Low surgical weight associated with ETV failure in pediatric hydrocephalus patients.

The use of endoscopic third ventriculostomy (ETV) for treatment of pediatric hydrocephalus has higher failure rates in younger patients. Here we investigate the impact of select perioperative variables, specifically gestational age, chronological age, birth weight, and surgical weight, on ETV failure rates. A retrospective review was performed on patients treated with ETV - with or without choroid plexus cauterization (CPC) - from 2010 to 2021 at a large academic center. Analyses included Cox regression for independent predictors and Kaplan-Meier survival curves for time to-event outcomes. In total, 47 patients were treated with ETV; of these, 31 received adjunctive CPC. Overall, 66% of the cohort experienced ETV failure with a median failure of 36 days postoperatively. Patients aged < 6 months at time of surgery experienced 80% failure rate, and those > 6 months at time of surgery experienced a 41% failure rate. Univariate Cox regression analysis showed weight at the time of ETV surgery was significantly inversely associated with ETV failure with a hazard ratio of 0.92 (95% CI 0.82, 0.99). Multivariate analysis redemonstrated the inverse association of weight at time of surgery with ETV failure with hazard ratio of 0.76 (95% CI 0.60, 0.92), and sensitivity analysis showed < 4.9 kg as the optimal cutoff predicting ETV/CPC failure. Neither chronologic age nor gestational age were found to be significantly associated with ETV failure.In this study, younger patients experienced higher ETV failure rates, but multivariate regression found that weight was a more robust predictor of ETV failure than chronologic age or gestational age, with an optimal cutoff of 4.9 kg in our small cohort. Given the limited sample size, further study is needed to elucidate the independent role of weight as a peri-operative variable in determining ETV candidacy in young infants. Previous presentations: Poster Presentation, Congress of Neurological Surgeons.

Autonomic dysfunction in patients with tectal plate compression: A systematic review.

INTRODUCTION: Pineal region lesions can result in tectal plate compression, hydrocephalus, and associated symptoms including headache, Parinaud's Syndrome, and epileptic phenomena. No studies have looked at the relationship between these lesions and the autonomic nervous system. METHODS: To evaluate the clinical presentation of pineal lesions secondary to tectal plate compression with a focus on autonomic dysfunction, a systematic review was completed following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Case reports and prospective and retrospective studies on patients with pineal or tectal region lesions were included. RESULTS: Of 73 identified studies, 43 underwent full text screening. 26 studies (n=363 patients; age range 0-69 years) were included. 47.1% of patients were male (n=171). Obstructive hydrocephalus was identified in 119 patients (32.8%). The most common symptom was headache (n=228, 62.8%), followed by epileptic phenomena (n=76, 20.9%). Vision related symptoms were identified in 88 patients (24.2%). 251 patients (69.1%) had symptoms associated with autonomic dysfunction including dizziness, nausea, pupillary dysfunction, photophobia and fatigue. Of the 200 (55%) patients who underwent surgery, 135 patients (67.5%) had improved or resolved symptoms post-operatively, including 120 patients with improved autonomic dysfunction symptoms. CONCLUSIONS: Though these lesions are most characterized by Parinaud's syndrome and hydrocephalus, this review suggests dysfunction of the autonomic nervous system may be at play and require consideration at initial presentation and treatment.

Postconception age at surgery as a predictor of ventriculoperitoneal shunt failure.

