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Chiang SN, Reckford J, Alexander AL, Birgfeld CB, Bonfield CM, Couture DE, David LR, French B, Gociman B, Goldstein JA, Golinko MS, Kestle JRW, Lee A, Magge SN, Pollack IF, Rottgers SA, Runyan CM, Smyth MD, Wilkinson CC, Skolnick GB, Strahle JM, Patel KB. What to do with an incidental finding of a fused sagittal suture: a modified Delphi study. J Neurosurg Pediatr 2024:1-8. [PMID: 38728754 DOI: 10.3171/2024.2.peds23521] [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: 11/26/2023] [Accepted: 02/28/2024] [Indexed: 05/12/2024]
Abstract
OBJECTIVE As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition. METHODS A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose. RESULTS Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment. CONCLUSIONS Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.
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Affiliation(s)
- Sarah N Chiang
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
- 2Department of Surgery, Division of Plastic and Reconstructive Surgery, University of California, Los Angeles, California
| | - Jocelyn Reckford
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Allyson L Alexander
- 3Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado
| | - Craig B Birgfeld
- 4Department of Surgery, Division of Plastic Surgery, University of Washington School of Medicine, Seattle, Washington
| | | | | | - Lisa R David
- 7Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Brooke French
- 8Division of Plastic and Reconstructive Surgery, Department of Surgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado
| | - Barbu Gociman
- 9Department of Surgery, Division of Plastic Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Michael S Golinko
- 11Plastic Surgery, Vanderbilt University School of Medicine, Nashville, Tennessee
| | - John R W Kestle
- 12Department of Neurosurgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Amy Lee
- 13Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington
| | - Suresh N Magge
- 14Department of Neurosurgery, University of Michigan Medical School, Ann Arbor, Michigan
| | - Ian F Pollack
- 15Neurological Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | | | - Christopher M Runyan
- 7Plastic and Reconstructive Surgery, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Matthew D Smyth
- 17Department of Neurosurgery, Johns Hopkins All Children's Hospital, St. Petersburg, Florida; and
| | - C Corbett Wilkinson
- 3Department of Neurosurgery, University of Colorado Anschutz School of Medicine, Aurora, Colorado
| | - Gary B Skolnick
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
| | - Jennifer M Strahle
- 18Department of Neurosurgery, Washington University School of Medicine, St. Louis, Missouri
| | - Kamlesh B Patel
- 1Department of Surgery, Division of Plastic and Reconstructive Surgery, Washington University School of Medicine, St. Louis, Missouri
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Elbadry RG, Neuberger I, Ryan MV, Maloney JA, Laarakker A, Graber S, Bernard T, Cooper E, Ritz C, Wilkinson CC. Axial MR Angiography in Evaluating Revascularization after Indirect Bypass Surgery for Moyamoya. Pediatr Neurosurg 2024:000539098. [PMID: 38684141 DOI: 10.1159/000539098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/29/2024] [Indexed: 05/02/2024]
Abstract
INTRODUCTION At our institution, revascularization after indirect moyamoya surgery is routinely evaluated using magnetic resonance angiography (MRA) rather than catheter angiography. This study reviews how revascularization can be visualized on axial MRA versus catheter angiography and compares clinical outcomes of surgeries evaluated by routine postoperative MRA versus routine catheter angiography. METHODS We reviewed the records of all patients treated at our institution who underwent unilateral encephaloduroarteriosynangiosis (EDAS)/pial synangiosis 2004-2021 at 1-21 years of age. Inclusion criteria included undergoing preoperative MRA within 18 months of surgery and postoperative MRA 3 to 30 months after surgery. Clinical outcome measures included postoperative stroke and transient ischemic attacks (TIAs), changes in symptoms (improved, unchanged, worsened), and new postoperative symptoms. Measures were compared between surgeries evaluated by routine postoperative MRA versus routine postoperative angiograms. For each surgery, we determined the ratios of the diameters and areas of the donor and contralateral corresponding vessels and the relative signal intensities of these two vessels on preoperative- and 3-to-30-month postoperative MRA. We did the same for the middle meningeal artery (MMA) ipsilateral to the donor artery and the contralateral MMA. We assessed changes from pre- to post-operation in diameter ratios, area ratios, relative signal intensity, ivy sign, and brain perfusion on arterial spin labeled (ASL) imaging. MRI and MRA measures of revascularization and flow were compared to Matsushima grades in patients who had postoperative catheter angiograms. RESULTS Fifty-one operations were included. There were no significant differences in rates of strokes, TIAs, changes or new symptoms after surgeries evaluated by routine postoperative MRA versus catheter angiogram. Significant associations existed between greater collateralization on postoperative MRA and greater median increases in preoperative-to-postoperative ratios of donor-vessel-over-contralateral-vessel diameter (p=0.0461) and ipsilateral-MMA-over-contralateral-MMA diameter (p=0.0135). The median increase in the ratio of the donor-vessel-over-corresponding-contralateral-vessel diameters was significantly higher for Matsushima grade A versus B (p=0.036). The median increase in the ratio of the sum of donor-and-ipsilateral-MMA diameters over the sum of the contralateral vessel diameters was significantly higher for improved-versus-unchanged perfusion on ASL imaging (p=0.0074). There was a nonsignificant association between greater postoperative collateralization on MRA and Matsushima grade (p=0.1160) Conclusion: Cerebral revascularization after EDAS/pial synangiosis can be evaluated on axial MRA by comparing the diameter and/or signal intensity of the donor vessel and ipsilateral MMA to those of the corresponding contralateral vessels on postoperative-versus-preoperative MRA. The use of routine postoperative MRA rather than catheter angiography does not appear to negatively affect outcomes.
