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Letter to the Editor. Chiari malformation type I in adults and children

Isaías Raymundo Ramírez Díaz

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Return to play after head injury in adolescent sports: evaluating football versus other sports

Bahie Ezzat, Eugene I. Hrabarchuk, Alexander J. Schupper, Addison Quinones, Muhammad Ali, Michael B. Lemonick, Benjamin Rodriguez, Alex Gometz, Mark Lovell, and Tanvir Choudhri

OBJECTIVE

Increased adolescent sports participation has raised concerns about higher rates of concussions, a prevalent injury among young athletes with potential long-term effects. Discrepancies in concussion recovery and management protocols across various sports underscore a critical issue in youth athletics. This study aimed to examine the relationship between sport type and the number of games missed following a concussion to inform targeted management strategies.

METHODS

Data from 7445 postinjury ImPACT tests for athletes aged 12–22 years, collected from 2009 to 2019, were analyzed across different sports: baseball, basketball, cheerleading, football, ice hockey, lacrosse, soccer, softball, swimming, track and field, volleyball, and wrestling. The number of days and normalized missed games (NMG), a metric accounting for the different number of games in a season for different sports, were used to evaluate the effect of concussions across different sports. ANOVA, t-tests, and linear regression analyses were performed to model the effect of sport type on games missed in a season while controlling for sex, age, concussion history, diagnosed learning disability (DLD), and attention-deficit/hyperactivity disorder (ADHD).

RESULTS

Multivariable linear regression analysis demonstrated that football participation significantly increased NMG (β 1.681, 95% CI 0.807–2.554; p < 0.001) and days missed (β 1.637, 95% CI 1.044–2.231; p < 0.001) after head injury. Concussion diagnoses were also found to significantly increase NMG (β 2.344, 95% CI 1.629–3.059; p < 0.001) and days missed (β 1.560, 95% CI 1.074–2.045; p < 0.001), as well as history of prior concussion (NMG: β 7.791, 95% CI 7.368–8.215; p < 0.001; days missed: β 5.232, 95% CI 4.945–5.520; p < 0.001). In contrast, factors such as age, sex, DLD, ADHD, and concussions causing loss of consciousness did not significantly affect NMG or days missed. ANOVA with Tukey Honest Significant Difference indicated that compared with football, ice hockey (mean difference [MD] 5.4 days, p = 0.011) and track and field (MD 4.1 days, p = 0.006) were associated with significantly more days being missed after head injury. Conversely, basketball (MD −3.0, p < 0.001) and volleyball (MD −2.6, p = 0.005) were associated with fewer missed games.

CONCLUSIONS

Adolescents playing football missed fewer days and games after concussion than other contact and noncontact sports, including ice hockey and track and field, raising questions about variations in return-to-play protocols and cultural attitudes within sports. Further research is needed to determine the factors affecting games missed across sport types in adolescent athletics and return-to-play protocols.

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What to do with an incidental finding of a fused sagittal suture: a modified Delphi study

Sarah N. Chiang, Jocelyn Reckford, Allyson L. Alexander, Craig B. Birgfeld, Christopher M. Bonfield, Daniel E. Couture, Lisa R. David, Brooke French, Barbu Gociman, Jesse A. Goldstein, Michael S. Golinko, John R. W. Kestle, Amy Lee, Suresh N. Magge, Ian F. Pollack, S. Alex Rottgers, Christopher M. Runyan, Matthew D. Smyth, C. Corbett Wilkinson, Gary B. Skolnick, Jennifer M. Strahle, and Kamlesh B. Patel

OBJECTIVE

As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition.

METHODS

A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose.

RESULTS

Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment.

CONCLUSIONS

Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.

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Development of moyamoya arteriopathy following treatment of intracranial tumors: clinical and radiographic characterization

Jong Seok Lee, Armide Storey, Arianna Lanpher, and Edward R. Smith

OBJECTIVE

Moyamoya arteriopathy can develop in patients with brain tumors, particularly when associated with neurofibromatosis type 1 (NF1) or cranial irradiation. The present study aimed to analyze the clinical outcomes of moyamoya after brain tumor treatment and elucidate the effect of revascularization on brain tumors.

