Utility of the material community deprivation index as a metric to identify at-risk children for severe traumatic brain injury.

OBJECTIVE: Pediatric traumatic brain injury (TBI) is a significant cause of morbidity and mortality with lasting effects including neurological deficits and psychological comorbidities. Recent studies have shown that social determinants of health are key factors that impact clinical outcomes in other pediatric traumatic injuries, suggesting that these health disparities may have a significant impact on patients sustaining TBI as well. The purpose of this study was to retrospectively review a cohort of pediatric patients diagnosed with TBI and elucidate the relationships among socioeconomic deprivation, patient-specific demographics, and morbidity and mortality. METHODS: The authors conducted a retrospective cross-sectional analysis of pediatric patients (≤ 18 years of age) treated for TBI at a level I pediatric trauma center between 2016 and 2020. Patients with concussion-related injuries without intracranial findings and those with nonaccidental trauma were excluded from the study. In addition to evaluating basic patient demographics, the authors geocoded patient addresses to allow identification of the patient's home census tract using the material community deprivation index (MCDI). The MCDI is a unique composite index score created by the combination of six census variables and ranges from 0 to 1 in severity. RESULTS: Of the 513 patients included in this study, 71 (13.8%) were diagnosed with severe TBI, 28 (5.5%) with moderate TBI, and 414 (80.7%) with mild TBI. Patients in quartile 4 (MCDI ≥ 0.45) were at a significantly higher risk of having a severe TBI than patients in quartile 1 (OR 2.29, 95% CI 1.1-4.71; p = 0.02). Black patients were more likely to have a firearm-related TBI (OR 3.74, 95% CI 2.01-8.7; p = 0.018) than non-Black patients. Patients who lived in a neighborhood with a lower MCDI were significantly more likely to be discharged home than those who lived in an area with a higher MCDI (OR 2.78, 95% CI 7.90-32.93; p < 0.001). CONCLUSIONS: This study demonstrated that inequities continue to exist within the pediatric TBI population and that the MCDI is a valuable tool to identify at-risk subpopulations. More specifically, patients who lived in a neighborhood with a higher MCDI were at higher risk of sustaining a severe TBI. By partnering with communities, families, and policymakers, healthcare providers could serve as advocates for these patients and work to minimize the social disparities that continue to exist.

Effect of allograft patch closure on incidence of spinal inclusion cyst formation following open fetal myelomeningocele repair.

OBJECTIVE: The aim of this study was to evaluate the incidence of spinal inclusion cyst (sIC) formation after open fetal myelomeningocele (fMMC) repair and the effect of dural patch closure. METHODS: The authors conducted a retrospective review of patients who underwent open fMMC repair at their institution between March 2011 and June 2020. All patients met the criteria for intervention defined by the Management of Myelomeningocele Study (MOMS). The primary outcomes investigated were development of sIC and need for surgical intervention. Secondary outcomes included need for CSF diversion, extent of reversal of hindbrain herniation, and ambulatory status. RESULTS: Of 56 patients who underwent open fMMC repair, 52 had adequate spinal imaging for review. Twelve of these patients (23%) developed sIC (95% CI 0.11-0.35). Six patients experienced symptoms and required surgical detethering with sIC resection. Six additional patients had evidence of sIC on surveillance MRI but remained asymptomatic. The authors found a statistically significant relationship between the use of a dural allograft patch and sIC formation (p = 0.05). In terms of sIC development, there was no statistically significant difference between patients who underwent primary closure and those who received an allograft at the level of the fascia (p = 0.34) or skin (p = 0.26). The rate of hydrocephalus requiring CSF diversion was 52%. Interestingly, 98% of patients had improvement in extent of hindbrain herniation. Dural patch closure did not have any effect on the rate of progressive hydrocephalus (p = 0.33) or degree of reversal of hindbrain herniation (p > 0.99). CONCLUSIONS: This study suggested that children with prenatally repaired MMC are at higher risk for development of sIC and associated symptoms than those who undergo postnatal repair. The presentation of symptoms was also earlier in these patients than previously reported after postnatal repair. The use of a dural allograft patch appears to have a positive correlation with sIC formation. Future investigations evaluating the incidence of sIC after fetoscopic MMC repair, in which primary dural closure typically cannot be achieved and a dural patch is most often utilized, will be helpful in facilitating prenatal counseling for patients considering fetal intervention.

