Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era

BACKGROUND

COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes.

MATERIAL AND METHODS

An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up.

RESULTS

Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%.

CONCLUSIONS

These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

TROPHY registry - status report

INTRODUCTION

The TROPHY registry has been established to conduct an international multicenter prospective data collection on the surgical management of neonatal intraventricular hemorrhage (IVH)-related hydrocephalus to possibly contribute to future guidelines. The registry allows comparing the techniques established to treat hydrocephalus, such as external ventricular drainage (EVD), ventricular access device (VAD), ventricular subgaleal shunt (VSGS), and neuroendoscopic lavage (NEL). This first status report of the registry presents the results of the standard of care survey of participating centers assessed upon online registration.

METHODS

On the standard of treatment forms, each center indicated the institutional protocol of interventions performed for neonatal post-hemorrhagic hydrocephalus (nPHH) for a time period of 2 years (Y1 and Y2) before starting the active participation in the registry. In addition, the amount of patients enrolled so far and allocated to a treatment approach are reported.

RESULTS

According to the standard of treatment forms completed by 56 registered centers, fewer EVDs (Y1 55% Y2 46%) were used while more centers have implemented NEL (Y1 39%; Y2 52%) to treat nPHH. VAD (Y1 66%; Y2 66%) and VSGS (Y1 42%; Y2 41%) were used at a consistent rate during the 2 years. The majority of the centers used at least two different techniques to treat nPHH (43%), while 27% used only one technique, 21% used three, and 7% used even four different techniques. Patient data of 110 infants treated surgically between 9/2018 and 2/2021 (13% EVD, 15% VAD, 30% VSGS, and 43% NEL) were contributed by 29 centers.

CONCLUSIONS

Our results emphasize the varying strategies used for the treatment of nPHH. The international TROPHY registry has entered into a phase of growing patient recruitment. Further evaluation will be performed and published according to the registry protocol.

Arterial vascularization patterns of the splenium: An anatomical study

The aim of this study was to provide detailed information about the arterial vascularization of the splenium of the corpus callosum (CC). The splenium is unique in that it is part of the largest commissural tract in the brain and a region in which pathologies are seen frequently. An exact description of the arterial vascularization of this part of the CC remains under debate. Thirty adult human brains (60 hemispheres) were obtained from routine autopsies. Cerebral arteries were separately cannulated and injected with colored latex. Then, the brains were fixed in formaldehyde, and dissections were performed using a surgical microscope. The diameter of the arterial branches supplying the splenium of the CC at their origin was investigated, and the vascularization patterns of these branches were observed. Vascular supply to the splenium was provided by the anterior pericallosal artery (40%) from the anterior circulation and by the posterior pericallosal artery (88%) and posterior accessory pericallosal artery (50%) from the posterior circulation. The vascularization pattern of the splenium differs in each hemisphere and is usually supplied by multiple branches. The arterial vascularization of the splenium of the CC was studied comprehensively considering the ongoing debate and the inadequacy of the studies on this issue currently available in the literature. This anatomical knowledge is essential during the treatment of pathologies in this region and especially for splenial arteriovenous malformations.

Callosal branches of the anterior cerebral artery: an anatomical report

Although the morphology of the corpus callosum is well defined, the arterial supply of this structure has not been comprehensively studied. To elucidate this further, 40 cerebral hemispheres from 30 adult cadaveric brains were obtained. The anterior cerebral arteries were cannulated and injected with red latex. The following were observed and documented: (1) the number, diameter, and course of the arteries supplying the corpus callosum; (2) the territories vascularized by these arteries; (3) any variations of the callosal arteries. Short callosal arteries were present in 58 hemispheres (96.6%) and supplied the superficial surface of the corpus callosum along its midline and were a primary arterial source to this structure. Long callosal arteries were found in 28 hemispheres (46.6%) and contributed to the pial plexus. The cingulocallosal arteries were present in all hemispheres and supplied the corpus callosum, cingulate gyrus, and also contributed to the pericallosal pial plexus. The recurrent cingulocallosal arteries were present in 17 hemispheres (28.3%) and also contributed to the pericallosal pial plexus. The median callosal artery, an anatomical variation, was present in 10 brains (33.3%). This vessel supplied the corpus callosum and the cingulate gyrus. The aim of the present study was to provide a detailed description of the arteries supplying the corpus callosum for those who encounter these vessels radiologically or surgically.

Keyhole Approach for Posterior Cervical Discectomy: Experience on 84 Patients

Anterior cervical discectomy with or without fusion has been commonly used for cervical disc disease since the description by Smith and Robinson in 1958. In this report, surgical technique, advantages, and disadvantages of the posterior approach, known as the posterior keyhole laminotomy-foraminotomy, are reviewed and motion versus fusion surgery discussed. Between 1996 and 2004, the keyhole laminotomy-foraminotomy was performed on 84 patients suffering from lateral cervical soft disc herniation or osteophytes. All the procedures were performed under the surgical microscope. A high-speed drill was used for drilling the bone. In 49 patients (58%), soft disc herniation was removed, while in 35 patients (42%) there were osteophytes. Successful relief of radiculopathy symptoms was achieved in 80 patients (96%). In 4 patients the symptoms recurred. One patient (1.2%) developed kyphosis. The only complication observed intraoperatively was a partial root injury in one patient (1.2%). Mean hospitalization time was 48 hours. The posterior approach is particularly appropriate in patients whose root compression is located posterolaterally. Advantages of this surgery are minimal lamina resection, good visualization of the nerve root, postoperative early mobilization and minimal hospitalization. Microsurgery enables us to both preserve the motion of operated segment and avoid cervical instability.

The neurotoxic effects of intrathecal midazolam and neostigmine in rabbits

In parallel with improvements in understanding pain neurophysiology, many chemicals have recently been investigated for spinal anaesthesia and analgesia. However, studies discussing the effects of these drugs on neural tissue indicate that knowledge about some aspects of neurotoxicity is limited. Forty-nine New Zealand albino rabbits, weighing 2.2 +/- 0.2 kg, were randomly assigned to seven groups of seven animals each. Single dose groups received intrathecally through the atlantooccipital membrane 0.9% saline 1.5 ml; midazolam 100 microg/kg (low dose midazolam group) or 500 microg/kg (high dose midazolam group); neostigmine 10 microg/kg (low dose neostigmine group) or 50 microg/kg (high dose neostigmine group). Two groups had seven days of repeated dosing with either midazolam 100 microg/kg/day (repeat midazolam group) or 10 microg/kg/day neostigmine (repeat neostigmine group). The animals were sacrificed on day 8, and two spinal cord sections from the fourth cervical level and fourth lumbar level were removed and prepared for histopathological study. Transmission electron microscopic evaluations were performed on transverse spinal cord sections by a neuropathologist blinded to the group allocation. Twenty myelinated axons and neurones in the cervical and lumbar sections were investigated for the histopathological study. This study indicates that midazolam and neostigmine have different neurotoxic effects that depend on the dose and the repetition of dosing when these drugs are administered intrathecally.

Intramedullary mature cystic teratoma of the conus medullaris. A case report

Intramedullary teratoma is extremely rare and to our knowledge has been reported in only nine cases in the literature. We report a case of mature cystic teratoma of the conus medullaris. The case was diagnosed by magnetic resonance imaging and operated with microneurosurgical techniques.