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Chesney KM, Keating GF, Patel N, Kilburn L, Fonseca A, Wu CC, Nazarian J, Packer RJ, Donoho DA, Oluigbo C, Myseros JS, Keating RF, Syed HR. The role of focused ultrasound for pediatric brain tumors: current insights and future implications on treatment strategies. Childs Nerv Syst 2024:10.1007/s00381-024-06413-9. [PMID: 38702518 DOI: 10.1007/s00381-024-06413-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 04/14/2024] [Indexed: 05/06/2024]
Abstract
INTRODUCTION Focused ultrasound (FUS) is an innovative and emerging technology for the treatment of adult and pediatric brain tumors and illustrates the intersection of various specialized fields, including neurosurgery, neuro-oncology, radiation oncology, and biomedical engineering. OBJECTIVE The authors provide a comprehensive overview of the application and implications of FUS in treating pediatric brain tumors, with a special focus on pediatric low-grade gliomas (pLGGs) and the evolving landscape of this technology and its clinical utility. METHODS The fundamental principles of FUS include its ability to induce thermal ablation or enhance drug delivery through transient blood-brain barrier (BBB) disruption, emphasizing the adaptability of high-intensity focused ultrasound (HIFU) and low-intensity focused ultrasound (LIFU) applications. RESULTS Several ongoing clinical trials explore the potential of FUS in offering alternative therapeutic strategies for pathologies where conventional treatments fall short, specifically centrally-located benign CNS tumors and diffuse intrinsic pontine glioma (DIPG). A case illustration involving the use of HIFU for pilocytic astrocytoma is presented. CONCLUSION Discussions regarding future applications of FUS for the treatment of gliomas include improved drug delivery, immunomodulation, radiosensitization, and other technological advancements.
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Affiliation(s)
- Kelsi M Chesney
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Gregory F Keating
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Nirali Patel
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Lindsay Kilburn
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
| | - Adriana Fonseca
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
| | - Cheng-Chia Wu
- Department of Radiation Oncology, Columbia University Irving Medical Center, New York, NY, USA
| | - Javad Nazarian
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
| | - Roger J Packer
- Brain Tumor Institute, Children's National Hospital, Washington, DC, USA
| | - Daniel A Donoho
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Chima Oluigbo
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - John S Myseros
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Hasan R Syed
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA.
- Department of Neurosurgery, George Washington University School of Medicine & Health Sciences, Washington, DC, USA.
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Patel N, Marino A, Tang T, Chesney K, Bryant JP, Robison T, Keating RF, Myseros JS, Syed HR. Evolution of surgical management of pineal region tumors in the pediatric population: a 17-year experience at a single institution. Pediatr Neurosurg 2024:000538745. [PMID: 38679003 DOI: 10.1159/000538745] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 03/29/2024] [Indexed: 05/01/2024]
Abstract
INTRODUCTION Pineal-region tumors have historically been challenging to treat. Advances in surgical techniques have led to significant changes in care and outcomes for these patients and this is well demonstrated by our single institution's experience over a 17-year-period in which the evolution of diagnosis, treatment, and outcomes of pineal tumors in pediatric patients will be outlined. METHODS We retrospectively collected data on all pediatric patients with pineal region lesions treated with surgery at Children's National Hospital (CNH) from 2005-2021. Variables analyzed included presenting symptoms, presence of hydrocephalus, diagnostic and surgical approach, pathology, and adverse events, among others. IRB approval was obtained (IRB: STUDY00000009), and consent was waived due to minimal risk to patients included. RESULTS A total of 43 pediatric patients with pineal region tumors were treated during a 17-year period. Most tumors in our series were germinomas (n=13, 29.5%) followed by pineoblastomas (n=10, 22.7%). 27 of the 43 patients (62.8%) in our series received a biopsy to establish diagnosis, and 44.4% went on to have surgery for resection. The most common open approach was posterior-interhemispheric (PIH, transcallosal) - used for 59.3% of the patients. Gross total resection was achieved in 50%; recurrence occurred in 20.9% and mortality in 11% over a median follow-up of 47 months. Endoscopic third ventriculostomy (ETV) was employed to treat hydrocephalus in 26 of the 38 patients (68.4%) and was significantly more likely to be performed from 2011-2021. Most (73%) of the patients who received an ETV also underwent a concurrent endoscopic biopsy. No difference was found in recurrence rate or mortality in patients who underwent resection compared to those who did not, but complications were more frequent with resection. There was disagreement between frozen and final pathology in 18.4% of biopsies. CONCLUSION This series describes the evolution of surgical approaches and outcomes over a 17-year-period at a single institution. Complication rates were higher with open resection, reinforcing the safety of pursuing endoscopic biopsy as an initial approach. The most significant changes occurred in the preferential use of ETVs over ventriculoperitoneal shunts. Though there has been a significant evolution in our understanding of and treatment for these tumors, in our series, the outcomes for these patients have not significantly changed over that time.
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Yahanda AT, Koueik J, Ackerman LL, Adelson PD, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Bierbrauer K, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jallo GI, Johnston JM, Kaufman BA, Keating RF, Khan NR, Krieger MD, Leonard JR, Maher CO, Mangano FT, Martin J, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer MS, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Tyler-Kabara EC, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD, Ahmed R. The role of occipital condyle and atlas anomalies on occipital cervical fusion outcomes in Chiari malformation type I with syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2024:1-9. [PMID: 38579359 DOI: 10.3171/2024.1.peds23229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 01/30/2024] [Indexed: 04/07/2024]
Abstract
OBJECTIVE Congenital anomalies of the atlanto-occipital articulation may be present in patients with Chiari malformation type I (CM-I). However, it is unclear how these anomalies affect the biomechanical stability of the craniovertebral junction (CVJ) and whether they are associated with an increased incidence of occipitocervical fusion (OCF) following posterior fossa decompression (PFD). The objective of this study was to determine the prevalence of condylar hypoplasia and atlas anomalies in children with CM-I and syringomyelia. The authors also investigated the predictive contribution of these anomalies to the occurrence of OCF following PFD (PFD+OCF). METHODS The authors analyzed the prevalence of condylar hypoplasia and atlas arch anomalies for patients in the Park-Reeves Syringomyelia Research Consortium database who underwent PFD+OCF. Condylar hypoplasia was defined by an atlanto-occipital joint axis angle (AOJAA) ≥ 130°. Atlas assimilation and arch anomalies were identified on presurgical radiographic imaging. This PFD+OCF cohort was compared with a control cohort of patients who underwent PFD alone. The control group was matched to the PFD+OCF cohort according to age, sex, and duration of symptoms at a 2:1 ratio. RESULTS Clinical features and radiographic atlanto-occipital joint parameters were compared between 19 patients in the PFD+OCF cohort and 38 patients in the PFD-only cohort. Demographic data were not significantly different between cohorts (p > 0.05). The mean AOJAA was significantly higher in the PFD+OCF group than in the PFD group (144° ± 12° vs 127° ± 6°, p < 0.0001). In the PFD+OCF group, atlas assimilation and atlas arch anomalies were identified in 10 (53%) and 5 (26%) patients, respectively. These anomalies were absent (n = 0) in the PFD group (p < 0.001). Multivariate regression analysis identified the following 3 CVJ radiographic variables that were predictive of OCF occurrence after PFD: AOJAA ≥ 130° (p = 0.01), clivoaxial angle < 125° (p = 0.02), and occipital condyle-C2 sagittal vertical alignment (C-C2SVA) ≥ 5 mm (p = 0.01). A predictive model based on these 3 factors accurately predicted OCF following PFD (C-statistic 0.95). CONCLUSIONS The authors' results indicate that the occipital condyle-atlas joint complex might affect the biomechanical integrity of the CVJ in children with CM-I and syringomyelia. They describe the role of the AOJAA metric as an independent predictive factor for occurrence of OCF following PFD. Preoperative identification of these skeletal abnormalities may be used to guide surgical planning and treatment of patients with complex CM-I and coexistent osseous pathology.
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Affiliation(s)
| | - Joyce Koueik
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Laurie L Ackerman
- 3Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - P David Adelson
- 4Department of Neurosurgery, West Virginia University School, Morgantown, West Virginia
| | - Gregory W Albert
- 5Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Philipp R Aldana
- 6Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- 7Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | | | - David F Bauer
- 9Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | | | - Karin Bierbrauer
- 10Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Douglas L Brockmeyer
- 11Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- 12Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, Georgia
| | - Daniel E Couture
- 13Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- 14Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Brian J Dlouhy
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Susan R Durham
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Richard G Ellenbogen
- 17Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- 18Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Herbert E Fuchs
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Gerald A Grant
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Patrick C Graupman
- 20Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- 21Divsion of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- 22Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Naina L Gross
- 23Warren Clinic Pediatric Neurosurgery, Saint Francis Health System, Tulsa, Oklahoma
| | - Daniel J Guillaume
- 24Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 25Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Gregory G Heuer
- 26Division of Pediatric Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - Mark Iantosca
- 27Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, Pennsylvania
| | - Bermans J Iskandar
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - George I Jallo
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - James M Johnston
- 30Department of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Bruce A Kaufman
- 31Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Robert F Keating
- 32Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus R Khan
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Mark D Krieger
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | - Jeffrey R Leonard
- 34Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Cormac O Maher
- 35Department of Neurosurgery, Stanford University, Palo Alto, California
| | - Francesco T Mangano
- 10Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Jonathan Martin
- 36Department of Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut
| | - J Gordon McComb
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, USC Keck School of Medicine, Los Angeles, California
| | | | | | - Arnold H Menezes
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael S Muhlbauer
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, Tennessee
| | - Brent R O'Neill
- 25Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Chevis N Shannon
- 41American Society for Reproductive Medicine, Birmingham, Alabama
| | - Joshua S Shimony
- 42Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Scellig S D Stone
- 43Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | | | - Mandeep S Tamber
- 44Division of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - James C Torner
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gerald F Tuite
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | | | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - John C Wellons
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - William E Whitehead
- 9Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | | | | | - Raheel Ahmed
- 2Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
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Patel N, Rock M, Dowlati E, Phan T, Sanchez CE, Myseros JS, Oluigbo C, Syed HR, Donoho DA, Keating RF. Socioeconomic Disparities Affecting the Presentation and Outcomes in Pediatric Subdural Empyema Patients. Neurosurgery 2024; 94:764-770. [PMID: 37878410 DOI: 10.1227/neu.0000000000002741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 06/12/2023] [Indexed: 10/27/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Pediatric subdural empyemas (SDE) carry significant morbidity and mortality, and prompt diagnosis and treatment are essential to ensure optimal outcomes. Nonclinical factors affect presentation, time to diagnosis, and outcomes in several neurosurgical conditions and are potential causes of delay in presentation and treatment for patients with SDE. To evaluate whether socioeconomic status, race, and insurance status affect presentation, time to diagnosis, and outcomes for children with subdural empyema. METHODS We conducted a retrospective cohort study with patients diagnosed with SDE between 2005 and 2020 at our institution. Information regarding demographics (age, sex, zip code, insurance status, race/ethnicity) and presentation (symptoms, number of prior visits, duration of symptoms) was collected. Outcome measures included mortality, postoperative complications, length of stay, and discharge disposition. RESULTS 42 patients were diagnosed with SDE with a mean age of 9.5 years. Most (85.7%) (n = 36) were male ( P = .0004), and a majority, 28/42 (66.7%), were African American ( P < .0001). There was no significant difference in socioeconomic status based on zip codes, although a significantly higher number of patients were on public insurance ( P = .015). African American patients had a significantly longer duration of symptoms than their Caucasian counterparts (8.4 days vs 1.8 days P = .0316). In total, 41/42 underwent surgery for the SDE, most within 24 hours of initial neurosurgical evaluation. There were no significant differences in the average length of stay. The average length of antibiotic duration was 57.2 days and was similar for all patients. There were no significant differences in discharge disposition based on any of the factors identified with most of the patients (52.4%) being discharged to home. There was 1 mortality (2.4%). CONCLUSION Although there were no differences in outcomes based on nonclinical factors, African American men on public insurance bear a disproportionately high burden of SDE. Further investigation into the causes of this is warranted.
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Affiliation(s)
- Nirali Patel
- Department of Neurosurgery, Children's National Hospital, Washington , District of Columbia , USA
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Magge SN, Fotouhi AR, Allhusen V, Collett BR, Skolnick GB, Naidoo SD, Smyth MD, Keating RF, Vyas R, Rogers GF, Patel KB. Cognitive Outcomes of Children With Sagittal Craniosynostosis Treated With Either Endoscopic or Open Calvarial Vault Surgery. JAMA Netw Open 2024; 7:e248762. [PMID: 38683606 PMCID: PMC11059043 DOI: 10.1001/jamanetworkopen.2024.8762] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 02/29/2024] [Indexed: 05/01/2024] Open
Abstract
Importance Several studies have reported a higher incidence of neurodevelopmental delays and cognitive deficits in patients with single-suture craniosynostosis; however, there are few studies examining the associations of repair type with cognitive outcomes. Objective To measure differences in neuropsychological outcomes between school-age children who were treated for sagittal craniosynostosis and unaffected controls and explore differences in cognitive function among children with sagittal craniosynostosis who were previously treated with either endoscopic strip craniectomy or open calvarial vault surgery. Design, Setting, and Participants This cohort study was performed between 2018 and 2022. Eligible participants included patients aged 5 to 17 years who had previously been seen as infants or toddlers (<3 years) at 1 of 3 surgical centers for craniosynostosis repair with either endoscopic surgery or open calvarial vault surgery. A separate cohort of unaffected controls were included for comparison. Data analysis was conducted from November 2023 to February 2024. Exposures Open calvarial vault surgery or endoscopic repair for single-suture craniosynostosis. Main Outcomes and Measures The primary outcome was the Differential Ability Scales-II (DAS-II) General Conceptual Ability (GCA) score, an index for overall intellectual ability. Secondary outcomes included DAS-II subscale scores (Verbal Ability, Nonverbal Reasoning, Spatial Ability, Working Memory, and Processing Speed), and Patient-Reported Outcomes Measurement Information System (PROMIS) cognitive function scores. Results A total of 81 patients with sagittal craniosynostosis (59 male [73%]; 22 female [27%]) and 141 controls (81 male [57%]; 60 female [43%]) were included. Of the 81 participants with sagittal craniosynostosis, 46 underwent endoscopic repair and 35 underwent open repair. Median (range) age at time of follow-up assessment was 7.7 (5.0-14.8) years for children with sagittal craniosynostosis and median age at assessment was 8.5 (7.7-10.5) years for controls. After controlling for age at assessment, sex, and socioeconomic status, there was no statistically significant or clinically meaningful difference in GCA scores between children who underwent endoscopic repair (adjusted mean score, 100; 95% CI, 96-104) and open repair (adjusted mean score, 103; 95% CI, 98-108) (P > .99). We found no significant difference in PROMIS scores between repair types (median [range] for endoscopic repair 54 [31-68] vs median [range] for open repair 50 [32-63]; P = .14). When comparing the treatment groups with the unaffected controls, differences in subscale scores for GCA and working memory were observed but were within normal range. Conclusions and Relevance In this cohort study, there were no statistically or clinically significant differences in cognitive outcomes among school-age children by and type of surgical procedure used to repair nonsyndromic sagittal craniosynostosis. These findings suggest primary care clinicians should be educated about different options for craniosynostosis surgery to ensure early referral of these patients so that all treatment options remain viable.
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Affiliation(s)
- Suresh N. Magge
- Department of Neurosurgery, University of Michigan, Ann Arbor
- Division of Neurosurgery, Children’s Hospital of Orange County Neuroscience Institute, Children’s Hospital of Orange County, Orange, California
- Division of Neurosurgery, Children’s National Hospital, Washington, DC
| | - Annahita R. Fotouhi
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
- College of Medicine, University of Kentucky, Lexington
| | - Virginia Allhusen
- Children’s Hospital of Orange County Research Institute, Orange, California
| | - Brent R. Collett
- Center for Child Health, Behavior, and Development, Seattle Children’s Research Institute, Seattle, Washington
| | - Gary B. Skolnick
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Sybill D. Naidoo
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
| | - Matthew D. Smyth
- Division of Neurosurgery, Johns Hopkins All Children’s Hospital, St Petersburg, Florida
| | - Robert F. Keating
- Division of Neurosurgery, Children’s National Hospital, Washington, DC
| | - Raj Vyas
- Division of Plastic Surgery, Children’s Hospital of Orange County, Orange, California
- Department of Plastic Surgery, University of California Irvine
| | - Gary F. Rogers
- Division of Plastic and Reconstructive Surgery, Children’s National Hospital, Washington, DC
| | - Kamlesh B. Patel
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Washington University School of Medicine, St Louis, Missouri
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Mortazavi A, Almeida ND, Hofmann K, Davidson L, Rotter J, Phan TN, Tsering D, Maxwell C, Karunakaran J, Veznedaroglu E, Caputy AJ, Heiss JD, Sandhu FA, Myseros JS, Oluigbo C, Magge SN, Shields DC, Rosner MK, Chatain GP, Keating RF. Multicenter comparison of Chiari malformation type I presentation in children versus adults. J Neurosurg Pediatr 2024:1-8. [PMID: 38394661 DOI: 10.3171/2023.12.peds22366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 12/18/2023] [Indexed: 02/25/2024]
Abstract
OBJECTIVE Treatment for Chiari malformation type I (CM-I) often includes surgical intervention in both pediatric and adult patients. The authors sought to investigate fundamental differences between these populations by analyzing data from pediatric and adult patients who required CM-I decompression. METHODS To better understand the presentation and surgical outcomes of both groups of patients, retrospective data from 170 adults and 153 pediatric patients (2000-2019) at six institutions were analyzed. RESULTS The adult CM-I patient population requiring surgical intervention had a greater proportion of female patients than the pediatric population (p < 0.0001). Radiographic findings at initial clinical presentation showed a significantly greater incidence of syringomyelia (p < 0.0001) and scoliosis (p < 0.0001) in pediatric patients compared with adult patients with CM-I. However, presenting signs and symptoms such as headaches (p < 0.0001), ocular findings (p = 0.0147), and bulbar symptoms (p = 0.0057) were more common in the adult group. After suboccipital decompression procedures, 94.4% of pediatric patients reported symptomatic relief compared with 75% of adults with CM-I (p < 0.0001). CONCLUSIONS Here, the authors present the first retrospective evaluation comparing adult and pediatric patients who underwent CM-I decompression. Their analysis reveals that pediatric and adult patients significantly differ in terms of demographics, radiographic findings, presentation of symptoms, surgical indications, and outcomes. These findings may indicate different clinical conditions or a distinct progression of the natural history of this complex disease process within each population, which will require prospective studies to better elucidate.
