Publications by authors named "Vijay M Ravindra"

82 Publications

Magnetic resonance-guided laser interstitial thermal therapy for pediatric periventricular nodular heterotopia-related epilepsy.

J Neurosurg Pediatr 2021 Sep 24:1-6. Epub 2021 Sep 24.

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

Objective: Periventricular nodular heterotopia (PVNH) is a result of disrupted neuronal migration from the ventricular system and can be a rare cause of refractory focal epilepsy. The goal of this case series was to describe the treatment of pediatric PVNH-related epilepsy with MR-guided laser interstitial thermal ablation.

Methods: Patients treated at a single institution with MR-guided laser interstitial thermal therapy (MRgLITT) for PVNH-related epilepsy were identified. Preoperative and postoperative seizure outcomes and procedural information were evaluated.

Results: Five children with PVNH treated with MRgLITT were reviewed; 1 child was treated twice. Three patients were female; the median age was 10.9 years. Five of 6 treatments were preceded by stereoelectroencephalography phase II monitoring. Three children experienced unilateral PVNH, and 2 had bilateral seizures. The median number of seizures recorded during phase II monitoring was 2; the median number of ablation targets was 2 (range 1-4). All patients experienced a decrease in seizure frequency; 4 patients (80%) had an Engel class ≤ III at the last follow-up (range I-IV). One child experienced right hemianopia posttreatment.

Conclusions: This case series investigation has illustrated a novel, minimally invasive approach for treating pediatric PVNH-related epilepsy. Further study of this technique with comparison with other surgical techniques is warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2021.5.PEDS21171DOI Listing
September 2021

Investigating the "Weekend Effect" on Outcomes of Patients Undergoing Endovascular Mechanical Thrombectomy for Ischemic Stroke.

J Stroke Cerebrovasc Dis 2021 Aug 7;30(10):106013. Epub 2021 Aug 7.

Department of Neurology, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT 84132, USA. Electronic address:

Objectives: With growing evidence of its efficacy for patients with large-vessel occlusion (LVO) ischemic stroke, the use of endovascular thrombectomy (EVT) has increased. The "weekend effect," whereby patients presenting during weekends/off hours have worse clinical outcomes than those presenting during normal working hours, is a critical area of study in acute ischemic stroke (AIS). Our objective was to evaluate whether a "weekend effect" exists in patients undergoing EVT.

Methods: This retrospective, cross-sectional analysis of the 2016-2018 Nationwide Inpatient Sample data included patients ≥18 years with documented diagnosis of ischemic stroke (ICD-10 codes I63, I64, and H34.1), procedural code for EVT, and National Institutes of Health Stroke Scale (NIHSS) score; the exposure variable was weekend vs. weekday treatment. The primary outcome was in-hospital death; secondary outcomes were favorable discharge, extended hospital stay (LOS), and cost. Logistic regression models were constructed to determine predictors for outcomes.

Results: We identified 6052 AIS patients who received EVT (mean age 68.7±14.8 years; 50.8% female; 70.8% White; median (IQR) admission NIHSS 16 (10-21). The primary outcome of in-hospital death occurred in 560 (11.1%); the secondary outcome of favorable discharge occurred in 1039 (20.6%). The mean LOS was 7.8±8.6 days. There were no significant differences in the outcomes or cost based on admission timing. In the mixed-effects models, we found no effect of weekend vs. weekday admission on in-hospital death, favorable discharge, or extended LOS.

Conclusion: These results demonstrate that the "weekend effect" does not impact outcomes or cost for patients who undergo EVT for LVO.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jstrokecerebrovasdis.2021.106013DOI Listing
August 2021

Rigid versus flexible neuroendoscopy: a systematic review and meta-analysis of endoscopic third ventriculostomy for the management of pediatric hydrocephalus.

J Neurosurg Pediatr 2021 Jul 23:1-11. Epub 2021 Jul 23.

3Department of Surgery, Division of Pediatric Neurosurgery, Ann & Robert H. Lurie Children's Hospital of Chicago; and.

Objective: Endoscopic third ventriculostomy (ETV), with or without choroid plexus cauterization (±CPC), is a technique used for the treatment of pediatric hydrocephalus. Rigid or flexible neuroendoscopy can be used, but few studies directly compare the two techniques. Here, the authors sought to compare these methods in treating pediatric hydrocephalus.

Methods: A systematic MEDLINE search was conducted using combinations of keywords: "flexible," "rigid," "endoscope/endoscopic," "ETV," and "hydrocephalus." Inclusion criteria were as follows: English-language studies with patients 2 years of age and younger who had undergone ETV±CPC using rigid or flexible endoscopy for hydrocephalus. The primary outcome was ETV success (i.e., without the need for further CSF diversion procedures). Secondary outcomes included ETV-related and other complications. Statistical significance was determined via independent t-tests and Mood's median tests.

Results: Forty-eight articles met the study inclusion criteria: 37 involving rigid endoscopy, 10 involving flexible endoscopy, and 1 propensity scored-matched comparison. A cumulative 560 patients had undergone 578 rigid ETV±CPC, and 661 patients had undergone 672 flexible ETV±CPC. The flexible endoscopy cohort had a significantly lower average age at the time of the procedure (0.33 vs 0.53 years, p = 0.001) and a lower preoperatively predicted ETV success score (median 40, IQR 32.5-57.5 vs 62.5, IQR 50-70; p = 0.033). Average ETV success rates in the rigid versus flexible groups were 54.98% and 59.65% (p = 0.63), respectively. ETV-related complication rates did not differ significantly at 0.63% for flexible endoscopy and 3.46% for rigid endoscopy (p = 0.30). There was no significant difference in ETV success or complication rate in comparing ETV, ETV+CPC, and ETV with other concurrent procedures.

Conclusions: Despite the lower expected ETV success scores for patients treated with flexible endoscopy, the authors found similar ETV success and complication rates for ETV±CPC with flexible versus rigid endoscopy, as reported in the literature. Further direct comparison between the techniques is necessary.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2021.2.PEDS2121DOI Listing
July 2021

Preoperative imaging patterns and intracranial findings in single-suture craniosynostosis: a study from the Synostosis Research Group.

J Neurosurg Pediatr 2021 Jun 25:1-7. Epub 2021 Jun 25.

1Department of Neurosurgery, and.

Objective: The diagnosis of single-suture craniosynostosis can be made by physical examination, but the use of confirmatory imaging is common practice. The authors sought to investigate preoperative imaging use and to describe intracranial findings in children with single-suture synostosis from a large, prospective multicenter cohort.

Methods: In this study from the Synostosis Research Group, the study population included children with clinically diagnosed single-suture synostosis between March 1, 2017, and October 31, 2020, at 5 institutions. The primary analysis correlated the clinical diagnosis and imaging diagnosis; secondary outcomes included intracranial findings by pathological suture type.

