Publications by authors named "Lissa C Baird"

33 Publications

Extradural decompression versus duraplasty in Chiari malformation type I with syrinx: outcomes on scoliosis from the Park-Reeves Syringomyelia Research Consortium.

J Neurosurg Pediatr 2021 Jun 18:1-9. Epub 2021 Jun 18.

25Division of Pediatric Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh Medical Center, Pittsburgh, PA.

Objective: Scoliosis is common in patients with Chiari malformation type I (CM-I)-associated syringomyelia. While it is known that treatment with posterior fossa decompression (PFD) may reduce the progression of scoliosis, it is unknown if decompression with duraplasty is superior to extradural decompression.

Methods: A large multicenter retrospective and prospective registry of 1257 pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for patients with scoliosis who underwent PFD with or without duraplasty.

Results: In total, 422 patients who underwent PFD had a clinical diagnosis of scoliosis. Of these patients, 346 underwent duraplasty, 51 received extradural decompression alone, and 25 were excluded because no data were available on the type of PFD. The mean clinical follow-up was 2.6 years. Overall, there was no difference in subsequent occurrence of fusion or proportion of patients with curve progression between those with and those without a duraplasty. However, after controlling for age, sex, preoperative curve magnitude, syrinx length, syrinx width, and holocord syrinx, extradural decompression was associated with curve progression > 10°, but not increased occurrence of fusion. Older age at PFD and larger preoperative curve magnitude were independently associated with subsequent occurrence of fusion. Greater syrinx reduction after PFD of either type was associated with decreased occurrence of fusion.

Conclusions: In patients with CM-I, syrinx, and scoliosis undergoing PFD, there was no difference in subsequent occurrence of surgical correction of scoliosis between those receiving a duraplasty and those with an extradural decompression. However, after controlling for preoperative factors including age, syrinx characteristics, and curve magnitude, patients treated with duraplasty were less likely to have curve progression than patients treated with extradural decompression. Further study is needed to evaluate the role of duraplasty in curve stabilization after PFD.
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http://dx.doi.org/10.3171/2020.12.PEDS20552DOI Listing
June 2021

Management strategies for recurrent pediatric craniopharyngioma: new recommendations.

J Neurosurg Pediatr 2021 Mar 5:1-8. Epub 2021 Mar 5.

1Department of Neurosurgery, Boston Children's Hospital, Boston, Massachusetts.

Objective: The goal of this study was to identify the independent risk factors for recurrence or progression of pediatric craniopharyngioma and to establish predictors of the appropriate timing of intervention and best management strategy in the setting of recurrence/progression, with the aim of optimizing tumor control.

Methods: This is a retrospective cohort study of all pediatric patients with craniopharyngioma who were diagnosed and treated at Boston Children's Hospital between 1990 and 2017. This study was approved by the institutional review board at Boston Children's Hospital. All statistical analyses were performed using Stata software.

Results: Eighty patients (43 males and 37 females) fulfilled the inclusion criteria. The mean age at the time of diagnosis was 8.6 ± 4.4 years (range 1.2-19.7 years). The mean follow-up was 10.9 ± 6.5 years (range 1.3-24.6 years). Overall, 30/80 (37.5%) patients developed recurrence/progression. The median latency to recurrence/progression was 12.75 months (range 3-108 months). Subtotal resection with no adjuvant radiotherapy (p < 0.001) and fine calcifications (p = 0.008) are independent risk factors for recurrence/progression. An increase (%) in the maximum dimension of the tumor at the time of recurrence/progression was considered a statistically significant predictor of the appropriate timing of intervention.

Conclusions: Based on the identified independent risk factors for tumor recurrence/progression and the predictors of appropriate timing of intervention in the setting of recurrence/progression, the authors propose an algorithm for optimal management of recurrent pediatric craniopharyngioma to increase the likelihood of tumor control.
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http://dx.doi.org/10.3171/2020.9.PEDS20606DOI Listing
March 2021

Postoperative MR imaging surveillance of pediatric craniopharyngioma: new institutional guidelines.

Childs Nerv Syst 2021 03 3;37(3):853-861. Epub 2020 Oct 3.

Department of Neurosurgery, Boston Children's Hospital, Boston, MA, USA.

Purpose: To develop postoperative surveillance protocols that yield efficient detection rates of tumor recurrence or progression using fewer imaging studies and less cost.

Method: This is a retrospective cohort study of all pediatric craniopharyngioma patients who have been diagnosed and treated at Boston Children's Hospital (BCH) between 1990 and 2017. All statistical analyses were performed using Stata.

Results: Eighty patients (43 males and 37 females) fulfilled the inclusion criteria. The mean age at time of diagnosis was 8.6 ± 4.4 years. The mean follow-up period was 10.9 ± 6.5 years. Overall 30/80 (37.5%) patients experienced tumor recurrence/progression. The median latency to recurrence/progression was 12.75 months (range 3 to 108 months), with 76.6% of the recurrences/progressions taking place within the first 2 years postoperatively. Given the lack of any clinical symptoms/signs associated with the vast majority of the recurrent/progressed cases, we propose postoperative MR imaging surveillance protocols that are substantially less intensive than the current practice. Therefore, we recommend the following postoperative MR imaging surveillance protocols, stratified by management strategies; 0, 9, 15, 36, 48, and 60 months for patients who underwent GTR, 0, 3, 6,12, 18, and 24 months for patients who underwent STR alone and 0, 3, 12, 72, 96, and 120 months for patients who underwent STR followed by subsequent XRT.

Conclusion: The proposed postoperative MR imaging surveillance protocols would provide a potential 50% decrement of healthcare costs. It may also minify the psychological burden of frequent MR scanning for these patients and their families.
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http://dx.doi.org/10.1007/s00381-020-04901-2DOI Listing
March 2021

Measure Twice: Promise of Liquid Biopsy in Pediatric High-Grade Gliomas.

Adv Radiat Oncol 2020 Mar-Apr;5(2):152-162. Epub 2020 Jan 28.

Department of Radiation Medicine, Oregon Health & Science University, Portland, Oregon.

Purpose: To review and critique the current state of liquid biopsy in pHGG.

Materials And Methods: Published literature was reviewed for articles related to liquid biopsy in pediatric glioma and adult glioma with a focus on high-grade gliomas.

Results: This review discusses the current state of liquid biomarkers of pHGG and their potential applications for liquid biopsy development.

