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Objective: To determine influence of sevoflurane on changes in cerebrospinal fluid pressure in children presenting for lumbar puncture. Methods: Cerebrospinal fluid pressure, end tidal carbon dioxide, and end tidal sevoflurane concentration measurements were obtained at 2-minute intervals for a total of 10 minutes (T0 to T5). Because of concerns regarding patient safety and comfort, the study measurements were completed at the end of the lumbar procedure, starting with the closing pressure and when sevoflurane was stopped. Results: As end tidal sevoflurane concentration decreased, cerebrospinal fluid pressure initially increased up to T2 before decreasing back to around the initial point. There was no significant correlation between sevoflurane level and cerebrospinal fluid pressure. Both weight status and presence or absence of optic edema did not have a significant impact on pressure over time. However, there was a statistically significant difference in the cerebrospinal fluid pressure over time between those with spontaneous respirations compared to those without. Conclusions: There was no significant correlation between the end tidal sevoflurane concentration and cerebrospinal fluid pressure. Assisted ventilation did produce a statistically significant increase in cerebrospinal fluid pressure and suggests that the most accurate measurements are in those with spontaneous respirations. [ABSTRACT FROM AUTHOR]

• CFTR modulators can increase Vitamin A absorption resulting in Hypervitaminosis A. • Elevated Serum Retinol can cause secondary intracranial hypertension. • Emergent management of fulminant intracranial hypertension is crucial. • Serial monitoring for vitamin toxicity in CF remains important. • Reporting complications of CFTR modulators is necessary for anticipatory guidance. [ABSTRACT FROM AUTHOR]

Aims: Examine ophthalmologic outcomes and complications of lumbar drain and cerebrospinal fluid shunts in pediatric fulminant intracranial hypertension. Methods: Patients under 21 years of age with a diagnosis of fulminant intracranial hypertension with temporary lumbar drain only, shunt after lumbar drain, and shunt only were included. Parameters investigated include lumbar drain data, medication freedom, time to resolution of papilledema, improvement in cranial nerve palsy, afferent pupillary defects, visual fields, visual acuity, and complications of each intervention. Results: Four patients had temporary lumbar drain, 2 temporary lumbar drain and cerebrospinal fluid shunt, and 3 shunt only. All achieved medication freedom and resolution of papilledema and cranial nerve palsies (if present). Most had resolution of preprocedure afferent pupillary defects. Minor residual visual field deficits occurred in 67%, and all had visual acuity improvement. One patient's lumbar drain dislodged, and one patient had 2 cerebrospinal fluid shunt revisions. Conclusion: Temporary lumbar drain with medical therapy may be a viable first approach to fulminant intracranial hypertension. [ABSTRACT FROM AUTHOR]

Mutations in the CLN6 gene cause late infantile neuronal ceroid lipofuscinosis, a neurodegenerative lysosomal storage disease of childhood onset. Clinically, individuals present with progressive motor and cognitive regression, ataxia, and early death. The aim of this study is to establish natural history data of individuals with classic, late-infantile-onset (age less than five years) CLN6 disease. We analyzed the natural history of 25 patients with late-infantile-onset CLN6, utilizing the Hamburg motor-language scale to measure disease progression. The key outcomes were CLN6 disease progression, assessed by rate of decline in motor and language clinical domain summary scores (0 to 6 total points); onset and type of first symptom; onset of first seizure; and time from first symptom to complete loss of function. Median age of total motor and language onset of decline was 42 months (interquartile range 36 to 48). The estimated rate of decline in total score was at a slope of −1.20 (S.D. 0.30) per year, after the start of decline. Complete loss of both motor and language function was found to be, on average, 88.1 months (S.D. 13.5). To our knowledge, this is the largest international study that monitors the longitudinal natural history and progression of CLN6 disease. These data may serve as a template for future interventional trials targeted to slow the progression of this devastating disease. [ABSTRACT FROM AUTHOR]