Posterior Quadrant Disconnection Procedure for Intractable Epilepsy: A Case Series of 5 Young Pediatric Patients.

BACKGROUND: Posterior quadrant disconnection (PQD) has been described as a treatment for patients with refractory posterior quadrant subhemispheric epilepsy. Surgical outcomes are difficult to interpret because of limited literature. OBJECTIVE: To provide insight regarding the operative technique and postsurgical seizure freedom in young pediatric patients who underwent surgical disconnection for the treatment of posterior quadrant subhemispheric epilepsy at our institution. METHODS: The authors retrospectively analyzed a series of 5 patients who underwent PQD between 2019 and 2021. Charts were reviewed for preoperative workup including noninvasive/invasive testing, operative reports, and postoperative follow-up data which included degree of seizure freedom, completion of disconnection, and complications. RESULTS: Five patients were included in this series. The median age at seizure onset was 12 months (range 3-24 months), and the median age at surgery was 36 months (range 22-72 months). Histopathology confirmed focal cortical dysplasia in 3 of 5 patients (2 patients with type IB; 1 with type IIID). The average length of follow-up after surgery was 16.8 months (range 12-24 months). All patients underwent complete disconnection of the posterior quadrant without complications. Four of 5 patients (80%) had Engel score of I, while the remaining patient had an Engel score of IIB. CONCLUSION: Our early results demonstrate that complete PQD can be successful at providing excellent seizure freedom and functional outcomes in carefully selected young pediatric patients who have concordant seizure semiology, noninvasive/invasive testing, and imaging findings with primary seizure onset zone within the ipsilateral posterior quadrant. Meticulous surgical planning and thorough understanding of the surgical anatomy and technique are critical to achieving complete disconnection.

Pediatric Hydrocephalus and the Primary Care Provider.

Hydrocephalus is a pathologic condition that results in the disruption of normal cerebrospinal fluid flow dynamics often characterized by an increase in intracranial pressure resulting in an abnormal dilation of the ventricles. The goal of this article was to provide the necessary background information to understand the pathophysiology related to hydrocephalus, recognize the presenting signs and symptoms of hydrocephalus, identify when to initiate a workup with further studies, and understand the management of pediatric patients with a new and preexisting diagnosis of hydrocephalus.

Partial suturectomy for phenotypical craniosynostosis caused by incomplete fusion of cranial sutures: a novel surgical solution.

OBJECTIVE: Patients presenting with head shape changes phenotypical for craniosynostosis may have incomplete fusion of the involved sutures. The surgical literature is lacking in appropriate management strategies for these patients. In this paper, the authors evaluate their experience with a novel treatment strategy: suturectomy of only the fused portion followed by helmeting therapy in patients with skull deformity secondary to incomplete suture synostosis. METHODS: Patients with craniosynostosis with incomplete suture fusion requiring operative intervention between 2018 and 2020 were included for evaluation. Patients were selected for partial suturectomy if the patent portion of the suture had a normal appearance. All patients underwent craniectomy of the involved portion of the synostosed suture. Intraoperative ultrasound was used to reassess the degree of fusion at the time of surgery and incision planning. A 2- to 3-cm strip craniectomy was performed under direct visualization through a single minimal access incision. Postoperative helmeting was utilized for all patients. Demographic and perioperative data were collected, including laser scan data in the form of cranial index (CI) and cranial vault asymmetry (CVA), defined as the difference between two diagonal measurements, from the frontozygomaticus to the opposite eurion. RESULTS: Four males and 1 female with a mean age of 2.8 months (range 1.1-3.9 months) at presentation were included. All patients had incomplete sagittal synostosis (one patient also had an incomplete left lambdoid synostosis and another had an incomplete left coronal synostosis). The mean age at surgery was 3.5 months (range 2.0-4.7 months) without any major complications. All patients were compliant with postoperative helmeting. The average age at the last follow-up was 12.8 months (range 5.3-23.7 months) with a mean follow-up duration of 9.3 months (range 0.5-19.6 months). Final laser scan evaluations were available for 3 patients and showed an improvement of the CI from an average of 71.3 (range 70-73) to 84.3 (range 82-86). The CVA improved from an average of 9.67 mm (range 2-22 mm) to 1.67 mm (range 1-2 mm). CONCLUSIONS: Minimally invasive direct excision of the involved portion of fused cranial sutures followed by helmet therapy for phenotypical craniosynostosis is a safe and effective treatment strategy. This technique is suitable for very young patients and appears to offer similar outcomes to complete suturectomy. Further studies are required to see if this approach reduces the deformity severity for patients requiring vault remodeling later in life.

