Volume null: Issue null: Journal of Neurosurgery: Pediatrics
Volume 25: Issue 2 (Feb 2020): Pages 97-208
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In Brief

Despite the high incidence of pediatric brain tumors, literature is scarce on examining risk of readmission among pediatric patients undergoing resection of intracranial tumors. The authors studied readmission rate following brain tumor surgery to stratify the risk factors of readmissions in this subset of pediatric patients.

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The study evaluates the need for screening spinal MRI scans in children who undergo resection of low-grade glioma tumors from their posterior fossa. The need (or not) of such scans has clinical and financial implications, and thus reflects the importance of this study.

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The authors’ study makes a significant contribution to the literature because it details the treatment of pediatric patients with ATRTs in Japan and shows the limitations of current multimodal treatments, especially craniospinal irradiation. This finding is important because most ATRTs occur in infants and young children.

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The authors evaluate the prevalence of hypertension among moyamoya disease (MMD) patients. It is important because the long-term deleterious effects of hypertension in pediatric MMD patients seem to be inevitable. As a result, a high prevalence of hypertension in pediatric MMD patients was found. Pediatric neurosurgeons ought to predict and prepare for the development of essential hypertension after surgical treatment of MMD.

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The authors shed light on the role of relaxin in cerebral cavernous malformations (CCMs) in adults and children by investigating the endothelial cell expression of relaxin 1, 2, and 3; vascular endothelial growth factor receptor–1 and –2; Ki-67; vascular geometry; and hemorrhage, as well as clinical presentation in 32 patients with surgically resected lesions. They demonstrate, for the first time, that relaxin is associated with CCMs and, hence, identified a new therapeutic target in the treatment of CCMs.

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The purpose of this study was to explore outcomes of treatment and factors that predict recurrence to help guide the management of pediatric intracranial arteriovenous malformations (AVMs). The authors conducted a retrospective chart review to identify patients treated with surgical and nonsurgical modalities and compared their outcomes to better understand how many and what types of AVMs recur and what areas of further study can be targeted to reduce recurrence in pediatric patients with AVMs.

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The authors used postoperative MRI along with diffusion tensor imaging in patients with drug-resistant epilepsy to investigate the role of residual temporal stem connections in recurrent seizures following endoscopic vertical approach hemispherotomy and used cadaveric studies to determine how this problem may be avoided. This study is important in identifying the problem of residual temporal stem during hemispheric disconnection, determining how to identify this problem during surgery, and identifying the role of repeat surgery if seizures are not controlled.

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The authors used direct brain stimulation to find the locations of language, as both seen and heard, in pediatric patients undergoing brain surgery. These findings are helpful to compare to previously reported adult language mapping results and are important to consider when removing brain lesions that are in and around these important sites in pediatric patients.

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The authors interviewed parents of children with traumatic brain injury (TBI) and clinicians who care for these children and asked what role parents should play in deciding whether or not to place an intracranial pressure monitor (ICP) in the child's skull. Important findings were that parents and clinicians agreed that decision making about ICP monitoring in children with TBI is the clinicians’ role, which should not be shared with the parents, while parent needs were to be informed and also be included as observers of the process of multidisciplinary decision making by the clinician teams.

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The authors studied the management of children with a congenital spinal cord anomaly and found that there are differences in the care these patients receive depending on where they live, how sick they generally are, and whether they have an abnormal fluid collection in the spinal cord. This study is important because it sheds light on these differences in a condition that has not been studied as deeply before.

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Telemedicine has a growing role in providing access to neurosurgical care in underserved communities. The authors studied the socioeconomic benefits of having a pediatric neurosurgery telemedicine clinic and quantified the cost savings to families. They calculated average cost savings as a function of distance from the telemedicine and main clinics.

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Currently, there is no clear answer of when to divert CSF in patients with posterior fossa tumors (PFTs). The ideal surgical option is also debatable. The protocol at the authors’ institution had been to perform endoscopic third ventriculostomy (ETV) before PFT resection as a temporizing measure if needed. They used the modified Canadian Preoperative Prediction Rule for Hydrocephalus (mCPPRH) retrospectively to determine which PFTs were at high risk of requiring CSF diversion. Until now, no study analyzed the role of ETV in children with high mCPPRH scores. Based on the findings from this study, the authors will change their practice.

