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Anderson L, Hopson B, Caudill C, Rocque BG, Blount J, Arynchyna-Smith A, Thrower J, Johnston J, Rozzelle C. Evaluation of multidisciplinary high-risk pregnancy clinic for myelomeningocele. Childs Nerv Syst 2024:10.1007/s00381-024-06337-4. [PMID: 38644383 DOI: 10.1007/s00381-024-06337-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2024] [Accepted: 02/26/2024] [Indexed: 04/23/2024]
Abstract
INTRODUCTION A cross-sectional study retrospectively evaluating the perceived usefulness of attending a multi-disciplinary, roundtable, educational prenatal clinic for mothers expecting children with myelomeningocele is presented. METHODS Mothers who currently have children with SB completed a survey which evaluated their overall preparedness, spina bifida education, delivery plans, surgical expectations, and expectations in terms of quality of life and development. Open comments were also collected. Statistical analysis was performed to identify differences between those who attended prenatal counseling and those who did not. RESULTS Approximately half of these mothers received some form of prenatal SB counseling. Mothers who attended prenatal counseling reported that they felt more informed and prepared throughout their pregnancy, during the delivery of their child and during their initial hospital stay than mothers who did not. They reported that the roundtable discussions were beneficial, and the education they received was useful in helping them form accurate expectations and feel more at ease. CONCLUSION This suggests that prenatal counseling and the High-Risk Pregnancy Clinic (HRPC) provides perceived utility to families and mothers and that the HRPC is an effective method of providing prenatal counseling to mothers whose unborn children have been diagnosed with myelomeningocele.
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Affiliation(s)
- Luke Anderson
- Marnix E. Heersink School of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Betsy Hopson
- Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA.
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA.
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, 1600 7th Ave S., Lowder 400, Birmingham, AL, USA.
| | - Caroline Caudill
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, 1600 7th Ave S., Lowder 400, Birmingham, AL, USA
| | - Brandon G Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, 1600 7th Ave S., Lowder 400, Birmingham, AL, USA
| | - Jeffrey Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, 1600 7th Ave S., Lowder 400, Birmingham, AL, USA
| | - Anastasia Arynchyna-Smith
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, 1600 7th Ave S., Lowder 400, Birmingham, AL, USA
| | - Jessica Thrower
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, 1600 7th Ave S., Lowder 400, Birmingham, AL, USA
| | - James Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, 1600 7th Ave S., Lowder 400, Birmingham, AL, USA
| | - Curtis Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, AL, USA
- Division of Pediatric Neurosurgery, University of Alabama at Birmingham, 1600 7th Ave S., Lowder 400, Birmingham, AL, USA
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Akbari SHA, Mooney J, Lepard J, Arynchyna-Smith A, McClugage S, Myers R, Grant J, Rozzelle C, Johnston JM. Racial differences in the care of pediatric sagittal craniosynostosis: a single-institution cohort study affecting state Medicaid policy. J Neurosurg Pediatr 2023; 32:464-471. [PMID: 37486863 DOI: 10.3171/2023.5.peds2335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/30/2023] [Indexed: 07/26/2023]
Abstract
OBJECTIVE Although research has shown the cost-effectiveness of endoscopic versus open repair of sagittal synostosis, few studies have shown how race, insurance status, and area deprivation impact care for these patients. The authors analyzed data from children evaluated for sagittal synostosis at a single institution to assess how socioeconomic factors, race, and insurance status affect the surgical treatment of this population. They hypothesized that race and indicators of disadvantage negatively impact workup and surgical timing for craniosynostosis surgery. METHODS Medical records of patients treated for sagittal synostosis between 2010 and 2019 were reviewed. Area deprivation index (ADI) and rural-urban commuting area codes, as well as median income by zip code, were used to measure neighborhood disadvantage. Black and White patients were compared as well as patients using Medicaid versus private insurance. RESULTS Fifty patients were prospectively included in the study. Thirty-one underwent open repair; 19 had endoscopic repair. All 8 (100%) Black patients had open repair, compared to 54.8% of White patients (p = 0.018). Black patients were more likely to use Medicaid compared to White patients (75.0% vs 28.6%, p = 0.019). White patients were younger at surgery (5.5 vs 10.0 months, p = 0.001), and Black patients had longer surgeries (147.5 minutes vs 110.0 minutes, p = 0.021). The median household income by zip code was similar for the two groups. Black patients were generally from areas of greater disadvantage compared to White patients, based on both state and national ADI scores (state: 7.5 vs 4.0, p = 0.013; national: 83.5 vs 60.0, p = 0.013). All (94.7%) but 1 patient undergoing endoscopic repair used private insurance compared to 14 (45.2%) patients in the open repair group (p = 0.001). Patients using Medicaid were from areas of greater disadvantage compared to those using private insurance by both state and national ADI scores (state: 6.0 vs 3.0, p = 0.001; national: 75.0 vs 52.0, p = 0.001). CONCLUSIONS Because Medicaid in the geographic region of this study did not cover helmeting after endoscopic repair of sagittal synostosis, these patients usually had open repair, resulting in significant racial and socioeconomic disparities in treatment of sagittal synostosis. This research has led to a change in Alabama Medicaid policy to now cover the cost of postoperative helmeting.
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Affiliation(s)
- S Hassan A Akbari
- 1Department of Neurosurgery, Penn State College of Medicine, Hershey, Pennsylvania; and
| | | | | | | | | | - Rene Myers
- 3Plastic Surgery, The University of Alabama at Birmingham, Alabama
| | - John Grant
- 3Plastic Surgery, The University of Alabama at Birmingham, Alabama
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Ravindra VM, Jensen H, Riva-Cambrin J, Wellons JC, Limbrick DD, Pindrik J, Jackson EM, Pollack IF, Hankinson TC, Hauptman JS, Tamber MS, Kulkarni AV, Rocque BG, Rozzelle C, Whitehead WE, Chu J, Krieger MD, Simon TD, Reeder R, McDonald PJ, Nunn N, Kestle JRW. Comparison of outcomes in the management of abdominal pseudocyst in children with shunted hydrocephalus: a Hydrocephalus Clinical Research Network study. J Neurosurg Pediatr 2023; 32:312-323. [PMID: 37327184 DOI: 10.3171/2023.4.peds23129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 04/26/2023] [Indexed: 06/18/2023]
Abstract
OBJECTIVE Abdominal pseudocyst (APC) can cause distal site failure in children with ventriculoperitoneal shunts and is specifically designated as an infection in Hydrocephalus Clinical Research Network (HCRN) protocols. Specific management and outcomes of children with APCs have not been reported in a multicenter study. In this study, the authors investigated the management and outcomes of APC in children with shunted hydrocephalus who were treated at centers in the HCRN. METHODS The HCRN Registry was queried to identify children < 18 years old with shunts who were diagnosed with an APC (i.e., a loculated abdominal fluid collection containing the peritoneal catheter with abdominal distention and/or displacement of peritoneal contents). The primary outcome was shunt failure after APC treatment. The primary variable was reimplantation of the distal catheter after pseudocyst treatment back into the peritoneum versus implantation in a nonperitoneal site. Other risk factors for shunt failure after APC treatment and variability in APC management were investigated. RESULTS Among 141 children from 14 centers who underwent first-time management of an APC over a 14-year period, the median time from previous shunt surgery to APC diagnosis was 3.8 months. Overall, 17.7% of children had a positive culture: APC cultures were positive in 14.2% and CSF cultures in 15.6%. Six other children underwent shunt revision without removal; all underwent reoperation within 1 month. There was no difference in shunt survival (log-rank test, p = 0.42) or number of subsequent revisions within 6, 12, or 24 months for shunts reimplanted in the abdomen versus those implanted in a nonperitoneal location. Nonperitoneal implantation was associated with more noninfectious revisions (42.3% vs 22.9%, p = 0.019), whereas infection was more common after reimplantation in the abdomen (25.7% vs 7.0%, p = 0.003). Univariable analysis demonstrated that younger age at APC diagnosis (8.3 vs 12.2 years, p = 0.006) and prior shunt procedure within 12 weeks of APC diagnosis (59.5% vs 40.5%, p = 0.012) were associated with shunt failure after APC treatment. Multivariable modeling confirmed that prior shunt surgery within 12 weeks of APC diagnosis was independently associated with failure (HR 1.79 [95% CI 1.04-3.07], p = 0.035). CONCLUSIONS In the HCRN, APCs in the setting of CSF shunts are usually managed with externalization. Shunt surgery within 12 weeks of APC diagnosis was associated with risk of failure after APC treatment. Although no differences were found in overall shunt failure rate, noninfectious shunt revisions were more common in the nonperitoneal distal catheter sites, and infection was a more common reason for failure after reimplantation of the shunt in the abdomen.
