Managing medically refractory elevated intracranial pressure in a pediatric patient on ECMO: illustrative case.

PURPOSE: We demonstrate the complexities of managing pediatric patients on extracorporeal membrane oxygenation (ECMO) therapy requiring neurosurgery, focusing on systemic anticoagulation, cardiac function, and medically refractory intracranial pressure (ICP). METHODS: A 3.5-year-old female with Tetralogy of Fallot developed severe ischemic cerebral edema following post-operative cardiac arrest and required ECMO. This case, along with four additional cases of children requiring neurosurgery while on ECMO, was examined. RESULTS: Emergency neurosurgical intervention in the primary case led to significant improvement, highlighting the delicate balance between managing ECMO-induced anticoagulation and urgent neurosurgical needs. The additional cases had variable outcomes, emphasizing the challenges of caring for these critically ill patients. CONCLUSION: Successful management of children requiring ECMO support and neurosurgical intervention requires thoughtful multidisciplinary care. This report illustrates some of the nuances in such decision-making, and demonstrates one potential path to a good outcome.

Comprehensive assessment of atypical and anaplastic pediatric meningiomas utilizing national cancer database: a retrospective cohort study.

PURPOSE: To examine demographic and clinical characteristics and their association with survival in grade 2 and 3 pediatric meningiomas in a large cohort using the National Cancer Database (NCDB). METHODS: We conducted a comprehensive analysis using data from NCDB between 2004 to 2018. Tumor-specific data included tumor grade and size. Treatment details, including surgical resection, extent of resection, and radiotherapy, were gathered. Our analytic approach incorporated logistic and Poisson regression, Kaplan-Meier survival estimates, and Cox proportional hazards models. RESULTS: Among the included 239 patients aged 0-21 years, age category distribution was significantly different between grade 2 and grade 3 tumors (p = 0.018). For grade 2 meningiomas, 51.5% of patients were female, and 76.7% were white. 85.3% of patients with grade 2 meningiomas underwent surgical resection, of which 67% underwent gross total resection. Overall survival (OS) was significantly different between resected and non-resected patients (p = 0.048). Uninsured patients were over seven times as likely to have prolonged length of stay (LOS) versus those with private insurance (OR = 7.663, p = 0.014). For grade 3 meningiomas, 51.4% of patients were male, and 82.9% were white. 91.4% of patients with grade 3 meningiomas underwent surgical resection, of which 53.3% underwent subtotal resection. OS was not significantly different between resected and non-resected patients (p = 0.659). CONCLUSION: In summary, there were significant differences in age, maximum tumor dimension, unplanned readmission, radiotherapy, and treatment combinations between grade 2 and 3 meningiomas. These findings highlight the intricacies of managing pediatric meningiomas and emphasize the necessity for tailored therapeutic approaches to enhance outcomes in the future.

Idiopathic membranous occlusion of the foramen of Monro: an unusual cause of hydrocephalus and headache in adults.

Occlusion of foramen of Monro is an uncommon clinical entity that usually presents in children. Common causes are obstructing mass, infectious etiologies or vascular malformation. Rarely, it may be an idiopathic stricture or membrane. We report a case of idiopathic membranous obstruction of the foramen of Monro in a 45-year-old male with no past medical or surgical history. He presented with new intermittent dull and burning bifrontal severe headache for 2 d, which was alleviated slightly by non-steroidal anti-inflammatory medication. Imaging showed marked dilation of the lateral ventricles with normal third and fourth ventricles. The patient was discharged initially with conservative medical management and close follows up; however, the headache continued to progress and neurosurgical intervention was offered. The patient underwent endoscopic exploration, fenestration of the septum pellucidum, and right ventriculoperitoneal shunt placement. Bilateral membranous obstruction of foramina of Monro and an auto-fenestrated cavum septum pellucidum were identified intraoperatively. The patient reported resolution of headache post-operatively without recurrence on 1-month follow up. This case is unusual in that the patient presented without any known neurologic history or prior intracranial infections. It became apparent at the time of surgery that chronic obstruction of the bilateral foramina with collapse of the third ventricle had developed, and the safest durable treatment for him was septostomy and cerebrospinal fluid (CSF) shunt placement.