Conclusions: While nascent, the progress toward identifying circulating analytes of pHGG primes the field of neuro-oncoogy for liquid biopsy development.
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http://dx.doi.org/10.1016/j.adro.2019.12.008DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7136635PMC
January 2020

Radiological and clinical predictors of scoliosis in patients with Chiari malformation type I and spinal cord syrinx from the Park-Reeves Syringomyelia Research Consortium.

J Neurosurg Pediatr 2019 Aug 16:1-8. Epub 2019 Aug 16.

23Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.

Objective: Scoliosis is frequently a presenting sign of Chiari malformation type I (CM-I) with syrinx. The authors' goal was to define scoliosis in this population and describe how radiological characteristics of CM-I and syrinx relate to the presence and severity of scoliosis.

Methods: A large multicenter retrospective and prospective registry of pediatric patients with CM-I (tonsils ≥ 5 mm below the foramen magnum) and syrinx (≥ 3 mm in axial width) was reviewed for clinical and radiological characteristics of CM-I, syrinx, and scoliosis (coronal curve ≥ 10°).

Results: Based on available imaging of patients with CM-I and syrinx, 260 of 825 patients (31%) had a clear diagnosis of scoliosis based on radiographs or coronal MRI. Forty-nine patients (5.9%) did not have scoliosis, and in 516 (63%) patients, a clear determination of the presence or absence of scoliosis could not be made. Comparison of patients with and those without a definite scoliosis diagnosis indicated that scoliosis was associated with wider syrinxes (8.7 vs 6.3 mm, OR 1.25, p < 0.001), longer syrinxes (10.3 vs 6.2 levels, OR 1.18, p < 0.001), syrinxes with their rostral extent located in the cervical spine (94% vs 80%, OR 3.91, p = 0.001), and holocord syrinxes (50% vs 16%, OR 5.61, p < 0.001). Multivariable regression analysis revealed syrinx length and the presence of holocord syrinx to be independent predictors of scoliosis in this patient cohort. Scoliosis was not associated with sex, age at CM-I diagnosis, tonsil position, pB-C2 distance (measured perpendicular distance from the ventral dura to a line drawn from the basion to the posterior-inferior aspect of C2), clivoaxial angle, or frontal-occipital horn ratio. Average curve magnitude was 29.9°, and 37.7% of patients had a left thoracic curve. Older age at CM-I or syrinx diagnosis (p < 0.0001) was associated with greater curve magnitude whereas there was no association between syrinx dimensions and curve magnitude.

Conclusions: Syrinx characteristics, but not tonsil position, were related to the presence of scoliosis in patients with CM-I, and there was an independent association of syrinx length and holocord syrinx with scoliosis. Further study is needed to evaluate the nature of the relationship between syrinx and scoliosis in patients with CM-I.
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http://dx.doi.org/10.3171/2019.5.PEDS18527DOI Listing
August 2019

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Pediatric Myelomeningocele: Executive Summary.

Neurosurgery 2019 09;85(3):299-301

Department of Neurosurgery, Mercer University Medical School, Macon, Georgia.

Background: The incidence of spina bifida (SB) in the developing world is higher than in the United States because of malnutrition and folic acid deficiency during pregnancy. Advances in technology have made prenatal repair of myelomeningocele (MM) possible.

Objective: The objective of the guidelines are, (1) To create clinical recommendations for best practices, based on a systematic review and analysis of available literature, (2) to obtain multi-disciplinary endorsement of these guidelines from relevant organizations, and (3) to disseminate the educational content to physicians to improve the care of infants with MM.

Methods: The Guidelines Task Force developed search terms and strategies used to search PubMed and Embase for literature published between 1966 and September 2016. Strict inclusion/exclusion criteria were used to screen abstracts and to develop a list of relevant articles for full-text review.

Results: Guidelines authors aimed to systematically review the literature and make evidence based recommendations about the timing of closure after birth, hydrocephalus, the impact of prenatal closure, and the effect of prenatal closure on ambulation ability and tethered spinal cord. Evidence concerning persistent ventriculomegaly and cognitive impairment was also evaluated. Hundreds of abstracts were identified and reviewed for each of the 5 topics. A total of 14 studies met stringent inclusion criteria.

Conclusion: Based on a comprehensive systematic review, a total of 5 clinical practice recommendations were developed, with 1 Level I, 2 Level II and 2 Level III recommendations.The full guideline can be found at https://www.cns.org/guidelines/guidelines-spina-bifida-chapter-1.
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http://dx.doi.org/10.1093/neuros/nyz261DOI Listing
September 2019

Complications following pediatric cranioplasty after decompressive craniectomy: a multicenter retrospective study.

J Neurosurg Pediatr 2018 09 8;22(3):225-232. Epub 2018 Jun 8.

17Department of Neurosurgery, Baylor College of Medicine, Houston, Texas.

OBJECTIVE In children, the repair of skull defects arising from decompressive craniectomy presents a unique set of challenges. Single-center studies have identified different risk factors for the common complications of cranioplasty resorption and infection. The goal of the present study was to determine the risk factors for bone resorption and infection after pediatric cranioplasty. METHODS The authors conducted a multicenter retrospective case study that included all patients who underwent cranioplasty to correct a skull defect arising from a decompressive craniectomy at 13 centers between 2000 and 2011 and were less than 19 years old at the time of cranioplasty. Prior systematic review of the literature along with expert opinion guided the selection of variables to be collected. These included: indication for craniectomy; history of abusive head trauma; method of bone storage; method of bone fixation; use of drains; size of bone graft; presence of other implants, including ventriculoperitoneal (VP) shunt; presence of fluid collections; age at craniectomy; and time between craniectomy and cranioplasty. RESULTS A total of 359 patients met the inclusion criteria. The patients' mean age was 8.4 years, and 51.5% were female. Thirty-eight cases (10.5%) were complicated by infection. In multivariate analysis, presence of a cranial implant (primarily VP shunt) (OR 2.41, 95% CI 1.17-4.98), presence of gastrostomy (OR 2.44, 95% CI 1.03-5.79), and ventilator dependence (OR 8.45, 95% CI 1.10-65.08) were significant risk factors for cranioplasty infection. No other variable was associated with infection. Of the 240 patients who underwent a cranioplasty with bone graft, 21.7% showed bone resorption significant enough to warrant repeat surgical intervention. The most important predictor of cranioplasty bone resorption was age at the time of cranioplasty. For every month of increased age the risk of bone flap resorption decreased by 1% (OR 0.99, 95% CI 0.98-0.99, p < 0.001). Other risk factors for resorption in multivariate models were the use of external ventricular drains and lumbar shunts. CONCLUSIONS This is the largest study of pediatric cranioplasty outcomes performed to date. Analysis included variables found to be significant in previous retrospective reports. Presence of a cranial implant such as VP shunt is the most significant risk factor for cranioplasty infection, whereas younger age at cranioplasty is the dominant risk factor for bone resorption.
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http://dx.doi.org/10.3171/2018.3.PEDS17234DOI Listing
September 2018

Incidence of symptomatic tethered spinal cord in pediatric patients presenting with neurofibromatosis types 1 and 2.

