Pediatric Neurosurgery

Shanahan, Regan M.; Wei, Chris Z.; Miller, Tracy; Deng, Hansen; Hadjipanayis, Constantinos G.; Niranjan, Ajay; Lunsford, L. Dade

doi: 10.1159/000551777pmid: 41961774

AbstractIntroduction: Despite the generally benign and slow-growing nature of many adult meningiomas, meningiomas in pediatric patients often exhibit more aggressive behavior. Gamma Knife stereotactic radiosurgery (SRS) is a non-invasive modality that is widely used as either an initial upfront or adjuvant management for meningiomas. We reviewed our 35-year meningioma experience to assess its role in pediatric patients. Methods: The authors reviewed the clinical and imaging data of 2,030 meningioma patients who underwent SRS between 1987 and 2022 at the University of Pittsburgh Medical Center (UPMC). We identified 9 patients <18 years (2 female; median age, 14.5 years). None of the patients had neurofibromatosis type 2. The neurological outcomes, overall survival, local tumor control, and development of adverse radiation effects were evaluated. Three patients received prior therapeutic radiation: one underwent prophylactic cranial irradiation for lymphoblastic leukemia, one received focal cranial irradiation for craniopharyngioma, and one underwent craniospinal irradiation for medulloblastoma. Seven patients had prior tumor resection, while two asymptomatic patients were diagnosed incidentally (one during craniopharyngioma surveillance imaging and the other after head trauma). The median cumulative tumor volume at SRS was 6.0 cc (range, 0.5–11.8 cc). The median margin dose prescribed was 14 Gy (range, 11–25 Gy). Results: At last follow-up, 5 patients were alive. Four patients had died, two from progressive intracranial disease and two from unrelated medical causes. The median overall survival was 8.9 years (range 2.0–16.2 years). The median progression free survival was 8.2 years (range 1.1–13.4 years). Five patients experienced tumor progression at a median of 2.1 years (range, 1.1–13.4 years) after SRS. After local tumor progression, 2 patients received repeat SRS, and the remaining patients required additional surgery, fractionated external beam radiotherapy, or chemotherapy. No patient developed adverse radiation effects, had malignant tumor transformation, or developed other types of CNS malignancies. Conclusion: Meningiomas are rare tumors in the pediatric age group and can exhibit aggressive behavior. Tumor control was achieved in 6 of 9 patients after one or more SRS procedures. SRS presents as a reasonable primary option or should be considered for early intervention after surgery. Patients and families should be counseled that multiple SRS sessions might be needed to achieve eventual tumor control.

Wang, Joshua

doi: 10.1159/000551837pmid: 41915606

Joseph, Jeena; Ganesh, Swaminathan; Raju, Krishnaprabhu

doi: 10.1159/000551876pmid: 41973674

AbstractIntroduction: Pediatric meningiomas are rare tumors with clinical and biological features distinct from adult meningiomas. This study reviews 20-year experience of managing pediatric meningiomas at a tertiary referral center, focusing on their clinical characteristics, pathological features, treatment outcomes, and prognostic factors. Methods: A retrospective analysis of 47 pediatric patients (<18 years) diagnosed with meningiomas between January 2005 and December 2024 was performed. Data on demographics, clinical presentation, radiological features, tumor location, histopathology, extent of resection, adjuvant therapy, and outcomes were collected. Recurrence rate and event-free survival were analyzed using Kaplan-Meier estimates, and predictors of recurrence were assessed with univariate and multivariate analyses. Results: Pediatric cases accounted for 3.9% of all meningiomas treated during the study period (47/1,194). The median age was 13 years (IQR, 10–15), with a slight female predominance (55.3%). Neurofibromatosis was present in 21% of patients. Most tumors were supratentorial (76.6%), and 19% were intraventricular. The mean tumor volume in the series was 61.4 ± 75.2 cm3. High-grade meningiomas (WHO grade II and III) comprised 61.7% of cases. Gross total resection was achieved in 82.9%, and 53.2% received adjuvant radiotherapy. At a median follow-up of 41 months (IQR, 20–74 months), recurrence occurred in 21.3% of patients. On multivariate analysis, higher MIB-1 labeling index and longer follow-up duration were independent predictors of recurrence. Conclusion: Pediatric meningiomas, though rare, often display aggressive histopathology and a high risk of recurrence despite gross total resection. Multivariate analysis identified the MIB-1 labeling index and longer follow-up duration as independent predictors of recurrence, highlighting the importance of proliferative activity and extended surveillance in long-term disease control. These findings underscore the importance of biomarker-driven risk stratification and ongoing post-treatment monitoring in pediatric meningioma management.