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Affiliation(s)
| | - Neil D Almeida
- 2George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Katherine Hofmann
- 3Division of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Laurence Davidson
- 3Division of Neurosurgery, Children's National Medical Center, Washington, DC
- 4Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Juliana Rotter
- 1Georgetown University School of Medicine, Washington, DC
| | - Tiffany N Phan
- 3Division of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Deki Tsering
- 3Division of Neurosurgery, Children's National Medical Center, Washington, DC
| | | | - Jehshua Karunakaran
- 2George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Anthony J Caputy
- 2George Washington University School of Medicine and Health Sciences, Washington, DC
| | - John D Heiss
- 6Surgical Neurology Branch, National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland
| | - Faheem A Sandhu
- 7Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, DC; and
| | - John S Myseros
- 3Division of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Chima Oluigbo
- 3Division of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Suresh N Magge
- 3Division of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Donald C Shields
- 2George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Michael K Rosner
- 2George Washington University School of Medicine and Health Sciences, Washington, DC
| | | | - Robert F Keating
- 3Division of Neurosurgery, Children's National Medical Center, Washington, DC
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Cobourn KD, Chesney KM, Mueller K, Fayed I, Tsering D, Keating RF. Isolated subependymal giant cell astrocytoma (SEGA) in the absence of clinical tuberous sclerosis: two case reports and literature review. Childs Nerv Syst 2024; 40:73-78. [PMID: 37658938 DOI: 10.1007/s00381-023-06105-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 07/25/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE Subependymal giant cell astrocytoma (SEGA) is a WHO grade I pediatric glioma arising in 5-15% of patients with tuberous sclerosis (TSC). Rare cases of isolated SEGA without TSC have been described. The etiology, genetic mechanisms, natural history, and response to treatment of these lesions are currently unknown. We describe two such cases of isolated SEGA with follow-up. METHODS Retrospective review was performed at a single institution to describe the clinical course of pathology-confirmed SEGA in patients with germline testing negative for TSC mutations. RESULTS Two cases of isolated SEGA were identified. Genetic analysis of the tumor specimen was available for one, which revealed an 18 base pair deletion in TSC1. Both cases were managed with surgical resection, one with preoperative embolization. In spite of a gross total resection, one patient experienced recurrence after three years. Treatment with an mTOR inhibitor led to a significant interval reduction of the mass on follow-up MRI. The patient tolerated the medication well for 6 years and is now off of treatment for 2 years with a stable lesion. CONCLUSION Cases of SEGA outside of the context of TSC are exceedingly rare, with only 48 cases previously described. The genetic mechanisms and treatment response of these lesions are poorly understood. To date, these lesions appear to respond well to mTOR inhibitors and may behave similarly to SEGAs associated with TSC. However, given that experience is extremely limited, these cases should be followed long term to better understand their natural history and treatment response.
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Affiliation(s)
- Kelsey D Cobourn
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Kelsi M Chesney
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Kyle Mueller
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Islam Fayed
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Deki Tsering
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA.
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8
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Fotouhi AR, Patel KB, Skolnick GB, Merrill CM, Hofmann KM, Mantilla-Rivas E, Collett BR, Allhusen VD, Naidoo SD, Rogers GF, Keating RF, Smyth MD, Magge SN. School-age anthropometric and patient-reported outcomes after open or endoscopic repair of sagittal craniosynostosis. J Neurosurg Pediatr 2023; 32:455-463. [PMID: 37486865 DOI: 10.3171/2023.5.peds2382] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/30/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE Several studies have compared perioperative parameters and early postoperative morphology between endoscope-assisted strip craniectomy with orthotic therapy (endoscopic repair) and cranial vault remodeling (open repair). To extend these results, the authors evaluated school-age anthropometric outcomes after these techniques across three institutions. METHODS School-aged children (age range 4-18 years) with previously corrected isolated sagittal craniosynostosis were enrolled. Upon inclusion, 3D photographs and patient-reported outcomes were obtained, and the cephalic index and head circumference z-scores were calculated. Analyses of covariance models controlling for baseline differences and a priori covariates were performed. RESULTS Eighty-one participants (median [range] age 7 [4-15] years) were included. The mean (95% CI) school-age cephalic index was significantly higher in the endoscopic cohort, though within the normal range for both groups (endoscopic 78% [77%-79%] vs open 76% [74%-77%], p = 0.027). The mean change in the cephalic index from preoperation to school age was significantly greater in the endoscopic group (9% [7%-11%] vs open 3% [1%-5%], p < 0.001). Compared to preoperative measurements, mean school-age head circumference z-scores decreased significantly more in the open cohort (-1.6 [-2.2 to -1.0] vs endoscopic -0.3 [-0.8 to -0.2], p = 0.002). Patient-reported levels of stigma were within the normal limits for both groups. CONCLUSIONS Endoscopic and open repair techniques effectively normalize school-age anthropometric outcomes. However, endoscopic repair produces a clinically meaningful and significantly greater improvement in the school-age cephalic index, with maintenance of head growth. These findings demonstrate the importance of early referral by pediatricians and inform treatment decisions.
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Affiliation(s)
- Annahita R Fotouhi
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Kamlesh B Patel
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gary B Skolnick
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Corinne M Merrill
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | | | | | - Brent R Collett
- 3Center for Child Health, Behavior, and Development, Seattle Children's Research Institute, Seattle, Washington
| | | | - Sybill D Naidoo
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Gary F Rogers
- 5Division of Plastic and Reconstructive Surgery, Children's National Hospital, Washington, DC
| | - Robert F Keating
- 2Division of Neurosurgery, Children's National Hospital, Washington, DC
| | - Matthew D Smyth
- 6Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Suresh N Magge
- 2Division of Neurosurgery, Children's National Hospital, Washington, DC
- 7Division of Neurosurgery, CHOC Neuroscience Institute, Children's Hospital of Orange County, Orange, California; and
- 8Department of Neurosurgery, University of California, Irvine, California
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9
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Patel N, Keating G, Solanki GA, Syed HR, Keating RF. Medulloblastomas, CNS embryonal tumors, and cerebellar mutism syndrome: advances in care and future directions. Childs Nerv Syst 2023; 39:2633-2647. [PMID: 37632526 DOI: 10.1007/s00381-023-06112-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 08/01/2023] [Indexed: 08/28/2023]
Abstract
Central nervous system (CNS) embryonal tumors, commonly found in pediatric patients, represent a heterogeneous mix of lesions with an overall poor (though improving) prognosis. Medulloblastomas are by far the most frequently encountered and most widely studied subtype, though others include atypical teratoid/rhabdoid tumors (AT/RTs), embryonal tumor with multilayered rosettes (ETMRs), and CNS neuroblastomas, FOX-R2 activated. The classification, diagnosis, and treatment of these lesions have evolved drastically over the years as their molecular underpinnings have been elucidated. We describe the most recent 2021 WHO Classification system, discuss current understanding of the genetic basis, and demonstrate current thinking in treatment for these highly complex tumors. Since surgical resection continues to remain a mainstay of treatment, preventing and managing surgical complications, especially cerebellar mutism syndrome (CMS), is paramount. We describe the current theories for the etiology of CMS and two centers' experience in mitigating its risks. As our surgical toolbox continues to evolve along with our understanding of these tumors, we hope future patients can benefit from both improved overall survival and quality of life.
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Affiliation(s)
- Nirali Patel
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Gregory Keating
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Guirish A Solanki
- Department of Pediatric Neurosurgery, Birmingham Children's Hospital, Birmingham, UK
| | - Hasan R Syed
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA.
| | - Robert F Keating
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
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10
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Cobourn KD, Patel N, Tsering D, Jamshidi AM, Abousy M, Myseros JS, Oluigbo C, Magge SN, Keating RF. Use of intraoperative topical antibiotics to reduce intrathecal baclofen pump surgical site infections: a single institution's experience over 24 years. J Neurosurg Pediatr 2023; 32:69-74. [PMID: 37060312 DOI: 10.3171/2023.3.peds22508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Accepted: 03/07/2023] [Indexed: 04/16/2023]
Abstract
OBJECTIVE Patients requiring intrathecal baclofen (ITB) therapy are at high risk for surgical site infections (SSIs) given their poor functional status. After years of a nominal infection rate, there was an inexplicable increase in ITB pump infections at the authors' institution and multiple investigations offered no solution. Use of intraoperative topical antibiotics is well-documented in the orthopedic literature and was considered for ITB pump insertion. In this study, the authors investigated whether intraoperative vancomycin and tobramycin powder at the ITB pump site could reduce SSIs. METHODS Operative and infection data were collected and analyzed retrospectively to determine the efficacy of this change. Patients were stratified into three cohorts (1998-2009, 2010-2012, and 2013-2021) to better understand the trends before and after implementation of intraoperative topical antibiotics. Each cohort had similar demographics. RESULTS One hundred fifty-four patients underwent 272 ITB pump procedures between 1998 and 2021 (131 in 1998-2009, 49 in 2010-2012, and 92 in 2013-2021) for cerebral palsy (69.5%), spastic quadriparesis due to traumatic brain injury (7.1%), anoxic brain injury (6.5%), and other causes (16.9%). Infection rates were reduced from a high of 32% in 2010-2011 to 3.8% over the last 2.5 years (p = 0.0094). There were no adverse effects from the use of topical antibiotics. CONCLUSIONS In the setting of an intractable rise in ITB pump infections, the addition of intraoperative topical antibiotics significantly reduced postoperative infections in a high-risk population. One could appreciate a significant drop each year in the rate of infections after the institution of intraoperative topical antibiotics. The reduction in SSIs significantly improved the long-term outcomes for these patients.
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11
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Shlobin NA, Hofmann K, Keating RF, Oluigbo CO. Deep Brain Stimulation and Intrathecal/Intraventricular Baclofen for Glutaric Aciduria Type 1: A Scoping Review, Individual Patient Data Analysis, and Clinical Trials Review. J Inherit Metab Dis 2023. [PMID: 37254447 DOI: 10.1002/jimd.12638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 05/24/2023] [Accepted: 05/25/2023] [Indexed: 06/01/2023]
Abstract
Glutaric aciduria type 1 (GA1) is an autosomal recessive disease frequently leading to dystonia. Deep brain stimulation (DBS), intrathecal baclofen (ITB), and intraventricular baclofen (IVB) are the current interventional treatment options for refractory dystonia. We performed a scoping review, individual patient data (IPD) analysis, and clinical trials review to summarize the existing literature on these interventions in this population, characterize outcomes, and suggest directions for future investigation. PubMed, Embase, and Scopus were searched following PRISMA guidelines. IPD were extracted from studies providing IPD for GA1 patients. ClinicalTrials.gov was reviewed. Of 139 articles, 7 studies with 10 patients were included. In study-level data, 2/4 (50.0%) DBS studies found no improvement in dystonia and 3/3 (100%) on baclofen found decreased dystonia and enteral medication regimen. In the IPD analysis, four studies with 5 patients (2 IVB, 2 DBS, 1 ITB) were included. The average percent reduction in dystonia was 29.9% ± 32.5% (median:18%, IQR:18-29.2%). Function improved in 4 (80.0%) patients. All patients with reported changes in enteral dystonia-related medication regimen (3/3, 100%) reported reduction in medication usage. No patients (0%) had perioperative complications. Mean follow-up length was 14.8 ± 12.2 months. No interventional clinical trials were found. ITB, IVB, and DBS represent present neuromodulatory approaches for the treatment of GA1. ITB and IVB reduce dystonia, while DBS has a heterogeneous effect. ITB and IVB improved function and reduced enteral medication regimens. These findings must be viewed with caution considering limited data and a serious risk of bias. Further large-scale studies are necessary to determine indications for ITB, IVB, and DBS and elucidate treatment algorithms. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, Illinois, United States
| | - Katherine Hofmann
- Deparment of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Robert F Keating
- Deparment of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Chima O Oluigbo
- Deparment of Neurosurgery, Children's National Hospital, Washington, DC, USA
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12
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Syed HR, Kilburn L, Fonseca A, Nazarian J, Oluigbo C, Myseros JS, Packer RJ, Keating RF. First-in-human sonodynamic therapy with ALA for pediatric diffuse intrinsic pontine glioma: a phase 1/2 study using low-intensity focused ultrasound : Technical communication. J Neurooncol 2023; 162:449-451. [PMID: 37046110 DOI: 10.1007/s11060-023-04269-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Accepted: 02/14/2023] [Indexed: 04/14/2023]
Affiliation(s)
- Hasan R Syed
- Children's National Hospital, Washington, DC, USA.
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13
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El Shatanofy M, Hofmann K, Myseros JS, Gaillard WD, Keating RF, Oluigbo C. Invasive Intracranial Electroencephalogram (EEG) Monitoring for Epilepsy in the Pediatric Patient With a Shunt. Cureus 2023; 15:e35279. [PMID: 36968898 PMCID: PMC10036197 DOI: 10.7759/cureus.35279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2023] [Indexed: 02/25/2023] Open
Abstract
The use of invasive intracranial electroencephalogram (EEG) monitoring in the patient with a cerebrospinal fluid (CSF) diversionary shunt presents a conundrum -- the presence of a percutaneous electrode passing into the intracranial compartment presents a pathway for entry of pathogens to which a chronically implanted device like a shunt is especially susceptible to infection. In this case report, we describe the clinical and radiological features, medical and surgical management, and treatment outcomes of pediatric patients with shunted hydrocephalus who underwent invasive intracranial monitoring over an eight-year period. Three cases of children undergoing invasive intracranial monitoring were included in this study. Invasive monitoring for each patient occurred over three to six days. In each case, invasive intracranial monitoring was completed successfully, without resulting infection or shunt malfunction. While the second procedure was complicated by the formation of a pneumocephalus, there was no associated midline shift, and invasive intracranial monitoring was completed without incidence. Each patient received further surgery that successfully reduced seizure frequency. This study suggests that, while children with CSF diversionary shunts are at an inherently increased risk for infection and other complications, invasive intracranial monitoring is a relatively safe and feasible option in these patients. Future studies should explore the optimal duration for intracranial monitoring in pediatric patients with chronically implanted devices.
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14
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Jha TR, Quigley MF, Mozaffari K, Lathia O, Hofmann K, Myseros JS, Oluigbo C, Keating RF. Prediction of shunt failure facilitated by rapid and accurate volumetric analysis: a single institution's preliminary experience. Childs Nerv Syst 2022; 38:1907-1912. [PMID: 35595938 DOI: 10.1007/s00381-022-05552-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2022] [Accepted: 05/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Shunt malfunction is a common complication and often presents with hydrocephalus. While the diagnosis is often supported by radiographic studies, subtle changes in CSF volume may not be detectable on routine evaluation. The purpose of this study was to develop a novel automated volumetric software for evaluation of shunt failure in pediatric patients, especially in patients who may not manifest a significant change in their ventricular size. METHODS A single-institution retrospective review of shunted patients was conducted. Ventricular volume measurements were performed using manual and automated methods by three independent analysts. Manual measurements were produced using OsiriX software, whereas automated measurements were produced using the proprietary software. A p value < 0.05 was considered statistically significant. RESULTS Twenty-two patients met the inclusion criteria (13 males, 9 females). Mean age of the cohort was 4.9 years (range 0.1-18 years). Average measured CSF volume was similar between the manual and automated methods (169.8 mL vs 172.5 mL, p = 0.56). However, the average time to generate results was significantly shorter with the automated algorithm compared to the manual method (2244 s vs 38.3 s, p < 0.01). In 3/5 symptomatic patients whose neuroimaging was interpreted as stable, the novel algorithm detected the otherwise radiographically undetectable CSF volume changes. CONCLUSION The automated software accurately measures the ventricular volumes in pediatric patients with hydrocephalus. The application of this technology is valuable in patients who present clinically without obvious radiographic changes. Future studies with larger cohorts are needed to validate our preliminary findings and further assess the utility of this technology.
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Affiliation(s)
- Tushar R Jha
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Mark F Quigley
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Khashayar Mozaffari
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA.
| | - Orgest Lathia
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Katherine Hofmann
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - John S Myseros
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Chima Oluigbo
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
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15
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Manrique M, Mantilla-Rivas E, Rana MS, Crowder H, Oh N, Oh AK, Keating RF, Rogers GF. Normocephalic sagittal craniosynostosis in young children is common and unrecognized. Childs Nerv Syst 2022; 38:1549-1556. [PMID: 35716184 DOI: 10.1007/s00381-022-05533-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 04/16/2022] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Sagittal craniosynostosis (SC) is usually diagnosed during early childhood by the presence of scaphocephaly. Recently, our group found 3.3% of children under 5 years of age with normocephalic sagittal craniosynostosis (NSC) using computed tomography (CT) scans. This paper aims to validate our preliminary findings using a larger cohort of patients, and analyze factors associated with incidental NSC. METHODS A retrospective review of head CT scans in patients aged 0 to 71 months who presented to the emergency department of our tertiary care institution between 2008 and 2020 was completed. Patients with syndromes associated with craniosynostosis (CS), history of hydrocephalus, or other brain/cranial abnormalities were excluded. Two craniofacial surgeons reviewed the CT scans to evaluate the presence and extent of CS. Demographic information, gestational age, past medical and family history, medications, and chief complaint were recorded as covariates, and differences between patients with and without CS were analyzed. Furthermore, comparison of the prevalence of CS across age groups was studied. Additional analysis exploring association between independent covariates and the presence of CS was performed in two sub-cohorts: patients ≤ 24 months of age and patients > 24 months of age. RESULTS A total of 870 scans were reviewed. SC was observed in 41 patients (4.71% - 25 complete, 16 incomplete), all with a normal cranial index (width/length > 0.7). The prevalence of SC increased up to 36 months of age, then plateaued through 72 months of age. Patients under 2 years of age with family history of neurodevelopmental disease had 49.32 (95% CI [4.28, 567.2]) times higher odds of developing CS. Sub-cohort of patients above 24 months of age showed no variable independently predicted developing CS. CONCLUSION NSC in young children is common. While the impact of this condition is unknown, the correlation with family history of neurodevelopmental disease is concerning.
