An effective strategy for salvage therapy in refractory or relapsed childhood brain tumours is yet to be established. A national retrospective review of 135 children diagnosed with treatment refractory or recurrent MB from 2000 to 2021 at 5 academic Canadian pediatric neurosurgical centers was performed. The mean age at diagnosis was 7.09 years (SD 4.37) with a male predominance (64.4

BACKGROUND:Patients undergoing craniotomy experience a higher risk of seizures in the ensuing months. Consensus is lacking regarding the appropriate timeframe for safe return to driving following craniotomy in patients not otherwise limited by neurological deficits or a history of epilepsy. METHODS:The Canadian Neurosurgery Research Collaborative (CNRC) distributed an anonymous, voluntary, electronic cross-sectional survey via SurveyMonkey to Canadian neurosurgeons. The survey comprised 16 questions designed to assess practice variations regarding recommendations for return to driving following craniotomy, stratified according to pathological diagnosis. RESULTS:Forty-eight Canadian neurosurgeons responded to the survey. Driving recommendations varied greatly, with most surgeons recommending return to driving within one month of the craniotomy. The rationale behind these restrictions varied widely, consistent with the lack of evidence-based data to guide decision-making. CONCLUSION:This study emphasizes the lack of standardized practices regarding return to driving recommendations for patients undergoing craniotomy without prior seizures. Development of national return to driving guidelines would assist Canadian clinicians in making informed decisions regarding the optimal timeframe for the safe return to driving.

BACKGROUND:Patients undergoing craniotomy experience a higher risk of seizures in the ensuing months. Consensus is lacking regarding the appropriate timeframe for safe return to driving following craniotomy in patients not otherwise limited by neurological deficits or a history of epilepsy. METHODS:We performed a systematic literature review on driving recommendations post-craniotomy. We then performed a scoping review on the risk of seizure post-craniotomy and used risk calculations and accepted risk thresholds from the epilepsy literature to develop an evidence-based approach to driving recommendations post-craniotomy. RESULTS:The systematic review of driving recommendations revealed national guidelines (the United Kingdom, New Zealand, Australia). We transposed risk calculations and accepted risk thresholds from the epilepsy literature (accident risk ratio [ARR] < 2; chance of occurrence of a seizure in the next year < 20%) to patients who undergo a craniotomy. Using data from a large meta-analysis of seizure risk post-craniotomy, we calculated ARRs for various underlying pathologies at different postoperative timepoints and compared them with accepted risk thresholds from the epilepsy literature. We determine that patients who undergo a craniotomy for a higher-risk condition (like high-grade glioma) may resume driving after at least 1 month without seizure, whereas those patients undergoing a craniotomy for lower-risk conditions (like infratentorial pathology) may resume driving without consideration for the risk of seizure. CONCLUSION:This systematic review of the literature and evidence-based approach to risk threshold calculations derived from the epilepsy literature provides a preliminary framework to guide clinicians regarding recommendations for return to driving following craniotomy.

BACKGROUND:Neurotechnology is rapidly evolving, challenging surgeons to expand their expertise in managing patients with implanted devices. More than 700,000 persons use cochlear implants. Many others have implanted pacemakers and neuromodulation devices. Understanding electrosurgical interactions is critical for patient safety, yet the literature on this remains limited. Conventional electrosurgery, which uses high-frequency alternating current for hemostasis, is contraindicated in cochlear implant users due to the risk of electromagnetic interference (EMI). EMI can cause heating, component malfunction, or device failure. Despite shielding, induction currents and voltage surges may exceed device tolerance, posing risks. OBSERVATIONS:While PlasmaBlade safety is documented in cardiac surgery, its use in neurosurgery is underreported. The authors present a case demonstrating its safe application during an occipitocervical fusion in a 17-year-old with an established cochlear implant. The PlasmaBlade enabled exposure without affecting implant integrity or auditory function. LESSONS:As neurotechnology becomes increasingly prevalent, using innovative safety strategies, including monitoring electromagnetic fields, and adopting refined technologies like the PlasmaBlade will be impactful. These advancements have the potential to improve patient outcomes and ensure safer care for individuals with implanted devices. https://thejns.org/doi/10.3171/CASE25167.

