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Andrew Jea, Merdas Al-Otibi, Arnaud Bonnard and James M. Drake

Object

The use of laparoscopy-assisted placement of the distal catheter of a ventriculoperitoneal (VP) shunt has been well described in the literature, and several advantages of laparoscopy over laparotomy have been documented.

Methods

The authors retrospectively reviewed the charts of 11 consecutive children with hydrocephalus of various origins who underwent surgery for initial VP shunt placement or for revision of an existing VP shunt system between July 1, 2006, and December 31, 2006. The peritoneal catheter in all of these cases was implanted using a laparoscopic procedure and with the aid of a pediatric general surgeon. Laparoscopy-assisted placement of the distal catheter was successful in all patients. There were no periprocedural complications. There was one complication, an incisional hernia, noted in the short-term follow-up period.

Conclusions

The authors illustrate that laparoscopy-assisted implantation of a peritoneal catheter is a safe, effective, minimally invasive, and technically easy approach for VP shunt placement or revision in children. It allows accurate placement of the distal catheter in the peritoneal cavity, enables retrieval of fractured catheter segments, and allows confirmation of the patency of the shunt system.

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Andrew Jea, Michael D. Taylor, Peter B. Dirks, Abhaya V. Kulkarni, James T. Rutka and James M. Drake

✓The authors describe the novel use of C-1 lateral mass screws in four children 8 years of age or younger, in whom occipitocervical or atlantoaxial fusion was performed for trauma or os odontoideum. The authors retrospectively reviewed the demographics and procedural data of four children, ranging in age from 2 to 8 years, who required and underwent surgical fixation. Although C1–2 screw/rod constructs involving individual C-1 lateral mass screws and C-2 pars interarticularis or pedicle screws have been widely applied in adults, only C1–2 transarticular screw fixation has been reported in children less than 8 years of age. This report demonstrates the successful results of rigid occipitocervical and atlantoaxial fusion in four children in whom C-1 lateral mass screws were placed as part of a screw/rod construct. There was one instance of a vertebral artery injury, and the lessons learned from this complication are discussed.

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Douglas L. Brockmeyer

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William E. Whitehead, Andrew Jea, Shobhan Vachhrajani, Abhaya V. Kulkarni and James M. Drake

✓ The authors present a technique in which real-time ultrasound monitoring is used to aid the insertion of cerebrospinal fluid (CSF) shunt ventricular catheters in children without patent fontanelles. Experience with the technique is reviewed.

Intraoperative ultrasound is used to identify the compartments of the lateral ventricles and the choroid plexus prior to catheter insertion. Distance and trajectory to the best location for the hole-bearing segment of the catheter are determined and the catheter is inserted while real-time ultrasound monitoring is performed. Ten pediatric patients without open fontanelles underwent CSF shunt placement with the aid of transcranial ultrasound guidance between July and December 2006. After enlarging an occipital or frontal bur hole to a diameter of 2 cm to accommodate a small-footprint ultrasound probe, a ventricular catheter was carefully advanced into the frontal or occipital horn of the lateral ventricle while continuous ultrasound monitoring was performed. All catheters were inserted with a single pass through the brain. The final position of the ventricular catheter was visualized using intraoperative ultrasound. Postoperative computed tomography scans revealed all ventricular catheters placed accurately into the intended compartment of the ventricular system (for example, frontal horn or trigone). No procedure-related complications were noted.

Real-time transcranial ultrasound monitoring through an enlarged bur hole is a feasible, safe, and effective technique for the placement of ventricular catheters in pediatric patients without a patent fontanelle.

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Merdas Al-Otibi, Andrew Jea and Abhaya V. Kulkarni

✓The authors describe the novel use of computed tomography (CT) venography in the preoperative evaluation of a child with Crouzon syndrome who was being considered for Chiari decompression. This 18-month-old girl presented with hydrocephalus (treated with a ventriculoperitoneal shunt) and persistent symptomatic Chiari malformation and associated syrinx. A CT venogram was obtained because of the well-described relationship between multisutural craniosynostosis and abnormal intracranial-to-extracranial venous drainage. The CT venogram showed widely dilated vertebral and paravertebral veins located in the paraspinous muscles of the craniocervical junction. Because of the risk of massive intraoperative blood loss and/or occlusion of important collateral draining veins leading to intracranial venous hypertension and intractably raised intracranial pressure, the planned posterior fossa decompression was not performed. Computed tomography venography is an easily obtained study that we recommend in the evaluation of children with multisutural craniosynostosis prior to cranial surgical interventions.

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Atul Goel

Abstract (Jea et al.)

The authors describe the novel use of C-1 lateral mass screws in four children 8 years of age or younger, in whom occipitocervical or atlantoaxial fusion was performed for trauma or os odontoideum. The authors retrospectively reviewed the demographics and procedural data of four children, ranging in age from 2 to 8 years, who required and underwent surgical fixation. Although C1–2 screw/rod constructs involving individual C-1 lateral mass screws and C-2 pars interarticularis or pedicle screws have been widely applied in adults, only C1–2 transarticular screw fixation has been reported in children less than 8 years of age. This report demonstrates the successful results of rigid occipitocervical and atlantoaxial fusion in four children in whom C-1 lateral mass screws were placed as part of a screw/rod construct. There was one instance of a vertebral artery injury, and the lessons learned from this complication are discussed.

