Browse

You are looking at 1 - 10 of 92 items for

  • Refine by Access: all x
  • By Author: Drake, James M. x
Clear All
Restricted access

Clinical characteristics of upper cervical spine injuries in children: a retrospective case series

Dayae Jeong, Suzanne Beno, James M. Drake, and Gabrielle Freire

OBJECTIVE

Pediatric cervical spine injuries (CSI) can be devastating, and children < 8 years are particularly at risk for upper CSI given unique anatomical differences. Diagnosis of these injuries can be delayed due to variable clinical presentations and a paucity of existing literature. The authors aimed to characterize the spectrum of pediatric upper CSI.

METHODS

This was a retrospective, single-center case series of trauma patients aged < 16 years who were assessed at a level I pediatric trauma center and diagnosed with upper CSI between 2000 and 2020. Patients were included if they had evidence of bony or ligamentous injury from the occiput to C2 on imaging or autopsy. Data were obtained from manual chart review and analyzed using descriptive statistics.

RESULTS

In total, 502 patients were screened and 202 met inclusion criteria. Of these, 31 (15%) had atlanto-occipital (AO) joint distractions, 10 (5%) had atlanto-axial (AA) joint distractions, 31 (15%) had fractures of C1–2, and 130 (64%) had ligamentous injury without joint distraction. Of the patients with AO injury, 15 patients had complete dislocation. They presented as hemodynamically unstable with signs of herniation and 14 died (93%). In contrast, 16 had incomplete dislocation (subluxation). They usually had stable presentations and survived with good outcomes. Of the patients with AA injury, 2 had complete dislocation, presented with arrest and signs of herniation, and died. In contrast, 8 patients with subluxation mostly presented as clinically stable and all survived with little residual disability. The most common fractures of C1 were linear fractures of the lateral masses and of the anterior and posterior arches. The most common fractures of C2 were synchondrosis, hangman, and odontoid fractures. Overall, these patients had excellent outcomes. Ligamentous injuries frequently accompanied other brain or spine injuries. When these injuries were isolated, patients recovered well.

CONCLUSIONS

Among upper CSI, AO and AA joint injuries emerged as particularly severe with high mortality rates. Both could be divided into complete dislocations or incomplete subluxations, with clear clinical differences and the former presenting with much more severe injuries. Lateral cervical spine radiography should be considered during resuscitation of unstable trauma patients to assess for these CSI subtypes. Fractures and ligamentous injuries were clinically heterogeneous, with presentations and outcomes depending on severity and associated injuries.

Restricted access

Complications following resection of primary and recurrent pediatric posterior fossa ependymoma

Armaan K. Malhotra, Liana Nobre, George M. Ibrahim, Abhaya V. Kulkarni, James M. Drake, James T. Rutka, Michael D. Taylor, Vijay Ramaswamy, Peter B. Dirks, and Michael C. Dewan

OBJECTIVE

Extent of resection (EOR) is the most important modifiable prognostic variable for pediatric patients with posterior fossa ependymoma. An understanding of primary and recurrent ependymoma complications is essential to inform clinical decision-making for providers, patients, and families. In this study, the authors characterize postsurgical complications following resection of primary and recurrent pediatric posterior fossa ependymoma in a molecularly defined cohort.

METHODS

The authors conducted a 20-year retrospective single-center review of pediatric patients undergoing resection of posterior fossa ependymoma at the Hospital for Sick Children in Toronto, Canada. Complications were dichotomized into major and minor groups; EOR was compared across complication categories. The association between complication occurrence with length of stay (LOS) and mortality was also assessed using multivariable regressions.

RESULTS

There were 60 patients with primary resection included, 41 (68%) of whom were alive at the time of data collection. Gross-total resection was achieved in 33 (58%) of 57 patients at primary resection. There were no 30-day mortality events following primary and recurrent ependymoma resection. Following primary resection, 6 patients (10%) had posterior fossa syndrome (PFS) and 36 (60%) developed cranial neuropathies, 56% of which recovered within 1 year. One patient (1.7%) required a tracheostomy and 9 patients (15%) required gastrostomy tubes. There were 14 ventriculoperitoneal shunts (23%) inserted for postoperative hydrocephalus. Among recurrent cases, there were 48 recurrent resections performed in 24 patients. Complications included new cranial neuropathy in 10 patients (21%), of which 5 neuropathies resolved within 1 year. There were no cases of PFS following resection of recurrent ependymoma. Gastrostomy tube insertion was required in 3 patients (6.3%), and 1 patient (2.0%) required a tracheostomy. Given the differences in the location of tumor recurrence, a direct comparison between primary and recurrent resection complications was not feasible. Following multivariate analysis adjusting for sex, age, molecular status, and EOR, occurrence of major complications was found to be associated with prolonged LOS but not mortality.