METHODS

The authors retrospectively reviewed clinical and radiographic findings in 27 patients with brain tumors who developed moyamoya requiring revascularization surgery between January 1985 and June 2017 at a single institution. The long-term clinical and neuroimaging-based outcomes were analyzed.

RESULTS

Among 27 patients, 22 patients underwent radiotherapy, and 12 patients had NF1. The mean ages at diagnosis of brain tumors and moyamoya were 4.4 years and 10.3 years, respectively. The mean interval between radiotherapy and moyamoya diagnosis was 4.0 years. The mean follow-up period after revascularization surgery was 8.5 years. Among 46 affected hemispheres in 27 patients, the patients who underwent radiotherapy (30 hemispheres in 22 patients) had a higher incidence of Suzuki stage 5 or 6 (20% [6/30] vs 0% [0/8]) and infarction (63.6% [14/22] vs 0% [0/5]) compared with patients without radiotherapy (8 hemispheres in 5 patients). After revascularization, stroke occurred in 4 patients, and 6 hemispheres showed Matsushima grade C, all of which occurred in patients with a history of radiotherapy. The residual brain tumors progressed in 4 of 21 patients (19%) after revascularization, comparable to the progression rates of brain tumors without revascularization in previous literature.

CONCLUSIONS

Patients with brain tumors can develop moyamoya that exhibits characteristic clinical and radiographic features of idiopathic MMD. Moyamoya associated with cranial irradiation has a higher incidence of stroke with less capacity for revascularization, requiring thorough evaluations and timely treatment. Revascularization does not appear to have any effect on the progression of existing brain tumors.

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Effects of hours of sleep on ImPACT concussion testing: comparing baseline with postinjury scores

Eugene I. Hrabarchuk, Roshini Kalagara, Bahie Ezzat, Frederika Rentzeperis, Tomasina M. Leska, Alexander J. Schupper, Benjamin Rodriguez, Muhammad Ali, Addison Quinones, Lily McCarthy, Mathew T. Carr, Arielle B. Lehman, Alex Gometz, Mark Lovell, and Tanvir F. Choudhri

OBJECTIVE

The influence of sleep on baseline and postconcussion neurocognitive performance prior to Immediate Post-Concussion Assessment and Cognitive Testing (ImPACT) is poorly understood. Since ImPACT is widely used in youth sport to assess neurocognitive performance before and after head injury, it is important to delineate factors that affect testing performance. While some have reported correlations between fewer hours of sleep and lower scores on baseline tests, others have not observed any such associations. Therefore, the authors sought to compare the relationship between sleep and neurocognitive performance on ImPACT at both baseline and postinjury.

METHODS

The authors queried a database of 25,815 ImPACT tests taken from 2009 to 2019 by athletes aged 12–22 years. There were 11,564 baseline concussion tests and 7446 postinjury concussion ImPACT tests used in the analysis. Linear regression was used to model the effect of sleep on baseline and postconcussion ImPACT scores adjusting for sex, age, learning disability, attention-deficit/hyperactivity disorder, number of prior concussions, number of games missed, and strenuous exercise before testing.

RESULTS

Mean composite scores expectedly were all significantly lower in the post–head injury group compared with the baseline group. In the multivariable analysis, at baseline, hours of sleep significantly affected symptom scores (β = −1.050, 95% CI −1.187 to −0.9138; p < 0.0001). In the postinjury multivariable analysis, verbal memory (β = 0.4595, 95% CI 0.2080–0.7110; p = 0.0003), visual memory (β = 0.3111, 95% CI 0.04463–0.5777; p = 0.0221), impulse control (β = −0.2321, 95% CI −0.3581 to −0.1062; p = 0.0003), and symptom scores (β = −0.9168, 95% CI −1.259 to −0.5750; p < 0.0001) were all affected by hours of sleep.