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Affiliation(s)
- M Manrique
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - E Mantilla-Rivas
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - M S Rana
- Sheikh Zayed Institute for Pediatric Surgical Innovation, Children's National Hospital, Washington, DC, USA
| | - H Crowder
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - N Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - A K Oh
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA
| | - R F Keating
- Department of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - G F Rogers
- Division of Plastic and Reconstructive Surgery, Children's National Hospital, DC, 20010, Washington, USA.
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16
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Akbari SHA, Yahanda AT, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Bierbrauer K, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jallo GI, Johnston JM, Kaufman BA, Keating RF, Khan NR, Krieger MD, Leonard JR, Maher CO, Mangano FT, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer MS, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Tyler-Kabara EC, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD. Complications and outcomes of posterior fossa decompression with duraplasty versus without duraplasty for pediatric patients with Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2022; 30:1-13. [PMID: 35426814 DOI: 10.3171/2022.2.peds21446] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2021] [Accepted: 02/28/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to determine differences in complications and outcomes between posterior fossa decompression with duraplasty (PFDD) and without duraplasty (PFD) for the treatment of pediatric Chiari malformation type I (CM1) and syringomyelia (SM). METHODS The authors used retrospective and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM1-SM who received PFD or PFDD and had at least 1 year of follow-up data. Preoperative, treatment, and postoperative characteristics were recorded and compared between groups. RESULTS A total of 692 patients met the inclusion criteria for this database study. PFD was performed in 117 (16.9%) and PFDD in 575 (83.1%) patients. The mean age at surgery was 9.86 years, and the mean follow-up time was 2.73 years. There were no significant differences in presenting signs or symptoms between groups, although the preoperative syrinx size was smaller in the PFD group. The PFD group had a shorter mean operating room time (p < 0.0001), fewer patients with > 50 mL of blood loss (p = 0.04), and shorter hospital stays (p = 0.0001). There were 4 intraoperative complications, all within the PFDD group (0.7%, p > 0.99). Patients undergoing PFDD had a 6-month complication rate of 24.3%, compared with 13.7% in the PFD group (p = 0.01). There were no differences between groups for postoperative complications beyond 6 months (p = 0.33). PFD patients were more likely to require revision surgery (17.9% vs 8.3%, p = 0.002). PFDD was associated with greater improvements in headaches (89.6% vs 80.8%, p = 0.04) and back pain (86.5% vs 59.1%, p = 0.01). There were no differences between groups for improvement in neurological examination findings. PFDD was associated with greater reduction in anteroposterior syrinx size (43.7% vs 26.9%, p = 0.0001) and syrinx length (18.9% vs 5.6%, p = 0.04) compared with PFD. CONCLUSIONS PFD was associated with reduced operative time and blood loss, shorter hospital stays, and fewer postoperative complications within 6 months. However, PFDD was associated with better symptom improvement and reduction in syrinx size and lower rates of revision decompression. The two surgeries have low intraoperative complication rates and comparable complication rates beyond 6 months.
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Affiliation(s)
- S Hassan A Akbari
- 1Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, PA
| | - Alexander T Yahanda
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Laurie L Ackerman
- 3Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - P David Adelson
- 4Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Raheel Ahmed
- 5Department of Neurological Surgery, University of Wisconsin at Madison, Madison, WI
| | - Gregory W Albert
- 6Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 7Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 8Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL
| | - Richard C E Anderson
- 9Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY
| | - David F Bauer
- 10Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tammy Bethel-Anderson
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karin Bierbrauer
- 36Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Douglas L Brockmeyer
- 11Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 12Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, GA
| | - Daniel E Couture
- 13Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | | | - Ramin Eskandari
- 18Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Herbert E Fuchs
- 19Department of Neurosurgery, Duke University School of Medicine, Durham, NC
| | - Gerald A Grant
- 20Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Patrick C Graupman
- 21Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 22Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 23Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 24Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 25Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 26Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 27Division of Pediatric Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Mark Iantosca
- 1Division of Pediatric Neurosurgery, Penn State Health Children's Hospital, Hershey, PA
| | - Bermans J Iskandar
- 5Department of Neurological Surgery, University of Wisconsin at Madison, Madison, WI
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - George I Jallo
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - James M Johnston
- 30Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL
| | - Bruce A Kaufman
- 31Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Robert F Keating
- 32Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nicklaus R Khan
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, TN
| | - Mark D Krieger
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Jeffrey R Leonard
- 34Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Francesco T Mangano
- 36Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - J Gordon McComb
- 16Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, CA
| | - Sean D McEvoy
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael S Muhlbauer
- 33Department of Neurosurgery, The University of Tennessee Health Science Center, Memphis, TN
| | - Brent R O'Neill
- 26Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 41Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, TN
| | - Joshua S Shimony
- 42Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Matthew D Smyth
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | - Scellig S D Stone
- 43Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Jennifer M Strahle
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Mandeep S Tamber
- 44Division of Neurosurgery, The University of British Columbia, Vancouver, BC, Canada
| | - James C Torner
- 15Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Gerald F Tuite
- 29Division of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL
| | | | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, NC
| | - John C Wellons
- 41Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 10Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
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17
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Pivazyan G, Dowlati E, Phan TN, Davidson L, Oluigbo C, Mai JC, Keating RF. Facilitation of Pediatric Posterior Fossa Vascular Malformation Resection Using Virtual Reality Platform: 2-Dimensional Operative Video. Oper Neurosurg (Hagerstown) 2022; 22:01787389-990000000-00132. [PMID: 35863322 DOI: 10.1227/ons.0000000000000147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2020] [Accepted: 12/15/2021] [Indexed: 02/18/2024] Open
Abstract
Pediatric posterior fossa arteriovenous malformations (AVMs) are rare entities that pose significant cumulative lifetime risk of rupture and require treatment. Microsurgical resection remains a good option for definitively treating posterior fossa AVMs in one setting. The drawback of endovascular embolization is the lower rates of nidus obliteration. Although stereotactic radiosurgery is a safe alternative, it takes several years to achieve the treatment goal all the while predisposing the patient to the risk of AVM rupture.1,2 Accurate localization and visualization remain challenging for microsurgical treatment of posterior fossa AVMs.3-5 Small size of a nidus, prone position, and proximity to eloquent areas make these lesions particularly difficult to localize and resect. We present the operative case of a 6-year-old boy with a small, ruptured posterior fossa AVM. After undergoing hematoma evacuation, the patient underwent microsurgical resection of a small right vermian AVM assisted by the virtual reality platform, Surgical Theater (Gates Mills, OH). Our video demonstrates the utility of a virtual augmented reality platform for addressing the challenges posed by a small posterior fossa AVM with respect to the need for precise three-dimensional localization of small lesions. The patient consented to the procedure. The participants and any identifiable individuals consented to publication of his/her image.
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Affiliation(s)
- Gnel Pivazyan
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Ehsan Dowlati
- Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Tiffany N Phan
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Laurence Davidson
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Chima Oluigbo
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
- Department of Neurosurgery, George Washington University, Washington, District of Columbia, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, MedStar Washington Hospital Center, Washington, District of Columbia, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
- Department of Neurosurgery, George Washington University, Washington, District of Columbia, USA
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18
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Phan TN, Prakash KJ, Elliott RJS, Pasupuleti A, Gaillard WD, Keating RF, Oluigbo CO. Virtual reality-based 3-dimensional localization of stereotactic EEG (SEEG) depth electrodes and related brain anatomy in pediatric epilepsy surgery. Childs Nerv Syst 2022; 38:537-546. [PMID: 34718866 DOI: 10.1007/s00381-021-05403-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Accepted: 10/23/2021] [Indexed: 11/30/2022]
Abstract
INTRODUCTION The increasing use of stereoelectroencephalography (SEEG) in the USA and the need for three-dimensional (3D) appreciation of complex spatial relationships between implanted stereotactic EEG depth electrodes and surrounding brain and cerebral vasculature are a challenge to clinicians who are used to two-dimensional (2D) appreciation of cortical anatomy having been traditionally trained on 2D radiologic imaging. Virtual reality and its 3D renderings have grown increasingly common in the multifaceted practice of neurosurgery. However, there exists a paucity in the literature regarding this emerging technology in its utilization of epilepsy surgery. METHODS An IRB-approved, single-center retrospective study identifying all SEEG pediatric patients in which virtual reality was applied was observed. RESULTS Of the 46 patients identified who underwent an SEEG procedure, 43.5% (20/46) had a 3D rendering (3DR) of their SEEG depth electrodes. All 3DRs were used during patient-family education and discussion among the Epilepsy multidisciplinary team meetings, while 35% (7/20) were used during neuronavigation in surgery. Three successful representative cases of its application were presented. DISCUSSION Our institution's experience regarding virtual reality in the 3D representation of SEEG depth electrodes and the application to pre-surgical planning, patient-family education, multidisciplinary communication, and intraoperative neuronavigation demonstrate its applicability in comprehensive epilepsy patient care.
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Affiliation(s)
- Tiffany N Phan
- Department of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | | | - Ross-Jordon S Elliott
- Department of Neurological Surgery, George Washington University, Washington, DC, USA
| | - Archana Pasupuleti
- Department of Neurology, Children's National Hospital, Washington, DC, USA
| | - William D Gaillard
- Department of Neurology, Children's National Hospital, Washington, DC, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.
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19
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Abstract
OBJECTIVE We present a data-driven method to build a spatiotemporal statistical shape model predictive of normal cranial growth from birth to the age of 2 years. METHODS The model was constructed using a normative cross-sectional computed tomography image dataset of 278 subjects. First, we propose a new standard representation of the calvaria using spherical maps to establish anatomical correspondences between subjects at the cranial sutures - the main areas of cranial bone expansion. Then, we model the cranial bone shape as a bilinear function of two factors: inter-subject anatomical variability and temporal growth. We estimate these factors using principal component analysis on the spatial and temporal dimensions, using a novel coarse-to-fine temporal multi-resolution approach to mitigate the lack of longitudinal images of the same patient. RESULTS Our model achieved an accuracy of 1.54 ± 1.05 mm predicting development on an independent longitudinal dataset. We also used the model to calculate the cranial volume, cephalic index and cranial bone surface changes during the first two years of age, which were in agreement with clinical observations. SIGNIFICANCE To our knowledge, this is the first data-driven and personalized predictive model of cranial bone shape development during infancy and it can serve as a baseline to study abnormal growth patterns in the population.
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Affiliation(s)
- Antonio R. Porras
- Department of Biostatistics and Informatics at the Colorado School of Public Health and the Department of Pediatrics at the School of Medicine, University of Colorado Anschutz Medical Campus.,Departments of Plastic & Reconstructive Surgery and Neurosurgery at the Children’s Hospital Colorado, Aurora. CO, 80045, USA
| | - Robert F. Keating
- Department of Neurosurgery at the Children’s National Hospital, Washington, DC, 20010, USA
| | - Janice S. Lee
- National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD, 20892, USA
| | - Marius George Linguraru
- Sheikh Zayed Institute of Pediatric Surgical Innovation at Children’s National Hospital, Washington, DC, 20010, USA.,Departments of Radiology and Pediatrics at the George Washington University School of Medicine and Health Sciences, Washington, DC, 20052, USA
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20
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Alexander H, Govindan RB, Anwar T, Chirumamilla VC, Fayed I, Keating RF, Gaillard WD, Oluigbo CO. Global and intertuberal epileptic networks in tuberous sclerosis based on stereoelectroencephalographic (sEEG) findings: a quantitative EEG analysis in pediatric subjects and surgical implications. Childs Nerv Syst 2022; 38:407-419. [PMID: 34455445 DOI: 10.1007/s00381-021-05342-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 08/23/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE Recent evidence favors a network concept in tuberous sclerosis (TSC) with seizure generation and propagation related to changes in global and regional connectivity between multiple, anatomically distant tubers. Direct exploration of network dynamics in TSC has been made possible through intracranial sampling with stereoelectroencephalography (sEEG). The objective of this study is to define epileptic networks in TSC using quantitative analysis of sEEG recordings. We also discuss the impact of the definition of these epileptic networks on surgical decision-making. METHODS Intracranial sEEG recordings were obtained from four pediatric patients who presented with medically refractory epilepsy secondary to TSC and subjected to quantitative signal analysis methods. Cortical connectivity was quantified by calculating pairwise coherence between all contacts and constructing an association matrix. The global coherence, defined as the ratio of the largest eigenvalue to the sum of all the eigenvalues, was calculated for each frequency band (delta, theta, alpha, beta, gamma). Spatial distribution of the connectivity was identified by plotting the leading principal component (product of the largest eigenvalue and its corresponding eigenvector). RESULTS Four pediatric subjects with TSC underwent invasive intracranial monitoring with sEEG, comprising 31 depth electrodes and 250 contacts, for localization of the epileptogenic focus and guidance of subsequent surgical intervention. Quantitative connectivity analysis revealed a change in global coherence during the ictal period in the beta/low gamma (14-30 Hz) and high gamma (31-80 Hz) bands. Our results corroborate findings from existing literature, which implicate higher frequencies as a driver of synchrony and desynchrony. CONCLUSIONS Coordinated high-frequency activity in the beta/low gamma and high gamma bands among spatially distant sEEG define the ictal period in TSC. This time-dependent change in global coherence demonstrates evidence for intra-tuberal and inter-tuberal connectivity in TSC. This observation has surgical implications. It suggests that targeting multiple tubers has a higher chance of seizure control as there is a higher chance of disrupting the epileptic network. The use of laser interstitial thermal therapy (LITT) allowed us to target multiple disparately located tubers in a minimally invasive manner with good seizure control outcomes.
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Affiliation(s)
- H Alexander
- Division of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Georgetown University School of Medicine, 3900 Reservoir Rd NW, Washington, DC, 20007, USA
| | - R B Govindan
- Division of Fetal and Transitional Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - T Anwar
- Division of Neurology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - V C Chirumamilla
- Division of Fetal and Transitional Medicine, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - I Fayed
- Division of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,MedStar Georgetown University Hospital, 3800 Reservoir Rd NW, Washington, DC, 20007, USA
| | - R F Keating
- Division of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA
| | - W D Gaillard
- George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.,Division of Neurology, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - C O Oluigbo
- Division of Neurosurgery, Children's National Hospital, 111 Michigan Ave NW, Washington, DC, 20010, USA. .,George Washington University School of Medicine and Health Sciences, 2300 I St NW, Washington, DC, 20052, USA.
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21
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Akbari SHA, Rizvi AA, CreveCoeur TS, Han RH, Greenberg JK, Torner J, Brockmeyer DL, Wellons JC, Leonard JR, Mangano FT, Johnston JM, Shah MN, Iskandar BJ, Ahmed R, Tuite GF, Kaufman BA, Daniels DJ, Jackson EM, Grant GA, Powers AK, Couture DE, Adelson PD, Alden TD, Aldana PR, Anderson RCE, Selden NR, Bierbrauer K, Boydston W, Chern JJ, Whitehead WE, Dauser RC, Ellenbogen RG, Ojemann JG, Fuchs HE, Guillaume DJ, Hankinson TC, O'Neill BR, Iantosca M, Oakes WJ, Keating RF, Klimo P, Muhlbauer MS, McComb JG, Menezes AH, Khan NR, Niazi TN, Ragheb J, Shannon CN, Smith JL, Ackerman LL, Jea AH, Maher CO, Narayan P, Albert GW, Stone SSD, Baird LC, Gross NL, Durham SR, Greene S, McKinstry RC, Shimony JS, Strahle JM, Smyth MD, Dacey RG, Park TS, Limbrick DD. Socioeconomic and demographic factors in the diagnosis and treatment of Chiari malformation type I and syringomyelia. J Neurosurg Pediatr 2021:1-10. [PMID: 34861643 DOI: 10.3171/2021.9.peds2185] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 09/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The goal of this study was to assess the social determinants that influence access and outcomes for pediatric neurosurgical care for patients with Chiari malformation type I (CM-I) and syringomyelia (SM). METHODS The authors used retro- and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM-I and SM who received surgical treatment and had at least 1 year of follow-up data. Race, ethnicity, and insurance status were used as comparators for preoperative, treatment, and postoperative characteristics and outcomes. RESULTS A total of 637 patients met inclusion criteria, and race or ethnicity data were available for 603 (94.7%) patients. A total of 463 (76.8%) were non-Hispanic White (NHW) and 140 (23.2%) were non-White. The non-White patients were older at diagnosis (p = 0.002) and were more likely to have an individualized education plan (p < 0.01). More non-White than NHW patients presented with cerebellar and cranial nerve deficits (i.e., gait ataxia [p = 0.028], nystagmus [p = 0.002], dysconjugate gaze [p = 0.03], hearing loss [p = 0.003], gait instability [p = 0.003], tremor [p = 0.021], or dysmetria [p < 0.001]). Non-White patients had higher rates of skull malformation (p = 0.004), platybasia (p = 0.002), and basilar invagination (p = 0.036). Non-White patients were more likely to be treated at low-volume centers than at high-volume centers (38.7% vs 15.2%; p < 0.01). Non-White patients were older at the time of surgery (p = 0.001) and had longer operative times (p < 0.001), higher estimated blood loss (p < 0.001), and a longer hospital stay (p = 0.04). There were no major group differences in terms of treatments performed or complications. The majority of subjects used private insurance (440, 71.5%), whereas 175 (28.5%) were using Medicaid or self-pay. Private insurance was used in 42.2% of non-White patients compared to 79.8% of NHW patients (p < 0.01). There were no major differences in presentation, treatment, or outcome between insurance groups. In multivariate modeling, non-White patients were more likely to present at an older age after controlling for sex and insurance status (p < 0.01). Non-White and male patients had a longer duration of symptoms before reaching diagnosis (p = 0.033 and 0.004, respectively). CONCLUSIONS Socioeconomic and demographic factors appear to influence the presentation and management of patients with CM-I and SM. Race is associated with age and timing of diagnosis as well as operating room time, estimated blood loss, and length of hospital stay. This exploration of socioeconomic and demographic barriers to care will be useful in understanding how to improve access to pediatric neurosurgical care for patients with CM-I and SM.
