Publications by authors named "Sandi K Lam"

66 Publications

Cutaneous Stigmata of the Spine: A Review of Indications for Imaging and Referral.

Pediatr Clin North Am 2021 Aug;68(4):895-913

Division of Pediatric Neurosurgery, Lurie Children's Hospital and Northwestern University Feinberg School of Medicine, 225 East Chicago Avenue, Box 28, Chicago, IL 60611, USA. Electronic address:

Cutaneous stigmata of the midline spine are a common question in pediatrics. They are known to be related to a higher likelihood of underlying dysraphic spinal abnormalities. Clear understanding of different types of cutaneous stigmata and correlating dysraphic findings can aid in appropriate imaging workup and timely management of patient pathology. In this article, the authors review midline spinal cutaneous findings in the pediatric population with occult spinal dysraphism.
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http://dx.doi.org/10.1016/j.pcl.2021.04.017DOI Listing
August 2021

Serious diagnoses at revisits in children discharged from the emergency department with back pain.

Acad Emerg Med 2021 Jul 10. Epub 2021 Jul 10.

Division of Emergency Medicine, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.

Background: Back pain is often benign but can be a harbinger for serious pathology. Little is known about the outcome in children with back pain but no serious diagnoses detected at the initial visit. We sought to estimate the rate of serious diagnoses at revisits among children initially discharged from the emergency department (ED) with back pain.

Methods: We performed a multicenter retrospective cohort study of patients from 45 pediatric hospitals in the Pediatric Health Information System database from October 1, 2015, to March 31, 2019. We included patients discharged from the ED with a principal diagnosis of back pain and excluded patients with trauma and concurrent or previously known serious diagnoses. We identified the rates and types of serious diagnoses made within 30 days of the index visit. We examined the rates of diagnostic tests at the index visit in patients with and without serious diagnoses.

Results: Of the 25,130 patients with back pain, 88 (0.4%, 95% confidence interval = 0.3% to 0.4%) had serious pathology diagnosed within 30 days. The most common diagnoses were anatomic (40%) and nonneurologic (39%) categories such as vertebral fracture and nephrolithiasis; infectious (19%) and neoplastic etiologies (3%) were less common. Diagnoses requiring acute interventions such as cauda equina syndrome (n = 2) and intraspinal abscess (n = 3) were rare. Patients with serious diagnoses at revisits underwent more blood tests and back ultrasound at the index visit compared to patients without serious diagnoses.

Conclusions: In pediatric patients discharged from the ED with a diagnosis of back pain and no serious or trauma diagnoses, there is a low rate of serious pathology on revisits. Of the serious diagnoses identified, high-acuity diseases were rare. For the subset of patients with clinical suspicion for serious pathology but none identified at the index visit, this represents an opportunity for further research to optimize their management.
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http://dx.doi.org/10.1111/acem.14336DOI Listing
July 2021

Degree of ventriculomegaly predicts school-aged functional outcomes in preterm infants with intraventricular hemorrhage.

Pediatr Res 2021 Jul 2. Epub 2021 Jul 2.

Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.

Background: Greater ventriculomegaly in preterm infants with intraventricular hemorrhage (IVH) has been associated with worse neurodevelopmental outcomes in infancy. We aim to explore the relationship between ventriculomegaly and school-age functional outcome.

Methods: Retrospective review of preterm infants with Grade III/IV IVH from 2006 to 2020. Frontal-occipital horn ratio (FOHR) was measured on imaging throughout hospitalization and last available follow-up scan. Pediatric Cerebral Performance Category (PCPC) scale was used to assess functional outcome at ≥4 years. Ordinal logistic regression was used to determine the relationship between functional outcome and FOHR at the time of Neurosurgery consult, neurosurgical intervention, and last follow-up scan while adjusting for confounders.

Results: One hundred and thirty-four infants had Grade III/IV IVH. FOHR at consult was 0.62 ± 0.12 and 0.75 ± 0.13 at first intervention (p < 0.001). On univariable analysis, maximum FOHR, FOHR at the last follow-up scan, and at Neurosurgery consult predicted worse functional outcome (p < 0.01). PVL, longer hospital admission, and gastrotomy/tracheostomy tube also predicted worse outcome (p < 0.05). PVL, maximum FOHR, and FOHR at consult remained significant on multivariable analysis (p < 0.05). Maximum FOHR of 0.61 is a fair predictor for moderate-severe impairment (AUC 75%, 95% CI: 62-87%).

Conclusions: Greater ventricular dilatation and PVL were independently associated with worse functional outcome in Grade III/IV IVH regardless of neurosurgical intervention.

Impact: Ventriculomegaly measured by frontal-occipital horn ratio (FOHR) and periventricular leukomalacia are independent correlates of school-age functional outcomes in preterm infants with intraventricular hemorrhage regardless of need for neurosurgical intervention. These findings extend the known association between ventriculomegaly and neurodevelopmental outcomes in infancy to functional outcomes at school age. FOHR is a fair predictor of school-age functional outcome, but there are likely other factors that influence functional status, which highlights the need for prospective studies to incorporate other clinical and demographic variables in predictive models.
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http://dx.doi.org/10.1038/s41390-021-01631-2DOI Listing
July 2021

Epilepsy surgery in infants up to 3 months of age: Safety, feasibility, and outcomes: A multicenter, multinational study.

Epilepsia 2021 Jun 14. Epub 2021 Jun 14.

Department of Neurosurgery, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA.

Objective: Drug-resistant epilepsy (DRE) during the first few months of life is challenging and necessitates aggressive treatment, including surgery. Because the most common causes of DRE in infancy are related to extensive developmental anomalies, surgery often entails extensive tissue resections or disconnection. The literature on "ultra-early" epilepsy surgery is sparse, with limited data concerning efficacy controlling the seizures, and safety. The current study's goal is to review the safety and efficacy of ultra-early epilepsy surgery performed before the age of 3 months.

Methods: To achieve a large sample size and external validity, a multinational, multicenter retrospective study was performed, focusing on epilepsy surgery for infants younger than 3 months of age. Collected data included epilepsy characteristics, surgical details, epilepsy outcome, and complications.