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Ritz C, Malik N, Wilkinson CC, Graber S. 352 Prevalence and Charactersitics of Moyamoya Syndrome in Patients With Down Syndrome. Neurosurgery 2023. [DOI: 10.1227/neu.0000000000002375_352] [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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Hawkins JC, Ryan MV, Graber S, Neuberger I, Slade J, Young M, Maloney JA, Wilkinson CC. Use of the Posterior Auricular Artery for Indirect Bypass in Moyamoya: A Pediatric Case Series. Pediatr Neurosurg 2023:000529735. [PMID: 36809759 DOI: 10.1159/000529735] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 01/27/2023] [Indexed: 02/23/2023]
Abstract
INTRODUCTION Encephaloduroarteriosynangiosis (EDAS) for moyamoya is predominantly performed using a branch of the superficial temporal artery (STA) as the donor artery. At times, other branches of the external carotid artery (ECA) are better suited for EDAS than is the STA. There is little information in the literature concerning using the posterior auricular artery (PAA) for EDAS in the pediatric age group. In this case series, we review our experience using the PAA for EDAS in children and adolescents. CASE PRESENTATIONS We describe the presentations, imaging, and outcomes of three patients in whom the PAA was used for EDAS, as well our surgical technique. There were no complications. All three patients were confirmed to have radiologic revascularization from their surgeries. All patients also had improvement of their preoperative symptoms, and no patient has had a stroke postoperatively. CONCLUSION The PAA is a viable option for use as a donor artery in EDAS for the treatment of moyamoya in children and adolescents.
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Vaughn AE, Louiselle AE, Tong S, Niemiec SM, Ahmad S, Zaretsky M, Galan HL, Behrendt N, Wilkinson CC, O'Neill B, Handler M, Derderian SC, Mirsky DM, Liechty KW. Early outcomes of a myofascial repair technique for fetal myelomeningocele. J Pediatr Surg 2023; 58:20-26. [PMID: 36289034 DOI: 10.1016/j.jpedsurg.2022.09.030] [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: 09/13/2022] [Accepted: 09/16/2022] [Indexed: 01/07/2023]
Abstract
PURPOSE Fetal repair of myelomeningocele (MMC) and myeloschisis leads to improved neurologic outcomes compared to postnatal repair, but the effects of modifications in closure techniques have not been extensively studied. Previous work has suggested that a watertight repair is requisite for improvement in hindbrain herniation (HBH) and to decrease postnatal hydrocephalus (HCP). Our institution adopted the myofascial closure technique for open fetal MMC repair in July 2019, which we hypothesized would result in decreased need for patch closure, improved HBH, and decreased rate of surgically-treated HCP. METHODS A single-center retrospective study of patients who underwent fetal MMC or myeloschisis repair between March 2013 and February 2022 was performed. Outcomes were evaluated (n = 70 prior to July 2019, n = 34 after July 2019). Statistical significance was determined by Fisher's exact and Chi square tests (p < 0.05 significant). RESULTS Patients who underwent myofascial closure were less likely to require a patch for skin closure (14.7% vs 58.6%, p < 0.0001). Myofascial closure was also associated with an increased rate of HBH improvement on two-week postoperative fetal MRI (93.9% vs 65.7%, p = 0.002). Surgically-treated HCP at one year was lower in the myofascial closure group (n = 21), however this did not reach statistical significance (23.8% vs 41.9%, p = 0.19). CONCLUSIONS We conclude that the myofascial closure technique for repair of fetal MMC and myeloschisis is associated with significantly decreased need for patch closure and improvement in hindbrain herniation compared to our previous skin closure technique. These results support a surgical approach that employs a multilayer watertight closure.
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Affiliation(s)
- Alyssa E Vaughn
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States.
| | - Amanda E Louiselle
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Suhong Tong
- Research Outcomes in Children's Surgery, Center for Children's Surgery, Children's Hospital Colorado, Aurora, CO, United States
| | - Stephen M Niemiec
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Saliha Ahmad
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Michael Zaretsky
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Henry L Galan
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - Nicholas Behrendt
- Department of Obstetrics and Gynecology, University of Colorado School of Medicine, Aurora, CO; Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - C Corbett Wilkinson
- Department of Neurosurgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Brent O'Neill
- Department of Neurosurgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Michael Handler
- Department of Neurosurgery, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - S Christopher Derderian
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
| | - David M Mirsky
- Department of Radiology, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, United States
| | - Kenneth W Liechty
- Division of Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Aurora, CO, Colorado Fetal Care Center, Children's Hospital Colorado, Aurora, CO, United States
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Finneran MM, Graber S, Poppleton K, Alexander AL, Wilkinson CC, O'Neill BR, Hankinson TC, Handler MH. Postoperative general medical ward admission following Chiari malformation decompression. J Neurosurg Pediatr 2022; 30:602-608. [PMID: 36115060 DOI: 10.3171/2022.7.peds22226] [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: 06/20/2022] [Accepted: 07/29/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Prior to 2019, the majority of patients at Children's Hospital Colorado were admitted to the pediatric intensive care unit (PICU) following Chiari malformation (CM) decompression surgery. This study sought to identify the safety and efficacy of postoperative general ward management for these patients. METHODS After a retrospective baseline assessment of 150 patients, a quality improvement (QI) initiative was implemented, admitting medically noncomplex patients to the general ward postoperatively following CM decompression. Twenty-one medically noncomplex patients were treated during the QI intervention period. All patients were assessed for length of stay, narcotic use, time to ambulation, and postoperative complications. RESULTS PICU admission rates postoperatively decreased from 92.6% to 9.5% after implementation of the QI initiative. The average hospital length of stay decreased from 3.4 to 2.6 days, total doses of narcotic administration decreased from 12.3 to 8.7, and time to ambulation decreased from 1.8 to 0.9 days. There were no major postoperative complications identified that were unsuitable for management on a conventional pediatric medical/surgical nursing unit. CONCLUSIONS Medically noncomplex patients were safely admitted to the general ward postoperatively at Children's Hospital Colorado after decompression of CM. This approach afforded decreased length of stay, decreased narcotic use, and decreased time to ambulation, with no major postoperative complications.