J Neurosurg Pediatr 2018 05 23;21(5):456-459. Epub 2018 Feb 23.

OBJECTIVE The relationship between a tethered cord (TC) and neurofibromatosis type 1 (NF1) and NF2 is not known. The purpose of this study was to define the incidence of TC in pediatric neurosurgical patients who present with NF. METHODS The authors performed a single-institution (tertiary care pediatric hospital) 10-year retrospective analysis of patients who were diagnosed with or who underwent surgery for a TC and/or NF. Clinical and radiological characteristics were analyzed, as was histopathology. RESULTS A total of 424 patients underwent surgery for a TC during the study period, and 67 patients with NF were seen in the pediatric neurosurgery clinic. Of these 67 patients, 9 (13%) were diagnosed with a TC, and filum lysis surgery was recommended. Among the 9 patients with NF recommended for TC-release surgery, 4 (44%) were female, the mean age was 8 years (range 4-14 years), the conus position ranged from L1-2 to L-3, and 3 (33%) had a filum lipoma, defined as high signal intensity on T1-weighted MR images. All 9 of these patients presented with neuromotor, skeletal, voiding, and/or pain-related symptoms. Histopathological examination consistently revealed dense fibroconnective tissue and blood vessels. CONCLUSIONS Despite the lack of any known pathophysiological relationship between NF and TC, the incidence of a symptomatic TC in patients with NF1 and NF2 who presented for any reason to this tertiary care pediatric neurosurgery clinic was 13%. Counseling patients and families regarding TC symptomatology might be indicated in this patient population.
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http://dx.doi.org/10.3171/2017.12.PEDS17306DOI Listing
May 2018

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Role of Cranial Molding Orthosis (Helmet) Therapy for Patients With Positional Plagiocephaly.

Neurosurgery 2016 Nov;79(5):E632-E633

*Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; ‡Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; §Advocate Children's Hospital, Oak Lawn, Illinois; ¶Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; ‖Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; #Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; **Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; ‡‡Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center; Le Bonheur Children's Hospital, Memphis, Tennessee; §§St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ¶¶Goryeb Children's Hospital of Atlantic Health Systems, Morristown, New Jersey; ‖‖Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; ##Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ***Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; ‡‡‡Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana.

Background: No evidence-based guidelines exist on the role of cranial-molding orthosis (helmet) therapy for patients with positional plagiocephaly.

Objective: To address the clinical question: "Does helmet therapy provide effective treatment for positional plagiocephaly?" and to make treatment recommendations based on the available evidence.

Methods: The US National Library of Medicine Medline database and the Cochrane Library were queried by using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and, based on the quality of the literature, recommendations were made (Levels I-III).

Results: Fifteen articles met criteria for inclusion into the evidence tables. There was 1 prospective randomized controlled trial (Class II), 5 prospective comparative studies (Class II), and 9 retrospective comparative studies (Class II).

Conclusion: There is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. Specific criteria regarding the measurement and quantification of deformity and the most appropriate time window in infancy for treatment of positional plagiocephaly with a helmet remains elusive. In general, infants with a more severe presenting deformity and infants who are helmeted early in infancy tend to have more significant correction (and even normalization) of head shape. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_5.
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http://dx.doi.org/10.1227/NEU.0000000000001430DOI Listing
November 2016

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Positional Plagiocephaly: The Role of Physical Therapy.

Neurosurgery 2016 Nov;79(5):E630-E631

*Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; ‡Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center; Le Bonheur Children's Hospital; Memphis, Tennessee; §Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana; ¶Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; ∥Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; #Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; **St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ‡‡Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; §§Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ¶¶Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; ‖‖Advocate Children's Hospital, Oak Lawn, Illinois; ##Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; ***Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; ‡‡‡Goryeb Children's Hospital of Atlantic Health Systems Morristown, New Jersey.

Background: Evidence-based guidelines are not currently available for the treatment of positional plagiocephaly and, in particular, for the use of physical therapy for treatment.

Objective: To answer the question: "does physical therapy provide effective treatment for positional plagiocephaly?" Treatment recommendations are created based on the available evidence.

Methods: The PubMed and the Cochrane Library were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and recommendations were made based on the quality of the literature (Levels I-III).

Results: Three studies met criteria for inclusion. Two randomized, controlled trials (Class I and Class II) and 1 prospective study assessing plagiocephaly as a secondary outcome measure (Class III) were included.

Conclusion: Within the limits of this systematic review, physical therapy is significantly more effective than repositioning education as a treatment for positional plagiocephaly. There is no significant difference between physical therapy and a positioning pillow as a treatment for positional plagiocephaly. However, given the American Academy of Pediatrics' recommendation against soft pillows in cribs to ensure a safe sleeping environment for infants, physical therapy must be recommended over the use of a positioning pillow. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_4.
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http://dx.doi.org/10.1227/NEU.0000000000001429DOI Listing
November 2016

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Management of Patients With Positional Plagiocephaly: The Role of Repositioning.

Neurosurgery 2016 Nov;79(5):E627-E629

*Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center; Le Bonheur Children's Hospital, Memphis, Tennessee; ‡University of Tennessee Health Science Center, Memphis, Tennessee; §Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; ¶Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; ‖Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; #Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; **St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ‡‡Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; §§Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ¶¶Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; ‖‖Advocate Children's Hospital, Oak Lawn, Illinois; ##Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; ***Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; ‡‡‡Goryeb Children's Hospital of Atlantic Health Systems, Morristown, New Jersey; §§§Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana.

Background: Plagiocephaly, involving positional deformity of the calvarium in infants, is one of the most common reasons for pediatric neurosurgical consultation.

Objective: To answer the question: "what is the evidence for the effectiveness of repositioning for positional plagiocephaly?" Treatment recommendations are provided based on the available evidence.

