Journal of Neurosurgery: Pediatrics
Volume 33: Issue 4 (Apr 2024)

Figure from Barkley et al. (pp 359-366).

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In Brief

This study aimed to investigate correlations between the Wechsler Intelligence Scale for Children (WISC) and the Benton Visual Retention Test (BVRT) scores in children with moyamoya disease (MMD). BVRT scores were significantly correlated with full-scale intelligence quotient and Working Memory Index, Processing Speed Index, and Verbal Comprehension Index/Verbal Intelligence Quotient scores on WISC. BVRT may be helpful in screening for intellectual impairments in children with MMD.

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OBJECTIVE

The purpose of this study was to describe the long-term outcomes and associated risks related to repeat stereotactic radiosurgery (SRS) for persistent arteriovenous malformations (AVMs) in pediatric patients.

METHODS

Under the auspices of the International Radiosurgery Research Foundation, this retrospective multicenter study analyzed pediatric patients who underwent repeat, single-session SRS between 1987 and 2022. The primary outcome variable was a favorable outcome, defined as nidus obliteration without hemorrhage or neurological deterioration. Secondary outcomes included rates and probabilities of hemorrhage, radiation-induced changes (RICs), and cyst or tumor formation.

RESULTS

The cohort included 83 pediatric patients. The median patient age was 11 years at initial SRS and 15 years at repeat SRS. Fifty-seven children (68.7%) were managed exclusively using SRS, and 42 (50.6%) experienced hemorrhage prior to SRS. Median AVM diameter and volume were substantially different between the first (25 mm and 4.5 cm3, respectively) and second (16.5 mm and 1.6 cm3, respectively) SRS, while prescription dose and isodose line remained similar. At the 5-year follow-up evaluation from the second SRS, nidus obliteration was achieved in 42 patients (50.6%), with favorable outcome in 37 (44.6%). The median time to nidus obliteration and hemorrhage was 35.5 and 38.5 months, respectively. The yearly cumulative probability of favorable outcome increased from 2.5% (95% CI 0.5%–7.8%) at 1 year to 44% (95% CI 32%–55%) at 5 years. The probability of achieving obliteration followed a similar pattern and reached 51% (95% CI 38%–62%) at 5 years. The 5-year risk of hemorrhage during the latency period after the second SRS reached 8% (95% CI 3.2%–16%). Radiographically, 25 children (30.1%) had RICs, but only 5 (6%) were symptomatic. Delayed cyst formation occurred in 7.2% of patients, with a median onset of 47 months. No radiation-induced neoplasia was observed.

CONCLUSIONS

The study results showed nidus obliteration in most pediatric patients who underwent repeat SRS for persistent AVMs. The risks of symptomatic RICs and latency period hemorrhage were quite low. These findings suggest that repeat radiosurgery should be considered when treating pediatric patients with residual AVM after prior SRS. Further study is needed to define the role of repeat SRS more fully in this population.

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OBJECTIVE

Cerebral cavernous malformations (CCMs) are the second most common vascular anomaly affecting the CNS in children. Although stereotactic radiosurgery (SRS) has been proposed as an alternative to microsurgery in the management of selected cases in adults, there is a paucity of studies focusing on pediatric patients. The aim of this study was to present the outcomes and associated risks of SRS in this subgroup of patients.

METHODS

This retrospective multicenter study included pediatric patients treated with single-session SRS for CCMs. The annual hemorrhage rate (AHR) was calculated before and after SRS in hemorrhagic lesions. The Engel classification was used to describe post-SRS epileptic control. Adverse radiation effects (AREs) and the occurrence of new neurological deficits were recorded.

RESULTS

The study included 50 patients (median age 15.1 [IQR 5.6] years) harboring 62 CCMs. Forty-two (84%) and 22 (44%) patients had a history of hemorrhage or epilepsy prior to SRS, respectively. The AHR from diagnosis to SRS excluding the first hemorrhage was 7.19 per 100 CCM-years, dropping to 3.15 per 100 CCM-years after treatment. The cumulative risk of first hemorrhage after SRS was 7.4% (95% CI 0%–14.3%) at 5 years and 23.6% (95% CI 0%–42.2%) at 10 years. Eight hemorrhagic events involving 6 CCMs in 6 patients were recorded in the post-SRS follow-up period; 4 patients presented with transient symptoms and 4 with permanent symptoms. Of the 22 patients with pre-SRS seizures, 11 were seizure free at the last follow-up (Engel class I), 6 experienced improvement (Engel class II or III), 5 had no improvement (Engel class IVA or IVB), and 1 experienced worsening (Engel class IVC). Radiographic AREs were documented in 14.5% (9/62) of CCMs, with 4 being symptomatic.

