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BACKGROUND: Magnetic resonance-guided laser interstitial thermal therapy (MRgLITT) is a minimally invasive alternative to surgical resection for drug-resistant mesial temporal lobe epilepsy (mTLE). Reported rates of seizure freedom are variable and long-term durability is largely unproven. Anterior temporal lobectomy (ATL) remains an option for patients with MRgLITT treatment failure. However, the safety and efficacy of this staged strategy is unknown. METHODS: This multicentre, retrospective cohort study included 268 patients consecutively treated with mesial temporal MRgLITT at 11 centres between 2012 and 2018. Seizure outcomes and complications of MRgLITT and any subsequent surgery are reported. Predictive value of preoperative variables for seizure outcome was assessed. RESULTS: Engel I seizure freedom was achieved in 55.8% (149/267) at 1 year, 52.5% (126/240) at 2 years and 49.3% (132/268) at the last follow-up ≥1 year (median 47 months). Engel I or II outcomes were achieved in 74.2% (198/267) at 1 year, 75.0% (180/240) at 2 years and 66.0% (177/268) at the last follow-up. Preoperative focal to bilateral tonic-clonic seizures were independently associated with seizure recurrence. Among patients with seizure recurrence, 14/21 (66.7%) became seizure-free after subsequent ATL and 5/10 (50%) after repeat MRgLITT at last follow-up≥1 year. CONCLUSIONS: MRgLITT is a viable treatment with durable outcomes for patients with drug-resistant mTLE evaluated at a comprehensive epilepsy centre. Although seizure freedom rates were lower than reported with ATL, this series represents the early experience of each centre and a heterogeneous cohort. ATL remains a safe and effective treatment for well-selected patients who fail MRgLITT.
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Epilepsia Refractaria , Epilepsia del Lóbulo Temporal , Epilepsia , Terapia por Láser , Humanos , Epilepsia del Lóbulo Temporal/cirugía , Estudios Retrospectivos , Convulsiones/cirugía , Epilepsia Refractaria/cirugía , Epilepsia/cirugía , Resultado del Tratamiento , Imagen por Resonancia Magnética , Rayos LáserRESUMEN
ABSTRACT: The posterior intraoccipital synchondrosis (PIOS) is a cartilaginous division separating the exoccipital and supraoccipital bones, allowing for flexibility of the cranial base at birth and which later ossifies in adolescence. The authors report a case of right PIOS synostosis that resembled right lambdoid synostosis, with left occipital bossing in a healthy, six-month-old female with an unremarkable birth history and no antecedent trauma. An initial referral was made from the pediatrician to oncology because of a concern over the presence and growth of a possible mass at the left occiput. Over 8 months, this mass grew and became more firm, accompanied by left occipital bossing and right occipital flattening. A computed tomography was obtained, which demonstrated the fusion of the PIOS, prompting a referral to plastic surgery. Cranial vault remodeling with switch cranioplasty was performed at age 14 months, complicated only by a superficial infection along the suture line. There are exceedingly few reports of PIOS synostosis, with occipital osteodiastasis related to birth trauma as the only prior explanation for this condition. With no birth trauma and delayed onset, our case likely represents idiopathic PIOS synostosis. With the many similarities in presentation, the surgical approaches commonly used for lambdoid synostosis, particularly switch cranioplasty, are suitable solutions to PIO synchondrosis with optimal functional and aesthetic outcomes.
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Craneosinostosis , Estética Dental , Suturas Craneales/diagnóstico por imagen , Suturas Craneales/cirugía , Craneosinostosis/complicaciones , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Femenino , Humanos , Lactante , Recién Nacido , Procedimientos Neuroquirúrgicos , Hueso Occipital/diagnóstico por imagen , Hueso Occipital/cirugía , SuturasRESUMEN
INTRODUCTION: This study compares anthropometric outcomes of 2 sagittal synostosis repair techniques: spring-assisted surgery and endoscope-assisted craniectomy with molding helmet therapy. METHODS: Patients undergoing spring-assisted surgery (n = 27) or endoscope-assisted craniectomy with helmet therapy (n = 40) at separate institutions were retrospectively reviewed. Pre- and 1-year postoperative computed tomography (CT) or laser scans were analyzed for traditional cranial index (CI), adjusted cranial index (aCI), and cranial vault volume (CVV). Nine patient-matched scans were analyzed for measurement consistency. RESULTS: The spring-assisted group was older at both time points (P < .050) and spring-assisted group CVV was larger preoperatively and postoperatively (P < .01). However, the change in CVV did not differ between the groups (P = .210). There was no difference in preoperative CI (helmet vs spring: 70.1 vs 71.2, P = .368) between the groups. Postoperatively, helmet group CI (77.0 vs 74.3, P = .008) was greater. The helmet group also demonstrated a greater increase in CI (6.9 vs 3.1, P < .001). The proportion of patients achieving CI of 75 or greater was not significantly different between the groups (helmet vs spring: CI, 65% vs 52%, P = .370). There was no detectable bias in CI between matched CT and laser scans. Differences were identified between scan types in aCI and CVV measurements; subsequent analyses used corrected CVV and aCI measures for laser scan measures. CONCLUSIONS: Both techniques had equivalent proportions of patients achieving normal CI, comparable effects on cranial volume, and similar operative characteristics. The study suggests that there may be greater improvement in CI in the helmet group. However, further research should be performed.