OBJECTIVE: The gold standard of pediatric hydrocephalus management is the ventriculoperitoneal (VP) shunt. However, VP shunts have high failure rates, and both young age and prematurity have been identified as potential risk factors for shunt failure, although neither variable describes total development at the time of surgery. This study aimed to further characterize age and shunt failure through the use of postconception age at surgery (PCAS) as well as investigate the 40-week PCAS threshold initially described in 1999. METHODS: A retrospective analysis was conducted on all first-time shunt placements at the authors' institution from 2010 to 2021. The National Surgical Quality Improvement Program (NSQIP) pediatric hydrocephalus dataset was used as a parallel analysis to ensure representativeness of the national pediatric hydrocephalus population. RESULTS: In the institutional cohort, infants with a PCAS < 40 weeks exhibited 2.4 times greater odds of shunt failure than those with a PCAS ≥ 40 weeks. In the NSQIP dataset, infants with a PCAS < 40 weeks had 1.45 times greater odds of shunt failure compared with those with a PCAS ≥ 40 weeks. CONCLUSIONS: The 40-week PCAS threshold appears to be a significant predictor of shunt failure in pediatric patients with hydrocephalus. This finding underscores the importance of considering the developmental stage at the time of surgery, rather than just prematurity status, when assessing shunt failure risk.

Synthetic interpolated DSA for radiation exposure reduction via gamma variate contrast flow modeling: a retrospective cohort study.

BACKGROUND: Digital subtraction angiography (DSA) yields high cumulative radiation dosages (RD) delivered to patients. We present a temporal interpolation of low frame rate angiograms as a method to reduce cumulative RDs. METHODS: Patients undergoing interventional evaluation and treatment of cerebrovascular vasospasm following subarachnoid hemorrhage were retrospectively identified. DSAs containing pre- and post-intervention runs capturing the full arterial, capillary, and venous phases with at least 16 frames each were selected. Frame rate reduction (FRR) of the original DSAs was performed to 50%, 66%, and 75% of the original frame rate. Missing frames were regenerated by sampling a gamma variate model (GVM) fit to the contrast response curves to the reduced data. A formal reader study was performed to assess the diagnostic accuracy of the "synthetic" studies (sDSA) compared to the original DSA. RESULTS: Thirty-eight studies met inclusion criteria (average RD 1,361.9 mGy). Seven were excluded for differing views, magnifications, or motion. GVMs fit to 50%, 66%, and 75% FRR studies demonstrated average voxel errors of 2.0 ± 2.5% (mean ± standard deviation), 6.5 ± 1.5%, and 27 ± 2%, respectively for anteroposterior projections, 2.0 ± 2.2%, 15.0 ± 3.1%, and 14.8 ± 13.0% for lateral projections, respectively. Reconstructions took 0.51 s/study. Reader studies demonstrated an average rating of 12.8 (95% CI 12.3-13.3) for 75% FRR, 12.7 (12.2-13.2) for 66% FRR and 12.0 (11.5-12.5) for 50% FRR using Subjective Image Grading Scale. Kendall's coefficient of concordance resulted in W = 0.506. CONCLUSION: FRR by 75% combined with GVM reconstruction does not compromise diagnostic quality for the assessment of cerebral vasculature. RELEVANCE STATEMENT: Using this novel algorithm, it is possible to reduce the frame rate of DSA by as much as 75%, with a proportional reduction in radiation exposure, without degrading imaging quality. KEY POINTS: • DSA delivers some of the highest doses of radiation to patients. • Frame rate reduction (FRR) was combined with bolus tracking to interpolate intermediate frames. • This technique provided a 75% FRR with preservation of diagnostic utility as graded by a formal reader study for cerebral angiography performed for the evaluation of cerebral vasospasm. • This approach can be applied to other types of angiography studies.

Clinical Indications for Rapid Sequence MRI in Pediatric Neurosurgical Patients and the Limitations and Barriers to Implementation.

Rapid and fast magnetic resonance imaging (MRI) protocols have become increasingly popular for pediatric neurosurgical patients as they are a great way to reduce ionizing radiation and sedation. While their popularity has increased, there are hurdles to overcome when transitioning to using them clinically, such as cost, staffing training, and motion artifact. Through this paper, we developed a protocol for clinical applications where rapid MRI can be a substitute or adjuvant in diagnostic workup. Further, we outline the relevant literature for the use of RS-MRI for the spine, TBI, and hydrocephalus pathologies while expanding upon the limitations and logistical barriers when transitioning to their use, a few of which are discussed above. Through this, we conclude that RS-MRI can be used diagnostically for spinal pathologies such as syrinx and hydrocephalus. Further, its lack of sensitivity for TBI findings makes rapid sequence magnetic resonance imaging (RS-MRI) a strong adjuvant with other advanced imaging or computed tomography (CT) for traumatic brain injury (TBI) pathologies.