The authors aimed to compare the opening pressures of children with demyelinating disease to children with primary intracranial hypertension. Medical records were reviewed for a primary diagnosis of demyelinating disease, or primary intracranial hypertension. Diagnosis of demyelinating disease was made according to either the 2007 or 2012 International Pediatric Multiple Sclerosis Study Group criteria. Primary intracranial hypertension diagnosis was confirmed by presence of elevated opening pressure, normal cerebrospinal fluid composition and neuroimaging. The authors compared 14 children with demyelinating disease to children with primary intracranial hypertension in 1:1 and 1:2 fashions. There was a statistically significant higher BMI in the primary intracranial hypertension group compared to the demyelinating group (P = .0203). The mean cerebrospinal fluid white blood cell count was higher in the demyelinating disease group compared to primary intracranial hypertension (P = .0002). Among both comparisons, the cerebrospinal fluid opening pressure, glucose, protein and red blood cell counts in children with demyelinating disease were comparable to age- and sex-matched controls with primary intracranial hypertension. [ABSTRACT FROM AUTHOR]

Primary (idiopathic) intracranial hypertension has been considered to be a rare entity, but with no precise estimates of the pediatric incidence in the United States. There have been attempts to revise the criteria over the years and adapt the adult criteria for use in pediatrics. The clinical presentation varies with age, and symptoms tending to be less obvious in younger individuals. In the prepubertal population, incidentally discovered optic disc edema is relatively common. By far the most consistent symptom is headache; other symptoms include nausea, vomiting tinnitus, and diplopia. Treatment mainstays include weight loss when appropriate and acetazolamide. Furosemide may exhibit a synergistic benefit when used in conjunction with acetazolamide. Surgical interventions are required relatively infrequently, but include optic nerve sheath fenestration and cerebrospinal fluid shunting. Pain and permanent vision loss are the two major complications of this disorder and these manifestations justify aggressive treatment. Once intracranial hypertension has resolved, up to two thirds of patients develop a new or chronic headache type that is different from their initial presenting headache. [ABSTRACT FROM AUTHOR]

Objective: The purpose of this study was to examine the presenting symptoms, demographics, and interventions in pediatric patients enrolled in the Intracranial Hypertension Registry.Methods: We analyzed confirmed intracranial hypertension patients ≤18 years at the time of initial diagnosis who were enrolled in the registry.Results: A total of 203 patients met the criteria for inclusion; 142 (70%) were considered primary intracranial hypertension. Females made up 72.5% (103 of 142) and 75.8% (47 of 61) in the primary intracranial hypertension and secondary intracranial hypertension groups, respectively. There were no clinically significant differences in age, body mass index, or opening pressure between the primary intracranial hypertension and secondary intracranial hypertension groups. Symptoms most often reported were headache and blurred vision. Bilateral optic disc edema occurred in 89.3% of primary intracranial hypertension and 78.7% of secondary intracranial hypertension patients. When divided into pre- and postpubertal status, 32.5% of patients were classified prepubertal; 77.3% of these had primary intracranial hypertension. This resulted in a female to male ratio of 1:1.04 for prepubertal and 6:1 for postpubertal primary intracranial hypertension patients. The body mass index was significantly higher in the postpubertal primary intracranial hypertension group (P = 0.0014). There was no significant difference in opening pressure.Conclusions: The common symptoms of intracranial hypertension, including headache, optic disc edema, and vision changes, occurred with similar frequencies in our cohort to those reported in the literature. In separate subanalyses, we found significantly higher rates of obesity in postpubertal females with primary intracranial hypertension. The female-to-male ratios in the postpubertal primary intracranial hypertension and secondary intracranial hypertension groups were higher than reported in the literature. [ABSTRACT FROM AUTHOR]