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Craneosinostosis , Craneosinostosis/diagnóstico por imagen , Craneosinostosis/cirugía , Craneotomía , Endoscopios , Humanos , Lactante , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
OBJECTIVE: Intracranial human brain recordings typically utilize recording systems that do not distinguish individual neuron action potentials. In such cases, individual neurons are not identified by location within functional circuits. In this paper, verified localization of singly recorded hippocampal neurons within the CA3 and CA1 cell fields is demonstrated. METHODS: Macro-micro depth electrodes were implanted in 23 human patients undergoing invasive monitoring for identification of epileptic seizure foci. Individual neurons were isolated and identified via extracellular action potential waveforms recorded via macro-micro depth electrodes localized within the hippocampus. A morphometric survey was performed using 3T MRI scans of hippocampi from the 23 implanted patients, as well as 46 normal (i.e., nonepileptic) patients and 26 patients with a history of epilepsy but no history of depth electrode placement, which provided average dimensions of the hippocampus along typical implantation tracks. Localization within CA3 and CA1 cell fields was tentatively assigned on the basis of recording electrode site, stereotactic positioning of the depth electrode in comparison with the morphometric survey, and postsurgical MRI. Cells were selected as candidate CA3 and CA1 principal neurons on the basis of waveform and firing rate characteristics and confirmed within the CA3-to-CA1 neural projection pathways via measures of functional connectivity. RESULTS: Cross-correlation analysis confirmed that nearly 80% of putative CA3-to-CA1 cell pairs exhibited positive correlations compatible with feed-forward connection between the cells, while only 2.6% exhibited feedback (inverse) connectivity. Even though synchronous and long-latency correlations were excluded, feed-forward correlation between CA3-CA1 pairs was identified in 1071 (26%) of 4070 total pairs, which favorably compares to reports of 20%-25% feed-forward CA3-CA1 correlation noted in published animal studies. CONCLUSIONS: This study demonstrates the ability to record neurons in vivo from specified regions and subfields of the human brain. As brain-machine interface and neural prosthetic research continues to expand, it is necessary to be able to identify recording and stimulation sites within neural circuits of interest.
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Electrofisiología , Hipocampo/fisiología , Vías Nerviosas/fisiología , Neuronas/fisiología , Estimulación Encefálica Profunda/métodos , Estimulación Eléctrica/métodos , Electrodos , Electrofisiología/métodos , HumanosRESUMEN
Spring-assisted surgery (SAS) has been shown to be an effective technique for correction of isolated sagittal craniosynostosis in patients less than 6 months of age. At their institution, the authors adopted a minimally invasive technique in 2010, using a shorter incision and an endoscope. A retrospective chart review of 101 patients with isolated, nonsyndromic, sagittal craniosynostosis, who underwent SAS, was performed in order to compare perioperative and clinical outcomes of the open (nâ=â51) and minimally-invasive (nâ=â50) approaches. Surgeries were performed by 2 neurosurgeons and 3 plastic surgeons, between 2005 and 2018. The pre and postoperative cephalic indices were not significantly different in both groups. Minimally-invasive spring placement required a longer operative time than the open approach, with the mean minimally-invasive operative time at 65âminutes, compared to 53âminutes (Pâ<â0.0001). Spring removal operative time was not significantly different, with the minimally-invasive operative time at 31âminutes versus 29âminutes (Pâ=â0.48). There were no significant differences in major or minor complications when comparing the open and minimally-invasive approaches. In conclusion, both the open and the minimally-invasive SAS techniques are effective for early correction of isolated sagittal craniosynostosis, although the minimally-invasive approach requires a longer operative time for spring placement.
