established to encourage adoption of evidence-based best practices for the care of children with hydrocephalus. A shunt infection prevention initiative is ongoing within the network, and an analysis of baseline data suggested important practice variation with respect to shunt infection prevention practices. In a first attempt to standardize care, the authors recommended adoption of an endorsed shunt infection prevention protocol within the network, and now present information related to protocol adoption, compliance, and its effect on shunt infection rates.

Methods: A memorandum was circulated to HCRNq sites endorsing and recommending adoption of a 7-step shunt infection prevention protocol. Patient and procedural data relevant to shunt surgery and infection prevention were then prospectively collected from 31 network sites. The relationship between the infection outcome and patient and procedural variables, including protocol adoption, was modeled using uni- and multivariable statistics.

Results: An unadjusted infection rate of 3.6% was observed over nearly 3500 shunt procedures, similar to what was observed at baseline, but with a narrower range, suggesting that some outlying sites were brought closer to the network average. An increased infection risk was associated with shunt placement for preterm posthemorrhagic hydrocephalus, the occurrence of prior shunt surgery within 6 months of the index procedure, and the use of antibiotic ointment. A reduced infection risk with the use of antibiotic-impregnated catheters was suggested. Adoption of the recommended protocol was modest, and as a result, significant practice variation continued to be observed. In this analysis, no relationship was observed between infection risk and the use of an infection prevention protocol.

Conclusions: This first attempt to encourage standardization of perioperative practices for shunt infection prevention, by endorsing an evidence-based shunt infection prevention protocol for use at network sites, resulted in incremental protocol adoption. Many shunt procedures continue to occur without the cover of a protocol. Although adherence to a protocol did not appear to influence infection risk in the present analysis, an opportunity to improve remains, with a potential beneficial effect on infection rates to follow. The authors continue to work toward further improvement in this regard.

Objective: Children with cerebral arteriovenous malformation (AVM) have a high risk of spontaneous intracerebral hemorrhage. The identification of patients at risk for AVM rupture and accurate prediction of outcomes are critical to guide management strategies. The authors examined the angioarchitectural features of pediatric AVMs associated with hemorrhagic presentation and reviewed the utility of the Ruptured AVM Grading Scale (RAGS) for outcome prognostication in pediatric patients treated surgically at a single institution.

Methods: The authors retrospectively reviewed the records of pediatric (age ≤ 18 years) patients who underwent resection of AVMs at their institution between 1998 and 2023. Demographic factors, clinical presentation, and angioarchitectural details including nidus size, location, venous drainage, presence of flow-related aneurysm, presence of an en passage vessel, and perforator vessel supply were collected. Clinical presentation and angioarchitecture were compared in patients with ruptured and unruptured AVMs. In patients with ruptured AVMs, the area under the receiver operating characteristic curve (AUROC) was calculated based on their RAGS scores at 3 follow-up time points using dichotomous analysis of the modified Rankin Scale score as the response variable.

Results: Of the 62 patients included in this study, 59.7% presented after rupture. Patients with ruptured AVMs had, on average, a smaller nidus (24.84 vs 38.24 mm, p < 0.001) and a higher percentage of deep venous drainage (64.9% vs 32.0%, p = 0.009). Multivariable logistic regression analysis confirmed smaller nidus diameter (OR 0.93, 95% CI 0.87-0.98, p = 0.016) and presence of deep venous drainage (OR 10.78, 95% CI 1.73-42.94, p = 0.011) as independent predictors of hemorrhagic presentation. Good clinical outcomes (modified Rankin Scale [mRS] score ≤ 2) at last follow-up were similar for the unruptured and ruptured cohorts (85.5% vs 88.0%, p = 0.230). For patients with ruptured AVMs, the AUROC values for the RAGS scoring system were 0.48 at 3 months, 0.67 at 1 year, and 0.70 at the last known follow-up.

Conclusions: Smaller AVM nidus size and deep venous drainage were associated with hemorrhagic presentation in children with AVMs. Although the AUROC for RAGS improved with longer follow-up periods, it did not reach the 0.8 threshold needed for clinical utility.

Objective: The treatment of sagittal craniosynostosis typically involves endoscopic suturectomy (ES) to allow skull expansion, followed by postoperative helmet orthosis, resulting in an improvement in cranial deformity as assessed using the cephalic index (CI). The impact of variations in surgical technique on long-term CI outcomes is not well understood, and there is controversy regarding whether adding barrel stave osteotomy (BSO) to standard ES leads to greater improvement in the CI postoperatively. This combined approach is thought to improve cranial shape and overall clinical outcomes but may increase operative burden. The aim of this study was to investigate the impact of BSO during ES on operative outcomes and postoperative cranial deformity in patients who underwent surgical correction of sagittal craniosynostosis.

