The natural course of mild and moderate prenatal ventriculomegaly has been widely reported. The authors retrospectively studied 122 pregnancies with mild or moderate ventriculomegaly between 2010 and 2018. Lateral ventricle dilation was stable or regressed in serial ultrasound studies in most patients with mild or moderate ventriculomegaly. Most cases had near-normal neurodevelopmental status. Due to the lack of sufficient data regarding the natural course, neurodevelopmental status, and prognosis of prenatal ventriculomegaly, the authors were interested in performing a study to find some answers to these questions. More prospective studies with larger sample sizes are needed to obtain more reliable results.
Ángela Ros-Sanjuán, Sara Iglesias-Moroño, Bienvenido Ros-López, Francisca Rius-Díaz, Andrea Delgado-Babiano, and Miguel Ángel Arráez-Sánchez
Researchers used the Health Outcome Questionnaire (HOQ)–Spanish version to describe the health status of pediatric patients with hydrocephalus treated by endoscopic third ventriculostomy and to identify factors related to worse status. Possible factors related to worse outcomes were the presence of epilepsy, a prior valve, many surgical procedures, and communicating or secondary hydrocephalus. This study helps to identify clinical factors to address to improve the quality of life in pediatric patients, and use of the HOQ scale allows one to evaluate their evolution in an objective way and compare the health status between different populations.
Andrew Reisner, Alexis D. Smith, David M. Wrubel, Bryan E. Buster, Michael S. Sawvel, Laura S. Blackwell, Nealen G. Laxpati, Barunashish Brahma, and Joshua J. Chern
The authors examined the utility of ventriculogallbladder (VGB) shunts in a series of children with hydrocephalus resulting from intraventricular hemorrhage related to extreme prematurity. VGB shunts can serve as a definitive treatment or as a bridge procedure until the patient is larger and comorbid abdominal or vascular issues have resolved sufficiently to allow conversion back to ventriculoperitoneal or ventriculoatrial devices. VGB shunts should be considered earlier in the treatment of this difficult-to-manage group with hydrocephalus related to extreme prematurity.
Michael D. White, Michael M. McDowell, Nitin Agarwal, and Stephanie Greene
The authors sought to characterize the long-term rates of shunt infection and malfunction in myelomeningocele (MMC) patients before and after adoption of the Hydrocephalus Clinical Research Network (HCRN) standardized surgical protocols to reduce ventriculoperitoneal (VP) shunt infections. A 21% per person-year revision rate and 2.1% per person-year infection rate were determined in 137 patients with MMC and VP shunts, and both rates improved with adoption of the HCRN protocols. Shunt externalization prior to revision was found to be associated with a higher infection rate.
Cory McFall, Alexandra D. Beier, Kelsey Hayward, Emily C. Alberto, Randall S. Burd, Bethany J. Farr, David P. Mooney, Kristin Gee, Jeffrey S. Upperman, Mauricio A. Escobar Jr., Nicole G. Coufal, Helen A. Harvey, and Gerald Gollin
A multiinstitution study examined the management of open skull fractures in children. The incidence of infectious complications was low and was not associated with the antibiotic strategy or site of wound care. Most minimally contaminated open skull fractures are probably best managed with a short duration of a single antibiotic and emergency department closure is appropriate unless there is significant contamination or fragment elevation is necessary.
Lennart Riemann, Daphne C. Voormolen, Katrin Rauen, Klaus Zweckberger, Andreas Unterberg, Alexander Younsi, and the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Investigators and Participants
The aim of this study was to evaluate the prevalence of postconcussive symptoms and their relation to health-related quality of life in pediatric and adolescent patients with mild traumatic brain injury (mTBI) with an indication for head CT imaging. Postconcussive symptoms were present in up to one-third of the patients and were significantly associated with decreased health-related quality of life. The authors report a considerable prevalence of postconcussive symptoms in the rarely studied subgroup of young mTBI patients receiving head CT imaging.
Mohammed A. Fouda, Madeline Karsten, Steven J. Staffa, R. Michael Scott, Karen J. Marcus, and Lissa C. Baird
Researchers used a novel algorithm to determine the appropriate timing of intervention in the setting of recurrence/progression of pediatric craniopharyngioma with the aim of optimizing tumor control. An increase (%) in the maximum dimension of the tumor at the time of recurrence/progression can be used as a predictor of the appropriate timing of intervention. This will help neurosurgeons to determine the appropriate timing of intervention and avoid any unnecessary procedures.