Results: A total of 403 children (67% male) were identified with single-suture synostosis. Sagittal (n = 267), metopic (n = 77), coronal (n = 52), and lambdoid (n = 7) synostoses were reported; the most common presentation was abnormal head shape (97%), followed by a palpable or visible ridge (37%). Preoperative cranial imaging was performed in 90% of children; findings on 97% of these imaging studies matched the initial clinical diagnosis. Thirty-one additional fused sutures were identified in 18 children (5%) that differed from the clinical diagnosis. The most commonly used imaging modality by far was CT (n = 360), followed by radiography (n = 9) and MRI (n = 7). Most preoperative imaging was ordered as part of a protocolized pathway (67%); some images were obtained as a result of a nondiagnostic clinical examination (5.2%). Of the 360 patients who had CT imaging, 150 underwent total cranial vault surgery and 210 underwent strip craniectomy. The imaging findings influenced the surgical treatment 0.95% of the time. Among the 24% of children with additional (nonsynostosis) abnormal findings on CT, only 3.5% required further monitoring.

Conclusions: The authors found that a clinical diagnosis of single-suture craniosynostosis and the findings on CT were the same with rare exceptions. CT imaging very rarely altered the surgical treatment of children with single-suture synostosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2021.2.PEDS2113DOI Listing
June 2021

A multicenter validation of the condylar-C2 sagittal vertical alignment in Chiari malformation type I: a study using the Park-Reeves Syringomyelia Research Consortium.

J Neurosurg Pediatr 2021 Jun 4:1-7. Epub 2021 Jun 4.

1Division of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah.

Objective: The condylar-C2 sagittal vertical alignment (C-C2SVA) describes the relationship between the occipitoatlantal joint and C2 in patients with Chiari malformation type I (CM-I). It has been suggested that a C-C2SVA ≥ 5 mm is predictive of the need for occipitocervical fusion (OCF) or ventral brainstem decompression (VBD). The authors' objective was to validate the predictive utility of the C-C2SVA by using a large, multicenter cohort of patients.

Methods: This validation study used a cohort of patients derived from the Park-Reeves Syringomyelia Research Consortium; patients < 21 years old with CM-I and syringomyelia treated from June 2011 to May 2016 were identified. The primary outcome was the need for OCF and/or VBD. After patients who required OCF and/or VBD were identified, 10 age- and sex-matched controls served as comparisons for each OCF/VBD patient. The C-C2SVA (defined as the position of a plumb line from the midpoint of the O-C1 joint relative to the posterior aspect of the C2-3 disc space), pBC2 (a line perpendicular to a line from the basion to the posteroinferior aspect of the C2 body), and clival-axial angle (CXA) were measured on sagittal MRI. The secondary outcome was the need for ≥ 2 CM-related operations.

Results: Of the 206 patients identified, 20 underwent OCF/VBD and 14 underwent repeat posterior fossa decompression. A C-C2SVA ≥ 5 mm was 100% sensitive and 86% specific for requiring OCF/VBD, with a 12.6% misclassification rate, whereas CXA < 125° was 55% sensitive and 99% specific, and pBC2 ≥ 9 was 20% sensitive and 88% specific. Kaplan-Meier analysis demonstrated that there was a significantly shorter time to second decompression in children with C-C2SVA ≥ 5 mm (p = 0.0039). The mean C-C2SVA was greater (6.13 ± 1.28 vs 3.13 ± 1.95 mm, p < 0.0001), CXA was lower (126° ± 15.4° vs 145° ± 10.7°, p < 0.05), and pBC2 was similar (7.65 ± 1.79 vs 7.02 ± 1.26 mm, p = 0.31) among those who underwent OCF/VBD versus decompression only. The intraclass correlation coefficient for the continuous measurement of C-C2SVA was 0.52; the kappa value was 0.47 for the binary categorization of C-C2SVA ≥ 5 mm.

Conclusions: These results validated the C-C2SVA using a large, multicenter, external cohort with 100% sensitivity, 86% specificity, and a 12.6% misclassification rate. A C-C2SVA ≥ 5 mm is highly predictive of the need for OCF/VBD in patients with CM-I. The authors recommend that this measurement be considered among the tools to identify the "high-risk" CM-I phenotype.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2020.12.PEDS20809DOI Listing
June 2021

Comparison of multimodal surgical and radiation treatment methods for pediatric craniopharyngioma: long-term analysis of progression-free survival and morbidity.

J Neurosurg Pediatr 2021 May 28:1-8. Epub 2021 May 28.

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

Objective: The authors compared survival and multiple comorbidities in children diagnosed with craniopharyngioma who underwent gross-total resection (GTR) versus subtotal resection (STR) with radiation therapy (RT), either intensity-modulated radiation therapy (IMRT) or proton beam therapy (PBT). The authors hypothesized that there are differences between multimodal treatment methods with respect to morbidity and progression-free survival (PFS).

Methods: The medical records of children diagnosed with craniopharyngioma and treated surgically between February 1997 and December 2018 at Texas Children's Hospital were reviewed. Surgical treatment was stratified as GTR or STR + RT. RT was further stratified as PBT or IMRT; PBT was stratified as STR + PBT versus cyst decompression (CD) + PBT. The authors used Kaplan-Meier analysis to compare PFS and overall survival, and chi-square analysis to compare rates for hypopituitarism, vision loss, and hypothalamic obesity (HyOb).

Results: Sixty-three children were included in the analysis; 49% were female. The mean age was 8.16 years (95% CI 7.08-9.27). Twelve of 14 children in the IMRT cohort underwent CD. The 5-year PFS rates were as follows: 73% for GTR (n = 31), 54% for IMRT (n = 14), 100% for STR + PBT (n = 7), and 77% for CD + PBT (n = 11; p = 0.202). The overall survival rates were similar in all groups. Rates of hypopituitarism (96% GTR vs 75% IMRT vs 100% STR + PBT, 50% CD + PBT; p = 0.023) and diabetes insipidus (DI) (90% GTR vs 61% IMRT vs 85% STR + PBT, 20% CD + PBT; p = 0.004) were significantly higher in the GTR group. There was no significant difference in the HyOb or vision loss at the end of study follow-up among the different groups. Within the PBT group, 2 patients presented a progressive vasculopathy with subsequent strokes. One patient experienced a PBT-induced tumor.