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Craneosinostosis/cirugía , Craneotomía , Humanos , Lactante , Neuroendoscopía/métodos , Complicaciones Posoperatorias , Procedimientos de Cirugía Plástica , Estudios Retrospectivos , Equipo Quirúrgico , Resultado del TratamientoRESUMEN
BACKGROUND: Controversy exists regarding the optimal surgical approach for non-syndromic sagittal synostosis. This study provides the first comparative analysis of the long-term behavioral, psychological, and executive function outcomes for patients who underwent either cranial vault remodeling (CVR) or spring-assisted strip craniectomy (SAS). METHODS: Thirty-six CVR patients and 39 SAS patients were evaluated. Parents and caregivers completed the Behavior Rating Inventory of Executive Function (BRIEF) and the Behavior Assessment System for Children, Second Edition (BASC-2) to evaluate behavioral, emotional, social, adaptive, and executive functioning skills. RESULTS: There were no statistically significant differences between the CVR and the SAS groups (Pâ>â0.05) in any of the BRIEF areas of function. Furthermore, the BASC-2 battery illustrated no significant differences in all areas analyzed except one. Among the 2 groups, the CVR group was rated as having fewer social withdrawal symptoms on the BASC-2 (47.00â±â10.27) compared to the SAS cohort (54.64â±â10.96), Fâ=â6.79, Pâ=â0.012, Cohen dâ=â0.688. However, both means were still within the normal range. CONCLUSIONS: Children undergoing SAS and CVR procedures for isolated sagittal synostosis were not rated as having clinically significant behavioral, emotional, social, adaptive, or executive functioning problems on parental forms.
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Craneotomía/métodos , Craneosinostosis/cirugía , Función Ejecutiva , Femenino , Humanos , Lactante , Masculino , Valores de Referencia , Cráneo/cirugía , Equipo Quirúrgico , Resultado del TratamientoRESUMEN
OBJECTIVE: Laser interstitial thermal therapy (LITT) for mesial temporal lobe epilepsy (mTLE) has reported seizure freedom rates between 36% and 78% with at least 1 year of follow-up. Unfortunately, the lack of robust methods capable of incorporating the inherent variability of patient anatomy, the variability of the ablated volumes, and clinical outcomes have limited three-dimensional quantitative analysis of surgical targeting and its impact on seizure outcomes. We therefore aimed to leverage a novel image-based methodology for normalizing surgical therapies across a large multicenter cohort to quantify the effects of surgical targeting on seizure outcomes in LITT for mTLE. METHODS: This multicenter, retrospective cohort study included 234 patients from 11 centers who underwent LITT for mTLE. To investigate therapy location, all ablation cavities were manually traced on postoperative magnetic resonance imaging (MRI), which were subsequently nonlinearly normalized to a common atlas space. The association of clinical variables and ablation location to seizure outcome was calculated using multivariate regression and Bayesian models, respectively. RESULTS: Ablations including more anterior, medial, and inferior temporal lobe structures, which involved greater amygdalar volume, were more likely to be associated with Engel class I outcomes. At both 1 and 2 years after LITT, 58.0% achieved Engel I outcomes. A history of bilateral tonic-clonic seizures decreased chances of Engel I outcome. Radiographic hippocampal sclerosis was not associated with seizure outcome. SIGNIFICANCE: LITT is a viable treatment for mTLE in patients who have been properly evaluated at a comprehensive epilepsy center. Consideration of surgical factors is imperative to the complete assessment of LITT. Based on our model, ablations must prioritize the amygdala and also include the hippocampal head, parahippocampal gyrus, and rhinal cortices to maximize chances of seizure freedom. Extending the ablation posteriorly has diminishing returns. Further work is necessary to refine this analysis and define the minimal zone of ablation necessary for seizure control.
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Epilepsia del Lóbulo Temporal/cirugía , Terapia por Láser/métodos , Adolescente , Adulto , Anciano , Anciano de 80 o más Años , Amígdala del Cerebelo/diagnóstico por imagen , Niño , Estudios de Cohortes , Epilepsia del Lóbulo Temporal/diagnóstico por imagen , Epilepsia Tónico-Clónica/diagnóstico por imagen , Epilepsia Tónico-Clónica/cirugía , Femenino , Humanos , Terapia por Láser/efectos adversos , Imagen por Resonancia Magnética , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Convulsiones/cirugía , Resultado del Tratamiento , Adulto JovenRESUMEN
Global access to neurosurgical care is still a work in progress, with many patients in low-income countries not able to access potentially lifesaving neurosurgical procedures. "Big Data" is an increasingly popular data collection and analytical technique predicated on collecting large amounts of data across multiple data sources and types for future analysis. The potential applications of Big Data to global outreach neurosurgery are myriad: from assessing the overall burden of neurosurgical disease to planning cost-effective improvements in access to neurosurgical care, and collecting data on conditions which are rare in developed countries. Although some global neurosurgical outreach programs have intelligently implemented Big Data principles in their global neurosurgery initiatives already, there is still significant progress that remains to be made. Big Data has the potential to drive the efficient improvement of access to neurosurgical care across low- and medium-income countries.