Appropriateness of Computed Tomography Scanning in the Diagnosis of Craniosynostosis.

INTRODUCTION: Although physicians from a variety of specialties encounter infants with possible craniosynostosis, judicious use of computed tomography (CT) imaging is important to avoid unnecessary radiation exposure and healthcare expense. The present study seeks to determine whether differences in specialty of ordering physician affects frequency of resulting diagnostic confirmations requiring operative intervention. METHODS: Radiology databases from 2 institutions were queried for CT reports or indications that included "craniosynostosis" or "plagiocephaly." Patient demographics, specialty of ordering physician, confirmed diagnosis, and operative interventions were recorded. Cost analysis was performed using the fixed unit cost for a head CT to calculate the expense before 1 study led to operative intervention. RESULTS: Three hundred eighty-two patients were included. 184 (48.2%) CT scans were ordered by craniofacial surgeons, 71 (18.6%) were ordered by neurosurgeons, and 127 (33.3%) were ordered by pediatricians. One hundred four (27.2%) patients received a diagnosis of craniosynostosis requiring operative intervention. Craniofacial surgeons and neurosurgeons were more likely than pediatricians to order CT scans that resulted in a diagnosis of craniosynostosis requiring operative intervention (P < 0.001), with no difference between craniofacial surgeons and neurosurgeons (P = 1.0). The estimated cost of obtaining an impact CT scan when ordered by neurosurgeons or craniofacial surgeons as compared to pediatricians was $2369.69 versus $13,493.75. CONCLUSIONS: Clinicians who more frequently encounter craniosynostosis (craniofacial and neurosurgeons) had a higher likelihood of ordering CT images that resulted in a diagnosis of craniosynostosis requiring operative intervention. This study should prompt multi-disciplinary interventions aimed at improving evaluation of pretest probability before CT imaging.

Three-dimensional printing and craniosynostosis surgery.

OVERVIEW: The goal of this study was to review the current application and status of three-dimensional printing for craniosynostosis surgery. METHODS: A literature review was performed using the PubMed/MEDLINE databases for studies published between 2010 and 2020. All studies demonstrating the utilization of three-dimensional printing for craniosynostosis surgery were included. RESULTS: A total of 15 studies were ultimately selected. This includes studies demonstrating novel three-dimensional simulation and printing workflows, studies utilizing three-dimensional printing for surgical simulation, as well as case reports describing prior experiences. CONCLUSION: The incorporation of three-dimensional printing into the domain of craniosynostosis surgery has many potential benefits. This includes streamlining surgical planning, developing patient-specific template guides, enhancing residency training, as well as aiding in patient counseling. However, the current state of the literature remains in the validation stage. Further study with larger case series, direct comparisons with control groups, and prolonged follow-up times is necessary before more widespread implementation is justified.

A Review on Variability in Treatment Protocols With Posterior Cranial Vault Distraction.

BACKGROUND: Prior studies have confirmed the ability of posterior cranial vault distraction osteogenesis (PVDO) to expand the intracranial volume in patients with craniosynostosis. To date, there is scant literature on the optimal distraction protocol for PVDO. The authors sought to review the literature and define a common protocol for posterior cranial vault distraction. METHODS: The authors performed a systematic review for published PVDO protocols. The data collected from these studies included age at the time of PVDO, number of distraction devices placed, time for latency, rate and rhythm of distraction, distraction length, time for consolidation, and surgical outcomes. RESULTS: A total of 286 patients were identified within 24 studies from 2011 to 2019. The mean age of patients identified was 25.34 months. After application of distractors, latency period ranged between 1 and 7 days, with most patients undergoing 5 to 7 days of latency. Once distraction was begun, the majority of patients (77.4%) underwent 1 mm of distraction daily. Total lengths of distraction ranged between 13 and 35 mm, with the largest cohort of patients undergoing 26 to 30 mm of total distraction. A total of 60 complications were reported for a total of 212 patients, yielding an overall complication rate of 28.3%. CONCLUSIONS: Although there is variability in reported PVDO protocols, the majority are similar to distraction osteogenesis protocols described for long bone sites. Increased patient age correlates with selection of a greater latency period and total distraction length, while frequency of complications is also increased.