Mitchell T. Foster, Dawn Hennigan, Rebecca Grayston, Kirsten van Baarsen, Geraint Sunderland, Christopher Paul Millward, Harishchandra Lalgudi Srinivasan, Deborah Ferguson, Teddy Totimeh, Barry Pizer, and Conor Mallucci
The researchers evaluated the usefulness and applicability of available neurosurgical morbidity scoring scales in a large cohort of pediatric brain tumors from a single center; their results were favorably comparable to those in the literature. An improved tool to quantify morbidity from pediatric neurooncology is necessary to enable comparative surgical and unit data and reporting.
Jason K. Chu, Peter A. Chiarelli, Nolan D. Rea, Norianne Pimentel, Benjamin E. Flyer, J. Gordon McComb, Susan R. Durham, and Mark D. Krieger
The authors identified preoperative clinical and radiographic risk factors for facial palsy after resection of commonly encountered pediatric posterior fossa tumors. The incidence of postoperative facial palsy can be as high as 20%, and recurrent operations and the presence of other preoperative cranial neuropathies were identified as significant risk factors in multivariate logistic regression analysis. These data can help to guide preoperative counseling when discussing the risks of surgery with patients and their families.
Researchers investigated phase-amplitude coupling of fast activity modulated by slow waves on scalp electroencephalography to evaluate the strength of the modulation index before and after disconnection surgery in children with intractable nonlesional epileptic spasms. A decreased modulation index value due to surgery correlates with good seizure outcomes. The modulation index may indicate epileptogenic neuronal modulation of the interhemispheric corpus callosum and intrahemispheric subcortical network for epileptic spasms.
Markus J. Bookland, Edward S. Ahn, Petronella Stoltz, and Jonathan E. Martin
The authors explored the feasibility of using image processing and machine learning algorithms to augment newborn cranial deformity screening, using 2D patient images. Machine learning algorithms, paired with image processing–based craniometrics, can classify orthogonal-view 2D images of the most common cranial deformity types with a high degree of accuracy. This study demonstrates the viability of software-based cranial deformity screening to augment current telehealth practices and reduce usage of expensive and radiation-intensive radiographic screening adjuncts.
Brandon W. Smith, Kate W. C. Chang, Hemant A. Parmar, Mohannad Ibrahim, and Lynda J. S. Yang
The diagnosis of a nerve root avulsion as an all-or-none phenomenon is troublingly simplistic. In this study, we demonstrated that there exists a large proportion of nerve root avulsions that include either the ventral rootlets or dorsal rootlets in isolation. These findings hope to bring to light the common presence of isolated dorsal or ventral avulsions for consideration during preoperative planning and surgical utilization of nerve roots.
Madeline B. Karsten, Steven J. Staffa, Craig D. McClain, Jennifer Amon, and Scellig S. D. Stone
This retrospective cohort study compares postoperative opioid use and clinical measures following selective dorsal rhizotomy between patients who received postoperative epidural analgesia and those who did not. Postoperatively, patients who received epidural analgesia required less systemic opioid use, had at least equivalent reported pain scores, and required less respiratory support. Given heightened concern for harmful effects of systemic opioids, these findings suggest an important strategy for limiting their use while maintaining pain control and potentially increasing safety.
Hypothalamic obesity is common among patients with craniopharyngioma. This study examined whether precise stereotactic radiosurgery reduces the risk of hypothalamic obesity in cases of craniopharyngioma with expected long-term survival. Our results revealed that precise radiosurgical dose planning can mediate the subsequent increase in BMI. There is every indication that meticulous Gamma Knife radiosurgery is an effective approach to treating craniopharyngioma while also reducing the risk of hypothalamic obesity.
In this study, the iPlan Flow software infusion simulation algorithm was evaluated for use in convection-enhanced delivery (CED) of drugs to the pediatric brainstem. The authors compared simulated outcomes with the actual radiolabeled infusion distribution and used similarity metrics to quantify the agreement between the actual and the estimated infusate distribution. The combined acceptance criteria were met for 8 of 10 evaluated patients, and based on this finding, the authors recommend the use of iPlan Flow software to optimize personalized CED treatment.