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Affiliation(s)
- Megan M Finneran
- 1Department of Neurosurgery, Carle BroMenn Medical Center, Normal, Illinois
| | - Sarah Graber
- 2Research Institute, Children's Hospital Colorado, Aurora
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora; and
| | - Kim Poppleton
- 2Research Institute, Children's Hospital Colorado, Aurora
| | - Allyson L Alexander
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora; and
- 4Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - C Corbett Wilkinson
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora; and
- 4Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Brent R O'Neill
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora; and
- 4Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Todd C Hankinson
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora; and
- 4Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
| | - Michael H Handler
- 3Department of Neurosurgery, Children's Hospital Colorado, Aurora; and
- 4Department of Neurosurgery, University of Colorado School of Medicine, Aurora, Colorado
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Ung TH, Delcont MR, Colakoglu S, Seinfeld J, French B, Wilkinson CC. Reconstruction of Complex Scalp Defect After Cirsoid Aneurysm Resection: A Multidisciplinary Approach. World Neurosurg 2020; 143:190-196. [DOI: 10.1016/j.wneu.2020.07.101] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 10/23/2022]
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Wilkinson CC, Stence NV, Serrano CA, Graber SJ, Batista-Silverman L, Schmidt-Beuchat E, French BM. Fusion patterns of major calvarial sutures on volume-rendered CT reconstructions. J Neurosurg Pediatr 2020; 25:519-528. [PMID: 32032951 DOI: 10.3171/2019.11.peds1953] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 11/25/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recently, the authors investigated the normal course of fusion of minor lateral calvarial sutures on "3D" volume-rendered head CT reconstructions in pediatric trauma patients. While evaluating these reconstructions, they found many more fused sagittal sutures than expected given the currently accepted prevalence of sagittal craniosynostosis. In the present study, using the same set of head CT reconstructions, they investigated the course of fusion of the sagittal as well as the lambdoid, coronal, and metopic sutures. METHODS They reviewed all volume-rendered head CT reconstructions performed in the period from 2010 through mid-2012 at Children's Hospital Colorado for trauma patients aged 0-21 years. Each sagittal, lambdoid, coronal, or metopic suture was graded as open, partially fused, or fused. The cephalic index (CI) was calculated for subjects with fused and partially fused sagittal sutures. RESULTS After exclusions, 331 scans were reviewed. Twenty-one subjects (6%) had fusion or partial fusion of the sagittal suture. Four of the 21 also had fusion of the medial lambdoid and/or coronal sutures. In the 17 subjects (5%) with sagittal suture fusion and no medial fusion of adjacent sutures, the mean CI was 77.6. None of the 21 subjects had been previously diagnosed with craniosynostosis. Other than in the 21 subjects already mentioned, no other sagittal or lambdoid sutures were fused at all. Nor were other coronal sutures fused medially. Coronal sutures were commonly fused inferiorly early during the 2nd decade of life, and fusion progressed superiorly and medially as subjects became older; none were completely fused by 18 years of age. Fusion of the metopic suture was first seen at 3 months of life; fusion was often not complete until after 2 years. CONCLUSIONS The sagittal and lambdoid sutures do not usually begin to fuse before 18 years of age. However, more sagittal sutures are fused before age 18 than expected given the currently accepted prevalence of craniosynostosis. This finding is of unknown significance, but likely many of them do not need surgery. The coronal suture often begins to fuse inferiorly early in the 2nd decade of life but does not usually complete fusion before 18 years of age. The metopic suture often starts to fuse by 3 months of age, but it may not completely fuse until after 2 years of age.
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Affiliation(s)
| | | | - Cesar A Serrano
- 3Department of Neurosurgery, West Virginia University, Morgantown, West Virginia; and
| | | | | | - Emily Schmidt-Beuchat
- 4Department of Obstetrics, Gynecology, and Reproductive Science, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Brooke M French
- 5Plastic Surgery, Children's Hospital Colorado, University of Colorado Denver, Anschutz Medical Campus, Aurora, Colorado
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Abstract
The authors present the case of a pediatric patient with Loeys-Dietz syndrome (LDS) who underwent craniotomy for clip ligation of a ruptured intracranial aneurysm. To the authors' knowledge, this is the youngest reported patient with LDS who has been treated for a ruptured intracranial aneurysm. The patient presented with aneurysmal subarachnoid hemorrhage even though the results of surveillance screening were negative, and the aneurysm arose from the wall of the parent artery away from an arterial branch point. She was treated with open clip ligation and recovered well. The authors review the other reported cases of treated intracranial aneurysms in patients with LDS.
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Affiliation(s)
- Steven B Carr
- 1Department of Neurosurgery, University of Colorado School of Medicine
| | - Greg Imbarrato
- 3Department of Neurosurgery, Advocate BroMenn Medical Center, Normal, Illinois
| | - Robert E Breeze
- 1Department of Neurosurgery, University of Colorado School of Medicine.,2Division of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado; and
| | - C Corbett Wilkinson
- 1Department of Neurosurgery, University of Colorado School of Medicine.,2Division of Neurosurgery, Children's Hospital Colorado, Aurora, Colorado; and
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O'Neill BR, Gallegos D, Herron A, Palmer C, Stence NV, Hankinson TC, Corbett Wilkinson C, Handler MH. Use of magnetic resonance imaging to detect occult spinal dysraphism in infants. J Neurosurg Pediatr 2017; 19:217-226. [PMID: 27911245 DOI: 10.3171/2016.8.peds16128] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [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
OBJECTIVE Cutaneous stigmata or congenital anomalies often prompt screening for occult spinal dysraphism (OSD) in asymptomatic infants. While a number of studies have examined the results of ultrasonography (US) screening, less is known about the findings when MRI is used as the primary imaging modality. The object of this study was to assess the results of MRI screening for OSD in infants. METHODS The authors undertook a retrospective review of all infants who had undergone MRI of the lumbar spine to screen for OSD over a 6-year period (September 2006-September 2012). All images had been obtained on modern MRI scanners using sequences optimized to detect OSD, which was defined as any fibrolipoma of the filum terminale (FFT), a conus medullaris ending at or below the L2-3 disc space, as well as more complex lesions such as lipomyelomeningocele (LMM). RESULTS Five hundred twenty-two patients with a mean age of 6.2 months at imaging were included in the study. Indications for imaging included isolated dimple in 235 patients (45%), asymmetrically deviated gluteal cleft in 43 (8%), symmetrically deviated (Y-shaped) gluteal cleft in 38 (7%), hemangioma in 28 (5%), other isolated cutaneous stigmata (subcutaneous lipoma, vestigial tail, hairy patch, and dysplastic skin) in 31 (6%), several of the above stigmata in 97 (18%), and congenital anomalies in 50 (10%). Twenty-three percent (122 patients) of the study population had OSD. Lesions in 19% of these 122 patients were complex OSD consisting of LMM, dermal sinus tract extending to the thecal sac, and lipomeningocele. The majority of OSD lesions (99 patients [81%]) were filar abnormalities, a group including FFT and low-lying conus. The rate of OSD ranged from 12% for patients with asymmetrically deviated gluteal crease to 55% for those with other isolated cutaneous stigmata. Isolated midline dimple was the most common indication for imaging. Among this group, 20% (46 of 235) had OSD. There was no difference in the rate of OSD based on dimple location. Those with OSD had a mean dimple position of 15 mm (SD 11.8) above the coccyx. Those without OSD had a mean dimple position of 12.2 mm (SD 19) above the coccyx (p = 0.25). CONCLUSIONS The prevalence of OSD identified with modern high-resolution MRI screening is significantly higher than that reported with US screening, particularly in patients with dimples. The majority of OSD lesions identified are FFT and low conus. The clinical significance of such lesions remains unclear.
