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Sun LR, Jordan LC, Smith ER, Aldana PR, Kirschen MP, Guilliams K, Gupta N, Steinberg GK, Fox C, Harrar DB, Lee S, Chung MG, Dirks P, Dlamini N, Maher CO, Lehman LL, Hong SJ, Strahle JM, Pineda JA, Beslow LA, Rasmussen L, Mailo J, Piatt J, Lang SS, Adelson PD, Dewan MC, Mineyko A, McClugage S, Vadivelu S, Dowling MM, Hersh DS. Pediatric Moyamoya Revascularization Perioperative Care: A Modified Delphi Study. Neurocrit Care 2024; 40:587-602. [PMID: 37470933 PMCID: PMC11023720 DOI: 10.1007/s12028-023-01788-0] [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] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/20/2023] [Indexed: 07/21/2023]
Abstract
BACKGROUND Surgical revascularization decreases the long-term risk of stroke in children with moyamoya arteriopathy but can be associated with an increased risk of stroke during the perioperative period. Evidence-based approaches to optimize perioperative management are limited and practice varies widely. Using a modified Delphi process, we sought to establish expert consensus on key components of the perioperative care of children with moyamoya undergoing indirect revascularization surgery and identify areas of equipoise to define future research priorities. METHODS Thirty neurologists, neurosurgeons, and intensivists practicing in North America with expertise in the management of pediatric moyamoya were invited to participate in a three-round, modified Delphi process consisting of a 138-item practice patterns survey, anonymous electronic evaluation of 88 consensus statements on a 5-point Likert scale, and a virtual group meeting during which statements were discussed, revised, and reassessed. Consensus was defined as ≥ 80% agreement or disagreement. RESULTS Thirty-nine statements regarding perioperative pediatric moyamoya care for indirect revascularization surgery reached consensus. Salient areas of consensus included the following: (1) children at a high risk for stroke and those with sickle cell disease should be preadmitted prior to indirect revascularization; (2) intravenous isotonic fluids should be administered in all patients for at least 4 h before and 24 h after surgery; (3) aspirin should not be discontinued in the immediate preoperative and postoperative periods; (4) arterial lines for blood pressure monitoring should be continued for at least 24 h after surgery and until active interventions to achieve blood pressure goals are not needed; (5) postoperative care should include hourly vital signs for at least 24 h, hourly neurologic assessments for at least 12 h, adequate pain control, maintaining normoxia and normothermia, and avoiding hypotension; and (6) intravenous fluid bolus administration should be considered the first-line intervention for new focal neurologic deficits following indirect revascularization surgery. CONCLUSIONS In the absence of data supporting specific care practices before and after indirect revascularization surgery in children with moyamoya, this Delphi process defined areas of consensus among neurosurgeons, neurologists, and intensivists with moyamoya expertise. Research priorities identified include determining the role of continuous electroencephalography in postoperative moyamoya care, optimal perioperative blood pressure and hemoglobin targets, and the role of supplemental oxygen for treatment of suspected postoperative ischemia.
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Affiliation(s)
- Lisa R Sun
- Division of Cerebrovascular Neurology, Division of Pediatric Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Lori C Jordan
- Department of Pediatrics, Division of Pediatric Neurology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Edward R Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA
| | - Philipp R Aldana
- Division of Pediatric Neurosurgery, University of Florida College of Medicine, Section of Neurosurgery, Wolfson Children's Hospital, Jacksonville, FL, USA
| | - Matthew P Kirschen
- Departments of Anesthesiology and Critical Care Medicine, Pediatrics and Neurology, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Kristin Guilliams
- Departments of Neurology, Pediatrics, and Radiology, Washington University School of Medicine, St. Louis, MO, USA
| | - Nalin Gupta
- Departments of Neurological Surgery and Pediatrics, University of California, San Francisco, CA, USA
| | - Gary K Steinberg
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Christine Fox
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Dana B Harrar
- Division of Neurology, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Melissa G Chung
- Department of Pediatrics, Divisions of Pediatric Neurology and Critical Care Medicine, Nationwide Children's Hospital, Columbus, OH, USA
| | - Peter Dirks
- Division of Neurosurgery, The Hospital for Sick Children, Toronto, Canada
| | - Nomazulu Dlamini
- Division of Neurology, The Hospital for Sick Children, Toronto, Canada
| | - Cormac O Maher
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, USA
| | - Laura L Lehman
- Department of Neurology, Boston Children's Hospital, Boston, MA, USA
| | - Sue J Hong
- Department of Pediatrics, Divisions of Critical Care and Child Neurology, Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Jennifer M Strahle
- Department of Neurosurgery, Washington University School of Medicine, St. Louis, MO, USA
| | - Jose A Pineda
- Department of Critical Care, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Departments of Neurology and Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Lindsey Rasmussen
- Department of Critical Care, Stanford University School of Medicine, Stanford, CA, USA
| | - Janette Mailo
- Division of Pediatric Neurology, Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Joseph Piatt
- Division of Neurosurgery, Nemours Children's Hospital Delaware, Wilmington, DE, USA
| | - Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - P David Adelson
- Department of Neurosurgery, WVU Medicine and WVU Medicine Children's Hospital, Morgantown, WV, USA
| | - Michael C Dewan
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Aleksandra Mineyko
- Department of Pediatrics, Section on Neurology, University of Calgary, Calgary, AB, Canada
| | - Samuel McClugage
- Department of Neurosurgery, Texas Children's Hospital, Houston, TX, USA
| | - Sudhakar Vadivelu
- Division of Pediatric Neurosurgery and Interventional Neuroradiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Michael M Dowling
- Departments of Pediatrics and Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - David S Hersh
- Division of Neurosurgery, Connecticut Children's, Hartford, CT, USA
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Kline O, Vishwanath K, Colbrunn B, Peachman A, Zhang J, Vadivelu S. Can diffuse reflectance spectroscopy identify shuntodynia in pediatric hydrocephalus patients? J Biomed Opt 2024; 29:037002. [PMID: 38476219 PMCID: PMC10929735 DOI: 10.1117/1.jbo.29.3.037002] [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] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 02/10/2024] [Accepted: 02/16/2024] [Indexed: 03/14/2024]
Abstract
Significance Shuntodynia is patient reported pain at the site of the implanted ventriculoperitoneal (VP) shunt. Pediatric hydrocephalus requiring shunt placement is a chronic and prevalent standard of care treatment and requires lifetime management. Shuntodynia is a subjective measure of shunt dysfunction. Quantitative, white-light tissue spectroscopy could be used to objectively identify this condition in the clinic. Aim Pediatric subjects were recruited for optical sensing during routine clinical follow-up visits, post-VP shunt implantations. Acquired optical signals were translated into skin-hemodynamic signatures and were compared between subjects that reported shuntodynia versus those that did not. Approach Diffuse reflectance spectroscopy (DRS) measurements were collected between 450 and 700 nm using a single-channel fiber-optical probe from (N = 35 ) patients. Multiple reflectance spectra were obtained by the attending physician from regions both proximal and distal to the VP shunt sites and from a matched contralateral site for each subject. Acquired reflectance spectra were processed quantitatively into functional tissue optical endpoints. A two-way, repeated measures analysis of variance was used to assess whether and which of the optical variables were statistically separable, across subjects with shuntodynia versus those without. Results Analyses indicated that intrapatient differences in vascular oxygen saturation measured between shunt sites relative to that obtained at the scar or contralateral sites was significantly lower in the pain group. We also find that the total hemoglobin concentrations at the shunt site were lowest relative to the other sites for subjects reporting pain. These findings suggest that shuntodynia pain arises in the scalp tissue around the implanted shunts and may be caused due to hypoxia and inflammation. Conclusions Optically derived hemodynamic variables were statistically significantly different in subjects presenting with shuntodynia relative to those without. DRS could provide a viable mode in routine bedside monitoring of subjects with VP shunts for clinical management and assessment of shuntodynia.
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Affiliation(s)
- Olivia Kline
- Miami University, Department of Physics, Oxford, Ohio, United States
| | | | - Boyd Colbrunn
- Miami University, Department of Physics, Oxford, Ohio, United States
| | - Andrew Peachman
- Miami University, Department of Physics, Oxford, Ohio, United States
| | - Jing Zhang
- Miami University, Department of Statistics, Oxford, Ohio, United States
| | - Sudhakar Vadivelu
- Cincinnati Children’s Hospital Medical Center, Department of Neurosurgery, Cincinnati, Ohio, United States
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Engel ER, Wusik K, Bright P, Vadivelu S, Taylor JM, Hammill A. Prevalence and Predictors of Hereditary Hemorrhagic Telangiectasia and Capillary-Malformation Arteriovenous Malformation Syndrome Among Children with Neurovascular Malformations. J Pediatr 2024; 264:113761. [PMID: 37797790 DOI: 10.1016/j.jpeds.2023.113761] [Citation(s) in RCA: 1] [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: 08/14/2023] [Revised: 09/18/2023] [Accepted: 09/25/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To investigate the prevalence and predictors of hereditary hemorrhagic telangiectasia (HHT) and capillary-malformation arteriovenous malformation (CM-AVM) syndrome among children with no prior personal or family history of these diseases who presented with an arteriovenous shunt lesion. STUDY DESIGN A retrospective chart review was completed on patients aged 0 through 21 years with arteriovenous shunt lesions evaluated at our Cerebrovascular Center. Diagnosis of definite or suspected HHT or CM-AVM was based on clinical features and genetic testing. Associations between final diagnosis and type and number of lesions, epistaxis, telangiectasias, CM, and pulmonary AVMs were assessed. RESULTS Eighty-nine patients were included. Thirteen (14.6%) had definite HHT, 11 (12.4%) suspected HHT, and 4 (4.5%) definite CM-AVM. Having ≥2 episodes of epistaxis/year and ≥ 2 sites with telangiectasias were each associated with definite HHT (P < .001). Having ≥ 2 CM was associated with definite CM-AVM (P < .001). Pulmonary AVM was associated with increased odds of having definite HHT (OR = 6.3, 95% CI: 1.2-33.4). Multiple lesions (OR = 24.5, 95% CI: 4.5-134.8) and arteriovenous fistulas (OR = 6.2, 95% CI: 1.9-20.3) each increased the likelihood of having definite HHT or CM-AVM. Genetic testing was positive in 31% of patients tested. CONCLUSIONS We recommend that children with neurovascular shunt lesions be offered genetic testing and undergo further evaluation for HHT and CM-AVM. Awareness and early diagnosis of these conditions is a critical step toward improving long-term outcomes and preventing disease-associated complications.
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Affiliation(s)
- Elissa R Engel
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH.
| | - Katie Wusik
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Philip Bright
- University of Kentucky College of Medicine, Northern Kentucky Campus, Highland Heights, KY
| | - Sudhakar Vadivelu
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Division of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - J Michael Taylor
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Adrienne Hammill
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH; Division of Hematology, Cancer and Blood Diseases Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
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Aldana PR, Hanel RA, Piatt J, Han SH, Bansal MM, Schultz C, Gauger C, Pederson JM, Iii JCW, Hulbert ML, Jordan LC, Qureshi A, Garrity K, Robert AP, Hatem A, Stein J, Beydler E, Adelson PD, Greene S, Grabb P, Johnston J, Lang SS, Leonard J, Magge SN, Scott A, Shah S, Smith ER, Smith J, Strahle J, Vadivelu S, Webb J, Wrubel D. Cerebral revascularization surgery reduces cerebrovascular events in children with sickle cell disease and moyamoya syndrome: Results of the stroke in sickle cell revascularization surgery retrospective study. Pediatr Blood Cancer 2023; 70:e30336. [PMID: 37057741 DOI: 10.1002/pbc.30336] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 08/09/2022] [Revised: 03/01/2023] [Accepted: 03/04/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND Recent studies suggest that cerebral revascularization surgery may be a safe and effective therapy to reduce stroke risk in patients with sickle cell disease and moyamoya syndrome (SCD-MMS). METHODS We performed a multicenter, retrospective study of children with SCD-MMS treated with conservative management alone (conservative group)-chronic blood transfusion and/or hydroxyurea-versus conservative management plus surgical revascularization (surgery group). We monitored cerebrovascular event (CVE) rates-a composite of strokes and transient ischemic attacks. Multivariable logistic regression was used to compare CVE occurrence and multivariable Poisson regression was used to compare incidence rates between groups. Covariates in multivariable models included age at treatment start, age at moyamoya diagnosis, antiplatelet use, CVE history, and the risk period length. RESULTS We identified 141 patients with SCD-MMS, 78 (55.3%) in the surgery group and 63 (44.7%) in the conservative group. Compared with the conservative group, preoperatively the surgery group had a younger age at moyamoya diagnosis, worse baseline modified Rankin scale scores, and increased prevalence of CVEs. Despite more severe pretreatment disease, the surgery group had reduced odds of new CVEs after surgery (odds ratio = 0.27, 95% confidence interval [CI] = 0.08-0.94, p = .040). Furthermore, comparing surgery group patients during presurgical versus postsurgical periods, CVEs odds were significantly reduced after surgery (odds ratio = 0.22, 95% CI = 0.08-0.58, p = .002). CONCLUSIONS When added to conservative management, cerebral revascularization surgery appears to reduce the risk of CVEs in patients with SCD-MMS. A prospective study will be needed to validate these findings.