Active Teaching Techniques Using Virtual Didactics: Novel Experience From a National Neurosurgery Resident Course.

OBJECTIVE: To investigate the attitudes of neurosurgery residents regarding active teaching techniques and virtual didactics based on a national neurosurgery resident sample. We also evaluated the relative cost and time commitment required for faculty participation in virtual versus in-person resident courses. DESIGN: The Society of Neurological Surgeons (SNS) national junior resident courses (JRCs) were reformatted for active teaching in a virtual setting in 2020 due to the COVID-19 pandemic. We analyzed course evaluations from the virtual 2020 courses in comparison to the 2019 in-person SNS JRCs. We also compared course budgets and agendas from these courses to identify comparative costs and the time commitment for faculty participation using these 2 course models. SETTING: Survey of nationwide participants in virtual junior resident courses. PARTICIPANTS: A total of 122 residents from 80 ACGME neurosurgery residency training programs attended the 2020 virtual JRC. RESULTS: The survey response rate of attendees was 36%. In-class engagement was thought to be good to great by 73% to 80% of the virtual learners. In-class activities and active learning techniques also were evaluated positively by 61% to 82% of respondents. Expenses were significantly lower for the virtual course, at $118 per course participant, than for the in-person course ($2722 per participant). There also was a 97.3% reduction of faculty hours and a 97.6% reduction of faculty cost for the virtual JRC compared to the in-person course. CONCLUSIONS: Neurosurgeon residents embraced the active teaching techniques used to teach portions of the prepandemic JRCs in a virtual format. Other aspects of the course curriculum could not be replicated virtually. Virtual courses were dramatically less expensive to produce, used fewer faculty teachers and required less time per faculty member. The data from this study may inform the choice of active teaching techniques for other neurosurgery residency and continuing medical education courses to optimize learner engagement and participant satisfaction in the virtual setting. We recommend that the curriculum of in-person courses emphasize hands-on, experiential learning and professional enculturation that cannot be recreated in the virtual space. Curricular elements suitable to virtual learning should take advantage of lower costs, reduced faculty time requirements, and scalability. They should also utilize active teaching techniques to improve learner engagement.

Concussion Symptomology By Symptom Resolution Time in US High School Athletes: Findings From The National Athletic Treatment, Injury and Outcomes Network (NATION) High School Surveillance Program.

CONTEXT: Concussions incurred during high school athletics are a significant health concern, and studies examining concussions with symptom resolution time (SRT) of 15-28 days have been limited. OBJECTIVE: To compare concussions that had a SRT of 15-28 days with concussions that had a SRT of >28 days among US High School athletes. DESIGN: Descriptive epidemiology study. SETTING: Secondary school athletic training clinics. PATIENTS OR OTHER PARTICIPANTS: Secondary school athletes. MAIN OUTCOME MEASURE(S): Concussion frequency, symptom number, and symptom prevalence. RESULTS: Among all 917 reported concussions (of which 50.8% had missing SRT), 88 had SRT recorded as 15-28 days and 29 had SRT recorded as >28 days. Greater frequencies of concussions with SRT >15 days were reported among boys' sports (n= 78) than girls' sports (n= 39). Boys' football (51.7%) and girls' basketball (11.5%) accounted for the largest proportions of all reported concussions with SRT of 15-28 days; boys' football (58.6%) accounted for the greatest proportion of concussions reported with SRT >28 days. The average number of symptoms in concussions with SRT of 15-28 days was 6.3±3.4 and 7.2±3.8 in those with SRT >28 days. The most frequently reported symptoms in concussions with both SRT of 15-28 days and >28 days were headache, dizziness, sensitivity to light, and difficulty concentrating. The prevalence of irritability was higher in concussions with SRT of 15-28 days as compared to concussions with SRT >28 days (26.1% vs. 13.8%); visual problems (48.3% vs. 35.2%) and hyperexcitability (24.1% vs. 15.9%) were more prevalent in concussion with SRT >28 days, although differences were not statistically significant. CONCLUSIONS: Symptom prevalence and total count were comparable between concussions with SRT of 15-28 days and >28 days with no statistically significant difference, suggesting symptom burden within these groups are more similar than they are different.