Results: Sixty-four patients underwent 69 surgeries before the age of 3 months. The most common pathologies were cortical dysplasia (28), hemimegalencephaly (17), and tubers (5). The most common procedures were hemispheric surgeries (48 procedures). Two cases were intentionally staged, and one was unexpectedly aborted. Nearly all patients received blood products. There were no perioperative deaths and no major unexpected permanent morbidities. Twenty-five percent of patients undergoing hemispheric surgeries developed hydrocephalus. Excellent epilepsy outcome (International League Against Epilepsy [ILAE] grade I) was achieved in 66% of cases over a median follow-up of 41 months (19-104 interquartile range [IQR]). The number of antiseizure medications was significantly reduced (median 2 drugs, 1-3 IQR, p < .0001). Outcome was not significantly associated with the type of surgery (hemispheric or more limited resections).

Significance: Epilepsy surgery during the first few months of life is associated with excellent seizure control, and when performed by highly experienced teams, is not associated with more permanent morbidity than surgery in older infants. Thus surgical treatment should not be postponed to treat DRE in very young infants based on their age.
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http://dx.doi.org/10.1111/epi.16959DOI Listing
June 2021

Pediatric spinal intramedullary anaplastic myxopapillary ependymoma: a case report.

Childs Nerv Syst 2021 Jun 14. Epub 2021 Jun 14.

Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children's Hospital, 225 E. Chicago Avenue, Chicago, IL, 60611, USA.

A 6-year-old girl presented with a 1-week history of progressive upper and lower extremity weakness and bilateral upper extremity dysesthesia. Imaging demonstrated a 4.7 × 1.2-cm enhancing intramedullary lesion in the cervical spine from level C2 to C5 with associated cystic components and syringomyelia. The patient underwent a C2-C5 laminoplasty, with gross total resection of the intramedullary lesion. Histological analysis showed small to medium-sized epithelioid cells, with predominantly a solid architecture focally infiltrating into the adjacent spinal cord tissue. Focal papillary differentiation was present along with peri-vascular pseudorosettes, mucin microcysts, and globules of dense collagen. Focal anaplasia was noted with mitosis (5/10 HPF), focal necrosis, and elevated Ki67 10-15%. These findings were consistent with a myxopapillary ependymoma with anaplastic features. CSF cytology was negative for tumor cells. MYCN amplification was not present. She was treated with targeted proton-beam radiation therapy. This is the fourth case of an intramedullary anaplastic myxopapillary ependymoma to date, and the first case in the cervical spine reported in the literature.
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http://dx.doi.org/10.1007/s00381-021-05171-2DOI Listing
June 2021

Intrawound Liposomal Bupivacaine in Pediatric Chiari Decompression: A Retrospective Study.

Pediatr Qual Saf 2021 May-Jun;6(3):e397. Epub 2021 May 5.

Division of Pediatric Neurosurgery, Ann and Robert H Lurie Children's Hospital of Chicago, Chicago, Ill.

Intrawound liposomal bupivacaine is a long-acting local anesthetic used to decrease postoperative pain in various procedures. Although it is used in posterior cervical and suboccipital approaches in the adult population, it is currently off-label for pediatrics. This quality improvement (QI) project examines intrawound liposomal bupivacaine for pediatric Chiari decompression and evaluates its role in postoperative opioid consumption.

Methods: We retrospectively analyzed all patients 0-18 years old of age who underwent Chiari decompression from January 2017 to July 2019 at our tertiary care hospital. Demographic and clinical data regarding postoperative opioid use, subjective and objective pain control, length of stay, discharge medications, and comorbid conditions were collected.

Results: We included 30 patients in this study: 19 females and 11 males. Of these, 6 received an intrawound injection of liposomal bupivacaine.

Patients: treated with liposomal bupivacaine require fewer opioids while admitted. There was no apparent difference in pain control immediately postoperatively, pain control at clinical follow-up, or inpatient length of stay between each group. Patients who received liposomal bupivacaine did not require opioid analgesics at the time of discharge from the hospital.

Conclusion: The use of intrawound liposomal bupivacaine may decrease inpatient and outpatient postoperative opioid consumption amongst pediatric patients following Chiari decompression while providing adequate pain control. We investigate liposomal bupivacaine perioperative blockade in this QI project as a viable option for opioid-sparing pain control in the postoperative setting for the pediatric population. Future investigation via clinical trials and more extensive prospective studies may glean further insights into efficacy.
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http://dx.doi.org/10.1097/pq9.0000000000000397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8104281PMC
May 2021

Pipeline embolization of cerebral aneurysms in pediatric patients: combined systematic review of patient-level data and multicenter retrospective review.

J Neurosurg Pediatr 2021 Apr 23:1-9. Epub 2021 Apr 23.

Departments of1Neurological Surgery and.

Objective: Cerebral aneurysms in the pediatric population are rare and optimal treatment strategies are not as well characterized as in adults. The Pipeline embolization device (PED) is an endoluminal flow diverter that is commonly used to treat aneurysms in adults, but experience with this device in children is limited. The authors sought to further characterize PED use and outcomes in this specific population by performing both a systematic review of patient-level data from studies reporting the use of the PED to treat pediatric aneurysms and a retrospective review of their experience.

Methods: A systematic review of the PubMed, Embase, and Scopus databases was performed to identify studies reporting the use of the PED in pediatric patients (age ≤ 18 years). Disaggregated data regarding demographics, aneurysm characteristics, treatment, and outcomes were collected. Retrospective data from the authors' two institutions were also included.

Results: Thirty studies comprising patient-level data on 43 pediatric patients with 47 aneurysms were identified. An additional 9 patients with 9 aneurysms were included from the authors' institutions for a total of 52 patients with 56 aneurysms. The mean patient age was 11.1 years. Presentations included aneurysm rupture (17.3%) and symptomatic mass effect (23.1%). Aneurysms were located in the anterior circulation in 55.4% of cases, and 73.2% were described as nonsaccular. Imaging follow-up was available for 89.3% with a mean follow-up of 13.3 months. Aneurysm occlusion was reported in 75%, with 1 case each (1.8%) demonstrating significant in-stent stenosis and parent vessel occlusion. Clinical follow-up was reported in 90.4% with a mean follow-up of 14.7 months. Good functional outcomes (modified Rankin Scale score of 0-1 or Glasgow Outcome Scale score of 5) were reported in 65.4% of the total population. Two major complications were reported, including 1 death.