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Affiliation(s)
- Vijay M Ravindra
- Departments of1Neurosurgery and
- 2Division of Neurosurgery, University of California, San Diego
- 3Department of Neurosurgery, Naval Medical Center San Diego, California
| | - Hailey Jensen
- 4Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jay Riva-Cambrin
- 5Department of Clinical Neurosciences, Section of Neurosurgery, University of Calgary, Alberta, Canada
| | - John C Wellons
- 6Division of Pediatric Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - David D Limbrick
- 7Department of Neurosurgery, St. Louis Children's Hospital, Washington University in St. Louis, Missouri
| | - Jonathan Pindrik
- 8Department of Neurological Surgery, Division of Pediatric Neurosurgery, Nationwide Children's Hospital, The Ohio State University, Columbus, Ohio
| | - Eric M Jackson
- 9Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Ian F Pollack
- 10Department of Neurosurgery, Children's Hospital of Pittsburgh, University of Pittsburgh, Pennsylvania
| | - Todd C Hankinson
- 11Department of Neurosurgery, Children's Hospital Colorado, University of Colorado, Aurora, Colorado
| | - Jason S Hauptman
- 12Department of Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Mandeep S Tamber
- 13Department of Surgery, Division of Neurosurgery, British Columbia Children's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
| | - Abhaya V Kulkarni
- 14Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Brandon G Rocque
- 15Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Curtis Rozzelle
- 15Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - William E Whitehead
- 16Department of Neurosurgery, Division of Pediatric Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Jason Chu
- Departments of17Neurosurgery, Division of Neurosurgery, and
| | - Mark D Krieger
- Departments of17Neurosurgery, Division of Neurosurgery, and
| | - Tamara D Simon
- 18Pediatrics, Children's Hospital Los Angeles, University of Southern California, Los Angeles, California; and
| | - Ron Reeder
- 4Pediatrics, University of Utah, Salt Lake City, Utah
| | - Patrick J McDonald
- 19Department of Surgery, Section of Neurosurgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nichol Nunn
- 4Pediatrics, University of Utah, Salt Lake City, Utah
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Maleknia P, McWilliams TD, Barkley A, Estevez-Ordonez D, Rozzelle C, Blount JP. Postoperative seizure freedom after vagus nerve stimulator placement in children 6 years of age and younger. J Neurosurg Pediatr 2023; 31:329-332. [PMID: 36670534 DOI: 10.3171/2022.12.peds22302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 12/27/2022] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Food and Drug Administration (FDA) approval for vagus nerve stimulator (VNS) implantation is limited to patients older than 4 years of age with medically refractory partial-onset seizures. In younger children with severe generalized epilepsy, however, VNS implantation remains off-label. In this study, the authors followed up on their previously reported cohort to review the longer-term safety and efficacy of VNS placement in children younger than 6 years with generalized medically refractory epilepsy (MRE), providing the largest cohort with > 2 years of follow-up to date in this age group. METHODS This was a retrospective observational cohort study of patients younger than 6 years of age with generalized MRE who underwent VNS implantation at a single institution between 2010 and 2020. Inclusion criteria encompassed failure of more than two antiepileptic drugs alone or in combination, neurologist referral for vagus nerve stimulation, informed consent with knowledge of the off-label status in young children, and > 1 year of follow-up. Outcome measures included seizure reduction rate ≥ 50% and postoperative morbidity defined nominally. Statistical analysis was conducted with Stata/SE. RESULTS Forty-five patients were included: 11 patients younger than 4 years of age and 34 between 4 and 6 years of age. There were no intraoperative complications. Perioperative complications within 1 year occurred in 11% (n = 5) of the patients and included two wound infections, a mild cough, hyperactivity, hoarseness, and 1 patient with persistent surgical site pain. A seizure reduction ≥ 50% was observed in 36.4% (n = 4) of the patients younger than 4 years of age at the 6-month and 1-, 2-, and 5-year follow-ups. In the 4- to 6-year-old cohort, this was observed in 32.4% (n = 11) of the patients at 6 months, 41.2% (n = 14) at 1 year, 38.2% (n = 13) at 2 years, and 41.2% (n = 14) at 5 years. CONCLUSIONS VNS implantation for patients younger than 4 years of age with generalized onset MRE has not been approved by the FDA. This retrospective study establishes feasibility, illustrates an acceptable safety profile in children younger than 6 years, and demonstrates efficacy comparable to that reported in older patients.
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Affiliation(s)
- Pedram Maleknia
- 1School of Medicine, University of Alabama at Birmingham; and
| | | | - Ariana Barkley
- 2Division of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Dagoberto Estevez-Ordonez
- 2Division of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Curtis Rozzelle
- 2Division of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
| | - Jeffrey P Blount
- 2Division of Neurosurgery, University of Alabama at Birmingham, Children's of Alabama, Birmingham, Alabama
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5
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Mooney JH, Salehani A, Shannon C, Rozzelle C. 746 PGY-6 Versus PGY-7 Neurosurgical Chief Year: A Survey of Residents and Program Directors. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/18/2023] Open
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Mooney J, Laskay NMB, Salehani A, Shannon CN, Rozzelle C. Postgraduate Year 6 Versus Postgraduate Year 7 Neurosurgical Chief Year: A Survey of Residents and Program Directors. World Neurosurg 2023; 171:e679-e685. [PMID: 36563850 DOI: 10.1016/j.wneu.2022.12.084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 12/17/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVE Recently, more neurosurgical residency programs have transitioned from a postgraduate year (PGY)-7 to a PGY-6 chief year. There has not been a national analysis of resident and program director perceptions regarding the timing of chief year conductance and its influence on overall program satisfaction. METHODS An online survey was distributed to all North American PGY 4-7 residents and program directors. Data regarding program size, protected research timing, chief year timing (PGY-6 vs. PGY-7), and resident and program director perceptions of the influence of neurosurgical chief year timing on program satisfaction and ability of residents to practice were recorded. Survey results were summarized descriptively. RESULTS A total of 134 respondents completed the survey. Thirty-five percent of respondents reported a recent program transition from a PGY-7 to PGY-6 chief year while 44% of respondents at programs conducting a PGY-7 chief year reported they were interested in transitioning to a PGY-6 chief year. The large majority (76%) of respondents at PGY-6 chief year programs stated they were overall satisfied with this. A large percentage of all respondents reported that a PGY-6 chief year provided increased opportunity for subspecialty focus, enfolded fellowships and career planning. CONCLUSIONS Program directors and residents at PGY-6 chief year programs report a high level of satisfaction with close to half of those at PGY-7 programs desiring to make this transition. Most PGY-6 chief year respondents report that this model allows for greater subspecialty focus and career planning during the PGY-7 year.
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Affiliation(s)
- James Mooney
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA.
| | - Nicholas M B Laskay
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Arsalaan Salehani
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Chevis N Shannon
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Curtis Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
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Dastagirzada YM, Alexiades NG, Kurland DB, Anderson SN, Brockmeyer DL, Bumpass DB, Chatterjee S, Groves ML, Hankinson TC, Harter D, Hedequist D, Jea A, Leonard JR, Martin JE, Oetgen ME, Pahys J, Rozzelle C, Strahle JM, Thompson D, Yaszay B, Anderson RCE. Developing consensus for the management of pediatric cervical spine disorders and stabilization: a modified Delphi study. J Neurosurg Pediatr 2023; 31:32-42. [PMID: 36308472 DOI: 10.3171/2022.9.peds22319] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2022] [Accepted: 09/14/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical spine disorders in children are relatively uncommon; therefore, paradigms for surgical and nonsurgical clinical management are not well established. The purpose of this study was to bring together an international, multidisciplinary group of pediatric cervical spine experts to build consensus via a modified Delphi approach regarding the clinical management of children with cervical spine disorders and those undergoing cervical spine stabilization surgery. METHODS A modified Delphi method was used to identify consensus statements for the management of children with cervical spine disorders requiring stabilization. A survey of current practices, supplemented by a literature review, was electronically distributed to 17 neurosurgeons and orthopedic surgeons experienced with the clinical management of pediatric cervical spine disorders. Subsequently, 52 summary statements were formulated and distributed to the group. Statements that reached near consensus or that were of particular interest were then discussed during an in-person meeting to attain further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS Forty-five consensus-driven statements were identified, with all participants willing to incorporate them into their practice. For children with cervical spine disorders and/or stabilization, consensus statements were divided into the following categories: A) preoperative planning (12 statements); B) radiographic thresholds of instability (4); C) intraoperative/perioperative management (15); D) postoperative care (11); and E) nonoperative management (3). Several important statements reaching consensus included the following recommendations: 1) to obtain pre-positioning baseline signals with intraoperative neuromonitoring; 2) to use rigid instrumentation when technically feasible; 3) to provide postoperative external immobilization for 6-12 weeks with a rigid cervical collar rather than halo vest immobilization; and 4) to continue clinical postoperative follow-up at least until anatomical cervical spine maturity was reached. In addition, preoperative radiographic thresholds for instability that reached consensus included the following: 1) translational motion ≥ 5 mm at C1-2 (excluding patients with Down syndrome) or ≥ 4 mm in the subaxial spine; 2) dynamic angulation in the subaxial spine ≥ 10°; and 3) abnormal motion and T2 signal change on MRI seen at the same level. CONCLUSIONS In this study, the authors have demonstrated that a multidisciplinary, international group of pediatric cervical spine experts was able to reach consensus on 45 statements regarding the management of pediatric cervical spine disorders and stabilization. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.