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The authors sought to evaluate the efficacy of hemispherectomy in pediatric epilepsy at their center and determine whether contralateral MRI abnormalities can predict seizure recurrence. This study is important as it will help guide surgical decision-making in children with intractable epilepsy.

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Authors of this study evaluated functional outcomes in 2-year-old infants treated for posthemorrhagic hydrocephalus at prematurity, using variables present at the time of the initial neurosurgical consult. They attempted to identify the predictors of functional outcomes that were present early in the disease process, which may aid with family discussions and clinical decision-making.

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This study evaluated the performance of North American pediatric neurosurgeons in health care transition and made suggestions regarding how to improve transitional care through both individual and organizational efforts.

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Keeping patients warm in the perioperative phase of care is unambiguously beneficial. However, operating room culture and ergonomics have functionally impeded implementation of protocols aimed at maintaining perioperative euthermia. In this study, the authors demonstrated the efficacy of an ergonomically acceptable protocol that prevents more than 90% of the perioperative hypothermia burden imposed by the current standard of care.

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In this study, the authors investigated the normal course of fusion and the prevalence of early fusion of the sagittal, coronal, lambdoid, and metopic sutures. Importantly, the data demonstrated that fusion of the sagittal suture occurs more commonly than generally thought, including in children with normal head shapes. They also demonstrate that the coronal suture normally starts to fuse inferiorly during the 2nd decade of life.

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The authors studied how hydrocephalus (increased fluid in the brain) causes inflammation within the brain. They used a genetic model of hydrocephalus and biochemical and histological tests to measure inflammation and tissue injury. The results show that hydrocephalus causes inflammation and white matter injury. These results highlight that, while inflammatory events such as hemorrhage can cause hydrocephalus, hydrocephalus itself can also cause inflammation.

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In total, the authors describe 5 published approaches to selective dorsal rhizotomy (SDR), ranging from multilevel laminectomies to laminotomy and foraminotomy approaches. They assess the technical nuances, benefits, and limitations of each of these techniques with regard to bony exposure, identification of nerve roots, and technical difficulty. The operative approach to SDR currently performed at the Hospital for Sick Children in Toronto is also illustrated in detail.

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The authors’ study provides long-term outcomes data on pediatric AVM patients treated with stereotactic radiosurgery. The study was derived from the largest multicenter observational cohort database, and it provides the best estimates of outcomes and complications in the pediatric population. The authors believe that these estimates will serve as important counseling information for patients and families.

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The researchers measured dural sinus volumes in children with syndromic craniosynostosis with and without intracranial hypertension. They found that children with intracranial hypertension had larger volumes in the straight sinus. These findings are a piece of the puzzle in understanding the pathophysiology of intracranial hypertension in craniosynostosis.

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The authors analyzed patients who required intervention for a pseudomeningocele—an abnormal collection of cerebrospinal fluid in the brain—after a craniotomy or craniectomy and found statistically significant associations of race and use of a dural patch graft (i.e., duraplasty) with the need for intervention. This study is important because a pseudomeningocele, especially in pediatric patients, does not always resolve on its own. To the authors’ knowledge no previous studies have examined risk factors associated with the need for pseudomeningocele treatment.

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In a large retrospective review study, the authors assessed the prevalence and severity of asymmetry of the pediatric skull associated with positional posterior plagiocephaly (PPP) and patient age in 1429 pediatric patients (2 months to 18 years old). The results demonstrated that PPP is prevalent in the pediatric population, most commonly presenting as mild asymmetry, and prevalence and severity decrease with increasing patient age, with no patients in the cohort having severe asymmetry that persisted into adolescence.

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The authors describe the use of recombinant human bone morphogenetic protein (BMP) in children with trisomy 21 and atlantoaxial instability during cervical spine revision to treat nonunion. The ability to obtain fusion in these children is based on both sound biomechanical principles of fixation and optimizing the biologic environment. Rigid fixation ensures proper biomechanics, while the use of BMP optimized the ability to form bone in these patients who have a propensity to develop nonunions.

