Pediatric Neurosurgery最新文献

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.

Introduction: Surgical extirpation of a cholesterol granuloma in the petrous apex, located dorsal to the petrous part of the internal carotid artery (ICA), is challenging. Herein, we report a pediatric case of a cholesterol granuloma of the petrous apex treated using the endoscopic contralateral transmaxillary (CTM) approach. Case Presentation: A 13-year-old boy presented with a left-sided headache, slight hypoesthesia in the left V1 area, and severe neuralgia of the left auriculotemporal nerve. Magnetic resonance imaging (MRI) revealed a high-intensity mass without gadolinium enhancement. The patient's headache was unresponsive to various medications. After careful evaluation, an endoscopic CTM approach was selected for the extirpation of the granuloma. Postoperatively, the patient did not experience headache or associated neurological complications. MRI at 46 months revealed no recurrence. Conclusion: The endoscopic CTM approach can be used for excising cholesterol granulomas of the petrous apex located posterior to the petrous part of the ICA without causing severe complications. This approach can be considered useful for pediatric cases in which granulomas are not accessible via the transnasal endoscopic transsphenoidal approach.

Introduction: Benign enlargement of subarachnoid space (BESS) is one of the causes of macrocephaly in infants. The aetiology of this condition remains a subject of controversy, with poor cerebrospinal fluid absorption as the most commonly believed underlying theory. Prematurity has been suggested as possible risk factor; however, this is a topic of debate with paucity of data. In this study, we investigated association of prematurity with BESS in our cohort of patients.

Methods: A retrospective review of patients seen in outpatient neurosurgical BESS clinic (period 2016-2023) was carried out. BESS was defined as enlarged frontal subarachnoid space diagnosed on CT or MRI brain obtained for macrocephaly. Demographics information including sex, age, prematurity/gestation at birth, grade of prematurity as well as any neurosurgical interventions were recorded. Prematurity was defined as per World Health Organization guidelines as birth at gestation<37 weeks. Grade of prematurity was defined as <28 weeks as extreme preterm, 28-32 weeks as severe preterm, 32-34 weeks as moderate preterm, and 34-37 weeks as late preterm.

Results: Over the period of study, 100 children with BESS were seen in the outpatient clinic setting with mean age of 12.3 months (range 0.5-54 months) with M78:F22 ratio (M:F = 3.5:1). Overall, 19 out of 100 children with BESS were born premature (19%) with a mean age of 11.9 months at diagnosis. Premature group included 0% extreme preterm, 21% severe preterm, 15.8% moderate preterm, and 63.2% late preterm. Rate of prematurity at 19% in this cohort was 2.4-fold the rate of UK prematurity of 7.5-7.9% (p = 0.023). Eight out of 100 (8%) patients had concurrent subdural collection of which one belonged to premature group. All subdural collections were managed non-operatively. There was no association between prematurity and subdural formation. No child required cerebrospinal fluid diversion.

Conclusion: BESS remains a poorly understood entity. Considering the baseline rate of live preterm births in UK at 7.5-7.9%, rate of prematurity in this cohort of children was significantly higher at 19%. This study may support that prematurity is a possible risk factor.

Introduction: Endoscopic third ventriculostomy (ETV) is a well-established neurosurgical procedure. Concurrently, the Endoscopic Third Ventriculostomy Success Score (ETVSS) is a recognized validation tool commonly used to prognosticate the efficacy of this intervention. The main aims of this study are to review our institutional experience with ETV for pediatric hydrocephalus and evaluate its correlation with the ETVSS. Secondary aims include identification of other factors that are not part of the existing ETVSS and to corroborate our findings with contemporary literature.