Evaluation of smartphone-integrated magnetometers in detection of safe electromagnetic devices for use near programmable shunt valves: a proof-of-concept study.

OBJECTIVE: External magnetic forces can have an impact on programmable valve mechanisms and potentially alter the opening pressure. As wearable technology has begun to permeate mainstream living, there is a clear need to provide information regarding safety of these devices for use near a programmable valve (PV). The aim of this study was to evaluate the magnetic fields of reference devices using smartphone-integrated magnetometers and compare the results with published shunt tolerances. METHODS: Five smartphones from different manufacturers were used to evaluate the magnetic properties of various commonly used (n = 6) and newer-generation (n = 10) devices using measurements generated from the internal smartphone magnetometers. PV tolerance testing using calibrated magnets of varying field strengths was also performed by smartphone magnetometers. RESULTS: All tested smartphone-integrated magnetometers had a factory sensor saturation point at around 5000 µT or 50 Gauss (G). This is well below the threshold at which a magnet can potentially deprogram a shunt, based on manufacturer reports as well as the authors' experimental data with a threshold of more than 300 G. While many of the devices did saturate the smartphone sensors at the source, the magnetic flux density of the objects decreases significantly at 2 inches. CONCLUSIONS: The existence of an upper limit on the magnetometers of all the smartphones used, although well below the published deprogramming threshold for modern programmable valves, does not allow us to give precise recommendations on those devices that saturate the sensor. Based on the authors' experimental data using smartphone-integrated magnetometers, they concluded that devices that measure < 40 G can be used safely close to a PV.

Comparison of two- and three-dimensional endoscopic visualization for fetal myelomeningocele repair: a pilot study using a fetoscopic surgical simulator.

INTRODUCTION: The objective of this study was to evaluate the utility of three-dimensional (3D) versus conventional two-dimensional (2D) endoscopy for fetal myelomeningocele repair using a low-fidelity fetoscopic surgical simulator. METHODS: A low-fidelity fetoscopic box trainer was developed for surgical simulation of myelomeningocele repair. Participants with varying surgical experience were recruited and completed three essential tasks (cutting skin, dural patch placement, and suturing skin) using both 2D and 3D endoscopic visualization. Participants were randomized to begin all tasks in either 2D or 3D. Time to completion was measured for each task, and each participant subsequently completed the NASA Load Index test and a questionnaire evaluating their experience. RESULTS: Sixteen participants completed the study tasks using both 2D and 3D endoscopes in the simulator. While the mean performance time across all tasks was shorter with 3D versus 2D endoscopy (cutting skin, 47 vs. 54 seconds; dural patch placement, 38 vs. 52 seconds; and suturing skin, 424 vs. 499 seconds), the results did not reach statistical significance. When comparing times to completion of each of the three tasks between levels of expertise, participants in the expert category were faster when suturing skin on the 2D modality (P = 0.047). Under 3D visualization, experts were faster at cutting the skin (P = 0.008). When comparing experiences using the NASA-TLX test, participants felt that their performance was better using 3D over the 2D system (P = 0.045). Overall, 13 of 16 (81.3%) participants preferred 3D over 2D visualization. CONCLUSIONS: Three-dimensional endoscopes could potentially be used in the near future for relative improvement in visualization and possibly performance during complex fetoscopic procedures such as prenatal repair of myelomeningocele defects. Further studies utilizing 3D scopes for other related procedures may potentially support clinical implementation of this technology in fetal surgery and also prove to be a useful tool in surgical training.

Surgical Interventions for Supratentorial Intracranial Hemorrhage: The Past, Present, and Future.

Spontaneous supratentorial intracranial hemorrhage is extremely disabling and is associated with high mortality. Primary treatment for patients with this disease process is maximal medical management with blood pressure control and correction of clotting disorders due to comorbid conditions or medications. Over the past decade, significant strides have been made in understanding the benefits of surgical intervention in the treatment of intracranial hemorrhage through multiple clinical trials. In this article, we review the evolution of surgical treatments beginning with the STICH trials, discuss new developments with minimally invasive surgical strategies, and provide a brief update regarding ongoing trials and future directions in the treatment of spontaneous supratentorial intracranial hemorrhage.