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Validation of a useful classification system of spinal lipomas, which the authors have done here, will enable clinicians to improve patient selection and discussion with patient representatives during the decision-making process.

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The authors used noninvasive preoperative CT perfusion to assess dynamic imaging of pathological hemispheres in pediatric patients with moyamoya disease. By comparing CT perfusion parameters in the diseased hemisphere with those in the normal hemisphere, they found that CT perfusion can be predictive of the angiographic severity of the disease to identify candidates for cerebral revascularization.

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Providing skin closure for open myelomeningocele skin defects, especially large defects, can be very challenging. Many of the current techniques employed to provide skin closure can result in excessive tension on the skin, which affects local blood supply and leads to a high rate of wound healing challenges. The abdominal reapproximation anchor (ABRA) system is a traction device developed for open wounds with retracted skin defects, allowing progressive traction with chronic cyclic tension to provide sound delayed primary closure and showing in the plastic surgery literature its effectiveness in place of skin grafting.

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The authors studied the clinical, analytical, and evolutionary characteristics of preterm infants with posthemorrhagic hydrocephalus to investigate risk factors that contribute to morbidity and thus find strategies to improve the prognosis and management of these infants. This study offers important knowledge about the management and characteristics of posthemorrhagic hydrocephalus in preterm infants and attempts to predict which of them will require ventriculoperitoneal shunting.

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The authors investigated the comprehensive cost of the 1st year of surgical treatment for patients with metopic, coronal, and lambdoid synostosis, comparing traditional open cranial vault remodeling and endoscope-assisted techniques. This study demonstrates a significant difference between the costs of these treatment approaches and adds an important practical perspective to the craniosynostosis literature, especially regarding nonsagittal synostosis, which is less commonly treated endoscopically.

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The authors conducted an exploratory study of the safety and efficacy of endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in Haitian infants with hydrocephalus. This is the first systematic study of outcomes for the endoscopic treatment of infantile hydrocephalus in Haiti and demonstrates the feasibility of ETV/CPC in the nation. Ultimately, the paper underscores the importance of continuing and maintaining hydrocephalus capacity–building efforts in low- and middle-income countries such as Haiti.

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The authors studied the components to effective helmet policies. The results of this study are important for primary prevention of traumatic brain injury, especially in low- and middle-income countries.

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The authors attempted to determine if cerebral blood flow (CBF) in children with syndromic craniosynostosis (sCS) is different than that of control subjects. It is important to determine what the effect of the syndrome is on CBF, the effect of cranial vault surgery on CBF, and to provide insight into the role of CBF in the complex dynamics of intracranial hypertension (ICH). This insight is important to create the tools to manage and prevent ICH in children with sCS.

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This study is important because it is the first and largest case series dedicated to evaluating the safety and efficacy of halo-gravity traction (HGT) for various cervical spine deformities that develop in children. The authors provide recommendations and describe their experience at a large tertiary referral center that specializes in preoperative HGT in children.

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The results of this study indicate that barbiturate coma can be an effective means of lowering intracranial pressure without causing concomitant severe side effects in children with refractory intracranial hypertension due to traumatic brain injury, followed by a good long-term outcome. To the authors’ knowledge only one article has so far been published covering this topic.

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Irrigation during intraventricular endoscopic surgery is critical for visualization, with normal intracranial pressure maintained by inexact balancing of fluid ingress and egress. The authors have developed a rate-controlled, foot pedal–activated system for precise intraventricular irrigation by using a standard irrigating bipolar electrocautery machine. In 19 consecutive surgeries, this single-operator approach provided good visualization of all intraventricular structures, with no perioperative complications. This easily adapted system improves on standard irrigating protocols for endoscopic intraventricular surgery.

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Through high-resolution pictures illustrating the white matter anatomy, the authors describe in detail the white matter tracts sectioned during each step of the anterior peri-insular quadrantotomy, a procedure thought to isolate epileptogenic foci in the frontal lobe for the treatment of refractory epilepsies. This study is important because precise knowledge of the microsurgical and white matter anatomy is essential for safe performance of this surgery while attaining the aim of a complete disconnection and ensuring the highest chance of seizure freedom in pediatric patients with intractable anterior quadrant epilepsy.