CONCLUSIONS

Hours of sleep did not alter neurocognitive metrics at baseline but did have an impact on post–head injury metrics. These findings suggest that individuals may be able to compensate for lack of sleep at baseline but not immediately after concussion. Concussions may reduce cognitive reserve or detract from the brain’s resources, making sleep even more important for proper neurocognitive functioning postconcussion. Future work will analyze the effects of sleep on postconcussion test performance.

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Letter to the Editor. Pediatric TSCI: a call for enhanced multidisciplinary management

Samuel Berchi Kankam, Oluwafeyisola Osifala, and Mohamed Jalloh

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Analysis of bihemispheric language function in pediatric neurosurgical patients using repetitive navigated transcranial magnetic stimulation

Tizian Rosenstock, Heike Schneider, Mitra Lara Neymeyer, Lena-Luise Becker, Bettina Schulz, Anna Tietze, Pablo Hernáiz Driever, Angela M. Kaindl, Peter Vajkoczy, Thomas Picht, and Ulrich-Wilhelm Thomale

OBJECTIVE

Language dominance in the developing brain can vary widely across anatomical and pathological conditions as well as age groups. Repetitive navigated transcranial magnetic stimulation (rnTMS) has been applied to calculate the hemispheric dominance ratio (HDR) in adults. In this study, the authors aimed to assess the feasibility of using rnTMS to identify language lateralization in a pediatric neurosurgical cohort and to correlate the preoperative rnTMS findings with the postoperative language outcome.

METHODS

A consecutive prospectively collected cohort of 19 children with language-associated lesions underwent bihemispheric rnTMS mapping prior to surgery (100 stimulation sites on each hemisphere). In addition to feasibility and adverse effects, the HDR (ratio of the left hemisphere to right hemisphere error rate) was calculated. The anatomical surgical site and postoperative language outcome at 3 months after surgery were assessed according to clinical documentation.

RESULTS

Repetitive nTMS mapping was feasible in all 19 children (mean age 12.5 years, range 4–17 years; 16 left-sided lesions) without any relevant adverse events. Thirteen children (68%) showed left hemispheric dominance (HDR > 1.1), and 2 children (11%) showed right hemispheric dominance (HDR < 0.9). In 4 children (21%), the bihemispheric error rates were nearly the same (HDR ≥ 0.9 and ≤ 1.1). Sixteen children underwent surgery (14 tumor/lesion resections and 2 hemispherotomies) and 3 patients continued conservative therapy. After surgery, 4 patients (25%) showed an improvement in language function, 10 (63%) presented with stable language function, and 2 (12.5%) experienced deterioration in language function. Of the 6 patients with right hemispheric language involvement, 4 (80%) had glial tumors, 1 (20%) had focal cortical dysplasia, and 1 (20%) experienced hypoxic brain injury. Children with right hemispheric language involvement (HDR ≤ 1.1) did not show any language deterioration postoperatively.

CONCLUSIONS

Bihemispheric rnTMS language mapping as a noninvasive mapping technique to assess lateralization of language function in the pediatric neurosurgical population is safe and feasible. Why relevant right hemispheric language function (HDR ≤ 1.1) was associated with postoperative unaltered language function needs to be validated in future studies. Bihemispheric rnTMS language mapping strengthens risk-benefit considerations prior to pediatric tumor/epilepsy surgery in language-associated areas.

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Clinical, radiological, and laboratory factors associated with mortality and functional outcomes in pediatric patients presenting with intracranial gunshot wounds

Roboan Guillen Arguello, Patrick J. McCarty, Jerome Volk III, Oritsejolomi Roberts, Mary O. Haastrup, and Frank Culicchia

OBJECTIVE

Firearm injuries are now the leading cause of death in children and young adults younger than 25 years of age in the US. Current management of these injuries is extrapolated from adult blunt and penetrating traumatic brain injury guidelines. The objectives of this study were to investigate and analyze the clinical, radiological, and laboratory factors associated with mortality and functional outcomes in pediatric patients presenting with intracranial gunshot wounds (GSWs).

