Mechanical Thrombectomy in Pediatric Large Vessel Occlusions Before Cerebrovascular Maturity: A Case Report and Technical Note.

Pediatric arterial ischemic stroke is a rare but increasingly acknowledged disorder. Large vessel occlusions in this population have been treated off-label with endovascular thrombectomy. However, there is limited evidence to guide management. Small children, before the age of five when the cerebrovasculature reaches adult size, present additional challenges. We report the case of cardioembolic basilar occlusion in a two-year-old and the technical details of endovascular management, currently lacking in published literature. We employed a 5 French slender sheath, typically used for radial access, as a femoral short sheath. We accessed the dominant vertebral artery with a 5 French intermediate catheter, navigated with a typical 0.027-inch microcatheter and 0.014-inch microwire, and performed direct aspiration thrombectomy of the basilar clot. No closure device was employed. The patient had a near-complete and durable recovery. Small children present additional challenges for the endovascular management of stroke. Pre-procedural imaging can be used to design an aspiration-capable system appropriate for the child's size. Endovascular thrombectomy in children is feasible with some modifications to adult protocols.

Side-firing intraoperative ultrasound applied to resection of pituitary macroadenomas and giant adenomas: A single-center retrospective case-control study.

Introduction: Multiple intraoperative navigation and imaging modalities are currently available as an adjunct to endoscopic transsphenoidal resection of pituitary adenomas, including intraoperative CT and MRI, fluorescence guidance, and neuronavigation. However, these imaging techniques have several limitations, including intraoperative tissue shift, lack of availability in some centers, and the increased cost and time associated with their use. The side-firing intraoperative ultrasound (IOUS) probe is a relatively new technology in endoscopic endonasal surgery that may help overcome these obstacles. Methods: A retrospective analysis was performed on patients admitted for resection of pituitary adenomas by a single surgeon at the University of Mississippi Medical Center. The control (non-ultrasound) group consisted of twelve (n=12) patients who received surgery without IOUS guidance, and the IOUS group was composed of fifteen (n=15) patients who underwent IOUS-guided surgery. Outcome measures used to assess the side-firing IOUS were the extent of tumor resection, postoperative complications, length of hospital stay (LOS) in days, operative time, and self-reported surgeon confidence in estimating the extent of resection intraoperatively. Results: Preoperative data analysis showed no significant differences in patient demographics or presenting symptoms between the two groups. Postoperative data revealed no significant difference in the rate of gross total resection between the groups (p = 0.716). Compared to the non-US group, surgeon confidence was significantly higher (p < 0.001), and operative time was significantly lower for the US group in univariate analysis (p = 0.011). Multivariate analysis accounting for tumor size, surgeon confidence, and operative time confirmed these findings. Interestingly, we noted a trend for a lower incidence of postoperative diabetes insipidus in the US group, although this did not quite reach our threshold for statistical significance. Conclusion: Incorporating IOUS as an aid for endonasal resection of pituitary adenomas provides real-time image guidance that increases surgeon confidence in intraoperative assessment of the extent of resection and decreases operative time without posing additional risk to the patient. Additionally, we identified a trend for reduced diabetes insipidus with IOUS.

Association of hospital characteristics with outcomes for pediatric neurosurgical accidental trauma patients.

OBJECTIVE: In the pediatric population, few studies have examined outcomes for neurosurgical accidental trauma care based on hospital characteristics. The purpose of this study was to explore the relationship between hospital ownership type and children's hospital designation with primary outcomes. METHODS: This retrospective cohort study utilized data from the Healthcare Cost and Utilization Project 2006, 2009, and 2012 Kids' Inpatient Database. Primary outcomes, including inpatient mortality, length of stay (LOS), and favorable discharge disposition, were assessed for all pediatric neurosurgery patients who underwent a neurosurgical procedure and were discharged with a primary diagnosis of accidental traumatic brain injury. RESULTS: Private, not-for-profit hospitals (OR 2.08, p = 0.034) and freestanding children's hospitals (OR 2.88, p = 0.004) were predictors of favorable discharge disposition. Private, not-for-profit hospitals were also associated with reduced inpatient mortality (OR 0.34, p = 0.005). A children's unit in a general hospital was associated with a reduction in hospital LOS by almost 2 days (p = 0.004). CONCLUSIONS: Management at freestanding children's hospitals correlated with more favorable discharge dispositions for pediatric patients with accidental trauma who underwent neurosurgical procedures. Management within a children's unit in a general hospital was also associated with reduced LOS. By hospital ownership type, private, not-for-profit hospitals were associated with decreased inpatient mortality and more favorable discharge dispositions.

Using the neutrophil-to-lymphocyte ratio to predict outcomes in pediatric patients with traumatic brain injury.