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Affiliation(s)
- Syed Hassan A Akbari
- 1Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | | | | | | | | | - James Torner
- 4Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - John C Wellons
- 6Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Leonard
- 7Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Francesco T Mangano
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James M Johnston
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Manish N Shah
- 10Department of Pediatric Surgery and Neurosurgery, The University of Texas McGovern Medical School, Houston, Texas
| | - Bermans J Iskandar
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Raheel Ahmed
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Gerald F Tuite
- 12Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Bruce A Kaufman
- 13Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - David J Daniels
- 14Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Eric M Jackson
- 15Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gerald A Grant
- 16Department of Neurosurgery, Stanford Child Health Research Institute, Stanford, California
| | - Alexander K Powers
- 17Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - Daniel E Couture
- 17Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - P David Adelson
- 18Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tord D Alden
- 19Department of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Philipp R Aldana
- 20Department of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Richard C E Anderson
- 21Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nathan R Selden
- 22Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karin Bierbrauer
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - William Boydston
- 23Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | - Joshua J Chern
- 23Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | | | - Robert C Dauser
- 24Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Richard G Ellenbogen
- 25Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Jeffrey G Ojemann
- 25Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Herbert E Fuchs
- 26Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Daniel J Guillaume
- 27Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 28Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Brent R O'Neill
- 28Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark Iantosca
- 1Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - W Jerry Oakes
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Paul Klimo
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Michael S Muhlbauer
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - J Gordon McComb
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Arnold H Menezes
- 32Department of Neurosurgery, University of Iowa Hospitals, Iowa City, Iowa
| | - Nickalus R Khan
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Toba N Niazi
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - John Ragheb
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Chevis N Shannon
- 6Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jodi L Smith
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Laurie L Ackerman
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Andrew H Jea
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Prithvi Narayan
- 36Department of Neurological Surgery, St. Christopher's Hospital, Philadelphia, Pennsylvania
| | - Gregory W Albert
- 37Department of Neurosurgery, University of Arkansas College of Medicine, Little Rock, Arkansas
| | - Scellig S D Stone
- 38Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Lissa C Baird
- 38Department of Neurosurgery, Harvard Medical School, Boston, Massachusetts
| | - Naina L Gross
- 39Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Susan R Durham
- 40Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; and
| | - Stephanie Greene
- 41Department of Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Robert C McKinstry
- 3Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Joshua S Shimony
- 3Radiology, Washington University School of Medicine, St. Louis, Missouri
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22
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CreveCoeur TS, Yahanda AT, Maher CO, Johnson GW, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Baird L, Bauer DF, Bierbrauer KS, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dauser RC, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Haller G, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Kelly MP, Khan N, Krieger MD, Leonard JR, Mangano FT, Mapstone TB, McComb JG, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O’Neill BR, Park TS, Ragheb J, Selden NR, Shah MN, Shannon C, Shimony JS, Smith J, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Limbrick DD. Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium. Neurosurgery 2021. [DOI: 10.1093/neuros/nyaa460_s089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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23
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Kozyrev DA, Soleman J, Tsering D, Keating RF, Hersh DS, Boop FA, Spennato P, Cinalli G, Tamburrini G, Thomale UW, Bollo RJ, Chatterjee S, Lalgudi Srinivasan H, Constantini S, Roth J. Pediatric thalamic incidentalomas: an international retrospective multicenter study. J Neurosurg Pediatr 2021:1-9. [PMID: 34715651 DOI: 10.3171/2021.6.peds20976] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 06/16/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Widespread use of modern neuroimaging has led to a surge in diagnosing pediatric brain incidentalomas. Thalamic lesions have unique characteristics such as deep location, surgical complexity, and proximity to eloquent neuronal structures. Currently, the natural course of incidental thalamic lesions is unknown. Therefore, the authors present their experience in treating such lesions. METHODS A retrospective, international multicenter study was carried out in 8 tertiary pediatric centers from 5 countries. Patients were included if they had an incidental thalamic lesion suspected of being a tumor and were diagnosed before the age of 20 years. Treatment strategy, imaging characteristics, pathology, and the outcome of operated and unoperated cases were analyzed. RESULTS Overall, 58 children (23 females and 35 males) with a mean age of 10.8 ± 4.0 years were included. The two most common indications for imaging were nonspecific reasons (n = 19; e.g., research and developmental delay) and headache unrelated to small thalamic lesions (n = 14). Eleven patients (19%) underwent early surgery and 47 were followed, of whom 10 underwent surgery due to radiological changes at a mean of 11.4 ± 9.5 months after diagnosis. Of the 21 patients who underwent surgery, 9 patients underwent resection and 12 underwent biopsy. The two most frequent pathologies were pilocytic astrocytoma and WHO grade II astrocytoma (n = 6 and n = 5, respectively). Three lesions were high-grade gliomas. CONCLUSIONS The results of this study indicate that pediatric incidental thalamic lesions include both low- and high-grade tumors. Close and long-term radiological follow-up is warranted in patients who do not undergo immediate surgery, as tumor progression may occur.
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Affiliation(s)
- Danil A Kozyrev
- 1Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Jehuda Soleman
- 1Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel.,9Department of Neurosurgery and Pediatric Neurosurgery, University and Children's Hospital of Basel, Switzerland.,10Faculty of Medicine, University of Basel, Switzerland
| | - Deki Tsering
- 2Division of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Robert F Keating
- 2Division of Neurosurgery, Children's National Medical Center, Washington, DC
| | - David S Hersh
- 3Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee.,11Department of Surgery, Connecticut Children's, Hartford, Connecticut; and.,12Departments of Surgery and Pediatrics, UConn School of Medicine, Farmington, Connecticut
| | - Frederick A Boop
- 3Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Pietro Spennato
- 4Department of Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Giuseppe Cinalli
- 4Department of Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Gianpiero Tamburrini
- 5Institute of Neurosurgery, Catholic University of the Sacred Heart, Milan, Italy
| | - Ulrich-Wilhelm Thomale
- 6Pediatric Neurosurgery, Campus Virchow Klinikum, Charité Universitätsmedizin, Berlin, Germany
| | - Robert J Bollo
- 7Division of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | | | | | - Shlomi Constantini
- 1Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Jonathan Roth
- 1Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
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24
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Mozaffari K, Davidson L, Chalif E, Phan TN, Sparks AD, Myseros JS, Oluigbo CO, Keating RF. Long-term outcomes of posterior fossa decompression for Chiari malformation type 1: which patients are most prone to failure? Childs Nerv Syst 2021; 37:2891-2898. [PMID: 34232379 DOI: 10.1007/s00381-021-05280-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 06/29/2021] [Indexed: 10/20/2022]
Abstract
PURPOSE The role of an osseous-only posterior fossa decompression (PFD) for Chiari malformation type 1 (CM1) remains controversial. We reviewed long-term outcomes for patients with CM1 undergoing a PFD to evaluate if there was any difference for failure when compared to patients undergoing a PFD with duraplasty (PFDD). METHODS Consecutive patients surgically treated at a single tertiary pediatric neurosurgery clinic over a 25-year period with at least 5 years of follow-up were evaluated. PFD patients were compared to those that initially received a PFDD. Demographics, surgical indications, surgical approach, outcomes, and complications were reviewed. RESULTS A total of 60 patients were included in this study of which 25 (41.67%) underwent PFD and 35 (58.33%) underwent PFDD. Mean age at surgery was 7.41 years (range 0.4 to 18 years) with a mean follow-up of 8.23 years (range 5 to 21 years). Those that received a PFD had a lower rate of radiographic syrinx improvement (p = 0.03), especially in the setting of holocord syringes. Failure rate was significantly higher in the PFD group (20% vs 2.90%, p = 0.03). However, complications were significantly higher in the PFDD group (17.14% vs 4.0%, p = 0.04). CONCLUSIONS PFD provides a safe treatment option with similar clinical improvements and lower post-operative complication rate compared to PFDD, albeit at the cost of greater chance of reoperation, especially in the setting of a holocord syrinx. Patients with a holocord syrinx should be considered for a PFDD as their initial procedure.
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Affiliation(s)
- Khashayar Mozaffari
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
| | - Laurence Davidson
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Eric Chalif
- George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Tiffany N Phan
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Andrew D Sparks
- Department of Surgery, The George Washington University Hospital, Washington, DC, USA
| | - John S Myseros
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Hospital, Washington, DC, USA
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25
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Soldozy S, Yağmurlu K, Akyeampong DK, Burke R, Morgenstern PF, Keating RF, Black JS, Jane JA, Syed HR. Three-dimensional printing and craniosynostosis surgery. Childs Nerv Syst 2021; 37:2487-2495. [PMID: 33779807 DOI: 10.1007/s00381-021-05133-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Accepted: 03/15/2021] [Indexed: 12/15/2022]
Abstract
OVERVIEW The goal of this study was to review the current application and status of three-dimensional printing for craniosynostosis surgery. METHODS A literature review was performed using the PubMed/MEDLINE databases for studies published between 2010 and 2020. All studies demonstrating the utilization of three-dimensional printing for craniosynostosis surgery were included. RESULTS A total of 15 studies were ultimately selected. This includes studies demonstrating novel three-dimensional simulation and printing workflows, studies utilizing three-dimensional printing for surgical simulation, as well as case reports describing prior experiences. CONCLUSION The incorporation of three-dimensional printing into the domain of craniosynostosis surgery has many potential benefits. This includes streamlining surgical planning, developing patient-specific template guides, enhancing residency training, as well as aiding in patient counseling. However, the current state of the literature remains in the validation stage. Further study with larger case series, direct comparisons with control groups, and prolonged follow-up times is necessary before more widespread implementation is justified.
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Affiliation(s)
- Sauson Soldozy
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA, 22908, USA
| | - Kaan Yağmurlu
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA, 22908, USA
| | - Daniel K Akyeampong
- Department of Plastic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - Rebecca Burke
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA, 22908, USA
| | - Peter F Morgenstern
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - Jonathan S Black
- Department of Plastic Surgery, University of Virginia Health System, Charlottesville, VA, USA
| | - John A Jane
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA, 22908, USA
| | - Hasan R Syed
- Department of Neurological Surgery, University of Virginia Health System, P.O. Box 800212, Charlottesville, VA, 22908, USA.
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26
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Foster CH, Vargas AJ, Wells E, Keating RF, Magge SN. Cerebral vasculopathy and strokes in a child with COVID-19 antibodies: illustrative case. Journal of Neurosurgery: Case Lessons 2021; 2:CASE21160. [PMID: 35854911 PMCID: PMC9265222 DOI: 10.3171/case21160] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Accepted: 03/31/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND The ability of coronavirus disease 2019 (COVID-19) to cause neurological insults in afflicted adults is becoming increasingly understood by way of an ever-growing amount of international data. By contrast, the pandemic illness’s neurological effects in the pediatric population are both poorly understood and sparsely reported. OBSERVATIONS In this case, the authors reported their experience with a preschool-age child with hydrocephalus who suffered multiterritory strokes presumed secondary to immune-mediated cerebral vasculopathy as a result of asymptomatic COVID-19 infection. LESSONS Growing evidence indicates that COVID-19 can cause neurological sequelae such as encephalitis and strokes. In this case report, the authors discussed a case of cerebral vasculopathy and strokes in a pediatric patient who was positive for COVID-19.
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Affiliation(s)
- Chase H. Foster
- Department of Neurosurgery, George Washington University Hospital, Washington, DC
| | - Anthony J. Vargas
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, California; and
| | | | - Robert F. Keating
- Department of Neurosurgery, George Washington University Hospital, Washington, DC
- Neurosurgery, Children’s National Hospital, Washington, DC
| | - Suresh N. Magge
- Division of Neurosurgery, Children’s Hospital of Orange County, Orange, California; and
- Neurosurgery, Children’s National Hospital, Washington, DC
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27
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Sadler B, Skidmore A, Gewirtz J, Anderson RCE, Haller G, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Averill C, Baird LC, Bauer DF, Bethel-Anderson T, Bierbrauer KS, Bonfield CM, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Khan N, Krieger MD, Leonard JR, Maher CO, Mangano FT, Mapstone TB, McComb JG, McEvoy SD, Meehan T, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O'Neill BR, Ragheb J, Selden NR, Shah MN, Shannon CN, Smith J, Smyth MD, Stone SSD, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD, Strahle JM. Extradural decompression versus duraplasty in Chiari malformation type I with syrinx: outcomes on scoliosis from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2021:1-9. [PMID: 34144521 DOI: 10.3171/2020.12.peds20552] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 12/03/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Scoliosis is common in patients with Chiari malformation type I (CM-I)-associated syringomyelia. While it is known that treatment with posterior fossa decompression (PFD) may reduce the progression of scoliosis, it is unknown if decompression with duraplasty is superior to extradural decompression. METHODS A large multicenter retrospective and prospective registry of 1257 pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for patients with scoliosis who underwent PFD with or without duraplasty. RESULTS In total, 422 patients who underwent PFD had a clinical diagnosis of scoliosis. Of these patients, 346 underwent duraplasty, 51 received extradural decompression alone, and 25 were excluded because no data were available on the type of PFD. The mean clinical follow-up was 2.6 years. Overall, there was no difference in subsequent occurrence of fusion or proportion of patients with curve progression between those with and those without a duraplasty. However, after controlling for age, sex, preoperative curve magnitude, syrinx length, syrinx width, and holocord syrinx, extradural decompression was associated with curve progression > 10°, but not increased occurrence of fusion. Older age at PFD and larger preoperative curve magnitude were independently associated with subsequent occurrence of fusion. Greater syrinx reduction after PFD of either type was associated with decreased occurrence of fusion. CONCLUSIONS In patients with CM-I, syrinx, and scoliosis undergoing PFD, there was no difference in subsequent occurrence of surgical correction of scoliosis between those receiving a duraplasty and those with an extradural decompression. However, after controlling for preoperative factors including age, syrinx characteristics, and curve magnitude, patients treated with duraplasty were less likely to have curve progression than patients treated with extradural decompression. Further study is needed to evaluate the role of duraplasty in curve stabilization after PFD.
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Affiliation(s)
- Brooke Sadler
- 1Department of Pediatrics, Washington University in St. Louis, MO
| | - Alex Skidmore
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jordan Gewirtz
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | | | - Gabe Haller
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Laurie L Ackerman
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - P David Adelson
- 5Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - Raheel Ahmed
- 6Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Gregory W Albert
- 7Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 8Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 9Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Christine Averill
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Lissa C Baird
- 10Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - David F Bauer
- 11Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tammy Bethel-Anderson
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Karin S Bierbrauer
- 12Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - Christopher M Bonfield
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Douglas L Brockmeyer
- 13Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 14Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, GA
| | - Daniel E Couture
- 15Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 39Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 18Department of Neurosurgery, University of Vermont, Burlington, VT
| | | | - Ramin Eskandari
- 20Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | | | - Timothy M George
- 22Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, TX
| | - Gerald A Grant
- 23Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital and Stanford University School of Medicine, Palo Alto, CA
| | - Patrick C Graupman
- 24Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 25Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 26Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 27Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 28Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 29Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 30Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Iantosca
- 31Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Bermans J Iskandar
- 6Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Eric M Jackson
- 32Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Andrew H Jea
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - James M Johnston
- 33Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Robert F Keating
- 34Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus Khan
- 36Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Mark D Krieger
- 37Department of Neurosurgery, Children's Hospital Los Angeles, CA
| | - Jeffrey R Leonard
- 38Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 3Department of Neurosurgery, University of Michigan School of Medicine, Ann Arbor, MI
| | - Francesco T Mangano
- 12Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | | | - J Gordon McComb
- 37Department of Neurosurgery, Children's Hospital Los Angeles, CA
| | - Sean D McEvoy
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 39Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Michael Muhlbauer
- 36Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, TN
| | - W Jerry Oakes
- 33Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Greg Olavarria
- 40Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - Brent R O'Neill
- 29Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - John Ragheb
- 41Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 10Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 42Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
- 47Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Jodi Smith
- 4Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, IN
| | - Matthew D Smyth
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Scellig S D Stone
- 44Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Gerald F Tuite
- 45Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, FL
| | - Scott D Wait
- 46Carolina Neurosurgery & Spine Associates, Charlotte, NC; and
| | - John C Wellons
- 43Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
- 47Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 11Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 1Department of Pediatrics, Washington University in St. Louis, MO
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Jennifer M Strahle
- 1Department of Pediatrics, Washington University in St. Louis, MO
- 2Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
- 35Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, MO
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28
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Roth J, Constantini S, Ekstein M, Weiner HL, Tripathi M, Chandra PS, Cossu M, Rizzi M, Bollo RJ, Machado HR, Santos MV, Keating RF, Oluigbo CO, Rutka JT, Drake JM, Jallo GI, Shimony N, Treiber JM, Consales A, Mangano FT, Wisoff JH, Teresa Hidalgo E, Bingaman WE, Gupta A, Erdemir G, Sundar SJ, Benifla M, Shapira V, Lam SK, Fallah A, Maniquis CAB, Tisdall M, Chari A, Cinalli G, Blount JP, Dorfmüller G, Christine Bulteau, Uliel-Sibony S. Epilepsy surgery in infants up to 3 months of age: Safety, feasibility, and outcomes: A multicenter, multinational study. Epilepsia 2021; 62:1897-1906. [PMID: 34128544 DOI: 10.1111/epi.16959] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/18/2021] [Accepted: 05/23/2021] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Drug-resistant epilepsy (DRE) during the first few months of life is challenging and necessitates aggressive treatment, including surgery. Because the most common causes of DRE in infancy are related to extensive developmental anomalies, surgery often entails extensive tissue resections or disconnection. The literature on "ultra-early" epilepsy surgery is sparse, with limited data concerning efficacy controlling the seizures, and safety. The current study's goal is to review the safety and efficacy of ultra-early epilepsy surgery performed before the age of 3 months. METHODS To achieve a large sample size and external validity, a multinational, multicenter retrospective study was performed, focusing on epilepsy surgery for infants younger than 3 months of age. Collected data included epilepsy characteristics, surgical details, epilepsy outcome, and complications. RESULTS Sixty-four patients underwent 69 surgeries before the age of 3 months. The most common pathologies were cortical dysplasia (28), hemimegalencephaly (17), and tubers (5). The most common procedures were hemispheric surgeries (48 procedures). Two cases were intentionally staged, and one was unexpectedly aborted. Nearly all patients received blood products. There were no perioperative deaths and no major unexpected permanent morbidities. Twenty-five percent of patients undergoing hemispheric surgeries developed hydrocephalus. Excellent epilepsy outcome (International League Against Epilepsy [ILAE] grade I) was achieved in 66% of cases over a median follow-up of 41 months (19-104 interquartile range [IQR]). The number of antiseizure medications was significantly reduced (median 2 drugs, 1-3 IQR, p < .0001). Outcome was not significantly associated with the type of surgery (hemispheric or more limited resections). SIGNIFICANCE Epilepsy surgery during the first few months of life is associated with excellent seizure control, and when performed by highly experienced teams, is not associated with more permanent morbidity than surgery in older infants. Thus surgical treatment should not be postponed to treat DRE in very young infants based on their age.