This study aims to determine the frequency of intracranial hypertension without papilledema in children. Charts of patients evaluated in a pediatric intracranial hypertension clinic at our institution were retrospectively reviewed. The patients were divided into 2 groups depending on whether they had presence or absence of optic nerve edema at the time of presentation. Age, body mass index, and opening cerebrospinal fluid pressures were considered continuous variables and compared by Wilcoxon rank sum test because of non-normality. A P-value of 0.05 was considered significant. A total of 228 charts were reviewed; 152 patients met the criteria for intracranial hypertension, and 27 patients (17.8%) met the criteria of headache without optic nerve edema. There was no clinically significant difference in age, body mass index, opening pressure, and modified opening pressure between the 2 groups. [ABSTRACT FROM AUTHOR]

We aimed to determine the frequency of intracranial hypertension without headache in children. We retrospectively analyzed patients evaluated in a pediatric intracranial hypertension referral center. Patients were divided into 2 groups depending on whether they complained of headache at the time of presentation. Age, body mass index, and opening cerebrospinal fluid pressures were considered continuous variables and compared by Wilcoxon rank-sum test because of non-normality. A P value of .05 was considered significant. A total of 228 charts were reviewed; 152 patients met the criteria for intracranial hypertension and 22/152 patients (14.5%) met the criteria of optic nerve edema without headache. There were clinically significant differences in age and body mass index between the 2 groups. The group without headache was typically younger and not obese. The opening pressure and modified opening pressure were not clinically significant between the 2 groups. [ABSTRACT FROM PUBLISHER]

Gender differences have been observed in a number of aspects of the pharmacology of opiates, including their antinociceptive activity, discriminative stimulus properties, the generation of physical dependence, and their positive reinforcing properties. The current experiments were carried out to rigorously examine whether gender differences exist in the intravenous (IV) self-administration of opiates in an operant conditioning paradigm. Both dose–response analyses and the determination of the strength of the reinforcing properties of opiates using a “breakpoint” analysis were examined. We found strong gender differences in the IV self-administration of two mu opiate agonists—heroin and morphine. At a standard fixed ratio (FR) of responding, females consumed significantly greater amounts of heroin and morphine than did males in a dose-dependent fashion. In addition, females also showed much higher breakpoints than did males: the highest FR breakpoint achieved in females was more than double that observed in males and the frequency distribution of breakpoints was shifted significantly to the right in females when compared to males. These data collectively show that mu opiate agonists may serve as reinforcing agents in females over a broader dose range than males and that they also self-administer considerably more opiates on a milligram per kilogram basis. Finally, we conclude that they will also expend much greater effort in an operant conditioning task to obtain opiate reinforcement. [Copyright &y& Elsevier]

OBJECTIVES: A seizure action plan (SAP) is a powerful tool that provides actionable information for caregivers during seizures. Guidelines have expressed the need for individualized SAPs. Our quality improvement team aimed to increase implementation of an SAP within a pediatric tertiary center, initially among epilepsy providers and expanded to all neurology providers. METHODS: Process changes were implemented using Plan-Do-Study-Act cycles and data were evaluated monthly using control charts. The team focused on tracking patients who received SAPs and identified opportunities for improvement, including reminders within the electronic medical record, and standardizing clinic processes. A secondary analysis was performed to trend emergency department (ED) use among our patient population. RESULTS: The SAP utilization rate among epilepsy providers increased from a baseline of 39% to 78% by December 2019 and reached the goal of 85% by June 2020, with a further increase to 92% by February 2022 and maintained. The SAP utilization rate among general neurology providers increased from 43% in 2018 to 85% by July 2020, and further increased to 93% by February 2022 and maintained. ED visits of established patients with epilepsy decreased from a baseline of 10.2 per 1000 to 7.5 per 1000. CONCLUSIONS: Quality improvement methodologies increased the utilization of a standardized SAP within neurology outpatient care centers. The SAP is a simplified tool that allows patients and providers to navigate a complex health care system. The utility of an SAP may potentially extend to minimizing unnecessary ED visits. [ABSTRACT FROM AUTHOR]