Methods: The National Library of Medicine MEDLINE database and the Cochrane Library were queried using MeSH headings and key words relevant to repositioning as a means to treat plagiocephaly and brachycephaly. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III).

Results: There were 3 randomized trials (Class I), 1 prospective cohort study (Class II), and 6 retrospective cohort studies (Class III). Repositioning education was found to be equal to a repositioning device and inferior to a physical therapy program. Five of the 7 cohort studies comparing repositioning with a helmet reported helmets to be better and take less time.

Conclusion: Within the limits of this systematic review, repositioning education is effective in affording some degree of correction in virtually all infants with positional plagiocephaly or brachycephaly. Most studies suggest that a molding helmet corrects asymmetry more rapidly and to a greater degree than repositioning education. In a Class I study, repositioning education was as effective as repositioning education in conjunction with a repositioning wrap/device. Another Class I study demonstrated that a bedding pillow was superior to physical therapy for some infants. However, in keeping with the American Academy of Pediatrics' warning against the use of soft positioning pillows in the sleeping environment, the Task Force recommends physical therapy over any positioning device. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_3.
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http://dx.doi.org/10.1227/NEU.0000000000001428DOI Listing
November 2016

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Diagnosis of Patients With Positional Plagiocephaly: The Role of Imaging.

Neurosurgery 2016 Nov;79(5):E625-E626

*Goryeb Children's Hospital of Atlantic Health Systems, Morristown, New Jersey; ‡Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; §Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; ¶Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; ‖Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; #Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center, and Le Bonheur Children's Hospital, Memphis, Tennessee; **St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ‡‡Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; §§Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ¶¶Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; ‖‖Advocate Children's Hospital, Oak Lawn, Illinois; ##Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; ***Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; ‡‡‡Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana.

Background: No evidence-based guidelines exist for the imaging of patients with positional plagiocephaly.

Objective: The objective of this systematic review and evidence-based guideline is to answer the question, Is imaging necessary for infants with positional plagiocephaly to make a diagnosis?

Methods: The National Library of Medicine Medline database and the Cochrane Library were queried with the use of MeSH headings and key words relevant to imaging as a means to diagnose plagiocephaly. Abstracts were reviewed, and an evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III).

Results: A total of 42 full-text articles were selected for review. Of these, 10 were eliminated; thus, 32 full-text were manuscripts selected. There was no Class I evidence, but 2 Class II and 30 Class III studies were included. Three-dimensional cranial topographical imaging, ultrasound, skull x-rays, computed tomography, and magnetic resonance imaging were investigated.

Conclusion: Clinical examination is most often sufficient to diagnose plagiocephaly (quality, Class III; strength, Level III). Within the limits of this systematic review, the evidence suggests that imaging is rarely necessary and should be reserved for cases in which the clinical examination is equivocal. Many of the imaging studies were not designed to address the diagnostic utility of the imaging modality, and authors were actually assessing the utility of the imaging in longitudinal follow-up, not initial diagnosis. For this reason, some of the studies reviewed were downgraded in Level of Evidence. When needed, 3-dimensional cranial topographical photo, skull x-rays, or ultrasound imaging is almost always sufficient for definitive diagnosis. Computed tomography scanning should not be used to diagnose plagiocephaly, but it may be necessary to rule out craniosynostosis. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_2.
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http://dx.doi.org/10.1227/NEU.0000000000001427DOI Listing
November 2016

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Role of Cranial Molding Orthosis (Helmet) Therapy for Patients With Positional Plagiocephaly.

Neurosurgery 2016 Nov;79(5):E632-E633

*Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; ‡Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; §Advocate Children's Hospital, Oak Lawn, Illinois; ¶Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; ‖Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; #Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; **Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; ‡‡Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center; Le Bonheur Children's Hospital, Memphis, Tennessee; §§St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ¶¶Goryeb Children's Hospital of Atlantic Health Systems, Morristown, New Jersey; ‖‖Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; ##Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ***Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; ‡‡‡Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana.

Background: No evidence-based guidelines exist on the role of cranial-molding orthosis (helmet) therapy for patients with positional plagiocephaly.

Objective: To address the clinical question: "Does helmet therapy provide effective treatment for positional plagiocephaly?" and to make treatment recommendations based on the available evidence.

Methods: The US National Library of Medicine Medline database and the Cochrane Library were queried by using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and, based on the quality of the literature, recommendations were made (Levels I-III).

Results: Fifteen articles met criteria for inclusion into the evidence tables. There was 1 prospective randomized controlled trial (Class II), 5 prospective comparative studies (Class II), and 9 retrospective comparative studies (Class II).

Conclusion: There is a fairly substantive body of nonrandomized evidence that demonstrates more significant and faster improvement of cranial shape in infants with positional plagiocephaly treated with a helmet in comparison with conservative therapy, especially if the deformity is severe, provided that helmet therapy is applied during the appropriate period of infancy. Specific criteria regarding the measurement and quantification of deformity and the most appropriate time window in infancy for treatment of positional plagiocephaly with a helmet remains elusive. In general, infants with a more severe presenting deformity and infants who are helmeted early in infancy tend to have more significant correction (and even normalization) of head shape. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_5.
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http://dx.doi.org/10.1227/NEU.0000000000001430DOI Listing
November 2016

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Management of Patients With Positional Plagiocephaly: The Role of Physical Therapy.

Neurosurgery 2016 Nov;79(5):E630-E631

*Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; ‡Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center; Le Bonheur Children's Hospital; Memphis, Tennessee; §Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana; ¶Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; ∥Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; #Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; **St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ‡‡Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; §§Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ¶¶Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; ‖‖Advocate Children's Hospital, Oak Lawn, Illinois; ##Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; ***Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; ‡‡‡Goryeb Children's Hospital of Atlantic Health Systems Morristown, New Jersey.

Background: Evidence-based guidelines are not currently available for the treatment of positional plagiocephaly and, in particular, for the use of physical therapy for treatment.

Objective: To answer the question: "does physical therapy provide effective treatment for positional plagiocephaly?" Treatment recommendations are created based on the available evidence.

Methods: The PubMed and the Cochrane Library were queried using MeSH headings and key words relevant to the objective of this systematic review. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected and graded according to their quality of evidence (Classes I-III). Evidentiary tables were constructed that summarized pertinent study results, and recommendations were made based on the quality of the literature (Levels I-III).

Results: Three studies met criteria for inclusion. Two randomized, controlled trials (Class I and Class II) and 1 prospective study assessing plagiocephaly as a secondary outcome measure (Class III) were included.