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Affiliation(s)
- Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Margaret Ekstein
- Pediatric Anesthesia Unit, Department of Anesthesia, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Manjari Tripathi
- Center of Excellence for Epilepsy and MEG, AIIMS, New Delhi, India
| | | | - Massimo Cossu
- "C. Munari" Centre for Epilepsy Surgery, Niguarda Hospital, Milan, Italy
| | - Michele Rizzi
- "C. Munari" Centre for Epilepsy Surgery, Niguarda Hospital, Milan, Italy
| | - Robert J Bollo
- Division of Pediatric Neurosurgery, University of Utah School of Medicine, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Hélio Rubens Machado
- Pediatric Neurosurgery, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Marcelo Volpon Santos
- Pediatric Neurosurgery, Ribeirão Preto Medical School, University of Sao Paulo, Ribeirão Preto, Sao Paulo, Brazil
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - James T Rutka
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - James M Drake
- Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - George I Jallo
- Institute for Brain Protection Sciences, Johns Hopkins All Children's Hospital, St. Petersburg, Florida, USA.,Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Nir Shimony
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.,Department of Neurosurgery, Geisinger Commonwealth School of Medicine, Danville, Pennsylvania, USA
| | - Jeffrey M Treiber
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.,Division of Pediatric Neurosurgery, Department of Surgery, Texas Children's Hospital, Houston, Texas, USA
| | - Alessandro Consales
- Department of Pediatric Neurosurgery, IRRCS Istituto Giannina Gaslini, Genoa, Italy
| | - Francesco T Mangano
- Department of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Jeffrey H Wisoff
- Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - Eveline Teresa Hidalgo
- Division of Pediatric Neurosurgery, Hassenfeld Children's Hospital, NYU Langone Health, New York, NY, USA
| | - William E Bingaman
- Department of Neurological Surgery, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Ajay Gupta
- Department of Neurology, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Gozde Erdemir
- Department of Neurology, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Swetha J Sundar
- Department of Neurological Surgery, Epilepsy Center, Cleveland Clinic, Cleveland, OH, USA
| | - Mony Benifla
- Pediatric Neurosurgery Department, Rambam Health Care Campus, Haifa, Israel
| | - Vladimir Shapira
- Pediatric Neurosurgery Department, Rambam Health Care Campus, Haifa, Israel
| | - Sandi K Lam
- Department of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, IL, USA.,Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Aria Fallah
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Cassia A B Maniquis
- Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Martin Tisdall
- Department of Neurosurgery, Great Ormond Street Hospital & Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Aswin Chari
- Department of Neurosurgery, Great Ormond Street Hospital & Developmental Neurosciences, Great Ormond Street Institute of Child Health, University College London, London, UK
| | - Giuseppe Cinalli
- Department of Pediatric Neurosurgery, Santobono-Pausilipon Children's Hospital, Naples, Italy
| | - Jeffrey P Blount
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Al, USA
| | - Georg Dorfmüller
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France
| | - Christine Bulteau
- Pediatric Neurosurgery Department, Rothschild Foundation Hospital, Paris, France.,MC2Lab, University of Paris, Boulogne-Billancourt, France
| | - Shimrit Uliel-Sibony
- Pediatric Neurology Unit, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
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29
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Szuflita NS, Phan TN, Boulter JH, Keating RF, Myseros JS. Nonoperative management of enlarging syringomyelia in clinically stable patients after decompression of Chiari malformation type I. J Neurosurg Pediatr 2021:1-6. [PMID: 34020421 DOI: 10.3171/2020.12.peds20621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Accepted: 12/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The authors aimed to describe the natural history and optimal management of persistent syringomyelia after suboccipital craniectomy for Chiari malformation type I (CM-I). METHODS A cohort of all patients who presented to a tertiary pediatric hospital with newly diagnosed CM-I between 2009 and 2017 was identified. Patients with persistent or worsened syringomyelia were identified on the basis of a retrospective review of medical records and imaging studies. The management of these patients and their clinical courses were then described. RESULTS A total of 153 children with CM-I and syringomyelia were evaluated between 2009 and 2017. Of these, 115 (68.8%) patients underwent surgical intervention: 40 patients underwent posterior fossa decompression (PFD) alone, 43 underwent PFD with duraplasty, and 32 underwent PFD with duraplasty and fourth ventricle stent placement. Eleven (7.19%) patients had increased syringomyelia on subsequent postoperative imaging. Three of these patients underwent revision surgery because of worsening scoliosis or pain, 2 of whom were lost to follow-up, and 4 were managed nonoperatively with close surveillance and serial MRI evaluations. The syringes decreased in size in 3 patients and resolved completely in 1 patient. CONCLUSIONS Persistent or worsened syringomyelia after CM-I decompression is uncommon. In the absence of symptoms, nonoperative management with close observation is safe for patients with persistent syrinx.
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Affiliation(s)
- Nicholas S Szuflita
- 1Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland; and
| | - Tiffany N Phan
- 2Division of Neurosurgery, Children's National Health System, Washington, DC
| | - Jason H Boulter
- 1Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland; and
| | - Robert F Keating
- 2Division of Neurosurgery, Children's National Health System, Washington, DC
| | - John S Myseros
- 2Division of Neurosurgery, Children's National Health System, Washington, DC
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30
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CreveCoeur TS, Yahanda AT, Maher CO, Johnson GW, Ackerman LL, Adelson PD, Ahmed R, Albert GW, Aldana PR, Alden TD, Anderson RCE, Baird L, Bauer DF, Bierbrauer KS, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dauser RC, Durham SR, Ellenbogen RG, Eskandari R, Fuchs HE, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Haller G, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Jea AH, Johnston JM, Keating RF, Kelly MP, Khan N, Krieger MD, Leonard JR, Mangano FT, Mapstone TB, McComb JG, Menezes AH, Muhlbauer M, Oakes WJ, Olavarria G, O'Neill BR, Park TS, Ragheb J, Selden NR, Shah MN, Shannon C, Shimony JS, Smith J, Smyth MD, Stone SSD, Strahle JM, Tamber MS, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Limbrick DD. Occipital-Cervical Fusion and Ventral Decompression in the Surgical Management of Chiari-1 Malformation and Syringomyelia: Analysis of Data From the Park-Reeves Syringomyelia Research Consortium. Neurosurgery 2021; 88:332-341. [PMID: 33313928 DOI: 10.1093/neuros/nyaa460] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 07/12/2020] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Occipital-cervical fusion (OCF) and ventral decompression (VD) may be used in the treatment of pediatric Chiari-1 malformation (CM-1) with syringomyelia (SM) as adjuncts to posterior fossa decompression (PFD) for complex craniovertebral junction pathology. OBJECTIVE To examine factors influencing the use of OCF and OCF/VD in a multicenter cohort of pediatric CM-1 and SM subjects treated with PFD. METHODS The Park-Reeves Syringomyelia Research Consortium registry was used to examine 637 subjects with cerebellar tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and at least 1 yr of follow-up after their index PFD. Comparisons were made between subjects who received PFD alone and those with PFD + OCF or PFD + OCF/VD. RESULTS All 637 patients underwent PFD, 505 (79.2%) with and 132 (20.8%) without duraplasty. A total of 12 subjects went on to have OCF at some point in their management (PFD + OCF), whereas 4 had OCF and VD (PFD + OCF/VD). Of those with complete data, a history of platybasia (3/10, P = .011), Klippel-Feil (2/10, P = .015), and basilar invagination (3/12, P < .001) were increased within the OCF group, whereas only basilar invagination (1/4, P < .001) was increased in the OCF/VD group. Clivo-axial angle (CXA) was significantly lower for both OCF (128.8 ± 15.3°, P = .008) and OCF/VD (115.0 ± 11.6°, P = .025) groups when compared to PFD-only group (145.3 ± 12.7°). pB-C2 did not differ among groups. CONCLUSION Although PFD alone is adequate for treating the vast majority of CM-1/SM patients, OCF or OCF/VD may be occasionally utilized. Cranial base and spine pathologies and CXA may provide insight into the need for OCF and/or OCF/VD.
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Affiliation(s)
- Travis S CreveCoeur
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Alexander T Yahanda
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Cormac O Maher
- Department of Neurosurgery, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Gabrielle W Johnson
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Laurie L Ackerman
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - P David Adelson
- Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Raheel Ahmed
- Department of Neurological Surgery, University of Wisconsin at Madison, Madison, Wisconsin
| | - Gregory W Albert
- Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Phillipp R Aldana
- Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Richard C E Anderson
- Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York
| | - Lissa Baird
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - David F Bauer
- Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Karin S Bierbrauer
- Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Douglas L Brockmeyer
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Daniel E Couture
- Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Robert C Dauser
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Susan R Durham
- Department of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Richard G Ellenbogen
- Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Herbert E Fuchs
- Department of Neurosurgery, Duke University, Durham, North Carolina
| | - Timothy M George
- Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, Texas
| | - Gerald A Grant
- Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital at Stanford, Stanford University School of Medicine, Palo Alto, California
| | - Patrick C Graupman
- Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- Divsion of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- Department of Neurological Surgery, Weill Cornell Medical College, New York Presbyterian Hospital, New York, New York
| | - Naina L Gross
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Daniel J Guillaume
- Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gabe Haller
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Todd C Hankinson
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Gregory G Heuer
- Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Iantosca
- Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Bermans J Iskandar
- Department of Neurological Surgery, University of Wisconsin at Madison, Madison, Wisconsin
| | - Eric M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Andrew H Jea
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - James M Johnston
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia
| | - Michael P Kelly
- Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Nickalus Khan
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Mark D Krieger
- Department of Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Jeffrey R Leonard
- Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - Timothy B Mapstone
- Department of Neurosurgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - J Gordon McComb
- Department of Neurosurgery, Children's Hospital of Los Angeles, Los Angeles, California
| | - Arnold H Menezes
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Michael Muhlbauer
- Department of Neurosurgery, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - W Jerry Oakes
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Greg Olavarria
- Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Brent R O'Neill
- Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Tae Sung Park
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - John Ragheb
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida
| | - Nathan R Selden
- Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Chevis Shannon
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - Joshua S Shimony
- Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Jodi Smith
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Matthew D Smyth
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Scellig S D Stone
- Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer M Strahle
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Mandeep S Tamber
- Department of Neurosurgery, The University of British Columbia, Vancouver, Canada
| | - James C Torner
- Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Gerald F Tuite
- Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Scott D Wait
- Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina
| | - John C Wellons
- Division of Pediatric Neurosurgery, Monroe Carell Jr Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - David D Limbrick
- Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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31
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Yahanda AT, Adelson PD, Akbari SHA, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bethel-Anderson T, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Dlouhy BJ, Durham SR, Ellenbogen RG, Eskandari R, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Hankinson TC, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Johnston JM, Keating RF, Krieger MD, Leonard JR, Maher CO, Mangano FT, McComb JG, McEvoy SD, Meehan T, Menezes AH, O'Neill BR, Olavarria G, Ragheb J, Selden NR, Shah MN, Shannon CN, Shimony JS, Smyth MD, Stone SSD, Strahle JM, Torner JC, Tuite GF, Wait SD, Wellons JC, Whitehead WE, Park TS, Limbrick DD. Dural augmentation approaches and complication rates after posterior fossa decompression for Chiari I malformation and syringomyelia: a Park-Reeves Syringomyelia Research Consortium study. J Neurosurg Pediatr 2021; 27:459-468. [PMID: 33578390 DOI: 10.3171/2020.8.peds2087] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 08/24/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Posterior fossa decompression with duraplasty (PFDD) is commonly performed for Chiari I malformation (CM-I) with syringomyelia (SM). However, complication rates associated with various dural graft types are not well established. The objective of this study was to elucidate complication rates within 6 months of surgery among autograft and commonly used nonautologous grafts for pediatric patients who underwent PFDD for CM-I/SM. METHODS The Park-Reeves Syringomyelia Research Consortium database was queried for pediatric patients who had undergone PFDD for CM-I with SM. All patients had tonsillar ectopia ≥ 5 mm, syrinx diameter ≥ 3 mm, and ≥ 6 months of postoperative follow-up after PFDD. Complications (e.g., pseudomeningocele, CSF leak, meningitis, and hydrocephalus) and postoperative changes in syrinx size, headaches, and neck pain were compared for autograft versus nonautologous graft. RESULTS A total of 781 PFDD cases were analyzed (359 autograft, 422 nonautologous graft). Nonautologous grafts included bovine pericardium (n = 63), bovine collagen (n = 225), synthetic (n = 99), and human cadaveric allograft (n = 35). Autograft (103/359, 28.7%) had a similar overall complication rate compared to nonautologous graft (143/422, 33.9%) (p = 0.12). However, nonautologous graft was associated with significantly higher rates of pseudomeningocele (p = 0.04) and meningitis (p < 0.001). The higher rate of meningitis was influenced particularly by the higher rate of chemical meningitis (p = 0.002) versus infectious meningitis (p = 0.132). Among 4 types of nonautologous grafts, there were differences in complication rates (p = 0.02), including chemical meningitis (p = 0.01) and postoperative nausea/vomiting (p = 0.03). Allograft demonstrated the lowest complication rates overall (14.3%) and yielded significantly fewer complications compared to bovine collagen (p = 0.02) and synthetic (p = 0.003) grafts. Synthetic graft yielded higher complication rates than autograft (p = 0.01). Autograft and nonautologous graft resulted in equal improvements in syrinx size (p < 0.0001). No differences were found for postoperative changes in headaches or neck pain. CONCLUSIONS In the largest multicenter cohort to date, complication rates for dural autograft and nonautologous graft are similar after PFDD for CM-I/SM, although nonautologous graft results in higher rates of pseudomeningocele and meningitis. Rates of meningitis differ among nonautologous graft types. Autograft and nonautologous graft are equivalent for reducing syrinx size, headaches, and neck pain.
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Affiliation(s)
- Alexander T Yahanda
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - P David Adelson
- 2Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ
| | - S Hassan A Akbari
- 3Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Gregory W Albert
- 4Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, AR
| | - Philipp R Aldana
- 5Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, FL
| | - Tord D Alden
- 6Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, IL
| | - Richard C E Anderson
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, NY
| | - David F Bauer
- 8Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, NH
| | - Tammy Bethel-Anderson
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Douglas L Brockmeyer
- 9Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, UT
| | - Joshua J Chern
- 10Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta, GA
| | - Daniel E Couture
- 11Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, NC
| | | | - Brian J Dlouhy
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Susan R Durham
- 14Department of Neurosurgery, University of Vermont, Burlington, VT
| | | | - Ramin Eskandari
- 16Department of Neurosurgery, Medical University of South Carolina, Charleston, SC
| | - Timothy M George
- 17Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, TX
| | - Gerald A Grant
- 18Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, CA
| | - Patrick C Graupman
- 19Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, MN
| | - Stephanie Greene
- 20Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Jeffrey P Greenfield
- 21Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, NY
| | - Naina L Gross
- 22Department of Neurosurgery, University of Oklahoma, Oklahoma City, OK
| | - Daniel J Guillaume
- 23Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, MN
| | - Todd C Hankinson
- 24Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Gregory G Heuer
- 25Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mark Iantosca
- 26Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, PA
| | - Bermans J Iskandar
- 27Department of Neurological Surgery, University of Wisconsin at Madison, WI
| | - Eric M Jackson
- 28Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD
| | - James M Johnston
- 3Division of Pediatric Neurosurgery, University of Alabama at Birmingham, AL
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Mark D Krieger
- 30Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, CA
| | - Jeffrey R Leonard
- 31Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, OH
| | - Cormac O Maher
- 32Department of Neurosurgery, University of Michigan, Ann Arbor, MI
| | - Francesco T Mangano
- 33Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, OH
| | - J Gordon McComb
- 30Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, CA
| | - Sean D McEvoy
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Thanda Meehan
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Arnold H Menezes
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Brent R O'Neill
- 24Department of Neurosurgery, Children's Hospital Colorado, Aurora, CO
| | - Greg Olavarria
- 34Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, FL
| | - John Ragheb
- 35Department of Neurological Surgery, University of Miami School of Medicine, Miami, FL
| | - Nathan R Selden
- 36Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, OR
| | - Manish N Shah
- 37Division of Pediatric Neurosurgery, McGovern Medical School, Houston, TX
| | - Chevis N Shannon
- 38Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - Joshua S Shimony
- 39Department of Radiology, Washington University School of Medicine, St. Louis, MO
| | - Matthew D Smyth
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - Scellig S D Stone
- 40Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, MA
| | - Jennifer M Strahle
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - James C Torner
- 13Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, IA
| | - Gerald F Tuite
- 41Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, FL
| | - Scott D Wait
- 42Carolina Neurosurgery & Spine Associates, Charlotte, NC; and
| | - John C Wellons
- 38Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, TN
| | - William E Whitehead
- 43Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, TX
| | - Tae Sung Park
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
| | - David D Limbrick
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, MO
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32
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Lajthia O, Rogers GF, Tsering D, Keating RF, Magge SN. Quantitative outcomes of endoscopic strip craniectomy for metopic craniosynostosis in children with severe trigonocephaly. Childs Nerv Syst 2021; 37:573-579. [PMID: 32812117 DOI: 10.1007/s00381-020-04849-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2019] [Accepted: 07/30/2020] [Indexed: 11/29/2022]
Abstract
PURPOSE To assess intermediate-term (> 3 years) outcomes of endoscopic strip craniectomy with postoperative helmet therapy (ESC + HT) for the treatment of infants with severe trigonocephaly. METHODS This retrospective study examined cranial morphology of consecutive patients with severe trigonocephaly treated with minimally invasive ESC + HT. Preoperative and follow-up clinical parameters were collected from patient charts. Interfrontal divergence angle (IFDA), a validated and accurate measure of forehead narrowing, was measured on preoperative CT scans and on preoperative and postoperative 2D photographs. RESULTS Seven patients (4 male, 3 female) were included with a mean age at surgery of 2.76 months (range 1.8 to 4.1 months) and mean clinical follow-up of 3.71 years (photographic follow-up 2.73 years). The mean operative time was 91.4 min, with a mean estimated blood loss (EBL) of 57.1 ml and mean hospital length of stay of 1.14 days. IFDA improved from 118.8° to 135.9° (p < 0.01), with the mean final measurement falling within normal limits. The head circumference percentile was not significantly changed in follow-up. There was a statistically significant improvement in the inner-to-outer canthal distance ratio (p = 0.01) in follow-up, showing an improvement in hypotelorism. There were no dural tears, CSF leaks, infections, or other significant surgical morbidities, and there were no serious complications related to the use of helmet therapy. All patients achieved excellent aesthetic results judged by photographic comparison. CONCLUSION This study demonstrated that patients treated with ESC + HT for metopic craniosynostosis showed measurable and significant improvement in forehead shape. This technique is a safe and effective alternative to more invasive surgical interventions.