Pediatric neurosurgeons have a structured and well-thought-out philosophy and practice regarding intraoperative decision-making that encompasses a range of approaches including the following: doing no harm, cultivating self-awareness, and seeing the whole patient; and concrete practices such as preparing in advance for uncertainty, working on teams, and learning from experience. These philosophies and practices can be structured and codified in order to teach residents how to develop intraoperative judgment techniques.
Researchers evaluated the role of depression and anxiety, accompanied with or without antidepressant use, on the incidence of and recovery from concussion. Depression or anxiety with antidepressant use was associated with increased incidence of concussion and impaired symptomatic and neurocognitive recovery. The findings suggest that premorbid depression with antidepressant use may be a risk factor for concussion.
The objective of this paper was to determine the clinical benefit in performing outpatient imaging in the setting of pediatric mild traumatic brain injury (TBI). The key finding was that there is no clinical benefit to routine outpatient imaging in pediatric mild TBI, unless there is a clinical change. The imaging does not change the clinical course or the management except for leading to more unnecessary tests and imaging. A reduction in the unnecessary use of routine imaging will benefit patients and curb the waste of resources.
In this article, the authors outline the important contributions of Dr. William R. Cheek to the field of pediatric neurosurgery. As one of the early leaders of the field, he helped to establish its organizational and educational framework and founded the Division of Pediatric Neurosurgery at Texas Childrens Hospital. The authors honor his legacy by appreciating his contributions to the field and continuing to push pediatric neurosurgery forward for the good of patients.
Researchers used radiographic imaging, clinical evaluation, patient-reported outcomes, and formal urodynamics to investigate the safety and short-term efficacy of spinal column shortening as treatment for children and emerging adults with secondary tethered cord syndrome. In this series of 41 patients, spinal column shortening was found to be a safe procedure with promising short-term outcomes. Given these findings, this study emphasizes the importance of and justification for further research into long-term outcomes of spinal column shortening, particularly in children.
This is the largest published study of tethered cord surgery (TCS) among people with myelomeningocele. Objectives were to describe the temporal incidence of TCS and variance between institutions and test the hypothesis that tethering is related to longitudinal spine growth by comparing the relationship between sex-specific spine growth rates and TCS. The authors found no sex-specific differences in TCS timing. This challenges traditional concepts that tethering is solely related to longitudinal spine growth.
The overwhelming majority of literature on instrumentation to the pelvis in children focuses on nonambulatory cohorts. The objective of this study was to address the minimal literature on early complications following fusion to the sacrum with instrumentation to the pelvis in the era of sacral-alar-iliac instrumentation in ambulatory pediatric patients. Instrumentation to the pelvis in this patient population allows for powerful deformity correction with a 36.0% (9/25) complication rate within a mean follow-up period of 24.3 months.
The authors present their experience with responsive neurostimulation in pediatric patients at a single institution and review the indications, strategies, outcomes, and technical considerations for RNS System implantation in this population. They emphasize the compassionate-use indication for this device in pediatric patients. All 5 patients in the study experienced medium-term improvements in seizure control after RNS System implantation, with decreases in seizure frequency greater than 50% from the baseline preoperative seizure frequency. No adverse events were seen.
Indications and surgical technique selection for arachnoid cyst fenestration in children are mainly based on individually weighing risks and benefits. The authors identified rigorous virtual planning and the use of neuronavigation enhanced by augmented realty as key features for surgical treatment, and especially for neuroendoscopy. Thereby, the authors safely achieved effective volume reduction and symptom relief with a reasonable complication rate. Infants may represent a special group of patients, having a more complex course of treatment than older children.
Using data from 14 pediatric neurosurgical centers in the Hydrocephalus Clinical Research Network, researchers sought to compare shunt–based and endoscopic third ventriculostomy (ETV)–based treatment strategies for children with Dandy–Walker syndrome–related hydrocephalus (DWSH). Shunt–based and ETV–based primary treatment of DWSH were similarly durable and had similar rates of complications. A pediatric neurosurgeon may reasonably consider ETV–based treatment for DWSH.
The authors identified differentiating features between children and adults undergoing endoscopic removal of a colloid cyst. Consistent with their congenital nature, cysts in children (n = 9) were more frequently smaller, seldom resulted in hydrocephalus, were more commonly incidental, and did not result in acute deterioration or sudden death compared with cysts in adults (n = 119). These age disparities likely call into question the utility of currently available natural history information for children with colloid cysts.