CONCLUSIONS

Single-session SRS reduces the CCM hemorrhage rate in the pediatric population and provides adequate seizure control.

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In Brief

The goal in this study was to identify causes and diagnostic methods for pediatric hydrocephalus in Asia, supporting clinical guidelines and public health decisions. Geographical and economic factors affect the cause of pediatric hydrocephalus in Asia. Lower-middle-income countries show higher rates of postinfectious hydrocephalus, whereas high-income countries report more nonpostinfectious cases. This review highlights regional and socioeconomic differences in pediatric hydrocephalus in Asia, emphasizing the need for customized healthcare and better diagnostics to guide prevention and management strategies.

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In Brief

Researchers aimed to determine the correlation between ultrasonographic optic nerve sheath diameter (ONSD) and intracranial pressure (ICP) in infants with hydrocephalus. In their research, ONSD showed a strong positive correlation with ICP (r = 0.77, p < 0.001). Correspondingly, ONSD was sensitive in estimating ICP, and for every 14.3–mm Hg increase in ICP, ONSD increased by 1.0 mm holding age constant. The clinical study revealed that ONSD could serve as a surrogate biomarker for raised ICP in infants with hydrocephalus.

Open access

In Brief

Imaging used for neuronavigation for neurosurgical procedures typically involves long MRI sequences or CT scans. Researchers report a rapid 1-minute MRI protocol and clinical application for image-guided ventricular access for children. The use of rapid MRI for neuronavigation in pediatric neurosurgery may minimize the need for anesthesia and radiation.

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In Brief

The authors conducted a retrospective observational cohort study across six hospitals between 2007 and 2015 to describe trends in shunt infection prevention techniques, including intrathecal (IT) antibiotics and antibiotic-impregnated catheters (AICs). They observed a trend of decreasing IT antibiotic use in Hydrocephalus Clinical Research Network (HCRN) hospitals and increased AIC utilization after 2012 in both HCRN and non-HCRN hospitals. This research provides a historical understanding of large-scale trends and a framework for future propensity analyses between the different techniques.

Open access

In Brief

The objective of this study was to describe the adverse event profile and accuracy associated with the stereotactic placement and subsequent removal of intratumoral catheters for the infusion of viral immunotherapy. Nineteen patients with 49 catheters were analyzed. There was only 1 event that required intervention, oversew of a CSF leak. Only 3 catheters were “misplaced.” The stereotactic intratumoral placement of catheters for viral immunotherapy infusion in pediatric tumor patients is safe and accurate.

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In Brief

The authors sought to quantify the complication rates following resection of primary and recurrent posterior fossa ependymomas in children. This study highlights the rates of cranial neuropathy, hydrocephalus, posterior fossa syndrome, gastrostomy, and tracheostomy (among others) in primary and recurrent cohorts. Recurrent surgery did not confer an increased complication risk compared with primary surgery. These findings augment the understanding of postoperative complications; ultimately, the aim for these data is to inform perioperative patient and family counseling.

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In Brief

This study aimed to explore changes in 3D morphometric parameters among children with metopic synostosis, a condition in which the joint between the front skull plates fuses prematurely. The authors found that, without treatment, some of the features of the condition differ and others do not among different age groups. These findings can help when counseling families who have children with metopic synostosis to make a decision on whether to operate, based on their own specific measurements.

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In Brief

As patients and their caregivers utilize online forums to exchange personal insights on and experiences with Chiari malformation type I (CM), this study aimed to discern the prevalent themes present on such forums. Through thematic analysis, the authors identified the diagnostic journey, symptomatology, surgical intervention, and emotional burden as the four primary concerns of patients and caregivers who participate on CM online discussion boards. This research may aid clinicians in understanding patient challenges associated with CM.