Methods: This is a single-institution, retrospective study. Patients under 19 years old who underwent ETV were included. Variables of interest such as patient characteristics, hydrocephalus etiology, procedural details, perioperative complications, neuroimaging features, and outcomes were collected. Radiological parameters curated from the literature such as third ventricular floor bowing, lamina terminalis bowing, third ventricular morphology index, and presence of prepontine adhesions (PPAs) are also included. For this study, the primary outcome measure is "ETV success," defined as no need for shunt insertion to divert CSF at any point in time after ETV. Subsequent outcome of each ETV is correlated with the ETVSS. Additional factors are also independently assessed for their impact on the ETVSS in our study cohort.

Results: Sixty-nine ETV cases were recruited for this study whereby ETV was successful in 63.8% (n = 44) cases. At 12 months' follow-up, their ETV stomas remained patent. Of note, 24.6% (n = 17) ETV failures occurred within 30 days of the procedure. In our series, ETV success correlated well with ETVSS. The ETV success rate was 0% for post-infectious and post-hemorrhagic etiologies. For the cases of ETV failure, definitive CSF diversion procedures were necessary within 3 months from their initial ETV. Logistic regression analysis showed ETVSS (odds ratio 1.068, p = 0.037) and the presence of PPA (p = 0.02) significantly correlated with ETV success.

Conclusion: Our institutional experience in the use of ETV for pediatric hydrocephalus corroborates with findings from contemporary literature. In the context of our study, the ETVSS is applicable and the absence of PPA on neuroimaging demonstrates good correlation with ETV success.

Introduction: Pineal parenchymal tumors of intermediate differentiation (PPTIDs) are rare, pinealocyte-derived brain tumors that occur primarily in adults. The clinical prognosis fits somewhere between the benign pineocytoma and highly malignant pineoblastoma. There is very little published literature regarding this tumor in children and the existing pediatric information is enfolded with adult data in single-center reviews. The most common treatment recommendation for adults is aggressive resection, possibly followed by craniospinal irradiation (CSI) and/or chemotherapy. However, the adult literature is inconsistent, often contradictory, and does not address specific considerations in pediatric patients. To our knowledge, there are no papers specifically addressing the management and clinical considerations of PPTID in pediatric patients. As such, the optimal treatment strategy in children is unknown.

Case presentation: We describe the treatment of a 6-year-old child who presented with obstructive hydrocephalus from a PPTID. The child was treated with a partial tumor resection followed by localized proton beam radiation. He has been followed for 8 years. Clinically, he is doing well, and his most recent MRI shows negligible residual tumor with no sign of recurrence.

Conclusions: Our case suggests safe resection followed by proton beam radiotherapy may be effective in treating children with this exceedingly rare entity. While further study is needed, this strategy may avoid unnecessary surgical risk and the consequences of CSI on the developing pediatric nervous system.

Introduction: Neuroendoscopy is gaining traction as a minimally invasive technique for the resection of cerebellar vermis tumors. This study investigates the effectiveness and clinical experience of neuroendoscopic surgery for cerebellar vermis tumor resection.

Methods: A retrospective analysis was conducted on the clinical data of 18 patients with cerebellar vermis tumors treated using the German STORZ neuroendoscope between January 2021 and January 2024 at the Department of Neurosurgery, Guizhou Provincial People's Hospital, and Guizhou Hospital of Shanghai Children's Center. The surgical outcomes, pathological diagnoses, postoperative complications, and follow-up results were analyzed.

Results: Of the 18 patients, total resection was achieved in 16 cases, subtotal resection in 1 case, and biopsy in 1 case. Postoperative pathology revealed 9 cases of medulloblastoma, 3 cases of ependymoma, and 5 cases of astrocytoma (2 WHO grade I, 2 grade II, and 1 grade III), along with 1 benign cerebellar lesion. Postoperative complications included malignant arrhythmia (1 case), cerebellar mutism (4 cases), and ataxia (13 cases). During the 1-36 months of follow-up, 2 patients developed communicating hydrocephalus, which improved following ventriculoperitoneal shunt placement. Recovery of cerebellar mutism occurred within an average of 21 days, while ataxia improved on average within 50 days. Tumor recurrence was observed in 3 patients.