Conclusions: GTR and CD + PBT presented similar rates of 5-year PFS. Hypopituitarism and DI rates were higher with GTR, but the rate of HyOb was similar among different treatment modalities. PBT may reduce the burden of hypopituitarism and DI, although radiation carries a risk of potential serious complications, including progressive vasculopathy and secondary malignancy. Further prospective study comparing neurocognitive outcomes is necessary.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2020.11.PEDS20803DOI Listing
May 2021

Fusion for subaxial bow hunter's syndrome results in remote osseous remodeling of the hyperostotic growth responsible for vertebral artery compression.

Surg Neurol Int 2021 17;12:104. Epub 2021 Mar 17.

Department of Neurosurgery, Naval Medical Center San Diego, San Diego, California, United States.

Background: The authors present a previously unreported case of a patient with diffuse idiopathic skeletal hyperostosis (DISH) who developed bow hunter's syndrome (BHS) or positional vertebrobasilar insufficiency. In addition, the authors demonstrate angiographic evidence of remote osseous remodeling after segmental fusion without direct decompression of the offending bony growth. BHS is a rare, yet well established, cause of posterior circulation ischemia and ischemic stroke. Several etiologies such as segmental instability and spondylosis have been described as causes, however, DISH has not been associated with BHS before this publication.

Case Description: A 77-year-old man who presented with BHS was found to have cervical spine changes consistent with DISH, and angiography confirmed right vertebral artery (VA) stenosis at C4-5 from a large pathological elongation of the right C5 lateral mass. Head rotation resulted in occlusion of the VA. The patient underwent an anterior cervical discectomy and fusion and reported complete resolution of his symptoms. A delayed angiogram and CT of the cervical spine demonstrated complete resolution of the baseline stenosis, no dynamic compression, and remote osseous remodeling of the growth, respectively.

Conclusion: This case represents the first publication in the literature of DISH as a causative etiology of BHS and of angiographic data demonstrating resolution of a compressive osseous pathology without direct decompression in BHS.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.25259/SNI_762_2020DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8053469PMC
March 2021

Impact of COVID-19 on the hospitalization, treatment, and outcomes of intracerebral and subarachnoid hemorrhage in the United States.

PLoS One 2021 14;16(4):e0248728. Epub 2021 Apr 14.

Department of Neurology, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah, United States of America.

Objective: To examine the outcomes of adult patients with spontaneous intracranial and subarachnoid hemorrhage diagnosed with comorbid COVID-19 infection in a large, geographically diverse cohort.

Methods: We performed a retrospective analysis using the Vizient Clinical Data Base. We separately compared two cohorts of patients with COVID-19 admitted April 1-October 31, 2020-patients with intracerebral hemorrhage (ICH) and those with subarachnoid hemorrhage (SAH)-with control patients with ICH or SAH who did not have COVID-19 admitted at the same hospitals in 2019. The primary outcome was in-hospital death. Favorable discharge and length of hospital and intensive-care stay were the secondary outcomes. We fit multivariate mixed-effects logistic regression models to our outcomes.

Results: There were 559 ICH-COVID patients and 23,378 ICH controls from 194 hospitals. In the ICH-COVID cohort versus controls, there was a significantly higher proportion of Hispanic patients (24.5% vs. 8.9%), Black patients (23.3% vs. 20.9%), nonsmokers (11.5% vs. 3.2%), obesity (31.3% vs. 13.5%), and diabetes (43.4% vs. 28.5%), and patients had a longer hospital stay (21.6 vs. 10.5 days), a longer intensive-care stay (16.5 vs. 6.0 days), and a higher in-hospital death rate (46.5% vs. 18.0%). Patients with ICH-COVID had an adjusted odds ratio (aOR) of 2.43 [1.96-3.00] for the outcome of death and an aOR of 0.55 [0.44-0.68] for favorable discharge. There were 212 SAH-COVID patients and 5,029 controls from 119 hospitals. The hospital (26.9 vs. 13.4 days) and intensive-care (21.9 vs. 9.6 days) length of stays and in-hospital death rate (42.9% vs. 14.8%) were higher in the SAH-COVID cohort compared with controls. Patients with SAH-COVID had an aOR of 1.81 [1.26-2.59] for an outcome of death and an aOR of 0.54 [0.37-0.78] for favorable discharge.

Conclusions: Patients with spontaneous ICH or SAH and comorbid COVID infection were more likely to be a racial or ethnic minority, diabetic, and obese and to have higher rates of death and longer hospital length of stay when compared with controls.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0248728PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8046225PMC
May 2021

Management of sagittal synostosis in the Synostosis Research Group: baseline data and early outcomes.

Neurosurg Focus 2021 04;50(4):E3

Divisions of1Pediatric Neurosurgery, Primary Children's Hospital, and.

Objective: Sagittal synostosis is the most common form of isolated craniosynostosis. Although some centers have reported extensive experience with this condition, most reports have focused on a single center. In 2017, the Synostosis Research Group (SynRG), a multicenter collaborative network, was formed to study craniosynostosis. Here, the authors report their early experience with treating sagittal synostosis in the network. The goals were to describe practice patterns, identify variations, and generate hypotheses for future research.

Methods: All patients with a clinical diagnosis of isolated sagittal synostosis who presented to a SynRG center between March 1, 2017, and October 31, 2019, were included. Follow-up information through October 31, 2020, was included. Data extracted from the prospectively maintained SynRG registry included baseline parameters, surgical adjuncts and techniques, complications prior to discharge, and indications for reoperation. Data analysis was descriptive, using frequencies for categorical variables and means and medians for continuous variables.

Results: Two hundred five patients had treatment for sagittal synostosis at 5 different sites. One hundred twenty-six patients were treated with strip craniectomy and 79 patients with total cranial vault remodeling. The most common strip craniectomy was wide craniectomy with parietal wedge osteotomies (44%), and the most common cranial vault remodeling procedure was total vault remodeling without forehead remodeling (63%). Preoperative mean cephalic indices (CIs) were similar between treatment groups: 0.69 for strip craniectomy and 0.68 for cranial vault remodeling. Thirteen percent of patients had other health problems. In the cranial vault cohort, 81% of patients who received tranexamic acid required a transfusion compared with 94% of patients who did not receive tranexamic acid. The rates of complication were low in all treatment groups. Five patients (2%) had an unintended reoperation. The mean change in CI was 0.09 for strip craniectomy and 0.06 for cranial vault remodeling; wide craniectomy resulted in a greater change in CI in the strip craniectomy group.

Conclusions: The baseline severity of scaphocephaly was similar across procedures and sites. Treatment methods varied, but cranial vault remodeling and strip craniectomy both resulted in satisfactory postoperative CIs. Use of tranexamic acid may reduce the need for transfusion in cranial vault cases. The wide craniectomy technique for strip craniectomy seemed to be associated with change in CI. Both findings seem amenable to testing in a randomized controlled trial.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2021.1.FOCUS201029DOI Listing
April 2021

U.S. Neurosurgical Response to COVID-19: Forging a Path Toward Disaster Preparedness.

