Journal of Neurosurgery: Pediatrics
Volume 33: Issue 6 (Jun 2024)

Figure from Huang et al. (pp 574–582).

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The identification of the H3K27M histone mutation in pontine and thalamic gliomas led to their recent reclassification in the 2021 WHO CNS Brain Tumor Classification as a new molecularly defined entity, diffuse midline gliomas (DMGs), H3K27-altered. 1 The resulting tsunami of basic science insights into disease pathogenesis and the improved safety profile of stereotactic biopsies have led to the initiation of several molecularly guided and immunotherapy-based clinical trials. 2–4

Yet should breakthrough treatments fail to reach the 300–400 patients who are diagnosed with DMGs annually, the field will fail to achieve its overarching goal of

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In Brief

Given the limited treatments and poor prognosis for diffuse midline gliomas (DMGs) and diffuse intrinsic pontine gliomas (DIPGs), socioeconomic status (SES) may impact treatment access and survival. This study revealed that patients from higher income families had longer overall survival and traveled more for treatment. Similarly, families with higher educational attainment traveled more for treatment. These findings suggest that SES influences DMG/DIPG outcomes; recognition of these treatment disparities may aid in equitable care moving forward.

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Researchers examined adaptive, social, and behavioral functioning among survivors treated for pediatric medulloblastoma with and without a history of postoperative cerebellar mutism syndrome (CMS). Survivors with a history of CMS demonstrated worse adaptive functioning with notable practical skill deficits several years posttreatment relative to survivors without a history of CMS. The findings demonstrate risk for ongoing functional deficits among survivors who experienced CMS, with implications for psychoeducation during treatment and screening for intervention needs in survivorship.

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In Brief

This study aimed to systematically analyze the distribution of pediatric brain tumor (PBT) types in sub-Saharan Africa (SSA). Glioma not otherwise specified was the most common PBT in the 4 SSA regions combined. However, medulloblastoma was more commonly reported in Southern SSA while the highest proportion of craniopharyngioma was in Western SSA. These findings provide insight into the trends of PBT types and the proportion of the top 3 common tumors across SSA.

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In Brief

Researchers retrospectively collected data from a single-center cohort of children with brain tumors invading or adjacent to CSF circulation pathways to analyze risk factors for a ventriculoperitoneal shunt within 6 months after tumor surgery. Medulloblastoma, lateral/third ventricle tumors, postoperative lateral/third ventricle hematoma, and the presence of a subdural hygroma in the nonoperated area within 48 hours after surgery were risk factors. Subdural hygroma, a newly discovered variable, indicating that it impaired CSF circulation, is worthy of further investigation.

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Anatomical, clinical, and radiographic characteristics associated with hydrocephalus development are presented for prenatally and postnatally treated myelomeningocele patients. The need for hydrocephalus treatment was associated with an increased fetal ventricle size, the postnatal frontal-occipital horn ratio (FOHR), and the mean rate of head circumference change. Hydrocephalus treatment occurred later in patients with prenatal repair, smaller heads, and lower FOHRs at birth. This has implications for follow-up timing for prenatally treated patients, who may live distant from their treatment site.

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In Brief

Differences in head growth and myelomeningocele-specific head circumference (HC) growth curves for patients who underwent prenatal and postnatal surgery are presented. Those repaired prenatally had larger HCs compared with the general population and those repaired postnatally. HC measurements of prenatal repair patients could be modeled well for myelomeningocele patients with hydrocephalus, whereas those of postnatal repair patients could not, potentially indicating different mechanisms of hydrocephalus development.

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In Brief

This study assessed the efficacy of inserting ventriculoperitoneal (VP) shunts earlier, at lower weights, in premature infants. Placement of VP shunts at lower weights did not negatively impact shunt survival outcomes. The authors provide evidence of a new low-weight threshold for VP shunt insertions in low-birth-weight infants.

