Journal of neurosurgery. Pediatrics最新文献

Objective: Knowledge translation approaches for augmenting the use of evidence in medical practice require identifying potential barriers to implementation. Important but poorly understood determinants of the uptake of knowledge translation tools are the intrinsic characteristics of health professionals themselves. In this study, the authors explored how surgeons' perceptions of evidence-based medicine (EBM) and their behavior in response to new evidence affect their awareness and use of evidence-based summaries designed for application at the point of care.

Methods: Faculty surgeons in two North American pediatric Hydrocephalus Clinical Research Networks, who had shunt infection prevention protocol compliance data for more than 10 shunt procedures in their respective clinical registries during the study period (September 2021-March 2023), participated in a cross-sectional survey regarding their attitudes, knowledge, and behaviors related to EBM and evidence-based practice. Univariable associations between these surgeon characteristics and two dependent variables were sought: 1) compliance with the steps of a perioperative protocol designed to minimize the incidence of shunt infection and 2) knowledge of evidence-based guidelines and recommendations relevant to the care of children with hydrocephalus.

Results: Ninety-two of 212 eligible surgeons responded to the survey. Most were inclined to implement new evidence in surgical practice. Compliance with the shunt infection prevention protocol was higher for those whose responses about their behavior in response to new information on the effectiveness of clinical strategies suggested that they value evidence over experience (i.e., those who actively seek or are receptive to new evidence) compared to those whose practice is driven by practical and pragmatic considerations (OR 5.27, 95% CI 1.08-25.74 for seekers and OR 4.32, 95% CI 1.48-12.58 for receptives vs pragmatists, p = 0.01). Overall knowledge of pediatric hydrocephalus-related guidelines was modest. Surgeons with a more favorable attitude toward the construct of EBM tended to correctly identify most of the published guideline statements presented to them (OR 1.07, 95% CI 1.00-1.16 for every 10-point increment on a 100-point visual analog scale, p = 0.05).

Conclusions: The authors demonstrate that surgeons have variable knowledge of, and behave differently to, evidence that should influence care. Measurable surgeon characteristics are associated with the application of evidence in surgical practice. Thus, to improve the use of evidence-based summaries at the point of care, surgeon attitudes and behaviors should be assessed when designing knowledge translation interventions.

Objective: MR-guided laser interstitial thermal therapy (MRgLITT) has emerged as a minimally invasive alternative to open resective epilepsy surgery for the ablation of seizure foci. This technique has become attractive to patients, caregivers, and epilepsy teams because it enables ablation of the seizure focus while avoiding craniotomy-specific complications of epilepsy surgery. For some indications, evidence suggests that MRgLITT is less effective than open surgery for achieving seizure control. However, open surgery after MRgLITT may be technically challenging or associated with higher complication rates due to the scar tissue generated by MRgLITT. Therefore, the authors investigated the indications and outcomes of open surgery after MRgLITT in a series of 7 pediatric epilepsy patients.

Methods: Patients who underwent MRgLITT surgery followed by resective surgery for an epilepsy focus between 2019 and 2024 at UPMC Children's Hospital of Pittsburgh were included in a retrospective analysis. Patients with less than 1 year of follow-up were excluded. Demographic, clinical, and procedural characteristics were collected for each patient, including seizure focus, baseline seizure burden and semiology, age at surgery, operative time, complications, and seizure outcomes.

Results: MRgLITT was successful in initially reducing seizure burden in 6 of 7 patients; however, return of seizure-like activity or aura phenomenon was the indication for open resection at an average of 23.29 months post-MRgLITT. Three patients required a second resective surgery due to persistent seizures. One year following the last open resection, 5 (71.4%) patients had attained International League Against Epilepsy class 1. Additionally, 4 of 7 patients had a significant reduction in antiseizure medications. Minimal complications were observed for both MRgLITT and open resective surgery in this case series.

Conclusions: In this case series, open resection after MRgLITT was observed to be a safe and effective method of surgical treatment of patients with refractory epilepsy after preliminary MRgLITT.

Objective: The aim of this study was to identify socioeconomic factors that underlie disparity by insurance type on time to surgery from epilepsy onset and from first diagnostic imaging identifying a structural lesion in children with drug-resistant epilepsy (DRE).

