Intracranial complications of sinogenic and otogenic infections in children: an ESPN survey on their occurrence in the pre-COVID and post-COVID era.

BACKGROUND: COVID-19 pandemic is thought to have changed the epidemiology of some pediatric neurosurgical disease: among them are the intracranial complications of sinusitis and otitis (ICSO). According to some studies on a limited number of cases, both streptococci-related sinusitis and ICSO would have increased immediately after the pandemic, although the reason is not clear yet (seasonal changes versus pandemic-related effects). The goal of the present survey of the European Society for Pediatric Neurosurgery (ESPN) was to collect a large number of cases from different European countries encompassing the pre-COVID (2017-2019), COVID (2020-2021), and post-COVID period (2022-June 2023) looking for possible epidemiological and/or clinical changes. MATERIAL AND METHODS: An English language questionnaire was sent to ESPN members about year of the event, patient's age and gender, presence of immune-deficit or other favoring risk factors, COVID infection, signs and symptoms at onset, site of primary infection, type of intracranial complication, identified germ, type and number of surgical operations, type and duration of medical treatment, clinical and radiological outcome, duration of the follow-up. RESULTS: Two hundred fifty-four cases were collected by 30 centers coming from 14 different European countries. There was a statistically significant difference between the post-COVID period (129 children, 86 cases/year, 50.7% of the whole series) and the COVID (40 children, 20 cases/year, 15.7%) or the pre-COVID period (85 children, 28.3 cases/year, 33.5%). Other significant differences concerned the presence of predisposing factors/concurrent diseases (higher in the pre-COVID period) and previous COVID infection (higher in the post-COVID period). No relevant differences occurred as far as demographic, microbiological, clinical, radiological, outcome, morbidity, and mortality data were concerned. Paranasal sinuses and middle ear/mastoid were the most involved primary site of infection (71% and 27%, respectively), while extradural or subdural empyema and brain abscess were the most common ICSO (73% and 17%, respectively). Surgery was required in 95% of cases (neurosurgical and ENT procedure in 71% and 62% of cases, respectively) while antibiotics in 99% of cases. After a 12.4-month follow-up, a full clinical and radiological recovery was obtained in 85% and 84% of cases, respectively. The mortality rate was 2.7%. CONCLUSIONS: These results suggest that the occurrence of ICSO was significantly increased after the pandemic. Such an increase seems to be related to the indirect effects of the pandemic (e.g., immunity debt) rather than to a direct effect of COVID infection or to seasonal fluctuations. ICSO remain challenging diseases but the pandemic did not affect the management strategies nor their prognosis. The epidemiological change of sinusitis/otitis and ICSO should alert about the appropriate follow-up of children with sinusitis/otitis.

Subependymal giant-cell astrocytoma: A surgical review in the modern era of mTOR inhibitors.

INTRODUCTION: Surgical removal has been the historical treatment for subependymal giant-cell astrocytoma (SEGA) in tuberous sclerosis complex (TSC) patients. In the past decade, mTOR inhibitors have shown efficacy in the treatment of SEGA, significantly reducing tumor size. The aim of this study was to assess the safety and efficacy of surgical treatment at a time when mTOR inhibitors have changed standard treatment. MATERIAL AND METHODS: We conducted a single-center retrospective study including all patients treated by surgery for SEGA from October 2003 to September 2019, with a review of all SEGA surgical case series, following PRISMA guidelines. Research focused on demographics, surgical indications, surgical approach, use of CSF shunt, morbidity and mortality, resection quality, recurrence rate and treatment of recurrence, follow-up and long-term clinical status. RESULTS: Eleven patients were included, with a median age at surgery of 16.0 years. Gross total resection was achieved in 8 patients (72%), with no permanent morbidity. One patient needed further surgery for tumor recurrence. Eighteen studies were reviewed, totaling 263 TSC patients affected by SEGA and 286 surgical procedures. Gross total resection was achieved in 81.1% of cases, mortality was 4.9% and permanent morbidity 6.1%. Tumor recurrence occurred in 11.5% of cases, and was secondary to partial tumor resection at first surgery in the majority of cases. CONCLUSION: Surgical treatment of SEGA is still a valid and effective option. Morbidity is low and complete disappearance of SEGA can be achieved in selected cases.

