OBJECTIVE:To predict the morbidity of sagittal suturectomy using preoperative computer tomographic measurement of frontal and parietal bone thickness in osteotomy sites. DESIGN:Retrospective analysis. SETTING:Tertiary children's hospital. PATIENTS:Fifty infants with nonsyndromic, isolated sagittal craniosynostosis who underwent extended sagittal suturectomy from 2015-2022. METHODS:Mean thickness of the frontal and parietal bone in regions of osteotomies were determined for each patient from preoperative CT images obtained within 30 days prior to suturectomy. The relationship between bone thickness (mm) and estimated blood loss (mL) was evaluated using Spearman's correlation and a multivariable model that adjusted for patient weight and surgery duration. The association between bone thickness and perioperative blood transfusion was evaluated using a multivariable logistic model controlling for patient weight and surgery duration. MAIN OUTCOME MEASURES:Estimated blood loss, perioperative blood transfusion. RESULTS:Frontal and parietal bone thickness in the region of osteotomies were positively correlated with estimated blood loss (p < 0.01). After adjusting for patient weight and duration of operation, both parietal and frontal bone thickness were associated with intraoperative blood loss (R2 = 0.292, p = 0.002 and R2 = 0.216, p = 0.026). Thicker frontal and parietal bone in the line of osteotomies resulted in significantly higher odds of blood transfusion. Bone thickness in the line of parietal osteotomies was 76% accurate at identifying patients who would require blood transfusion (p = 0.004). CONCLUSIONS:Frontal and parietal bone thickness in the line of osteotomies is associated with blood loss and perioperative blood transfusion for sagittal suturectomy operations.

Craniofacial surgery requires a multidisciplinary care approach in the perioperative period. In an effort to guide clinical decision making and standardize care, many institutions have implemented craniofacial surgical pathways, describing numerous variables to monitor and specific actions that must be completed by each involved discipline in the perioperative period. Adherence to these pathways can be challenging given the complexity of the protocol and the multiple disciplines involved. In an effort to improve adherence to our institution's perioperative pathway, the authors implemented a quarterly, multidisciplinary craniofacial operative team meeting to review the pathway and improve the quality of care. The authors report results from a retrospective review of craniosynostosis suturectomy operations at a single site in the 2 years before and 2 years after the start of our team meeting to review perioperative care. A total of 141 operations were included (70 before the meeting and 71 after). Perioperative outcomes and adherence to our surgical pathway were compared. Following the start of our team meetings, there was a significant decrease in the time under anesthesia, patients requiring blood transfusion, and total hospital length of stay (P<0.05). There was also improved adherence to the craniofacial pathway, with significantly more operations applying peripheral nerve blocks to all locations specified in our pathway with the proper drug contents (P<0.05). Our findings suggest that craniofacial operative team meetings with a goal of reviewing the surgical pathway and discussing improvements in care plans with all involved providers can significantly improve adherence to operative pathways and surgical outcomes.

OBJECTIVE:Neurosurgeon scientists play a unique role in advancing neuroscience research. While previous publications have explored trends in federal and foundation funding among neurosurgeons, funding is often dominated by neurosurgical oncologists and functional neurosurgeons. Less is known about the research efforts of pediatric neurosurgeons. The aim of this study was to survey the members of the American Society of Pediatric Neurosurgeons (ASPN) to provide an overview of past research experience, current involvement, funding, and research priorities among pediatric neurosurgeons, and to gather insights that could shape future efforts to advance pediatric neurosurgical research. METHODS:A survey was developed using the REDCap platform and distributed to all ASPN members via email. Survey questions used branching logic and were organized into 5 sections: 1) demographics, 2) research experience during training, 3) research experience as an attending physician, 4) research priorities, and 5) multicenter consortiums. RESULTS:One hundred thirty-nine respondents completed more than half of the survey, for an overall response rate of 52.1%. Most respondents (96.4%) participated in research during their training, but only 38.1% had received a grant during training. In contrast, 83.9% of respondents were actively engaged in research as an attending physician, and 48.7% reported active funding (60.7% federal, 41.8% from foundations, and 42.9% internal). Furthermore, 74.8% of respondents reported being a member of a multicenter research consortium, and 82.4% agreed that multicenter research is important. Seventy percent of respondents agreed that the ASPN should facilitate multicenter consortium-based pediatric neurosurgical research, offering free-text responses with the following suggestions: 1) set aside time at the annual meeting to discuss multicenter research (22.9%); 2) encourage collaboration and facilitate networking (42.9%); 3) provide centralized core services such as a data coordinator and biostatistician (12.9%); and 4) provide training, education, and mentoring (7.1%). CONCLUSIONS:The survey provided a cross-sectional analysis of the pediatric neurosurgical research landscape, highlighting the current state of research experience, funding, and the perspectives of pediatric neurosurgeons regarding research priorities. Despite the challenges, there is clear recognition of the importance of multicenter research collaboration. These findings reinforce the ongoing necessity of organized initiatives to support pediatric neurosurgical research and offer actionable insights into how organized pediatric neurosurgery can contribute to this critical endeavor.

