Journal of neurosurgery. Pediatrics最新文献

Objective: The posterior fossa is the most common location for primary brain tumors in pediatric patients, and these infratentorial lesions are the leading cause of solid-tumor mortality. Resection remains a cornerstone of managing many of these tumors. However, the overall rate of perioperative complications in pediatric patients who have undergone posterior fossa tumor resection and the associated risk factors have not been explored. Therefore, the authors of this paper aimed to explore the association between clinical characteristics and the likelihood of complications with the intention of guiding patient counseling and directing areas for quality improvement to expand value-based care.

Methods: This is a retrospective cohort study utilizing the National Surgical Quality Improvement Program Pediatric data from 2012 to 2022 to track 30-day perioperative complications in patients 18 years of age or younger who underwent posterior fossa tumor resection. The primary outcome was postsurgical complications within 30 days. A generalized additive model was used to evaluate the relationship of clinical (e.g., age, pulmonary or cardiac conditions) and surgical (e.g., CSF diversion, operating time) factors with 30-day complications.

Results: Approximately 1 in 3 pediatric patients (1314/4044) experienced a perioperative complication within 30 days of posterior fossa tumor resection. The most common complications were bleeding or a need for transfusion (15.0%) and unplanned reoperation (14.6%). The rate of unplanned, related readmissions within 30 days was 8.5%. Variables significantly associated with greater odds of complications included an American Society of Anesthesiologists status of IV or V, emergent or urgent surgery, malignant tumor, sepsis/septic shock/systemic inflammatory response syndrome, structural CNS abnormality, steroid use, the need for ventricular catheter or CSF diversion, a history of pulmonary conditions, and a history of nutritional support. The probability of complications was highest in patients younger than 1 year of age relative to that in older patients. Longer operation times were also associated with an increased probability of perioperative complications.

Conclusions: While high, the perioperative complication rate of 33% is comparable to previously reported rates for pediatric intracranial tumor resection in smaller sample sizes. The study results suggest that several clinical and surgical factors are associated with a greater risk of perioperative complications in children undergoing posterior fossa tumor resection. Understanding the impact that this has on surgical morbidity can inform risk stratification and presurgical counseling for patients and their families.

Objective: This study investigates the potential of artificial intelligence (AI), specifically ChatGPT 4o, to revolutionize the readability of patient education materials in pediatric neurosurgery. The American Medical Association and the National Institutes of Health recommend that educational materials be written at a 3rd- to 7th-grade reading level for accessibility. However, existing resources often exceed this range, hindering comprehension for many patients.

Methods: This study analyzed 38 patient education materials on hydrocephalus, spina bifida, tethered cord syndrome, cerebral palsy, Chiari malformation, and craniosynostosis from 7 top-ranked US children's hospitals. The Flesch-Kincaid grade level calculator was used to assess readability before and after AI modification.

Results: ChatGPT effectively reduced the mean reading level from 10.60 (SD 0.57) to 6.18 (SD 0.28; p < 0.05), achieving the target 6th-grade level across all conditions.

Conclusions: Despite some limitations in maintaining word count and precise grade-level control, the results demonstrate the promising potential of AI in significantly enhancing the accessibility of pediatric neurosurgical education materials, which may lead to more inclusive patient communication and understanding.

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.