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Background: A carotid-cavernous fistula (CCF) is a well-recognized entity resulting from an abnormal connection between the internal carotid artery (ICA) or external carotid artery and the cavernous sinus. Typical CCF symptomology includes proptosis, chemosis, orbital bruit, headache, facial pain, and cranial nerve (CN) palsies. While CCFs most often occur posttraumatically, they can also occur spontaneously, secondary to cavernous ICA aneurysm rupture. Very rarely, they can occur secondary to the rupture of an anomalous persistent trigeminal artery (PTA) aneurysm., Observations: Herein, the authors describe the case of a 54-year-old woman who presented with a CN VI palsy and headache due to a CCF secondary to a PTA aneurysm rupture. The CCF was ultimately treated via coil embolization of the aneurysm and the parent PTA vessel., Lessons: Though such occurrences are rare, clinicians should be vigilant in assessing for the presence of a PTA in patients with a CCF, as a PTA-associated CCF requires unique treatment considerations. In some cases where the PTA plays a crucial role in the posterior circulation supply, preservation of the parent vessel PTA is crucial. However, in cases in which an adequate posterior circulation collateral supply exists, embolization of the aneurysm and the parent vessel PTA is a reasonable treatment option for fistula closure. https://thejns.org/doi/10.3171/CASE24287.

Purpose: Children and adolescents who sustain concussion in rural communities are lost to follow-up after initial evaluation more often than their urban counterparts. Thus, this study aims to determine the feasibility and accessibility of a novel virtual pediatric concussion clinic at a rural academic hospital., Methods: Data regarding patients referred to a virtual concussion clinic at a rural Pediatric Level 2 Trauma Center over a 16-month period was prospectively collected. Patients experiencing concussive symptoms were referred to the pediatric neurosurgery clinical registered nurse and received a phone call following an injury. Referrals to therapy were made based on symptoms reported., Results: Data from 44 patients was collected: 9 did not follow-up in concussion clinic despite leaving a voicemail. Forty-three were referred from the emergency department. The median time from referral placed to completing a virtual follow-up was 4.5 days. Among the referrals, 3 (8.6%) were to pediatric neurology, 10 (28.6%) to occupational therapy (OT), 6 (17.1%) to physical therapy (PT), 4 (11.4%) to speech-language pathology (SLP), and 25 (71.4%) did not receive referrals as their symptoms had abated. Patients followed with pediatric neurology post-injury for an average of 75.9 days, OT for an average of 52.7 days, and PT for an average of 2.3 days., Conclusion: This is a feasible model to follow patients and place referrals for additional therapeutic services in a rural community. With 79.5% of patients completing a follow-up, the clinic demonstrates easy accessibility and reliable adherence., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Competing Interests: Disclosures None.

Objective: This study aimed to determine clinical care practices for infants at risk for posthemorrhagic hydrocephalus (PHH) across level IV neonatal intensive care units (NICUs)., Study Design: Cross-sectional survey that addressed center-specific surveillance, neurosurgical intervention, and follow-up practices within the Children's Hospitals Neonatal Consortium., Results: We had a 59% (20/34 sites) response rate, with 10 sites having at least two participants. Respondents included neonatologists (53%) and neurosurgeons (35%). Most participants stated having a standard guideline for PHH (79%). Despite this, 42% of respondents perceive inconsistencies in management. Eight same-center pairs of neonatologists and neurosurgeons were used to determine response agreement. Half of these pairs disagreed on nearly all aspects of care. The greatest agreement pertained to a willingness to adopt a consensus-based protocol., Conclusion: Practice variation in the management of infants at risk of PHH in level IV NICUs exists despite the perception that a common practice is available and used., Key Points: · Practice variation exists despite the perception that common practices are available/used for PHH.. · Our survey had same-center pairs of neonatologist and neurosurgeons to determine response agreement.. · The greatest agreement pertained to a willingness to adopt a consensus-based protocol.., Competing Interests: None declared., (Thieme. All rights reserved.)