Abstract BACKGROUND Non-germinomatous germ cell tumors (NGGCT) constitute 35%- 45% of intracranial germ cell tumors. Growing teratoma syndrome has been observed in patients with NGGCTs after starting chemotherapy. While growing teratomas are typically benign, this process can rarely involve malignant transformation and result in poor prognosis. We present the case of a patient with pineal NGGCT and growing teratoma syndrome with malignant transformation to embryonal rhabdomyosarcoma. CASE REPORT A 13-year-old male presented with headaches and vision changes. An MRI brain demonstrated a 26 x 25 x 19 mm (AP X TR X CC) mixed solid and cystic pineal mass with no evidence of metastatic disease. Due to elevated alpha fetoprotein levels in the serum and cerebrospinal fluid, he was diagnosed with intracranial NGGCT. Treatment was initiated with alternating cycles of Carboplatin/Etoposide and Ifosfamide/Etoposide. After 2 cycles of chemotherapy, a complete biochemical response was noted but MRI showed increased tumor size (presumed growing teratoma syndrome). The patient underwent complete tumor resection. Histology showed embryonal rhabdomyosarcoma as a somatic malignancy arising in a mature teratoma. Further molecular characterization revealed somatic NF1 and KRAS pathogenic mutations that are consistent with the primary diagnosis. Methylation profiling, however, did not exhibit a match with any known malignancies. Continued complete response was noted following two additional chemotherapy cycles. The patient is planned for six total chemotherapy cycles followed by high-dose craniospinal radiation with boost to the primary tumor. CONCLUSIONS Malignant transformation is a rare phenomenon in NGGCT. There is no standard of care for these patients. Further studies are needed to define ideal therapy for this patient population.

Purpose: To determine long-term outcome for seizure control and clinical predictors for seizure freedom in patients undergoing surgical treatment for epilepsy associated with hypothalamic hamartoma (HH).Methods: 155 patients underwent surgical treatment for HHs and treatment-resistant epilepsy at one center (Barrow Neurological Institute at St. Joseph's Hospital and Medical Center, Phoenix, Arizona, USA) between February 2003 and June 2010. Data collection included medical record review and direct follow-up interviews to determine seizure outcome. Statistical analysis included descriptive summaries of patient characteristics and time-to-event analysis for seizure freedom.Results: Long-term survival with follow-up of at least five years since first surgical treatment was available for 108 patients (69.7% of the treatment cohort). The surgical approach for first HH intervention consisted of transventricular endoscopic resection (n = 57; 52.8%), transcallosal interforniceal resection (n = 35; 32.4%), pterional resection (n = 7; 6.5%), and gamma knife radiosurgery (n = 9; 8.3%). Multiple surgical procedures were required for 39 patients (36.1%). There were 10 known deaths from all causes in the treatment cohort (6.5%). Of these, one (0.6%) was related to immediate complications of HH surgery, three (1.9%) were attributed to Sudden Unexpected Death in Epileptic Persons (SUDEP), and one (0.6%) to complications of status epilepticus. For surviving patients with long-term follow-up, 55 (50.9%) were seizure-free for all seizure types. Univariable analysis showed that seizure-freedom was related to 1) absence of a pre-operative history for central precocious puberty (p = 0.01), and 2) higher percentage of HH lesion disconnection after surgery (p = 0.047). Kaplan-Meier survival analysis shows that long-term seizure outcome following HH surgery is comparable to short-term results. Summary: These uncontrolled observational results show that long-term seizure control following HH surgical treatment is comparable to other forms of epilepsy surgery. Late relapse (at least one year after surgery) and SUDEP do occur, but in a relatively small number of treated patients. These results inform clinical practice and serve as a comparable benchmark for newer technologies for HH surgery, such as magnetic resonance imagingguided laser interstitial thermal therapy, where long-term outcome results are not yet available.

