Assessing pediatric neurosurgery capacity in La Paz, Bolivia: an illustrative institutional experience of a lower-middle-income country in South America.

OBJECTIVE: The current pediatric neurosurgery capacity in lower-middle-income countries (LMICs) in South America is poorly understood. Correspondingly, the authors sought to interrogate the neurosurgical inpatient experience of the sole publicly funded pediatric hospital in one of the largest regional departments of Bolivia to better understand this capacity. METHODS: A retrospective review of all neurosurgical procedures performed at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2019 and 2023 was conducted after institutional approval using a recently implemented national electronic medical record system. RESULTS: A total of 475 neurosurgical admissions satisfied inclusion for analysis over the 5-year span. The majority of admissions were from within the La Paz Department (87%) via the emergency department (77%), without private insurance (83%). The most common indications for neurosurgical intervention were trauma (35%), followed by hydrocephalus (28%), congenital disease (12%), infection (5%), and craniosynostosis (3%). Overall, the median age at time of surgery was 2.0 years, and the median operating time was 1.5 hours with a minority of intraoperative complications (2%). The most common inpatient complication was unplanned return to the operating room (19%), most commonly seen in congenital indications. At final discharge, the median postoperative length of stay was 10 days. Twenty-seven (6%) of the 475 patients died during hospitalization, most commonly seen in tumor indications. Of the 448 patients who were discharged, 299 (67%) returned for at least one follow-up appointment. CONCLUSIONS: There is restricted breadth in neurosurgical indications and outcomes achievable at the Children's Hospital of La Paz, Bolivia. As such, the capacity of pediatric neurosurgery at institutions in LMICs in South America such as this one is very limited. Identifying and prioritizing actionable interventions to improve this capacity is institution- and LMIC-dependent, and as such, future efforts will need to be tailored appropriately.

Pediatric neurosurgical medulloblastoma outcomes in La Paz, Bolivia: How a Lower Middle-Income Country (LMIC) institution in South America compares to the United States.

BACKGROUND: How pediatric medulloblastoma patients fare in Lower Middle-Income Country (LMICs) in South America is not well understood. Correspondingly, the aim of this study was to summarize the pediatric neurosurgical experience of an institution in La Paz, and compare outcomes to that of a generalized High Income Country (HIC) United States (US) experience. METHODS: A retrospective review of all pediatric neurosurgical medulloblastoma patients at the Children's Hospital of La Paz, Bolivia (Hospital del Niño "Dr. Ovidio Aliaga Uria") between 2014 and 2023 was conducted and compared to a generalized US experience abstracted from the US National Cancer Database (NCDB) and National Inpatient Sample (NIS) databases. Categorical, continuous and survival data were statistically summarized and compared. RESULTS: A total of 24 pediatric medulloblastoma patients underwent neurosurgical treatment at the Hospital del Niño. In this La Paz cohort, there were 15 (63%) males and 9 (38%) females, with a mean age of 5.6 years old at diagnosis. The majority of patients underwent subtotal resection (STR, 79%), while the remaining patients underwent biopsy only. Ten (42%) patients expired during their hospitalization, and mean length of stay overall was 39 days. Only 8 (33%) patients received adjuvant treatment after surgery. Median overall survival from diagnosis in the La Paz cohort was 1.9 months. Compared to the US databases, the La Paz cohort experienced significantly more emergency room admissions for surgery, less gross total resection, more STR, more return to operating room for ventriculoperitoneal shunting, more bacteremia, more tracheostomy procedures, more percutaneous gastrostomy placements, longer lengths of stay, less adjuvant chemotherapy, less radiation therapy, shorter follow-up, and ultimately, significantly shorter overall survival (all P < 0.050). CONCLUSIONS: Pediatric neurosurgical medulloblastoma outcomes at the Children's Hospital of La Paz, Bolivia are significantly inferior to that of a generalized US experience. Future research is required to identify institution- and country-specific initiatives to improve discrepancies between institutions in LMICs in South America compared to HICs.

Unraveling the complexity of the senescence-associated secretory phenotype in adamantinomatous craniopharyngioma using multimodal machine learning analysis.

