Surgical interventions and short-term outcomes for preterm infants with post-haemorrhagic hydrocephalus: a multicentre cohort study

OBJECTIVE

To (1) describe differences in types and timing of interventions, (2) report short-term outcomes and (3) describe differences among centres from a large national cohort of preterm infants with post-haemorrhagic hydrocephalus (PHH).

DESIGN

Cohort study of the Children's Hospitals Neonatal Database from 2010 to 2022.

SETTING

41 referral neonatal intensive care units (NICUs) in North America.

PATIENTS

Infants born before 32 weeks' gestation with PHH defined as acquired hydrocephalus with intraventricular haemorrhage.

INTERVENTIONS

(1) No intervention, (2) temporising device (TD) only, (3) initial permanent shunt (PS) and (4) TD followed by PS (TD-PS).

MAIN OUTCOME MEASURES

Mortality and meningitis.

RESULTS

Of 3883 infants with PHH from 41 centres, 36% had no surgical intervention, 16% had a TD only, 19% had a PS only and 30% had a TD-PS. Of the 46% of infants with TDs, 76% were reservoirs; 66% of infants with TDs required PS placement. The percent of infants with PHH receiving ventricular access device placement differed by centre, ranging from 4% to 79% (p<0.001). Median chronological and postmenstrual age at time of TD placement were similar between infants with only TD and those with TD-PS. Infants with TD-PS were older and larger than those with only PS at time of PS placement. Death before NICU discharge occurred in 12% of infants, usually due to redirection of care. Meningitis occurred in 11% of the cohort.

CONCLUSIONS

There was significant intercentre variation in rate of intervention, which may reflect variability in care or referral patterns. Rate of PS placement in infants with TDs was 66%.

Neurosurgeon-Led Advocacy for Folic Acid Fortification to Prevent Spina Bifida

The Publisher regrets that this article is an accidental duplication of an article that has already been published, http://doi.org/10.1016/j.wneu.2023.02.013. The duplicate article has therefore been withdrawn. The full Elsevier Policy on Article Withdrawal can be found at https://www.elsevier.com/about/policies/article-withdrawal.

The role of neurosurgeons in global public health: the case of folic acid fortification of staple foods to prevent spina bifida

OBJECTIVE

The global neurosurgery movement arose at the crossroads of unmet neurosurgical needs and public health to address the global burden of neurosurgical disease. The case of folic acid fortification (FAF) of staple foods for the prevention of spina bifida and anencephaly (SBA) represents an example of a new neurosurgical paradigm focused on public health intervention in addition to the treatment of individual cases. The Global Alliance for the Prevention of Spina Bifida-F (GAPSBiF), a multidisciplinary coalition of neurosurgeons, pediatricians, geneticists, epidemiologists, food scientists, and fortification policy experts, was formed to advocate for FAF of staple foods worldwide. This paper serves as a review of the work of GAPSBiF thus far in advocating for universal FAF of commonly consumed staple foods to equitably prevent SBA caused by folic acid insufficiency.

METHODS

A narrative review was performed using the PubMed and Google Scholar databases.

RESULTS

In this review, the authors describe the impact of SBA on patients, caregivers, and health systems, as well as characterize the multifaceted requirements for proper spina bifida care, including multidisciplinary clinics and the transition of care, while highlighting the role of neurosurgeons. Then they discuss prevention policy approaches, including supplementation, fortification, and hybrid efforts with folic acid. Next, they use the example of FAF of staple foods as a model for neurosurgeons' involvement in global public health through clinical practice, research, education and training, and advocacy. Last, they describe mechanisms for involvement in the above initiatives as a potential academic tenure track, including institutional partnerships, organized neurosurgery, neurosurgical expert groups, nongovernmental organizations, national or international governments, and multidisciplinary coalitions.

CONCLUSIONS

The role of neurosurgeons in caring for children with spina bifida extends beyond treating patients in clinical practice and includes research, education and training, and advocacy initiatives to promote context-specific, evidence-based initiatives to public health problems. Promoting and championing FAF serves as an example of the far-reaching, impactful role that neurosurgeons worldwide may play at the intersection of neurosurgery and public health.

Management of Sleep Apnea in Children with Chiari I Malformation: A Retrospective Study

INTRODUCTION

The literature indicates that decompression of Chiari I malformations (CM-1) may resolve symptoms of sleep apnea. This study aims to identify the incidence of obstructive sleep apnea (OSA), central sleep apnea (CSA), and mixed sleep apnea in a cohort of pediatric CM-1 patients treated at our institution. We also assessed apnea-hypopnea index and symptomatology before and after surgery to investigate if Chiari decompression is a viable treatment for sleep apnea in CM-1 patients. Improvement relative to ENT surgical intervention was also considered.