The slope of the learning curve in 600 consecutive endoscopic transsphenoidal pituitary surgeries.

BACKGROUND: Endonasal endoscopic transsphenoidal surgery (EETS) for pituitary adenoma has become a mainstay of treatment over the last two decades and it is generally accepted that once this learning curve is achieved, a plateau is reached with little incremental improvement. OBJECTIVE: The objective of this study was to assess the slope of the learning curve over a long period of time for a variety of outcomes measures. METHODS: We examined outcomes and complications in a consecutive series of 600 EETS for pituitary adenoma grouped into quartiles based on date of surgery. RESULTS: GTR significantly increased across quartiles from 55 to 79% in the last quartile (p < 0.005). The rate of intraoperative CSF leak significantly decreased from 60% in the first quartile to 33% in the last quartile and the rate of lumbar drain placement from 28% in the first quartile to 6% in the last quartile (p < 0.005). Hormonal remission for secreting adenomas increased from 68% in the first quartile to 90% in the last quartile (p < 0.05). The rate of post-operative CSF leak trended lower (3% in first quartile to 0.7% in last two quartiles). The greatest improvement in outcome occurred between the first and second quartiles (19.9%), but persistent improvement occurred between the second and third (6.7%) and third and fourth quartiles (8.0%). CONCLUSION: Although the slope of the learning curve is steeper earlier in a surgeon's experience, the slope does not plateau and continues to increase even over more than a decade.

Gene therapy blockade of dorsal striatal p11 improves motor function and dyskinesia in parkinsonian mice.

Complications of dopamine replacement for Parkinson's disease (PD) can limit therapeutic options, leading to interest in identifying novel pathways that can be exploited to improve treatment. p11 (S100A10) is a cellular scaffold protein that binds to and potentiates the activity of various ion channels and neurotransmitter receptors. We have previously reported that p11 can influence ventral striatal function in models of depression and drug addiction, and thus we hypothesized that dorsal striatal p11 might mediate motor function and drug responses in parkinsonian mice. To focally inhibit p11 expression in the dorsal striatum, we injected an adeno-associated virus (AAV) vector producing a short hairpin RNA (AAV.sh.p11). This intervention reduced the impairment in motor function on forced tasks, such as rotarod and treadmill tests, caused by substantia nigra lesioning in mice. Measures of spontaneous movement and gait in an open-field test declined as expected in control lesioned mice, whereas AAV.sh.p11 mice remained at or near normal baseline. Mice with unilateral lesions were then challenged with l-dopa (levodopa) and various dopamine receptor agonists, and resulting rotational behaviors were significantly reduced after ipsilateral inhibition of dorsal striatal p11 expression. Finally, p11 knockdown in the dorsal striatum dramatically reduced l-dopa-induced abnormal involuntary movements compared with control mice. These data indicate that focal inhibition of p11 action in the dorsal striatum could be a promising PD therapeutic target to improve motor function while reducing l-dopa-induced dyskinesias.

Pediatric intramedullary spinal cord tumors: A national cancer database analysis of demographics, patterns of care, and survival.