Mil Med 2021 05;186(5-6):549-555

Department of Surgery, US Naval Hospital Okinawa, Chatan, Okinawa 904-0103, Japan.

Introduction: The worldwide COVID-19 pandemic poses challenges to healthcare capacity and infrastructure. The authors discuss the structure and efficacy of the U.S. Navy's response to COVID-19 and evaluate the utility of this endeavor, with the objective of providing future recommendations for managing worldwide healthcare and medical operational demands from the perspective of Navy Neurosurgery.

Materials And Methods: The authors present an extensive review of topics and objectively highlight the efforts of U.S. Navy Neurosurgery as it pertains to the humanitarian mission during the COVID-19 pandemic.

Results: During the humanitarian mission (March 27, 2020-April 14, 2020), the response of active duty and reserve neurosurgeons in the U.S. Navy was robust. Neurosurgical coverage was present on board the U.S. Navy Ships Mercy and Comfort, with additional neurosurgical deployment to New York City for intensive care unit management and coverage.

Conclusions: The U.S. Navy neurosurgical response to the COVID-19 pandemic was swift and altruistic. Although neurosurgical pathologies were limited among the presenting patients, readiness and manpower continue to be strong influences within the Armed Forces. The COVID-19 response demonstrates that neurosurgical assets can be rapidly mobilized and deployed in support of wartime, domestic, and global humanitarian crises to augment both trauma and critical care capabilities.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usab081DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989245PMC
May 2021

Successful flow diversion treatment of ruptured infectious middle cerebral artery aneurysms with the use of Pipeline Flex with Shield technology.

Interv Neuroradiol 2021 Apr 28;27(2):225-229. Epub 2021 Jan 28.

Department of Neurosurgery, University of Texas Health San Antonio, San Antonio, TX, USA.

Background: Rupture of infectious intracranial aneurysms (IIAs) is associated with a high likelihood of mortality. Endovascular treatment of IIAs via parent artery sacrifice offers good efficacy and outcomes; however, depending on the lesion's location, neurologic deficit may result.

Case Description: We describe a pediatric patient with ruptured IIAs off the left middle cerebral artery (MCA) treated with coil embolization and endovascular flow diversion using the Pipeline Flex Embolization Device (PED) with Shield technology. We chose to place a flow diverter because 1) there was a second, more distal IIA not amenable to direct coil embolization, 2) there was significant potential for aneurysm regrowth and need for retreatment, and 3) we believed the diseased parent MCA needed to be reconstructed.

Conclusions: In the setting of previous hemicraniectomy, PED-Shield gave us the option to discontinue dual antiplatelet therapy should the patient require further neurosurgical intervention. Our case supports a role for PED-Shield to address ruptured pseudoaneurysms.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1591019921990506DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8050536PMC
April 2021

Magnetic Resonance-Guided Laser Interstitial Thermal Therapy for Palliative Rhizotomy: A Novel Technical Application.

Oper Neurosurg (Hagerstown) 2021 03;20(4):413-418

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

Background: Spastic cerebral palsy is caused by an insult to the developing brain. Various medical and surgical procedures are used to reduce tone.

Objective: To describe a novel method of magnetic resonance-guided laser interstitial thermal ablation for palliative rhizotomy.

Methods: Patients treated at a single institution with percutaneous rhizotomy using magnetic resonance-guided laser interstitial thermal therapy were identified. Preoperative and postoperative Modified Ashworth Scale scores were collected as well as procedural information.

Results: Two male children (7.8 and 19 yr, respectively) with spastic quadriparesis were treated using this technique. Neither patient experienced surgical or perioperative complications, and both were discharged from the hospital within 48 h. Each of them demonstrated improvement in his Modified Ashworth Scale score with no need for retreatment for spasticity at last follow-up.

Conclusion: These 2 cases illustrate a novel technique for treating spasticity in the setting of cerebral palsy. Further study of this technique in additional patients, and comparison with traditional methods of surgical tone reduction, are warranted.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ons/opaa415DOI Listing
March 2021

Transpacific Aeromedical Evacuation for a Ruptured Brain Arteriovenous Malformation During the COVID-19 Pandemic.

Mil Med 2021 05;186(5-6):e632-e636

Department of Neurosurgery, Walter Reed National Military Medical Center, Bethesda, MD 20889, USA.

The COVID-19 pandemic has altered preexisting patient treatment algorithms and referral patterns, which has affected neurosurgical care worldwide. Brain arteriovenous malformations are complex vascular lesions that frequently present with intracerebral hemorrhage. Care for these patients is best performed at large medical centers by specialists with high volumes. The authors describe the care of a patient who presented in extremis to a resource-limited, community-sized military treatment facility (MTF) in Southeast Asia. In the MTF, the patient underwent emergent neurosurgical therapy. However, given newly implemented restrictions enacted to mitigate COVID-19 spread, local transfer for definitive care to a tertiary care facility was not possible. In order to attain definitive care for the patient, a transpacific aeromedical evacuation augmented with a critical care air transport team was utilized for transfer to a tertiary care, teaching hospital. This case demonstrates the safe treatment of a patient with hemorrhagic arteriovenous malformations and postoperative management under limited conditions in an MTF outside the CONUS. Given the unique circumstances and challenges the pandemic presented, the authors feel that this patient's outcome was only possible by leveraging all the capability military medicine has to offer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/milmed/usaa531DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798835PMC
May 2021

Clinical Effectiveness of S2-Alar Iliac Screws in Spinopelvic Fixation in Pediatric Neuromuscular Scoliosis: Systematic Literature Review.

Global Spine J 2020 Dec 7;10(8):1066-1074. Epub 2020 Jan 7.

3989Baylor College of Medicine, Houston, TX, USA.

Study Design: Systematic literature review.

Objectives: To comprehensively review the S2-alar iliac (S2-AI) screw technique for pelvic fixation in pediatric neuromuscular scoliosis.

Methods: Articles identified from the PubMed and EMBASE databases were reviewed for relevance and applicability, and the studies were summarized.

Results: Eight articles met the inclusion criteria. A total of 277 pediatric patients underwent spinopelvic fixation using S2-AI fixation for neuromuscular scoliosis; the mean follow-up was 3 years (range = 0.75-6 years). Six articles had level III evidence (5 retrospective cohort studies, 1 observational study), and 2 articles had level IV evidence (case series). Wound complications occurred in 34 (12.2%) patients. Instrumentation complications occurred in 36 patients (13.0%), including lucency around the screw (6.5%), screw fracture (3.6%), disengaging of the set/screw or rod from the tulip head (2.8%), and screw displacement (0.7%). Three patients (1.1%) required reoperation for instrumentation failures. The overall reoperation rate-including 3 hardware replacements and 3 cases of L5-S1 pseudarthrosis-was 2.1%. The mean Cobb angle correction was 51.4°, and the mean pelvic obliquity correction was 14.8°; deformity correction was maintained at 3- and 5-year follow-ups. There were 10 (3.6%) cases of implant prominence/implant-related pain, 1 case of sacroiliac joint pain (resolved with longer screw placement), and no major neurological or vascular complications secondary to S2-AI screw placement.

