The role of blood product removal in intraventricular hemorrhage of prematurity: a meta-analysis of the clinical evidence.

INTRODUCTION: Premature neonates have a high risk of intraventricular hemorrhage (IVH) at birth, the blood products of which activate inflammatory cascades that can cause hydrocephalus and long-term neurological morbidities and sequelae. However, there is no consensus for one treatment strategy. While the mainstay of treatment involves CSF diversion to reduce intracranial pressure, a number of interventions focus on blood product removal at various stages including extraventricular drains (EVD), intra-ventricular thrombolytics, drainage-irrigation-fibrinolytic therapy (DRIFT), and neuroendoscopic lavage (NEL). METHODS: We performed a systematic review and meta-analysis to compare the risks and benefits commonly associated with active blood product removal treatment strategies. We searched MEDLINE, Embase, Scopus, Cochrane Library, and CINAHL databases through Dec 2020 for articles reporting on outcomes of EVDs, thrombolytics, DRIFT, and NEL. Outcomes of interest were rate of conversion to ventriculoperitoneal shunt (VPS), infection, mortality, secondary hemorrhage, and cognitive disability. RESULTS: Of the 10,398 articles identified in the search, 23 full-text articles representing 22 cohorts and 530 patients were included for meta-analysis. These articles included retrospective, prospective, and randomized controlled studies on the use of EVDs (n = 7), thrombolytics (n = 8), DRIFT therapy (n = 3), and NEL (n = 5). Pooled rates of reported outcomes for EVD, thrombolytics, DRIFT, and NEL for ventriculoperitoneal shunt (VPS) placement were 51.1%, 43.3%, 34.3%, and 54.8%; for infection, 15.4%, 12.5%, 4.7%, and 11.0%; for mortality, 20.0%, 11.6%, 6.0%, and 4.9%; for secondary hemorrhage, 5.8%, 7.8%, 20.0%, and 6.9%; for cognitive impairment, 52.6%, 50.0%, 53.7%, and 50.9%. Meta-regression using type of treatment as a categorical covariate showed no effect of treatment modality on rate of VPS conversion or cognitive disability. CONCLUSION: There was a significant effect of treatment modality on secondary hemorrhage and mortality; however, mortality was no longer significant after adjusting for year of publication. Re-hemorrhage rate was significantly higher for DRIFT (p < 0.001) but did not differ among the other modalities. NEL also had lower mortality relative to EVD (p < 0.001) and thrombolytics (p = 0.013), which was no longer significant after adjusting for year of publication. Thus, NEL appears to be safer than DRIFT in terms of risk of hemorrhage, and not different than other blood-product removal strategies in terms of mortality. Outcomes-in terms of shunting and cognitive impairment-did not differ. Later year of publication was predictive of lower rates of mortality, but not the other outcome variables. Further prospective and randomized studies will be necessary to directly compare NEL with other temporizing procedures.

Pediatric spinal intramedullary anaplastic myxopapillary ependymoma: a case report.

A 6-year-old girl presented with a 1-week history of progressive upper and lower extremity weakness and bilateral upper extremity dysesthesia. Imaging demonstrated a 4.7 × 1.2-cm enhancing intramedullary lesion in the cervical spine from level C2 to C5 with associated cystic components and syringomyelia. The patient underwent a C2-C5 laminoplasty, with gross total resection of the intramedullary lesion. Histological analysis showed small to medium-sized epithelioid cells, with predominantly a solid architecture focally infiltrating into the adjacent spinal cord tissue. Focal papillary differentiation was present along with peri-vascular pseudorosettes, mucin microcysts, and globules of dense collagen. Focal anaplasia was noted with mitosis (5/10 HPF), focal necrosis, and elevated Ki67 10-15%. These findings were consistent with a myxopapillary ependymoma with anaplastic features. CSF cytology was negative for tumor cells. MYCN amplification was not present. She was treated with targeted proton-beam radiation therapy. This is the fourth case of an intramedullary anaplastic myxopapillary ependymoma to date, and the first case in the cervical spine reported in the literature.

Vision Outcomes for Pediatric Patients With Optic Pathway Gliomas Associated With Neurofibromatosis Type I: A Systematic Review of the Clinical Evidence.

