Pediatric blunt cerebrovascular injury: the McGovern screening score.

OBJECTIVE The objective of this study was to assess the incidence, diagnosis, and treatment of pediatric blunt cerebrovascular injury (BCVI) at a busy Level 1 trauma center and to develop a tool for accurately predicting pediatric BCVI and the need for diagnostic testing. METHODS This is a retrospective cohort study of a prospectively collected database of pediatric patients who had sustained blunt trauma (patient age range 0-15 years) and were treated at a Level 1 trauma center between 2005 and 2015. Digital subtraction angiography, MR angiography, or CT angiography was used to confirm BCVI. Recently, the Utah score has emerged as a screening tool specifically targeted toward evaluating BCVI risk in the pediatric population. Using logistical regression and adding mechanism of injury as a logit, the McGovern score was able to use the Utah score as a starting point to create a more sensitive screening tool to identify which pediatric trauma patients should receive angiographic imaging due to a high risk for BCVI. RESULTS A total of 12,614 patients (mean age 6.6 years) were admitted with blunt trauma and prospectively registered in the trauma database. Of these, 460 (3.6%) patients underwent angiography after blunt trauma: 295 (64.1%), 107 (23.3%), 6 (1.3%), and 52 (11.3%) patients underwent CT angiography, MR angiography, digital subtraction angiography, and a combination of imaging modalities, respectively. The BCVI incidence (n = 21; 0.17%) was lower than that in a comparable adult group (p < 0.05). The mean patient was age 10.4 years with a mean follow-up of 7.5 months. Eleven patients (52.4%) were involved in a motor vehicle collision, with a mean Glasgow Coma Scale score of 8.6. There were 8 patients (38.1%) with carotid canal fracture, 6 patients (28.6%) with petrous bone fracture, and 2 patients (9.5%) with infarction on initial presentation. Eight patients (38.1%) were managed with observation alone. The Denver, modified Memphis, Eastern Association for the Surgery of Trauma (EAST), and Utah scores, which are the currently used screening tools for BCVI, misclassified 6 (28.6%), 6 (28.6%), 7 (33.3%), and 10 (47.6%) patients with BCVI, respectively, as "low risk" and not in need of subsequent angiographic imaging. By incorporating the mechanism of injury into the score, the McGovern score only misclassified 4 (19.0%) children, all of whom were managed conservatively with no treatment or aspirin. CONCLUSIONS With a low incidence of pediatric BCVI and a nonsurgical treatment paradigm, a more conservative approach than the Biffl scale should be adopted. The Denver, modified Memphis, EAST, and Utah scores did not accurately predict BCVI in our equally large cohort. The McGovern score is the first BCVI screening tool to incorporate the mechanism of injury into its screening criteria, thereby potentially allowing physicians to minimize unnecessary radiation and determine which high-risk patients are truly in need of angiographic imaging.

Phase-contrast cerebrospinal fluid flow magnetic resonance imaging in qualitative evaluation of patency of CSF flow pathways prior to infusion of chemotherapeutic and other agents into the fourth ventricle.

PURPOSE: Nuclear medicine studies have previously been utilized to assess for blockage of cerebrospinal fluid (CSF) flow prior to intraventricular chemotherapy infusions. To assess CSF flow without nuclear medicine studies, we obtained cine phase-contrast MRI sequences that assess CSF flow from the fourth ventricle down to the sacrum. METHODS: In three clinical trials, 18 patients with recurrent malignant posterior fossa tumors underwent implantation of a ventricular access device (VAD) into the fourth ventricle, either with or without simultaneous tumor resection. Prior to infusing therapeutic agents into the VAD, cine MRI phase-contrast CSF flow sequences of the brain and total spine were performed. Velocity encoding (VENC) of 5 and 10 cm/s was used to confirm CSF flow from the fourth ventricular outlets to the cervical, thoracic, and lumbar spine. Qualitative CSF flow was characterized by neuroradiologists as present or absent. RESULTS: All 18 patients demonstrated CSF flow from the outlets of the fourth ventricle down to the sacrum with no evidence of obstruction. One of these patients, after disease progression, subsequently showed obstruction of CSF flow. No patient required a nuclear medicine study to assess CSF flow prior to initiation of infusions. Fourteen patients have received infusions to date, and none has had neurological toxicity. CONCLUSIONS: CSF flow including the fourth ventricle and the total spine can be assessed noninvasively with phase-contrast MRI sequences. Advantages over nuclear medicine studies include avoiding both an invasive procedure and radiation exposure.

