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Neil Feldstein


The choice of surgical procedure for decompression of Chiari I malformations is often influenced by the presence of syringomyelia. The goal of this study was to determine if syringomyelia and/or scoliosis are influenced by dural opening versus nondural opening suboccipital decompressive (SOD) procedures.


A retrospective review of 54 pediatric patients over a 13-year period presenting with Chiari I malformation and syringomyelia at time of diagnosis is presented. Between 1994 and 2002 nearly all patients underwent SOD with duraplasty (n = 26), while between 2003 and 2007 nearly all patients underwent SOD without dural opening (n = 28). Sixteen of 26 patients who underwent duraplasty presented with scoliosis while 8 of 28 patients without duraplasty had scoliosis. All of the patients had a complete spinal cord MRI before and after surgery.


MRI studies clearly demonstrated a greater degree of resolution of the syrinx in the duraplasty group. However, the degree of resolution of the syrinx did not correlate with clinical outcome (that is, improvement of symptoms or progression of scoliosis). Progression of scoliosis was rare in either group.


While much controversy exists as to the best method of decompression in patients with Chiari I malformations, it does not appear from this study that dural opening influences the clinical progression of syringomyelia or scoliosis.

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Paul R. Gigante, Neil A. Feldstein and Richard C. E. Anderson

Os odontoideum is a common cause of atlantoaxial instability in the pediatric population. The authors present the cases of 2 patients whose initial clinical presentation and MR imaging findings were suggestive of an intramedullary neoplasm, but whose ultimate diagnosis was determined to be cervical spine instability and cord injury due to os odontoideum.

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Jason A. Ellis, Juan C. Mejia Munne, Neil A. Feldstein and Philip M. Meyers

Sinus pericranii is an uncommon congenital cranial venous malformation that may become symptomatic in the pediatric population. Both dominant and accessory sinus pericranii, as determined by the intracranial venous drainage pattern, have been described. The dominant variety drain a significant proportion of the intracranial venous outflow while the accessory variety have minimal or no role in this. Classic teachings hold that dominant sinus pericranii should never be treated while accessory sinus pericranii may be safely obliterated. This determination of dominance is solely based on a qualitative assessment of standard venous phase catheter cerebral angiography, leaving some doubt regarding the actual safety of obliteration. In this paper the authors describe a simple and unique method for determining whether intracranial venous outflow may be compromised by sinus pericranii treatment. This involves performing catheter angiography while the lesion is temporarily obliterated by external compression. Analysis of intracranial venous outflow in this setting allows visualization of angiographic changes that will occur once the sinus pericranii is permanently obliterated. Thus, the safety of surgical intervention can be more fully appraised using this technique.

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Expansion of arachnoid cysts in children

Report of two cases and review of the literature

Ganesh Rao, Richard C. E. Anderson, Neil A. Feldstein and Douglas L. Brockmeyer

✓Arachnoid cysts are intracranial, space-occupying lesions that typically remain stable in size on serial imaging. The authors describe two cases of rapidly enlarging arachnoid cysts, including one located in the anterior fossa.

In the first case a 7-month-old boy presented with increasing head circumference and a rapidly enlarging arachnoid cyst in the left middle fossa, which had been documented by serial imaging over the preceding 6 months. In the second case a 4-year-old girl presented with an arachnoid cyst compressing the right frontal lobe. The cyst had not been present on imaging studies performed during the perinatal period. In both cases, a craniotomy for open fenestration of the cyst was performed with successful resolution of the mass effect.

Rare cases of expansion of arachnoid cysts have been reported in the literature. In this article the authors report the dramatic enlargement of two arachnoid cysts, including the first description of enlargement of an arachnoid cyst located in the anterior fossa.

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Jason A. Ellis, Paul C. McCormick II, Neil A. Feldstein and Saadi Ghatan


Cystic lesions in the atrium (trigone) of the lateral ventricle may become symptomatic due to obstruction of physiological CSF circulation and/or from mass effect on adjacent structures. A minimally invasive approach that not only allows for straightforward access to multiple regions of the atrial cyst wall, but also enables direct inspection of the entire lateral ventricular system, has not been elaborated. In this paper the authors describe their experience with the endoscopic transoccipital horn approach for treating cystic lesions in the atrium of the lateral ventricle.


A retrospective review was performed of all patients who underwent endoscopic surgical treatment for cysts in the atrium of the lateral ventricle between 1999 and 2014.


The cohort consisted of 13 consecutive patients who presented with symptomatic lateral ventricular entrapment due to the presence of an atrial cyst. There were 9 male and 4 female patients, with a median age of 5 years. Headache was the most common complaint at presentation. The transoccipital horn approach facilitated successful cyst reduction and fenestration in all cases. Temporal and occipital horn entrapment was reversed in all cases, with reestablishment of a physiological CSF flow pattern throughout the ventricles. Hydrocephalus was also reversed in all patients presenting with this neuroimaging finding at presentation. No cyst or ventricular entrapment was noted to recur during a mean follow-up period of 36 months. No patient in the study cohort required repeat surgery or permanent CSF diversion postoperatively.