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Affiliation(s)
| | | | | | - Claire Palmer
- Pediatrics, Children's Hospital Colorado, Aurora; and
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Freeman J, Deleyiannis F, Bernard TJ, Fenton LZ, Somme S, Wilkinson CC. Moyamoya in a Patient with Smith-Magenis Syndrome. Pediatr Neurosurg 2017; 52:195-204. [PMID: 28380489 DOI: 10.1159/000459627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2016] [Accepted: 02/03/2017] [Indexed: 11/19/2022]
Abstract
Occurrence of moyamoya syndrome in a patient with Smith-Magenis syndrome (SMS) has previously been reported once in a 10-year-old Asian female. We report a second case of moyamoya in a patient with SMS, in a now 25-year-old Asian female diagnosed with both conditions as a child. In addition to describing her medical and surgical history, we provide a detailed report of her omental transposition, in which the omental circulation was anastomosed to the superior thyroid artery and external jugular vein. To our knowledge, this is the first report of omental transposition for moyamoya in which omental vessels are anastomosed to vessels in the neck, as well as the second report of moyamoya in a patient with SMS.
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Affiliation(s)
- Jacob Freeman
- Department of Neurosurgery, University of Colorado School of Medicine, Aurora, CO, USA
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Poonia S, Graber S, Corbett Wilkinson C, O'neill BR, Handler MH, Hankinson TC. Outcome of hospital discharge on postoperative Day 1 following uncomplicated tethered spinal cord release. J Neurosurg Pediatr 2016; 17:651-6. [PMID: 26849810 DOI: 10.3171/2015.10.peds15318] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [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 Postoperative management following the release of simple spinal cord-tethering lesions is highly variable. As a quality improvement initiative, the authors aimed to determine whether an institutional protocol of discharging patients on postoperative day (POD) 1 was associated with a higher rate of postoperative CSF leaks than the prior protocol of discharge on POD 2. METHODS This was a single-center retrospective review of all children who underwent release of a spinal cord-tethering lesion that was not associated with a substantial fascial or dural defect (i.e., simple spinal cord detethering) during 2 epochs: prior to and following the institution of a protocol for discharge on POD 1. Outcomes included the need for and timing of nonroutine care of the surgical site, including return to the operating room, wound suturing, and nonsurgical evaluation and management. RESULTS Of 169 patients identified, none presented with CSF-related complications prior to discharge. In the preintervention group (n = 113), the postoperative CSF leak rate was 4.4% (5/113). The mean length of stay was 2.3 days. In the postintervention group, the postoperative CSF leak rate was 1.9% (1/53) in the patients with postdischarge follow-up. The mean length of stay in that group was 1.3 days. CONCLUSIONS At a single academic children's hospital, a protocol of discharging patients on POD 1 following uncomplicated release of a simple spinal cord-tethering lesion was not associated with an increased rate of postoperative CSF leaks, relative to the previous protocol. The rates identified are consistent with the existing literature. The authors' practice has changed to discharge on POD 1 in most cases.
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Affiliation(s)
| | - Sarah Graber
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and
| | - C Corbett Wilkinson
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and
| | - Brent R O'neill
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and
| | - Michael H Handler
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and
| | - Todd C Hankinson
- Pediatric Neurosurgery, Children's Hospital Colorado, University of Colorado Anschutz Medical Campus; and.,Adult and Child Center for Health Outcomes Research and Delivery Science, University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Hankinson TC, Dudley RWR, Torok MR, Patibandla MR, Dorris K, Poonia S, Wilkinson CC, Bruny JL, Handler MH, Liu AK. Short-term mortality following surgical procedures for the diagnosis of pediatric brain tumors: outcome analysis in 5533 children from SEER, 2004-2011. J Neurosurg Pediatr 2016; 17:289-97. [PMID: 26588456 DOI: 10.3171/2015.7.peds15224] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [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] [Indexed: 11/06/2022]
Abstract
OBJECT Thirty-day mortality is increasingly a reference metric regarding surgical outcomes. Recent data estimate a 30-day mortality rate of 1.4-2.7% after craniotomy for tumors in children. No detailed analysis of short-term mortality following a diagnostic neurosurgical procedure (e.g., resection or tissue biopsy) for tumor in the US pediatric population has been conducted. METHODS The Surveillance, Epidemiology and End Results (SEER) data sets identified patients ≤ 21 years who underwent a diagnostic neurosurgical procedure for primary intracranial tumor from 2004 to 2011. One- and two-month mortality was estimated. Standard statistical methods estimated associations between independent variables and mortality. RESULTS A total of 5533 patients met criteria for inclusion. Death occurred within the calendar month of surgery in 64 patients (1.16%) and by the conclusion of the calendar month following surgery in 95 patients (1.72%). Within the first calendar month, patients < 1 year of age (n = 318) had a risk of death of 5.66%, while those from 1 to 21 years (n = 5215) had a risk of 0.88% (p < 0.0001). By the end of the calendar month following surgery, patients < 1 year (n = 318) had a risk of death of 7.23%, while those from 1 to 21 years (n = 5215) had a risk of 1.38% (p < 0.0001). Children < 1 year at diagnosis were more likely to harbor a high-grade lesion than older children (OR 1.9, 95% CI 1.5-2.4). CONCLUSIONS In the SEER data sets, the risk of death within 30 days of a diagnostic neurosurgical procedure for a primary pediatric brain tumor is between 1.16% and 1.72%, consistent with contemporary data from European populations. The risk of mortality in infants is considerably higher, between 5.66% and 7.23%, and they harbor more aggressive lesions.