Currently no guidelines for repeating a lumbar puncture to guide management in primary intracranial hypertension (PIH) exist. An institutional database of patients 18 years and younger followed in the institution's pediatric intracranial hypertension clinic was examined for opening pressure changes in PIH at diagnosis, before medication wean, and following medication wean, as well as to examine whether measurements at the time of diagnosis differed between those with and without disease recurrence. Forty-two patients were included in this study; 36% were male and the mean age at diagnosis was 11.01 years. Treatment duration averaged 9.68 months in those without recurrence and 8.5 months in those with recurrence. Average body mass index percentile of patients with disease recurrence was 83.7 and 72.1 in those without recurrence (P = 0.16). Average opening pressure values of all patients at diagnosis, prewean, and postwean was 36.53 cm H 2 O, 30.7 cm H 2 O, and 31.1 cm H 2 O, respectively. There was no statistically significant difference in opening pressures across these time points (P = 0.14). The change in opening pressure from diagnosis to postwean was statistically significant with a reduction of 5.18 cm H 2 O (P = 0.04). There was no statistical difference between change in opening pressure at diagnosis versus postwean between those with and without recurrence (P = 0.17). This clinical observational study suggests that mean opening pressure measurements in patients with PIH remain elevated both before and after medication wean despite papilledema resolution and patient-reported PIH symptoms. Clinically, this suggests that other features such as signs of optic disc edema and symptoms should be used to inform a clinical determination of disease recurrence and treatment course. [ABSTRACT FROM AUTHOR]

Cerliponase alfa is a recombinant human tripeptidyl peptidase 1 (TPP1) enzyme replacement therapy for the treatment of neuronal ceroid lipofuscinosis type 2 (CLN2 disease), which is caused by mutations in the TPP1 gene. We aimed to determine the long-term safety and efficacy of intracerebroventricular cerliponase alfa in children with CLN2 disease. This analysis includes cumulative data from a primary 48-week, single-arm, open-label, multicentre, dose-escalation study (NCT01907087) and the 240-week open-label extension with 6-month safety follow-up, conducted at five hospitals in Germany, Italy, the UK, and the USA. Children aged 3–16 years with CLN2 disease confirmed by genetic analysis and enzyme testing were eligible for inclusion. Treatment was intracerebroventricular infusion of 300 mg cerliponase alfa every 2 weeks. Historical controls with untreated CLN2 disease in the DEM-CHILD database were used as a comparator group. The primary efficacy outcome was time to an unreversed 2-point decline or score of 0 in the combined motor and language domains of the CLN2 Clinical Rating Scale. This extension study is registered with ClinicalTrials.gov , NCT02485899 , and is complete. Between Sept 13, 2013, and Dec 22, 2014, 24 participants were enrolled in the primary study (15 female and 9 male). Of those, 23 participants were enrolled in the extension study, conducted between Feb 2, 2015, and Dec 10, 2020, and received 300 mg cerliponase alfa for a mean of 272·1 (range 162·1–300·1) weeks. 17 participants completed the extension and six discontinued prematurely. Treated patients were significantly less likely than historical untreated controls to have an unreversed 2-point decline or score of 0 in the combined motor and language domains (hazard ratio 0·14, 95% CI 0·06 to 0·33; p<0·0001). All participants experienced at least one adverse event and 21 (88%) experienced a serious adverse event; nine participants experienced intracerebroventricular device-related infections, with nine events in six participants resulting in device replacement. There were no study discontinuations because of an adverse event and no deaths. Cerliponase alfa over a mean treatment period of more than 5 years was seen to confer a clinically meaningful slowing of decline of motor and language function in children with CLN2 disease. Although our study does not have a contemporaneous control group, the results provide crucial insights into the effects of long-term treatment. BioMarin Pharmaceutical. [ABSTRACT FROM AUTHOR]

The article discusses research being done on primary intracranial hypertension. It references the study "Over-the-Counter Self-Medication Leading to Intracranial Hypertension in a Young Lady," by A. M. Reddy et al. published in the 2014 issue of the "Journal of Neurosciences in Rural Practice." Topics discussed include the manifestations of intracranial hypertension in a middle-aged female patient, the history of the disease and the use of steroids to treat the disease.