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OBJECTIVE

Craniovertebral junction (CVJ) abnormalities are common and well documented in mucopolysaccharidosis type I–Hurler syndrome (MPS IH), often causing severe spinal canal narrowing. However, the requirement for surgical decompression and/or fusion is uncommon. Although hematopoietic cell transplant (HCT) has been shown to prolong the lives of patients with MPS IH, its effect in halting or reversing musculoskeletal abnormalities is less clear. Unfortunately, there are currently no universal guidelines for imaging or indication for surgical interventions in these patients. The goal of this study was to track the progression of the CVJ anatomy in patients with MPS IH following HCT, and to examine radiographic features in patients who needed surgical intervention.

METHODS

Patients with MPS IH treated at the University of Minnesota with allogeneic HCT between 2008 and 2020 were retrospectively reviewed. Patients who underwent CVJ surgery were identified with chart review. All MPS IH cervical scans were examined, and the odontoid retroflexion angle, clivoaxial angle (CXA), canal width, and Grabb-Oakes distance (pB-C2) were measured yearly for up to 7 years after HCT. Longitudinal models based on the measurements were made. An intraclass correlation coefficient was used to measure interrater reliability. Nine children without MPS IH were examined for control CVJ measurements.

RESULTS

A total of 253 cervical spine MRI scans were reviewed in 54 patients with MPS IH. Only 4 (7.4%) patients in the study cohort required surgery. Three of them had posterior fossa and C1 decompression, and 1 had a C1–2 fusion. There was no statistically significant difference in the spinal parameters that were examined between surgery and nonsurgery groups. Among the measurements, canal width and CXA varied drastically in patients with different neck positions. Odontoid retroflexion angle and CXA tended to decrease with age. Canal width and pB-C2 tended to increase with age.

CONCLUSIONS

Based on the data, the authors observed an increase in canal width and pB-C2, whereas the CXA and odontoid retroflexion angle became more acute as the patients aged after HCT. The longitudinal models derived from these data mirrored the development in children without MPS IH. Spinal measurements obtained on MR images alone are not sufficient in identifying patients who require surgical intervention. Symptom monitoring and clinical examination, as well as pathological spinal cord changes on MRI, are more crucial in assessing the need for surgery than is obtaining serial imaging.

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In Brief

The authors aimed to identify factors associated with fusion success among pediatric patients undergoing occiput-C2 rigid instrumentation and fusion. Fusion failure was seen in 38% of patients, a higher rate than previously reported in the literature. Additionally, the authors' findings suggest that postoperative immobilization in a rigid cervical collar may be beneficial and the use of structural rib autograft should be considered, as it was associated with a 75% greater chance of successful fusion.

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CSF shunt infections caused by gram-negative bacteria are difficult to treat given the limited treatment options and the emergence of carbapenem-resistant strains. In this study, the authors evaluated the characteristics of children with CSF shunt infections caused by gram-negative bacteria to identify the risk factors for acquiring carbapenem-resistant infections. Clinicians should be aware of carbapenem resistance in patients with risk factors such as a prolonged hospital stay > 7 days and prior carbapenem treatment.

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The authors present neurocognitive outcomes and associated clinical factors 5 years after craniofacial surgery in children with craniosynostosis. This study demonstrated favorable neurocognitive outcomes after minimally invasive strip craniectomy across various types of synostosis. Age at assessment, increased intracranial pressure, and maternal education level were significantly correlated with neurocognitive outcomes. This study provides important clinical information to neurosurgeons involved in craniofacial surgical procedures.

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Researchers used a novel, rapid, and minimally invasive capillary blood collection technique to identify a blood protein signature to predict children at risk of persisting posttraumatic headache (PTH) at 2 weeks postinjury. A total of 907 proteins were reproducibly identified from 82 children at emergency department presentation within 48 hours of concussion. While HBZ, CSTB, CNDP1, HBG1, and ZYX were weakly associated with PTH at 2 weeks postinjury, there was no specific blood protein signature predictor of PTH in children after concussion.