Conclusions: Despite substantial differences in aneurysm location and type between published pediatric and adult patient populations treated with the PED, the use of the PED in the pediatric population appears to be safe. While the short-term effectiveness is also similar to that of adults, additional studies are needed to further characterize the long-term outcomes and better define the use of this device in pediatric patients.
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http://dx.doi.org/10.3171/2020.10.PEDS20324DOI Listing
April 2021

Clonally Focused Public and Private T Cells in Resected Brain Tissue From Surgeries to Treat Children With Intractable Seizures.

Front Immunol 2021 6;12:664344. Epub 2021 Apr 6.

Department of Neurosurgery, David Geffen School of Medicine at the University of California, Los Angeles, CA, United States.

Using a targeted transcriptomics approach, we have analyzed resected brain tissue from a cohort of 53 pediatric epilepsy surgery cases, and have found that there is a spectrum of involvement of both the innate and adaptive immune systems as evidenced by the differential expression of immune-specific genes in the affected brain tissue. The specimens with the highest expression of immune-specific genes were from two Rasmussen encephalitis cases, which is known to be a neuro-immunological disease, but also from tuberous sclerosis complex (TSC), focal cortical dysplasia, and hemimegalencephaly surgery cases. We obtained T cell receptor (TCR) Vβ chain sequence data from brain tissue and blood from patients with the highest levels of T cell transcripts. The clonality indices and the frequency of the top 50 Vβ clonotypes indicated that T cells in the brain were clonally restricted. The top 50 Vβ clonotypes comprised both public and private (patient specific) clonotypes, and the TCR Vβ chain third complementarity region (CDR3) of the most abundant public Vβ clonotype in each brain sample was strikingly similar to a CDR3 that recognizes an immunodominant epitope in either human cytomegalovirus or Epstein Barr virus, or influenza virus A. We found that the frequency of 14 of the top 50 brain Vβ clonotypes from a TSC surgery case had significantly increased in brain tissue removed to control recurrent seizures 11 months after the first surgery. Conversely, we found that the frequency in the blood of 18 of the top 50 brain clonotypes from a second TSC patient, who was seizure free, had significantly decreased 5 months after surgery indicating that T cell clones found in the brain had contracted in the periphery after removal of the brain area associated with seizure activity and inflammation. However, the frequency of a public and a private clonotype significantly increased in the brain after seizures recurred and the patient underwent a second surgery. Combined single cell gene expression and TCR sequencing of brain-infiltrating leukocytes from the second surgery showed that the two clones were CD8 effector T cells, indicating that they are likely to be pathologically relevant.
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http://dx.doi.org/10.3389/fimmu.2021.664344DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8056262PMC
April 2021

The role of surgery in the management of Lennox-Gastaut syndrome: A systematic review and meta-analysis of the clinical evidence.

Epilepsia 2021 Apr 24;62(4):888-907. Epub 2021 Feb 24.

Division of Pediatric Neurosurgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA.

Lennox-Gastaut syndrome (LGS) is a severe form of childhood onset epilepsy in which patients require multiple medications and may be candidates for palliative surgical intervention. In this meta-analysis, we sought to evaluate the impact of palliative vagus nerve stimulation (VNS), corpus callosotomy (CC), and resective surgery (RS) by analyzing their impact on seizure control, antiepileptic drug (AED) usage, quality of life (QOL), behavior, cognition, prognostic factors, and complications. A systematic search of PubMed MEDLINE, Scopus, and Cochrane Database of Systematic Reviews was performed to find articles that met the following criteria: (1) prospective/retrospective study with original data, (2) at least one LGS surgery patient aged less than 18 years, and (3) information on seizure frequency reduction (measured as percentage, Engel class, or qualitative comment). Seizures were analyzed quantitatively in a meta-analysis of proportions and a random-effects model, whereas other outcomes were analyzed qualitatively. Forty studies with 892 LGS patients met the selection criteria, with 19 reporting on CC, 17 on VNS, four on RS, two on RS + CC, one on CC + VNS, and one on deep brain stimulation. CC seizure reduction rate was 74.1% (95% confidence interval [CI] = 64.5%-83.7%), and VNS was 54.6% (95% CI = 42.9%-66.3%), which was significantly different (p < .001). RS seizure reduction was 88.9% (95% CI = 66.1%-99.7%). Many VNS patients reported alertness improvements, and most had no major complications. VNS was most effective for atonic/tonic seizures; higher stimulation settings correlated with better outcomes. CC patients reported moderate cognitive and QOL improvements; disconnection syndrome, transient weakness, and respiratory complications were noted. Greater callosotomy extent correlated with better outcomes. AED usage most often did not change after surgery. RS showed considerable QOL improvements for patients with localized seizure foci. In the reported literature, CC appeared to be more effective than VNS for seizure reduction. VNS may provide a similar or higher level of QOL improvement with lower aggregate risk of complications. Patient selection, anatomy, and seizure type will inform decision-making.
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http://dx.doi.org/10.1111/epi.16851DOI Listing
April 2021

Timing of Temporizing Neurosurgical Treatment in Relation to Shunting and Neurodevelopmental Outcomes in Posthemorrhagic Ventricular Dilatation of Prematurity: A Meta-analysis.

J Pediatr 2021 Jul 21;234:54-64.e20. Epub 2021 Jan 21.

Department of Neurological Surgery, McGaw Medical Center of Northwestern University, Chicago, IL; Division of Neurosurgery, Ann & Robert Lurie Children's Hospital, Chicago, IL.

Objective: To determine the relationship between timing of initiation of temporizing neurosurgical treatment and rates of ventriculoperitoneal shunt (VPS) and neurodevelopmental impairment in premature infants with post-hemorrhagic ventricular dilatation (PHVD).

Study Design: We searched MEDLINE, EMBASE, CINAHL, Web of Science, the Cochrane Database of Systematic Reviews, and the Cochrane Center Register of Controlled Trials for studies that reported on premature infants with PHVD who underwent a temporizing neurosurgical procedure. The timing of the temporizing neurosurgical procedure, gestational age, birth weight, outcomes of conversion to VPS, moderate-to-severe neurodevelopmental impairment, infection, temporizing neurosurgical procedure revision, and death at discharge were extracted.

