OBJECTIVE:Cerebral cavernous malformations (CCMs) are low-flow vascular malformations commonly found in the central nervous system with the potential to cause neurological deficits, seizures, and headache through bleeding and growth. CCMs are typically assessed with imaging such as MRI or CT. However, there is a clinical need to reduce the cost, risk (with sedation/anesthesia in children), and travel associated with these imaging studies. Prior work from the authors' group and others have highlighted the potential utility of noninvasive biomarkers as tools to potentially complement the use of imaging. Here, the authors present YES1, a member of the Src family kinases, as a potential plasma-based biomarker associated with the presence of CCM. METHODS:Plasma samples from symptomatic patients with pathology-confirmed CCM (n = 16) (aged 1-22 years) and healthy matched control subjects (n = 24) (aged 1-19 years) were obtained and compared after institutional review board approval. Protein levels of CCM and control plasma were analyzed using the Olink Proximity Extension Assay (PEA), and ELISA was used to confirm findings. Patient-derived primary cells and CCM tissues were stained for YES1. CCM tissues were sequenced to evaluate the mutational profile of YES1. RESULTS:Compared to healthy controls, patients with CCM showed significantly higher levels of plasma YES1 (approximately 4.5-fold higher, p = 0.002). Analysis confirmed the presence of YES1 in the source CCM tissue, linking pathology with putative biomarker expression. Whole exome sequencing (WES) revealed functional mutations in the gene encoding for YES1, providing an avenue of investigation to explore and to explain the overexpression of YES1. CONCLUSIONS:Here, for the first time, the authors present a putative diagnostic biomarker for CCM, YES1, that was demonstrated to be significantly elevated in the plasma of affected patients, with high correlative expression in the source tissue. Together, these data further support the development of CCM-related noninvasive biomarkers and may add insight into their pathogenesis.
OBJECTIVE:While studies have investigated normative ranges of anterior fontanelle (AF) closure and surface area (SA), they have focused on full-term children born without significant comorbidities that may impact the AF SA. Understanding the trends of AF SA and closure in patients with common pediatric conditions can help inform guidelines for screening the size of the AF and determining when to intervene. This study aimed to investigate the AF SA in pediatric patients between 0 and 24 months of age born either at term or prematurely. METHODS:A retrospective chart review investigated 346 pediatric patients between the ages of 0 and 24 months who underwent head CT imaging between January 2012 and December 2021. Patients with craniosynostosis and hydrocephalus were excluded. Mann-Whitney U-tests and Fisher's exact tests were used to compare the distribution of demographic variables between the term and premature patient cohorts. The length of the AF was measured in the coronal and sagittal planes to calculate SA. Mann-Whitney U-tests were used to compare median AF SA in the premature versus term cohorts of each age group. RESULTS:A total of 346 patients were identified, with an average patient age of 156 days (5.2 months). Most patients were male (53.2%) and White (66.2%). Fifty-six patients (16.2%) in the study cohort were premature, and 290 (83.8%) were born at term. The most common indication for CT of the head/brain was trauma (51.2%). Overall, the median AF SA for children born at term increased until age 2 months, then decreased until closure, while the AF SA for premature children peaked at 5-6 months. The median AF SA was significantly larger in premature compared with term patients at 5-6 and 7-9 months (p < 0.05). With corrected ages for the premature cohort, there were no statistically significant differences in median AF SA between the patients born prematurely and at term. CONCLUSIONS:This study provides insight into the hypothesis that AF SA varies, and specifically is larger, in premature children compared with children born at term. An enlarged AF in premature pediatric patients might signify normal development and may not necessitate neurosurgical referral.