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Affiliation(s)
- Todd C Hankinson
- Pediatric Neurosurgery and.,Adult and Child Center for Health Outcomes Research
| | - Roy W R Dudley
- Division of Neurosurgery, Department of Pediatric Surgery, Montreal Children's Hospital, McGill University Health Centers, Montreal, Quebec, Canada
| | | | | | | | | | | | - Jennifer L Bruny
- Pediatric Surgery, Department of Surgery, University of Colorado School of Medicine, Children's Hospital Colorado
| | | | - Arthur K Liu
- Department of Radiation Oncology, University of Colorado Anschutz Medical Campus, Aurora, Colorado; and
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Abstract
This series reports 2 pediatric cases of calvarial cavernous hemangioma (cavernoma, cavernous malformation) treated surgically at Children's Hospital Colorado between 2008 and 2010. Both cases presented as painless bony masses which enlarged over time. Both patients underwent surgical resection without complication and have remained recurrence free since surgery. Because so few cases have been reported among pediatric populations, little is known regarding the epidemiology and prognosis of calvarial cavernous hemangiomas in children. These cases represent interesting additions to the small body of literature on these rare tumors.
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Abstract
We report a case of a dural-based chondroma in the right frontal extra-axial region. Chondromas are benign cartilaginous tumors which are uncommon intracranially. Their diagnosis should be predicated on the exclusion of a chondrosarcoma and clinical studies should be performed to rule out any underlying tumor predisposition syndromes.
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Oluigbo CO, Wilkinson CC, Stence NV, Fenton LZ, McNatt SA, Handler MH. Comparison of outcomes following decompressive craniectomy in children with accidental and nonaccidental blunt cranial trauma. J Neurosurg Pediatr 2012; 9:125-32. [PMID: 22295915 DOI: 10.3171/2011.11.peds09449] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [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 The goal of this study was to compare clinical outcomes following decompressive craniectomy performed for intracranial hypertension in children with nonaccidental, blunt cranial trauma with outcomes of decompressive craniectomy in children injured by other mechanisms. METHODS All children in a prospectively acquired database of trauma admissions who underwent decompressive craniectomy over a 9-year span, beginning January 1, 2000, are the basis for this study. Clinical records and neuroimaging studies were systematically reviewed. RESULTS Thirty-seven children met the inclusion criteria. Nonaccidental head trauma was the most common mechanism of injury (38%). The mortality rate in patients with abusive brain injury (35.7%) was significantly higher (p < 0.05) than in patients with other causes of traumatic brain injury (4.3%). Children with inflicted head injuries had a 12-fold increase in the odds of death and 3-fold increase in the odds of a poor outcome (King's Outcome Scale for Closed Head Injury score of 1, 2, or 3). CONCLUSIONS Children with nonaccidental blunt cranial trauma have significantly higher mortality following decompressive craniectomy than do children with other mechanisms of injury. This understanding can be interpreted to mean either that the threshold for decompression should be lower in children with nonaccidental closed head injury or that decompression is unlikely to alter the path to a fatal outcome. If decompressive craniectomy is to be effective in reducing mortality in the setting of nonaccidental blunt cranial trauma, it should be done quite early.
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Affiliation(s)
- Chima O Oluigbo
- Department of Neurosurgery, The Children's Hospital and University of Colorado, Aurora, Colorado 80045, USA
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17
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Abstract
OBJECT The incidence, type, and severity of pediatric cervical spine injuries (CSIs) are related to age and mechanism of injury. In this study, the authors assessed the prevalence of CSIs in infants with head trauma treated in their institution. METHODS The authors reviewed the medical records of children younger than 1 year of age who presented to The Children's Hospital with head injuries between January 1993 and December 2007. They excluded infants with head injuries resulting from motor vehicle accidents and known falls from heights greater than 10 ft. For each patient, collected data included age, cause of injury, diagnosis, discharge disposition, and outcome. Relevant imaging data were reviewed, and when appropriate, autopsy reports were also reviewed. RESULTS Nine hundred five infants with head trauma and without a major mechanism/cause were identified. Their mean age was 4.3 months. Of the 905 patients, only 2 cases of CSI were detected, giving a prevalence of 0.2%. The mechanism of injury in these 2 patients was nonaccidental trauma (NAT). CONCLUSIONS The study revealed a very low prevalence of CSIs in infants with head trauma (0.2%). Routine cervical spine imaging in these infants, therefore, appears to have low diagnostic yield. The mechanism of head injury was NAT in the 2 patients who sustained an associated CSI. This supports the need for more stringent cervical spine imaging criteria for the infant with suspected NAT.
