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Jordan S. Terner, Roberto Travieso, Su-shin Lee, Antonio J. Forte, Anup Patel and John A. Persing

superimposed deformational plagiocephaly. D and E: Frontal (D) and lateral (E) views of a patient with combined sagittal and metopic craniosynostosis showing a deceivingly less severe–appearing deformity. In the normal pediatric skull, ICV, BTV, and CSF volume continually increase through early childhood. Yet, this increase is most rapid during the first 2.5 years of life, allowing the brain to reach more than 80% of its adult size in this period. Untreated craniosynostosis may lead to an inhibition of brain growth and in some cases an increase in intracranial

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Richard P. Menger, Piyush Kalakoti, Andrew J. Pugely, Anil Nanda and Anthony Sin

initial hospitalization is critical to the delivery of pediatric spinal care. To our knowledge, a comprehensive analysis has not previously been performed of the modifiable and nonmodifiable risk factors associated with the outcomes of initial hospitalization in adolescent patients undergoing deformity correction for idiopathic scoliosis using a large administrative cohort. Further, a thorough assessment of the effect of hospital surgical volume on outcomes is needed for AIS surgery. In the present study, we seek to evaluate hospital and patient factors related to

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Bianca Francisca Maria Rijken, Bianca Kelly den Ottelander, Marie-Lise Charlotte van Veelen, Maarten Hans Lequin and Irene Margreet Jacqueline Mathijssen

mutation has been found, are called complex cases. 18 , 19 The treatment of craniosynostosis consists of skull vault surgery. This procedure is performed to prevent or to treat elevated intracranial pressure (ICP) by enlarging the intracranial volume (ICV). Surgery is preferably performed within 1 year after birth, because the risk of developing raised ICP is higher when the operation is performed later in life. 24 Furthermore, the mental outcome is better compared with patients who undergo a cranial vault expansion later in life. 24 Moreover, the skull deformity is

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Bahram Mokri

Cerebrospinal fluid (CSF) volume depletion, due to CSF leakage or CSF shunt overdrainage, is typically indicated when patients present with orthostatic headaches, with or without several other symptoms: neck or interscapular pain, nausea, emesis, diplopia, changes in hearing, visual blurring, facial numbness or weakness, and radicular upper-limb symptoms. Cerebrospinal fluid pressures typically are quite low and head magnetic resonance images typically reveal diffuse pachy-meningeal gadolinium enhancement, with or without evidence of sagging of the brain and less frequently with subdural fluid collections, enlarged cerebral venous sinuses or pituitary gland or decreased ventricular size.

Magnetic resonance imaging has revolutionized detection of spontaneous CSF leaks, leading to identification of far more cases and recognition of several clinical/imaging forms of presentation of the disorder. These forms, which are different from the “typical” presentation, include a group with consistently normal CSF pressures (normal pressure), another group without abnormal meningeal enhancement (normal meninges), and a group without headache (acephalic). Each of these forms can be seen in a setting of documented and ongoing CSF volume depletion. Awareness of CSF volume depletion is increasing, and its clinical and imaging spectrum is broadening.

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Barbara J. Fisher, Glenn S. Bauman, Christopher E. Leighton, Larry Stitt, J. Gregory Cairncross and David R. Macdonald

Object

The authors conducted a retrospective review to examine and document the frequency, degree, and timing of the radiologically confirmed response to radiotherapy of low-grade gliomas in children.

Methods

Between 1963 and 1995, 80 patients 17 years of age or younger were referred to the London Regional Cancer Centre in London, Ontario, after diagnosis of a low-grade glioma. All patients underwent surgical resection or biopsy procedures and 47 underwent radiotherapy (40 postoperatively and seven at the time of tumor progression). Nineteen patients with residual measurable lesions who received radiation therapy were selected for volumetric analysis of tumor response to this treatment. The extent and timing of response to radiation were determined by the process of comparing postoperative, preirradiation computerized tomography (CT) scans with postirradiation, follow-up CT scans. For one patient the comparison was made by using serial magnetic resonance images.

Residual tumor was found on postoperative CT scans in all cases. The mean preradiotherapy tumor volume was 17.1 cm3, and the postradiotherapy volume was reduced to a mean of 11.5 cm3. A reduction in tumor was demonstrated in eight patients by the time of their first postirradiation follow-up CT scan and in two patients a slower reduction in volume over time was shown, bringing the total number of "responders" to 10. In five of these 10 patients the tumor had shown a maximum response by the time of the first postirradiation CT scan; the median time to response was 3.3 months. A 25% or greater reduction in tumor volume was seen in eight (42%) of the 19 patients. A 50% or greater reduction was noted in five (26%) of the patients. A complete response was demonstrated at 7, 12, and 15 months, and 5 years, respectively, in four patients (21%). One responder's tumor eventually increased in size after radiotherapy and he died of his disease.