Purpose: The purpose of this article was to appraise the various methods of reconstruction for meningomyelocele (MMC) defects. Methods: A systematic review of the literature was performed to evaluate all reconstructions for MMC. The method of reconstruction was categorized by: primary closure with and without fascial flaps, random pattern flaps, VY advancement flaps (VY), perforator flaps, and myocutaneous flaps. Perforator flaps were subsequently subcategorized based on the type of flap. Results: Upon systematic review, 567 articles were screened with 104 articles assessed for eligibility. Twenty-nine articles were further reviewed and included for qualitative synthesis. Two hundred seventy patients underwent MMC repair. The lowest rates of major wound complications (MWC) were associated with myocutaneous and random pattern flaps. A majority of MWC was in the lumbrosacral/sacral region (87.5% of MWC). In this region, random patterns and perforator flaps demonstrated the lowest rate of MWC (4.5, 8.1%). Conclusions: Plastic surgery consultation should be strongly considered for MMC with defects in the lumbosacral/sacral region. Perforator flaps are excellent options for the reconstruction of these defects.

OBJECTIVE:Long-term follow-up is often recommended for patients with hydrocephalus, but the frequency of clinical follow-up, timing and modality of imaging, and duration of surveillance have not been clearly defined. Here, the authors used the modified Delphi method to identify areas of consensus regarding the modality, frequency, and duration of hydrocephalus surveillance following surgical treatment.METHODS:Pediatric neurosurgeons serving as institutional liaisons to the Hydrocephalus Clinical Research Network (HCRN), or its implementation/quality improvement arm (HCRNq), were invited to participate in this modified Delphi study. Thirty-seven consensus statements were generated and distributed via an anonymous electronic survey, with responses structured as a 4-point Likert scale (strongly agree, agree, disagree, strongly disagree). A subsequent, virtual meeting offered the opportunity for open discussion and modification of the statements in an effort to reach consensus (defined as ≥ 80% agreement or disagreement).RESULTS:Nineteen pediatric neurosurgeons participated in the first round, after which 15 statements reached consensus. During the second round, 14 participants met virtually for review and discussion. Some statements were modified and 2 statements were combined, resulting in a total of 36 statements. At the conclusion of the session, consensus was achieved for 17 statements regarding the following: 1) the role of standardization; 2) preferred imaging modalities; 3) postoperative follow-up after shunt surgery (subdivided into immediate postoperative imaging, delayed postoperative imaging, routine clinical surveillance, and routine radiological surveillance); and 4) postoperative follow-up after an endoscopic third ventriculostomy. Consensus could not be achieved for 19 statements.CONCLUSIONS:Using the modified Delphi method, 17 consensus statements were developed with respect to both clinical and radiological follow-up after a shunt or endoscopic third ventriculostomy. The frequency, modality, and duration of surveillance were addressed, highlighting areas in which no clear data exist to guide clinical practice. Although further studies are needed to evaluate the clinical utility and cost-effectiveness of hydrocephalus surveillance, the current study provides a framework to guide future efforts to develop standardized clinical protocols for the postoperative surveillance of patients with hydrocephalus. Ultimately, the standardization of hydrocephalus surveillance has the potential to improve patient care as well as optimize the use of healthcare resources.

Introduction: Numerous surgical techniques have been described for correction of sagittal synostosis. However, many do not address the often-persistent temporal constraint. To address the deformity, the endoscopic surgical technique used at this institution was modified to include frontal bone releasing osteotomies across the coronal sutures in the area of the temporal constraint. The purpose of this study was to evaluate the early benefit of this technique. Methods: A retrospective review of electronic health records was performed for 31 consecutive patients who received frontal bone releasing osteotomies and 33 consecutive patients before frontal bone releasing osteotomies were initiated in May of 2015. Both cohorts were age matched and underwent the same postsurgical orthotic therapy protocol. The Whitaker classification system and a visual analog scale were used to evaluate for temporal constraint. Images were reviewed at 6 months after the postsurgical orthotic was removed. Results: Patients who received frontal bone releasing osteotomies had significantly improved Whitaker grade scores (1.27 vs 1.64, P < .05) and greater improvement in visual analog scores (39.97 vs 25.64, P < .05) compared with those who did not. Both ratings showed good interrater reliability. Conclusions: During the early postsurgical period, greater and more rapid improvement in the temporal constraint was seen in the group of patients who had additional frontal bone releasing osteotomies during the correction of sagittal synostosis. Longer-term follow-up is needed to evaluate maintenance of the improvement as relapse and poor growth in this area are known to occur.