Objective: Hypothermia in adult surgical patients has been correlated with an increase in the occurrence of surgical site wound infections, increased bleeding, slower recovery from anesthetics, prolonged hospitalization, and increased healthcare costs. Pediatric surgical patients are at potentially increased risk for hypothermia because of their smaller body size, limited stores of subcutaneous fat, and less effective regulatory capacity. This risk is exacerbated during pediatric spinal surgery by lower preoperative temperature, increased surface exposure to cold during induction and positioning, and prolonged surgical procedure times. The purpose of this quality improvement initiative was to reduce the duration of hypothermia for pediatric patients undergoing spine surgery., Methods: Demographic and clinical data were collected on 162 patients who underwent spinal deformity surgery between October 1, 2017, and July 31, 2019. Data points included patient age, gender, diagnosis, surgical procedure, and temperature readings throughout different phases of perioperative care. Temperatures were obtained upon arrival to the day of surgery, upon presentation to the operating room, during prone positioning, at incision, and at the end of the procedure. Twelve patients were analyzed prior to implementation of a protocol, while 150 patients composed the post-protocol group., Results: Using descriptive statistics, the authors found that the average body temperature at the time of incision was 34.0°C prior to the adoption of a preoperative warming protocol, and 35.3°C following a preoperative warming protocol (p = 0.001). There were no complications, such as burns, hyperthermia, or arrhythmias, related to preoperative warming of patients., Conclusions: The placement of a warming blanket on the bed prior to patient arrival and actively targeting normothermia reduced the incidence and duration of hypothermia in pediatric patients undergoing spine surgery with no adverse events.

Purpose: Pure arterial malformations of the brain are rare vascular lesions., Methods: We present a 10-year-old healthy boy who presented with an incidental finding of pure arterial malformation., Results: Our case seems to represent the second description of pure arterial malformation discovered incidentally in a child., Conclusion: We review the clinical presentation, angiographic findings, and management of our case in the context of other reported pediatric cases.

Neonatal germ cell tumors are rare and comprise both benign and malignant neoplasms. Teratoma with nephroblastoma is a malignant subset defined pathologically by the presence of nephroblastoma and teratoma elements. Although teratoma with nephroblastoma is most often found in the kidney, 24 of 59 reported cases are associated with extrarenal locations, such as the mediastinum or retroperitoneum. To our knowledge, this is the first patient in the literature with intracranial/pineal teratoma with nephroblastoma, which was managed with staged transcranial approaches resulting in gross total resection and no adjuvant therapy (surveillance observation imaging). We further augmented the patient's management by comprehensive genomic profiling of the tumor to better understand the molecular biology and explore options for targeted therapy., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Background: Metastatic angiosarcoma to the brain is a rare entity without an established management protocol., Case Description: A man with primary cardiac angiosarcoma presented with a rare brain metastasis. The patient underwent successful resection of the brain metastasis and was initiated on chemotherapy only for his systemic disease. The patient did not develop local recurrence. A review of primary and metastatic central nervous system angiosarcoma, its pathologic features, clinical disease course, treatment strategies, and genomics is also provided., Conclusions: Angiosarcomas are rare tumors that are difficult to treat. Gross total resection of a central nervous system metastasis is recommended before initiation of adjuvant chemotherapy or radiation therapy. Close follow-up is still required given the propensity for continued metastasis of these tumors. Future treatments may be developed based on the genomics of angiosarcomas., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Epilepsy is a common disease in the pediatric population, and the majority of cases are controlled with medications and lifestyle modification. For the children whose seizures are pharmacoresistant, continued epileptic activity can have a severely detrimental impact on cognitive development. Early referral of children with drug-resistant seizures to a pediatric epilepsy surgery center for evaluation is critical to achieving optimal patient outcomes. There are several components to a thorough presurgical evaluation, including a detailed medical history and physical examination, noninvasive testing including electroencephalogram, magnetic resonance imaging (MRI) of the brain, and often metabolic imaging. When necessary, invasive diagnostic testing using intracranial monitoring can be used. The identification of an epileptic focus may allow resection or disconnection from normal brain structures, with the ultimate goal of complete seizure remission. Additional operative measures can decrease seizure frequency and/or intensity if a clear epileptic focus cannot be identified. In this review, we will discuss the nuances of presurgical evaluation and decision-making in the management of children with drug-resistant epilepsy (DRE)., Competing Interests: The authors have no conflicts of interest to declare.

