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ObjectivesDrug-resistant epilepsies (DRE) are associated with significant morbidity, mortality, and poor quality of life in children and young people (CYP). Epilepsy surgery has been a successful treatment modality for focal DRE.1 For many CYP with focal DRE, identifying a focus can be challenging and requires specialist investigations like single-photon emission computed tomography (SPECT).2 Our aim of this study is to evaluate the contribution of SPECT in epilepsy surgery decision-making.MethodsWe conducted a retrospective observational cohort study of all CYP who underwent SPECT at the Scottish centre for epilepsy surgery (Edinburgh, U.K.) between 2012 and 2022. We reviewed the epilepsy surgery evaluation data, including seizure semiology, neuroimaging, electroencephalogram (EEG), comorbidity, and age group. We also reviewed every SPECT study, including the need for treatment reduction and general anaesthesia (GA).ResultsThere were 26 CYP (12 males, 14 females) who underwent SPECT between 1 year old and 18 years old. The median age was 11 (IQR=6).62% (16/26) had definitive seizure semiology localisation and lateralisation before SPECT, while 65% (17/26) had definitive EEG localisation and lateralisation before SPECT. 58% (15/26) had specific MRI abnormalities before SPECT. 69% (18/26) needed GA for SPECT. 27% (7/26) of CYP required multiple attempts of SPECT before conclusive results were deduced. Amongst the 7 cases, 6 of them were due to a lack of seizure activities, while 1 of them was due to the lack of service provision.In this population of the study, 19% (5/26) have mostly daytime seizures, and 31% (8/26) have predominantly night-time seizures, while 50% (13/26) have both. It is also challenging to conduct SPECT in our cohort of patients, as 50% (13/26) have a degree of learning disability or behavioural problems.50% (13/26) of CYP who had SPECT contributed further to their epilepsy surgery decision-making. Out of the 13 CYP, 5 of them went on to have immediate surgical resection, while 8 of them had further invasive monitoring followed by surgical resection based on the results of SPECT. 12% (3/26) of CYP who had SPECT showed non-concordant results with the other investigations and invasive monitoring, while 35% (9/26) of CYP who had SPECT have not contributed further to our understanding of their seizures.ConclusionSPECT has shown to contribute to epilepsy surgery decision-making in selected cases. We should consider all patient and seizure parameters carefully before performing SPECT on CYP, especially in the need for GA in some cases.ReferencesEpilepsies in children and young people: investigative procedures and management, Scottish Intercollegiate Guidelines Network, May 2021.Ponisio MR, et al. The Role of SPECT and PET in Epilepsy, March 2021.

PurposePaediatric cervical spine injuries are fortunately a rare entity. However, they do have the potential for devastating neurological sequelae with lifelong impact on the patient and their family. Thus, management ought to be exceptional from the initial evaluation at the scene of the injury, through to definitive management and rehabilitation.MethodsWe set out to review cervical spine injuries in children and advise on current best practice with regards to management.ResultsEpidemiology, initial management at the scene of injury, radiological findings and pitfalls of cervical spine trauma are outlined. Strategies for conservative and surgical management are detailed depending on the pattern of injury. The management of spinal cord injuries without radiological abnormality (SCIWORA) and cranio-cervical arterial injuries is also reviewed.ConclusionsDue to a paucity of evidence in these rare conditions, expert opinion is necessary to guide best practice management and to ensure the best chance of a good outcome for the injured child.