OBJECTIVE:Pediatric intracranial abscesses are rare, life-threatening infections requiring prompt surgery and coordinated subspecialty care. Reports during COVID-19 described nationwide surges, but national operative trends and equity data remain sparse. Therefore, this study aimed to define decade-long trends in surgical management, outcomes, and racial disparities in children in the US who underwent intracranial abscess surgery, with an emphasis on pandemic-era changes. METHODS:This was a retrospective, multicenter cohort study of American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) Pediatric (2013-2023) children undergoing surgery for intracranial abscess/empyema by neurosurgery and/or otolaryngology; outcomes were compared using nonparametric/exact tests (α = 0.05) in R. RESULTS:Among 232 children (median age 11.9 years; 71.6% male), the annual operative volume rose 10-fold. The proportion of indexed operations performed by neurosurgery declined from 75% in 2013 to 7.5% in 2023, while the proportion performed by otolaryngology increased from 0% to 62.5% over the same period. Black children were less likely to undergo neurosurgery-only procedures than they were to undergo otolaryngology surgery with or without neurosurgery (4.3% vs 34.4%, p = 0.008). Black and Hispanic children had longer hospital stays than White children (12.5 and 11 days, respectively, vs 9 days; p = 0.026) and higher mortality (0.5%). Neurological complication rates (0.9%) were uniformly low. During COVID-19, patients were older (median age 12.5 vs 10.9 years, p = 0.014), had more extradural/subdural disease (47% vs 33%, p = 0.044), and had longer operations (median 203 vs 169 minutes, p = 0.020), while admission-to-incision time, readmission, and mortality rates were unchanged. CONCLUSIONS:From 2013 to 2023, occurrences of pediatric intracranial abscess surgery increased dramatically, with a marked increase during the later study period (2020-2023), temporally overlapping with the COVID-19 pandemic, and peaking in 2022-2023. Over the same period, the specialty performing the indexed operation shifted progressively from neurosurgery to otolaryngology. Short-term outcomes remained favorable, but Black and Hispanic children experienced reduced neurosurgical access and longer hospitalization, underscoring the need to address structural determinants of pediatric neurosurgical equity.
OBJECTIVE:Sinogenic intracranial abscess is a severe complication of sinusitis. Timely identification of patients requiring neurosurgical intervention can be challenging. This study aimed to evaluate preoperative clinical and radiographic variables to identify features that correlate with neurosurgical intervention and outcomes in pediatric patients with sinogenic intracranial infection. METHODS:This was a single-center retrospective study of pediatric patients who were surgically treated for sinogenic intracranial infection. Patients were grouped into an otolaryngological treatment (ENT)-only cohort and neurosurgical treatment (NSGY) cohort, with the latter including those who underwent neurosurgery alone or neurosurgery plus otolaryngology treatments. Variables included abscess volume, peri-infection T2-weighted hyperintensity volume and thickness, inflammatory marker levels (white blood cells, neutrophils, C-reactive protein [CRP], erythrocyte sedimentation rate [ESR]), Lund-Mackay sinus disease severity score, clinical symptoms, and infectious organisms. Outcomes included radiographic residual disease, length of stay, reoperation, readmission, and neurological deficits. Univariate and multivariate logistic regression and receiver operating characteristic (ROC) analyses were performed to identify and evaluate significant factors. RESULTS:Ninety patients met the inclusion criteria (mean ± SD age 11.43 ± 3.33 years; 61.11% of patients were male), with 56 in the ENT group and 34 in the NSGY group. In univariate analysis, larger abscess volume, larger perilesional T2-weighted hyperintensity, older age, elevated ESR and CRP level, and lower Lund-Mackay scores were associated with NSGY. In multivariate analysis, abscess volume (OR 1.11, 95% CI 1.03-1.19, p = 0.0055) and CRP level (OR 1.10, 95% CI 1.00-1.20, p = 0.048) remained the only independent correlates. ROC analyses showed that abscess volume had excellent discriminatory power (area under the curve 0.89) with an optimal threshold at 7.57 cm3. Streptococcus anginosus was the most common microorganism and was more prevalent in the NSGY group (p = 0.017). There were no significant differences in radiographic outcomes, length of stay, reoperation or readmission rates, or neurological deficits between the NSGY and ENT cohorts after adjusting for baseline disease severity. CONCLUSIONS:Preoperative abscess volume was best correlated with neurosurgical intervention. While neurosurgical patients had more severe baseline disease, it was not associated with worse outcomes. Given the retrospective and single-center design, these findings likely reflect appropriate patient selection and institutional practice rather than causality. Future prospective studies are needed to further investigate the relationship among clinical variables, interventions, and outcomes.