Surgical declarative knowledge learning: concept and acceptability study.

Improving surgical training by means of technology assistance is an important challenge that aims to directly impact surgical quality. Surgical training includes the acquisition of two categories of knowledge: declarative knowledge (i.e. 'knowing what') and procedural knowledge (i.e. 'knowing how'). It is essential to acquire both before performing any particular surgery. There are currently many tools for acquiring procedural knowledge, such as simulators. However, few approaches or tools allow a trainer to formalize and record surgical declarative knowledge, and a trainee to have easy access to it. In this paper, we propose an approach for structuring surgical declarative knowledge according to procedural knowledge and based on surgical process modeling. A dedicated software application has been implemented. We evaluated the concept and the software usability on two procedures with different medical populations: endoscopic third ventriculostomy involving 6 neurosurgeons and preparation of a surgical table for craniotomy involving 4 scrub nurses. The results of both studies show that surgical process models could be a well-adapted approach for structuring and visualizing surgical declarative knowledge. The software application was perceived by neurosurgeons and scrub nurses as an innovative tool for managing and presenting surgical knowledge. The preliminary results show that the feasibility of the proposed approach and the acceptability and usability of the corresponding software. Future experiments will study impact of such an approach on knowledge acquisition.

Impact of the complexity of surgical procedures and intraoperative interruptions on neurosurgical team workload.

BACKGROUND: Neurosurgical teams are exposed to various stressors: complexity of surgical procedures, environment, time pressure and interruptions contribute to increasing the perceived workload. OBJECTIVE: This study aimed to evaluate the impact of interruptions and surgical complexity on neurosurgical team workload. METHODS: A prospective observational study was conducted on thirty surgical procedures of graduated complexity recorded in our Department of Neurosurgery. A scale was created and used by neurosurgeons to evaluate the perceived complexity of the surgical procedure. Interruptions and severity of interruptions were noted. The workloads of the neurosurgeon, surgical assistant, scrub nurse and circulating nurse were measured on the Surgery Task Load Index (SURG-TLX) at the end of the procedure. RESULTS: A mean 24.6 interruptions per hour were recorded. The mean interference level of the interruptions was 3.5/7. Mean surgical complexity was 4.3/10. Mean sterile team workload was 43.4/100. The multiple linear regression model showed that sterile team workload increased with surgical complexity (ß=6.692, P=.0002) but decreased in spite of increases in the number of interruptions per hour (ß=-0.855, P=.027). Neurosurgeon and surgical assistant workload increased with surgical complexity (ß=11.53, P<0.0001 and ß=7.42, P=0.0007, respectively). Scrub nurse workload decreased in spite of increases in the number of interruptions per hour (ß=-1.11, P=.026). CONCLUSION: Our study suggests positive effects of some interruptions during elective neurosurgical procedures with strong team familiarity.

How ultrasonography can contribute to diagnosis of craniosynostosis.

INTRODUCTION: The aim of this article was to provide an overview of ultrasound (US) techniques for the investigation of cranial sutures in infants. MATERIAL AND METHODS: We first describe a high-resolution sonography technique and its limitations. We then analyze the reliability, effectiveness and role of ultrasonography in routine practice using a PubMed literature review. RESULTS: Ten studies reported excellent correlations between ultrasonography and 3D-CT. Cranial US for the diagnosis of a closed suture had 100% sensitivity in 8 studies and 86-100% specificity before the age of 12 months. Negative findings mean imaging investigation can be stopped. If ultrasonography confirms diagnosis, neurosurgical consultation is required. Thus, 3D-CT can be postponed until appropriate before surgery. CONCLUSION: Cranial suture ultrasound is an effective and reliable technique for the diagnosis of craniosynostosis. It has many advantages: it is fast and non-irradiating, and no sedation is required. It should be used as first-line imaging in infants below the age of 8-12 months when craniosynostosis is clinically suspected.