BACKGROUND: Cellular senescence can have positive and negative effects on the body, including aiding in damage repair and facilitating tumor growth. Adamantinomatous craniopharyngioma (ACP), the most common pediatric sellar/suprasellar brain tumor, poses significant treatment challenges. Recent studies suggest that senescent cells in ACP tumors may contribute to tumor growth and invasion by releasing a senesecence-associated secretory phenotype. However, a detailed analysis of these characteristics has yet to be completed. METHODS: We analyzed primary tissue samples from ACP patients using single-cell, single-nuclei, and spatial RNA sequencing. We performed various analyses, including gene expression clustering, inferred senescence cells from gene expression, and conducted cytokine signaling inference. We utilized LASSO to select essential gene expression pathways associated with senescence. Finally, we validated our findings through immunostaining. RESULTS: We observed significant diversity in gene expression and tissue structure. Key factors such as NFKB, RELA, and SP1 are essential in regulating gene expression, while senescence markers are present throughout the tissue. SPP1 is the most significant cytokine signaling network among ACP cells, while the Wnt signaling pathway predominantly occurs between epithelial and glial cells. Our research has identified links between senescence-associated features and pathways, such as PI3K/Akt/mTOR, MYC, FZD, and Hedgehog, with increased P53 expression associated with senescence in these cells. CONCLUSIONS: A complex interplay between cellular senescence, cytokine signaling, and gene expression pathways underlies ACP development. Further research is crucial to understand how these elements interact to create novel therapeutic approaches for patients with ACP.

The epidemiologic associations of food availability with national incidence and mortality rates of pediatric central nervous system tumors.

BACKGROUND: The epidemiology of central nervous system (CNS) tumors in pediatric patients worldwide continues to be defined. To date, there has been no evaluation of how national food availability may associate with the incidence and mortality of these tumors. Correspondingly, the aim of this study was to define if such associations exist. METHODS: The most updated incidence and mortality rates of CNS tumors in pediatric patients were abstracted by country from the Global Burden of Disease database. Data regarding food availability parameters were identified and abstracted from the Food Systems Dashboard database. Associations were tested using univariate and multivariate regression analyses. RESULTS: There were sufficient data in a total of 175 countries worldwide describing the required outcomes. Median incidence and mortality rates across these countries were 1.63 per 100,000 and 0.80 per 100,000, respectively. Higher incidence rates of pediatric CNS tumors were statistically associated with lower availability of fruit and vegetables (P = 0.02), higher average protein supply (P < 0.01), lower share of dietary energy from cereal and roots (P < 0.01), lower supply of meat (P < 0.01), lower supply of nuts and seeds (P < 0.01), lower supply of vegetable oils (P < 0.01), and higher supply of vegetables (P < 0.01). Higher mortality rates due to pediatric CNS tumors were statistically associated with lower availability of fruit and vegetables (P = 0.048), lower supply of fish (P = 0.046), and lower supply of nuts and seeds (P = 0.04). When categorizing countries based on income status, there was a decrease in significant associations found more pronounced in low-middle income countries. CONCLUSIONS: There are many novel associations between national food availability and the incidence and mortality rates of pediatric CNS tumors across the world, which may be more pronounced and divergent in low-middle income countries. A greater understanding is needed to identify what specific components of the significant parameters influence these trends and how public health efforts may best address these associations to improve overall outcomes.

Awake Craniotomy in Pediatric Patients: A Meta-analysis of Operative Outcomes.

BACKGROUND: Awake craniotomy allows neurosurgeons to make critical decisions when operating in eloquent regions of the brain. The phenomenon of "waking up" during surgery is underexplored in pediatric patients, and the operative outcomes following awake craniotomy are not well understood. Correspondingly, the aim of this study was to quantitatively aggregate the contemporary metadata regarding the operative outcomes of awake craniotomy when used in the pediatric setting. METHODS: Multiple electronic databases from inception to June 2023 were searched following PRISMA guidelines. Respective cohort-level outcomes were then abstracted and pooled by means of meta-analysis utilizing random-effects modeling, and trends evaluated by meta-regression analysis. RESULTS: There were 4 observational studies that satisfied all selection criteria, describing a total cohort of 57 pediatric patients undergoing awake craniotomy. There were 34 (60%) male patients with a median age of 14 years old, with lesions on the left side in 80% of cases when reported. Meta-analysis demonstrated pooled incidences of intraoperative complication to be 17% (95% CI 4%-37%), the need to convert cases to general anesthesia to be 2% (95% CI 0%-9%), immediate postoperative complication to be 18% (95% CI 6%-33%), and long-term complications to be 6% (95% CI 0%-15%). The most common intraoperative complication reported was seizure. Certainty of these estimates were very low due to limited metadata. Meta-regression did not indicate any trend bias due to study and cohort parameters. CONCLUSIONS: Multiple studies have demonstrated the feasibility of the awake craniotomy approach in pediatric patients. The risks for intraoperative and postoperative complications are non-zero, with their incidences trending towards incidences seen in the adult demographic. It is likely formal neuropsychologic preparation and follow-up will increase the candidacy and success of this approach in the future.