OBJECTIVE:The aim of this study was to evaluate whether MRI-based anatomical factors, including fat lateralization and spinal cord rotation, are associated with postoperative retethering in pediatric spinal lipoma. METHODS:This retrospective cohort study included pediatric patients (< 18 years old) who underwent spinal lipoma resection at King Chulalongkorn Memorial Hospital between 1999 and 2024, with a minimum follow-up of 12 months. Fat lateralization was graded on axial MRI based on the extent of lipomatous involvement relative to the dorsal and ventral nerve roots and dichotomized as nonlateralized (grades 0-1) or lateralized (grades 2-3). Spinal cord rotation was measured on axial MRI and categorized as < 20° or ≥ 20°. The cord-sac ratio (CSR) was classified as < 0.3, 0.3-0.5, or > 0.5. Associations with extent of resection and retethering were analyzed using appropriate statistical tests and Kaplan-Meier survival analysis. RESULTS:Eighty-six patients were included, with a mean follow-up of 9.7 years. Subtotal resection was significantly associated with spinal cord rotation ≥ 20° (p = 0.0003) and fat lateralization (p < 0.001). Both rotation and lateralization were correlated with higher CSR categories (p = 0.012 and p = 0.0095, respectively). Retethering occurred in 22.1% of patients and was significantly associated with cord rotation ≥ 20° (36.7% vs 14.3%, p = 0.028) and CSR > 0.5 (p = 0.0003). Extent of resection showed a trend toward lower retethering rates after total or near-total resection. Dorsal lipomas demonstrated the highest retethering rate, although this did not reach statistical significance. CONCLUSIONS:Preoperative MRI features, particularly spinal cord rotation and CSR, are important imaging markers associated with surgical complexity and postoperative retethering in pediatric spinal lipoma. Fat lateralization is strongly associated with limited extent of resection and unfavorable anatomy. Incorporating these anatomical parameters into preoperative assessment may improve risk stratification, surgical planning, and patient counseling.
OBJECTIVE:The objective was to quantify risks of hydrocephalus, cerebrospinal fluid (CSF) shunt placement, and shunt malfunction in children < 3 years of age with congenital heart defect (CHD) versus matched controls. METHODS:This was a multicenter retrospective cohort study conducted using TriNetX. Children < 3 years with CHD were propensity score matched 1:1 to controls on the basis of demographic characteristics and comorbidities. Outcomes were hydrocephalus (ICD-10 code G91), CSF shunt placement, and shunt malfunction (ICD-10 T85.0). Associations were reported as risk ratios (RRs) with 95% confidence intervals (CIs). RESULTS:Of 83,258 children with CHD and 418,476 controls, matching yielded 64,413 per group with excellent balance (all standardized mean differences < 0.02). Compared to matched controls, CHD patients were associated with higher rates of hydrocephalus (1.1% vs 0.2%, RR 4.98, 95% CI 4.15-5.97), shunt placement (0.4% vs 0.04%, RR 9.11, 95% CI 6.12-13.55), and shunt malfunction (2.5% vs 0.4%, RR 5.75, 95% CI 5.07-6.53) (all p < 0.001). Across physiology, elevations were consistent; within CHD, the rate of shunt malfunction was higher in patients with cyanotic defects than those with acyanotic defects (4.6% vs 2.5%, RR 1.86, 95% CI 1.61-2.14, p < 0.001). The strongest associations were observed in defect types most frequently encountered during the first 3 years of life. Hydrocephalus risk was increased in patients with patent ductus arteriosus (PDA) (2.2% vs 0.4%, RR 5.12, 95% CI 3.93-6.68), atrial septal defect (ASD) (1.1% vs 0.3%, RR 4.47, 95% CI 3.65-5.47), atrioventricular septal defect (AVSD) (1.0% vs 0.2%, RR 4.32, 95% CI 3.57-5.23), ventricular septal defect (VSD) (0.9% vs 0.3%, RR 2.79, 95% CI 2.01-3.88), and coarctation (2.1% vs 0.6%, RR 3.50, 95% CI 1.74-7.05). Shunt placement was likewise more common in patients with PDA (0.8% vs 0.1%, RR 9.14, 95% CI 5.27-15.87), ASD (0.4% vs 0.1%, RR 7.84, 95% CI 5.17-11.89), AVSD (0.4% vs 0.05%, RR 7.85, 95% CI 5.22-11.80), and VSD (0.3% vs 0.1%, RR 4.33, 95% CI 2.31-8.11) (all p < 0.001). Shunt malfunction was most pronounced in patients with tetralogy of Fallot (7.4% vs 0.7%, RR 11.30, 95% CI 5.94-21.49) and coarctation (6.8% vs 0.6%, RR 11.60, 95% CI 6.10-22.05) and remained elevated across septal lesions (AVSD 2.5%, ASD 2.4%, and VSD 3.1%) and PDA (3.8%) (all p < 0.001). CONCLUSIONS:CHD is associated with increased risk of hydrocephalus, shunting, and shunt malfunction in early childhood. Risks increase with septal lesions, PDA, and coarctation, with a higher rate of shunt malfunction in patients with cyanotic physiology. These findings support early cardiology-neurosurgery surveillance and care.