Results: Sixty-two full-length articles and 6 conference abstracts (n = 2533 patients) published through November 2020 were included. Pooled rate for conversion to VPS was 60.5% (95% CI, 54.9-65.8), moderate-severe neurodevelopmental impairment 34.8% (95% CI, 27.4-42.9), infection 8.2% (95% CI, 6.7-10.1), revision 14.6% (95% CI, 10.4-20.1), and death 12.9% (95% CI, 10.2-16.4). The average age at temporizing neurosurgical procedure was 24.2 ± 11.3 days. On meta-regression, older age at temporizing neurosurgical procedure was a predictor of conversion to VPS (P < .001) and neurodevelopmental impairment (P < .01). Later year of publication predicted increased survival (P < .01) and external ventricular drains were associated with more revisions (P = .001). Tests for heterogeneity reached significance for all outcomes and a qualitative review showed heterogeneity in the study inclusion and diagnosis criteria for PHVD and initiation of temporizing neurosurgical procedure.

Conclusions: Later timing of temporizing neurosurgical procedure predicted higher rates of conversion to VPS and moderate-severe neurodevelopmental impairment. Outcomes were often reported relative to the number of patients who underwent a temporizing neurosurgical procedure and the criteria for study inclusion and the initiation of temporizing neurosurgical procedure varied across institutions. There is need for more comprehensive outcome reporting that includes all infants with PHVD regardless of treatment.
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http://dx.doi.org/10.1016/j.jpeds.2021.01.030DOI Listing
July 2021

Standard work tools for dynamic stereoelectroencephalography using ROSA: naming convention and perioperative planning.

J Neurosurg Pediatr 2021 Jan 22:1-9. Epub 2021 Jan 22.

1Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana.

Objective: The grid-based orthogonal placement of depth electrodes (DEs), initially defined by Jean Talairach and Jean Bancaud, is known as stereo-electroencephalography (sEEG). Although acceptance in the United States was initially slow, advances in imaging and technology have spawned a proliferation of North American epilepsy centers offering sEEG. Despite publications highlighting minimal access techniques and varied indications, standard work for phase I targeted DE has not been defined. In this article, the authors propose the term "dynamic sEEG" and define standard work tools and related common data elements to promote uniformity in the field.

Methods: A multidisciplinary approach from July to August 2016 resulted in the production of 4 standard work tools for dynamic sEEG using ROSA: 1) a 34-page illustrated manual depicting a detailed workflow; 2) a planning form to collocate all the phase I data; 3) a naming convention for DEs that encodes the data defining it; and 4) a reusable portable perioperative planning and documentation board. A retrospective review of sEEG case efficiency was performed comparing those using standard work tools (between July 2016 and April 2017) with historical controls (between March 2015 and June 2016). The standard work tools were then instituted at another epilepsy surgery center, and the results were recorded.

Results: The process for dynamic sEEG was formally reviewed, including anesthesia, positioning, perioperative nursing guidelines, surgical steps, and postoperative care for the workflow using cranial fixation and ROSA-guided placement. There was a 40% improvement in time per electrode, from 44.7 ± 9.0 minutes to 26.9 ± 6.5 minutes (p = 0.0007) following the development and use of the manual, the naming convention, and the reusable portable perioperative planning and documentation board. This standardized protocol was implemented at another institution and yielded a time per electrode of 22.3 ± 4.4 minutes.

Conclusions: The authors propose the term dynamic sEEG for stereotactic depth electrodes placed according to phase I workup data with the intention of converting to ablation. This workflow efficiency can be optimized using the standard work tools presented. The authors also propose a novel naming convention that encodes critical data and allows portability among providers. Use of a planning form for common data elements optimizes research, and global adoption could facilitate multicenter studies correlating phase I modality and seizure onset zone identification.
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http://dx.doi.org/10.3171/2020.8.PEDS20420DOI Listing
January 2021

Vision Outcomes for Pediatric Patients With Optic Pathway Gliomas Associated With Neurofibromatosis Type I: A Systematic Review of the Clinical Evidence.

J Pediatr Hematol Oncol 2021 05;43(4):135-143

Department of Neurological Surgery, Division of Pediatric Neurosurgery.

Children with neurofibromatosis type I (NF1) have a higher predisposition for low-grade astrocytomas of the optic pathway, commonly referred to as optic pathway gliomas (OPGs). OPGs can result in visual deterioration. Treatment outcomes in OPG-NF1 management are often reported around tumor stabilization. We sought to compare vision outcomes associated with different OPG treatment strategies to inform about this important functional metric. A meta-analysis exploring the different modalities to treat children with OPG-NF1 was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using multiple databases. Of the 113 articles identified in the search, 23 full text articles, representing 564 patients, were included for review. These articles included retrospective, prospective, and randomized controlled studies on observation (n=9), chemotherapy (n=19), radiation therapy (n=6), and surgery (n=7). Of the patients undergoing observation, 87% (60/69) demonstrated stable acuity. In the chemotherapy studies, 27.3% (72/264) demonstrated improved acuity/visual field and/or visual-evoked potential amplitudes, 39.4% (104/264) stable acuity, and 33.3% (88/264) deterioration. Both the radiation and surgical treatments reported worsening acuity at 90.9% (10/11) and 73.3% (11/15), respectively. Causal associations are not known. Indications for and timing of treatment choice warrant larger scale study to provide further understanding.
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http://dx.doi.org/10.1097/MPH.0000000000002060DOI Listing
May 2021

Endovascular Thrombectomy for Pediatric Acute Ischemic Stroke: A Multi-Institutional Experience of Technical and Clinical Outcomes.

Neurosurgery 2020 12;88(1):46-54

Department of Neurosurgery, University of Utah School of Medicine, Division of Pediatric Neurosurgery, Primary Children's Hospital, Salt Lake City, Utah.

Background: Endovascular thrombectomy is a promising treatment for acute ischemic stroke in children, but outcome and technical data in pediatric patients with large-vessel occlusions are lacking.

Objective: To assess technical and clinical outcomes of thrombectomy in pediatric patients.

