Minipterional craniotomy for resection of epileptogenic cavernous malformation.

Epilepsy is a common symptom of pediatric cavernous malformations. In medically refractory patients, surgery can achieve high seizure freedom rates with low morbidity. This video depicts the use of a minipterional craniotomy and transsulcal resection of a frontal opercular cavernous malformation in a 13-year-old female with medically intractable epilepsy. At 1-year follow-up, she was evaluated as Engel class I with a significant improvement in her quality of life. Principles of cavernous malformation resection for the treatment of epilepsy are also reviewed. The video can be found here: https://stream.cadmore.media/r10.3171/2024.4.FOCVID2441.

The Impact of Phenobarbital on the Ability of Electroencephalogram to Predict Adverse Outcome in Asphyxiated Neonates during Therapeutic Hypothermia.

OBJECTIVE: Classification of electroencephalogram (EEG) background has been established to predict outcome in neonates with hypoxic ischemic encephalopathy (HIE). However, the impact of phenobarbital therapy on the predictability of EEG background has not been studied. Our objective is to determine if EEG background after treatment with phenobarbital during therapeutic hypothermia (TH) remains a good predictor for brain injury in neonates with HIE. STUDY DESIGN: This is a single-center, retrospective study of consecutive neonates with HIE who underwent TH and EEG monitoring from October 2017 to March 2021. Per institutional protocol, all infants received a dose of prophylactic phenobarbital and bumetanide therapy at the onset of TH for sedative and neuroprotective measures. The initial 3 hours of EEG background activity was classified based on national guidelines. Infants were separated into two groups based on EEG background scores: group 1 (normal-mild, n = 30) and group 2 (moderate-severe, n = 36). Brain magnetic resonance imaging (MRI) results were scored based on the National Institute of Child Health and Human Development (NICHD) criteria. Adverse outcomes were defined as death before MRI or NICHD brain injury score > 1A. RESULTS: Infants in group 2 had lower Apgar scores at 5 minutes of age, severe acidemia, moderate to severe encephalopathy score, and earlier initiation of EEG monitoring than infants in group 1. Moderate to severe EEG background score was associated with presence of brain injury on MRI or death (p = 0.003), and this association remained significant even after adjustment for independent risk factors (odds ratio = 56.24 [95% confidence interval = 1.841-1718], p = 0.021). CONCLUSION: Phenobarbital therapy does not affect the ability of EEG to predict adverse outcome in infants with perinatal asphyxia during TH. KEY POINTS: · EEG has a clinical utility for predicting outcome in neonates with hypoxia-ischemia.. · Phenobarbital therapy is commonly used in neonates, and may impact EEG background findings.. · In spite phenobarbital therapy, moderate to severe EEG background abnormalities in infants with perinatal asphyxia during TH remain an excellent predictor for poor outcome..

Prevalence of Seizures and Risk Factors for Mortality in a Continuous Cohort of Pediatric Extracorporeal Membrane Oxygenation Patients.

OBJECTIVES: To evaluate the risk factors for mortality in pediatric extracorporeal membrane oxygenation patients. DESIGN: Retrospective, single-center study. SETTING: PICU and Pediatric cardiothoracic ICU in an urban, quaternary care center. PATIENTS: All neonatal and pediatric patients requiring extracorporeal membrane oxygenation at our institution between January 2014 and December 2018, who underwent a standardized continuous electroencephalogram neuromonitoring protocol during most of the duration of extracorporeal membrane oxygenation support. We excluded patients who had extracorporeal membrane oxygenation initiated at another institution. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Sixty-six children required extracorporeal membrane oxygenation support during this period. Four patients were excluded, three due to lack of electroencephalogram data, one with extracorporeal membrane oxygenation initiated at other institution. In the remaining 62, 11 patients (17%) had seizures, of which 5 (45%) had status epilepticus. Eight of 11 patients (72%) had exclusively electrographic seizures. A total of 33 patients (53.2%) died, of which 22 died during extracorporeal membrane oxygenation course, and one died 3 years after hospital discharge. Mean survival from extracorporeal membrane oxygenation initiation was 766.9 days (standard deviation, 691.7; median, 546.5; interquartile range 1-3, 97.7-1255.0). In multivariate analysis, increased risk of mortality was associated with the use of extracorporeal cardiopulmonary resuscitation (hazard ratio, 4.33; 95% CI, 1.75-10.72; p = 0.002), imaging findings of cerebral edema (hazard ratio, 14.31; 95% CI, 5.18-39.54; p < 0.001), high lactate level (> 100 mg/dL within 2 hr preextracorporeal membrane oxygenation) (hazard ratio, 1.22; 95% CI, 1.03-1.44; p = 0.022), and prolonged deep hypothermic circulatory arrest (hazard ratio, 3.43; 95% CI, 1.65-7.13; p < 0.001). Presence of seizures was associated with imaging findings of cerebral edema (hazard ratio, 4.16; 95% CI, 1.04-16.58; p = 0.04). CONCLUSIONS: Seizures are common in children requiring extracorporeal membrane oxygenation support, with a high rate of electrographic seizures and status epilepticus, as in prior studies. Presence of cerebral edema is both risk factor for mortality and seizures. Other risk factors for mortality include extracorporeal cardiopulmonary resuscitation, high lactate levels, and prolonged deep hypothermic circulatory arrest.

Use of Continuous EEG Monitoring in Children Presenting With Encephalopathy Following Convulsive Status Epilepticus.

PURPOSE: The Critical Care Continuous EEG Task Force of the American Clinical Neurophysiology Society recommends continuous EEG (cEEG) monitoring in patients with persistent encephalopathy following convulsive status epilepticus. This recommendation is based on data, which correlates prolonged nonconvulsive seizures and nonconvulsive status epilepticus with worse neurologic outcomes. Compliance with these recommendations may be limited by barriers such as inadequate resource and staff availability. We surveyed members of the Child Neurology Society to determine the barriers that prevent them from appropriately using cEEG, and how they have successfully overcome such obstacles. METHODS: A survey was electronically distributed to Child Neurology Society members, which assessed demographics, current clinical practices, and cEEG utilization in critically ill children, with an emphasis on resource availability and strategies to overcome resource limitations. RESULTS: One hundred forty-six physicians from Child Neurology Society completed the survey. Fifty-three (39.8%) respondents use cEEG to detect nonconvulsive seizures/nonconvulsive status epilepticus in most (>90%) of their pediatric patients who present with persistent encephalopathy following convulsive status epilepticus. Forty-four respondents (34.4%) perceive barriers to performing cEEG monitoring, and 107 (84.9%) of the respondents are implementing changes to overcome barriers. The two most commonly reported barriers included inadequate availability of technicians and EEG machines. The most common changes included hiring new EEG technologists and purchasing new machines. Other barriers included identification of appropriate patients and availability of remote EEG monitoring capabilities. CONCLUSIONS: Barriers, such as resource limitations, prevent compliance with the American Clinical Neurophysiology Society cEEG monitoring recommendations. Recognizing common limitations and learning from each other about successful strategies to overcome these barriers may improve care.