Focused ultrasound-mediated blood-brain barrier opening is safe and feasible with moderately hypofractionated radiotherapy for brainstem diffuse midline glioma.

BACKGROUND: Diffuse midline glioma (DMG) is a pediatric tumor with dismal prognosis. Systemic strategies have been unsuccessful and radiotherapy (RT) remains the standard-of-care. A central impediment to treatment is the blood-brain barrier (BBB), which precludes drug delivery to the central nervous system (CNS). Focused ultrasound (FUS) with microbubbles can transiently and non-invasively disrupt the BBB to enhance drug delivery. This study aimed to determine the feasibility of brainstem FUS in combination with clinical doses of RT. We hypothesized that FUS-mediated BBB-opening (BBBO) is safe and feasible with 39 Gy RT. METHODS: To establish a safety timeline, we administered FUS to the brainstem of non-tumor bearing mice concurrent with or adjuvant to RT; our findings were validated in a syngeneic brainstem murine model of DMG receiving repeated sonication concurrent with RT. The brainstems of male B6 (Cg)-Tyrc-2J/J albino mice were intracranially injected with mouse DMG cells (PDGFB+, H3.3K27M, p53-/-). A clinical RT dose of 39 Gy in 13 fractions (39 Gy/13fx) was delivered using the Small Animal Radiation Research Platform (SARRP) or XRAD-320 irradiator. FUS was administered via a 0.5 MHz transducer, with BBBO and tumor volume monitored by magnetic resonance imaging (MRI). RESULTS: FUS-mediated BBBO did not affect cardiorespiratory rate, motor function, or tissue integrity in non-tumor bearing mice receiving RT. Tumor-bearing mice tolerated repeated brainstem BBBO concurrent with RT. 39 Gy/13fx offered local control, though disease progression occurred 3-4 weeks post-RT. CONCLUSION: Repeated FUS-mediated BBBO is safe and feasible concurrent with RT. In our syngeneic DMG murine model, progression occurs, serving as an ideal model for future combination testing with RT and FUS-mediated drug delivery.

The role of focused ultrasound for pediatric brain tumors: current insights and future implications on treatment strategies.

INTRODUCTION: Focused ultrasound (FUS) is an innovative and emerging technology for the treatment of adult and pediatric brain tumors and illustrates the intersection of various specialized fields, including neurosurgery, neuro-oncology, radiation oncology, and biomedical engineering. OBJECTIVE: The authors provide a comprehensive overview of the application and implications of FUS in treating pediatric brain tumors, with a special focus on pediatric low-grade gliomas (pLGGs) and the evolving landscape of this technology and its clinical utility. METHODS: The fundamental principles of FUS include its ability to induce thermal ablation or enhance drug delivery through transient blood-brain barrier (BBB) disruption, emphasizing the adaptability of high-intensity focused ultrasound (HIFU) and low-intensity focused ultrasound (LIFU) applications. RESULTS: Several ongoing clinical trials explore the potential of FUS in offering alternative therapeutic strategies for pathologies where conventional treatments fall short, specifically centrally-located benign CNS tumors and diffuse intrinsic pontine glioma (DIPG). A case illustration involving the use of HIFU for pilocytic astrocytoma is presented. CONCLUSION: Discussions regarding future applications of FUS for the treatment of gliomas include improved drug delivery, immunomodulation, radiosensitization, and other technological advancements.

Evolution of Surgical Management of Pineal Region Tumors in the Pediatric Population: A 17-Year Experience at a Single Institution.