A woman in her mid-50s who had undergone a subtotal resection of a peritorcular meningioma 3 years earlier presented with symptoms suggestive of increased intracranial pressure. A delayed diagnosis of a torcular dural arteriovenous fistula (dAVF) diagnosis was made on MRI. Digital subtraction angiography confirmed a torcular dAVF (Borden type II). Staged 3 rounds of transarterial (TA) embolisation were performed using n-butyl cyanoacrylate, ethylene vinyl alcohol copolymer and coils of the complex torcular dAVF, which significantly reduced the flow and corresponded with improved symptoms of pulsatile tinnitus, vision and headache. We reviewed previously reported cases of dAVFs that developed after craniotomy for meningioma resection. Despite its rarity, a torcular dAVF can develop after craniotomy and progress from low to high grade due to its location. Diagnosis requires a thorough understanding of subtle imaging findings, which may be present in follow-up studies obtained for tumour surveillance.

Objectives Off-road vehicle (ORV) and motorcycle use is common in Canada; however, risk of serious injury is heightened when these vehicles are operated without helmets and under the influence of alcohol. This study evaluated the impact of alcohol intoxication on helmet non-use and mortality among ORV and motorcycle crashes. Methods Using data collected from the Nova Scotia Trauma Registry, a retrospective analysis (2002-2017) of ORV and motorcycle crashes resulting in major traumatic brain injury was performed. Patients were grouped by blood alcohol concentration (BAC) as negative (< 2 mmol/L), legally intoxicated (2-17.3 mmol/L) or criminally intoxicated (> 17.3 mmol/L). Logistic regression models were constructed to test for helmet non-use and mortality. Results A total of 424 trauma patients were included in the analysis (220 ORV, 204 motorcycle). Less than half (45%) of patients involved in ORV crashes were wearing helmets and 65% were criminally intoxicated. Most patients involved in motorcycle crashes were helmeted at time of injury (88.7%) and 18% were criminally intoxicated. Those with criminal levels of intoxication had 3.7 times the odds of being unhelmeted and were 3 times more likely to die prehospital compared to BAC negative patients. There were significantly increased odds of in-hospital mortality among those with both legal (OR = 5.63), and criminal intoxication levels (OR = 4.97) compared to patients who were BAC negative. Conclusion Alcohol intoxication is more frequently observed in ORV versus motorcycle crashes. Criminal intoxication is associated with helmet non-use. Any level of intoxication is a predictor of increased in-hospital mortality.

We describe reconstruction of a sternal cleft in a neonate using acellular dermal matrix, full-thickness calvarial bone graft and myocutaneous pectoralis flaps.

Background: Following craniotomy, there is widespread agreement that post-operative neurological impairments require specialized evaluation to evaluate fitness to drive. However, for patients who had a craniotomy and do not have neurological deficits or known seizures, there is less consensus as to when return to driving is safe. In this study, we aim to review existing guidelines regarding driving post-craniotomy and assess the current practices for post-craniotomy recommendations in Canada. Methods: Our study has three components: 1) systematic review of existing guidelines for return to driving after cranial procedure; 2) review of primary evidence (cohort studies) regarding seizure risk following a craniotomy, depending of the underlying pathology; 3) online questionnaire distributed to Canadian neurosurgeons by the Canadian Neurosurgery Collaborative (CNRC) network. Results: Our systematic review unveiled various sets of guidelines for driving after a craniotomy. For instance, UK Driving and Vehicle Licensing Agency writes into law specific guidelines for return to driving varying based on underlying pathology. Their results were drawn from large cohort studies measuring the occurrence of post-operative seizures after craniotomy for a variety of conditions. The questionnaire is currently being distributed to Canadian neurosurgeons. Conclusions: Our study lays the first steps towards the development of Canadian guidelines for return to driving post-craniotomy.

Due to resource restrictions related to the COVID-19 pandemic, many pediatric patients are facing substantial delays for surgery, potentially resulting in additional distress for caregivers. We aimed to assess the experiences and psychosocial distress of parents during COVID-19 as they relate to the pandemic, waiting for surgery, and the combined effects of both events. The was a cross-sectional qualitative study. Parents with children who faced treatment delays during the initial wave of the COVID-19 pandemic for elective, non-emergent procedures across a variety of surgical specialties were recruited. Semi-structured telephone interviews and thematic analysis were utilized. Thematic saturation was reached with eighteen participants. Four themes were identified: coping with COVID-19, distress levels, quality and nature of communication with the surgical team, and the experience of COVID-19 related hospital restrictions. Participants reported varying levels of distress due to the delay in surgery, such as the fear of developmental delay or disease progression for their child. They also indicated their own physical and mental health had been impacted by emotional distress related to both COVID-19 and delays in treatment. Most participants experienced the COVID-19-related hospital restrictions as distressing. This related predominantly to limiting in-hospital caregivers to only one caregiver. Participants were found to have substantial levels of psychosocial distress. Targeted social and emotional support may be helpful in reducing parental distress as the pandemic timeframe continues. Within the limits of individual health systems, reducing restrictions to the number of allowed care givers may help allay distress felt by parents.