Epidemiology of pediatric sports-related concussions presenting to the emergency room over the last decade in the United States.

BACKGROUND: There continues to be clinical significance of pediatric sports-related concussion (pSRC) for pediatric specialists. The overall trends of pSRC are not well understood. The aim of this study was to summarize the epidemiology of pSRC presenting to the emergency room (ER) in the United States (US) over the last decade. METHODS: The National Electronic Injury Surveillance System (NEISS) database was retrospectively interrogated to identify pediatric (≤ 18 years) presenting to ERs in the US between 2013 and 2022. Weighted estimates and 95 % confidence intervals (CI) were generated using survey data analyses, and trends evaluated using linear regression analyses. RESULTS: In 2022, an estimated total of 96,135 [95 % CI 71,486-120,783] cases of pSRC presented to the ER, equivalent to 132 [97-165] cases per 100,000 pediatric population. There has been a significant downtrend in pSRC presentations over the last decade (P = 0.02), with 2020 having the lowest number of cases in the 2013-2022 time period. In terms of gender, the latest proportion of presentations were 65 % [63-67 %] male and 35 % [33-37 %] female, with there being a significantly higher proportion of females and lower proportion of males over the last decade (P < 0.01). Of all causes for pSRC, the most frequent by proportion were football in 23 % [20-26 %], soccer in 9.6 % [7.7-12 %], basketball in 8.6 % [7.0-10 %], bicycle in 5.0 % [4.0-6.3 %], and baseball 4.1 % [3.3-5.0 %], with both football and basketball rates decreasing over the last decade. In 2020, there was a noticeable, non-sustained, decrease in proportion of football and basketball presentations, and an increase in proportion of bicycle presentations. Finally, there were multiples differences between sports and gender with only four in common sports causes amongst the ten most common sports (football, basketball, soccer, bicycle), although they were differently ranked by gender. CONCLUSIONS: In the last decade, the incidence of pSRC presenting to the ER in the US has decreased. This is likely driven by decrease in proportion of football and basketball related injuries, which in turn has led to an increase in proportion of female pSRC which more commonly result from other sports. The Covid-19 pandemic in 2020 resulted in a number of trend anomalies which have since largely resolved. This data implicates that future prevention and treatment protocols should be more individualized.

Global, Regional, and National Incidence and Mortality Trends in Pediatric Central Nervous System Tumors over the Past 2 Decades.

BACKGROUND: Pediatric tumors of the brain and central nervous system (CNS) are a worldwide issue with variances in epidemiology. How exactly incidence and mortality rates have changed over time has not been summarized. Correspondingly, the aim of this study was to quantitively define the global, regional, and national epidemiological trends of these tumors. METHODS: A retrospective review of data from the Global Burden of Disease Study 2019 Database was performed incorporating data from 1999 to 2019. Global, regional, and national outcomes for pediatric CNS tumors were collected for incidence and mortality at a worldwide level, as well as across 7 continental regions, and then 204 countries and territories. RESULTS: Globally, the latest incidence of pediatric CNS tumors was 47,600 (uncertainty interval, 36,500-55,200) at a rate of 1.8 (1.4-2.2) per 100,000, with 23,500 (18,000-27,500) deaths due to these tumors at a rate of 0.9 (0.7-1.1) per 100,000 population. Both rates per 100,000 have decreased over the past 2 decades. With respect to regions, East Asia and Pacific had the highest incidence and mortality cases overall, but in terms of rate per 100,000, North America and Latin America and Caribbean had the highest values, respectively. There were 3/7 (43%) and 6/7 (86%) regions with decreasing incidence and mortality rates per 100,000 over the past 2 decades. China, India, and Pakistan were the 3 countries with both the highest incidence and mortality cases overall; however, San Marino, Denmark, and Norway had the highest incidence rates per 100,000, and Albania, Armenia, and Haiti had the highest mortality rates per 100,000. In the past 2 decades, 79/204 (39%) and 120/204 (59%) countries observed decreasing incidence and mortality rates per 100,000, respectively. CONCLUSIONS: Pediatric CNS tumors remains a worldwide issue, with there being multiple regions and countries worldwide that continue to experience uptrending incidence and mortality rates per 100,000. For both incidence and mortality, there is a clear discordance between regions and countries that report the highest number of cases versus the highest rate of cases per 100,000. Future research efforts are needed to identify positive intervention measures that respect the epidemiology of these tumors at global, regional, and national levels.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions.

