Intracranial pseudoaneurysms are extremely challenging lesions for the neurosurgeon because of their poor natural history and difficulty repairing a true defect in the vessel wall. Flow diversion offers a novel treatment option by creating a scaffold for neointimal growth over the defective vessel wall, but it has rarely been used and studied in the pediatric population. In the largest pediatric series to date, the authors share their surgical experience and illustrate technical and management nuances.
The authors aimed to investigate the clinical features of pediatric patients with cerebral cavernous malformation (CCM) and to compare the clinical outcomes of treatment applied on the basis of the treatment strategy at their institution. In patients with persistent seizures, recurrent bleeding, and mass effects, lesionectomy showed good performance and seizure outcomes. These results are expected to be useful in establishing surgical indications for pediatric patients with CCM.
Using data from the National Spina Bifida Patient Registry, the authors evaluated the total number of lifetime shunt revisions among 1691 children for whom all lifetime hydrocephalus surgical procedures were included in the registry. The estimated median time from shunt placement to first shunt failure was 2.34 years, and 45% of children never experienced a shunt failure. Male sex and White race were associated with more lifetime shunt surgical procedures.
Surgical treatment of sagittal craniosynostosis is more challenging in older patients, and the effect of age on surgical technique selection remains unclear. Surgeons in the multi-institutional Synostosis Research Group were surveyed and patient outcomes analyzed. More surgically involved techniques were preferred in older patients, and these open calvarial vault remodeling techniques demonstrated efficacy and safety. Patient age is an important driver in technique selection when treating sagittal synostosis in older patients.
The authors report their institutional experience using responsive neurostimulation (RNS) in pediatric patients with intractable epilepsy. RNS implantation in carefully selected pediatric patients appears to be safe and efficacious in reducing seizure burden. Because of advances in epilepsy monitoring and experience in epilepsy surgery, patients who may not have been considered surgical candidates are now able to benefit from RNS and achieve significant reductions in disabling seizures.
Researchers retrospectively investigated the frequency of residual germinoma lesions after completion of chemotherapy, as well as their management, long-term consequences, and prognosis. Radiologically visible residual lesions were detected in 43.5% patients just after chemoradiotherapy; however, half of these lesions decreased in size 1 year after treatment. None of the residual lesions increased in size on long-term follow-up. Therefore, the authors do not recommend early salvage resection for residual lesions after completion of chemoradiotherapy in germinoma patients.
In efforts to maximize healthcare resources targeted toward the COVID-19 pandemic, elective operations were shut down. During this interim, academicians in various fields focused on research work. In this study the authors evaluated the increase in academic productivity within pediatric neurosurgery, with number of clinical manuscript submissions as the metric. The authors identified an increase in submissions, with a transient shift in level of evidence. The COVID-19 pandemic has altered the clinical and academic landscape in pediatric neurosurgery in both a transient and enduring fashion.
This snapshot of the current fellowship directors offers a window to the paths to leadership in pediatric neurosurgery as gleaned from survey responses and publicly available sources. Pediatric neurosurgery is a unique area of focused practice in neurosurgery, which is reflected in the characteristics of the current fellowship directors. This current state of pediatric neurosurgery leaders will serve as a point of reference from which to observe the evolution of our field in the future.
The authors present their experience in obtaining the nuchal ligament and using it to repair the dura mater in pediatric patients with neoplasia undergoing resection through a suboccipital midline approach. Compared with artificial dura mater, the nuchal ligament was shown to significantly reduce CSF-related complications and was a simple, less-invasive, and more cost-efficient dural repair material.
The authors aimed to describe the existing quality improvement (QI) landscape, including current initiatives and training opportunities within the field of pediatric neurosurgery. They discovered that areas of opportunity include pediatric neurosurgery-specific QI education, tactics for obtaining institutional support to build QI infrastructure, and increased visibility of QI work within pediatric neurosurgery. There is great interest and opportunity in pediatric neurosurgery QI-related efforts, as goal-oriented research is imperative to improved patient outcomes.
