Pediatric Neurosurgery最新文献

Background: Destructive surgical treatment for drug-resistant epilepsy may lead to complete seizure relief. In cases where a surgical cure is unavailable, epilepsy surgery can still alleviate seizure burden by decreasing reliance on medication, decreasing the severity or frequency of seizures, or decreasing the frequency of status epilepticus.

Summary: In this article, we discuss the role of palliative epilepsy surgical techniques in pediatric patients, relevant syndromes characterized by refractory epilepsy, and pertinent procedures and considerations. We review both destructive and neuromodulatory therapies, the current evidence supporting their use, and discuss future indications and expansion of techniques.

Key message: Our expanding epilepsy surgery armamentarium has the potential to provide significant palliative therapy for our pediatric patients and significantly improve their quality of life.

Background: In pediatric patients with drug-resistant epilepsy, successful localization of the seizure onset zone (SOZ) is critical to surgical planning and outcome prognostication. SOZ localization requires the identification of seizures captured through intracranial electroencephalography (iEEG), necessitating prolonged hospital stays for invasive monitoring and two-stage surgical procedures at minimum. Localization of SOZ in automated fashion using only interictal data would enable a substantial reduction in the time required for pre-resection iEEG recording. Using iEEG to model brain functional connectivity (FC) is an approach that has shown significant potential.

Summary: We conduct a literature review on directed FC methods and their use in preoperative SOZ localization. Granger Causality, an approach originally used to analyze economic time series, has evolved into multiple similar methodologies for directed FC graph creation. Several modalities show strong correlations between electrodes with specific FC patterns and SOZs, but there is no current tool that can reliably predict SOZs from interictal iEEG data.

Key messages: Multiple studies show a pattern of increased inward FC in electrodes located in the SOZ during interictal periods, with reversed information flow during seizures, suggesting the increased inward flow toward the SOZ may represent inhibitory pathways, which, when absent, lead to a more epileptogenic state. Further analysis of the changes in directed FC across longer periods may help elucidate how to select optimal segments for localization.

Introduction: Surgical removal of trigonal intraventricular tumors presents significant challenges. These tumors are primarily supplied by branches of the choroidal artery group arising from the inferior side. To access the vascular pedicles, the shortest and most direct surgical corridor to the trigone is generally preferred, making the transcortical transparietal approach a common choice. However, this approach carries a high risk of damaging critical subcortical white matter tracts. Injury to these tracts can result in language deficits (on the left side), spatial neglect syndrome (on the right side), as well as sensory disturbances and visual field deficits. To minimize disruption to these white matter tracts, the high parietal approach is often recommended. However, this technique presents its own challenges, particularly in achieving early control of arterial feeders, which becomes even more critical in larger trigonal tumors.

Case presentation: We present the case of a 13-year-old boy with a large trigonal intraventricular tumor. Given his lack of significant symptoms and his young age, our surgical strategy focused on maximizing the preservation of his neurological function. We developed a novel combined transtemporal and high parietal approach. The small transtemporal approach allows early devascularization, followed by the high parietal approach, which facilitates tumor resection while preserving the vital white matter tracts along the lateral wall of the trigone.

Conclusion: We propose a novel combined technique that offers a balance between optimal tumor resection and functional preservation, particularly in cases of large and hypervascularized trigonal tumors.

Introduction: Thalamic strokes are uncommon in children and often arise from underlying conditions such as coagulopathy. Their clinical and radiological resemblance to neoplasms - with shared symptoms and overlapping MRI features - makes accurate diagnosis particularly challenging.

Case presentation: A 2-year-old boy with trisomy 21 (Down syndrome) presented with 5 days of altered mentation and fussiness, nausea, vomiting, and seizures. CT head demonstrated a right thalamic edematous lesion. MRI showed a lesion with imaging features suggestive of a thalamic neoplasm that was ultimately found to be an infarct secondary to right internal cerebral vein thrombus. The patient was treated with heparin and returned to his clinical baseline.

Conclusion: Given their predisposition to coagulopathy, patients with Down syndrome require meticulous imaging evaluation. CT venogram can be an essential part of workup for this patient population.

Introduction: There are no predictive outcome scales that have been validated in pediatric patients with brain tumors. An index can help identify children with increased risk for negative postoperative results. The Johns Hopkins Adjusted Clinical Groups (JHACG) frailty and the Elixhauser Comorbidity Index (ECI) have been used independently in adult brain tumor patients to identify patients who are at an increased risk for detrimental outcomes. We investigated whether JHACG and ECI can better predict hospital length of stay (LOS), nonroutine discharge, and 1-year readmission in pediatric patients undergoing craniotomy for primary brain tumors.