Fetoscopic Multilayer, Dural Patch Closure Technique for Intrauterine Myelomeningocele Repair: 2-Dimensional Operative Video.

Myelomeningocele (MMC) is the most common open neural tube defect associated with long-term survival. In 2011, The Management of Myelomeningocele Study (MOMS) trial demonstrated that fetal repair for MMC reduced the rate of shunted hydrocephalus and improved developmental, motor, and ambulation outcomes at 30 mo compared to postnatal intervention.1 Recent studies have demonstrated the safety and feasibility of fetoscopic MMC repair as well as reduction in preterm birth, lower risk of uterine dehiscence, and the option of vaginal delivery with this approach compared to open fetal repair.2-4 The patient is a 25-yr-old female, G4 P2, who presented at 20 wk's gestation with ultrasound findings concerning for MMC and Chiari II malformation. These findings were further corroborated with fetal magnetic resonance imaging. After extensive prenatal counseling in a multidisciplinary fashion and discussion regarding risks and benefits of prenatal closure of the MMC, the patient chose to undergo prenatal repair and surgical consent was obtained. At 25 wk's gestation, the patient underwent a fetoscopic multilayer closure with dural patch repair using a standardized, 3-port, carbon dioxide insufflation technique for the intrauterine treatment of MMC without any postoperative complications. The duration of the entire procedure was 275 min. At 36 wk's and 1 d's gestational age, the patient had a spontaneous vaginal delivery, resulting in a healthy male newborn. The surgical site was well healed without complications, and follow-up radiographic imaging was reassuring. This edited, 2-dimensional operative video highlights the key steps of the fetoscopic closure with follow-up postnatal clinical and radiographic outcomes.

The historical evolution of microvascular decompression for trigeminal neuralgia: from Dandy's discovery to Jannetta's legacy.

Although the symptoms of trigeminal neuralgia (TN) have been well described throughout the history of medicine, its etiology was initially not well understood by most surgeons. The standard procedure used to treat TN today, microvascular decompression (MVD), evolved due to the efforts of numerous neurosurgeons throughout the twentieth century. Walter Dandy was the first to utilize the cerebellar (suboccipital) approach to expose the trigeminal nerve for partial sectioning. He made unique observations about the compression of the trigeminal nerve by nearby structures, such as vasculature and tumors, in TN patients. In the 1920s, Dandy unintentionally performed the first MVD of the trigeminal nerve root. In the 1950s, Palle Taarnhøj treated a TN patient by performing the first intentional decompressive procedure on the trigeminal nerve root solely through the removal of a compressive tumor. By the 1960s, W. James Gardner was demonstrating that the removal of offending lesion(s) or decompression of nearby vasculature alleviated pressure on the trigeminal nerve and the pain associated with TN. By the 1990s, Peter Jannetta proved Dandy's original hypothesis; he visualized the compression of the trigeminal nerve at the root entry zone in TN patients using an intraoperative microscope. In this paper, we recount the historical evolution of MVD for the treatment of TN.

Generation of diffuse intrinsic pontine glioma mouse models by brainstem-targeted in utero electroporation.

BACKGROUND: Diffuse intrinsic pontine gliomas (DIPGs) are highly lethal childhood brain tumors. Their unique genetic makeup, pathological heterogeneity, and brainstem location all present challenges to treatment. Developing mouse models that accurately reflect each of these distinct features will be critical to advance our understanding of DIPG development, progression, and therapeutic resistance. The aims of this study were to generate new mouse models of DIPG and characterize the role of specific oncogenic combinations in DIPG pathogenesis. METHODS: We used in utero electroporation (IUE) to transfect neural stem cells in the developing brainstem with PiggyBac DNA transposon plasmids. Combinations of platelet-derived growth factor B (PDGFB), PdgfraD842V, or PdgfraWT, combined with dominant negative Trp53 (DNp53) and H3.3K27M expression, induced fully penetrant brainstem gliomas. RESULTS: IUE enabled the targeted transfection of brainstem neural stem cells. PDGFB + DNp53 + H3.3K27M induced the rapid development of grade IV gliomas. PdgfraD842V + DNp53 + H3.3K27M produced slower forming grade III gliomas. PdgfraWT + DNp53 + H3.3K27M produced high- and low-grade gliomas with extended latencies. PDGFB, PdgfraD842V, and PdgfraWT DIPG models display unique histopathological and molecular features found in human DIPGs. H3.3K27M induced both overlapping and unique gene expression changes in PDGFB and PdgfraD842V tumors. Paracrine effects of PDGFB promote disruption of pericyte-endothelial interactions and angiogenesis in PDGFB DIPG mouse models. CONCLUSION: Brainstem-targeted IUE provides a rapid and flexible system to generate diverse DIPG mouse models. Using IUE to investigate mutation and pathohistological heterogeneity of DIPG will provide a valuable tool for future genetic and preclinical studies.