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In Brief

In this retrospective cohort study of children aged 8–12 years who sustained a sport-related concussion (SRC), half of all patients presented to the emergency department and 38% received head imaging. Athletes took slightly more than 1 week to return to learn and approximately 1 month for symptom resolution and to return to play. This study aids in characterizing demographics, injury characteristics, symptom scores, and outcomes in an understudied population of youth athletes experiencing SRC.

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TO THE READERSHIP: An error appeared in the Letter to the Editor by Kelly et al. (Kelly L, Dinesh B, O’Connell K, et al. Intracranial invasive group A streptococcus: importance of culture-independent diagnostics. J Neurosurg Pediatr. Published online November 24, 2023. doi:10.3171/2023.9.PEDS23409).

Due to a production error, was not included in the published letter. The table appears on the following page.

TABLE 1.

Clinical characteristics of patients

Patient 1Patient 2Patient 3
Age in yrs, sex44, F45, M45, M
Past medical historyNoneNoneNone
Clinical presentationDecreased  
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TO THE EDITOR: We congratulate Hutton et al. on their paper in which they comprehensively outline the intracranial complications of invasive group A streptococcus (iGAS) infection in a pediatric population in the United Kingdom over a 2-month period in 2022 (Hutton D, Kameda-Smith M, Afshari FT, et al. Intracranial invasive group A streptococcus: a neurosurgical emergency in children. J Neurosurg Pediatr. 2023;32[4]:478-487). The infections in their paper included subdural empyema with associated encephalitis (n = 2), extradural empyema (n = 1), intracranial abscess (n = 1), and diffuse meningoencephalitis (n = 1). A paucity

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TO THE EDITOR: We are writing to express our appreciation for the article by Aum et al. (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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In Brief

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

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 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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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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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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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. 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.

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

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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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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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 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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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 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

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

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

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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In Brief

The authors present the largest experience of pediatric auditory brainstem implants (ABIs) in the United States, with an emphasis on safety and postoperative auditory outcomes. ABI placement resulted in significant auditory improvement in up to 79% of patients. The authors hope that this provides an impetus for further multicenter collaborations and larger studies to improve the understanding of the effects of this procedure.

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Punchak and colleagues present a single-center retrospective cohort study of 72 patients less than 1 year of age who underwent surgery for complex tethered cord over a 14.5-year study period. Most patients were diagnosed with lipomyelomeningocele (56.9%), among whom 10 (13.9%) had chaotic, but the study population also included patients with lipomyeloschisis, intradural lipoma, and terminal myelocystocele.

Sixty-three patients (87.5%) had no clinical symptoms and underwent prophylactic laminectomy and tethered cord release. Surgical techniques included both complete and subtotal resection of spinal lipomas, as well as both primary dural closure and expansile duraplasty. Eighteen previously asymptomatic

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In Brief

This systematic review highlights differences in pediatric thoracic outlet syndrome (TOS) from adult TOS: a 1.84:1 female-to-male ratio, a lower neurogenic prevalence (75%), and increased venous and arterial cases. Pediatric TOS exhibits fewer bony abnormalities (10.65%) than adult TOS (30%). Treatments involve muscle resection (95.26%), neurolysis (78.02%), and bone resection (72.41%), with 89% of patients reporting symptom improvement. Recognizing these distinctions offers valuable insights for accurate diagnosis and tailored treatments in pediatric TOS management.

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OBJECTIVE

Among patients with a history of prior lipomyelomeningocele repair, an association between increased lumbosacral angle (LSA) and cord retethering has been described. The authors sought to build a predictive algorithm to determine which complex tethered cord patients will develop the symptoms of spinal cord retethering after initial surgical repair with a focus on spinopelvic parameters.

METHODS

An electronic medical record database was reviewed to identify patients with complex tethered cord (e.g., lipomyelomeningocele, lipomyeloschisis, myelocystocele) who underwent detethering before 12 months of age between January 1, 2008, and June 30, 2022. Descriptive statistics were used to characterize the patient population. The Caret package in R was used to develop a machine learning model that predicted symptom development by using spinopelvic parameters.