•Minimally invasive surgical approaches are safe treatments for paediatric lumbar disc herniation.•No particular surgical approach shows clear superiority of outcomes.•Lumbosacral anatomic variants likely predispose patients to disc herniation.•Surgery for lumbar disc herniation is equally or more efficacious for paediatric patients in comparison with adults. Lumbar disc herniation (LDH) is a rare cause of morbidity in the paediatric population that can result in disruption to education and participation in social and athletic activities. Modern minimally invasive techniques have increasingly been adopted in paediatric spine surgery. The purpose of this review was to assess characteristics of paediatric LDH, evaluate current surgical techniques and their outcomes in recent literature, and compare paediatric outcomes with adults. A literature search was carried out identifying articles published from 2008 to 2018 relating to surgical treatment of LDH in children and adolescents. Original articles were scrutinised for outcome data and complications then compared by surgical approach. Over the last decade 1094 surgical cases have been published, mostly L4/L5 (52%) and L5/S1 (41%) intervertebral discs. These were predominantly operated with microdiscectomy and minimally invasive techniques: percutaneous endoscopic and tubular approaches to discectomy. Cystic fibrosis, trauma, extensive athletic activity, facet joint asymmetries and lumbosacral transition vertebrae may be risk factors for LDH. 55% had total resolution of pain after surgery, complications are rare and unsatisfactory resolution of pain and re-operation uncommon. In the short and medium-term, overall, paediatric patients do not have worse surgical outcomes than adult patients; they may recover faster and improve more. Minimally invasive approaches for LDH in adolescents are safe and efficacious. No technique has yet demonstrated clear superiority. Delaying surgery for conservative treatment is warranted, but for how long remains unclear.

ObjectivesExternal ventricular drain (EVD) insertion is a common neurosurgical procedure. EVD-related infection (ERI) is a major complication that can lead to morbidity and mortality. In this study, we aimed to establish a national ERI rate in the UK and Ireland and determine key factors influencing the infection risk.MethodsA prospective multicentre cohort study of EVD insertions in 21 neurosurgical units was performed over 6 months. The primary outcome measure was 30-day ERI. A Cox regression model was used for multivariate analysis to calculate HR.ResultsA total of 495 EVD catheters were inserted into 452 patients with EVDs remaining in situ for 4700 days (median 8 days; IQR 4–13). Of the catheters inserted, 188 (38%) were antibiotic-impregnated, 161 (32.5%) were plain and 146 (29.5%) were silver-bearing. A total of 46 ERIs occurred giving an infection risk of 9.3%. Cox regression analysis demonstrated that factors independently associated with increased infection risk included duration of EVD placement for ≥8 days (HR=2.47 (1.12–5.45); p=0.03), regular sampling (daily sampling (HR=4.73 (1.28–17.42), p=0.02) and alternate day sampling (HR=5.28 (2.25–12.38); p<0.01). There was no association between catheter type or tunnelling distance and ERI.ConclusionsIn the UK and Ireland, the ERI rate was 9.3% during the study period. The study demonstrated that EVDs left in situ for ≥8 days and those sampled more frequently were associated with a higher risk of infection. Importantly, the study showed no significant difference in ERI risk between different catheter types.

Suprasellar meningiomas often invade the optic canals (OCs). The feasibility of removing these tumors through a minimal-access endonasal route has been demonstrated, but the importance, safety, and timing of OC exploration and decompression are not well described. To create a simple decision-tree algorithm for OC exploration and decompression in the endonasal endoscopic surgery for planum sphenoidale and tuberculum sella meningiomas. We identified a consecutive series of 8 planum sphenoidale and tuberculum sella meningiomas resected endonasally. \"Late\" OC exploration and decompression was performed in 4 of 8 patients. The extent of resection, visual outcome, and complications were recorded. Five patients had OC invasion on magnetic resonance imaging. Endoscopic inspection did not reveal additional OC invasion. The OC was opened bilaterally in 2 patients and unilaterally in 2 patients. Gross total resection was achieved in 6 of 7 patients in whom it was the goal. Vision improved in 3 patients (3 of 3 OCs opened) and was stable in 4 (1 of 4 OCs opened). In 1 patient, the bitemporal hemianopsia improved, but there was unilateral deterioration (no OC invasion) because the tumor was extremely adherent to 1 optic nerve. After an average follow-up of 20.9 months, all patients had an Glasgow Outcome Scale score of 5, and there were no cerebrospinal fluid leaks. Exploration and decompression of the OC are feasible, safe, and important to optimize visual outcome and to minimize recurrence in planum sphenoidale and tuberculum sella meningiomas resected endonasally. It may not be important to open the canal early during surgery because tumor debulking can be performed without manipulating the optic nerves. Early decompression, however, is technically feasible.