Conclusion: Within the limits of this systematic review, physical therapy is significantly more effective than repositioning education as a treatment for positional plagiocephaly. There is no significant difference between physical therapy and a positioning pillow as a treatment for positional plagiocephaly. However, given the American Academy of Pediatrics' recommendation against soft pillows in cribs to ensure a safe sleeping environment for infants, physical therapy must be recommended over the use of a positioning pillow. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_4.
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http://dx.doi.org/10.1227/NEU.0000000000001429DOI Listing
November 2016

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline on the Management of Patients With Positional Plagiocephaly: The Role of Repositioning.

Neurosurgery 2016 Nov;79(5):E627-E629

*Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center; Le Bonheur Children's Hospital, Memphis, Tennessee; ‡University of Tennessee Health Science Center, Memphis, Tennessee; §Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; ¶Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; ‖Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; #Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; **St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ‡‡Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; §§Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ¶¶Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; ‖‖Advocate Children's Hospital, Oak Lawn, Illinois; ##Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; ***Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; ‡‡‡Goryeb Children's Hospital of Atlantic Health Systems, Morristown, New Jersey; §§§Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana.

Background: Plagiocephaly, involving positional deformity of the calvarium in infants, is one of the most common reasons for pediatric neurosurgical consultation.

Objective: To answer the question: "what is the evidence for the effectiveness of repositioning for positional plagiocephaly?" Treatment recommendations are provided based on the available evidence.

Methods: The National Library of Medicine MEDLINE database and the Cochrane Library were queried using MeSH headings and key words relevant to repositioning as a means to treat plagiocephaly and brachycephaly. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III).

Results: There were 3 randomized trials (Class I), 1 prospective cohort study (Class II), and 6 retrospective cohort studies (Class III). Repositioning education was found to be equal to a repositioning device and inferior to a physical therapy program. Five of the 7 cohort studies comparing repositioning with a helmet reported helmets to be better and take less time.

Conclusion: Within the limits of this systematic review, repositioning education is effective in affording some degree of correction in virtually all infants with positional plagiocephaly or brachycephaly. Most studies suggest that a molding helmet corrects asymmetry more rapidly and to a greater degree than repositioning education. In a Class I study, repositioning education was as effective as repositioning education in conjunction with a repositioning wrap/device. Another Class I study demonstrated that a bedding pillow was superior to physical therapy for some infants. However, in keeping with the American Academy of Pediatrics' warning against the use of soft positioning pillows in the sleeping environment, the Task Force recommends physical therapy over any positioning device. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_3.
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http://dx.doi.org/10.1227/NEU.0000000000001428DOI Listing
November 2016

Guidelines: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guideline for the Diagnosis of Patients With Positional Plagiocephaly: The Role of Imaging.

Neurosurgery 2016 Nov;79(5):E625-E626

*Goryeb Children's Hospital of Atlantic Health Systems, Morristown, New Jersey; ‡Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; §Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; ¶Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; ‖Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; #Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center, and Le Bonheur Children's Hospital, Memphis, Tennessee; **St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ‡‡Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; §§Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ¶¶Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; ‖‖Advocate Children's Hospital, Oak Lawn, Illinois; ##Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; ***Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; ‡‡‡Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana.

Background: No evidence-based guidelines exist for the imaging of patients with positional plagiocephaly.

Objective: The objective of this systematic review and evidence-based guideline is to answer the question, Is imaging necessary for infants with positional plagiocephaly to make a diagnosis?

Methods: The National Library of Medicine Medline database and the Cochrane Library were queried with the use of MeSH headings and key words relevant to imaging as a means to diagnose plagiocephaly. Abstracts were reviewed, and an evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). Based on the quality of the literature, a recommendation was rendered (Level I, II, or III).

Results: A total of 42 full-text articles were selected for review. Of these, 10 were eliminated; thus, 32 full-text were manuscripts selected. There was no Class I evidence, but 2 Class II and 30 Class III studies were included. Three-dimensional cranial topographical imaging, ultrasound, skull x-rays, computed tomography, and magnetic resonance imaging were investigated.

Conclusion: Clinical examination is most often sufficient to diagnose plagiocephaly (quality, Class III; strength, Level III). Within the limits of this systematic review, the evidence suggests that imaging is rarely necessary and should be reserved for cases in which the clinical examination is equivocal. Many of the imaging studies were not designed to address the diagnostic utility of the imaging modality, and authors were actually assessing the utility of the imaging in longitudinal follow-up, not initial diagnosis. For this reason, some of the studies reviewed were downgraded in Level of Evidence. When needed, 3-dimensional cranial topographical photo, skull x-rays, or ultrasound imaging is almost always sufficient for definitive diagnosis. Computed tomography scanning should not be used to diagnose plagiocephaly, but it may be necessary to rule out craniosynostosis. The full guidelines document can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly/Chapter_2.
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http://dx.doi.org/10.1227/NEU.0000000000001427DOI Listing
November 2016

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for the Management of Patients With Positional Plagiocephaly: Executive Summary.

Neurosurgery 2016 Nov;79(5):623-624

*Kids Specialty Center, Women's & Children's Hospital, Lafayette, Louisiana; ‡Department of Pediatric Neurological Surgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania; §Goryeb Children's Hospital of Atlantic Health Systems, Morristown, New Jersey; ¶Semmes-Murphey Neurologic & Spine Institute; Department of Neurosurgery, University of Tennessee Health Science Center, and Le Bonheur Children's Hospital, Memphis, Tennessee; ‖Department of Neurological Surgery, Oregon Health and Science University, Portland, Oregon; #Department of Surgery, Division of Neurosurgery, Rutgers Robert Wood Johnson Medical School, New Brunswick, New Jersey; **Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire; ‡‡Division of Pediatric Neurosurgery, University of Florida Health Jacksonville, Jacksonville, Florida; §§Division of Neurosurgery, University of Vermont Medical Center, Burlington, Vermont; ¶¶St. Louis Cleft-Craniofacial Center, SSM Health Cardinal Glennon Children's Hospital at Saint Louis University, Division of Plastic Surgery, Saint Louis University School of Medicine, St. Louis, Missouri; ‖‖Department of Neurosurgery, Palmetto Health University of South Carolina Medical Group, Columbia, South Carolina; ##Guidelines Department, Congress of Neurological Surgeons, Schaumburg, Illinois; ***Department of Neurosurgery, University of Illinois at Chicago, Chicago, Illinois; ‡‡‡Advocate Children's Hospital, Oak Lawn, Illinois.

