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OBJECTIVE The authors sought to determine the outcome of using the pleural space as the terminus for ventricular CSF-diverting shunts in a pediatric population. METHODS All ventriculopleural (VPl) shunt insertions or revisions done between 1978 and 2018 in patients at Children’s Hospital Los Angeles were identified. Data recorded for analysis were age, sex, weight, etiology of hydrocephalus, previous shunt history, reason for VPl shunt insertion or conversion from a ventriculoperitoneal (VP) or ventriculoatrial (VA) shunt, valve type, nature of malfunction, presence of shunt infection or pleural effusion, and conversion to a different distal site. RESULTS A total of 170 patients (mean age 14 ± 4 years) with a VPl shunt who were followed up for a mean of 57 ± 53 months were identified. The reasons for conversion to a VPl shunt for 167 patients were previous shunt infection in 57 (34%), multiple abdominal procedures in 44 (26%), inadequate absorption of CSF in 34 (20%), abdominal pseudocyst in 25 (15%), and obesity in 7 (4%). No VPl revisions were required in 97 (57%) patients. Of the 73 (43%) patients who did require revision, the most common reason was proximal obstruction in 32 (44%). The next most frequent complication was pleural effusion in 22 (30%) and included 3 patients with shunt infection. All 22 patients with a clinically significant pleural effusion required changing the distal end of the shunt from the pleural space. Pleural effusion was more likely to occur in VPl shunts without an antisiphon valve. Of the 29 children < 10 years old, 7 (24%) developed a pleural effusion requiring a revision of the distal catheter to outside the pleural space compared with 15 (11%) who were older (p = 0.049). There were 14 shunt infections with a rate of 4.2% per procedure and 8.2% per patient. CONCLUSIONS VPl shunts in children younger than 10 years of age have a significantly higher rate of symptomatic pleural effusion, requiring revision of the shunt’s terminus to a different location. VPl shunt complication rates are similar to those of VP shunts. The technical difficulty of inserting a VPl shunt is comparable to that of a VP shunt. In a patient older than 10 years, all else being equal, the authors recommend that the distal end of a shunt be placed into the pleural space rather than the right atrium if the peritoneal cavity is not suitable.

Background/Aims: Down syndrome is the most common inherited disorder. Some patients develop atlantoaxial instability. Existing screening guidelines were developed prior to availability of MRI. We present predictors for deficit using dynamic MRI of the craniocervical junction. Methods: A retrospective review of Down syndrome patients from 2001 to 2015 was carried out. Patients were considered symptomatic if they had clinical deficits or signal change on MRI. Measurements were taken at the atlantoaxial junction and structural abnormalities noted. Analysis was performed with SPSS. Results: A total of 36 patients were included. Patients averaged 93 months of age with a follow-up of 57 months. No asymptomatic patients developed myelopathy during follow-up. During dynamic imaging, symptomatic patients had greater changes in space available for the cord (SAC) (5.2 vs. 2.7 mm; p < 0.001) and atlantodental interval (ADI) (2.8 vs. 1.3 mm; p = 0.04). These patients were also more likely to have a bony anomaly (50 vs. 13%; p = 0.03). Conclusion: This study characterizes the range of motion seen on dynamic MRI and provides parameters that can be used to distinguish patients at risk for neurologic injury. Changes greater than 3 mm in ADI or 5 mm in SAC during dynamic MRI or any bony abnormality warrants further investigation. Patients without these features may be able to avoid an unnecessary intervention.

Background/Aims: Intracranial germ-cell tumors (GCTs) are a heterogeneous group of tumors that vary in their response to treatment. Standard treatment consists of chemotherapy and radiation therapy, with the consideration of second-look surgery in resistant disease. The present study aims to inform therapy by characterizing features on pretreatment imaging associated with recurrence. Methods: Children with intracranial GCTs treated at a single institution between January 2000 and October 2016 were retrospectively reviewed under an Institutional Review Board-approved protocol. Imaging variables identified on pretreatment imaging were calcifications, cysts, heterogeneity of enhancement, blood products, hydrocephalus, gradient echo susceptibility, restricted diffusion, invasiveness, and extent of edema. Tumor recurrence was used as the primary outcome variable. Results and Conclusion: Fifty-two patients (39 males, mean age at diagnosis: 13 ± 5 years, 34 germinoma, 18 nongerminomatous GCT [NGGCT]) were reviewed. Thirty-three percent of the patients reviewed had recurrence (7 germinoma, 11 NGGCT). Recurrence was associated with invasiveness as seen on preoperative imaging (p = 0.0385) and cystic tumor (p = 0.048).

OBJECT Posthemorrhagic hydrocephalus (PHH) in the preterm infant remains a major neurological complication of prematurity. The authors first described insertion of a specially designed low-profile subcutaneous ventricular catheter reservoir for temporary management of hydrocephalus in 1983. This report presents the follow-up experience with the surgical management of PHH in this population and describes outcomes both in infants who were stable for permanent shunt insertion and those initially temporized with a ventricular reservoir (VR) prior to permanent ventriculoperitoneal (VP)/ventriculoatrial (VA) shunt placement. METHODS A retrospective review was undertaken of the medical records of all premature infants surgically treated for posthemorrhagic hydrocephalus (PHH) between 1997 and 2012 at Children’s Hospital Los Angeles. RESULTS Over 14 years, 91 preterm infants with PHH were identified. Fifty neonates received temporizing measures via a VR that was serially tapped for varying time periods. For the remaining 41 premature infants, VP/VA shunt placement was the first procedure. Patients with a temporizing measure as their initial procedure had undergone CSF diversion significantly earlier in life than those who had permanent shunting as the initial procedure (29 vs 56 days after birth, p < 0.01). Of the infants with a VR as their initial procedure, 5/50 (10%) did not undergo subsequent VP/VA shunt placement. The number of shunt revisions and the rates of loculated hydrocephalus and shunt infection did not statistically differ between the 2 groups. CONCLUSIONS Patients with initial VR insertion as a temporizing measure received a CSF diversion procedure significantly earlier than those who received a permanent shunt as their initial procedure. Otherwise, the outcomes with regard to shunt revisions, loculated hydrocephalus, and shunt infection were not different for the 2 groups.