BACKGROUND: Chiari malformation type I (CIM) diagnoses have increased in recent years. Controversy regarding the best operative management prompted a review of the literature to offer guidance on surgical interventions. OBJECTIVE: To assess the literature to determine (1) whether posterior fossa decompression or posterior fossa decompression with duraplasty is more effective in preoperative symptom resolution; (2) whether there is benefit from cerebellar tonsillar resection/reduction; (3) the role of intraoperative neuromonitoring; (4) in patients with a syrinx, how long should a syrinx be observed for improvement before additional surgery is performed; and 5) what is the optimal duration of follow-up care after preoperative symptom resolution. METHODS: A systematic review was performed using the National Library of Medicine/PubMed and Embase databases for studies on CIM in children and adults. The most appropriate surgical interventions, the use of neuromonitoring, and clinical improvement during follow-up were reviewed for studies published between 1946 and January 23, 2021. RESULTS: A total of 80 studies met inclusion criteria. Posterior fossa decompression with or without duraplasty or cerebellar tonsil reduction all appeared to show some benefit for symptom relief and syrinx reduction. There was insufficient evidence to determine whether duraplasty or cerebellar tonsil reduction was needed for specific patient groups. There was no strong correlation between symptom relief and syringomyelia resolution. Many surgeons follow patients for 6-12 months before considering reoperation for persistent syringomyelia. No benefit or harm was seen with the use of neuromonitoring. CONCLUSION: This evidence-based clinical guidelines for the treatment of CIM provide 1 Class II and 4 Class III recommendations. In patients with CIM with or without syringomyelia, treatment options include bone decompression with or without duraplasty or cerebellar tonsil reduction. Improved syrinx resolution may potentially be seen with dural patch grafting. Symptom resolution and syrinx resolution did not correlate directly. Reoperation for a persistent syrinx was potentially beneficial if the syrinx had not improved 6 to 12 months after the initial operation. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/3-surgical-interventions .

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Diagnosis.

BACKGROUND: Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians. OBJECTIVE: To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM. METHODS: PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines. RESULTS: The literature search yielded 567 abstracts, of which 151 were selected for full-text review, 109 were then rejected for not meeting the inclusion criteria or for being off-topic, and 42 were included in this systematic review. CONCLUSION: Three Grade C recommendations were made based on Level III evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/1-imaging .

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Symptoms.

BACKGROUND: Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians. OBJECTIVE: To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM. METHODS: PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines. RESULTS: The literature search yielded 430 abstracts, of which 79 were selected for full-text review, 44 were then rejected for not meeting the inclusion criteria or for being off-topic, and 35 were included in this systematic review. CONCLUSION: Four Grade C recommendations were made based on Class III evidence, and 1 question had insufficient evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/2-symptoms .

Healthcare disparities in pediatric neurosurgery: a scoping review.

OBJECTIVE: The aim of this scoping review was to identify relevant articles that have contributed to the body of knowledge describing pediatric neurosurgical healthcare disparities. Identifying healthcare disparities in pediatric neurosurgery is essential to understanding how to best provide care for this unique patient population. Although it is undoubtedly important to increase the knowledge of pediatric neurosurgical healthcare disparities, it is also important to understand the current state of the literature. METHODS: This scoping review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews (PRISMA-ScR) guidelines. The search terms "pediatric neurosurgical disparities" and "pediatric neurosurgical inequities" were entered into the following databases: PubMed, Scopus, and Embase. RESULTS: The initial database search returned a total of 366 results from the PubMed, Embase, and Scopus databases. One hundred thirty-seven duplicates were removed, and the remaining articles were screened by title and abstract. Articles were excluded on the basis of the inclusion and exclusion criteria. Of the remaining 229 articles, 168 were excluded. Sixty-one full-text articles were then examined for eligibility, and 28 did not reach the specified inclusion and exclusion criteria. The remaining 33 articles were included for final review. The results of the reviewed studies were stratified on the basis of disparity type. CONCLUSIONS: Although there has been an increase in the number of publications discussing pediatric neurosurgical healthcare disparities within the last decade, there still remains a scarcity of information regarding healthcare disparities in neurosurgery. Furthermore, less information exists that specifically addresses healthcare disparities in the pediatric population.