OBJECTIVE: Query the National Cancer Database (NCDB) to delineate epidemiologic frequency, care patterns, and survival outcomes of pediatric intramedullary spinal cord tumors (IMSCTs). METHODS: IMSCTs included ependymoma, astrocytoma, and hemangioblastoma. We examined data from the NCDB spanning 2004-2018, focusing on IMSCT in children aged 0-21 years. Our analysis included logistic and Poisson regression, Kaplan-Meier survival estimates, and Cox proportional hazards models. RESULTS: This study included 1066 patients aged 0-21 years. 59.4 % of patients were male, while 83.1 % were white. The most common tumor histology was ependymoma (57.5 %), followed by astrocytoma (36.1 %) and hemangioblastoma (6.4 %). 24.9 % of patients received radiotherapy, with radiotherapy utilization being highest among patients aged 6-10 years. Chemotherapy utilization was highest in patients aged 0-5 years. 87.2 % of patients underwent surgical resection, with higher rates in patients aged 16-21 years. Overall survival did not differ significantly between resected and non-resected patients (p = 0.315). Patients in rural areas had worse OS than those in metro areas (HR = 4.42, p = 0.048). Patients with astrocytoma had worse OS compared to other histologies (HR = 2.21, p = 0.003). Astrocytoma patients were over twice as likely to have prolonged LOS compared to ependymoma patients (OR = 2.204, p < 0.001). CONCLUSIONS: In summary, our analysis utilizing the NCDB database provides a comprehensive overview of demographics, care patterns, and outcomes for the largest cohort of pediatric IMSCTs to date. These insights underscore the complexity of managing IMSCTs and emphasize the need for tailored approaches to improve patient outcomes.

Urology case report: Multifactorial bladder dysfunction in the setting of down syndrome.

A 16-year-old male patient with Down syndrome diagnosed with AKI and urinary tract infection was treated with meropenem for ESBL-positive E. coli in urine culture. Persistently elevated creatinine and persistent post-void residual (PVR) of >300 mL led to further testing, which revealed urethral stricture and a lower sacral Tarlov cyst. Due to no complete improvement with urethral dilatation, he underwent laminectomy and Tarlov cyst fenestration. Creatinine normalized, with increased urine output and robust flow. Due to a PVR of >100 mL, he received behavioral therapy, including sitting and timed voiding, and the PVR was reduced to <5 mL.

Use of a mini balloon microcatheter to facilitate penetration of fine vascular networks and curative embolization in vein of Galen malformations.

Background Patients with vein of Galen malformations (VOGMs) can develop fine angiogenic networks with fistulous connections to the precursor of the vein of Galen. In these cases, transarterial embolization (TAE) with liquid embolic agents (LEAs) is challenging due to reflux in the pedicle leading to the network, causing poor penetration. Transvenous approaches carry a risk of hemorrhage from pathologic vasculature. Dual-lumen balloon microcatheters like the Scepter Mini (Microvention, Aliso Viejo, CA) improve distal pedicle access, preventing reflux.Objective Here, we report on the use of the Scepter Mini for TAE of angiogenic VOGM.Methods A single-institution retrospective chart review identified all VOGMs treated with Scepter Mini microcatheters. Clinical data, angioarchitecture, and technical parameters were reviewed.Results 17 Scepter Mini catheters were used in 12 embolization procedures of 7 patients with VOGM at a median age of 2.1 years. Patients presented with hydrocephalus (100%) and gross motor and speech delays (57.1%). Networks developed extra-axially into the subependymal zone fed by posterior choroidal, posterior cerebral, and thalamoperforator arteries. Posterior choroidal branches (n=7/17, 41.2%) were most frequently catheterized to achieve distal access to the network. Embolization with Onyx-18 and significant network penetration occurred in 17/17 uses. Near tip entrapment with LEA cast displacement occurred in 1/17 uses. Another patient experienced postprocedural intraventricular hemorrhage requiring a third ventriculostomy without permanent neurologic deficit.Conclusion The Scepter Mini provided excellent distal access with penetration to the fistula and extra-axial network reduction with few complications. The Scepter Mini provides a means for successful treatment of technically challenging angiogenic VOGM.

Milestones for neurosurgery sub-interns: a novel evaluation tool to quantitatively differentiate residency applicants.