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Affiliation(s)
- Yosef M Dastagirzada
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | | | - David B Kurland
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | | | - Douglas L Brockmeyer
- 4Department of Pediatric Neurosurgery, Primary Children's Medical Center, University of Utah, Salt Lake City, Utah
| | - David B Bumpass
- 5Department of Orthopedic Surgery, University of Arkansas, Little Rock, Arkansas
| | | | - Mari L Groves
- 7Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Hankinson
- 8Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - David Harter
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
| | - Daniel Hedequist
- 9Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Andrew Jea
- 10Department of Neurological Surgery, University of Oklahoma, Oklahoma City, Oklahoma
| | - Jeffrey R Leonard
- 11Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Jonathan E Martin
- 12Division of Pediatric Neurosurgery, Connecticut Children's, Hartford, Connecticut
| | - Matthew E Oetgen
- 13Division of Orthopedic Surgery and Sports Medicine, Children's National Hospital, Washington, DC
| | - Joshua Pahys
- 14Department of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Curtis Rozzelle
- 15Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham, Alabama
| | - Jennifer M Strahle
- 16Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Dominic Thompson
- 17Department of Neurosurgery, Great Ormond Street Hospital for Children, London, United Kingdom; and
| | - Burt Yaszay
- 18Department of Orthopedics, University of Washington, Seattle Children's Hospital, Seattle, Washington
| | - Richard C E Anderson
- 1Department of Neurological Surgery, New York University, Hassenfeld Children's Hospital, New York, New York
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Siegel L, Yan H, Warsi N, Wong S, Suresh H, Weil AG, Ragheb J, Wang S, Rozzelle C, Albert GW, Raskin J, Abel T, Hauptman J, Schrader DV, Bollo R, Smyth MD, Lew SM, Lopresti M, Kizek DJ, Weiner HL, Fallah A, Widjaja E, Ibrahim GM. Connectomic profiling and Vagus nerve stimulation Outcomes Study (CONNECTiVOS): a prospective observational protocol to identify biomarkers of seizure response in children and youth. BMJ Open 2022; 12:e055886. [PMID: 35396292 PMCID: PMC8995963 DOI: 10.1136/bmjopen-2021-055886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Vagus nerve stimulation (VNS) is a neuromodulation therapy that can reduce the seizure burden of children with medically intractable epilepsy. Despite the widespread use of VNS to treat epilepsy, there are currently no means to preoperatively identify patients who will benefit from treatment. The objective of the present study is to determine clinical and neural network-based correlates of treatment outcome to better identify candidates for VNS therapy. METHODS AND ANALYSIS In this multi-institutional North American study, children undergoing VNS and their caregivers will be prospectively recruited. All patients will have documentation of clinical history, physical and neurological examination and video electroencephalography as part of the standard clinical workup for VNS. Neuroimaging data including resting-state functional MRI, diffusion-tensor imaging and magnetoencephalography will be collected before surgery. MR-based measures will also be repeated 12 months after implantation. Outcomes of VNS, including seizure control and health-related quality of life of both patient and primary caregiver, will be prospectively measured up to 2 years postoperatively. All data will be collected electronically using Research Electronic Data Capture. ETHICS AND DISSEMINATION This study was approved by the Hospital for Sick Children Research Ethics Board (REB number 1000061744). All participants, or substitute decision-makers, will provide informed consent prior to be enrolled in the study. Institutional Research Ethics Board approval will be obtained from each additional participating site prior to inclusion. This study is funded through a Canadian Institutes of Health Research grant (PJT-159561) and an investigator-initiated funding grant from LivaNova USA (Houston, TX; FF01803B IIR).
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Affiliation(s)
- Lauren Siegel
- Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Han Yan
- Division of Neurosurgery, Hospital for Sick Children, Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Nebras Warsi
- Division of Neurosurgery, Hospital for Sick Children, Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Simeon Wong
- Program in Neuroscience and Mental Health, Hospital for Sick Children Research Institute, Toronto, Ontario, Canada
| | - Hrishikesh Suresh
- Division of Neurosurgery, Hospital for Sick Children, Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Alexander G Weil
- Pediatric Neurosurgery, Department of Surgery, Sainte Justine Hospital, University of Montreal, Montreal, Quebec, Canada
| | - John Ragheb
- Division of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Shelly Wang
- Division of Neurosurgery, Nicklaus Children's Hospital, Miami, Florida, USA
| | - Curtis Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Gregory W Albert
- Department of Neurosurgery, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Jeffrey Raskin
- Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Taylor Abel
- Department of Neurological Surgery, UPMC Children's Hospital of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jason Hauptman
- Department of Neurosurgery, Seattle Children's Hospital, Seattle, Washington, USA
| | - Dewi V Schrader
- Department of Pediatrics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Bollo
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah, USA
| | - Matthew D Smyth
- Department of Neurosurgery, Washington University School of Medicine in St Louis, Milwaukee, Wisconsin, USA
| | - Sean M Lew
- Department of Neurosurgery, Children's Hospital of Wisconsin, Milwaukee, Wisconsin, USA
| | - Melissa Lopresti
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Dominic J Kizek
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Howard L Weiner
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Aria Fallah
- Neurosurgery, University of California Los Angeles, Los Angeles, California, USA
| | - Elysa Widjaja
- Department of Diagnostic Imaging, Hospital for Sick Children, Toronto, Ontario, Canada
| | - George M Ibrahim
- Division of Neurosurgery, Hospital for Sick Children, Department of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
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9
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Alexiades NG, Shao B, Braga BP, Bonfield CM, Brockmeyer DL, Browd SR, DiLuna M, Groves ML, Hankinson TC, Jea A, Leonard JR, Lew SM, Limbrick DD, Mangano FT, Martin J, Pahys J, Powers A, Proctor MR, Rodriguez L, Rozzelle C, Storm PB, Anderson RCE. Development of best practices in the utilization and implementation of pediatric cervical spine traction: a modified Delphi study. J Neurosurg Pediatr 2021; 27:649-660. [PMID: 33799292 DOI: 10.3171/2020.10.peds20778] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 10/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Cervical traction in pediatric patients is an uncommon but invaluable technique in the management of cervical trauma and deformity. Despite its utility, little empirical evidence exists to guide its implementation, with most practitioners employing custom or modified adult protocols. Expert-based best practices may improve the care of children undergoing cervical traction. In this study, the authors aimed to build consensus and establish best practices for the use of pediatric cervical traction in order to enhance its utilization, safety, and efficacy. METHODS A modified Delphi method was employed to try to identify areas of consensus regarding the utilization and implementation of pediatric cervical spine traction. A literature review of pediatric cervical traction was distributed electronically along with a survey of current practices to a group of 20 board-certified pediatric neurosurgeons and orthopedic surgeons with expertise in the pediatric cervical spine. Sixty statements were then formulated and distributed to the group. The results of the second survey were discussed during an in-person meeting leading to further consensus. Consensus was defined as ≥ 80% agreement on a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). RESULTS After the initial round, consensus was achieved with 40 statements regarding the following topics: goals, indications, and contraindications of traction (12), pretraction imaging (6), practical application and initiation of various traction techniques (8), protocols in trauma and deformity patients (8), and management of traction-related complications (6). Following the second round, an additional 9 statements reached consensus related to goals/indications/contraindications of traction (4), related to initiation of traction (4), and related to complication management (1). All participants were willing to incorporate the consensus statements into their practice. CONCLUSIONS In an attempt to improve and standardize the use of cervical traction in pediatric patients, the authors have identified 49 best-practice recommendations, which were generated by reaching consensus among a multidisciplinary group of pediatric spine experts using a modified Delphi technique. Further study is required to determine if implementation of these practices can lead to reduced complications and improved outcomes for children.
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Affiliation(s)
- Nikita G Alexiades
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
| | - Belinda Shao
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York.,2Rutgers New Jersey Medical School, Newark, New Jersey
| | - Bruno P Braga
- 3Department of Neurosurgery, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Christopher M Bonfield
- 4Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Douglas L Brockmeyer
- 5Department of Pediatric Neurosurgery, Primary Children's Hospital, University of Utah, Salt Lake City, Utah
| | - Samuel R Browd
- 6Department of Neurosurgery, University of Washington/Seattle Children's Hospital, Seattle, Washington
| | - Michael DiLuna
- 7Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut
| | - Mari L Groves
- 8Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Todd C Hankinson
- 9Department of Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Andrew Jea
- 10Department of Neurological Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Jeffrey R Leonard
- 11Department of Neurosurgery, Nationwide Children's Hospital, The Ohio State University College of Medicine, Columbus, Ohio
| | - Sean M Lew
- 12Department of Pediatric Neurosurgery, Children's Wisconsin, Milwaukee, Wisconsin
| | - David D Limbrick
- 13Department of Neurological Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Francesco T Mangano
- 14Division of Pediatric Neurosurgery, Cincinnati Children's Hospital, Cincinnati, Ohio
| | - Jonathan Martin
- 15Division of Pediatric Neurosurgery, Connecticut Children's Hospital, Hartford, Connecticut
| | - Joshua Pahys
- 16Department of Pediatric Orthopedic Surgery, Shriners Hospital for Children, Philadelphia, Pennsylvania
| | - Alexander Powers
- 17Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem, North Carolina
| | - Mark R Proctor
- 18Department of Neurosurgery, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Luis Rodriguez
- 19Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida
| | - Curtis Rozzelle
- 20Department of Neurosurgery, Division of Pediatric Neurosurgery, University of Alabama, Birmingham; and
| | - Phillip B Storm
- 21Department of Neurosurgery, University of Pennsylvania/Children's Hospital of Philadelphia, Pennsylvania
| | - Richard C E Anderson
- 1Department of Neurological Surgery, Columbia University Medical Center, New York, New York
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10
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Bonfield CM, Shannon CN, Reeder RW, Browd S, Drake J, Hauptman JS, Kulkarni AV, Limbrick DD, McDonald PJ, Naftel R, Pollack IF, Riva-Cambrin J, Rozzelle C, Tamber MS, Whitehead WE, Kestle JRW, Wellons JC. Hydrocephalus treatment in patients with craniosynostosis: an analysis from the Hydrocephalus Clinical Research Network prospective registry. Neurosurg Focus 2021; 50:E11. [PMID: 33794488 DOI: 10.3171/2021.1.focus20979] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 01/06/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Hydrocephalus may be seen in patients with multisuture craniosynostosis and, less commonly, single-suture craniosynostosis. The optimal treatment for hydrocephalus in this population is unknown. In this study, the authors aimed to evaluate the success rate of ventriculoperitoneal shunt (VPS) treatment and endoscopic third ventriculostomy (ETV) both with and without choroid plexus cauterization (CPC) in patients with craniosynostosis. METHODS Utilizing the Hydrocephalus Clinical Research Network (HCRN) Core Data Project (Registry), the authors identified all patients who underwent treatment for hydrocephalus associated with craniosynostosis. Descriptive statistics, demographics, and surgical outcomes were evaluated. RESULTS In total, 42 patients underwent treatment for hydrocephalus associated with craniosynostosis. The median gestational age at birth was 39.0 weeks (IQR 38.0, 40.0); 55% were female and 60% were White. The median age at first craniosynostosis surgery was 0.6 years (IQR 0.3, 1.7), and at the first permanent hydrocephalus surgery it was 1.2 years (IQR 0.5, 2.5). Thirty-three patients (79%) had multiple different sutures fused, and 9 had a single suture: 3 unicoronal (7%), 3 sagittal (7%), 2 lambdoidal (5%), and 1 unknown (2%). Syndromes were identified in 38 patients (90%), with Crouzon syndrome being the most common (n = 16, 42%). Ten patients (28%) received permanent hydrocephalus surgery before the first craniosynostosis surgery. Twenty-eight patients (67%) underwent VPS treatment, with the remaining 14 (33%) undergoing ETV with or without CPC (ETV ± CPC). Within 12 months after initial hydrocephalus intervention, 14 patients (34%) required revision (8 VPS and 6 ETV ± CPC). At the most recent follow-up, 21 patients (50%) required a revision. The revision rate decreased as age increased. The overall infection rate was 5% (VPS 7%, 0% ETV ± CPC). CONCLUSIONS This is the largest prospective study reported on children with craniosynostosis and hydrocephalus. Hydrocephalus in children with craniosynostosis most commonly occurs in syndromic patients and multisuture fusion. It is treated at varying ages; however, most patients undergo surgery for craniosynostosis prior to hydrocephalus treatment. While VPS treatment is performed more frequently, VPS and ETV are both reasonable options, with decreasing revision rates with increasing age, for the treatment of hydrocephalus associated with craniosynostosis.