Researchers studied the effects of in utero myelomeningocele flap-assisted closure. When compared with traditional techniques, there was no difference in key short-, intermediate-, and long-term outcomes. Flap-assisted in utero myelomeningocele closure is a safe technique that could help expand the inclusion criteria for fetal myelomeningocele repair.
This study is a retrospective review of 102 children with encephalocele whose neurodevelopmental status and the factors affecting outcome were evaluated. Of the variables including posterior location, size of sac, presence of neural tissue, ventriculomegaly, symptomatic hydrocephalus, and postoperative infection, which were found to have effects on neurodevelopmental outcome on univariate analysis, only neural tissue presence had a statistically significant association with neurodevelopmental delay on multivariate analysis.
Researchers performed a systematic review and meta-analysis of the molecular-based differences in overall survival for recurrent infratentorial ependymomas in children. The overall mortality rate for patients with recurrent tumors was 49.1%. More than 80% of recurrent tumors were of posterior fossa group A (PFA) molecular subtype, and both PFA tumors and those with 1q gain demonstrated worse prognosis. At recurrence, there was improved survival for patients who underwent surgery, but extent of resection did not influence outcome.
Fibrous dysplasia with anterior skull base involvement can result in progressive visual loss and impairment from optic nerve compression. Surgical decompression of the optic nerve can prevent visual loss and may even restore vision. Endonasal decompression of the optic nerve can do this safely and effectively in pediatric patients.
Interhospital transfer (IHT) to obtain a higher level of care for pediatric patients requiring neurosurgical interventions is common. Pediatric patients with malignant brain tumors often require subspecialty care commonly provided at specialized centers. The authors aimed to assess the impact of IHT in pediatric neurosurgical patients with malignant brain tumors to identify areas of improvement in treatment of this patient population.
Pediatric patients (age < 19 years) with malignant primary brain tumors undergoing craniotomy for resection between 2010 and 2018 were retrospectively identified in the Nationwide Readmissions Database. Patient and hospital data for each index admission provided by the Nationwide Readmissions Database was analyzed by univariate and multivariate analyses. Further analysis evaluated association of IHT on specific patient- or hospital-related characteristics.
In a total of 2279 nonelective admissions for malignant brain tumors in pediatric patients, the authors found only 132 patients (5.8%) who underwent IHT for a higher level of care. There is an increased likelihood of transfer when a patient is younger (< 7 years old, p = 0.006) or the disease process is more severe, as characterized by higher pediatric complex chronic conditions (p = 0.0004) and increased all patient refined diagnosis-related group mortality index (p = 0.02). Patients who are transferred (OR 1.87, 95% CI 1.04–3.35; p = 0.04) and patients who are treated at pediatric centers (OR 6.89, 95% CI 4.23–11.22; p < 0.0001) are more likely to have a routine discharge home. On multivariate analysis, transfer status was not associated with a longer length of stay (incident rate ratio 1.04, 95% CI 0.94–1.16; p = 0.5) or greater overall costs per patient ($20,947.58, 95% CI −$35,078.80 to $76,974.00; p = 0.50). Additionally, IHT is not associated with increased likelihood of death or major complication.
IHT has a significant role in the outcome of pediatric patients with malignant brain tumors. Transfer of this patient population to hospitals providing subspecialized care results in a higher level of care without a significant burden on overall costs, risks, or mortality.
Surgery is the cornerstone in the management of pediatric brain tumors. To provide safe and effective health services, quantifying and evaluating quality of care are important. To do this, there is a need for universal measures in the form of indicators reflecting quality of the delivered care. The objective of this study was to analyze currently applied quality indicators in pediatric brain tumor surgery and identify factors associated with poor outcome at a tertiary neurosurgical referral center in western Norway.
All patients younger than 18 years of age who underwent surgery for an intracranial tumor at the Department of Neurosurgery at Haukeland University Hospital in Bergen, Norway, between 2009 and 2020 were included. The primary outcomes of interest were classic quality indicators: 30-day readmission, 30-day reoperation, 30-day mortality, 30-day nosocomial infection, and 30-day surgical site infection (SSI) rates; and length of stay. The secondary aim was the identification of risk factors related to unfavorable outcome. The authors also conducted a systematic literature review. Articles concerning pediatric brain tumor surgery reporting at least two quality indicators were of interest.