Chiari I malformation management in patients with heritable connective tissue disorders.

Background: Chiari malformation type I (CMI) is relatively common neurosurgical condition typically treated with posterior fossa decompression. However, the management of CMI in patients with heritable connective tissue disorders (CTDs), such as Ehlers-Danlos Syndrome, Marfan Syndrome, or Osteogenesis Imperfecta, involves a unique set of perioperative challenges. Objective: This study aims to define the demographic information, comorbidities, and perioperative course of patients with concomitant CMI and CTD. Methods: Patients with CMI admitted for surgical decompression from 2008 to 2015 were captured using the National Inpatient Sample (NIS). Information was collected based on ICD-9 codes. Descriptive and regression analyses were performed in SPSS (version 26). Results: 38,169 CMI patients, 353 of whom had CTD (0.92%), were identified. CMI patients with CTD were more likely to be female (p < 0.001) and present during teenage (p = 0.033) or young adult years (p < 0.001). They had more chronic issues (p < 0.001): systemic comorbidities include postural orthostatic tachycardia syndrome, cardiac dysrhythmias, and gastroparesis (all p < 0.001). CNS comorbidities include migraine, tethered spinal cord, and epilepsy (all p < 0.001). They have increased joint instability (both p < 0.001), as well as craniocervical instability (CCI). More posterior cervical fusion surgeries and application of cervical halo devices were seen during the same inpatient stay (both p < 0.001). Conclusions: Patients with concurrent CTD and CMI were more likely to present with complex Chiari and associated CCI. They were also younger, more often female, and had more systemic, CNS, and joint abnormalities. As such, preoperative recognition of an underlying CTD is imperative to achieve optimal outcomes in this patient population.

Clinical course of pediatric gunshot wounds involving the spine and spinal cord: the Miami experience.

OBJECTIVE: Civilian gunshot wounds (GSWs) involving the skeletal spine and spinal cord in pediatric patients are fortunately rare. Nevertheless, their presentation mandates judicious evaluation, and their clinical outcomes remain poorly defined. Thus, the authors aimed to characterize the clinical course of this traumatic presentation in the pediatric population based on their institutional experience. METHODS: A retrospective review of a level I trauma center database was performed for the period 2011-2021. Clinical data were included for patients aged ≤ 18 years who had presented with radiographic and clinical evidence of a GSW to the spine and had at least one documented follow-up at least 6 months after injury. The primary outcomes of the study were the categorization of gunshot injuries and the results of neurological and functional examinations. RESULTS: A total of 13 patients satisfied the study selection criteria. The mean patient age was 15.7 ± 1.6 years, and all presentations were assault in nature. Most of the patients were male (n = 12, 92%) in gender, Black in race (n = 11, 85%), and from zip codes with a median household income below the local county average (n = 10, 77%). All patients presented with a minimum Glasgow Coma Scale score of 14. Examination at presentation revealed American Spinal Injury Association Impairment Scale (AIS) grade A in 3 cases (23%), grade B in 2 (15%), grade C in 1 (8%), grade D in 2 (15%), and grade E in 5 (38%). Gunshot injury involved all regions of the spine, most commonly the cervical and thoracic spine (n = 6 for each, 46%). In terms of skeletal injury, the most common injuries were to the facet (n = 10, 77%) and the pedicle (n = 8, 62%), with evidence of intracanal injury in 9 patients (69%). Neurosurgical intervention was pursued in 1 patient (8%). Overall, 7 patients (54%) experienced a complication during admission, and the median length of hospitalization was 12 days (range 1-88 days) without any mortality events. Within 90 days from discharge, 2 patients (15%) were readmitted to the hospital for further care. The mean follow-up was 28.9 months (range 6-74 months), by which only 1 patient (8%) had an improved AIS examination; all other patients remained at their initial AIS grade. CONCLUSIONS: Pediatric GSWs involving the spine are typically nonfatal presentations, and their long-term functional outlook appears contingent on clinical examination findings at initial presentation. Although neurosurgical intervention is not necessary in most cases, judicious evaluation of radiographic and clinical examinations by a neurosurgical team is strongly recommended to optimize recovery.