Children with neurofibromatosis type I (NF1) have a higher predisposition for low-grade astrocytomas of the optic pathway, commonly referred to as optic pathway gliomas (OPGs). OPGs can result in visual deterioration. Treatment outcomes in OPG-NF1 management are often reported around tumor stabilization. We sought to compare vision outcomes associated with different OPG treatment strategies to inform about this important functional metric. A meta-analysis exploring the different modalities to treat children with OPG-NF1 was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines using multiple databases. Of the 113 articles identified in the search, 23 full text articles, representing 564 patients, were included for review. These articles included retrospective, prospective, and randomized controlled studies on observation (n=9), chemotherapy (n=19), radiation therapy (n=6), and surgery (n=7). Of the patients undergoing observation, 87% (60/69) demonstrated stable acuity. In the chemotherapy studies, 27.3% (72/264) demonstrated improved acuity/visual field and/or visual-evoked potential amplitudes, 39.4% (104/264) stable acuity, and 33.3% (88/264) deterioration. Both the radiation and surgical treatments reported worsening acuity at 90.9% (10/11) and 73.3% (11/15), respectively. Causal associations are not known. Indications for and timing of treatment choice warrant larger scale study to provide further understanding.

Visual Outcomes After Treatment for Sporadic Optic Pathway Gliomas in Pediatric Patients: A Systematic Review.

OBJECTIVE: Optic pathway gliomas (OPGs) typically occur in the first decade of life and 40%-50% are not associated with neurofibromatosis 1 (NF1) (sporadic). Management strategies are often patient specific because of the variable and unpredictable course. No study has summarized the effect of treatment strategies on visual outcomes in the subset of pediatric patients with sporadic OPG. METHODS: We conducted a systematic review to determine the nature of visual outcomes in pediatric patients with sporadic, non-NF1-associated OPG using the PubMed, Embase, Scopus, Cochrane, and CINAHL Plus databases. Visual outcomes were categorized as improved, unchanged, or deteriorated. RESULTS: Of 1316 results, 31 articles were included. Treatment indications are unknown with full clinical detail. A total of 45.2% (14/31) reported deteriorated outcomes after treatment, 35.5% (11/31) no change, and 19.4% (6/31) improvement. Of radiotherapy studies, 50.0% (4/8) found no change, 37.5% (3/8) deterioration, and 12.5% (1/8) improvement. Of chemotherapy studies, 35.7% (5/14) each showed improvement and deterioration, whereas 28.6% (4/14) showed no change. Of surgical studies, 62.5% (5/8) indicated deterioration, and 37/5% (3/8) indicated no change. The singular study examining observation reported deterioration in visual outcomes. Factors associated with poor visual outcomes included signs and symptoms of visual decline at presentation, involvement of the intraorbital optic nerve, and intracranial hypertension requiring surgery. Causality cannot be determined from systematic review. CONCLUSIONS: Most studies showed that vision in pediatric patients with sporadic OPG is stable to poor after observation, chemotherapy, radiotherapy, or surgery. Chemotherapy may be associated with most favorable visual outcomes.

Laser speckle imaging to evaluate scalp flap blood flow during closure in neurosurgical procedures.

Background: To measure the degree of relative ischemia caused by skin closure, we explored the potential utility of intraoperative surface blood flow measurement with laser speckle imaging (LSI). Methods: Prospective observational study of eight subjects that underwent intraoperative LSI during elective cranial neurosurgical procedures at the time of skin closure. Results: Seven 1st time incisions, with closure techniques including sutures (n = 3), staples (n = 3), and one after galeal sutures. When compared to the control region, there was a mean 63.7% reduction in flow across all seven subjects (range 18.7-95.32%). Comparing by closure type, a higher flow reduction in the three subjects with suture closure (80.7% reduction) compared to staples (61.9% reduction, P = 0.0379). One subject had a complex wound where tightening and loosening of sutures were performed to ensure adequate perfusion. Suturing resulted in significantly more local decreased flow compared to staples (P < 0.0001). Conclusion: These findings demonstrate the relative feasibility of using LSI for preoperative vascular flow assessment in planning complex incision closure. These data also provide preliminary support for the hypothesis that skin closure itself causes relative ischemia compared to deep approximation or cautery of the skin edge and that the relative ischemia from staples closure is generally less than from suture closure.

