Journal of Neurosurgery: Pediatrics
Volume 28: Issue 1 (Jul 2021)

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Rajiv R. Iyer and Douglas L. Brockmeyer
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Luke G. McVeigh, Miracle C. Anokwute, Ahmed Belal, Natasha V. Raman, Kristin Zieles, Konrad M. Szymanski, Rosalia Misseri, and Andrew Jea

In Brief

Researchers used radiographic imaging, clinical evaluation, patient-reported outcomes, and formal urodynamics to investigate the safety and short-term efficacy of spinal column shortening as treatment for children and emerging adults with secondary tethered cord syndrome. In this series of 41 patients, spinal column shortening was found to be a safe procedure with promising short-term outcomes. Given these findings, this study emphasizes the importance of and justification for further research into long-term outcomes of spinal column shortening, particularly in children.

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Richard Menger, Paul J. Park, Elise C. Bixby, Gerard Marciano, Meghan Cerpa, David Roye, Benjamin D. Roye, Michael Vitale, and Lawrence Lenke

In Brief

The overwhelming majority of literature on instrumentation to the pelvis in children focuses on nonambulatory cohorts. The objective of this study was to address the minimal literature on early complications following fusion to the sacrum with instrumentation to the pelvis in the era of sacral-alar-iliac instrumentation in ambulatory pediatric patients. Instrumentation to the pelvis in this patient population allows for powerful deformity correction with a 36.0% (9/25) complication rate within a mean follow-up period of 24.3 months.

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Mark S. Dias, Ming Wang, Elias B. Rizk, Robin Bowman, Michael D. Partington, Jeffrey P. Blount, Brandon G. Rocque, Betsy Hopson, Daria Ettinger, Amy Lee, William O. Walker, and on behalf of the National Spina Bifida Patient Registry Group

In Brief

This is the largest published study of tethered cord surgery (TCS) among people with myelomeningocele. Objectives were to describe the temporal incidence of TCS and variance between institutions and test the hypothesis that tethering is related to longitudinal spine growth by comparing the relationship between sex-specific spine growth rates and TCS. The authors found no sex-specific differences in TCS timing. This challenges traditional concepts that tethering is solely related to longitudinal spine growth.

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Nicholas S. Szuflita, Tiffany N. Phan, Jason H. Boulter, Robert F. Keating, and John S. Myseros

In Brief

The objective of this study was to describe a potential management strategy for an uncommon sequela of Chiari malformation type I (CM-I) decompression. The authors found that deferment of surgery in favor of close follow-up is a safe treatment plan for some patients who have worsening syrinx without worsening neurological status after CM-I decompression. These findings help provide a basis for decision-making in an ambiguous clinical scenario.

Open access
Eva Wembacher-Schroeder, Nicole Kerstein, Evan D. Bander, Neeta Pandit-Taskar, Rowena Thomson, and Mark M. Souweidane

In Brief

In this study, the iPlan Flow software infusion simulation algorithm was evaluated for use in convection-enhanced delivery (CED) of drugs to the pediatric brainstem. The authors compared simulated outcomes with the actual radiolabeled infusion distribution and used similarity metrics to quantify the agreement between the actual and the estimated infusate distribution. The combined acceptance criteria were met for 8 of 10 evaluated patients, and based on this finding, the authors recommend the use of iPlan Flow software to optimize personalized CED treatment.

Free access
Chun-Lung Chou, Hsin-Hung Chen, Huai-Che Yang, Yi-Wei Chen, Ching-Jen Chen, Yu-Wei Chen, Hsiu-Mei Wu, Wan-Yuo Guo, David Hung-Chi Pan, Wen-Yuh Chung, Tai-Tong Wong, and Cheng-Chia Lee

In Brief

Hypothalamic obesity is common among patients with craniopharyngioma. This study examined whether precise stereotactic radiosurgery reduces the risk of hypothalamic obesity in cases of craniopharyngioma with expected long-term survival. Our results revealed that precise radiosurgical dose planning can mediate the subsequent increase in BMI. There is every indication that meticulous Gamma Knife radiosurgery is an effective approach to treating craniopharyngioma while also reducing the risk of hypothalamic obesity.