The authors included 82 patients aged 0–17 years. The 30-day outcomes for unplanned reoperation, unplanned remission, mortality, nosocomial infection, and SSI were 9.8%, 14.6%, 0%, 6.1%, and 3.7%, respectively. Unplanned reoperation was associated with eloquent localization (p = 0.009), primary emergency surgery (p = 0.003), and CSF diversion procedures (p = 0.002). Greater tumor volume was associated with unplanned readmission (p = 0.008), nosocomial infection (p = 0.004), and CSF leakage (p = 0.005). In the systematic review, after full-text screening, 16 articles were included and provided outcome data for 1856 procedures. Overall, the 30-day mortality rate was low, varying from 0% to 9.3%. The 30-day reoperation rate varied from 1.5% to 12%. The SSI rate ranged between 0% and 3.9%, and 0% to 17.4% of patients developed CSF leakage. Four studies reported infratentorial tumor location as a risk factor for postoperative CSF leakage.
The 30-day outcomes in the authors’ department were comparable to published outcomes. The most relevant factors related to unfavorable outcomes are tumor volume and location, both of which are not modifiable by the surgeon. This highlights the importance of risk adjustment. This evaluation of quality indicators reveals concerns related to the unclear and nonstandardized definitions of outcomes. Standardized outcome definitions and documentation in a large and multicentric database are needed in the future for further evaluation of quality indicators.
Researchers explored whether inherent factors and surgery have an influence on postoperative symptomatic hydrocephalus. They studied tumor characteristics and surgery-related factors that might have an impact on the occurrence of postoperative hydrocephalus and developed a model consisting of tumor metastasis and postoperative ventricular blood, which had a better discrimination than a model consisting only of preoperative factors. The risk of postoperative hydrocephalus varies among children. Our study shows that tumor metastasis and postoperative ventricular blood might increase the risk of hydrocephalus.
TO THE EDITOR: We read with interest the article by Oushy and colleagues1 (Oushy S, Gilder HE, Nesvick CL, et al. Delayed recurrence of pediatric arteriovenous malformations after radiologically confirmed obliteration. J Neurosurg Pediatr. 2022;30:195-202) on the delayed recurrence of pediatric brain arteriovenous malformations (AVMs). The authors reviewed 68 angiographically cured pediatric AVMs, the majority of which were treated with radiosurgery. The authors identified one recurrence and two potential recurrences that were excluded because of incomplete imaging sets available. The authors concluded that delayed recurrence following radiographic cure of pediatric AVMs is rare. While
Despite the small size of the cohort and inherent lack of power associated with observational, single-center studies, the paper "Newborns with myelomeningocele: their health-related quality of life and daily functioning 10 years later"1 by Spoor and colleagues provides important data that address an active issue in the Netherlands and beyond. It provides a 10-year follow-up on a small cohort of children with myelomeningocele (MMC) evaluated for pain/suffering, neurologic capabilities, and quality of life (QOL). The study uses pediatric validated outcome measures including the KIDSCREEN-27, Pediatric Evaluation of Disability Inventory (PEDI-CAT), and measures of communication and ambulatory
TO THE READERSHIP: An error appeared in the article by Tulipan et al. (Tulipan N, Wellons JC III, Thom EA, et al. Prenatal surgery for myelomeningocele and the need for cerebrospinal fluid shunt placement. J Neurosurg Pediatr. 2015;16:613-620).
Credit for copyrighted text was not included in the footnotes of Tables 2 and 3 for material previously published in The New England Journal of Medicine. The tables appear on the following pages with the proper credit given in the footnotes.
