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Paul Steinbok, Stephen Hentschel, D. Douglas Cochrane and John R. W. Kestle

✓ The rationale for obtaining surveillance computerized tomography (CT) scans or magnetic resonance (MR) images in pediatric patients with brain tumors is that early detection of recurrence may result in timely treatment and better outcome. The purpose of this study was to investigate the value of surveillance cranial images in a variety of common pediatric brain tumors managed at a tertiary care pediatric hospital.

A retrospective chart review was performed of children with astrocytoma of the cerebral hemisphere, cerebellum, optic chiasm/hypothalamus, or thalamus; cerebellar or supratentorial high-grade glioma; supratentorial ganglioglioma; posterior fossa or supratentorial primitive neuroectodermal tumor (PNET); and posterior fossa ependymoma. Data were analyzed to determine the frequency with which recurrences were identified on a surveillance image and how the type of image at which recurrence was identified related to outcome.

In 159 children, 17 of 44 recurrences were diagnosed by surveillance imaging. The percentage of recurrences identified by surveillance imaging was 64% for ependymoma, 50% for supratentorial PNET, 43% for optic/hypothalamic astrocytoma, and less than 30% for other tumors. The rate of diagnosis of recurrence per surveillance image varied from 0% to 11.8% for different tumor types. Only for ependymomas did there appear to be an improved outcome when recurrence was identified prior to symptoms.

Our results indicate that, using the protocols outlined in this study, surveillance imaging was not valuable in identifying recurrence of cerebellar astrocytoma or supratentorial ganglioglioma during the study period, but was probably worth-while in identifying recurrence of posterior fossa ependymoma and optic/hypothalamic astrocytoma and, possibly, medulloblastoma. Surveillance protocols could be made more effective by individualizing them for each type of tumor, based on current data on the patterns of recurrence.

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John R. W. Kestle, Lothar Resch, Charles H. Tator and Walter Kucharczyk

✓ A case of spinal cord infarction resulting from embolization of fibrocartilaginous intervertebral disc material is presented. Cases from the literature are reviewed and the theories of pathogenesis are discussed. In all reported cases the diagnosis was not made until postmortem examination.

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Editorial

Prediction, with restriction

Alan R. Cohen

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Abhaya V. Kulkarni, James M. Drake, John R. W. Kestle, Conor L. Mallucci, Spyros Sgouros and Shlomi Constantini

Object

The authors recently developed and internally validated the ETV Success Score (ETVSS)—a simplified means of predicting the 6-month success rate of endoscopic third ventriculostomy (ETV) for a child with hydrocephalus, based on age, etiology of hydrocephalus, and presence of a previous shunt. A high ETVSS predicts a high chance of early ETV success. In this paper, they assess the clinical utility of the ETVSS by determining whether long-term survival outcomes for ETV versus shunt insertion are different within strata of ETVSS (low, moderate, and high scores).

Methods

A multicenter, international cohort of children (≤ 19 years old) with newly diagnosed hydrocephalus treated with either ETV (489 patients) or shunt insertion (720 patients) was analyzed. The ETVSS was calculated for all patients. Survival analyses with time-dependent modeling of the hazard ratios were performed.

Results

For the High-ETVSS Group (255 ETV-treated patients, 117 shunt-treated patients), ETV appeared to have a lower risk of failure right from the early postoperative phase and became more favorable with time. For the Moderate-ETVSS Group (172 ETV-treated patients, 245 shunt-treated patients), ETV appeared to have a higher initial failure rate, but after about 3 months the instantaneous risk of ETV failure became slightly lower than shunt failure (that is, the hazard ratio became < 1). For the Low-ETVSS Group (62 ETV-treated patients, 358 shunt-treated patients), the early risk of ETV failure was much higher than the risk of shunt failure, but the instantaneous risk of ETV failure became lower than the risk of shunt failure at about 6 months following surgery (the hazard ratio became < 1).

Conclusions

Across all ETVSS strata, the risk of ETV failure becomes progressively lower compared with the risk of shunt failure with increasing time from the surgery. In the best ETV candidates (ETVSS ≥ 80), however, the risk of ETV failure is lower than the risk of shunt failure very soon after surgery, while for less-than-ideal ETV candidates (ETVSS ≤ 70), the risk of ETV failure is initially higher than the risk of shunt failure and only becomes lower after 3–6 months from surgery. These results need to be confirmed by larger, prospective, and preferably randomized studies.

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Richard C. E. Anderson, Peter Kan, Paul Klimo, Douglas L. Brockmeyer, Marion L. Walker and John R. W. Kestle

Object. Intracranial pressure (ICP) monitoring has become routine in the management of patients with traumatic brain injury (TBI). Many surgeons prefer to use external ventricular drains (EVDs) over fiberoptic monitors to measure ICP because of the added benefit of cerebrospinal fluid drainage. The purpose of this study was to examine a consecutive series of children with TBI and compare the incidence of complications after placement of an EVD, a fiberoptic intraparencyhmal monitor, or both.