Hydrocephalus (HCP) is a neurological disease resulting from the disruption of the cerebrospinal fluid (CSF) drainage mechanism in the brain. Reliable draining of CSF is necessary to treat hydrocephalus. The current standard of care is an implantable shunt system. However, shunts have a high failure rate caused by mechanical malfunctions, obstructions, infection, blockage, breakage, and over or under drainage. Such shunt failures can be difficult to diagnose due to nonspecific systems and the lack of long-term implantable pressure sensors. Herein, we present the evaluation of a fully realized and passive implantable valve made of hydrogel to restore CSF draining operations within the cranium. The valves are designed to achieve a non-zero cracking pressure and no reverse flow leakage by using hydrogel swelling. The valves were evaluated in a realistic fluidic environment with ex vivo CSF and brain tissue. They display a successful operation across a range of conditions, with negligible reverse flow leakage. Additionally, a novel wireless pressure sensor was incorporated alongside the valve for in situ intracranial pressure measurement. The wireless pressure sensor successfully replicated standard measurements. Those evaluations show the reproducibility of the valve and sensor functions and support the system’s potential as a chronic implant to replace standard shunt systems.

PURPOSE: We propose a reconstructive algorithm based on retrospective review of meningomyelocele (MM) repairs at our institution and systematic review of the literature. METHODS: A retrospective review of human infants undergoing MM repair over 5 years at a single children’s hospital. Location and size of defect, major wound complications (MWC) (return to the operating room), minor wound complications (mWC) (any wound breakdown treated without return to operating room, superficial infection, or CSF leak), and follow up were recorded. Interviews of neurosurgeons and plastic surgeons were performed on approach MMC repairs. A systematic review of the literature was performed to evaluate all reconstructions for MM. Inclusion criteria included articles that discussed reconstructive technique, age, defect location and size, and complications (MWC and mWC). Exclusion criteria included age greater than 1 year, articles published prior to 1984, and non-English language. Additionally, articles missing individual patient data, reconstructions using greater than two flaps, or use of alloplastic/xenograft were excluded. Flaps were categorized by reconstructive method: primary closure with and without fascial flaps (PC), random pattern flap (based on unnamed vessels) (RP), VY advancement flap (VY), perforator flap (based on unnamed vessels) (PF), myocutaneous flap (defined muscle flap or perforators off named muscle), and keystone island perforator flap (islanded fasciocutaneous flap based on random regional musculocutaneous perforators) (KIPF). RESULTS: In our cohort, there were 39 patients who underwent repair with three MWC (8%). An estimated 79% of cases (n = 31) were performed by neurosurgery with PC. Two (5%) had an MWC. Plastic surgery was consulted for 20% of the cases (n = 8), with 1 patient (13%) having an MWC. Of the three total MWC for MM repair, two were located in the lumbosacral area and one in the lumbar area. All complications occurred with defects greater than 50 cm2. On interviews of neurosurgeons, plastic surgery consultation occurs when there is a paucity of soft tissue (lack of adequate skin or redundant tissue) or subsequent wound breakdown. Upon systematic review, 551 articles were screened with 95 articles assessed for eligibility. Twenty-seven articles were further reviewed and included for qualitative synthesis. Two hundred fifty-six patients underwent MM repair: 41 PC (16%), 71 RP (28%), 25 VY (10%), 61 PF (24%), 26 myocutaneous flap (10%), and 32 KIPF (13%). MM were located at thoracic (n = 6), thoracolumbar (n = 84), lumbar (n = 15), lumbrosacral/sacral (n = 151). Lowest MWC were associated with KIPF (6%), RP (7%), myocutaneous flap (11%), VY (13%), PC (15%), and PF (17%), respectively. A majority of MWC were in the lumbrosacral/sacral region (90% of MWC). In this region, PC was used for average defect [9.7 cm2 (3–28.3 cm2) with 16% MWC]. The only reconstructions for sacral MM were PF (n = 2) and KIPF (n = 7). PF average defect was 6.8 cm2 (3.5–10 cm2) with no MWC and 1 mWC. KIPF average defect was 43.7 cm2 (8–100 cm2) with 1 MWC and 3 mWC (3% and 9%, respectively). CONCLUSIONS: Plastic surgery consultation should be strongly considered for MM with defects in the lumbosacral/sacral region. KIPF and PF should be considered for sacral defects.