CONCLUSIONS

These results detail the spectrum of postsurgical morbidity following primary and recurrent posterior fossa ependymoma resection. The crude complication rate following resection of infratentorial recurrent ependymoma was lower than that of primary ependymoma, although a statistical comparison revealed no significant differences between the groups. These results should serve to inform providers of the morbidity profile following surgical management of posterior fossa ependymoma and inform perioperative counseling of patients and their families.

Open access

Sinus pericranii in the setting of a posterior fossa pilocytic astrocytoma: illustrative case

Youngkyung Jung, Jennifer L. Quon, and James M. Drake

BACKGROUND

Sinus pericranii (SP) is a rare vascular anomaly, with an uncertain etiology. Often discovered as superficial lesions, they can be primary or secondary in nature. Herein, we report a rare case of SP in the setting of a large posterior fossa pilocytic astrocytoma associated with a significant venous network.

OBSERVATIONS

A 12-year-old male presented with acute clinical deterioration in extremis with a 2-month history of lethargy and headaches. Outside plain computed tomography imaging revealed a large posterior fossa cystic lesion, probably a tumor, with severe hydrocephalus. There was also a midline small skull defect at the opisthocranion, without visible vascular anomalies. An external ventricular drain was placed with rapid recovery. Contrast imaging revealed a large midline SP emanating from occipital bone with a large intraosseous, and subcutaneous venous plexus in the midline draining inferiorly into venous plexus around the craniocervical junction. A posterior fossa craniotomy without contrast imaging could have resulted in catastrophic hemorrhage. A small modified off-center craniotomy provided access to the tumor with a gross total excision.

LESSONS

SP is a rare but significant phenomenon. Its presence does not necessarily preclude resection of underlying tumors, provided that a careful preoperative assessment of the venous anomaly is undertaken.

Free access

A robotic MR-guided high-intensity focused ultrasound platform for intraventricular hemorrhage: assessment of clot lysis efficacy in a brain phantom

Hrishikesh Raghuram, Thomas Looi, Samuel Pichardo, Adam C. Waspe, and James M. Drake

OBJECTIVE

Intraventricular hemorrhage (IVH) is a neurovascular complication due to premature birth that results in blood clots forming within the ventricles. Magnetic resonance–guided high-intensity focused ultrasound (MRgHIFU) has been investigated as a noninvasive treatment to lyse clots. The authors designed and constructed a robotic MRgHIFU platform to treat the neonatal brain that facilitates ergonomic patient positioning. The clot lysis efficacy of the platform is quantified using a brain phantom and clinical MRI system.

METHODS

A thermosensitive brain-mimicking phantom with ventricular cavities was developed to test the clot lysis efficacy of the robotic MRgHIFU platform. Whole porcine blood was clotted within the phantom’s cavities. Using the MRgHIFU platform and a boiling histotripsy treatment procedure (500 W, 10-msec pulse duration, 1.0% duty cycle, and 40-second duration), the clots were lysed inside the phantom. The contents of the cavities were vacuum filtered, and the remaining mass of the solid clot particles was used to quantify the percentage of clot lysis. The interior of the phantom’s cavities was inspected for any collateral damage during treatment.

RESULTS

A total of 9 phantoms were sonicated, yielding an average (± SD) clot lysis of 97.0% ± 2.57%. Treatment resulted in substantial clot lysis within the brain-mimicking phantoms that were apparent on postsonication T2-weighted MR images. No apparent collateral damage was observed within the phantom after treatment. The results from the study showed the MRgHIFU platform was successful at lysing more than 90% of a blood clot at a statistically significant level.

CONCLUSIONS

The robotic MRgHIFU platform was shown to lyse a large percentage of a blood clot with no observable collateral damage. These results demonstrate the platform’s ability to induce clot lysis when targeting through simulated brain matter and show promise toward the final application in neonatal patients.

Free access

Design and validation of a hemispherectomy simulator for neurosurgical education

Grace M. Thiong’o, Thomas Looi, James T. Rutka, Abhaya V. Kulkarni, and James M. Drake

OBJECTIVE

Early adaptors of surgical simulation have documented a translation to improved intraoperative surgical performance. Similar progress would boost neurosurgical education, especially in highly nuanced epilepsy surgeries. This study introduces a hands-on cerebral hemispheric surgery simulator and evaluates its usefulness in teaching epilepsy surgeries.