Methods: The Nationwide Readmissions Database was queried for pediatric brain tumor resections between 2016 and 2019. In total, 237 and 1,235 patients with benign and malignant tumors were identified, respectively. Frailty, ECI, and Frailty+ECI were assessed as predictors using generalized linear mixed-effects models. Receiver operating characteristic curves evaluated predictive performance.

Results: Frailty+ECI, frailty, and ECI scores similarly predicted hospital LOS, nonroutine discharge, and 1-year readmission in the benign tumor cohort. In the malignant cohort, Frailty+ECI (area under the curve [AUC] 0.895) outperformed frailty alone (AUC 0.742, p = 0.001) but performed similar to ECI score alone (AUC 0.893, p = 0.438) in predicting hospital LOS. Concerning nonroutine discharge prediction, Frailty+ECI (AUC 0.871) also outperformed frailty alone (AUC 0.744, p = 0.04) while performing similarly to ECI score alone (AUC 0.869, p = 0.871). All indices performed in a similar way to predict 1-year readmission in this cohort.

Conclusion: Our study showed that Frailty+ECI demonstrated a robust ability to predict hospital LOS and nonroutine discharge disposition in pediatric patients undergoing malignant brain tumor resection. These findings suggest that combining these indices may improve the prediction of postoperative outcomes in this population. While further studies are warranted, these findings can be used as a risk assessment index to coordinate care plans with the patient and their family after an operation.

Introduction: Hemispherotomy is an effective treatment for children with drug-resistant epilepsy (DRE). While hemispherotomy techniques and indications have evolved, access remains predominantly constrained to high-resource settings.

Methods: We performed a retrospective analysis of children who underwent hemispherotomy from 2011 to 2023 by a hybrid team, including local Panamanian and US neurologists, neurosurgeons, and EEG technicians and analyzed surgical, epilepsy, and quality of life (QoL) parameters. Follow-up data were collected according to the International Consortium for Health Outcomes Measurement (ICHOM) guidelines for children with epilepsy.

Results: Twenty-three children underwent hemispherotomy. The median age at surgery was 10 years (range 2-20). The median follow-up time was 6 years (range 1-13). The etiology of DRE included malformations of cortical development in 14 children (60.8%), including 8 (34.8%) with schizencephaly, and secondary causes in 9 children (39.1%). Seizure frequency improved for all 23 children (100%): Engel I was achieved in 15 children (65.2%), Engel II (26.1%) in six children, and Engel III (8.7%) in two children. Patients with seizure freedom had significantly fewer preoperative seizures per day than patients with seizure recurrence. Complications occurred in six children (26.1%): 2 wound infections, 2 meningitis, 1 femoral vein thrombosis, and 1 wound hematoma with return to OR. There were no perioperative mortality and no postoperative hydrocephalus or CSF diversion. QoL-related outcomes were available for 16 children: 16/16 (100%) reported that the surgery was a worthwhile and repeatable choice, 14 (87.5%) reported improved cognitive function, the median QOLCE-16 score was 62.5 ± 21.

Conclusion: Hemispherotomy for DRE in selected children is a safe and effective surgery in a public children's hospital in a low-resource setting. At last follow-up, the majority of children were seizure-free, and all children had decreased seizure frequency. Families reported improved cognitive function, improved QoL and high satisfaction with their decision to pursue this surgery.

Background: Drug-resistant epilepsy is a debilitating condition that afflicts individuals across all demographics, including children. The only recourse for many of these individuals is neurosurgery to reduce seizure burden, by either resecting or ablating the cerebral source or modulating it with a stimulator device. In either case, a thorough presurgical evaluation is required to identify brain regions of interest and construct an appropriate surgical plan. The scope of this evaluation has grown rapidly over the years as new and refined techniques have emerged. The aim of this article was to condense the most salient points regarding investigational tools used commonly in this process and provide a framework from which epilepsy management providers can tailor their own epilepsy surgery pathway.

Summary: This article will discuss criteria to identify appropriate candidates for epilepsy surgery, as well as various techniques that are used to localize seizure onset, interictally active areas, dysfunctional regions, and eloquent cortex. Topics reviewed include neuroimaging (MRI, PET, SPECT), electrophysiology (EEG and MEG), and functional mapping procedures (fMRI, TMS, neuropsychologic evaluation, intracarotid amobarbital test).

Key messages: A comprehensive, multimodal presurgical evaluation including imaging, electrophysiology, and functional mapping is essential to establish the bounds of the epileptogenic zone in relation to eloquent cortex.