ABSTRACT Accessory cranial sutures have been described in the literature and are most commonly associated with the parietal bone. These sutures are typically identified incidentally and there have been no reported cases of accessory cranial sutures leading to abnormal head shape.The authors present the case of a 3-month-old patient with multiple congenital anomalies and an accessory parietal suture leading to abnormal head shape. The patient was successfully treated with cranial orthotic therapy. To our knowledge, this is the first reported case of an accessory cranial suture leading to abnormal head shape.

Pediatric intracranial injuries due to penetrating gunshot wounds are a rare entity that is often fatal. A subset of patients may experience an intracerebral arterial injury; however, literature on the pediatric population is limited. This study analyzes a large institution’s experience with pediatric head gunshot wounds and intracranial arterial injuries. All pediatric patients ≤ 18 years of age who presented to our institution with a penetrating gunshot wound from 2008 to 2018 were retrospectively analyzed. Thirty-seven patients presented with an intracerebral penetrating gunshot injury. There were 18 deaths (49%) in the cohort. A total of 20 patients (54%) had vascular imaging. Of the remaining 17 patients with no vascular imaging, 13 (35%) died before any vascular studies were obtained. Four (20%) of the 20 patients with vascular imaging experienced an intracerebral arterial injury. Three of these 4 patients died before treatment could be administered. One patient with a firearm injury underwent embolization of a distal middle cerebral artery pseudoaneurysm and was discharged home with a Glasgow Outcome Scale score of 5 on follow-up. Pediatric patients with penetrating intracranial gunshot wounds often die before vascular imaging can be obtained.

Hydrocephalus (HCP) is a chronic neurological brain disorder caused by a malfunction of the cerebrospinal fluid (CSF) drainage mechanism in the brain. The current standard method to treat HCP is a shunt system. Unfortunately, the shunt system suffers from complications including mechanical malfunctions, obstructions, infections, blockage, breakage, overdrainage, and/or underdrainage. Some of these complications may be attributed to the shunts' physically large and lengthy course making them susceptible to external forces, siphoning effects, and risks of infection. Additionally, intracranial catheters artificially traverse the brain and drain the ventricle rather than the subarachnoid space. We report a 3D-printed microelectromechanical system-based implantable valve to improve HCP treatment. This device provides an alternative approach targeting restoration of near-natural CSF dynamics by artificial arachnoid granulations (AGs), natural components for CSF drainage in the brain. The valve, made of hydrogel, aims to regulate the CSF flow between the subarachnoid space and the superior sagittal sinus, in essence, substituting for the obstructed arachnoid granulations. The valve, operating in a fully passive manner, utilizes the hydrogel swelling feature to create nonzero cracking pressure, PT ≈ 47.4 ± 6.8 mmH2O, as well as minimize reverse flow leakage, QO ≈ 0.7 μL/min on benchtop experiments. The additional measurements performed in realistic experimental setups using a fixed sheep brain also deliver comparable results, PT ≈ 113.0 ± 9.8 mmH2O and QO ≈ 3.7 μL/min. In automated loop functional tests, the valve maintains functionality for a maximum of 1536 cycles with the PT variance of 44.5 mmH2O < PT < 61.1 mmH2O and negligible average reverse flow leakage rates of ∼0.3 μL/min.