Impact of intraventricular hemorrhage symmetry on endoscopic third ventriculostomy with choroid plexus cauterization for posthemorrhagic hydrocephalus: an institutional experience of 50 cases.

OBJECTIVE: The success rate of endoscopic third ventriculostomy with choroid plexus cauterization (ETV/CPC) in the management of posthemorrhagic hydrocephalus (PHH) following intraventricular hemorrhage (IVH) in infants is not well defined. Furthermore, parameters of IVH at initial presentation have not been tested for predictive associations of ETV/CPC success in this setting. The authors sought to summarize their institutional outcomes to identify possible predictors of ETV/CPC success within this niche. METHODS: A retrospective review was conducted of all ETV/CPC procedures performed at the authors' institution for PHH between 2011 and 2021. Patients were screened against a set of selection criteria including follow-up time of at least 6 months. Associations with ETV/CPC failure were evaluated using regression and Kaplan-Meier analyses. RESULTS: A total of 50 patients satisfied all criteria. There were 32 (64%) male and 18 (36%) female patients with a mean gestational birth age of 26 weeks. The presenting IVH was symmetric in 30 (60%) and asymmetric in 20 (40%) patients, and the maximum IVH grade was IV in 30 (60%) patients overall. Six months after the procedure, ETV/CPC success was seen in 18 (36%) patients and failure in 32 (64%) patients. The median overall follow-up was 42 months, at which point ETV/CPC success was observed in 11 (22%) patients and ETV/CPC failure in 39 (78%) patients. Regression analyses indicated that radiological IVH symmetry was a statistically significant predictor of ETV/CPC failure at 6 months (OR 3.46, p = 0.04) and overall (OR 5.33, p = 0.03). Overall rates of failure were 89% versus 62% (p = 0.02) when comparing symmetric versus asymmetric IVH patients, and time to failure occurred at median times of 1.4 versus 6.5 months (p = 0.03) after the initial procedure. Higher maximum IVH grade and younger age at initial ETV/CPC only trended toward increased failure rates. When the etiology component of the ETV Success Score was adjusted such that symmetric IVH was scored 0, the area under the curve for failure at 6 months increased from 0.58 to 0.69. CONCLUSIONS: Overall, approximately 1 in 5 infants with PHH can expect to not require further intervention following ETV/CPC. The authors demonstrate that IVH symmetry is statistically predictive of ETV/CPC failure in this setting independent of all other parameters, where PHH infants with symmetric IVH are more likely to experience failure, and sooner, than PHH infants with asymmetric IVH. When discussing possible success rates of ETV/CPC for PHH, IVH symmetry should be considered.

Racial disparities in pediatric malignant glioma management: current state of affairs in the United States.

BACKGROUND: The diagnosis of malignant glioma confers a poor prognosis in the pediatric population. In the adult demographic, racial disparities exist with respect to access to care and survival. Yet to date no efforts have been made to characterize racial disparities in the care of malignant pediatric gliomas. Correspondingly, the aim of this study was to understand if racial disparities exist in the setting of malignant pediatric gliomas. METHODS: All pediatric malignant gliomas patients with known race status (White, Black, Other) in the US National Cancer Database (NCDB) between the years 2005-2016 were retrospectively reviewed. Demographic, socioeconomic and clinical data were then abstracted and analyzed by comparison and regression techniques. RESULTS: A total of 1803 pediatric malignant glioma cases were identified, with 48% female and a median age of 8 years old. Brainstem locations were reported in 48% of cases. Socioeconomically, there were statistically significant differences with respect to insurance status, yearly income, household education level and metropolitan residences between the racial groups (all P < 0.01). With respect to treatment, there was statistical difference in the proportion of patients treated with surgical resection (White 43% vs Black 34% vs Other 37%, P = 0.02). There were no differences between race groups for radiation therapy (P = 0.73) or chemotherapy (P = 0.12). The odds of surgical resection were significantly less in the Black group compared to the White group (OR 0.69, P < 0.01), although there was no difference in overall survival between the two groups in those treated with (P = 0.44) or without (P = 0.27) surgical resection. Primary associations of surgical resection in the Black group were brainstem location (P < 0.05) and lower yearly household income quartiles (P < 0.05). CONCLUSIONS: Racial disparities exist amongst the management of pediatric malignant gliomas, with undefined impact on survival and quality of life. In this perspective, we identified associations between Black patients and access to surgical treatment. Understanding that there are many elements to patient care, including quality of life, should encourage all clinicians and carers to consider racial disparities appropriately when managing malignant pediatric glioma patients.

