Pediatric Hydrocephalus

Pediatric Hydrocephalus

by Giuseppe Cinalli (Editor), M. Memet Özek (Editor), Christian Sainte-Rose (Editor)

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Since the first edition of this book, the impressive development of neuroendoscopy has dramatically changed the surgical approach to hydrocephalus, the main pathology pediatric neurosurgeons worldwide have to deal with. This revised and updated second edition, written by worldwide leaders in the field, fully reflects this progress: not only existing chapters have been reviewed whenever required, but new ones have been added thus taking into consideration every aspect of hydrocephalus, even when associated with the rarest pathologies. The general part include now more data on history, biomechanics, circulation and molecular basis. Special consideration for fetal surgery has been added, whereas the section on neonatal hydrocephalus has been further developed. Section 4, on the different pathologies associated with hydrocephalus, has been significantly expanded. and is now amazingly detailed, as well as the section on shunt treatment. Infections are now dealt with in two different chapters, and special attention to shunt complications (the nightmare of every Pediatric Neurosurgeon.) is paid in five different chapters. A very complete overview of the endoscopic treatment, that will surely draw the reader’s attention thanks to the wonderful full color images, is also included. Written by acknowledged experts in the field, this title is an indispensable tool for all those facing this pathology in their daily practice.

Pediatric neurosurgery

Pediatric neurosurgery

Books

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Journals

Child’s Nervous System http://link.springer.com/journal/381

Journal of Pediatric Neurosciences http://www.pediatricneurosciences.com/

JOURNAL OF NEUROSURGERY:PEDIATRICS http://thejns.org

NEUROPEDIATRICS https://www.thieme-connect.com/products/ejournals/journal/10.1055/s-00000041

Pediatric neurosurgery journal

Regional comparison demonstrated a preference for the Journal of Neurosurgery and Child’s Nervous System, respectively, but four of the top five journals were common to both groups. Applying the verbal formulation of Bradford’s law to the North American citation database, a pattern of citation density was identified across the first three zones. Journals residing in the most highly cited first zone are presented as the core journals.

Bradford’s law can be applied to identify the core journals of neurosurgical subspecialties. While regional differences exist between the most highly cited and most frequently published in journals among North American and European pediatric neurosurgeons, there is commonality between the top five core journals in both groups 1).

Societies

International Bureau for Epilepsy

International League Against Epilepsy

Pediatric Neurosurgery Chapter of the Latinamerican Federation of Neurosurgical Societies (FLANC)

Resources

Hydrocephalus Association

About Kids Health Brain Tumours

Association for Spina Bifida and Hydrocephalus

Brain Tumour Research Assistance and Information Network

Hydrocephalus Foundation

Hydro Kids

International Bureau for Epilepsy

International League Against Epilepsy

The purpose of a study was to identify the national trends of exposure to pediatric procedures during neurosurgical residency and to subsequently evaluate how neurosurgery residents’ experiences correlate with the minimum requirements set forth by the American College of Graduate Medical Education (ACGME).

ACGME resident case logs from residents graduating between 2013 and 2017 were retrospectively reviewed. These reports were analyzed to determine trends in resident operative experience in pediatric procedures. The number of cases performed by residents was compared to the required minimums set by the ACGME within each pediatric surgical category. A linear regression analysis and t tests were utilized to analyze the change in cases performed over the study period.

A mean of 98.8 procedures were performed for each of the 877 residents graduating between 2013 and 2017. The total number of pediatric procedures declined at a rate of 1.7 cases/year (r2 = 0.77, p = 0.05). Spine and cerebrospinal fluid diversion procedures showed decreasing trends at rates of 1.9 (r2 = 0.70, p = 0.08) and 1.2 (r2 = 0.70, p = 0.08) cases/year, respectively. The number of trauma and brain tumor cases were shown to have increasing rates at 1.0 (r2 = 0.86, p = 0.02) and 0.3 (r2 = 0.69, p = 0.08) cases/year, respectively, with trauma cases showing significant increases. There was also a trend of increasing cases logged as the lead resident surgeon by 12.9 cases/year (r2 = 0.99, p < 0.001). The number of cases performed by the average graduating resident was also significantly higher than the minimums required by the ACGME; residents, on average, performed 3 times the required minimum number of pediatric cases.

Neurosurgical residents graduating from 2013 to 2017 reported significantly higher volumes of pediatric neurosurgery cases than the standards set for by the ACGME. During this time, there was also a significant trend of increasing cases logged as the lead resident surgeon, suggesting more involvement in the critical portions of pediatric cases. There was also a significant, but not clinically impactful, decrease in pediatric case volumes during this time. However, the overall data indicate that residents are continuing to gain valuable pediatric experience during residency training 2).