In this study, the authors aimed to assess the current quality of life in a cohort of myelomeningocele (MMC) patients they first reported on when the patients were newborns, 10 years ago. The authors found that future unbearable suffering is hard to predict and may not always occur in newborns with MMC. Showing the difficulty of defining and predicting unbearable suffering after birth as well as in future life, this paper underlines the extreme importance of adequate counseling for upcoming parents confronted with an MMC pregnancy.
the Global Alliance for the Prevention of Spina Bifida-F (GAPSBiF)
The authors reviewed the work of the Global Alliance for the Prevention of Spina Bifida-F (GAPSBiF) in advocating for universal folic acid fortification of staple foods for the prevention of spina bifida and anencephaly. They used the example of folic acid fortification of staple foods as a model for neurosurgeon involvement in public health advocacy. This issue demonstrates the importance of neurosurgeons serving as advocates for diseases with which they are most familiar.
The authors aimed to evaluate the incidence rate of transient neurological events (TNEs) and discuss the factors associated with pediatric moyamoya disease. The incidence rate of TNEs in childhood moyamoya disease was 26.4%. All cases in this series underwent either direct or combined revascularization surgery. The clinical background was almost identical to TNEs in adults. Focal hyperperfusion was strongly correlated with the incidence of TNEs. These findings are important insights for elucidating the pathophysiology of TNEs.
According to the authors' institutional experience, pediatric gunshot wounds involving the skeletal spine and spinal cord are not expected to be fatal should the patient present as otherwise hemodynamically stable. Despite structural injury, the neurological function of these patients is not likely to worsen in light of the conservative management over time. There can be instances in which neurosurgical intervention may confer a neurological advantage in well-selected cases.
A group of international, multidisciplinary pediatric cervical spine experts aimed to provide a clinical framework for clinicians caring for children with cervical spine disorders. Using a modified Delphi approach, they developed consensus statements addressing various aspects of clinical management and decision-making (e.g., preoperative planning, radiographic thresholds of instability, perioperative management, and nonoperative management) for this unique patient population. These statements reflect current practices and can serve as a foundation for further studies in the field.
Postoperative surgical site infections are common following pediatric spinal surgery, and limited pediatric-specific guidelines for prevention exist. This network meta-analysis and systematic review compared perioperative prophylactic methods. Betadine irrigation plus intrawound vancomycin powder was the most strongly supported infection prevention method.
The authors report their initial experience with MRI-guided laser interstitial thermal therapy (MRIgLITT) to complete hemispherotomy and temporoparietooccipital (TPO) disconnections. Six pediatric patients with seizure persistence or recurrence due to an incomplete hemispherotomy (4 patients) or TPO (2 patients) underwent 8 surgical procedures with MRIgLITT. Five patients achieved successful seizure control after MRIgLITT. This technique has been proven to be safe and will become a good technical option to complete disconnective surgeries in select cases.
Posterior fossa tumors are commonly seen in the pediatric population. Approximately 10%–30% will develop postresection hydrocephalus, hence the Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH) score was developed to optimize the care of these patients.1 More and more studies are being conducted to develop prediction models capable of replacing clinical judgment such as this, employing Bayesian inference and more recently artificial intelligence for model creation and validation. Hence, the methodology behind the development of these predictive models in the context specific to pediatric neurosurgery must be perfected. We congratulate Mijderwijk et al. on publishing their article
Researchers conducted a systematic review and meta-analysis to evaluate the literature regarding the neurodevelopmental outcomes of children with premature coronal suture fusion. Scores of general neurodevelopment were below average but within one standard deviation of normal. The findings may guide the implementation of regular neurocognitive assessments and early learning support for these children.
Over the years, several external validation studies have been performed for the (modified) Canadian Preoperative Prediction Rule for Hydrocephalus (CPPRH) in pediatric patients with posterior fossa tumors.1–3 External validation is essential before implementing the CPPRH in clinical practice. This should be applied sensibly because the conclusions drawn from a prediction model may have consequences for many patients.4 We want to highlight some methodological considerations for external validation studies in order to aid future reporting and possible clinical uptake.