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In Brief

Spanish speakers have higher rates of unfavorable neurosurgical outcomes; however, no study has explored the experiences of individuals receiving or delivering neurosurgical care in language-discordant settings. In this qualitative study, the authors identified challenges faced by pediatric neurosurgery providers and Spanish-speaking parents communicating across a language barrier, including a desire for opportunities to ask questions and engage in care, for additional educational resources, and for more in-person interpreters. The authors propose solutions to address these challenges.

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From a young age, I have always loved books. Growing up, I favored mystery novels and epic sagas of heroic protagonists, but as I have gotten older, my focus has deviated toward nonfiction with medical sciences, human interaction and communication, and especially biographies of standout people with fascinating, remarkable pinnacles they have achieved. If there is a type of nonfiction story that I enjoy most, though, it is that of the underdog and the comeback. This is the story of my life and how I went from being a baby born with left-sided shoulder dystocia to (almost) a

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In Brief

The authors aimed to identify a potential association of COVID-19 infection, known to induce a hypercoagulable state, and ventriculoatrial (VA) shunt complications in pediatric patients with hydrocephalus. Patients with VA shunts had a higher risk for mechanical shunt complications during the year following a positive COVID-19 test. These results aid in considerations for the clinical management of complex hydrocephalus in patients with VA shunts following the COVID-19 pandemic.

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In Brief

The objective of this study was to describe the technique of focal selective dorsal rhizotomy, which can be combined with orthopedic deformity correction. The authors discussed the rationale for the use of this procedure and the outcomes in a preliminary cohort of 10 patients. Primary outcome measures of the modified Ashworth scale and Gait Deviation Index both improved in this cohort. The authors conclude that while further investigation is needed, this is a promising new procedure to focally reduce tone in children with spasticity.

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In Brief

Researchers investigated the role of genetic mutations on behavior in children with surgically corrected sagittal synostosis. Children with high probability of loss of function intolerant (pLI) genes had greater difficulties with aggression and externalizing problems. For children with nonhigh pLI genes, older age at surgery was associated with worse behavior. Genetics may play a role in long-term behavioral outcomes, however timing of surgical intervention may be a greater predictor for children without such genes.

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TO THE EDITOR: I have read with great interest the article by Holste et al. 1 (Holste KG, Vernamonti J, Bah MG, et al. Ventriculoatrial and ventriculoperitoneal shunt malfunction and infection in infants with necrotizing enterocolitis. J Neurosurg Pediatr. 2023;32[5]:590-596). The authors are to be congratulated for describing in precise detail the issues that relate to the complexity in managing these infants.

Another management alternative, ventriculogallbladder (VGB) shunt placement, has been previously reported in the described setting. 2,3 The advantages of VGB shunt placement are that it shows efficacy as a form

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In Brief

Researchers conducted a multicenter diffusion tensor imaging study to investigate white matter microstructural abnormalities in children with spastic cerebral palsy who underwent selective dorsal rhizotomy (SDR). Alterations in white matter diffusion properties were identified in the brain in association with gross motor function and spasticity. The findings may help clinicians to better identify surgical candidates based on the pre- to post-SDR white matter changes and their potential correlation with improvement in post-SDR spasticity and motor functions.

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In Brief

Researchers used a novel technique for cranial cervical fusion utilizing a patient's own rib and recombinant bone growth factor. The authors showed that this technique provided a very high rate of fusion with no increase in complications. This research is significant because this high rate of fusion is higher than in other published articles, potentially providing a way to minimize the need for additional surgical procedures in patients who need this surgery.

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In Brief

The researchers evaluated proposed prediction tools for ruling out cervical spine injury (CSI) in young children with blunt trauma. While neither score perfectly predicted the need for advanced imaging, these tools may complement clinical judgment and inform objective pediatric CSI assessment.