Incidence, follow-up, and postnatal clinical progress of children with central nervous system anomalies on fetal MRI.

OBJECTIVE: MRI is increasingly employed to assess intrauterine fetal anomalies. Central nervous system (CNS) anomalies are common structural conditions that warrant evaluation with fetal MRI and subsequent prenatal consultation with a pediatric neurosurgeon. As the use of fetal MRI increases, there is greater impetus to understand the most common CNS structural anomalies diagnosed in utero, as well as their natural histories. METHODS: The authors performed a single-center retrospective review of fetal MRI evaluations performed between January 2012 and December 2020. Children who underwent both prenatal and postnatal neurosurgical evaluations of CNS anomalies were included. Specific CNS anomalies on fetal MRI, associated extra-CNS findings, and suspicion for genetic abnormality or syndromes were noted. Postnatal clinical status and interventions were assessed. RESULTS: Between January 2012 and December 2020, a total of 469 fetal MRI evaluations were performed; of these, 114 maternal-fetal pairs had CNS anomalies that warranted prenatal consultation and postnatal pediatric neurosurgical follow-up. This cohort included 67 male infants (59%), with a mean ± SD follow-up of 29.8 ± 25.0 months after birth. Fetal MRI was performed at 27.3 ± 5.8 weeks of gestational age. The most frequently reported CNS abnormalities were ventriculomegaly (57%), agenesis or thinning of the corpus callosum (33%), Dandy-Walker complex (DWC) (21%), neuronal migration disorders (18%), and abnormalities of the septum pellucidum (17%). Twenty-one children (18%) required neurosurgical intervention at a mean age of 2.4 ± 3.7 months. The most common surgical conditions included myelomeningocele, moderate to severe ventriculomegaly, encephalocele, and arachnoid cyst. Corpus callosum agenesis or thinning was associated with developmental delay (p = 0.02) and systemic anomalies (p = 0.05). The majority of prenatal patients referred for DWC had Dandy-Walker variants that did not require surgical intervention. CONCLUSIONS: The most common conditions for prenatal neurosurgical assessment were ventriculomegaly, corpus callosum anomaly, and DWC, whereas the most common surgical conditions were myelomeningocele, hydrocephalus, and arachnoid cyst. Only 18% of prenatal neurosurgical consultations resulted in surgical intervention during infancy. The majority of referrals for prenatal mild ventriculomegaly and DWC were not associated with developmental or surgical sequelae. Patients with corpus callosum abnormalities should be concurrently referred to a neurologist for developmental assessments.

Myelomeningocele Including Fetal Prescription.

Myelomeningocele (MMC) is one of the most common birth defects, affecting 0.2 to 0.4 per 1,000 live births in the United States. The most strongly associated risk factor is low folate level in pregnancy. For this reason, 0.4- to 1.0-mg supplementation with folic acid is recommended in all pregnancies, and high-risk pregnancies are recommended to supplement with 4.0 mg of folic acid daily. The mechanism behind the development of MMC is believed to be failure of the caudal end of the neural tube to close during primary neurulation. Screening for MMC is achieved by using α-fetoprotein levels in maternal serum or amniocentesis in the first and second trimesters of pregnancy. Ultrasonography and fetal magnetic resonance imaging are used to confirm the presence of MMC as well as the location and size of the defect. Based on the results of the Management of Myelomeningocele Study, fetal repair is performed between 23 weeks and 25 weeks and 6 days of gestational age for appropriate candidates. Postnatal repair is more common and is performed 24 to 72 hours after birth. In general, patients with lesions at lower anatomical levels have a better prognosis. Most children with MMC will have neurogenic bladder and bowel dysfunction that affect the patient's and the caregiver's quality of life. Patients with higher levels of mobility, better familial support, and higher economic status report improved quality of life compared with other patients with MMC.