Reducing blood loss in pediatric craniosynostosis surgery by use of tranexamic acid.

INTRODUCTION: Craniosysnostosis surgical corrections are routine procedures in the pediatric neurosurgical field. However, these procedures result in significant blood loss. Tranexamic acid (TXA) is an antifibrinolytic drug, which has demonstrated a significant reduction in perioperative blood loss in many pediatric surgical procedures such as cardiac surgery and scoliosis surgery. We conducted a systematic review to evaluate protocols of TXA use in pediatric craniosynostosis procedures and its effect on intraoperative blood loss and transfusions. MATERIAL AND METHODS: A comprehensive literature review of the National Library of Medicine (PubMed) database was performed to identify relevant studies. We included any clinical study reporting on blood loss or blood transfusion for pediatric craniosynostosis surgery with intraoperative use of tranexamic acid, with the following limits: publication date from inception to May 2019; reports in English. RESULTS: Thirteen studies were eligible for our review. Of the 13 studies, 4 were prospective, randomised, double-blind controlled trials, 9 were retrospective studies, tailored as a "before-after" studies, comparing blood loss and transfusion without/with TXA. TXA significantly decreases the number and volume of packed red blood cell transfusions and the rate of transfusion in children undergoing craniosynostosis surgery. Significantly fewer fresh frozen plasma transfusions were required in the TXA groups in 2 randomised studies. Length of stay in hospital was significantly lower with the use of TXA in three studies. Advantages of TXA administration also include an excellent patient tolerance of side effects, ease of administration and low cost. CONCLUSION: TXA significantly reduces blood loss and the need for transfusions in children undergoing craniosynostosis surgery. TXA administration should be a routine part of strategy to reduce blood loss and limit transfusions in these procedures.

Recent advances in trigonocephaly.

INTRODUCTION: The aim of this review was to report on recent advances in trigonocephaly since the last report on craniosynostosis published in 2006. MATERIAL AND METHODS: The review was conducted in accordance with the PRISMA guidelines. Research focused on four main topics: epidemiology, neurodevelopmental disorders, genetics and surgical techniques. RESULTS: Forty reports were included. The prevalence of trigonocephaly increased during the last two decades both in Europe and in the United States, but no clear contributing factors have yet been identified. Neurodevelopmental disorders are frequent in syndromic trigonocephaly and not particularly rare in non-syndromic cases (up to 34%). Developmental retardation (speech, motor or global) was almost always present in children exposed to valproic acid. Chromosomal abnormalities described in metopic synostosis comprised deletion of chromosome 11q24, deletion or trisomy of 9p and deletion of 7p, deletions of 3q, 13q, 12pter, 22q11, and duplication of 15q25. SMAD6 mutations should be systematically screened for in familial cases. Recent advances in surgical techniques have mainly concerned endoscopic-assisted procedures, as they significantly reduce perioperative morbidity. CONCLUSIONS: Neurosurgeons, maxillofacial and plastic surgeons will be increasingly concerned with trigonocephaly because of the increase in prevalence observed over the last two decades. Cytogenetic alterations are probably underestimated in this craniosynostosis, considering the high rate of neurodevelopmental retardation compared to other single-suture synostoses. Genetic counselling is therefore more and more effective in this pathology. An objective method to evaluate the cosmetic results of both endoscopic and open surgeries is necessary, as some under-corrections have been reported with minimally invasive surgery.

[Dermatologic toxicities of immune checkpoint inhibitors]. / Toxicités dermatologiques des inhibiteurs de checkpoint immunologiques.

The development of immune checkpoint inhibitors (monoclonal antibodies targeting PD-1/PD-L1 or CTLA-4) represents a significant advance in the treatment of multiple cancers. Given their particular mechanism of action, which involves triggering CD4+/CD8+ T-cell activation and proliferation, they are associated with a specific safety profile. Their adverse events are primarily immune-related, and can affect practically all organs. In this context, dermatological toxicity is the most common, though it mostly remains mild to moderate and does not require discontinuation of treatment. More than a third of patients are faced with cutaneous adverse events, usually in the form of a maculopapular rash, pruritus or vitiligo (only in patients treated for melanoma). Much more specific dermatologic disorders, however, may occur such as lichenoid reactions, induced psoriasis, sarcoidosis, auto-immune diseases (bullous pemphigoid, dermatomyositis, alopecia areata), acne-like rash, xerostomia, etc. Rigorous dermatological evaluation is thus mandatory in the case of atypical, persistent/recurrent or severe lesions. In this article, we review the incidence and spectrum of dermatologic adverse events reported with immune checkpoint inhibitors. Finally, a management algorithm is proposed.