Factors associated with radiation necrosis and intracranial control in patients treated with immune checkpoint inhibitors and stereotactic radiotherapy.

BACKGROUND AND PURPOSE: Emerging data suggest immune checkpoint inhibitors (ICI) and stereotactic radiosurgery (SRS) or radiotherapy (SRT) may work synergistically, potentially increasing both efficacy and toxicity. This manuscript characterizes factors associated with intracranial control and radiation necrosis in this group. MATERIALS AND METHODS: All patients had non-small cell lung cancer, renal cell carcinoma, or melanoma and were treated from 2013 to 2021 at two institutions with ICI and SRS/SRT. Univariate and multivariate analysis were used to analyze factors associated with local failure (LF) and grade 2+ (G2 + ) radiation necrosis. RESULTS: There were 179 patients with 549 metastases. The median follow up from SRS/SRT was 14.7 months and the median tumor size was 7 mm (46 tumors ≥ 20 mm). Rates of LF and G2 + radiation necrosis per metastasis were 5.8% (32/549) and 6.9% (38/549), respectively. LF rates for ICI +/- 1 month from time of radiation versus not were 3% (8/264) and 8% (24/285) (p = 0.01), respectively. G2 + radiation necrosis rates for PD-L1 ≥ 50% versus < 50% were 17% (11/65) and 3% (5/203) (p=<0.001), respectively. PD-L1 ≥ 50% remained significantly associated with G2 + radiation necrosis on multivariate analysis (p = 0.03). Rates of intracranial failure were 54% (80/147) and 17% (4/23) (p = 0.001) for those without and with G2 + radiation necrosis, respectively. CONCLUSIONS: PD-L1 expression (≥50%) may be associated with higher rates of G2 + radiation necrosis, and there may be improved intracranial control following the development of radiation necrosis. Administration of ICIs with SRS/SRT is overall safe, and there may be some local control benefit to delivering these concurrently.

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Surgical Interventions.

BACKGROUND: Chiari malformation type I (CIM) diagnoses have increased in recent years. Controversy regarding the best operative management prompted a review of the literature to offer guidance on surgical interventions. OBJECTIVE: To assess the literature to determine (1) whether posterior fossa decompression or posterior fossa decompression with duraplasty is more effective in preoperative symptom resolution; (2) whether there is benefit from cerebellar tonsillar resection/reduction; (3) the role of intraoperative neuromonitoring; (4) in patients with a syrinx, how long should a syrinx be observed for improvement before additional surgery is performed; and 5) what is the optimal duration of follow-up care after preoperative symptom resolution. METHODS: A systematic review was performed using the National Library of Medicine/PubMed and Embase databases for studies on CIM in children and adults. The most appropriate surgical interventions, the use of neuromonitoring, and clinical improvement during follow-up were reviewed for studies published between 1946 and January 23, 2021. RESULTS: A total of 80 studies met inclusion criteria. Posterior fossa decompression with or without duraplasty or cerebellar tonsil reduction all appeared to show some benefit for symptom relief and syrinx reduction. There was insufficient evidence to determine whether duraplasty or cerebellar tonsil reduction was needed for specific patient groups. There was no strong correlation between symptom relief and syringomyelia resolution. Many surgeons follow patients for 6-12 months before considering reoperation for persistent syringomyelia. No benefit or harm was seen with the use of neuromonitoring. CONCLUSION: This evidence-based clinical guidelines for the treatment of CIM provide 1 Class II and 4 Class III recommendations. In patients with CIM with or without syringomyelia, treatment options include bone decompression with or without duraplasty or cerebellar tonsil reduction. Improved syrinx resolution may potentially be seen with dural patch grafting. Symptom resolution and syrinx resolution did not correlate directly. Reoperation for a persistent syrinx was potentially beneficial if the syrinx had not improved 6 to 12 months after the initial operation. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/3-surgical-interventions .