Background: Positional plagiocephaly is a common problem seen by pediatricians, pediatric neurologists, and pediatric neurosurgeons.

Objective: To create evidence-based guidelines for the treatment of pediatric positional plagiocephaly.

Methods: This guideline was prepared by the Plagiocephaly Guideline Task Force, a multidisciplinary team made up of physician volunteers (clinical experts), medical librarians, and clinical guidelines specialists. The task force conducted a series of systematic literature searches of PubMed and the Cochrane Library, according to standard protocols for each topic addressed in subsequent chapters of this guideline.

Results: The systematic literature searches returned 396 abstracts relative to the 4 main topics addressed in this guideline. The results were analyzed and are described in detail in each subsequent chapter included in this guideline.

Conclusion: Evidence-based guidelines for the management of infants with positional plagiocephaly will help practitioners manage this common disorder. The full guidelines documents can be located at https://www.cns.org/guidelines/guidelines-management-patients-positional-plagiocephaly.
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http://dx.doi.org/10.1227/NEU.0000000000001426DOI Listing
November 2016

First Treatment in Infants With Hydrocephalus: The Case for Endoscopic Third Ventriculostomy/Choroid Plexus Cauterization.

Authors:
Lissa C Baird

Neurosurgery 2016 08;63 Suppl 1:78-82

Department of Neurological Surgery, Doernbecher Children's Hospital, Oregon Health and Science University, Portland, Oregon.

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http://dx.doi.org/10.1227/NEU.0000000000001299DOI Listing
August 2016

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 7: Antibiotic-impregnated shunt systems versus conventional shunts in children: a systematic review and meta-analysis.

J Neurosurg Pediatr 2014 Nov;14 Suppl 1:53-9

Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri

Object: The objective of this systematic review and meta-analysis was to answer the following question: Are antibiotic-impregnated shunts (AISs) superior to standard shunts (SSs) at reducing the risk of shunt infection in pediatric patients with hydrocephalus?

Methods: Both the US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to AIS use in children. Abstracts were reviewed, after which studies meeting the inclusion criteria were selected. An evidentiary table was assembled summarizing the studies and the quality of their evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using the chi-square and I(2) statistics. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).

Results: Six studies, all Class III, met our inclusion criteria. All but one study focused on a retrospective cohort and all but one were conducted at a single institution. Four of the studies failed to demonstrate a lowered infection rate with the use of an AIS. However, when the data from individual studies were pooled together, the infection rate in the AIS group was 5.5% compared with 8.6% in the SS group. Using a random-effects model, the cumulative RR was 0.51 (95% CI 0.29-0.89, p < 0.001), indicating that a shunt infection was 1.96 times more likely in patients who received an SS.

Conclusions: We recommend AIS tubing because of the associated lower risk of shunt infection compared to the use of conventional silicone hardware (quality of evidence: Class III; strength of recommendation: Level III).

Recommendation: Antibiotic-impregnated shunt (AIS) tubing may be associated with a lower risk of shunt infection compared with conventional silicone hardware and thus is an option for children who require placement of a shunt.

Strength Of Recommendation: Level III, unclear degree of clinical certainty.
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http://dx.doi.org/10.3171/2014.7.PEDS14327DOI Listing
November 2014

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 6: Preoperative antibiotics for shunt surgery in children with hydrocephalus: a systematic review and meta-analysis.

J Neurosurg Pediatr 2014 Nov;14 Suppl 1:44-52

Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri

Object: The objective of this systematic review and meta-analysis was twofold: to answer the question "What is the evidence for the effectiveness of prophylactic intravenous antibiotics for infection prevention in shunt surgery?" and to make treatment recommendations based on the available evidence.

Methods: The US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words relevant to prophylactic antibiotic use in children undergoing a shunt operation. Abstracts were reviewed to identify which studies met the inclusion criteria. An evidentiary table was assembled summarizing the studies and the quality of evidence (Classes I-III). A meta-analysis was conducted using a random-effects model to calculate a cumulative estimate of treatment effect using risk ratio (RR). Heterogeneity was assessed using chi-square and I(2) statistics. A sensitivity analysis was also conducted. Based on the quality of the literature and the result of the meta-analysis, a recommendation was rendered (Level I, II, or III).

Results: Nine studies (4 Class I, 3 Class II, and 2 Class III) met our inclusion criteria. Of 7 randomized controlled trials (RCTs), 3 were downgraded from Class I to Class II because of significant quality issues, and all RCTs were potentially underpowered. In only 2 Class in retrospective cohort studies were preoperative antibiotic agents found to be protective against shunt infection. When data from the individual studies were pooled together, the infection rate in the prophylactic antibiotics group was 5.9% compared with 10.7% in the control group. Using a random-effects model, the cumulative RR was 0.55 (95% CI 0.38-0.81), indicating a protective benefit of prophylactic preoperative intravenous antibiotics. A sensitivity analysis of RCTs only (n = 7) also demonstrated a statistical benefit, but an analysis of higher-quality RCTs only (n = 4) did not. Conclusions Within the limits of this systematic review and meta-analysis, administration of preoperative antibiotic agents for shunt surgery in children was found to lower the infection risk (quality of evidence: Class II; strength of recommendation, Level II).

Recommendation: The use of preoperative antibiotic agents can be recommended to prevent shunt infection in patients with hydrocephalus. It was only by combining the results of the various underpowered studies (meta-analysis) that the use of preoperative antibiotics for shunt surgery in children was shown to lower the risk of shunt infection.

Strength Of Recommendation: Level II, moderate degree of clinical certainty.
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http://dx.doi.org/10.3171/2014.7.PEDS14326DOI Listing
November 2014

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 5: Effect of valve type on cerebrospinal fluid shunt efficacy.

J Neurosurg Pediatr 2014 Nov;14 Suppl 1:35-43

Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri

Object: The objective of this systematic review was to examine the existing literature to compare differing shunt components used to treat hydrocephalus in children, find whether there is a superior shunt design for the treatment of pediatric hydrocephalus, and make evidence-based recommendations for the selection of shunt implants when placing shunts.

Methods: Both the US National Library of Medicine PubMed/MEDLINE database and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words chosen to identify publications comparing the use of shunt implant components. Abstracts of these publications were reviewed, after which studies meeting the inclusion criteria were selected. An evidentiary table was compiled summarizing the selected articles and quality of evidence. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider evidence-based treatment recommendations.