Staphylococcus aureus screening and decolonization reduces the risk of surgical site infections in patients undergoing deep brain stimulation surgery.

In a controlled before-and-after study in a single centre, it was aimed to determine whether identification of Staphylococcus aureus nasal carriers followed by nasal mupirocin ointment and chlorhexidine soap reduced surgical site infections (SSIs) among 182 patients undergoing deep brain stimulation. In all, 119 patients were included in the control group and 63 in the screening group. There was a significant SSI decrease from 10.9% to 1.6% between the two groups (P<0.04; relative risk: 0.13; 95% confidence interval: 0.003-0.922). There were eight SSIs involving S. aureus in the control group, none in the screening group. No specific risk factors for SSI were identified.

Anterior cervical interbody fusion using polyetheretherketone cage filled with synthetic bone graft in acute cervical spine injury.

PURPOSE: The aim of this study was to assess the interbody fusion rate for patients treated by anterior cervical interbody fusion (ACIF) using polyetheretherketone (PEEK) cages filled with synthetic bone graft in acute cervical spine injury. MATERIALS AND METHODS: Twenty-nine patients (mean age: 49 years) with monosegmental instability due to cervical spine injury were followed. We assessed the rate of and time to interbody fusion at 1-year follow-up. In case of secondary displacement, we analysed its causes and surgical management. RESULTS: The rate of fusion was 86.2%. The mean time to fusion was 7.2 months. Interbody fusion was observed at 3 months in 4 patients, at 6 months in 14 and at 1 year in 7. Four patients had secondary displacement within 3 months. CONCLUSION: ACIF with a PEEK cage filled with synthetic bone graft seems to be an alternative to iliac crest bone graft with no morbidity related to the harvest site.

[Prognostic factors of adult medulloblastomas: A review of the literature and perspectives]. / Facteurs pronostiques des médulloblastomes de l'adulte : revue de la littérature et perspectives.

Adult medulloblastoma is a rare disease. Characteristics which are different from those of the pediatric population have been reported in recent years: a more frequent localization in the cerebellar hemispheres, higher proportion of the desmoplastic subtype, lower incidence of metastatic spread and delayed recurrences. It is probable that these differences are a consequence of specific cytogenetic and molecular characteristics distinguishing the two populations. A number of prognostic factors have been described in the adult population such as age, gender, histopathology, residual disease after surgery, M stage. However, the increased presence of activating mutations in the Sonic Hedgehog cell pathway, and to a lesser degree in the Wingless pathway, may explain the clinical discrepancies. Also, differences in the cytogenetic profile such as the loss of 10q and gain of 17q seem to play a critical role in the prognosis of these patients. It is obvious that knowledge of oncogene amplifications and cytogenetic markers is the key to the future management of medulloblastomas. Molecular inhibitors targeting cell signaling pathways that are activated in medulloblastoma will play an increasing role in future trials.

[Intracerebral cysts revealed by extrapyramidal symptoms]. / Kystes intracérébraux révélés par des symptômes extrapyramidaux.

We report 3 cases of intracerebral cyst revealed by an unusual evolution of extrapyramidal symptoms. Diagnosis was based on MRI and the patients were treated by a cystoperitoneal or a cysto-atrial shunt. The surgical procedure was successful in the 3 cases, resulting in the rapid disappearance of symptoms.

Anterior screw fixation of type IIB odontoid fractures in octogenarians.