Conclusions: This review suggests that the use of S2-AI screws in pediatric neuromuscular scoliosis is efficacious with a reasonable safety profile and provides a useful technique for pelvic fixation in children with scoliosis.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568219899658DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7645097PMC
December 2020

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyaa312DOI Listing
December 2020

Defining the role of the condylar-C2 sagittal vertical alignment in Chiari malformation type I.

J Neurosurg Pediatr 2020 Jul 17:1-6. Epub 2020 Jul 17.

1Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City, Utah; and.

Objective: The authors' objective was to better understand the anatomical load-bearing relationship between the atlantooccipital joint and the upper cervical spine and its influence on the clinical behavior of patients with Chiari malformation type I (CM-I) and craniocervical pathology.

Methods: In a single-center prospective study of patients younger than 18 years with CM-I from 2015 through 2017 (mean age 9.91 years), the authors measured the occipital condyle-C2 sagittal vertebral alignment (C-C2SVA; defined as the position of a plumb line from the midpoint of the occiput (C0)-C1 joint relative to the posterior aspect of the C2-3 disc space), the pB-C2 (a line perpendicular to a line from the basion to the posteroinferior aspect of the C2 body on sagittal MRI), and the CXA (clivoaxial angle). Control data from 30 patients without CM-I (mean age 8.97 years) were used for comparison. The primary outcome was the need for anterior odontoid resection and/or occipitocervical fusion with or without odontoid reduction. The secondary outcome was the need for two or more Chiari-related operations.

Results: Of the 60 consecutive patients with CM-I identified, 7 underwent anterior odontoid resection or occipitocervical fusion and 10 underwent ≥ 2 decompressive procedures. The mean C-C2SVA was greater in the overall CM-I group versus controls (3.68 vs 0.13 mm, p < 0.0001), as was the pB-C2 (7.7 vs 6.4 mm, p = 0.0092); the CXA was smaller (136° vs 148°, p < 0.0001). A C-C2SVA ≥ 5 mm was found in 35% of CM-I children and 3.3% of controls (p = 0.0006). The sensitivities and specificities for requiring ventral decompression/occipitocervical fusion were 100% and 74%, respectively, for C-C2SVA ≥ 5 mm; 71% and 94%, respectively, for CXA < 125°; and 71% and 75%, respectively, for pB-C2 ≥ 9 mm. The sensitivities and specificities for the need for ≥ 2 decompressive procedures were 60% and 70%, respectively, for C-C2SVA ≥ 5 mm; 50% and 94%, respectively, for CXA < 125°; and 60% and 76%, respectively, for pB-C2 ≥ 9 mm. The log-rank test demonstrated significant differences between C-C2SVA groups (p = 0.0007) for the primary outcome. A kappa value of 0.73 for C-C2SVA between raters indicated substantial agreement.

Conclusions: A novel screening measurement for craniocervical bony relationships, the C-C2SVA, is described. A significant difference in C-C2SVA between CM-I patients and controls was found. A C-C2SVA ≥ 5 mm is highly predictive of the need for occipitocervical fusion/ventral decompression in patients with CM-I. Further validation of this screening measurement is needed.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2020.4.PEDS20113DOI Listing
July 2020

Comparison of anticoagulation and antiplatelet therapy for treatment of blunt cerebrovascular injury in children <10 years of age: a multicenter retrospective cohort study.

Childs Nerv Syst 2021 01 29;37(1):47-54. Epub 2020 May 29.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Drive East, Salt Lake City, UT, 84132, USA.

Purpose: Blunt cerebrovascular injury (BCVI) is uncommon in the pediatric population. Among the management options is medical management consisting of antithrombotic therapy with either antiplatelets or anticoagulation. There is no consensus on whether administration of antiplatelets or anticoagulation is more appropriate for BCVI in children < 10 years of age. Our goal was to compare radiographic and clinical outcomes based on medical treatment modality for BCVI in children < 10 years.

Methods: Clinical and radiographic data were collected retrospectively for children screened for BCVI with computed tomography angiography at 5 academic pediatric trauma centers.

Results: Among 651 patients evaluated with computed tomography angiography to screen for BCVI, 17 patients aged less than 10 years were diagnosed with BCVI (7 grade I, 5 grade II, 1 grade III, 4 grade IV) and received anticoagulation or antiplatelet therapy for 18 total injuries: 11 intracranial carotid artery, 4 extracranial carotid artery, and 3 extracranial vertebral artery injuries. Eleven patients were treated with antiplatelets (10 aspirin, 1 clopidogrel) and 6 with anticoagulation (4 unfractionated heparin, 2 low-molecular-weight heparin, 1 transitioned from the former to the latter). There were no complications secondary to treatment. One patient who received anticoagulation died as a result of the traumatic injuries. In aggregate, children treated with antiplatelet therapy demonstrated healing on 52% of follow-up imaging studies versus 25% in the anticoagulation cohort.

Conclusion: There were no observed differences in the rate of hemorrhagic complications between anticoagulation and antiplatelet therapy for BCVI in children < 10 years, with a nonsignificantly better rate of healing on follow-up imaging in children who underwent antiplatelet therapy; however, the study cohort was small despite including patients from 5 hospitals.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s00381-020-04672-wDOI Listing
January 2021

Predicting Death After Thrombectomy in the Treatment of Acute Stroke.

Front Surg 2020 8;7:16. Epub 2020 Apr 8.

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, UT, United States.