METHODS

Initially, the anatomical realism of the simulator and its perceived effectiveness as a training tool were evaluated by two epilepsy neurosurgeons. The surgeons independently simulated hemispherotomy procedures and provided questionnaire feedback. Both surgeons agreed on the anatomical realism and effectiveness of this training tool. Next, construct validity was evaluated by modeling the proficiency (task-completion time) of 13 participants, who spanned the experience range from novice to expert.

RESULTS

Poisson regression yielded a significant whole-model fit (χ2 = 30.11, p < 0.0001). The association between proficiency when using the training tool and the combined effect of prior exposure to hemispherotomy surgery and career span was statistically significant (χ2 = 7.30, p = 0.007); in isolation, pre-simulation exposure to hemispherotomy surgery (χ2 = 6.71, p = 0.009) and career length (χ2 = 14.21, p < 0.001) were also significant. The mean (± SD) task-completion time was 25.59 ± 9.75 minutes. Plotting career length against task-completion time provided insights on learning curves of epilepsy surgery. Prediction formulae estimated that 10 real-life hemispherotomy cases would be needed to approach the proficiency seen in experts.

CONCLUSIONS

The cerebral hemispheric surgery simulator is a reasonable epilepsy surgery training tool in the quest to increase preoperative practice opportunities for neurosurgical education.

Free access

The Hydrocephalus Clinical Research Network quality improvement initiative: the role of antibiotic-impregnated catheters and vancomycin wound irrigation

Jason Chu, Hailey Jensen, Richard Holubkov, Mark D. Krieger, Abhaya V. Kulkarni, Jay Riva-Cambrin, Curtis J. Rozzelle, David D. Limbrick Jr., John C. Wellons III, Samuel R. Browd, William E. Whitehead, Ian F. Pollack, Tamara D. Simon, Mandeep S. Tamber, Jason S. Hauptman, Jonathan Pindrik, Robert P. Naftel, Patrick J. McDonald, Todd C. Hankinson, Eric M. Jackson, Brandon G. Rocque, Ron Reeder, James M. Drake, John R. W. Kestle, and for the Hydrocephalus Clinical Research Network

OBJECTIVE

Two previous Hydrocephalus Clinical Research Network (HCRN) studies have demonstrated that compliance with a standardized CSF shunt infection protocol reduces shunt infections. In this third iteration, a simplified protocol consisting of 5 steps was implemented. This analysis provides an updated evaluation of protocol compliance and evaluates modifiable shunt infection risk factors.

METHODS

The new simplified protocol was implemented at HCRN centers on November 1, 2016, for all shunt procedures, excluding external ventricular drains, ventricular reservoirs, and subgaleal shunts. Procedures performed through December 31, 2019, were included (38 months). Compliance with the protocol, use of antibiotic-impregnated catheters (AICs), and other variables of interest were collected at the index operation. Outcome events for a minimum of 6 months postoperatively were recorded. The definition of infection was unchanged from the authors’ previous report.

RESULTS

A total of 4913 procedures were performed at 13 HCRN centers. The overall infection rate was 5.1%. Surgeons were compliant with all 5 steps of the protocol in 79.4% of procedures. The infection rate for the protocol alone was 8.1% and dropped to 4.9% when AICs were added. Multivariate analysis identified having ≥ 2 complex chronic conditions (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.26–2.44, p = 0.01) and a history of prior shunt surgery within 12 weeks (OR 1.84, 95% CI 1.37–2.47, p < 0.01) as independent risk factors for shunt infection. The use of AICs (OR 0.70, 95% CI 0.50–0.97, p = 0.05) and vancomycin irrigation (OR 0.36, 95% CI 0.21–0.62, p < 0.01) were identified as independent factors protective against shunt infection.

CONCLUSIONS

The authors report the third iteration of their quality improvement protocol to reduce the risk of shunt infection. Compliance with the protocol was high. These updated data suggest that the incorporation of AICs is an important, modifiable infection prevention measure. Vancomycin irrigation was also identified as a protective factor but requires further study to better understand its role in preventing shunt infection.