METHODS

We identified 75 patients who underwent polysomnography (PSG) from our database of 465 CM-1 patients. Sleep apnea diagnosis was based on the sleep physician's overall interpretation of the PSG. Symptomatology pre- and post-surgery was analyzed.

RESULTS

Of the 75 CM-1 patients that underwent PSG, 23 were diagnosed with sleep apnea. Sixteen had OSA, 6 had CSA, and 1 had mixed apnea. Twelve OSA patients received ENT intervention. Eight improved and 2 further improved after Chiari decompression. Of the 4 patients that did not improve, one of those later improved following Chiari decompression. Of the 6 CSA patients, 2 underwent Chiari decompression, but only one improved. The mixed apnea patient underwent several ENT interventions that did not relieve symptoms but improved following Chiari decompression.

DISCUSSION/CONCLUSIONS

Based on our results, sleep apnea in CM-1 patients may be obstructive, central, or mixed and is likely multifactorial. A multidisciplinary approach to the management of these patients is important, including neurosurgery, otolaryngology, and sleep medicine. Future prospective studies will lend further insight into this condition and its management.

Sleep related breathing disorders in the spina bifida population ages 1-20 years: A retrospective study in Arkansas

PURPOSE

Sleep related breathing disorders (SRBD) are seen at disproportionately higher rates in children with spina bifida compared with their same aged peers. SRBD such as obstructive sleep apnea (OSA) or central apnea are associated with developmental and cognitive consequences, and sudden death.

METHODS

Participants aged 1 to 20 years with a diagnosis of spina bifida were recruited from a pediatric academic hospital spinal cord specialty clinic to evaluate the prevalence and impact of sleep disorders in the spina bifida population; 76 polysomnogram (PSG) reports spanning a 3-year period were reviewed in this retrospective cohort study.

RESULTS

Of the PSGs reviewed, 37 (49%) indicated the presence of SRBD, and 28 (76%) of those children required an escalation of management (surgical intervention or additional respiratory support). These results are consistent with previous studies and further emphasize the clinical impact of SRBD on children with spina bifida by describing the interventions that followed an abnormal PSG.

CONCLUSION

The high prevalence of SRBD in the spina bifida population supports the need for additional research to develop sleep questionnaires specific to spina bifida that can predict abnormal PSG clinically and to determine the standard of care following an abnormal PSG, chiefly in OSA and central apnea.

Management of an odontoid synchondrosis fracture causing chronic translational anterior atlanto-axial subluxation in a child with autism: case report

The authors report an unusual case of an odontoid synchondrosis fracture causing chronic translational anterior atlanto-axial subluxation and present a discussion of the unique management of this case. Traumatic translational anterior atlanto-axial subluxation is a rare manifestation within pediatrics. Patients with preexisting abnormalities in ligamentous or bony structures may present with unusual symptomatology, which could result in delay of treatment. A 6-year-old male patient with autism who presented with acute respiratory arrest was noted to have an odontoid synchondrosis fracture and severe anterior translational atlanto-axial subluxation. Initial attempts at reduction with halo traction were tried for first-line treatment. However, because of concern regarding possible inadvertent worsening of the impingement, the presence of comorbid macrocephaly, and possible instability with only C1-2 fusion, a posterior C1 laminectomy was performed. Further release of the C1-2 complex and odontoid peg from extensive fibrous tissue allowed for complete reduction. Acute injuries of the C1-2 complex may not present as expected, and the presence of pain is not a reliable symptom. Halo traction is an appropriate initial treatment, but some patients may require surgical realignment and stabilization.

Extending the Neuroanatomic Territory of Diffuse Midline Glioma, K27M Mutant: Pineal Region Origin

Diffuse midline glioma, H3-K27M mutant (DMG-K27M) is a newly described, molecularly distinct infiltrative glioma that almost exclusively arises in midline CNS structures, including the brain stem, especially the pons, as well as the thalamus and spinal cord with rare examples seen in the cerebellum, third ventricle, and hypothalamus. To our knowledge, only 1 case of a molecularly confirmed DMG-K27M arising in the pineal region has been previously reported. We present the second occurrence of a tissue-confirmed DMG-K27M of the pineal region, which, to our knowledge, is the first case reported in a child and the first case with documented preoperative MRI. This case, in addition to a prior report described in an adult, defines the lower end of a broad age range of DMG-K27M onset (12-65 years) and establishes the pineal gland as a bona fide site of origin for this newly codified midline glioma.