Methods: Retrospective data were abstracted from children (< 18 years) who underwent epilepsy surgery at the University of California, San Francisco (UCSF), between 2012 and 2022 with a diagnosis of DRE and structural abnormality on MRI. Univariable and multivariable Cox proportional hazard regression were used to assess associations between socioeconomic barriers (English-language speaking, ethnicity, race, single-parent household, number of parents working, number of siblings, receipt of Supplemental Security Income [SSI], distance from hospital, and practice setting of referral center) and time from epilepsy onset to surgery. Secondary outcomes included durations during the surgical workup: timing to first diagnostic MRI, neurosurgery clinic visit, and surgery.

Results: Fifty-two patients with public insurance and 48 patients with private insurance underwent resective surgery for DRE. Preoperative clinical variables and Engel class outcome did not differ between groups. The majority of socioeconomic variables differed between the groups. Time to surgery from epilepsy onset was longer in the public insurance group (mean 62.4 [SE 7.0] vs 44.3 [SE 6.0] months, HR 0.65, 95% CI 0.43-0.97) as was time from first diagnostic MRI to first neurosurgery clinic visit (21.7 [SE 3.9] vs 11.5 [SE 3.5] months, HR 0.60, 95% CI 0.40-0.90). Time from epilepsy onset to first diagnostic MRI and neurosurgery clinic visit to surgery did not differ across groups. On multivariable analysis, a greater number of antiseizure medications (ASMs) trialed was an independent predictor of longer time to surgery (HR 0.84, 95% CI 0.77-0.92) and first diagnostic MRI (HR 0.90, 95% CI 0.83-0.99) from epilepsy onset. A single-parent household (HR 0.60, 95% CI 0.38-0.95) and receiving SSI (HR 0.57, 95% CI 0.33-0.97) were associated with longer time to surgery from MRI diagnosis. A single-parent household was associated with a longer time to the neurosurgery visit from the first diagnostic MRI study (HR 0.52, 95% CI 0.33-0.83).

Conclusions: Children with DRE and MRI findings of a structural abnormality with public insurance received surgery later from the time of epilepsy onset compared with those with private insurance at UCSF. During the course between epilepsy onset and surgery, the time from first diagnostic MRI to the first neurosurgery visit accounted for delay between groups. While socioeconomic variables differed between patients with private and public insurance, insurance type was the most consistent variable associated with disparity in the time interval to surgery.

Objective: Community-acquired intracranial abscess and empyema can be associated with significant morbidity and mortality among children. Treatment strategies are made with local expert opinion supported by international guidelines, which are based on mostly low-quality evidence. Thus, the authors aimed to report their experience with the presentation, management, and outcomes of a pediatric cohort with intracranial abscess and empyema managed by their regional neuro-microbiological multidisciplinary team (MDT).

Methods: Data were collected from a prospectively collected database and supplemented with retrospective record review for all children (age < 18 years) with intracranial abscess and empyema managed by a neuro-microbiological MDT from January 2014 to June 2023.

Results: Sixty-one children (median age 11.8 years, IQR 6.9-14.4 years) were included; 11 with abscesses, 25 with epidural empyemas, and 25 with subdural empyemas. Empyema was more strongly associated with fever (p = 0.03) and raised inflammatory markers (p = 0.002) as presenting features. Thirty-nine of 61 children (63.9%) had at least 1 previous clinical presentation before diagnosis. The overall mean time from symptom onset to diagnosis was 13.1 days (SD 10.7 days), while patients with cerebral abscesses had a significantly longer time to diagnosis of 23.6 days (SD 3.9 days, p < 0.001). Most cases were secondary to contiguous spread of sinusitis (38/61, 62%) or ear infection (14/61, 23%). Four weeks or less of intravenous (IV) antibiotic treatment was administered in 64% of patients, with no difference in outcome compared with patients who received more than 4 weeks of treatment. Those who received longer courses of IV treatment had a greater risk of drug-induced neutropenia. Overall mortality was 3% (2/61). Full recovery was achieved in 36 patients (59%) at discharge. Of those who completed treatment, there were no cases of recurrence within 6 months.

Conclusions: Using an MDT approach, successful management of intracranial infections was achievable using IV antibiotics for shorter durations. Further work is required to optimize outcomes for patients and to address barriers that delay diagnosis.

Objective: The long-term effects of revascularization surgery on the developing pediatric brain in patients with moyamoya disease (MMD) are yet to be fully understood. In this study, the authors aimed to evaluate long-term brain volume changes following revascularization surgery and to explore their clinical significance in this patient population.