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Affiliation(s)
- Orgest Lajthia
- Division of Neurosurgery, Children's National Hospital, 4th Floor, Suite 100, 111 Michigan Avenue NW, Washington, DC, 20010, USA.,Department of Neurosurgery, Georgetown University Medical Center, Washington, DC, USA
| | - Gary F Rogers
- Division of Plastic Surgery, Children's National Health System, Washington, DC, USA
| | - Deki Tsering
- Division of Neurosurgery, Children's National Hospital, 4th Floor, Suite 100, 111 Michigan Avenue NW, Washington, DC, 20010, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Hospital, 4th Floor, Suite 100, 111 Michigan Avenue NW, Washington, DC, 20010, USA.,Department of Neurosurgery, George Washington University School of Medicine, Washington, DC, USA
| | - Suresh N Magge
- Division of Neurosurgery, Children's National Hospital, 4th Floor, Suite 100, 111 Michigan Avenue NW, Washington, DC, 20010, USA. .,Department of Neurosurgery, George Washington University School of Medicine, Washington, DC, USA.
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33
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Rymarczuk GN, Keating RF, Coughlin DJ, Felbaum D, Myseros JS, Oluigbo C, Yadav B, Sharma K, Magge SN. A Comparison of Ventriculoperitoneal and Ventriculoatrial Shunts in a Population of 544 Consecutive Pediatric Patients. Neurosurgery 2020; 87:80-85. [PMID: 31586189 DOI: 10.1093/neuros/nyz387] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 07/17/2019] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Although ventriculoperitoneal shunts (VPS) remain the first-line option in most instances of pediatric hydrocephalus, the long-term efficacy of ventriculoatrial shunts (VAS) remains unknown. OBJECTIVE To characterize the long-term outcomes and adverse occurrences associated with both VPS and VAS at our institution. METHODS The authors retrospectively analyzed all cerebrospinal fluid (CSF) shunting procedures performed over a 13-yr period at a single institution. A total of 544 pediatric shunt patients were followed for at least 90 d (VPS: 5.9 yr; VAS: 5.3 yr). RESULTS A total of 54% of VPS and 60% of VAS required at least 1 revision. VPS demonstrated superior survival overall; however, if electively scheduled VAS lengthening procedures are not considered true "failures," no statistical difference is noted in overall survival (P = .08). VPS demonstrated significantly greater survival in patients less than 7 yr of age (P = .001), but showed no difference in older children (P = .4). VAS had a significantly lower rate of infection (P < .05) and proximal failure (P < .001). CONCLUSION VAS can be a useful alternative to VPS when the abdomen is unsuitable, particularly in older children. Although VPS demonstrates superior overall survival, it should be understood that elective VAS lengthening procedures are often necessary, especially in younger patients. If elective lengthening procedures are not considered true failures, then the devices show similar survival.
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Affiliation(s)
- George N Rymarczuk
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia.,Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Robert F Keating
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
| | - Daniel J Coughlin
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Daniel Felbaum
- Department of Neurosurgery, Georgetown University, Washington, District of Columbia
| | - John S Myseros
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
| | - Chima Oluigbo
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
| | - Bhupender Yadav
- Department of Interventional Radiology, Children's National Health System, Washington, District of Columbia
| | - Karun Sharma
- Department of Interventional Radiology, Children's National Health System, Washington, District of Columbia
| | - Suresh N Magge
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
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Keating RF. James Tait Goodrich, MD, PhD. (4/16/1946-3/30/2020). Childs Nerv Syst 2020; 36:2189-2191. [PMID: 32737564 DOI: 10.1007/s00381-020-04805-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine, Washington, DC, 20010, USA.
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Rymarczuk GN, Keating RF, Coughlin DJ, Felbaum D, Myseros JS, Oluigbo C, Yadav B, Sharma K, Magge SN. A Comparison of Ventriculoperitoneal and Ventriculoatrial Shunts in a Population of 544 Consecutive Pediatric Patients. Neurosurgery 2020; 87:80-85. [PMID: 31586189 DOI: 10.1093/neuros/nyz387.erratum.in:neurosurgery.2020feb1;86(2):315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2018] [Accepted: 07/17/2019] [Indexed: 05/26/2023] Open
Abstract
BACKGROUND Although ventriculoperitoneal shunts (VPS) remain the first-line option in most instances of pediatric hydrocephalus, the long-term efficacy of ventriculoatrial shunts (VAS) remains unknown. OBJECTIVE To characterize the long-term outcomes and adverse occurrences associated with both VPS and VAS at our institution. METHODS The authors retrospectively analyzed all cerebrospinal fluid (CSF) shunting procedures performed over a 13-yr period at a single institution. A total of 544 pediatric shunt patients were followed for at least 90 d (VPS: 5.9 yr; VAS: 5.3 yr). RESULTS A total of 54% of VPS and 60% of VAS required at least 1 revision. VPS demonstrated superior survival overall; however, if electively scheduled VAS lengthening procedures are not considered true "failures," no statistical difference is noted in overall survival (P = .08). VPS demonstrated significantly greater survival in patients less than 7 yr of age (P = .001), but showed no difference in older children (P = .4). VAS had a significantly lower rate of infection (P < .05) and proximal failure (P < .001). CONCLUSION VAS can be a useful alternative to VPS when the abdomen is unsuitable, particularly in older children. Although VPS demonstrates superior overall survival, it should be understood that elective VAS lengthening procedures are often necessary, especially in younger patients. If elective lengthening procedures are not considered true failures, then the devices show similar survival.
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Affiliation(s)
- George N Rymarczuk
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Robert F Keating
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
| | - Daniel J Coughlin
- Division of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, Maryland
| | - Daniel Felbaum
- Department of Neurosurgery, Georgetown University, Washington, District of Columbia
| | - John S Myseros
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
| | - Chima Oluigbo
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
| | - Bhupender Yadav
- Department of Interventional Radiology, Children's National Health System, Washington, District of Columbia
| | - Karun Sharma
- Department of Interventional Radiology, Children's National Health System, Washington, District of Columbia
| | - Suresh N Magge
- Division of Neurosurgery, Children's National Health System, Washington, District of Columbia
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Cobourn K, Marayati F, Tsering D, Ayers O, Myseros JS, Magge SN, Oluigbo CO, Keating RF. Cerebellar mutism syndrome: current approaches to minimize risk for CMS. Childs Nerv Syst 2020; 36:1171-1179. [PMID: 31273496 DOI: 10.1007/s00381-019-04240-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2019] [Accepted: 05/28/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Cerebellar mutism syndrome (CMS) is a serious source of morbidity following posterior fossa surgery in the pediatric population. However, methods for effectively decreasing its incidence and impact remain unclear. It is our aim to examine the impact of adjusting surgical factors, namely the use of a telovelar approach and avoidance of cavitronic ultrasonic aspirator, on the incidence of CMS in our population as well as outlining potential pre-, intra-, and postoperative factors that may contribute to its development. METHODS Retrospective review was performed to identify patients undergoing posterior fossa surgery for resection of a medulloblastoma. Demographic, surgical, and postoperative data were collected. These data were analyzed for possible correlations to the risk of developing CMS via univariate analysis. For factors found to be significant, a multivariate analysis was performed to assess their independence. RESULTS Seven of 65 patients (10.8%) developed CMS postoperatively. Factors found to be significantly associated with a higher risk of CMS were the degree of retraction utilized during the procedure (p = 0.0000) and incision of the vermis (p = 0.0294). Although they did not reach the threshold of statistical significance, tumor vascularity (p = 0.19), adoption of a transvermian approach (p = 0.19), and lack of intraoperative imaging (p = 0.17) exhibited strongly suggestive trends towards a correlation with CMS. DISCUSSION In an effort to reduce the incidence and severity of CMS in our population, our institution adopted surgical practices that minimize tissue trauma and mitigate postoperative edema. This included the use of a telovelar over a transvermian approach to obviate the need for vermian incision, avoidance of the CUSA, and minimization of heavy retraction during surgery. This was successful in reducing the incidence of CMS from 39% in our medulloblastoma patients to 10.8%. The development of CMS after posterior fossa surgery appears to be a "two-hit" phenomenon requiring a combination of existing predisposition, surgical injury, and postoperative exacerbation. Therefore, it is critical to identify the factors involved at each stage and investigate treatments to target them appropriately.
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Affiliation(s)
- Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | - Fares Marayati
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Princeton University, Princeton, NJ, USA
| | - Deki Tsering
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA
| | - Owen Ayers
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,Princeton University, Princeton, NJ, USA
| | - John S Myseros
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Suresh N Magge
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA.,George Washington University School of Medicine, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, 4th Floor, Suite 100, 111 Michigan Ave NW, Washington, DC, 20010, USA. .,George Washington University School of Medicine, Washington, DC, USA.
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Hale AT, Adelson PD, Albert GW, Aldana PR, Alden TD, Anderson RCE, Bauer DF, Bonfield CM, Brockmeyer DL, Chern JJ, Couture DE, Daniels DJ, Durham SR, Ellenbogen RG, Eskandari R, George TM, Grant GA, Graupman PC, Greene S, Greenfield JP, Gross NL, Guillaume DJ, Heuer GG, Iantosca M, Iskandar BJ, Jackson EM, Johnston JM, Keating RF, Leonard JR, Maher CO, Mangano FT, McComb JG, Meehan T, Menezes AH, O'Neill B, Olavarria G, Park TS, Ragheb J, Selden NR, Shah MN, Smyth MD, Stone SSD, Strahle JM, Wait SD, Wellons JC, Whitehead WE, Shannon CN, Limbrick DD. Factors associated with syrinx size in pediatric patients treated for Chiari malformation type I and syringomyelia: a study from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2020; 25:1-11. [PMID: 32114543 DOI: 10.3171/2020.1.peds19493] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 01/07/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Factors associated with syrinx size in pediatric patients undergoing posterior fossa decompression (PFD) or PFD with duraplasty (PFDD) for Chiari malformation type I (CM-I) with syringomyelia (SM; CM-I+SM) are not well established. METHODS Using the Park-Reeves Syringomyelia Research Consortium registry, the authors analyzed variables associated with syrinx radiological outcomes in patients (< 20 years old at the time of surgery) with CM-I+SM undergoing PFD or PFDD. Syrinx resolution was defined as an anteroposterior (AP) diameter of ≤ 2 mm or ≤ 3 mm or a reduction in AP diameter of ≥ 50%. Syrinx regression or progression was defined using 1) change in syrinx AP diameter (≥ 1 mm), or 2) change in syrinx length (craniocaudal, ≥ 1 vertebral level). Syrinx stability was defined as a < 1-mm change in syrinx AP diameter and no change in syrinx length. RESULTS The authors identified 380 patients with CM-I+SM who underwent PFD or PFDD. Cox proportional hazards modeling revealed younger age at surgery and PFDD as being independently associated with syrinx resolution, defined as a ≤ 2-mm or ≤ 3-mm AP diameter or ≥ 50% reduction in AP diameter. Radiological syrinx resolution was associated with improvement in headache (p < 0.005) and neck pain (p < 0.011) after PFD or PFDD. Next, PFDD (p = 0.005), scoliosis (p = 0.007), and syrinx location across multiple spinal segments (p = 0.001) were associated with syrinx diameter regression, whereas increased preoperative frontal-occipital horn ratio (FOHR; p = 0.007) and syrinx location spanning multiple spinal segments (p = 0.04) were associated with syrinx length regression. Scoliosis (HR 0.38 [95% CI 0.16-0.91], p = 0.03) and smaller syrinx diameter (5.82 ± 3.38 vs 7.86 ± 3.05 mm; HR 0.60 [95% CI 0.34-1.03], p = 0.002) were associated with syrinx diameter stability, whereas shorter preoperative syrinx length (5.75 ± 4.01 vs 9.65 ± 4.31 levels; HR 0.21 [95% CI 0.12-0.38], p = 0.0001) and smaller pB-C2 distance (6.86 ± 1.27 vs 7.18 ± 1.38 mm; HR 1.44 [95% CI 1.02-2.05], p = 0.04) were associated with syrinx length stability. Finally, younger age at surgery (8.19 ± 5.02 vs 10.29 ± 4.25 years; HR 1.89 [95% CI 1.31-3.04], p = 0.01) was associated with syrinx diameter progression, whereas increased postoperative syrinx diameter (6.73 ± 3.64 vs 3.97 ± 3.07 mm; HR 3.10 [95% CI 1.67-5.76], p = 0.003), was associated with syrinx length progression. PFD versus PFDD was not associated with syrinx progression or reoperation rate. CONCLUSIONS These data suggest that PFDD and age are independently associated with radiological syrinx improvement, although forthcoming results from the PFDD versus PFD randomized controlled trial (NCT02669836, clinicaltrials.gov) will best answer this question.
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Affiliation(s)
- Andrew T Hale
- 1Vanderbilt University School of Medicine, Medical Scientist Training Program, Nashville, Tennessee
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - P David Adelson
- 3Division of Pediatric Neurosurgery, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Gregory W Albert
- 4Division of Neurosurgery, Arkansas Children's Hospital, Little Rock, Arkansas
| | - Philipp R Aldana
- 5Division of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Tord D Alden
- 6Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Illinois
| | - Richard C E Anderson
- 7Division of Pediatric Neurosurgery, Department of Neurological Surgery, Children's Hospital of New York, Columbia-Presbyterian, New York, New York
| | - David F Bauer
- 8Department of Neurosurgery, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire
| | - Christopher M Bonfield
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - Douglas L Brockmeyer
- 10Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah
| | - Joshua J Chern
- 11Division of Pediatric Neurosurgery, Children's Healthcare of Atlanta University, Atlanta, Georgia
| | - Daniel E Couture
- 12Department of Neurological Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - David J Daniels
- 13Department of Neurosurgery, Mayo Clinic, Rochester, Minnesota
| | - Susan R Durham
- 14Department of Neurosurgery, University of Vermont, Burlington, Vermont
| | - Richard G Ellenbogen
- 15Division of Pediatric Neurosurgery, Seattle Children's Hospital, Seattle, Washington
| | - Ramin Eskandari
- 16Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina
| | - Timothy M George
- 17Division of Pediatric Neurosurgery, Dell Children's Medical Center, Austin, Texas
| | - Gerald A Grant
- 18Division of Pediatric Neurosurgery, Lucile Packard Children's Hospital, Palo Alto, California
| | - Patrick C Graupman
- 19Division of Pediatric Neurosurgery, Gillette Children's Hospital, St. Paul, Minnesota
| | - Stephanie Greene
- 20Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jeffrey P Greenfield
- 21Department of Neurological Surgery, Weill Cornell Medical College, NewYork-Presbyterian Hospital, New York, New York
| | - Naina L Gross
- 22Department of Neurosurgery, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma
| | - Daniel J Guillaume
- 23Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Gregory G Heuer
- 24Division of Pediatric Neurosurgery, Children's Hospital of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mark Iantosca
- 25Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - Bermans J Iskandar
- 26Department of Neurological Surgery, University of Wisconsin at Madison, Wisconsin
| | - Eric M Jackson
- 27Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - James M Johnston
- 28Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Jeffrey R Leonard
- 30Division of Pediatric Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio
| | - Cormac O Maher
- 31Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Francesco T Mangano
- 32Division of Pediatric Neurosurgery, Cincinnati Children's Medical Center, Cincinnati, Ohio
| | - J Gordon McComb
- 33Division of Pediatric Neurosurgery, Children's Hospital of Los Angeles, California
| | - Thanda Meehan
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Arnold H Menezes
- 35Department of Neurosurgery, University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - Brent O'Neill
- 36Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Greg Olavarria
- 37Division of Pediatric Neurosurgery, Arnold Palmer Hospital for Children, Orlando, Florida
| | - Tae Sung Park
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - John Ragheb
- 38Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida
| | - Nathan R Selden
- 39Department of Neurological Surgery and Doernbecher Children's Hospital, Oregon Health & Science University, Portland, Oregon
| | - Manish N Shah
- 40Division of Pediatric Neurosurgery, McGovern Medical School, Houston, Texas
| | - Matthew D Smyth
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Scellig S D Stone
- 41Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Jennifer M Strahle
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
| | - Scott D Wait
- 42Carolina Neurosurgery & Spine Associates, Charlotte, North Carolina; and
| | - John C Wellons
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- 43Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - Chevis N Shannon
- 2Surgical Outcomes Center for Kids, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
- 9Division of Pediatric Neurosurgery, Monroe Carell Jr. Children's Hospital of Vanderbilt University, Nashville, Tennessee
| | - David D Limbrick
- 34Department of Neurological Surgery, Washington University in St. Louis School of Medicine, St. Louis, Missouri
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Sacino M, Huang SS, Alexander H, Fayed I, Keating RF, Oluigbo CO. An Initial Cost-Effectiveness Analysis of Magnetic Resonance-Guided Laser Interstitial Thermal Therapy in Pediatric Epilepsy Surgery. Pediatr Neurosurg 2020; 55:141-148. [PMID: 32829333 DOI: 10.1159/000509329] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Accepted: 06/09/2020] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a new technology that provides a clinically efficacious and minimally invasive alternative to conventional microsurgical resection. However, little data exist on how costs compare to traditional open surgery. The goal of this paper is to investigate the cost-effectiveness of MRgLITT in the treatment of pediatric epilepsy. METHODS We retrospectively analyzed the medical records of pediatric patients who underwent MRgLITT via the Visualase® thermal therapy system (Medtronic, Inc., Minneapolis, MN, USA) between December 2013 and September 2017. Direct costs associated with preoperative, operative, and follow-up care were extracted. Benefit was calculated in quality-adjusted life years (QALYs), and the cost-effectiveness was derived from the discounted total direct costs over QALY. Sensitivity analysis on 4 variables was utilized to assess the validity of our results. RESULTS Twelve consecutive pediatric patients with medically refractory epilepsy underwent MRgLITT procedures. At the last postoperative follow-up, 8 patients were seizure free (Engel I, 66.7%), 2 demonstrated significant improvement (Engel II, 16.7%), and 2 patients showed worthwhile improvement (Engel III, 16.7%). The average cumulative discounted QALY was 2.11 over the lifetime of a patient. Adjusting for inflation, MRgLITT procedures had a cost-effectiveness of USD 22,211 per QALY. Our sensitivity analysis of cost variables is robust and supports the procedure to be cost--effective. CONCLUSION Our data suggests that MRgLITT may be a cost-effective alternative to traditional surgical resection in pediatric epilepsy surgery.