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In Brief

Endoscopic third ventriculostomy (ETV) can be a viable alternative to ventriculoperitoneal shunting for CSF diversion. The ETV Success Score can help guide the decision between the two. At times, patients with low ETV Success Scores are recommended to undergo ETV nonetheless, with the hope of attaining a shunt-free life. The impact of this decision, if the patient experienced ETV failure and required ventriculoperitoneal shunting, is elucidated in this article by studying the downstream effects of ETV failure on subsequent shunt complication rates.

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In Brief

The Hospital del Niño "Dr. Ovidio Aliaga Uria," La Paz, Bolivia, is the only publicly funded pediatric hospital that offers neurosurgery to the region. The authors conducted the first audit of the inpatient outcomes within the neurosurgery department and report a limited capacity for a growing population with increasing reliance on universal healthcare. To improve capacity and outcomes, institution- and country-specific interventions need to be considered.

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In Brief

The objective of this study was to examine national trends of pediatric cerebral arteriovenous malformation care and to assess the effect of hospital volume on outcomes. Endovascular care was more prevalent at high-volume hospitals, and higher volume correlated with several better outcomes, particularly when children undergo intervention. Additionally, patients from higher-income quartiles were more likely to be treated at high-volume hospitals, indicating that access to appropriate treatment for all races and socioeconomic classes must be a focus.

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TO THE EDITOR: Mamaril-Davis et al. 1 analyzed the association of subdural hemorrhage, retinal hemorrhage, and fracture with the diagnosis of child abuse in early childhood based on data from the trauma registry of their institution (Mamaril-Davis JC, Riordan K, Sumdani H, et al. Subdural hematoma, retinal hemorrhage, and fracture triad as a clinical predictor for the diagnosis of child abuse. J Neurosurg Pediatr. 2024;33[2]:142-148). There are grossly misleading errors in their calculations of test statistics.

Sensitivity is the capacity of a diagnostic test to detect a target condition. Arithmetically, it is the ratio of

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In Brief

The authors retrospectively reviewed a 35-year cohort of children who received treatment for a cerebellar pilocytic astrocytoma and determined that children receiving multiple resections were more likely to receive adjuvant chemo/radiotherapy and to experience more complications of therapy. Therefore they conclude that residual disease in patients with cerebellar pilocytic astrocytoma should be maintained under clinicoradiological surveillance postoperatively, with adoption of a more conservative approach when residual disease is not significantly changing over time.

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Traumatic brain injury (TBI) is a potentially life-altering or life-ending condition that affects individuals of all ages and walks of life. There is emerging evidence in the adult TBI literature to suggest that biomarkers have the potential to both refine management and predict outcomes. By contrast, pediatric TBI research lags notably behind, largely due to ethical and logistical difficulties in conducting high-quality clinical research in this cohort. Furthermore, children are a developmentally dynamic population, which adds additional complexities to both bench and clinical research. This review summarizes the recent updates in the field of pediatric TBI research and

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TO THE EDITOR: I read with special interest the paper by Mortazavi et al. 1 about the clinical, radiographic, and treatment-related differences between pediatric and adult patients with Chiari malformation type I (Mortazavi A, Almeida ND, Hofmann K, et al. Multicenter comparison of Chiari malformation type I presentation in children versus adults. J Neurosurg Pediatr. Published online February 23, 2024. doi:10.3171/2023.12.PEDS22366). The study provides valuable insights about the similarities and differences in these patients. After a thorough reading, I believe there are some key elements that it would be valuable to comment on.

Interestingly, the

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In Brief

Researchers assessed how sport type affects recovery time following concussive and nonconcussive head injury in adolescent athletes, measured by days and games missed. Results showed that football players generally missed fewer days and games postconcussion than those in other sports, hinting at differences in return-to-play protocols and concussion attitudes. Highlighting the intricate link between sport type and recovery, the research underscores the need for customized concussion management strategies, contributing to safer, individualized treatment in youth sports.