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Affiliation(s)
- Philipp R Aldana
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, Florida, USA
| | - Joseph Piatt
- Division of Neurosurgery, Nemours Neuroscience Center, A.I. duPont Hospital for Children, Wilmington, Delaware, USA
| | - Sabrina H Han
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Manisha M Bansal
- Department of Pediatric Hematology/Oncology, Nemours Children's Health System and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Corinna Schultz
- Department of Pediatrics, Nemours Center for Cancer and Blood Disorders, Nemours Children's Hospital, Wilmington, Delaware, USA
| | - Cynthia Gauger
- Department of Pediatric Hematology/Oncology, Nemours Children's Health System and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - John M Pederson
- Superior Medical Experts, St. Paul, Minnesota, USA
- Nested Knowledge, St. Paul, Minnesota, USA
| | - John C Wellons Iii
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Monica L Hulbert
- Department of Pediatrics, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Adnan Qureshi
- Department of Neurology, Zeenat Qureshi Stroke Institute, University of Missouri, Columbia, Missouri, USA
| | - Kelsey Garrity
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Adam P Robert
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Asmaa Hatem
- Department of Neurosurgery, University of Florida College of Medicine - Jacksonville and Wolfson Children's Hospital, Jacksonville, Florida, USA
| | - Jennifer Stein
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Emily Beydler
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - P David Adelson
- Barrow Neurological Institute, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Stephanie Greene
- Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Paul Grabb
- Department of Neurosurgery, Children's Mercy Hospital, Kansas, Missouri, USA
| | - James Johnston
- Department of Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama, USA
| | - Shih-Shan Lang
- Department of Neurosurgery and Pediatric Neurosurgery, University of Pennsylvania School of Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Jeffrey Leonard
- Department of Neurosurgery, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Suresh N Magge
- Department of Neurosurgery, CHOC Neuroscience Institute, Children's Health of Orange County, Orange, California, USA
| | - Alex Scott
- Department of Neurosurgery, Washington University School of Medicine, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Sanjay Shah
- Department of Pediatric Hematology/Oncology, Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Edward R Smith
- Department of Neurosurgery, Children's Hospital Boston, and Harvard Medical School, Boston, Massachusetts, USA
| | - Jodi Smith
- Department of Pediatric Neurosurgery, Goodman Campbell Brain and Spine, Peyton Manning Children's Hospital, Indianapolis, Indiana, USA
| | - Jennifer Strahle
- Department of Neurosurgery, Washington University School of Medicine, Washington University in Saint Louis, St Louis, Missouri, USA
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Jennifer Webb
- Department of Hematology/Oncology, Children's National Hospital, Washington, District of Columbia, USA
| | - David Wrubel
- Department of Neurosurgery, Children's Healthcare of Atlanta, Egleston Hospital, Atlanta, Georgia, USA
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Marasligiller SA, Williams BK, Vadivelu S, Correa ZM, Abruzzo TA, Nicola MD, Lane A, Geller JI. Ocular survival after intra-arterial chemotherapy for retinoblastoma improves with accrual of experience and programmatic evolution. Pediatr Blood Cancer 2023; 70:e30071. [PMID: 36349521 PMCID: PMC9790034 DOI: 10.1002/pbc.30071] [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: 03/27/2022] [Revised: 08/14/2022] [Accepted: 09/19/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND Intra-arterial chemotherapy (IAC) for the treatment of intraocular retinoblastoma has gained recognition as a method to improve ocular salvage; however, there is a paucity of evidence supporting treatment factors prognosticating ocular survival. METHODS All patients with retinoblastoma treated with IAC at a single institution between December 2008 and December 2019 were evaluated. Patient demographics, tumor classification, prior treatments, procedural data, other non-IAC therapies, adverse reactions, procedural complications, ocular outcomes, and overall survival were assessed via retrospective chart review. Factors suggestive of increased ocular survival were identified via univariate and multivariate analyses. The impact of accrued treatment experience was evaluated by grouping eyes by the respective year, IAC treatment was initiated. RESULTS Forty-nine eyes of 43 patients were treated for retinoblastoma with IAC (256 total procedures). At least grade 3 neutropenia was observed following 19% of IAC procedures. The risk of neutropenia was not statistically different between single or multidrug IAC. Comparing those who received balloon-assisted intra-arterial chemotherapy (bIAC) in more than two-thirds of cycles to those who did not, the risk of arterial access site complications was not statistically different. Multivariate analysis revealed a significantly lower risk of enucleation associated with treatment era in years (hazard ratio [HR] = 0.52-1.00, p < .05) and laser therapies (HR = 0.02-0.60, p < .05). CONCLUSIONS Ocular survival rates in patients treated with IAC for retinoblastoma at our institution have increased over time. Accrued treatment experience and programmatic changes have likely contributed. Larger, prospective series may lead to a better understanding of factors that consistently contribute to better ocular salvage.
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Affiliation(s)
- Stefan A Marasligiller
- Division of Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
| | - Basil K Williams
- Ocular Oncology Service, Department of Ophthalmology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Sudhakar Vadivelu
- Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - Zelia M Correa
- Ocular Oncology Service, Department of Ophthalmology, University of Cincinnati, Cincinnati, Ohio, USA
- Ocular Oncology Program, Retina Service, Bascom Palmer Eye Institute, University of Miami, Miami, Florida, USA
| | - Todd A Abruzzo
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
- Department of Radiology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona, USA
| | - Maura Di Nicola
- Ocular Oncology Service, Department of Ophthalmology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Adam Lane
- Division of Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, USA
| | - James I Geller
- Division of Oncology, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, Ohio, USA
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Tsang C, Nelson J, McCulloch C, Smith ER, Vadivelu S, Akers A, Lee C, Zabramski J, Zafar A, Torbey MT, Morrison L, Awad IA, Kim H. Abstract WP18: Association Of Quality Of Life Domains And Clinical Symptoms In Familial Cerebral Cavernous Malformation Patients. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background:
Familial cerebral cavernous malformation (FCCM) is characterized by multiple brain lesions at risk for intracranial hemorrhage (ICH) and neurological morbidity, affecting quality of life (QoL). PROMIS-29 is a QoL survey validated in some neurological diseases but has not yet been evaluated for FCCM. We aimed to assess whether PROMIS-29 health domains are associated with clinical symptoms in FCCM patients.
Methods:
PROMIS-29 surveys assessing seven QoL domains were completed by 198 FCCM patients >=18 years either at a baseline or follow-up visit in the Brain Vascular Malformation Consortium CCM study. Raw PROMIS-29 domain scores were converted to T scores that are standardized to a reference population with mean 50 and SD 10, and oriented so that higher scores are unfavorable. One-sample t-tests and p-values assessed whether mean T-scores were significantly different from 50 (p<0.05). Multivariable linear regression was used to test whether domain scores were associated with history of ICH, seizures, or headaches at time of survey, adjusting for age and sex.
Results:
Compared to a reference population, FCCM patients had significantly higher anxiety (52.7, 95% CI: 51.3-54.2, p<0.001), pain (52.5, 95% CI: 51.0-54.0, p=0.002), and physical functioning scores (52.0, 95% CI: 51.4-54.5, p<0.001), but lower social participation scores (46.9, 95% CI: 45.4-48.5, p<0.001). History of ICH and headaches were significantly associated with 4 domains each (all >3 points, p<0.05, Table), while seizures were not associated. Fatigue was the only affected domain in common.
Conclusion:
FCCM patients differed significantly from the reference population on anxiety, pain, physical functioning, and social participation domains. These same domains were significantly associated with history of ICH or headaches in patients. Further studies will determine whether changes in health domains are associated with changes in clinical symptoms.
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Affiliation(s)
- Cynthia Tsang
- Univ of California, San Francisco, San Francisco, CA
| | | | | | | | | | - Amy Akers
- Angioma Alliance, Charlottesville, VA
| | | | | | | | | | | | | | - Helen Kim
- Univ of California, San Francisco, San Francisco, CA
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Taylor JM, Chang M, Vaughan J, Horn PS, Zhang B, Leach JL, Vadivelu S, Abruzzo T. Cerebral Arterial Growth in Childhood. Pediatr Neurol 2022; 134:59-66. [PMID: 35839526 DOI: 10.1016/j.pediatrneurol.2022.06.017] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 12/08/2021] [Revised: 05/22/2022] [Accepted: 06/19/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Improved understanding of cerebral arterial growth in children may lead to advances in the diagnosis and treatment of pediatric cerebrovascular disease. We correlated cross-sectional diameters of major cerebral arterial structures with age, sex, head circumference, weight, and height in children without cerebrovascular disease. METHODS Children with normal brain magnetic resonance imaging (MRI) were retrospectively identified and stratified into 23 age cohorts from birth to age 18 years. Absence of vascular disease was verified by medical record review. Demographic and biometric data were obtained from medical records. Intracranial arterial diameter (IAD) was measured on T2-weighted fast spin echo brain MRI of vertebral, basilar, internal carotid artery, and circle of Willis arterial segments. RESULTS A total of 307 subjects are included in the analysis, including 5833 vessel segments (mean age 8.4 years, 53% female). Indications for imaging were headache (73%), seizure (26%) and concussion (1%). IAD rapidly increased during the first year of life (mean growth velocity 0.064 to 0.213 mm/month) and then plateaued or slightly decreased between age one and 18 years (mean growth velocity -0.002 to 0.003 mm/month). Multivariable analysis shows strongest correlation with head circumference as a predictor of IAD. Weaker correlations are associated with weight and age. Height and sex are not well correlated with IAD. CONCLUSIONS Intracranial arteries grow rapidly during the first year of life and then sharply plateau or slightly decrease in luminal diameter between infancy and early adulthood. IAD is more closely correlated with head circumference than age.
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Affiliation(s)
- J Michael Taylor
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati, College of Medicine, Cincinnati, Ohio.
| | - Michael Chang
- Division of Ophthalmology, West Virginia University, School of Medicine, Morgantown, West Virginia
| | - Jessica Vaughan
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Paul S Horn
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; University of Cincinnati, College of Medicine, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Bin Zhang
- University of Cincinnati, College of Medicine, Cincinnati, Ohio; Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - James L Leach
- University of Cincinnati, College of Medicine, Cincinnati, Ohio; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Sudhakar Vadivelu
- University of Cincinnati, College of Medicine, Cincinnati, Ohio; Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio; Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Todd Abruzzo
- Department of Radiology, Phoenix Children's Medical Group, Phoenix, Arizona; Mayo Clinic College of Medicine, Phoenix, Arizona; University of Arizona, College of Medicine, Phoenix, Arizona
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Abruzzo T, van den Berg R, Vadivelu S, Hetts SW, Dishop M, Cornejo P, Narayanan V, Ramsey KE, Coopwood C, Medici-van den Herik EG, Roosendaal SD, Lawton M, Bernes S. Arterioectatic Spinal Angiopathy of Childhood: Clinical, Imaging, Laboratory, Histologic, and Genetic Description of a Novel CNS Vascular Pathology. AJNR Am J Neuroradiol 2022; 43:1060-1067. [PMID: 35772802 DOI: 10.3174/ajnr.a7551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 04/18/2022] [Indexed: 11/07/2022]
Abstract
Pediatric patients with myelopathy expressing intradural spinal vascular ectasia without arteriovenous shunting were studied at four tertiary referral neuropediatric centers. Patients were identified by retrospective review of institutional records and excluded if spinal vascular pathology could be classified into a previously described category of spinal vascular malformation. Four patients meeting the study criteria were enrolled in the study. Clinical, magnetic resonance imaging, catheter-directed angiography, laboratory, histological and genetic data were analyzed to characterize the disease process and elucidate underlying pathomechanisms. Our study revealed a highly lethal, progressive multi-segmental myelopathy associated with a unique form of non-inflammatory spinal angiopathy featuring diffuse enlargement and tortuosity of spinal cord arteries, spinal cord hyperemia, and spinal cord edema (Arterioectatic Spinal Angiopathy of Childhood). The condition was shown to mimic venous congestive myelopathy associated with pediatric spinal cord arteriovenous shunts on MRI but to have distinct pathognomonic findings on catheter-directed angiography. Clinicopathological, genetic, and neuroimaging features, which are described in detail, closely overlap with those of mitochondrial disease.