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Affiliation(s)
| | - Chevis N Shannon
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Samuel Browd
- 3Department of Neurosurgery, University of Washington, Seattle, Washington
| | - James Drake
- 4Division of Neurosurgery, University of Toronto, Ontario, Canada
| | - Jason S Hauptman
- 3Department of Neurosurgery, University of Washington, Seattle, Washington
| | | | - David D Limbrick
- 5Department of Neurosurgery, Washington University School of Medicine in St. Louis, Missouri
| | - Patrick J McDonald
- 6Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Robert Naftel
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Ian F Pollack
- 7Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jay Riva-Cambrin
- 8Division of Neurosurgery, University of Calgary, Alberta, Canada
| | - Curtis Rozzelle
- 9Department of Neurosurgery, University of Alabama at Birmingham School of Medicine, Birmingham, Alabama; and
| | - Mandeep S Tamber
- 6Division of Neurosurgery, University of British Columbia, Vancouver, British Columbia, Canada
| | | | | | - John C Wellons
- 1Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
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11
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Zimmerman K, May B, Barnes K, Arynchyna A, Alford EN, Arata C, Dreer L, Aban I, Johnston J, Rozzelle C, Blount JP, Rocque BG. Anxiety, depression, fatigue, and headache burden in the pediatric hydrocephalus population. J Neurosurg Pediatr 2020; 26:483-489. [PMID: 32707553 PMCID: PMC8934588 DOI: 10.3171/2020.4.peds19697] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2019] [Accepted: 04/30/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Childhood hydrocephalus is a common chronic medical condition. However, little is known about the burden of headache and psychological comorbidities in children living with hydrocephalus. The purpose of this study was to determine the prevalence and severity of these conditions among the pediatric hydrocephalus population. METHODS During routine neurosurgery clinic visits from July 2017 to February 2018, the authors administered four surveys to children ages 7 years and older: Pediatric Migraine Disability Assessment (PedMIDAS), Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety, PROMIS Depression, and PROMIS Fatigue. The PedMIDAS is an assessment of headache disability in pediatric and adolescent patients. The PROMIS measures are pediatric self-reported instruments to assess social and emotional health. PROMIS measures utilize T-scores (mean 50, SD 10) to compare anxiety, depression, and fatigue in specific populations to those in the US general population. Clinical and demographic data were collected from the medical record (hydrocephalus etiology, shunt infection, race, etc.) and tested for associations with survey measure scores. RESULTS Forty children completed the PedMIDAS. Ten percent of them were in the severe headache range, 5% were in the moderate range, and 5% were in the mild range. There was a statistically significant association between undergoing a cluster of shunt operations and headache burden (p = 0.003).Forty children completed all three PROMIS measures. The mean anxiety score was 45.8 (SD 11.7), and 2.5% of children scored in the severe anxiety range, 17.5% in the moderate range, and 20% in the mild range. The mean depression score was 42.7 (SD 10.0), with 2.5% of children scoring in the severe depression range, 5% in the moderate range, and 12.5% in the mild range. The mean fatigue score was 45.1 (SD 16.4), with 15% percent of children scoring in the severe fatigue range, 10% in the moderate range, and 7.5% in the mild range. There were no statistically significant associations between child anxiety, depression, or fatigue and clinical or demographic variables. CONCLUSIONS Children with hydrocephalus have an average burden of headache, anxiety, depression, and fatigue as compared to the general population overall. Having a cluster of shunt operations correlates with a higher headache burden, but no clinical or demographic variable is associated with anxiety, depression, or fatigue.
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Affiliation(s)
- Kathrin Zimmerman
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
| | - Bobby May
- School of Medicine, University of Mississippi Medical Center
| | - Katherine Barnes
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
| | - Anastasia Arynchyna
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
| | - Elizabeth N. Alford
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
| | - Caroline Arata
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
| | - Laura Dreer
- Department of Psychology, University of Alabama at Birmingham
| | - Inmaculada Aban
- Department of Statistics, University of Alabama at Birmingham
| | - James Johnston
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
| | - Curtis Rozzelle
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
| | - Jeffrey P. Blount
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
| | - Brandon G. Rocque
- Department of Neurosurgery, Division of Pediatrics, University of Alabama at Birmingham
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12
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Bernstock JD, Alva E, Cohen JL, Lobbous M, Chagoya G, Elsayed GA, Orr BA, Rozzelle C, Rocque B, Blount J, Johnston JM, Li R, Fiveash JB, Dhall G, Reddy AT, Friedman GK. Treatment of pediatric high-grade central nervous system tumors with high-dose methotrexate in combination with multiagent chemotherapy: A single-institution experience. Pediatr Blood Cancer 2020; 67:e28119. [PMID: 31850678 DOI: 10.1002/pbc.28119] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 11/18/2019] [Accepted: 11/19/2019] [Indexed: 11/06/2022]
Abstract
BACKGROUND Effective treatment for pediatric embryonal brain tumors includes dose-intensive multiagent chemotherapy (DIMAC) followed by high-dose chemotherapy with stem cell rescue (HDCSCR). Use of repeated cycles of DIMAC including high-dose methotrexate (HDMTX) without HDCSCR has not been described. PROCEDURE We retrospectively reviewed the responses/toxicities in 13 patients (aged 2-155 months, median 22 months) with central nervous system (CNS) tumors (atypical teratoid rhabdoid tumors, CNS embryonal tumors not otherwise specified, pineoblastoma, embryonal tumor with multilayered rosettes, and CNS sarcoma) treated over a 12-year period with repeated cycles of HDMTX followed by etoposide, cisplatin, cyclophosphamide, and vincristine. RESULTS Six patients (46.2%) had disseminated disease at presentation and five (38.5%) had gross total resection. A total of 64 courses of therapy were administered with a median of five courses per patient. Eight patients (61.5%) received radiation therapy (one at relapse). By completion of therapy, 11 patients (84.6%) achieved a response (six complete, five partial). Six of the 13 patients (46.2%) remain alive with a median follow-up of 48 months (6-146). Acute toxicities included fever/neutropenia (70.3%), bacteremia (15.6%), and grade 3 mucositis (18.8%). Long-term complications included learning disability, seizure disorder, and brain necrosis, without treatment-related deaths. CONCLUSIONS DIMAC with HDMTX without HDCSCR may be an effective treatment option for selected patients with embryonal or high-grade CNS tumors.