INTRODUCTION: Pineal region tumors have historically been challenging to treat. Advances in surgical techniques have led to significant changes in care and outcomes for these patients, and this is well demonstrated by our single institution's experience over a 17-year-period in which the evolution of diagnosis, treatment, and outcomes of pineal tumors in pediatric patients will be outlined. METHODS: We retrospectively collected data on all pediatric patients with pineal region lesions treated with surgery at Children's National Hospital (CNH) from 2005 to 2021. Variables analyzed included presenting symptoms, presence of hydrocephalus, diagnostic and surgical approach, pathology, and adverse events, among others. IRB approval was obtained (IRB: STUDY00000009), and consent was waived due to minimal risk to patients included. RESULTS: A total of 43 pediatric patients with pineal region tumors were treated during a 17-year period. Most tumors in our series were germinomas (n = 13, 29.5%) followed by pineoblastomas (n = 10, 22.7%). Twenty seven of the 43 patients (62.8%) in our series received a biopsy to establish diagnosis, and 44.4% went on to have surgery for resection. The most common open approach was posterior interhemispheric (PIH, transcallosal) - used for 59.3% of the patients. Gross total resection was achieved in 50%; recurrence occurred in 20.9% and mortality in 11% over a median follow-up of 47 months. Endoscopic third ventriculostomy (ETV) was employed to treat hydrocephalus in 26 of the 38 patients (68.4%) and was significantly more likely to be performed from 2011 to 2021. Most (73%) of the patients who received an ETV also underwent a concurrent endoscopic biopsy. No difference was found in recurrence rate or mortality in patients who underwent resection compared to those who did not, but complications were more frequent with resection. There was disagreement between frozen and final pathology in 18.4% of biopsies. CONCLUSION: This series describes the evolution of surgical approaches and outcomes over a 17-year-period at a single institution. Complication rates were higher with open resection, reinforcing the safety of pursuing endoscopic biopsy as an initial approach. The most significant changes occurred in the preferential use of ETVs over ventriculoperitoneal shunts. Though there has been a significant evolution in our understanding of and treatment for these tumors, in our series, the outcomes for these patients have not significantly changed over that time.

Medulloblastomas, CNS embryonal tumors, and cerebellar mutism syndrome: advances in care and future directions.

Central nervous system (CNS) embryonal tumors, commonly found in pediatric patients, represent a heterogeneous mix of lesions with an overall poor (though improving) prognosis. Medulloblastomas are by far the most frequently encountered and most widely studied subtype, though others include atypical teratoid/rhabdoid tumors (AT/RTs), embryonal tumor with multilayered rosettes (ETMRs), and CNS neuroblastomas, FOX-R2 activated. The classification, diagnosis, and treatment of these lesions have evolved drastically over the years as their molecular underpinnings have been elucidated. We describe the most recent 2021 WHO Classification system, discuss current understanding of the genetic basis, and demonstrate current thinking in treatment for these highly complex tumors. Since surgical resection continues to remain a mainstay of treatment, preventing and managing surgical complications, especially cerebellar mutism syndrome (CMS), is paramount. We describe the current theories for the etiology of CMS and two centers' experience in mitigating its risks. As our surgical toolbox continues to evolve along with our understanding of these tumors, we hope future patients can benefit from both improved overall survival and quality of life.

Interplay between vascular hemodynamics and the glymphatic system in the pathogenesis of idiopathic normal pressure hydrocephalus, exploring novel neuroimaging diagnostics.

As the aging population continues to grow, so will the incidence of age-related conditions, including idiopathic normal pressure hydrocephalus (iNPH). The pathogenesis of iNPH remains elusive, and this is due in part to the poor characterization of cerebral spinal fluid (CSF) dynamics within the brain. Advancements in technology and imaging techniques have enabled new breakthroughs in understanding CSF physiology, and therefore iNPH pathogenesis. This includes understanding the hemodynamic and microvascular components involved in CSF influx and flow. Namely, the glymphatic system appears to be the great mediator, facilitating perivascular CSF flow via astrocytic aquaporin channels located along the endothelium of the pial vasculature. The interplay between glymphatics and both arterial pulsatilty and venous compliance has also been recently demonstrated. It appears then that CSF flow, and therefore glymphatic function, are highly dependent on cardiocirculatory and vascular factors. Impairment in any one component, whether it be related to arterial pulsatility, microvascular changes, reduced venous drainage, or astrogliosis, contributes greatly to iNPH, although it is likely a combination thereof. The strong interplay between vascular hemodynamics and CSF flow suggests perfusion imaging and cerebral blood flow quantification may be a useful diagnostic tool in characterizing iNPH. In addition, studies detecting glymphatic flow with magnetic resonance imaging have also emerged. These imaging tools may serve to both diagnose iNPH and help delineate it from other similarly presenting disease processes. With a better understanding of the vascular and glymphatic factors related to iNPH pathogenesis, physicians are better able to select the best candidates for treatment.

Compressive epidural collection as an unusual complication of FESS for a pediatric mycetoma.

