National multicentered retrospective review of clinical and intraoperative factors associated with the development of cerebellar mutism after pediatric posterior fossa tumor resection.

BACKGROUND: Cerebellar mutism (CM) is characterized by a significant loss of speech in children following posterior fossa (PF) surgery. The biological origin of CM remains unclear and is the subject of ongoing debate. Significant recovery from CM is less likely than previously described despite rigorous multidisciplinary neuro-rehabilitational efforts. METHODS: A national multi-centered retrospective review of all children undergoing PF resection in four midsized Canadian academic pediatric institutions was undertaken. Patient, tumor and surgical factors associated with the post-operative development of CM were reviewed. Retrospective identification of PF surgery patients including those developing and those that did not (internal control). RESULTS: The study identified 258 patients across the 4 centers between 2010 and 2020 (mean age 6.73 years; 42.2% female). Overall, CM was experienced in 19.5% of patients (N = 50). Amongst children who developed CM histopathology included medulloblastoma (35.7%), pilocytic astrocytoma (32.6%) and ependymoma (17.1%). Intraoperative impression of adherence to the floor of the 4th ventricle was positive in 36.8%. Intraoperative abrupt changes in blood pressure and/or heart rate were identified in 19.4% and 17.8% of cases. The clinical resolution of CM was rated to be complete, significant resolution, slight improvement, no improvement and deterioration in 56.0%, 8.0%, 20.0%, 14.0% and 2.0%, respectively. In the cohort of children who experienced post-operative CM as compared to their no-CM counterpart, proportionally more tumors were felt to be adherent to the floor of the 4th ventricle (56.0% vs 49.5%), intraoperative extent of resection was a GTR (74% vs 68.8%) and changes in heart rate were noted (≥ 20% from baseline) (26.0% vs 15.9%). However, a multiple regression analysis identified only abrupt changes in HR (OR 5.97, CI (1.53, 23.1), p = 0.01) to be significantly associated with the development of post-operative CM. CONCLUSION: As a devastating surgical complication after posterior fossa tumor surgery with variable clinical course, identifying and understanding the operative cues and revising intraoperative plans that optimizes the child's neurooncological and clinical outcome are essential.

Quality of life and satisfaction in surgical versus conservative treatment of nonsyndromic children with craniosynostosis.

OBJECTIVE: Craniosynostosis represents the second most common reason for referral to pediatric neurosurgery. However, the quality of life and neurodevelopmental impact of leaving this physical disorder uncorrected is poorly understood. METHODS: This multicenter cross-sectional study identified previously managed nonsyndromic infants (< 24 months of age) with single-suture craniosynostosis at both pediatric neurosurgical centers in Alberta, Canada. The primary variable of interest was the allocated treatment (surgical vs conservative). The primary outcome was the Pediatric Quality of Life Inventory (PedsQL), a validated measure of quality of life examining physical, emotional, social, and school functioning. Treatment decision satisfaction and the reasons for selected management were quantified and collected directly from caregivers. RESULTS: One hundred fourteen children met the inclusion criteria: 78% underwent surgery and 22% had conservative treatment. The most common suture affected was sagittal (54%), followed by metopic (33%), coronal (10%), and lambdoid (3%). Caregivers most commonly opted for surgery because of severe appearance (80%). Seventy-six percent and 72% of the caregivers of children with conservative management did so due to concerns of surgical risks and mild appearance, respectively. There was a statistically significant relationship between both the parents' (p < 0.001) and the surgeon's (p = 0.001) impression of a severe head shape and surgical management. Parental satisfaction with their child's appearance as well as satisfaction with their treatment decision did not differ between management types. Regarding quality of life, on univariate analysis, the conservative group had a statistically higher physical summary score (p = 0.01), psychosocial summary score (p = 0.004), and mean total scale score (p = 0.003) compared to the surgical group. However, after adjusting for severity and age at consult, no significant independent associations between management type and any of the PedsQL summary scores were found. CONCLUSIONS: Alberta families have a high number of children with craniosynostosis treated with conservative management. Conservatively managed infants were largely minimally affected patients, particularly those with metopic synostosis. The study found no independent association between management type (surgery vs conservative) and quality of life when adjusted for important patient factors.

Prevalence of post-traumatic stress disorder in caregivers of pediatric neurosurgical patients.

BACKGROUND: Having a child receive a neurosurgical diagnosis creates significant stress and anxiety in caregivers. The stress of these life-threatening and emotionally charged diagnoses may put caregivers at risk for developing post-traumatic stress disorder (PTSD). While PTSD has been studied in a variety of caregivers of pediatric populations, to the best of our knowledge, it has yet to be examined in caregivers commonly seen in general pediatric neurosurgical practices. This study was designed to gain an understanding of the prevalence of PTSD within this population. METHODS: A cross-sectional survey method was utilized. Participants completed both a survey to provide demographic information, and the Posttraumatic Stress Checklist for DSM-5 (PCL-5) which is used to make a provisional diagnosis of PTSD. Surveys were distributed both in person and online between December 2018 and April 2019. RESULTS: One hundred sixty-eight surveys were included in the study. According to the DSM-5 diagnostic criteria, 44.6% (n = 75) of caregivers screened positively for a provisional diagnosis of PTSD. The specific neurosurgical diagnosis (p = 0.002), number of surgeries (p = 0.008), and category of the last surgery (p = 0.026) impacted the rate of PTSD symptoms in this population. Most caregivers who screened positive for PTSD experience a high level of disturbing memories and physical reactions to the events and avoid reminders of the medical experience. Caregivers also report a loss of interest in activities, feel distant from other people, and have difficulties with concentration and sleep. There was no significant relationship between caregivers who identified having a high level of anxiety before their child was diagnosed and who screened positive for PTSD. CONCLUSION: This study has identified a higher number of caregivers screening positive for PTSD within pediatric neurosurgical patients, than previously reported in other populations. Specific neurosurgical diagnosis, number of surgeries, and category of last surgery all impact a positive screen for the condition. Caregivers who avoid remembering events surrounding their child's diagnosis are at a higher risk of having the condition. The results highlight the need to identify ways to decrease the impact of a pediatric neurosurgical diagnosis on the mental health of caregivers. Future research focused on early mental health intervention for caregivers of pediatric neurosurgical patients may be helpful in reducing the long-term impact of this difficult condition.