Methods: We undertook a retrospective cohort study of pediatric patients who experienced acute ischemic stroke from April 2017 to April 2019 who had immediate, 30-, and 90-d follow-up. Patients were treated with endovascular thrombectomy at 5 US pediatric tertiary care facilities. We recorded initial and postprocedural modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b, initial and postprocedural Pediatric National Institutes of Health Stroke Scale (PedNIHSS) score, and pediatric modified Rankin scale (mRS) score 0 to 2 at 90 d.

Results: There were 23 thrombectomies in 21 patients (mean age 11.6 ± 4.9 yr, median 11.5, range 2.1-19; 52% female). A total of 19 (83%) thrombectomies resulted in mTICI grade ≥ 2b recanalization. The median PedNIHSS score was 13 on presentation (range 4-33) and 2 (range 0-26) at discharge (mean reduction 11.3 ± 6.1). A total of 14 (66%) patients had a mRS score of 0 to 2 at 30-d follow-up; 18/21 (86%) achieved that by 90 d. The median mRS was 1 (range 0-4) at 30 d and 1 (range 0-5) at 90 d. One patient required a blood transfusion after thrombectomy.

Conclusion: In this large series of pediatric patients treated with endovascular thrombectomy, successful recanalization was accomplished via a variety of approaches with excellent clinical outcomes; further prospective longitudinal study is needed.
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http://dx.doi.org/10.1093/neuros/nyaa312DOI Listing
December 2020

Global trends in the evaluation and management of cerebrospinal fluid shunt infection: a cooperative ISPN survey.

Childs Nerv Syst 2020 12 9;36(12):2949-2960. Epub 2020 Jun 9.

Department of Neurosurgery, National Children's Hospital of Costa Rica, "Dr. Carlos Saenz Herrera", San José, Costa Rica.

Introduction: Ventriculoperitoneal shunts (VPS) is commonly performed by pediatric neurosurgeons and there is no consensus in management of VPS infection as it relates to diagnosis and treatment.

Objective: We utilized an international practitioner-based survey to study the variability in VPS infection diagnostic and therapeutic measures.

Methods: A survey gauging practice patterns of pediatric neurosurgeons regarding VPS and its complication management was distributed. Survey endpoints were analyzed by VPS case volume and pediatric-focused case volume regarding diagnostic measures, use of cerebrospinal fluid (CSF) profile, microbiology, and treatment.

Results: A total of 439 surveys were distributed, with a response rate of 31%. Responders ranged from Americas (44.9%), European (31.4%), Asian (18.6%), African (2.5%), to Australian continents (2.5%). Practitioners were stratified based on number and percentage pediatric VPS performed. Institutions performing highest VPS and percentage pediatric case volumes had lower rate of VPS infection. Shunt tap was the most widely used diagnostic study. Overall CSF profile did not affect decision making towards VPS internalization, except for leukocyte count ≤ 20 × 10/L. Practitioners utilized 3 negative cultures prior to VPS internalization. Discrepancies in surgical management were noted amongst centers with high versus low VPS volume and proportion of pediatric-focused case volume. Practice patterns were not noted to be organism dependent. Antibiotic-impregnated shunts were utilized in the Americas and Europe over other regions but only in one third of all initial VPS or as a preventive strategy after a VPS infection has been resolved respectively.

Discussion: Survey results from 6 continents in VPS management revealed patterns of lower infection in high-volume centers, 3 negative cultures prior to internalization and aggressive surgical VPS infection management in high-volume institutions.
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http://dx.doi.org/10.1007/s00381-020-04699-zDOI Listing
December 2020

Pinning in pediatric neurosurgery: the modified rubber stopper technique.

J Neurosurg Pediatr 2020 Apr 10:1-6. Epub 2020 Apr 10.

3Department of Neurosurgery, Northwestern University Feinberg School of Medicine, Chicago; and.

Head immobilization devices with skull pins are commonly used by neurosurgeons to stabilize the head for microsurgical techniques and to maintain accurate intraoperative neuronavigation. Pediatric patients, who may have open fontanelles, unfused sutures, and thin skulls, are vulnerable to complications during placement in pins. We review the various methods of pinning in pediatric neurosurgery and revisit the modified rubber stopper technique using a commonly available rubber stopper from a medication bottle over a standard adult pin of a Mayfield head clamp to prevent the pins from plunging through the thin pediatric skull.
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http://dx.doi.org/10.3171/2020.1.PEDS19541DOI Listing
April 2020

Pediatric intracranial arteriovenous malformations: Examining rehabilitation outcomes.

J Pediatr Rehabil Med 2020 ;13(1):7-15

Division of Pediatric Neurosurgery, Lurie Children's Hospital, Department of Neurosurgery, Northwestern University, Chicago, IL, USA.

Purpose: Arteriovenous malformation (AVM) rupture in children can cause debilitating neurological injury. Rehabilitation is key to recovery, though literature details little regarding rehabilitation outcomes. We examined a single-center experience with pediatric AVMs as related to acute inpatient rehabilitation outcomes.

Methods: At our institution, a retrospective chart review was completed examining all cases of intracranial AVMs in patients age 18 and younger who completed our acute inpatient rehabilitation program between 2012-2018. Patient characteristics, clinical data, treatment modality, and functional outcomes were reviewed.

Results: 14 patients with AVMs underwent acute inpatient rehabilitation; nine (64.3%) treated surgically at our institution, two (14.3%) non-surgically at our institution, and three (21.4%) surgically at an outside facility prior to transitioning care at our institution. Eight (57.1%) were male, seven (50.0%) Caucasian, and seven (50.0%) Hispanic. Seven (50.0%) presented with AVM rupture; six (42.9%) were found incidentally on imaging. Clinical courses, treatment outcomes, and post-treatment complications varied. Several patients underwent repeat treatment or additional procedures. Neurological deficits identified included hemiparesis, dystonia, spasticity, epilepsy, hydrocephalus, and ataxia. Inpatient rehabilitation unit length of stay was on average 21 days (SD 9.02, range 9-41). Functional Independence Measure for Children (WeeFIM®) scores, including self-care, mobility, and cognition, demonstrated improvement upon discharge. The mean total change was 36.7 points in those treated surgically, 16.5 in those treated non-surgically, and 25.7 in those treated surgically at another facility.

