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Paul Klimo Jr. and Liliana C. Goumnerova


The authors retrospectively reviewed the charts of all patients harboring brainstem tumors treated at their institution, excluding those with tectal gliomas, who underwent an endoscopic third ventriculocisternostomy.


Endoscopic third ventriculocisternostomy was performed in 13 patients with tumors involving the brainstem: nine patients with diffuse pontine gliomas, two with posterior fossa ependymomas, one with a cervicomedullary tumor, and one with a pontine primitive neuroectodermal tumor. No technical difficulties attributable to the location of the tumors or surgery-related complications were encountered. Immediate symptomatic relief of hydrocephalus was achieved in all patients, and there was an associated decrease in steroid and analgesic agent requirements. Only one patient eventually required a shunt.


Endoscopic third ventriculocisternostomy can be used in the terminal treatment of patients with brainstem tumors, yielding good results without significant surgical morbidity.

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Paul Klimo Jr. and Richard H. Schmidt

✓The elucidation of predictive factors of cerebral vasospasm following aneurysmal subarachnoid hemorrhage (SAH) is a major area of both clinical and basic science research. It is becoming clear that many factors contribute to this phenomenon. The most consistent predictor of vasospasm has been the amount of SAH seen on the postictal computed tomography scan. Over the last 30 years, it has become clear that the greater the amount of blood within the basal cisterns, the greater the risk of vasospasm. To evaluate this risk, various grading schemes have been proposed, from simple to elaborate, the most widely known being the Fisher scale. Most recently, volumetric quantification and clearance models have provided the most detailed analysis. Intraventricular hemorrhage, although not supported as strongly as cisternal SAH, has also been shown to be a risk factor for vasospasm.

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Paul Klimo Jr. and John R. W. Kestle

✓The choice of outcome (or outcomes) and their measurement are critical for a sound clinical trial. Surgeons have traditionally measured simple outcomes such as death, duration of survival, or tumor recurrence but have recently developed more sophisticated measures of the effect of an intervention. Many outcome measures require a lengthy maturation process, which includes a determination of the instrument's validity, reliability, and sensitivity; thus, using established instruments rather than creating new ones is recommended. The authors illustrate several guidelines for the determination of appropriate outcome measures by using examples from their experience and describe several outcome measures that can be used in pediatric neurosurgery. These include general outcome measures such as the Pediatric Evaluation of Disability Inventory and the Functional Independence Measure for Children, which measure physical function and independence in chronically ill and disabled children as well as disease-specific measures for hydrocephalus (Hydrocephalus Outcome Questionnaire), cerebral palsy (gross motor function and performance measures), head injury (Pediatric Cerebral Performance Category and Children's Coma Scale), and oncology (Pediatric Cancer Quality-of-Life Inventory).

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Scott Boop, Mary Axente, Blakely Weatherford and Paul Klimo Jr.


Research on pediatric abusive head trauma (AHT) has largely focused on clinical presentation and management. The authors sought to review a single-institution experience from a public health perspective to gain a better understanding of the local population affected, determine overall incidence and seasonal trends, and provide details on the initial hospitalization, including extent of injuries, neurosurgical interventions, and hospital charges.


All cases of AHT involving patients who presented to Le Bonheur Children's Hospital (LBCH) from 2009 through 2014 were identified. AHT was defined as skull fracture or intracranial hemorrhage in a child under the age of 5 years with a suspicious mechanism or evidence of other intentional injuries, such as retinal hemorrhages, old or new fractures, or soft-tissue bruising. Injuries were categorized as Grade I (skull fracture only), Grade II (intracranial hemorrhage or edema not requiring surgical intervention), or Grade III (intracranial hemorrhage requiring intervention or death due to brain injury).


Two hundred thirteen AHT cases were identified. The demographics of the study population are similar to those reported in the literature: the majority of the patients involved were 6 months of age or younger (55%), male (61%), African American (47%), and publicly insured (82%). One hundred one neurosurgical procedures were performed in 58 children, with the most common being bur hole placement for treatment of subdural collections (25%) and decompressive hemicraniectomy (22%). The annual incidence rate rose from 2009 (19.6 cases per 100,000 in the population under 5 years of age) to 2014 (47.4 cases per 100,000) and showed seasonal peaks in January, July, and October (6-year average single-month incidence, respectively, 24.7, 21.7, and 24.7 per 100,000). The total hospital charges were $13,014,584, with a median cost of $27,939. Treatment costs for children who required surgical intervention (i.e., those with Grade III) were up to 10 times those of children with less severe injuries.


In the authors' local population, victims of AHT are overwhelmingly infants, are more often male than female, and are disproportionately from lower socioeconomic ranks. The incidence is increasing and initial hospitalization charges are substantial and variable. The authors introduce a simple 3-tiered injury classification scheme that adequately stratifies length of hospital stay and cost.

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Ruchira M. Jha, Paul Klimo Jr. and Edward R. Smith

Achondroplasia has a known association with foramen magnum stenosis that can result in cervicomedullary compression, which is most often due to a hypertrophied posterior occipital rim and an undersized transverse diameter. The authors present a unique case of a child with achondroplasia with symptomatic craniocervical compression from marked overgrowth of his opisthion anterior to the posterior arch of the atlas. This 22-month-old child with achondroplasia presented with severe respiratory and motor disabilities, including progressive quadriparesis and apneic episodes requiring continuous positive airway pressure. Magnetic resonance imaging and CT scans revealed marked foramen magnum stenosis from overgrowth of the opisthion, a hypoplastic C-1 ring, and spinal cord edema at the cervicomedullary junction. Foramen magnum decompression and a C-1 laminectomy were performed. Postoperatively, steady motor improvement has been observed and the patient no longer requires ventilatory support. To the authors' knowledge, this is the first report of this unusual anatomical entity.

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Paul Klimo Jr., Richard C. E. Anderson and Douglas L. Brockmeyer

✓Two cases of a previously undescribed cervical spinal anomaly distinct from cervical spondylolysis are presented. The authors report the first detailed description of a congenital vertebral anomaly characterized by multilevel cervical spondylolysis, sagittal deformity, and spinal cord compression. The sine qua non of the condition is a lack of communication between the anterior and posterior columns of the cervical spinal canal, which may occur over several vertebral levels. A kyphotic deformity of the anterior column occurs, whereas the posterior column may have relatively normal alignment. The underlying biomechanical stresses caused by the anterior–posterior column disconnection result in spinal instability and progressive kyphotic deformity, often to a profound degree. Two children, 2 and 3 years of age, presented with congenital multilevel disconnection and myelopathy. In the first stage of treatment, each underwent an anterior decompression, reduction, and reconstruction of the involved segments. This was followed by posterior stabilization and fusion as a separate procedure. In both patients, the myelopathy improved and a solid, circumferential fusion was achieved. The authors’ success in treating these patients indicates that management of these conditions can be based on the principles of deformity correction, spinal cord decompression, and combined anterior–posterior arthrodesis.