Purpose Based on an initial hypothesis that the abdominal radiograph is rarely useful in the radiographic shunt series (SS), this study sought to determine which components of the SS are useful in identifying and diagnosing shunt dysfunction. This enquiry broadened to evaluate which modalities were most clinically useful in patients who ultimately underwent shunt revision for their suspected dysfunction. Methods Arm1: Abdominal radiographs (AXR) performed over a 2-year period were reviewed retrospectively to identify shunt abnormalities. Arm 2: Retrospective analysis of acute imaging and shunt series was performed on patients who had undergone shunt revision at the same hospital over a 10-year period. Results Arm 1: Seventy-five AXR performed were part of a formal SS. Eight reported a shunt abnormality. Two were within the abdomen; both findings were artefactual. Arm 2: One hundred seventy-nine patients are included. Ninety-six had abnormal imaging 72 h prior to revision; most were on CT ( n  = 67). Thirty-one demonstrated shunt leak, fracture or migration. Ninety-three patients had an SS the week before their revision; only 15% ( n  = 14) were abnormal. Conclusion This is a study evaluating the utility of radiographs in paediatric shunt malfunction. SS has low clinical yield; based on our findings, as well as background research, we recommend low-dose CT head (US or MRI) should be used as first line investigation, with tailored use of plain films to assist neurosurgical planning.

Why did you do this work?Epilepsy is one of the most prevalent neurological diseases in childhood, affecting 1 in 220 children under 18 years old.1 Treatment with anti-epileptic drugs will not achieve seizure freedom in around 25% of these children.2 Surgical treatment is an option in selected cases and is a standard of care in this cohort, depending on aetiology and seizure burden. In Scotland, these children are reviewed by the Scottish Paediatric Epilepsy Surgery Service (SPESS) multidisciplinary team (MDT). We examined rates of seizure freedom following surgery and compared the outcomes to international data and to children from one centre assessed by the MDT who were not deemed suitable for surgery.What did you do?Cases were identified from the SPESS database for children assessed from 2010 to 2022, with some additional information taken from electronic health records (TrakCare). Surgical data was from all centres in Scotland whereas medical data was from Lothian only. Follow-up assessment was conducted at 6 and 12 months. Baseline characteristics included age, sex and MRI findings. Engel’s classification was used to summarise surgery outcome, with Engel’s class I representing seizure freedom. In Lothian children who continued medical treatment, outcome was classified as continuing seizures with or without treatment or seizure-free. A multivariate logistic regression model was used to assess whether specific characteristics were predictive of seizure freedom.What did you find?Of the 280 children discussed at MDT meetings (mean age 9.8 ± 5 years; 55.4% male), 114 (40.7%) were selected for epilepsy surgery (53.5% male, with a mean duration of DRE of 2.6 years). The mean time from first seizure to surgery was 6.2 years. At 12 months post-surgery, 68.8% of the children were seizure-free (Engel class I), which is consistent with international data reporting seizure freedom rates between 62.5% and 96% at 12 months.3 4 Factors associated with a higher likelihood of seizure freedom included an older age at seizure onset, a shorter duration of DRE, and abnormal MRI findings.In the Lothian cohort who continued medical treatment, 42.9% achieved seizure freedom at 12 months. The difference in outcomes between the surgical and non-surgical groups was not statistically significant (p = 0.053).What does it mean?Our study found that children selected for epilepsy surgery had a high rate of seizure freedom at 12 months, similar to international reports. While children who continued medical treatment had worse outcomes, the difference was not statistically significant however this data is not fully comparable as it was from Lothian only. These findings highlight the importance of timely identification and referral of suitable candidates for epilepsy surgery to improve long-term outcomes.ReferencesEpilepsy prevalence, incidence and other statistics Joint Epilepsy Council of the UK and Ireland. 2011.Sultana B, Panzini MA, Veilleux Carpentier A, Comtois J, Rioux B, Gore G, et al. Incidence and Prevalence of Drug-Resistant Epilepsy: A Systematic Review and Meta-analysis. Neurology. 2021 Apr 27 [cited 2024 Mar 18];96(17):805–17. Available from: https://pubmed.ncbi.nlm.nih.gov/33722992/Mir A, Jallul T, Alotaibi F, Amer F, Najjar A, Alhazmi R, et al. Outcomes of resective surgery in pediatric patients with drug-resistant epilepsy: A single-center study from the Eastern Mediterranean Region. Epilepsia Open. 2023 Sep 1 [cited 2024 Mar 12];8(3):930–45. Available from: https://onlinelibrary.wiley.com/doi/full/10.1002/epi4.12761Teutonico F, Mai R, Veggiotti P, Francione S, Tassi L, Borrelli P, et al. Epilepsy surgery in children: Evaluation of seizure outcome and predictive elements. Epilepsia 2013 Oct [cited 2024 Mar 8];54(SUPPL.7):70–6. Available from: https://onlinelibrary.wiley.com/doi/full/10.1111/epi.12312