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Affiliation(s)
- Joel S Katz
- Department of Pediatric Neurosurgery, The Children's Hospital, University of Colorado, Aurora, Colorado 80045, USA
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18
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Bernard TJ, Fenton LZ, Apkon SD, Boada R, Wilkening GN, Wilkinson CC, Soep JB, Miyamoto SD, Tripputi M, Armstrong-Wells J, Benke TA, Manco-Johnson MJ, Goldenberg NA. Biomarkers of hypercoagulability and inflammation in childhood-onset arterial ischemic stroke. J Pediatr 2010; 156:651-6. [PMID: 20022340 DOI: 10.1016/j.jpeds.2009.10.034] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [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: 12/30/2008] [Revised: 10/05/2009] [Accepted: 10/27/2009] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To test the hypothesis that acute elevations of biomarkers of hypercoagulability and inflammation are common in children with arterial ischemic stroke (AIS), particularly among etiologic subtypes that carry an increased risk of recurrent stroke. STUDY DESIGN In this prospective/retrospective institutional-based cohort study of acute childhood-onset AIS (n = 50) conducted between 2005 and 2009, D-dimer, factor VIII (FVIII) activity, C-reactive protein (CRP), and erythrocyte sedimentation rate (ESR) were serially evaluated at the time of clinical blood sampling. Patients were classified by stroke subtype as cardioembolic, moyamoya, non-moyamoya arteriopathy, or other. RESULTS Both D-dimer and CRP were frequently elevated in acute childhood-onset AIS and exhibited a decreasing trend with time. Acute D-dimer levels were significantly higher in cardioembolic AIS compared with noncardioembolic AIS (median, 2.04 microg/mL [range 0.54-4.54 microg/mL] vs 0.32 microg/mL [0.22-3.18 microg/mL]; P = .002). At an optimal threshold of > or = 0.50 microg/mL, the sensitivity and specificity of D-dimer for cardioembolic subtype were 78% and 79%, respectively. CONCLUSIONS Our findings identify D-dimer and CRP as candidate biomarkers for etiology and prognosis in childhood-onset AIS. Further studies should investigate the role of these and other biomarkers of hypercoagulability and inflammation in childhood-onset AIS.
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Affiliation(s)
- Timothy J Bernard
- Department of Pediatrics, Section of Child Neurology, Mountain States Regional Hemophilia and Thrombosis Center, University of Colorado Denver and The Children's Hospital, Aurora, CO 80045-0507, USA.
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Abstract
The authors present the case of a 21-month-old girl with a posterior cervical subcutaneous/spinal lipoma that contained heterotopic bone. The patient demonstrated no neurological deficits and the lesion was resected without complication. The lesion was determined to be an ossifying lipoma. The literature on ossifying lipomas and osteolipomas is reviewed and the differences between the two are enumerated.
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Affiliation(s)
- Ashley Brones
- Department of Neurosurgery, University Health Sciences Center, The Children's Hospital, Denver, Colorado 80045, USA.
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20
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Abstract
OBJECT Cranial bandages are commonly applied over scalp incisions immediately after cerebrospinal fluid (CSF) shunt surgery, putatively to prevent complications, particularly infection. These bandages require resources, consume the time of healthcare workers, and incur non-negligible expenses. It is therefore both reasonable and important to examine the efficacy of cranial bandaging. METHODS The combined experience of 3 neurosurgeons over 6.75 years with using no cranial bandaging after operations for implantation or revision of CSF shunts is the basis of this report. These data were prospectively accrued and retrospectively analyzed. RESULTS The infection rate was 4.2% (95% CI 3.1-5.6%) for 1064 operations performed without postoperative cranial bandaging after either shunt insertion or revision surgery through clean or clean-contaminated wounds. The age distribution extended from premature infants through adults 77 years of age. CONCLUSIONS The results of this investigation support the position that bandaging scalp wounds after CSF shunt implantation or revision surgery adds no benefit beyond the easier, simpler, faster, and cheaper practice of using antibiotic ointment as a dressing without bandaging.
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Affiliation(s)
- Ken R Winston
- Department of Neurosurgery of The University of Colorado Denver School of Medicine, The Children's Hospital and Denver Health Medical Center, Denver, Colorado, USA.
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21
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Streubel S, Corbett Wilkinson C. P.414 Transpalatal repair of a basal encephalocele in a child. J Craniomaxillofac Surg 2008. [DOI: 10.1016/s1010-5182(08)72202-9] [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: 10/21/2022] Open
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22
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Kleinschmidt-DeMasters BK, Lovell MA, Donson AM, Wilkinson CC, Madden JR, Addo-Yobo SO, Lillehei KO, Foreman NK. Molecular array analyses of 51 pediatric tumors shows overlap between malignant intracranial ectomesenchymoma and MPNST but not medulloblastoma or atypical teratoid rhabdoid tumor. Acta Neuropathol 2007; 113:695-703. [PMID: 17431644 DOI: 10.1007/s00401-007-0210-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2006] [Revised: 02/16/2007] [Accepted: 02/17/2007] [Indexed: 10/23/2022]
Abstract
Gene microarray has been used to identify prognostic markers and genes of interest for therapeutic targets; a less common use is to show possible histogenetic relationships between rare tumor types and more common neoplasms. Intracranial malignant ectomesenchymoma (MEM) is a pediatric tumor postulated to arise from neural crest cells that contain divergent neuroectodermal and mesenchymal tissues, principally mature ganglion cells and rhabdomyosarcoma (RMS). We investigated a case of MEM by molecular, cytogenetic, and gene array analyses and compared results with our previously unpublished series of 51 pediatric tumors including conventional RMS, Ewing sarcoma (EWS), medulloblastoma (MED), atypical teratoid rhabdoid tumor (ATRT), and malignant peripheral nerve sheath tumor (MPNST); the latter is a sarcoma also with potential for divergent differentiation. Standard cytogenetic analyses and RT-PCR testing for the classic gene rearrangements seen in RMS [t(2;13)-PAX3/FKHR] and EWS ([t(11;22) & t(21;22)-EWS/FLI-1 & EWS/ERG), were used for characterization of the MEM, with gene expression microarray analyses on all tumor types. Gene rearrangement studies were negative in MEM. Gene expression microarray analyses showed tight clustering of the MEM with the MPNST (n = 2), but divergence from other pediatric tumors. MEM and MPNST both showed complex karyotypes, but without diagnostic translocations. Despite the presence of malignant skeletal muscle differentiation in the MEM, gene array testing showed no overlap with RMS, MED, or ATRT, but rather with MPNST. This suggests a common stem cell origin or embryonic gene recapitulation for these tumors and provides novel insights into their underlying biology.
