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Mari Olsen, Anne Vik, Espen Lien, Kari Schirmer-Mikalsen, Oddrun Fredriksli, Turid Follestad, Oddrun Sandrød, Torun G. Finnanger, and Toril Skandsen

OBJECTIVE

The primary aim of this study was to evaluate the global outcome longitudinally over 5 years in children and adolescents surviving moderate to severe traumatic brain injury (msTBI) to investigate changes in outcome over time. The secondary aim was to explore how age at the time of injury affected outcome.

METHODS

All children and adolescents (aged 0–17 years; subdivided into children aged 0–10 years and adolescents aged 11–17 years) with moderate (Glasgow Coma Scale [GCS] score 9–13) or severe (GCS score ≤ 8) TBI who were admitted to a level I trauma center in Norway over a 10-year period (2004–2014) were prospectively included. In addition, young adults (aged 18–24 years) with msTBI were included for comparison. Outcome was assessed with the Glasgow Outcome Scale–Extended (GOS-E) at 6 months, 12 months, and 5 years after injury. The effect of time since injury and age at injury on the probability of good outcome was estimated by the method of generalized estimating equations.

RESULTS

A total of 30 children, 39 adolescents, and 97 young adults were included, among which 24 children, 38 adolescents, and 76 young adults survived and were planned for follow-up. In-hospital mortality from TBI was 7% for children, 3% for adolescents, and 18% for young adults. In surviving patients at the 5-year follow-up, good recovery (GOS-E score 7 or 8) was observed in 87% of children and all adolescents with moderate TBI, as well as in 44% of children and 59% of adolescents with severe TBI. No patient remained in a persistent vegetative state. For all patients, the odds for good recovery increased from 6 to 12 months (OR 1.79, 95% CI 1.15–2.80; p = 0.010), although not from 12 months to 5 years (OR 0.98, 95% CI 0.62–1.55; p = 0.940). Children/adolescents (aged 0–17 years) had higher odds for good recovery than young adults (OR 2.86, 95% CI 1.26–6.48; p = 0.012).

CONCLUSIONS

In this population-based study of pediatric msTBI, surprisingly high rates of good recovery over 5 years were found, including good recovery for a large majority of children and all adolescents with moderate TBI. Less than half of the children and more than half of the adolescents with severe TBI had good outcomes. The odds for good recovery increased from 6 to 12 months and were higher in children/adolescents (aged 0–17 years) than in young adults.

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Cordell M. Baker, Andrew Parker Cox, Joshua C. Hunsaker, Jonathan Scoville, and Robert J. Bollo

OBJECTIVE

Multiple studies have evaluated the use of MRI for prognostication in pediatric patients with severe traumatic brain injury (TBI) and have found a correlation between diffuse axonal injury (DAI)–type lesions and outcome. However, there remains a limited understanding about the use of MRI for prognostication after severe TBI in children who have undergone cranial surgery.

METHODS

Children with severe TBI who underwent craniectomy or craniotomy at Primary Children’s Hospital in Salt Lake City, Utah, between 2010 and 2019 were identified retrospectively. Of these 92 patients, 43 underwent postoperative brain MRI within 4 months of surgery. Susceptibility-weighted imaging (SWI) and FLAIR sequences were used to designate areas of hemorrhagic and nonhemorrhagic cerebral lesions related to DAI. Patients were then stratified based on the location of the DAI as read by a neuroradiologist as superficial, deep, or brainstem. The location of the DAI and other variables associated with poor outcome, including Glasgow Coma Scale (GCS) score, pediatric trauma score, mechanism of injury, and time to surgery, were analyzed for correlation with poor outcome. Outcomes were reported using the King’s Outcome Scale for Childhood Head Injury (KOSCHI).

RESULTS

In the 43 children with severe TBI who underwent postoperative brain MRI, the median GCS score on arrival was 4. The most common cause of injury was falls (14 patients, 33%). The most common primary intracranial pathology was subdural hematoma in 26 patients (60%), followed by epidural hematoma in 9 (21%). Fifteen patients (35%) had cerebral herniation and 31 (72%) had evidence of contusion. Variables associated with poor outcome included cerebral herniation (r = 0.338, p = 0.027) and location of DAI (r = 0.319, p = 0.037). In a separate analysis, brainstem DAI was shown to predict poor outcome, whereas location (no, superficial, or deep DAI) did not. Logistic regression showed that brainstem DAI (OR 22.3, p = 0.020) had a higher odds ratio than cerebral herniation (OR 10.5, p = 0.044) for poor outcome. Thirty-six children (84%) had a satisfactory outcome at last follow-up; 3 (7%) children died.