close follow-up. He has not undergone any chemotherapy or radiotherapy, and though there is residual tumor, this has exhibited no growth over the 17 months since initial diagnosis. Our case was

Objective To test the hypothesis that de novo genetic variants are responsible for moyamoya disease (MMD) in children with unaffected relatives, we performed exome sequencing of 28 affected children and their unaffected parents. Methods Exome sequencing was performed on 28 trios of affected patients with MMD and unaffected parents. Results We identified 3 novel rare de novo RNF213 variants, 1 in the RING domain and 2 in a highly conserved region distal to the RING domain (4,114-4,120). These de novo cases of MMD present at a young age with aggressive MMD and uniquely have additional occlusive vascular lesions, including renal artery stenosis. Two previously reported cases had de novo variants in the same limited region and presented young with aggressive MMD, and 1 case had narrowing of the inferior abdominal aorta. Conclusions These results indicate a novel syndrome associated with RNF213 rare variants defined by de novo mutations disrupting highly conserved amino acids in the RING domain and a discrete region distal to the RING domain delimited by amino acids 4,114 to 4,120 leading to onset of severe MMD before 3 years of age and occlusion of other arteries, including the abdominal aorta, renal, iliac, and femoral arteries.

Abstract Background Diagnostic delays in pediatric neuro-oncology is a subject of distress for families and providers. We aimed to evaluate the symptom diagnostic interval (SDI) and influencing variables for children with CNS tumors. Methods This retrospective study analyzed 210 patients diagnosed from 2001–2018 and managed at the tertiary care facility in Halifax, Canada. SDI was defined as time from first symptom until tissue diagnosis or, if not available, imaging diagnosis. Non-parametric tests were used to compare SDI between groups. Results Median SDI was 12.4 weeks (IQR 4.3–30), longer than 7 other studies of 1308 children reporting medians of 4.5–10 weeks (p < 0.01). Most common tumors and their median SDI included low-grade glioma (LGG) (n=97, 46%; 17.9 weeks), medulloblastoma (n=31, 15%; 8.7 weeks), high-grade glioma (HGG) and DIPG (n=23, 11%; 5.6 weeks), and ependymoma (n=13, 6%; 13.6 weeks). The most common initial reported symptom included headache (n=63; 30%), nausea/vomiting (n=27, 18%), seizure (n=24, 12%), and visual impairment (n=13, 6.3%). Patients aged 0–3 years had a shorter SDI than patients 10 years and older (SDI 8.7 vs 14.6 weeks; p = 0.03). Tumor category showed longer SDI for LGG versus HGG (p = 0.003), DIPG (p = 0.02), medulloblastoma (p = 0.03) and other embryonal tumors (p = 0.03). Longer SDI was not associated with increased risk of disease progression for LGG (p = 0.93), medulloblastoma (p = 0.89), or ependymoma (p = 0.5). No difference in SDI was found with regard to diagnosis era, ethnicity, socioeconomic status, or distance to the tertiary care facility. Conclusion SDI at our centre is longer than previously reported studies. SDI is linked to tumor biology and its relevance within specific tumor groups deserves further investigation given it doesn’t appear to predict tumor progression/recurrence, yet families and providers feel distress when delays in diagnosis are perceived.

ABSTRACT: Background: The T2 hypointensity has been suggested to be associated with intracranial metastatic adenocarcinomas (IMA). The purpose of our study was to determine the association of T2 hypointensity with IMA. Methods: All patients with pathologically confirmed metastatic brain tumors who had a magnetic resonance imaging (MRI) at our institution in the last 10 years were retrospectively assessed. Qualitative assessment of the lesions on MRI was done by two separate readers who were blinded to the pathological diagnosis. For qualitative assessment, the T2 hypointensity in the lesion was compared with the contralateral normal appearing white matter. Odds ratio, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated. Results: Of 107 patients with intracranial metastasis, only 73 (40 females; 33 males; mean age 61 years) had MRI available for review. Of these, only 46 (25 females; 21 males; mean age 61 years) had pathologically proven IMA. T2 hypointensity was seen in 20% of IMA. The odds ratio of T2 hypointensity in IMA was 3 compared to nonadenocarcinomas but was not statistically significant (p = 0.16). Intralesional hemorrhage was seen in 20. When controlled for hemorrhage, the odds ratio for T2 hypointensity in IMA was 4.7. The specificity, sensitivity, PPV, and NPV for T2 hypointensity to diagnose IMA were 92%, 19%, 81%, and 40%, respectively. Conclusion: T2 hypointensity was seen only in 20% of IMA with an odds ratio of 4.7. T2 hypointensity showed a high specificity and PPV for diagnosis of IMA.