Segmental spinal dysgenesis: a report of early surgical intervention and outcome in a 14-month-old child

Segmental spinal dysgenesis is a rare spinal deformity that is the result of failure of formation resulting in some cases spondyloptosis and neurological dysfunction usually at the thoracolumbar junction. There is little known concerning surgical intervention and timing in these patients. The goal of this case report is to present a case involving 14 months old diagnosed with segmental spinal dysgenesis with stenosis at the thoracolumbar junction soon after birth, treated with definitive posterior spinal fusion and subsequent follow-up.

The deepithelialized skin flap for closure of large myelomeningoceles: a common plastic surgery technique for a novel neurosurgery application

PURPOSE

The study aims to demonstrate proof of principle of a common plastic surgery technique of deepithelialization for repair of large myelomeningoceles (MMCs). Whereas repair typically consists of a watertight dural closure followed by a muscle or fasciocutaeneous layer, excess skin, however, need not be discarded and can be deepithelialized to augment or, in selective cases, replace the muscle repair.

METHODS

The study was performed through a retrospective chart review of two patients.

RESULTS

Step-by-step figures illustrate the technique. Two patients each born with large MMCs measuring 10 × 11 cm and 6 × 9 cm, respectively, were reviewed. Excess skin was deepithelialized to create an additional layer of vascularized tissue over the muscle repair. There were no post-operative complications at 3-month follow-up.

CONCLUSIONS

In large MMCs with excess skin, the use of a deepithelialized skin flap can potentially be an alternative or adjunct to a muscle flap to buttress the dural repair.

Disconnective Hemispherotomy for Medically Intractable Status Epilepticus in an 8-Year-Old Child

We report here the unusual case of an 8-year-old child with left hemispheric focal epilepsy secondary to a perinatal infarction who presented with new onset absence seizures and eventual nonconvulsive status epilepticus that was refractory to medical management. Following review at our multidisciplinary Epilepsy Surgery conference, the patient underwent disconnective surgical hemispherotomy with immediate cessation of his seizures; and has remained seizure-free at 4 months following surgery. In this context, we present here an overview of hemispherectomy and related procedures, including peri-insular disconnective hemispherotomy, and we discuss the efficacy of surgery for challenging hemispheric epilepsies.

Surgical management of intrauterine devices migrated towards intra-abdominal structures: 20-year experience of a tertiary center

AIMS

To share surgical management experiences of intra-abdominal intrauterine devices (IUDs) in tertiary center.

MATERIAL AND METHODS

A total of 27 patients were retrospectively analyzed. This retrospective study was conducted between September 1992 and April 2013 at Department of Obstetrics and Gynecology Tepecik Research and Training Hospital, Izmir, Turkey. Demographic findings, diagnostic methods, and operative notes of patients were obtained from the patient file.

FINDINGS

Of the 27 IUDs, nine (33.3%) were in omentum, four (15%) were in Douglas pouch, one in left sacrouterine ligament, one in uterovesical space and one in fundus posterior, six (22%) in left adnexial region, one in abdominal wall, one was subdiaphragmatic, one in ligamentum latum, and one in jejunum. Almost all of the patients had TCu-380 A IUDs. Seventeen patients (63%) were managed by laparoscopy, whereas laparotomy was required in ten (37%). Adhesions were found in 23 of 27 (85%) patients with varying degrees. In four cases the incision was extended due to adhesions.

CONCLUSION

A missing string was the first finding of an intra-abdominal IUD. Pelvic ultrasonography, X-ray, and hysteroscopy methods should be performed in order to detect the localization of IUD in case of a missing string. Surgical approach should be the first treatment option for intra-abdominal IUDs.

Predictors of the need for cerebrospinal fluid diversion in patients with myelomeningocele

OBJECT

Many patients with myelomeningocele (MMC) develop hydrocephalus, and most will undergo CSF diversion. The goal of this retrospective study was to determine whether there was a change in the shunt rate over the 7 consecutive years of the study. The authors will also identify the criteria used to determine the need for shunt placement.

METHODS

During a 7-year period, 73 patients underwent MMC closure at Arkansas Children's Hospital. The shunt rate for each year was calculated. Clinical characteristics were evaluated, including apneic and bradycardic spells, CSF leak, level of the MMC, head circumference, and rate of head growth. In addition, radiological images were reviewed, and the frontooccipital horn ratio (FOHR), ventricular index (VI), and thalamooccipital distance (TOD) were calculated. Comparisons were made between those patients who underwent shunt placement and those who did not.