Not all ventriculomegaly is created equal: diagnostic overview of fetal, neonatal and pediatric ventriculomegaly.

Fetal ventriculomegaly refers to a condition in which there is enlargement of the ventricular spaces, typically on prenatal ultrasound. It can be associated with other CNS or extra-CNS abnormalities, and this relationship is crucial to understand as it affects overall neonatal outcome. Isolated ventriculomegaly has been described in the literature with variable clinical outcome. Typically, outcome is based on the etiology and degree of ventriculomegaly. When associated with a pathologic condition, ventriculomegaly can be a result of hydrocephalus. While initial diagnosis is usually made on prenatal ultrasound, fetal magnetic resonance imaging is preferred to further elucidate any associated CNS malformations. In this paper, the authors aim to provide a comprehensive review of the diagnosis, associated etiologies, prognosis, and treatment options related to fetal, neonatal, and pediatric ventriculomegaly and hydrocephalus. In addition, preliminary data is provided from our institutional cohort of patients with a prenatal diagnosis of ventriculomegaly followed through the perinatal period.

Growing up with spina bifida: bridging the gaps in the transition of care from childhood to adulthood.

Spina bifida is the most common nonchromosomal birth defect, resulting in permanent disability of multiple organ systems, yet compatible with long-term survival. Important advances across various disciplines have now improved survival among the spina bifida population. Although the majority of individuals living with spina bifida are now adults, there are few publications in the neurosurgical literature regarding the care of adults with spina bifida, associated medical conditions, surgical interventions, and long-term complications. The major goals for transitioning adult patients with spina bifida are preservation of function and promotion of independence as well as general overall health. Nevertheless, many gaps exist in our knowledge and understanding of the complex needs of this aging patient population. The goal of this paper was to provide a comprehensive updated review of the literature regarding the challenges and considerations involved in the transitional care to adulthood for patients with spina bifida. Unique to this review, the authors provide a first-hand personal communication and interview with an adult patient with spina bifida that discusses many of these challenges with transition.

Spinal cord stimulation failure: evaluation of factors underlying hardware explantation.

OBJECTIVE: Spinal cord stimulation has been shown to improve pain relief and reduce narcotic analgesic use in cases of complex refractory pain syndromes. However, a subset of patients ultimately undergoes removal of the spinal cord stimulator (SCS) system, presumably because of surgical complications or poor efficacy. This retrospective study addresses the paucity of evidence regarding risk factors and underlying causes of spinal cord stimulation failures that necessitate this explantation. METHODS: In this retrospective single-center review, 129 patients underwent explantation of SCS hardware during a 9-year period (2005-2013) following initial placement at the authors' institution or elsewhere. Medical history, including indication of implantation, device characteristics, revision history, and reported reasons for removal of hardware, were reviewed. RESULTS: The 74 (57%) women and 55 (43%) men were a median of 49 years old (IQR 41-61 years) at explantation; the median time to explantation was 20 months (IQR 7.5-45.5 months). Thoracic or upper lumbar leads were placed in 89.9% of patients primarily for the diagnosis of postsurgical failed-back surgery syndrome (70.5%), chronic regional pain syndrome (14.7%), and neuropathic pain (8.5%). More than half of patients were legally disabled. Initial postoperative reduction in pain was reported in 81% of patients, and 37.8% returned to work. Among 15 patients with acute postsurgical complications (12 infections, 2 hemorrhages, 1 immediate paraplegia), the median time to removal was 2 months. Primary reasons for hardware removal were lack of stimulation efficacy (81%), electrode failure due to migration (14%), and allergic reactions to implanted hardware in 2 patients. The 72 patients who underwent formal psychiatric evaluation before implantation were affected by high rates of major depression (64%), anxiety (34%), posttraumatic stress disorder (PTSD) (12%), drug or alcohol abuse (12%), and physical or sexual abuse (22%). CONCLUSIONS: The authors' findings provide insight regarding the mechanisms of spinal cord stimulation failure that resulted in total removal of the implanted system. The relationship between spinal cord stimulation failure and certain psychiatric disorders, such as PTSD, depression, and anxiety, is highlighted. Ultimately, this work may shed light on potential avenues to reduce morbidity and improve patient outcomes.