External validation assesses the performance of a prediction model in a data set not
The researchers studied radiosurgery treatment of young patients presenting with rare hypothalamic hamartomas (HHs) and refractory seizures. HH is located deep in the brain and it is a surgical challenge associated with a number of risks. Small-volume HH is shown to be amenable to treatment first through noninvasive radiosurgery, with good seizure control and low risks of adverse effects.
Early suturectomy with a rigid endoscope followed by orthotic cranial helmet therapy is an accepted treatment option for single-suture craniosynostosis. To the authors’ knowledge, flexible endoscope–assisted suture release (FEASR) has not been previously described. Presented herein is their experience with FEASR for the treatment of isolated sagittal craniosynostosis.
A retrospective analysis of the health records of patients who had undergone FEASR between March 2018 and December 2020 was performed. Patients under the age of 6 months who had been diagnosed with isolated sagittal synostosis were considered eligible for FEASR. Exclusion criteria included syndromic synostosis or multiple-suture synostosis. The cephalic index, the primary measure of the cosmetic endpoint, was calculated at prespecified intervals: immediately preoperatively and 6 weeks and 12 months postoperatively. Parental satisfaction with the cosmetic outcome was determined throughout the clinical follow-up and documented according to a structured questionnaire for the first 12 months.
A total of 18 consecutive patients met the criteria for study inclusion. The mean patient age at the time of surgery was 3.4 months (range 2–6 months). All patients underwent a wide craniectomy with no need to convert to an open procedure. The mean craniectomy width was 3.61 cm. Estimated blood loss ranged from 5 to 30 ml. The mean operative time was 75 minutes. No intraoperative complications were observed. The average length of stay was 2.6 days. The mean cephalic index was 67.7 preoperatively, 77.1 at 6 weeks postoperatively, and 76.3 at 1 year postoperatively. The mean percentage change in the cephalic index from preoperatively to the 12-month follow-up was 10.44 (p < 0.001). The mean follow-up was 17 months (range 12–28 months). All parents were satisfied with the cosmetic outcome of the procedure. No patients developed symptoms of raised intracranial pressure (ICP) or needed invasive ICP monitoring during the follow-up period. No patients required reoperation.
In this modest single-hospital series, the authors demonstrated the feasibility of FEASR in treating sagittal synostosis with favorable cosmetic outcomes. The morbidity profile and resource utilization of the procedure appear similar to those of procedures conducted via traditional rigid endoscopy.
TO THE EDITOR: With great interest, we read the retrospective study by Schramm et al.1 (Schramm S, Mehta A, Auguste KI, et al. Navigated transcranial magnetic stimulation mapping of the motor cortex for preoperative diagnostics in pediatric epilepsy. J Neurosurg Pediatr. 2021;28:287-294), who reviewed their database from a single institution. Preoperative motor mapping with navigated transcranial magnetic stimulation (nTMS) has been well-studied in adults and its advantages have led to the establishment of nTMS mapping as a technique for preoperative workup.2 Studies on the application of nTMS in children are mostly consistent,
Pediatric epilepsy refractory to conservative measures can respond to surgical interventions such as resection and disconnection. Response in these patients following repeat (or second) surgery, however, is unclear. The authors evaluated the contemporary metadata to demonstrate that approximately one-half of patients undergoing repeat surgery will achieve complete seizure freedom in both resection and disconnection approaches. Therefore, repeat surgery should be considered in the setting of pediatric epilepsy that does not fully respond to initial surgery.
Tumor treating fields (TTFields) are low-intensity, alternating electric fields that disrupt tumor cell growth and provide minimal side effects for patients. Medulloblastoma (MB) is the most common pediatric brain tumor, and while survival rates are high, the majority of survivors exhibit long-term neurocognitive complications. TTFields reduced MB cell growth and decreased cell motility and invasion. TTFields also worked synergistically with chemotherapeutics, making this therapy a novel and less toxic method to treat young patients.
Postoperative cerebellar mutism syndrome (pCMS) is a common complication of posterior fossa surgery. This study aimed to investigate the relationship between postoperative MRI features and cerebellar mutism syndrome. The results showed that damage to the cerebro-cerebellar circuit was associated with pCMS. Furthermore, the extent of damage to the cerebro-cerebellar circuit was related to the duration of mutism. These results help in understanding the mechanism of pCMS and the variation of the duration of mutism.