Conclusion: Neuroendoscopic resection of cerebellar vermis tumors, performed by skilled operators, provides effective surgical exposure and offers a viable alternative to traditional microscopy with satisfactory clinical outcomes.

Introduction: Hereditary bleeding disorders stem from the absence or insufficient levels of particular clotting proteins, essential for facilitating coagulation in the clotting cascade. Among the most prevalent are hemophilia A (deficiency of factor VIII), hemophilia B (deficiency of factor IX), and von Willebrand disease (VWD). Management of pharmacoresistant epilepsy is more difficult in a patient with bleeding disorder due to increased risk of bleeding during surgery. While patients who have both a bleeding disorder and epilepsy are rare, reporting on the management of these patients who may require intracranial monitoring for pharmacoresistant epilepsy offers valuable insights into the challenges and considerations necessary for safely navigating the complex intersection of bleeding risk and seizure control.

Case presentation: Two patients with bleeding disorders (VWD and factor XI deficiency) underwent invasive intracranial monitoring for medical refractory epilepsy followed by epilepsy focus resection surgery. Both patients were found to have a bleeding disorder during their preoperative laboratory work. After abnormal laboratories were reported, both patients were referred to hematology for further evaluation and surgical planning. The first patient was a 10-year-old boy with medically refractory focal epilepsy who was found to have type IIM VWD. He underwent surgery for subdural grid placement followed by resection on postoperative day 6. He required wilate® (human von Willebrand factor/coagulation factor VIII complex) infusions from the day of surgery prior to surgery through postoperative day 14. The second case was a 2-year-old boy with a history of tuberous sclerosis and medically refractory epilepsy who was found to have factor XI deficiency (hemophilia C) who required fresh frozen plasma and platelet transfusions throughout his hospitalization. He underwent surgery for sEEG followed by resection of the tubers. Both patients remained stable throughout their invasive monitoring and completed epilepsy resection surgeries without reported complications. Both patients achieved seizure freedom after surgery since their most recent follow-up of 1 month and 13 months.

Conclusion: The two patients successfully underwent invasive neuromonitoring with subdural grids and sEEG for seizure focus identification followed by resective epilepsy surgery without bleeding complications while achieving seizure freedom. While epilepsy patients with a bleeding disorder should not automatically be denied surgery due to the increased risk of hemorrhage, it is crucial that any decision is based on a comprehensive, multidisciplinary evaluation. This case report highlights the potential for future meta-analysis and further conversations regarding improved protocols for patients with bleeding disorders.

Introduction: The emergence of connectomics in neurosurgery has allowed for construction of detailed maps of white matter connections, incorporating both structural and functional connectivity patterns. The advantage of mapping cerebral vascular lesions to guide surgical approach shows great potential. We aim to identify the clinical utility of connectomics for the surgical treatment of pediatric arteriovenous malformations (AVMs).

Case presentation: We present two illustrative cases of the application of connectomics to the management of cerebral AVM in a 9-year-old and 8-year-old female. Using magnetic resonance anatomic and diffusion tensor imaging, a machine learning algorithm generated patient-specific representations of the corticospinal tract for the first patient, and the optic radiations for the second patient. The default mode network and language network were also examined for each patient. The imaging output served as an adjunct to guide operative decision-making. It assisted with selection of the superior parietal lobule as the operative corridor for the first case. Furthermore, it alerted the surgeon to white matter tracts in close proximity to the AVM nidus during resection. Finally, it aided in risk versus benefit analysis regarding treatment approach, such as craniotomy for resection for the first patient versus radiosurgery for the second patient. Both patients had favorable neurologic outcomes at the available follow-up period.

Conclusion: Use of the software integrated well with clinical workflow. The output was used for planning and overlaid on the intraoperative neuro-navigation system. It improved visualization of eloquent regions, especially those networks not visible on standard anatomic imaging. Future studies will focus on expanding the cohort, conducting in pre- and postoperative connectomic analysis with correlation to clinical outcome measures, and incorporating functional magnetic resonance imaging.