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In Brief

The objective of this study was to develop a multicenter consensus on an optimal treatment and monitoring algorithm for normocephalic children who may have a prematurely fused sagittal suture. Through the Delphi method, surgery was not recommended in patients older than 18 months without signs or symptoms of intracranial pressure elevation. However, for children younger than 18 months, a shared decision-making process should be utilized. This novel algorithm combined the expertise of 19 surgeons to guide diagnosis and indications for operative management, with the goal of reducing neurocognitive complications as well as unnecessary exposures to general anesthesia and complex operations.

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In Brief

Researchers sought to determine if pediatric patients with moyamoya and a history of brain tumors can ungergo successful revascularization and whether that revascularization adds greater risk of tumor recurrence. Revascularization successfully engrafted and did not appear to increase the risk of tumor recurrence. These findings will help clinicians and affected families to better understand treatment options and risks in this population.

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OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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TO THE EDITOR: Pediatric traumatic spinal cord injury (TSCI) poses a significant challenge, gravely affecting the neurodevelopmental progression of affected children. Recent comprehensive meta-analyses have revealed a stark disparity in the prevalence and impact of pediatric TSCI, with low- and middle-income countries (LMICs) facing a disproportionately higher burden than their high-income counterparts. 1,2 These findings highlight the critical need for advanced healthcare systems, particularly those with specialized capabilities for managing pediatric TSCI. While Sandhu et al. 3 observed that insurance status in the United States does not independently determine the utilization and outcomes of healthcare resources

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In Brief

The authors used bihemispheric repetitive navigated transcranial magnetic stimulation (rnTMS) language mapping to examine children with cerebral language-associated tumors/lesions and calculated a hemispheric dominance ratio (HDR) to assess language lateralization. In their cohort, they observed that children with bilateral language involvement (HDR 90%-110%) or right hemispheric language dominance (HDR < 90%) showed no new language deficits postoperatively. Bihemispheric rnTMS language mapping offers a promising alternative to invasive procedures such as the Wada test. However, its validity must be characterized in subsequent multicenter studies.

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In Brief

The authors retrospectively studied factors associated with 30-day mortality and functional outcomes at the latest follow-up in pediatric patients with intracranial gunshot wound injuries. Those who died were more likely to have initial Glasgow Coma Scale scores ≤ 8, bilateral fixed pupils, a transventricular trajectory, deep nuclear/third ventricle involvement, bihemispheric trajectory, international normalized ratio > 1.5, and a St. Louis Scale score ≥ 5. Compared to adults, a higher proportion of children with these devastating injuries appear to have better functional outcome at latest follow-up.

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In Brief

The aim of this study was to develop an in vitro model to test cellular adherence to shunt coatings. This was accomplished by successfully growing microglial cells on silicone discs with or without protein fouling. Traditional in vivo testing is exceptionally expensive, and this model has the potential to significantly reduce the financial barrier to materials testing.

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TO THE EDITOR: We are writing to express our appreciation for the article by Aum et al. 1 (Aum DJ, Reynolds RA, McEvoy SD, et al. Laser interstitial thermal therapy compared with open resection for treating subependymal giant cell astrocytoma. J Neurosurg Pediatr. 2024;33[1]:95-104). The authors adeptly explore the use of magnetic resonance–guided laser interstitial thermal therapy (MRgLITT) in treating subependymal giant cell astrocytomas (SEGAs) and compare it with open resection.

MRgLITT, a new, minimally invasive technology for the treatment of intracranial pathology, involves implanting a laser diode intracranially through a small hole in the

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In Brief

The goal of this study was to quantify the burden of overtriage of minor head injuries at a pediatric trauma center and to investigate geographic and social associations. That overtriage is prevalent was known from previous work, but these data suggest that social privilege and family expectations promote it. Social and psychological factors that lead to excessive treatment have received limited attention in the trauma literature.