Conclusion: We found that all pediatric patients with intracranial AVMs, across all treatment modalities, demonstrated improved outcomes across all functional domains after an acute inpatient rehabilitation program.
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http://dx.doi.org/10.3233/PRM-190609DOI Listing
June 2021

An update on pediatric surgical epilepsy: Part II.

Surg Neurol Int 2019 27;10:258. Epub 2019 Dec 27.

Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H Lurie Children's Hospital, Chicago, IL, USA.

Background: Recent advances may allow surgical options for pediatric patients with refractory epilepsy not previously deemed surgical candidates. This review outlines major technological developments in the field of pediatric surgical epilepsy.

Methods: The literature was comprehensively reviewed and summarized pertaining to stereotactic electroencephalography (sEEG), laser ablation, focused ultrasound (FUS), responsive neurostimulation (RNS), and deep brain stimulation (DBS) in pediatric epilepsy patients.

Results: sEEG allows improved seizure localization in patients with widespread, bilateral, or deep-seated epileptic foci. Laser ablation may be used for destruction of deep-seated epileptic foci close to eloquent structures; FUS has a similar potential application. RNS is a palliative option for patients with eloquent, multiple, or broad epileptogenic foci. DBS is another palliative approach in children unsuitable for respective surgery.

Conclusion: The landscape of pediatric epilepsy is changing due to improved diagnostic and treatment options for patients with refractory seizures. These interventions may improve seizure outcomes and decrease surgical morbidity, though further research is needed to define the appropriate role for each modality.
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http://dx.doi.org/10.25259/SNI_418_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935971PMC
December 2019

An update on pediatric surgical epilepsy: Part I.

Surg Neurol Int 2019 27;10:257. Epub 2019 Dec 27.

Department of Neurosurgery, Division of Pediatric Neurosurgery, Northwestern University Feinberg School of Medicine/Ann and Robert H. Lurie Children's Hospital, Chicago, IL, USA.

Epilepsy affects many children worldwide, with drug-resistant epilepsy affecting 20-40% of all children with epilepsy. This carries a significant burden for patients and their families and is strongly correlated with poor cognitive outcomes, depression, anxiety, developmental delay, and impaired activities of daily living. For this reason, we sought to explore the role of pediatric epilepsy surgery and provide an overview of the factors contributing to epilepsy surgery planning and execution. We review the necessary preoperative evaluations, surgical indications, planning considerations, and surgical options to provide a clear pathway in the evaluation and planning of pediatric epilepsy surgery.
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http://dx.doi.org/10.25259/SNI_417_2019DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6935959PMC
December 2019

The role of spinal angiography in the evaluation and treatment of pediatric spinal vascular pathology: a case series and systematic review.

Childs Nerv Syst 2020 02 14;36(2):325-332. Epub 2019 Aug 14.

Division of Pediatric Neurosurgery, Texas Children's Hospital, 6701 Fannin St., Ste. 1230, Houston, TX, 77030, USA.

Object: While it has been extensively studied in adults, the role of spinal angiography in children with suspected spinal vascular malformations is not fully characterized. With special implications regarding technique, radiation dose, and pathology, we sought to review our single-center experience with pediatric spinal vascular pathology and use a systematic review of the literature to further identify its role in pediatrics.

Methods: A retrospective chart review was conducted under IRB approval for all patients age 0-18 years old who underwent spinal angiography at our institution between 2007 and 2018 for concern for spinal vascular pathology. A simultaneous systematic review was conducted via dedicated search terms in two distinct databases and reviewed to identify all studies referring to spinal angiography or angiograms in pediatric patients.

Results: Six patients were included. Three patients (50%) had vascular malformations confirmed on diagnostic angiography and underwent subsequent endovascular treatment. Two patients (33.3%), one with hematomyelia and one with spinal cord infarction, had negative diagnostic angiograms. One patient (16.7%) had a spinal tumor and underwent angiography for further evaluation preoperatively. Spinal angiography was used to aid in diagnosis, preoperative planning, and treatment in these cases. It was demonstrated to be safe in this patient population, with no untoward events, minimal radiation dose, and possible therapeutic applications in select cases. The systematic review identified 11 studies regarding pediatric spinal angiography. These ranged from single case reports to case series of up to 38 patients and highlighted the role of spinal angiography in diagnosis, endovascular treatment, preoperative planning, and postoperative follow-up.

Conclusions: Spinal angiography may be used in a variety of scenarios to better understand the architecture of vascular spinal lesions and facilitate endovascular intervention. While its application in both adult and pediatric pathology is limited to select cases, spinal angiography remains a key diagnostic procedure when approaching vascular lesions or tumors of the spine, assessing for etiology of spinal cord infarcts, and in the evaluation of unexplained hemorrhage in the spinal canal.
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http://dx.doi.org/10.1007/s00381-019-04329-3DOI Listing
February 2020

Endovascular stenting for rescue of a failed donor graft during superficial temporal artery to middle cerebral artery bypass surgery: case report.

J Neurosurg Pediatr 2019 Aug 9:1-5. Epub 2019 Aug 9.

1Division of Neurosurgery, Texas Children's Hospital, Houston; and.

Direct bypass has been used to salvage failed endovascular treatment; however, little is known of the reversed role of endovascular management for failed bypass.The authors report the case of a 7-year-old patient who underwent a superficial temporal artery to middle cerebral artery (STA-MCA) bypass for treatment of a giant MCA aneurysm and describe the role of endovascular rescue in this case. Post-bypass catheter angiogram showed occlusion of the proximal extracranial STA donor with patent anastomosis, possibly due to STA dissection. A self-expanding Neuroform Atlas stent was deployed across the dissection flap, and follow-up images showed revascularization of the STA with good MCA runoff.This case demonstrates that direct extracranial-intracranial bypass failure can infrequently originate from the STA donor vessel and that superselective angiogram can be useful for identification and treatment in such cases. With more advanced endovascular techniques the tide has turned in the treatment of complex cerebrovascular cases, with this case being an early example of successful rescue stenting for endovascular management of a failed donor after STA-MCA bypass.
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http://dx.doi.org/10.3171/2019.5.PEDS1977DOI Listing
August 2019

Association between postoperative DTI metrics and neurological deficits after posterior fossa tumor resection in children.