Treatments for acute stroke have significantly improved in the past decade, with emergent thrombectomy emerging as the standard of care. Despite these advancements, death after successful thrombectomy continues to pose a significant problem. Identifying patients least likely to benefit from thrombectomy would improve use of a limited resource and management of patient expectations. We retrospectively reviewed the medical records of patients who underwent emergent thrombectomy of either anterior or posterior circulation strokes between January 2012 and January 2017. Relevant patient clinical data was collected and analyzed in a multivariable regression with a primary outcome of death at 90 days. A total of 134 patients underwent emergent endovascular thrombectomy during the study period; sufficient clinical data was available in 111 of the them. Of these, 42 patients died during the 90 day post-procedural period and 69 patients survived this period. The mean NIHSS score at presentation was 14.9 in surviving patients and 19.6 in non-surviving patients ( < 0.002). Surviving patients were less likely to have a history of cancer (4.4% vs. 26.2%, < 0.002), achieved higher rates of revascularization (78.3% vs. 50.0%, < 0.003), had a lower rate of hemorrhagic conversion (21.7% vs. 47.6%, < 0.004), and experienced fewer technical complications during their treatment (7.4% vs. 26.2%, < 0.01). Overall, there were 16 intraprocedural complications and no procedural deaths. As emergent thrombectomy for the treatment of acute stroke becomes more prevalent, appropriate patient selection will be crucial in the utilization of a limited and costly intervention. Death within 90 days after thrombectomy appears to be more prevalent among patients with higher NIHSS at presentation, those with postprocedural hemorrhage or intraprocedural complications, and those with a history of cancer.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3389/fsurg.2020.00016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7156540PMC
April 2020

Prenatal counseling for myelomeningocele in the era of fetal surgery: a shared decision-making approach.

J Neurosurg Pediatr 2020 Feb 28:1-8. Epub 2020 Feb 28.

1Division of Pediatric Neurosurgery.

Objective: The Management of Myelomeningocele Study demonstrated that fetal surgery, as compared to postnatal repair, decreases the rate of hydrocephalus and improves expected motor function. However, fetal surgery is associated with significant maternal and neonatal risks including uterine wall dehiscence, prematurity, and fetal or neonatal death. The goal of this study was to provide information about counseling expectant mothers regarding myelomeningocele in the era of fetal surgery.

Methods: The authors conducted an extensive review of topics pertinent to counseling in the setting of myelomeningocele and introduce a new model for shared decision-making to aid practitioners during counseling.

Results: Expectant mothers must decide in a timely manner among several potential options, namely termination of pregnancy, postnatal surgery, or fetal surgery. Multiple factors influence the decision, including maternal health, fetal heath, financial resources, social support, risk aversion, access to care, family planning, and values. In many cases, it is a difficult decision that benefits from the guidance of a pediatric neurosurgeon.

Conclusions: The authors review critical issues of prenatal counseling for myelomeningocele and discuss the process of shared decision-making as a framework to aid expectant mothers in choosing the treatment option best for them.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.12.PEDS19449DOI Listing
February 2020

Transcallosal Interforniceal Approach for a Large Choroid Plexus Tumor in a 4-Month-Old Boy: 2-Dimensional Operative Video.

Oper Neurosurg (Hagerstown) 2020 Sep;19(3):E295

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

Tumors in the third ventricle constitute a challenge for the neurosurgeon, regardless of the chosen approach. The additional risk of severe blood loss in the pediatric population, specially for choroid plexus tumors, which are the most common ventricular tumors in children, adds a significant challenge in these cases. Therefore, a careful selection of the approach in addition to surgical technique is crucial for a favorable outcome. In this video, we discuss the approach selected for the treatment of a large choroid plexus tumor in a 4-mo-old male and highlight the surgical technique chosen for this case, a transcallosal interforniceal approach.1 Appropriate consent for the video authorization and the procedure was obtained from the parent of the patient. Images in video from Rhoton AL Jr, The Cerebrum, Neurosurgery, 2007, 61, suppl_1, SHC-37-SHC-119, by permission of the Congress of Neurological Surgeons.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/ons/opz419DOI Listing
September 2020

Preoperative computed tomography perfusion in pediatric moyamoya disease: a single-institution experience.

J Neurosurg Pediatr 2020 Jan 24:1-8. Epub 2020 Jan 24.

4Department of Neurosurgery, Northwestern University Feinberg School of Medicine; and.

Objective: Moyamoya disease is a progressive occlusive arteriopathy for which surgical revascularization is indicated. In this retrospective study, the authors investigated the use of preoperative CT perfusion with the aim of establishing pathological data references.

Methods: The authors reviewed the medical records of children with moyamoya disease treated surgically at one institution between 2016 and 2019. Preoperative CT perfusion studies were used to quantify mean transit time (MTT), cerebral blood volume (CBV), cerebral blood flow (CBF), and time to peak (TTP) for the anterior, middle, and posterior cerebral artery vascular territories for each patient. CT perfusion parameter ratios (diseased/healthy hemispheres) and absolute differences were compared between diseased and normal vascular territories (defined by catheter angiography studies). Sensitivity, specificity, and positive (PPV) and negative (NPV) predictive values for CT perfusion parameters for severe angiographic moyamoya were calculated.

Results: Nine children (89% female) had preoperative CT perfusion data; 5 of them had evidence of unilateral hemispheric disease and 4 had bilateral disease. The mean age at revascularization was 77 months (range 40-144 months). The etiology of disease was neurofibromatosis type 1 (3 patients), Down syndrome (2), primary moyamoya disease (2), cerebral proliferative angiopathy (1), and sickle cell disease (1). Five patients had undergone unilateral revascularization. Among these patients, pathological vascular territories demonstrated increased MTT in 66% of samples, increased TTP in 66%, decreased CBF in 47%, and increased CBV in 87%. Severe moyamoya (Suzuki stage ≥ 4) had diseased/healthy ratios ≥ 1 for MTT in 78% of cases, for TTP in 89%, for CBF in 67%, and for CBV in 89%. The MTT and TTP region of interest ratio ≥ 1 demonstrated 89% sensitivity, 67% specificity, 80% PPV, and 80% NPV for the prediction of severe angiographic moyamoya disease.

Conclusions: Pathological hemispheres in these children with moyamoya disease demonstrated increased MTT, TTP, and CBV and decreased CBF. The authors' results suggest that preoperative CT perfusion may, with high sensitivity, be useful in deciphering perfusion mismatch in brain tissue in children with moyamoya disease. More severe angiographic disease displays a more distinct correlation, allowing surgeons to recognize when to intervene in these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.10.PEDS19450DOI Listing
January 2020

Salvage sacrococcygeal resection for yolk sac tumors after chemotherapy: report of 2 cases.

J Neurosurg Pediatr 2019 Oct 4:1-8. Epub 2019 Oct 4.

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

Pediatric germ cell tumors (GCTs) are neoplasms that originate from primordial germ cells and, according to their site of presentation, are classified as gonadal or extragonadal. The most common site of extragonadal GCTs in children is the sacrococcygeal region, and the standard management is multimodal with a focus on chemotherapy. In selected instances, sacrococcygeal resection is performed. Herein, the authors report on 2 patients who presented with presacral yolk sac tumors managed with multimodal treatment. Both patients underwent salvage sacrococcygeal resection for oncological control and surgical removal of the sacral vertebral elements: a 27-month-old girl with a recurrent sacrococcygeal yolk sac tumor following chemotherapy and initial resection and a 24-month-old boy in whom a primary sacrococcygeal yolk sac tumor was resected following chemotherapy. These 2 cases illustrate the complexity in the management of these unusual tumors and will help neurosurgeons with the understanding of yolk sac tumors in the sacrococcygeal region.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.7.PEDS19321DOI Listing
October 2019

Neuroprotection for ischemic stroke in the endovascular era: A brief report on the future of intra-arterial therapy.