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Affiliation(s)
- Joshua D Bernstock
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Neurosurgery, Brigham and Women's, Harvard Medical School, Boston, Massachusetts
| | - Elizabeth Alva
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Joshua L Cohen
- Medical Scientist Training Program, University of Alabama at Birmingham, Birmingham, Alabama
| | - Mina Lobbous
- Department of Neurology, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Gustavo Chagoya
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Galal A Elsayed
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brent A Orr
- Pathology Department, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Curtis Rozzelle
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Brandon Rocque
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Jeffrey Blount
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - James M Johnston
- Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
| | - Rong Li
- Department of Pathology, Children's of Alabama, Birmingham, Alabama
| | - John B Fiveash
- Department of Radiation Oncology, University of Alabama at Birmingham, Birmingham, Alabama
| | - Girish Dhall
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama
| | - Alyssa T Reddy
- Department of Neurology, University of California at San Francisco, San Francisco, California
| | - Gregory K Friedman
- Division of Pediatric Hematology and Oncology, Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama.,Department of Neurosurgery, University of Alabama at Birmingham, Birmingham, Alabama
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13
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Simon TD, Kronman MP, Whitlock KB, Browd SR, Holubkov R, Kestle JRW, Kulkarni AV, Langley M, Limbrick DD, Luerssen TG, Oakes WJ, Riva-Cambrin J, Rozzelle C, Shannon CN, Tamber M, Wellons JC, Whitehead WE, Mayer-Hamblett N. Reinfection rates following adherence to Infectious Diseases Society of America guideline recommendations in first cerebrospinal fluid shunt infection treatment. J Neurosurg Pediatr 2019; 23:1-9. [PMID: 30771757 DOI: 10.3171/2018.11.peds18373] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2018] [Accepted: 11/14/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVECSF shunt infection treatment requires both surgical and antibiotic decisions. Using the Hydrocephalus Clinical Research Network (HCRN) Registry and 2004 Infectious Diseases Society of America (IDSA) guidelines that were not proactively distributed to HCRN providers, the authors previously found high adherence to surgical recommendations but poor adherence to intravenous (IV) antibiotic duration recommendations. In general, IV antibiotic duration was longer than recommended. In March 2017, new IDSA guidelines expanded upon the 2004 guidelines by including recommendations for selection of specific antibiotics. The objective of this study was to describe adherence to both 2004 and 2017 IDSA guideline recommendations for CSF shunt infection treatment, and to report reinfection rates associated with adherence to guideline recommendations.METHODSThe authors investigated a prospective cohort of children younger than 18 years of age who underwent treatment for first CSF shunt infection at one of 7 hospitals from April 2008 to December 2012. CSF shunt infection was diagnosed by recovery of bacteria from CSF culture (CSF-positive infection). Adherence to 2004 and 2017 guideline recommendations was determined. Adherence to antibiotics was further classified as longer or shorter duration than guideline recommendations. Reinfection rates with 95% confidence intervals (CIs) were generated.RESULTSThere were 133 children with CSF-positive infections addressed by 2004 IDSA guideline recommendations, with 124 at risk for reinfection. Zero reinfections were observed among those whose treatment was fully adherent (0/14, 0% [95% CI 0%-20%]), and 15 reinfections were observed among those whose infection treatment was nonadherent (15/110, 14% [95% CI 8%-21%]). Among the 110 first infections whose infection treatment was nonadherent, 74 first infections were treated for a longer duration than guidelines recommended and 9 developed reinfection (9/74, 12% [95% CI 6%-22%]). There were 145 children with CSF-positive infections addressed by 2017 IDSA guideline recommendations, with 135 at risk for reinfection. No reinfections were observed among children whose treatment was fully adherent (0/3, 0% [95% CI 0%-64%]), and 18 reinfections were observed among those whose infection treatment was nonadherent (18/132, 14% [95% CI 8%-21%]).CONCLUSIONSThere is no clear evidence that either adherence to IDSA guidelines or duration of treatment longer than recommended is associated with reduction in reinfection rates. Because IDSA guidelines recommend shorter IV antibiotic durations than are typically used, improvement efforts to reduce IV antibiotic use in CSF shunt infection treatment can and should utilize IDSA guidelines.
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Affiliation(s)
- Tamara D Simon
- Departments of1Pediatrics and
- 2Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Matthew P Kronman
- Departments of1Pediatrics and
- 2Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Kathryn B Whitlock
- 2Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
| | - Samuel R Browd
- 3Neurosurgery, University of Washington, Seattle Children's Hospital, Seattle
| | | | - John R W Kestle
- 5Division of Pediatric Neurosurgery, Primary Children's Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Abhaya V Kulkarni
- 6Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Marcie Langley
- 5Division of Pediatric Neurosurgery, Primary Children's Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - David D Limbrick
- 7Department of Neurosurgery, St. Louis Children's Hospital, Washington University in St. Louis, Missouri
| | - Thomas G Luerssen
- 8Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - W Jerry Oakes
- 9Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | - Jay Riva-Cambrin
- 5Division of Pediatric Neurosurgery, Primary Children's Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Curtis Rozzelle
- 9Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | - Chevis N Shannon
- 9Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | - Mandeep Tamber
- 10Division of Neurosurgery, Children's Hospital of Pittsburgh, Pennsylvania
| | - John C Wellons
- 9Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | - William E Whitehead
- 8Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Nicole Mayer-Hamblett
- Departments of1Pediatrics and
- 2Center for Clinical and Translational Research, Seattle Children's Research Institute, Seattle, Washington
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14
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Simon TD, Kronman MP, Whitlock KB, Browd SR, Holubkov R, Kestle JRW, Kulkarni AV, Langley M, Limbrick DD, Luerssen TG, Oakes J, Riva-Cambrin J, Rozzelle C, Shannon CN, Tamber M, Wellons III JC, Whitehead WE, Mayer-Hamblett N. Patient and Treatment Characteristics by Infecting Organism in Cerebrospinal Fluid Shunt Infection. J Pediatric Infect Dis Soc 2018; 8:235-243. [PMID: 29771360 PMCID: PMC6601384 DOI: 10.1093/jpids/piy035] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Previous studies of cerebrospinal fluid (CSF) shunt infection treatment have been limited in size and unable to compare patient and treatment characteristics by infecting organism. Our objective was to describe variation in patient and treatment characteristics for children with first CSF shunt infection, stratified by infecting organism subgroups outlined in the 2017 Infectious Disease Society of America's (IDSA) guidelines. METHODS We studied a prospective cohort of children <18 years of age undergoing treatment for first CSF shunt infection at one of 7 Hydrocephalus Clinical Research Network hospitals from April 2008 to December 2012. Differences between infecting organism subgroups were described using univariate analyses and Fisher's exact tests. RESULTS There were 145 children whose infections were diagnosed by CSF culture and addressed by IDSA guidelines, including 47 with Staphylococcus aureus, 52 with coagulase-negative Staphylococcus, 37 with Gram-negative bacilli, and 9 with Propionibacterium acnes. No differences in many patient and treatment characteristics were seen between infecting organism subgroups, including age at initial shunt, gender, race, insurance, indication for shunt, gastrostomy, tracheostomy, ultrasound, and/or endoscope use at all surgeries before infection, or numbers of revisions before infection. A larger proportion of infections were caused by Gram-negative bacilli when antibiotic-impregnated catheters were used at initial shunt placement (12 of 23, 52%) and/or subsequent revisions (11 of 23, 48%) compared with all other infections (9 of 68 [13%] and 13 of 68 [19%], respectively). No differences in reinfection were observed between infecting organism subgroups. CONCLUSIONS The organism profile encountered at infection differs when antibiotic-impregnated catheters are used, with a higher proportion of Gram-negative bacilli. This warrants further investigation given increasing adoption of antibiotic-impregnated catheters.
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Affiliation(s)
- Tamara D Simon
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Washington,Seattle Children’s Research Institute, Washington,Correspondence: T. Simon, MD, MSPH, Associate Professor, University of Washington Department of Pediatrics, Division of Hospital Medicine, Seattle Children’s Research Institute Building 1, M/S JMB9, 1900 Ninth Avenue, Seattle, WA 98101 ()
| | - Matthew P Kronman
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Washington,Seattle Children’s Research Institute, Washington
| | | | - Samuel R Browd
- Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Washington
| | | | - John R W Kestle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Canada
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City
| | - David D Limbrick
- Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in St. Louis, Missouri
| | - Thomas G Luerssen
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Jerry Oakes
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, University of Utah, Salt Lake City,Present Affiliation: Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta
| | - Curtis Rozzelle
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham
| | - Chevis N Shannon
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham,Present Affiliation: Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Mandeep Tamber
- Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pennsylvania
| | - John C Wellons III
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham,Present Affiliation: Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Washington,Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Washington
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15