Objective: The rate of neurosurgery guidelines publications was compared over time with all other specialties. Neurosurgical guidelines and quality of supporting evidence were then analyzed and compared by subspecialty., Methods: The authors first performed a PubMed search for "Neurosurgery" and "Guidelines." This was then compared against searches performed for each specialty of the American Board of Medical Specialties. The second analysis was an inventory of all neurosurgery guidelines published by the Agency for Healthcare Research and Quality Guidelines clearinghouse. All Class I evidence and Level 1 recommendations were compared for different subspecialty topics., Results: When examined from 1970-2010, the rate of increase in publication of neurosurgery guidelines was about one third of all specialties combined (P < 0.0001). However, when only looking at the past 5 years the publication rate of neurosurgery guidelines has converged upon that for all specialties. The second analysis identified 49 published guidelines for assessment. There were 2733 studies cited as supporting evidence, with only 243 of these papers considered the highest class of evidence (8.9%). These papers were used to generate 697 recommendations, of which 170 (24.4%) were considered "Level 1" recommendations., Conclusion: Although initially lagging, the publication of neurosurgical guidelines has recently increased at a rate comparable with that of other specialties. However, the quality of the evidence cited consists of a relatively low number of high-quality studies from which guidelines are created. Wider implications of this must be considered when defining and measuring quality of clinical performance in neurosurgery., (Copyright © 2016 Elsevier Inc. All rights reserved.)

In the approximately 1% of children affected by epilepsy, pharmacoresistance and early age of seizure onset are strongly correlated with poor cognitive outcomes, depression, anxiety, developmental delay, and impaired activities of daily living. These children often require multiple surgical procedures, including invasive diagnostic procedures with intracranial electrodes to identify the seizure-onset zone. The recent development of minimally invasive surgical techniques, including stereotactic electroencephalography (SEEG) and MRI-guided laser interstitial thermal therapy (MRgLITT), and new applications of neurostimulation, such as responsive neurostimulation (RNS), are quickly changing the landscape of the surgical management of pediatric epilepsy. In this review, the authors discuss these various technologies, their current applications, and limitations in the treatment of pediatric drug-resistant epilepsy, as well as areas for future research. The development of minimally invasive diagnostic and ablative surgical techniques together with new paradigms in neurostimulation hold vast potential to improve the efficacy and reduce the morbidity of the surgical management of children with drug-resistant epilepsy.

Pediatric epilepsy is a debilitating condition that impacts millions of patients throughout the world. Approximately 20-30% of children with recurrent seizures have drug-resistant epilepsy (DRE). For these patients, surgery offers the possibility of not just seizure freedom but significantly improved neurocognitive and behavioral outcomes. The spectrum of surgical options is vast, ranging from outpatient procedures such as vagus nerve stimulation to radical interventions including hemispherectomy. The thread connecting all of these interventions is a common goal-seizure freedom, an outcome that can be achieved safely and durably in a large proportion of patients. In this review, we discuss many of the most commonly performed surgical interventions and describe the indications, complications, and outcomes specific to each.

Introduction: Fresh frozen plasma (FFP) is a frequently used human blood product to reverse the effects of vitamin K antagonists. While FFP is relatively economical, its large fluid volume can lead to hospitalization complications, therefore increasing the overall cost of use., Materials & Methods: A recently published article by Sarode et al., in Circulation, described the rate of volume overload associated with FFP use for reversal of vitamin K antagonists. This condition, described as transfusion-associated circulatory overload, has a defined rate of intensive care admission, which also has a well-reported average cost. The additional monetary value of intensive care unit admission and caring for fluid overload is then compared to the cost of another product, four-factor prothrombin complex concentrates, which does not, as per the Sarode paper, result in fluid overload., Results: The increased costs attributed to FFP-associated fluid overload for vitamin K antagonist reversal partly defrays the increased upfront cost of four-factor prothrombin complex concentrates., Discussion: FFP is commonly used to acutely reverse the effects of vitamin K antagonists. However, its use requires significant time for infusion, may lead to fluid overload, and is not fully effective in compete anticoagulation reversal. One alternative therapy for anticoagulant reversal is use of prothrombin complex concentrates, which are rapidly infused, are not associated with fluid overload, and are effective in complete reversal of coagulation measurements. This should be considered for patients with acute bleeding emergencies.