Results: Two hundred sixty-nine articles were identified using the search parameters, and 43 articles were recalled for full-text review. Of these, 22 papers met the study criteria for a comparison of shunt components and were included in the evidentiary table. The included studies consisted of 1 Class I study, 11 Class II studies, and 10 Class III studies. The remaining 21 articles were excluded.

Conclusions: An analysis of the evidence did not demonstrate a clear advantage for any specific shunt component, mechanism, or valve design over another.

Recommendation: There is insufficient evidence to demonstrate an advantage for one shunt hardware design over another in the treatment of pediatric hydrocephalus. Current designs described in the evidentiary tables are all treatment options.

Strength Of Recommendation: Level I, high degree of clinical certainty.

Recommendation: There is insufficient evidence to recommend the use of a programmable valve versus a nonprogrammable valve. Programmable and nonprogrammable valves are both options for the treatment of pediatric hydrocephalus.

Strength Of Recommendation: Level II, moderate degree of clinical certainty.
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http://dx.doi.org/10.3171/2014.7.PEDS14325DOI Listing
November 2014

Pediatric hydrocephalus: systematic literature review and evidence-based guidelines. Part 4: Cerebrospinal fluid shunt or endoscopic third ventriculostomy for the treatment of hydrocephalus in children.

J Neurosurg Pediatr 2014 Nov;14 Suppl 1:30-4

Department of Neurological Surgery, Saint Louis University, St. Louis, Missouri

Object: The objective of this systematic review was to examine the existing literature comparing CSF shunts and endoscopic third ventriculostomy (ETV) for the treatment of pediatric hydrocephalus and to make evidence-based recommendations regarding the selection of surgical technique for this condition.

Methods: Both the US National Library of Medicine and the Cochrane Database of Systematic Reviews were queried using MeSH headings and key words specifically chosen to identify published articles detailing the use of CSF shunts and ETV for the treatment of pediatric hydrocephalus. Articles meeting specific criteria that had been determined a priori were examined, and data were abstracted and compiled in evidentiary tables. These data were then analyzed by the Pediatric Hydrocephalus Systematic Review and Evidence-Based Guidelines Task Force to consider treatment recommendations based on the evidence.

Results: Of the 122 articles identified using optimized search parameters, 52 were recalled for full-text review. One additional article, originally not retrieved in the search, was also reviewed. Fourteen articles met all study criteria and contained comparative data on CSF shunts and ETV. In total, 6 articles (1 Class II and 5 Class III) were accepted for inclusion in the evidentiary table; 8 articles were excluded for various reasons. The tabulated evidence supported the evaluation of CSF shunts versus ETV.

Conclusions: Cerebrospinal fluid shunts and ETV demonstrated equivalent outcomes in the clinical etiologies studied.

Recommendation: Both CSF shunts and ETV are options in the treatment of pediatric hydrocephalus.

Strength Of Recommendation: Level II, moderate clinical certainty.
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http://dx.doi.org/10.3171/2014.7.PEDS14324DOI Listing
November 2014

Moyamoya syndrome associated with Alagille syndrome: outcome after surgical revascularization.

J Pediatr 2015 Feb 30;166(2):470-3. Epub 2014 Oct 30.

Division of Gastroenterology, Hepatology, and Nutrition, The Hospital for Sick Children, Toronto, Ontario, Canada; University of Toronto, Toronto, Ontario, Canada. Electronic address:

Vasculopathy is well-described in Alagille syndrome (ALGS); however, few data exist regarding neurosurgical interventions. We report 5 children with ALGS with moyamoya who underwent revascularization surgery. Postsurgical complications included 1 stroke and 1 death from thalamic hemorrhage. Global function improved in survivors. Revascularization is reasonably safe in patients with ALGS and may improve neurologic outcomes.
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http://dx.doi.org/10.1016/j.jpeds.2014.10.067DOI Listing
February 2015

Spontaneous regression of an epidermoid cyst of the cavernous sinus.

J Clin Neurosci 2014 Aug 13;21(8):1433-5. Epub 2014 Apr 13.

Harvard Medical School, Boston, MA, USA; Department of Neurosurgery, Children's Hospital Boston, Boston, MA, USA.

Epidermoid cysts are rare lesions in the pediatric population. The natural history of epidermoids is usually that of slow growth, although rupture and cases of malignant transformation have been reported. Spontaneous regression of an intracranial epidermoid cyst has not previously been described to our knowledge. We present a 3-year-old boy who presented with severe vertigo. MRI was performed which revealed a 2cm non-enhancing lesion in the right cavernous sinus. The lesion was T1-hypoinsense, T2-hyperintense, and with evidence of restricted diffusion, consistent with an epidermoid cyst. The patient was followed with annual MRI studies over the next 3years, demonstrating progressive reduction in the size of the lesion over time, with complete resolution after 3years. The child's symptoms also resolved during this period. Long-term follow-up imaging at 5years showed no evident lesion. To our knowledge, this is the first report documenting spontaneous regression of an intracranial epidermoid cyst. While isolated, this finding demonstrates the potential for involution of epidermoids and lends support to the clinical practice of careful observation of these lesions, especially when located in areas associated with high potential surgical morbidity. Importantly, the novelty of this observation suggests a need for further study to better elucidate the underlying mechanism of this regression.
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http://dx.doi.org/10.1016/j.jocn.2013.11.054DOI Listing
August 2014

Results of a North American survey of rapid-sequence MRI utilization to evaluate cerebral ventricles in children.

J Neurosurg Pediatr 2014 Jun 11;13(6):636-40. Epub 2014 Apr 11.

Department of Neurological Surgery, Oregon Health & Science University, Portland, Oregon.

Object: Growing concern about potential adverse effects of ionizing radiation exposure during imaging studies is particularly relevant to the pediatric population. To decrease radiation exposure, many institutions use rapid-sequence (or quick-brain) MRI to evaluate cerebral ventricle size. There are obstacles, however, to widespread implementation of this imaging modality. The purpose of this study was to define and quantify these obstacles to positively affect institutional and governmental policy.

Methods: A 9-question survey was emailed to pediatric neurosurgeons who were either members or candidate members of the American Society of Pediatric Neurosurgeons at every one of 101 institutions in the US and Canada having such a neurosurgeon on staff. Responses were compiled and descriptive statistics were performed.