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Simon TD, Kronman MP, Whitlock KB, Gove NE, Mayer-Hamblett N, Browd SR, Cochrane DD, Holubkov R, Kulkarni AV, Langley M, Limbrick DD, Luerssen TG, Oakes WJ, Riva-Cambrin J, Rozzelle C, Shannon C, Tamber M, Wellons JC, Whitehead WE, Kestle JRW. Reinfection after treatment of first cerebrospinal fluid shunt infection: a prospective observational cohort study. J Neurosurg Pediatr 2018; 21:346-358. [PMID: 29393813 PMCID: PMC5880734 DOI: 10.3171/2017.9.peds17112] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE CSF shunt infection requires both surgical and antibiotic treatment. Surgical treatment includes either total shunt removal with external ventricular drain (EVD) placement followed by new shunt insertion, or distal shunt externalization followed by new shunt insertion once the CSF is sterile. Antibiotic treatment includes the administration of intravenous antibiotics. The Hydrocephalus Clinical Research Network (HCRN) registry provides a unique opportunity to understand reinfection following treatment for CSF shunt infection. This study examines the association of surgical and antibiotic decisions in the treatment of first CSF shunt infection with reinfection. METHODS A prospective cohort study of children undergoing treatment for first CSF infection at 7 HCRN hospitals from April 2008 to December 2012 was performed. The HCRN consensus definition was used to define CSF shunt infection and reinfection. The key surgical predictor variable was surgical approach to treatment for CSF shunt infection, and the key antibiotic treatment predictor variable was intravenous antibiotic selection and duration. Cox proportional hazards models were constructed to address the time-varying nature of the characteristics associated with shunt surgeries. RESULTS Of 233 children in the HCRN registry with an initial CSF shunt infection during the study period, 38 patients (16%) developed reinfection over a median time of 44 days (interquartile range [IQR] 19-437). The majority of initial CSF shunt infections were treated with total shunt removal and EVD placement (175 patients; 75%). The median time between infection surgeries was 15 days (IQR 10-22). For the subset of 172 infections diagnosed by CSF culture, the mean ± SD duration of antibiotic treatment was 18.7 ± 12.8 days. In all Cox proportional hazards models, neither surgical approach to infection treatment nor overall intravenous antibiotic duration was independently associated with reinfection. The only treatment decision independently associated with decreased infection risk was the use of rifampin. While this finding did not achieve statistical significance, in all 5 Cox proportional hazards models both surgical approach (other than total shunt removal at initial CSF shunt infection) and nonventriculoperitoneal shunt location were consistently associated with a higher hazard of reinfection, while the use of ultrasound was consistently associated with a lower hazard of reinfection. CONCLUSIONS Neither surgical approach to treatment nor antibiotic duration was associated with reinfection risk. While these findings did not achieve statistical significance, surgical approach other than total removal at initial CSF shunt infection was consistently associated with a higher hazard of reinfection in this study and suggests the feasibility of controlling and standardizing the surgical approach (shunt removal with EVD placement). Considerably more variation and equipoise exists in the duration and selection of intravenous antibiotic treatment. Further consideration should be given to the use of rifampin in the treatment of CSF shunt infection. High-quality studies of the optimal duration of antibiotic treatment are critical to the creation of evidence-based guidelines for CSF shunt infection treatment.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/Seattle Children's Hospital,Seattle Children's Research Institute, Seattle, Washington
| | - Matthew P. Kronman
- Department of Pediatrics, University of Washington/Seattle Children's Hospital,Seattle Children's Research Institute, Seattle, Washington
| | | | - Nancy E. Gove
- Seattle Children's Research Institute, Seattle, Washington
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/Seattle Children's Hospital,Seattle Children's Research Institute, Seattle, Washington
| | - Samuel R. Browd
- Department of Neurosurgery, University of Washington/Seattle Children's Hospital
| | - D. Douglas Cochrane
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | | | - Abhaya V. Kulkarni
- Division of Neurosurgery, The Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - David D. Limbrick
- Department of Neurosurgery, St. Louis Children's Hospital, Washington University in St. Louis, Missouri
| | - Thomas G. Luerssen
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - W. Jerry Oakes
- Section of Pediatric Neurosurgery, Children's of Alabama, Division of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Jay Riva-Cambrin
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada
| | - Curtis Rozzelle
- Section of Pediatric Neurosurgery, Children's of Alabama, Division of Neurosurgery, University of Alabama at Birmingham, Alabama
| | - Chevis Shannon
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Mandeep Tamber
- Division of Neurosurgery, Children's Hospital of Pittsburgh, Pennsylvania
| | - John C. Wellons
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - William E. Whitehead
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - John R. W. Kestle
- Division of Pediatric Neurosurgery, Primary Children's Hospital, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Wellons JC, Shannon CN, Holubkov R, Riva-Cambrin J, Kulkarni AV, Limbrick DD, Whitehead W, Browd S, Rozzelle C, Simon TD, Tamber MS, Oakes WJ, Drake J, Luerssen TG, Kestle J. Shunting outcomes in posthemorrhagic hydrocephalus: results of a Hydrocephalus Clinical Research Network prospective cohort study. J Neurosurg Pediatr 2017; 20:19-29. [PMID: 28452657 DOI: 10.3171/2017.1.peds16496] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE Previous Hydrocephalus Clinical Research Network (HCRN) retrospective studies have shown a 15% difference in rates of conversion to permanent shunts with the use of ventriculosubgaleal shunts (VSGSs) versus ventricular reservoirs (VRs) as temporization procedures in the treatment of hydrocephalus due to high-grade intraventricular hemorrhage (IVH) of prematurity. Further research in the same study line revealed a strong influence of center-specific decision-making on shunt outcomes. The primary goal of this prospective study was to standardize decision-making across centers to determine true procedural superiority, if any, of VSGS versus VR as a temporization procedure in high-grade IVH of prematurity. METHODS The HCRN conducted a prospective cohort study across 6 centers with an approximate 1.5- to 3-year accrual period (depending on center) followed by 6 months of follow-up. Infants with premature birth, who weighed less than 1500 g, had Grade 3 or 4 IVH of prematurity, and had more than 72 hours of life expectancy were included in the study. Based on a priori consensus, decisions were standardized regarding the timing of initial surgical treatment, upfront shunt versus temporization procedure (VR or VSGS), and when to convert a VR or VSGS to a permanent shunt. Physical examination assessment and surgical technique were also standardized. The primary outcome was the proportion of infants who underwent conversion to a permanent shunt. The major secondary outcomes of interest included infection and other complication rates. RESULTS One hundred forty-five premature infants were enrolled and met criteria for analysis. Using the standardized decision rubrics, 28 infants never reached the threshold for treatment, 11 initially received permanent shunts, 4 were initially treated with endoscopic third ventriculostomy (ETV), and 102 underwent a temporization procedure (36 with VSGSs and 66 with VRs). The 2 temporization cohorts were similar in terms of sex, race, IVH grade, head (orbitofrontal) circumference, and ventricular size at temporization. There were statistically significant differences noted between groups in gestational age, birth weight, and bilaterality of clot burden that were controlled for in post hoc analysis. By Kaplan-Meier analysis, the 180-day rates of conversion to permanent shunts were 63.5% for VSGS and 74.0% for VR (p = 0.36, log-rank test). The infection rate for VSGS was 14% (5/36) and for VR was 17% (11/66; p = 0.71). The overall compliance rate with the standardized decision rubrics was noted to be 90% for all surgeons. CONCLUSIONS A standardized protocol was instituted across all centers of the HCRN. Compliance was high. Choice of temporization techniques in premature infants with IVH does not appear to influence rates of conversion to permanent ventricular CSF diversion. Once management decisions and surgical techniques are standardized across HCRN sites, thus minimizing center effect, the observed difference in conversion rates between VSGSs and VRs is mitigated.
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Affiliation(s)
- John C Wellons
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Richard Holubkov
- Data Coordinating Center, University of Utah, Salt Lake City, Utah
| | - Jay Riva-Cambrin
- Division of Neurosurgery, University of Calgary, Alberta, Canada
| | | | - David D Limbrick
- Department of Neurosurgery, Washington University St. Louis, Missouri
| | - William Whitehead
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Samuel Browd
- Department of Neurosurgery, University of Washington Medical Center, Seattle, Washington
| | - Curtis Rozzelle
- Department of Neurosurgery, University of Alabama-Birmingham, Alabama
| | - Tamara D Simon
- Department of Pediatrics, University of Washington Medical Center, Seattle, Washington
| | - Mandeep S Tamber
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania; and
| | - W Jerry Oakes
- Department of Neurosurgery, University of Alabama-Birmingham, Alabama
| | - James Drake
- Department of Neurosurgery, University of Toronto, Ontario, Canada
| | - Thomas G Luerssen
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - John Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
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Simon TD, Kronman MP, Whitlock KB, Gove N, Browd SR, Holubkov R, Kestle JR, Kulkarni AV, Langley M, Limbrick DD, Luerssen TG, Oakes J, Riva-Cambrin J, Rozzelle C, Shannon C, Tamber M, Wellons JC, Whitehead WE, Mayer-Hamblett N. Variability in Management of First Cerebrospinal Fluid Shunt Infection: A Prospective Multi-Institutional Observational Cohort Study. J Pediatr 2016; 179:185-191.e2. [PMID: 27692463 PMCID: PMC5123958 DOI: 10.1016/j.jpeds.2016.08.094] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2016] [Revised: 08/15/2016] [Accepted: 08/26/2016] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To describe the variation in approaches to surgical and antibiotic treatment for first cerebrospinal fluid (CSF) shunt infection and adherence to Infectious Diseases Society of America (IDSA) guidelines. STUDY DESIGN We conducted a prospective cohort study of children undergoing treatment for first CSF infection at 7 Hydrocephalus Clinical Research Network hospitals from April 2008 through December 2012. Univariate analyses were performed to describe the study population. RESULTS A total of 151 children underwent treatment for first CSF shunt-related infection. Most children had undergone initial CSF shunt placement before the age of 6 months (n = 98, 65%). Median time to infection after shunt surgery was 28 days (IQR 15-52 days). Surgical management was most often shunt removal with interim external ventricular drain placement, followed by new shunt insertion (n = 122, 81%). Median time from first negative CSF culture to final surgical procedure was 14 days (IQR 10-21 days). Median duration of intravenous (IV) antibiotic use duration was 19 days (IQR 12-28 days). For 84 infections addressed by IDSA guidelines, 7 (8%) met guidelines and 61 (73%) had longer duration of IV antibiotic use than recommended. CONCLUSIONS Surgical treatment for infection frequently adheres to IDSA guidelines of shunt removal with external ventricular drain placement followed by new shunt insertion. However, duration of IV antibiotic use in CSF shunt infection treatment was consistently longer than recommended by the 2004 IDSA guidelines.