Survey of Techniques Utilized to Access Ventricular Shunts and Reservoirs.

AIMS: This study assessed variations in pediatric neurosurgical technique when accessing shunts and ventricular access devices (VADs). METHODS: A 12-question survey was developed and sent to members of the American Association of Neurological Surgeons (AANS) whose self-identified subspecialty was pediatric neurosurgery. RESULTS: Four hundred and twenty surveys were sent out, and 149 responses were received (35.5% response rate); 95.3% of respondents always use sterile gloves, 55.0% never use a sterile gown, and 69.8% always have a member of the neurosurgery team perform the procedure. The majority of respondents answered "sometimes" for use of a facemask (38.3%), sterile drapes (39.6%), site shaving (45.6%), having an attending present (68.5%), and having an assistant hold the patient's head (78.5%). The majority reported using a 23- or 25-gauge butterfly needle for site entry (96.6%), and betadine or ChloraPrep™ as the preferred antiseptic solution (64.4%). The frequency in which CSF is sent for analysis is not standardized in 31.5% of respondents, and wait time for the antiseptic solution to dry is not standardized in 62.4%. CONCLUSIONS: There is great variation in the technique for accessing shunts and VADs. Future studies are needed to assess whether these discrepancies affect infection rates.

Correlating Prenatal Imaging Findings of Fetal Ventriculomegaly with the Need for Surgical Intervention in the First 3 Months after Birth.

BACKGROUND/AIMS: This study evaluates the predictive value of prenatal imaging measurements regarding the need for cerebrospinal fluid (CSF) diversion for fetal hydrocephalus in the first 3 months after birth. METHODS: We retrospectively reviewed a consecutive case series of patients with fetal hydrocephalus from January 2011 to December 2014 (n = 45). Prenatal measurements included head circumference (HC), biparietal diameter (BPD), and lateral ventricle (LV) width. Patients requiring CSF diversion within 12 weeks of birth were compared to those who did not require CSF diversion using the Wilcoxon rank sum test, and receiver-operating characteristic analysis was used to evaluate threshold values. RESULTS: CSF diversion was required within 12 weeks of birth in 30 of 45 patients. Mean LV width (mm) during the entire pregnancy was greater for the surgery group than the nonsurgery group. Neither BPD nor HC showed differences between the groups. A mean LV size ≥15 mm predicted the need for CSF diversion with a sensitivity of 67% and specificity of 73%. CONCLUSION: LV width is the prenatal imaging measurement that best predicts the need for postnatal CSF diversion.

An Outcomes Comparison Between Autologous and Alloplastic Cranioplasty in the Pediatric Population.

BACKGROUND: The use of alloplastic material in cranial reconstruction has been well described in the adult population, especially when a paucity of autologous tissue exists. In children it is unknown how long-term growth, however, may be affected by the implantation of nonexpansible alloplastic material. Therefore, the authors sought to compare the outcomes of pediatric patients undergoing alloplastic versus autologous cranial reconstruction. METHODS: To assess the safety and long-term outcomes of alloplastic cranioplasty in children, an institutional review board-approved, retrospective, single institution review of pediatric patients undergoing cranioplasty was performed from 2000 to 2014. The age at surgery, cause of the cranial defect, defect size, time since initial surgery to reconstruction, implant type, and complications were assessed. Postreconstruction imaging was reviewed if available. RESULTS: A reconstructive cranioplasty was performed in 41 pediatric patients (ages 1-19 years, average 7.35 years). Thirty patients underwent alloplastic reconstruction (age 4.37 ±â€Š5.57 years), and 11 underwent autologous reconstruction (age 2.00 ±â€Š3.74 years). The size of the cranial defects was 144.01 ±â€Š393.04 cm for autologous and 405.31 ±â€Š572.96 cm for alloplastic reconstructions. Follow-up for all patients was an average of 2.33 ±â€Š2.76 years (0.1-9 years). No patients in either group showed evidence of elevated intracranial pressure after cranioplasty. In long-term follow-up, none of the implants were exposed or lost because of infection. Computed tomography and physical examination demonstrated that there was no skull growth restriction in either group. CONCLUSIONS: Our data show that alloplastic cranioplasty in the pediatric population is a safe alternative, when autologous cranial bone is not available.