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Affiliation(s)
- T Abruzzo
- From the Barrow Neurological Institute at Phoenix Children's Hospital and Department of Radiology (T.A., P.C., S.B.) .,Department of Child Health (T.A., M.D., P.C., S.B.), College of Medicine, University of Arizona, Phoenix, Arizona
| | - R van den Berg
- Department of Radiology and Nuclear Medicine (R.v.d.B., S.D.R.), Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - S Vadivelu
- Department of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - S W Hetts
- Department of Radiology (S.W.H.), University of California, San Francisco, San Francisco, California
| | - M Dishop
- Department of Pathology and Laboratory Medicine (M.D.).,Department of Child Health (T.A., M.D., P.C., S.B.), College of Medicine, University of Arizona, Phoenix, Arizona
| | - P Cornejo
- From the Barrow Neurological Institute at Phoenix Children's Hospital and Department of Radiology (T.A., P.C., S.B.).,Department of Child Health (T.A., M.D., P.C., S.B.), College of Medicine, University of Arizona, Phoenix, Arizona
| | - V Narayanan
- Translational Genomics Research Institute (V.N., K.E.R.), Phoenix, Arizona
| | - K E Ramsey
- Translational Genomics Research Institute (V.N., K.E.R.), Phoenix, Arizona
| | - C Coopwood
- College of Medicine (C.C.), University of Arizona, Tucson, Arizona
| | | | - S D Roosendaal
- Department of Radiology and Nuclear Medicine (R.v.d.B., S.D.R.), Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - M Lawton
- Department of Neurosurgery (M.L.), Phoenix Children's Hospital, Phoenix, Arizona
| | - S Bernes
- From the Barrow Neurological Institute at Phoenix Children's Hospital and Department of Radiology (T.A., P.C., S.B.).,Department of Neurology (S.B.).,Department of Child Health (T.A., M.D., P.C., S.B.), College of Medicine, University of Arizona, Phoenix, Arizona
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9
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Larsh T, Wu SW, Vadivelu S, Grant GA, O'Malley JA. Deep Brain Stimulation for Pediatric Dystonia. Semin Pediatr Neurol 2021; 38:100896. [PMID: 34183138 DOI: 10.1016/j.spen.2021.100896] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/05/2021] [Accepted: 05/06/2021] [Indexed: 12/26/2022]
Abstract
Dystonia is one of the most common pediatric movement disorders and can have a profound impact on the lives of children and their caregivers. Response to pharmacologic treatment is often unsatisfactory. Deep brain stimulation (DBS) has emerged as a promising treatment option for children with medically refractory dystonia. In this review we highlight the relevant literature related to DBS for pediatric dystonia, with emphasis on the background, indications, prognostic factors, challenges, and future directions of pediatric DBS.
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Affiliation(s)
- Travis Larsh
- Center for Pediatric Neurology, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Steve W Wu
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Gerald A Grant
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Stanford University School of Medicine, Palo Alto, CA
| | - Jennifer A O'Malley
- Department of Neurology, Division of Child Neurology, Stanford University School of Medicine, Palo Alto, CA.
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10
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Abruzzo T, Abraham K, Karani KB, Geller JI, Vadivelu S, Racadio JM, Zhang B, Correa ZM. Correlation of Technical and Adjunctive Factors with Quantitative Tumor Reduction in Children Undergoing Selective Ophthalmic Artery Infusion Chemotherapy for Retinoblastoma. AJNR Am J Neuroradiol 2021; 42:354-361. [PMID: 33361377 PMCID: PMC7872184 DOI: 10.3174/ajnr.a6905] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Accepted: 09/04/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Selective ophthalmic artery infusion chemotherapy has improved ocular outcomes in children with retinoblastoma. Our aim was to correlate quantitative tumor reduction and dichotomous therapeutic response with technical and adjunctive factors during selective ophthalmic artery infusion chemotherapy for retinoblastoma. An understanding of such factors may improve therapeutic efficacy. MATERIALS AND METHODS All patients with retinoblastoma treated by selective ophthalmic artery infusion chemotherapy at a single center during a 9-year period were reviewed. Only first-cycle treatments for previously untreated eyes were studied. Adjunctive factors (intra-arterial verapamil, intranasal oxymetazoline external carotid balloon occlusion) and technical factors (chemotherapy infusion time, fluoroscopy time) were documented by medical record review. Quantitative tumor reduction was determined by blinded comparison of retinal imaging acquired during examination under anesthesia before and 3-4 weeks after treatment. The dichotomous therapeutic response was classified according to quantitative tumor reduction as satisfactory (≥ 50%) or poor (<50%). RESULTS Twenty-one eyes met the inclusion criteria. Patients ranged from 2 to 59 months of age. Adjuncts included intra-arterial verapamil in 15, intranasal oxymetazoline in 14, and external carotid balloon occlusion in 14. Quantitative tumor reduction ranged from 15% to 95%. Six showed poor dichotomous therapeutic response. A satisfactory dichotomous therapeutic response was correlated with intra-arterial verapamil (P = .03) in the aggregate cohort and in a subgroup undergoing treatment with single-agent melphalan at a dose of <5 mg (P = .02). In the latter, higher average quantitative tumor reduction correlated with intra-arterial verapamil (P < .01). CONCLUSIONS Intra-arterial verapamil during selective ophthalmic artery infusion chemotherapy is correlated with an improved therapeutic response, particularly when treating with lower doses of single-agent melphalan.
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Affiliation(s)
- T Abruzzo
- From the Departments of Radiology (T.A., J.M.R.)
- Departments of Neurosurgery (T.A.)
- Radiology (KA., K.B.K., T.A.)
- Department of Neurosciences (T.A.), Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona
- Departments of Radiology and Child Health (T.A.), University of Arizona College of Medicine, Phoenix, Arizona
| | | | | | - J I Geller
- Oncology (J.I.G.), Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | | | - J M Racadio
- From the Departments of Radiology (T.A., J.M.R.)
| | - B Zhang
- Epidemiology and Biostatistics (B.Z.)
- Epidemiology and Biostatistics (B.Z.)
| | - Z M Correa
- Ophthalmology (Z.M.C.)
- Ophthalmology (Z.M.C.), University of Cincinnati Medical Center, Cincinnati, Ohio
- Department of Ophthalmology (Z.M.C.), Wilmer Eye Institute, Johns Hopkins University Medical Center, Baltimore, Maryland
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11
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Grant N, Taylor JM, Plummer Z, Myers K, Burrow T, Luchtman-Jones L, Byars A, Hammill A, Wusick K, Smith E, Leach J, Vadivelu S. Case Report: Cerebral Revascularization in a Child With Mucopolysaccharidosis Type I. Front Pediatr 2021; 9:606905. [PMID: 34178879 PMCID: PMC8224401 DOI: 10.3389/fped.2021.606905] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 04/16/2021] [Indexed: 11/13/2022] Open
Abstract
Mucopolysaccharidosis (MPS) type I is a rare lysosomal storage disorder caused by an accumulation of glycosaminoglycans (GAGs) resulting in multisystem disease. Neurological morbidity includes hydrocephalus, spinal cord compression, and cognitive decline. While many neurological symptoms have been described, stroke is not a widely-recognized manifestation of MPS I. Accordingly, patients with MPS I are not routinely evaluated for stroke, and there are no guidelines for managing stroke in patients with this disease. We report the case of a child diagnosed with MPS I who presented with overt stroke and repeated neurological symptoms with imaging findings for severe ventriculomegaly, infarction, and bilateral terminal carotid artery stenosis. Direct intracranial pressure evaluation proved negative for hydrocephalus. The patient was subsequently treated with cerebral revascularization and at a 3-year follow-up, the patient reported no further neurological events or new ischemia on cerebral imaging. Cerebral arteriopathy in patients with MPS I may be associated with GAG accumulation within the cerebrovascular system and may predispose patients to recurrent strokes. However, further studies are required to elucidate the etiology of cerebrovascular arteriopathy in the setting of MPS I. Although the natural history of steno-occlusive arteriopathy in patients with MPS I remains unclear, our findings suggest that cerebral revascularization is a safe treatment option that may mitigate the risk of future strokes and should be strongly considered within the overall management guidelines for patients with MPS I.
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Affiliation(s)
- Nathan Grant
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - J Michael Taylor
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Zach Plummer
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Kasiani Myers
- Division of Hematology - Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Thomas Burrow
- Division of Human Genetics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Lori Luchtman-Jones
- Division of Hematology - Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Anna Byars
- Division of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Adrienne Hammill
- Division of Hematology - Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Katie Wusick
- Division of Hematology - Oncology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Edward Smith
- Department of Neurosurgery, Boston Children's Hospital, Boston, MA, United States
| | - James Leach
- Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Sudhakar Vadivelu
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.,Department of Radiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
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12
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Nagaraj UD, Kline-Fath BM, Calvo-Garcia MA, Vadivelu S, Venkatesan C. Fetal and postnatal MRI findings of Blake pouch remnant causing obstructive hydrocephalus. Radiol Case Rep 2020; 15:2535-2539. [PMID: 33072233 PMCID: PMC7548422 DOI: 10.1016/j.radcr.2020.09.039] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 09/17/2020] [Accepted: 09/20/2020] [Indexed: 11/17/2022] Open
Abstract
Blake pouch remnant, also known as Blake pouch cyst or persistent Blake pouch, is a posterior fossa embryologic anomaly that is often seen in isolation with most affected patients being asymptomatic. However, even in isolation, Blake pouch remnant can result in obstructive hydrocephalus requiring early neurosurgical intervention making it an important diagnosis for the fetal radiologist to consider. We present a rare case of a patient with prenatally diagnosed "inferior vermian hypoplasia" on fetal MRI that went on to develop progressive obstructive hydrocephalus in infancy secondary to what was determined to be a Blake pouch remnant.
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Affiliation(s)
- Usha D Nagaraj
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.,College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Beth M Kline-Fath
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.,College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Maria A Calvo-Garcia
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA.,College of Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Sudhakar Vadivelu
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Charu Venkatesan
- College of Medicine, University of Cincinnati, Cincinnati, OH, USA.,Department of Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
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13
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Sun LR, Linds A, Sharma M, Rafay M, Vadivelu S, Lee S, Brandão LR, Appavu B, Estepp JH, Hukin J, Hassanein SMA, Chan A, Beslow LA. Cancer and Tumor-Associated Childhood Stroke: Results From the International Pediatric Stroke Study. Pediatr Neurol 2020; 111:59-65. [PMID: 32951663 DOI: 10.1016/j.pediatrneurol.2020.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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: 05/15/2020] [Revised: 06/01/2020] [Accepted: 06/02/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND The prevalence of cancer among children with stroke is unknown. This study sought to evaluate cancer- and tumor-associated childhood ischemic stroke in a multinational pediatric stroke registry. METHODS Children aged 29 days to less than 19 years with arterial ischemic stroke or cerebral sinovenous thrombosis enrolled in the International Pediatric Stroke Study between January 2003 and June 2019 were included. Data including stroke treatment and recurrence were compared between subjects with and without cancer using Wilcoxon rank sum and chi-square tests. RESULTS Cancer or tumor was present in 99 of 2968 children (3.3%) with arterial ischemic stroke and 64 of 596 children (10.7%) with cerebral sinovenous thrombosis. Among children in whom cancer type was identified, 42 of 88 arterial ischemic stroke cases (48%) had brain tumors and 35 (40%) had hematologic malignancies; 45 of 58 cerebral sinovenous thrombosis cases (78%) had hematologic malignancies and eight (14%) had brain tumors. Of 54 cancer-associated arterial ischemic stroke cases with a known cause, 34 (63%) were due to arteriopathy and nine (17%) were due to cardioembolism. Of 46 cancer-associated cerebral sinovenous thrombosis cases with a known cause, 41 (89%) were related to chemotherapy-induced or other prothrombotic states. Children with cancer were less likely than children without cancer to receive antithrombotic therapy for arterial ischemic stroke (58% vs 80%, P = 0.007) and anticoagulation for cerebral sinovenous thrombosis (71% vs 87%, P = 0.046). Recurrent arterial ischemic stroke (5% vs 2%, P = 0.04) and cerebral sinovenous thrombosis (5% vs 1%, P = 0.006) were more common among children with cancer. CONCLUSIONS Cancer is an important risk factor for incident and recurrent childhood stroke. Stroke prevention strategies for children with cancer are needed.
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Affiliation(s)
- Lisa R Sun
- Division of Pediatric Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland; Division of Cerebrovascular Neurology, Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland.
| | - Alexandra Linds
- Division of Neurology, Child Health Evaluative Sciences Program, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Mukta Sharma
- Division of Hematology Oncology, Children's Mercy, University of Missouri Kansas City, Kansas City, Missouri
| | - Mubeen Rafay
- Section of Pediatric Neurology, Department of Pediatrics and Child Health, Children's Hospital Research Institute of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio; Division of Neurosurgery, Department of Radiology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Palo Alto, California
| | - Leonardo R Brandão
- Division of Haematology/Oncology, Department of Paediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Brian Appavu
- Department of Child Health and Neurology, University of Arizona College of Medicine - Phoenix Barrow Neurologic Institute at Phoenix Children's Hospital, Phoenix, Arizona
| | - Jeremie H Estepp
- Department of Hematology, St. Jude Children's Research Hospital, Memphis, Tennessee; Department of Pathology, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Juliette Hukin
- Division of Neurology, Department of Pediatrics, Children's and Women's Health Centre, Vancouver, British Columbia, Canada; Division of Oncology, Department of Pediatrics, Children's and Women's Health Centre, Vancouver, British Columbia, Canada
| | - Sahar M A Hassanein
- Department of Pediatrics, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Anthony Chan
- Department of Paediatrics, McMaster Children's Hospital, McMaster University, Hamilton, Ontario, Canada
| | - Lauren A Beslow
- Division of Neurology, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania; Department of Neurology, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania; Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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14
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Falcone J, Ho C, Eskandari R, Vadivelu S, Madsen JR, Muhonen MG. A Noninvasive Retrograde Flushing System for Shunted Hydrocephalus: Initial Case Series of 25 Patients. Cureus 2020; 12:e8940. [PMID: 32765986 PMCID: PMC7401447 DOI: 10.7759/cureus.8940] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Hydrocephalus is a common neurosurgical pathology associated with high patient morbidity and systemwide healthcare costs. A significant portion of these costs are related to the failure of ventricular shunting systems. Despite decades of research and technological development, the rate of shunt failure and revision has not significantly improved. The Reflow™ Ventricular System (Anuncia, Inc., Lowell, MA) is a recent technological development with the potential to prolong the shunt lifespan. This system introduces a noninvasive means of flushing a shunt proximally with a controlled, repeatable pulse of cerebral spinal fluid (CSF) and of creating a new ventricular opening for occluded shunts. In this multicenter case series, we present the early clinical experiences with this device and discuss its potential.