Purpose Cerebrospinal fluid (CSF) leakage is a challenging complication of intradural cranial surgery, and children are particularly at risk. The use of dural sealants confers protection in adults, but pediatric studies are scarce. We evaluated the safety and efficacy of Evicel ® fibrin sealant as an adjunct to primary dural suturing in children undergoing cranial surgery. Methods A multicenter trial prospectively enrolled pediatric subjects (< 18 years) undergoing cranial neurosurgery who, upon completion of primary sutured dural repair, experienced CSF leakage. As agreed by the EMA Evicel ® Pediatric Investigation Plan, 40 subjects were intra-operatively randomized 2:1 to Evicel ® or additional sutures (‘Sutures’). Data analysis was descriptive. The efficacy endpoint was treatment success rate, with success defined as intra-operative watertight closure after provocative Valsalva maneuver (primary endpoint). Safety endpoints were postoperative CSF leakage (incisional CSF leakage, pseudomeningocele or both) and surgical site complications (secondary endpoints). Results Forty subjects (0.6–17 years) were randomized to Evicel ® (N = 25) or Sutures (N = 15) (intention-to-treat). Intracranial tumor was the most common indication and procedures were mostly supratentorial craniotomies. Success rates were 92.0% for Evicel ® and 33.3% for Sutures, with a 2.76 estimated ratio of success rates (Farrington-Manning 95% CI [1.53, 6.16]). Sensitivity analyses in per-protocol and safety sets showed similar results. Despite a higher rescue treatment rate, the frequencies of postoperative CSF leakage and wound complications were higher for Sutures than for Evicel ® . Conclusion This small-scale prospective study shows Evicel ® treatment to be safe and effective as an adjunct to primary sutured dura mater closure in a pediatric population. Compared to additional sutures, Evicel ® was associated with reduced postoperative CSF leakage and surgical site complications. (Trial registration: The trial was registered as NCT02309645 and EudraCT 2013-003558-26).

Intracranial parameningeal rhabdomyosarcomas are rare, aggressive, rapidly progressive paediatric malignancies that carry a poor prognosis. The authors report a case of a 2-year-old boy who initially presented with a left facial palsy, ataxia and, shortly after, bloody otorrhoea. MRI imaging was initially suggestive of a vestibular schwannoma. However, there was rapid progression of symptoms and further MRI imaging showed very rapid increase in tumour size with mass effect and development of a similar tumour on the contralateral side. A histological diagnosis of bilateral parameningeal embryonal rhabdomyosarcoma was made. Despite treatment, progression led to hydrocephalus and diffuse leptomeningeal disease, from which the patient did not survive. Few intracranial parameningeal rhabdomyosarcomas have previously been reported and these report similar presenting symptoms and rapid disease progression. However, this is the first reported case of a bilateral intracranial parameningeal embryonal rhabdomyosarcoma which, on initial presentation and imaging, appeared to mimic a vestibular schwannoma.