Lyme disease is the most common vector-borne disease in the United States and has been associated with secondary intracranial hypertension. We reviewed 11 pediatric patients with Lyme-associated secondary intracranial hypertension. All patients presented with headache, ten had papilledema, 7 with a rash, and 5 with a cranial nerve palsy. All patients were treated with acetazolamide, and 3 received combination therapy with furosemide. Three patients were considered to have fulminant intracranial hypertension because of the severity in their presenting courses. Two of the fulminant intracranial hypertension patients were treated with a temporary lumbar drain in addition to medications, whereas 1 fulminant intracranial hypertension patient was treated exclusively with medical therapy alone. The addition of a lumbar drain decreased the time to resolution of papilledema compared to medical management alone. Final visual acuity was 20/20 in each eye of all patients, suggesting that a titrated approach to therapy depending on the severity of presentation can result in good visual outcomes in these cases. Additionally, symptoms can recur after medication wean, so patients should be monitored closely with any discontinuation of intracranial pressure lowering medications. [ABSTRACT FROM AUTHOR]

Background: The proportion of children with recurrent signs and symptoms of intracranial hypertension after medication wean has been reported to be between 18% and 50%. Few studies have reported intracranial hypertension recurrence risk in children while adjusting for each individual's observed follow-up time after medication wean. In addition, the role of intracranial hypertension etiology on the risk of disease recurrence has not been widely studied.Methods: The medical charts of patients with intracranial hypertension treated with intracranial pressure-lowering medication were analyzed retrospectively for disease recurrence. Baseline characteristics from diagnosis were recorded in addition to information regarding duration of therapy, medication wean, and recurrence. Survival analyses as well as Poisson regression models with time under observation as an offset were performed.Results: One hundred and thirty-three patients were included in the study. The cumulative risk of intracranial hypertension recurrence increased rapidly within the first six months after medication wean and was 1.5% at one month, 9.5% at three months, and 20% at six months. This risk leveled off near 12 to 18 months.Conclusions: While the cumulative risk of intracranial hypertension recurrence increases most dramatically within the first six months after medication wean, it does not appear to taper until 12 to 18 months. Given the possibility of delayed or asymptomatic recurrences, long-term follow-up is ideal, although patients can likely be seen less frequently after the first 12 to 18 months after medication wean. [ABSTRACT FROM AUTHOR]

Background: Metagenomic next-generation sequencing offers an unbiased approach to identifying viral pathogens in cerebrospinal fluid of patients with meningoencephalitis of unknown etiology. Methods: In an 11-month case series, we investigated the use of cerebrospinal fluid metagenomic next-generation sequencing to diagnose viral infections among pediatric hospitalized patients presenting with encephalitis or meningoencephalitis of unknown etiology. Cerebrospinal fluid from patients with known enterovirus meningitis were included as positive controls. Cerebrospinal fluid from patients with primary intracranial hypertension were included to serve as controls without known infections. Results: Cerebrospinal fluid metagenomic next-generation sequencing was performed for 37 patients. Among 27 patients with encephalitis or meningoencephalitis, 4 were later diagnosed with viral encephalitis, 6 had non–central nervous system infections with central nervous system manifestations, 6 had no positive diagnostic tests, and 11 were found to have a noninfectious diagnosis. Metagenomic next-generation sequencing identified West Nile virus (WNV) in the cerebrospinal fluid of 1 immunocompromised patient. Among the 4 patients with known enterovirus meningitis, metagenomic next-generation sequencing correctly identified enteroviruses and characterized the viral genotype. No viral sequences were detected in the cerebrospinal fluid of patients with primary intracranial hypertension. Metagenomic next-generation sequencing also identified sequences of nonpathogenic torque Teno virus in cerebrospinal fluid specimens from 13 patients. Conclusions: Our results showed viral detection by cerebrospinal fluid metagenomic next-generation sequencing only in 1 immunocompromised patient and did not offer a diagnostic advantage over conventional testing. Viral phylogenetic characterization by metagenomic next-generation sequencing could be used in epidemiologic investigations of some viral pathogens, such as enteroviruses. The finding of torque Teno viruses in cerebrospinal fluid by metagenomic next-generation sequencing is of unknown significance but may merit further exploration for a possible association with noninfectious central nervous system disorders. [ABSTRACT FROM AUTHOR]