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Diagnosis.

BACKGROUND: Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians. OBJECTIVE: To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM. METHODS: PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines. RESULTS: The literature search yielded 567 abstracts, of which 151 were selected for full-text review, 109 were then rejected for not meeting the inclusion criteria or for being off-topic, and 42 were included in this systematic review. CONCLUSION: Three Grade C recommendations were made based on Level III evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/1-imaging .

Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines for Patients With Chiari Malformation: Symptoms.

BACKGROUND: Chiari I malformation (CIM) is characterized by descent of the cerebellar tonsils through the foramen magnum, potentially causing symptoms from compression or obstruction of the flow of cerebrospinal fluid. Diagnosis and treatment of CIM is varied, and guidelines produced through systematic review may be helpful for clinicians. OBJECTIVE: To perform a systematic review of the medical literature to answer specific questions on the diagnosis and treatment of CIM. METHODS: PubMed and Embase were queried between 1946 and January 23, 2021, using the search strategies provided in Appendix I of the full guidelines. RESULTS: The literature search yielded 430 abstracts, of which 79 were selected for full-text review, 44 were then rejected for not meeting the inclusion criteria or for being off-topic, and 35 were included in this systematic review. CONCLUSION: Four Grade C recommendations were made based on Class III evidence, and 1 question had insufficient evidence. The full guidelines can be seen online at https://www.cns.org/guidelines/browse-guidelines-detail/2-symptoms .

Social Disparities in Helmet Usage in Bicycle Accidents Involving Children.

Background Bicycle helmet use has a known protective health benefit; yet, pediatric populations have suboptimal helmet rates, which increases the risk of severe injuries. It is imperative to have an updated assessment of behavioral social disparities and for providers to be aware of them to better counsel patients. The study objective was to identify social determinants correlated with helmet use in children involved in bicycle accidents. Based on previous literature, we hypothesized that higher socioeconomic status, female sex, and Caucasian race were associated with increased helmet use. Methods A retrospective case series of 140 pediatric cases of bicycle-related traumas assessing helmet status. Participants presented to the emergency room with injuries due to a bicycle-related trauma and were subsequently admitted to the University of North Carolina (UNC) Hospital System in Chapel Hill, North Carolina (NC), from June 2006 to May 2020. The Institutional Review Board (IRB) approved study comprised a retrospective chart review of 140 cases from the pediatric (<18 years of age) trauma database with coding indicating bicycle-related injury. Zip codes were used to approximate the median household income utilizing the Proximity One government database. The primary exposure was helmet status, which was determined from the electronic record chart review. The hypothesis was formulated before the start of the study. The main outcomes measured in the study included age, sex, race, helmet status, zip code, insurance status, injury types, and mortality. Results There were a total of 140 study participants, of which 35 were female and 105 were male. Males comprised 79.6% of the non-helmeted group, while females were in the minority in both helmet status groups, with 65.7% still being non-helmeted. Additionally, 51.9% of patients who were helmeted used private insurance, and 59.3% of those non-helmeted used public insurance. Of the 71 head injuries, 88.7% were non-helmeted. Principally, this study found that 80.7% of children involved in a bicycle-related accident were not helmeted.  Conclusions Despite NC legislation mandating that children under 16 years of age wear helmets while operating bicycles, many children injured in bicycle-related trauma are not complying with this requirement. This study demonstrates that specific populations have decreased rates of helmet usage and emphasize the continued need to monitor helmet behaviors.

Infantile Myofibromatosis With Cutaneous, Visceral, and CNS Involvement: A Multimodal Approach to Therapy.