CONCLUSIONS

The majority of children in this series who presented with a severe TBI and underwent craniectomy or craniotomy made a satisfactory recovery. In patients in whom there is a concern for poor outcome, the location of DAI-type lesions with SWI and FLAIR may assist in prognostication. The authors’ results revealed that DAI-type lesions in the brainstem and evidence of cerebral herniation may indicate a poorer prognosis; however, more studies with larger cohorts are needed to make definitive conclusions.

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William C. Chen, Matthieu Lafreniere, Christina Phuong, S. John Liu, Joe D. Baal, Michael Lometti, Olivier Morin, Benjamin Ziemer, Harish N. Vasudevan, Calixto-Hope G. Lucas, Shawn L. Hervey-Jumper, Philip V. Theodosopoulos, Stephen T. Magill, Shannon Fogh, Jean L. Nakamura, Lauren Boreta, Penny K. Sneed, Michael W. McDermott, David R. Raleigh, and Steve E. Braunstein

OBJECTIVE

The authors’ objective was to examine the safety and efficacy of salvage intracranial cesium-131 brachytherapy in combination with resection of recurrent brain tumors.

METHODS

The authors conducted a retrospective chart review of consecutive patients treated with intraoperative intracranial cesium-131 brachytherapy at a single institution. Permanent suture-stranded cesium-131 seeds were implanted in the resection cavity after maximal safe tumor resection. The primary outcomes of interest were local, locoregional (within 1 cm), and intracranial control, as well as rates of overall survival (OS), neurological death, symptomatic adverse radiation effects (AREs), and surgical complication rate graded according to Common Terminology Criteria for Adverse Events version 5.0.

RESULTS

Between 2016 and 2020, 36 patients received 40 consecutive cesium-131 implants for 42 recurrent brain tumors and received imaging follow-up for a median (interquartile range [IQR]) of 17.0 (12.7–25.9) months. Twenty patients (55.6%) with 22 implants were treated for recurrent brain metastasis, 12 patients (33.3%) with 16 implants were treated for recurrent atypical (n = 7) or anaplastic (n = 5) meningioma, and 4 patients (11.1%) were treated for other recurrent primary brain neoplasms. All except 1 tumor (97.6%) had received prior radiotherapy, including 20 (47.6%) that underwent 2 or more prior radiotherapy treatments and 23 (54.8%) that underwent prior resection. The median (IQR) tumor size was 3.0 (2.3–3.7) cm, and 17 lesions (40.5%) had radiographic evidence of ARE prior to salvage therapy. Actuarial 1-year local/locoregional/intracranial control rates for the whole cohort and patients with metastases and meningiomas were 91.6%/83.4%/47.9%, 88.8%/84.4%/45.4%, and 100%/83.9%/46.4%, respectively. No cases of local recurrence of any histology (0 of 27) occurred after gross-total resection (p = 0.012, log-rank test). The 1-year OS rates for the whole cohort and patients with metastases and meningiomas were 82.7%, 79.1%, and 91.7%, respectively, and the median (IQR) survival of all patients was 26.7 (15.6–36.4) months. Seven patients (19.4%) experienced neurological death from progressive intracranial disease (7 of 14 total deaths [50%]), 5 (13.9%) of whom died of leptomeningeal disease. Symptomatic AREs were observed in 9.5% of resection cavities (n = 4), of which 1 (2.4%) was grade 3 in severity. The surgical complication rate was 16.7% (n = 7); 4 (9.5%) of these patients had grade 3 or higher complications, including 1 patient (2.4%) who died perioperatively.

CONCLUSIONS

Cesium-131 brachytherapy resulted in good local control and acceptable rates of symptomatic AREs and surgical complications in this heavily pretreated cohort, and it may be a reasonable salvage adjuvant treatment for this patient population.

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Qingyuan Liu, Xinyi Leng, Junhua Yang, Yi Yang, Pengjun Jiang, Maogui Li, Shaohua Mo, Shuzhe Yang, Jun Wu, Hongwei He, and Shuo Wang

OBJECTIVE

The probable stability of the lesion is critical in guiding treatment decisions in unruptured intracranial aneurysms (IAs). The authors aimed to develop multidimensional predictive models for the stability of unruptured IAs.

METHODS

Patients with unruptured IAs in the anterior circulation were prospectively enrolled and regularly followed up. Clinical data were collected, IA morphological features were assessed, and adjacent hemodynamic features were quantified with patient-specific computational fluid dynamics modeling. Based on multivariate logistic regression analyses, nomograms incorporating these factors were developed in a primary cohort (patients enrolled between January 2017 and February 2018) to predict aneurysm rupture or growth within 2 years. The predictive accuracies of the nomograms were compared with the population, hypertension, age, size, earlier rupture, and site (PHASES) and earlier subarachnoid hemorrhage, location, age, population, size, and shape (ELAPSS) scores and validated in the validation cohort (patients enrolled between March and October 2018).