Ventricular access device placement in the fourth ventricle to treat malignant fourth ventricle brain tumors: technical note.

PURPOSE: Ventricular access devices (VADs) are commonly placed in the lateral ventricle but rarely placed in other ventricular compartments. This manuscript describes technical aspects of VAD placement into the fourth ventricle for the purpose of treating malignant posterior fossa brain tumors. METHODS: As part of a pilot clinical trial to treat recurrent malignant brain tumors in children, seven patients underwent posterior fossa craniotomy and placement of a ventricular catheter under direct vision into the fourth ventricle. The catheter was placed without passing through any brain parenchyma. It was then connected to a VAD placed subcutaneously at the inferior aspect of the incision. Three of the seven patients underwent simultaneous subtotal resection of recurrent tumor located in the fourth ventricle or cerebellum, and one patient underwent simultaneous tumor biopsy. The VAD was used to administer chemotherapy (methotrexate) in five of the seven patients. RESULTS: Six patients had no new neurological deficits after surgery, and one patient had partial left-sided facial weakness that was attributed to resection of tumor close to the floor of the fourth ventricle. No new neurological deficits were caused by VAD placement or by methotrexate infusions into the fourth ventricle. CONCLUSIONS: A VAD for chemotherapy infusion can be placed safely into the fourth ventricle without damaging the brainstem or cerebellum. Attention to anatomical details specific to the fourth ventricle are important when placing a fourth ventricle VAD and when using it to administer chemotherapy.

Linear nondisplaced skull fractures in children: who should be observed or admitted?

OBJECT: In this study the authors reviewed clinical management and outcomes in a large series of children with isolated linear nondisplaced skull fractures (NDSFs). Factors associated with hospitalization of these patients and costs of management were also reviewed. METHODS: After institutional review board approval, the authors retrospectively reviewed clinical records and imaging studies for patients between the ages of 0 and 16 years who were evaluated for NDSFs at a single children's hospital between January 2009 and December 2013. Patients were excluded if the fracture was open or comminuted. Additional exclusion criteria included intracranial hemorrhage, more than 1 skull fracture, or pneumocephalus. RESULTS: Three hundred twenty-six patients met inclusion criteria. The median patient age was 19 months (range 2 weeks to 15 years). One hundred ninety-three patients (59%) were male and 133 (41%) were female. One hundred eighty-four patients (56%) were placed under 23-hour observation, 87 (27%) were admitted to the hospital, and 55 patients (17%) were discharged from the emergency department. Two hundred seventy-eight patients (85%) arrived by ambulance, 36 (11%) arrived by car, and 12 (4%) were airlifted by helicopter. Two hundred fifty-seven patients (79%) were transferred from another institution. The mean hospital stay for patients admitted to the hospital was 46 hours (range 7-395 hours). The mean hospital stay for patients placed under 23-hour observation status was 18 hours (range 2-43 hours). The reasons for hospitalization longer than 1 day included Child Protective Services involvement in 24 patients and other injuries in 11 patients. Thirteen percent (n = 45) had altered mental status or loss of consciousness by history. No patient had any neurological deficits on examination, and none required neurosurgical intervention. Less than 16% (n = 50) had subsequent outpatient follow-up. These patients were all neurologically intact at the follow-up visit. CONCLUSIONS: Hospitalization is not necessary for many children with NDSFs. Patients with mental status changes, additional injuries, or possible nonaccidental injury may require observation.

Methotrexate administration directly into the fourth ventricle in children with malignant fourth ventricular brain tumors: a pilot clinical trial.