Perceived benefits and barriers to a career in pediatric neurosurgery: a survey of neurosurgical residents

Research suggests that there may be a growing disparity between the supply of and demand for both pediatric specialists and neurosurgeons. Whether pediatric neurosurgeons are facing such a disparity is disputable, but interest in pediatric neurosurgery (PNS) has waxed and waned as evidenced by the number of applicants for PNS fellowships. The authors undertook a survey to analyze current neurosurgical residents’ perceptions of both benefits and deterrents to a pediatric neurosurgical career. METHODS: All residents and PNS fellows in the United States and Canada during the academic year 2008-2009 were invited to complete a Web-based survey that assessed 1) demographic and educational information about residents and their residency training, particularly as it related to training in PNS; 2) residents’ exposure to mentoring opportunities from pediatric neurosurgical faculty and their plans for the future; and 3) residents’ perceptions about how likely 40 various factors were to influence their decision about whether to pursue a PNS career. RESULTS: Four hundred ninety-six responses were obtained: 89% of the respondents were male, 63% were married, 75% were in at least their 3rd year of postgraduate training, 61% trained in a children’s hospital and 29% in a children’s “hospital within a hospital,” and 72% were in programs having one or more dedicated PNS faculty members. The residencies of 56% of respondents offered 6-11 months of PNS training and nearly three-quarters of respondents had completed 2 months of PNS training. During medical school, 92% had been exposed to neurosurgery and 45% to PNS during a clinical rotation, but only 7% identified a PNS mentor. Nearly half (43%) are considering a PNS career, and of these, 61% are definitely or probably considering post-residency fellowship. On the other hand, 68% would prefer an enfolded fellowship during residency. Perceived strengths of PNS included working with children, developing lasting relationships, wider variety of operations, fast healing and lack of comorbidities, and altruism. Perceived significant deterrents included shunts, lower reimbursement, cross-coverage issues, higher malpractice premiums and greater legal exposure, and working with parents and pediatric health professionals. The intrinsic nature of PNS was listed as the most significant deterrent (46%) followed by financial concerns (25%), additional training (12%), longer work hours (12%), and medicolegal issues (4%). The majority felt that fellowship training and PNS certification should be recommended for surgeons treating of all but traumatic brain injuries and Chiari I malformations and performing simple shunt-related procedures, although they felt that these credentials should be required only for treating complex craniosynostosis. CONCLUSIONS: The nature of PNS is the most significant barrier to attracting residents, although reimbursement, cross-coverage, and legal issues are also important to residents. The authors provide several recommendations that might enhance resident perceptions of PNS and attract trainees to the specialty 3).


Central nervous system tumors account for the highest mortality among pediatric malignancies.

1)

Venable GT, Shepherd BA, Roberts ML, Taylor DR, Khan NR, Klimo P Jr. An application of Bradford’s law: identification of the core journals of pediatric neurosurgery and a regional comparison of citation density. Childs Nerv Syst.2014 Aug 7. [Epub ahead of print] PubMed PMID: 25098356.
2)

White MD, Zollman J, McDowell MM, Agarwal N, Abel TJ, Hamilton DK. Neurosurgical Resident Exposure to Pediatric Neurosurgery: An Analysis of Resident Case Logs. Pediatr Neurosurg. 2019 May 21:1-7. doi: 10.1159/000500299. [Epub ahead of print] PubMed PMID: 31112956.
3)

Dias MS, Sussman JS, Durham S, Iantosca MR. Perceived benefits and barriers to a career in pediatric neurosurgery: a survey of neurosurgical residents. J Neurosurg Pediatr. 2013 Nov;12(5):422-33. doi: 10.3171/2013.7.PEDS12597. Epub 2013 Aug 30. PubMed PMID: 23992238.

Pediatric cerebral arteriovenous malformation

Pediatric cerebral arteriovenous malformation

Although brain arteriovenous malformations (bAVMs) account for a very small proportion of cerebral pathologies in the pediatric population, they are the cause of roughly 50% of spontaneous intracranial hemorrhages. Pediatric bAVMs tend to rupture more frequently and seem to have higher recurrence rates than bAVMs in adults 1) 2) 3) 4) 5) 6) 7).

Natural History

The natural history of untreated cerebral AVMs in children is worse than in adults, in relation to a longer life expectation, a higher annual risk of AVM bleeding (3.2% vs. 2.2%) and a higher incidence of posterior fossa and basal ganglia AVMs, most of which present with massive haemorrhages 8).

Treatment

The management of pediatric bAVMs is particularly challenging. In general, the treatment options are conservative treatment, microsurgeryendovascular therapy (EVT), gamma knife radiosurgery (GKRS), proton-beam stereotactic radiosurgery (PSRS), or a combination of the above.