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Affiliation(s)
- B K Kleinschmidt-DeMasters
- University of Colorado at Denver and Health Science Center, 4200 East Ninth Avenue, B-216, Denver, CO 80262, USA.
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23
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Kleinschmidt‐DeMasters BK, Lovell MA, Donson AM, Wilkinson CC, Addo‐Yobo SO, Lillehei KO, Foreman NK. Molecular and gene array analyses of rare pediatric mesenchymal tumors: malignant intracranial ectomesenchymoma compared to rhabdomyosarcoma, malignant peripheral nerve sheath tumor, and Ewing sarcoma. FASEB J 2007. [DOI: 10.1096/fasebj.21.5.a27-c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
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Wilkinson CC, Multani J, Bailes JE. Chronic subdural hematoma presenting with symptoms of transient ischemic attack (TIA): a case report. W V Med J 2001; 97:194-6. [PMID: 11558288] [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: 02/21/2023]
Abstract
Rarely, chronic subdural hematomas (CSDH) will present with symptoms mimicking transient ischemic attacks (TIAs). We report the case of an elderly man who presented with intermittent numbness and weakness of his left upper extremity typical of symptoms arising from a right sensorimotor cortex TIA. He was treated with empiric antiplatelet therapy for several days before a head CT was performed. The head CT and a subsequent MRI showed a CSDH with an acute component and cortical compression. Upon evacuation of the hematoma, his symptoms resolved. In cases of suspected TIA, a head CT should always be performed before beginning antiplatelet therapy. If there is an underlying hematoma, such therapy is dangerous, as it can potentiate more bleeding and leave the true pathology unaddressed.
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Affiliation(s)
- C C Wilkinson
- Dept. of Neurosurgery, West Virginia University School of Medicine, Morgantown, USA
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25
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Paek BW, Farmer DL, Wilkinson CC, Albanese CT, Peacock W, Harrison MR, Jennings RW. Hindbrain herniation develops in surgically created myelomeningocele but is absent after repair in fetal lambs. Am J Obstet Gynecol 2000; 183:1119-23. [PMID: 11084552 DOI: 10.1067/mob.2000.108867] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVE The purpose of our study was to determine whether prenatal repair of myelomeningocele prevents or reverses hindbrain herniation in the sheep model. STUDY DESIGN A myelomeningocele was surgically created in fetal sheep. One group was repaired later in utero; the others were delivered without repair. After delivery, lambs were assessed for the presence of hindbrain herniation. RESULTS In all lambs that had not undergone repair of the myelomeningocele, severe hindbrain herniation developed, whereas the brains of all lambs that had undergone fetal repair were normal. CONCLUSION Prenatal repair of myelomeningocele prevents or reverses development of hindbrain herniation in the fetal lamb model.
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Affiliation(s)
- B W Paek
- Division of Pediatric Surgery, Department of Surgery, and The Fetal Treatment Center, University of California at San Francisco, 94143-0570, USA
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26
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Wilkinson CC, Albanese CT, Jennings RW, Feldstein VA, Goldberg JD, Baehner FL, Farrell JA, Peacock WJ, Harrison MR. Fetal neurenteric cyst causing hydrops: case report and review of the literature. Prenat Diagn 1999; 19:118-21. [PMID: 10215067 DOI: 10.1002/(sici)1097-0223(199902)19:2<118::aid-pd478>3.0.co;2-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Routine prenatal ultrasound revealed a unilocular cystic mass associated with upper thoracic hemivertebrae that grew to 6 cm at 28 weeks and was associated with hydrops. A thoraco-amniotic shunt decompressed the cyst and resolved the hydrops, but the shunt occluded 17 days later. Preterm labour led to vaginal delivery at 31 2/7 weeks. Postnatally, the cyst was decompressed by thoracentesis due to respiratory distress. It was resected on day four of life. Severe tracheobronchomalacia was present post-operatively, presumably due to prenatal mass effect of the cyst. At one year of age, the child has recovered completely without adverse respiratory or neurological sequelae.
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Affiliation(s)
- C C Wilkinson
- Fetal Treatment Center, University of California, San Francisco 94143-0570, USA
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27
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Gyetko MR, Chen GH, McDonald RA, Goodman R, Huffnagle GB, Wilkinson CC, Fuller JA, Toews GB. Urokinase is required for the pulmonary inflammatory response to Cryptococcus neoformans. A murine transgenic model. J Clin Invest 1996; 97:1818-26. [PMID: 8621764 PMCID: PMC507249 DOI: 10.1172/jci118611] [Citation(s) in RCA: 151] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Urokinase (uPA) is hypothesized to provide proteolytic activity enabling inflammatory cells to traverse tissues during recruitment, and it is implicated as a cytokine modulator. Definitive evaluation of these hypotheses in vivo has previously been impossible because uPA could not completely and irreversibly be eliminated. This limitation has been overcome through the development of uPA-deficient transgenic mice (uPA-/-). Using these mice, we evaluated the importance of uPA in the pulmonary inflammatory response to Cryptococcus neoformans (strain 52D). C. neoformans was inoculated into uPA-/- and control mice (uPA+/+), and cell recruitment to the lungs was quantitated. The number of CFU in lung, spleen and brain was determined to assess clearance, and survival curves were generated. By day 21 after inoculation, uPA-/- mice had markedly fewer pulmonary inflammatory (CD45+), CD4+, and CD11b/CD18+ cells compared with uPA+/+ controls (P<0.0007); pulmonary CFUs in the uPA-/- mice continued to increase, whereas CFUs diminished in uPA+/+ mice(P<0.005). In survival studies, only 3/19 uPA+/+ mice died, whereas 15/19 uPA-/- mice died (p<0.001). We have demonstrated that uPA is required for a pulmonary inflammatory response to C. neoformans. Lack of uPA results in inadequate cellular recruitment, uncontrolled infection, and death.