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Affiliation(s)
- Tamara D. Simon
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Matthew P. Kronman
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Kathryn B. Whitlock
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Nancy Gove
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
| | - Samuel R. Browd
- Department of Neurosurgery, University of Washington/Seattle Children’s Hospital, Seattle, Washington
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - John R.W. Kestle
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Abhaya V. Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Toronto, Canada
| | - Marcie Langley
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - David D. Limbrick
- Department of Neurosurgery, St. Louis Children’s Hospital, Washington University in Saint Louis, St. Louis, Missouri
| | - Thomas G. Luerssen
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Jerry Oakes
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama
| | - Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Primary Children’s Medical Center, Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Curtis Rozzelle
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama
| | - Chevis Shannon
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama
| | - Mandeep Tamber
- Division of Neurosurgery, Children’s Hospital of Pittsburgh, Pittsburgh, Pennsylvania
| | - John C. Wellons
- Section of Pediatric Neurosurgery, Children’s Hospital of Alabama, Division of Neurosurgery, University of Alabama – Birmingham, Birmingham, Alabama
| | - William E. Whitehead
- Division of Pediatric Neurosurgery, Texas Children’s Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - Nicole Mayer-Hamblett
- Department of Pediatrics, University of Washington/Seattle Children’s Hospital, Seattle, Washington,Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, Washington
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Alva E, Friedman G, Li R, Rozzelle C, Rocque B, Blount J, Johnston J, Fiveash J, Reddy A. EPT-23TREATMENT OF HIGH-GRADE CENTRAL NERVOUS SYSTEM TUMORS WITH HIGH-DOSE METHOTREXATE IN COMBINATION WITH MULTI-AGENT CHEMOTHERAPY: A SINGLE INSTITUTION EXPERIENCE. Neuro Oncol 2016. [DOI: 10.1093/neuonc/now069.22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Kestle JRW, Holubkov R, Douglas Cochrane D, Kulkarni AV, Limbrick DD, Luerssen TG, Jerry Oakes W, Riva-Cambrin J, Rozzelle C, Simon TD, Walker ML, Wellons JC, Browd SR, Drake JM, Shannon CN, Tamber MS, Whitehead WE. A new Hydrocephalus Clinical Research Network protocol to reduce cerebrospinal fluid shunt infection. J Neurosurg Pediatr 2016; 17:391-6. [PMID: 26684763 DOI: 10.3171/2015.8.peds15253] [Citation(s) in RCA: 83] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT In a previous report by the same research group (Kestle et al., 2011), compliance with an 11-step protocol was shown to reduce CSF shunt infection at Hydrocephalus Clinical Research Network (HCRN) centers (from 8.7% to 5.7%). Antibiotic-impregnated catheters (AICs) were not part of the protocol but were used off protocol by some surgeons. The authors therefore began using a new protocol that included AICs in an effort to reduce the infection rate further. METHODS The new protocol was implemented at HCRN centers on January 1, 2012, for all shunt procedures (excluding external ventricular drains [EVDs], ventricular reservoirs, and subgaleal shunts). Procedures performed up to September 30, 2013, were included (21 months). Compliance with the protocol and outcome events up to March 30, 2014, were recorded. The definition of infection was unchanged from the authors' previous report. RESULTS A total of 1935 procedures were performed on 1670 patients at 8 HCRN centers. The overall infection rate was 6.0% (95% CI 5.1%-7.2%). Procedure-specific infection rates varied (insertion 5.0%, revision 5.4%, insertion after EVD 8.3%, and insertion after treatment of infection 12.6%). Full compliance with the protocol occurred in 77% of procedures. The infection rate was 5.0% after compliant procedures and 8.7% after noncompliant procedures (p = 0.005). The infection rate when using this new protocol (6.0%, 95% CI 5.1%-7.2%) was similar to the infection rate observed using the authors' old protocol (5.7%, 95% CI 4.6%-7.0%). CONCLUSIONS CSF shunt procedures performed in compliance with a new infection prevention protocol at HCRN centers had a lower infection rate than noncompliant procedures. Implementation of the new protocol (including AICs) was associated with a 6.0% infection rate, similar to the infection rate of 5.7% from the authors' previously reported protocol. Based on the current data, the role of AICs compared with other infection prevention measures is unclear.
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Affiliation(s)
- John R W Kestle
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Richard Holubkov
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - D Douglas Cochrane
- Division of Pediatric Neurosurgery, British Columbia Children's Hospital, Vancouver, British Columbia
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - David D Limbrick
- Department of Neurosurgery, St. Louis Children's Hospital, St. Louis, Missouri
| | - Thomas G Luerssen
- Department of Neurosurgery, Texas Children's Hospital, Houston, Texas
| | - W Jerry Oakes
- Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama
| | - Jay Riva-Cambrin
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Curtis Rozzelle
- Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Birmingham, Alabama
| | - Tamara D Simon
- Department of Pediatrics, Division of Hospital Medicine, Seattle Children's Hospital, Seattle, Washington
| | - Marion L Walker
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - John C Wellons
- Department of Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee; and
| | - Samuel R Browd
- Department of Pediatrics, Division of Hospital Medicine, Seattle Children's Hospital, Seattle, Washington
| | - James M Drake
- Division of Neurosurgery, Hospital for Sick Children, Toronto, Ontario, Canada
| | - Chevis N Shannon
- Department of Neurosurgery, Monroe Carell Jr. Children's Hospital at Vanderbilt, Nashville, Tennessee; and
| | - Mandeep S Tamber
- Department of Neurosurgery, Children's Hospital of Pittsburgh of UPMC, Pittsburgh, Pennsylvania
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Riva-Cambrin J, Kestle JRW, Holubkov R, Butler J, Kulkarni AV, Drake J, Whitehead WE, Wellons JC, Shannon CN, Tamber MS, Limbrick DD, Rozzelle C, Browd SR, Simon TD. Risk factors for shunt malfunction in pediatric hydrocephalus: a multicenter prospective cohort study. J Neurosurg Pediatr 2016; 17:382-90. [PMID: 26636251 DOI: 10.3171/2015.6.peds14670] [Citation(s) in RCA: 153] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT The rate of CSF shunt failure remains unacceptably high. The Hydrocephalus Clinical Research Network (HCRN) conducted a comprehensive prospective observational study of hydrocephalus management, the aim of which was to isolate specific risk factors for shunt failure. METHODS The study followed all first-time shunt insertions in children younger than 19 years at 6 HCRN centers. The HCRN Investigator Committee selected, a priori, 21 variables to be examined, including clinical, radiographic, and shunt design variables. Shunt failure was defined as shunt revision, subsequent endoscopic third ventriculostomy, or shunt infection. Important a priori-defined risk factors as well as those significant in univariate analyses were then tested for independence using multivariate Cox proportional hazard modeling. RESULTS A total of 1036 children underwent initial CSF shunt placement between April 2008 and December 2011. Of these, 344 patients experienced shunt failure, including 265 malfunctions and 79 infections. The mean and median length of follow-up for the entire cohort was 400 days and 264 days, respectively. The Cox model found that age younger than 6 months at first shunt placement (HR 1.6 [95% CI 1.1-2.1]), a cardiac comorbidity (HR 1.4 [95% CI 1.0-2.1]), and endoscopic placement (HR 1.9 [95% CI 1.2-2.9]) were independently associated with reduced shunt survival. The following had no independent associations with shunt survival: etiology, payer, center, valve design, valve programmability, the use of ultrasound or stereotactic guidance, and surgeon experience and volume. CONCLUSIONS This is the largest prospective study reported on children with CSF shunts for hydrocephalus. It confirms that a young age and the use of the endoscope are risk factors for first shunt failure and that valve type has no impact. A new risk factor-an existing cardiac comorbidity-was also associated with shunt failure.
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Affiliation(s)
- Jay Riva-Cambrin
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah
| | - John R W Kestle
- Division of Pediatric Neurosurgery, Department of Neurosurgery, Primary Children's Hospital, University of Utah
| | - Richard Holubkov
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Jerry Butler
- Department of Pediatrics, University of Utah, Salt Lake City, Utah
| | - Abhaya V Kulkarni
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - James Drake
- Division of Neurosurgery, Hospital for Sick Children, University of Toronto, Ontario, Canada
| | - William E Whitehead
- Division of Pediatric Neurosurgery, Texas Children's Hospital, Department of Neurosurgery, Baylor College of Medicine, Houston, Texas
| | - John C Wellons
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Chevis N Shannon
- Department of Neurosurgery, Vanderbilt University, Nashville, Tennessee
| | - Mandeep S Tamber
- Division of Pediatric Neurosurgery, University of Pittsburgh, Pennsylvania
| | - David D Limbrick
- Division of Pediatric Neurosurgery, Washington University, St. Louis, Missouri
| | - Curtis Rozzelle
- Section of Pediatric Neurosurgery, Children's Hospital of Alabama, Division of Neurosurgery, University of Alabama-Birmingham, Alabama; and
| | | | - Tamara D Simon
- Pediatrics, University of Washington/Seattle Children's Hospital, Seattle, Washington
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Brockmeyer DL, Oakes WJ, Rozzelle C, Johnston J, Rocque BG, Anderson RCE, Feldstein N, Martin J, Tuite GF, Rodriguez L, Wetjen N, Aldana P, Pincus D, Storm P, Proctor MR, Lew S. Letter to the Editor: Chiari malformation Type 1 and atlantoaxial instability: a letter from the Pediatric Craniocervical Society. J Neurosurg Spine 2015; 23:820-1. [DOI: 10.3171/2015.3.spine15233] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Whitehead WE, Riva-Cambrin J, Wellons JC, Kulkarni AV, Browd S, Limbrick D, Rozzelle C, Tamber MS, Simon TD, Shannon CN, Holubkov R, Oakes WJ, Luerssen TG, Walker ML, Drake JM, Kestle JRW. Factors associated with ventricular catheter movement and inaccurate catheter location: post hoc analysis of the hydrocephalus clinical research network ultrasound-guided shunt placement study. J Neurosurg Pediatr 2014; 14:173-8. [PMID: 24926971 DOI: 10.3171/2014.5.peds13481] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Shunt survival may improve when ventricular catheters are placed into the frontal horn or trigone of the lateral ventricle. However, techniques for accurate catheter placement have not been developed. The authors recently reported a prospective study designed to test the accuracy of catheter placement with the assistance of intraoperative ultrasound, but the results were poor (accurate placement in 59%). A major reason for the poor accurate placement rate was catheter movement that occurred between the time of the intraoperative ultrasound image and the first postoperative scan (33% of cases). The control group of non-ultrasound using surgeons also had a low rate of accurate placement (accurate placement in 49%). The authors conducted an exploratory post hoc analysis of patients in their ultrasound study to identify factors associated with either catheter movement or poor catheter placement so that improved surgical techniques for catheter insertion could be developed. METHODS The authors investigated the following risk factors for catheter movement and poor catheter placement: age, ventricular size, cortical mantle thickness, surgeon experience, surgeon experience with ultrasound prior to trial, shunt entry site, shunt hardware at entry site, ventricular catheter length, and use of an ultrasound probe guide for catheter insertion. Univariate analysis followed by multivariate logistic regression models were used to determine which factors were independent risk factors for either catheter movement or inaccurate catheter location. RESULTS In the univariate analyses, only age < 6 months was associated with catheter movement (p = 0.021); cortical mantle thickness < 1 cm was near-significant (p = 0.066). In a multivariate model, age remained significant after adjusting for cortical mantle thickness (OR 8.35, exact 95% CI 1.20-infinity). Univariate analyses of factors associated with inaccurate catheter placement showed that age < 6 months (p = 0.001) and a posterior shunt entry site (p = 0.021) were both associated with poor catheter placement. In a multivariate model, both age < 6 months and a posterior shunt entry site were independent risk factors for poor catheter placement (OR 4.54, 95% CI 1.80-11.42, and OR 2.59, 95% CI 1.14-5.89, respectively). CONCLUSIONS Catheter movement and inaccurate catheter placement are both more likely to occur in young patients (< 6 months). Inaccurate catheter placement is also more likely to occur in cases involving a posterior shunt entry site than those involving an anterior shunt entry site. Future clinical studies aimed at improving shunt placement techniques must consider the effects of young age and choice of entry site on catheter location.
