Journal of Neurosurgery: Pediatrics
Volume 33: Issue 3 (Mar 2024)

Illustration from Caklili et al. (pp 223–235). © Savas Ceylan, published with permission.

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In Brief

This study aimed to identify the risk factors for postoperative hydrocephalus after hemispherotomy. Multivariate logistic regression analysis of the clinical data on 51 children revealed that age at surgery, postoperative intraventricular hemorrhage volume, and duration of postoperative high fever were associated with the occurrence of hydrocephalus. The results of this study indicate that the risk of hydrocephalus should be considered in cases of early surgical indication in children.

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OBJECTIVE

Hemispherectomy surgery is an effective procedure for pediatric patients with intractable hemispheric epilepsy. Hydrocephalus is a well-documented complication of hemispherectomy contributing substantially to patient morbidity. Despite some clinical and operative factors demonstrating an association with hydrocephalus development, the true mechanism of disease is incompletely understood. The aim of this study was to investigate a range of clinical and surgical factors that may contribute to hydrocephalus to enhance understanding of the development of this complication and to aid the clinician in optimizing peri- and postoperative surgical management.

METHODS

A retrospective chart review was conducted on all pediatric patients younger than 21 years who underwent hemispherectomy surgery at the Cleveland Clinic between 2002 and 2016. Data collected for each patient included general demographic information, neurological and surgical history, surgical technique, pathological analysis, presence and duration of perioperative CSF diversion, CSF laboratory values obtained while an external ventricular drain (EVD) was in place, length of hospital stay, postoperative aseptic meningitis, and in-hospital surgical complications (including perioperative stroke, hematoma formation, wound breakdown, and/or infection). Outcomes data included hemispherectomy revision and Engel grade at last follow-up (based on the Engel Epilepsy Surgery Outcome Scale).

RESULTS

Data were collected for 204 pediatric patients who underwent hemispherectomy at the authors’ institution. Twenty-eight patients (14%) developed hydrocephalus requiring CSF diversion. Of these 28 patients, 13 patients (46%) presented with hydrocephalus during the postoperative period (within 90 days), while the remaining 15 patients (54%) presented later (beyond 90 days after surgery). Multivariate analysis revealed postoperative aseptic meningitis (OR 7.0, p = 0.001), anatomical hemispherectomy surgical technique (OR 16.3 for functional/disconnective hemispherectomy and OR 7.6 for modified anatomical, p = 0.004), male sex (OR 4.2, p = 0.012), and surgical complications (OR 3.8, p = 0.031) were associated with an increased risk of hydrocephalus development, while seizure freedom (OR 0.3, p = 0.038) was associated with a decreased risk of hydrocephalus.

CONCLUSIONS

Hydrocephalus remains a prominent complication following hemispherectomy, presenting both in the postoperative period and months to years after surgery. Aseptic meningitis, anatomical hemispherectomy surgical technique, male sex, and surgical complications show an association with an increased rate of hydrocephalus development while seizure freedom postsurgery is associated with a decreased risk of subsequent hydrocephalus. These findings speak to the multifactorial nature of hydrocephalus development and should be considered in the management of pediatric patients undergoing hemispherectomy for medically intractable epilepsy.

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OBJECTIVE

The Neurolocate module is a 3D frameless patient registration module that is designed for use with the Neuromate stereotactic robot. Long-term electrical stimulation of the globus pallidus internus (GPi) and subthalamic nucleus (STN) via deep brain electrode implantation is particularly successful in a select group of movement disorders in pediatric patients. This study aimed to review the targeting accuracy of deep brain stimulation (DBS) electrode implantation in a single center, comparing standard frame-based techniques to the frameless Neurolocate module.

METHODS

Twenty-four pediatric patients underwent implantation of bilateral DBS electrodes under general anesthesia during the period of August 2018–August 2022. All patients underwent robot-assisted stereotactic implantation of DBS electrodes using an intraoperative O-arm 3D scanner to confirm the final electrode position. These coordinates were compared with the planned entry and target, with attention to depth, radial, directional, and absolute errors, in addition to Euclidean distance (ED). The primary outcome evaluated the accuracy and safety of the Neurolocate frameless technology compared with standard frame-based techniques.