METHODS

Medical records were screened for all patients younger than 21 years of age with an intracranial GSW who presented to the University Medical Center in New Orleans, Louisiana, from 2012 to 2022. Demographics and radiological, clinical, and laboratory data were extracted, and chi-square and Fisher’s exact tests were used to evaluate individual association with mortality and functional outcome. Odds ratios were calculated from the cross tabulations for categorical variables and univariate binary logistic regression models for continuous variables. Multivariate binary logistic regression was used to adjust for effects of covariates and isolate the contributions of predictor variables for mortality and functional outcome.

RESULTS

Ninety-six patients (82 male, 14 female) had a median age of 18 (interquartile range [IQR] 15–20) years. The 30-day inpatient, 60-day, and 6-month mortality rates among these patients were 53.1%, 0%, and 2.4%, respectively. Those who died were more likely to have an initial Glasgow Coma Scale score ≤ 8 (p < 0.001), bilateral fixed pupils (p < 0.001), transventricular trajectory (p < 0.001), deep nuclear/third ventricle involvement (p = 0.004), bihemispheric trajectory (p = 0.025), injury to ≥ 3 lobes (p = 0.015), parietal lobe involvement (p = 0.023), base deficit < −5 mEq/L (p = 0.013), international normalized ratio (INR) > 1.5 (p = 0.007), and a St. Louis Scale (SLS) score ≥ 5 (p < 0.001). The survivors with favorable functional outcome were more likely to have lower median SLS scores (p = 0.016) and injury to < 3 lobes (p < 0.001). In a multivariate analysis, bilaterally fixed nonreactive pupils were positively associated with mortality and negatively associated with favorable functional outcome, whereas the Injury Severity Score (ISS) and injury to ≥ 3 lobes were negatively associated with favorable functional outcome only.

CONCLUSIONS

This is one of the largest series of pediatric intracranial GSWs to date. The authors identified certain clinical (bilateral fixed pupils, SLS score ≥ 5, ISS > 16), laboratory (INR > 1.5, base deficit < −5 mEq/L), and radiological (transventricular trajectory, deep nuclear/third ventricle involvement, parietal lobe involvement) factors that were associated with death and poor functional outcome in this pediatric cohort.

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Development of an in vitro ventricular shunt material testing model and utility of PEG as antifouling coating

Nicholas J. Prindeze, Stephen G. Szeto, Neta Glaser, Cyan B. Brown, Dan E. Azagury, and Cormac O. Maher

OBJECTIVE

CSF shunts, most commonly the ventriculoperitoneal shunt, remain a first and last line of management for children and adults with hydrocephalus. However, the failure rates of these shunts are extremely high, leaving many patients with the need for revision surgical procedures. The objective of this study was to develop a model to assess the efficacy of a nonfouling ventricular catheter. A second objective was to test polyethylene glycol (PEG) as an antifouling coating.

METHODS

Microglial cells were grown on medical-grade catheter silicone with biofouling simulated by collagen incubation over a range of concentrations from 31 to 103 µg/ml and durations from 2 to 18 hours. After ideal fouling conditions were identified, catheter silicone was then coated with PEG as an antifouling surface, and cell growth on this surface was compared to that on uncoated standard catheter silicone.

RESULTS

Collagen biofouling increased cell growth on silicone surfaces with an ideal concentration of 69 µg/ml and incubation of 6 hours. PEG coating of silicone catheter material yielded 70-fold lower cell growth (p < 0.0001), whereas collagen-fouled PEG-coated silicone yielded 157-fold lower cell growth (p < 0.0001).

CONCLUSIONS

Catheter coating significantly reduced cell growth, particularly in the setting of biofouling. The application of antifouling surfaces to ventricular shunts shows considerable promise for improving efficacy.

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Letter to the Editor. New insights of MRgLITT: a first-line treatment?

Maria Sole Venanzi, Domenico Tortora, Gianluca Piatelli, and Alessandro Consales