RESULTS

Among 231 patients with 272 unruptured IAs in the primary cohort, hypertension, aneurysm location, irregular shape, size ratio, normalized wall shear stress average, and relative resident time were independently related to the 2-year stability of unruptured IAs. The nomogram including clinical, morphological, and hemodynamic features (C+M+H nomogram) had the highest predictive accuracy (c-statistic 0.94), followed by the nomogram including clinical and morphological features (C+M nomogram; c-statistic 0.89), PHASES score (c-statistic 0.68), and ELAPSS score (c-statistic 0.58). Similarly, the C+M+H nomogram had the highest predictive accuracy (c-statistic 0.94) in the validation cohort (85 patients with 97 unruptured IAs).

CONCLUSIONS

Hemodynamics have predictive values for 2-year stability of unruptured IAs treated conservatively. Multidimensional nomograms have significantly higher predictive accuracies than conventional risk prediction scores.

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Shunsuke Omodaka, Hidenori Endo, Kuniyasu Niizuma, Toshiki Endo, Kenichi Sato, Atsushi Saito, Hiroki Uchida, Yasushi Matsumoto, and Teiji Tominaga

OBJECTIVE

Recent MR vessel wall imaging studies of unruptured intracranial aneurysms (UIAs) have revealed that aneurysm wall enhancement (AWE) can be an indicator for aneurysm evolution; however, the degree of AWE among different types of evolving UIAs has yet to be clarified. The authors assessed the degree of AWE in unruptured posterior communicating artery (PcomA) aneurysms with oculomotor nerve palsy (ONP), which may be a subgroup of evolving UIAs with rapid enlargement and high rupture risk.

METHODS

The degree of AWE was analyzed in 35 consecutive evolving PcomA aneurysms (19 with and 16 without ONP). UIAs were considered to be evolving when showing growth or ONP. A 3D T1-weighted fast spin echo sequence was obtained after contrast media injection, and the contrast ratio of the aneurysm wall against the pituitary stalk (CRstalk) was calculated as the indicator of AWE. The CRstalk in evolving UIAs with ONP was compared with that in UIAs without ONP.

RESULTS

The CRstalk was significantly higher in evolving UIAs with ONP than in those without ONP (0.85 vs 0.57; p = 0.006). In multivariable analysis, the CRstalk remained a significant indicator for ONP presentation in evolving UIAs (OR 6.13, 95% CI 1.21–31.06).

CONCLUSIONS

AWE was stronger in evolving PcomA aneurysms with ONP than in those without ONP, suggesting the potential utility of AWE for risk stratification in evolving UIAs. The degree of AWE can be a promising indicator of a rupture-prone UIA, which can be useful information for the decision-making process in the treatment of UIAs.

Open access

Qiang Jian, Zhenlei Liu, Wanru Duan, Jian Guan, Fengzeng Jian, and Zan Chen

BACKGROUND

Treatment of severe rigid 360° fused cervical kyphosis (CK) is challenging and often requires a combined approach for ankylosis release, establishment of sagittal balance, and fixation with fusion.

OBSERVATIONS

Four patients with iatrogenic 360° fused severe rigid CK (Cobb angle ≥40°) were enrolled for this retrospective analysis. All patients in the case series were female, with an average age of 27 years. All patients previously underwent posterior laminectomy/laminoplasty and cervical tumor resection when they were children (13–17 years). They underwent correction surgery with a 540° posterior-anterior-posterior approach. Preoperative and final follow-up radiography and computed tomography (CT) were used to evaluate kyphosis correction, internal fixation implants, and bone fusion. The preoperative and final follow-up average C2–7 Cobb angles were −32.4° ± 12.0° and 5.3° ± 7.1°, respectively. Preoperative and final follow-up CK angles averaged −47.2° ± 7.4° and −0.9° ± 16.1°, respectively. The mean correction angle was 46.3° ± 9.6°. At final follow-up, CT showed stable fixation and solid bone fusion.

LESSONS

The rare iatrogenic severe kyphosis with 360° ankylosis requires a combined approach. The 540° posterior-anterior-posterior approach can completely release the bony fusion, and the CK can be corrected using an anterior plate. This technique can achieve good results and is an effective strategy.