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Affiliation(s)
| | - Cindy Ho
- Neurosurgery, Children's Hospital of Orange County, Orange County, USA
| | - Ramin Eskandari
- Neurosurgery, Medical University of South Carolina, Charleston, USA
| | - Sudhakar Vadivelu
- Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, USA
| | - Joseph R Madsen
- Neurosurgery, Boston Children's Hospital/Harvard Medical School, Boston, USA
| | - Michael G Muhonen
- Neurosurgery, Children's Hospital of Orange County, Orange County, USA
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15
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Porter Z, Yang G, Vuong S, Hanna B, Madsen J, Vadivelu S. In situ clearance of a proximal shunt malfunction in a child with hydrocephalus post cerebral arteriovenous malformation rupture noted intraoperatively. Surg Neurol Int 2020; 11:116. [PMID: 32494391 PMCID: PMC7265405 DOI: 10.25259/sni_156_2020] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 04/21/2020] [Indexed: 11/08/2022] Open
Abstract
Background: Hydrocephalus shunt malfunctions remain treated with surgical intervention only. Despite efforts at identifying or preventing CSF shunt obstruction, no evidence currently exists to restore CSF flow following proximal occlusion, non-invasively. Case Description: We present direct intraoperative evidence in the case of a 5-year-old male who developed hydrocephalus subsequent to hemorrhagic presentation post cerebral arteriovenous malformation rupture. After weeks of externalized CSF diversion for clearance of CSF red blood cells, he was taken to the operating room for removal of the external ventricular drain and placement of a ventriculoperitoneal shunt for hydrocephalus. At conclusion of placing his ventriculoperitoneal shunt with ReFlow flusher assist device, his shunt valve reservoir was noted to not refill. Following manual depression of the ReFlow flusher, we identified clearance of debris from the obstructed ventricular catheter allowing reestablished CSF flow through the shunt system under live intraoperative ultrasonography. Subsequently, there was return of brisk refill to the shunt valve reservoir. Conclusion: Observations here demonstrate a potentially useful technical strategy toward clearance of proximal shunt obstructions, in situ.
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Affiliation(s)
- Zachary Porter
- Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - George Yang
- Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Shawn Vuong
- Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Baher Hanna
- Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
| | - Joseph Madsen
- Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts, United States
| | - Sudhakar Vadivelu
- Department of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio, United States
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16
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Vaughan J, Taylor M, Leach JL, Horn P, Vadivelu S, Abruzzo T. Abstract TMP113: Non-invasive Estimate of Intracranial Arterial Luminal Diameter in Children. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.tmp113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Growth of the intracranial arteries facilitates the rapid increase in cerebral growth in the first 2 decades of life. In the age of cerebral endovascular treatment, many questions arise in the pediatric cohort regarding the safety and efficacy of these therapeutic approaches. Small arterial diameter may influence treatment selection in the very young, but to date little normative data is available to define vascular growth in infants and children.
Methods:
Subjects in this single-institution, retrospective cohort study were identified by MRI brain imaging keyword query as “normal” with age 0-18 years old at the time of the study. Medical records were reviewed to capture weight, length, and head circumference and exclude cerebrovascular or connective tissue disease risk factors. MRI T2-weighted images were measured to calculate the head circumference and arterial diameter in axial and coronal planes. A growth curve was created from the head circumferences and intracranial artery diameters to compare luminal caliber to age, sex and recorded growth parameters.
Results:
317 subjects (170 female, 147 male) are included in the analysis. Luminal diameter was observed to increase rapidly in all arterial segments over the first 3 years of life. Compared to weight and length, head circumference most closely correlated with arterial size. Head circumference growth is most rapid during the first 3 years, tracking closely with the rate of luminal growth. An example relationship between arterial diameter and head circumference is shown in Figure 1.
Conclusions:
This is the largest cohort of cerebral arterial luminal growth in childhood. We show that arterial diameter can be measured non-invasively on MRI brain and correlated to routinely measured growth parameters. A better understanding of normal arterial growth is essential to our treatment of cerebrovascular disease in children.
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Affiliation(s)
| | - Michael Taylor
- Neurology, Cincinnati Children’s Hosp Med Ctr, Cincinnati, OH
| | - James L Leach
- Radiology, Cincinnati Children’s Hosp Med Ctr, Cincinnati, OH
| | - Paul Horn
- Neurology, Cincinnati Children’s Hosp Med Ctr, Cincinnati, OH
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17
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Vadivelu S, Harker P, Zuccarello M. Letter to the Editor. Moyamoya: patient selection rather than de-selection in the very young. J Neurosurg Pediatr 2019; 25:1-2. [PMID: 31561228 DOI: 10.3171/2019.6.peds19346] [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: 11/06/2022]
Affiliation(s)
- Sudhakar Vadivelu
- 1Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and
- 2University of Cincinnati College of Medicine, Cincinnati, OH
| | - Pablo Harker
- 1Cincinnati Children's Hospital Medical Center, Cincinnati, OH; and
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18
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Boucher AA, Gurunathan A, Taylor JM, Ricci KW, Vadivelu S, Quinn CT. Hemoglobin Southampton complicated by cerebral ischemia, moyamoya, and hydroxyurea-induced methemoglobinemia. Am J Hematol 2019; 94:949-954. [PMID: 31095774 DOI: 10.1002/ajh.25509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 05/08/2019] [Accepted: 05/13/2019] [Indexed: 11/11/2022]
Affiliation(s)
- Alexander A Boucher
- Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Arun Gurunathan
- Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - John M Taylor
- University of Cincinnati College of Medicine, Cincinnati, Ohio.,Neurology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Kiersten W Ricci
- Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sudhakar Vadivelu
- University of Cincinnati College of Medicine, Cincinnati, Ohio.,Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Charles T Quinn
- Hematology, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.,University of Cincinnati College of Medicine, Cincinnati, Ohio
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19
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Chen AM, Karani KB, Taylor JM, Zhang B, Furthmiller A, De Vela G, Leach JL, Vadivelu S, Abruzzo TA. Cervicocerebral quantitative arterial tortuosity: a biomarker of arteriopathy in children with intracranial aneurysms. J Neurosurg Pediatr 2019; 24:1-8. [PMID: 31349231 DOI: 10.3171/2019.5.peds1982] [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] [Received: 02/06/2019] [Accepted: 05/21/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Although intracranial arterial aneurysms (IAAs) of childhood are usually idiopathic, it is possible that underlying arteriopathy escapes detection when using conventional diagnostic tools. Quantitative arterial tortuosity (QAT) has been studied as a biomarker of arteriopathy. The authors analyzed cervicocerebral QAT in children with idiopathic IAAs to assess the possibility of arteriopathy. METHODS Cases were identified by text-string searches of imaging reports spanning the period January 1993 through June 2017. QAT of cervicocerebral arterial segments was measured from cross-sectional studies using image-processing software. Other imaging and clinical data were confirmed by retrospective electronic record review. Children with idiopathic IAAs and positive case controls, with congenital arteriopathy differentiated according to aneurysm status (with and without an aneurysm), were compared to each other and to healthy controls without vascular risk factors. RESULTS Cervicocerebral QAT was measured in 314 children: 24 with idiopathic IAAs, 163 with congenital arteriopathy (including 14 arteriopathic IAAs), and 127 healthy controls. QAT of all vertebrobasilar segments was larger in children with IAAs (idiopathic and arteriopathic forms) (p < 0.05). In children with congenital arteriopathy without an aneurysm, QAT was decreased for the distal cervical vertebral arteries and increased for the supraspinal vertebral artery relative to healthy children. QAT of specific cervicocerebral segments correlated with IAA size and rupture status. CONCLUSIONS Cervicocerebral QAT is a biomarker of arteriopathy in children with IAA, even in the absence of other disease markers. Additional findings suggest a correlation of cervicocerebral QAT with IAA size and rupture status and with the presence of IAA in children with congenital arteriopathy.
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Affiliation(s)
- Alan M Chen
- 1Radiology Associates of Tallahassee, Tallahassee, Florida
| | | | - J Michael Taylor
- Divisions of3Neurology
- 6University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Bin Zhang
- 4Biostatistics and Epidemiology, and
- 6University of Cincinnati College of Medicine, Cincinnati, Ohio
| | | | | | - James L Leach
- 2Department of Radiology and
- 6University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Sudhakar Vadivelu
- 2Department of Radiology and
- 5Neurosurgery, Cincinnati Children's Hospital Medical Center
- 6University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Todd A Abruzzo
- 7Department of Radiology, Phoenix Children's Medical Group
- 8Mayo Clinic College of Medicine; and
- 9University of Arizona, College of Medicine, Phoenix, Arizona
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Taylor JM, Quinn C, Vadivelu S, Luchtman-Jones L. Abstract WMP119: An MRI Surveillance Protocol for Pediatric Sickle Cell Anemia. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.wmp119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Sickle cell anemia (SCA) is a leading cause of stroke and neurologic disability in children. In the 20 years since the publication of the STOP trial, chronic transfusion therapy and hydroxyurea have shown efficacy as disease-modifying therapies, especially by improvement of transcranial Doppler (TCD) velocities and reduction in the incidence of overt stroke. Despite the publication of the SIT Trial 2014, screening for silent stroke is not universally implemented. Here we report our center’s experience with screening neuroimaging in young children with SCA.
Methods:
This is a single center, retrospective case series of patients with SCA (HbSS and HbSb
0
-thalassemia) managed in a comprehensive sickle cell center. Patients undergo TCD screening per STOP guidelines beginning at age 24 months. Screening MRI/MRA brain are also recommended at 5, 10, 15, and 20 years of age. Imaging data for the children 5-9 years of age are reported.
Results:
There were 39 subjects within the defined age range, 37 of whom were receiving disease-modifying therapy (hydroxyurea, N=34; chronic transfusions, N=3). Mean age of initiation of disease-modifying therapy was 4.2 years. MRI/MRA of the brain was obtained according to our screening protocol in only 21 (54%), indicating incomplete screening and opportunity for quality improvement. Indeed, most MRIs were obtained for a clinical concern and/or a non-normal TCD (85%). Abnormal parenchyma and/or vasculature was identified in 11 of 21 (52%) imaged subjects. In patients imaged before starting disease modifying therapy, 2 of 9 had stroke (22%). In patients imaged after starting disease modifying therapy, 7 of 12 had stroke and or arteriopathy (58%).
Conclusions:
Over half (52%) of young children (5-9 years) with SCA in our center who had an MRI/MRA had abnormal findings, indicating a high yield for potentially actionable results. This may be an under-estimate of CNS disease burden, because 46% of the population did not undergo screening MRI/MRA. Proactive screening for cerebrovascular complications in SCA may allow early intervention that further improves patient outcomes.
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Affiliation(s)
| | - Charles Quinn
- Hematology, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
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Wusik K, Hammill A, Patel M, Vadivelu S, Taylor JM. Abstract TP503: Screening Algorithm for Hereditary Hemorrhagic Telangiectasia in Pediatric Brain AVM. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Hereditary Hemorrhagic Telangiectasia (HHT) is a rare cause of familial arteriovenous malformation (AVM) which may present symptomatically in the brain, spine, pulmonary, or hepatic circulation. Symptoms and signs of HHT - including epistaxis, GI bleeding, and cutaneous telangiectasia - may not be manifest at the time of AVM diagnosis. Natural history studies suggesting a more benign course for HHT-associated AVM compared to sporadic AVM may reflect a sampling bias if the true frequency of HHT is under-estimated. In this study, we report our experience with HHT screening in a population with pediatric brain AVM.
Methods:
Patients followed in the multidisciplinary Cincinnati Children’s Hospital Cerebrovascular Center are interviewed by a genetics counselor after identification of a brain AVM. A comprehensive medical and family history are collected and patients are offered screening for HHT using a 5 gene panel (Ambry Genetics: ACVRL1, ENG, SMAD4, RASA1, GDF2). Further testing with bubble echocardiogram and skin examination is offered to identify clinical criteria for HHT per Curacao criteria.