Free access

Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network

William E. Whitehead, Jay Riva-Cambrin, John C. Wellons III, Abhaya V. Kulkarni, David D. Limbrick Jr., Vanessa L. Wall, Curtis J. Rozzelle, Todd C. Hankinson, Patrick J. McDonald, Mark D. Krieger, Ian F. Pollack, Mandeep S. Tamber, Jonathan Pindrik, Jason S. Hauptman, Robert P. Naftel, Chevis N. Shannon, Jason Chu, Eric M. Jackson, Samuel R. Browd, Tamara D. Simon, Richard Holubkov, Ron W. Reeder, Hailey Jensen, Jenna E. Koschnitzky, Paul Gross, James M. Drake, and John R. W. Kestle

OBJECTIVE

The primary objective of this trial was to determine if shunt entry site affects the risk of shunt failure.

METHODS

The authors performed a parallel-design randomized controlled trial with an equal allocation of patients who received shunt placement via the anterior entry site and patients who received shunt placement via the posterior entry site. All patients were children with symptoms or signs of hydrocephalus and ventriculomegaly. Patients were ineligible if they had a prior history of shunt insertion. Patients received a ventriculoperitoneal shunt after randomization; randomization was stratified by surgeon. The primary outcome was shunt failure. The planned minimum follow-up was 18 months. The trial was designed to achieve high power to detect a 10% or greater absolute difference in the shunt failure rate at 1 year. An independent, blinded adjudication committee determined eligibility and the primary outcome. The study was conducted by the Hydrocephalus Clinical Research Network.

RESULTS

The study randomized 467 pediatric patients at 14 tertiary care pediatric hospitals in North America from April 2015 to January 2019. The adjudication committee, blinded to intervention, excluded 7 patients in each group for not meeting the study inclusion criteria. For the primary analysis, there were 229 patients in the posterior group and 224 patients in the anterior group. The median patient age was 1.3 months, and the most common etiologies of hydrocephalus were postintraventricular hemorrhage secondary to prematurity (32.7%), myelomeningocele (16.8%), and aqueductal stenosis (10.8%). There was no significant difference in the time to shunt failure between the entry sites (log-rank test, stratified by age < 6 months and ≥ 6 months; p = 0.061). The hazard ratio (HR) of a posterior shunt relative to an anterior shunt was calculated using a univariable Cox regression model and was nonsignificant (HR 1.35, 95% CI, 0.98–1.85; p = 0.062). No significant difference was found between entry sites for the surgery duration, number of ventricular catheter passes, ventricular catheter location, and hospital length of stay. There were no significant differences between entry sites for intraoperative complications, postoperative CSF leaks, pseudomeningoceles, shunt infections, skull fractures, postoperative seizures, new-onset epilepsy, or intracranial hemorrhages.

CONCLUSIONS

This randomized controlled trial comparing the anterior and posterior shunt entry sites has demonstrated no significant difference in the time to shunt failure. Anterior and posterior entry site surgeries were found to have similar outcomes and similar complication rates.

Free access

Prediction of persistent ventricular dilation by initial ventriculomegaly and clot volume in a porcine model

Grace Y. Lai, William Chu Kwan, Karolina Piorkowska, Matthias W. Wagner, Pouya Jamshidi, Birgit Ertl-Wagner, Thomas Looi, Adam C. Waspe, and James M. Drake

OBJECTIVE

While intraventricular hemorrhage (IVH) is associated with posthemorrhagic ventricular dilation (PHVD), not all infants affected by high-grade IVH develop PHVD. The authors aimed to determine clot-associated predictors of PHVD in a porcine model by varying the amount and rate of direct intraventricular injection of whole autologous blood.

METHODS

Seven 1-week-old piglets underwent craniectomy and injection of autologous blood into the right lateral ventricle. They survived for a maximum of 28 days. MRI was performed prior to injection, immediately postoperatively, and every 7 days thereafter. T1-weighted, T2-weighted, and susceptibility-weighted imaging (SWI) sequences were used to segment ventricular and clot volumes. Spearman correlations were used to determine the relationship between blood and clot volumes and ventricular volumes over time.

RESULTS

The maximum ventricular volume was up to 12 times that of baseline. One animal developed acute hydrocephalus on day 4. All other animals survived until planned endpoints. The interaction between volume of blood injected and duration of injection was significantly associated with clot volume on the postoperative scan (p = 0.003) but not the amount of blood injected alone (p = 0.38). Initial postoperative and day 7 clot volumes, but not volume of blood injected, were correlated with maximum (p = 0.007 and 0.014) and terminal (p = 0.014 and 0.036) ventricular volumes. Initial postoperative ventricular volume was correlated with maximum and terminal ventricular volume (p = 0.007 and p = 0.014).