Methods. A retrospective chart review was conducted to identify children with TBI who met the criteria for insertion of an ICP monitor. All patients underwent head CT scanning on admission and after placement of an ICP monitor.

During a 5-year period 80 children met the criteria for inclusion in the study. Eighteen children (22.5%) underwent EVD placement only, 18 (22.5%) underwent placement of a fiberoptic device only, and 44 (55%) received both. A total of 62 fiberoptic devices (48%) were inserted, and 68 EVDs (52%) were placed. Overall, there was a fourfold increased risk of complications in children who received an EVD compared with those in whom a fiberoptic monitor was placed (p = 0.004). Hemorrhagic complications were detected in 12 (17.6%) of 62 patients who received an EVD compared with four (6.5%) of 62 patients who received a fiberoptic monitor (p = 0.025). Six (8.8%) of 68 EVDs were malpositioned and required replacement; in three (50%) of these cases a hemorrhagic complication occurred. Only one infection was noted in a patient with an EVD (1.5%).

Conclusions. In this retrospective cohort of pediatric patients with TBI, complication rates were significantly higher in those receiving EVDs than in those in whom fiberoptic monitors were placed. Although the majority of these complications did not entail clinical sequelae, surgeons should be aware of the different complication rates when choosing the most appropriate device for each patient.

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Peter Kan, Aminullah Amini, Kristine Hansen, George L. White Jr., Douglas L. Brockmeyer, Marion L. Walker and John R. W. Kestle

Object

Severe traumatic brain injury (TBI) is often accompanied by early death due to transtentorial herniation. Decompressive craniectomy, performed alone or in conjunction with evacuation of the mass lesion, can reduce the incidence of raised intracranial pressure (ICP). In this paper the authors evaluate mortality and morbidity and long-term outcomes in children who underwent decompressive craniectomy for severe TBI at a single institution.

Methods

Children with severe TBI who underwent decompressive craniectomy at the Primary Children’s Medical Center between 1996 and 2005 were identified retrospectively. Descriptive statistics were used to report postoperative mortality and morbidity rates. Long-term recovery in patients who survived was reported using the King’s Outcome Scale for Closed Head Injury (KOSCHI).

Fifty-one children with a mean follow-up period of 18.6 months were identified. Nonaccidental trauma accounted for 23.5% of cases. The mean preoperative Glasgow Coma Scale (GCS) score was 4.6. Six patients underwent decompressive craniectomy for elevated ICP only; all other patients underwent decompressive craniectomy in conjunction with removal of the mass lesion. The mean postoperative GCS score was 9.7, and 69.4% of patients had normal ICP levels immediately after surgery. Sixteen children (31.4%) died, including five of six children who underwent decompressive craniectomy for raised ICP alone. Among surviving patients, 2.9% required a tracheostomy, 11.4% required a gastrostomy, 40% experienced posttraumatic shunt-dependent hydrocephalus, and 20% suffered posttraumatic epilepsy requiring antiepileptic agents. The mean KOSCHI score at the last follow-up examination was 4.5 and the mean time to cranioplasty was 2.3 months.

Conclusions

Posttraumatic hydrocephalus and epilepsy were common complications encountered by children with severe TBI who underwent decompressive craniectomy. In patients who underwent decompressive surgery for raised ICP only, the mortality rate was exceedingly high.

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Randy L. Jensen, Gmaan Alzhrani, John R. W. Kestle, Douglas L. Brockmeyer, Sara M. Lamb and William T. Couldwell

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John R. W. Kestle

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Douglas Kondziolka, Thomas Lemley, John R. W. Kestle, L. Dade Lunsford, Gerhard H. Fromm and Peter J. Jannetta

✓ To evaluate the reported benefit of ipsilateral single-application ophthalmic anesthetic eyedrops in patients with typical trigeminal neuralgia, a randomized double-blind placebo-controlled trial was performed. Forty-seven patients were randomly assigned to receive two drops of either proparacaine (25 cases) or saline placebo (22 cases). The experimental and placebo groups were equivalent in regard to patient age, distribution of trigeminal neuralgia pain, duration of pain, current medication regimens, and number of prior procedures performed. Pain response was assessed at 3, 10, and 30 days after instillation using two pain rating scales and a measure of pain frequency. Treatment failure was defined in advance as any of the following: a lack of clinical response, the need for an increase in medication, or the need for surgery. No significant difference in outcomes was found between the two groups either when using a verbal pain rating scale (p = 0.24) or when comparing overall pain status (unchanged, improved throughout the study period, or temporarily improved) (p = 0.98). No difference in the frequency of trigeminal neuralgia attacks between the two treatment groups (scaled within five levels of pain frequency) was detected (p = 0.09). During follow-up monitoring, 11 patients in the test drug group and 14 in the placebo group required surgery because of persistent pain (p = 0.24). The results of this study indicate that single-application topical ophthalmic anesthesia reduces neither the severity nor the frequency of pain in comparison to placebo administration. Although a simple and safe treatment, the single application of topical ophthalmic eyedrops provides no short- or long-term benefit to patients with trigeminal neuralgia.