BACKGROUND: Infantile myofibromatosis (IM) is a rare benign tumor of infancy. Cases with solitary and multicentric disease usually spontaneously regress, but multicentric disease with visceral involvement carries a poor prognosis. Few cases of multicentric disease with central nervous system (CNS) involvement have been reported, and none report survival. OBSERVATIONS: We present a newborn with multicentric IM with cutaneous, visceral, and CNS involvement. She was treated with vinblastine, methotrexate, and the novel addition of intrathecal methotrexate with treatment response after 1 year of therapy. CONCLUSIONS: Multicentric IM with CNS involvement can be successfully treated with a multimodal approach of chemotherapy with the addition of intrathecal methotrexate and surgery.

Survey Study of Clerkship Curriculum on Learner's Choice to Pursue Surgery: Positive Impact of Extracurricular Opportunities.

OBJECTIVE: Prior studies have focused on the role of the learning environment on students' decisions to pursue surgery, but few have analyzed the impact of the clerkship curriculum. This study assessed surgical clerkship curricula across United States (US) medical schools and their impact on students' likelihood of pursuing a surgical residency. DESIGN: A cross-sectional survey was developed to assess surgery clerkship characteristics. Questions included clerkship duration, number of offered and required surgical services, method of service assignment, and number of advanced clinical electives (e.g., fourth-year sub-internships) and additional surgical clinical opportunities (e.g., surgical elective rotations). Survey results were merged by the Association of American Medical Colleges with the percentages of students who matched into a surgical specialty. Linear regression models estimated the association of covariates with the percentage of students who (1) matched in surgical specialties, (2) were interested in surgery at medical school matriculation and ultimately matched into surgical residency (retention rate), and (3) were not interested in surgery at medical school matriculation but ultimately matched into surgical residency (recruitment rate). SETTING: The survey was distributed to clerkship directors and coordinators at 66 medical schools through the Association for Surgical Education (ASE) from 5/1/2021 to 8/1/2021. PARTICIPANTS: All US medical schools in the ASE. RESULTS: A total of 21 medical schools responded (34.8% response rate). The overall retention rate was 36.4%, and the overall recruitment rate was 25.0%. Clerkships were 4 to 12 weeks. In 81% of programs, students submitted preferences and were assigned services. The percentage of students applying to surgical specialties was not associated with clerkship duration (p=0.79) or the number of required services (p=0.15), subspecialty services offered (p=0.33), or advanced clinical electives (p=0.24) but was associated with a program's having additional surgical clinical opportunities (p=0.02). Most of these factors were not associated with retention or recruitment rates. CONCLUSIONS: Offering more extracurricular surgical clinical opportunities was associated with having more students pursue surgical careers. Though limited by a relatively small sample size, our findings suggest that having shorter clerkships or limited subspecialty offerings may not have a significant influence on students' career choices.

Combined rapid sequence MRI protocol and skull radiography as an alternative to head CT in the evaluation of abusive head trauma in children: a pilot study.

The aim of our pilot study was to compare the performance of the RS-MRI protocol combined with skull radiography versus CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage in patients with abusive head trauma (AHT). Additionally, our study aimed to determine whether the presence of scalp hematoma predicts concurrent skull fracture. We conducted a pilot study through retrospective chart review of 24 patients between ages 0 and 15 months who experienced AHT and who received CT, MRI, and skull radiography between May 2020 and August 2021. Two blinded board certified neuroradiologists reviewed the skull radiographs alongside the rapid trauma MRI. Their impressions were documented and compared with findings derived from CT. Combination imaging detected ten out of the 12 skull fractures noted on CT (sensitivity 83.3%, specificity 100%, p=0.48). RS-MRI detected 15 out of the 16 intracranial hemorrhages detected by CT (sensitivity 93.75%, p >0.9). When scalp hematoma was detected on RS-MRI, nine out of the 12 had associated skull fractures when reviewed by radiologist 1 (sensitivity 75%, specificity 100%, p=0.22), and seven out of the 12 had associated skull fractures when reviewed by radiologist 2 (sensitivity 58%, specificity 92%, p=0.25). In pediatric patients with suspected AHT, we found that RS-MRI combined with skull radiographs was not significantly different than CT for the detection of skull fractures, scalp hematomas, and intracranial hemorrhage. This combination has the potential to replace the use of CT as a screening tool for abusive head trauma, while avoiding the risks of sedation often required for routine MRI.