OBJECTIVE:MRI is a cornerstone of pediatric spinal evaluation but frequently requires sedation or general anesthesia in young children due to prolonged scan times. This use of anesthesia introduces periprocedural risks and logistical barriers that can delay care and increase burden for families. Fast-spine MRI (fsMRI) protocols offer a motion-tolerant, abbreviated alternative that may allow nonsedated imaging for selected pediatric indications. This study evaluates the clinical feasibility and operational impact of nonsedated fsMRI compared with routine pediatric spine MRI, with secondary analysis of institutional cost. METHODS:All pediatric spine MR studies obtained between January 1, 2023, and December 31, 2024, at the authors' institution were retrospectively reviewed. Imaging protocol, scan duration, and patient age were recorded. Patients were stratified into younger (≤ 6 years) and older (≥ 7 years) cohorts. Financial data, including direct institutional cost, charge amount, payment received, and collection rate, were analyzed to assess economic impact. RESULTS:A total of 2358 pediatric spine MR images were included (643 fsMRI, 1715 routine MRI). Across all patients, fsMRI reduced the mean table time from 100.2 ± 51.3 minutes to 34.6 ± 12.5 minutes (p < 0.0001). The time reduction was most pronounced in the younger cohort (105.9 ± 54.8 minutes vs 35.7 ± 12.7 minutes, p < 0.0001). The mean direct institutional cost for fsMRI was $133.59 lower per scan ($284.12 vs $417.71), with a significantly higher collection rate (53.9% vs 47.4%, p = 0.0054). CONCLUSIONS:Fast-spine MRI substantially reduces scan time, effectively removing the barrier of sedation for many young children. By serving as a rapid, nonsedated screening tool, this protocol offers a safer alternative to routine MRI that significantly expands appointment availability and improves access to care for all pediatric patients.
OBJECTIVE:Recurrence after angiographically confirmed microsurgical obliteration of brain arteriovenous malformations (bAVMs) is considered rare but occurs more frequently in children than in adults. Reported recurrence rates vary widely. The authors aimed to determine recurrence rates at a high-volume pediatric referral center and identify clinical and radiographic predictors of recurrence. METHODS:The authors retrospectively analyzed 129 children with bAVMs who presented to the Hospital for Sick Children between 1998 and 2023 and underwent complete resection. These cases were partitioned into recurrence and no recurrence groups with subsequent univariate and multivariable Cox proportional hazards regression. Given the relatively small number of recurrences (n = 14), a parsimonious model with key predictors (arteriovenous malformation [AVM] size, venous drainage) was constructed, and Firth's penalized Cox regression was applied to reduce bias from sparse events. Hazard ratios (HRs) with 95% confidence intervals (CIs) are reported. RESULTS:The recurrence rate after surgical cure was 10.9% (14/129), with a mean time to recurrence of 30.4 ± 21.6 months; the most delayed recurrence occurred at 11.6 years. On univariate Cox analysis, deep venous drainage (HR 9.7, 95% CI 2.8-33.1; p = 0.0005) and AVM size (HR 1.4 per cm, 95% CI 1.1-1.6; p = 0.0007) were significantly associated with recurrence. Eloquence approached significance (HR 2.2, 95% CI 0.7-6.6; p = 0.1). In multivariable and Firth-penalized models, deep venous drainage remained an independent predictor of recurrence, with AVM size demonstrating a trend toward increased recurrence risk. Age, sex, hemorrhagic presentation, AVM location, and embolization were not associated with recurrence. CONCLUSIONS:Children and adolescents develop recurrent AVMs at a higher rate than adult patients despite angiographic cure after initial resection. On multivariable analysis, deep venous drainage was independently associated with recurrence. Further work can help elucidate clinical and radiographic predictors of disease recurrence.