Background: There remains debate regarding the need for venous imaging in pediatric intracranial hypertension.Methods: Records of patients aged 18 years or younger who were evaluated in the intracranial hypertension clinic at Nationwide Children's Hospital in Columbus, Ohio, were reviewed. Past medical history, diagnostic evaluation, and presenting symptoms were examined to evaluate differences in symptomatology presentation and risk factors in patients with pediatric intracranial hypertension with and without thrombosis.Results: A total of 226 patients met inclusion criteria, 145 were diagnosed with primary intracranial hypertension, 81 with secondary intracranial hypertension, with 17 noted to have venous sinus thrombosis as the cause of their secondary intracranial hypertension. Of those with thrombosis, 41.2% did not have any thrombosis risk factors. Headache was the most prominent symptom, present in 73.8% (n = 107) of patients with primary intracranial hypertension, 87.5% (n = 56) of patients with secondary intracranial hypertension without thrombosis, and 82.4% (n = 14) with thrombosis.Conclusions: The only clinically significant difference in presenting symptomatology between the thrombosis and the other groups was nausea or vomiting. Predisposing factors to develop thrombosis were absent in 41.2% of patients. Hence, the need for venous imaging in pediatric intracranial hypertension cannot be clearly determined by clinical presentation or risk factors alone. Patients with indwelling catheters should receive imaging in the region of their catheter to rule out catheter-associated thrombosis. [ABSTRACT FROM AUTHOR]

Background: Cryopyrin-associated periodic syndrome is characterized by periodic fever, rash, and joint pain. Papilledema rarely occurs. We present our series of patients with cryopyrin-associated periodic syndrome who clinically met the diagnostic criteria for Muckle-Wells syndrome and our experience with secondary intracranial hypertension.Methods: Retrospective review of all patients with cryopyrin-associated periodic syndrome at Nationwide Children's Hospital from October 2015 to September 2017.Results: Eighteen children met inclusion criteria: 15 females and three males, aged 1.5 to 16.2 years. Fifteen had periodic fever genetic testing; three had a known genetic defect identified, eight had a defect identified not currently known to be associated with cryopyrin-associated periodic syndrome, and four had no defect identified. Six patients (30%) developed headaches and were diagnosed with secondary intracranial hypertension. Lumbar puncture opening pressures ranged from 28 to 45 cm H2O. Only one patient had papilledema. Initial treatment was medical in all cases, by increasing interleukin-1 inhibitor dose and/or acetazolamide. One patient required a ventriculoperitoneal shunt for headache management. No visual acuity loss was detected. All six patients with secondary intracranial hypertension had a known genetic mutation or genetic variant of unknown significance; five involved the NLRP3 gene.Conclusions: In our series of 18 patients with cryopyrin-associated periodic syndrome, secondary intracranial hypertension occurred at a higher than expected rate. We suspect that genetic defects involving the NLRP3 gene may be a risk factor. Papilledema was present in only one patient. Physicians treating cryopyrin-associated periodic syndrome should be aware of this vision-threatening association and potential therapeutic approach. [ABSTRACT FROM AUTHOR]