PURPOSE: Type IIB odontoid fractures (OF) in elderly patients are life-threatening conditions. Optimal treatment of these fractures is still controversial. The aim of this study was to assess the clinical and radiological outcome of surgically treated type IIB OF by anterior screw fixation in octogenarians. METHODS: Eleven octogenarians with type IIB OF were operated using anterior screw fixation. Follow-up assessment included operative mortality and morbidity rates, long-term functional outcome and fracture union and stability. RESULTS: There was neither operative mortality nor morbidity. Five patients had excellent clinical outcome, two good outcome, one fair and three poor. Two patients died of unrelated causes 2 months after surgery. Radiographs showed stable bone union in four patients and stable fibrous union in five patients. CONCLUSIONS: Given the results in this short series, we suggest that anterior screw fixation of Type IIB OF may be offered as primary treatment in octogenarians.

A framework for the recognition of high-level surgical tasks from video images for cataract surgeries.

The need for a better integration of the new generation of computer-assisted-surgical systems has been recently emphasized. One necessity to achieve this objective is to retrieve data from the operating room (OR) with different sensors, then to derive models from these data. Recently, the use of videos from cameras in the OR has demonstrated its efficiency. In this paper, we propose a framework to assist in the development of systems for the automatic recognition of high-level surgical tasks using microscope videos analysis. We validated its use on cataract procedures. The idea is to combine state-of-the-art computer vision techniques with time series analysis. The first step of the framework consisted in the definition of several visual cues for extracting semantic information, therefore, characterizing each frame of the video. Five different pieces of image-based classifiers were, therefore, implemented. A step of pupil segmentation was also applied for dedicated visual cue detection. Time series classification algorithms were then applied to model time-varying data. Dynamic time warping and hidden Markov models were tested. This association combined the advantages of all methods for better understanding of the problem. The framework was finally validated through various studies. Six binary visual cues were chosen along with 12 phases to detect, obtaining accuracies of 94%.

Spontaneous regression of a symptomatic atlanto-occipital joint cyst. Case report.

Synovial cysts (SCs) are well-recognized entities occurring at various spinal sites, although atlanto-occipital joint cyst is a rare occurrence. Similarly both hypoglossal nerve palsy (as an initial clinical onset) and spontaneous cervical cyst resolution are rare. In this report, the authors describe an atlanto-occipital SC revealed by hypoglossal nerve palsy in a 75-year-old woman. Due to the paucity of neurological signs and the patient's advanced age, she was managed conservatively; 8 months later the cyst resolved completely. We discuss the potential factors involved in the pathogenesis and the therapeutic options for this uncommon cervical entity. We advise conservative treatment as a first therapeutic option for SC without signs of spinal cord compression.

Brown-Sequard syndrome revealing intradural thoracic disc herniation.

Brown-Sequard syndrome (BSS) is a rare form of severe myelopathy characterised by a clinical picture reflecting hemisection of the spinal cord. This syndrome is mostly due to a penetrating injury to the spine but many other non-traumatic causes have been described. Intradural thoracic disc herniation (TDH) is one of the rare aetiologies of this syndrome. Despite progress in imaging techniques, diagnosis and treatment remain difficult. We retrospectively reviewed one of the largest reported series of six patients with BSS revealing intradural TDH between 2003 and 2007. There was a marked female predominance and the mean age was 44 years. Before surgery, half of the patients had a severe neurological deficit. The mean duration of symptoms until surgery was 8.5 months (range 0.5-24 months). Spine magnetic resonance imaging (MRI) or spine computer tomography scan showed calcified TDH between T5-T6 and T9-T10. The intradural location of the thoracic herniation was strongly suspected from the clinical data. All the patients underwent posterolateral transpedicular surgery with an operative microscope to open the dura mater. The intradural location of the herniation was overlooked in one case and the patient underwent a second procedure. The dura mater was carefully closed. Two patients' condition worsened immediately after the surgery before slowly improving. All the other patients improved their neurological status immediately after the surgery and at 12 months follow-up. BSS with TDH on the spine MRI scan may be a warning symptom of the intradural location of the herniated disc. In such cases, spine surgeons are advised to use an operative magnification and to open the dura mater to avoid missing this potentially curable cause of severe myelopathy.