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Affiliation(s)
- Matthew Sacino
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA
| | - Sean S Huang
- Department of Health Systems Administration, Georgetown University, Washington, District of Columbia, USA
| | - Hepzibha Alexander
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Georgetown University School of Medicine, Washington, District of Columbia, USA
| | - Islam Fayed
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Department of Neurosurgery, MedStar Georgetown University Hospital, Washington, District of Columbia, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA.,Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, Washington, District of Columbia, USA, .,Department of Neurosurgery, George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, USA,
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Koueik J, Sandoval-Garcia C, Kestle JRW, Rocque BG, Frim DM, Grant GA, Keating RF, Muh CR, Oakes WJ, Pollack IF, Selden NR, Tubbs RS, Tuite GF, Warf B, Rajamanickam V, Broman AT, Haughton V, Rebsamen S, George TM, Iskandar BJ. Outcomes in children undergoing posterior fossa decompression and duraplasty with and without tonsillar reduction for Chiari malformation type I and syringomyelia: a pilot prospective multicenter cohort study. J Neurosurg Pediatr 2019; 25:1-9. [PMID: 31628281 DOI: 10.3171/2019.8.peds19154] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Accepted: 08/01/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Despite significant advances in diagnostic and surgical techniques, the surgical management of Chiari malformation type I (CM-I) with associated syringomyelia remains controversial, and the type of surgery performed is surgeon dependent. This study's goal was to determine the feasibility of a prospective, multicenter, cohort study for CM-I/syringomyelia patients and to provide pilot data that compare posterior fossa decompression and duraplasty (PFDD) with and without tonsillar reduction. METHODS Participating centers prospectively enrolled children suffering from both CM-I and syringomyelia who were scheduled to undergo surgical decompression. Clinical data were entered into a database preoperatively and at 1-2 weeks, 3-6 months, and 1 year postoperatively. MR images were evaluated by 3 independent, blinded teams of neurosurgeons and neuroradiologists. The primary endpoint was improvement or resolution of the syrinx. RESULTS Eight clinical sites were chosen based on the results of a published questionnaire intended to remove geographic and surgeon bias. Data from 68 patients were analyzed after exclusions, and complete clinical and imaging records were obtained for 55 and 58 individuals, respectively. There was strong agreement among the 3 radiology teams, and there was no difference in patient demographics among sites, surgeons, or surgery types. Tonsillar reduction was not associated with > 50% syrinx improvement (RR = 1.22, p = 0.39) or any syrinx improvement (RR = 1.00, p = 0.99). There were no surgical complications. CONCLUSIONS This study demonstrated the feasibility of a prospective, multicenter surgical trial in CM-I/syringomyelia and provides pilot data indicating no discernible difference in 1-year outcomes between PFDD with and without tonsillar reduction, with power calculations for larger future studies. In addition, the study revealed important technical factors to consider when setting up future trials. The long-term sequelae of tonsillar reduction have not been addressed and would be an important consideration in future investigations.
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Affiliation(s)
- Joyce Koueik
- 1Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
| | | | - John R W Kestle
- 2Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Brandon G Rocque
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - David M Frim
- 4Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois
| | - Gerald A Grant
- 5Department of Pediatric Neurosurgery, Stanford Health Care, Palo Alto, California
| | - Robert F Keating
- 6Department of Neurosurgery, Children's National Health System, Washington, DC
| | - Carrie R Muh
- 7Department of Neurosurgery, Duke University Medical Center, Durham, North Carolina
| | - W Jerry Oakes
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - Ian F Pollack
- 8Department of Neurosurgery, UPMC Children's Hospital of Pittsburgh, Pennsylvania
| | - Nathan R Selden
- 9Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon
| | - R Shane Tubbs
- 3Department of Neurosurgery, Children's of Alabama, Birmingham, Alabama
| | - Gerald F Tuite
- 10Department of Neurosurgery, Johns Hopkins All Children's Hospital, Tampa, Florida
| | - Benjamin Warf
- 11Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | | | | | - Victor Haughton
- 13Radiology, University of Wisconsin-Madison, Wisconsin; and
| | - Susan Rebsamen
- 13Radiology, University of Wisconsin-Madison, Wisconsin; and
| | - Timothy M George
- 14Department of Neurosurgery, Dell Medical School, Austin, Texas
| | - Bermans J Iskandar
- 1Department of Neurological Surgery, University of Wisconsin, Madison, Wisconsin
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40
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Alexander H, Tsering D, Myseros JS, Magge SN, Oluigbo C, Sanchez CE, Keating RF. Management of Chiari I malformations: a paradigm in evolution. Childs Nerv Syst 2019; 35:1809-1826. [PMID: 31352576 DOI: 10.1007/s00381-019-04265-2] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Accepted: 06/17/2019] [Indexed: 12/29/2022]
Abstract
PURPOSE Despite decades of experience and research, the etiology and management of Chiari I malformations (CM-I) continue to raise more questions than answers. Controversy abounds in every aspect of management, including the indications, timing, and type of surgery, as well as clinical and radiographic outcomes. This review aims to outline past experiences, consolidate current evidence, and recommend directions for the future management of the Chiari I malformation. METHODS A review of recent literature on the management of CM-I in pediatric patients is presented, along with our experience in managing 1073 patients who were diagnosed with CM-I over the past two decades (1998-2018) at Children's National Medical Center (CNMC) in Washington DC. RESULTS The general trend reveals an increase in the diagnosis of CM-I at younger ages with a significant proportion of these being incidental findings (0.5-3.6%) in asymptomatic patients as well as a rise in the number of patients undergoing Chiari posterior fossa decompression surgery (PFD). The type of surgical intervention varies widely. At our institution, 104 (37%) Chiari surgeries were bone-only PFD with/without outer leaf durectomy, whereas 177 (63%) were PFD with duraplasty. We did not find a significant difference in outcomes between the PFD and PFDD groups (p = 0.59). An analysis of failures revealed a significant difference between patients who underwent tonsillar coagulation versus those whose tonsils were not manipulated (p = 0.02). CONCLUSION While the optimal surgical intervention continues to remain elusive, there is a shift away from intradural techniques in favor of a simple, extradural approach (including dural delamination) in pediatric patients due to high rates of clinical and radiographic success, along with a lower complication rate. The efficacy, safety, and necessity of tonsillar manipulation continue to be heavily contested, as evidence increasingly supports the efficacy and safety of less tonsillar manipulation, including our own experience.
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Affiliation(s)
- H Alexander
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Georgetown University School of Medicine, Washington, DC, USA
| | - D Tsering
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA
| | - J S Myseros
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - S N Magge
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - C Oluigbo
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - C E Sanchez
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA.,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, Washington, DC, USA. .,Department of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, 20010, USA.
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Alexander H, Govindan RB, Garrett CT, Anwar T, Fayed I, Keating RF, Gaillard W, Oluigbo C. Global and Intertuberal Epileptic Networks in Tuberous Sclerosis Based on Stereoelectroencephalographic (sEEG) Findings: A Quantitative EEG Analysis in Pediatric Subjects and Surgical Implications. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Alexander H, Tsering D, Myseros JS, Magge SN, Oluigbo C, Sanchez CE, Keating RF. When Does an Incidental Chiari I Malformation Require Surgery? A 10-Year Prospective Study on the Evolution and Natural History. Neurosurgery 2019. [DOI: 10.1093/neuros/nyz310_201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Strahle JM, Taiwo R, Averill C, Torner J, Shannon CN, Bonfield CM, Tuite GF, Bethel-Anderson T, Rutlin J, Brockmeyer DL, Wellons JC, Leonard JR, Mangano FT, Johnston JM, Shah MN, Iskandar BJ, Tyler-Kabara EC, Daniels DJ, Jackson EM, Grant GA, Couture DE, Adelson PD, Alden TD, Aldana PR, Anderson RCE, Selden NR, Baird LC, Bierbrauer K, Chern JJ, Whitehead WE, Ellenbogen RG, Fuchs HE, Guillaume DJ, Hankinson TC, Iantosca MR, Oakes WJ, Keating RF, Khan NR, Muhlbauer MS, McComb JG, Menezes AH, Ragheb J, Smith JL, Maher CO, Greene S, Kelly M, O'Neill BR, Krieger MD, Tamber M, Durham SR, Olavarria G, Stone SSD, Kaufman BA, Heuer GG, Bauer DF, Albert G, Greenfield JP, Wait SD, Van Poppel MD, Eskandari R, Mapstone T, Shimony JS, Dacey RG, Smyth MD, Park TS, Limbrick DD. Radiological and clinical predictors of scoliosis in patients with Chiari malformation type I and spinal cord syrinx from the Park-Reeves Syringomyelia Research Consortium. J Neurosurg Pediatr 2019; 24:1-8. [PMID: 31419800 DOI: 10.3171/2019.5.peds18527] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2018] [Accepted: 05/09/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Scoliosis is frequently a presenting sign of Chiari malformation type I (CM-I) with syrinx. The authors' goal was to define scoliosis in this population and describe how radiological characteristics of CM-I and syrinx relate to the presence and severity of scoliosis. METHODS A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°). RESULTS Based on available imaging of patients with CM-I and syrinx, 260 of 825 patients (31%) had a clear diagnosis of scoliosis based on radiographs or coronal MRI. Forty-nine patients (5.9%) did not have scoliosis, and in 516 (63%) patients, a clear determination of the presence or absence of scoliosis could not be made. Comparison of patients with and those without a definite scoliosis diagnosis indicated that scoliosis was associated with wider syrinxes (8.7 vs 6.3 mm, OR 1.25, p < 0.001), longer syrinxes (10.3 vs 6.2 levels, OR 1.18, p < 0.001), syrinxes with their rostral extent located in the cervical spine (94% vs 80%, OR 3.91, p = 0.001), and holocord syrinxes (50% vs 16%, OR 5.61, p < 0.001). Multivariable regression analysis revealed syrinx length and the presence of holocord syrinx to be independent predictors of scoliosis in this patient cohort. Scoliosis was not associated with sex, age at CM-I diagnosis, tonsil position, pB-C2 distance (measured perpendicular distance from the ventral dura to a line drawn from the basion to the posterior-inferior aspect of C2), clivoaxial angle, or frontal-occipital horn ratio. Average curve magnitude was 29.9°, and 37.7% of patients had a left thoracic curve. Older age at CM-I or syrinx diagnosis (p < 0.0001) was associated with greater curve magnitude whereas there was no association between syrinx dimensions and curve magnitude. CONCLUSIONS Syrinx characteristics, but not tonsil position, were related to the presence of scoliosis in patients with CM-I, and there was an independent association of syrinx length and holocord syrinx with scoliosis. Further study is needed to evaluate the nature of the relationship between syrinx and scoliosis in patients with CM-I.
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Affiliation(s)
- Jennifer M Strahle
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Rukayat Taiwo
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Christine Averill
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - James Torner
- 2Department of Epidemiology, University of Iowa, Iowa City, Iowa
| | - Chevis N Shannon
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Christopher M Bonfield
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Gerald F Tuite
- 4Department of Neurosurgery, Neuroscience Institute, All Children's Hospital, St. Petersburg, Florida
| | - Tammy Bethel-Anderson
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jerrel Rutlin
- 5Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Douglas L Brockmeyer
- 6Department of Pediatric Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - John C Wellons
- 3Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Jeffrey R Leonard
- 7Department of Neurological Surgery, The Ohio State University College of Medicine, Columbus, Ohio
| | - Francesco T Mangano
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James M Johnston
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Manish N Shah
- 10Department of Pediatric Surgery and Neurosurgery, The University of Texas McGovern Medical School, Houston, Texas
| | - Bermans J Iskandar
- 11Department of Neurological Surgery, University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Elizabeth C Tyler-Kabara
- 12Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - David J Daniels
- 13Department of Neurosurgery, The Mayo Clinic, Rochester, Minnesota
| | - Eric M Jackson
- 14Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Gerald A Grant
- 15Department of Neurosurgery, Stanford Child Health Research Institute, Stanford, California
| | - Daniel E Couture
- 16Department of Neurosurgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina
| | - P David Adelson
- 17Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona
| | - Tord D Alden
- 18Department of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Philipp R Aldana
- 19Department of Pediatric Neurosurgery, University of Florida College of Medicine, Jacksonville, Florida
| | - Richard C E Anderson
- 20Department of Neurological Surgery, Columbia University College of Physicians and Surgeons, New York, New York
| | - Nathan R Selden
- 21Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Lissa C Baird
- 21Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon
| | - Karin Bierbrauer
- 8Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Joshua J Chern
- 22Department of Neurosurgery, Children's Healthcare of Atlanta, Georgia
| | | | - Richard G Ellenbogen
- 24Department of Neurosurgery, University of Washington Medicine, Seattle, Washington
| | - Herbert E Fuchs
- 25Department of Neurosurgery, Duke University School of Medicine, Durham, North Carolina
| | - Daniel J Guillaume
- 26Department of Neurosurgery, University of Minnesota Medical School, Minneapolis, Minnesota
| | - Todd C Hankinson
- 27Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark R Iantosca
- 28Department of Neurosurgery, Penn State Milton S. Hershey Medical Center, Hershey, Pennsylvania
| | - W Jerry Oakes
- 9Division of Neurosurgery, University of Alabama School of Medicine, Birmingham, Alabama
| | - Robert F Keating
- 29Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Nickalus R Khan
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Michael S Muhlbauer
- 30Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - J Gordon McComb
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Arnold H Menezes
- 32Department of Neurosurgery, University of Iowa Hospitals, Iowa City, Iowa
| | - John Ragheb
- 33Department of Pediatric Neurosurgery, Miami Children's Hospital and University of Miami Miller School of Medicine, Miami, Florida
| | - Jodi L Smith
- 34Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Cormac O Maher
- 35Department of Neurosurgery, University of Michigan, Ann Arbor, Michigan
| | - Stephanie Greene
- 12Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
| | - Michael Kelly
- 36Department of Orthopedic Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Brent R O'Neill
- 27Department of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado
| | - Mark D Krieger
- 31Division of Neurosurgery, Children's Hospital Los Angeles, California
| | - Mandeep Tamber
- 37Department of Neurosurgery, The University of British Columbia, Vancouver, British Columbia, Canada
| | - Susan R Durham
- 38Department of Neurosurgery, University of Vermont College of Medicine, Burlington, Vermont
| | | | - Scellig S D Stone
- 40Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts
| | - Bruce A Kaufman
- 41Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Gregory G Heuer
- 42Division of Neurosurgery, Children's Hospital of Philadelphia, Pennsylvania
| | - David F Bauer
- 43Department of Neurosurgery, Dartmouth Geisel School of Medicine, Hanover, New Hampshire
| | - Gregory Albert
- 44Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Jeffrey P Greenfield
- 45Department of Neurological Surgery, Weill Cornell Medical Center, New York, New York
| | - Scott D Wait
- 46Department of Neurological Surgery, Levine Children's Hospital, Charlotte, North Carolina
| | - Mark D Van Poppel
- 46Department of Neurological Surgery, Levine Children's Hospital, Charlotte, North Carolina
| | - Ramin Eskandari
- 47Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina; and
| | - Timothy Mapstone
- 48Department of Neurosurgery, Oklahoma University Medical Center, Oklahoma City, Oklahoma
| | - Joshua S Shimony
- 5Department of Radiology, Washington University School of Medicine, St. Louis, Missouri
| | - Ralph G Dacey
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Matthew D Smyth
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Tae Sung Park
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - David D Limbrick
- 1Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
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Bartoli A, Soleman J, Berger A, Wisoff JH, Hidalgo ET, Mangano FT, Keating RF, Thomale UW, Boop F, Roth J, Constantini S. Treatment Options for Hydrocephalus Following Foramen Magnum Decompression for Chiari I Malformation: A Multicenter Study. Neurosurgery 2019; 86:500-508. [DOI: 10.1093/neuros/nyz211] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2018] [Accepted: 02/24/2019] [Indexed: 12/13/2022] Open
Affiliation(s)
- Andrea Bartoli
- Department of Neurosurgery, Geneva University Hospitals, Geneva, Switzerland
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
| | - Jehuda Soleman
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
- Department of Neurosurgery and Division of Pediatric Neurosurgery, University Hospital of Basel, Basel, Switzerland
| | - Assaf Berger
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
| | - Jeffrey H Wisoff
- Division of Pediatric Neurosurgery, NYU Langone Health, New York, New York
| | | | - Francesco T Mangano
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Ulrich W Thomale
- Pediatric Neurosurgery, Charité Universitätsmedizin, Berlin, Germany
| | - Frederick Boop
- Department of Pediatrics, Neuroscience Institute, University of Tennessee Health Science Center, Le Bonheur Children's Hospital, Memphis, Tennessee
| | - Jonathan Roth
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
| | - Shlomi Constantini
- Department of Neurosurgery, Tel Aviv Medical Center, Tel Aviv University, Tel Aviv, Israel
- Department of Pediatric Neurosurgery, Dana Children's Hospital Tel Aviv, Tel Aviv University, Tel Aviv, Israel
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Magge SN, Bartolozzi AR, Almeida ND, Tsering D, Myseros JS, Oluigbo CO, Rogers GF, Keating RF. A comparison of endoscopic strip craniectomy and pi craniectomy for treatment of sagittal craniosynostosis. J Neurosurg Pediatr 2019; 23:708-714. [PMID: 30925476 DOI: 10.3171/2019.1.peds18203] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 01/14/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Sagittal craniosynostosis is managed with a wide variety of operative strategies. The current investigation compares the clinical outcomes of two widely performed techniques: pi craniectomy and minimally invasive endoscopic strip craniectomy (ESC) followed by helmet therapy. METHODS This IRB-approved retrospective study examined patients diagnosed with nonsyndromic, single-suture sagittal craniosynostosis treated with either pi craniectomy or ESC. Included patients had a minimum postoperative follow-up of 5 months. RESULTS Fifty-one patients met the inclusion criteria (pi 21 patients, ESC 30 patients). Compared to patients who underwent ESC, the pi patients were older at the time of surgery (mean age 5.06 vs 3.11 months). The mean follow-up time was 23.2 months for ESC patients and 31.4 months for pi patients. Initial cranial index (CI) was similar between the groups, but postoperatively the ESC patients experienced a 12.3% mean increase in CI (from 0.685 to 0.767) compared to a 5.34% increase for the pi patients (from 0.684 to 0.719), and this difference was statistically significant (p < 0.001). Median hospital length of stay (1 vs 2 days) and operative duration (69.5 vs 93.3 minutes) were significantly less for ESC (p < 0.001 for both). The ESC patients showed a trend toward better results when surgery was done at younger ages. Craniectomy width in ESC cases was positively associated with CI improvement (slope of linear regression = 0.69, p = 0.026). CONCLUSIONS While both techniques effectively treated sagittal craniosynostosis, ESC showed superior results compared to pi craniectomy. ESC showed a trend for better outcomes when done at younger ages, although the trend did not reach statistical significance. A wider craniectomy width (up to 2 cm) was associated with better outcomes than smaller craniectomy widths among the ESC patients.