OBJECTIVE: The study objective was to create a novel milestones evaluation form for neurosurgery sub-interns and assess its potential as a quantitative and standardized performance assessment to compare potential residency applicants. In this pilot study, the authors aimed to determine the form's interrater reliability, relationship to percentile assignments in the neurosurgery standardized letter of recommendation (SLOR), ability to quantitatively differentiate tiers of students, and ease of use. METHODS: Medical student milestones were either adapted from the resident Neurological Surgery Milestones or created de novo to evaluate a student's medical knowledge, procedural aptitude, professionalism, interpersonal and communication skills, and evidence-based practice and improvement. Four milestone levels were defined, corresponding to estimated 3rd-year medical student through 2nd-year resident levels. Faculty and resident evaluations as well as student self-evaluations were completed for 35 sub-interns across 8 programs. A cumulative milestone score (CMS) was computed for each student. Student CMSs were compared both within and between programs. Interrater reliability was determined with Kendall's coefficient of concordance (Kendall's W). Student CMSs were compared against their percentile assignments in the SLOR using analysis of variance with post hoc testing. CMS-derived percentile rankings were assigned to quantitatively distinguish tiers of students. Students and faculty were surveyed on the form's usefulness. RESULTS: The average faculty rating overall was 3.20, similar to the estimated competency level of an intern. Student and faculty ratings were similar, whereas resident ratings were lower (p < 0.001). Students were rated most highly in coachability and feedback (3.49 and 3.67, respectively) and lowest in bedside procedural aptitude (2.90 and 2.85, respectively) in both faculty and self-evaluations. The median CMS was 26.5 (IQR 21.75-29.75, range 14-32) with only 2 students (5.7%) achieving the highest rating of 32. Programs that evaluated the most students differentiated the highest-performing students from the lowest by at least 13 points. A program with 3 faculty raters demonstrated scoring agreement across 5 students (p = 0.024). The CMS differed significantly between SLOR percentile assignments, despite 25% of students being assigned to the top fifth percentile. CMS-driven percentile assignment significantly differentiated the bottom, middle, and top third of students (p < 0.001). Faculty and students strongly endorsed the milestones form. CONCLUSIONS: The medical student milestones form was well received and differentiated neurosurgery sub-interns both within and across programs. This form has potential as a replacement for numerical Step 1 scoring as a standardized, quantitative performance assessment for neurosurgery residency applicants.

Evaluation of a Role for Virtual Neurosurgical Education for Medical Students Over 2 Years of a Global Pandemic.

BACKGROUND: Subinternships are critical experiences for medical students applying into neurosurgery to acquire knowledge of the field and network with colleagues. During the coronavirus disease 2019 pandemic, in-person rotations were suspended for 2020 and reduced for 2021. In 2020, our department developed a neurosurgical course to address this need. The course was continued in 2021, enabling assessment of student perceptions as the pandemic progresses. METHODS: The virtual course consisted of weekly 1-hour seminars over a 3- to 4-month period. Prior to starting, participants were sent a comprehensive survey assessing their backgrounds, experiences, and confidences in core concepts across neurosurgical subdisciplines. Participants also completed postcourse surveys assessing the course's value and their confidence in the same topics. Responses from students completing both precourse and postcourse surveys were included, analyzed in pairwise fashion, and compared across course years. RESULTS: Students shared similar baseline characteristics in terms of demographics, educational background, and exposure to neurosurgery prior to the course. In the 2020 and 2021 cohorts, quality ratings for presentations were favorable for all seminars, and participants reported significantly increased confidence in core topics across all neurosurgical disciplines after the course (2020: 3.36 ± 0.26, P < 0.0001; 2021: 3.56 ± 0.93, P = 0.005). Most participants felt the course would remain useful following the pandemic in both the 2020 (96.9%) and 2021 (100.0%) cohorts. CONCLUSIONS: Survey results suggest that the course adds value for students seeking a basic didactic curriculum to supplement their education, and perhaps, an online curriculum for medical students would still be beneficial going forward as in-person rotations resume.

Bibliometric Evaluation of U.S. Neurosurgery Subspecialties and Academic Rank Using RCR Index.