BACKGROUND: This study aims to identify the prevalence of and risk factors for seizure development after supratentorial brain tumor resection in pediatric patients. This could be used to guide the postoperative management and usage of anti-epileptic drugs (AEDs). METHODS: Retrospective study was conducted for patients between 0 and 21 years with supratentorial tumor resection between 2005 and 2015 at a single institution. RESULTS: Two hundred patients (114 males/86 females) were identified. Median age at resection (±SD) was 9.025 ± 5.720 years and mean follow-up was 4 ± 2 years. Resection was gross total in 82 patients (41%) and partial in 118 patients (59%); 66 patients (33%) experienced preoperative seizures, and 67 patients (34%) experienced postoperative seizures; 18 patients (27%) had early seizures, and 49 patients (73%) had late seizures. Univariate analysis identified risk factors for postoperative seizures as: preoperative seizures (P < 0.001), age less than 2 years (P = 0.003), temporal location (P < 0.001), thalamic location (P = 0.017), preoperative hyponatremia (P = 0.017), World Health Organization grade (P = 0.008), and pathology (P = 0.005). Multivariate regression identified 5 robust risk factors: temporal location (odds ratio [OR] 4.7, 95% CI: 1.7–13.3, P = 0.003), age 0.05). CONCLUSIONS: This study reveals 5 risk factors for postoperative seizures after resection of supratentorial tumors. These factors should be considered in postoperative management of these patients.

Background/Aims: Pilocytic astrocytomas are common pediatric tumors. Molecular profiles vary with location of origin. Comparisons of proliferation have not been reported. We sought to identify differences in growth by region and whether these predict clinical behavior. Methods: A retrospective review of all patients undergoing surgery for a pilocytic astrocytoma at Children’s Hospital LA from 2003 to 2015 was completed. Tumor location, determined by imaging, was stratified into infratentorial, supratentorial, or optic pathway. Proliferation was measured by Ki-67 immunostaining. A p value of 0.05 was deemed significant. Results: 77 patients were identified. 51 had posterior fossa tumors, 12 had supratentorial tumors, and 14 had optic pathway tumors. Mean Ki-67 score was 3.67, 4.09, and 3.83%, respectively (p = 0.82). Ki-67 of ≥4% trended towards recurrence (p = 0.11), incomplete resection (p = 0.15), and younger age at presentation (p = 0.04). Ki-67 was weakly correlated with shorter survival after surgery (r = –0.103, p = 0.41). Partial resection strongest predicted recurrence (p < 0.001; OR = 13.0). Conclusion: Proliferative index does not change by location. Higher cell proliferation was seen in younger patients and associated with shorter time to and a higher risk of recurrence. Further study is needed to identify predictors for clinical behavior. Importance of Study: This study provides a detailed analysis of the proliferative indices of tumors arising from characteristic locations within the brain. With recent advances in our understanding of the differences in molecular and genetic profiles despite similar histologic diagnoses, we felt that it was important to review whether there were unique components of tumor behavior that could be identified. In turn, we sought to determine whether tumor behavior could be used to predict the clinical course. This knowledge is important, given that not every tumor may undergo complete surgical resection, and that some lesions may require more aggressive upfront adjuvant therapy or be closely monitored for recurrence.

Despite major advances in medicine, racial and socioeconomic disparities continue to affect health care outcomes. Higher overall infant mortality has been reported for black neonates compared with their Hispanic and white counterparts. The underlying basis for these differences remains unclear. A potential influencing factor is the management of premature neurologic complications in this disadvantaged group. This study examines racial and socioeconomic disparities on mortality in preterm infants with posthemorrhagic hydrocephalus (PHH).Data from the Nationwide Inpatient Sample and Kids Inpatient Database were combined from 2000 to 2010. Discharges with International Classification of Diseases, Ninth Revision, Clinical Modification codes for preterm births with intraventricular hemorrhage and PHH were included. Relative risk (RR) ratios for mortality, complications, length of stay, and hospital costs were obtained with multivariate analysis after controlling for patient-level, hospital-level, and admission-level factors.When controlling for patient and hospital factors, black neonates had increased mortality compared with whites and Hispanics (RR = 1.47; P0.01). This association existed despite lower rates of congenital cardiac defects (RR = 0.84; P0.01), gastrointestinal complications (RR = 0.84; P0.01), and general complications of prematurity (RR = 0.95; P = 0.04) in the black cohort. Preterm infants insured by Medicaid had increased mortality compared with those with private insurance (RR = 1.2; P = 0.04) after adjusting for patient and hospital factors.Among preterm infants with intraventricular hemorrhage and resultant PHH, black infants and those insured by Medicaid have significantly increased mortality but these 2 effects are independent. Further studies are needed to fully understand the factors affecting these racial and socioeconomic disparities.