Use of Standardized History and Physical Examination for Neurosurgical Patients Improves Clinical Documentation and Reimbursement.

BACKGROUND: Documentation is the cornerstone of good patient care and vital to proper coding and billing. Consistent and standardized documentation improves communication among physicians and can lead to better reimbursement. By understanding which elements in the neurosurgery history and physical examination are omitted the most often and the effects on the coding level, institutional-specific solutions can be implemented. METHODS: We performed a retrospective study of neurosurgical patients at a single academic institution who undergone a neurosurgery history and physical examination for an initial inpatient admission from July 2015 to July 2016. The data collected included documentation type (typed, dictated, dynamic documentation without a template, neurosurgery history and physical examination template [NHPT]) and ultimate coding level (1, 2, or 3) determined by a review by a professional coder. RESULTS: A total of 609 notes were reviewed. Of the 609 notes, 88 (14.4%) were missing an element of documentation. The most common missing element was the physical examination (40 of 88; 45.5%), followed by a combination (27 of 88; 30.7%), review of systems (14 of 88; 15.9%), and medical, family, and/or social history (7 of 88; 8.0%). The dynamic documentation without template notes had the highest percentage of missing elements (49 of 96; 51.0%), followed by the typed notes (7 of 49; 14.3%) and dictated notes (30 of 268; 11.2%) compared with the NHPT notes (2 of 196; 1.0%). CONCLUSION: The most common missing elements for inpatient neurosurgery documentation were the review of systems and physical examination. The documents with the highest percentage of missing elements were those that used dynamic documentation without a template. We recommend implementing a dedicated NHPT to improve capturing these elements for improved clinical documentation. Such changes could also improve the coding level and subsequent reimbursement.

Spreading depolarization may represent a novel mechanism for delayed fluctuating neurological deficit after chronic subdural hematoma evacuation.

OBJECTIVE: Most patients with chronic subdural hematoma (cSDH) recover after surgical evacuation with a straightforward course. There is a subset of patients who develop transient and fluctuating deficits not explained by seizures, stroke, or mass effect after evacuation. The objective of this study was to investigate whether these postoperative neurological deficits may be related to temporary brain dysfunction caused by cortical spreading depolarizations (SDs). METHODS: The authors conducted a prospective observational study of 40 patients who underwent cSDH evacuation. At the time of surgery, a 1 × 6 subdural electrode strip was placed on the cortex parallel to the subdural drain. Clinical outcomes were assessed utilizing the Markwalder Grading Scale, need for clinical EEG for new deficit, and presence of new deficits. RESULTS: Definitive SD was detected in 6 (15%) of 40 patients. Baseline and cSDH characteristics did not differ between patients with and without SD. More patients experienced postoperative neurological deterioration if they had SD (50%) compared to those without SD (8.8%; p = 0.03). Only 2 patients in the entire cohort demonstrated early neurological deterioration, both of whom had SD. One of these cases demonstrated a time-locked new focal neurological deficit (aphasia) at the start of a series of multiple clusters of SD. CONCLUSIONS: This is the first observation of SD occurring after cSDH evacuation. SD occurred at a rate of 15% and was associated with neurological deterioration. This may represent a novel mechanism for otherwise unexplained fluctuating neurological deficit after cSDH evacuation. This could provide a new therapeutic target, and SD-targeted therapies should be evaluated in prospective clinical trials.

Resolution of giant basilar artery aneurysm compression and reversal of sensorineural hearing loss with use of a flow diverter: case report.

The authors present an unusual case of a 15-year-old boy in whom sensorineural hearing loss and disequilibrium developed in the setting of a giant basilar artery aneurysm. This patient was treated with a flow-diverting stent and had complete resolution of his clinical symptoms including hearing loss. This case demonstrates the efficacy of flow diversion in select pediatric patients with posterior circulation aneurysms. The features that are thought to result in successful treatment are discussed.