The purpose of this study was to evaluate sleep-disordered breathing outcomes and the need for respiratory support following decompression in a pediatric population with Chiari malformation type I. Although obstructive and central apnea indices improved significantly following decompression, many subjects required long-term positive airway pressure therapy following surgery. Sleep-disordered breathing outcomes following decompression surgery will help inform surgical candidate selection, anticipatory guidance for children and families, and postoperative follow-up in patients with Chiari malformation type I who have sleep-disordered breathing.
The purpose of this study was to evaluate imaging parameters of children with Chiari malformation type I (CM-I) to identify factors that correlate with future surgical treatment. In a cohort of 731 patients evaluated for CM-I, 200 of whom had been treated surgically, the authors found that a lower tonsil position, CM-1.5 features, and the presence of congenital cervical fusion were associated with surgical treatment. This study stresses the importance of clinical and symptom evaluation in the surgical decision-making about CM-I.
Cerebral aneurysms are rare in children. This study sought to characterize the use of the Pipeline embolization device (PED) for treatment of pediatric aneurysms through a combined systematic literature review of patient-level data and multi-institutional retrospective experience. Despite substantial differences between pediatric and adult aneurysms, PED use in children appears to be safe with a short-term efficacy similar to that in adults. This study therefore adds to the growing literature supporting PED use in children.
The authors investigated the efficacy of posttetanic motor evoked potentials (MEPs) in pediatric neurosurgery patients. Tetanic stimulation of the pudendal nerve prior to transcranial electrical stimulation was found to augment the amplitude of MEPs during pediatric neurosurgery, and the effect on posttetanic MEPs after tetanic stimulation of the pure sensory branch of the pudendal nerve was stronger than that of the standard median and tibial nerves, which contain a mixture of sensory and motor fibers. Elicitation of pudendal nerve MEPs might be useful in pediatric patients in whom it is difficult to elicit conventional MEPs.
The authors sought to investigate what happens to unfused upper thoracic (UT) curves in adolescent idiopathic scoliosis patients after fusion of their primary curves. In 450 patients, the UT curve spontaneously improved 86% of the time and no patients had worsening. Larger preoperative main thoracic curve magnitude and greater main thoracic curve correction were associated with UT curve improvement. Patients with improved spontaneous UT curves had a mean improvement of 50%.
Researchers studied the basic clinical outcomes after pediatric intracerebral hemorrhage (pICH) using a large cohort study and metanalysis. They found that 1 in 6 children died after pICH and that the majority of children had residual neurological deficits at their latest follow-up. In the cohort study, the authors found younger age was associated with higher odds of death. This study sheds light on the functional prognosis of intracerebral hemorrhage in children.
The authors examined whether hospital ownership type and children's hospital designation impacted primary outcomes for pediatric neurosurgery patients. They found that freestanding children's hospitals may be the optimal setting for pediatric patients undergoing neurosurgery for accidental trauma. The federal government invests in children's hospitals to provide specialized clinical care to pediatric patients and valuable training experience to pediatric subspecialists. This study provides evidence that these investments measurably improve outcomes.
A group of experts conducted a modified Delphi study to identify best practices in pediatric cervical spine traction given the lack of evidence-based guidance in the literature. Consensus was reached on 49 best-practice recommendations spanning the utilization and implementation of traction for pediatric cervical trauma and deformity. These recommendations provide a foundation for clinicians to better incorporate cervical traction into their practices.
Hemispherotomy is a major procedure that involves a large craniotomy and significant morbidity. Here, the authors present the preliminary findings of 6 patients who underwent a new technique, robotic thermocoagulative hemispherotomy (ROTCH). This is a minimally invasive “bloodless” procedure. All patients had an International League Against Epilepsy class 1 outcome (except 1 patient with a class 2 outcome). Based on these results, ROTCH seems to be a promising and efficacious technique.
Wearable and portable electronics are rapidly becoming more numerous and mainstream. Many patients with programmable shunt valves either are subjected to strict restrictions or may be unsuspectingly exposing their valves to strong magnets. Ubiquitous smartphone magnetometer technology was shown to be effective at screening devices for safe use in proximity to programmable valves. This concept can be exploited to enhance patient quality of life and safety.