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Jonathan J. Lee, Dave Clarke, Eric Hoverson, Elizabeth C. Tyler-Kabara, and Winson S. Ho
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Armin Mortazavi, Ross-Jordon S. Elliott, Tiffany N. Phan, John Schreiber, William D. Gaillard, and Chima O. Oluigbo

In Brief

The authors present their experience with responsive neurostimulation in pediatric patients at a single institution and review the indications, strategies, outcomes, and technical considerations for RNS System implantation in this population. They emphasize the compassionate-use indication for this device in pediatric patients. All 5 patients in the study experienced medium-term improvements in seizure control after RNS System implantation, with decreases in seizure frequency greater than 50% from the baseline preoperative seizure frequency. No adverse events were seen.

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Nir Shimony, Travis Dailey, David Barrow, Anh Bui, Mohammad Hassan A. Noureldine, Meleine Martínez-Sosa, Luis F. Rodriguez, Carolyn M. Carey, Gerald F. Tuite, and George I. Jallo

In Brief

The objective of this paper was to determine the clinical benefit in performing outpatient imaging in the setting of pediatric mild traumatic brain injury (TBI). The key finding was that there is no clinical benefit to routine outpatient imaging in pediatric mild TBI, unless there is a clinical change. The imaging does not change the clinical course or the management except for leading to more unnecessary tests and imaging. A reduction in the unnecessary use of routine imaging will benefit patients and curb the waste of resources.

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Muhammad Ali, Nek Asghar, Adam Li, Theodore Hannah, Zachary Spiera, Naoum Fares Marayati, Nickolas Dreher, John Durbin, Alex Gometz, Mark Lovell, and Tanvir Choudhri

In Brief

Researchers evaluated the role of depression and anxiety, accompanied with or without antidepressant use, on the incidence of and recovery from concussion. Depression or anxiety with antidepressant use was associated with increased incidence of concussion and impaired symptomatic and neurocognitive recovery. The findings suggest that premorbid depression with antidepressant use may be a risk factor for concussion.

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Leeat Granek, Shahar Shapira, Shlomi Constantini, and Jonathan Roth

In Brief

Pediatric neurosurgeons have a structured and well-thought-out philosophy and practice regarding intraoperative decision-making that encompasses a range of approaches including the following: doing no harm, cultivating self-awareness, and seeing the whole patient; and concrete practices such as preparing in advance for uncertainty, working on teams, and learning from experience. These philosophies and practices can be structured and codified in order to teach residents how to develop intraoperative judgment techniques.

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Nisha Gadgil, Ganesh Rao, Raymond Sawaya, Daniel Yoshor, Lucia Ruggieri, Natalie Cormier, Daniel J. Curry, William E. Whitehead, Guillermo Aldave, David F. Bauer, Samuel McClugage III, and Howard L. Weiner

In Brief

In this article, the authors outline the important contributions of Dr. William R. Cheek to the field of pediatric neurosurgery. As one of the early leaders of the field, he helped to establish its organizational and educational framework and founded the Division of Pediatric Neurosurgery at Texas Childrens Hospital. The authors honor his legacy by appreciating his contributions to the field and continuing to push pediatric neurosurgery forward for the good of patients.

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Aaron M. Yengo-Kahn, John C. Wellons III, Todd C. Hankinson, Jason S. Hauptman, Eric M. Jackson, Hailey Jensen, Mark D. Krieger, Abhaya V. Kulkarni, David. D. Limbrick Jr., Patrick J. McDonald, Robert P. Naftel, Jonathan A. Pindrik, Ian F. Pollack, Ron Reeder, Jay Riva-Cambrin, Curtis J. Rozzelle, Mandeep S. Tamber, William E. Whitehead, John R. W. Kestle, and for the Hydrocephalus Clinical Research Network

In Brief

Using data from 14 pediatric neurosurgical centers in the Hydrocephalus Clinical Research Network, researchers sought to compare shunt–based and endoscopic third ventriculostomy (ETV)–based treatment strategies for children with Dandy–Walker syndrome–related hydrocephalus (DWSH). Shunt–based and ETV–based primary treatment of DWSH were similarly durable and had similar rates of complications. A pediatric neurosurgeon may reasonably consider ETV–based treatment for DWSH.