Functional endoscopic sinus surgery (FESS) is a treatment of choice for fungal sinus ball (mycetoma), which is considered safe with a very low major complication rate. We present an unusual case of a 12-year-old female, who underwent FESS for a sphenoid sinus mycetoma and which was complicated by an acute, compressive epidural fluid collection. This presumably resulted from sinus irrigation in the setting of an under-appreciated skull base and mucosal defects causing a ball-valve effect. Our patient had a temporary neurologic deficit with complete recovery, however, similar complications can have fatal consequences.

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.

Bone grafting and biologics for spinal fusion in the pediatric population: current understanding and future perspective.

Pediatric spinal fusions have been associated with nonunion rates of approximately 25%, putting patients at risk for neurological complications while simultaneously incurring significant costs for revision surgery. In an effort to decrease nonunion rates, various bone grafts and biologics have been developed to increase osseous formation and arthrosis. The current gold-standard bone graft is autologous bone taken from the iliac crest or ribs, but this procedure is associated with significant morbidity and postoperative pain due to an additional graft harvesting procedure. Other bone graft substitutes and biologics include allografts, demineralized bone matrix, bone morphogenetic protein, and bioactive glass. Ultimately, these substitutes have been studied more extensively in the adult population, and there is a paucity of strong evidence for the use of these agents within the pediatric population. In this review, the authors will discuss in detail the characteristics of the various bone graft substitutes, their fusion efficacy, and their safety profile in this subpopulation.

Clinical characteristics and long-term outcomes for patients who undergo cytoreductive surgery for thoracic meningiomas: a retrospective analysis.

OBJECTIVE: Primary spinal meningiomas represent a rare indolent neoplasm usually situated in the intradural-extramedullary compartment. They have a predilection for afflicting the thoracic spine and most frequently present with sensory and/or motor symptoms. Resection is the first-line treatment for symptomatic tumors, whereas other clinical factors will determine the need for adjuvant therapy. In this study, the authors aimed to elucidate clinical presentation, functional outcomes, and long-term outcomes in this population in order to better equip clinicians with the tools to counsel their patients. METHODS: This is a retrospective analysis of patients treated at the authors' institution between 1998 and 2018. All patients with thoracic meningiomas who underwent resection and completed at least one follow-up appointment were included. Multiple preoperative clinical variables, hospitalization details, and long-term outcomes were collected for the cohort. RESULTS: Forty-six patients who underwent resection for thoracic meningiomas were included. The average age of the cohort was 59 years, and the median follow-up was 53 months. Persistent sensory and motor symptoms were present in 29 patients (63%). Fifteen lesions were ventrally positioned. There were 43 WHO grade I tumors, 2 WHO grade II tumors, and 1 WHO grade III tumor; the grade III tumor was the only case of recurrence. The median length of hospitalization was 4 days. Seventeen patients (37%) were discharged to rehabilitation facilities. Thirty patients (65.2%) experienced resolution or improvement of symptoms, and there were no deaths within 30 days of surgery. Only 1 patient developed painful kyphosis and was managed medically. Ventral tumor position, new postoperative deficits, and length of stay did not correlate with disposition to a facility. Age, ventral position, blood loss, and increasing WHO grade did not correlate with length of stay. CONCLUSIONS: Outcomes are overall favorable for patients who undergo resection of thoracic meningiomas. Symptomatic patients often experience improvement, and patients generally do not require significant future operations. Tumors located ventrally, while anatomically challenging, do not necessarily herald a significantly worse prognosis or limit the extent of resection.

A system divided: the state of neurosurgical training in modern-day Vietnam.

The current report is the first of its kind in describing the neurosurgical training in modern-day Vietnam. Starting with in-depth face-to-face interviews, followed by electronically distributed questionnaires, a detailed picture of the training systems emerged.Neurosurgical training in Vietnam is multifaceted and dichotomous. The country of nearly 100 million people currently has only one neurosurgery-specific residency program, at the University of Medicine and Pharmacy at Ho Chi Minh City (UMPHCMC). This program lasts for 3 years, and Westerners might recognize many similarities to programs native to their countries. A similar training program exists in the north, at the Hanoi Medical University, but at this institution, trainees focus on neurosurgery only in the final year of their 3-year training. Neurosurgical training that resembles the program in Hanoi permeates the rest of the country, and the goal for all of the programs is to rapidly produce surgeons who can be dispersed throughout the country to treat patients requiring urgent neurosurgical procedures who are medically unsuitable for transfer to large urban centers and multispecialty hospitals. For the privilege of practicing elective neurosurgery, trainees around the country are required to acquire further training in Ho Chi Minh City or Hanoi or during fellowships abroad.A clear description of the neurosurgical training systems in Vietnam is hard to achieve, as there exist many diverse pathways and no standard definition of the endpoint for training. Unification and a clearer certification standard will likely help to elevate the standards of training and the state of neurosurgical practice in Vietnam.