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Macrodatos , Salud Global , Procedimientos Neuroquirúrgicos , Países en Desarrollo , Accesibilidad a los Servicios de Salud , Humanos , NeurocirugiaRESUMEN
Basal ganglia nongerminomatous germ cell tumors comprise 10% to 15% of germ cell tumor and have substantial morbidity at the time of local failure. In this submitted image we present a case where neoadjuvant chemotherapy unmasked a unilateral caudate head loss consistent with Huntingtonian changes. Careful review of the patient's imaging identified disease within the dorsal striatum that was not previously identified at the time of diagnosis. Review of the diffusion tensor fractional anisotropy imaging identified progressive white matter likely secondary to the occult disease within the dorsal striatum. Although this patient was asymptomatic and had no signs of a movement disorder, similar findings have been noted to be a prelude to such findings several months later. The occult disease was incorporated into the patient's radiotherapy planning target volume as oversight of these changes would have led to a marginal miss and potential early disease relapse.
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Neoplasias Encefálicas/complicaciones , Enfermedad de Huntington/complicaciones , Enfermedad de Huntington/diagnóstico , Neoplasias de Células Germinales y Embrionarias/complicaciones , Neoplasias Encefálicas/tratamiento farmacológico , Quimioterapia Adyuvante , Niño , Cuerpo Estriado/patología , Imagen de Difusión por Resonancia Magnética , Humanos , Masculino , Terapia Neoadyuvante , Neoplasias de Células Germinales y Embrionarias/tratamiento farmacológico , Neuroimagen/métodosRESUMEN
There has been a profound increase in the number of patients undergoing head computed tomography after minor injuries and the identification of epidural hematomas has risen concurrently. Although emergent craniotomy and evacuation has been the conventional standard for management, some epidural hematomas can be managed nonoperatively in carefully selected patients. Because of the difficulty in clinically monitoring epidural hematoma absorption and resolution because of the attributed risks of imaging radiation exposure in pediatric patients, the exact incidence of epidural hematoma ossification is unknown. Integrating epidural hematoma calcification into management algorithms is not clearly defined in the literature. The authors report a case of a 2-year-old girl with a calcified epidural hematoma requiring surgical treatment. With the incidence of epidural hematomas rising, providers should be aware of the rare but consequential incidence of epidural hematoma ossification. After literature review and discussion of the pathophysiology, the authors present an algorithmic approach to account for this rare entity. For conservative management of asymptomatic epidural hematomas, providers should consider follow-up magnetic resonance imaging to evaluate resolution in 2 to 3 months. If the magnetic resonance imaging indicates a failure to resolve, a computed tomography scan should then be performed to evaluate ossification and possible need for surgical intervention.
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Calcinosis/etiología , Hematoma Epidural Craneal/complicaciones , Calcinosis/diagnóstico por imagen , Preescolar , Craneotomía , Duramadre/diagnóstico por imagen , Femenino , Hematoma Epidural Craneal/diagnóstico , Hematoma Epidural Craneal/cirugía , Humanos , Imagen por Resonancia Magnética , Tomografía Computarizada por Rayos XRESUMEN
BACKGROUND: Blood loss is the leading cause of mortality after major craniofacial surgery. Autologous blood donation, short-term normovolemic hemodilution, and intraoperative blood salvage have shown low efficacy in decreasing transfusions. Tranexamic acid (TXA) is a synthetic antifibrinolytic drug that competitively decreases the conversion of plasminogen to plasmin, thereby suppressing fibrinolysis. The purpose of this study was to investigate the impact that TXA administration has on intraoperative blood loss and blood product transfusion in pediatric patients undergoing cranial vault reconstruction. METHODS: An Internal Review Board-approved retrospective study was conducted on a consecutive series of pediatric patients undergoing cranial vault reconstruction from January 2009 to June 2012. Seventeen consecutive patients who received TXA at the time of cranial vault reconstruction were compared with 20 patients who did not receive TXA. Criteria for blood product transfusion were identical for both groups. Outcomes including perioperative blood loss, volume of blood transfused, and adverse effects were analyzed. RESULTS: The TXA group had a significantly lower perioperative blood loss (9.4 versus 21.1 mL/kg, P < 0.0001) and lower volume of perioperative mean blood product transfusion (12.8 versus 31.3 mL/kg, P < 0.0001) compared with the non-TXA group. There was no significant difference in demographic data, infection rate, change in preoperative to postoperative hematocrit, duration of surgery, or complication rates between the TXA and non-TXA groups. No drug-related adverse effects were identified in patients who received TXA. CONCLUSIONS: The use of TXA in pediatric cranial vault reconstruction significantly reduces perioperative blood loss and blood product transfusion requirements. The TXA administration is safe and may improve patient outcomes by decreasing the likelihood of adverse effects related to blood product transfusion.