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Affiliation(s)
- Suresh N Magge
- Divisions of1Neurosurgery and.,3George Washington UniversitySchool of Medicine and Health Sciences, Washington, DC; and
| | - Arthur R Bartolozzi
- 4Department of Orthopedic Surgery, Stanford University,Palo Alto, California
| | - Neil D Almeida
- 3George Washington UniversitySchool of Medicine and Health Sciences, Washington, DC; and
| | | | - John S Myseros
- Divisions of1Neurosurgery and.,3George Washington UniversitySchool of Medicine and Health Sciences, Washington, DC; and
| | - Chima O Oluigbo
- Divisions of1Neurosurgery and.,3George Washington UniversitySchool of Medicine and Health Sciences, Washington, DC; and
| | - Gary F Rogers
- 2Plastic Surgery, Children's National Health System.,3George Washington UniversitySchool of Medicine and Health Sciences, Washington, DC; and
| | - Robert F Keating
- Divisions of1Neurosurgery and.,3George Washington UniversitySchool of Medicine and Health Sciences, Washington, DC; and
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Alexander H, Cobourn K, Fayed I, Depositario-Cabacar D, Keating RF, Gaillard WD, Oluigbo CO. Magnetic resonance-guided laser interstitial thermal therapy for the treatment of non-lesional insular epilepsy in pediatric patients: thermal dynamic and volumetric factors influencing seizure outcomes. Childs Nerv Syst 2019; 35:453-461. [PMID: 30627771 DOI: 10.1007/s00381-019-04051-0] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 01/03/2019] [Indexed: 11/26/2022]
Abstract
PURPOSE To investigate the safety and efficacy of stereoelectroencephalography (sEEG) directed magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) in medically refractory insular epilepsy in pediatric patients, define the relationship between ablation volumes and seizure control, and analyze the relationship between thermal energy and ablation volumes. METHODS A single-institution, retrospective review of pediatric patients with insular epilepsy who underwent sEEG directed MRgLITT over a 10-month period was performed. Perioperative, imaging, and outcome data were analyzed. Seizure outcomes were determined based on Engel score (Engel I versus Engel II-IV). Insula and ablation volumes were measured, and the proportion of insula volume ablated was calculated. Thermal energy was calculated in joules. RESULTS Four patients underwent sEEG directed MRgLITT of insular epileptogenic foci. The ablation volume was higher in patients with Engel I outcome (3.93 cm3) compared to Engel II-IV outcome (1.02 cm3). The proportion of ablation to insula volume was lowest in patients with Engel II-IV outcome (25.09%). The mean energy requirement to create a unit volume of ablation in the insula is 1205.86 J. A linear trend was noted between thermal ablation energy and ablation volume (R2 = 0.884). Over a mean follow-up period of 104 days, three patients were seizure-free (Engel I), and one patient saw significant improvement in seizure frequency (Engel III). CONCLUSIONS The proportion of insula ablated, as well as the volume of ablation, are related to seizure outcome with increasing ablation volumes corresponding to improved seizure control. Further analysis of insula laser ablation thermal dynamics and volumes is needed.
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Affiliation(s)
- Hepzibha Alexander
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Kelsey Cobourn
- Division of Neurosurgery, Children's National Medical Center, Georgetown University School of Medicine, Washington, DC, USA
| | - Islam Fayed
- Division of Neurosurgery, Children's National Medical Center, MedStar Georgetown University Hospital, Washington, DC, USA
| | - Dewi Depositario-Cabacar
- Division of Neurology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Robert F Keating
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - William D Gaillard
- Division of Neurology, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Chima O Oluigbo
- Division of Neurosurgery, Children's National Medical Center, George Washington University School of Medicine and Health Sciences, Washington, DC, USA.
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47
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Lajthia O, Chao JW, Mandelbaum M, Myseros JS, Oluigbo C, Magge SN, Zarella CS, Oh AK, Rogers GF, Keating RF. Efficacy of immediate replacement of cranial bone graft following drainage of intracranial empyema. J Neurosurg Pediatr 2018; 22:317-322. [PMID: 29932367 DOI: 10.3171/2018.3.peds17509] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Intracranial empyema is a life-threatening condition associated with a high mortality rate and residual deleterious neurological effects if not diagnosed and managed promptly. The authors present their institutional experience with immediate reimplantation of the craniotomy flap and clarify the success of this method in terms of cranial integrity, risk of recurrent infection, and need for secondary procedures. METHODS A retrospective analysis of patients admitted for management of intracranial empyema during a 19-year period (1997-2016) identified 33 patients who underwent emergency drainage and decompression with a follow-up duration longer than 6 months, 23 of whom received immediate bone replacement. Medical records were analyzed for demographic information, extent and location of the infection, bone flap size, fixation method, need for further operative intervention, and duration of intravenous antibiotics. RESULTS The mean patient age at surgery was 8.7 ± 5.7 years and the infections were largely secondary to sinusitis (52.8%), with the most common location being the frontal/temporal region (61.3%). Operative intervention involved removal of a total of 31 bone flaps with a mean surface area of 22.8 ± 26.9 cm2. Nearly all (96.8%) of the bone flaps replaced at the time of the initial surgery were viable over the long term. Eighteen patients (78.3%) required a single craniotomy in conjunction with antibiotic therapy to address the infection, whereas the remaining 21.7% required more than 1 surgery. Partial bone flap resorption was noted in only 1 (3.2%) of the 31 successfully replaced bone flaps. This patient eventually had his bone flap removed and received a split-calvaria bone graft. Twenty-one patients (91.3%) received postoperative CT scans to evaluate bone integrity. The mean follow-up duration of the cohort was 43.9 ± 54.0 months. CONCLUSIONS The results of our investigation suggest that immediate replacement and stabilization of the bone flap after craniectomy for drainage of intracranial empyemas has a low risk of recurrent infection and is a safe and effective way to restore bone integrity in most patients.
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Affiliation(s)
- Orgest Lajthia
- 1Department of Neurosurgery, Children's National Medical Center, Washington, DC.,2Department of Neurosurgery, Georgetown University Medical Center, Washington, DC
| | - Jerry W Chao
- 3Department of Plastic Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Max Mandelbaum
- 3Department of Plastic Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - John S Myseros
- 1Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Chima Oluigbo
- 1Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | - Suresh N Magge
- 1Department of Neurosurgery, Children's National Medical Center, Washington, DC
| | | | - Albert K Oh
- 3Department of Plastic Surgery, The George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Gary F Rogers
- 5Department of Plastic Surgery, Children's National Medical Center, Washington, DC
| | - Robert F Keating
- 1Department of Neurosurgery, Children's National Medical Center, Washington, DC
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Cobourn K, Fayed I, Keating RF, Oluigbo CO. Early outcomes of stereoelectroencephalography followed by MR-guided laser interstitial thermal therapy: a paradigm for minimally invasive epilepsy surgery. Neurosurg Focus 2018; 45:E8. [DOI: 10.3171/2018.6.focus18209] [Citation(s) in RCA: 27] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVEStereoelectroencephalography (sEEG) and MR-guided laser interstitial thermal therapy (MRgLITT) have both emerged as minimally invasive alternatives to open surgery for the localization and treatment of medically refractory lesional epilepsy. Although some data are available about the use of these procedures individually, reports are almost nonexistent on their use in conjunction. The authors’ aim was to report early outcomes regarding efficacy and safety of sEEG followed by MRgLITT for localization and ablation of seizure foci in the pediatric population with medically refractory lesional epilepsy.METHODSA single-center retrospective review of pediatric patients who underwent sEEG followed by MRgLITT procedures was performed. Demographic, intraoperative, and outcome data were compiled and analyzed.RESULTSFour pediatric patients with 9 total lesions underwent sEEG followed by MRgLITT procedures between January and September 2017. The mean age at surgery was 10.75 (range 2–21) years. Two patients had tuberous sclerosis and 2 had focal cortical dysplasia. Methods of stereotaxy consisted of BrainLab VarioGuide and ROSA robotic guidance, with successful localization of seizure foci in all cases. The sEEG procedure length averaged 153 (range 67–235) minutes, with a mean of 6 (range 4–8) electrodes and 56 (range 18–84) contacts per patient. The MRgLITT procedure length averaged 223 (range 179–252) minutes. The mean duration of monitoring was 6 (range 4–8) days, and the mean total hospital stay was 8 (range 5–11) days. Over a mean follow-up duration of 9.3 (range 5.1–16) months, 3 patients were seizure free (Engel class I, 75%), and 1 patient saw significant improvement in seizure frequency (Engel class II, 25%). There were no complications.CONCLUSIONSThese early data demonstrate that sEEG followed by MRgLITT can be used safely and effectively to localize and ablate epileptogenic foci in a minimally invasive paradigm for treatment of medically refractory lesional epilepsy in pediatric populations. Continued collection of data with extended follow-up is needed.
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Roth J, Soleman J, Paraskevopoulos D, Keating RF, Constantini S. Incidental brain tumors in children: an international neurosurgical, oncological survey. Childs Nerv Syst 2018; 34:1325-1333. [PMID: 29802595 DOI: 10.1007/s00381-018-3836-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2018] [Accepted: 05/13/2018] [Indexed: 11/29/2022]
Abstract
PURPOSE Incidental pediatric brain tumors (IPBT) are increasingly being diagnosed. Currently, there is no consensus regarding the need and timing of their treatment. In the current study, we identify trends among pediatric neurosurgeons and oncologists with regard to IPBT management and approval of growth hormone replacement therapy (GHRT). METHODS A questionnaire presenting six different cases of IPBT was emailed to all members of several leading societies in pediatric neurosurgery and oncology. Collected data included basic information concerning the responders (profession, experience, continent of practice), as well as responses to multiple questions regarding treatment of the lesion, permission to supply GHRT, and free text for comments. RESULTS One hundred forty-three responses were eligible for analysis (92 neurosurgeons, 51 oncologists, from a total of 6 continents). Initial recommendations for each case were heterogeneous. However, a few consistent trends were identified: Lesions that were stable over time lead to a common shift in treatment recommendation to a more conservative one. Growing lesions were commonly treated more aggressively. Neither profession nor experience had a consistent impact on recommendations. CONCLUSIONS Management recommendations for IPBT varied among the responders and seem to be influenced by many factors. However, stable lesions lead to a shift in management towards a "watch and wait" approach, while in growing lesions responders tended towards a "biopsy" or "resection" approach. This highlights the need for better understanding of the natural course of incidental brain tumors in children, as well as evaluating the potential risk for malignant transformation.
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Affiliation(s)
- Jonathan Roth
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel.
| | - Jehuda Soleman
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel
- Department of Neurosurgery, Division of Pediatric Neurosurgery, University Hospital and Children's Hospital of Basel, Basel, Switzerland
| | - Dimitris Paraskevopoulos
- Department of Neurosurgery, Barts Health NHS Trust, St. Bartholomew's and The Royal London Hospital, London, UK
- Blizard Institute, Barts and The London School of Medicine, Queen Mary University London, London, UK
| | - Robert F Keating
- Departments of Neurosurgery and Pediatrics, Children's National Medical Center, Washington DC, USA
| | - Shlomi Constantini
- Department of Pediatric Neurosurgery, Dana Children's Hospital, Tel Aviv Medical Center, Tel Aviv University, 6 Weizman Street, 64239, Tel Aviv, Israel
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50
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Sacino MF, Huang SS, Keating RF, Gaillard WD, Oluigbo CO. An initial cost-effectiveness analysis of intraoperative magnetic resonance imaging (iMRI) in pediatric epilepsy surgery. Childs Nerv Syst 2018; 34:495-502. [PMID: 29159426 DOI: 10.1007/s00381-017-3658-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2017] [Accepted: 11/09/2017] [Indexed: 11/24/2022]
Abstract
PURPOSE Previous studies have illustrated the clinical utility of the addition of intraoperative magnetic resonance imaging (iMRI) to conventional microsurgical resection. While iMRI requires initial capital cost investment, long-term reduction in costly follow-up management and reoperation costs may prove economically efficacious. The objective of this study is to investigate the cost-effectiveness of the addition of iMRI utilization versus conventional microsurgical techniques in focal cortical dysplasia (FCD) resection in pediatric patients with medically refractory epilepsy. METHODS We retrospectively reviewed the medical records of pediatric subjects who underwent surgical resection of FCD at the Children's National Health System between March 2005 and April 2015. Patients were assigned to one of three cohorts: iMRI-assisted resection, conventional resection with iMRI-assisted reoperation, or conventional resection. Direct costs included preoperative, operative, postoperative, long-term follow-up, and antiepileptic drug (AED) costs. The cost-effectiveness was calculated as the sum total of all direct medical costs over the quality-adjusted life years (QALYs). We also performed sensitivity analysis on numerous variables to assess the validity of our results. RESULTS Fifty-six consecutive pediatric patients underwent resective surgery for medically intractable FCD. Ten patients underwent iMRI-assisted resection; 7 underwent conventional resection followed by iMRI-assisted reoperation; 39 patients underwent conventional microsurgical resection. Taken over the lifetime of the patient, the cumulative discounted QALY of patients in the iMRI-assisted resection cohort was about 2.91 years, versus 2.61 years in the conventional resection with iMRI-assisted reoperation cohort, and 1.76 years for the conventional resection cohort. Adjusting for inflation, iMRI-assisted surgeries have a cost-effectiveness ratio of $16,179 per QALY, versus $28,514 per QALY for the conventional resection with iMRI-assisted reoperation cohort, and $49,960 per QALY for the conventional resection cohort. Sensitivity analysis demonstrated that no one single variable significantly altered cost-effectiveness across all three cohorts compared to the baseline results. CONCLUSION The addition of iMRI to conventional microsurgical techniques for resection of FCD in pediatric patients with intractable epilepsy resulted in increased seizure freedom and reduction in long-term direct medical costs compared to conventional surgeries. Our data suggests that iMRI may be a cost-effective addition to the surgical armamentarium for epilepsy surgery.
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Affiliation(s)
- Matthew F Sacino
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - Sean S Huang
- Department of Health Systems Administration, Georgetown University, Washington, DC, USA
| | - Robert F Keating
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA
| | - William D Gaillard
- Department of Neurology, Children's National Medical Center, Washington, DC, USA
| | - Chima O Oluigbo
- Department of Neurosurgery, Children's National Medical Center, 111 Michigan Avenue NW, Washington, DC, USA.
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