Polyglutamine expansions in the transcriptional co-repressor Atrophin-1, encoded by ATN1, cause the neurodegenerative condition dentatorubral-pallidoluysian atrophy (DRPLA) via a proposed novel toxic gain of function. We present detailed phenotypic information on eight unrelated individuals who have de novo missense and insertion variants within a conserved 16-amino-acid "HX repeat'' motif of ATN1. Each of the affected individuals has severe cognitive impairment and hypotonia, a recognizable facial gestalt, and variable congenital anomalies. However, they lack the progressive symptoms typical of DRPLA neurodegeneration. To distinguish this subset of affected individuals from the DRPLA diagnosis, we suggest using the term CHEDDA (congenital hypotonia, epilepsy, developmental delay, digit abnormalities) to classify the condition. CHEDDA-related variants alter the particular structural features of the HX repeat motif, suggesting that CHEDDA results from perturbation of the structural and functional integrity of the HX repeat. We found several non-homologous human genes containing similar motifs of eight to 10 HX repeat sequences, including RERE, where disruptive variants in this motif have also been linked to a separate condition that causes neurocognitive and congenital anomalies. These findings suggest that perturbation of the HX motif might explain other Mendelian human conditions.

Bristol, Ruth E MD; Sarris, Christina E MD, BS; Singh, Davinder MD; Hooft, Nicole MD Author Information

Purpose: Cranial defects in children have been repaired with various materials ranging from autologous bone to synthetic materials. There is little published literature on the outcomes of titanium mesh cranioplasty (TMC) in calvarial reconstruction in the pediatric population. This study evaluates a pediatric cohort who underwent calvarial defect reconstruction with titanium mesh and assesses the efficacy and outcomes of TMC. Methods: An Institutional Review Board approved retrospective review of patients <= 18 years of age who underwent cranioplasty from 1999 to 2014 at 2 centers was performed. The cohort undergoing TMC was studied. Results: A total of 159 cranioplasties were performed. Autologous reconstruction included 84 bone flap replacements and 36 split calvarial bone graft reconstructions. Six patients underwent PEEK implant reconstruction. Titanium mesh cranioplasty was performed on 33 patients. Two patients underwent 2 separate cranioplasties. The median age of patients was 6 years (19 months to 18 years). The most common underlying etiologies were congenital syndromes/craniosynostosis (13 patients), and trauma (11). The majority of patients had prior cranial surgeries (85%). Various types of titanium mesh were used with sizes ranging from 2 x 3 cm to 19 x 20 cm, with some patients requiring distinct areas of defect reconstruction. Perioperative complications were noted in 2 patients that subsequently improved. Two patients had late soft tissue problems with complications of wound infections requiring resection of a portion of the mesh. Patients were followed an average of 4 years (range 13 days to 6.8 years), with 2 patients lost to follow-up. Overall, all patients with follow-up achieved a cranial contour with good symmetry to the unaffected side, as well as effective protection to the brain. Conclusions: Titanium mesh cranioplasty is an effective option for correcting pediatric cranial defects when autologous bone availability is limited and soft tissue coverage allows placement of an implant. The interim outcome for these patients is favorable with few complications and no evidence of growth restriction in the authors' series. Follow-up will be ongoing for these patients.

BACKGROUND: Hypothalamic hamartomas (HH) are rare lesions associated with treatment-resistant epilepsy. Open surgery results in modest seizure control (about 50%) but has a significant associated morbidity. Radiosurgery is limited to a subset of patients due to latent therapeutic effects. Magnetic resonance imaging-guided laser interstitial thermal therapy (LITT) offers a novel minimally invasive option. OBJECTIVE: To evaluate a single center's outcomes for the LITT treatment of HH. METHODS: We retrospectively reviewed our experience with LITT for the treatment of HH using our institution's prospectively maintained patient database. RESULTS: Eighteen patients (mean age, 21.1 yr; median age, 11 yr) underwent 21 total LITT treatments for HH. Mean follow-up was 17.4 mo. The length of stay was 1 night for 16 (89%) patients. At the end of follow-up, 11 of 18 patients (61%) had full disconnection of the HH, and 12 of 15 (80%) patients with gelastic seizures and 5 (56%) of 9 patients with nongelastic seizures were seizure free (International League Against Epilepsy Class 1). Immediate complications included a 39% (7/18) incidence of neurological deficits, including 1 case of hemiparesis. At the end of follow-up, 22% of patients (4/18) had persistent deficits. The hypothyroidism that occurred was delayed in 11% of patients (2/18), as was short-term memory loss (22%, 4/18) and weight gain (22%, 4/18). CONCLUSION: LITT therapy for HH can achieve excellent rates of seizure control with low morbidity and a short postoperative stay in a majority of patients. Additional research is needed to assess the durability of results and the full spectrum of cognitive outcomes.