Methods: The authors conducted a retrospective chart review of children who had been treated with ES for sagittal craniosynostosis between 2010 and 2021 at British Columbia Children's Hospital. Demographics, operative outcomes, and postoperative longitudinal CI measurements were collected and compared between patients who had undergone ES with BSO (ES+BSO) and those who had undergone ES alone. Operative outcomes related to anesthesia and surgical time, blood loss, and hospital length of stay were analyzed, as were changes in the CI at various follow-up times. A mixed-effects model was used to compare longitudinal CI measurements between treatment groups, controlling for patient age, preoperative CI, and duration of helmet therapy.

Results: Eighty-five patients were included in the analysis, 67 treated with ES+BSO and 18 treated with ES. Operative outcomes, including length of hospital stay, operative time, time under anesthesia, blood loss, and need for transfusion did not differ significantly between treatment groups (p > 0.05). The mean follow-up for the last CI measurements was 56.0 months. While preoperative CI was similar for the two groups (mean 67.4 for ES+BSO vs 66.8 for ES, p = 0.61), CI was significantly higher in the ES+BSO group immediately postoperatively (p = 0.004) and at the 6-month (p = 0.01), 2-year (p = 0.02), and final (p = 0.002) follow-ups. A mixed-effects model revealed that the addition of BSO led to significantly greater CI measurements independent of age, preoperative CI, and helmeting duration (estimated effect size 2.21, p = 0.001).

Conclusions: In this series, the addition of BSO to ES significantly improved immediate and long-term cranial deformity in patients with sagittal craniosynostosis, without increasing the operative burden.

Objective: Chiari malformation type I (CM-I) is a common condition characterized by the cerebellar tonsillar position below the foramen magnum. Radiographic measurements are important for diagnosing CM-I but have limited use in predicting the severity of the condition and the need for surgery. The fourth ventricle roof angle (FVRA), a measure of deformation or bowing of the roof of the fourth ventricle, has been presented as a tool for predicting brainstem dysfunction in patients with CM-I; however, this has not been validated. Utilizing a database of pediatric patients with CM-I from a large single center, this study aimed to validate the finding that the FVRA can serve as a predictor of brainstem dysfunction in pediatric CM-I and to present additional potential correlations of interest between the FVRA and symptoms and other radiographical measurements.

Methods: Radiographic measurements were retrospectively reviewed for 388 pediatric patients evaluated for CM-I at Children's of Alabama from November 2010 to 2017. Fourth ventricle bowing was determined to be present if the FVRA was > 65°. Univariate and multivariate logistic regression analyses were performed to identify significant associations with the FVRA, brainstem dysfunction, and surgery. Brainstem dysfunction was defined as the presence of lower cranial nerve dysfunction and/or sleep apnea.

Results: Multivariate logistic regression showed significant association of lower brainstem dysfunction with tonsillar position (OR 1.17, 95% CI 1.06-1.29), basilar invagination (OR 0.66, 95% CI 0.47-0.91), supraoccipital length (OR 0.86, 95% CI 0.77-0.96), and tussive headache (OR 6.62, 95% CI 1.95-22.46). The presence of bowing did not show a significant association with brainstem dysfunction in the multivariable model (OR 1.02, 95% CI 0.27-3.81), and it was not significantly associated with undergoing surgery after controlling for symptoms that always resulted in surgery (p = 0.483).

Conclusions: Univariate logistic regression analysis demonstrated that an FVRA greater than 65° is significantly associated with brainstem dysfunction. In a multivariate logistic regression model, however, the presence of bowing was not independently associated with brainstem dysfunction. As such, additional studies are needed before FVRA can be utilized clinically.

Objective: The role of timely nutritional support in the recovery of pediatric traumatic brain injury (PTBI) patients is crucial yet underexplored. The authors planned a retrospective study to investigate the timing of feeding initiation (early feeding [≤ 48 hours] or delayed feeding [> 48 hours]), feeding pattern, and causes of feeding delay/interruption in this cohort and studied the association of delayed feeding with outcomes in PTBI from a single center in a lower-middle-income country.

Methods: This retrospective, single-center study included PTBI patients ≤ 15 years of age admitted to the neurotrauma intensive care unit (NICU) within 24 hours of head injury over a period of 1 year. Demographic data, injury characteristics, and nutritional data were recorded from hospital electronic records. The outcome was measured in terms of NICU length of stay (LOS) and hospital LOS, infectious complications, neurological recovery at discharge, and mortality.

Results: One hundred PTBI patients were included, with mild (n = 28, 28%), moderate (n = 28, 28%), and severe (n = 44, 44%) traumatic brain injury (TBI). Patients had a median Glasgow Coma Scale (GCS) score of 9 (IQR 7, 13) at admission. Enteral nutrition was initiated early in 48% (n = 48) of patients. Only 39 of 100 patients reached 70% of their caloric target within 7 days. Causes of feeding interruption were planned surgical/radiological and airway procedures (n = 89, 59.0%), feed intolerance (n = 25, 16.6%), feed refusal (n = 22, 14.6%), and hemodynamic instability (n = 15, 9.9%). Early initiation of enteral feeding was positively associated with reduced NICU LOS (r = 0.25) and overall hospital LOS (r = 0.33). Patients receiving early nutrition had a shorter hospital LOS (5.5 vs 10 days, p = 0.043) and higher GCS score at discharge (15 vs 13, p = 0.002). In mild TBI cases, early feeding significantly reduced NICU (2.5 vs 7.5 days, p = 0.01) and hospital (3.5 vs 13 days, p = 0.002) LOSs and improved discharge GCS score (15 vs 14.5, p = 0.02). These benefits were not observed in moderate or severe TBI patients. In multivariate analysis, undergoing neurosurgery influenced hospital LOS and discharge GCS score, and admission GCS score predicted mortality. The in-hospital mortality rate was 17%.