Results:
Brain AVM was identified in 12 patients followed in our center with age range 5 weeks to 17 years at AVM diagnosis. Recurrent epistaxis was present in 6 (50%) of our patients. Family history is negative for HHT in all cases although 75% of patients had at least 1 first degree relative with recurrent epistaxis. Additional diagnostics were completed in 10 of 12 patients, including genetic testing in 9 individuals. No pathogenic mutations were identified in this small cohort but 2 patients showed variants of unknown significance in ENG (p.R3C and p.E41K). Of the 10 patients who completed additional screening for HHT, 2 met criteria for definite HHT (ages 3 and 17) and 2 for possible HHT (ages 2 and 10).
Conclusions:
In our cohort of pediatric brain AVM patients, 33% met criteria for possible or definite HHT. The clinical symptoms and signs of HHT emerge over time. Using a standard diagnostic algorithm for reassessment of Curacao criteria may help facilitate correct and timely diagnosis. For cases confirmed with definite HHT, genetic counseling and gene testing should be considered.
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Affiliation(s)
| | | | - Manish Patel
- Interventional Radiology, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
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Taylor JM, Vadivelu S, Kinnett D, Byars A. Abstract TP508: Neuropsychological Outcomes in Children With Arterial Ischemic Stroke. Stroke 2019. [DOI: 10.1161/str.50.suppl_1.tp508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective:
Pediatric stroke is a rare disease with potential for lifelong impact on cognition, social function, and financial productivity. Neuropsychological testing is critically important for understanding the impact of acquired brain injury on the component elements of cognition. Unfortunately patients cannot always access comprehensive testing resources due to a variety of barriers including limited behavioral health provider availability, cost, and insurance coverage. Physicians must be familiar with common neurocognitive difficulties after pediatric stroke to aide timely resource referral. In our study we review the neuropsychological profile of pediatric arterial ischemic stroke (AIS) patients.
Methods:
This is a single center retrospective case series of AIS patients evaluated from 2015-June 2018 by our multidisciplinary cerebrovascular center. Patients were referred for neuropsychology evaluation routinely after identification of stroke. The test battery was determined at the discretion of the evaluating psychologist and administered per standard protocol. Aggregate results are presented with mean ± standard deviation. Medical records have been abstracted and correlated to lesion laterality, time elapsed since injury, and neurologic comorbidities including ADHD and epilepsy.
Results:
The CV center cares for 120 children with AIS. 38 children have undergone neuropsychological testing in the study interval (23 females, 15 males). Median age at evaluation is 12 years. The mean full scale IQ for this cohort is 81±18 scoring in the low average range compared to the healthy population. The cohort showed lowest performance in visual spatial index (83±15) and working memory (84±16). Verbal comprehension (89±18), fluid reasoning (87±13), and processing speed indices (85±16) showed minimally higher scores. Conclusion Children with stroke are at risk for cognitive deficits with visual spatial and working memory difficulties most prominent in our cohort. Appropriate therapeutic and educational resources should be directed to address cognitive deficits when identified. Clinician recognition of support needs in this population will facilitate timely referral for intervention.
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Affiliation(s)
| | | | - Douglas Kinnett
- Rehabilitation, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
| | - Anna Byars
- Neurology, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
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Abstract
PURPOSE Transverse myelitis (TM) is an acute inflammatory spinal cord injury. Asymptomatic Chiari I malformation (CMI) management is highly controversial, particularly when associated with a spinal syrinx. Here, we assess the occurrence of CMI in the pediatric TM population and management outcomes. METHODS We performed a retrospective cohort study based on 61 consecutively identified pediatric TM cases over an -8-year period. We reviewed demographic characteristics, radiographic findings, presenting symptoms, and long-term outcomes. RESULTS Eight CMI cases were identified within the TM cohort; all presented with TM by 16 months of age and affecting the cervical spinal cord. In three cases, CMI developed 15 months to 6 years after the onset of TM. One in 10 children with TM had CMI. CONCLUSION These findings demonstrate a high prevalence of CMI in patients with TM. Large prospective clinical studies are needed to further investigate the natural history and recovery strategies of CMI involved with neuroinflammatory disorders.
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Affiliation(s)
- Sathya Vadivelu
- a Department of Pediatric Rehabilitation Medicine , Johns Hopkins University and the Kennedy Krieger Institute , Baltimore , MD , USA
| | - Sudhakar Vadivelu
- b Division of Pediatric Neurosurgery , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA.,c Department of Neurosurgery , University of Cincinnati School of Medicine , Cincinnati , OH , USA
| | - Maureen Mealy
- d Department of Neurology , Johns Hopkins University and the Kennedy Krieger Institute , Baltimore , MD , USA
| | - Smurti Patel
- c Department of Neurosurgery , University of Cincinnati School of Medicine , Cincinnati , OH , USA
| | - Libby Kosnik-Infinger
- b Division of Pediatric Neurosurgery , Cincinnati Children's Hospital Medical Center , Cincinnati , OH , USA
| | - Daniel Becker
- d Department of Neurology , Johns Hopkins University and the Kennedy Krieger Institute , Baltimore , MD , USA
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DeVela G, Taylor JM, Zhang B, Linscott LL, Chen AM, Karani KB, Furthmiller A, Leach JL, Vadivelu S, Abruzzo T. Quantitative Arterial Tortuosity Suggests Arteriopathy in Children With Cryptogenic Stroke. Stroke 2018. [PMID: 29540605 DOI: 10.1161/strokeaha.117.020321] [Citation(s) in RCA: 7] [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] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Quantitative arterial tortuosity (QAT) is a ratio of vessel length between 2 points to the shortest linear distance between same points. QAT has been reported as an imaging biomarker of arteriopathy in pediatric arterial ischemic stroke (AIS) because of dissection and transient cerebral arteriopathy. We sought to determine whether QAT abnormalities are present in other subtypes of pediatric AIS. METHODS Children with AIS-absent conventional biomarkers of arteriopathy and case-controls who underwent magnetic resonance angiography were classified by stroke mechanism. The primary study population consisted of cryptogenic AIS cases. AIS with bow hunter physiology and cardiogenic emboli were also evaluated. AIS because of nontraumatic dissection served as positive controls. Patients without vascular risk factors served as negative controls. Segmental QAT of cervicocerebral arteries were measured using automated image processing and differences between groups analyzed. RESULTS In negative controls, QAT showed significant age-related variability for most arterial segments. Positive controls showed significantly increased QAT of the distal extracranial vertebral arteries (VAs) and decreased QAT of the intracranial VA relative to negative controls. Cryptogenic stroke and bow hunter physiology cases were similar to positive controls showing increased QAT of the distal extracranial VA and decreased QAT of the intracranial VA relative to negative controls. Cardioembolic stroke cases were similar to negative controls showing decreased QAT of the distal extracranial VA and increased QAT of the intracranial VA relative to positive controls. CONCLUSIONS Pediatric cryptogenic stroke is frequently associated with cervicocerebral arteriopathies expressing altered QAT. QAT may be a diagnostic biomarker of arteriopathy in pediatric AIS.
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Affiliation(s)
- Gabriel DeVela
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
| | - J Michael Taylor
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ.
| | - Bin Zhang
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
| | - Luke L Linscott
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
| | - Alan M Chen
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
| | - Kunal B Karani
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
| | - Andrew Furthmiller
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
| | - James L Leach
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
| | - Sudhakar Vadivelu
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
| | - Todd Abruzzo
- From the Department of Radiology, and Division of Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, OH (G.D., A.M.C., K.B.K., A.F., J.L.L., S.V.); Division of Neurology (J.M.T.), Division of Biostatistics and Epidemiology (B.Z.), and Department of Radiology (L.L.L.), Primary Children's Hospital, University of Utah School of Medicine, Salt Lake City; and Department of Radiology (T.A.), Phoenix Children's Medical Group, AZ
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Taylor JM, DeVela G, Leach JL, Vadivelu S, Zhang B, Linscott L, Chen A, Furthmiller A, Abruzzo T. Abstract TMP101: Magnetic Resonance Quantitative Arterial Tortuosity Reveals Evidence of Otherwise Occult Arteriopathy in Pediatric Patients With Cryptogenic Arterial Ischemic Stroke. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.tmp101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Quantitative arterial tortuosity (QAT) has been reported as an imaging biomarker of arteriopathy in pediatric arterial ischemic stroke (AIS) due to dissection and transient cerebral arteriopathy. We sought to determine if QAT abnormalities are present in cryptogenic pediatric AIS patients.
Methods:
Children with non-cardiogenic non-traumatic AIS and normal case controls who underwent MRA of the head and/or neck were identified by retrospective electronic medical record review. Patients with pre-existing clinical risk factors for AIS were excluded. The remaining cases were classified according to stroke subtype. The study population consisted of cryptogenic stroke cases. Patients with AIS due to spontaneous dissection were compared as positive case controls. Patients considered to have Bow Hunter’s Physiology (BHP), and normal case controls were also compared. QAT indices of 5 cervicocerebral arterial segments were measured in all patients using automated image processing software, and differences between groups were analyzed.
Results:
In normal children, QAT of the cervicocerebral arteries showed significant age-related variability, but no sex-related differences. In pediatric patients with cryptogenic stroke, QAT indices of the cervicocerebral arteries were significantly different relative to normal case controls (p<0.05), and similar to those measured in positive case controls with spontaneous dissection. The cervicocerebral QAT indices of pediatric AIS patients with BHP were not significantly different than those measured in normal controls.
Conclusions:
QAT is a specific and independent biomarker of arteriopathy in otherwise cryptogenic pediatric AIS, even when conventional clinical or imaging biomarkers of arteriopathy are absent. QAT shows promise as an independent diagnostic criterion for arteriopathy in children with AIS.
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Affiliation(s)
| | - Gabe DeVela
- Div of Radiology, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
| | - James L Leach
- Div of Radiology, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
| | - Sudhakar Vadivelu
- Div of Neurosurgery, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
| | - Bin Zhang
- Div of Biostatistics and Epidemiology, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
| | - Luke Linscott
- Div of Radiology, Univ of Utah Sch of Medicine, Salt Lake City, UT
| | - Alan Chen
- Div of Radiology, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
| | | | - Todd Abruzzo
- Div of Radiology, Cincinnati Childrens Hosp Med Ctr, Cincinnati, OH
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Plummer Z, Taylor JM, Abruzzo T, Vadivelu S. Abstract WP387: Diagnosis and Surgical Management of Rotational Vertebral Artery Occlusion in Children. Stroke 2018. [DOI: 10.1161/str.49.suppl_1.wp387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Rotational vertebral artery occlusion (RVAO) is associated with significant posterior circulation morbidity, recurrence, and lacks evidenced based treatment recommendations. Upper cervical spine abnormalities, lack of traumatic history, and dynamic vessel imaging aid in diagnosis and treatment options. Here, we evaluate our cohort of children with RVAO for associated musculoskeletal, angiographic, and arterial tortuosity factors in light of management strategies and outcomes.
Methods:
Five pediatric patients with RVAO were evaluated with dynamic arterial compression with either CT based angiography or digital subtraction angiography. Solitary factors such as ponticulous posticus, hypermobility comorbidities, 3D-print models and arterial tortuosity index were examined in relation to management strategies.
Results:
Musculoskeletal abnormalities were associated in all cases presenting with evidence of dynamic angiographic compression. Not all cases had evidence angiographic compression. A mild elevation in arterial tortuosity index was observed. All five patients were managed with treatment approaches including antiplatelet/coagulation therapies, vertebral artery decompression, and/or posterior cervical fusion.
Conclusion:
Treatment strategies relied on identifiable compression factors associated with the level of vertebral artery dissection. In children, upper cervical bony abnormalities and dynamic compression at the VA3 level are common to RVAO diagnosis. Further examination of arterial tortuosity as an index in understanding the susceptibility of children towards RVAO is required.
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Affiliation(s)
| | - John M Taylor
- Neurology, Cincinnati Childrens Hosp, Cincinnati, OH
| | - Todd Abruzzo
- Interventional Neuroradiology, Cincinnati Childrens Hosp, Cincinnati, OH
| | - Sudhakar Vadivelu
- Neurosurgery and Interventional Neuroradiology, Cincinnati Childrens Hosp, Cincinnati, OH
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Peeters S, Skoch J, Holt H, Mubita L, Choudhary EA, Vadivelu KP, Gilbert DL, Wu SW, Keebaugh AC, Air E, Vadivelu S. Functional Neuroanatomy of Secondary Self-Injurious Behavior. Pediatr Neurosurg 2018; 53:71-80. [PMID: 29402877 DOI: 10.1159/000485385] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [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: 06/19/2017] [Accepted: 11/13/2017] [Indexed: 11/19/2022]
Abstract
BACKGROUND Secondary self-injurious behavior (SSIB) is underreported and predominantly not associated with suicide. In both adults and children, SSIB can cause intractable self-harm and is associated with a variety of clinical disorders, particularly those involving dysfunctional motor control. METHODS We performed a literature review evaluating the clinical efficacy of deep-brain stimulation (DBS) as modulating SSIB observations and review current progress in preclinical SSIB animal studies. RESULTS Neuromodulation is an effective therapeutic option for several movement disorders. Interestingly, this approach is emerging as a potentially effective treatment for movement disorder-associated SSIB (secondary); however, it is important to understand the neuroanatomy, clinical appraisal, and outcome data when considering surgical therapy for SSIB. CONCLUSION The current review examines the literature encompassing animal models and human case studies while identifying existing hypotheses from cytoarchitectonic-based targeting to neurotransmitter-based pathways. This review also highlights the need for awareness of an underrecognized pathology that may be amenable to DBS.