INTRODUCTION: Academic productivity, a key feature of academic neurosurgery, has been linked to academic rank, subspecialty, and institutional rank. Relative Citation Ratio (RCR) has emerged as a new metric of scholarly output that can make field-normalized comparisons between researchers, a feature unavailable in prior metrics such as h-index. Here we evaluate the influence of academic rank and neurosurgical subspecialties on RCR scores. METHODS: We identified 1640 academic neurosurgeons from 115 ACGME-accredited programs in the United States, along with their neurosurgical specialty and demographic information, using publicly available data. Mean RCR (m-RCR) and weighted RCR (w-RCR) for each neurosurgeon were queried from the iCite database, which included publications from 2002-2020. m-RCR and w-RCR scores were compared across subspecialties and academic rank using multivariable regression while controlling for demographic factors. RESULTS: Multivariable analysis indicated that academic neurosurgeons in general neurosurgery (P = 0.039) and pediatric neurosurgery (P = 0.003) had lower m-RCR scores than their peers in other subspecialties. w-RCR did not differ significantly among subspecialties. Higher academic rank was associated with increased m-RCR (P < 0.05) and w-RCR scores (P < 0.0001). CONCLUSIONS: Professors have a higher m-RCR score relative to assistant professors, while general and pediatric neurosurgery were linked to lower m-RCR values. Although neurosurgical subspecialty choice did not influence w-RCR, a higher w-RCR score corresponded to a higher academic rank. Overall, the RCR metric can be utilized for field-normalized comparisons of faculty who differ in academic rank and subspecialty.

Middle Meningeal Artery Embolization for Chronic Subdural Hematoma Using N-Butyl Cyanoacrylate With D5W Push Technique.

BACKGROUND: Middle meningeal artery (MMA) embolization has been recognized as a promising treatment for patients with subdural hematoma (SDH). OBJECTIVE: To present the technical feasibility and efficacy of n-butyl cyanoacrylate (n-BCA) embolization in the largest consecutive cohort to date. METHODS: We retrospectively reviewed our consecutive cases of recurrent SDH treated with MMA embolization using diluted n-BCA with the "sugar rush" technique. In brief, a 2.1-Fr microcatheter was used to selectively catheterize the frontal and posterior branches of the MMA. 5% dextrose in water (D5W) was injected through an intermediate catheter while injecting n-BCA through the microcatheter. Complete obliteration of MMA and lack of SDH recurrence in a 3-6 months follow-up computed tomography scan were defined as efficacy outcomes. Cranial nerve palsy, vision loss, transient neurological deficit, and stroke were defined as safety outcomes. RESULTS: A total of 61 patients were identified with a mean (±standard deviation) age of 62.5 ± 9 years. In 6 patients (10%), coil embolization of the origin of the frontal or posterior branch was performed because super-selective catheterization of the branch was unsuccessful because of tortuous anatomy. Complete obliteration of frontal and posterior branches was achieved in 100% of the cases. Recurrent SDH was seen in 3 patients (5%). No incidence of cranial nerve palsy, vision loss, or stroke occurred. One patient suffered a transient neurological deficit. CONCLUSION: MMA embolization using diluted n-BCA with concomitant D5W injection is associated with a high degree of distal penetration and complete branch occlusion and minimal risk of cranial nerve palsy or other thromboembolic complications.

Pineal region tumors: an optimal approach for simultaneous endoscopic third ventriculostomy and biopsy.