J Clin Neurosci 2019 Nov 17;69:289-291. Epub 2019 Aug 17.

Department of Neurosurgery, University of Michigan, Ann Arbor, MI, United States. Electronic address:

Mechanical thrombectomy is now at the forefront of the treatment of large vessel acute ischemic stroke (AIS). Selective intra-arterial (IA) access has opened a new avenue for neuroprotection in AIS that has the potential to maximize local benefit while minimizing systemic effects. On a cellular level, neuroprotective strategies are aimed at reducing inflammation and free-radical formation, maintaining blood-brain barrier fidelity, and preventing cellular death. Strategies under investigation include IA infusion of neuroprotective agents, IA administration of stem cells, and selective IA hypothermia. In this technical report, we briefly discuss pathologic mechanisms in AIS and highlight potential neuroprotective strategies that are administered selectively via the IA route.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1016/j.jocn.2019.08.001DOI Listing
November 2019

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.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.5.PEDS1977DOI Listing
August 2019

A national analysis of 9655 pediatric cerebrovascular malformations: effect of hospital volume on outcomes.

J Neurosurg Pediatr 2019 Aug 2:1-10. Epub 2019 Aug 2.

2Department of Neurosurgery, Children's Hospital Boston.

Objective: Comprehensive multicenter data on the surgical treatment of pediatric cerebrovascular malformations (CVMs) in the US are lacking. The goal of this study was to identify national trends in patient demographics and assess the effect of hospital case volume on outcomes.

Methods: Admissions for CVMs (1997-2012) were identified from the nationwide Kids' Inpatient Database. Admissions with and without craniotomy were reviewed separately. Patients were categorized by whether they were treated at low-, medium-, or high-volume centers (< 10, 10-40, > 40 cases/year, respectively). A generalized linear model was used to evaluate the association of hospital pediatric CVM case volume and clinical variables assessing outcomes.

Results: Among the 9655 patients, 1828 underwent craniotomy and 7827 did not. Patient age and race differed in the two groups, as did the rate of private medical payers. High-volume hospitals had fewer nonroutine discharges (11.2% [high] vs 16.4% [medium] vs 22.3% [low], p = 0.0001). For admissions requiring craniotomy, total charges ($106,282 [high] vs $126,215 [medium] vs $134,978 [low], p < 0.001) and complication rates (0.09% [high] vs 0.11% [medium] vs 0.16% [low], p = 0.001) were lower in high-volume centers.

Conclusions: This study revealed that further investigation may be needed regarding barriers to surgical treatment of pediatric CVMs. The authors found that surgical treatment of pediatric CVM at high-volume centers is associated with significantly fewer complications, better dispositions, and lower costs, but for noncraniotomy patients, low-volume centers had lower rates of complications and death and lower costs. These findings may support the consideration of appropriate referral of CVM patients requiring surgery or with intracranial hemorrhage toward high-volume, specialized centers.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.5.PEDS19155DOI Listing
August 2019

A study of pediatric cerebral arteriovenous malformations: clinical presentation, radiological features, and long-term functional and educational outcomes with predictors of sustained neurological deficits.

J Neurosurg Pediatr 2019 04;24(1):1-8

3Department of Neurosurgery, Harvard Medical School, Division of Pediatric Neurosurgery, Boston Children's Hospital, Boston, Massachusetts; and.

Objective: Large experiences with the treatment of pediatric arteriovenous malformations (AVMs) remain relatively rare, with limited data on presentation, treatment, and long-term functional outcomes. Because of the expected long lifespan of children, caregivers are especially interested in outcome measures that assess quality of life. The authors' intention was to describe the long-term functional outcomes of pediatric patients who undergo AVM surgery and to identify predictors of sustained neurological deficits.

Methods: The authors analyzed a 21-year retrospective cohort of pediatric patients with intracranial AVMs treated with microsurgery at two institutions. The primary outcome was a persistent neurological deficit at last follow-up. Secondary outcome measures included modified Rankin Scale (mRS) score and independent living.

Results: Overall, 97 patients (mean age 11.1 ± 4.5 years; 56% female) were treated surgically for intracranial AVMs (mean follow-up 77.5 months). Sixty-four patients (66%) presented with hemorrhage, and 45 patients (46%) had neurological deficits at presentation. Radiologically, 39% of lesions were Spetzler-Martin grade II. Thirty-seven patients (38%) with persistent neurological deficits at last follow-up were compared with those without deficits; there were no differences in patient age, presenting Glasgow Coma Scale score, AVM size, surgical blood loss, or duration of follow-up. Multivariate analysis demonstrated that a focal neurological deficit on presentation, AVM size > 3 cm, and lesions in eloquent cortex were independent predictors of persistent neurological deficits at long-term follow-up. Overall, 92% of the children had an mRS score ≤ 2 on long-term follow-up.

Conclusions: Pediatric patients with AVMs treated with microsurgical resection have good functional and radiological outcomes. There is a high rate (38%) of persistent neurological deficits, which were independently predicted by preoperative deficits, AVMs > 3 cm, and lesions located in eloquent cortex. This information can be useful in counseling families on the likelihood of long-term neurological deficits after cerebral AVM surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2019.2.PEDS18731DOI Listing
April 2019

EQ-5D Quality-of-Life Analysis and Cost-Effectiveness After Skull Base Meningioma Resection.

Neurosurgery 2019 09;85(3):E543-E552

Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah.

Background: Skull base meningioma management is complicated by their proximity to intracranial neurovascular structures because complete resection may pose a risk of worsening morbidity.

Objective: To assess the influence of clinical outcomes and surgical management on patient-perceived quality-of-life outcomes, value, and cost-effectiveness.

Methods: Patients who underwent resection of a skull base meningioma, had adequate clinical follow-up, and completed EQ-5D-3L questionnaires preoperatively and at 1 mo and 1 yr postoperatively were identified in a retrospective review. Cost data from the Value Driven Outcomes database were analyzed.