J Neurosurg Pediatr 2019 Jul 19:1-7. Epub 2019 Jul 19.

1Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas; and.

Objective: Resection of posterior fossa tumors in children may be associated with persistent neurological deficits. It is unclear if these neurological deficits are associated with persistent structural damage to the cerebellar pathways. The purpose of this research was to define longitudinal changes in diffusion tensor imaging (DTI) metrics in white matter cerebellar tracts and the clinical correlates of these metrics in children undergoing resection of posterior fossa tumors.

Methods: Longitudinal brain DTI was performed in a cohort of pediatric patients who underwent resection of posterior fossa tumors. Fractional anisotropy (FA) of the superior cerebellar peduncles (SCPs) and middle cerebellar peduncles (MCPs) was measured on preoperative, postoperative, and follow-up DTI. Early postoperative (< 48 hours) and longer-term follow-up neurological deficits (mutism, ataxia, and extraocular movement dysfunction) were documented. Statistical analysis was performed to determine differences in FA values based on presence or absence of neurological deficits. Statistical significance was set at p < 0.05.

Results: Twenty children (mean age 6.1 ± 4.1 years [SD], 12 males and 8 females) were included in this study. Follow-up DTI was performed at a median duration of 14.3 months after surgery, and the median duration of follow-up was 19.7 months. FA of the left SCP was significantly reduced on postoperative DTI in comparison with preoperative DTI (0.44 ± 0.07 vs 0.53 ± 0.1, p = 0.003). Presence of ataxia at follow-up was associated with a persistent reduction in the left SCP FA on follow-up DTI (0.43 ± 0.1 vs 0.55 ± 0.1, p = 0.016). Patients with early postoperative mutism who did not recover at follow-up had significantly decreased FA of the left SCP on early postoperative DTI in comparison with those who recovered (0.38 ± 0.05 vs 0.48 ± 0.06, p = 0.04).

Conclusions: DTI after resection of posterior fossa tumors in children shows that persistent reduction of SCP FA is associated with ataxia at follow-up.
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http://dx.doi.org/10.3171/2019.5.PEDS1912DOI Listing
July 2019

Blunt cerebrovascular injury in pediatric trauma: a national database study.

J Neurosurg Pediatr 2019 Jul 19:1-10. Epub 2019 Jul 19.

1Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, New Mexico; and.

Objective: The incidence of blunt cerebrovascular injury (BCVI) has not been well characterized in the pediatric population. The goal of this study was to describe the incidence, patient characteristics, and risk factors for pediatric patients with cerebrovascular injuries.

Methods: The authors collected data from the Kids' Inpatient Database (KID), a nationally representative database of pediatric admissions, for years 2000, 2003, 2006, 2009, and 2012.

Results: Among an estimated 646,549 admissions for blunt trauma, 2150 were associated with BCVI, an overall incidence of 0.33%. The incidence of BCVI nearly doubled from 0.24% in 2000 to 0.49% in 2012. Patients 4 to 13 years of age were less likely to have BCVI than those in the youngest (0-3 years) and oldest age groups comprising adolescents (14-17 years) and young adults (18-20 years). BCVIs were associated with cervical (adjusted OR [aOR] 4.6, 95% CI 3.8-5.5), skull base (aOR 3.0, 95% CI 2.5-3.6), clavicular (aOR 1.4, 95% CI 1.1-1.8), and facial (aOR 1.2, 95% CI 1.0-1.5) fractures, as well as intracranial hemorrhage (aOR 2.7, 95% CI 2.2-3.2) and traumatic brain injury (aOR 2.0, 95% CI 1.7-2.3). Mechanism of injury was also independently associated with BCVI: motor vehicle collision (aOR 1.7, 95% CI 1.3-2.2) and struck pedestrian (aOR 1.4, 95% CI 1.0-1.9). Among pediatric patients with BCVI, 37.4% had cerebral ischemic infarction with an in-hospital mortality of 12.7%, and patients with stroke had 20% mortality.

Conclusions: The incidence of pediatric BCVI is increasing, likely due to increased use of screening, but remains lower than that in the adult population. Risk factors include the presence of cervical, facial, clavicular, and skull base fractures, similar to that of the adult population. Diagnosed BCVI is associated with a relatively high incidence of stroke with increased morbidity and mortality. The use of adult screening criteria is likely reasonable given the similarity in the risk factors identified in this study. Further studies are needed to investigate the role of treatment with antiplatelet agents or anticoagulation.
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http://dx.doi.org/10.3171/2019.5.PEDS18765DOI Listing
July 2019

Protecting Against Postoperative Dyspnea and Dysphagia After Occipitocervical Fusion.

Oper Neurosurg (Hagerstown) 2020 03;18(3):254-260

Section of Pediatric Neurosurgery, Riley Hospital for Children, Indiana University School of Medicine, Indianapolis, Indiana.

Background: Upper airway obstruction leading to dyspnea and dysphagia after occipitocervical fusion is a rare complication that has significant morbidity.

Objective: To estimate the frequency of postoperative dyspnea and dysphagia in children after occipitocervical fusion and to identify variables associated with its occurrence.

Methods: We retrospectively reviewed outcomes from all pediatric occipitocervical fusions at our institution between 2007 and 2014. Pre- and postoperative computed tomography (CT) scans were compared to determine differences in the clivoaxial (OC2) angles.

Results: Sixty-seven pediatric patients underwent occipitocervical fusions. Median age was 9.6 yr (range 6 mo-18 yr). Fifty-six of 62 patients (90.3%) with at least 1 yr of follow-up had successful fusions. Eleven had pre-existing symptoms or otherwise compromised examination (eg, severe traumatic brain injury). None of 15 patients placed in extension (>2 degrees) relative to preoperative CT in Situ position developed new dyspnea or dysphagia. Nine of forty patients (23%) kept in Situ or flexed position developed new symptoms of dyspnea or dysphagia. Dysphagia in patients fused in the in Situ position was milder and resolved within a few weeks. No patient under age 5 (n = 20) developed symptoms of dyspnea or dysphagia regardless of head position. There were 3 cases of infection, 1 clinically silent vertebral artery injury, and 3 deaths at last follow-up.