Open access

Jorge A. Roa, Sarah White, Ernest J. Barthélemy, Arthur Jenkins III, and Konstantinos Margetis

BACKGROUND

Coccydynia refers to debilitating pain in the coccygeal region of the spine. Treatment strategies range from conservative measures (e.g., ergonomic adaptations, physical therapy, nerve block injections) to partial or complete removal of the coccyx (coccygectomy). Because the surgical intervention is situated in a high-pressure location close to the anus, a possible complication is the formation of sacral pressure ulcers and infection at the incision site.

OBSERVATIONS

In this case report, the authors presented a minimally invasive, fully endoscopic approach to safely perform complete coccygectomy for treatment of refractory posttraumatic coccydynia.

LESSONS

Although this is a single case report, the authors hope that this novel endoscopic approach may achieve improved wound healing, reduced infection rates, and lower risk of penetration injury to retroperitoneal organs in patients requiring coccygectomy.

Open access

Anna L. Slingerland, Lissa C. Baird, and R. Michael Scott

BACKGROUND

During initial exposure and removal of craniopharyngioma in pediatric patients with severe visual field deficits, the authors have encountered severe deformation of the optic apparatus by taut anterior cerebral arteries as seen during both frontal craniotomy and transsphenoidal exposures.

OBSERVATIONS

The authors report two pediatric patients with craniopharyngioma whose severe preoperative visual deficits were associated not only with large suprasellar masses but also with severe optic nerve and chiasm compression by taut anterior cerebral arteries. In each patient, the optic nerves were partially cleft by these vessels’ indenting them.

LESSONS

The role of a taut anterior cerebral artery complex in compression of the optic apparatus in patients with suprasellar tumors has been reported previously, but the intraoperative images in these two cases dramatically reveal this phenomenon.

Open access

Yoshio Araki, Kinya Yokoyama, Kenji Uda, Fumiaki Kanamori, Michihiro Kurimoto, Yoshiki Shiba, Takashi Mamiya, Kai Takayanagi, Kazuki Ishii, Masahiro Nishihori, Kazuhito Takeuchi, Kuniaki Tanahashi, Yuichi Nagata, Yusuke Nishimura, Sho Okamoto, Masaki Sumitomo, Takashi Izumi, and Ryuta Saito

BACKGROUND

Transient neurological deficits (TNDs) develop after cerebral revascularization in patients with moyamoya disease (MMD). The authors report a rare pediatric MMD case with extensive decreased cerebral blood flow (CBF) and prolonged TNDs after combined revascularization.

OBSERVATIONS

A 9-year-old boy presented with transient left upper limb weakness, and MMD was diagnosed. A right-sided combined surgery was performed. Two years after the surgery, frequent but transient facial (right-sided) and upper limb weakness appeared. The left internal carotid artery terminal stenosis had progressed. Therefore, a left combined revascularization was performed. The patient’s motor aphasia and right upper limb weakness persisted for approximately 10 days after surgery. Magnetic resonance angiography showed that the direct bypass was patent, but extensive decreases in left CBF were observed using single photon emission tomography. With adequate fluid therapy and blood pressure control, the neurological symptoms eventually disappeared, and CBF improved.

LESSONS

The environment of cerebral hemodynamics is heterogeneous after cerebral revascularization for MMD, and the exact mechanism of CBF decreases was not identified. TNDs are significantly associated with the onset of stroke during the early postoperative period. Therefore, appropriate treatment is desired after determining complex cerebral hemodynamics using CBF studies.

Open access

Albin A. John, Joey Grochmal, and Jason Felton

BACKGROUND

Posterior atlantoaxial dislocations (i.e., complete anterior odontoid dislocation) without C1 arch fractures are a rare hyperextension injury most often found in high-velocity trauma patients. Treatment options include either closed or open reduction and optional spinal fusion to address atlantoaxial instability due to ligamentous injury.

OBSERVATIONS

A 60-year-old male was struck while on his bicycle by a truck and sustained an odontoid dislocation without C1 arch fracture. Imaging findings additionally delineated a high suspicion for craniocervical instability. The patient had neurological issues due to both a head injury and ischemia secondary to an injured vertebral artery. He was stabilized and transferred to our facility for definitive neurosurgical care.

LESSONS

The patient underwent a successful transoral digital closed reduction and posterior occipital spinal fusion via a fiducial-based transcondylar, C1 lateral mass, C2 pedicle, and C3 lateral mass construct. This unique reduction technique has not been recorded in the literature before and avoided potential complications of overdistraction and the need for odontoidectomy. Furthermore, the use of bone fiducials for navigated screw fixation at the craniocervical junction is a novel technique and recommended particularly for placement of technically demanding transcondylar screws and C2 pedicle screws where pars anatomy is potentially unfavorable.