OBJECTIVE:The aim of this study was to evaluate the prognostic value of intraoperative EEG during corpus callosotomy (CC) in pediatric patients with drug-resistant epilepsy (DRE), with a particular focus on bisynchronization blockade and its correlation with long-term seizure outcomes. METHODS:A retrospective review was performed of pediatric patients with DRE and injurious drop attacks who underwent CC between 2005 and 2024. Patients were stratified into three groups based on intraoperative scalp EEG findings: 1) > 50% bisynchronization blockade, 2) < 50% blockade, and 3) absent bisynchronization. Baseline clinical characteristics, surgical approach, and extent of CC were recorded. Seizure outcomes were assessed using Engel and International League Against Epilepsy (ILAE) classifications with a minimum follow-up of 1 year. Whether atonic seizures resolved postoperatively was also evaluated. Group comparisons were performed using Fisher's exact test and Kruskal-Wallis rank-sum testing. RESULTS:Forty-six patients met the inclusion criteria. The majority underwent complete CC (65%), most via an open approach (67%). At 1 year, freedom from atonic seizures (ILAE class 1Engel class I) was highest in the > 50% blockade group (70.0%) compared with the < 50% blockade (40.0%) and absent bisynchronization (25%) groups (p = 0.042). At last follow-up (mean 5.3 years), the > 50% blockade group similarly achieved significantly higher rates of atonic seizure freedom (ILAE class 1/Engel class I, 76%) compared with 0% in the < 50% blockade and 25% in the absent bisynchronization groups (p < 0.001). Outcomes for total seizure freedom varied and did not reach statistical significance between groups. CONCLUSIONS:Achieving > 50% intraoperative bisynchronization blockade during CC was strongly associated with improved long-term atonic seizure freedom. These findings support the role of intraoperative EEG as a prognostic marker of effective seizure control.
OBJECTIVE:In the US, deep brain stimulation (DBS) is accessible to pediatric patients with dystonia who are 7 years of age and older through an FDA Humanitarian Device Exemption (HDE). The aim of this study was to assess the safety, feasibility, and outcomes of DBS for dystonia in children younger than 7 years of age who are excluded from the FDA HDE. METHODS:Data were collected (February 2015-December 2025) through The Child & Youth Comprehensive Longitudinal Database for DBS, which is a prospective registry of pediatric DBS from 5 tertiary pediatric hospitals in North America. Participants younger than 7 years of age who underwent DBS targeting the globus pallidus internus for the treatment of dystonia were included. Demographics, operative details, and postoperative outcomes and complications were analyzed. RESULTS:Twelve children underwent 14 DBS-related surgeries, with a mean follow-up duration of 2.66 years (range 0.50-10.85 years). The mean age at the time of surgery was 4.72 years (range 2.96-6.83 years), and the mean weight was 16.5 kg (range 9.3-30.8 kg). Half of the children had prior ICU admissions for status dystonicus, and 9 DBS surgeries (64.3%) were performed urgently. Three children had transgression of stereotactic frame pins beyond the inner table of the skull, while 4 other children had wound complications requiring surgical intervention. No patients experienced neurological sequelae, and those requiring explantation of infected hardware were reimplanted successfully once the infections were treated. Overall, there was a mean reduction of 40.1% in the Burke-Fahn-Marsden movement subscale at 6 months postoperatively (p < 0.05), which persisted to 12 months. Three children died due to underlying conditions > 6 months from their respective surgeries. CONCLUSIONS:DBS had demonstrable benefits in children younger than 7 years of age with severe refractory dystonia, albeit with higher surgical risks compared with older children. Further research is warranted to better inform treatment decisions and regulatory oversight.