The magnitude of the radiographically demonstrated response to radiation did not correlate significantly with clinical outcome (that is, survival or symptom improvement).

Conclusions

On the basis of this CT scan analysis of the response of low-grade gliomas in children to radiotherapy, the authors suggest that these lesions respond to radiation, as demonstrated by tumor shrinkage on serial imaging. Major or complete responses occur occasionally. However, low-grade gliomas in children mimic other benign brain tumors such as pituitary adenomas and meningiomas in that, although growth is frequently arrested after radiotherapy, residual tumor can persist for many years, illustrating that tumor shrinkage may not be a good measure of treatment efficacy.

Nevertheless, radiation therapy can result in improvement of clinical symptomatology in association with or independent of visible tumor reduction. As radiation treatment techniques become increasingly conformal and because studies indicate that lower doses of radiation may be equally effective, improvement of symptoms may be an important consideration when weighing treatment options, particularly in patients with residual or unresectable disease.

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Moritz Scherer, Christine Jungk, Alexander Younsi, Philipp Kickingereder, Simon Müller and Andreas Unterberg

procedures have been included in a prospective registry containing clinical and surgical as well as volumetric data. As a general principle, a maximal safe tumor resection with preservation of neurological and functional integrity is aspired to. A mainstay of the iMRI registry is the prospective definition of the goal of surgery, along with a volumetric definition of target resection volume prior to each procedure. We identified 224 consecutive iMRI-guided glioma resections (WHO Grades I–IV) in 210 patients from our registry who were treated between January 2011 and

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Ahmed Rawanduzy, Anker Hansen, Thomas W. Hansen and Maiken Nedergaard

Several lines of evidence indicate that the extent of ischemic injury is not defined immediately following arterial occlusion; rather that infarction expands over time. Episodes of spreading depression have been linked to this secondary increase in infarct volume. Tissue bordering the infarct fails to repolarize following spreading depression and is incorporated into the infarction. The result is that ischemic infarcts expand stepwise following each episode of spreading depression. Another line of evidence has demonstrated that gap junction blockers effectively inhibit spreading depression.

These observations suggest that the efflux of potentially harmful cytosolic messengers from ischemic cells into surrounding nonischemic cells might cause amplification of injury in focal stroke. It is therefore conceivable that minimizing gap junction permeability might reduce final infarct volume. To test this hypothesis, the authors pretreated rats with the gap junction blocker, octanol, before occluding the middle cerebral artery and compared the sizes of the ischemic lesions to those in rats that received vehicle dimethyl sulfoxide prior to arterial occlusion. Histopathological analysis was performed 24 hours later. The 12 octanol-treated animals showed a significantly decreased mean infarction volume (80 ± 16 mm3) compared with the nine control rats (148 ± 9 mm3). In a separate set of experiments, the frequency of experimentally induced waves of spreading depression was evaluated following octanol treatment. Octanol pretreatment resulted in complete inhibition in two of nine animals, transient inhibition in five of nine, and no inhibition in two of nine.

The results indicate that gap junction inhibitors, when not limited by toxicity, have significant therapeutic potential in the treatment of acute stroke.

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Piyush Kalakoti, Osama Ahmed, Papireddy Bollam, Symeon Missios, Jessica Wilden and Anil Nanda

a diversity of practice settings, we used the National (Nationwide) Inpatient Sample (NIS), a prospective hospital discharge database representing a random, validated sample of all inpatient admissions to nonfederal hospitals in the US. We identified independent predictors associated with adverse short-term outcomes in patients undergoing DBS procedures for 3 primary movement disorders: essential tremor, PD, and dystonia. Additionally, we investigated the effect of hospital caseload volume on outcomes following DBS. To our knowledge, this study provides the latest

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Sumeet Vadera, Alvin Y. Chan, Lilit Mnatsankanyan, Mona Sazgar, Indranil Sen-Gupta, Jack Lin and Frank P. K. Hsu

provide access to surgery for patients with medically refractory epilepsy. Preoperative workups were performed by the referring neurologist, and cases were presented via video-teleconference during a dedicated epilepsy surgery conference. We sought to examine how these partnerships affected patient access to surgery and what impact this had upon institutional profitability as well as to provide a model by which other institutions may increase epilepsy surgical volume. Methods Strategic Partnership The National Association of Epilepsy Centers (NAEC) designated the

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Piyush Kalakoti, Symeon Missios, Richard Menger, Sunil Kukreja, Subhas Konar and Anil Nanda

across the United States. Using this database, we identified independent associations of patient- and hospital-related characteristics with inpatient outcomes in patients who underwent resection for benign intradural spinal tumors. In addition, we explored the effect of hospital case volume on inpatient outcomes after resection of intradural spine tumors. Methods Data Source The NIS, the largest publicly available all-payer database, developed for the Healthcare Cost and Utilization Project (HCUP) by the Agency of Healthcare Research and Quality in Rockville