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OBJECTIVE

Indirect revascularization is a common and effective treatment for pediatric moyamoya disease. However, in several cases postoperative angiogenesis is not sufficient. It is not fully understood which factors are involved in the development of postoperative collateral circulation. In this study, the authors aimed to elucidate the factors related to postoperative angiogenesis in indirect revascularization.

METHODS

Among the patients who underwent indirect revascularization for moyamoya disease from January 2015 to December 2022, those whose angiogenesis was evaluated using angiography were included. Age, onset symptoms, comorbidities, preoperative imaging findings, surgical details, perioperative complications, postoperative imaging findings, and modified Rankin Scale (mRS) score at the last outpatient visit were retrospectively examined.

RESULTS

Ninety cases (53 patients; 37 bilateral, 16 unilateral) were included. Sixty-eight cases (75.6%) were symptomatic. The mean age at surgery was 7.9 years, and the mean postoperative follow-up duration was 48.5 months. Frontotemporal encephalo-duro-arterio-synangiosis (EDAS) was performed in all cases, and simultaneous frontal encephalo-galeo-synangiosis (EGS) was performed in 34 cases. Postoperative angiography revealed insufficient angiogenesis in 14 of 90 cases (15.6%) after frontotemporal EDAS and in 8 of 34 cases (23.5%) after frontal EGS. A high degree of ivy sign depicted on preoperative MRI was found to be significantly correlated with good angiogenesis after both surgical procedures (p = 0.00030 for EDAS and p = 0.0039 for frontal EGS). In addition, an advanced preoperative Suzuki stage was significantly correlated with good postoperative angiogenesis after EDAS (p = 0.00040). Good angiogenesis was significantly correlated with postoperative improvement of the ivy sign in both procedures (p = 0.0005 in EDAS and p = 0.030 in frontal EGS) as well as correlated with a better mRS score at long-term follow-up after EDAS (p = 0.018).

CONCLUSIONS

Preoperative ivy sign and Suzuki classification are related to the degree of angiogenesis achieved after indirect revascularization for pediatric moyamoya disease.

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OBJECTIVE

Chiari malformation type I (CM-I) is a congenital disorder occurring in 0.1% of the population. In symptomatic cases, surgery with posterior fossa decompression (PFD) is the treatment of choice. Surgery is, however, associated with peri- and postoperative complications that may require readmission or renewed surgical intervention. Given the associated financial costs and the impact on patients’ well-being, there is a need for predictive tools that can assess the likelihood of such adverse events. The aim of this study was therefore to leverage machine learning algorithms to develop a predictive model for 30-day readmissions and reoperations after PFD in pediatric patients with CM-I.

METHODS

This was a retrospective study based on data from the National Surgical Quality Improvement Program–Pediatric database. Eligible patients were those undergoing PFD (Current Procedural Terminology code 61343) for CM-I between 2012 and 2021. Patients undergoing surgery for tumors or vascular lesions were excluded. Unplanned 30-day readmission and unplanned 30-day reoperation were the main study outcomes. Additional outcome data considered included the length of hospital stay, 30-day complications, discharge disposition, and 30-day mortality. Training and testing samples were randomly generated (80:20) to study the 30-day readmission and reoperation using logistic regression, decision tree, random forest (RF), K-nearest neighbors, and Gaussian naive Bayes algorithms.

RESULTS

A total of 7106 pediatric patients undergoing PFD were included. The median age was 9.2 years (IQR 4.7, 14.2 years). Most of the patients were female (56%). The 30-day readmission and reoperation rates were 7.5% and 3.4%, respectively. Headaches (32%) and wound-related complications (30%) were the most common reasons for 30-day readmission, while wound revisions and evacuation of fluid or blood (62%), followed by CSF diversion-related procedures (28%), were the most common reasons for 30-day reoperation. RF classifiers had the highest predictive accuracy for both 30-day readmissions (area under the curve [AUC] 0.960) and reoperations (AUC 0.990) compared with the other models. On feature importance analysis, sex, developmental delay, ethnicity, respiratory disease, premature birth, hydrocephalus, and congenital/genetic anomaly were some of the variables contributing the most to both RF models.