RESULTS

One patient was excluded due to death in the perinatal period. Of the 72 remaining patients, 54 (75%) underwent placement of a ventriculoperitoneal shunt. This rate did not change significantly over time. Between the cohorts with and without a shunt there was no significant difference in age, sex, or race. There was no significant difference in apneic episodes or bradycardic episodes. There was a statistically significant difference in fontanelle characteristics, head circumference at birth, and rate of head growth. Patients who required CSF diversion had a mean head growth of 0.32 cm/day compared with those who did not receive a shunt (0.13 cm/day; p < 0.05). All radiological parameters were found to be statistically significant.

CONCLUSIONS

In this study, several classic indicators of hydrocephalus in the neonate were not found to be significantly associated with the need for CSF diversion. Fontanelle characteristics, head circumference at birth, and head growth velocity were associated with the need for shunt placement. Imaging information including the VI, TOD, and FOHR are statistically significant measures to evaluate prior to placement of a ventriculoperitoneal shunt. The optimal patient with MMC for CSF diversion will have full to tense fontanelle, increasing head circumference of more than 3 mm/day, and radiological evidence of an elevated VI, TOD, and/or FOHR.

Stridor at birth predicts poor outcome in neonates with myelomeningocele

BACKGROUND

Stridor, associated with vocal cord paralysis, in neonates with myelomeningocele (MMC) is a recognized symptom related to Chiari II malformation (CM). In most children, stridor appears after birth. Control of hydrocephalus, if present, and urgent decompression of the CM are recommended for treatment of these patients. Such management typically improves symptoms. Occasionally, stridor is present at birth and may be secondary, in part, to maldevelopment or prenatal ischemia of the brain stem, rather than treatable compression. There is minimal literature describing the outcome after Chiari decompression in this population. The purpose of this study was to review the outcomes of neonates with MMC and stridor at birth and compare it to MMC patients who develop stridor later. We hypothesized that unlike stridor which develops after birth, stridor at birth predicts a dismal outcome, despite aggressive surgical treatment.

METHODS

Retrospective review of newborns with MMC and CM was performed in our institution from 1975 to 2010. Patients with stridor at birth and those who developed stridor later in infancy were identified. Outcomes were analyzed. Autopsy findings were reviewed when available.

RESULTS

Six patients with MMC who presented with stridor at birth were identified. Five of these patients had decompression of CM and treatment of hydrocephalus, if present, within the first 2 weeks of life. All patients died: three within 1 month and the oldest at 62 months. In the three patients with autopsies, vernix caseosa meningitis was present. Eight patients presented with stridor later in infancy. CM decompression was performed in seven of them. One patient out of the seven with late onset of stridor died at 13 months after CM surgery. The mortality rate after CM decompression was worse in patients with stridor at birth than those presenting later with stridor (chi-square p = 0.015).

CONCLUSIONS

In newborns with MMC, stridor at birth may predict dismal outcome despite CM decompression. Unlike the situation in neonates who develop stridor after birth, the outcome in those presenting with stridor at birth does not seem to be impacted by decompression of the CM. Nonoperative management may be an option to offer in this population. Additionally, vernix caseosa meningitis may contribute to the severe irreversible brain stem dysfunction in these newborns.

Benign inverted papilloma with intracranial extension: prognostic factors and outcomes

We describe a case of benign inverted papilloma with intracranial extension treated with endoscopic resection combined with craniotomy. Intracranial involvement of inverted papilloma, in the absence of malignancy, is uncommon. We present an analysis of the literature identifying the characteristics and outcomes of benign intracranial inverted papilloma. PubMed database was searched using keywords intracranial, inverted or inverting, and papilloma. There are 17 reports of benign inverted papilloma with intracranial extension reported with a mean age of 49.2 years (range, 23 to 92 years), a female predominance, 22% of cases with an associated mucocele, and 60% recurrent disease. The most common sites of invasion are the frontal sinus or cribriform plate. The prognosis for benign intracranial inverted papilloma is dependent on the presence of dural invasion and the achievement of total resection. There are no reported recurrences after craniofacial resection with a mean follow-up of 7.9 years. Adjuvant radiation therapy has demonstrated benefit in cases of residual disease after resection. We expect that endoscopic resection, the standard treatment for sinonasal inverted papilloma, will be increasingly used in the presence of intracranial extension.

Hypertension, age, and location predict rupture of small intracranial aneurysms

BACKGROUND

Although current guidelines for the management of unruptured intracranial aneurysms (IAs) suggest aneurysms larger than 7 mm should be considered for treatment, a significant number of subarachnoid hemorrhages are caused by IAs 7 mm or smaller. Thus, we sought to identify risk factors associated with the rupture of IAs 7 mm or smaller.