In 2019 Meling et al., performed a systematic review, according to the PRISMA guidelines, with the result that none of the options seem to offer a clear advantage over the others when used alone. Microsurgery provides the highest obliteration rate, but has higher incidence of neurological complications. EVT may play a role when used as adjuvant therapy, but as a stand-alone therapy, the efficacy is low and the long-term side effects of radiation from the multiple sessions required in deep-seated pediatric bAVMs are still unknown. GKRS has a low risk of complication, but the obliteration rates still leave much to be desired. Finally, PSRS offers promising results with a more accurate radiation that avoids the surrounding tissue, but data is limited due to its recent introduction. Overall, a multi-modal approach, or even an active surveillance, might be the most suitable when facing deep-seated bAVM, considering the difficulty of their management and the high risk of complications in the pediatric population 9).


In 2016 El-Ghanem et al., published a Review of the Existing Literature:

Microsurgical resection remains the gold standard for the treatment of all accessible pediatric AVMs. Embolization and radiosurgery should be considered as an adjunctive therapy. Embolization provides a useful adjunct therapy to microsurgery by preventing significant blood loss and to radiosurgery by decreasing the volume of the AVM. Radiosurgery has been described to provide an alternative treatment approach in certain circumstances either as a primary or adjuvant therapy 10).

Outcome

Intracranial haemorrhage is the presenting clinical manifestation in 75-80% of paediatric patients and is associated with a high morbidity and mortality 11).

Case series

A prospectively maintained database of children between January 1997 and October 2012 for bAVMs was retrospectively queried to identify all consecutive ruptured bAVMs treated by surgery, embolization, and radiosurgery. The impact of baseline clinical and bAVM characteristics on clinical outcome, rebleeding rate, annual bleeding rate, and bAVM obliteration was studied using univariate and multivariate Cox regression analysis.

One hundred six children with ruptured bAVMs were followed up for a total of 480.5 patient-years (mean, 4.5 years). Thirteen rebleeding events occurred, corresponding to an annual bleeding rate of 2.71±1.32%, significantly higher in the first year (3.88±1.39%) than thereafter (2.22±1.38%; P<0.001) and in the case of associated aneurysms (relative risk, 2.68; P=0.004) or any deep venous drainage (relative risk, 2.97; P=0.002), in univariate and multivariate analysis. Partial embolization was associated with a higher annual bleeding rate, whereas initial surgery for intracerebral hemorrhage evacuation was associated with a lower risk of rebleeding.

Associated aneurysms and any deep venous drainage are independent risk factors for rebleeding in pediatric ruptured bAVMs. Immediate surgery or total embolization might be advantageous for children harboring such characteristics, whereas radiosurgery might be targeted at patients without such characteristics 12).

References

1) , 8) , 11)

Di Rocco C, Tamburrini G, Rollo M. Cerebral arteriovenous malformations in children. Acta Neurochir (Wien). 2000;142(2):145-56; discussion 156-8. PubMed PMID: 10795888.
2)

Millar C, Bissonnette B, Humphreys RP. Cerebral arteriovenous malformations in children. Can J Anaesth. 1994;41:321–331.
3)

Kiris T, et al. Surgical results in pediatric Spetzler-Martin grades I–III intracranial arteriovenous malformations. Childs Nerv Syst. 2005;21:69–74. discussion 75–76.
4)

Hoh BL, et al. Multimodality treatment of nongalenic arteriovenous malformations in pediatric patients. Neurosurgery. 2000;47:346–357. discussion 357–358.
5)

Kondziolka D, et al. Arteriovenous malformations of the brain in children: a forty year experience. Can J Neurol Sci. 1992;19:40–45.
6)

11. Wilkins RH. Natural history of intracranial vascular malformations: a review. Neurosurgery. 1985;16:421–430.
7)

Jankowitz BT, et al. Treatment of pediatric intracranial vascular malformations using Onyx-18. J Neurosurg Pediatr. 2008;2:171–176.
9)

Meling TR, Patet G. What is the best therapeutic approach to a pediatric patient with a deep-seated brain AVM? Neurosurg Rev. 2019 Apr 13. doi: 10.1007/s10143-019-01101-8. [Epub ahead of print] Review. PubMed PMID: 30980204.
10)

El-Ghanem M, Kass-Hout T, Kass-Hout O, Alderazi YJ, Amuluru K, Al-Mufti F, Prestigiacomo CJ, Gandhi CD. Arteriovenous Malformations in the Pediatric Population: Review of the Existing Literature. Interv Neurol. 2016 Sep;5(3-4):218-225. Epub 2016 Sep 1. Review. PubMed PMID: 27781052; PubMed Central PMCID: PMC5075815.
12)

Blauwblomme T, Bourgeois M, Meyer P, Puget S, Di Rocco F, Boddaert N, Zerah M, Brunelle F, Rose CS, Naggara O. Long-term outcome of 106 consecutive pediatric ruptured brain arteriovenous malformations after combined treatment. Stroke. 2014 Jun;45(6):1664-71. doi: 10.1161/STROKEAHA.113.004292. Epub 2014 May 1. PubMed PMID: 24788975.
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