Results: A total of 52 patients (83.0% women, mean age 51.9 yr) were categorized by worsened (n = 7), unchanged (n = 24), or improved (n = 21) EQ-5D-3L index scores at 1-mo follow-up. No difference in subcategory cost contribution or total cost was seen in the 3 groups. Patients with improved scores showed a steady improvement through each follow-up period, whereas those with unchanged or worsened scores did not. Mean quality-adjusted life years (QALYs) and cost per QALY improved for all groups but at a higher rate for patients with better outcomes at 30-d follow-up. Female sex, absence of proptosis, nonfrontotemporal approaches, no optic nerve decompression, and absence of surgical complications demonstrated improved EQ-5D-3L scores at 1-yr follow-up. A mean cost per QALY of $27 731.06 ± 22 050.58 was observed for the whole group and did not significantly differ among patient groups (P = .1).

Conclusion: Patients undergoing resection of skull base meningiomas and who experience an immediate improvement in EQ-5D are likely to show continued improvement at 1 yr, with improved QALY and reduced cost per QALY.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1093/neuros/nyz040DOI Listing
September 2019

Defining a new neurosurgical complication classification: lessons learned from a monthly Morbidity and Mortality conference.

J Neurosurg 2019 Jan 18:1-5. Epub 2019 Jan 18.

OBJECTIVEThe absence of a commonly accepted standardized classification system for complication reporting confounds the recognition, objective reporting, management, and avoidance of perioperative adverse events. In the past decade, several classification systems have been proposed for use in neurosurgery, but these generally focus on tallying specific complications and grading their effect on patient morbidity. Herein, the authors propose and prospectively validate a new neurosurgical complication classification based on understanding the underlying causes of the adverse events.METHODSA new complication classification system was devised based on the authors' previous work on morbidity in endovascular surgery. Adverse events were prospectively compiled for all neurosurgical procedures performed at their tertiary care academic medical center over the course of 1 year into 5 subgroups: 1) indication errors; 2) procedural errors; 3) technical errors; 4) judgment errors; and 5) critical events. The complications were presented at the monthly institutional Morbidity and Mortality conference where, following extensive discussion, they were assigned to one of the 5 subgroups. Additional subgroup analyses by neurosurgical subspecialty were also performed.RESULTSA total of 115 neurosurgical complications were observed and analyzed during the study period. Of these, nearly half were critical events, while technical errors accounted for approximately one-third of all complications. Within neurosurgical subspecialties, vascular neurosurgery (36.5%) had the most complications, followed by spine & peripheral nerve (21.7%), neuro-oncology (14.8%), cranial trauma (13.9%), general neurosurgery (12.2%), and functional neurosurgery (0.9%).CONCLUSIONSThe authors' novel neurosurgical complication classification system was successfully implemented in a prospective manner at their high-volume tertiary medical center. By employing the well-established Morbidity and Mortality conference mechanism, this simple system may be easily applied at other neurosurgical centers and may allow for uniform analyses of perioperative morbidity and the introduction of corrective initiatives.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2018.9.JNS181004DOI Listing
January 2019

Degenerative Lumbar Spine Disease: Estimating Global Incidence and Worldwide Volume.

Global Spine J 2018 Dec 24;8(8):784-794. Epub 2018 Apr 24.

Harvard Medical School, Boston, MA, USA.

Study Design: Meta-analysis-based calculation.

Objectives: Lumbar degenerative spine disease (DSD) is a common cause of disability, yet a reliable measure of its global burden does not exist. We sought to quantify the incidence of lumbar DSD to determine the overall worldwide burden of symptomatic lumbar DSD across World Health Organization regions and World Bank income groups.

Methods: We used a meta-analysis to create a single proportion of cases of DSD in patients with low back pain (LBP). Using this information in conjunction with LBP incidence rates, we calculated the global incidence of individuals who have DSD and LBP (ie, their DSD has neurosurgical relevance) based on the Global Burden of Disease 2015 database.

Results: We found that 266 million individuals (3.63%) worldwide have DSD and LBP each year; the highest and lowest estimated incidences were found in Europe (5.7%) and Africa (2.4%), respectively. Based on population sizes, low- and middle-income countries have 4 times as many cases as high-income countries. Thirty-nine million individuals (0.53%) worldwide were found to have spondylolisthesis, 403 million (5.5%) individuals worldwide with symptomatic disc degeneration, and 103 million (1.41%) individuals worldwide with spinal stenosis annually.

Conclusions: A total of 266 million individuals (3.63%) worldwide were found to have DSD and LBP annually. Significantly, data quality is higher in high-income countries, making overall quantification in low- and middle-income countries less complete. A global effort to address degenerative conditions of the lumbar spine in regions with high demand is important to reduce disability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/2192568218770769DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6293435PMC
December 2018

North American survey on the post-neuroimaging management of children with mild head injuries.

J Neurosurg Pediatr 2018 10;23(2):227-235

Departments of1Neurological Surgery.

OBJECTIVEThere remains uncertainty regarding the appropriate level of care and need for repeating neuroimaging among children with mild traumatic brain injury (mTBI) complicated by intracranial injury (ICI). This study's objective was to investigate physician practice patterns and decision-making processes for these patients in order to identify knowledge gaps and highlight avenues for future investigation.METHODSThe authors surveyed residents, fellows, and attending physicians from the following pediatric specialties: emergency medicine; general surgery; neurosurgery; and critical care. Participants came from 10 institutions in the United States and an email list maintained by the Canadian Neurosurgical Society. The survey asked respondents to indicate management preferences for and experiences with children with mTBI complicated by ICI, focusing on an exemplar clinical vignette of a 7-year-old girl with a Glasgow Coma Scale score of 15 and a 5-mm subdural hematoma without midline shift after a fall down stairs.RESULTSThe response rate was 52% (n = 536). Overall, 326 (61%) respondents indicated they would recommend ICU admission for the child in the vignette. However, only 62 (12%) agreed/strongly agreed that this child was at high risk of neurological decline. Half of respondents (45%; n = 243) indicated they would order a planned follow-up CT (29%; n = 155) or MRI scan (19%; n = 102), though only 64 (12%) agreed/strongly agreed that repeat neuroimaging would influence their management. Common factors that increased the likelihood of ICU admission included presence of a focal neurological deficit (95%; n = 508 endorsed), midline shift (90%; n = 480) or an epidural hematoma (88%; n = 471). However, 42% (n = 225) indicated they would admit all children with mTBI and ICI to the ICU. Notably, 27% (n = 143) of respondents indicated they had seen one or more children with mTBI and intracranial hemorrhage demonstrate a rapid neurological decline when admitted to a general ward in the last year, and 13% (n = 71) had witnessed this outcome at least twice in the past year.CONCLUSIONSMany physicians endorse ICU admission and repeat neuroimaging for pediatric mTBI with ICI, despite uncertainty regarding the clinical utility of those decisions. These results, combined with evidence that existing practice may provide insufficient monitoring to some high-risk children, emphasize the need for validated decision tools to aid the management of these patients.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3171/2018.7.PEDS18263DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717430PMC
October 2018
-->