METHODS

We identified 100 patients with subarachnoid hemorrhage resulting from IAs 7 mm or smaller between January 2001 and 2004. Patients were compared with controls (n = 51) with unruptured IAs 7 mm or smaller, diagnosed by conventional angiography or three-dimensional computerized angiography, with respect to aneurysm characteristics (size, location, and age of presentation) and risk factors (hypertension, smoking, cocaine use, and family history).

RESULTS

Hypertensive patients with IAs 7 mm or smaller were 2.6 times more likely to experience rupture (P = 0.01; 95% confidence interval, 1.21-5.53) than patients with normal blood pressure. Posterior circulation aneurysms were 3.5 times more likely to rupture than anterior circulation aneurysms (P = 0.048; 95% confidence interval, 0.95-19.4). After adjustment for location and hypertension, the age of patient on presentation was associated with a trend toward inverse correlation with aneurysmal rupture risk (P = 0.07). Hypertension and posterior location remained significant independent predictors in the logistic regression model.

CONCLUSION

Among patients with small aneurysms (< or = 7 mm), hypertension, relatively young age, and posterior circulation were significant risk factors for rupture. Given the minimal long-term morbidity and mortality of treatment of unruptured aneurysms in large, tertiary medical centers, management of unruptured aneurysms 7 mm or smaller should be governed by factors other than size, specifically age, history of hypertension, and location.

An unusual presentation of Nelson's syndrome with apoplexy and subarachnoid hemorrhage

A thirty-eight year-old lady with a history of bilateral adrenalectomy for Cushing's disease seven years previously, presented with sudden onset of severe headache, nausea, vomiting and loss of consciousness. She was somnolent and confused. She had neck stiffness, sixth nerve palsy and mydriasis on the left side. Computerized tomography (CT) and magnetic resonance imaging (MRI) studies revealed a non-homogeneous, grade IV D pituitary mass lesion associated with hemorrhage in the chiasmatic, interhemispheric, cerebellopontine, perimesencephalic cisterns and a hematoma within the frontal lobe. Angiography showed only bilateral elevation of horizontal segments of the anterior cerebral arteries. According to this angiographic evidence, it was presumed that the subarachnoid hemorrhage and the intracerebral hematoma were linked to pituitary adenoma apoplexy. ACTH level was 450 pg/ml. The hemorrhagic lesion with suprasellar extension was totally removed by left pterional craniotomy. Histological examination revealed a necrotic, ACTH-secreting pituitary adenoma. Even though apoplexy is a well known complication of pituitary adenomas, to our knowledge subarachnoid hemorrhage and intracerebral hematoma as a result of pituitary apoplexy in the context of Nelson's syndrome has not previously been reported.

Presentation and management of supratentorial and infratentorial arachnoid cysts. Review of 25 cases

BACKGROUND

To discuss the presentation, diagnosis, management modalities and outcomes of the arachnoid cysts.

METHODS

EXPERIMENTAL DESIGN

Retrospective study with a mean follow-up period of 31 months (ranging between 9 months and 5 years).

SETTING

Institutional practice (The Military Medical Faculty Hospital). Patients and the participants: 25 patients with arachnoid cysts treated surgically.

INTERVENTION

Fenestration and drainage of the cyst into cisterns in 13 cases, cyst-peritoneal shunting in 8 cases and cyst excision in 4 cases.

MEASURE

The arachnoid cysts were followed-up by Computed Tomography or/and Magnetic Resonance Imaging.

RESULTS

The results are excellent in 21 cases, moderate in 2 cases and poor in 2 cases.

CONCLUSIONS

Regardless of the procedure used for arachnoid cyst treatment, the outcomes are somewhat similar if the surgical indications and techniques are properly selected.

Comparison of nephroangiotomography, intravenous subtraction angiography and digital subtraction angiography in the diagnosis of renal hypertension

Nephroangiotomography (NATG), intravenous subtraction angiography (ISA) and digital subtraction angiography (DSA) were compared with regard to their specificity and diagnostic value, their expenditure of time, equipment and staff as well as to their risk for the patients. The interpretation of NATG is inferior to ISA. The hitting quota of ISA and DSA is equal. The expenditure of time and staff for ISA is important, whereas the equipment for DSA is considerable; however, it has a wider use. In case of a low patient number, ISA delivers sufficient results in the diagnosis of renal hypertension with the advantage that it can also be performed in smaller radiological institutes.