Introduction: Surgical resection of intracranial tumors in pediatric patients poses the potential risk of new-onset postoperative seizures, prompting debates over the prophylactic use of anti-seizure medication (ASMs). This retrospective study focusses on the incidence and risk factors associated with the occurrence of new-onset postoperative seizures within 30 days following surgery in pediatric patients with brain tumors who did not receive ASM prophylaxis pre- and perioperatively.

Methods: A meticulous review of clinical records spanning from June 2018 to December 2022 was conducted, examining data from pediatric patients undergoing craniotomies for intracranial tumors. Patients with preoperative seizures or those taking perioperative ASMs were excluded. The data encompassed demographic details, preoperative variables, tumor characteristics, surgical intricacies, and clinical course including 30-day mortality. The primary outcome was the incidence of new-onset postoperative seizures, further categorized as early (within 1 week) or late (1 week to 30 days). Univariate and multivariate logistic regression analyses were used to explore correlations between various variables and seizure outcomes.

Results: In a cohort of 306 cases, the incidence of new-onset postoperative seizures was 7.8% of whom 4.2% experienced early seizures. Of them, 3 patients developed status epilepticus. Multivariate analysis identified several significant risk factors including postoperative hyponatremia, supratentorial tumor localization, and young age, especially age under 1 year.

Conclusion: In this retrospective study, we identified supratentorial tumor localization, hyponatremia and age younger than 1 year as risk factors for new-onset postoperative seizures among pediatric patients. Especially in infants below the age of 1 year, we recommend meticulous monitoring of postoperative sodium levels and noninvasive epilepsy monitoring after supratentorial tumor resection. Future prospective studies are needed to explore the potential effectiveness of administering perioperative prophylactic antiepileptic drugs (ASMs) within this specific subset of the pediatric population.

Introduction: Mild head trauma is frequent in Paediatrics and its management varies widely across clinicians. Questions regarding patients' management, outcomes, head trauma prevention, the adequacy of computerized tomography (CT) prescription and the adherence to the Pediatric Emergency Care Applied Research Network (PECARN) rule are still discussed.

Methods: We performed a retrospective observational study of mild head trauma patients who underwent head CT, characterizing the presenting signs and symptoms, mechanisms of injury, head CT lesions, and outcomes. Statistical associations between signs and symptoms, CT lesions, PECARN risk groups and outcomes were explored.

Results: Three hundred and eleven patients were included, with 18.8% of patients under 2 years having CT traumatic lesions, against 7.9% of patients over 2 years old. The majority were aligned skull fractures. Parietal/temporal/occipital scalp haematoma, being under 3 months of age, and the presence of more than 2 vomits on admission, were associated with head CT traumatic lesions (OR 6.39, OR 2.84, OR 2.84, respectively). Clinically important lesions were rare (0.56%) and associated to the PECARN high-risk group (p = 0.005). All patients had no functional sequelae. The most common causes of head trauma were bed falls and ground falls. Baby stroller/egg falls due to no retention system usage were not rare and most bicycle fall victims were not wearing a helmet.

Conclusion: This study reinforces the usefulness of PECARN rule guiding CT scans prescription and patients´ management. Parietal/temporal/occipital scalp haematoma, being under 3 months of age and having more than two vomits are associated traumatic CT findings. Preventable head trauma frequency underlines the need for public policies reinforcement.

Introduction: This study aimed to develop and validate a reliable, multidomain scale for assessing childhood hydrocephalus severity and to enhance communication, guide treatment decisions, and improve patient care.

Methods: A stepwise consensus approach informed by a modified Delphi technique was employed. Healthcare professionals participated in anonymous surveys and face-to-face meetings to define the core domains of the scale. Content validity, internal consistency, and inter-rater reliability were assessed.

Results: The Delphi process yielded a refined 7-item, 10-point Childhood Hydrocephalus Severity Scale (CHS) focusing on age, Evans index, associated malformations, neurological deficit, intraventricular hemorrhage, and mid-arm circumference. Content validity analysis using the Content Validity Index (CVI) demonstrated strong agreement (mean I-CVI = 0.91) among experts regarding the relevance of CHS items. All individual item CVI scores exceeded 0.8, supporting the inclusion of each factor. The CHS exhibited excellent internal consistency (Cronbach's alpha = 0.988). High intraclass correlation coefficients (ICCs) were observed for both single measures (ICC = 0.902, 95% CI: 0.862-0.931) and average measures (ICC = 0.985, 95% CI: 0.978-0.990), indicating near-perfect agreement between raters. Both ICC values were statistically significant (p < 0.001).

Conclusion: The CHS demonstrates promising potential as a reliable and valid tool for childhood hydrocephalus severity assessment. This scale has the potential to enhance communication, guide treatment decisions, and improve patient care in childhood hydrocephalus.