A systematic review of endovascular stent-electrode arrays, a minimally invasive approach to brain-machine interfaces.

OBJECTIVE: The goal of this study was to systematically review the feasibility and safety of minimally invasive neurovascular approaches to brain-machine interfaces (BMIs). METHODS: A systematic literature review was performed using the PubMed database for studies published between 1986 and 2019. All studies assessing endovascular neural interfaces were included. Additional studies were selected based on review of references of selected articles and review articles. RESULTS: Of the 53 total articles identified in the original literature search, 12 studies were ultimately selected. An additional 10 articles were included from other sources, resulting in a total of 22 studies included in this systematic review. This includes primarily preclinical studies comparing endovascular electrode recordings with subdural and epidural electrodes, as well as studies evaluating stent-electrode gauge and material type. In addition, several clinical studies are also included. CONCLUSIONS: Endovascular stent-electrode arrays provide a minimally invasive approach to BMIs. Stent-electrode placement has been shown to be both efficacious and safe, although further data are necessary to draw comparisons between subdural and epidural electrode measurements given the heterogeneity of the studies included. Greater access to deep-seated brain regions is now more feasible with stent-electrode arrays; however, further validation is needed in large clinical trials to optimize this neural interface. This includes the determination of ideal electrode material type, venous versus arterial approaches, the feasibility of deep brain stimulation, and more streamlined computational decoding techniques.

Endoscopic endonasal surgery outcomes for pediatric craniopharyngioma: a systematic review.

OBJECTIVE: The goal of this study was to systematically review the outcomes of endoscopic endonasal surgery (EES) for pediatric craniopharyngiomas so as to assess its safety and efficacy. METHODS: A systematic literature review was performed using the PubMed and MEDLINE databases for studies published between 1986 and 2019. All studies assessing outcomes following EES for pediatric craniopharyngiomas were included. RESULTS: Of the total 48 articles identified in the original literature search, 13 studies were ultimately selected. This includes comparative studies with other surgical approaches, retrospective cohort studies, and case series. CONCLUSIONS: EES for pediatric craniopharyngiomas is a safe and efficacious alternative to other surgical approaches. Achieving gross-total resection with minimal complications is feasible with EES and is comparable, if not superior in some cases, to traditional means of resection. Ideally, a randomized controlled trial might be implemented in the future to further elucidate the effectiveness of EES for resection of craniopharyngiomas.

The impact of COVID-19 on neurosurgeons and the strategy for triaging non-emergent operations: a global neurosurgery study.

OBJECT: The COVID-19 pandemic has disrupted all aspects of society globally. As healthcare resources had to be preserved for infected patients, and the risk of in-hospital procedures escalated for uninfected patients and staff, neurosurgeons around the world have had to postpone non-emergent procedures. Under these unprecedented conditions, the decision to defer cases became increasingly difficult as COVID-19 cases skyrocketed. METHODS: Data was collected by self-reporting surveys during two discrete periods: the principal survey accrued responses during 2 weeks at the peak of the global pandemic, and the supplemental survey accrued responses after that to detect changes in opinions and circumstances. Nine hypothetical surgical scenarios were used to query neurosurgeons' opinion on the risk of postponement and the urgency to re-schedule the procedures. An acuity index was generated for each scenario, and this was used to rank the nine cases. RESULTS: There were 494 respondents to the principal survey from 60 countries. 258 (52.5%) reported that all elective cases and clinics have been shut down by their main hospital. A total of 226 respondents (46.1%) reported that their operative volume had dropped more than 50%. For the countries most affected by COVID-19, this proportion was 54.7%. There was a high degree of agreement among our respondents that fast-evolving neuro-oncological cases are non-emergent cases that nonetheless have the highest risk in postponement, and selected vascular cases may have high acuity as well. CONCLUSION: We report on the impact of COVID-19 on neurosurgeons around the world. From their ranking of the nine case scenarios, we deduced a strategic scheme that can serve as a guideline to triage non-emergent neurosurgical procedures during the pandemic. With it, hopefully, neurosurgeons can continue to serve their patients without endangering them either neurologically or risking their exposure to the deadly virus.