A preliminary survey of pediatric neurosurgeons working at different centers around the world suggested differences in clinical practice resulting in variation in the risk of pediatric cerebellar mutism (CM) and cerebellar mutism syndrome (CMS) after posterior fossa (PF) tumor resection. The purposes of this study were (1) to determine the incidence and severity of CM and CMS after midline PF tumor resection in children treated at these centers and (2) to identify potentially modifiable factors related to surgical management (rather than tumor biology) that correlate with the incidence of CM/CMS.

Cerebellopontine angle (CPA) tumours account for 6-10% of intracranial tumours. The most common CPA tumours are vestibular schwannomas (VS), also known as acoustic neuromas, benign tumours of the vestibulocochlear nerve. Less common but symptomatic skull base lesions are glomus jugulare tumours (GJT), of which approximately 40% are identified as CPA tumours. Initial symptoms for GJT may include hearing loss and tinnitus and progress to various cranial nerve dysfunctions. Three well-accepted treatment modalities for such tumours include surgical resection, radiotherapy and/or conservative management employing serial MR or CT imaging. Patients' quality of life may be impacted by different treatment methods, so treatment decisions should be client centered.

OBJECTIVES:Craniosynostosis is typically diagnosed and surgically corrected within the first year of life. The diagnosis and surgical correction of the condition can be a very stressful experience for families. Despite this, there is little research exploring the impact that craniosynostosis has on families, especially in the period immediately following diagnosis and correction. In this study, the authors aimed to qualitatively examine the psychosocial experience of families with a child diagnosed with craniosynostosis. DESIGN:Qualitative study. SETTING:Tertiary care paediatric health centre. PARTICIPANTS:Mothers of children newly diagnosed with single-suture, non-syndromic craniosynostosis. INTERVENTION:Semistructured interviews regarding parental experience with the initial diagnosis, their decision on corrective surgery for their child, the operative experience, the impact of craniosynostosis on the family and the challenges they encountered throughout their journey. PRIMARY AND SECONDARY OUTCOME MEASURES:Thematic analysis, a type of qualitative analysis that provides an in-depth account of participant's experiences, was used to analyse the interview data. RESULTS:Over a 4-year period, 12 families meeting eligibility criteria completed the study. Three main themes (six subthemes) emerged from the preoperative interviews: frustration with diagnostic delays (parental intuition and advocacy, hope for improved awareness), understanding what to expect (healthcare supports, interest in connecting with other families) and justifying the need for corrective surgery (influence of the surgeon, struggle with cosmetic indications). Two main themes (four subthemes) were drawn from the postoperative interviews: overcoming fear (the role of healthcare professionals, transition home) and relief (reduction in parental anxiety, cosmetic improvements). CONCLUSIONS:Overall, the diagnosis of craniosynostosis has a profound impact on families, leading them to face many struggles throughout their journey. A better understanding of these experiences will help to inform future practice, with a hope to improve this experience for other families moving forward.

# Needs assessment for postgraduate trauma training in general surgery: a qualitative study {#article-title-2} Trauma is considered a key component of surgical training. However, recent changes in practice patterns and training paradigms have resulted in a critical review of curricula for surgical

Patients with vestibular schwannomas (VS) typically present with hearing loss and tinnitus as well as variable cranial nerve dysfunctions. Surgical resection, stereotactic radiotherapy and/or conservative management employing serial magnetic resonance or computed tomography imaging serve as the main treatment options. Quality of life (QoL) may be impacted by the extent of tumour burden and exacerbated or relieved by treatment. Subjective assessment and quality of life inventories provide valuable information in client centered approaches with important implications for treatment. The intention of QoL measurements affecting VS patients within a clinical setting is to facilitate discussions regarding treatment options and objectively evaluate patient- centered clinical outcomes in a naturalistic setting.

Flanged ventricular catheters are now used infrequently. Many patients with longstanding hydrocephalus still harbor these catheters, either as their current ventricular catheter, or as a retained catheter from a prior implant. The removal of flanged ventricular catheters is sometimes necessary, and may be challenging due to intraventricular adhesions. We describe the use of an endoscopic technique for the successful retrieval of flanged ventricular catheters in two patients. The technique described in this report may be helpful for patients that have flanged ventricular catheters that must be removed.