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Antifibrinolíticos/uso terapéutico , Craneosinostosis/cirugía , Procedimientos de Cirugía Plástica/métodos , Ácido Tranexámico/uso terapéutico , Antifibrinolíticos/administración & dosificación , Pérdida de Sangre Quirúrgica/prevención & control , Transfusión Sanguínea/estadística & datos numéricos , Preescolar , Estudios de Cohortes , Craneotomía/métodos , Femenino , Estudios de Seguimiento , Hematócrito , Humanos , Lactante , Masculino , Tempo Operativo , Complicaciones Posoperatorias , Premedicación , Estudios Retrospectivos , Seguridad , Ácido Tranexámico/administración & dosificación , Resultado del TratamientoRESUMEN
OBJECTIVE: As many as 5% of normocephalic children may have a prematurely fused sagittal suture, yet the clinical significance and best course of management of this finding remain unclear. Providers in the Synostosis Research Group were surveyed to create a multicenter consensus on an optimal treatment and monitoring algorithm for this condition. METHODS: A four-round modified Delphi method was utilized. The first two rounds consisted of anonymous surveys distributed to 10 neurosurgeons and 9 plastic surgeons with expertise in craniosynostosis across 9 institutions, and presented 3 patients (aged 3 years, 2 years, and 2 months) with incidentally discovered fused sagittal sutures, normal cephalic indices, and no parietal dysmorphology. Surgeons were queried about their preferred term for this entity and how best to manage these patients. Results were synthesized to create a treatment algorithm. The third and fourth feedback rounds consisted of open discussion of the algorithm until no further concerns arose. RESULTS: Most surgeons preferred the term "premature fusion of the sagittal suture" (93%). At the conclusion of the final round, all surgeons agreed to not operate on the 3- and 2-year-old patients unless symptoms of intracranial hypertension or papilledema were present. In contrast, 50% preferred to operate on the 2-month-old. However, all agreed to utilize shared decision-making, taking into account any concerns about future head shape and neurodevelopment. Panelists agreed that patients over 18 months of age without signs or symptoms suggesting elevated intracranial pressure (ICP) should not undergo surgical treatment. CONCLUSIONS: Through the Delphi method, a consensus regarding management of premature fusion of the sagittal suture was obtained from a panel of North American craniofacial surgeons. Without signs or symptoms of ICP elevation, surgery is not recommended in patients over 18 months of age. However, for children younger than 18 months, surgery should be discussed with caregivers using a shared decision-making process.
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Suturas Craneales , Craneosinostosis , Técnica Delphi , Hallazgos Incidentales , Humanos , Craneosinostosis/cirugía , Suturas Craneales/cirugía , Preescolar , Femenino , Masculino , Lactante , Neurocirujanos , AlgoritmosRESUMEN
Objective: Here, we demonstrate the first successful use of static neural stimulation patterns for specific information content. These static patterns were derived by a model that was applied to a subject's own hippocampal spatiotemporal neural codes for memory. Approach: We constructed a new model of processes by which the hippocampus encodes specific memory items via spatiotemporal firing of neural ensembles that underlie the successful encoding of targeted content into short-term memory. A memory decoding model (MDM) of hippocampal CA3 and CA1 neural firing was computed which derives a stimulation pattern for CA1 and CA3 neurons to be applied during the encoding (sample) phase of a delayed match-to-sample (DMS) human short-term memory task. Main results: MDM electrical stimulation delivered to the CA1 and CA3 locations in the hippocampus during the sample phase of DMS trials facilitated memory of images from the DMS task during a delayed recognition (DR) task that also included control images that were not from the DMS task. Across all subjects, the stimulated trials exhibited significant changes in performance in 22.4% of patient and category combinations. Changes in performance were a combination of both increased memory performance and decreased memory performance, with increases in performance occurring at almost 2 to 1 relative to decreases in performance. Across patients with impaired memory that received bilateral stimulation, significant changes in over 37.9% of patient and category combinations was seen with the changes in memory performance show a ratio of increased to decreased performance of over 4 to 1. Modification of memory performance was dependent on whether memory function was intact or impaired, and if stimulation was applied bilaterally or unilaterally, with nearly all increase in performance seen in subjects with impaired memory receiving bilateral stimulation. Significance: These results demonstrate that memory encoding in patients with impaired memory function can be facilitated for specific memory content, which offers a stimulation method for a future implantable neural prosthetic to improve human memory.