An anatomical study of the foramen of Monro: implications in management of pineal tumors presenting with hydrocephalus.

BACKGROUND: For pineal tumors presenting with hydrocephalus, simultaneous endoscopic third ventriculostomy (ETV) and tumor biopsy is commonly used as the initial step in management. To analyze the restriction which the foramen of Monro poses to this procedure, one must start with a detailed description of the microsurgical anatomy of the foramen in living subjects. However, the orientation and shape of the foramen of Monro make this description difficult with conventional imaging techniques. METHOD: Virtual reality technology was applied on MRIs on living subject without hydrocephalus, as well as patients with hydrocephalus, to generate precise anatomical models with sub-millimeter accuracy. The morphometry of the foramen of Monro was studied in each group. In addition, displacement of the margins of the foramen was studied in detail for simultaneous ETV and pineal tumor biopsy through a single burr hole. RESULTS: In 30 normal subjects, the foramen of Monro had oval-shaped openings averaging 5.23 mm2. The foramen was larger in people above age 55 (p = 0.007) and on the left side compared to the right (p = 0.002). For patients with clinical presentation of hydrocephalus, the average opening was 32.6 mm2. Simulated single burr hole simultaneous ETV and pineal tumor biopsy was performed in 10 specimens. Average displacement of the posterior and anterior margins of the foramen was 5.71 mm and 5.76 mm, respectively. However, maximum displacement reached 9.3 mm posteriorly and 10 mm anteriorly. CONCLUSIONS: The foramen of Monro is an oval-shaped cylinder that changes in size and orientation in the hydrocephalic patient. If universally applied to all patients regardless of foramen and tumor size, ETV/biopsy can displace structures around the Foramen of Monro up to 1 cm, which can potentially lead to neurological damage. Careful pre-operative assessment is critical to determine if a single burr hole approach is safe.

Endoscopic third ventriculostomy in children with a fiber optic neuroendoscopy.

OBJECTIVE: Endoscopic third ventriculostomy (ETV) provides a shunt-free treatment for obstructive hydrocephalus children. With rapidly evolving technology, the semi-rigid fiber optic neuroendoscopy shows a potential application in ETV by blunt fenestration. A retrospective analysis of our experience is reviewed. METHODS: The authors review infants and children who underwent ETV using this technique from June 2004 to June 2016 with radiological and clinical follow-up done by a single surgeon. Patients who underwent ETV with channel scope were excluded. Demographic variables and operative reports were collected. Improvement of preoperative symptoms and avoidance of additional cerebrospinal fluid (CSF) diversion procedures were considered a success. The ETV success score (ETVSS) was used to correlate with clinical outcomes. RESULTS: A total of 79 patients were included with a mean age of 8.3 ± 5.5 years, and 40.5% were female. The mean clinical and radiographic follow-up was 38.6 ± 40.9 months. The overall complication rate was 6.3%, while 73.4% were considered successful. The ETV failure cases received conversion to ventriculoperitoneal shunt or redo of ETV with a median time of 2 months. The mean ETV success score was 74.3 ± 11.8 with positive correlation between success rate (P < 0.05). Kaplan-Meier failure-free survival rates of 30-day, 90-day, 6-month, 1-year, and 2-year were 89.9, 83.5, 78.5, 75.9, and 74.6%. Eight patients required redo ETV, and five of these patients required eventual shunt placements. Approximately 61.9% of failure occurred within 3 months. Patients with post-intraventricular hemorrhage (IVH) /infection, and age younger than 12 months had the poorest outcome (P < 0.05). CONCLUSIONS: Blunt dissection of the third ventricle floor under endoscopic vision with the stylet tip of a fiber optic neuroendoscopy is safe and requires less equipment in the pediatric population. This technique is successful with an optimistic long-term outcome except for infants and the post-IVH and infectious subgroups.

S2-AI screw placement with the aide of electronic conductivity device monitoring: a retrospective analysis.