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Affiliation(s)
- M R Gyetko
- Department of Internal Medicine, Ann Arbor Veterans Affairs Medical Center and University of Michigan Medical Center, Ann Arbor, Michigan 48109, USA
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Abstract
Mononuclear phagocytes (Mphi) produce urokinase-type plasminogen activator (uPA) and also express a specific cell-surface receptor for urokinase, uPAR. The concomitant expression of these proteins provides a mechanism by which Mphi can degrade extracellular matrix proteins during directed cell migration. In this study, we sought to determine if uPAR plays a role in Mphi chemotaxis that is distinct from its role in matrix proteolysis. Exposing adherent monocytes to a chemotactic gradient causes plasma membrane uPAR to localize strongly to the leading edge of cell migration. Adherence alone or exposure to FMLP had no effect on uPAR expression. Using Boyden chamber chemotaxis assays, we demonstrate that treating mononuclear cells with an anti-uPAR mAb (either as an intact mAb or F[ab']2) ablates chemotaxis induced by FMLP and monocyte chemotactic peptide-1 (P < 0.001). Inactivating the catalytic activity of uPAR-bound uPA had no effect on chemotaxis. Similarly, blocking uPAR expression with an antisense oligonucleotide to uPAR completely ablates chemotaxis, but blocking uPA expression with an antisense oligonucleotide to uPA has a minimal effect. We therefore demonstrate that expression and unimpeded function of uPAR plays an obligate role in M phi chemotaxis by mechanisms that are largely independent of its ligand, uPA. Combined with its known role in mediating pericellular proteolysis, these observations demonstrate that uPAR is essential for both locomotion and traversing tissue barriers during M phi migration.
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Affiliation(s)
- M R Gyetko
- Division of Pulmonary and Critical Care Medicine, Ann Arbor Veterans Affairs Medical Center, Michigan
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Gyetko MR, Hsu CH, Wilkinson CC, Patel S, Young E. Monocyte 1 alpha-hydroxylase regulation: induction by inflammatory cytokines and suppression by dexamethasone and uremia toxin. J Leukoc Biol 1993; 54:17-22. [PMID: 8336075 DOI: 10.1002/jlb.54.1.17] [Citation(s) in RCA: 53] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Alveolar macrophages acquire 1 alpha-hydroxylase activity in inflammation, and thereby metabolize 25 hydroxyvitamin D3 (25 D3) to the active metabolite, 1 alpha,25-dihydroxyvitamin D3 (1,25 D3, calcitriol). Calcitriol is a potent differentiation agent that modulates mononuclear phagocyte activation and effector functions. The mediators that induce macrophage 1 alpha-hydroxylase activity are not well delineated. Furthermore, it is unclear whether calcitriol is a product only of terminally differentiated macrophages or whether less mature mononuclear phagocytes can produce it as well. The ability of newly recruited monocytes to produce calcitriol as an autocrine differentiation agent is particularly important in inflammation, as it may substantially expand the functional repertoire of these cells. To assess the effects of cytokines on 1 alpha-hydroxylase activity, blood monocytes were cultured in the presence and absence of human recombinant tumor necrosis factor alpha (TNF-alpha), interferon-gamma (IFN-gamma), and interleukins 1 and 2 and then incubated with 25 D3 substrate. The conditioned media were assayed for calcitriol by high-performance liquid chromatography and competitive receptor binding assay. No detectable calcitriol was produced by unstimulated monocytes. However, all the cytokines markedly increased monocyte calcitriol production (range 133-151 pg/mg protein; in all cases P < .001). We then determined whether calcitriol production was suppressed by preincubation with either dexamethasone or the putative uremia toxin guanidinosuccinic acid (GSA). Dexamethasone pretreatment significantly inhibited subsequent cytokine-induced calcitriol production by monocytes, as did GSA (average 69 and 63% of control, respectively).
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Affiliation(s)
- M R Gyetko
- Division of Pulmonary and Critical Care Medicine, Ann Arbor Department of Veterans Affairs, MI
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30
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Abstract
This study delineates the regulatory effect of interleukin-1 (IL-1) and interleukin-2 (IL-2) on monocyte plasminogen activator (PA) activity. Mononuclear phagocytes regulate net PA activity by modulating the expression of urokinase-type PA (uPA) and a specific plasminogen activator inhibitor, PAI-2. To understand the regulation of mononuclear phagocyte PA activity, it is important to compare the expression of uPA and PAI-2. In this study, we determined the relative abundance of secreted PA and PA inhibitor activity in human monocyte-conditioned medium after stimulation with human recombinant IL-1 or IL-2. In agreement with our previous description of tumor necrosis factor-alpha and interferon-gamma stimulation of mononuclear phagocytes, we found no detectable PA activity in conditioned medium. Both IL-1 and IL-2 had dose-dependent effects, significantly up-regulating PA inhibitor activity in monocyte-conditioned medium (up to 11-fold). To further investigate the mechanism underlying this effect, Northern blot analysis was done to measure steady-state mRNA for uPA and PAI-2. Consistent with the increase in secreted PA inhibitor activity, we found that both IL-1 and IL-2 significantly increased steady-state mRNA for PAI-2. In addition, however, both IL-1 and IL-2 increased steady-state mRNA for uPA. IL-1 appears to increase mRNA for uPA to a greater extent than does IL-2. We conclude that IL-1 and IL-2 modulate monocyte proteolytic activity by increasing expression of uPA and PAI-2 with a resultant predominance of PAI-2. We further conclude that cytokine-specific regulation of plasminogen activity is achieved partly by varying the proportionate expression of uPA and PAI-2.
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Affiliation(s)
- M R Gyetko
- Pulmonary Section, Department of Veterans Affairs Medical Center, Ann Arbor, MI
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31
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Abstract
1. The electrophoretic patterns of water-soluble proteins of avian muscle showed differences due both to species and to muscle type. 2. Each muscle pattern within a species showed a unique protein band which distinguished that species from other species.
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Abstract
1. Carnosine and anserine have been measured in samples of breast and leg muscles from three turkeys. 2. The results show that there is a large difference in the dipeptide content between the two types of muscle.
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