Predictors of Return to Normal Neurological Function After Surgery for Moderate and Severe Degenerative Cervical Myelopathy: An Analysis of A Global AOSpine Cohort of Patients.

BACKGROUND: Multiple studies have established the safety and efficacy of surgical intervention for degenerative cervical myelopathy (DCM). Although the main goal of surgery is symptom stabilization, a subset of patients achieves remarkable improvements. OBJECTIVE: To identify predictors of return to normal neurological function after surgery for moderate or severe DCM. METHODS: This is an analysis of 2 prospective multicenter studies (the AOSpine CSM-North America and CSM-International studies) conducted between 2005 and 2011. For patients with complete preoperative magnetic resonance imaging (MRI) and 2-yr follow-up, characteristics were compared between those who achieved a modified Japanese Orthopaedic Association (mJOA) score of 18 at 2 yr (no signs of myelopathy) vs controls. Only patients with baseline mJOA ≤ 14 (moderate and severe myelopathy) were included to minimize ceiling effects. RESULTS: A total of 51 patients (20.3%) out of 251 with moderate or severe baseline myelopathy achieved an mJOA score of 18 at 2 yr. On stepwise multiple logistic regression analysis, T1-weighted (T1W1)-hypointensity (odds ratio [OR] 0.10; 95% confidence interval [CI], 0.01-0.79; P = .03) and longer walking time on the 30-m walking test (OR 0.95; 95% CI, 0.92-0.99; P = .03) were independent predictors of outcome, with an area under the curve of 0.71 for the model. CONCLUSION: In this study, T1W-hypointensity on MRI and longer walking time were found to predict a less likelihood of achieving return to normal neurological function after surgery for moderate or severe DCM. These findings may provide useful information for patient counseling and perioperative expectations.

Comprehensive anatomy of the foramen ovale critical to percutaneous stereotactic radiofrequency rhizotomy: cadaveric study of dry skulls.

OBJECTIVE: Percutaneous stereotactic radiofrequency rhizotomy (PSR) is often used to treat trigeminal neuralgia, a serious condition that results in lancinating, episodic facial pain. Thorough understanding of the microsurgical anatomy of the foramen ovale (FO) and its surrounding structures is required for efficient, effective, and safe use of this technique. This morphometric study compares anatomical and surgical orientations to identify the variations of the FO and assess cannulation difficulty. METHODS: Bilateral foramina from 174 adult human dry skulls (348 foramina) were analyzed using anatomical and surgical orientations in photographs from standardized projections. Measurements were obtained for shape, size, adjacent structures, and morphometric variability effect on cannulation. The risk of potential injury to surrounding structures was also assessed. RESULTS: The authors identified 6 distinctive shapes of the FO and 5 anomalous variants from the anatomical view, and 6 shapes from the surgical view. In measurements of surface area of this foramen obtained using the surgical view, loss (average 18.5% ± 5.7%) was significant compared with the anatomical view. Morphometrically, foramen size varied significantly and obstruction from a calcified pterygoalar ligament occurred in 7.8% of specimens. Importantly, 8% of foramina were difficult to cannulate, thus posing a 12% risk of inadvertent cannulation of the foramen lacerum. CONCLUSIONS: Significant variability in the FO's shape and size probably affected its safe and effective cannulation. Preoperative imaging by 3D head CT may be helpful in predicting ease of cannulation and in guiding treatment decisions, such as a percutaneous approach over microvascular decompression or radiosurgery.

Middle Fossa Approach for Resection of Vestibular Schwannomas: A Decade of Experience.