OBJECTIVE:Although myelomeningocele (MMC) remains a leading cause of infant disability and death in many low- and middle-income countries, data regarding access to timely neurosurgical care remain limited. The goal of this study was to characterize sociodemographic and clinical factors associated with delayed presentation for neurosurgical repair of MMC in Zambian infants. METHODS:Infants with MMC presenting to a major tertiary academic hospital in Lusaka, Zambia, for MMC repair between May 1, 2024, and October 21, 2025, were enrolled in a prospective cohort study. The primary outcome was delayed patient presentation for postnatal neurosurgical care, defined as > 72 hours from birth. Univariate and multivariate logistic regression models were fit to assess the impact of demographic and clinical factors on late presentation to this tertiary care center. RESULTS:One hundred eighteen infants (53% male, n = 62) were enrolled, with 22% (n = 25) born prematurely. Seventy-one percent (n = 84) had a delayed presentation to the tertiary hospital. The median age at first neurosurgical evaluation was 8.0 (IQR 3.0-22.0) days. The median maternal age was 25.0 (IQR 20.0-30.0) years, with a median parity of 2 (IQR 1-4). Most mothers (67%, n = 79) had either no formal education or completed primary school only, and of those who answered the question, the majority were married (72%, 47/65). The self-reported median monthly household income was 16.56 (IQR 4.42-26.50) US dollars. The median distance from the primary referring center to the tertiary hospital was 414.9 (IQR 206.5-577.0) km. Preterm infants (OR 3.997, p = 0.027) and those who traveled ≥ 500 km to receive care (OR 5.085, p = 0.001) were more likely to present late, while those who received ≥ 1 antenatal ultrasound after 20 weeks' gestation tended to have earlier presentation (OR 0.363, p = 0.032). No statistically significant association was found between late presentation and any of the following: maternal age at delivery, education level, marital status, parity, multiplicative increases in monthly household income, infant sex, and presence of any congenital anomalies or comorbidities (p > 0.05). CONCLUSIONS:Longer distances to care and preterm birth were associated with delayed patient presentation, while receipt of antenatal ultrasound was associated with earlier presentation. Further investigations aimed at enhancing antenatal and postnatal care, as well as improving transportation access to neurosurgical tertiary care services, are warranted.
OBJECTIVE:The role of bracing in stable pediatric thoracolumbar compression fractures remains uncertain, with limited pediatric-specific evidence to guide practice. Therefore, the aim of this study was to determine the impact of prescribed bracing on symptom recovery, return to activity (RTA), radiographic remodeling, and reinjury in children and adolescents with this common injury. METHODS:The authors performed a retrospective cohort analysis with AO Spine type A1 stable vertebral compression fractures treated at a single academic children's hospital in 2016-2025. Inclusion criteria comprised an age ≤ 18 years, radiographically confirmed type A1 thoracic or lumbar compression fracture, and adequate follow-up with radiographic documentation. Outcomes included symptoms at follow-up, RTA clearance, and vertebral height restoration. Cohort comparisons were performed, as were region-stratified analyses. Both univariate and multivariable analyses along with interaction models were performed, and random forest classifiers were trained. RESULTS:Two hundred three pediatric patients with a median age of 12 years (range 2-18 years) were included in this study. The braced group was slightly older (median age 13 vs 11 years, p = 0.004). Forty-eight percent of the entire cohort was female (52% vs 43%, p = 0.132). Bracing was prescribed in 56% of cases. Injury severity was similar between groups (median height loss: 19.7% braced vs 20.4% unbraced, p = 0.261). At the first follow-up (FU1) 4-6 weeks postinjury, 42% of braced patients remained symptomatic versus 31% of unbraced patients, with braced patients with thoracic fractures showing more than 3 times higher odds of persistent symptoms (OR 3.2, 95% CI 1.48-6.67, p = 0.003). This effect persisted at the second follow-up (FU2) 3-6 months postinjury (p = 0.026). Bracing was also associated with a delayed RTA at FU1 (p = 0.001), although this effect diminished by FU2. Radiographically, braced patients demonstrated vertebral height restoration significantly sooner (brace × time interaction, p = 0.002), but this did not correspond to improved symptoms or function. Reinjury within 1 year was also more common in braced patients (11.5% vs 3.3%, OR 3.77, 95% CI 1.04-13.67, p = 0.04). CONCLUSIONS:In a pediatric cohort with stable thoracolumbar compression fractures, prescribed bracing was not associated with symptomatic or functional improvement and was correlated with delayed recovery and increased reinjury risk, despite accelerated radiographic remodeling. These findings add to the growing literature questioning a default brace prescription in thoracolumbar compression fractures. Future prospective studies will be necessary to validate these findings.