Kant, Mathias; Helmuth, Timothy; Dias, Mark S.

doi: 10.1159/000551485pmid: 41843732

AbstractIntroduction: Infant carriers (car seats, bouncy chairs) can cause injuries when used for other than their intended purpose. Methods: We studied children aged 0–24 months with carrier related injuries reported to the Pennsylvania Trauma Outcome Study (PTOS) dataset (2001–2022 inclusive). Results: There were 562 injured children, averaging 23 injuries per year. Mean age was 3.3 months; 54.3% were male. Most (82.7%) fell from an elevated surface; 88.7% fell an estimated 2–5 feet. Head injuries (intracranial injury/hemorrhage and/or skull fracture) were present in 85.6%. Admission Glasgow Coma Scores were most commonly 15 (79.1%); 7 had GCS <12. Average Injury Severity Score was 9.3 (range 1–30). Average length of stay was 1.4 days; 30% spent >1 day in the intensive care unit. Two children underwent cranial operations. There were no deaths, and 82.9% were discharged home. Conclusion: Falls in, or from, infant carriers are a significant public health concern. Education, advocacy, and changes in carrier design may help reduce the frequency of these injuries.

Stanton, Amanda N.; Fredricks, Nathan S.; Price, Anthony M.; Koutsouras, George W.; Martin, Macey; Chen, Heidi; Lawrence, Alice P.; Martin, Elizabeth N.; Naftel, Robert P.

doi: 10.1159/000551915pmid: 41961756

AbstractIntroduction: While selective dorsal rhizotomy (SDR) improves spasticity, the benefit in hereditary spastic paraplegia (HSP) remains unclear. This study describes a single institution’s outcomes and experience with SDR in children with HSP. Methods: We conducted a retrospective chart review of pediatric patients (≤18 years) with HSP who underwent SDR at Monroe Carell Jr. Children’s Hospital between July 2013 and January 2024. Patients were evaluated with standardized assessments, including the Modified Ashworth Scale (MAS), Gross Motor Function Classification System (GMFCS), Gross Motor Function Measure-66 (GMFM-66), Manual Ability Classification System (MACS), Functional Mobility Scale (FMS), 10-Meter Walk Test (10MWT), Pediatric Balance Scale (PBS), and Pediatric Quality of Life (PedsQL) Cerebral Palsy Module. Results: Six patients (2 males, 4 females) aged 4–14 years underwent SDR, with a median follow-up of 17.65 months (range 11.8–38.9). Our cohort had four ATL1 and two SPAST mutations. Five patients had uncomplicated HSP, while 1 had complicated HSP. A median of 60% of rootlets were cut bilaterally (range 56–63). No major surgical complications occurred. Median MAS decreased from 16 preoperatively to 0 postoperatively. GMFM-66 improved from 74.8 to 79.1. In FMS testing, three patients achieved independent ambulation across all surfaces. 10MWT times improved from a median of 5.6 to 4.7 s. MACS scores improved in one patient and were otherwise stable. Balance scores remained stable or improved. Absolute PedsQL scores improved in 5 patients, with pain and fatigue showing greatest reduction. At follow-up, only 1 patient required orthotic support, compared to four preoperatively. Conclusion: SDR may offer marked reductions in spasticity, with associated improvements in ambulation, functional mobility, quality of life, and orthotic dependence. SDR was safe and well tolerated. Larger studies are needed to confirm statistical significance, define long-term efficacy, and optimize patient selection.

Patch, Olivia; Bowen, Evan; Giles, Tyler; Weaver, Kristin

doi: 10.1159/000551494pmid: 41843719

AbstractIntroduction: The purpose of this article was to describe a case of an unusual congenital occipital bone defect in a pediatric patient and the corresponding neurosurgical management. Case Presentation: The authors present a case of a 2-week-old male referred for neurosurgical evaluation after occipital bony prominences were detected on a postnatal exam. The patient was born full-term via uncomplicated vaginal delivery and underwent a head ultrasound, which disclosed an occipital heterotopic ossification. Physical exam revealed dimpling bilaterally over bony prominences at the occiput. Computed tomography and magnetic resonance image confirmed symmetric exostoses without clear intracranial involvement. However, fibrous adhesions were noted extending through the dermis, suggesting dermal involvement likely secondary to the bony changes, although no definitive sinus tracts were identified. The patient was monitored for the first year of life with no symptoms or developmental concerns. At follow-up at 15 months of age, the bony prominences and overlying fat pad were noticeably enlarged, which prompted corrective surgery. The exostosis was excised to restore normal occipital contour, and excess fat and skin were removed. Pathology revealed cartilage, cortical and trabecular bone, hematopoiesis, and mild intramedullary fibrosis. The surgery was successful with no complications, and the patient had an uneventful recovery. Postoperatively, the patient continues to meet developmental milestones without neurological deficits or complications. Conclusion: This case highlights the surgical management of an unusual occipital exostosis in an asymptomatic pediatric patient. It underscores the importance of individualized preoperative planning, comprehensive imaging, and ongoing clinical monitoring to assess changes over time.