Results: Fifty-six institutions completed the survey. Forty-four (79%) of the 56 institutions currently have a rapid-sequence MRI protocol to evaluate ventricle size, while 36 (64%) use it routinely. Of the 44 institutions with a rapid-sequence MRI protocol, 29 (66%) have had a rapid-sequence MRI protocol for less than 5 years while 39 (89%) have had a rapid-sequence MRI protocol for no more than 10 years. Thirty-six (88%) of 41 rapid-sequence MRI users responding to this question obtain a T2-weighted rapid-sequence MRI while 13 (32%) obtain a T1-weighted rapid-sequence MRI. Twenty-eight (64%) of 44 institutions never use sedation while an additional 12 (27%) rarely use sedation to obtain a rapid-sequence MRI (less than 5% of studies). Of the institutions with an established rapid-sequence MRI protocol, obstacles to routine use include lack of emergency access to MRI facilities in 18 (41%), lack of staffing of MRI facilities in 12 (27%), and the inability to reimburse a rapid-sequence MRI protocol in 6 (14%). In the 12 institutions without rapid-sequence MRI, obstacles to implementation include lack of emergency access to MRI facilities in 8 (67%), lack of staffing of MRI facilities in 7 (58%), the inability to reimburse in 3 (25%), and lack of administrative support in 3 (25%). To evaluate pediatric head trauma, 53 (96%) of 55 institutions responding to this question use noncontrast CT, no institution uses rapid-sequence MRI, and only 2 (4%) use standard MRI.

Conclusions: Many North American institutions have a rapid-sequence MRI protocol to evaluate ventricle size, with most developing this technique within the past 5 years. Most institutions never use sedation, and most obtain T2-weighted sequences. The greatest obstacles to the routine use of rapid-sequence MRI in institutions with and in those without a rapid-sequence MRI protocol are the lack of emergency access and staffing of the MRI facility during nights and weekends.
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http://dx.doi.org/10.3171/2014.2.PEDS13567DOI Listing
June 2014

Third-ventricular neurocysticercosis: hydraulic maneuvers facilitating endoscopic resection.

Childs Nerv Syst 2014 Mar 15;30(3):541-6. Epub 2013 Sep 15.

Harvard Medical School, Boston, MA, USA.

Background: Neurocysticercosis, an infection of the central nervous system with the larval cysts of the pork tapeworm, Taenia solium, is the most common parasitic disease of the central nervous system. The disease is a major global cause of acquired epilepsy and may also manifest as intracranial hypertension due to mass effect from large cysts or to cerebrospinal fluid flow obstruction by intraventricular cysts or inflammation of the subarachnoid space. While the condition is endemic in several regions of the world and has been appreciated as a public health problem in such regions for several decades, its emergence in the USA in areas far from the Mexican border is a more recent phenomenon.

Methods: We present a case of surgically corrected acute hydrocephalus in a recent Haitian emigrant child due to a third ventricular neurocysticercal cyst complex.

Results: We describe the endoscope-assisted en bloc removal of the complex, together with hydraulic maneuvers facilitating the removal of the intact cyst.

Conclusions: Simple hydraulic maneuvers can facilitate the endoscopic en bloc removal of third ventricular neurocysticercal cysts.
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http://dx.doi.org/10.1007/s00381-013-2273-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4281270PMC
March 2014

A single spinal lesion arising from an intradural meningioma contiguous with an extradural lymphoma.

J Neurosurg Spine 2012 Sep 20;17(3):263-7. Epub 2012 Jul 20.

Department of Neurosurgery, University of California, San Diego, California 92093-0987, USA.

The authors describe here a unique case of contiguous, synchronous meningioma and lymphoma in the spinal column. Both tumors were present at the same vertebral level, one intradural and the other extradural. A patient presented with bilateral leg pain, acute weakness, and sensory loss in the lower extremities. Magnetic resonance imaging revealed an intradural mass at T6-7 with ambiguous boundaries relative to the thecal sac and compressing the spinal cord. The patient underwent resection of the epidural and intradural mass at T6-7. Histopathology revealed the epidural specimen to be a double-hit B-cell lymphoma and the intradural mass to be a transitional meningioma. Postoperatively, the patient did well, with an immediate return of strength and sensation. A postoperative MR image showed complete resection of the intradural mass. The authors suggest that biopsy may be prudent in patients with known systemic lymphoma presenting with a spinal lesion that has unclear boundaries relative to the thecal sac prior to commencing radiation and chemotherapy.
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http://dx.doi.org/10.3171/2012.6.SPINE11913DOI Listing
September 2012

Craniofacial reconstruction as a treatment for elevated intracranial pressure.

Childs Nerv Syst 2012 Mar 9;28(3):411-8. Epub 2011 Nov 9.

Division of Neurosurgery, University of California at San Diego, San Diego, CA, USA.

Introduction: Craniofacial procedures may be needed to address symptomatic intracranial hypertension. The authors review their institutional experience in the treatment of children with symptomatic increased intracranial pressure (ICP) utilizing craniofacial reconstructive procedures.

Methods: The senior authors' (HSM, SRC) craniofacial experience of 222 patients over a 7-year period from 2000 to 2007 at a single institution (Rady Children's Hospital, San Diego) is reviewed. Seventeen patients were identified who were felt to be candidates for craniofacial surgery with symptomatic increased ICP.

Results: Patient diagnoses included single-suture craniosynostosis, craniofacial dysostoses, shunt-induced craniostenosis, and shunt-associated intracranial hypertension (slit-ventricle syndrome). Seventeen patients underwent 21 craniofacial procedures. Age at surgery ranged from 3 months to 13 years with a mean of 5 years. Preoperative symptoms and signs included headaches, unexplained irritability, seizures, papilledema, and visual loss. All patients had diagnostic neuroimaging. Seven patients had preoperative invasive ICP measurements. Surgery was deferred on three of these patients based on these measurements. The mean total operative (including anesthetic preparation) and surgical times were 3 h 12 min and 2 h 20 min, respectively. Percentage operative blood loss averaged 11.3%. In six procedures, no transfusions were required. Average hospital stay was 4 days. There was no perioperative mortality or significant surgery associated morbidity. All patients have had postoperative clinical improvement in signs and symptoms of increased ICP.

Conclusions: Using modern diagnostic and surgical techniques, including invasive ICP monitoring, increased intracranial pressure can be successfully managed by an experienced, multidisciplinary, craniofacial team. Our treatment paradigm and operative management scheme is discussed.
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http://dx.doi.org/10.1007/s00381-011-1615-6DOI Listing
March 2012
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