Conclusions: Early enteral feeding was initiated in 48% of PTBI patients. Common delays/interruptions were due to planned procedures. Early enteral feeding was associated with shorter NICU and hospital LOSs. However, a definite association of early enteral feeding with improved neurological outcomes could not be established.

Objective: Neurosurgeon scientists play a unique role in advancing neuroscience research. While previous publications have explored trends in federal and foundation funding among neurosurgeons, funding is often dominated by neurosurgical oncologists and functional neurosurgeons. Less is known about the research efforts of pediatric neurosurgeons. The aim of this study was to survey the members of the American Society of Pediatric Neurosurgeons (ASPN) to provide an overview of past research experience, current involvement, funding, and research priorities among pediatric neurosurgeons, and to gather insights that could shape future efforts to advance pediatric neurosurgical research.

Methods: A survey was developed using the REDCap platform and distributed to all ASPN members via email. Survey questions used branching logic and were organized into 5 sections: 1) demographics, 2) research experience during training, 3) research experience as an attending physician, 4) research priorities, and 5) multicenter consortiums.

Results: One hundred thirty-nine respondents completed more than half of the survey, for an overall response rate of 52.1%. Most respondents (96.4%) participated in research during their training, but only 38.1% had received a grant during training. In contrast, 83.9% of respondents were actively engaged in research as an attending physician, and 48.7% reported active funding (60.7% federal, 41.8% from foundations, and 42.9% internal). Furthermore, 74.8% of respondents reported being a member of a multicenter research consortium, and 82.4% agreed that multicenter research is important. Seventy percent of respondents agreed that the ASPN should facilitate multicenter consortium-based pediatric neurosurgical research, offering free-text responses with the following suggestions: 1) set aside time at the annual meeting to discuss multicenter research (22.9%); 2) encourage collaboration and facilitate networking (42.9%); 3) provide centralized core services such as a data coordinator and biostatistician (12.9%); and 4) provide training, education, and mentoring (7.1%).

Conclusions: The survey provided a cross-sectional analysis of the pediatric neurosurgical research landscape, highlighting the current state of research experience, funding, and the perspectives of pediatric neurosurgeons regarding research priorities. Despite the challenges, there is clear recognition of the importance of multicenter research collaboration. These findings reinforce the ongoing necessity of organized initiatives to support pediatric neurosurgical research and offer actionable insights into how organized pediatric neurosurgery can contribute to this critical endeavor.

Objective: Selective dorsal rhizotomy (SDR) is a proven surgical treatment of spastic diplegia to improve function in patients suffering from spasticity compared to physical therapy alone. Few studies have addressed the benefit for those with spastic hemiplegia. The aim of this study was to describe and evaluate the efficacy of SDR in patients with spastic hemiplegia.

Methods: A retrospective chart review was performed on pediatric patients (< 18 years of age) who underwent SDR at Monroe Carell Jr. Children's Hospital from July 2013 through January 2024 with a diagnosis of spastic hemiplegic cerebral palsy. Patients underwent pre- and postoperative physical therapy testing at approximately 1 year. Any patients found to have spastic triplegia with asymmetrical hypertonia in the lower extremities, or those without postoperative evaluations, were excluded. Outcome measures included the modified Ashworth Scale (mAS), Gross Motor Function Measure-66 (GMFM-66), timed (10 m) walk test, Gross Motor Function Classification System (GMFCS), and the Pediatric Quality of Life Cerebral Palsy (PedsQL CP) module. Pre- versus postoperative comparisons were performed using a Wilcoxon signed-rank test and the differences were considered statistically significant when p values were < 0.05.

Results: Twenty-one patients underwent SDR for spastic hemiplegic cerebral palsy with pre- and postoperative physical therapy assessments. The patients were 52.4% male, 81.0% White, with a median age of 5 years at the time of surgery. The most common etiology for spastic hemiplegia was stroke (52.4%). All patients had a preoperative GMFCS level of I (85.7%) or II (14.3%). The median percentage of rootlets cut during the procedure was 60% on the affected side. The sum of the mAS extremity score was improved by 5 points (p < 0.001), the GMFM-66 score was improved by a median of 3.1 (p = 0.002), while the PedsQL CP module improved by a median of 12.3 percentage points (p = 0.003). Orthotic use was reduced from 90.5% preoperatively to 66.7% at follow-up.

Conclusions: SDR is an effective treatment in patients with spastic hemiplegia resulting in significant improvement in motor function, quality of life, and tone.