A living ex vivo platform for functional, personalized brain cancer diagnosis.

Functional precision medicine platforms are emerging as promising strategies to improve pre-clinical drug testing and guide clinical decisions. We have developed an organotypic brain slice culture (OBSC)-based platform and multi-parametric algorithm that enable rapid engraftment, treatment, and analysis of uncultured patient brain tumor tissue and patient-derived cell lines. The platform has supported engraftment of every patient tumor tested to this point: high- and low-grade adult and pediatric tumor tissue rapidly establishes on OBSCs among endogenous astrocytes and microglia while maintaining the tumor's original DNA profile. Our algorithm calculates dose-response relationships of both tumor kill and OBSC toxicity, generating summarized drug sensitivity scores on the basis of therapeutic window and allowing us to normalize response profiles across a panel of U.S. Food and Drug Administration (FDA)-approved and exploratory agents. Summarized patient tumor scores after OBSC treatment show positive associations to clinical outcomes, suggesting that the OBSC platform can provide rapid, accurate, functional testing to ultimately guide patient care.

Transillumination of an Anterior Fontanelle Dermoid Cyst.

Dermoid cysts are slowly growing benign lesions of ectodermal tissue that often occur in the anterior fontanelle. Clinicians often rely on a negative transillumination test to begin the process of correctly diagnosing a dermoid cyst. However, here the authors present a case of a 7-month-old girl who presents with a transilluminating dermoid cyst.

Increasing Seizures, Encephalopathy, and Hypothermia in an 18-Year-Old Woman.

ABSTRACT: An 18-year-old woman with a history of focal epilepsy presents with increasingly frequent seizures, encephalopathy, multiple laboratory abnormalities, and hypothermia. During her hospital course, her symptoms waxed and waned. Multiple etiologies of her symptoms were considered, but the spontaneous resolution of her symptoms and an abnormal MRI of the brain revealed the final diagnosis.

Sinonasal complications of severe acute respiratory syndrome coronavirus-2: A single center case series.

Background: The emergence of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) has resulted in an unprecedented global pandemic. Most infected patients are either asymptomatic or have mild upper respiratory infection symptoms. However, life-threatening sequelae have been observed. In this report, we reviewed nine cases of patients with severe complications from sinonasal disease in the setting of acute SARS-CoV-2 infection. Methods: IRB approval was obtained prior to study initiation. A retrospective chart review was performed of patients admitted to a tertiary hospital with complex sinonasal symptoms that required otolaryngologic evaluation and management in the setting of concomitant SARS-CoV-2 infection. Results: Nine patients, ranging from ages 3 to 71 years, with sinonasal disease and simultaneous SARS-CoV-2 infection were identified. Initial presentations ranged from asymptomatic infection to mild/moderate disease (nasal obstruction, cough) or more severe sequelae including epistaxis, proptosis, or neurologic changes. SARS-CoV-2 tests were positive from one to 12 days after symptom onset, with three patients receiving SARS-CoV-2-directed treatment. Complex disease presentations included bilateral orbital abscesses, suppurative intracranial infection, cavernous sinus thrombosis with epidural abscess, systemic hematogenous spread with abscess development in four distinct anatomic locations, and hemorrhagic benign adenoidal tissue. Eight of nine patients (88.8%) required operative intervention. Patients with abscesses also required prolonged, culture-directed antibiotic courses. Conclusion: Though most SARS-CoV-2 infections are asymptomatic and/or self-limited, there is significant morbidity and mortality in patients with severe disease sequela as outlined in our reported cases. This suggests early identification and treatment of sinonasal disease in this patient population is critical to minimizing poor outcomes. Further research on the pathophysiology of these atypical presentations is needed. Level of Evidence: 4 (Case Series).