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Affiliation(s)
- Sophie Peeters
- Division of Pediatric Neurosurgery and Neurology, Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
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Skoch J, Tahir R, Abruzzo T, Taylor JM, Zuccarello M, Vadivelu S. Predicting symptomatic cerebral vasospasm after aneurysmal subarachnoid hemorrhage with an artificial neural network in a pediatric population. Childs Nerv Syst 2017; 33:2153-2157. [PMID: 28852853 DOI: 10.1007/s00381-017-3573-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 06/17/2017] [Accepted: 08/09/2017] [Indexed: 01/23/2023]
Abstract
PURPOSE Artificial neural networks (ANN) are increasingly applied to complex medical problem solving algorithms because their outcome prediction performance is superior to existing multiple regression models. ANN can successfully identify symptomatic cerebral vasospasm (SCV) in adults presenting after aneurysmal subarachnoid hemorrhage (aSAH). Although SCV is unusual in children with aSAH, the clinical consequences are severe. Consequently, reliable tools to predict patients at greatest risk for SCV may have significant value. We applied ANN modeling to a consecutive cohort of pediatric aSAH cases to assess its ability to predict SCV. METHODS A retrospective chart review was conducted to identify patients < 21 years of age who presented with spontaneously ruptured, non-traumatic, non-mycotic, non-flow-related intracranial arterial aneurysms to our institution between January 2002 and January 2015. Demographics, clinical, radiographic, and outcome data were analyzed using an adapted ANN model using learned value nodes from the adult aneurysmal SAH dataset previously reported. The strength of the ANN prediction was measured between - 1 and 1 with - 1 representing no likelihood of SCV and 1 representing high likelihood of SCV. RESULTS Sixteen patients met study inclusion criteria. The median age for aSAH patients was 15 years. Ten underwent surgical clipping and 6 underwent endovascular coiling for definitive treatment. One patient experienced SCV and 15 did not. The ANN applied here was able to accurately predict all 16 outcomes. The mean strength of prediction for those who did not exhibit SCV was - 0.86. The strength for the one patient who did exhibit SCV was 0.93. CONCLUSIONS Adult-derived aneurysmal SAH value nodes can be applied to a simple AAN model to accurately predict SCV in children presenting with aSAH. Further work is needed to determine if ANN models can prospectively predict SCV in the pediatric aSAH population in toto; adapted to include mycotic, traumatic, and flow-related origins as well.
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Affiliation(s)
- Jesse Skoch
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA.,Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA
| | - Rizwan Tahir
- Department of Neurosurgery, Henry Ford Hospital, 2799 West Grand Blvd, Detroit, MI, 48202, USA
| | - Todd Abruzzo
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.,Division of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - John M Taylor
- Division of Neurology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA
| | - Mario Zuccarello
- Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA
| | - Sudhakar Vadivelu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA. .,Department of Neurosurgery, University of Cincinnati College of Medicine, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA. .,Division of Radiology, Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave, Cincinnati, OH, 45229, USA. .,Cincinnati Children's Hospital Medical Center, 3333 Burnet Ave. MLC-2016, Cincinnati, OH, 45229 - 3039, USA.
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Vadivelu S, Xu K, Tolj V, Rege R, Darkins L, Vishwanath K. Neurovascular toxicity of N-methyl-d-aspartate is markedly enhanced in the developing mouse central nervous system. Neurosci Lett 2017. [PMID: 28636928 DOI: 10.1016/j.neulet.2017.06.027] [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] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Penumbral perfusion is critical to brain viability. Proximal arterial occlusion and deep brain stroke has variable effect on cortical dysfunction. Cortical microvessel collaterals may be recruited and at times sufficient for partial parenchymal perfusion. Postnatal neural and endothelial cells are markedly vulnerable to glutamate excitotoxicity. Early vascular cell stress may promote partial protective neural preconditioning though postnatally a developmental window of the cerebral microvasculature may be particularly vulnerable to injury. We tested the hypothesis that postnatal NMDA excitotoxic injury, when cerebral endothelial cells' central energy source is via glycolysis, is age specific. Neurovascular responses of cortical viability were directly identified with diffuse reflectance patterns of perfusion properties in a non-invasive manner, over time. Histological evaluation for neural and vascular cytoarchitectonic abnormalities were evaluated 4- 7days post injury. Optical diffuse reflectance recordings were obtained at the injection site prior to, immediately after and 48h post injury. Extent of neurovascular injury at the infarct zone was greatest at PND 5 and cortical perfusion responses identified with recordings of pattern change. These data further suggest excitotoxic injury to both neural and vascular cells, in vivo, can enhance CNS injury in the young and neuroprotective strategies may benefit from vascular directed therapies.
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Affiliation(s)
- Sudhakar Vadivelu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States.
| | - Kui Xu
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Vanja Tolj
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Rahul Rege
- Division of Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, United States
| | - Lindsay Darkins
- Department of Physics, Miami University, Oxford, OH, United States
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Larson PS, Willie JT, Vadivelu S, Azmi-Ghadimi H, Nichols A, Fauerbach LL, Johnson HB, Graham D. MRI-guided stereotactic neurosurgical procedures in a diagnostic MRI suite: Background and safe practice recommendations. J Healthc Risk Manag 2017; 37:31-39. [PMID: 28719087 DOI: 10.1002/jhrm.21275] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
The development of navigation technology facilitating MRI-guided stereotactic neurosurgery has enabled neurosurgeons to perform a variety of procedures ranging from deep brain stimulation to laser ablation entirely within an intraoperative or diagnostic MRI suite while having real-time visualization of brain anatomy. Prior to this technology, some of these procedures required multisite workflow patterns that presented significant risk to the patient during transport. For those facilities with access to this technology, safe practice guidelines exist only for procedures performed within an intraoperative MRI. There are currently no safe practice guidelines or parameters available for facilities looking to integrate this technology into practice in conventional MRI suites. Performing neurosurgical procedures in a diagnostic MRI suite does require precautionary measures. The relative novelty of technology and workflows for direct MRI-guided procedures requires consideration of safe practice recommendations, including those pertaining to infection control and magnet safety issues. This article proposes a framework of safe practice recommendations designed for assessing readiness and optimization of MRI-guided neurosurgical interventions in the diagnostic MRI suite in an effort to mitigate patient risk. The framework is based on existing clinical evidence, recommendations, and guidelines related to infection control and prevention, health care-associated infections, and magnet safety, as well as the clinical and practical experience of neurosurgeons utilizing this technology.
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Affiliation(s)
| | - Jon T Willie
- Emory University Department of Neurosurgery in Atlanta, Georgia
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Larson PS, Vadivelu S, Azmi-Ghadimi H, Nichols A, Fauerbach L, Johnson HB. Neurosurgical laser ablation and MR thermometry: Risks of multisite workflow pattern. J Healthc Risk Manag 2017; 36:7-18. [PMID: 28415147 DOI: 10.1002/jhrm.21258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Neurosurgical laser ablation is a relatively new but rapidly growing application of stereotactic neurosurgery that allows neurosurgeons to treat many previously untreatable conditions with the added benefit of shorter hospitalizations and recovery times. The vast majority of these procedures, however, are performed using a multisite workflow pattern involving transport of the patient between the operating room (OR), the computed tomography (CT) suite, and the magnetic resonance imaging (MRI) suite, often necessitating patient transfer through public pathways and requiring multiple trips if laser fiber placement is not accurate. There are significant risks posed to the patient with this practice and no existing guidelines addressing it. This article serves to identify those risks and present recommendations for safety optimization and risk reduction for those health care facilities using a multisite workflow pattern.
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Affiliation(s)
- Paul S Larson
- University of California San Francisco Medical Center
| | | | | | - Amy Nichols
- University of California San Francisco Medical Center
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Vadivelu S, Masood Z, Krueger B, Marciano R, Chen D, Houseman C, Insinga S. Long-term resolution of delayed onset hypoglossal nerve palsy following occipital condyle fracture: Case report and review of the literature. J Craniovertebr Junction Spine 2017; 8:149-152. [PMID: 28694600 PMCID: PMC5490350 DOI: 10.4103/jcvjs.jcvjs_34_17] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
The authors present the case of a patient that demonstrates resolution of delayed onset hypoglossal nerve palsy (HNP) subsequent to occipital condyle fracture following a motor vehicle accident. Decompression of the hypoglossal nerve and craniocervical fixation led to satisfactory long-term (>5 years) outcome. There is a scarcity of literature in recognizing HNPs following trauma and a lack of pathophysiological understanding to both a delayed presentation and to resolution versus persistence. This is the first report demonstrating long-term resolution of hypoglossal nerve injury following trauma to the craniocervical junction.
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Affiliation(s)
- Sudhakar Vadivelu
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Zihan Masood
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Bryan Krueger
- Division of Pediatric Neurosurgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA.,Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Rudy Marciano
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - David Chen
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - Cliff Houseman
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
| | - Salvatore Insinga
- Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY, USA
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Abstract
OBJECTIVE
The incidence of posttraumatic ventriculomegaly (PTV) and shunt-dependent hydrocephalus after nonaccidental head trauma (NAHT) is unknown. In the present study, the authors assessed the timing of PTV development, the relationship between PTV and decompressive craniectomy (DC), and whether PTV necessitated placement of a permanent shunt. Also, NAHT/PTV cases were categorized into a temporal profile of delay in admission and evaluated for association with outcomes at discharge.
METHODS
The authors retrospectively reviewed the cases of patients diagnosed with NAHT throughout a 10-year period. Cases in which sequential CT scans had been obtained (n = 28) were evaluated for Evans' index to determine the earliest time ventricular dilation was observed. Discharge outcomes were assessed using the King's Outcome Scale for Childhood Head Injury score.
RESULTS
Thirty-nine percent (11 of 28) of the patients developed PTV. A low admission Glasgow Coma Scale (GCS) score predicted early PTV presentation (within < 3 days) versus a high GCS score (> 1 week). A majority of PTV/NAHT patients presented with a subdural hematoma (both convexity and interhemispheric) and ischemic stroke, but subarachnoid hemorrhage was significantly associated with PTV/NAHT (p = 0.011). Of 6 patients undergoing a DC for intractable intracranial pressure, 4 (67%) developed PTV (p = 0.0366). These patients tended to present with lower GCS scores and develop ventriculomegaly early. Only 2 patients developed hydrocephalus requiring shunt placement.
CONCLUSIONS
PTV presents early after NAHT, particularly after a DC has been performed. However, the authors found that only a few PTV/NAHT patients developed shunt-dependent hydrocephalus.