OBJECTIVE: The brain's inflammatory reaction to traumatic brain injury (TBI) generally peaks between 24 and 48 h after injury. This inflammatory cascade can be neuroprotective or may mediate secondary brain injury beyond the initial TBI. Therefore, circulating inflammatory markers may be useful for predicting outcomes in pediatric TBI. The goal of this study was to determine whether elevations in peripheral blood neutrophil-to-lymphocyte ratios (NLRs) are associated with adverse outcomes in pediatric TBI patients. PATIENTS AND METHODS: 188 pediatric patients (0-18 years) presenting to our institution with TBI from 2007 to 2017 were retrospectively reviewed. Absolute neutrophil and lymphocyte counts from a complete blood count (CBC) were used to calculate NLRs on admission (<12 h) and approximately 24, 48, and 72 h after injury. Data points included Glasgow Coma Scale (GCS) on admission, presence of post-traumatic amnesia (PTA), loss of consciousness (LOC), and Glasgow Outcome Scale Extended Pediatric Version (GOS-E Peds) with a median outcome span of 86 days. RESULTS: A one-way ANOVA demonstrated statistically significant differences in NLR at 24 h (p = 0.004) and 48 h (p=0.003) among patients stratified by GOS-E Peds. No significant differences in NLR were observed at any time point based on GCS or PTA. Patients who experienced LOC had a significantly higher NLR on admission (p=0.013) and at 24 h (p<0.001) than those who did not. CONCLUSION: In this study, relatively higher NLRs at 24 and 48 h post-TBI were associated with worse outcomes in pediatric patients. This suggests that NLR may be a useful and cost-effective outcome predictor in pediatric TBI as well as a possible future target for therapeutic intervention, warranting larger prospective trials.

Impact of Telephone Follow-Up on Patient Satisfaction in a Pediatric Neurosurgery Clinic.

Patient satisfaction is a key metric used to measure quality in health care. However, patient satisfaction measures in the pediatric population are less studied and understood than in the adult population. The purpose of this study was to evaluate the impact of telephone follow-up on patient satisfaction in an outpatient pediatric neurosurgery clinic. A standardized telephone follow-up call was performed within 1 week of a child's clinic visit. Pearson's χ2 or Fisher's exact tests were used to assess changes in patient satisfaction measures after implementation of the telephone follow-up call initiative. The proportion of overall "top-box" physician rating significantly increased from 85.5% in 2017 to 95.6% in 2018 (P = .04). There was also a nonsignificant upward trend in the proportion of respondents noting that they would recommend this provider, as well as in all measures of physician communication quality and office staff quality. A simple telephone call to new patients after an outpatient pediatric neurosurgery clinic visit resulted in statistically significant and clinically meaningful changes in patient satisfaction scores.

Peripheral blood neutrophil-to-lymphocyte ratio in preterm infants with intraventricular hemorrhage.

OBJECTIVES: Intraventricular hemorrhage (IVH) remains a major complication of prematurity, affecting 20-25% of premature infants of very low birth weight. Preterm infants with IVH are at risk for developing significant complications, including posthemorrhagic hydrocephalus and seizures. Multiple studies have reported an association between the neutrophil-to-lymphocyte ratio (NLR) in peripheral blood and outcomes after acute intracranial hemorrhage in adults. However, the prognostic value of the NLR in preterm infants, particularly those with IVH, has not been investigated previously. PATIENTS AND METHODS: This retrospective, observational cohort study included premature infants with IVH and a neonatal reservoir placed between January 2013 and January 2018. For each patient, peripheral blood and available cerebrospinal fluid laboratory results within 50 days of IVH diagnosis were averaged. NLR was calculated by dividing the absolute neutrophil count by the absolute lymphocyte count. Differences in NLR levels for patients with seizures or shunt placement were analyzed. RESULTS: Data for 13 surviving preterm infants (mean gestational age, 26.5 ± 3.0 weeks) were analyzed. The mean peripheral NLR (n = 13) was 1.6 ± 1.3 for all patients. Patients who experienced seizures had significantly higher peripheral blood NLR (p = 1.2 × 10-6, t-test) than those who did not, and an NLR > 3 correlated with seizure outcomes (p = 0.0035, Fisher's exact). Patients with sepsis or meningitis also had NLR values >3 (p = 0.01 and 0.005, respectively) but there was no correlation between the sepsis/meningitis and seizures patients. No significant correlation was found between NLR and the development of hydrocephalus. CONCLUSION: The development of seizures in preterm infants with IVH is known to significantly increase morbidity. In this study, higher peripheral blood NLR (>3) correlated with the development of seizures, independent of sepsis or meningitis. Further prospective validation of the role of NLR as a predictive marker for seizures in preterm infants is warranted.