Methods: This retrospective multicenter study included data collected between January 2011 and June 2021 at three hospitals. Changes in lateral ventricle and intracranial space volumes were quantified by comparing preoperative MRI studies with those obtained during the final follow-up at least 1 year postsurgery. Associations between these volumetric changes and clinical as well as radiological factors were analyzed.

Results: The study included 61 pediatric patients with MMD. Following revascularization surgery, the mean absolute volume of the lateral ventricles significantly increased from 9.7 to 11.0 cm3 (p < 0.0001), and the intracranial space volume increased from 812.0 to 834.4 cm3 (p < 0.0001). A weak correlation was identified between follow-up duration and volume changes in both the lateral ventricles (r = 0.26, p = 0.04) and the intracranial space (r = 0.28, p = 0.03). Approximately 75% of cases showed a greater rate of ventricular volume increase relative to intracranial space expansion, with 16.4% (10 cases) exhibiting disproportionately larger lateral ventricle enlargement exceeding 50%. Univariate analysis revealed that combined revascularization, compared with indirect anastomosis alone, resulted in significantly greater lateral ventricle enlargement (p = 0.003). Additionally, severe headaches that persist after surgery (p = 0.0008) and new cerebral infarction during the long-term follow-up (p = 0.028) were significantly associated with increased lateral ventricle volume. Multivariate analysis identified an age > 4 years, combined revascularization, severe postoperative headaches, and new cerebral infarction during the long-term follow-up as independent predictors of postoperative ventricular enlargement.

Conclusions: This study revealed a previously unrecognized pattern of gradual lateral ventricle volume changes in pediatric patients with MMD following revascularization surgery. These findings underscore the importance of long-term MRI monitoring to detect subtle but clinically relevant morphological changes. The results suggest that vigilant monitoring of these changes could help optimize clinical outcomes and improve quality of life in this vulnerable patient population.

Objective: Astroblastomas (ABs) are rare glial tumors categorized by MN1 gene alterations in the WHO 2021 CNS tumor guidelines. While previously reported primarily in cerebral hemispheres, there have been few reports regarding primary spinal ABs, and no established guidelines have been published on the management of these lesions. Here, the authors present an illustrative case with a systematic review exploring presenting characteristics, diagnosis, management, and outcomes of spinal AB.

Methods: The patient's electronic medical record was retrospectively reviewed. Additionally, a systematic literature review was performed by searching the PubMed, Cochrane Library, Embase, and Web of Science databases for articles published through June 20, 2024, and all English-language articles describing patients with primary spinal AB were analyzed. Conference abstracts and articles describing secondary spinal AB or cerebral AB were excluded. Eleven previous cases of primary spinal AB were identified. Articles were screened by multiple reviewers to limit bias. For each case, clinical presentation, surgical pathology, molecular testing, treatment strategies, clinical course, and outcome were tabulated and compared.

Results: A 6-year-old male presented with thoracic back pain and limp and was found to have a high-grade thoracic AB with EWSR1::BEND2 fusion, treated with resection and radiation therapy; he is clinically stable at 12 months of follow-up. A systematic review yielded 11 prior cases; patient ages ranged from 3 months to 36 years, with most cases being pediatric. Clinical presentations commonly featured back pain, motor weakness, and gait disturbances. All cases except one underwent resection. Common pathological findings included perivascular hyalinization, pseudorosettes, pseudopapillae, high cellularity, and positive staining for glial fibrillary acidic protein/epithelial membrane antigen/S100. Molecular testing showed direct MN1 alteration in 6 cases, while the remaining cases showed MN1 methylation, EWSR1::BEND2 fusion, and MAMLD1::BEND2 fusion. Eight patients underwent chemotherapy, and 7 underwent radiation therapy. Except for 2 reported deaths, most patients were alive at the last follow-up (range 1 month-15 years). Progression of spinal AB occurred in one-third (4/12) of cases.

Conclusions: With the present report of a patient whose tumor exhibited EWSR1::BEND2 fusion, there are now 12 total reports in the literature of primary spinal AB. These cases span various pathological and molecular testing results, treatment strategies, and clinical courses. Given the diversity of current molecular signatures of spinal AB, this summative assessment of the current literature offers insights to inform guidelines for classifying AB and developing evidence-based treatment strategies going forward.