CONCLUSIONS

Initial postoperative, maximum, and terminal ventricular dilations were associated with the amount of clot formed, rather than the amount of blood injected. This supports the hypothesis that PHVD is determined by clot burden rather than the presence of blood products and allows further testing of early clot lysis to minimize PHVD risk.

Free access

Impact of ventricle size on neuropsychological outcomes in treated pediatric hydrocephalus: an HCRN prospective cohort study

Jay Riva-Cambrin, Abhaya V. Kulkarni, Robert Burr, Curtis J. Rozzelle, W. Jerry Oakes, James M. Drake, Jessica S. Alvey, Ron W. Reeder, Richard Holubkov, Samuel R. Browd, D. Douglas Cochrane, David D. Limbrick, Robert Naftel, Chevis N. Shannon, Tamara D. Simon, Mandeep S. Tamber, Patrick J. McDonald, John C. Wellons III, Thomas G. Luerssen, William E. Whitehead, and John R. W. Kestle

OBJECTIVE

In pediatric hydrocephalus, shunts tend to result in smaller postoperative ventricles compared with those following an endoscopic third ventriculostomy (ETV). The impact of the final treated ventricle size on neuropsychological and quality-of-life outcomes is currently undetermined. Therefore, the authors sought to ascertain whether treated ventricle size is associated with neurocognitive and academic outcomes postoperatively.

METHODS

This prospective cohort study included children aged 5 years and older at the first diagnosis of hydrocephalus at 8 Hydrocephalus Clinical Research Network sites from 2011 to 2015. The treated ventricle size, as measured by the frontal and occipital horn ratio (FOR), was compared with 25 neuropsychological tests 6 months postoperatively after adjusting for age, hydrocephalus etiology, and treatment type (ETV vs shunt). Pre- and posttreatment grade point average (GPA), quality-of-life measures (Hydrocephalus Outcome Questionnaire [HOQ]), and a truncated preoperative neuropsychological battery were also compared with the FOR.

RESULTS

Overall, 60 children were included with a mean age of 10.8 years; 17% had ≥ 1 comorbidity. Etiologies for hydrocephalus were midbrain lesions (37%), aqueductal stenosis (22%), posterior fossa tumors (13%), and supratentorial tumors (12%). ETV (78%) was more commonly used than shunting (22%). Of the 25 neuropsychological tests, including full-scale IQ (q = 0.77), 23 tests showed no univariable association with postoperative ventricle size. Verbal learning delayed recall (p = 0.006, q = 0.118) and visual spatial judgment (p = 0.006, q = 0.118) were negatively associated with larger ventricles and remained significant after multivariate adjustment for age, etiology, and procedure type. However, neither delayed verbal learning (p = 0.40) nor visual spatial judgment (p = 0.22) was associated with ventricle size change with surgery. No associations were found between postoperative ventricle size and either GPA or the HOQ.

CONCLUSIONS

Minimal associations were found between the treated ventricle size and neuropsychological, academic, or quality-of-life outcomes for pediatric patients in this comprehensive, multicenter study that encompassed heterogeneous hydrocephalus etiologies.

Open access

Pediatric multicompartmental trigeminal schwannoma: illustrative case

Alexander P. Landry, Vincent C. Ye, Kerry A. Vaughan, James M. Drake, Peter B. Dirks, and Michael D. Cusimano

BACKGROUND

Trigeminal schwannoma (TS) is an uncommon and histologically benign intracranial lesion that can involve any segment of the fifth cranial nerve. Given its often impressive size at diagnosis and frequent involvement of critical neurovascular structures of the skull base, it represents a challenging entity to treat. Pediatric TS is particularly rare and presents unique challenges. Similarly, tumors with extension into multiple compartments (e.g., middle cranial fossa, posterior cranial fossa, extracranial spaces) are notoriously difficult to treat surgically. Combined or staged surgical approaches are typically required to address them, with radiosurgical treatment as an adjunct.

OBSERVATIONS

The authors presented the unusual case of a 9-year-old boy with a large, recurrent multicompartmental TS involving Meckel’s cave, the cerebellopontine angle, and the infratemporal fossa. Near-total resection was achieved using a frontotemporal-orbitozygomatic craniotomy with a combined interdural and extradural approach.

LESSONS

The case report adds to the current literature on multicompartmental TSs in children and their management. The authors also provided a simplified classification of TS that can be generalized to other skull base tumors. Given a lack of precedent, the authors intended to add to the discussion regarding surgical management of these rare and challenging skull base lesions.