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OBJECTIVE: Congenital anomalies of the atlanto-occipital articulation may be present in patients with Chiari malformation type I (CM-I). However, it is unclear how these anomalies affect the biomechanical stability of the craniovertebral junction (CVJ) and whether they are associated with an increased incidence of occipitocervical fusion (OCF) following posterior fossa decompression (PFD). The objective of this study was to determine the prevalence of condylar hypoplasia and atlas anomalies in children with CM-I and syringomyelia. The authors also investigated the predictive contribution of these anomalies to the occurrence of OCF following PFD (PFD+OCF). METHODS: The authors analyzed the prevalence of condylar hypoplasia and atlas arch anomalies for patients in the Park-Reeves Syringomyelia Research Consortium database who underwent PFD+OCF. Condylar hypoplasia was defined by an atlanto-occipital joint axis angle (AOJAA) ≥ 130°. Atlas assimilation and arch anomalies were identified on presurgical radiographic imaging. This PFD+OCF cohort was compared with a control cohort of patients who underwent PFD alone. The control group was matched to the PFD+OCF cohort according to age, sex, and duration of symptoms at a 2:1 ratio. RESULTS: Clinical features and radiographic atlanto-occipital joint parameters were compared between 19 patients in the PFD+OCF cohort and 38 patients in the PFD-only cohort. Demographic data were not significantly different between cohorts (p > 0.05). The mean AOJAA was significantly higher in the PFD+OCF group than in the PFD group (144° ± 12° vs 127° ± 6°, p < 0.0001). In the PFD+OCF group, atlas assimilation and atlas arch anomalies were identified in 10 (53%) and 5 (26%) patients, respectively. These anomalies were absent (n = 0) in the PFD group (p < 0.001). Multivariate regression analysis identified the following 3 CVJ radiographic variables that were predictive of OCF occurrence after PFD: AOJAA ≥ 130° (p = 0.01), clivoaxial angle < 125° (p = 0.02), and occipital condyle-C2 sagittal vertical alignment (C-C2SVA) ≥ 5 mm (p = 0.01). A predictive model based on these 3 factors accurately predicted OCF following PFD (C-statistic 0.95). CONCLUSIONS: The authors' results indicate that the occipital condyle-atlas joint complex might affect the biomechanical integrity of the CVJ in children with CM-I and syringomyelia. They describe the role of the AOJAA metric as an independent predictive factor for occurrence of OCF following PFD. Preoperative identification of these skeletal abnormalities may be used to guide surgical planning and treatment of patients with complex CM-I and coexistent osseous pathology.
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Malformación de Arnold-Chiari , Articulación Atlantooccipital , Atlas Cervical , Hueso Occipital , Fusión Vertebral , Siringomielia , Humanos , Malformación de Arnold-Chiari/cirugía , Malformación de Arnold-Chiari/diagnóstico por imagen , Siringomielia/cirugía , Siringomielia/diagnóstico por imagen , Femenino , Masculino , Atlas Cervical/anomalías , Atlas Cervical/cirugía , Atlas Cervical/diagnóstico por imagen , Niño , Hueso Occipital/cirugía , Hueso Occipital/diagnóstico por imagen , Hueso Occipital/anomalías , Fusión Vertebral/métodos , Adolescente , Articulación Atlantooccipital/diagnóstico por imagen , Articulación Atlantooccipital/cirugía , Articulación Atlantooccipital/anomalías , Resultado del Tratamiento , Preescolar , Descompresión Quirúrgica/métodos , Estudios Retrospectivos , Vértebras Cervicales/cirugía , Vértebras Cervicales/anomalías , Vértebras Cervicales/diagnóstico por imagenRESUMEN
OBJECT: There has been a tremendous increase in the incidence of deformational plagiocephaly in children throughout the world. Therapeutic options include observation, active counterpositioning, external orthotics, and surgery. The current treatment in the US is highly debated, but it typically includes external orthotic helmets in patients with moderate to severe plagiocephaly presenting between 4 and 10 months of age or in children with significant comorbidities limiting passive (no-pressure) therapy. The present study was designed to evaluate 3 key issues: 1) the accuracy of the Argenta classification in defining a progressive degree of severity, 2) identification of an upper age limit when treatment is no longer effective, and 3) the effectiveness of an off-the-shelf prefabricated helmet in correcting deformational plagiocephaly. METHODS: An institutional review board-approved retrospective study was conducted of all patients at the authors' clinic in whom deformational plagiocephaly was assessed using the Argenta classification system over a 6-year period; the patients underwent helmet therapy, and a minimum of 3 clinic visits were recorded. Inclusion criteria consisted of an Argenta Type II-V plagiocephalic deformity. Patients' conditions were categorized both by severity of the deformity and by patients' age at presentation. Statistical analysis was conducted using survival analysis. RESULTS: There were 1050 patients included in the study. Patients with Type III, IV, and V plagiocephaly required progressively longer for deformity correction to be achieved than patients with Type II plagiocephaly (53%, 75%, and 81% longer, respectively [p < 0.0001]). This finding verified that the Argenta stratification indicated a progressive severity of deformity. No statistically significant difference in the time to correction was noted among the different age categories, which suggests that the previously held upper time limit for correction may be inaccurate. An overall correction rate to Type I plagiocephaly of 81.6% was achieved irrespective of severity and degree of the original deformity. This suggests that an inexpensive off-the-shelf molding helmet is highly effective and that expensive custom-fitted orthoses may not be necessary. The patients in the older age group (> 12 months) did not have a statistically significant longer interval to correction than the patients in the youngest age group (< 3 months). The mean length of follow-up was 6.3 months. CONCLUSIONS: Patients treated with passive helmet therapy in the older age group (> 12 months) had an improvement in skull shape within the same treatment interval as the patients in the younger age group (< 3 months). This study supports the use of passive helmet therapy for improvement in deformational plagiocephaly in infants from birth to 18 months of age and verifies the stratification of degree of deformity used in the Argenta classification system.