RESULTS

Of the 24 bilateral DBS electrode implantations performed, 62.5% used Neurolocate technology: 87.5% were delivered to the GPi and the remaining 12.5% to the STN. The mean patient age was 11.0 (range 4–18) years and 70.8% were male. The median absolute errors in x-, y-, and z-axes were 0.35, 0.75, and 0.9 mm, respectively, using the Neurolocate module compared with 0.30, 0.95, and 1.1 mm using the standard frame-based technique. The median ED from the planned target to the actual electrode position with the Neurolocate module was 1.28 mm versus 1.69 mm using standard frame-based techniques. No major perioperative complications occurred.

CONCLUSIONS

Stereotactic robot-assisted DBS implantation with the frameless Neurolocate module is safe for use in the pediatric population, showing good surgical accuracy and no inferiority to standard frame-based techniques. The Neurolocate module for robotic DBS surgery has the potential to improve surgical targeting accuracy, surgical time, patient comfort, and safety.

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OBJECTIVE

Awake craniotomy with intraoperative mapping is the widely accepted procedure for adult patients undergoing supratentorial tumor or epileptogenic focus resection near eloquent cortex. In children, awake craniotomies are notably less common due to concerns for compliance and emotional or psychological repercussions. Despite this, successfully tolerated awake craniotomies have been reported in patients as young as 8 years of age, with success rates comparable to those of adults. The authors sought to describe their experience with pediatric awake craniotomies, including insight regarding feasibility and outcomes.

METHODS

A retrospective review was completed for all pediatric (age < 18 years) patients at Children’s Wisconsin for whom an awake craniotomy was attempted from January 2004 until March 2020. Institutional review board approval was granted.

RESULTS

Candidate patients had intact verbal ability, cognitive profile, and no considerable anxiety concerns during neuropsychology assessment. Nine patients presented with seizure. Five patients were diagnosed with tumor and secondary epilepsy, 3 with tumor only, and 3 with epilepsy only. All patients who underwent preoperative functional MRI successfully completed and tolerated testing paradigms. A total of 12 awake craniotomies were attempted in 11 patients, with 1 procedure aborted due to intraoperative bleeding. One patient had a repeat procedure. The mean patient age was 15.5 years (range 11.5–17.9 years). All patients returned to or maintained baseline motor and speech functions by the latest follow-up (range 14–130 months). Temporary deficits included transient speech errors, mild decline in visuospatial reasoning, leg numbness, and expected hemiparesis. Of the 8 patients with a diagnosis of epilepsy prior to surgery, 7 patients achieved Engel class I designation at the 1-year follow-up, 6 of whom remained in class I at the latest follow-up.

CONCLUSIONS

This study analyzes one of the largest cohorts of pediatric patients who underwent awake craniotomy for maximal safe resection of tumor or epileptogenic lesions. For candidate patients, awake craniotomy is safe, feasible, and effective in carefully selected children.

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In Brief

The aim of this study was to evaluate the impact of the endoscopic endonasal approach on the surgical outcomes of pediatric craniopharyngiomas, as well as the factors affecting the resection rate and recurrence. Gross-total resection should be the goal of pediatric craniopharyngioma treatment, but the authors' treatment approach was to provide a balance between radical surgery with maximum safety and adjuvant treatment for long-term disease control. This study demonstrates that pediatric craniopharyngiomas are more aggressive tumors compared with those found in adults and presents factors affecting resection and recurrence rates over long-term follow-up.

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In Brief

The objective of this study was to report the clinical and neuroradiological features of H3 G34-mutant diffuse hemispheric glioma (G34m-DHG) and try to differentiate it from IDH-wild-type glioblastoma (IDH-WT-GBM) by quantitative MRI characteristics. G34m-DHGs occur most frequently in the frontal and parietal lobes in adolescents and young adults, demonstrate mild or no contrast enhancement, and can differ from IDH-WT-GBMs by their MRI characteristics, which may contribute to prognostic evaluation and assist in clinical settings.

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In Brief

Neuroblastoma is a common tumor occurring in children and can involve the spine and spinal cord. The role of surgery for this disease is not well understood. In this study, surgery was most common for patients who had neurologic deficits, but this group also had a more aggressive disease course. Surgery should be considered carefully in the context of the patient's overall treatment regimen.