Objective: We analyzed the incidence and demographic features of pediatric intracranial hypertension.Methods: Inpatient and outpatient encounters of children aged 18 years or younger who were diagnosed with primary (idiopathic) or secondary intracranial hypertension between January 2010 and December 2013 were identified. Data were collected from a subspecialty clinic devoted to intracranial hypertension and the sole children's hospital in a large Midwestern city of the United States. Estimated incidence rates were calculated based on the number of newly diagnosed patients in our hospital's primary service area, which includes seven central Ohio counties. Sex, race, body mass index, socioeconomic status, and geographic distribution were also noted.Results: A total of 74 pediatric patients were diagnosed with intracranial hypertension (49 primary/idiopathic and 25 secondary) between January 2010 and December 2013. Using census data, we determined the pediatric population in our service area during the four-year period. The Ohio Hospital Association's database indicated that 92.3% of patients aged 0 to 17 years residing in the region sought care at our institution. By combining these data, we calculated an annual incidence of primary and secondary intracranial hypertension of 0.63 and 0.32 per 100,000 children, respectively.Conclusions: The estimated annual incidence of pediatric primary intracranial hypertension in our seven county service area in central Ohio is similar to previous pediatric reports from other countries and is 67% of that reported in the US adult population. [ABSTRACT FROM AUTHOR]

Background Mucopolysaccharidosis type III is a progressive disease with worsening airway, pulmonary, and cardiac involvement that may complicate anesthetic care. Aim To prospectively evaluate the incidence of airway issues and complications during magnetic resonance imaging (MRI) and lumbar puncture (LP) during general anesthesia with a native airway for patients with mucopolysaccharidosis type III. Method The study was a part of the natural history study. Anesthesia was induced with sevoflurane, which was discontinued after intravenous access was obtained. General anesthesia with a native airway was provided by dexmedetomidine and propofol. Dexmedetomidine (0.5 μg·kg−1) was administered over 5 min followed by a continuous infusion at 0.5 μg·kg−1·h−1. A continuous infusion of propofol was started at 150 μg·kg−1·min−1. A bolus dose of propofol (1 mg·kg−1) was administered and the propofol infusion was increased as needed. Airway management and vital signs were recorded for the entire procedure until discharge. Results Twenty-five patients (6.9 ± 3.1 years) received total of 43 MRI and LP procedures in the cohort. No patient failed sedation. Although mask induction with sevoflurane was not clinically problematic, upper airway obstruction was noted during 14 procedures (33%). This required the application of continuous positive airway pressure, temporary oral airway placement, jaw thrust, or shoulder roll. Airway dynamics improved once the anesthesia was transitioned to intravenous anesthetic agents. Although a small shoulder roll was needed to improve airway patency for 11 cases (26%), a large shoulder roll tended to make the upper airway obstruction worse. Oxygen desaturation (≤90%) was noted during MRI in three cases (7%). Conclusion A combination of dexmedetomidine and propofol provided effective general anesthesia with a native airway during the procedures. Although upper airway obstruction was noted, it resolved with simple airway maneuvers without further airway intervention. [ABSTRACT FROM AUTHOR]

Aim: The aim of this article is to compare 90-day and 30-day recall of Pediatric Migraine Disability Assessment (PedMIDAS) elements and headache frequency against daily entries from an Internet headache diary among pediatric patients and their parents. Methods: In a prospective cohort study, patients aged 10-18 years with episodic migraine or probable migraine completed a 90-day Internet-based headache diary that incorporated PedMIDAS questions. Following the 90-day diary period, patients and parents completed modified PedMIDAS instruments to assess 90-day and 30-day recall. Intraclass correlation coefficients (ICC) were calculated to measure recall reliability. The Kruskal-Wallis and Jonckheere-Terpstra tests were used to explore recall accuracy as it relates to each participant's self-reported confidence in recall and to patient age. Results: Fifty-two subjects completed 90 consecutive diary entries. Comparing 30-day to 90-day recall of PedMIDAS elements, ICC scores improved by 26.2% (patients) and 17.5% (parents). Patients had better recall than their parents for all study measures. Self-reported confidence in recall and patient age had limited and inconsistent effects on recall accuracy. Conclusion: The optimal recall interval to assess migraine disability must balance recall accuracy with generalizability across a range of headache frequencies. When compared to daily diary entries, recall accuracy of PedMIDAS elements and headache frequency improves at 30 days compared to 90 days. Parent report of migraine disability should not be used as a replacement for patient report. [ABSTRACT FROM AUTHOR]