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Dispositivos de Protección de la Cabeza , Plagiocefalia no Sinostótica/terapia , Factores de Edad , Preescolar , Femenino , Estudios de Seguimiento , Humanos , Lactante , Masculino , Plagiocefalia no Sinostótica/diagnóstico , Plagiocefalia no Sinostótica/patología , Estudios Retrospectivos , Resultado del TratamientoRESUMEN
INTRODUCTION: Blunt cerebrovascular injury (BCVI) is an increasingly detected pattern in trauma with significant morbidity, putting patients at risk for subsequent stoke. Complex screening protocols exist to determine who should undergo CT angiography of the neck (CTAN) to evaluate for BCVI. Once identified, stroke incidence may be reduced with appropriate treatment across grades. We hypothesize that an expanded and simplified method for identifying patients with clinical suspicion for BCVI based upon injury above the clavicle (ATC) will illustrate a previously undiagnosed cohort of patients. METHODS: A single-institution retrospective review of adult (age ≥18 years) blunt trauma patients with BCVI from January 1, 2010 to December 31, 2019 was conducted at a tertiary academic medical center. Patients undergoing CTAN were divided into 2 groups based upon qualification by either the expanded Denver criteria or clinical evidence of any injury ATC. RESULTS: A total of 219 patients were diagnosed with BCVI (25 566 blunt trauma admissions, .9% incidence). Seventeen patients (8%) who did not satisfy expanded Denver were diagnosed with BCVI by ATC, most commonly undergoing CTAN due to facial trauma (n = 8). There were no differences in distribution of carotid artery injuries (CAI) and vertebral artery injuries (VAI) in the expanded Denver criteria group compared to the ATC group. CONCLUSIONS: CTAN for blunt trauma with any injury ATC is an easy-to-use screening tool and may be seamlessly included with initial whole-body imaging.
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Traumatismos de las Arterias Carótidas , Traumatismos Cerebrovasculares , Accidente Cerebrovascular , Lesiones del Sistema Vascular , Heridas no Penetrantes , Adulto , Humanos , Adolescente , Lesiones del Sistema Vascular/complicaciones , Traumatismos Cerebrovasculares/diagnóstico por imagen , Traumatismos Cerebrovasculares/complicaciones , Heridas no Penetrantes/complicaciones , Accidente Cerebrovascular/etiología , Estudios Retrospectivos , Angiografía CerebralRESUMEN
OBJECTIVE: The authors of this study evaluated the safety and efficacy of stereotactic laser ablation (SLA) for the treatment of drug-resistant epilepsy (DRE) in children. METHODS: Seventeen North American centers were enrolled in the study. Data for pediatric patients with DRE who had been treated with SLA between 2008 and 2018 were retrospectively reviewed. RESULTS: A total of 225 patients, mean age 12.8 ± 5.8 years, were identified. Target-of-interest (TOI) locations included extratemporal (44.4%), temporal neocortical (8.4%), mesiotemporal (23.1%), hypothalamic (14.2%), and callosal (9.8%). Visualase and NeuroBlate SLA systems were used in 199 and 26 cases, respectively. Procedure goals included ablation (149 cases), disconnection (63), or both (13). The mean follow-up was 27 ± 20.4 months. Improvement in targeted seizure type (TST) was seen in 179 (84.0%) patients. Engel classification was reported for 167 (74.2%) patients; excluding the palliative cases, 74 (49.7%), 35 (23.5%), 10 (6.7%), and 30 (20.1%) patients had Engel class I, II, III, and IV outcomes, respectively. For patients with a follow-up ≥ 12 months, 25 (51.0%), 18 (36.7%), 3 (6.1%), and 3 (6.1%) had Engel class I, II, III, and IV outcomes, respectively. Patients with a history of pre-SLA surgery related to the TOI, a pathology of malformation of cortical development, and 2+ trajectories per TOI were more likely to experience no improvement in seizure frequency and/or to have an unfavorable outcome. A greater number of smaller thermal lesions was associated with greater improvement in TST. Thirty (13.3%) patients experienced 51 short-term complications including malpositioned catheter (3 cases), intracranial hemorrhage (2), transient neurological deficit (19), permanent neurological deficit (3), symptomatic perilesional edema (6), hydrocephalus (1), CSF leakage (1), wound infection (2), unplanned ICU stay (5), and unplanned 30-day readmission (9). The relative incidence of complications was higher in the hypothalamic target location. Target volume, number of laser trajectories, number or size of thermal lesions, or use of perioperative steroids did not have a significant effect on short-term complications. CONCLUSIONS: SLA appears to be an effective and well-tolerated treatment option for children with DRE. Large-volume prospective studies are needed to better understand the indications for treatment and demonstrate the long-term efficacy of SLA in this population.