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Matthias Schulz, Yasin Oezkan, Andreas Schaumann, Miriam Sieg, Anna Tietze, and Ulrich-Wilhelm Thomale

In Brief

Indications and surgical technique selection for arachnoid cyst fenestration in children are mainly based on individually weighing risks and benefits. The authors identified rigorous virtual planning and the use of neuronavigation enhanced by augmented realty as key features for surgical treatment, and especially for neuroendoscopy. Thereby, the authors safely achieved effective volume reduction and symptom relief with a reasonable complication rate. Infants may represent a special group of patients, having a more complex course of treatment than older children.

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Jordan I. Gewirtz and Jennifer M. Strahle
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Anthony S. Larson, Lorenzo Rinaldo, Waleed Brinjikji, and James P. Klaas
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Francesco Cardinale, Philippe Kahane, Stefano Francione, and Philippe Ryvlin
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Giorgio Lo Russo
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In Brief

Authors of this study assessed stereo-electroencephalography (SEEG) safety in the pediatric setting, focusing on surgical complications, and explored whether robot assistance was associated with a change in practice, surgical parameters, and clinical outcomes. SEEG complications are uncommon and usually transient or treatable. Robot assistance enabled implantation of more electrodes and improved epilepsy surgery outcome compared to those in non—robot-assisted cases. This is the largest single-center, exclusively pediatric SEEG series that includes robot assistance so far.

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In Brief

Through a systematic review and meta-analysis, the authors compared the use of rigid and flexible endoscopes in endoscopic third ventriculostomy (ETV) with or without choroid plexus cauterization (±CPC). They found similar ETV success and complication rates for ETV±CPC with flexible versus rigid endoscopy, despite lower calculated ETV success scores for patients treated with flexible endoscopy. The choice of surgical instrument has not previously been directly compared and may warrant further study.

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In Brief

Both spring-mediated cranioplasty (SMC) and endoscopic strip craniectomy (ESC) have been associated with favorable perioperative outcomes as compared to those with open vault reconstruction. However, there are limited data comparing perioperative outcomes between SMC and ESC. Using a large prospective multicenter registry, authors of this study compared perioperative outcomes between these two minimally invasive approaches. The study findings revealed similar perioperative transfusion outcomes, with SMC insertion procedures having higher ICU admission rates and longer hospital stays.

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In Brief

This study assessed the effectiveness of external lumbar drainage in children with idiopathic intracranial hypertension and worsening papilledema despite medications for lowering intracranial pressure. Performed early when vision is preserved, this intervention typically results in rapid and sustainable resolution of patients’ symptoms and papilledema with a good visual outcome, suggesting that it may be considered as second-stage therapy in this setting, after failed medical therapy, before proceeding to definitive surgeries that carry inherent risks and failures.

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In Brief

The object of this study was to describe the complex and opposing physiology in children with a single cardiac ventricle and acute brain injury. When such patients require intubation and mechanical ventilation, tight control of arterial carbon dioxide, minimizing mean airway pressure, and early extubation are important. These patients can be safely intubated for prolonged periods of time by understanding the complex cardiopulmonary and neurovascular interactions.

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In Brief

This study reported 2-year results of brain growth after surgical treatment in a randomized trial for postinfectious hydrocephalus in Sub-Saharan Africa. There were no significant differences in cognitive score or brain volume between the surgical treatment arms; however, after initial brain growth during the 1st year, there was substantial normalized brain volume loss between years 1 and 2. The study emphasizes the importance of primary infection prevention and mitigation strategies to maximize brain growth potential.

Open access

In Brief

The authors created normative childhood brain growth curves with percentiles for clinical use. Brain volume peaked at 10–12 years, and males exhibited larger age-adjusted total brain volumes than females despite body size normalization. However, the authors unexpectedly discovered that the brain has a universal age-dependent relationship to cerebrospinal fluid independent of sex or body size. Normative brain growth curves will be of value in managing childhood disease in which cognitive development, brain growth, and fluid accumulation are interrelated.

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In Brief

The authors aimed to provide a systematic review of the clinical applications as well as the rate and nature of complications of laser interstitial thermal therapy in the pediatric population. Currently, the most common applications of laser interstitial thermal therapy are for the treatment of refractory epilepsy and surgically inaccessible brain tumors. The overall complication rate was approximately 16%, with no deaths. This work represents the first systematic review that examines the utility of laser interstitial thermal therapy in the pediatric population.