Hamilton, Kimberly; Reynolds, Renee; Durham, Susan

doi: 10.1159/000552004pmid: 42044138

AbstractBackground: Mentorship plays an important role in the career development of a surgeon, shaping technical skills, professional identity and career paths. The needs and roles of both the mentee and the mentor change over the course of a professional career but the most successful form of mentorship includes a receptive mentee and a mentor who is engaged and dedicated to the process. Summary: We present a reflective commentary by three pediatric neurosurgeons at early, mid, and late career phases on the evolution of finding meaning and purpose in mentoring throughout a pediatric neurosurgical career. Key Message: Mentorship is dynamic and bidirectional throughout one’s career. It maximizes professional growth for both the mentor and mentee and ultimately enriches the specialty.

Ando, Ryo; Numata, Osamu

doi: 10.1159/000551092pmid: 41722072

AbstractIntroduction: Foramen magnum stenosis (FMS) and ventriculomegaly are frequent in achondroplasia due to cranial base hypoplasia. While FMS can cause spinal cord compression, the optimal treatment strategy remains debated. We reviewed our single-center experience and explored factors influencing surgical decisions. Methods: We retrospectively analyzed 18 children with achondroplasia evaluated between 2008 and 2024. MRI was used to assess FMS by anterior-posterior diameter and cerebrospinal fluid (CSF) area at the foramen magnum level. Ventriculomegaly was defined as an Evans Index ≥0.30. CT was used to evaluate foramen magnum morphology and synchondrosis fusion. Surgical indications were based on imaging findings of compression and intramedullary changes. Results: The median age at initial imaging was 9.5 months. Thirteen patients underwent foramen magnum decompression (FMD) and 5 were managed conservatively. The surgical group showed significantly smaller craniocervical junction CSF spaces compared with nonsurgical cases (p < 0.05). Synchondrosis fusion occurred earlier in achondroplasia than in controls. Ventriculomegaly was present in 66%, but its severity did not correlate with FMD. All surgical cases achieved decompression without major complications. Of the 13 surgical patients, 9 were followed for more than 1 year (median follow-up: 122 months). Within this subgroup, 4 developed radiological bone regrowth with re-stenosis, but all remained asymptomatic and none required reoperation. Conclusions: FMS in achondroplasia poses major risks, yet its natural history and management remain unclear. Our findings support early imaging-based screening and timely intervention in cases with cord compression. While FMD effectively relieves compression, it does not address underlying ossification abnormalities, requiring continued surveillance. Premature synchondrosis fusion may play a key role, and future studies should consider combined surgical and medical approaches to improve outcomes.

Buccilli, Barbara

doi: 10.1159/000552621pmid: 42207739

da Costa, Marcos Devanir Silva; Lazaretto Padua, Wagner; de Souza Melo, Thais Cristina; Cardoso Nôvo, Paloam; Seiji Suzuki, Fernando; Dastoli, Patricia; Cavalheiro, Sergio

doi: 10.1159/000550833pmid: 41642736

AbstractIntroduction: Primary fourth ventricle outlet obstruction (PFVOO) is a rare cause of obstructive hydrocephalus in children. Diagnosis often requires high clinical suspicion and advanced magnetic resonance imaging (MRI) sequences, and the optimal management remains a matter of debate. Case Presentation: We report a 3-year-old girl with unexplained tetraventricular hydrocephalus who presented with progressive macrocephaly, intermittent headaches, and atypical stereotyped head movements. She had previously undergone ventriculoperitoneal shunting in infancy, which failed after 18 months. High-resolution 3D-CISS MRI confirmed a patent aqueduct and a membranous obstruction at the foramen of Magendie, establishing the diagnosis of idiopathic PFVOO. An endoscopic third ventriculostomy (ETV) was performed uneventfully, and postoperative MRI confirmed ventricular size reduction. The patient remains clinically stable 2 years later, representing one of the longest pediatric follow-ups reported after ETV for PFVOO. Conclusion: PFVOO should be included in the differential diagnosis of unexplained tetraventricular hydrocephalus in children when conventional imaging is inconclusive. Advanced MRI sequences such as 3D-CISS are valuable for identifying subtle outlet obstructions. This case, extending the pediatric follow-up to 2 years, reinforces ETV as a safe and durable first-line treatment option in selected patients with PFVOO.