BACKGROUND: The middle cranial fossa (MCF) approach is a challenging surgical technique for the resection of small and intermediate sized, primarily intracanalicular, vestibular schwannomas (VS), with the goal of hearing preservation (HP). OBJECTIVE: To describe a decade-long, single institutional experience with the MCF approach for resection of VS. METHODS: This is a retrospective cohort study of 63 patients who underwent the MCF approach for resection of VS from 2006 to 2016. Audiometric data included pure-tone average (PTA), low-tone pure-tone average (LtPTA), word recognition score, and American Academy of Otolaryngology-Head and Neck Surgery (AAO-HNS) hearing classification at presentation and follow-up. Patients with postoperative serviceable (AAO-HNS class A-B) and/or useful (AAO-HNS class A-C) hearing were compared to those without HP. Facial nerve function was assessed using the House-Brackmann scale. RESULTS: The mean age and duration of follow-up were 50 ± 13 yr and 21 ± 21 mo, respectively. The mean tumor size was 10 ± 4 mm. The serviceable and usable HP rates were 54% and 50%, respectively. Some residual hearing was preserved in 71% of patients. Large tumor size (P = .05), volume (P = .03), and extrameatal tumor extension (P = .03) were associated with poor audiometric outcomes. The presence of a fundal fluid cap (P = .01) was a favorable finding. At definitive testing, LtPTA was significantly better preserved than traditional PTA (P = .01). Facial nerve outcomes, tumor control rates, and durability of audiometric outcomes were excellent. 47% of patients pursued aural rehabilitation. CONCLUSION: In our series, the MCF approach for VS provided excellent rates of tumor and facial nerve function, with durable serviceable HP.

Understanding the complex pathophysiology of idiopathic intracranial hypertension and the evolving role of venous sinus stenting: a comprehensive review of the literature.

Idiopathic intracranial hypertension (IIH) is a disease defined by elevated intracranial pressure without established etiology. Although there is now consensus on the definition of the disorder, its complex pathophysiology remains elusive. The most common clinical symptoms of IIH include headache and visual complaints. Many current theories regarding the etiology of IIH focus on increased secretion or decreased absorption of cerebrospinal fluid (CSF) and on cerebral venous outflow obstruction due to venous sinus stenosis. In addition, it has been postulated that obesity plays a role, given its prevalence in this population of patients. Several treatments, including optic nerve sheath fenestration, CSF diversion with ventriculoperitoneal or lumboperitoneal shunts, and more recently venous sinus stenting, have been described for medically refractory IIH. Despite the availability of these treatments, no guidelines or standard management algorithms exist for the treatment of this disorder. In this paper, the authors provide a review of the literature on IIH, its clinical presentation, pathophysiology, and evidence supporting treatment strategies, with a specific focus on the role of venous sinus stenting.

Routine surveillance imaging following mild traumatic brain injury with intracranial hemorrhage may not be necessary.

BACKGROUND: Mild traumatic brain injury (mTBI) comprises the majority of pediatric traumatic brain injury. Children with mTBI even with traumatic intracranial hemorrhage (tICH) rarely experience a clinically significant neurologic decline (CSND). The utility of routine surveillance imaging in the pediatric population also remains controversial, especially owing to concerns about the risks of radiation exposure at a young age. This study aims to identify demographic or injury-related characteristics that may facilitate recognition of children at risk of progression with mTBI. METHODS: We performed a retrospective review of patients <16 years old with mTBI (GCS 13-15) and tICH admitted to a Level I pediatric trauma center between 2009 and 2014. Management of these patients was directed by the Cincinnati Children's Hospital Medical Center Minor Head Injury Algorithm. We reviewed each chart with emphasis on patient demographics, injury specific data, and radiographic or clinical progression. RESULTS: 154 patients met inclusion criteria with mean age of 4 [0-16]; 116 sustained an tICH and 38 patients had isolated skull fractures. Repeat neuroimaging was obtained in 68 patients (59%). Only 9 patients (13%) with tICH had radiographic progression, none of which resulted in CSND. In addition, 9 patients experienced CSND, leading to neurosurgical intervention in 6 patients. Notably, none of these patients had repeat imaging prior to their neurologic changes. Both CSND and need for intervention were significantly higher in patients with epidural hematomas than other types of tICH (19.2% vs. 1.1%, p = 0.002). Of 154 patients, 19 did not have documented follow-up, 135 were seen as outpatients and 65 (48%) had follow up neuroimaging. All patients who had surveillance imaging in the outpatient setting had stable or resolved tICH. CONCLUSION: Few children with mTBI and tICH experience clinical decline. Importantly, all patients that required neurosurgical intervention were identified by clinical changes rather than via repeat imaging. Our study suggests that in the vast majority of cases, clinical monitoring alone is safe and sufficient in patients in order to avoid exposure to repeat radiographic imaging. LEVEL OF EVIDENCE: Level III, prognostic and epidemiological.