Marcia Kerr

Follow-up of Children Exposed In Utero to 17 α-Hydroxyprogesterone Caproate Compared With Placebo

OBJECTIVE: To assess whether there are evident adverse effects of 17 &agr;-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 &agr;-hydroxyprogesterone caproate, with a 2:1 allocation to 17 &agr;-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 &agr;-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 &agr;-hydroxyprogesterone caproate and placebo children. Scores for gender-specific roles (Preschool Activities Inventory) were within the normal range and similar between 17 &agr;-hydroxyprogesterone caproate and placebo groups. CONCLUSION: 17 &agr;-hydroxyprogesterone caproate seems to be safe for the fetus when administered in the second and third trimesters. LEVEL OF EVIDENCE: II

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 childrens 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.

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 ± 5.57 years), and 11 underwent autologous reconstruction (age 2.00 ± 3.74 years). The size of the cranial defects was 144.01 ± 393.04 cm2 for autologous and 405.31 ± 572.96 cm2 for alloplastic reconstructions. Follow-up for all patients was an average of 2.33 ± 2.76 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.

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.

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

PurposeVentricular 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.MethodsAs 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.ResultsSix 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.ConclusionsA 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.

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 patients 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.