CONCLUSIONS

Using a large-scale nationwide dataset, machine learning models for the prediction of both 30-day readmissions and reoperations were developed and achieved high accuracy. This highlights the utility of machine learning in risk stratification and surgical decision-making for pediatric CM-I.

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In Brief

Responsive neurostimulation (RNS) serves as a neuromodulatory intervention conventionally applied in the management of focal epilepsy characterized by ≤ 2 cortical foci. Patients manifesting multifocal or regionally initiated seizures may derive potential benefits through the strategic utilization of thalamocortical connections for the dispersion of the modulatory signal. Within the confines of this investigation, the authors systematically scrutinized a cohort of such individuals who underwent RNS targeting thalamic nuclei, revealing that nearly 50% experienced notable clinical seizure reduction subsequent to intervention. This discernible outcome unfolds a promising trajectory in the realm of therapeutic approaches for refractory epilepsy.

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This study aimed to analyze the association between ventricular catheter (VC) tissue obstructions and shunt malfunction in 9 hydrocephalus etiologies. Posthemorrhagic hydrocephalus was the most common etiology. Proximal VC obstruction was the most frequent cause of failure and was accompanied by tissue aggregates in more than 75% of the studied cases. The presence of tissue in the VC did not seem to be associated with hydrocephalus etiology.

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In Brief

Researchers aimed to identify key clinical and socioeconomic factors associated with shunt failure in patients presenting to pediatric emergency departments (EDs). Enlarged ventricles, lethargy, and bradycardia were positively linked to the need for shunt revision, whereas seizures were significantly associated with not requiring shunt revision. Socioeconomic status had a less definitive role. Analyzing these variables may enable more effective patient prioritization and resource allocation for shunt evaluation in the pediatric ED.

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In Brief

A systematic review examined social determinants of health (SDOH) in children with drug-resistant epilepsy to understand factors influencing time to pediatric epilepsy surgical program referral or receipt of epilepsy surgery. Eighteen studies were included. Patients who underwent surgical evaluation and/or surgery were most commonly non-Hispanic White and privately insured, with higher household income and college-educated caregivers. The authors highlight SDOH influences on access to pediatric epilepsy surgery, which point to future directions toward health equity.

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In Brief

The authors performed a systematic review and contributed 2 cases of their own to try to gain insight into indications, complications, and outcomes for concurrent spinal instrumentation and intradural procedure. Overall, the addition of spinal instrumentation is safe (i.e., low risk of CSF leakage, new neurological deficit, spinal instrumentation failure, and effect on adjuvant radiotherapy). However, the authors' experience shows a definable rate of risk, and thorough consultation with patients and parents is warranted.

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In Brief

Researchers sought to identify the association and potential impact of developmental anomalies involving the occipital condyles and atlas vertebra on instrumentation outcomes following posterior fossa decompression (PFD) in pediatric patients with Chiari type I malformation and syringomyelia. The authors identified condylar hypoplasia as an independent predictive factor for occurrence of fusion following PFD. Atlas anomalies were more likely to present in patients who underwent fusion following PFD. Preoperative identification of these skeletal abnormalities may guide surgical planning in CM-I with coexistent osseous pathology.

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In Brief

The etiology and pathophysiology of Chiari malformation type I remain unclear and continue to contribute to innumerable controversial discussions. In an attempt to elucidate a possible etiology for CM-I, evaluating how children with CM-I compare with adults with the condition could potentially offer clues to the source and significance of their respective tonsillar herniation. This study demonstrated that there are clear differences between adults and children, and it is likely that adult patients are presenting with a more complex and very different condition.