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Affiliation(s)
- Sudhakar Vadivelu
- 1The Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra Northwell School of Medicine at Cohen Children's Medical Center and Northwell Health System, Manhasset, New York; and
| | - Harold L. Rekate
- 1The Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra Northwell School of Medicine at Cohen Children's Medical Center and Northwell Health System, Manhasset, New York; and
| | - Debra Esernio-Jenssen
- 2Department of Pediatrics, University of Florida School of Medicine at Shands Children's Hospital, Gainesville, Florida
| | - Mark A. Mittler
- 1The Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra Northwell School of Medicine at Cohen Children's Medical Center and Northwell Health System, Manhasset, New York; and
| | - Steven J. Schneider
- 1The Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra Northwell School of Medicine at Cohen Children's Medical Center and Northwell Health System, Manhasset, New York; and
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Garzon MC, Epstein LG, Heyer GL, Frommelt PC, Orbach DB, Baylis AL, Blei F, Burrows PE, Chamlin SL, Chun RH, Hess CP, Joachim S, Johnson K, Kim W, Liang MG, Maheshwari M, McCoy GN, Metry DW, Monrad PA, Pope E, Powell J, Shwayder TA, Siegel DH, Tollefson MM, Vadivelu S, Lew SM, Frieden IJ, Drolet BA. PHACE Syndrome: Consensus-Derived Diagnosis and Care Recommendations. J Pediatr 2016; 178:24-33.e2. [PMID: 27659028 PMCID: PMC6599593 DOI: 10.1016/j.jpeds.2016.07.054] [Citation(s) in RCA: 144] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2016] [Revised: 05/23/2016] [Accepted: 07/29/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Maria C. Garzon
- Departments of Dermatology and Pediatrics, Columbia University, New York, NY
| | - Leon G. Epstein
- Departments of Pediatrics and Neurology, The Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Geoffrey L. Heyer
- Departments of Pediatrics and Neurology, Nationwide Children’s Hospital, The Ohio State University, Columbus, OH
| | - Peter C. Frommelt
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, WI
| | - Darren B. Orbach
- Division of Neurointerventional Radiology, Boston Children’s Hospital, Boston, MA
| | - Adriane L. Baylis
- Department of Plastic Surgery, Nationwide Children’s Hospital, Columbus, OH
| | - Francine Blei
- Department of Pediatrics/ Hematology, Lenox Hill Hospital, Northwell Health, Great Neck, NY
| | | | - Sarah L. Chamlin
- Division of Pediatric Dermatology, The Ann and Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL
| | - Robert H. Chun
- Department of Otolaryngology, Medical College of Wisconsin, Milwaukee, WI
| | - Christopher P. Hess
- Departments of Radiology and Neurology, University of California, San Francisco, San Francisco, CA
| | - Shawna Joachim
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Wendy Kim
- Division of Dermatology, Departments of Medicine and Pediatrics, Loyola University Medical Center, Maywood, IL
| | | | - Mohit Maheshwari
- Department of Radiology, Medical College of Wisconsin, Milwaukee, WI
| | - Garrett N. McCoy
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI
| | - Denise W. Metry
- Department of Dermatology, Texas Children’s Baylor, Houston, TX
| | - Priya A. Monrad
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI
| | - Elena Pope
- Section of Pediatric Dermatology, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Julie Powell
- Department of Dermatology, University of Montreal, Montreal, Québec, Canada
| | | | - Dawn H. Siegel
- Department of Dermatology, Medical College of Wisconsin, Milwaukee, WI
| | | | - Sudhakar Vadivelu
- Department of Neurosurgery, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH
| | - Sean M. Lew
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI
| | - Ilona J. Frieden
- Department of Dermatology, University of California, San Francisco, San Francisco, CA
| | - Beth A. Drolet
- Departments of Dermatology and Pediatrics, Medical College of Wisconsin, Milwaukee, WI
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Smith P, Linscott LL, Vadivelu S, Zhang B, Leach JL. Normal Development and Measurements of the Occipital Condyle-C1 Interval in Children and Young Adults. AJNR Am J Neuroradiol 2016; 37:952-7. [PMID: 26514612 DOI: 10.3174/ajnr.a4543] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [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: 06/03/2015] [Accepted: 08/03/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Widening of the occipital condyle-C1 interval is the most specific and sensitive means of detecting atlanto-occipital dislocation. Recent studies attempting to define normal measurements of the condyle-C1 interval in children have varied substantially. This study was performed to test the null hypothesis that condyle-C1 interval morphology and joint measurements do not change as a function of age. MATERIALS AND METHODS Imaging review of subjects undergoing CT of the upper cervical spine for reasons unrelated to trauma or developmental abnormality was performed. Four equidistant measurements were obtained for each bilateral condyle-C1 interval on sagittal and coronal images. The cohort was divided into 7 age groups to calculate the mean, SD, and 95% CIs for the average condyle-C1 interval in both planes. The prevalence of a medial occipital condyle notch was calculated. RESULTS Two hundred forty-eight joints were measured in 124 subjects with an age range of 2 days to 22 years. The condyle-C1 interval varies substantially by age. Average coronal measurements are larger and more variable than sagittal measurements. The medial occipital condyle notch is most prevalent from 1 to 12 years and is uncommon in older adolescents and young adults. CONCLUSIONS The condyle-C1 interval increases during the first several years of life, is largest in the 2- to 4-year age range, and then decreases through late childhood and adolescence. A single threshold value to detect atlanto-occipital dissociation may not be sensitive and specific for all age groups. Application of this normative data to documented cases of atlanto-occipital injury is needed to determine clinical utility.
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Affiliation(s)
- P Smith
- From the Departments of Radiology (P.S., L.L.L., J.L.L.)
| | - L L Linscott
- From the Departments of Radiology (P.S., L.L.L., J.L.L.)
| | | | - B Zhang
- Epidemiology and Biostatistics (B.Z.), Cincinnati Children's Hospital Medical Center, University of Cincinnati Medical School, Cincinnati, Ohio
| | - J L Leach
- From the Departments of Radiology (P.S., L.L.L., J.L.L.)
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Corcoran B, Linscott LL, Leach JL, Vadivelu S. Application of Normative Occipital Condyle-C1 Interval Measurements to Detect Atlanto-Occipital Injury in Children. AJNR Am J Neuroradiol 2016; 37:958-62. [PMID: 26744446 DOI: 10.3174/ajnr.a4641] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2015] [Accepted: 10/31/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Prior studies have found that widening or asymmetry of the occipital condyle-C1 interval on CT is a sensitive and specific marker for atlanto-occipital dislocation. Previously reported abnormal occipital condyle-C1 interval values are not age-specific, possibly leading to false-positive findings in younger children, in whom this joint space is normally larger than that in adults. This study assesses the utility of applying age-specific normative occipital condyle-C1 interval ranges to documented cases of atlanto-occipital injury compared with previously reported abnormal cutoff values. MATERIALS AND METHODS Retrospective review of CT and MR imaging of 14 subjects with atlanto-occipital injury was performed, and occipital condyle-C1 interval measurements were made for each subject. Sensitivities and specificities of proposed occipital condyle-C1 interval cutoffs of 2 and 3 SDs above the mean and previously published occipital condyle-C1 interval cutoffs for atlanto-occipital injury were then calculated on the basis of occipital condyle-C1 interval measurements for each subject. RESULTS An occipital condyle-C1 interval 2 SDs above the age-specific mean has a sensitivity of 50% and specificity of 89%-100%, depending on the age group. An occipital condyle-C1 interval 3 SDs above the age-specific mean has a sensitivity of 50% and a specificity of 95%-100%. A 4.0-mm occipital condyle-C1 interval has a sensitivity of 36% and a specificity of 100% in all age groups. A 2.5-mm occipital condyle-C1 interval has a sensitivity of 93% and a specificity of 18%-100%. CONCLUSIONS Occipital condyle-C1 interval widening cutoffs used to establish atlanto-occipital injury lack both sensitivity and specificity in children and young teenagers. MR imaging is necessary to establish a diagnosis of atlanto-occipital injury in children and young teenagers when the appropriate mechanism of injury is present.
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Affiliation(s)
- B Corcoran
- From the Departments of Radiology (B.C., L.L.L., J.L.L.)
| | - L L Linscott
- From the Departments of Radiology (B.C., L.L.L., J.L.L.)
| | - J L Leach
- From the Departments of Radiology (B.C., L.L.L., J.L.L.)
| | - S Vadivelu
- Neurosurgery (S.V.), Cincinnati Children's Hospital Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
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Stetson N, Vadivelu S, Li JY, Setton A, Chalif DJ. Angiographic Evidence of a Purely Pial Bihemispheric Intracranial Hemangiopericytoma. Case Rep Neurol Med 2016; 2016:5245078. [PMID: 26881155 PMCID: PMC4736393 DOI: 10.1155/2016/5245078] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2015] [Accepted: 12/17/2015] [Indexed: 11/17/2022] Open
Abstract
Background. Classification of hemangiopericytoma (HPC) has evolved to a mesenchymal, nonmeningothelial grade two or three neoplasm according to the World Health Organization; however its blood supply has always been defined by dual origin, pial and dural contribution. Case Description. We present the case of a patient with an intracranial HPC with only pial vascular supply. Angiography confirmed the lack of dural supply to this bihemispheric intracranial mass. Subsequent histologic examination confirmed the diagnosis of hemangiopericytoma. Angiographic evidence here is atypical of the natural history of hemangiopericytomas with dual vascular supply and was critical in the decision-making towards surgical resection without tumor embolization. Conclusion. Data presented suggests the lack of dural vascular supply alone does not rule out the diagnosis of hemangiopericytoma.
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Affiliation(s)
- Nathaniel Stetson
- Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY 11030, USA
| | - Sudhakar Vadivelu
- Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY 11030, USA
- Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, 3333 Burnet Avenue, MLC 2016, Cincinnati, OH 45229-3039, USA
| | - Jiang Y. Li
- Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY 11030, USA
| | - Avi Setton
- Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY 11030, USA
| | - David J. Chalif
- Cushing Neuroscience Institute and Department of Neurosurgery, Hofstra North Shore-LIJ School of Medicine, Manhasset, NY 11030, USA
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Vadivelu S, Esernio-Jenssen D, Rekate HL, Narayan RK, Mittler MA, Schneider SJ. Delay in Arrival to Care in Perpetrator-Identified Nonaccidental Head Trauma: Observations and Outcomes. World Neurosurg 2015; 84:1340-6. [PMID: 26118721 DOI: 10.1016/j.wneu.2015.06.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [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: 04/06/2015] [Revised: 06/12/2015] [Accepted: 06/13/2015] [Indexed: 10/23/2022]
Abstract
BACKGROUND Children who sustained nonaccidental head trauma (NAHT) are at severe risk for mortality within the first 24 hours after presentation. OBJECTIVE Extent of delay in seeking medical attention may be related to patient outcome. METHODS A 10-year, single-institution, retrospective review of 48 cases treated at a large tertiary Children's Hospital reported to the New York State Central Registrar by the child protection team was conducted. The perpetrator was identified in 28 cases on the basis of confession or conviction. The medical and legal records allowed for identification of time of injury and the interval between injury and arrival to the hospital; this information was categorized as follows: <6 hours (without delay); 6-12 hours (moderate delay); and >12 hours (severe delay). The King's Outcome Scale for Childhood Head Injury (KOSCHI) score was recorded for each case. RESULTS All children were 3 years of age or younger (2.1-34 months) and predominantly male (68%; 19/28). On arrival, 61% of patients (17/28) presented with moderate or severe delay. A low arrival Glasgow Coma Scale (GCS) score (P < 0.0001) and extracranial injuries (P < 0.0061) correlated with worse clinical patient outcomes. Patients with an arrival GCS score <7 predominantly arrived without delay or with moderate delay. Patients presenting without delay or with severe delay were more likely to have a higher KOSCHI outcome score on discharge (P < 0.0426). Four of the 6 patients who died presented after moderate delay. CONCLUSION Patients presenting to medical care 6-12 hours after NAHT (moderate delay) appeared to have worse outcomes than those presenting earlier or later.
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Affiliation(s)
- Sudhakar Vadivelu
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA.
| | - Debra Esernio-Jenssen
- Department of Pediatrics, University of Florida School of Medicine at Shands Children's Hospital, Gainesville, Florida, USA
| | - Harold L Rekate
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Raj K Narayan
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Mark A Mittler
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
| | - Steven J Schneider
- The Cushing Neuroscience Institutes and the Department of Neurosurgery, Hofstra North Shore-Long Island Jewish School of Medicine at Cohen Children's Medical Center and the North Shore-Long Island Jewish Health System, Manhasset, New York, USA
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Vadivelu S, Stewart TJ, Qu Y, Horn K, Liu S, Li Q, Silver J, McDonald JW. NG2+ progenitors derived from embryonic stem cells penetrate glial scar and promote axonal outgrowth into white matter after spinal cord injury. Stem Cells Transl Med 2015; 4:401-11. [PMID: 25713464 DOI: 10.5966/sctm.2014-0107] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
The glial scar resulting from spinal cord injury is rich in chondroitin sulfate proteoglycan (CSPG), a formidable barrier to axonal regeneration. We explored the possibility of breaching that barrier by first examining the scar in a functional in vitro model. We found that embryonic stem cell-derived neural lineage cells (ESNLCs) with prominent expression of nerve glial antigen 2 (NG2) survived, passed through an increasingly inhibitory gradient of CSPG, and expressed matrix metalloproteinase 9 (MMP-9) at the appropriate stage of their development. Outgrowth of axons from ESNLCs followed because the migrating cells sculpted pathways in which CSPG was degraded. The degradative mechanism involved MMP-9 but not MMP-2. To confirm these results in vivo, we transplanted ESNLCs directly into the cavity of a contused spinal cord 9 days after injury. A week later, ESNLCs survived and were expressing both NG2 and MMP-9. Their axons had grown through long distances (>10 mm), although they preferred to traverse white rather than gray matter. These data are consistent with the concept that expression of inhibitory CSPG within the injury scar is an important impediment to regeneration but that NG2+ progenitors derived from ESNLCs can modify the microenvironment to allow axons to grow through the barrier. This beneficial action may be partly due to developmental expression of MMP-9. We conclude that it might eventually be possible to encourage axonal regeneration in the human spinal cord by transplanting ESNLCs or other cells that express NG2.