Objective: Secondary bone closure following single-suture craniosynostosis (SSCS) correction has been previously reported. However, the incidence of such secondary closure, which leads to increased intracranial pressure (ICP), following strip craniectomy for sagittal synostosis (SS) has not been systematically described. The possibility of secondary closure must be taken into account when determining the optimal long-term follow-up regimen after the procedure. Secondary closure leading to high ICP can cause silent papilledema, optic atrophy, and even blindness. In this study, the authors investigated the long-term follow-up of children who underwent early, open, and wide strip craniectomy for SS. They analyzed the incidence of secondary closure that led to increased ICP and the subsequent need for surgical or medical intervention.

Methods: This was a single-center, retrospective, observational study with a follow-up of 2 to 25 years (9.1 ± 6.2 years). The study cohort included 286 children who underwent strip craniectomy for SS at the age of 2-4 months.

Results: Three of 286 patients developed papilledema with documented increased ICP (formal ICP monitoring for 3 days). Two of them required cranial vault expansion at the ages of 1.8 and 1.9 years. The third patient was diagnosed with papilledema and borderline high values of ICP at the age of 2.8 years. He was treated with acetazolamide, resulting in persistent normalization of his fundoscopic examination findings, even after the acetazolamide treatment was stopped (8 months).

Conclusions: This study verifies that the incidence of secondary closure is very low following early, open, and wide strip craniectomy for SS. However, careful clinical and ophthalmological follow-up is advised during the first few years following surgery.

Objective: The explosive growth of available high-quality imaging data coupled with new progress in hardware capabilities has enabled a new era of unprecedented performance in brain segmentation tasks. Despite the explosion of new data released by consortiums and groups around the world, most published, closed, or openly available segmentation models have either a limited or an unknown role in pediatric brains. This study explores the utility of state-of-the-art automated ventricular segmentation tools applied to pediatric hydrocephalus. Two popular, fast, whole-brain segmentation tools were used (FastSurfer and QuickNAT) to automatically segment the lateral ventricles and evaluate their accuracy in children with hydrocephalus.

Methods: Forty scans from 32 patients were included in this study. The patients underwent imaging at the University of Minnesota Medical Center or satellite clinics, were between 0 and 18 years old, had an ICD-10 diagnosis that included the word hydrocephalus, and had at least one T1-weighted pre- or postcontrast MPRAGE sequence. Patients with poor quality scans were excluded. Dice similarity coefficient (DSC) scores were used to compare segmentation outputs against manually segmented lateral ventricles.

Results: Overall, both models performed poorly with DSCs of 0.61 for each segmentation tool. No statistically significant difference was noted between model performance (p = 0.86). Using a multivariate linear regression to examine factors associated with higher DSC performance, male gender (p = 0.66), presence of ventricular catheter (p = 0.72), and MRI magnet strength (p = 0.23) were not statistically significant factors. However, younger age (p = 0.03) and larger ventricular volumes (p = 0.01) were significantly associated with lower DSC values. A large-scale visualization of 196 scans in both models showed characteristic patterns of segmentation failure in larger ventricles.

Conclusions: Significant gaps exist in current cutting-edge segmentation models when applied to pediatric hydrocephalus. Researchers will need to address these types of gaps in performance through thoughtful consideration of their training data before reaching the ultimate goal of clinical deployment.

Objective: This scoping review aims to provide a comprehensive analysis of our current understanding of the role of neurosurgery in treating recurrent medulloblastoma in children. Focusing specifically on repeat resection and biopsy, this review offers insights into the existing strengths and weaknesses of the literature and explores future directions for the treatment of recurrent medulloblastoma cases.

Methods: This review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews guidelines. The Ovid MEDLINE, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Scopus, and Cochrane databases were searched for terms regarding medulloblastoma, pediatric patients, and tumor subtypes.

Results: A total of 2381 articles were retrieved from the database search along with an additional 7 studies from manual reference searching. After deduplication, 1347 articles were screened by title and abstract for inclusion and exclusion criteria. Full-text review was completed for 45 articles, and 21 were included in the final review. This review found limited evidence suggesting potential survival benefits of repeat resection in select cases, while the role of biopsy remains largely investigational.

Conclusions: Despite significant scholarship on primary medulloblastoma, new approaches are urgently needed concerning surgical options for recurrence. More common interventions such as repeat resection are limited due to the metastatic propensity of medulloblastoma at relapse and the lack of information about the specific applications to tumor subtypes. Robust protocols and studies involving the utility of repeat biopsy at relapse for targeted therapy are lacking and further studies are required. The absence of studies evaluating the role of surgery revealed by this review highlights that to truly understand the biology of personalized approaches to recurrent medulloblastoma, it will be critical that neurosurgeons are intimately involved in these efforts.