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In Brief

This paper examined a large single-practice cohort to study the efficacy of primary laparoscopic repositioning of the distal shunt catheter for treatment of sterile abdominal CSF pseudocysts. Recurrence at 1 year was significantly lower for those with normal systemic inflammatory markers than for those with high markers. Some sterile pseudocysts with normal systemic inflammatory markers can be effectively treated with laparoscopic repositioning.

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In Brief

Researchers investigated how the timing of sport-related concussions within a season affects initial symptoms and recovery metrics in high school athletes. Most sport-related concussions occurred in the late season. There were no significant differences in initial symptoms or recovery durations based on when the concussion occurred (i.e., early, middle, or late season). However, concussion sustained in the playoff period was associated with notably higher symptom scores. This study highlights the potential impact of competitive context on concussion symptom severity in adolescent athletes.

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In Brief

The objective of this study was to synthesize knowledge on giant aneurysms in pediatric patients and identify factors associated with rupture risk and poor outcome. Young age and posterior circulation were found to be associated with aneurysm rupture, and endovascular treatment and unruptured presentation were associated with favorable outcome. This is the largest and most comprehensive study on giant aneurysms in pediatric patients and provides several prognostic factors to help neurosurgeons counsel patients and their families.

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OBJECTIVE

The occurrence and predictors of symptomatic subdural hygroma (SSH) subsequent to the fenestration of pediatric intracranial arachnoid cysts (IACs) are unclear. In this study, the authors aimed to investigate the likelihood of an SSH following IAC fenestration and the impact on operative efficacy with the ultimate goal of constructing a nomogram.

METHODS

The medical records of 1782 consecutive patients who underwent surgical treatment at the Xin Hua Hospital Affiliated to Shanghai Jiao Tong University School of Medicine were reviewed. Among these patients, a training cohort (n = 1214) underwent surgery during an earlier period and was used for the development of a nomogram. The remaining patients formed the validation cohort (n = 568) and were used to confirm the performance of the developed model. The development of the nomogram involved the use of potential predictors, while internal validation was conducted using a bootstrap-resampling approach.

RESULTS

SSH was detected in 13.2% (160 of 1214) of patients in the training cohort and in 11.1% (63 of 568) of patients in the validation cohort. Through multivariate analysis, several factors including Galassi type, IAC distance to the basal cisterns, temporal bulge, midline shift, IAC shape in the coronal view, area of the stoma, and artery location near the stoma were identified as independent predictors of SSH. These 7 predictors were used to construct a nomogram, which exhibited a concordance statistic (C-statistic) of 0.826 and demonstrated good calibration. Following internal validation, the nomogram maintained good calibration and discrimination with a C-statistic of 0.799 (95% CI 0.665–0.841). Patients who had nomogram scores < 30 or ≥ 30 were considered to be at low and high risk of SSH occurrence, respectively.

CONCLUSIONS

The predictive model and derived nomogram achieved satisfactory preoperative prediction of SSH. Using this nomogram, the risk for an individual patient can be estimated, and the appropriate surgery can be performed in high-risk patients.

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In Brief

The authors obtained aggregated baseline pediatric neurosurgery well-being data at a tertiary care institution. Problematic profiles were present in more than half (n = 7 [53.8%]) of the pediatric neurosurgery trainees, who cited higher emotional exhaustion than the general population of healthcare providers. Targeting factors that contribute to emotional exhaustion may have an impact on improving the overall well-being of pediatric neurosurgery trainees.

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Abstract #1: Development and Validation of a Remote Video Acquisition and Analysis Protocol using Artificial Intelligence (AI) for Evaluation of Gait and Upper Extremity Function – ASPN Seed Grant Funded Project (2023), An Interim Update

Albert Tu, MD

Introduction

3D motion analysis is invaluable when assessing patients with movement disorders. This technology however, is expensive and labour intensive, thus not readily available in many centres. Recent developments in artificial intelligence for pose estimation allow for development of automated evaluation algorithms for 3D movement using 2D video data.

Objectives

We have created an AI augmented pipeline to evaluate patient extremity function

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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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In Brief

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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In Brief

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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In Brief

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.