OBJECT: Simultaneous endoscopic third ventriculostomy (ETV) and tumor biopsy is a widely accepted therapeutic and diagnostic procedure for patients with noncommunicating hydrocephalus secondary to a pineal region tumor. Multiple approaches have been advocated, including the use of a steerable fiberoptic or rigid lens endoscope via 1 or 2 trajectories. However, the optimal approach has not been established based on the individual anatomical characteristics of the patient. METHODS: A retrospective review of patients undergoing simultaneous ETV and tumor biopsy was undertaken. Preoperative MR images were examined to measure the width of the anterior third ventricle and maximal diameters of the tumor, Monro foramen (right), and massa intermedia. The distances between the tumor and massa intermedia, tumor and anterior commissure, midbrain and massa intermedia, and the dorsum sella and anterior commissure were also recorded. Single and dual trajectory approaches were compared using paired t-tests for each parameter. RESULTS: Over an 8-year interval, 15 patients underwent simultaneous ETV and tumor management. These patients ranged from 6 to 71 years of age (mean 36.7 years); 5 were younger than 18 years of age. Seven were treated using a dual trajectory approach, and 8 were treated using a single trajectory approach. All cases were completed without complications or the need for an additional CSF diversionary procedure within 6 months. The diagnostic yield at biopsy was 86.7%. There were no statistically significant differences between the single and dual trajectory groups for the measured parameters. However, the dual trajectory group demonstrated a larger anterior third ventricular diameter (1.43 vs 1.21 cm, p = 0.29). The single trajectory group trended toward a smaller tumor-anterior commissure interval (2.23 vs 2.51 cm, p = 0.24) and a larger dorsum sella-anterior commissure distance (1.67 vs 1.49 cm, p = 0.28). CONCLUSIONS: These data confirm the safety and diagnostic efficacy of simultaneous ETV and biopsy for tumors of the pineal region. Although no statistically significant differences were seen in the authors' recorded measurements, several trends suggest a role for a tailored approach to selecting a single or dual trajectory approach when using a rigid endoscope.

Giant chondrosarcoma of the falx in an adolescent: A case report.

BACKGROUND: Intracranial chondrosarcomas are slowly growing malignant cartilaginous tumors that are especially rare in adolescents. CASE DESCRIPTION: A 19-year-old woman with no medical history presented with symptoms of intermittent facial twitching and progressive generalized weakness for 6 months. The patient's physical examination was unremarkable. Imaging revealed a large bifrontal mass arising from the falx cerebri, with significant compression of both cerebral hemispheres and downward displacement of the corpus callosum. The patient underwent a bifrontal craniotomy for gross total resection of tumor. Neuropathologic examination revealed a bland cartilaginous lesion most consistent with low-grade chondrosarcoma. Her postoperative course was uneventful, and she was discharged to home on postoperative day 3. CONCLUSION: This is an unusual case of an extra-axial, non-skull base, low-grade chondrosarcoma presenting as facial spasm in an adolescent patient.

Middle Meningeal Artery Embolization of a Pediatric Patient With Progressive Chronic Subdural Hematoma.

BACKGROUND AND IMPORTANCE: Evidence suggests middle meningeal artery (MMA) embolization benefits adult patients with chronic subdural hematoma (CSDH) at high risk for recurrence or hemorrhagic complications. Yet, there has not been any report discussing MMA embolization in the pediatric population. Thus, we present a case of an infant with CSDH successfully managed with MMA embolization without surgical management. CLINICAL PRESENTATION: A 5-mo-old girl with idiopathic dilated cardiomyopathy underwent surgical implantation of a left ventricular assist device for a bridge to heart transplantation. This was complicated by left ventricular thrombus causing stroke. She was placed on dual antiplatelet antithrombotic therapy on top of bivalirudin infusion. She sustained a left middle cerebral artery infarction, but did not have neurological deficits. Subsequent computed tomography scans of the head showed a progressively enlarging asymptomatic CSDH, and the heart transplant was repeatedly postponed. The decision was made to proceed with MMA embolization at the age of 7 mo. Bilateral modified MMA embolization, using warmed, low-concentration n-butyl-cyanoacrylate (n-BCA) from distal microcatheter positioning, allowed the embolic material to close the distal MMA and subdural membranous vasculature. The patient underwent successful heart transplant and the CSDH improved significantly. She remained neurologically asymptomatic and had normal neurological development after the MMA embolization. CONCLUSION: MMA embolization may represent a safe and effective minimally invasive option for pediatric CSDH, especially for patients at high risk for surgery or hematoma recurrence.