The authors set out to compare morphological outcomes of endoscopic strip craniectomy for metopic craniosynostosis in patients treated prior to 4 months of age and at 4 or 5 months of age. Age at repair was not associated with the 1-year postoperative interfrontal divergence angle or frontal width. These results suggest that endoscopic repair of metopic synostosis may be performed up to 5 months of age with satisfactory results.
TO THE EDITOR: We read with great interest the article by Mansur et al.1 (Mansur A, Morgan B, Lavigne A, et al. Comparison of intrathecal baclofen pump insertion and selective dorsal rhizotomy for nonambulatory children with predominantly spastic cerebral palsy. J Neurosurg Pediatr. 2022;30:217-223) regarding the short- and medium-term outcomes, care needs, and complications between intrathecal baclofen (ITB) pump and selective dorsal rhizotomy (SDR) in nonambulatory patients with spastic quadriplegic and diplegic cerebral palsy (CP) (Gross Motor Function Classification System [GMFCS] levels IV and V). The authors are to be congratulated on their work,
Aneurysmal bone cysts are benign hypervascular tumors that are traditionally treated with preoperative embolization followed by complete resection. Complicated tumor and vascular anatomy often preclude safe resection. The authors present 3 cases of neoadjuvant denosumab use in surgically unresectable tumors to calcify and devascularize the lesions, allowing for safer, more complete resection.
The authors investigated the parent-reported cosmetic outcomes after wound closure using Dermabond Prineo (DP), a skin closure system consisting of tissue adhesive glue and self-adhesive mesh, in 50 pediatric spine procedures. The use of DP facilitated both professional and parental wound care and led to excellent cosmetic results. DP possibly aids in the reduction of postoperative CSF leaks and infections after pediatric spine surgery.
Several growth-preserving surgical techniques are employed in the management of early-onset scoliosis (EOS). The authors’ objective was to compare the use of traditional growing rods (TGRs), magnetically controlled growing rods (MCGRs), Shilla growth guidance techniques, and vertically expanding prosthetic titanium ribs (VEPTRs) for the management of EOS.
A systematic review of electronic databases, including Ovid MEDLINE and Cochrane, was performed. Outcomes of interest included correction of Cobb angle, T1–S1 distance, and complication rate, including alignment, hardware failure and infection, and planned and unplanned reoperation rates. The percent changes and 95% CIs were pooled across studies using random-effects meta-analysis.
A total of 67 studies were identified, which included 2021 patients. Of these, 1169 (57.8%) patients underwent operations with TGR, 178 (8.8%) Shilla growth guidance system, 448 (22.2%) MCGR, and 226 (11.1%) VEPTR system. The mean ± SD age of the cohort was 6.9 ± 1.2 years. The authors found that the Shilla technique provided the most significant improvement in coronal Cobb angle immediately after surgery (mean [95% CI] 64.2° [61.4°–67.2°]), whereas VEPTR (27.6% [22.7%–33.6%]) and TGR (45% [42.5%–48.5%]) performed significantly worse. VEPTR also performed significantly worse than the other techniques at final follow-up. The techniques also provided comparable gains in T1–S1 height immediately postoperatively (mean [95% CI] 10.5% [9.0%–12.0%]); however, TGR performed better at final follow-up (21.3% [18.6%–24.1%]). Complications were not significantly different among the patients who underwent the Shilla, TGR, MCGR, and VEPTR techniques, except for the rate of infections. The TGR technique had the lowest rate of unplanned reoperations (mean [95% CI] 15% [10%–23%] vs 24% [19%–29%]) but the highest number of planned reoperations per patient (5.31 [4.83–5.82]). The overall certainty was also low, with a high risk of bias across studies.