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RATIONALE: Deep brain stimulation (DBS) of the hippocampus is proposed for enhancement of memory impaired by injury or disease. Many pre-clinical DBS paradigms can be addressed in epilepsy patients undergoing intracranial monitoring for seizure localization, since they already have electrodes implanted in brain areas of interest. Even though epilepsy is usually not a memory disorder targeted by DBS, the studies can nevertheless model other memory-impacting disorders, such as Traumatic Brain Injury (TBI). METHODS: Human patients undergoing Phase II invasive monitoring for intractable epilepsy were implanted with depth electrodes capable of recording neurophysiological signals. Subjects performed a delayed-match-to-sample (DMS) memory task while hippocampal ensembles from CA1 and CA3 cell layers were recorded to estimate a multi-input, multi-output (MIMO) model of CA3-to-CA1 neural encoding and a memory decoding model (MDM) to decode memory information from CA3 and CA1 neuronal signals. After model estimation, subjects again performed the DMS task while either MIMO-based or MDM-based patterned stimulation was delivered to CA1 electrode sites during the encoding phase of the DMS trials. Each subject was sorted (post hoc) by prior experience of repeated and/or mild-to-moderate brain injury (RMBI), TBI, or no history (control) and scored for percentage successful delayed recognition (DR) recall on stimulated vs. non-stimulated DMS trials. The subject's medical history was unknown to the experimenters until after individual subject memory retention results were scored. RESULTS: When examined compared to control subjects, both TBI and RMBI subjects showed increased memory retention in response to both MIMO and MDM-based hippocampal stimulation. Furthermore, effects of stimulation were also greater in subjects who were evaluated as having pre-existing mild-to-moderate memory impairment. CONCLUSION: These results show that hippocampal stimulation for memory facilitation was more beneficial for subjects who had previously suffered a brain injury (other than epilepsy), compared to control (epilepsy) subjects who had not suffered a brain injury. This study demonstrates that the epilepsy/intracranial recording model can be extended to test the ability of DBS to restore memory function in subjects who previously suffered a brain injury other than epilepsy, and support further investigation into the beneficial effect of DBS in TBI patients.
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[This corrects the article DOI: 10.3389/fnhum.2022.933401.].
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OBJECTIVE: The goal of this study was to assess the social determinants that influence access and outcomes for pediatric neurosurgical care for patients with Chiari malformation type I (CM-I) and syringomyelia (SM). METHODS: The authors used retro- and prospective components of the Park-Reeves Syringomyelia Research Consortium database to identify pediatric patients with CM-I and SM who received surgical treatment and had at least 1 year of follow-up data. Race, ethnicity, and insurance status were used as comparators for preoperative, treatment, and postoperative characteristics and outcomes. RESULTS: A total of 637 patients met inclusion criteria, and race or ethnicity data were available for 603 (94.7%) patients. A total of 463 (76.8%) were non-Hispanic White (NHW) and 140 (23.2%) were non-White. The non-White patients were older at diagnosis (p = 0.002) and were more likely to have an individualized education plan (p < 0.01). More non-White than NHW patients presented with cerebellar and cranial nerve deficits (i.e., gait ataxia [p = 0.028], nystagmus [p = 0.002], dysconjugate gaze [p = 0.03], hearing loss [p = 0.003], gait instability [p = 0.003], tremor [p = 0.021], or dysmetria [p < 0.001]). Non-White patients had higher rates of skull malformation (p = 0.004), platybasia (p = 0.002), and basilar invagination (p = 0.036). Non-White patients were more likely to be treated at low-volume centers than at high-volume centers (38.7% vs 15.2%; p < 0.01). Non-White patients were older at the time of surgery (p = 0.001) and had longer operative times (p < 0.001), higher estimated blood loss (p < 0.001), and a longer hospital stay (p = 0.04). There were no major group differences in terms of treatments performed or complications. The majority of subjects used private insurance (440, 71.5%), whereas 175 (28.5%) were using Medicaid or self-pay. Private insurance was used in 42.2% of non-White patients compared to 79.8% of NHW patients (p < 0.01). There were no major differences in presentation, treatment, or outcome between insurance groups. In multivariate modeling, non-White patients were more likely to present at an older age after controlling for sex and insurance status (p < 0.01). Non-White and male patients had a longer duration of symptoms before reaching diagnosis (p = 0.033 and 0.004, respectively). CONCLUSIONS: Socioeconomic and demographic factors appear to influence the presentation and management of patients with CM-I and SM. Race is associated with age and timing of diagnosis as well as operating room time, estimated blood loss, and length of hospital stay. This exploration of socioeconomic and demographic barriers to care will be useful in understanding how to improve access to pediatric neurosurgical care for patients with CM-I and SM.