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Affiliation(s)
- William E Whitehead
- Texas Children's Hospital, Houston, Baylor College of Medicine, Houston, Texas
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Momaya A, Rozzelle C, Davis K, Estes R. Delayed presentation of a cervical spine fracture dislocation with posterior ligamentous disruption in a gymnast. Am J Orthop (Belle Mead NJ) 2014; 43:272-274. [PMID: 24945477] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Cervical spine injuries are uncommon but potentially devastating athletic injuries. We report a case of a girl gymnast who presented with a cervical spine fracture dislocation with posterior ligamentous disruption several days after injury. To our knowledge, this type of presentation with such severity of injury in a gymnast has not been reported in the literature. The patient was performing a double front tuck flip and sustained a hyperflexion, axial-loading injury. She experienced mild transient numbness in her bilateral upper and lower extremities lasting for about 5 minutes, after which it resolved. The patient was neurologically intact during her clinic visit, but she endorsed significant midline cervical tenderness. Plain radiographs and computed tomography imaging of the cervical spine revealed a C2-C3 fracture dislocation. She underwent posterior open reduction followed by C2-C3 facet arthrodesis and internal fixation. This case highlights the importance of very careful evaluations of neck injuries and the maintenance of high suspicion for significant underlying pathology.
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Affiliation(s)
| | | | | | - Reed Estes
- University of Alabama at Birmingham Sports Medicine, Birmingham, AL.
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Griessenauer CJ, Bilal M, Kankirawatana P, Kulbersh B, Shane Tubbs R, Rozzelle C. Lymphatic malformation of the tongue with coexisting intractable epilepsy treated with corpus callosotomy: A case report. Clin Neurol Neurosurg 2014; 117:68-70. [DOI: 10.1016/j.clineuro.2013.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2013] [Revised: 10/13/2013] [Accepted: 11/29/2013] [Indexed: 11/28/2022]
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Kim H, Kankirawatana P, Killen J, Harrison A, Oh A, Rozzelle C, Blount J, Knowlton R. Magnetic source imaging (MSI) in children with neocortical epilepsy: Surgical outcome association with 3D post-resection analysis. Epilepsy Res 2013; 106:164-72. [DOI: 10.1016/j.eplepsyres.2013.04.004] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2012] [Revised: 02/27/2013] [Accepted: 04/09/2013] [Indexed: 11/28/2022]
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Rizk E, Chern JJ, Tagayun C, Tubbs RS, Hankinson T, Rozzelle C, Oakes WJ, Blount JP, Wellons JC. Institutional experience of endoscopic suprasellar arachnoid cyst fenestration. Childs Nerv Syst 2013; 29:1345-7. [PMID: 23345020 DOI: 10.1007/s00381-013-2032-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2012] [Accepted: 01/14/2013] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Suprasellar arachnoid cysts can differ from other arachnoid cysts in several ways, making a separate analysis of these cysts worthwhile. Herein, we present the outcome and perform volumetric analysis of six children with suprasellar arachnoid cysts treated with endoscopic ventriculocystocisternostomy in order to evaluate the long-term outcomes. PATIENTS AND METHODS Operative and postoperative data were retrospectively reviewed for six patients harboring suprasellar arachnoid cysts. Imaging was then used to follow success of surgical intervention. RESULTS Six patients with suprasellar arachnoid cysts underwent ventriculocystocisternostomy. Presenting symptoms were headaches in three patients, developmental delay in another, and an incidental finding in the remaining patients. All patients had enlarged lateral and third ventricles on initial imaging. Average age at presentation was 145.7 months (65.4-250.2). Follow-up was an average of 46.5 months (3-84). The average cyst size was 153.96 cm(3) (42.98-369.20) preoperatively and an average of 39.92 cm(3) (3.20-101.47) at follow-up. CONCLUSIONS Based on our experience, suprasellar arachnoid cyst treatment with ventriculocystocisternostomy is an adequate surgical intervention. Suprasellar and third ventricular size does respond to the surgical intervention at long-term follow-up.
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Affiliation(s)
- Elias Rizk
- Pediatric Neurosurgery, Children's Hospital, 1600 7th Avenue South ACC 400, Birmingham, AL, USA
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Kim H, Harrison A, Kankirawatana P, Rozzelle C, Blount J, Torgerson C, Knowlton R. Major white matter fiber changes in medically intractable neocortical epilepsy in children: A diffusion tensor imaging study. Epilepsy Res 2013; 103:211-20. [PMID: 22917916 DOI: 10.1016/j.eplepsyres.2012.07.017] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2012] [Revised: 07/25/2012] [Accepted: 07/30/2012] [Indexed: 11/25/2022]
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Kim H, Lee C, Knowlton R, Rozzelle C, Blount JP. Safety and utility of supplemental depth electrodes for localizing the ictal onset zone in pediatric neocortical epilepsy. J Neurosurg Pediatr 2011; 8:49-56. [PMID: 21721889 DOI: 10.3171/2011.4.peds10519] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT Depth electrodes provide a better sampling of sulci and regions of cortex that lie tangential to the plane of subdural electrodes. The aim of this study was to evaluate the utility of supplemental depth electrodes in the surgical treatment of pediatric patients with neocortical epilepsy. METHODS Cases involving 12 consecutive pediatric patients (mean age [SD] 10.9 ± 4.4 years) were reviewed. Focal resective surgery (in 9 cases) or functional hemispherectomy (in 3 cases) was performed after intracranial monitoring. The mean total number of electrodes was 118 ± 29; the mean numbers of grid, strip, and depth electrodes were 95 ± 27, 10 ± 6, and 13 ± 5, respectively The most common pathological condition was focal cortical dysplasia. RESULTS In 4 cases, depth electrodes demonstrated the ictal onset zone in an area not easily accessible by grids or strips (in the basal temporal region in 3 cases and the upper opercular region in 1 case). In 3 of these 4 cases, the ictal onset zone was defined exclusively by the depth electrodes. In each of these 3 cases, the surface electrodes (on grids or strips) demonstrated early propagation but not ictal onset. In 9 cases, the depth electrodes also demonstrated the early propagation zone. The information about the ictal onset zone and the early propagation zone helped to provide additional information that affected the extent (in 7 cases) or depth (in 3 cases) of the resection. The proportion of the electrodes involved in resection relative to the total number of implanted electrodes was low (mean ± SD, 0.26 ± 0.09). Nine patients (75.0%) became seizure free (Engel class IA outcome) after surgery (mean duration of follow-up 25.7 ± 4.29 months). There were no surgical complications related to intracranial electroencephalography monitoring. CONCLUSIONS Most patients (75.0%) became seizure free after extensive monitoring and more limited resection of seizure-onset regions. Supplemental depth electrodes contribute to improved outcome by providing information about the ictal onset zone that is not accessible by grid or strip electrodes in some cases. The supplemental depth electrodes conferred an extra dimension of depth to the analysis, which allowed for successful outcome with more limited resection.
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Affiliation(s)
- Hyunmi Kim
- Department of Pediatrics, Division of Pediatric Neurology, University of Alabama at Birmingham, Alabama 35233, USA
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Tubbs RS, Griessenauer CJ, Hankinson T, Rozzelle C, Wellons JC, Blount JP, Oakes WJ, Cohen-Gadol AA. Retroclival Epidural Hematomas. Neurosurgery 2010; 67:404-6; discussion 406-7. [DOI: 10.1227/01.neu.0000372085.70895.e7] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND
Retroclival epidural hematomas (REDHs) are infrequently reported. To our knowledge, only 19 case reports exist in the literature.
OBJECTIVE
This study was performed to better elucidate this pathology.
METHODS
We prospectively collected data for all pediatric patients diagnosed with REDH from July 2006 through June 2009. Data included mechanism of injury, Glasgow Coma Scale score, neurological examination, treatment modality, and outcome. Magnetic resonance imaging was used to measure REDH dimensions.
RESULTS
Eight children were diagnosed with REDH, and the hematomas were secondary to motor vehicle–related trauma in all cases. The mean age of patients was 12 years (range 4–17 years). The mean REDH height (craniocaudal) was 4.0 cm, and the mean thickness (dorsoventral) was 1.0 cm. At presentation, the mean Glasgow Coma Scale score was 8 (range 3–14), and there was no correlation between hematoma size and presenting symptoms. Two patients died soon after injury, and 2 additional patients had atlanto-occipital dislocation that required surgical intervention. No patient underwent surgical evacuation of the REDH. The mean follow-up was 14 months. At most recent follow-up, 4 patients are neurologically intact, 1 patient has a complete spinal cord injury, and 1 patient has mild bilateral abducens nerve palsy.
CONCLUSION
To our knowledge, this study of 8 pediatric patients is the largest series of patients with REDH thus far reported. Based on our study, we found that REDH is likely to be underdiagnosed, atlanto-occipital dislocation should be considered in all cases of REDH, and many patients with REDH will have minimal long-term neurological injury.
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Affiliation(s)
- R. Shane Tubbs
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | | | - Todd Hankinson
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | - Curtis Rozzelle
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | - John C. Wellons
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | | | - W. Jerry Oakes
- Pediatric Neurosurgery, Children's Hospital, Birmingham, Alabama
| | - Aaron A. Cohen-Gadol
- Clarian Neuroscience, Goodman-Campbell Brain and Spine, Department of Neurological Surgery, Indiana University, Indianapolis, Indiana
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