OBJECTIVE:Posthemorrhagic hydrocephalus (PHH) is a significant complication of intraventricular hemorrhage (IVH) in preterm neonates. Neuroendoscopic lavage (NEL) is a treatment option. The authors aimed to evaluate the effectiveness and safety of NEL alone for early treatment of PHH in neonates. METHODS:This systematic review and meta-analysis were conducted according to Cochrane Collaboration guidelines and the PRISMA statement. A comprehensive search of databases (PubMed, Embase, Google Scholar, and Web of Science) was conducted to identify studies evaluating NEL in the treatment of PHH in neonates. The analysis used random-effects models. The primary outcome was dependency on a ventriculoperitoneal (VP) shunt. Secondary outcomes included infection rates, multiloculated hydrocephalus, and mortality. RESULTS:The authors evaluated 312 neonates from 9 studies. The pooled analysis revealed a shunt dependency rate of 58.3% (95% CI 52.5-64.2%, I2 = 10%). The infection rate was 5.6% (95% CI 1.7-9.6%, I2 = 48.4%), while the incidence of multiloculated hydrocephalus was 6.5% (95% CI 1.56-11.4%, I2 = 32.6%). Mortality was low at 2.4% (95% CI 0%-4.9%, I2 = 25.2%). CONCLUSIONS:This meta-analysis of NEL for neonatal PHH showed moderate rates of shunt dependence, along with low rates of infection and mortality. These findings suggest that NEL is a safe procedure associated with relatively low VP shunt dependence; however, well-designed randomized controlled trials are required to confirm these results and to compare NEL with traditional management strategies. Systematic review registration no.: CRD42024556947 (https://www.crd.york.ac.uk/prospero/).
OBJECTIVE:It is unclear whether shunt survival differs for infants in whom prior endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) failed compared with those treated initially by shunt placement. Results among four previous studies spanning a range of age groups have suggested either no effect or a protective effect of prior endoscopic treatment on shunt survival. The aim of this study was to determine whether prior ETV/CPC positively impacts shunt survival among infants with hydrocephalus regardless of etiology. METHODS:The authors conducted a historical cohort review of all patients under 12 months corrected age who underwent ventriculoperitoneal shunt (VPS) placement either with or without prior ETV/CPC at their institution between December 2008 and December 2023. Statistical analyses included Cox regression modeling, Kaplan-Meier survival curves, and log-rank testing to evaluate the time to shunt failure. RESULTS:The study included 122 infants with and 46 infants without prior ETV/CPC who underwent VPS placement. There were no statistically significant differences between groups regarding sex, race, gestational age at birth, or corrected age at initial treatment for hydrocephalus. The distribution of etiologies and initial frontal-occipital horn ratios (FOHRs) were similar. The median pre-shunt FOHR was greater in the ETV/CPC group. The patients in the primary shunt placement group were all candidates for ETV/CPC based on retrospective review. Seventy-one infants (58%) with prior ETV/CPC remained free of shunt revision compared with 17 infants (37%) with primary shunt placement (OR 2.4, 95% CI 1.1-5.1; p = 0.01). The estimated 2-year shunt survival probability was 75% with and 50% without prior ETV/CPC (log-rank p = 0.001). The estimated 5-year survival was 60% with and 45% without prior ETV/CPC (p = 0.045). CONCLUSIONS:Infants who underwent ETV/CPC prior to VPS placement had better shunt survival than those who did not. ETV/CPC might reduce the risk of subsequent shunt failure, indicating the potential benefit of the procedure even when it fails.