This analysis suggested that the Shilla technique was associated with a greater early coronal Cobb angle correction, whereas use of VEPTR was associated with a lower correction rate at any time point. TGR offered the most significant height gain at final follow-up. The complication rates were comparable across all surgical techniques. The optimal surgical approach should be tailored to individual patients, taking into consideration the strengths and limitations of each option.
The objective of this study was to adapt the current Vestibular/Ocular Motor Screening (VOMS) tool for pediatric patients aged 5-9 years and establish the clinical utility of this tool in concussion patients. The adapted tool, the VOMC-Child (VOMS-C), accurately classified concussion patients and control participants with good accuracy in a model that also included concussion risk factors and had an acceptable false-positive rate consistent with that for adolescent samples. These findings provide the first step to validating an age-appropriate vestibular/ocular motor assessment as part of a comprehensive multidomain assessment for young children with a suspected concussion.
The neurosurgical team sought to identify the efficacy of postoperative general ward management following Chiari malformation (CM) decompression surgery among pediatric patients. Medically noncomplex patients were safely admitted to the general ward postoperatively with the additional benefit of decreased length of stay, decreased narcotic use, and decreased time to ambulation. Postoperative monitoring in the intensive care unit after CM decompression surgery can be bypassed with appropriate patient selection.
The authors quantified the clot lysis efficacy of a robotic neonatal magnetic resonance-guided high-intensity focused ultrasound (MRgHIFU) neurosurgery platform using a brain-mimicking phantom. The platform was able to lyse more than 90% of a clot with statistical significance and no apparent collateral damage to the phantom. These findings 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.
TO THE EDITOR: We read with interest the article by Akbari et al.1 (Akbari SHA, Yahanda AT, Ackerman LL, et al. Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr. 2022;30:39-51), which reports better outcomes but more postoperative complications with posterior fossa decompression with duraplasty compared to posterior fossa decompression. As the first large-scale, multi-institutional study of pediatric patients undergoing these procedures, although the article did not have surprising results,
The aim of this paper was to estimate the annual hemorrhage risk before and after treatment of pediatric patients (age < 21 years) with deep-seated brain arteriovenous malformations. Radiosurgery reduced the risk from 3.26% to 0.64% and may be beneficial when the risk-benefit profile is deemed acceptable.
In a large cohort of children with severe traumatic brain injury undergoing emergency hemicraniectomy, researchers identified diffuse axonal injury in the diencephalon and brainstem as powerful predictors of poor outcome.
TO THE EDITOR: I read with interest the article by Whitehead et al.1 (Whitehead WE, Riva-Cambrin J, Wellons JC III, et al. Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr. Published online November 19, 2021. doi:10.3171/2021.9.PEDS21391). Dr. Whitehead and colleagues concluded that anterior and posterior entry site shunt surgeries have similar outcomes and similar complication rates.1 They reported that there were no significant differences between entry sites for intraoperative complications, shunt infections, postoperative seizures, new-onset epilepsy, or intracranial
TO THE EDITOR: We read with great interest the article by Garcia et al.1 regarding the factors associated with seizures at initial presentation in pediatric patients with cerebral arteriovenous malformations (AVMs) (Garcia JH, Winkler EA, Morshed RA, et al. Factors associated with seizures at initial presentation in pediatric patients with cerebral arteriovenous malformations. J Neurosurg Pediatr. 2021;28:663-668). In this article, the authors performed a retrospective study based on a single-center database to investigate the risk factors associated with seizures at initial presentation in pediatric patients with cerebral AVMs. The results indicated that pediatric patients
Social determinants of health can have a profound effect on outcomes. The authors sought to determine if there are sociodemographic differences between patients who underwent fetal surgery versus those who underwent postnatal surgery for myelomeningocele. There was a significant difference in the commercial insurance rate and a marked difference in the racial and ethnic makeup of the two groups. Future studies should account for these demographic differences, and fetal centers should commit to minimizing preventable disparities.