RESULTS

A total of 72 patients were identified (28/72 [38.9%] were male). The most commonly observed dysraphism was lipomyelomeningocele (41/72 [56.9%]). The mean ± SD age at index MRI was 2.1 ± 2.2 months, at which time 87.5% of patients (63/72) were asymptomatic. The mean ± SD lumbar lordosis at the time of index MRI was 23.8° ± 11.1°, LSA was 36.5° ± 12.3°, sacral inclination was 30.4° ± 11.3°, and sacral slope was 23.0° ± 10.5°. Overall, 39.6% (25/63) of previously asymptomatic patients developed new symptoms during the mean ± SD follow-up period of 44.9 ± 47.2 months. In the recursive partitioning model, patients whose LSA increased at a rate ≥ 5.84°/year remained asymptomatic, whereas those with slower rates of LSA change experienced neurological decline (sensitivity 77.5%, specificity 84.9%, positive predictive value 88.9%, and negative predictive value 70.9%).

CONCLUSIONS

This is the first study to build a machine learning algorithm to predict symptom development of spinal cord retethering after initial surgical repair. The authors found that, after initial surgery, patients who demonstrate a slower rate of LSA change per year may be at risk of developing neurological symptoms.

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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 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.

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In Brief

Researchers evaluated whether noninvasive near-infrared spectroscopy (NIRS) values were associated with seizures in pediatric severe abusive head trauma (AHT). In this series of 19 patients, the largest known to date, NIRS did not consistently predict early posttraumatic seizures. However, NIRS showed increased cerebral oxygenation preceding and during seizure activity in certain patients with local seizure activity. Future studies may help elucidate the relationship between seizures and cerebral oxygenation in the AHT population.

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In Brief

This study investigated the use of postconception age at surgery (PCAS) as a metric for predicting first ventriculoperitoneal shunt failure. It found that PCAS was a better metric than either postnatal age or gestational age at delivery in stratifying shunt outcomes, and identified that a 40-week PCAS threshold was significant in stratifying failure rates at both 30 days and 1 year postsurgery. This finding may help inform management for young or premature infants with hydrocephalus.

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, , , , , , , , , and
Shu-Ling Chong , on behalf of Pediatric Acute and Critical Care Medicine Asian Network (PACCMAN) and Red Colaborativa Pediátrica de Latinoamérica (LARed Network)

In Brief

This study aimed to compare clinical outcomes and healthcare utilization for children with moderate to severe traumatic brain injuries (TBIs) between low- and middle-income countries (LMICs) and non-LMICs in Asia and Latin America. The authors found that children with TBIs in LMICs were more likely to have poor functional outcomes and required greater resource utilization. These findings build on previous data and provide a platform for future work to mitigate these disparities and improve clinical outcomes.

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In Brief

Researchers analyzed skull base parameters to estimate the endoscopic surgical window in children. The measurement of intersiphon distance showed clinical significance through its correlation with the actual surgical window and the intraoperative endoscopic view. This study will assist clinicians in making decisions regarding the surgical approach and will lead to further investigation into the clinical application of skull base parameters.

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In Brief

The authors aimed to characterize the spectrum of traumatic pediatric upper cervical spine injuries (CSI), from the occiput to C2. Atlanto-occipital and atlanto-axial distraction injuries could be divided into complete dislocations and incomplete subluxations, with the former clearly representing a more serious injury. Fractures and ligamentous injuries were clinically heterogeneous. This is one of the largest reviews of pediatric upper CSI and the first to delineate clear clinical differences based on degree of joint distraction.

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This study aimed to evaluate pediatric hydrocephalus care access in Nigeria using the Lancet Commission on Global Surgery Three Delays framework. It noted substantial delays in seeking, reaching, and receiving care, particularly for families with a lower socioeconomic status and women with lower health literacy. This study highlights the urgent need to address disparities in pediatric hydrocephalus care in Nigeria and similar low-resource settings globally and provides evidence to support the implementation of interventions.

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This work aimed to apply an accounting principle, time-driven activity-based costing (TDABC), in a novel manner to a pediatric neurosurgery outpatient practice. TDABC was coupled with processes in the care delivery model for a pediatric neurosurgical clinic at Oklahoma Children's Hospital. TDABC may more accurately capture opportunity cost for each member of the care team. Opportunities for optimization of the value care pathway are revealed for physician leaders.

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The objective of this work was to critically evaluate the Endoscopic Third Ventriculostomy Success Score (ETVSS) in a large, multicenter modern cohort of patients and determine if prediction could be improved. The authors found that neither re-categorization of variables nor the addition of imaging variables substantially improved prediction compared with the original ETVSS. This study confirms that the ETVSS demonstrates good predictive ability in a modern ETV cohort.