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Robert H. Rosenwasser

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Roukoz B. Chamoun, Michel E. Mawad, William E. Whitehead, Thomas G. Luerssen and Andrew Jea

Object

Currently, no diagnostic or treatment standards exist for extracranial carotid artery dissection (CAD) in children after trauma. The purpose of this study was to review and describe the characteristics, diagnosis, and treatment of this rather uncommon sequelae of pediatric trauma.

Methods

A systematic review of the literature was performed to examine the pertinent studies of traumatic extracranial carotid artery (CA) injuries in children.

Results

No randomized trials were identified; however, 19 case reports or small case series consisting of 34 pediatric patients were found in the literature. The diagnosis of CAD was made in 33 of 34 patients only after the onset of ischemic symptomatology. Twenty-four of 34 patients underwent cerebral angiography to confirm diagnosis; MR angiography affirmed the diagnosis in 6 of 34 patients. There was little published experience with CA ultrasonography or CT angiography for diagnosis. Thirty of 34 patients were treated with medical therapy or observation; 2 of 4 patients treated with observation alone died. There was little experience with open surgical treatment of CAD in the pediatric population, and there were no studies on the endovascular treatment of traumatic CAD in children. The literature does not support anticoagulation therapy over antiplatelet therapy.

Conclusions

As a result of this review of the literature, the authors propose the algorithms for the evaluation and treatment of traumatic extracranial CADs in children. These recommendations include utilizing MR angiography as a screening tool in cases in which the clinical suspicion of CAD is high, using conventional cerebral angiography to confirm the diagnosis, implementing antiplatelet therapy as initial medical management, and reserving endovascular stenting in cases of failed medical treatment.

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Andrew Jea, Shobhan Vachhrajani, Keyne K. Johnson and James T. Rutka

Object

Although corpus callosotomy has been used effectively since the late 1930s to treat severe, medically intractable seizure disorders, particularly atonic or drop-attack seizures, controversy remains as to when, how, and how much surgery should be performed. Intraoperative determination of the extent of callosotomy, the need to stage the procedure, and the side of the interhemispheric approach represent technical issues that remain debatable. The authors report the 12-year experience of the senior author as well as surgical outcomes with corpus callosotomy using a frameless stereotactic neuronavigation system (ISG View Wand and BrainLab).

Methods

Thirteen consecutive children at The Hospital for Sick Children underwent single-stage corpus callosotomy for medically intractable seizures. The mean age was 10.3 years. Five children underwent partial callosotomy, and 8 underwent complete callosotomy. The side of operative approach to avoid large parasagittal bridging veins was determined by preoperative study of 3D MR imaging/MR venography reconstructed by the neuronavigation system. The extent of callosotomy was determined using intraoperative feedback from the neuronavigation system and postoperative MR imaging.

Results

The extent of callosotomy determined by intraoperative neuronavigation and postoperative MR imaging correlated closely in all cases. There were no operative deaths. There was no significant postoperative morbidity related to venous infarction. Four of 5 patients in the partial callosotomy cohort and 7 of 8 patients in the complete callosotomy cohort showed significant improvement in seizure control.

Conclusions

The use of frameless stereotactic neuronavigation is a safe, effective, and important surgical adjunct in the planning and execution of successful corpus callosotomy in children with intractable epilepsy.

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Benjamin W. Y. Lo, Abhaya V. Kulkarni, James T. Rutka, Andrew Jea, James M. Drake, Maria Lamberti-Pasculli, Peter B. Dirks and Lehana Thabane

Object

Cephaloceles represent primary axial mesodermal defects, occurring in 0.8–4 per 10,000 live births. Prior studies have reported posterior location, hydrocephalus, microcephaly, seizure, and presence of brain tissue as poor prognostic markers for neurological outcome. However, these studies were small and the results were analyzed using univariate tests. The purpose of this study was to investigate the potential risk factors for the occurrence of developmental delay in patients with cephaloceles, using both univariate and multivariable regression techniques.

Methods

This is a retrospective cohort study of cephalocele cases treated at the Hospital for Sick Children between 1990 and 2006. Two independent investigators collected the data from the Hospital for Sick Children Encephalocele Database and hospital charts. Developmental assessments were made by general pediatricians and neuropsychologists. Both univariate analysis (α = 0.10) and multivariable logistic regression analysis (α = 0.05) were performed.

Results

Eighty-five cases of cephaloceles were identified. The patient group consisted of 48 boys and 37 girls. Sixty-eight lesions were encephaloceles and 17 were meningoceles. The distribution was as follows: frontal (40 lesions), occipital (33), and parietal (12). Associated conditions included hydrocephalus (23), seizure disorder (17), microcephaly (6), corpus callosal abnormalities (15), heterotopias (9), cerebral dysgenesis (11), and myelomeningocele (1). Evaluation of long-term development revealed that 41 patients (48%) had normal development, 9 (11%) had mild delay, 14 (16%) had moderate delay, and 21 (25%) had severe delay. Hydrocephalus, seizure disorder, microcephaly, presence of associated intracranial abnormalities, and presence of brain tissue were significantly associated with poor outcome on univariate analysis. Multivariable analysis revealed hydrocephalus and presence of intracranial abnormalities to be statistically significant predictors of developmental delay.

Conclusions

To the authors' knowledge, this is one of the largest North American cephalocele series documented. Unlike prior studies, location of the cephaloceles is not a significant predictor of outcome. The multivariable regression analysis demonstrates hydrocephalus and the presence of associated intracranial abnormalities as variables with cumulative predictive effects for developmental delay.