Clinical outcomes of patients undergoing shunt externalization were retrospectively reviewed to test the hypothesis that reimplantation with a ventriculoatrial shunt (VAS) rather than return to a ventriculoperitoneal shunt (VPS) is not associated with increased failure rate and may permit shorter externalization duration. There was no significant difference in shunt survival between patients with VASs and those with VPSs, although the externalization period was not shorter with VASs. Early conversion to a VAS may be a viable treatment option following shunt externalization.
The aim of this study was to evaluate a noninvasive biomarker (diffusion tensor imaging [DTI]) and establish its value as a predictor for the need of surgery for hydrocephalus in patients treated with prenatal repair of a myelomeningocele. DTI is an objective biomarker that significantly differentiates between prenatal myelomeningocele patients who need CSF diversion for hydrocephalus and those who do not. Ultimately, these results will help clinicians better evaluate and treat patients with myelomeningocele-associated hydrocephalus, thereby potentially avoiding the long–term neurocognitive ramifications of this lifelong condition.
The objective of this paper was to evaluate the clinical and hemodynamic benefits of an occipital artery–middle cerebral artery bypass for patients with pediatric moyamoya disease who had recurrent symptoms after initial revascularization. Cerebrovascular reactivity values in both middle cerebral artery and posterior cerebral artery territories are significantly improved, with clinical improvement after occipital artery–middle cerebral artery bypass despite progression of posterior cerebral artery stenosis in most patients. The occipital artery–middle cerebral artery bypass is an effective rescue therapy for cases of pediatric moyamoya disease.
The objective of this study was to compare the quality of imaging using EOS low-dose radiography to conventional radiography to evaluate peritoneal shunt tubing. The authors found that overall image quality and hardware delineation of EOS radiography did not significantly differ from conventional radiography for the evaluation of cerebral shunts. EOS appears to be a lower-cost and lower-radiation alternative to radiography for shunt evaluation.
The authors examined trends in the surgical treatment of pediatric hydrocephalus over an 8-year period and found that important changes in the treatment of this condition have occurred over a very short time frame. This work represents the first study using high-quality registry data to examine changes in the surgical care of pediatric hydrocephalus in North America.
In this study the authors compared the survival between pediatric patients with high-grade gliomas who underwent gross-total resection after one or more reoperations versus those with subtotal resection. The authors found that median overall survival was 17 months, and progression-free survival was 10 months for all patients. The authors also found no differences in survival between patients with gross-total resection after reoperation when compared with those who achieved subtotal resection. These findings highlight the importance of the first attempt to remove the tumor, because the second surgery aiming to achieve gross-total resection may not provide the patient with longer survival.
Using finite element modeling techniques, the authors investigated craniocervical biomechanics in a pediatric patient with Down syndrome (DS). Two age-matched models with identical material properties, one of a patient with DS and one of a child without DS, were created and tested. The authors found increases in craniocervical motion with the DS model, supporting the hypothesis that bony geometry plays a large part in the excessive craniocervical motion that occurs in DS patients and calling into question the role of ligamentous laxity.
The authors present a novel method of extraoperative stereoelectroencephalography (SEEG) monitoring complemented by subsequent intraoperative recordings, designed to tailor multistaged resections in rolandic and perirolandic cortex in a highly selected group of patients with pharmacoresistant rolandic and perirolandic focal epilepsy. The results testified to the feasibility and demonstrated the value of the combined benefits of both extra- and intraoperative SEEG recordings when resecting the rolandic and perirolandic areas. With the proposed novel hybrid method one can precisely limit the volume of resection necessary to abort epileptic activity while preserving the functional cortex as much as possible.
Intrinsic epidermoid tumors of the brainstem are rare, histologically benign lesions associated with a high surgical morbidity and mortality due to their eloquent location. The authors describe a novel technique of endoscope-assisted microsurgery for managing symptomatic lesions and recommend a strategy of conservative surgery with resection of as much of the tumor capsule as is safely possible.
This paper’s objective is to demonstrate a novel innovative approach to tissue-sparing hemispherotomy in patients with intractable hemispheric epilepsy without a lateral ventricle. The surgery successfully disconnected the pathologic hemisphere and the patient has been seizure free with significant improvement in achieving developmental milestones. This technique illustrates a surgical disconnection option with low morbidity for patients who would otherwise undergo a hemispherectomy with a higher risk of significant morbidity and mortality.