OBJECTIVE:Craniofacial distraction osteogenesis (DO) is an established technique for the management of complex craniosynostosis but remains limited by the morbidity associated with external activation ports, including infection, wound breakdown, CSF leakage, and mechanical failure. The magnet-actuated craniofacial (MAC) distraction system was developed to eliminate externalized activation components by enabling fully internalized, contactless, noninvasive actuation. The authors of this study aim to evaluate the surgical feasibility, mechanical reliability, and positional stability of the MAC system in a cadaveric human cranial model. METHODS:The MAC system was subjected to comprehensive preclinical biomedical and mechanical engineering validation, including finite element analysis, benchtop force-torque testing, magnetic coupling characterization, and assessment of back-drivability resistance and torque-limiting safety features. Following validation, the system was implanted in preserved cadaveric human heads. Devices were placed in a parasagittal coronal configuration. After a latency period, distraction was performed at a rate of 1 mm/day for 10 days, followed by a simulated 60-day consolidation period. CT imaging was performed at predefined intervals to assess device position, distraction distance, and positional stability. RESULTS:Preclinical testing demonstrated that the MAC system maintained structural integrity under loads exceeding those expected during craniofacial distraction, with a minimum factor of safety of 3 and no evidence of material yielding or mechanical instability. In the cadaveric model, device implantation was surgically feasible without anatomical conflict. An average distraction of 6-9 mm was achieved with controlled, incremental advancement. No device migration, hardware loosening, or unintended back-drivability was observed during active distraction or consolidation. The device maintained the achieved distraction distance at the end of the consolidation period. CONCLUSIONS:This cadaveric feasibility study demonstrates that a fully internalized MAC distraction system can achieve controlled, stable cranial vault distraction without the need for external activation ports. The MAC system exhibited reliable mechanical performance, positional stability, and resistance to back-drivability under anatomically relevant conditions. These findings support further in vivo investigation of biological responses, long-term durability, and clinical safety prior to translation to pediatric craniofacial surgery.
OBJECTIVE:Moyamoya disease (MMD) is a progressive arteriopathy of intracranial internal carotid arteries. The authors identified a characteristic angiographic finding associated with arterio-arterial collaterals in which ischemic brain recruits blood supply from the posterior circulation with robust splenial-to-anterior pericallosal artery anastomoses, manifesting as a characteristic "mustache" appearance on an anterior-posterior angiogram projection. In this paper, a cohort of pediatric patients with MMD is presented to assess the utility of this finding as a potential marker of disease severity and angiogenic potential and its predictive value for surgical intervention. METHODS:A retrospective single-center review of pediatric patients with MMD who underwent bilateral surgical revascularization from 2014 to 2020 was performed. The presence of a mustache sign was determined and its presence or absence was correlated with Suzuki and Matsushima grades and clinical outcome. RESULTS:A total of 100 pediatric patients (200 total hemispheres) with MMD were identified (mean age 11 [SD 7] years). Of the total hemispheres, 12% exhibited a low Suzuki grade (I or II) with the remainder exhibiting a high Suzuki grade (III-VI), and 59% demonstrated a mustache sign. If a mustache sign was present, this demonstrated a 94% positive predictive value for the presence of a high Suzuki grade and 77% positive predictive value for a Matsushima grade A/B outcome postoperatively. CONCLUSIONS:As MMD severity correlated with the development of different forms of collateralization, a unique angiographic finding of a mustache sign is highlighted, which is seen in advanced MMD and indicates robust arterio-arterial collateralization with anticipated benefit from surgical revascularization.