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In Brief

Evaluating patients undergoing complex tethered cord release reoperations, the authors found that intraoperative transcranial motor evoked potentials in 100% of cases, and triggered electromyography responses in 85.7%, could be generated at or below the level of clinical function. The presence of positive stimulation potentials below the level of clinical function indicates a degree of preserved neuronal connectivity. These findings suggest novel future treatment approaches, including using devices targeted to stimulation of neurological pathways.

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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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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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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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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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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

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.

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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  
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 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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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 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.

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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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In Brief

In a large cohort of children with severe traumatic brain injury undergoing emergency hemicraniectomy, researchers identified diffuse axonal injury in the diencephalon and brainstem as powerful predictors of poor outcome.

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TO THE EDITOR: I read with interest the article by Whitehead et al. 1 (Whitehead WE, Riva-Cambrin J, Wellons JC III, et al. Anterior versus posterior entry site for ventriculoperitoneal shunt insertion: a randomized controlled trial by the Hydrocephalus Clinical Research Network. J Neurosurg Pediatr. Published online November 19, 2021. doi:10.3171/2021.9.PEDS21391). Dr. Whitehead and colleagues concluded that anterior and posterior entry site shunt surgeries have similar outcomes and similar complication rates. 1 They reported that there were no significant differences between entry sites for intraoperative complications, shunt infections, postoperative seizures, new-onset epilepsy, or intracranial

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TO THE EDITOR: We read with great interest the article by Garcia et al. 1 regarding the factors associated with seizures at initial presentation in pediatric patients with cerebral arteriovenous malformations (AVMs) (Garcia JH, Winkler EA, Morshed RA, et al. Factors associated with seizures at initial presentation in pediatric patients with cerebral arteriovenous malformations. J Neurosurg Pediatr. 2021;28[6]:663-668). In this article, the authors performed a retrospective study based on a single-center database to investigate the risk factors associated with seizures at initial presentation in pediatric patients with cerebral AVMs. The results indicated that pediatric patients

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In Brief

Social determinants of health can have a profound effect on outcomes. The authors sought to determine if there are sociodemographic differences between patients who underwent fetal surgery versus those who underwent postnatal surgery for myelomeningocele. There was a significant difference in the commercial insurance rate and a marked difference in the racial and ethnic makeup of the two groups. Future studies should account for these demographic differences, and fetal centers should commit to minimizing preventable disparities.

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The article by Oyemolade and colleagues addresses an initial 30-month experience following the introduction of a neurosurgical program in southwest Nigeria. 1 The information presented is timely and important to the growth and development of global pediatric neurosurgery. This descriptive study provides important primary data that offer insight into barriers to neurosurgical care in lower-middle income countries (LMICs). At present, nearly all high-quality data on outcomes, quality of care, and guidelines for neurotrauma care originate in high-income countries. 2 As the authors detail, there is a profound need for systems of surgical care in LMICs, and

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In Brief

In this systematic review, the authors sought to review the published evidence on the use of cranial neuromodulation—deep brain stimulation (DBS) and responsive neurostimulation (RNS)—for pediatric drug-resistant epilepsy (DRE). From 35 studies, they found 72 children who had undergone DBS and 42 who had undergone RNS. Overall, 75% and 73.2% of DBS and RNS patients, respectively, experienced > 50% reduction in seizures. This study shows the paucity of evidence for promising treatment options for pediatric DRE.

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TO THE EDITOR: We read with great interest the article by Adamski et al. 1 (Adamski A, O’Brien MW, Adamo MA. Shuntogram utility in predicting future shunt failures. J Neurosurg Pediatr. 2021;28[3]:315-319).

Adamski et al. provided an excellent description of the contrast-based shuntogram technique and presented their experience with 95 cases, reporting a positive predictive value (PPV) of 100% and a negative predictive value (NPV) of 61.2% for valve failure within 1 year from the performance of the test. Of the patients with a negative result (with a normal flow of contrast), 38.8% were later

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TO THE EDITOR: We read with great interest the article by Berns et al. 1 (Berns J, Priddy B, Belal A, et al. Standardization of cerebrospinal fluid shunt valves in pediatric hydrocephalus: an analysis of cost, operative time, length of stay, and shunt failure. J Neurosurg Pediatr. 2021;27[4]:400-405). In particular, we regard "standardization" of shunt va