Conclusion: Positioning of the child's head prior to occipitocervical fusion has considerable impact on outcomes, especially in older children. Careful measurements of the OC2 angle during surgery to ensure optimal head positioning in Situ or slightly extended position may prevent postoperative dysphagia or dyspnea.
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http://dx.doi.org/10.1093/ons/opz122DOI Listing
March 2020

Minimally Invasive Tubular Tethered Cord Release in the Pediatric Population.

World Neurosurg 2019 Aug 13;128:e912-e917. Epub 2019 May 13.

Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas, USA. Electronic address:

Background: Tethered cord syndrome (TCS) refers to a clinical constellation of signs and symptoms associated with tension in the spinal cord and associated with pathologies related to abnormally low-lying conus medullaris. As minimally invasive spinal operations have become more prevalent in the past decade, we applied expanding indications to selected intradural procedures, such as tethered cord release (TCR). We present the first series of minimally invasive muscle-sparing TCR in the pediatric population.

Methods: A retrospective review of the Texas Children's Hospital, Houston, neurosurgical database was conducted for patients who underwent TCR between 2010 and 2017. Charts were reviewed to determine the source of TCS and whether surgery was conducted in a minimally invasive fashion. To establish a cohort of control population, age-matched cases of open TCR were selected in the same. Exclusion criterion was non-fatty filum sources of TCS. The length of stay, operative time, estimated blood loss, and postoperative complications were recorded.

Results: Eleven patients underwent minimally invasive TCR. Mean age of the patients was 10.1 years. All patients underwent L4-5 tubular laminotomy and cord detethering by 2 pediatric neurosurgeons at Texas Children's Hospital. The average length of stay in the hospital was 2.6 days. The average operative time was 167 minutes and average estimated blood loss was 8.2 mL. Ten patients reported clinical improvement and 1 patient was lost to follow-up.

Conclusions: Minimally invasive TCR is a safe and represents a viable alternative to the open approach with advantages such as minimal estimated blood loss, shortened length of stay, and postoperative pain control.
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http://dx.doi.org/10.1016/j.wneu.2019.05.026DOI Listing
August 2019

Nonsyndromic Craniosynostosis.

Clin Plast Surg 2019 Apr 30;46(2):123-139. Epub 2019 Jan 30.

Division of Plastic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, 6701 Fannin Street, CC 610.00, Houston, TX 77030, USA. Electronic address:

Nonsyndromic craniosynostosis is significantly more common than syndromic craniosynostosis, affecting the sagittal, coronal, metopic, and lambdoid sutures in decreasing order of frequency. Nonsyndromic craniosynostosis is most frequently associated with only 1 fused suture, creating a predictable head shape. Repair of craniosynostosis is recommended to avoid potential neurodevelopmental delay. Early intervention at 3 to 4 months of age allows minimally invasive approaches, but requires postoperative molding helmet therapy and good family compliance. Open techniques are deferred until the child is older to better tolerate the associated surgical stress. Cranial vault remodeling is generally well-tolerated with a low rate of complications.
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http://dx.doi.org/10.1016/j.cps.2018.11.001DOI Listing
April 2019

Indirect revascularization for moyamoya disease: A pediatric neuroanesthesiology perspective.

Surg Neurol Int 2018 2;9:224. Epub 2018 Nov 2.

Department of Neurosurgery, Division of Pediatric Neurosurgery, Baylor College of Medicine/Texas Children's Hospital, Houston, TX 77030, USA.

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http://dx.doi.org/10.4103/sni.sni_151_18DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6238324PMC
November 2018

Language lateralization with resting-state and task-based functional MRI in pediatric epilepsy.

J Neurosurg Pediatr 2018 10;23(2):171-177

Division of Pediatric Neurology, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, Arizona.

In Brief: The study compared two types of functional MRI (fMRI) to see which side of the brain is most responsible for language: traditional task-based fMRI, which requires a high level of patient interaction, and resting-state fMRI, which is typically performed with the patient under light sedation and has no interaction requirement. The authors found that the test correlation was 93%, indicating resting state fMRI has potential to locate language in those unable to participate in task-based fMRI.
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http://dx.doi.org/10.3171/2018.7.PEDS18162DOI Listing
October 2018

Measures of Health-Related Quality of Life Outcomes in Pediatric Neurosurgery: Literature Review.

World Neurosurg 2019 Feb 3;122:252-265. Epub 2018 Nov 3.

Division of Pediatric Neurosurgery, Texas Children's Hospital, Houston, Texas, USA; Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA.

Background: Improving value in healthcare means optimizing outcomes and minimizing costs. The emerging pay-for-performance era requires understanding of the effect of healthcare services on health-related quality of life (HRQoL). Pediatric and surgical subspecialties have yet to fully integrate HRQoL measures into practice. The present study reviewed and characterized the HRQoL outcome measures across various pediatric neurosurgical diagnoses.

Methods: A literature review was performed by searching PubMed and Google Scholar with search terms such as "health-related quality of life" and "pediatric neurosurgery" and then including the specific pathologies for which a HRQoL instrument was found (e.g., "health-related quality of life" plus "epilepsy"). Each measurement was evaluated by content and purpose, relative strengths and weaknesses, and validity.

Results: We reviewed 68 reports. Epilepsy, brain tumor, cerebral palsy, spina bifida, hydrocephalus, and scoliosis were diagnoses found in reported studies that had used disease-specific HRQoL instruments. Information using general HRQoL instruments was also reported. Internal, test-retest, and/or interrater reliability varied across the instruments, as did face, content, concurrent, and/or construct validity. Few instruments were tested enough for robust reliability and validity. Significant variability was found in the usage of these instruments in clinical studies within pediatric neurosurgery.

Conclusions: The HRQoL instruments used in pediatric neurosurgery are currently without standardized guidelines and thus exhibit high variability in use. Clinicians should support the development and application of these methods to optimize these instruments, promote standardization of research, improve performance measures to reflect clinically modifiable and meaningful outcomes, and, ultimately, lead the national discussion in healthcare quality and patient-centered care.
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http://dx.doi.org/10.1016/j.wneu.2018.10.194DOI Listing
February 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