STUDY DESIGN: A retrospective analysis of two consecutive patients who underwent a novel surgical technique. OBJECTIVE: A report of a novel surgical technique utilizing an electronic conductivity device guidance to aide placement of S2-Alar-Iliac (S2-AI) instrumentation. Electronic conductivity guidance for instrumentation of the thoracolumbar spine is an accepted means of improving intraoperative accuracy. Although commercially available for percutaneous techniques, there is a paucity of literature regarding its use. Percutaneous implantation of S2-AI screws has been previously described as another technique surgeons can avail, primarily employing fluoroscopy as a means of intraoperative feedback. We describe a novel technique that utilizes electronic conductivity as an added feedback measure to increase accuracy of percutaneous S2-AI fixation. METHODS: Two patients were treated by the senior author (FAS) who underwent surgery employing S2-AI fixation utilizing an electronic conductivity device (Pediguard cannulated probe, Spineguard, Paris, France). The surgical technique, case illustrations, and radiographic outcomes are discussed. RESULTS: Stable and accurate fixation was attained in both patients. There were no peri-operative complications related to hardware placement. CONCLUSION: To the authors' knowledge, this is the first reported literature combining S2-AI screws with electronic conductivity for immediate intraoperative feedback. This technique has the opportunity to provide surgeons with increased accuracy for placement of S2-AI screws while improving overall radiation safety. This feedback can be particularly helpful when surgeons are learning new techniques such as placement of S2AI screws.

Socioeconomic Disparities Affecting the Presentation and Outcomes in Pediatric Subdural Empyema Patients.

BACKGROUND AND OBJECTIVES: Pediatric subdural empyemas (SDE) carry significant morbidity and mortality, and prompt diagnosis and treatment are essential to ensure optimal outcomes. Nonclinical factors affect presentation, time to diagnosis, and outcomes in several neurosurgical conditions and are potential causes of delay in presentation and treatment for patients with SDE. To evaluate whether socioeconomic status, race, and insurance status affect presentation, time to diagnosis, and outcomes for children with subdural empyema. METHODS: We conducted a retrospective cohort study with patients diagnosed with SDE between 2005 and 2020 at our institution. Information regarding demographics (age, sex, zip code, insurance status, race/ethnicity) and presentation (symptoms, number of prior visits, duration of symptoms) was collected. Outcome measures included mortality, postoperative complications, length of stay, and discharge disposition. RESULTS: 42 patients were diagnosed with SDE with a mean age of 9.5 years. Most (85.7%) (n = 36) were male ( P = .0004), and a majority, 28/42 (66.7%), were African American ( P < .0001). There was no significant difference in socioeconomic status based on zip codes, although a significantly higher number of patients were on public insurance ( P = .015). African American patients had a significantly longer duration of symptoms than their Caucasian counterparts (8.4 days vs 1.8 days P = .0316). In total, 41/42 underwent surgery for the SDE, most within 24 hours of initial neurosurgical evaluation. There were no significant differences in the average length of stay. The average length of antibiotic duration was 57.2 days and was similar for all patients. There were no significant differences in discharge disposition based on any of the factors identified with most of the patients (52.4%) being discharged to home. There was 1 mortality (2.4%). CONCLUSION: Although there were no differences in outcomes based on nonclinical factors, African American men on public insurance bear a disproportionately high burden of SDE. Further investigation into the causes of this is warranted.

Fetal Neurosurgical Interventions for Spinal Malformations, Cerebral Malformations, and Hydrocephalus: Past, Present, and Future.

In this article we review the last 40 years of progress in fetal neurosurgery with special attention to current controversies and upcoming challenges in the field. We surveyed the published literature describing prenatal interventions for spinal malformations, cerebral malformations, and hydrocephalus. Even the most mature treatment paradigm, intrauterine repair of myelomeningocele, stands to benefit from advances in imaging and therapeutic modalities to improve patient selection, refine surgical techniques, validate novel biologic therapies, and streamline postoperative patient care. Other conditions under evaluation include congenital cerebral malformations, such as encephalocele, cerebrovascular malformations, and hydrocephalus. We describe cross-cutting needs for advances in fetal neuroimaging, basic disease models and new therapeutic devices to support further progress across various neurosurgical conditions affecting patients during the fetal period.