We hypothesize that chemotherapy can be safely administered directly into the fourth ventricle to treat recurrent malignant brain tumors in children. For the first time in humans, methotrexate was infused into the fourth ventricle in children with recurrent, malignant brain tumors. A catheter was surgically placed into the fourth ventricle and attached to a ventricular access device. Cerebrospinal fluid (CSF) flow was confirmed by CINE MRI postoperatively. Each cycle consisted of 4 consecutive daily methotrexate infusions (2 milligrams). Disease response was monitored with serial MRI scans and CSF cytologic analysis. Trough CSF methotrexate levels were sampled. Five patients (3 with medulloblastoma and 2 with ependymoma) received 18, 18, 12, 9, and 3 cycles, respectively. There were no serious adverse events or new neurological deficits attributed to methotrexate. Two additional enrolled patients were withdrawn prior to planned infusions due to rapid disease progression. Median serum methotrexate level 4 h after infusion was 0.04 µmol/L. Range was 0.02-0.13 µmol/L. Median trough CSF methotrexate level 24 h after infusion was 3.18 µmol/L (range 0.53-212.36 µmol/L). All three patients with medulloblastoma had partial response or stable disease until one patient had progressive disease after cycle 18. Both patients with ependymoma had progressive disease after 9 and 3 cycles, respectively. Low-dose methotrexate can be infused into the fourth ventricle without causing neurological toxicity. Some patients with recurrent medulloblastoma experience a beneficial anti-tumor effect both within the fourth ventricle and at distant sites.

Follow-up of children exposed in utero to 17 alpha-hydroxyprogesterone caproate compared with placebo.

OBJECTIVE: To assess whether there are evident adverse effects of 17 alpha-hydroxyprogesterone caproate after in utero exposure. METHODS: This study evaluated surviving children of mothers who participated in a multicenter placebo-controlled trial of weekly intramuscular 17 alpha-hydroxyprogesterone caproate, with a 2:1 allocation to 17 alpha-hydroxyprogesterone caproate and placebo, respectively. The guardian was interviewed about the child's general health. Children underwent a physical examination and developmental screen with the Ages and Stages Questionnaire. Gender-specific roles were assessed with the Preschool Activities Inventory. RESULTS: Of 348 eligible surviving children, 278 (80%) were available for evaluation (194 in the 17 alpha-hydroxyprogesterone caproate group and 84 in the placebo group). The mean age at follow-up was 48 months. No significant differences were seen in health status or physical examination, including genital anomalies, between 17 alpha-hydroxyprogesterone caproate and placebo children. Scores for gender-specific roles (Preschool Activities Inventory) were within the normal range and similar between 17 alpha-hydroxyprogesterone caproate and placebo groups. CONCLUSION: 17 alpha-hydroxyprogesterone caproate seems to be safe for the fetus when administered in the second and third trimesters.

Maternal stressors during prolonged antepartum hospitalization following transfer for maternal-fetal indications.

Our objective was to identify stressors in women requiring prolonged hospitalization following maternal-fetal transfer to a tertiary care center. Using a modified version of the previously validated Antepartum Hospital Stressors Inventory (AHSI), all women transferred to our university-based maternal-fetal service between May 2000 and June 2002 and hospitalized for greater than 1 month completed a semi-structured interview. The AHSI uses Likert scales to evaluate environment, health factors, communication with health care providers, family separation, self-image, and emotional and family status issues as stressors. Nine consecutive women met inclusion criteria and all agreed to participate. Median maternal age was 27 years (range 19 to 33), and gestational age at transfer was 25 weeks (range 20 to 31). Parity ranged from 0 to 3 and educational level ranged from grade 2 to graduate degrees. The women were from Caucasian, Hispanic, and Asian racial-ethnic backgrounds; all were married. Median distance from transferring hospital was 20 miles (range 10 to 275 miles). All patients reported separation from family, sleeping alone, anxiety about the pregnancy and the baby's health, boredom, and eating hospital meals as the greatest stressors. Stress was relieved in all women by ultrasounds, family members staying in the room, cable television, and internet access. Routine beauty maintenance, massage, physical therapy, and continued contact with referring physician were also cited as stress alleviators. Following maternal-fetal transfer, prolonged antepartum hospitalization is associated with stress that may be alleviated by access to the outside world via television and the internet, liberal visitation, access to health and beauty maintenance, and ongoing contact with the referring physician.