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In Brief

The authors describe a modification of indirect revascularization for the anterior cerebral artery territory in pediatric moyamoya disease. Using the pericranium and the dura mater, the approach was employed in a wide range of clinical scenarios, offering robust vascular supply that was both safe and durable, as supported by long-term clinical and radiographic follow-up.

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In Brief

This study reports the results of pediatric hemivertebra resections performed by a two–attending surgeons, two-specialty team over a 12-year period. In a cohort of 22 patients, there was a 14% rate of change in neuromonitoring, 32% rate of nonneurological complications, and 27% rate of unplanned return to the operating room. A review of single-surgeon series is provided for comparison, and some of the less tangible benefits of the two–attending surgeon, two-specialty approach are discussed.

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In Brief

The authors followed a large cohort of children with bottom-of-sulcus dysplasia following surgery or laser ablation. The lesion was often missed initially on MRI and PET studies. The majority of the patients underwent invasive EEG evaluations before surgery. More than three-fourths of the patients achieved seizure freedom after surgery. The pathology often extended beyond the MRI-visible lesion, based on intracranial EEG and postsurgical histology results.

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In Brief

Identification of infants at risk for nonaccidental trauma remains of critical importance; however, there is no standardly accepted evaluation process. Following application of a standard protocol to evaluate infants presenting with skull fractures, researchers identified a thorough evaluation of the social situation and a skeletal survey as high-yield aspects of an evaluation for possible abuse. Future assessment of this protocol as applied in the emergency department may improve identification while conserving healthcare resources.

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In Brief

In patients with Chiari malformation type I (CM-I), the authors sought to identify a novel radiographic marker that has greater predictive potential of clinical severity than tonsillar herniation. The fourth ventricle roof angle (FVRA) was identified to have excellent interrater variability, can assess fourth ventricular bowing in CM-I, and was found to be more predictive of brainstem dysfunction than tonsillar herniation. This finding will be useful in further describing CM-I radiographically and clinically by identifying patients more likely to be symptomatic with brainstem dysfunction.

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In Brief

Researchers analyzed navigated transcranial magnetic stimulation (nTMS) motor mapping data in a cohort of pediatric patients with epilepsy set to undergo epilepsy surgery. Motor mappings were successful in a majority of cases, and there were no nTMS-related adverse effects. There was a significant correlation of mapping success and age, implying a minimum age necessary for mapping success. Further research regarding potential outcome benefits arising from preoperative nTMS motor mapping in this cohort may be warranted.

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In Brief

This study followed the outcomes of patients with isolated congenital aqueductal stenosis (CAS) into early childhood. The authors found that patients with CAS are at a significantly increased risk of developing ophthalmological abnormalities and experiencing delays in developmental milestones. There was a significant correlation between those outcomes that was independent of CSF diversion history. Larger cohort studies are needed to determine if earlier CSF diversion leads to improved ophthalmological and developmental outcomes.

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In Brief

The objective of the current study was to describe the use of preoperative imaging in children clinically diagnosed with single-suture synostosis and to assess the impact of imaging on surgical planning. The authors found that CT imaging is commonly done but rarely alters the surgical plan. The majority of imaging studies were ordered as part of institutional protocols. This study confirms previous studies on the utility of preoperative imaging in a large, multicenter cohort.

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In Brief

This study characterized the variability, strengths, and limitations of rapid-sequence MRI (RSMRI) protocols for pediatric traumatic brain injury (TBI), including the reduction of radiation exposure. While traumatic pathology missed by RSMRI, such as small hemorrhages and linear, nondisplaced skull fractures, was frequently described as clinically insignificant, in some cases these findings may be prognostically and/or forensically significant. Institutions should integrate RSMRI into pediatric TBI management judiciously, relying on clinical context and institutional capabilities.

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In Brief

Researchers investigated the utility of contrast-based shuntograms in aiding the management of patients with shunted hydrocephalus, particularly in terms of a negative result. More than two-thirds of patients (68.3%) with a negative shuntogram study had a true negative result and therefore did not require operative shunt exploration over the subsequent 30 days. Contrast-based shuntograms are a reasonable, safe option in the management of neurosurgical patients presenting with symptoms concerning for shunt failure but without clear radiographic evidence.