The endoscopic transoccipital horn approach represents a safe and effective treatment strategy for patients with symptomatic atrial cysts of the lateral ventricle. Using this minimally invasive technique, all poles of the lateral ventricular system can be visualized and the unobstructed flow of CSF can be confirmed after cyst resection obviating the need for additional diversion.

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Hannah E. Goldstein, Neil A. Feldstein and Richard C. E. Anderson

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Alfred T. Ogden, Neil A. Feldstein and Paul C. McCormick

Although there has been considerable experience with anterior approaches to ventral intradural, extramedullary, and pial-based spinal lesions, there is no information in the literature regarding the safety and feasibility of the resection of an intramedullary tumor via an anterior approach. The authors report on the gross-total resection of an intramedullary cervical pilocytic astrocytoma via a C-7 corpectomy and anterior myelotomy. The surgery proceeded without complication, and postoperatively the patient maintained the preoperative deficit of mild unilateral hand weakness but had no sensory deficits. Follow-up MR imaging at 6 months showed gross-total macroscopic resection. Selected intramedullary tumors can be safely removed via an anterior approach. This approach avoids the typical sensory dysfunction associated with posterior midline myelotomy.

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Todd C. Hankinson, Elizabeth J. Fontana, Richard C. E. Anderson and Neil A. Feldstein

The traditional reasons for surgical intervention in children with single-suture craniosynostosis (SSC) are cosmetic improvement and the avoidance/treatment of intracranial hypertension, which has been thought to contribute to neurocognitive deficits. Despite considerable work on the topic, the exact prevalence of intracranial hypertension in the population of patients with SSC is unknown, although it appears to be present in only a minority. Additionally, recent neuropsychological and anatomical literature suggests that the subtle neurocognitive deficits identified in children with a history of SSC may not result from external compression. They may instead reflect an underlying developmental condition that includes disordered primary CNS development and early suture fusion. This implies that current surgical techniques are unlikely to prevent neurocognitive deficits in patients with SSC. As such, the most common indication for surgical treatment in SSC is cosmetic, and most patients benefit from considerable subjective cosmetic normalization following surgery. Pediatric craniofacial surgeons have not, however, agreed upon objective means to assess postoperative cranial morphological improvement. We should therefore endeavor to agree upon objective craniometric tools for the assessment of operative outcomes, allowing us to accurately compare the various surgical techniques that are currently available.

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Ilya Laufer, Murray Engel, Neil Feldstein and Mark M. Souweidane

✓Chiari malformations may present with a wide range of symptoms and signs. Nevertheless, focal foot weakness as a presentation of a Chiari malformation has not been described in the pediatric neurosurgical literature. Two children with Chiari malformations and holocord syringomyelia presented with manifestations of a supposed isolated lumbar radiculopathy. Neurological deficits completely resolved after decompressive suboccipital craniectomy and cervical laminectomy. These cases emphasize the importance of imaging the entire craniospinal axis and avoidance of therapeutic intervention specifically aimed at a radiculopathic process when initial imaging fails to show a structural abnormality at the spinal level of deficit. The possible pathophysiological origins for this unusual presentation are discussed. Based on the experience gained with these patients, recommendations are made regarding the diagnostic workup and management of this entity in children presenting with focal deficits that are not supported by imaging of the affected root levels. Chiari malformations may rarely masquerade as lower motor and sensory deficits, and appropriate treatment may result in excellent recovery of function.

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Omar N. Syed, Todd C. Hankinson, William J. Mack, Neil A. Feldstein and Richard C. E. Anderson

Pediatric neurosurgeons frequently care for children with traumatic scalp and skull injury. Foreign objects are often observed on imaging and may influence the clinician's decision-making process. The authors report on 2 cases of poorly visualized hair beads that had become embedded into the skull during blunt trauma. In both cases, skull radiography and CT scanning demonstrated depressed, comminuted fractures with poorly demonstrated spherical radiolucencies in the overlying scalp. The nature of these objects was initially unclear, and they could have represented air that entered the scalp during trauma. In one case, scalp inspection demonstrated no evidence of the bead. In the other case, a second bead was observed at the site of scalp laceration. In both cases, the beads were surgically removed, the fractures were elevated, and the patients recovered uneventfully. Radiolucent fashion accessories, such as hair beads, may be difficult to appreciate on clinical examination and may masquerade as clinically insignificant air following cranial trauma. If they are not removed, these foreign bodies may pose the risk of an infection. Pediatric neurosurgeons should consider hair accessories in the differential diagnosis of foreign bodies that may produce skull fracture following blunt trauma.