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Affiliation(s)
- Sudhakar Vadivelu
- The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at the Kennedy Krieger Institute, Baltimore, Maryland, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Todd J Stewart
- The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at the Kennedy Krieger Institute, Baltimore, Maryland, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Yun Qu
- The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at the Kennedy Krieger Institute, Baltimore, Maryland, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kevin Horn
- The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at the Kennedy Krieger Institute, Baltimore, Maryland, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Su Liu
- The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at the Kennedy Krieger Institute, Baltimore, Maryland, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Qun Li
- The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at the Kennedy Krieger Institute, Baltimore, Maryland, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jerry Silver
- The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at the Kennedy Krieger Institute, Baltimore, Maryland, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - John W McDonald
- The International Center for Spinal Cord Injury, Hugo W. Moser Research Institute at the Kennedy Krieger Institute, Baltimore, Maryland, USA; Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri, USA; Department of Neurosciences, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA; Department of Neurology and Neuroscience, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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Sayama C, Vadivelu S, Livingston A, Ho A, Izaddoost SA, Briceño V, Luerssen TG, Jea A. Soft-tissue defects after spinal instrumentation in 5 children: risk factors, management strategies, and outcomes. J Neurosurg Pediatr 2014; 14:644-53. [PMID: 25259603 DOI: 10.3171/2014.8.peds13664] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [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
OBJECT Wound-related complications following complex posterior spine procedures in children may result in the need for serial debridements and may place spinal instrumentation at risk. In this study, the authors review their experience with the management of soft-tissue defects from spinal instrumentation in 5 high-risk pediatric patients. The use of various rotational and transpositional flaps in the management of these complicated cases is discussed, as well as their outcomes. METHODS The authors retrospectively reviewed the medical records of 5 patients who returned to the Neuro-Spine service at Texas Children's Hospital for erosion of spinal instrumentation through the skin between September 1, 2007, and October 31, 2012. Patient demographics and clinical and operative data were recorded. RESULTS Risk factors such as young age (1 case), poor nutritional status (1 case), multiple previous surgeries (3 cases), severe neurological deficits (2 cases), and history of radiation therapy for malignancy (2 cases) were noted in the 5 patients. The paraspinous flap (4 cases) was the mainstay of the treatment. Follow-up ranged from 7.5 to 17.5 months (mean 11 ± 4.2 months). One of the patients required more than 1 procedure for revision of the wound. Cultures were positive in 2 of the 5 cases. Spinal instrumentation was removed in 3 of the 5 cases; however, in all 3 of the cases there was evidence of delayed instability that developed after the removal of spinal instrumentation. CONCLUSIONS The use of local tissue flaps is safe and efficacious for treatment of posterior wound complications due to spinal instrumentation in children. Removal of spinal instrumentation should be avoided due to the development of delayed instability. Highly vascularized tissue is used to speed healing, clear bacteria, and eliminate dead space, obviating the need to remove contaminated spinal instrumentation.
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Affiliation(s)
- Christina Sayama
- Neuro-Spine Program, Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine
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Vadivelu S, Desai SK, Illner A, Luerssen TG, Jea A. Infected lumbar dermoid cyst mimicking intramedullary spinal cord tumor: Observations and outcomes. J Pediatr Neurosci 2014; 9:21-6. [PMID: 24891897 PMCID: PMC4040026 DOI: 10.4103/1817-1745.131475] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
We report two unusual cases of a 17-month-old boy with a previously undiagnosed lumbar dermal sinus tract terminating in an intradural dermoid cyst and holocord edema or syrinx, presenting with paraparesis and sphincter dysfunction secondary to an intramedullary abscess and a 26-month-old boy with a previously undiagnosed lumbar dermal sinus tract terminating in an infected dermoid cyst and intramedullary abscess, presenting with recurrent episodes of meningitis and hydrocephalus. Pre-operative magnetic resonance imaging (MRI) studies in these patients were initially confused for an intramedullary spinal cord tumor; however, the presence of an associated dermal sinus tract made this diagnosis of neoplasm less likely. Total excision of the dermal sinus tract, debulking of the dermoid cyst and drainage of the intramedullary abscess through an L1-L5 osteoplastic laminoplasty and midline myelotomy, followed by long-term antibiotic therapy resulted in a good functional recovery. Post-operative MRI of the spine showed removal of the dermoid cyst, decreased inflammatory granulation tissue and resolution of the holocord edema or syrinx. We also performed a literature review to determine the cumulative experience of management of intramedullary abscess in this rare clinical setting.
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Affiliation(s)
- Sudhakar Vadivelu
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Neuro-spine Program, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Sohum K Desai
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Neuro-spine Program, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Anna Illner
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Neuro-spine Program, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Thomas G Luerssen
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Neuro-spine Program, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
| | - Andrew Jea
- Department of Neurosurgery, Division of Pediatric Neurosurgery, Neuro-spine Program, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas, USA
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Abstract
Chronic neuropathic pain is a debilitating disease process associated with several medical disorders. Different from pain caused by inflammation, neuropathic pain is a diffuse pain disorder often found to be recalcitrant to the limited medical treatments available. Intractable nerve pain may benefit from other therapies capable of longer-lasting pain coverage or greater efficacy. A growing number of reports have emerged suggesting a role for stem cells as a cellular delivery source with neuroprotective agents opposing the effects of nerve damage. Here, the authors review the current experimental therapies examining the use of stem cells for the treatment of neuropathic pain disorders.
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Affiliation(s)
- Sudhakar Vadivelu
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030, USA.
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Vadivelu S, Sivaganesan A, Patel AJ, Agadi S, Schmidt RJ, Mani P, Jea A. Practice Trends in the Utilization of Intraoperative Neurophysiological Monitoring in Pediatric Neurosurgery as a Function of Complication Rate, and Patient-, Surgeon-, and Procedure-Related Factors. World Neurosurg 2014; 81:617-23. [DOI: 10.1016/j.wneu.2013.11.010] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 10/24/2013] [Accepted: 11/06/2013] [Indexed: 10/26/2022]
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Gressot LV, Vadivelu S, Hwang SW, Fulkerson DH, Luerssen TG, Jea A. Spondylolysis of C-2 in children 3 years of age or younger: clinical presentation, radiographic findings, management, and outcomes with a minimum 12-month follow-up. J Neurosurg Pediatr 2014; 13:196-203. [PMID: 24359209 DOI: 10.3171/2013.11.peds13422] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Cervical spondylolysis is a rare condition that results from a pars interarticularis defect. The C-6 level is the most frequently involved site in the cervical spine. Its clinical presentations range from incidental radiographic findings to neck pain and, rarely, neurological deficits. Although 150 patients with subaxial cervical spondylolysis have been reported, a mere 24 adult and pediatric patients with C-2 spondylolysis have been described. The long-term outcomes of very young children with bilateral C-2 spondylolysis are of great interest, yet only a few longitudinal studies exist. METHODS The authors retrospectively reviewed 5 cases of bilateral C-2 spondylolysis at Texas Children's Hospital and Riley Children's Hospital; these were combined with 5 other cases in the literature, yielding a total of 10 patients. Data regarding the patients' age, sex, C2-3 angulation and displacement, associated spine anomalies, neurological deficits, treatment, and most recent follow-up were recorded. RESULTS The patients' ages ranged from 3 to 36 months (mean 12.9 months). There were 6 boys and 4 girls. The C2-3 angulation, displacement, and width of pars defect were measured when available. The mean C2-3 angulation was 9.5° (range 1-34°), the mean C2-3 displacement was 4.78 mm (range 1.1-10.8 mm), and the mean width of the pars defect was 4.16 mm (range 0.9-7 mm). One patient developed myelopathy and spinal cord injury. All 10 of the patients were treated initially with conservative therapy: 3 with close observation alone, 1 with a rigid cervical collar, 4 with a Minerva jacket, 1 with a sternal-occipital-mandibular immobilizer, and 1 with a halo vest. Three patients ultimately underwent surgery for internal fixation due to progressive instability or development of neurological symptoms. All patients were neurologically intact at the last follow-up (mean 44.3 months, range 14-120 months). CONCLUSIONS Based on the literature and the authors' own experience, they conclude that most very young children with C-2 spondylolysis remain neurologically intact and maintain stability in long-term follow-up despite the bony defect. This defect is often an asymptomatic incidental finding and may be managed conservatively. More aggressive therapy including surgery is indicated for those patients with a neurological deficit from spinal cord compromise secondary to stenosis and local C-2 kyphosis, progressive deformity, or worsening C2-3 instability.
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Affiliation(s)
- Loyola V Gressot
- Division of Pediatric Neurosurgery, Texas Children's Hospital, and Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
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Ng WF, Mitchell S, Lendrem D, Bowman S, Price E, Pease C, Emery P, Andrews J, Bombardieri M, Sutcliffe N, Pitzalis C, Lanyon P, Hunter J, Gupta M, McLaren J, Regan M, Cooper A, Giles I, Isenberg D, Vadivelu S, Coady D, Griffiths B. SAT0242 How good are the eular sjögren’s syndrome disease activity index (ESSDAI), and EULAR sjögren’s syndrome patients reported index (ESSPRI) in predicting health status in primary sjögren’s syndrome? Ann Rheum Dis 2014. [DOI: 10.1136/annrheumdis-2012-eular.3189] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Vadivelu S, Prasad P, Adesina AM, Kim E, Luerssen TG, Jea A. Giant invasive spinal schwannoma in children: a case report and review of the literature. J Med Case Rep 2013; 7:289. [PMID: 24377829 PMCID: PMC3880164 DOI: 10.1186/1752-1947-7-289] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 10/09/2013] [Indexed: 11/10/2022] Open
Abstract
INTRODUCTION Giant invasive spinal schwannoma is defined as a tumor that extends over two or more vertebral levels, erodes vertebral bodies, and extends into the extraspinal space disrupting myofascial planes. Because of its rarity, there have been few published reports describing clinical features and surgical outcomes, especially in the pediatric patient population. CASE PRESENTATION We analyzed the medical record, pathologic findings, and radiographic studies of a 14-year-old Hispanic boy who presented to Texas Children's Hospital with a three-month history of progressive spastic paraparesis. Preoperative computed tomography and magnetic resonance imaging reports showed a large mass lesion centered at the left T7-8 neural foramen with intra- and extraspinal extension, resulting in severe spinal cord compression and vertebral body erosion, and protrusion into the retropleural space and descending aorta. Our patient underwent a single-stage posterior approach for complete resection of the tumor with reconstruction and stabilization of the vertebral column. The pathological examination was consistent with schwannoma. At the six-month follow-up, our patient had resolution of preoperative symptoms and remains neurologically intact without any radiographic evidence of recurrent tumor. CONCLUSION To the best of our knowledge, our case represents the fourth child with giant invasive spinal schwannoma reported in the literature. We describe our case and review the literature to discuss the aggregate clinical features, surgical strategies, and operative outcomes for giant invasive spinal schwannoma in the pediatric age group.
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Affiliation(s)
- Sudhakar Vadivelu
- Neuro-spine Program, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
- Present Address: Division of Pediatric Neurosurgery, Cincinnati Children’s Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, OH 45229, USA
| | - Prashant Prasad
- Neuro-spine Program, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Adekunle M Adesina
- Division of Neuropathology, Texas Children’s Hospital, Department of Pathology, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Eugene Kim
- Division of Pediatric Surgery, Texas Children’s Hospital, 6621 Fannin Street, Houston, TX 77030, USA
| | - Thomas G Luerssen
- Neuro-spine Program, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
| | - Andrew Jea
- Neuro-spine Program, Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, 6621 Fannin Street, Houston, TX 77030, USA
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Abstract
Tuberculous involvement of the central nervous system (CNS) and vertebral column is the most lethal and disabling form of tuberculosis (TB). Several factors contribute to poor outcome, including cerebrovascular involvement with ischemia, hydrocephalus, direct parenchymal injury and formation of abscess and inflammation in the brain and spinal cord, hyponatremia, seizures, and delayed diagnosis. Spinal spondylitis from TB and associated spinal deformity is the leading cause of paraplegia in developing countries. The evidence for supportive treatment of TB infection of the CNS is limited, leading to substantial differences in management protocols. Many of the treatment approaches used in TB infection of the CNS have been extrapolated from treatment of other acute neurological disorders such as bacterial meningitis and traumatic brain injury. We review data from the available literature and highlight questions relating to the neurological and neurosurgical care of children with TB infection of the CNS and vertebral column.
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Vadivelu S, Vadivelu S, Mealy MA, Becker D. Increased Incidence of Chiari 1 Malformation in Children with Transverse Myelitis. PM R 2013. [DOI: 10.1016/j.pmrj.2013.08.008] [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: 11/30/2022]
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Ng WF, Lendrem D, Mitchell S, Bowman S, Price E, Pease C, Emery P, Andrews J, Bombardieri M, Sutcliffe N, Pitzalis C, Lanyon P, Hunter J, Gupta M, McLaren J, Regan M, Cooper A, Giles I, Isenberg D, Vadivelu S, Coady D, Griffiths B. FRI0448 Evaluating health status of 620 patients with primary sjÖgren’s syndrome using EQ-5D. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2012-eular.2905] [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: 11/04/2022]
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50
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Ng WF, Miller A, Bowman S, Price E, Kitas G, Pease C, Emery P, Lanyon P, Hunter J, Gupta M, Giles I, Isenberg D, MaClaren J, Regan M, Cooper A, Young-Min S, Bombardieri M, Sutcliffe N, Pitzalis C, Vadivelu S, Coady D, MacKay K, Moots R, Mitchell S, Mchugh N, Dasgupta B, Trenell M. FRI0323 Level of physical activity in primary sjögren’s syndrome and its predictors. Ann Rheum Dis 2013. [DOI: 10.1136/annrheumdis-2013-eular.1450] [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: 11/03/2022]
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