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In Brief

The authors sought to determine if there was a difference in scoliosis outcomes between patients with Chiari malformation type I (CM-I) and scoliosis who received posterior fossa decompression (PFD) with or without duraplasty. After controlling for relevant preoperative variables, the authors found that those patients receiving duraplasty were less likely to have progression of their scoliosis compared with those who received extradural PFD, although rates of spinal fusion between the two groups were similar. This finding has implications for clinical management of patients with CM-I and scoliosis.

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In Brief

Utilizing a national cancer registry, the authors sought to characterize the risk of secondary neoplasm development after external-beam radiation therapy (EBRT) treatment of low-grade gliomas (LGGs) in pediatric patients. After controlling for available covariates and adjusting for competing risks, EBRT was associated with an increased risk of secondary neoplasm development for pediatric survivors of LGGs. The study results have suggested that the long-term implications of EBRT should be considered when making treatment decisions for these patients.

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In Brief

With a nationwide survey, the authors investigated current stereoelectroencephalography (SEEG) practices among US pediatric epilepsy surgeons. SEEG was found to be widely used in pediatric patients and considered safe and satisfactory in defining critical epileptogenic networks. Wide variations in some aspects of SEEG use, including electrode number, laterality, and insular assessment, were also revealed, with statistically significant associations of SEEG program duration and patient age with number of electrodes used. These findings provide insight into how US pediatric epilepsy surgeons manage drug-resistant epilepsy and underscore the advantages of interinstitutional collaboration.

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In Brief

The objective of this study was to characterize changes in head impact exposure (HIE) across football seasons and to evaluate the relationship between changes in HIE and changes in imaging metrics identified in youth football players. This study demonstrated a significant positive association between changes in HIE metrics and changes in imaging metrics between consecutive seasons. Reducing HIE, especially in practice sessions, may decrease the number of abnormal imaging findings from one season to the next in youth football.

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In Brief

The authors investigated late mortality and morbidity during long-term follow-up of a pediatric patient population with moyamoya disease who underwent revascularization surgery at a single center. Of 460 patients receiving surgery over a 28-year period, 15 patients (3.3%) experienced late death or significant neurological morbidity; 8 of those patients experienced intracerebral and/or intraventricular hemorrhage, and 7 patients died of preexisting comorbidities. The authors stress the importance of long-term follow-up of this patient population in hopes of preventing these late events.

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In Brief

The authors analyzed data from a large retrospective study of achondroplasia patients treated during 1957—2017 at four different centers and documented that the median age of patients undergoing cervicomedullary decompression has decreased and the use of neuroimaging and screening modalities has increased over time, suggesting that better surveillance has contributed to earlier identification and intervention in achondroplasia patients with cervicomedullary stenosis. These findings may help guide family counseling about achondroplasia and provide a benchmark of treatments at some of the largest skeletal dysplasia programs in the world.

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In Brief

Pediatric isolated linear skull fracture commonly results from head trauma and rarely requires surgery, yet patients are often admitted. The authors used a national database to investigate admission trends across the United States. Overall, fracture-associated admissions decreased, hospital costs increased, and admissions shifted from smaller rural hospitals to larger urban centers. Neurosurgery has an evolving role in the care of these patients, and this study provides a platform for future discussions about indications for admission.

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In Brief

The authors report the results of the 10-year development and refinement of a multidisciplinary protocol at their institution to manage the treatment of pediatric patients with odontogenic brainstem compression requiring odontoidectomy. A minimally invasive approach was developed, with the combined benefits of the transnasal and transoral routes to perform odontoid resection, along with important otolaryngological considerations that improve surgical exposure and minimize morbidity. Together, these factors help provide favorable outcomes in patients with complex odontogenic brainstem compression.

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In Brief

The objective of this study was to externally validate the condylar—C2 sagittal vertical axis (C-C2SVA) in a large, multicenter cohort. The authors found the C-C2SVA to be a highly sensitive diagnostic test for identifying children who require ventral brainstem decompression or occipitocervical fusion. The C-C2SVA is a novel measurement that can now be used to help screen and identify high-risk Chiari malformation patients.

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In Brief

The authors, based at Great Ormond Street Hospital, set out to evaluate the spectrum of spinal dysraphisms in a complex urological condition (cloacal exstrophy) with poor clinical outcomes in a systematic manner. A large proportion of complex lipomas and terminal myelocystoceles were discovered in this cohort. This is the first comprehensive and large-scale effort on this subject.