The article by Oyemolade and colleagues addresses an initial 30-month experience following the introduction of a neurosurgical program in southwest Nigeria.1 The information presented is timely and important to the growth and development of global pediatric neurosurgery. This descriptive study provides important primary data that offer insight into barriers to neurosurgical care in lower-middle income countries (LMICs). At present, nearly all high-quality data on outcomes, quality of care, and guidelines for neurotrauma care originate in high-income countries.2 As the authors detail, there is a profound need for systems of surgical care in LMICs, and
In this systematic review, the authors sought to review the published evidence on the use of cranial neuromodulation—deep brain stimulation (DBS) and responsive neurostimulation (RNS)—for pediatric drug-resistant epilepsy (DRE). From 35 studies, they found 72 children who had undergone DBS and 42 who had undergone RNS. Overall, 75% and 73.2% of DBS and RNS patients, respectively, experienced > 50% reduction in seizures. This study shows the paucity of evidence for promising treatment options for pediatric DRE.
TO THE EDITOR: We read with great interest the article by Adamski et al.1 (Adamski A, O’Brien MW, Adamo MA. Shuntogram utility in predicting future shunt failures. J Neurosurg Pediatr. 2021;28:315-319).
Adamski et al. provided an excellent description of the contrast-based shuntogram technique and presented their experience with 95 cases, reporting a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 61.2% for valve failure within 1 year from the performance of the test. Of the patients with a negative result (with a normal flow of contrast), 38.8% were later
TO THE EDITOR: We read with great interest the article by Berns et al.1 (Berns J, Priddy B, Belal A, et al. Standardization of cerebrospinal fluid shunt valves in pediatric hydrocephalus: an analysis of cost, operative time, length of stay, and shunt failure. J Neurosurg Pediatr. 2021;27:400-405). In particular, we regard "standardization" of shunt valves with great concern. As two of the surgeons whose cases are presented in this article, we have particular insight into this project.
The "shunt design trial" that Berns et al. included in their analysis demonstrated that three valves commonly
Investigators applied lesion network mapping to children with focal cortical dysplasia who underwent surgery for drug-resistant epilepsy. Lesion volumes with persistent seizures after surgery tended to have stronger connectivity to attention and motor networks and weaker connectivity to the default mode network, compared with lesion volumes with seizure-free surgical outcomes. Network connectivity–based lesion-outcomes mapping may offer new insight for determining the impact of lesion volumes discerned according to both size and specific location.
The goal of this paper was to describe a neurosurgical educational partnership and the early results in developing pediatric craniofacial expertise in Southeast Asia. After brief, focused training through partnership with an institution in the United States followed by consistent telecollaboration, Vietnamese neurosurgical colleagues were able to rapidly scale up treatment of craniosynostosis with good outcomes. Global neurosurgical partnerships are feasible and effective methods of education and development of local neurosurgical expertise in low- and middle-income countries.
The authors describe the joint collaboration of the Necker-Enfants Malades and the Sainte-Anne Hospital for transitional care in surgical neurooncology. They suggest that neurosurgeons involved in transitional care should combine both pediatric and adult surgical neurooncology skills to optimize care management of these patients within a dedicated multidisciplinary organization framework. This study highlights the importance of organizing a transitional care in surgical neurooncology to improve patient care.
The authors aimed to provide a systematic review of the clinical applications as well as the rate and nature of complications of laser interstitial thermal therapy in the pediatric population. Currently, the most common applications of laser interstitial thermal therapy are for the treatment of refractory epilepsy and surgically inaccessible brain tumors. The overall complication rate was approximately 16%, with no deaths. This work represents the first systematic review that examines the utility of laser interstitial thermal therapy in the pediatric population.
In this issue of the Journal of Neurosurgery: Pediatrics, Bixby et al.1 provide a glimpse into the possible future of complex pediatric spinal deformity surgery: use of a team-based, two-specialty approach dedicated to tackling the formidable challenges associated with congenital hemivertebra-driven scoliosis. In this schema, pediatric orthopedic spine surgeons and pediatric neurosurgeons work together across the operating table to provide safety, value, and improved outcomes for patients with complex spinal deformity. Theoretically, this approach makes perfect sense, and one would be hard pressed to argue against it. After all, each specialty brings unique talents