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In Brief

This study aimed to find risk factors for predicting shunt failures in pediatric patients. Increased attention during surgery must be given to patients of extremely young age, with close monitoring after surgery. Shunt failure rates were high within the first few months, with decreasing trends over time.

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In Brief

The authors compare different treatment modalities for children with craniopharyngioma. Proton beam therapy, with comparable rates of 5-year progression-free survival for complete resection, may reduce the burden of hypopituitarism and diabetes insipidus. However, radiation adds the risk of potential complications in the long term, such as progressive vasculopathy or second malignancies. This is the first study to specifically examine the role of protons with a comparison to surgery and photon therapy in the treatment of pediatric craniopharyngioma.

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In Brief

The authors report on how their external validation of a predictive model (the modified Canadian Preoperative Prediction Rule for Hydrocephalus [mCPPRH]) did not show a high predictability regarding the children who would require permanent CSF diversion following tumor resection due to persistent hydrocephalus. Clinical judgment remains the mainstay of choosing perioperative treatment. The study provides evidence that the model in its current iteration does not have a high predictive accuracy, and therefore should be used with caution by clinicians.

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In Brief

This study sought to determine whether imaging modality and interobserver variability were factors in ventricular size disparity seen on imaging studies. Retrospective comparison showed that measurements with MRI were 2 mm larger on average than measurements with ultrasound. Centers involved in counseling families about fetal intervention for spina bifida need to be aware of these possible imaging-based disparities.

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In Brief

Late failure can occur after shunt placement or endoscopic third ventriculostomy. However, follow-up practices greatly vary. Therefore, the authors surveyed surgeons at hospitals that are part of the Hydrocephalus Clinical Research Network (HCRN) or its implementation/quality improvement arm, the HCRNq, and found that while there is a general consensus that hydrocephalus patients should have long-term follow-up, radiological surveillance is characterized by considerable variey in terms of modality, frequency, and actions taken when changes are identified in asymptomatic patients. These results highlight opportunities for further clinical research.

Open access

In Brief

In this study, the iPlan Flow software infusion simulation algorithm was evaluated for use in convection-enhanced delivery (CED) of drugs to the pediatric brainstem. The authors compared simulated outcomes with the actual radiolabeled infusion distribution and used similarity metrics to quantify the agreement between the actual and the estimated infusate distribution. The combined acceptance criteria were met for 8 of 10 evaluated patients, and based on this finding, the authors recommend the use of iPlan Flow software to optimize personalized CED treatment.

Restricted access

In Brief

The objective of this paper was to determine the clinical benefit in performing outpatient imaging in the setting of pediatric mild traumatic brain injury (TBI). The key finding was that there is no clinical benefit to routine outpatient imaging in pediatric mild TBI, unless there is a clinical change. The imaging does not change the clinical course or the management except for leading to more unnecessary tests and imaging. A reduction in the unnecessary use of routine imaging will benefit patients and curb the waste of resources.

Restricted access

In Brief

In this article, the authors outline the important contributions of Dr. William R. Cheek to the field of pediatric neurosurgery. As one of the early leaders of the field, he helped to establish its organizational and educational framework and founded the Division of Pediatric Neurosurgery at Texas Childrens Hospital. The authors honor his legacy by appreciating his contributions to the field and continuing to push pediatric neurosurgery forward for the good of patients.

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In Brief

Clinical outcomes of patients undergoing shunt externalization were retrospectively reviewed to test the hypothesis that reimplantation with a ventriculoatrial shunt (VAS) rather than return to a ventriculoperitoneal shunt (VPS) is not associated with increased failure rate and may permit shorter externalization duration. There was no significant difference in shunt survival between patients with VASs and those with VPSs, although the externalization period was not shorter with VASs. Early conversion to a VAS may be a viable treatment option following shunt externalization.

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In Brief

The aim of this study was to evaluate a noninvasive biomarker (diffusion tensor imaging [DTI]) and establish its value as a predictor for the need of surgery for hydrocephalus in patients treated with prenatal repair of a myelomeningocele. DTI is an objective biomarker that significantly differentiates between prenatal myelomeningocele patients who need CSF diversion for hydrocephalus and those who do not. Ultimately, these results will help clinicians better evaluate and treat patients with myelomeningocele-associated hydrocephalus, thereby potentially avoiding the long–term neurocognitive ramifications of this lifelong condition.